Monday, August 19, 2013

DO or MD?

I wrote to an associate, who is a DO (Doctor of Osteopathic Medicine), with the following question:

"I have a young friend who is trying to choose between a DO and an MD.  Would you have advice for her?"

The reply was immediate and strongly felt.  I copy it with permission and seek your responses:

This is really a philosophical choice. I applied to both and got in first to a DO school while wait-listed at a couple MD schools. I had no higher aspirations than to practice medicine and do good for people.

The sad reality is that there is a not so subtle and in many cases flagrant prejudice against DOs. Simply put, MDs and MD institutions discriminate against DOs. Hiring practices in many states or regions discriminate against DOs. I heard of a case recently where there was a sick patient on an airplane flying domestically, not foreign, and the responding doc was a DO. When the doc said we have to go down now in the best interest of the patient the pilot refused because the doc was “just” a DO.

It sounds cruel to say it but the question is similar in many ways to asking whether you want to be white or black, or whether you want to be male or female. As a DO you will be a discriminated against minority. Overall you will make less money, you will not have access to the best paying  or most prestigious jobs, you will unlikely be able to achieve an academic appointment at a prestigious MD led institution and you will constantly be asked to explain yourself. “Just what is a DO anyway, doc?” The good thing is that you will always do good work no matter where or for whom because the education is very good and all American.

If her aspirations are simple then it really doesn’t matter. The philosophy of osteopathic medicine is very appealing and I think most human and appropriate. The education is at least as good as MD, especially in a university affiliated school. But the dark side is that the MD world will always look down on you as something less than adequate or someone significantly less than worthy or competent. If her aspirations are to function in a university setting, maybe do research, maybe aspire to lofty public health goals or something along these lines, forget DO school and go to an MD school even if it is an offshore school. Sadly, it is the letters after her name that will count, not the education. Sure there are a few token DO stars here and there, but the MDs rule and DOs are viewed as second rate, generally speaking, in the towers of medicine, especially in the ivory ones.

My advice? See if you can discern your long term goals. Then make your choice based on that discernment. We are all idealists at first. Try to see past that. It is not an easy task.

Best of luck to her.

25 comments:

Bruce Randolph Tizes said...

From Facebook:

I am an allopath (MD), and have worked over many years with many osteopaths (DO) and allopaths. Generally speaking, I have experienced no difference whatsoever in acumen, knowledge, skill, etc. -- with the exception that a few DOs perform osteopathic manipulation. Good luck to your young friend. I suggest the decision be reached largely on factors other than the degree... such as location, feel of the school of medicine, cost, etc. By the way, New York State has taken the approach of conferring MD degrees on licensed foreign medical graduates holding something other than the MD degree. I presume they did so to reduce confusion in the marketplace... eliminating distinctions without a difference. My preference would be to have one terminal degree for ease of public identification.

http://www.op.nysed.gov/prof/med/med-mdconferral.htm

Silvia Brandon PĂ©rez said...

From Facebook:

I would go for a DO; I am considering becoming a DO at the age of 64, a nutritionist AND possibly an acupuncturist or Doctor of Traditional Chinese Medicine. I am sorry to say that in the US allopathic medicine has become a very corrupt business where doctors are paid by pharmaceuticals (the word actually should be 'bribed') to prescribe and over-prescribe unnecessary medication. Iatrogenic deaths are a large part of the medical picture in industrialized nations. I love chiropractors, DOs and TCM physicians, and lately, Ayurveda. I realize I am sounding a bit harsh here... I recently lost my husband.

Beverly Heywood Rogers said...

From Facebook:

The writer may be commenting on his experience from an academic viewpoint. In private practice, I don't think this distinction makes much difference. We had a prominent hem/onc in our shop who was president of the medical staff, chair of his department, etc. (in community hospitals those positions are not permanent), and I only incidentally discovered he was a D.O. No one ever mentioned it.

Katie Crommett said...

From Facebook:

Thanks for sharing Paul. I like your associate's perspective. Someday I hope the medical community can come together to guide people through health instead of boggle the system to make a basic need even that more confusing and complicated.

@meducate said...

From Twitter:

Amazing the bias/prejudice issues still exist. I thought they were over.

Paul Grundy said...

From Facebook:

I like the osteopathic principles as an MD an allopath. I think they should be ours as well major principles of osteopathic medicine:
1 The body is a unit. An integrated unit of mind, body, and spirit;
2 The body possesses self-regulatory mechanisms, having the inherent capacity to defend, repair, and remodel itself;
3 Structure and function are reciprocally interrelated;
4 Rational therapy is based on consideration of the first three principles.

Ellen said...

Sadly, your associate seems to have been minimally angered and perhaps traumatized by discriminatory practices aimed at DOs. He makes the following brief statement: "The philosophy of osteopathic medicine is very appealing and I think most human and appropriate.:

But does not elaborate on it at all. Has s/he lost sight of the underlying benefit that creates a practice environment that, for the right person, would be a much better fit than standard medicine? Does the delight of a better fit ultimately allow one to transcend the other nonsense??

Years ago I ended up selecting a PCP (who turned out to be a DO) based on the recommendation of a friend. Now, I am currently in the position of looking for a PCP and am frustrated that I cannot find a DO as that would be my first choice – hands down. Why? My experience was that I received a more wholistic approach to analyzing my health status and there were more treatment options (e.g. cranial-sacral massage therapy) that were considered “valid.” And, in each case (I’ve now had 2 DOs) they spent more time with me asking key questions.

With only 2 data points I don’t know whether to attribute that to DO practice protocols or perhaps to the type of person who is attracted to the DO credentialing process or something else. Regardless, I am a believer.

dave said...

As a patient I search fo DO's first due to their osteopathic principles - I am a whole and more than "the part that hurts". Until recently my primary care was a DO as well as two of the three specialists that I saw. Since a move to a college town that has an MD program I have been unable to find many DO's but have been fortunate to find a primary care MD that has a DO mindset.

Thomas said...

My partner is a DO; many docs in my network are DOs; we have opened a DO med school in Indianapolis with the backing of two large health care networks. I believe part of the perception goes back to the 50s when DO was not a recognized professional degree. Lots of confusion between DO and DC. We privilege and accredit and pay MDs and DOs by the same standards.

Joshua said...

I agree that the philosophy of osteopathic medicine is a crucial element that seems to have been lost in many allopathic schools. But not all. And perhaps more recently this is returning to MD schools (when I attended medical school in 1998 we had several course and mentors emphasizing holistic principles in treating patients rather than illnesses). I've worked with some outstanding DO colleagues, and some of the brightest academic and private practitioners I've worked with have been DO physicians.

One interesting development is that DO schools seem to be proliferating at a rate far outpacing MD schools. My brief inquiries into this seem to bring up some troubling realities: there are fewer regulatory hurdles (such as curriculum and faculty requirements) to starting an osteopathic school. Therefore it would seem to be less expensive to start a DO school. The requirement of an affiliated teaching hospital is more loosely held. Medical students rotate at my hospital from MD and DO schools, and while the allopathic schools want to see faculty CVs, research and publications, COI attestations, the didactic curriculum outline, etc., the osteopathic schools mainly seem to want to know how many students we can handle.

Has the laudable goal of a more holistic education been superseded by the drive to make more money in medical education by cutting costs and lowering our expectations for curriculum? I would bet some MD schools are doing the same, but the trends are troubling.

David said...

I have read with interest these comments on DO vs. MD education and want to offer some personal thoughts, which are somewhat anecdotal since I am not aware of studies looking at the question.

As a young man growing up in the Jewish community of Detroit, I knew a lot of young men who intended to go to medical school. In general, those who went to the osteopathic schools were those who were rejected by the medical schools to which they applied. In those days, late 1950s and 1960s, that usually meant the Univ. of Michigan or Wayne State Univ. The Mexican and Caribbean schools were rarely considered at that time. So, if a bias existed, it was because we all knew that the academically more challenged students went to the DO schools. Obviously, some of these people matured academically and furthermore, the correlation between one’s high school and college grades, versus later performance as doctors is not tight so it is entirely plausible they could be good doctors.

My second point involves what I learned during my reviews of many medical malpractice cases, some of which involved DO trained anesthesiologists. I’m not referring to the incompetence of a DO anesthesiologist versus an MD anesthesiologist since in many cases, the quality of care by either the defendant DOs or MDs was substandard. What struck me was the nature of the hospital in which the DO anesthesiologists did their training, in contrast to my residency program at the Univ. California San Francisco, or the Harvard programs like the MGH where I was on the faculty for 25 years, or the BWH, Beth Israel Hospital, and Children’s Hospital, not to mention the many other fine anesthesia residency programs around the country like Johns Hopkins, UPenn, Columbia, Univ. of Washington, Northwestern, etc. As I learned from reading their depositions, these DO hospitals were like relatively small community hospitals, had a limited patient population available for resident education, and produced little, if any research work. As the editor-in-chief of a major peer reviewed journal of clinical anesthesiology research, I rarely received a research article from a DO anesthesia group for review and potential publication. They had their own Board certification process upon which I cannot comment, but having been a Senior Board examiner for the American Board of Anesthesiology for 25 years, I can attest to the rigor of our exam process. Of course, there may be many fine DO anesthesia clinicians, but are they involved in the level of complexity seen at major medical centers with which you are familiar, and do they possess the skills, knowledge, and judgment required to practice at a very high level?

DO students occasionally obtain residencies in MD anesthesia programs and I know of no information to suggest their ultimate performance differs from MD graduates. My comments only refer to those who do their internships and residencies in their own small DO hospitals. So, yes, in that respect and as a generalization, I do think there probably is a difference in the expertise of well trained anesthesiologists from good MD anesthesia residency programs compared to those trained in the DO programs. Assuming this generalization applies across many other residency and subspecialty programs, e.g. in surgery, internal medicine, radiology, pathology, I can understand from where some of the bias emanates. I agree that it shouldn’t be based on a simple DO vs. MD degree, but on the quality and substance of the education and training received.

Thank you for putting this question on your blog.

Sean said...

As an MD married to a DO, I have watched this debate from a unique perspective for a while now.

it seems to me that we have created a false dichotomy. The central theme of this discussion revolves around the idea of "separate but equal." But that isn't possible. We've been there before. It just isn't real.

Are there some MDs who are anti-DO? Yes. Are there some DOs who are anti-MD? Yes. But for those of us in the mainstream--for those of us who have room for a little more nuance and a little less room for things to be so black-and-white--we have to move beyond asking this question of MD versus DO. As long as we keep framing it in those terms, and as long as we see the two as separate but equally valid pathways, we will never find an answer.

We are asking the wrong question. A better question is: Why do we feel the need to distinguish between the two? And who is really perpetuating the dichotomy?

Paul Levy said...

Sean,

You have to choose when you want training, so the dichtomoy exists for those who are applying to school. What are you suggesting should be the case?

Larry said...

I generally hate generalizations, and this one is particularly egregious! I will be the first to admit there remain pockets of bias against D.O’s throughout the country, but to say “the MD world will always look down on you” goes a bit too far, in my opinion. Perhaps it is because I am “just a family doctor” (when I was in medical school, a relative’s husband asked me what my specialty was going to be. When I answered Family Medicine, his response was “Oh, just a family doctor, huh?”), but I believe osteopathic physicians have an excellent educational experience. In a previous group, one of my partners was a DO, I have shared call with DO’s, and never had any reason to be concerned about their knowledge base, or quality of care delivered by them. In my current role, I am an executive in a large health care system that is staffed primarily by MD’s, although DO’s comprise about 20% of our medical staff. Our hospitalist program’s director is a DO, and has a reputation as being an excellent physician. We have multiple residency programs within our system, all of which currently accept both MD and DO candidates.

I believe, historically, DO’s reputations have suffered from both the fact that many entered primary care with only a one-year internship, and no further post-graduate training. In addition, many of the osteopathic post graduate training programs (residencies and fellowships) did not have great reputations. Both these situations led to some lack of respect. I believe there are fewer physicians entering osteopathic practice without residency training, and the programs have improved in quality as well, so that situation has changed, and continues to improve, in general.

As with most debates like this, I think it depends on the individual physician. There are great, high quality, well trained, caring osteopathic physicians. There are also DO’s at the other end of that spectrum. The same holds true for allopathic doctors. The trick is finding the good ones, whichever the degree!

Larry said...

Further, with regard to your friend:

To some extent, I believe the advice you received from your DO colleague, is good advice. She needs to look at where her ultimate interests may lie. This is difficult, because most pre-med students think they know what they want to do, but really end up changing their minds after they really experience the profession and get more experience in clinical rotations. However, for instance, if she believes her interest may lie in academic or private sector research, it will be easier for her to achieve that with an MD degree (not impossible with a DO, just more difficult). If she is more interested in clinical practice, then I think either path is acceptable. I would advise looking at the specific schools (both allopathic and osteopathic) she finds appealing, and applying in several of them (some of each). She needs to attend a good school, with a good reputation, and a history of producing good, successful, high quality physicians. I wouldn’t really get too hung up on the specific degree. This is all assuming she has investigated the differences in philosophies of each program and has no real strong concerns with either.

I hope that helps. Best of luck to her and her career.

Brandon Moore said...

From Facebook:

Really interesting piece and was insightful to read. As a current DO student, though, I can't help but wonder if the author is an older doctor. While there is some discrimination against DO's, and we still have to explain what the degree is to patients, I do not feel it is as bad as this piece paints it to be. I have had feedback from many DO residents, seen our residency placements, and talked to both MD's and DO's about their experiences, and the playing field is quickly leveling.

Students from my school managed to land some pretty competitive spots at places like the Mayo Clinic and UAB hospital. I have talked to several middle-aged MD's and they all say they love working with their DO colleagues. My sister is an allopathic third year student and she has seen many DO students in residency programs at her hospital and they seem to be very successful in the field now. It is true, though, that some of the more competitive residency programs have older MD chiefs that would rather take an MD over a DO, but if a DO student kills their boards, it is very possible to get into derm, anes, or ortho. The one thing I will say that is entirely incorrect is the Caribbean schools remark. The match rate for DO programs is in the low 90% area, while Stateside MD programs are around 98%. Caribbean MD programs in the last study I saw were barely breaching the 50% mark and after all, the point of med school is to attain a residency match!

In addition, the AOA (osteopathic) and AAMC (allopathic) administrative boards are not working together to share residencies, although the board tests will probably never be combined. Progress is happening, albeit slowly, and DO programs are proving, through board scores and residency performance, that the programs are separate but equal. There is a lingering stigma that since admission requirements (MCAT mostly) were generally lower to attend DO schools, that they make inferior or unprepared physicians. Of course, this is not true, and the MCAT is generally a very poor predictor of board and residency performance haha.

Most students at my school plan on taking both the USMLE and COMLEX and applying to both MD and DO residencies. So, this doc definitely hits the nail on the head in some aspects, but I can't help but think his opinions are based on the older climate. Thanks for posting this.

Baruch Pierre and Kelli said...

From Facebook:

Baruch Stone: They are the same.

Pierre Belperron: Not the same. That's a good thing. Some of the physicians I have admired most and would seek out have been DO's, and am not surprised that many in the MD clique harbor a prejudice.

Kelli Harper: I am a 4th year osteopathic medical student who has worked with MD's and DO's and this has not been my experience at all. If anyone wants more information or insight, feel free to message me.

Brad F said...

Paul
Given your past position--at an institution not welcoming of DOs-- what impressions did you have at the time?

(I say not welcoming because of their absence. I know folks apply)

If asked 5 years ago, "should we interview and accept a well qualified DO candidate," against the wishes of a division or dept head, how would you react?

You speak your mind. Maybe you experienced it first hand. Please share.

Brad

Paul Levy said...

I had no impressions at the time. I had little background in health care and didn't know anything about the topic and it never came to my attention. After all, I was in the heartland of academic medicine, and DOs were not very visible.

In any event, I was not very involved at all in physician recruitment. That function is not under the purview of the CEO. So if the issue had come up, I probably never would have heard about it.

If a division or department head was opposed, though, the person never would have been recruited, as the chiefs rule the roost on such matters.

Sarah Michael said...

Paul,

Thanks for posting this. It’s a fascinating and troubling topic of great personal interest to me. Unfortunately I’m a little wordy, so I’ll post my thoughts in two pieces.

I’m a DO resident currently undertaking the challenge of building a career for myself in academia and I understand where your associate is coming from. I would counsel a pre-med in the same way.

I too had simple aspirations when I applied to medical school, and like your colleague weighed my opportunities and their costs, though in hindsight things, as usual, are clearer.

As a medical student I felt as many of the other young commenters did, wholly idealistic and never having before experienced the discrimination that I now understand is pervasive. I established my school’s chapters of the AMA and state medical society despite opposition from the school administration, fighting what I then considered – and still do – to be reverse discrimination. We met as a secret society for 18 months, not permitted to even use our institution’s facilities for meetings or email lists to announce them. Over time, involvement grew to over 99% of students despite the restrictions and our administrators eventually caved under the pressure. At the time of my graduation, ours was the most engaged and active organization on campus.

Things were less rosy at the time I graduated. I was fortunate to at least realize by the time I was applying to residency that I needed an academic environment. Applying as DO was a bigger stretch than I had anticipated. Many of the programs I was interested in charge DO students over $1000 to rotate at their institutions while charging MD students nothing. Some don’t even accept clerkship applications from DO students at all. I’ve heard many rationalizations for this, all of which are less than satisfying.

I rotated at programs where I felt I might fit in and be competitive in the Match but where the blatant discouragement was not present. At one such program, I noticed they had no DO faculty or residents. I emailed the clerkship director after being accepted to inquire about whether that reflected preferences in hiring or was just coincidental. I didn’t want to waste their time or mine if I wouldn’t be considered. The clerkship director referred me to the assistant program director and I was subsequently informed that they get very few DO applicants but would be thrilled for me to rotate with them and would absolutely consider me for a position there.

Sarah Michael said...

...Continued from previous

My rotation was excellent. I felt comfortable there and received positive feedback from the residents and attendings. Every day, I was asked if I would consider coming back for residency. Certainly, I told them, and departed with assurances that I would see everyone again at my interview. I was never offered one.

At every single interview I did attend, I was asked at least once to relay my experiences at that institution. I can surmise enough details to know that they said wonderful things about my clinical abilities, but declined me an interview and indicated I had no probability of matching there, after all of that, because I would be a DO. Worse, I will never know the full ramifications their “letter of recommendation” on my Match or career.

I was deeply hurt by the abject rejection, the lie that preceded it, and the silence that ensued after. These people will still be colleagues after all and I will see them at every conference I attend for the rest of my career. I have mixed emotions about protecting the identity of this place in the way I have. On one hand, sunlight is the best disinfectant. But is that asking for even more trouble than they have already provided me? Does letting them off the hook perpetuate the acceptance of this discrimination in academia? You cannot blame those who ask the question; MD or DO? But I regret the culture that requires it and further resent being stuck between sacrificing my career and my values.

I’m fortunate to have been accepted to a residency that is providing me with all of the things I was looking for. Our department is even becoming more academically rigorous. I’m thrilled to be here for the changes we’re making and I believe my program director chose to bring me here as part of his vision for the future, but he too has fallen into the trap. In addition to actually making us better academically, he’s trying to increase the appearance of a successful academic department. One strategy he’s using to achieve that: no DOs were interviewed during the last recruiting season. This he does despite a track record of choosing DOs to be Chief Residents. I know he doesn’t think we’re bad doctors, teachers, or academicians, but I’m sure he knows a lot of other people who do. He is meeting the expectations of the community. It troubles me deeply that I wouldn’t be given an opportunity to interview where I am now if I had applied only one year later.

I know what I would do if I had the choice to make over again. Mastering medicine is difficult enough without this.

Anonymous said...

Sarah's comment exactly mirrors my fears for your friend. (Although, in fairness, they may not have invited her back for an interview for reasons other than the type of degree she had.)

The more I read about this, the more I wonder why the DO degree still exists. Do their medical schools get the same subsidies from the government? Do they do research, etc as do most MD schools? Is the quality of education really the same? Seems like they should just merge the degrees and get it over with; the practice of medicine will just burn out any 'holistic' impulses pretty quickly, I fear.

Anonymous said...

historically MDs tried really hard to destroy DOs but I don't think DOs are 2nd rated doctors. For example, UCI med school was a DO school before they switched. It's not matter of competency. It more matter of social acceptance and desire to go to well known universities.

Anonymous said...

From an MD student, honestly we view DOS as students who couldn't get into an MD school. My friend who goes to a DO school told me that more than half of his class were denied from an MD school so they opted for DO.

Paul Levy said...

Does denial from MD schools mean anything about underlying ability to be a great doctor?

My view: Not in the least.

Or putting it another way, does acceptance by MD schools suggest anything about underlying ability to be a great doctor?

My view: Not in the least.

But I welcome other thoughts on those points.