Aragona, Giaimo and Radis report no relevant financial disclosures.
During a September 2021 interview on The Tonight Show with Jimmy Fallon, comedian Hasan Minhaj referred to doctors of osteopathic medicine, or DOs, as “off-brand doctors” compared with their MD counterparts.
The medical community — MDs and DOs alike — hit back.
Faced with that negative reaction, Minhaj released a video walking back some of his comments. He has also addressed the controversy onstage during his stand-up sets.
However, the incident resulted in a few important consequences, intended or not. On one hand, Minhaj and his comments seemed to perpetuate the stigma that has historically existed for many doctors with those particular letters after their name. On the other hand, the swift and unified response from the health care community served as real-world evidence that, perhaps rallied to solidarity by the shared crucible of the COVID-19 pandemic, medical practitioners of all stripes stand together.
A third byproduct, of course, was an increased awareness among the general public about DOs in general, the important roles they play in the U.S. health care system and non-debate about what separates them from MDs.
Erika Visser Aragona
“At this point, I do not see that there is a difference between a DO and an MD,” Erika Visser Aragona, DO, a board-certified family medicine physician at Saint Alphonsus Hospital, in Idaho, and adjunct professor at the Idaho College of Osteopathic Medicine, told Healio. “There are far more similarities than differences.”
Crossover between DO and MD training programs is now the rule rather than the exception. Meanwhile, the number of DOs continue to grow: More than one-quarter of current U.S. medical students are enrolled in osteopathic medicine programs. With that proliferation, patients are increasingly likely to receive competent care from a DO at some point in their life. Although patients of another generation may have had concerns about receiving care from a DO, that is not the case as much anymore.
There is hope that all of this will serve to put the debate surrounding DOs and MDs to bed forever. A clear look at the history, education and approaches taken by DOs may hurry that outcome.
‘Mind, body and spirit’
“From its founding in 1874 by Andrew Taylor Still, a Civil War surgeon, the differences between osteopathic and allopathic education have centered on the philosophy of osteopathic medicine, which focuses on a holistic approach to practice, emphasizing the connectivity of mind, body and spirit,” Charles Radis, DO, clinical professor of medicine at the University of New England, College of Osteopathic Medicine (UNECOM), in Maine, said in an interview. “DOs believe that the health of the musculoskeletal system is intrinsically connected to and reflects the health of other body systems.”
Joseph A. Giaimo
Joseph A. Giaimo, DO, president of the American Osteopathic Association and an AOA board certified pulmonologist, told Healio that DOs account for 11.5% of U.S. physicians today.
“More importantly, they hold some of the most prominent positions in the medical profession, including serving as the physician to the president of the United States and overseeing care for the NASA medical team,” he said.
However, Radis stressed that DOs did not always hold such vaunted positions. Recognizing the root of the stigma that fueled Minhaj’s comment is important to moving forward.
“In 1982, when I began my internal medicine residency at Brighton Medical Center, in Portland, Maine, the two professions were just beginning to cautiously mix,” Radis said.
He described a divided Portland, with DOs at Brighton Medical Center and predominantly MDs “across town” at Maine Medical Center. This health care structure was mirrored in many smaller markets across the country.
However, even then, signs that the walls would come down were emerging.
“Paradoxically, many of the larger medical institutions, such as New England Medical Center, the Cleveland Clinic and Yale New Haven Hospital, welcomed me for elective rotations in immunology, dermatology, infectious disease, endocrinology and rheumatology,” he said.
In 1991, when Radis was preparing to pursue a fellowship in rheumatology, the University of Pittsburgh Presbyterian Medical Center was ready to admit its first DO rheumatology fellow. “Me,” he said.
Upon his return to Maine in 1993, he joined Rheumatology Associates, where five of the other partners were MDs.
“This is now the norm: DOs and MDs in the same practice,” he said. “The pace of change has been extraordinary. By the time Jackie Cawley, DO, became president of the Maine Medical Center Staff in 2007, more than 150 DOs were on staff.”
It is clear, then, that DOs have penetrated every aspect of the U.S. health care system. It is next important to understand how, exactly, they got there.
‘Exactly the same’ education
Like many DOs, Aragona trained alongside MDs and completed a dual residency.
“Our education was exactly the same,” she said.
Moreover, in her role as a teacher at an osteopathic medical school, Aragona works alongside faculty who have both sets of letters next to their names.
“Like any other medical school, it is not exclusive to one or the other,” she said.
If there is a difference between the two, it is that DOs spend more time “putting their hands on patients” and viewing medicine as a “body-mind experience,” according to Aragona.
“We are more focused on preventing disease, instead of waiting for something to happen and then treating it,” she said.
The education that goes into this approach is formidable. Osteopathic schools require up to 200 hours of manipulation training in addition to the standard course work and basic science of an MD education, according to Radis.
“Similar to MD students, the third and fourth years of DO training are in hospitals and physicians’ offices where DO medical students mingle and compete with MD students as they rotate through primary care and specialist services,” he said. “If anything, the divide between DOs and MDs is narrowing as allopathic medical schools and tertiary medical centers are adopting many of the holistic principles pioneered by osteopathic medicine.”
The integration of residency matching programs is also hastening the erasure of the divide, according to Aragona.
“We are seeing a lot more DOs matching with MD programs and vice versa,” she said.
The next step may be to unify the testing for DO and MD programs, for a few important reasons.
“There are three sets of 8-hour exams for each,” Aragona said. “This is a lot for anyone who is still deciding between a DO or MD program.”
The other reason to integrate the testing is cost.
“These tests are more than $1,000 apiece,” Aragona added. “Calibrating and scoring the tests across the board is still in the works.”
As regulatory organizations take these steps, ongoing advocacy is essential to minimizing misconceptions about what DOs are able to do.
Embracing the osteopathic way
The moment with Minhaj provided an opportunity for advocating on behalf of DOs, which Aragona said is “critical” right now.
“The American Osteopathic Association, led by CEO Kevin M. Klauer, DO, EJD, has been extremely vocal in sharing opinions from DOs, MDs and other health professionals,” she said. “They were clear that this is not acceptable, particularly during this pandemic, when misinformation about medicine can potentially be so consequential.”
However, being vocal about the issue does not necessarily mean being combative.
“We are stifling the negativity and countering with the positives,” Aragona said.
Providing space for health care providers of all credentials to express their opinions on social media is crucial to reaching the general public and dispelling myths.
For Giaimo, if there is one overarching myth, it is that there is still a rift between DOs and MDs at all.
“Many of my patients specifically seek out DOs for their empathetic, whole-person approach,” he said. “Some patients may not be familiar with osteopathic medicine on their first visit, but when they learn about our philosophy, they embrace it whole-heartedly.”
Patients today are “increasingly savvy health care consumers,” according to Giaimo.
“Many are actively looking for the kind of comprehensive health care DOs provide,” he said. “As an osteopathic pulmonologist, I see patients every day who are seeking a global approach to wellness, especially in light of the COVID pandemic.”
Radis also said that it is “rare” for a patient to question the letters on his nametag.
“It is even rarer for a patient to question the care they are receiving,” he added, noting that there are no longer separate facilities for the two types of professionals.
“Prominent DO educators such as rheumatologist Len Calabrese, DO, at the Cleveland Clinic, invariably have a mixture of both MD and DO students rotating through their clinical services,” Radis added.
Despite all this positivity, the Minhaj incident highlighted that it is necessary to keep the pressure on to put the discussion to rest. Awareness campaigns are critical to reaching that goal.
Protecting the brand
“In 2021, we launched an ongoing osteopathic brand campaign aimed at building increased awareness and understanding of osteopathic medicine among patients and the public,” Giaimo said. “The multi-channel campaign, now entering its second year, highlights the compassionate whole-person care DOs provide to their patients and has garnered more than 54 million consumer impressions thus far.”
Moreover, the initiative provides all DOs with talking points, tools and resources aimed at educating both individual patients and the general public.
However, beyond these far-reaching efforts, Aragona highlighted another issue that is causing confusion and possibly contributing to the stigma.
“We have to be careful about mid-level practitioners like PAs or physical therapists calling themselves doctors,” she said. “A lot of patients will ask if I am a chiropractor or herbalist. I dispel that assumption by letting them know that I trained in a program with MDs and DOs. That usually clears up the questions.”
Aragona additionally stressed that, by explaining the differences between a DO and these other practitioners, her aim is to “celebrate” what they do and the important contributions they make to health care.
“It is just a matter of transparency in the titles that are used,” she said.
For example, a patient may not know the difference between a DO and a physical therapist. If the patient feels unsatisfied with the care provided by the latter believing it is a DO, it can perpetuate negative associations.
Another complicating issue is that DO means different things in different countries.
“The verbiage needs to be addressed,” Aragona said.
Whether or not that verbiage will change remains to be seen. Regardless, experts like Giaimo urge ongoing “education and understanding” to eliminate any remaining negative associations that exist for Dos.
“Helping patients and prospective patients understand what makes osteopathic medicine distinctive is an important part of our mission at the American Osteopathic Association,” he said. “We partner each day with state and local osteopathic organizations across the country to advocate for DOs and increase understanding of osteopathic medicine.”
For more information:
Erika Visser Aragona, DO, can be reached at 3217 W Bavaria, Eagle, ID; email: firstname.lastname@example.org.
Joseph A. Giaimo, DO, can be reached at 142 E. Ontario St., Chicago, IL; email: email@example.com.
Charles Radis, DO, can be reached at 11 Hills Beach Rd, Biddeford, Maine; email: firstname.lastname@example.org.