In 1978 David Rearick was the first osteopathic physician to apply to practice at 505-bed Kennestone Hospital in Marietta, Ga. The hospital's credentialing committee, uncertain about his qualifications, sent a team to Chicago to review his training and education at the Chicago College of Osteopathic Medicine.
"That's how ignorant they were about D.O.s," Rearick says. "More power to them to do that because they were impressed."
Much has changed in the past two decades. With equality in licensing, hospital mergers and the rise of large medical groups, osteopathic physicians find themselves commonly training, practicing and teaching in the same institutions as their more numerous allopathic colleagues. About 62% of the nation's nearly 37,000 D.O.s are in primary care, which makes them a valuable commodity in managed-care networks.
Clinical differences are blurring. Medical school textbooks, curricula and training are largely parallel. And in the field, M.D.s and D.O.s swap techniques. Some M.D.s practice osteopathic-style musculoskeletal manual manipulation, while some D.O.s do not.
The growing cadre of osteopathic physicians taking leadership roles in large managed-care organizations could help eliminate misunderstandings about the qualifications of D.O.s. They include Norman Vinn, chief operating officer in charge of medical services for western operations at Birmingham, Ala.-based MedPartners, a leading physician practice management company; Bernard Master, founder and chairman of Columbus, Ohio-based Health Power HMO; and Sol Lizerbram, chairman and president of San Diego-based FPA Medical Management, another leading PPM company.
"There isn't the day-to-day prejudice that there was," says Rearick, whose own career reflects the mainstreaming of D.O.s. Until the beginning of this month, Rearick was chairman of the department of family practice at Promina Northwest Physicians Group, a 180-physician multispecialty practice in Marietta that today has 10 D.O.s in its ranks. On Aug. 1, he became network medical director for Aetna U.S. Healthcare Plans in Georgia.
Yet the same changes that are expanding opportunities for osteopathic physicians are threatening to erode their century-old identity as medical reformers--doctors who venerate noninvasive techniques and a holistic approach.
As the American Osteopathic Association turns 100 this year, relations are warming between osteopathic and allopathic organizations. Proposed joint initiatives aimed at improving medical care could further erode the distinctions between the two medical styles. Osteopathic physicians, who constitute just 5.5% of practicing doctors in the U.S., could see their identity swallowed up.
Historically, allopathic and osteopathic relations have been marked by suspicion and hostility in large part because of allopathic medicine's political and legal efforts to block the establishment of osteopathic medicine.
Today the two medical branches are finding common ground in preserving funding for education and training, battling intrusive managed-care forces and controlling physician supply.
One example came in February, when the AOA, the American Medical Association, the Association of American Medical Colleges, the American Association of Colleges of Osteopathic Medicine and other groups held a joint news conference in Washington to recommend that Congress stem the tide of international medical graduates.
Such collaboration would have been unheard of a few years ago.
Credit two meetings sponsored by the New York-based Josiah Macy Jr. Foundation. Leaders from both professions, many of whom had never met, gathered first in 1995 in Dallas to open dialogue and again last year in Santa Fe, N.M., to explore specific areas for collaboration.
The panel produced a series of recommendations, only some of which sparked action.
Recommendations to establish common standards for physician licensing, credentialing and accreditation have not been acted upon, says D. Kay Clawson, M.D., former executive vice chancellor for University of Kansas Medical Center, who chaired the Macy conferences.
But in one area that made progress, two joint research studies were designed on the efficacy of osteopathic manipulative treatment, or OMT, for low back pain and nonmigrainous headaches. Such joint studies on the value of OMT could lead to its widespread use-or nonuse-by both types of physicians.
However, the studies, which were headed by researchers at Rush-Presbyterian-St. Luke's Medical Center in Chicago and Henry Ford Medical Center in Detroit, have yet to find funding, partly because they are not considered to be on the cutting edge of science, Clawson says.
Physician oversupply could be an even tougher challenge. Leaders in both fields agree the number of U.S. medical school graduates should be capped at current levels, but achieving that goal will be difficult unless Congress first restricts the number of international medical school graduates who enter U.S. residency programs.
The Macy panel recommended that Congress reduce entry-level residency positions to the current number of U.S. medical school graduates, about 17,000, and give funding priority to residencies filled by U.S. medical school graduates.
But Congress shows no inclination to restrict international medical school graduates, who constituted about 7,000, or 30%, of first-year residents in 1994, according to the AAMC.
Meanwhile, osteopathic medicine is on an expansion track. Two new medical schools were opened in the past decade with one more in development. Osteopathic physicians have increased their numbers by 20% since 1993 (See charts, pages 18 and 22).
"The more D.O.s we can train, the more likely we are to maintain our separate and distinct philosophy," says AOA President John Sevastos, D.O.
Sevastos says more osteopathic schools won't contribute to oversupply. "We have always produced a majority of primary-care doctors, and this is now what everyone says we need," he says.
The AOA, which is the accrediting body for osteopathic medical schools and training programs as well as a professional trade association, takes a boosterish approach. The cover of its official publication, The D.O., exclaimed "One of our own" last fall when Lt. Gen. Ronald R. Blanck, D.O., was named surgeon general of the U.S. Army.
While membership in the AOA remains high-in excess of 60% of practicing osteopathic physicians-about 21% of D.O.s belong to the 297,000-member AMA, which enjoys far more political clout.
In some ways, D.O.s still struggle for equal status. This year the AOA introduced legislation to rewrite Louisiana's medical practice act to recognize osteopathic exams as a legitimate test for licensing physicians. Louisiana is the only state where the osteopathic exam series is not recognized.
And even Congress has slighted D.O.s. Last year, it finally got around to changing a 6-year-old law that allowed Medicaid payments to M.D.s who treated pregnant women and children, but not to D.O.s. Although the law was not enforced against D.O.s who collected their Medicaid payments, the oversight irked many osteopathic physicians.
More often these days, the battle is for public perception, which lumps osteopathic physicians with chiropractors, herbalists and other alternative practitioners and considers M.D. the equivalent of "physician."
Some osteopathic physicians are quick to correct those who say "osteopaths." Rearick calls it a "cultish old term."
"You get a little upset. When you think physician, you should think M.D. or D.O.," Rearick says. "Every piece of hospital stationery, every prescription pad, Boy Scout permission form, school checkup form--where it has a place to sign your name and they put M.D. and not D.O. on the line--it's out of ignorance."
Still, the walls between allopathic and osteopathic medicine are not ready to come down entirely.
While there is consensus on goals such as increasing funding for graduate medical education, there is not always agreement on how those goals should be accomplished. For example, osteopathic medical schools recently endorsed the idea of funding GME training through a consortium of medical schools, teaching hospitals, physician offices and community health centers. Allopathic medical schools, however, have made no similar endorsement.
But maintaining the osteopathic identity does not negate collaboration on standards for education and training, says Frederick Humphrey II, D.O., dean of the School of Osteopathic Medicine at the University of Medicine and Dentistry of New Jersey. At his school, about 20% of the faculty members are M.D.s.
"I think we're moving in that direction (toward collaboration), and I don't know that that's going to be reversed by anything," he says.