Preface and Acknowledgments

Thomas H. Meikle, Jr., M.D.

President, Josiah Macy, Jr. Foundation

Although there are two legally recognized medical professions in the United States, the larger allopathic medical profession, which comprises about 600,000 practitioners with the M.D. degree, understands little about the smaller osteopathic medical profession, which is made up of about 35,000-practitioners with the D.O. Degree. Ignorance about the osteopathic medical profession also extends throughout the nation's other health care professions.

Despite a long history of antagonism to osteopathic medicine, leaders of organized allopathic medicine, as well as health care policy makers, have recently shown increased interest in learning more about osteopathic medicine. This interest has focused especially on osteopathic medicine's success in utilizing community- based medical schools and residency programs to produce

graduates, a majority of who become generalist physicians who practice primary health care. Interest also has been expressed in osteopathic manual medicine, as other health care practitioners and the public explore the therapeutic benefits of "hands on" medicine -- the physician's touching of the patient.

To provide a source of information about osteopathic medicine that would target the interests of other health professionals, the Macy Foundation initiated a project in June 1994 to produce a monograph, Osteopathic Medicine- Past, Present and Future. The Foundation commissioned three papers for the monograph: "The History of Osteopathic Medicine”, "Contemporary Philosophy and Practice of Osteopathic Medicine”, and "Osteopathic Medical Education."

In March 1995, the Foundation convened a one-and-one-half-day meeting in Dallas to review and discuss the papers commissioned for the monograph. The meeting, which was chaired by D. Kay Clawson, M.D., was attended by either the president or the executive director of most of the major organizations that represent the two professions: the American Medical Association, the Association of American Medical Colleges, the American Hospital Association, the American Osteopathic Association, the American Association of Colleges of Osteopathic Medicine, the American Osteopathic Healthcare Association, and by governmental representatives from the U.S. Department of Health and Human Services and the Council on Graduate Medical Education.

Although the meeting had been convened to review papers for the monograph, the discussions among the participants revealed a broader interest in examining issues confronting both professions, and in improving communications between the professions. As a result of these discussions, a longer conference, "Current Challenges to M.D.s and D.O.s," will be held in February 1996.

Many individuals contributed to the success of the meeting in Dallas, but especially: D. Kay Clawson, who chaired the conference and the planning committee; the members of the planning committee; the writers of the papers -- Norman Gevitz, Raymond Hruby, Barbara Ross-Lee, and Douglas Wood; the members of the last day's panel -- Thomas Allen, Jo Boufford, Jordan Cohen, and Lawrence Haspel; and the keynote speaker, Edward O'Neil.

Logistical planning and support for the conference was skillfully managed by members of the Foundation's staff -- Victoria del Corral, Joan Finger, and Rina Fortini -- and the transcripts of the proceedings of the conference were edited by Coimbra Sirica.


Chairman’s Introduction

D. Kay Clawson, M.D.

Osteopathic medicine originated with the teachings of Andrew Still (1828-1917). Dr. Still, a doctor of medicine, had been trained as an allopathic physician, but he came to believe that the treatment of deformity and disease of the day was inadequate, and devised a number of new methods of treatment, which largely relied upon manipulative treatment.

Initially, he trained his fellow M.D.s in his methods, but by the 1890s, him and his followers had begun to establish schools of osteopathic medicine, and these taught graduates that osteopathic medicine was as much a separate social movement as it was a method for treating illness. Although osteopathic medicine eventually adapted itself to scientific progress, a schism developed between the traditional allopathic practitioners and the new osteopathic physicians.

Yielding to the opposition of the allopathic profession, many states were slow to license the new practitioners. Despite significant economic and legal barriers, however, the osteopathic profession persevered, and its members can now obtain licensing in every state. They also share equal status with M.D.s in the U.S. armed forces and in other federal and state programs.

For more than 100 years, osteopathic medicine has played a major role in the practice of primary care and in the service of the residents of rural America. In recent decades, the profession has developed its own residency training programs in all of the general fields of medicine, as well as in manipulative (manual) medicine.

Despite this history of success on the part of osteopathic medicine, major misunderstandings and misconceptions have characterized the relationship between the allopathic and osteopathic professions. And the public has remained confused about the differences between osteopathic manipulative therapy and chiropractic treatment.

In an effort to provide information about osteopathic medicine, the Josiah Macy, Jr. Foundation convened a meeting that brought together representatives of both professions to critique papers commissioned for this monograph on osteopathic medicine.

The discussions seemed surprisingly fruitful when they revealed details about each profession’s efforts in such areas as admissions, holism, preventive medicine, and graduate medical education, and they provided the participants with a new context within which to view colleagues in the other profession.

This monograph, which reports on the results of the meeting, is made up of three commissioned papers, the discussions that followed the presentations of the papers, and an extensive database about osteopathic physicians. The meeting itself generated an interest among leaders of both professions to continue discussions to seek opportunities for cooperation and collaboration.


Keynote Address

Edward O’Neil, Ph.D.

To fully explore the topic of osteopathic medicine's relationship to other professions demands that we understand these relationships within the context of the health care environment now and in the future. It goes without saying that these are tremendously dynamic times for the health care system and for health care professionals. The American health care system is experiencing the most fundamental transformation in our history. What was recently conceived of as reform, brought about by a set of policy changes, is now being driven head long into a transformation, fueled by the enormous power of the trillion-dollar health care market. In five brief years, the legal, financial, and organizational framework of much of health care in the United States has been transformed into systems of integrated care that combine primary, specialty and hospital care. These emerging systems attempt to manage the care delivered to the enrolled populations in such a manner as to achieve some combination of cost reduction, enhanced satisfaction of the patient as a consumer, and improvement of the quality of health care outcomes. Within another decade, integrated care systems will provide health care to 80-90 percent of the insured population of the U.S. To speculate about a profession's future outside of this context is to waste time.

Osteopathic medicine arrives at this critical juncture in health care with two important, distinctive, though perhaps flawed traditions as a health profession. The first tradition, osteopathic medicine's commitment to holism, has marked the rhetoric of the practice of this profession since it’s beginning. Clearly this is an imprecise concept, but let us use a working definition that holism is anything that ties outside of the biomedical framework of disease-focused medicine. Over the past decade the public's acceptance and demand for such holistic approaches in the prevention, diagnosis and treatment of disease has grown considerably. This has been coupled with the mainstream scientific community's acceptance of these modalities as legitimate subjects of research and, increasingly, the conclusion that many of these offer effective intervention strategies to maintain or restore health. The question that must be asked of osteopathic medicine is whether it has participated and does it continue to participate in this broadening of the scientific basis of health, as the health care system moves away from the reductionist biomedical model that has dominated this century. Or, does osteopathic medicine remain essentially a discipline of allopathic medicine, with only a modest distinction borne out of its sometimes anemic commitment to manipulative therapy?

This debate is a familiar one to osteopathic professionals. It might be characterized as the conflict between the "distinctiveness" camp and the "inclusionist" lobby. From outside the profession it seems clear that for osteopathic medicine, most of the twentieth century has been one continuous movement toward allopathic medicine, and toward the loss of those elements that distinguished it at its inception. The most shocking evidence of this is the reality that today two-thirds of the newly trained osteopaths seek graduate medical training in allopathic residency programs. In a study of osteopathic students, less than half thought there was anything that distinguished osteopathic medicine from allopathic medicine, and less than 20 percent reported a systematic exposure to a philosophy, a set of values, or a pattern of clinical practice that would distinguish the two branches of medicine. There is also little evidence that osteopathic medicine has contributed much to the movement to broaden medicine to include the richer frontiers of the new holistic medicine. This movement is more attended to by allopathic practitioners, or, in greater number, by those individuals entirely outside of medicine. Beyond the use of manipulative therapies, osteopathic medicine's initial and essentially nineteenth century counterpoint to allopathic medicine, the profession retains few vestiges of holism.

Though related to this shadow of holism, the second tradition of the profession is distinct. It is the profession's commitment to primary care and, in particular, to rural practice. Over the past decade there has been a renaissance of primary care. Both governmental and market based insurers of care recognize it as a way to reduce cost and improve the quality of care. The public, which once seemed jaded at the prospect of receiving care from a mere generalist, has begun to express value for the practitioner who offers life-long continuity of care that is comprehensive in its nature and humanistic in its orientation. The career choices and practice patterns of osteopathic physicians have long anticipated such a change. As other papers prepared for this symposium have demonstrated, the practice patterns of the osteopathic physicians have been significantly different from that of the allopathic physicians in this regard. But, these papers have also noted a significant change in the pattern of practice, and little evidence that primary care is a conscious and deliberate emphasis of the profession.

The question that must be asked here regards the nature of the commitment to primary care by osteopathic medicine. Is it a fundamental orientation of the profession, or did the profession develop that orientation by default because of its history? Could osteopathic medicine have focused on primary care only because it had been excluded politically and economically from the mainstream expansion of the health care system that began in the 1950's? Did osteopathic medicine stay in primary care in rural areas because of a conscious set of values, or were its practitioners unwilling, unable, or not permitted to compete with allopathic physicians in the big city hospitals outside the Midwest?

The historical answer to these questions of past motivation and current reality is likely to be equivocal, with the truth lying a bit on both sides. The reason for framing the questions is more than merely rhetorical, however. It is in answering these questions that the profession of osteopathic medicine can advance and demonstrate what role it will play in the emerging system of health care in the United States.

At no time in this century has the health care system in America been better positioned to value the best of what osteopathic medicine has to offer. The traditions of holism and primary care must be articulated and lived in away that captures this opportunity. To be successful, the holism of osteopathic medicine must be broadened to include the full richness of the bio-psycho-social model of health and sickness. This model must be applied, not with blind faith, but with an empirical commitment to producing the evidence base that will demonstrate the model's efficacy to even the staunchest disbelievers in the new market-oriented health systems.

Primary care must grow away from its image as a non-specialty, to become a strong and dominant force in the delivery of health care, one that values and advocates for the whole individual and works to elegantly integrate the resources of a rich and diverse health care system. To do this will take osteopathic medicine to the next level of achievement as a health profession. To believe that all will come to osteopathic medicine because of its historical commitment to holism and primary care, may be to believe in something that will never be and, perhaps, never was.


Session I: The History of Osteopathic Medicine

Norman Gevitz, Ph.D.

In trying to understand the nature and history of osteopathic medicine, it is vitally important to recognize that it has a dual identity, that at the same time it is both a social movement and a profession. By a social movement, I mean an ongoing group effort to achieve certain goals based on a distinctive and shared belief system. By profession, I mean the effort to carve out and sustain a field of occupational endeavor, which is characterized by its own schools, associations, practice facilities, literature, and licensure provisions.

While some social movements arise from within a given profession, and either succeed or fail in their reforms within the existing social structure, other movements, such osteopathy, offer a more radical perspective and challenge to the status quo. As a consequence, movement supporters and the defenders of orthodoxy want nothing to do with each other, and the insurgents seek their own separate way. In turn, the defenders of the existing order work to exclude and eliminate the challengers. For most of osteopathic history these processes of avoidance and exclusion have accurately described relations between osteopathic and allopathic medicine. In recent decades, however, significant changes in the policies and practices of both professions have raised important questions about the future of osteopathic medicine as a social movement, and its continued viability as an independent profession.

In my efforts here to convey the more-than-one-hundred-year history of osteopathic medicine, I will organize the material by focusing on the six major challenges the profession has faced over time, each of which roughly corresponds to a different generation of osteopathic practitioners. I will briefly examine the struggles of the first five generations of D.O.s, then examine what I would argue is the principal issue facing osteopathic medicine today -- the challenge of distinctiveness -- and conclude with a discussion of what I believe D.O.s must do to address this challenge if they wish to survive and prosper.



The first generation struggled with what can be called the "challenge of innovation." By innovation, I mean the development of the basic philosophical underpinnings and practical applications of a new system of healing. One hundred and thirty years ago, Andrew Taylor still (1828-1917) looked on helplessly as fellow Kansas doctors tried in vain to save the lives of three of his children, who had been stricken with spinal meningitis, Still, an orthodox physician who had been trained through the apprenticeship system of the day, came to the conclusion that contemporary orthodox medical treatment was but a series of experiments, sometimes harmful, many times simply ineffective. He sought a different approach to understanding disease, which would allow for an alternative treatment regimen to the common depletive remedies of venesection and calomel. "Like Columbus," he declared, "I trimmed my sail and launched my craft as an explorer."

The route he took was tortuous. He tried the existing drug-based systems of homeopathy, founded by the German physician Samuel Hahnemann (1755-1843), and eclecticism, fashioned by. New York physician Wooster Beach (1794-1868). While he shared their critique of orthodox medical practices, he found their approaches just as wanting. The central issue in medicine, he would maintain, was not which drug to use and in what dosage, but whether drugging itself was an appropriate form of therapy. Still ultimately reasoned that the body itself was an efficient chemical laboratory that, in health, made all the drugs it naturally needed. Thus, in sickness, the answer would not be found in more drugs. The solution was to find out what caused the disturbance and remove the interference so the body could return to its normal state of health.

Still's philosophical beliefs led him to investigate drugless substitutes -- including magnetic healing and bone setting. His experience with each demonstrated that many patients with a variety of unrelated chronic diseases that had not been relieved by orthodox ministrations, were receiving considerable benefits from his manual manipulations, which he based on these unorthodox practices. Eventually, Still fused aspects of these two alternative traditions with his ideas to form a unique and coherent belief system. Like the magnetic healers, Still would argue that the effects of disease were due to the obstruction or imbalances of the fluids, principally the blood, in his view. But he believed that these physiological changes were caused by misaligned bones, particularly of the spinal column. By the late 1880s, after several years of success demonstrating his new approach, he called his system "osteopathy." And in 1892, he established a school in Kirksville, MO, to train others in his philosophy, as well as in his methods of diagnosis and therapy.

Into Still's theoretical base, more formally educated followers, most notably his first faculty, incorporated the knowledge generated by other, more orthodox manipulative traditions, such as Swedish movements and massage, and squared osteopathic teachings with the germ theory of disease. Despite Still's declaration that "I believe but very little of the germ theory and care much less," his first faculty accepted the existence and etiological role of microorganisms in several diseases. They argued that while bacteriology seemed to undermine part of Still's original theory, immunology clearly supported him. A germ, they hypothesized, might be the active cause of a disease, but spinal displacements, or what were now being called spinal "lesions" could be predisposing causes. If, as they believed, these structural lesions produced derangement of physiological functions, it would follow that in their presence the body would be put automatically into a state of lowered resistance. Thus correcting lesions shortly after they occurred would lessen the likelihood of germs gaining a foothold in the body. By correcting lesions after infection had struck, the body's natural defenses could then more effectively respond to the invaders. Though Still often argued with his faculty that they thought too medically, he let them prevail. As a result, osteopathy, in the future, was characterized by its efforts to accommodate itself to scientific progress by interpreting new findings for its own ends -- and not by fighting these discoveries.



As a social movement, osteopathy was off to a successful beginning. Patients swarmed into Kirksville from across the Midwest, and by 1898, more than seven hundred students were enrolled in Still's school. However, whether osteopathy would become institutionalized depended upon how well it was accepted elsewhere. The profession's success would be measured in terms of its practitioners' ability to establish private practices, create other schools, forge state and national associations, and obtain legal standing. The early graduates faced a continuing struggle to overcome prospective patients' unfamiliarity with the system. Efforts by D.O.s to promote themselves through sensational advertising sometimes led them to "bad mouth" their allopathic competitors. This naturally drew the active opposition of regular medical practitioners, who sought to bar D.O.s from practice, or even to have them jailed, In a number of states, osteopathic practitioners won court rulings in support of their claims that their manipulative techniques did not constitute the practice of medicine since they dispensed no drugs. In these same states and elsewhere, D.O.s often succeeded in obtaining laws that legitimized their practices while setting minimum educational standards governing applicants for licensure. By 1913, of the 39 states that had passed osteopathic practice laws, 17 had provided for independent licensure boards, Ten years later, these figures rose to 46 and 27, respectively.

Not surprisingly, as osteopathy's reputation grew among the general public, some of Still's early graduates established their own schools. Though a number of the schools were of short duration, by the time of the Flexner Report, schools were operating in Chicago, Kansas City, Philadelphia, Des Moines, Los Angeles, and Boston as well as the parent institution in Kirksville. In 1904, of the estimated 4,000 D.O.s in practice, approximately one-half were graduates of these other schools.

The rapid proliferation of schools and practitioners was accompanied by the development of associations to represent their members and respond to the issues each constituency faced. The American Osteopathic Association (AOA) was fashioned in 1901 out of a group of practitioners who had begun to meet four years earlier, and the Associated Colleges of Osteopathy was established in 1898. Both these organizations worked to standardize the curriculum, to secure uniform licensure, to fight imitators -- most notably the chiropractors -- and to maintain cooperative relations among competing practitioners. While often characterized by internal disarray over policies and goals, and facing the active opposition of regular medicine in the courts, legislatures, and in the media, the two organizations promoted solidarity and cohesion among D.O.s, and their various efforts led to the institutionalization of the movement. Thus, osteopathy, much to the surprise of its early and vociferous detractors, would not prove to be a transitory fad or fashion, but an ongoing phenomenon.



The third generation tackled the question of whether D.O.s should be "limited" or "complete" health care providers. A few years after Still established his school in Kirksville, he announced that he wished his graduates to be general practitioners, caring for patients with a wide variety of medical complaints, and able to perform common surgical procedures and deliver babies. He also sanctioned the use of three classes of drugs -- anesthetics, antidotes, and antiseptics -- which he believed had proven their worth. He enlarged his curriculum, in part to meet legislative demands, and offered a wide array of basic science courses -- excluding pharmacology. Still also increased the length of his curriculum from several months instruction to two years, and other schools quickly followed suit.

A growing number of Still's followers, however, believed that osteopathic schools should integrate into the curriculum more of the existing materia medica, including vaccines and serums, endocrines, colchicine, and digitalis, as well as drugless modalities such as suggestive therapeutics, electrotherapy, and hydrotherapy. They also maintained that osteopathic practitioners should decide for themselves what diagnostic and therapeutic tools were appropriate, and have the legal and professional freedom to use these modalities.

Still was unimpressed with the much heralded changes in medical therapy. He argued that the chemical and biological tools employed by orthodox M.D.s were often toxic to the body. Furthermore, even if they temporarily relieved symptoms, the regulars, in employing these modalities, were ignoring the structural basis of disease. In all cases, wherever M.D.s said they could cure a disease through drugs, Still maintained that osteopathy, through its manual methods, could also do so -- and more safely. Medicine and osteopathy, argued Still, were theoretically opposed to one another. Like oil and water, they could not be mixed. Those D.O.s who called themselves "broad osteopaths" disagreed, arguing that if a drug had practical therapeutic benefits it should be integrated into osteopathic methods, independent of theoretical considerations. Thus, why not combine colchicine with manipulation of the foot to treat gout, or employ digitalis and manipulation of the spine in cases of dropsy.

By 1915, the self-proclaimed "lesionists," who favored a restricted materia medica, seemed to be losing the battle. But osteopathic fundamentalism reasserted itself during the great pandemic of 1918 and 1919, when D.O. practitioners found considerable success in manipulatively treating patients who had contracted the so-called "Swine flu," with its common sequela of pneumonia. Word-of-mouth publicity attracted clients who presented themselves to D.O.s, not only for the relief of chronic illnesses, but for acute illnesses, and these patients encouraged others to do the same. Nevertheless, while distinctive osteopathic methods reasserted their preeminence in the D.O.s’ armamentarium, the D.O.s' desire to be recognized as full-fledged physicians and surgeons gained more support each passing year. By 1929, the AOA gave its permission for the schools to integrate a complete course in materia medica and pharmacology into their curricula. D.O.s across the country now lobbied intensely for the same unlimited scope of licensure granted M.D.s. To become a profession, a group Must free itself from the charismatic leadership and dominance of one individual, and slowly but assuredly, osteopathic physicians were coming out from under the imposing shadow of Andrew Taylor Still.



The fourth generation of osteopathic practitioners faced the challenge of bringing the educational standards of their profession to a level of equivalency with their allopathic counterparts. After Abraham Flexner's scathing indictment of both medical and, osteopathic schools in his Carnegie Foundation Report of 1910, efforts to upgrade allopathic education were accelerated in the subsequent twenty five years, the number of M.D.--granting schools dropped precipitously, Only a handful of schools that had not been approved by The American Medical Association (AMA) continued to exist. The great majority of allopathic schools became integral parts of universities, and they benefited either directly or indirectly from state support or philanthropy. A massive program to upgrade existing medical school facilities and provide needed equipment was undertaken throughout the country. All approved M.D. schools raised their pre-professional requirement to at least two years of college, and all had their students spend a significant amount of time working in the laboratories, in the clinics, and at the bedside. Reasonable standards were established for internship and residency training, with the Postgraduate Year I becoming all but obligatory for practice, and the residency becoming an increasingly popular prospect for each new class of graduates. In the space of a quarter of a century, American medical education, once considered an embarrassment, was now generally regarded as second to none in the world, in terms of overall quality.

After the publication of the Flexner report, osteopathic schools, unlike the homeopathic, eclectic, and physio-medical schools, did not generally close their doors. While these other institutions had produced M.D.s, and would thus have been required to meet AMA standards or their equivalent, osteopathic colleges remained accredited by the American Osteopathic Association. The AOA believed that educational reform was important, but that it had to occur at a pace that could be met without jeopardizing the existence of its training institutions. Furthermore, unlike M.D. schools, osteopathic colleges remained unaffiliated with universities, and received no appreciable state support and very little outside philanthropy. Some improvements in the infrastructure of osteopathic schools were made in the quarter-century after Flexner's report, but by the mid 1930s, most D.O. schools required only a high school diploma to enter, and had limited laboratory facilities. Didactic lectures took up a good portion of the clinical curriculum, internships in the small number of osteopathic hospitals were not numerous, and the few residencies available were unstandardized.

The low educational requirements maintained by osteopathic schools did not go unnoticed by the AMA and others. D.O. efforts to secure changes in state laws to allow them to practice as "physicians and surgeons" were often blocked in the legislatures; M.D.s argued that it was not good public policy to allow two widely different standards to exist for those who wished to practice medicine. Even when D.O.s succeeded in obtaining changes in the law, particularly in "independent board states," they faced an additional basic science exam, which was administered by a state agency to D.O.s, M.D.s, and chiropractors. Only then could the D.O.s take their own licensure test. Although they did considerably better than the chiropractors, many D.O.s, unlike the M.D. candidates, found themselves unable to pass. Similar problems existed for D.O.s on "composite" and "M.D." licensure boards. With D.O.s having increasing difficulty getting licensed as physicians and surgeons, and with M.D.s calling for independent investigations into the quality of D.O. schools, reformers within the osteopathic profession committed themselves to a more rapid pace of change in their undergraduate and graduate programs.

In the second quarter of a century that followed the Flexner Report, from 1936 to 1960, osteopathic medicine, which had neither the benefit of university affiliation, nor significant state or external philanthropic support, turned to D.O.s in the field to underwrite the construction of new laboratories and the hiring of additional and more qualified basic science faculty. Clinical opportunities expanded as well. D.O.s who had been denied entry into the armed forces medical corps during World War 11, now ironically found themselves taking care of many of the patients of drafted M.D.s. Because osteopathic practitioners were excluded from allopathic hospitals, old and new patients joined with D.O.s to build many more osteopathic hospitals, which greatly increased both the number of clinical clerkships and internships. Minimum standards for internships and residencies were established, and on the undergraduate level, demand for places in the D.O. schools rope after the war, which eventually led the schools to adopt three years of college as a prerequisite for matriculation. Once lagging far behind M.D. candidates in passing both basic science board and medical licensure tests, D.O.s dramatically reduced the gap by 1960. There were, to be sure, several areas in osteopathic education that needed continued improvement, but there was little doubt that osteopathic education was now resting on a firmer base. D.O.s had taken another step forward.



In their efforts to duplicate the M.D.s' unlimited scope of practice, and to gain equivalency with respect to the minimum standards governing undergraduate and graduate education, the radical ideology that characterized early osteopathy had progressively weakened. Many of the allopathic drugging and surgical practices that D.O.s had condemned or questioned, had been either abandoned, modified, or won favor in the osteopathic community, and the new modalities proved irresistible. In 1935, came the introduction of the first of the synthetically produced sulfonamides, useful against the hemolytic streptococci and staphylococci. Penicillin, effective against the range of gram positive bacteria first became available in the 1940s, and was quickly followed by streptomycin, aureomycin, chloramphenicol, and tetracycline. These antibiotics provided physicians with a powerful arsenal of antibiotics for fighting disease. In addition, a wide range of analgesics, anti- inflammatory agents, muscle relaxants, tranquilizers, and other drugs, were introduced prior to 1960. Finally, new surgical procedures and other interventions had demonstrated their value for both prolonging life and minimizing or eliminating disabilities.

From the 1930's onward, changes in the osteopathic curriculum, were designed primarily to improve students' prospects of passing externally administered basic science and licensure exams. Distinctive osteopathic methods were given less time and emphasis as students became exposed to pharmacology, internal medicine, obstetrics and gynecology, and surgery, and to the controlled, scientific studies that proved the value of drug, surgical, and other interventions. Although important basic research done under osteopathic auspices had demonstrated scientifically the existence of, and provided an understanding for the so-called osteopathic lesion (now called somatic dysfunction), no comparable controlled clinical trials were undertaken in this period. This meant that the relative utility of osteopathic manipulative medicine was based on largely anecdotal case histories or "years of experience."

As osteopathic and allopathic standards and practices grew closer, some D.O.s questioned whether they should maintain their separateness given their lesser status in the mind of most of the American public. Correspondingly, many M.D.s no longer thought of D.O.s as "cultists," but as less qualified physicians. Consequently, some D.O.s and M.D.s came to the view that amalgamation of the two professionals would be desirable. Nowhere was this sentiment stronger than in California. In the early 1960s, an agreement was reached between the California Osteopathic Association and California Medical Association. With the blessing of the AMA, some 2000 of the state's 2300 D.O.s, agreed to accept a new M.D. degree, good for purposes of licensure in California. The College of Osteopathic Physicians and Surgeons was transformed into an accredited medical school which became affiliated with the University of California at Irvine, and the state's many osteopathic hospitals became allopathic institutions. Finally, licensure of new D.O.s in the state was prohibited through a ballot initiative passed in 1962.

With one of its six colleges and one-fifth of the profession now lost, many observers thought that osteopathic medicine would soon expire. This belief gained greater currency later in the decade, when the AMA opened its membership to D.O.s, paving the way for them to enter allopathic postdoctoral programs, and working to allow those D.O.s in allopathic residencies to be eligible for board certification. The AMA also made overtures to other osteopathic schools to convert.

To the consternation of many leaders of the AMA, and to the surprise of others, osteopathic medicine not only successfully resisted further state mergers, conversion of its colleges, and raids on its student body, but organizationally and academically grew stronger in certain key areas in the two decades following the California merger. For many ex-D.O.s in the "Golden State," not all had worked out as they had hoped. The credentials of ex-D.O. specialists were not accepted for appointment to traditional allopathic hospital staffs; a significant minority of ex-D.O.s were not fully welcomed or integrated into the regular organizational structure of the California Medical Association; and many ex-D.O.s who had served on the faculty of the former osteopathic school soon found themselves out of administrative roles, or no longer asked to teach. Finally, although their new M.D. degree appeared to be readily accepted by their patients in California, no other state medical board was willing to examine or license ex-D.O.s on the basis of their "honorary" diplomas. As a consequence, many undecided D.O.s elsewhere in the country, who had adopted a wait- and-see attitude with respect to the desirability of merger, decided they would prefer to remain D.O.s.

Other D.O.s, who were strongly opposed to the California amalgamation efforts from the beginning launched an aggressive campaign to take advantage of these events to solidify the osteopathic profession. As the M.D.s began to remove the barriers that had prevented D.O.s from joining their ranks, osteopathic state societies renewed their campaign to achieve unlimited licensure in the remaining states -- a feat ultimately accomplished in 1974. The federal government, bowing to AOA pressure, agreed to admit D.O.s into the armed services medical corps and the Public Health Service, and made osteopathic schools eligible for the same capitation and other grant programs available to allopathic medical schools.

Osteopathic schools, which had historically produced generalist physicians who served in rural and other underserved areas, became desirable to state planners; with generous start-up and capitation funds now available, there was an explosion in osteopathic undergraduate education. In 1968 there were but 5 schools. In 1981 there were 15 -- including, for the first time, university-affiliated colleges. There was also a corresponding tripling in the number of graduates during those years. Although this increase was to eventually produce serious negative consequences for the profession on the postdoctoral level, osteopathic leaders believed they had won the battle to remain a separate and independent profession -- at least in the short run.



In the last two decades, osteopathic medicine has had to face significant and difficult structural and ideological issues. Though on the surface these problems seem unrelated, they are tied together in a most fundamental way. The current challenge for osteopathic medicine is that of distinctiveness -- the need for this profession to carve out an independent identity based on a distinct philosophy that should be reflected in the content of what is taught, the practice of its clinicians, and in the environment of its institutions.

Though the number of osteopathic schools and graduates multiplied quickly in the 1970s, the number of osteopathic training hospitals during the same period declined slightly. The number of internship and residency positions in existing facilities increased through the mid-1980s, but there was growing anxiety with each new senior class that there would not be a quality internship position available for them. This problem was greatly exacerbated by the closure of several osteopathic hospitals later in the 1980s, which led a greater percentage of osteopathic graduates to choose non- AOA approved internships in allopathic hospitals.

The closure of these osteopathic hospitals can be attributed to a number of well-documented factors affecting both allopathic and osteopathic institutions, Greater third-party oversight has led to tests and procedures being done out-of-hospital, sharply reducing the overall need for hospitalization. A patient's average length of stay has been dramatically reduced through insurance company authorizations, peer review, and, DRGs. With an over-bedding problem in many localities, those institutions that were smaller, were undercapitalized, had older plants, and were located in areas with large numbers of uninsured or inadequately insured people were less likely to remain economically solvent, and, consequently, were more likely to close their doors.

Nevertheless, the demise of osteopathic hospitals must also be attributed to the diminution of osteopathic medicine as a social movement. Since the 1960s, a greater number of allopathic hospitals have been granting admitting privileges to D.O.s, thus diminishing the referral base for neighboring osteopathic facilities. The principal reason for maintaining osteopathic hospitals is to allow D.O.s to practice medicine and surgery according to distinctive osteopathic principles. However, osteopathic distinctiveness in osteopathic hospitals has declined to a point that it makes little or no difference to D.O.s in their decisions to affiliate with a given hospital. In the D.O.s’ efforts through the decades to obtain the same scope of practice as M.D.s and raise the standards of the profession, the distinctive aspects of osteopathic medicine have moved from the center of the movement to the periphery. Obviously, if more osteopathic physicians had been educated to see both the necessity and desirability of affiliating with and supporting distinctiveness in osteopathic hospitals, the osteopathic profession would have been in a stronger position to face the more general challenges posed by changes in health care financing.

In order for osteopathic medicine to have an independent future, its practitioners need to consider how to weave the profession's philosophy into the fabric of its institutions. It would appear that the profession has to focus its energies on demonstrating that the structure, content, and product of the osteopathic educational system is sufficiently distinctive from its allopathic counterpart. Given the equal legal status D.O.s have achieved with respect to M.D.s, it 'is increasingly necessary for D.O.s to make clear to health care planners, to the public, and to themselves, the fundamental reasons why there should be two types of physicians, two types of medical schools, two types of postgraduate programs, two types of hospitals, two types of licensure agencies, two types of national board exams, and two types of medical degrees. If osteopathic physicians cannot demonstrate that they are distinctive in terms of their philosophy, in the content of what they teach, or in their practice, then they will have no compelling reason to continue as members of an independent profession.

It is all too obvious that the distinctive philosophical and practical aspects of osteopathic medicine are no longer at the core of their undergraduate or graduate curricula. As a consequence of the D.O.s' drive to achieve parity and equality with M.D. institutions, the osteopathic elements that were irrelevant to these goals were left to wither, and quite naturally diminished in importance in the curriculum. Eventually those osteopathic elements came to represent just another content area. As such, osteopathic principles and practice were separated from other basic science and clinical courses, and were viewed by an increasing number of D.O.s as something vestigial and unnecessary.

The osteopathic profession survived the California merger. But a number of the educational trends that had characterized the California osteopathic school in the decades prior to amalgamation, are still extant in osteopathic medical education and have not been satisfactorily addressed. In most osteopathic colleges, osteopathic principles and practice have been relegated to the first two years of the curriculum. What knowledge and skills students obtain are then allowed to diminish in a clinical environment that does not encourage the use of these distinctive elements of osteopathic medical practice.

As a consequence, it is hardly surprising that a significant number of -- the current generation of osteopathic students view as quite narrow the philosophical and practice differences between osteopathic and allopathic educational programs. When it comes time for them to choose postdoctoral educational opportunities, a fair number of D.O.s will seek out the programs that they believe will fulfill their desires to be the best physicians they can be, irrespective of whether the programs are osteopathic or allopathic. In other words, many osteopathic students will base their choice of a given postdoctoral program on its "perceived" overall quality, and not on the distinctiveness and putative importance of the osteopathic approach. Osteopathic leaders cannot blame the students who pursue an allopathic route to graduate training and certification if the osteopathic schools cannot demonstrate to these students that there is a significant degree of distinctiveness to osteopathic education, and that this distinctiveness is a positive attribute that will make the students the better physicians they seek to be. Similarly, osteopathic leaders cannot fault these students if osteopathic postdoctoral educational programs offer little if anything that is distinctly osteopathic in philosophy and content to give candidates a reason to choose an osteopathic program over a competing allopathic residency.

Many osteopathic leaders have become distracted and paralyzed by other significant but less compelling issues with respect to the future of their profession. For example, a number of D.O.s have rightly identified and stressed the importance of changes or forces coming from outside osteopathic medicine. There is little doubt that the osteopathic profession must be concerned about the larger environment and be ready to respond. But to effectively respond to forces from without, D.O.s need first to be solid at the core -- to know who they are and their reason for being.

As a symptom of their efforts to cope with the uncertainty brought about by the now fading specter of comprehensive health care reform, D.O. leaders have shown great interest in producing even greater numbers of osteopathic primary care physicians. Primary care is an area that the profession has long emphasized, and there is no question that D.O.s have done more to advance the "political" fortunes of their profession by producing a higher percentage of primary care physicians for underserved areas than have their allopathic counterparts. By continuing to focus on primary, D.O.s can potentially exert a tremendous amount of leverage on state legislators and the federal government with respect to generating both economic and political support for the continued independence of their profession. 

Thus, one can understand the fears of some osteopathic leaders when faced with the increasing number of graduating D.O.s who

are opting for non-primary care specialties. This does call for a degree of concern, but it is questionable whether this slight-to- moderate turn downward should take precedence over the core problem of osteopathic distinctiveness. Consider the recent data published in the May 1994 issue of the journal, D.O., on 1987 D.O. graduates. This article indicates that 65 percent of this cohort are practicing in primary care specialties. Furthermore, when the AOA data were collated with AAMC figures, the II medical schools in the nation that produced the highest percentage of graduates entering primary care were all osteopathic schools, and the other four osteopathic colleges were among the next ten best. Osteopathic leaders must ask themselves to what extent their performance in producing primary care physicians is a problem.

Osteopathic leaders need to consider what long-term good can serve as the "political" justification for their profession's continued independence, if those very same primary care D.O.s they wish to produce in such large numbers see no compelling philosophical reason for maintaining that political independence. A "primary care" emphasis does not alone signify a commitment to the maintenance of a "parallel profession" of medicine. There must be a distinctive philosophy and practice at the foundation of osteopathic primary care if political independence is to continue to have meaning to osteopathic practitioners.


Session II: Contemporary Philosophy and Practice of Osteopathic Medicine

Raymond J. Hruby, D.O.

"Our greatest danger is that our success will give birth to complacency -- and only complacency can do us in. The future of osteopathic medicine is not in the hands of those who oppose us, but rather in the bands of those who believe in it the most.

- George W. Northup, D.O.


Osteopathic medicine as we know it began with Andrew Taylor Still, M.D. (1828 - 1917), who introduced-its concepts in 1874. Still's basic idea -- that the human body was much like a machine, one that would function well if all its parts were in the proper mechanical relationship with each other, was unique compared to the medical thinking of the time.

Doctor Still gradually formulated the ideas that would become known as Osteopathy. He believed that the human body should be studied as a whole, that all elements of a person's body, mind and spirit had to be incorporated into the total care of that person. He believed that the body had self-regulatory and self-healing powers, that the body contained within it the elements necessary for maintaining health. Still believed that when the body was property treated, these elements would also assist in the recovery from illness. His view of the body as a machine led to the belief that disease is the result of alterations in the structural relationships of the body parts, which result in an inability of the body to resist or recover from illness.

Although Still applied this philosophy to his medical practice with great success, while continuing to prudently utilize the medical and surgical approaches of the time, he  was unable to convince the established medical community of the soundness of his ideas. Because of Still's rejection by the medical establishment, and the overwhelming public demand for his services, he established in 1892 the first college of osteopathic medicine, the American School of Osteopathy, in Kirksville, Missouri. The course of study at the first osteopathic school was based on a set of principles that remain relevant to contemporary osteopathic medicine. This paper describes how these principles, along with the changing nature of healthcare, have shaped tile practice of osteopathic medicine over time. Osteopathic principles are restated in order to reflect their application to today's health care system.



1. The Unity of the Body.

The first of the major principles of osteopathic medicine is that the human body is a unit, an integrated organism in which no part functions independently. This regulation, coordination and integration of the body through multiple biological systems is often referred to as the principle of body unity. According to this principle, abnormalities in the structure or function of one part of the body may unfavorably influence other parts, and, eventually, the body as a whole. Thus the body is viewed as an interrelated group of organ systems, each one dependent on the others, and each one working with the others to meet the demands of the internal and external environments of the body.                             I

Doctor Still believed that diseases affecting the viscera of the body would also affect the musculo-skeletal system. Similarly, abnormalities in the structure or function of the musculo-skeletal system could also adversely affect the viscera. Until Still's times treatment of disease was focused on individual organs or organ systems. This disease model continues to be the basis of modern medical practice. Consideration was not given to the interrelation of the various systems of the body; rather, the focus was on the disease itself.

2. Self-regulatory and Self-healing Systems.

The second major principle of osteopathic medicine is that the body has an inherent capacity to maintain its own health and to heal itself. By extension, this principle implies that there must be adequate circulation to and from all tissues of the body, and there must be proper nervous system function in order to coordinate the actions of all of the body's organs and systems.

Still believed that the body contained within itself all that it needed to be healthy, or, if ill, all that it needed to overcome the illness and return to a healthy state. The role of the osteopathic physician was to help the body utilize its own self-healing mechanisms to overcome disease and maintain health. Still's concept of self- regulation and self-healing has been called the vis medicatrix naturae, or "the healing power of nature."

3. The Relationship Between Structure and Function.

The third osteopathic principle is that structure and function are interrelated, that the musculo-skeletal system can reflect and produce changes in other body systems. Doctor Still placed great importance on the role of the musculo-skeletal system in health and disease. The interrelationship between structure and function is one of the most unique aspects of osteopathic medicine.

As mentioned earlier, Still favored a mechanistic approach to health care. He saw that the musculo-skeletal system (bones, muscles, ligaments and connective tissues) was the largest collective system of the body, making up 60 percent or more of the body's mass. Through careful study and experimentation, he was able to associate abnormalities in the structural system of the body with signs and symptoms of various diseases. He developed manipulative methods (now known as osteopathic manipulative treatment) to remove these structural abnormalities to alleviate the patient's illness. These experiences led Still to believe that diseases, as we commonly think of them, were really the result in part of bodily malfunctions, not the cause of them. Often that bodily malfunction was an abnormality in the musculo-skeletal system, which decreased the ability of the nervous and/or circulatory systems to function properly. This, in turn, led to a lowering of the body's resistance, and eventually to what we diagnose as illness.

4. Rational Treatment Approach.

The fourth principle of osteopathic medicine simply states that rational treatment is based upon integration of the first three principles into the total care of the patient. Thus treatment is based on the principles of body unity, self-regulatory and self-healing mechanisms, the somatic component of disease, the interrelationship between structure and function, and the appropriate use of manipulative treatment.

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More than 100 years ago, osteopathic medicine arose in the belief that the neuro-musculo-skeletal system played a more significant role in the maintenance of health and the diagnosis and treatment of illness than was conventionally recognized. Today, osteopathic medicine is the only health profession in the United States whose colleges teach students this approach to the preventive, diagnostic, and therapeutic modalities that are described in their curricula. The distinctiveness of osteopathic principles is manifested in the way they are taught throughout the medical school curricula and the post-.graduate education that follows. This reinforces the rationale for and the use of palpatory diagnosis and manipulative treatment; the recognition of the self-healing capacity of the human body; the importance of prevention; and the emphasis on holistic patient care and on a close and personal relationship between the patient and the physician. This emphasis on a structural approach, as well as on the other contemporary osteopathic principles, is what most demonstrates to patients the distinctive difference between a D.O. and an M.D.

As osteopathic medicine enters its second century, and the health care system of the United States faces major changes, it is useful to clarify and restate the basic principles of osteopathic medicine. The concepts of osteopathic medicine that were established during the past century are based on certain "principles or articles of faith," described earlier in this paper. As osteopathic medicine has gained recognition as a profession, the principles that define its philosophy have evolved. The following section outlines these redefined principles in the context of today's complex health care system:

1. Osteopathic medicine is limited to the practice of rational medicine based on the medical sciences.

As a system of prevention, diagnosis, and treatment, osteopathic medicine is founded upon traditional medical values such as rational observation and deduction, the scientific method, established therapeutic modalities, and the fundamental medical sciences, such as anatomy, biochemistry, pathology, physiology, and pharmacology. The scientific basis for medicine (either osteopathic or allopathic) represents the fundamental principle on which all medical services are based.

2. Osteopathic medicine treats the individual as a whole.

Osteopathic medicine recognizes that all factors that concern health, including physiological, mental and emotional factors, must be weighed in the prevention, diagnosis, and treatment of illnesses. Every ill person presents a unique problem that will require therapies that are specifically directed to the whole person.

In spite of recent increased interest in holistic approaches to patient care, there is still a common tendency among physicians to isolate illness within a certain organ or system in the body. The osteopathic physician, however, is trained to recognize that when the body is ill, the effects are diffuse. A specific organ or system may become the prime focus of illness, but the effects of that illness can be felt to some degree throughout the entire body. In a similar fashion, when responding to an illness, the specific organ or system does not operate in isolation. The entire body, by way of the circulatory, nervous, endocrine and immune systems, is brought into action in a concerted effort to overcome the body-wide effects of the illness. Only when the whole body has returned to its normal balance has the alleviation of illness truly been achieved.

Still's concept of holism, however, went beyond the idea of the human body as a unit, and included a holism of body, mind and spirit. Osteopathy involved what he referred to as "the law of mind, matter, and motion." Today these terms are commonly referred to as body, mind and spirit. Doctor Still strongly believed that all pertinent influences on the human being had to be taken into consideration when the physician was faced with a patient needing treatment. He stated, "...after all our explorations, we have to decide that man is triune when complete." Thus, for A. T. Still, holism was more than an open-mindedness to other forms of diagnosis and treatment. Rather, it was an approach to the patient that required the physician to consider the totality of the human being when diagnosing illness or planning treatment. Osteopathic medicine emphasizes that a patient be considered as a whole person -- a member of a family living in a specific environment. It is the person, not the pathological condition that must be treated. Early on, osteopathic medicine rejected the traditional view, which has prevailed for the past 50 years, in favor of the holistic approach. This holistic model of health care has been favored for over a century by the osteopathic profession, not only because of its superiority, but because the disease model has several limitations:

a. By focusing only on treatment, the disease model does not differentiate very well between patients who remain healthy after receiving treatment, and those who must continue to return for treatment.

b. Many of the causes for which people need medical care fall out- side the disease treatment perspective. Many health care costs are for treating diseases that are related to behavioral factors not addressed by a disease model -- violence, smoking, legal and illicit drug use, and lack of fitness.

c. The disease model fails to recognize the self-healing process.

3. Osteopathic medicine recognizes the body's ability to be self-regulating and self-healing.

Osteopathic medicine has traditionally emphasized that the human body has an inherent capacity for maintaining health and recovering from illness. The role of the osteopathic practitioner is to understand, promote, and enhance this capacity to overcome disease and maintain health. Because the osteopathic profession recognized that self healing occurred, it was the first health care profession to endorse serious scientific study and the understanding of forms of treatment that work with the body's own healing mechanisms. As the evidence of self-healing grew, the osteopathic profession came to espouse a philosophy of personal responsibility for health maintenance, as well as promoting osteopathic physicians to act as health educators, as well as treatment specialists.

Doctor Still believed that the human body should be studied as a whole, that all elements of a person's body, mind and spirit had to be incorporated into the total care of that person. He believed that the body had self-regulatory and self-healing powers, that the body contained within it all the substances necessary for maintaining health. When the body was properly stimulated, Still believed that these substances would also assist in recovering from illness. He viewed the body as a machine, a machine that would function at its optimum level only when all its parts were in proper relationship to one another. Doctor Still did not see disease as an outside agent somehow inflicting itself on the body. Rather, disease was the result of alterations in the structural relationships of the body parts that led to an inability of the body to resist illness or to recover from it.

 4. Osteopathic medicine acknowledges the structure-function interrelationship.

Since the 19th century, allopathic as well as osteopathic medicine has recognized the interrelationship of structure and function. This initial principle of Dr. Still's holds true today in the importance accorded the musculo-skeletal system in both health and illness. Through careful study, osteopathic physicians have been able to associate abnormalities in the structural system of the body with signs and symptoms of various diseases.

Still noted that "disease is the result of anatomical abnormalities followed by physiologic discord." Osteopathic physicians later referred to these abnormal areas in the musculo-skeletal system as “osteopathic lesions." These are palpable areas, particularly in segmentally related areas of the paraspinal tissues that are associated with visceral diseases as well as common musculo-skeletal problems. Today, the term "somatic dysfunction" is used to describe these anatomical abnormalities. Somatic dysfunction is defined as "impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements."

Osteopathic theory and practice holds that somatic dysfunction is present with virtually every illness. The coexistence of somatic

dysfunction with visceral pathology is referred to as the "somatic component of disease." The treatment of somatic dysfunction must be included in the overall care of the patient in order to ensure the most nearly complete and least invasive approach to managing the patient's illness. Osteopathic manipulative therapy is used to deal with the somatic component or components present with any given disease process.

Based on the principle of the interrelationship between structure and function, and the use of manipulative treatment, the osteopathic physician has knowledge of a unique system of diagnosis and treatment. This approach alone can often assist patients in recovering from illness. At other times, it allows for recovery with little or no medication, and in some cases may help the patient to avoid surgery.

5. Osteopathic medicine endorses the use of manipulative treatment.

Osteopathic manipulative treatment (OMT), which focuses on the musculo-skeletal system, has been and is a distinguishing hallmark of the osteopathic profession. The distinctiveness of the osteopathic approach is manifested in the use of palpatory diagnosis and manipulative treatment, either singly or in combination with other diagnostic and therapeutic modalities for the treatment of illness. Structural diagnosis and manipulative methods are used primarily to increase mobility in restricted areas of the musculo-skeletal function and to reduce pain. Additionally, when appropriately used, osteopathic manipulative procedures can assist the patient in overcoming illness and maintaining health.

A. T. Still's recognition that the musculo-skeletal system has an important role in health and disease was a revolutionary concept. His discovery that the use of manipulative methods could assist the patient in recovering from illness, often with little or no use of drugs or surgery, is one of his most important contributions to the practice of medicine.

6. Osteopathic medicine emphasizes a close and personal relationship between physician and patient.

Because of the complex nature of a human being, and the intricate relationships among the body, the mind, and the parts of the whole, long-term familiarity with a patient's personality and habits is essential to providing high quality health care. As medical care has become more compartmentalized, the interaction between patient and physician has become compromised. Because Osteopathic medicine emphasizes a close and personal relationship between patient and physician, the Osteopathic physician is the best qualified person to supervise the health of members of the family, to treat their illnesses, and to diagnose illnesses, as well as to treat or direct patients for specific therapies. Osteopathic medicine believes that knowledge of a patient's medical history, family situation, and general and physical idiosyncrasies, are necessary to enhance the effectiveness of a physician's technical skill and the worth of mechanical/laboratory devices for the diagnosis and treatment of illness.

7. Osteopathic medicine recognizes that health care requires intelligent collaboration between the lay public and practitioners.

Effective, high quality health care does not depend upon the medical professions alone. Often, the best physicians can do little for a patient who chooses not to comply with therapy. Osteopathic medicine recognizes that the therapeutic relationship between physician and patient must incorporate the concept of collaboration between both parties as vitally important to the efficiency of the physician.

8. Osteopathic medicine relies upon a variety of medical services.

Osteopathic medicine endorses a wide variety of health care services, ranging from osteopathic manipulative treatment to various surgical therapies. The services that are provided by various health care specialists must be coordinated for effective health care.

High quality health care requires that practitioners be knowledgeable, and that proper coordination be maintained among all practitioners providing services. The osteopathic physician with a holistic perspective (with an emphasis on patient education as a part of comprehensive treatment) is the best provider to effectively coordinate health care.

9. Osteopathic medicine emphasizes prevention.

The ideas of prevention and promotion of health are fundamental and have pervaded all areas of osteopathic medicine. The purpose of treatment is to assist the body and mind to accomplish restoration of good health, to interfere with the progress of disease, and to prevent complications and postpone death 

Prevention, diagnosis, and treatment are inseparable aspects of the science and art of osteopathic medicine. They have a common purpose -- the promotion and maintenance of health, and they are based on a common body of knowledge.

10. Osteopathic medicine endorses the application of all services of modern scientific medicine that are needed to meet the needs of all people.

Judging from the viewpoint of society, the qualitative aspects of health care cannot be dissociated from the quantitative aspects. No matter how effective a practitioner is in treating an individual patient, osteopathic medicine does not fulfill its functions adequately until effective health care is within reach of all individuals. Our implicit view of the health care system is that all must have access; that the number of healthy people should be increased, and that those who are ill should be returned to good health as quickly as possible, with minimum cost.

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