Comparison of MD and DO in the United States

This article discusses similarities and differences between doctors of osteopathic medicine (DOs) and doctors of medicine (MDs) in the United States.

Holders of a DO are known as osteopathic physicians, while holders of an MD are sometimes referred to as allopathic physicians when a distinction is made, although this term is not universally accepted and may be considered by some to be pejorative. There is disagreement on the extent of the difference between osteopathic and conventional medicine. According to the Cecil Textbook of Medicine, 22 ed., other than teaching manipulation,  medical training for an osteopathic degree (DO) is now virtually indistinguishable from that which leads to the MD degree. Osteopathic physicians complete conventional residencies in hospitals and training programs; are licensed in all states; and have rights and responsibilities, such as military service, that are identical to MD qualified physicians and surgeons.

History
There is a history of territorialism between the MD and DO qualified physicians' worlds, though animosity between the groups has subsided in recent years. In 2005, Jordan Cohen, the president of the Association of American Medical Colleges wrote, 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
The gender and racial distribution of MDs and DOs are similar. There are significantly more MDs than DOs. In 2004, 17,000 students matriculated as first-year students at MD programs, while 3,800 students matriculated at osteopathic programs, a ratio of 5 MD students for every 1 osteopathic student.

Changing numbers
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 140% (from about 1,150 to about 2,800). Osteopathic graduates are expected to increase to 3,300 by the year 2010 and as many as 4,000 by 2015. 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.

Cultural differences
Some authors describe less quantifiable distinctions between the two. 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. But the differences are there, subtle but deep." Several studies have investigated these differences. One compared the patient interactions of MDs and DOs. The study found that "osteopathic physicians were more likely to use patient's first names and to discuss the social, family and emotional impact of illnesses." For example, "66% of DOs discussed a patient's emotional state compared with about one-third of MDs." The same study found that MD qualified "physicians scored higher in discussing literature or scientific basis of treatment." Another study analyzed 341.4 million patient visits to general and family medicine specialists in the United States, including 64.9 million visits to osteopathic physicians and 276.5 million visits to MDs. It found that there was no significant difference between MDs and DOs "with regard to time spent with patients and preventive medicine services."

Self-characterization
A Harvard study found significant differences in the attitudes of MDs and DOs. The study found that 40.1% of MD students and physicians described themselves as "socioemotionally" oriented over "technoscientific" orientation. 63.8% of their osteopathic counterparts self-identified as socioemotional. (p < .0001)

Perceptions
One study of osteopathic physicians 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 physicians, but less than half felt their patients identified them as such. The study asked respondents to identify points of philosophical and practical difference between MDs and DOs; no more than 1/3 of respondents could agree on any single such point of difference.

Self-identification
As the training of DOs and MDs becomes less distinct, some have expressed concern that their unique characteristics 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." Osteopathic medical organizations and medical schools all include the word osteopathic in their names, and such groups actively promote an "osteopathic approach" to medicine. This is in sharp contrast with the term allopathic. No major medical society or medical school includes the word allopathic in its title, nor do they adhere to an allopathic approach to medicine. However, as interest in alternative medical therapies increases, the term allopathic has been used to describe conventional medical practices - a usage which many have criticized. Indeed, many reject the term allopath as derogatory.

Medical schools
The Liaison Committee on Graduate Medical Education (LCME) accredits the 131 US medical schools that award the MD, while the American Osteopathic Association (AOA) Commission on Osteopathic College Accreditation (COCA) accredits the 25 colleges of osteopathic medicine in 28 locations in the United States that award the DO degree. There are only two US universities that have accredited programs that give both MD and DO qualifications: Michigan State University, and the University of Medicine and Dentistry of New Jersey.

Osteopathic manipulative medicine
Many authors note the most obvious difference between the curricula of DO and MD schools, Osteopathic Manipulative Medicine (OMM), a type of manual therapy taught at only osteopathic schools. Natural Standard, a complementary and alternative medicine group, lists several types of injuries and illnesses in which evidence-based studies suggest OMM may provide some benefit. A 2001 survey of osteopathic physicians 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 osteopathic physicians have become more like MD qualified physicians in all respects: fewer perform OMT, more prescribe drugs, and many perform surgery as a first option.

Applicant aptitude indicators
Some authors note the differences in average GPA and MCAT scores of those who matriculate at DO schools versus those who matriculate at MD schools within the United States. In 2007, the average MCAT score and GPA was 30.9 and 3.66 for students entering US-based MD programs, and 25.3 and 3.45 for DO applicants. As many as one out of every three students admitted to an osteopathic medical school has been previously rejected by MD programs. In general, Osteopathic Medical students have a pass rate less than that of their MD counterparts (81% vs 93%) on the United States Medical Licensing Exam (USMLE), as well as a failure rate more than 3 times as high. Among DO graduates who take Step 3 of the USMLE exam, however, pass rates for first-time takers are identical (95%) to those of first-time takers who are MD graduates. . Osteopathic students who do not wish to apply into MD-associated residency programs are not required to take the USMLE and instead take the three-part Comprehensive Osteopathic Medical Licensure Examination (COMLEX) that is sponsored by the National Board of Osteopathic Medical Examiners (NBOME) and which is a prerequisite for DO-associated residency programs, which are available in almost every specialty of medicine and surgery. Furthermore, the same study notes that "despite correlations between MCAT and Step 1 licensing exams, correlations between the latter and clinical performance are weak. Performance as a physician correlates better with proficiency in the humanities and with personal characteristics such as motivation, conscientiousness, integrity, empathy, and a robust psychological constitution." The author notes that the "better performance [of Osteopathic students] on their own National Board of Osteopathic Medical Examiners (NBOME) exam has been attributed to its greater emphasis on clinical context."

Residency
Graduates of both osteopathic and MD certified medical schools are eligible to apply to residency programs through the National Resident Matching Program (NRMP). In 2003, 99% of new US MDs and 43% of new US osteopaths went on to train in ACGME-accredited residency programs.

The American Osteopathic Association accredits osteopathic residency programs. There have been calls to end the remaining barriers between the two types of programs. Since 1985, a single residency training program can be dual-accredited by both the ACGME and the AOA.

In 2001, the AOA adopted a provision making it possible for a resident (who is a DO) in any MD program to apply for osteopathic approval of their training. The topic of dual-accreditation is controversial. Opponents claim that by merging osteopathic 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. MDs are generally not permitted to train in osteopathic (AOA-accredited) residencies, though this has become a subject of debate within the osteopathic profession. The American Osteopathic Association has agreed to study the issue of permitting MDs to train in DO (AOA-accredited) residencies.

Primary Care
There are notable differences in the specialty choices of MDs and DOs. One study attributes this to a difference in the 'cultures' of their medical schools. "In comparison with allopathic schools [MD], the cultural practices and educational structures in osteopathic medical schools better support the production of primary care physicians." According to one survey, 54.6% of deans of conventional medical schools reported that training future primary care physicians was more important to their institutions than training future specialist physicians, compared with 100% of osteopathic medical school deans. (F = 893.11,95, p < .0001).

Continuing medical education
To maintain a license to practice medicine, US physicians are required to complete additional training every few years, so called continuing medical education, CME. There are subtle differences in the CME requirements for MD and DO qualified physicians, and in how these CME credits are approved. The requirements for maintaining a physician license for MD or DO qualified physicians are almost identical in most states, though there are small differences. For example, in the case of Pennsylvania, MD licenses begin on December 31, whereas DO ones begin on October 31.

Professional advantages for MD qualified physicians
MD qualification training is the most widely available and recognized type of medical training. Like the DO, it gives the option to practice in any of the medical specialties, but unlike the DO, the MD is internationally recognized as a medical degree. Thus, when practicing overseas, the MD is easier to negotiate with than is the DO, where the DO degree isn't always understood or recognized. Because they are a minority in American medicine, DOs are more likely than their MD counterparts to have to explain or even defend their training. In the United States, ACGME-accredited residency training programs are generally considered more prestigious and offer higher reimbursement salaries. The majority of US osteopathic medical students attend ACGME-accredited residency programs. Based on a 2004 publication, the most common reason given by osteopathic medical students choosing an ACGME residency is the perception among osteopathic graduates that ACGME programs offer superior training.