Doctor of Osteopathic Medicine
|Andrew Taylor Still (founder)|
The Doctor of Osteopathic Medicine (D.O.) is a professional doctoral degree for physicians and surgeons offered by medical schools in the United States. A D.O. graduate may become licensed as an osteopathic physician, having equivalent rights, privileges, and responsibilities as a physician who has earned the Doctor of Medicine (M.D.) degree. D.O. physicians are licensed to practice the full scope of medicine and surgery in 65 countries, and in all 50 U.S. states. They constitute 7% of all U.S. physicians. As of 2016, there were more than 129,000 osteopathic medical physicians and osteopathic medical students in the United States.
In the US, D.O. degrees are offered at 34 medical schools at 51 locations in 32 states, compared to M.D. degrees offered at 140 schools. Since 2007, total D.O. student enrollment has been increasing yearly. In 2015, more than 20% of all medical school enrollment in the US comprised D.O. students. The curricula at osteopathic medical schools are similar to those at M.D.-granting medical schools, which focus the first two years on the biomedical and clinical sciences, then two years on core clinical training in the clinical specialties.
Upon completing medical school, a D.O. graduate may enter an internship or residency training program, which may be followed by fellowship training. Some D.O. graduates attend the same graduate medical education programs as their M.D. counterparts, and then take M.D. specialty board exams, while other D.O. graduates enter osteopathic programs, and take D.O. specialty board examinations.
One notable difference between D.O. and M.D. training is that D.O. training adds 300 – 500 hours studying techniques for hands-on manipulation of the human musculoskeletal system.
The practice of osteopathy began in the United States in 1874. The term "osteopathy" was coined by physician and surgeon Andrew Taylor Still, MD, DO. Still named his new school of medicine "osteopathy," reasoning that "the bone, osteon, was the starting point from which [he] was to ascertain the cause of pathological conditions." Still founded the American School of Osteopathy (now A.T. Still University of the Health Sciences) in Kirksville, Missouri, for the teaching of osteopathy on May 10, 1892. While the state of Missouri granted the right to award the MD degree, he remained dissatisfied with the limitations of conventional medicine and instead chose to retain the distinction of the DO degree. In 1898 the American Institute of Osteopathy started the Journal of Osteopathy and by that time four states recognized the profession.
The osteopathic medical profession has evolved into two branches: non-physician manual medicine osteopaths who were educated and trained outside the United States and U.S. trained full scope of medical practice osteopathic physicians. The regulation of non-physician manual medicine osteopaths varies greatly between jurisdictions. In the United States, osteopathic physicians holding the D.O. degree have attained the same rights, privileges, and responsibilities as physicians with a Doctor of Medicine (M.D.) degree. Osteopathic physicians and non-physician osteopaths are so distinct that in practice they function as separate professions.
As originally conceived by Andrew Still, the letters "DO" stood for "Diplomate in Osteopathy" and the title conferred by the degree was "Doctor of Osteopathy". Subsequently, the degree also came to be entitled "Doctor of Osteopathic Medicine", and in more recent times the AOA has preferred that this title be used exclusively, resolving in a 1960 conference:
Be it resolved, that the American Osteopathic Association institute a policy, both officially in our publications and individually on a conversational basis, to use the terms osteopathic medicine in place of the word osteopathy and osteopathic physician and surgeon in place of osteopath; the words osteopathy and osteopath being reserved for historical, sentimental, and informal discussions only.
Nevertheless, a minority of DOs continue to use the old terms and the American Academy of Osteopathy retains the old usage in its name.
In 2015, there were 96,954 osteopathic medical doctors in the United States and 123,075 total DOs and osteopathic medical students. The proportion of females in the profession has steadily increased since the 1980s. In 1985, about 10 percent of D.O. physicians were female, compared with 40 percent in 2015. Between 2008 and 2012, 49 percent of new D.O. graduates were females.
During the 2011-12 academic year, the osteopathic medical student body consisted of: 69 percent white/non-Hispanic, 19 percent Asian or Pacific Islander, 3.5 percent Hispanic, 3 percent African-American, and 0.5 percent Native American or Alaskan. The remainder were listed as "other or not entered." The five-year change in osteopathic medical student enrollment by ethnicity has increased by 19 percent for white/non-Hispanic students, 36 percent for Asian-American students, 24 percent for Black/African American students and 60 percent for Hispanic/Latino students.
Education, training and distinctiveness
Osteopathic medical school curricula are virtually identical to those at schools granting the M.D. degree (Doctor of Medicine). Once admitted to an osteopathic medical school, it takes four years to graduate, and the schooling is divided into the pre-clinical and clinical years. The pre-clinical years, the first and second years, focus on the biomedical and clinical sciences. The clinical years, the third and fourth years, consist of core clinical training and sub-internships in the clinical specialties. Osteopathic medical school accreditation standards require training in internal medicine, obstetrics/gynecology, pediatrics, family medicine, surgery, psychiatry, emergency medicine, radiology, preventive medicine, and public health. According to Harrison's Principles of Internal Medicine, "the training, practice, credentialing, licensure, and reimbursement of osteopathic physicians is virtually indistinguishable from those of physicians with M.D. qualifications, with 4 years of osteopathic medical school followed by specialty and subspecialty training and board certification."
D.O. schools provide an additional 300–500 hours in the study of hands-on manual medicine and the body's musculoskeletal system, which is referred to as osteopathic manipulative medicine (OMM). Historically, osteopaths subscribed to the view that such body manipulation can bring about systemic healing – a belief which is a form of pseudomedicine – but today American osteopathic physicians have largely evolved away from such pre-scientific ideas. Osteopathic physicians who use OMM predominantly use it to treat musculoskeletal conditions, for which there is conflicting evidence. Particular criticism has been targeted at craniosacral therapy, a component of OMM taught at many D.O. schools that has limited scientific support.
Even though the D.O. is a professional degree and not a research doctorate (i.e., a Ph.D.), many holders of the D.O. degree conduct clinical and basic scientific research and publish in peer-reviewed journals during training and after graduation; an academic physician whose work emphasizes basic research is called a physician-scientist. Combined medical and research training is offered through programs granting an DO/PhD.
Before entering osteopathic medical school, an application must complete a four-year undergraduate degree and take a national standardized exam called the Medical College Admissions Test (MCAT); however, some combined undergraduate/medical programs exist. Some authors note the differences in the average MCAT scores and grade point average of students who matriculate at D.O. schools compared to those who matriculate at M.D. schools within the United States. In 2015, the average MCAT and GPA for students entering U.S.-based M.D. programs were 31.4 and 3.70, respectively, and 27.33 and 3.55 for D.O. matriculants, although the gap has been getting smaller every year. D.O. medical schools are more likely to accept non-traditional students who are older and entering medicine as a second career or coming from non-science majors.
D.O. medical students are required to take the Comprehensive Osteopathic Medical Licensure Examination (COMLEX-USA), which is sponsored by the National Board of Osteopathic Medical Examiners (NBOME). The COMLEX-USA is series of four osteopathic medical licensing examinations. The first two steps of the COMLEX-USA are taken during medical school and are prerequisites for osteopathic residency programs, which are available in almost every specialty of medicine and surgery. The third step exam consists of a written portion and a physical exam evaluation. The physical exam evaluation (COMLEX- PE), is only available in select regions in the country and graded as a PASS/FAIL exam. Finally, the step 4 portion of the COMLEX is taken during residency.
In addition to the COMLEX-USA, D.O. medical students may choose to sit for the M.D. licensure examinations, which are called the United States Medical Licensing Examination (USMLE). This is typically done if the student desires to enter an M.D. residency. However, this is not always required, as some M.D. residency programs do not require the USMLE from D.O. applicants. USMLE pass rates for D.O. and M.D. students in 2012 are as follows: Step 1: 91% and 94%, Step 2 CK: 96% and 97%, and Step 2 CS: 87% and 97%, respectively (this number may be misleading as only 46 D.O. students compared to 17,118 M.D. students were evaluated for Step 2 CS) Step 3: 100% and 95% (this number may be misleading, as only 16 D.O. students compared to 19,056 M.D. students, were evaluated for Step 3).
Licensing and board certification
To obtain a license to practice medicine in the United States, osteopathic medical students must pass the Comprehensive Osteopathic Medical Licensing Examination (COMLEX), the licensure exam administered by the National Board of Osteopathic Medical Examiners throughout their medical training. Students are given the option of also taking the United States Medical Licensing Examination (USMLE) to apply for some Accreditation Council for Graduate Medical Education (ACGME) residency programs. Those that have received or are in the process of earning an M.D. or D.O. degree are both eligible to sit for the USMLE. Because of their additional training, only D.O. candidates are eligible to sit for the COMLEX.
Upon completion of internship and residency requirements for their chosen medical specialty, and depending on whether the program attended as ACGME or AOA accredited, holders of the D.O. may elect to be board certified by either a specialty board (through the American Medical Association's American Board of Medical Specialties) or an osteopathic specialty board (through the American Osteopathic Association Bureau of Osteopathic Specialists certifying boards). In February 2014, the American Osteopathic Association and the Accreditation Council for Graduate Medical Education agreed to unify allopathic and osteopathic Graduate medical education starting in 2020.
Depending on the state, medical licensure may be issued from a combined board (D.O. and M.D.) or a separate board of medical examiners. All of the 70 state medical boards are members of the Federation of State Medical Boards.
Currently, there are no osteopathic programs located outside of the United States that would qualify an individual to practice as an osteopathic physician in the United States. Foreign osteopathic degrees are not recognized by any state in the U.S. as being equivalent to American D.O. degrees.
International practice rights
The following is an "International Licensure Summary" for U.S.-trained Doctors of Osteopathic Medicine, as listed by the American Osteopathic Association:
|Country||Year of Latest Policy||Medical Practice Rights||Requirements for Licensure|
|Argentina||2006||Unlimited||Foreign physicians must submit credentials to various agencies and then appear before any of the National Universities in order to have their diploma recognized.|
|Australia||2013||Unlimited||According to documents published online, the Medical Board of Australia has “agreed to accept the DO USA as a primary medical qualification for the purposes of medical registration provided that the DO USA was awarded by a medical school which has been accredited by the Commission on Osteopathic College Accreditation.”"|
|Austria||2009||Unlimited||Hospital must have position unable to be filled by Austrian physician.|
|Bahamas||2004||Unlimited||U.S. license recognized.|
|Bahrain||2010||Unlimited||U.S. license recognized.|
|Belize||2009||Unlimited||Must complete a Belizean residency for permanent license eligibility.|
|Bermuda||1997||Unlimited||Required at least 2 years of GME and examination or interview by the Council’s Examination Committee. Non-Bermudans must have approval from the Ministry of Labour & Home Affairs to work on the island.|
|Brazil||2007||Unlimited||Completion of Brazilian board exam, establishing residency & some training in Brazilian hospital is required.|
|Canada||Alberta||Unlimited||Requires at least 2 years of GME accredited by the ACGME or AOA and must have passed the Universities Coordinating Council Exam, a basic sciences exam, and have passed all three parts of the LMCC.|
|British Columbia||Unlimited||Requires at least 1 year of GME approved by the AOA or the ACGME, completed at least 1 year of GME in Canada, passed all three parts of the LMCC.|
|Manitoba||Unlimited||U.S. license recognized.|
|New Brunswick||Unlimited||Requires at least 2 years of GME approved by the AOA or the ACGME and have passed all 3 parts of the LMCC. Reciprocity pathway for D.O. physicians with a Maine license.|
|Newfoundland||Unlimited||The Medical Act 2011 allows full licensure of osteopathic physicians, both for the country’s full registry & its educational registry.|
|NW Territories||Unlimited||U.S. license recognized.|
|Nova Scotia||Unlimited||Requires a Canadian or ACGME residency.|
|Ontario||Unlimited||Requires a Canadian or ACGME residency.|
|Prince Edward Island||Unlimited|
|Quebec||Unlimited||Requires 1 year of GME approved by the AOA or ACGME, 1 year of GME in Quebec passed the written, oral and clinical board examination of the College of Family Physicians of Canada and must speak French fluently.|
|Yukon Territory||Unlimited||U.S. license recognized.|
|Cayman Islands (UK)||1983||Unlimited||U.S. license recognized.|
|Central African Republic||1990||Unlimited||U.S. licensure and annual attendance at the National Congress for Physicians.|
|Chile||2008||Unlimited||A written exam in Spanish is required, besides a series of practical tests involving common procedures (CPR, intubation, lumbar puncture, etc.).|
|China||2009||Unlimited||U.S.-D.O. physicians are permitted to apply for "Short Term Medical Practice."|
|Colombia||1996||Unlimited||Same requirements as other foreign physicians.|
|Costa Rica||2009||Unlimited||Same requirements as other foreign physicians.|
|Dominican Republic||2000||Unlimited||U.S. license & board certification recognized.|
|Ecuador||1990||Unlimited||Same requirements as other foreign physicians. Reciprocity exists with most Latin American countries.|
|Ethiopia||2011||Unlimited||Must renew the license every 5 years.|
|Finland||1996||Unlimited||Same requirements as other foreign physicians.|
|France||2009||Limited||OMM only. The French government does not recognize the full scope of practice osteopathic medicine.|
|Germany||2008||Unlimited||Same requirements as other foreign physicians. Depends on need. Decisions made on individual basis.|
|Greece||2009||Unlimited||Greek citizenship required, unless, in rare instances, there exists a crucial need for certain types of specialist physicians. Further, a work permit must be obtained, a difficult task, and speaking Greek is an unwritten requirement. These are the same requirements as other foreign physicians.|
|Grenada||2007||Unlimited||U.S. license recognized.|
|Guyana||1996||Unlimited||Case-by case basis.|
|Honduras||2009||Unlimited||National Autonomous University must accredit all foreign titles. After accreditation is completed, the applicant must seek registration with the Medical College of Honduras (MCH).|
|Hong Kong||1998||Unlimited||Written examination. Personal interview. Training approval.|
|India||2012||Unlimited||Unlimited for short-term work.|
|Indonesia||1992||Unlimited & Restricted||Foreign physicians affiliated with a university project or a mission have unlimited practice rights. No private practice allowed.|
|Iran||2009||Unlimited||Iranian citizens who have received both the DO degree from a US osteopathic school and are board certified in a clinical specialty. Osteopathic degrees from other countries are not accepted. The process of evaluation of the medical education and clinical training is under the jurisdiction of the Ministry of Health and Medical Education (MoHME).|
|Israel||2007||Unlimited||Same requirements as other foreign physicians. Hebrew required.|
|Italy||2009||Unlimited||Physicians are discouraged from seeking employment in Italy without firm contracts and work permits. If there is a U.S. state law outlining reciprocity with Italy, a statement to this effect from the Italian Consulate will warrant better chances.|
|Jamaica||1994||Limited & Restricted||D.O. physicians were permitted to supply some services while participating in a specific mission project.|
|Lebanon||2004||Unlimited||AOA letter required. Examination required.|
|Lesotho||1990s||Unlimited||Applicants must appear before the Medical, Dental and Pharmacy Council to answer some medical questions and present their credentials. The Council will also make a recommendation about where the applicant’s skills would be most helpful in the country.|
|Liberia||1990s||Unlimited||Same requirements as other foreign physicians.|
|Luxembourg||1987||Unlimited||The practice of medicine in Luxembourg by a doctor who is not an EU national is very rare.|
|Malta||2010||Unlimited||Accepted on a case by case basis if training meets the minimum educational requirements for physicians in the EU (Article 24 of Directive 2005/36/EC). Examination required.|
|Mexico||2011||Unlimited & Restricted||Health Secretary Quijano of the Yucatán State of Mexico signed a Proclamation recognizing U.S.-trained osteopathic physicians in that state; D.O. physicians can now obtain short-term & long-term licensure through the Health Secretary’s office. All other Mexican states require work permits - only available in conjunction with the association of a short-term medical mission project.|
|Micronesia||1993||Unlimited||Statutes specifically include DOs|
|Nepal||2008||Unlimited||Approval by the Nepal Medical Council & a visa from the Immigration Department.|
|Netherlands||2009||Unlimited||Same requirements as other foreign physicians.|
|New Zealand||2008||Unlimited||Hearing required. Case-by-case basis.|
|Nigeria||2010||Unlimited||U.S. Licensure and completion of specialty training required.|
|Norway||2009||Limited||OMM only, but DOs may apply for recognition as medical doctors.|
|Pakistan||2011||Unlimited||U.S. osteopathic medical schools meet the Medical and Dental Council’s statutory regulations for international medical graduates. Scope is unlimited, but practice setting may be restricted|
|Panama||2009||Unlimited||Panamanian citizenship required.|
|Papua New Guinea||2010||Unlimited||Work permit required. Short-term or a long-term volunteer service license also available.|
|Peru||2011||Unlimited||Process for licensure is the same as for other IMGs.|
|Poland||2009||Unlimited||Examination & Polish required.|
|Qatar||2011||Unlimited||Must possess a valid work visa, and pass written and oral examinations.|
|Russia||2006||Unlimited||Foreign physicians make arrangements to practice through Russian sponsors, such as hospitals or businesses.|
|Saint Lucia||2000||Unlimited||U.S. credentials recognized.|
|Saudi Arabia||2009||Unlimited||Foreign physician must be recruited by a government agency, a corporation or a private health care entity, such as a hospital.|
|Sierra Leone||1993||Unlimited||Notarized U.S. credentials.|
|South Africa||2009||Limited||OMM only|
|Sweden||2005||Unlimited||U.S. license recognized.|
|Taiwan||2008||Unlimited||The ROC government recognizes U.S. D.O. degree. Applicants must take Taiwan Examination Yuan to obtain Taiwanese license.|
|Tanzania||1985||Unlimited||U.S. license & GME recognized. Temporary work permits are available|
|United Arab Emirates||2009||Unlimited||Examination required.|
|United Kingdom||2005||Unlimited||U.S.-trained D.O. physicians are eligible for full medical practice rights. Applicants must pass the PLAB examination and work for one year in the National Health Service. Following that year, the applicants will be able to apply for a license to practice privately. For GMC registration as a specialist, postgraduate training will need to be separately recognized by the Postgraduate Medical Education and Training Board (PMETB). GOsC registration is also required.|
|Venezuela||2007||Unlimited||Recognized legal status under the "law of the practice of medical."|
|Vietnam||1995||Unlimited||Foreign physicians can fill vacancies in hospitals that are in need of certain specialists.|
|Zambia||2009||Unlimited||U.S. licensure required.|
|OMM: Osteopathic Manipulative Medicine|
Notes and references
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