Comparison of MD and DO in the United States
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|Andrew Taylor Still (founder)|
In the United States, physicians (medical doctors) who practice medicine hold either the Doctor of Medicine degree (MD) or the Doctor of Osteopathic Medicine degree (DO). MD and DO physicians complete similar residency programs in hospitals, can be licensed in all 50 states, and have rights and responsibilities common to physicians.
Historically, MDs and DOs significantly differed in their approach to medical treatment. Early allopathic medicine was primarily based on scientific practices though certain exceptions are noteworthy (e.g., doctors prescribing arsenic for syphilis). In contrast, osteopathic medicine was founded in the mid-nineteenth century on the premise of healing the body through osteopathic musculoskeletal manipulation. Other than DO medical students learning osteopathic manipulative medicine, the modern medical training for MDs and DOs is indistinguishable.
In the United States, DOs are fully licensed medical doctors and have full medical practice rights throughout the United States. The DO degree is accepted in 44 countries abroad. Currently, less than 10% of US physicians have a DO degree. A Doctor of Osteopathic Medicine (DO) is different than an osteopath: a DO is a physician, while an osteopath is not.
- 1 Background
- 2 Demographics
- 3 Research and scholarly work
- 4 Cultural differences
- 5 Medical education and training
- 6 Professional opportunities
- 7 See also
- 8 References
- 9 External links
While allopathic medicine has followed the development of society, osteopathic medicine is a more recent development. Frontier physician Andrew Taylor Still founded the American School of Osteopathy in Kirksville, MO in 1892 as a protest against the present medical system. A. T. Still believed that the conventional medical system lacked credible efficacy, was morally corrupt, and treated effects rather than causes of disease. Throughout the 1900s, DOs fought to gain practice rights and government recognition. The first state to pass such regulations allowing DOs medical practice rights was California in 1901, the last was Nebraska in 1989.
In a 2005 editorial about mitigating the impending shortage of physicians in the United States, Jordan Cohen, MD, then-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.
The American Medical Association'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."
There are significantly more MDs than DOs, though the number of DOs is increasing, due to the increase in number of DO schools and the increase in applicants for medical schools as a whole. Of first-year medical students matriculating in 2016, 25.9% (7,369 students) entered DO medical programs and 74.1% (21,030 students) entered MD programs. The Association of American Medical Colleges projects that from 2016 to 2021, first-year DO student enrollment will increase by 19.4% versus a 5.7% increase in MD students.
Of the 860,917 physicians actively practicing in the United States in 2015, 7.6% hold a DO degree, 67.1% hold an MD degree granted in the U.S., and 24.3% are international medical graduates. The percentage of physicians that hold a DO degree varies by specialty, with the greatest representation in Family Medicine/General Practice (16.5% of general practitioners), Physical Medicine & Rehabilitation (13.8%), and Emergency Medicine (11.2%).
As of 2015, 9.0% of residents and fellows in medical training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), which accredits all MD residency programs, hold a DO degree. 65.1% of the 19,302 DO graduates enrolled in post-doctoral training are in ACGME-accredited programs, with the remainder in AOA programs. In 2020, the ACGME will take over the accreditation of all residency programs in the United States for both MDs and DOs.
The geographic distribution of MD and DO physicians is not uniform. As of 2012, the states with the greatest ratio of active physicians holding a DO degree versus active physicians holding an MD degree were Oklahoma (20.7% of physicians), Iowa, Michigan, Maine, and West Virginia. During that same year, the states with the greatest ratio of active physicians holding an MD degree versus a DO degree were Louisiana, Washington, D.C., Massachusetts, Maryland, and Connecticut. The states with the greatest per capita number of DO physicians are Maine, Michigan, Pennsylvania, Oklahoma, and Iowa. The states with the greatest per capita number of MD physicians are Washington, D.C., Massachusetts, Maryland, New York, and Connecticut. Doctors holding a DO degree are more likely to practice in rural areas.
The sex and racial distribution of DOs and MDs are similar. 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). 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.
A 2012 survey of students applying to both U.S. MD and DO schools found that 46% were admitted only to a DO school, 9% were admitted only to an MD school, 26% were admitted to both, and 19% were not admitted to any medical schools. Geographic location was the top reason given by both DO and MD students for choosing the school in which they enrolled.
Research and scholarly work
In comparison to allopathic medicine, osteopathic medicine has been criticized for the relative lack of research and lesser emphasis on scientific inquiry at D.O. schools in comparison with M.D. schools. According to the Journal of the American Osteopathic Association, the "inability to institutionalize research, particularly clinical research, at osteopathic institutions has, over the years, weakened the acculturation, socialization, and distinctive beliefs and practices of osteopathic students and graduates."
Some authors describe subjective distinctions in patient interactions, but 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."
Several studies have investigated these differences. A study conducted during 2003-04 analyzed patient visits to general and family medicine physicians in the U.S., including 65 million visits to DOs and 277 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.
A small study of 18 physicians compared patient interactions and found that osteopathic physicians were more likely to use patients' 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 32% of MDs. Only four of the 26 characteristics tested resulted in a statistically significant difference between the DO and MD patient interactions.
A study conducted during 1993-94 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.
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 medical physicians, while 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.
As the training of DOs and MDs becomes less distinct, some have expressed concern that the unique characteristics of osteopathic medicine will be lost. Others welcome the rapprochement and already consider modern medicine to be the type of medicine practiced by both "MD and DO type doctors." One persistent difference is the respective acceptance of the terms "allopathic" and "osteopathic." DO medical schools and organizations 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 in the 19th century 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. Today, the term "allopathic physician" is used infrequently, usually in discussions relating to comparisons with osteopathic medicine or alternative medicine. Some authors argue that the terms "osteopathic" and "allopathic" should be dropped altogether, since their original meanings bear little relevance to the current practice of modern medicine
Medical education and training
The Liaison Committee on Medical Education (LCME) accredits the 144 U.S. medical schools that award the MD degree, while the American Osteopathic Association (AOA)'s Commission on Osteopathic College Accreditation (COCA) accredits the 33 osteopathic medical schools in 48 locations in the U.S. that award the DO degree.
Michigan State University, Rowan University, and Nova Southeastern University offer both MD and DO accredited programs. In 2009, Kansas City University proposed starting a dual MD/DO program in addition to the existing DO program, and the University of North Texas explored the possibility of starting an MD program that would be offered alongside the DO program. Both proposals were met with controversy. Proponents argued that adding an MD program would lead to the creation of more local residency programs and improve the university’s ability to acquire research funding and state funding. Opponents argue that adding an MD program could cause the DO program to lose its identity and drain resources from the established osteopathic program.
61% of graduating seniors at osteopathic medical schools evaluated that over half of their required in-hospital training was delivered by MD physicians. Overall, osteopathic medical schools have more modest research programs compared to MD schools, and fewer DO schools own a hospital. Historically, osteopathic medical schools had associations with osteopathic hospitals, which were usually small, rural, community based hospitals. 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.
Osteopathic medical schools tend to have a stronger focus on primary care medicine than MD schools. DO 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.
Osteopathic manipulative medicine
Many authors note the most obvious difference between the curricula of DO and MD 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 DO schools. As of 2006, the average osteopathic student spent almost 8 weeks on clerkships for OMM during their third and fourth years. The National Institute of Health's National Center for Complementary and Integrative Health states 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. Spinal manipulation is generally a safe treatment for low-back pain. Serious complications are very rare. 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 MD physicians in all respects: fewer perform OMT, more prescribe drugs, and many perform surgery as a first option. 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. Only in the last several years could a DO charge for both an office visit (Evaluation & Management services) and use a procedure (CPT) code when performing OMT; previously, it was bundled.
Student aptitude indicators
There is some difference in average GPA and MCAT scores of those who matriculate at DO schools versus those who matriculate at MD schools, though the gaps have lessened over time. In 2016, the average MCAT and GPA for students entering U.S.-based MD programs were 508.7 and 3.70, respectively, and 502.2 and 3.54 for DO matriculants. DO medical schools are more likely to accept non-traditional students, who are older, coming to medicine as a second career, etc.
DO medical students are required to take the Comprehensive Osteopathic Medical Licensure Examination (COMLEX-USA) that is administered by the National Board of Osteopathic Medical Examiners (NBOME). This exam is a prerequisite for DO-associated residency programs, which are available in almost every specialty of medicine and surgery. DO medical students may also choose to sit for the USMLE if they wish to take an MD residency and about 48% take USMLE Step 1. However, if they have taken COMLEX, it may or may not be needed, depending on the individual institution’s program requirements.
Currently, the American Osteopathic Association (AOA) accredits all DO residency programs and the ACGME accredits all MD residency programs. Graduates of both DO and MD medical schools are eligible to apply to ACGME-accredited residency programs through the National Resident Matching Program (NRMP). As of 2014, 54% of DOs in post-doctoral training are enrolled in an ACGME-accredited residency program and 46% are enrolled in an AOA-accredited residency program. The most common reason (72%) given by DO graduating seniors choosing an ACGME residency or AOA/ACGME dually-accredited program was a more suitable geographic location.
Since 1985, a single residency training program can be dual-accredited by both the ACGME and the AOA. 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. In 2001, the AOA adopted a provision making it possible for a DO resident in any MD program to apply for osteopathic approval of their training. The topic of dual-accreditation is controversial. Opponents claim that by merging DO students into the "MD world," the unique quality of osteopathic philosophy will be lost. Supporters claim the programs are popular because of the higher prestige and higher resident reimbursement salaries associated with MD programs.
Over 5 years starting in July 2015, the AOA, AACOM, and the ACGME will create a single, unified accreditation system for graduate medical education programs in the United States. This will ensure that all physicians trained in the U.S. will have the same graduate medical education accreditation, and as of June 30, 2020, the AOA will cease its accreditation functions.
Resident specialty choice
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 [DO] better support the production of primary care physician." According to one 1999 survey, 54.6% of deans of MD medical schools reported that training future primary care physicians was more important to their institutions than training future specialist physicians, compared with 100% of DO medical school deans.
Steps to licensure
|Standardized admissions examination||Medical College Admissions Test (MCAT)|
|Medical school application service||AMCAS/TMDSAS||AACOMAS/TMDSAS|
|Years of medical school||4|
|Medical Licensing Exams (MLE)||USMLE required||
|MD (ACGME)||One must be selected:
(After June 30, 2020)
|Board certification||MD medical specialty boards||Either DO or MD medical specialty boards|
Continuing medical education
To maintain a professional license to practice medicine, U.S. physicians are required to complete ongoing additional training, known as continuing medical education (CME). CME requirements differ from state to state and between the American Osteopathic Medical Association (DO) and the American Medical Association (MD) governing bodies.
There are currently more MD schools than DO schools offering medical training in the United States. However, the DO medical profession is expanding rapidly, with approximately 1 in 4 medical students now entering a DO medical school. 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 available to DOs who have first completed a one-year AOA-approved residency. However, in 2020, both the ACGME and the AOA residency programs will merge. Thus all DO applicants will attend an ACGME approved residency. Some former AOA residencies may apply for AOA distinction, which will yield an Osteopathic focus (OMM, etc.) to the training.
Both degrees are recognized internationally as a medical degree. Accredited DO and MD medical schools are both included in the World Health Organization’s World Directory of Medical Schools. DOs are recognized and accepted by international medical organizations such as Doctors Without Borders.
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