Physicians in the United States hold either the Doctor of Medicine degree (MD) or the Doctor of Osteopathic Medicine degree (DO). Institutions awarding the MD are accredited by the Liaison Committee on Medical Education (LCME) or Educational Commission for Foreign Medical Graduates (ECFMG). Institutions awarding the DO are accredited by the Commission on Osteopathic College Accreditation (COCA). The MD degree is obtained at either domestic or international schools. The DO degree is obtained at domestic schools only. Foreign-trained osteopaths are not recognized as physicians in the United States.
The curriculum and coursework at MD- and DO-granting schools is similar. Osteopathic manipulative medicine (OMM) is taught at DO-granting schools only. Some OMM practices, such as cranial therapy, are subject to significant criticism regarding their efficacy and therapeutic value.
Both MD and DO degree holders must complete Graduate Medical Education (GME) after medical school in order to practice medicine in the United States. Practicing physicians holding the MD will have completed GME training at a program approved by the Accreditation Council for Graduate Medical Education (ACGME). Practicing physicians holding the DO will have completed GME training at a program approved by either the American Osteopathic Association (AOA) or ACGME.
Starting in 2020, all GME programs will be accredited and governed by the ACGME. The AOA will no longer function as an accrediting body for GME. Historically AOA-approved GME programs will either gain approval by the ACGME or dissolve.
Physicians who bear an MD or DO can be licensed to practice medicine in all states. The degrees are legally equivalent.
The history of the MD and DO degree, and the rights of the degree holder to practice medicine in the United States, differ significantly.
History and Background
While allopathic medicine
has followed the development of society, osteopathic medicine is a more
recent development. The first MD school in the United States opened in
1807 in New York. In 1845, the American Medical Association
was formed, and standards were put into place, with a three-year
program including lectures, dissection, and hospital experience. In
1892, frontier physician Andrew Taylor Still founded the American School of Osteopathy in Kirksville, MO
as a protest against the present medical system. A. T. Still believed
that the conventional medical system lacked credible efficacy, was
morally corrupt, and treated effects rather than causes of disease.
Throughout the 1900s, DOs gained practice rights and government
recognition. The first state to pass regulations allowing DOs medical
practice rights was California in 1901, the last was Nebraska in 1989.
Up through the 1960s, osteopathic medicine was labeled a cult by the
American Medical Association, and collaboration by physicians with
osteopathic practitioners was considered to be unethical.
The American Medical Association's current definition of a
physician is "an individual who has received a 'Doctor of Medicine' or a
'Doctor of Osteopathic Medicine' degree or an equivalent degree
following successful completion of a prescribed course of study from a
school of medicine or osteopathic medicine."
In a 2005 editorial about mitigating the impending shortage of
physicians in the United States, Jordan Cohen, MD, then-president of the
Association of American Medical Colleges (AAMC) stated:
After more than a century of often bitterly contentious relationships between the osteopathic and allopathic medical professions, we now find ourselves living at a time when osteopathic and allopathic graduates are both sought after by many of the same residency programs; are in most instances both licensed by the same licensing boards; are both privileged by many of the same hospitals; and are found in appreciable numbers on the faculties of each other's medical schools.
Demographics
Medical training
Of
the 860,917 physicians actively practicing in the United States in
2015, 67.1% hold an MD degree granted in the U.S., 24.3% are
international medical graduates, and 7.6% hold a DO degree. The percentage of physicians that hold a DO degree varies by specialty, with the greatest representation in Family Medicine/General Practice (16.5% of general practitioners), Physical Medicine & Rehabilitation (13.8%), and Emergency Medicine (11.2%).
As of 2015, 9.0% of residents and fellows in medical training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), which accredits all MD residency programs, hold a DO degree.
65.1% of the 19,302 DO graduates enrolled in post-doctoral training are
in ACGME-accredited programs, with the remainder in AOA programs. In 2020, the ACGME will take over the accreditation of all residency programs in the United States for both MDs and DOs.
Trends
There are
significantly more MDs than DOs. The number of DOs is increasing. A
2012 survey of students applying to both U.S. MD and DO schools found
that 9% of applicants were admitted only to an MD school, 46% were
admitted only to a DO school, 26% were admitted to both, and 19% were
not admitted to any medical schools. Geographic location was the top reason given by both DO and MD students for choosing the school in which they enrolled.
Of first-year medical students matriculating in 2016, 25.9% (7,369
students) entered US-DO schools and 74.1% (21,030 students) entered
US-MD schools.
The Association of American Medical Colleges projects that from 2016 to
2021, first-year DO student enrollment will increase by 19.4% versus a
5.7% increase in MD students.
Between 1980 and 2005, the annual number of new MDs remained stable at
around 16,000. During the same period, the number of new DOs increased
by more than 150% (from about 1,000 to about 2,800). The number of new MDs per 100,000 people fell from 7.5 to 5.6, while the number of new DOs per 100,000 rose from 0.4 to 0.8.
Geographic distribution
The
geographic distribution of MD and DO physicians is not uniform. As of
2012, the states with the greatest ratio of active physicians holding a
DO degree versus active physicians holding an MD degree were Oklahoma (20.7% of physicians), Iowa, Michigan, Maine, and West Virginia. During that same year, the states with the greatest ratio of active physicians holding an MD degree versus a DO degree were Louisiana, Washington, D.C., Massachusetts, Maryland, and Connecticut. The states with the greatest DO physicians in active practice are Pennsylvania, California, Florida, New York, Michigan, Texas, and Ohio. The states with the greatest per capita number of MD physicians are Washington, D.C., Massachusetts, Maryland, New York, and Connecticut. Doctors holding a DO degree are more likely to practice in rural areas.
The sex and racial distribution of DOs and MDs are similar.
Research and scholarly activity
In
comparison to allopathic medical schools, osteopathic medical schools
are criticized by some for a relative lack of research activity and
lesser emphasis on scientific inquiry. According to the Journal of the American Osteopathic Association,
the "inability to institutionalize research, particularly clinical
research, at osteopathic institutions has, over the years, weakened the
acculturation, socialization, and distinctive beliefs and practices of
osteopathic students and graduates."
Allopathic medical schools have applied for and received 800 times more funding for scientific and clinical research from the National Institutes of Health
than osteopathic schools have. Osteopathic schools ranked last out of
17 types of educational institutions, including veterinary medicine,
optometry, social work, and dentistry. In 2014, the Journal of the American Osteopathic Association
stated that research from osteopathic schools amounted to "fewer than
15 publications per year per school, and more than a quarter of these
publications had never been cited. Clearly, scholarly contributions from
osteopathic medical schools are unacceptably low in both quantity and
quality."
Cultural differences
Patient interactions
Several
studies have investigated whether there is a difference in the approach
to patients by MDs and DOs. A study of patient visits to general and family medicine
physicians in the U.S., including 277 million visits to MDs and 65
million visits to DOs, found that there was no significant difference
between DOs and MDs with regard to time spent with patients and
preventive medicine services.
The study of approximately 341 million healthcare visits founds
that there was no difference on the rate that doctors provided to
patients diet or nutrition counseling, weight reduction counseling,
exercise counseling, tobacco use or exposure counseling, and mental
health or stress reduction counseling. Some authors
describe subjective distinctions in patient interactions, but Avery
Hurt writes, "In actual practice, the variations between the two types
of physicians are often so slight as to be unnoticeable to patients, and
a day in the life of each can appear indistinguishable. The differences
are there—subtle, but deep."
Self-characterization and identification
A
study conducted during 1993–94 found significant differences in the
attitudes of DOs and MDs. The study found that 40.1% of MD students and
physicians described themselves as "socioemotionally" oriented over
"technoscientific" orientation. 63.8% of their DO counterparts
self-identified as socioemotional.
One study of DOs attempted to investigate their perceptions of
differences in philosophy and practice between themselves and their MD
counterparts. 88% of the respondents had a self-identification as osteopathic medical physicians, while less than half felt their patients identified them as such.
As the training of DOs and MDs becomes less distinct, some have
expressed concern that the unique characteristics of osteopathic
medicine will be lost.
Others welcome the rapprochement and already consider modern medicine
to be the type of medicine practiced by both "MD and DO type doctors."
One persistent difference is the respective acceptance of the terms
"allopathic" and "osteopathic." DO medical schools and organizations all
include the word osteopathic in their names, and such groups
actively promote an "osteopathic approach" to medicine. While
"osteopathy" was a term used by its founder AT Still in the 19th century to describe his new philosophy of medicine, "allopathic medicine" was originally a derogatory term coined by Samuel Hahnemann to contrast the conventional medicine of his day with his alternative system of homeopathic medicine.
Today, the term "allopathic physician" is used infrequently, usually in
discussions relating to comparisons with osteopathic medicine or
alternative medicine. Some authors argue that the terms "osteopathic"
and "allopathic" should be dropped altogether, since their original
meanings bear little relevance to the current practice of modern
medicine.
Medical education and training
Medical schools
The Liaison Committee on Medical Education (LCME) accredits the 144 U.S. medical schools that award the MD degree, while the American Osteopathic Association (AOA)'s Commission on Osteopathic College Accreditation (COCA) accredits the 38 osteopathic medical schools that award the DO degree. Osteopathic schools tend to be affiliated with smaller universities.
Michigan State University, Rowan University, and Nova Southeastern University offer both MD and DO accredited programs. In 2009, Kansas City University proposed starting a dual MD/DO program in addition to the existing DO program, and the University of North Texas explored the possibility of starting an MD program that would be offered alongside the DO program.
Both proposals were met with controversy. Proponents argued that adding
an MD program would lead to the creation of more local residency
programs and improve the university’s ability to acquire research
funding and state funding, while opponents wanted to protect the
discipline of osteopathy.
61% of graduating seniors at osteopathic medical schools
evaluated that over half of their required in-hospital training was
delivered by MD physicians.
Overall, osteopathic medical schools have more modest research programs
compared to MD schools, and fewer DO schools are part of universities
that own a hospital. Osteopathic medical schools tend to have a stronger focus on primary care medicine than MD schools.
DO schools have developed various strategies to encourage their
graduates to pursue primary care, such as offering accelerated 3-year
programs for primary care, focusing clinical education in community health centers, and selecting rural or under-served urban areas for the location of new campuses.
Osteopathic manipulative medicine
Many authors note the most obvious difference between the curricula of DO and MD schools is osteopathic manipulative medicine (OMM),
a form of hands-on care used to diagnose, treat and prevent illness or
injury and is taught only at DO schools. As of 2006, the average
osteopathic medical student spent almost 8 weeks on clerkships for OMM
during their third and fourth years. The National Institute of Health's National Center for Complementary and Integrative Health
states that overall, studies have shown that spinal manipulation can
provide mild-to-moderate relief from low-back pain and appears to be as
effective as conventional medical treatments. In 2007 guidelines, the American College of Physicians and the American Pain Society
include spinal manipulation as one of several treatment options for
practitioners to consider using when pain does not improve with
self-care. Spinal manipulation is generally a safe treatment for low-back pain. Serious complications are very rare.
A 2001 survey of DOs found that more than 50% of the respondents used
OMT (osteopathic manipulative treatment) on less than 5% of their
patients. The survey was the latest indication that DOs have become more
like MD physicians in all respects: fewer perform OMT, more prescribe
drugs, and many perform surgery as a first option.
One area which has been implicated, but not been formally studied
regarding the decline in OMT usage among DOs in practice, is the role of
reimbursement changes.
Only in the last several years could a DO charge for both an office
visit (Evaluation & Management services) and use a procedure (CPT)
code when performing OMT; previously, it was bundled.
Student aptitude indicators
There is a statistical difference in average GPA and MCAT
scores of those who matriculate at DO schools versus those who
matriculate at MD schools. In 2016, the average MCAT and GPA for
students entering U.S.-based MD programs were 508.7 and 3.70, respectively, and 502.2 and 3.54 for DO matriculants.
DO medical schools are more likely to accept non-traditional students,
who are older, coming to medicine as a second career, etc.
MD students take United States Medical Licensing Examination (USMLE)'s series of three licensing exams during and after medical school.
DO students are required to take the Comprehensive Osteopathic Medical Licensure Examination (COMLEX-USA) that is administered by the National Board of Osteopathic Medical Examiners
(NBOME). This exam is a prerequisite for DO-associated residency
programs, which are available in almost every specialty of medicine and
surgery. DO medical students may also choose to sit for the USMLE if they wish to take an MD residency and about 48% take USMLE Step 1.
However, if they have taken COMLEX, it may or may not be needed,
depending on the individual institution’s program requirements.
Residency
Currently, the ACGME accredits all MD residency programs, while the American Osteopathic Association (AOA) accredits all DO residency programs. DO students may choose to apply to ACGME-accredited residency programs through the National Resident Matching Program
(NRMP) rather than completing a DO residency. As of 2014, 54% of DOs in
post-doctoral training are enrolled in an ACGME-accredited residency
program and 46% are enrolled in an AOA-accredited residency program.
Since 1985, a single residency training program can be dual-accredited by both the ACGME and the AOA.
The number of dually accredited programs increased from 11% of all AOA
approved residencies in 2006 to 14% in 2008, and then to 22% in 2010.
In 2001, the AOA adopted a provision making it possible for a DO
resident in any MD program to apply for osteopathic approval of their
training.
The topic of dual-accreditation is controversial. Opponents claim that
by merging DO students into the "MD world," the unique quality of
osteopathic philosophy will be lost.
Supporters claim the programs are popular because of the higher
prestige and higher resident reimbursement salaries associated with MD
programs.
Over 5 years starting in July 2015, the AOA, AACOM, and the ACGME
will create a single, unified accreditation system for graduate medical
education programs in the United States.
This will ensure that all physicians trained in the U.S. will have the
same graduate medical education accreditation, and as of June 30, 2020,
the AOA will cease its accreditation functions.
There are notable differences in the specialty choices of DOs and MDs. 60% of DOs work in primary care specialties, compared to 35% of MDs.
Steps to licensure
| MD | DO | |||||
|---|---|---|---|---|---|---|
| Standardized admissions examination | Medical College Admission Test (MCAT) | |||||
| Medical school application service | AMCAS/TMDSAS | AACOMAS/TMDSAS | ||||
| Years of medical school | 4 | |||||
| Medical Licensing Exams (MLE) | USMLE required |
| ||||
| Residency (Current) |
MD (ACGME) | One must be selected:
| ||||
| Residency (After June 30, 2020) |
ACGME | |||||
| Board certification | MD medical specialty boards | Either DO or MD medical specialty boards | ||||
Continuing medical education
To maintain a professional license to practice medicine, U.S.
physicians are required to complete ongoing additional training, known
as continuing medical education
(CME). CME requirements differ from state to state and between the
American Osteopathic Medical Association (DO) and the American Medical
Association (MD) governing bodies.
International Recognition
An
MD is accepted worldwide, while the DO degree is accepted in 45
countries abroad. Accredited DO and MD medical schools are both included
in the World Health Organization’s World Directory of Medical Schools.
MDs and DOs are both accepted by international medical organizations such as Doctors Without Borders.
