Beyond OMT: Time for a New Chapter in Osteopathic Medicine
http://www.100md.com
《美国整骨期刊》
Oklahoma State University College of Osteopathic Medicine Tulsa, Oklahoma
Andrew Taylor Still, MD, DO, founded the American School of Osteopathy (now Kirksville College of Osteopathic Medicine of A.T. Still University of Health Sciences) in Kirksville, Mo, in 1892 as a radical protest against the turn-of-the-century medical system.1 Dr Still believed that the conventional medical system lacked credible efficacy, was morally corrupt, and treated effects rather than causes of disease. 1 He founded osteopathic medicine in rural Missouri at a time when medications, surgery, and other traditional therapeutic regimens often caused more harm than good. Some of the medicines commonly given to patients during this time were arsenic, castor oil, whiskey, and opium. In addition, unsanitary surgery often resulted in more deaths than cures.
Dr Still practiced allopathic medicine for some 30 years before he concluded that "known drugs have been a failure and the patient dies just as quickly with them, and often more quickly, than without them."1 Dr Still not only believed the conventional system of medicine failed to heal patients, he also believed it was morally corrupting to them.2
Dr Still was a Christian minister with a strong sense of morality. His moral vision often conflicted with the prevailing values of the allopathic medical system, which he said, "was no science, and the system of drugs was only a trade, followed by the doctor for the money that could be obtained by it from the ignorant sick."2 He saw the allopathic medical system as corrupted with greed that built "temples to the god who purged, puked, perspired, opiated, drank whiskey and other stimulants; destroyed its thousands, ruined nations, established whiskey saloons, opium dens...."2 In contrast to the widespread belief that drugs were the solution for patients, he believed that drugs were the root of patients' problems.
All diseases resulted from deviations from the body's perfect structure, according to Dr Still. Such deviations created physiological imbalances in function. Dr Still wrote, "The Osteopath seeks first physiological perfection of form, by normally adjusting the osseous frame work, so that all arteries may deliver blood to nourish and construct all parts."2 After the perfect form has been corrected with osteopathic manipulative treatment (OMT), Dr Still believed that God and nature would heal the disease. He, thus, pioneered the holistic approach to medicine, arguing that "[finding] health should be the object of the doctor. Anyone can find disease."2
Osteopathic medicine was more compassionate than conventional medicine, believed Dr Still. He encouraged his followers to improve upon past theories of disease and treatment to create a better medical system. Shortly after founding the American School of Osteopathy, he wrote that osteopathic medical students should "use any means that are better than any known method of the past, as used in surgery, as used in obstetrics, and the treatment of diseases generally."2 Thus, Dr Still created osteopathic medicine as a separate and radical new philosophy that improved upon allopathic medicine on many fronts, especially on the fronts of morality, humanity, and efficacy.
Today, more than 100 years after Dr Still first raised the banner of osteopathic medicine, osteopathic physicians walk on a precarious tight rope with their allopathic brothers and sisters. Since Dr Still's time, osteopathic physicians have successfully fought for "separate but equal rights," and they now practice side by side with their allopathic counterparts. Osteopathic physicians are fully licensed in all 50 states, and more than 50% of osteopathic medical school graduates now attend residency programs accredited by the allopathic Accreditation Council for Graduate Medical Education.3
In a 2001 survey of osteopathic physicians by Johnson et al,4 more than 50% of the respondents said they used OMT on less than 5% of their patients. The survey was the latest indication that osteopathic physicians have become more like allopathic physicians in all respects—fewer perform OMT, more prescribe drugs, and many perform surgery as a first option.
What has happened since the 1890s to make so many osteopathic physicians move so close to the allopathic medical system Many osteopathic physicians are struggling for the answer to this question. Meanwhile, the leadership of the osteopathic medical profession has yet to clearly define the profession's uniqueness in modern medicine. A 2002 survey of osteopathic physicians by Johnson et al5 found that "not a single philosophic concept or resultant practice behavior had concurrence from more than a third of the respondents as distinguishing osteopathic from allopathic medicine." Johnson et al4 concluded that many osteopathic physicians, especially those who are recent graduates, no longer use OMT for a variety of reasons, including institutional barriers, negative professional attitudes, and lack of postgraduate training.
I believe that such surveys, while insightful in certain areas, overlook the most important and critical reason for the failure of osteopathic physicians to use OMT—a lack of randomized controlled studies to support the efficacy of OMT. A paradox has developed: training in osteopathic medical schools emphasizes evidence-based medicine, but graduates of these schools do not apply the same level of scientific scrutiny to OMT research.6
I found this problem highlighted when I conducted an electronic search of recent literature in regard to low back pain. Using the National Library of Medicine's PubMed and Ovid MEDLINE databases, as well as the OSTMED database, I search for literature dated from January 1990 through December 2005 containing the terms osteopathic manipulative treatment and low back pain. This search yielded only a small number of randomized controlled studies specific to low back pain, and the conclusions of these studies varied considerably.
The study that was most favorable to manipulation, by Andersson et al,7 found that OMT may be as efficacious as conventional medical therapy. A study of moderate favorability, by Licciardone et al,8 indicated that the efficacy of OMT is no better than that of sham manipulation. The least favorable study, by Assendelft et al,9 concluded that, "Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school."
As the old saying goes, "There are lies, damn lies, and statistics." Yet, if OMT in its most favorable study is only as efficacious as conventional medical care for patients with somatic dysfunction, what does this say about the other conditions that OMT is used for Perhaps more time and research will help resolve the paradox of osteopathic medicine. However, the osteopathic medical profession has been waiting 100 years for research to firmly support the efficacy of OMT. Many osteopathic physicians simply refuse to wait any longer.
Dr Still believed that osteopathic medicine was more compassionate, efficacious, and moral than the medical system of the 19th century. His writings illustrate his compassion and conviction when he challenged his followers to improve upon existing theories of disease and treatment.1,2 Considering the primitive nature of medications and surgical practices during the 1890s, OMT was arguably an improvement upon many contemporary medical practices. Since then, however, modern medicine has made substantial progress in pharmacology, imaging, surgery, and many other diagnostic and therapeutic modalities. This progress has made the conventional medicine of the 21st century much more compassionate and efficacious than it was during the 19th century.
In the face of the many improvements in conventional medicine since 1892—and with the lack of research substantiating the efficacy of OMT—would Dr Still maintain today that OMT represents an improvement upon conventional medical practices Or would he seek to begin a new chapter in osteopathic medicine—one that focuses on the other positive factors that make osteopathic medicine distinctive Dr Still highlighted one such distinction when he stated, "We are here to call a horse a horse, to demonstrate what we assert, and leave the results to be accepted or rejected by men and women who can and will think in the words of our own blessed language."1
Osteopathic medicine is unique because patients have embraced osteopathic physicians for their pragmatism and communication skills.10,11 Osteopathic medicine owes its success to those patients who see beyond OMT. It is time for the leadership of the osteopathic medical profession to also look beyond OMT, or the real uniqueness of this profession will become lost.
References
3. American Osteopathic Association's Commission on Osteopathic College Accreditation—Executive Committee and the Subcommittee on Osteopathic Educational Elements. Report of the AOA Commission on Osteopathic College Accreditation—Executive Committee and the Subcommittee on Osteopathic Educational Elements: Resolution 274 (A/2004) "Match participation and rotations with osteopathic physicians, proposed requirements for osteopathic." Paper adopted at: Annual Meeting of the AOA House of Delegates; July 15–17, 2005; Chicago, Ill.
4. Johnson SM, Kurtz ME. Diminished use of osteopathic manipulative treatment and its impact on the uniqueness of the osteopathic profession. Acad Med. 2001;76:821 –828.
5. Johnson SM, Kurtz ME. Perceptions of philosophic and practice differences between US osteopathic physicians and their allopathic counterparts. Soc Sci Med.2002; 55:2141 –2148.
6. Howell JD. The paradox of osteopathy [editorial]. N Engl J Med. 1999;341:1465 –1468.
7. Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. N Engl J Med.1999; 341:1426 –1431.
8. Licciardone JC, Stoll ST, Fulda KG, Russo DP, Siu J, Winn W, et al. Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spine.2003; 28:1355 –1362.
11. Licciardone JC. The unique role of osteopathic physicians in treating patients with low back pain. J Am Osteopath Assoc. 2004;104:S13–S18. Available at: http://www.jaoa.org/cgi/reprint/104/11var iadtimes=7;(GREG P. HANSEN, MS III)
Andrew Taylor Still, MD, DO, founded the American School of Osteopathy (now Kirksville College of Osteopathic Medicine of A.T. Still University of Health Sciences) in Kirksville, Mo, in 1892 as a radical protest against the turn-of-the-century medical system.1 Dr Still believed that the conventional medical system lacked credible efficacy, was morally corrupt, and treated effects rather than causes of disease. 1 He founded osteopathic medicine in rural Missouri at a time when medications, surgery, and other traditional therapeutic regimens often caused more harm than good. Some of the medicines commonly given to patients during this time were arsenic, castor oil, whiskey, and opium. In addition, unsanitary surgery often resulted in more deaths than cures.
Dr Still practiced allopathic medicine for some 30 years before he concluded that "known drugs have been a failure and the patient dies just as quickly with them, and often more quickly, than without them."1 Dr Still not only believed the conventional system of medicine failed to heal patients, he also believed it was morally corrupting to them.2
Dr Still was a Christian minister with a strong sense of morality. His moral vision often conflicted with the prevailing values of the allopathic medical system, which he said, "was no science, and the system of drugs was only a trade, followed by the doctor for the money that could be obtained by it from the ignorant sick."2 He saw the allopathic medical system as corrupted with greed that built "temples to the god who purged, puked, perspired, opiated, drank whiskey and other stimulants; destroyed its thousands, ruined nations, established whiskey saloons, opium dens...."2 In contrast to the widespread belief that drugs were the solution for patients, he believed that drugs were the root of patients' problems.
All diseases resulted from deviations from the body's perfect structure, according to Dr Still. Such deviations created physiological imbalances in function. Dr Still wrote, "The Osteopath seeks first physiological perfection of form, by normally adjusting the osseous frame work, so that all arteries may deliver blood to nourish and construct all parts."2 After the perfect form has been corrected with osteopathic manipulative treatment (OMT), Dr Still believed that God and nature would heal the disease. He, thus, pioneered the holistic approach to medicine, arguing that "[finding] health should be the object of the doctor. Anyone can find disease."2
Osteopathic medicine was more compassionate than conventional medicine, believed Dr Still. He encouraged his followers to improve upon past theories of disease and treatment to create a better medical system. Shortly after founding the American School of Osteopathy, he wrote that osteopathic medical students should "use any means that are better than any known method of the past, as used in surgery, as used in obstetrics, and the treatment of diseases generally."2 Thus, Dr Still created osteopathic medicine as a separate and radical new philosophy that improved upon allopathic medicine on many fronts, especially on the fronts of morality, humanity, and efficacy.
Today, more than 100 years after Dr Still first raised the banner of osteopathic medicine, osteopathic physicians walk on a precarious tight rope with their allopathic brothers and sisters. Since Dr Still's time, osteopathic physicians have successfully fought for "separate but equal rights," and they now practice side by side with their allopathic counterparts. Osteopathic physicians are fully licensed in all 50 states, and more than 50% of osteopathic medical school graduates now attend residency programs accredited by the allopathic Accreditation Council for Graduate Medical Education.3
In a 2001 survey of osteopathic physicians by Johnson et al,4 more than 50% of the respondents said they used OMT on less than 5% of their patients. The survey was the latest indication that osteopathic physicians have become more like allopathic physicians in all respects—fewer perform OMT, more prescribe drugs, and many perform surgery as a first option.
What has happened since the 1890s to make so many osteopathic physicians move so close to the allopathic medical system Many osteopathic physicians are struggling for the answer to this question. Meanwhile, the leadership of the osteopathic medical profession has yet to clearly define the profession's uniqueness in modern medicine. A 2002 survey of osteopathic physicians by Johnson et al5 found that "not a single philosophic concept or resultant practice behavior had concurrence from more than a third of the respondents as distinguishing osteopathic from allopathic medicine." Johnson et al4 concluded that many osteopathic physicians, especially those who are recent graduates, no longer use OMT for a variety of reasons, including institutional barriers, negative professional attitudes, and lack of postgraduate training.
I believe that such surveys, while insightful in certain areas, overlook the most important and critical reason for the failure of osteopathic physicians to use OMT—a lack of randomized controlled studies to support the efficacy of OMT. A paradox has developed: training in osteopathic medical schools emphasizes evidence-based medicine, but graduates of these schools do not apply the same level of scientific scrutiny to OMT research.6
I found this problem highlighted when I conducted an electronic search of recent literature in regard to low back pain. Using the National Library of Medicine's PubMed and Ovid MEDLINE databases, as well as the OSTMED database, I search for literature dated from January 1990 through December 2005 containing the terms osteopathic manipulative treatment and low back pain. This search yielded only a small number of randomized controlled studies specific to low back pain, and the conclusions of these studies varied considerably.
The study that was most favorable to manipulation, by Andersson et al,7 found that OMT may be as efficacious as conventional medical therapy. A study of moderate favorability, by Licciardone et al,8 indicated that the efficacy of OMT is no better than that of sham manipulation. The least favorable study, by Assendelft et al,9 concluded that, "Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school."
As the old saying goes, "There are lies, damn lies, and statistics." Yet, if OMT in its most favorable study is only as efficacious as conventional medical care for patients with somatic dysfunction, what does this say about the other conditions that OMT is used for Perhaps more time and research will help resolve the paradox of osteopathic medicine. However, the osteopathic medical profession has been waiting 100 years for research to firmly support the efficacy of OMT. Many osteopathic physicians simply refuse to wait any longer.
Dr Still believed that osteopathic medicine was more compassionate, efficacious, and moral than the medical system of the 19th century. His writings illustrate his compassion and conviction when he challenged his followers to improve upon existing theories of disease and treatment.1,2 Considering the primitive nature of medications and surgical practices during the 1890s, OMT was arguably an improvement upon many contemporary medical practices. Since then, however, modern medicine has made substantial progress in pharmacology, imaging, surgery, and many other diagnostic and therapeutic modalities. This progress has made the conventional medicine of the 21st century much more compassionate and efficacious than it was during the 19th century.
In the face of the many improvements in conventional medicine since 1892—and with the lack of research substantiating the efficacy of OMT—would Dr Still maintain today that OMT represents an improvement upon conventional medical practices Or would he seek to begin a new chapter in osteopathic medicine—one that focuses on the other positive factors that make osteopathic medicine distinctive Dr Still highlighted one such distinction when he stated, "We are here to call a horse a horse, to demonstrate what we assert, and leave the results to be accepted or rejected by men and women who can and will think in the words of our own blessed language."1
Osteopathic medicine is unique because patients have embraced osteopathic physicians for their pragmatism and communication skills.10,11 Osteopathic medicine owes its success to those patients who see beyond OMT. It is time for the leadership of the osteopathic medical profession to also look beyond OMT, or the real uniqueness of this profession will become lost.
References
3. American Osteopathic Association's Commission on Osteopathic College Accreditation—Executive Committee and the Subcommittee on Osteopathic Educational Elements. Report of the AOA Commission on Osteopathic College Accreditation—Executive Committee and the Subcommittee on Osteopathic Educational Elements: Resolution 274 (A/2004) "Match participation and rotations with osteopathic physicians, proposed requirements for osteopathic." Paper adopted at: Annual Meeting of the AOA House of Delegates; July 15–17, 2005; Chicago, Ill.
4. Johnson SM, Kurtz ME. Diminished use of osteopathic manipulative treatment and its impact on the uniqueness of the osteopathic profession. Acad Med. 2001;76:821 –828.
5. Johnson SM, Kurtz ME. Perceptions of philosophic and practice differences between US osteopathic physicians and their allopathic counterparts. Soc Sci Med.2002; 55:2141 –2148.
6. Howell JD. The paradox of osteopathy [editorial]. N Engl J Med. 1999;341:1465 –1468.
7. Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. N Engl J Med.1999; 341:1426 –1431.
8. Licciardone JC, Stoll ST, Fulda KG, Russo DP, Siu J, Winn W, et al. Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spine.2003; 28:1355 –1362.
11. Licciardone JC. The unique role of osteopathic physicians in treating patients with low back pain. J Am Osteopath Assoc. 2004;104:S13–S18. Available at: http://www.jaoa.org/cgi/reprint/104/11