Comparison of MD and DO in the United States

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Osteopathic medicine
in the United States


Andrew Taylor Still (founder)

Doctor of Osteopathic Medicine (DO)

Medicine · US Medical education

Asclepius staff.svg

Schools · Physicians

Osteopathic Manipulative Medicine

AOA · AACOM · AAO · COMLEX

MD & DO Comparison

Specialty Colleges · AOA BOS

In the United States, there are two types of physicians that practice medicine. Most physicians hold the Doctor of Medicine degree (M.D.), while osteopathic physicians hold the Doctor of Osteopathic Medicine degree (D.O.).[1] Other than teaching osteopathic manipulative medicine, the medical training for an M.D. and D.O. is virtually indistinguishable. D.O. physicians complete conventional residencies in hospitals and training programs, are licensed in all states, and have rights and responsibilities, such as military service, that are identical to M.D. physicians and surgeons.[2]

Background[edit]

In 2005, Jordan Cohen, the president of the Association of American Medical Colleges (AAMC) stated:

After more than a century of often bitterly contentious relationships between the osteopathic and allopathic medical professions, we now find ourselves living at a time when osteopathic and allopathic graduates are both sought after by many of the same residency programs; are in most instances both licensed by the same licensing boards; are both privileged by many of the same hospitals; and are found in appreciable numbers on the faculties of each other's medical schools.[3]

The AMA's current definition of a physician is "an individual who has received a 'Doctor of Medicine' or a 'Doctor of Osteopathic Medicine' degree or an equivalent degree following successful completion of a prescribed course of study from a school of medicine or osteopathic medicine."[4]

Demographics[edit]

First year medical school enrollment, 1975–2007.
  MD
  DO

The sex and racial distribution of DOs and MDs are similar.[5] Currently, there are significantly more MDs than DOs.[6] In the 2011-2012 application cycle, 5,788 students matriculated as first-year students into DO medical programs[7] and 19,517 students matriculated as first-year students into MD programs.[8]

A 2010 survey of students applying to both U.S. M.D. and D.O schools found that 35% were admitted only to a DO school, 11% were admitted only to an M.D. school, 26% were admitted to both, and the remaining 52% were not admitted to any medical schools.[9] Geographic location was the top reason students gave for choosing the school in which they enrolled.[9]

Of physicians practicing in the United States, 7% are osteopathic physicians (2010),[10] 26% are international medical graduates (2012),[11] and 67% are allopathic physicians. Between 1980 and 2005, the annual number of new MDs remained stable at around 16,000. During the same period, the number of new DOs increased by more than 200% (from about 1,150 to about 2,800).[12] Graduates from DO medical programs are expected to increase to as many as 4,000 by 2015.[13] The number of new MDs per 100,000 people fell from 7.5 to 5.6, while the number of new DOs per 100,000 rose from 0.4 to 0.8.[12]

The distribution of both M.D. and D.O. physicians in the United States is not uniform, as the number of physicians per capita varies. As of 2009, the states with the most M.D. physicians per capita were the District of Columbia, Massachusetts, Maryland, and New York.[14] The states with the lowest number of M.D. physicians per capita were Idaho, Oklahoma, Mississippi, Wyoming and Nevada.[14] Osteopathic physicians are more concentrated in the midwestern states than in other regions of the U.S. As of 2011, the states with the most osteopathic physicians per capita were Michigan, Maine, Oklahoma, Pennsylvania.[15] The states with the lowest number of D.O. physicians per capita were Louisiana, Alabama, Nebraska, and North Carolina.[15]

Cultural differences[edit]

Some authors describe less quantifiable distinctions between the two medical professions. Avery Hurt writes, "In actual practice, the variations between the two types of physicians are often so slight as to be unnoticeable to patients, and a day in the life of each can appear indistinguishable. But the differences are there, subtle but deep."[16] Several studies have investigated these differences. One study compared the patient interactions of DOs and MDs. The study found that "osteopathic physicians were more likely to use patient's first names and to discuss the social, family and emotional impact of illnesses." For example, "66% of DOs discussed a patient's emotional state compared with about one-third of MDs." The same study found that MD qualified "physicians scored higher in discussing literature or scientific basis of treatment."[17] Another study analyzed 341.4 million patient visits to general and family medicine specialists in the United States, including 64.9 million visits to DOs and 276.5 million visits to MDs. It found that there was no significant difference between DOs and MDs "with regard to time spent with patients and preventive medicine services."[18]

Self-characterization[edit]

A Harvard study found significant differences in the attitudes of DOs and MDs. The study found that 40.1% of MD students and physicians described themselves as "socioemotionally" oriented over "technoscientific" orientation. 63.8% of their DO counterparts self-identified as socioemotional. (p < .0001)[19]

Perceptions[edit]

One study of DOs attempted to investigate their perceptions of differences in philosophy and practice between themselves and their MD counterparts. 88% of the respondents had a self-identification as osteopathic physicians, but less than half felt their patients identified them as such. The study asked respondents to identify points of philosophical and practical difference between DOs and MDs; no more than 1/3 of respondents could agree on any single such point of difference.[20]

Self-Identification[edit]

As the training of DOs and MDs becomes less distinct, some have expressed concern that their unique characteristics will be lost.[21] Others welcome the rapprochement and already consider modern medicine to be the type of medicine practiced by both "MD and DO type doctors."[22] One persistent difference is the respective acceptance of the terms "allopathic" and "osteopathic." DO medical organizations and medical schools all include the word osteopathic in their names, and such groups actively promote an "osteopathic approach" to medicine. While "osteopathy" was a term used by its founder AT Still to describe his new philosophy of medicine, "allopathic medicine" was originally a derogatory term coined by Samuel Hahnemann to contrast the conventional medicine of his day with his alternative system of homeopathic medicine.[23][24] Today, the term "allopathic physician" is used infrequently, usually in discussions relating to osteopathic medicine or alternative medicine. Some authors argue that the term should be dropped altogether, since its original meaning bears little relevance to the current practice of modern medicine[25] and conventional medicine has never endorsed any principle of allopathy.[26] Similarly, the use of the terms "osteopath" and "osteopathy" are now discouraged when describing osteopathic physicians that have earned the degree of Doctor of Osteopathic Medicine and the field of osteopathic medicine, respectively.[27][28]

Medical education and training[edit]

MDs and DOs in Texas by practice type.[29]

Medical schools[edit]

The Liaison Committee on Medical Education (LCME) accredits the 141 U.S.-medical schools[30][31] that award the M.D. degree, while the American Osteopathic Association (AOA) Commission on Osteopathic College Accreditation (COCA) accredits the 30 colleges of osteopathic medicine in 42 locations in the United States that award the D.O. degree.[32]

Michigan State University and Rowan University are the only universities that have both M.D. and D.O. accredited programs.[33] In 2009, Kansas City University proposed starting a dual MD/DO program in addition to the existing DO program,[34] and the University of North Texas, explored the possibility of starting independent M.D. program that would be offered alongside the DO program.[33] Both proposals were met with controversy. Proponents argued that adding an MD program would lead to more local residencies created, and improve the university’s ability to acquire research funding and state funding. Opponents argue that adding the MD programs could cause the osteopathic program to lose its focus on "holistic care," would result in more competition for the already limited number of existing residencies (if more were not opened), and would drain resources from the established osteopathic programs.

Overall, osteopathic medical schools have more modest research programs compared to M.D. schools, and fewer D.O. schools own a hospital.[35] Historically, osteopathic medical schools had associations with osteopathic hospitals, which were usually small, rural, community based hospitals.[36] However, in 1990s and 2000s, economic and regulatory pressures caused many small hospitals, including most osteopathic hospitals, to either close or join larger hospital networks.[36][37]

Osteopathic medical schools tend to have a stronger focus on primary care medicine than M.D. schools.[35] D.O. schools have developed various strategies to encourage their graduates to pursue primary care, such as offering accelerated 3-year programs for primary care, focusing clinical education in community health centers, and selecting rural or under-served urban areas for the location of new campuses.[35]

Osteopathic manipulative medicine[edit]

Many authors note the most obvious difference between the curricula of D.O. and M.D. schools is osteopathic manipulative medicine (OMM), a form of hands-on care used to diagnose, treat and prevent illness or injury and is taught only at D.O. schools. As of 2006, the average osteopathic student spent almost 8 weeks on clerkships for OMM during their third and fourth years.[38] The National Institute of Health's National Center for Complementary and Alternative Medicine states[39] that overall, studies have shown that spinal manipulation can provide mild-to-moderate relief from low-back pain and appears to be as effective as conventional medical treatments. In 2007 guidelines, the American College of Physicians and the American Pain Society include spinal manipulation as one of several treatment options for practitioners to consider using when pain does not improve with self-care.[40][41] Spinal manipulation is generally a safe treatment for low-back pain. Serious complications are very rare.[42] A 2001 survey of DOs found that more than 50% of the respondents used OMT (osteopathic manipulative treatment) on less than 5% of their patients. The survey was the latest indication that DOs have become more like M.D. qualified physicians in all respects: fewer perform OMT, more prescribe drugs, and many perform surgery as a first option.[43] One area which has been implicated, but not been formally studied regarding the decline in OMT usage among DOs in practice, is the role of reimbursement changes.[44] Only in the last several years could a D.O. charge for both an office visit (Evaluation & Management services) and use a procedure (CPT) code when performing OMT; previously, it was bundled.[45]

Student aptitude indicators[edit]

Some authors note the differences in average GPA and MCAT scores of those who matriculate at D.O. schools versus those who matriculate at M.D. schools within the United States. In 2012, the average MCAT and GPA for students entering U.S.-based M.D. programs were 31.2 and 3.68,[46] respectively, and 26.85 and 3.51 for D.O. matriculants,[47] although the gap has been getting smaller every year.[48] Up to one third of students matriculating at a D.O. medical school were not accepted by M.D. programs;[49] however, DO medical schools are more likely to accept non-traditional students,[50][51] who are older, coming to medicine as a second career, etc. D.O. medical students are required to take the Comprehensive Osteopathic Medical Licensure Examination (COMLEX-USA) that is sponsored by the National Board of Osteopathic Medical Examiners (NBOME). This exam is a prerequisite for D.O.-associated residency programs, which are available in almost every specialty of medicine and surgery. D.O. medical students may also choose to sit for the USMLE[52] if they wish to take an M.D. residency; however, if they have taken COMLEX, it may or may not be needed, depending on the individual institution’s program requirements.[53][54][55][56] USMLE pass rates for D.O. and M.D. students in 2012 are as follows: Step 1: 91% and 94%, Step 2 CK: 96% and 97%, and Step 2 CS: 87% and 97% respectively (this number may be misleading as only 46 D.O. students compared to 17,118 M.D. students were evaluated for Step 2 CS) Step 3: 100% and 95% (this number may be misleading, as only 16 D.O. students compared to 19,056 M.D. students, were evaluated for Step 3).[57]

Residency[edit]

Applicants in the 2007 Main NRMP Residency Match[58]

Graduates of both D.O. and M.D. medical schools are eligible to apply to residency programs through the National Resident Matching Program (NRMP), which represents ACGME-accredited programs. In 2003, 99% of new U.S. MDs and 43% of new U.S. DOs went on to train in ACGME-accredited residency programs.[21]

Currently, the American Osteopathic Association accredits all D.O. residency programs. However, there have been calls to end the remaining barriers between the two types of programs.[59][60][61] Since 1985, a single residency training program can be dual-accredited by both the ACGME and the AOA.[21][62][63] By 2015, all post-graduate training for both DOs and MDs will be accredited by the ACGME.[64]

In 2001, the AOA adopted a provision making it possible for a D.O. resident in any M.D. program to apply for osteopathic approval of their training.[65] The topic of dual-accreditation is controversial. Opponents claim that by merging D.O. students into the "M.D. world", the unique quality of osteopathic philosophy will be lost.[21] Supporters claim the programs are popular because of the higher prestige and higher resident reimbursement salaries associated with M.D. programs.[66]

In 2010-2011, approximately 41% of U.S. osteopathic medical students indicated that they intend to pursue an AOA or AOA/ACGME dually-accredited residency programs while 39% indicated that they intend to pursue an ACGME accredited residency program.[67] In 2010-2011, approximately 12% of U.S. osteopathic medical students indicated that they intend to pursue an AOA/ACGME dually-accredited residency program, while 29% planned to pursue an AOA residency and 39% planned to pursue an ACGME-accredited residency program.[67] The number of dually accredited programs increased from 11% of all AOA approved residencies in 2006 to 14% in 2008, and then to 22% in 2010.[68] The most common reason (74%) given by D.O. medical students choosing an ACGME residency or AOA/ACGME dually-accredited program was a more suitable geographic location.[67] M.D. physicians are generally not permitted to train in DO (AOA-accredited) residencies, though this has become a subject of debate within the D.O. profession. The American Osteopathic Association has agreed to study the issue of permitting M.D. physicians to train in D.O. (AOA-accredited) residencies.[69][70]

As of July 2015, the AOA, AACOM, and the ACGME will create a single, unified accreditation system for graduate medical education programs in the United States.[71][72] This will ensure that all physicians trained in the U.S. will have the same graduate medical education accreditation - ACGME.

Resident specialty choice[edit]

Primary care[edit]

There are notable differences in the specialty choices of DOs and MDs. One study attributes this to a difference in the 'cultures' of their medical schools, concluding that the "practices and educational structures in osteopathic medical schools [D.O.] better support the production of primary care physician."[73] According to one survey, 54.6% of deans of M.D. medical schools reported that training future primary care physicians was more important to their institutions than training future specialist physicians, compared with 100% of D.O. medical school deans. (F = 893.11,95, p < .0001).[73]

Licensure[edit]

Steps to licensure
M.D. D.O.
Medical School Application service AMCAS/TMDSAS AACOMAS/TMDSAS
Years of medical school 4 4
Medical Licensing Exam (MLE) Step 1 USMLE required
USMLE optional (~50%)
COMLEX required
MLE, Step 2 USMLE required COMLEX required
residency M.D. (ACGME) one must be selected:
M.D. (ACGME)
D.O. (AOA)
combined M.D./D.O.
AOA approval of an ACGME program[65]
Board Certification Medical specialty boards Either M.D. or D.O. medical specialty boards

Continuing medical education[edit]

To maintain a license to practice medicine, U.S. physicians are required to complete additional training every few years, so called continuing medical education (CME). There are subtle differences in the CME requirements for M.D. and D.O. qualified physicians, and in how these CME credits are approved. The requirements for maintaining a physician license for M.D. or D.O. qualified physicians are almost identical in most states, though there are small differences. For example, in the case of Pennsylvania, M.D. licenses begin on December 31, whereas D.O. ones begin on October 31.[74]

Professional opportunities[edit]

There are currently more M.D. schools than D.O. schools offering medical training in the United States, however, the D.O. medical profession is rapidly expanding, with more than 1 in 5 medical students now entering a D.O. medical school.[75] Both DOs and MDs have the option to train and practice in any of the medical specialties and sub-specialties. One exception is the Neuromusculoskeletal Medicine specialty which is only available to D.O.s who have completed a one year traditional internship year.[76]

Both degrees are recognized internationally as a medical degree. Accredited D.O. and M.D. medical schools are both included in the World Health Organization’s World Directory of Medical Schools.[77]

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External links[edit]