Osteopathic Manipulative Medicine (OMM) in the American Healthcare System

00:01 So let’s talk about osteopathic medicine in specific.

00:06 Osteopathic medicine started in 1874 when A.T. Still flung the banner of osteopathy into the wind and started talking about natural healing.

00:15 1874 was before antibiotics, before sterile technique, and before sterile surgery.

00:22 It was a very, very different environment, and in that environment, we had eclectic physicians who used multiple different philosophies.

00:30 We had homeopathic physicians looking at like healing like.

00:34 We had allopathic physicians who trained in the apprentice model and osteopathic physicians whom also started off as an apprentice-based training which looked at natural healing and the innate ability of the body to heal itself, of working within the individual, and for the individual.

00:52 And this is because A.T. Still wasn’t happy with the prevailing health of the time, saying it was too confusing to people, people didn’t know what to expect, and he felt having a philosophy— having a standard mattered.

01:05 So, he opened up an osteopathic medical school in Kirksville, Missouri shortly after 1874.

01:10 He admitted women and he admitted minorities.

01:12 He wanted a holistic class and a holistic system where people learned together.

01:19 He set up a system where there was only one class a year, that became a learning community, and students taught each other.

01:26 He had competition though.

01:29 Others started schools that were quicker and said, “Let’s boil this down to teaching you only the techniques you need to know and let’s focus only on the musculoskeletal system,” and he said, “No. This is about thinking.

01:42 This is about working through problems from the individual basis.” And because of the competition, he was forced to make changes and he said, “No longer are you going to learn only what’s in this book, we’re going to be science based. We’re going to change based on what we learn and it’s not 500 hours of musculoskeletal medicine education, it’s a philosophy that stands behind the education.” So in 1897, osteopathic medicine stated it was science based and it would change with the times, and that meant, while initially surgery was not taught— in 1910, sterile technique was introduced— Lister said that you have to wash your hands and you have to avoid contaminating a sterile field.

02:27 And by 1926, it was mandated that every osteopathic medical school teach surgery.

02:33 Pathology was also added at that time and pharmacology was added as well.

02:39 So as these sciences advanced, they were adopted by osteopathic medicine.

02:45 We also developed our own GME and our own hospitals because if we were going to train generalists first who then specialize and if we were going to train doctors who learned how to take care of people, it was important that we train in environments where this was valued.

03:02 And Flexner, which came about in the early 1900’s, said there should not be departments of family medicine in MD schools, that education should be specialty based and osteopathic medicine went the other way and said, “No. This should be generalist based.

03:18 You need to understand the person before you understand the disease, and every disease will effect people differently, and people may have different desires.” So understanding that is important in having a supportive system where people who think alike will work together mattered.

03:37 So the osteopathic internship was developed which was a rotating internship where you spent time in every field and you learned to be a general physician before you could specialize.

03:50 So a separate hospital system developed and there were, at its height, 3000 osteopathic institutions that served communities, that did it all for the community.

04:01 Then in the 1990’s to 2000, there was a consolidation of the healthcare industries and our hospitals, the osteopathic hospitals, became part of allopathic hospitals.

04:12 They became part of systems and things changed, and we have to adopt to the new system.

04:20 We had separate licensure in many states where you can get licensed as a DO or an MD.

04:26 At this point, most states have joint licensure where it’s the same requirements for both MD’s and DO’s, and osteopathic medical school gives you full training and licensing to do everything any other physician is licensed to do.

04:43 The 500 to 600 hours that you were trained in musculoskeletal medicine is decreasing.

04:49 Right now, the average is about 210 and that’s all you get in osteopathic medical school, the rest is saved for residency.

04:57 But along with these changes, and the closure of osteopathic hospitals, led to a change to where there’s no longer a requirement for an osteopathic internship.

05:07 In 1992, the testing came together and you could take the osteopathic boards with training in ACGME hospitals, and that changed a lot.

05:18 So the self-regulation that we have overlaps with the regulation of the ACGME and state licensing boards.

05:26 We’re still in the transition.

05:28 At this point in 2018, there’s still 5 states that require the osteopathic internship which would no longer exist as a freestanding osteopathic internship after 2020.

05:40 So there are a lot of changes going on right now.

05:45 We still have a requirement that to graduate from an osteopathic medical school you have to pass the NBOME exams.

05:51 So you take the osteopathic exams to get licensed and then you have the option of choosing osteopathic boards for specialization or the ABMS boards.

06:01 The NBME still lets you take board exams out of sequence and the flex no longer exists.

06:07 That was done away with and merged within the USMLA which is part of the NBME.

06:14 When you get out into practice, each hospital and each healthcare facility will have their own way of credentialing you, and credentialing is saying you may be licensed to do something, but we want to makes sure that for our institution you understand how we work, what resources we have, and what tools we have to make sure you’re comfortable doing it.

06:33 So if you’re going to deliver a baby in 1 hospital, you have to know what their surgical suites are like and what tools they have, and that’s credentialing for within a particular system.

06:44 For DO’s, what do you have to do for EMGs, or if you want to do nerve conduction velocities how do you get there.

06:52 So credentialing is an individual institutional issue, not a state issue and not a professional issue.

06:59 So the profession can say you’re able to do it but then to do it in a facility that will support you, you need to be credentialed.

07:07 So again, accreditation is the institution, certification is the individual, and credentialing is within the place you’re doing a procedure or caring for a specific person a specific way, you get credentialed.

07:21 So again, “WTF,” they’re going to credential you to treat the feet.

07:26 They may have different requirements if you want to treat the abdomen.

07:31 So if you want to train in an osteopathic environment, it’s typically community settings.

07:37 It’s typically outpatient and inpatient.

07:40 One of the big differences between LCME and COCA requirements, LCME has you train mostly in academic institutions and very little time allowed outside in an office or an outpatient setting.

07:54 DO’s train more now in patient settings and they still have to train in academic institutions, but because the majority of care is achieved in outpatient settings and offices, that’s where a lot of training has to occur.

08:09 So a lot of DO’s will train in critical access hospitals, community hospitals, and smaller areas of practice.

08:15 We’ll get to the Tenets and the philosophy underlying it in the next lecture, but it is important to understand the structure and function relationship, the idea of the body’s innate ability to heal itself, and how we look at the musculoskeletal system in health and illness.

08:33 This becomes much more important in the current environment where people want to say what they’re getting and what kind of care they want because people want health now.

08:42 They want to optimize what they’re able to do and that’s part of our Tenets in starting from where the patient is and starting from what we can do to optimize their health and make their functioning easier and more comfortable.