Letter to the AACOM Society of Osteopathic Medical Educators (SOME)

Long response to the following question posed after completion of a national conference:

What educational projects can SOME sponsor that will be of benefit to your campus, and the profession?

One of the most perplexing issues that continues to face the profession remains full faced and largely un-addressed in the literature and in research today largely because there has not been a concerted effort to define the Distinctiveness of Osteopathic Medicine on its own terms. What has been promulgated through all our education programs is that DO ≠ MD + OMM.

This has been characterized as a valid thought process. In fact there is something that appears illusory in reference to research paradigms to qualify and/or quantify that statement. In our efforts to demonstrate the other half of that promulgated idea, that we are separate or distinct but equal, we have gone far to demonstrate our professional qualifications as deliverers of specialized medical health care. Those very efforts have obscured the visibility of the underlying differences that actually can be measured in social science terms through heuristic and salutogenic research (more about this in a second).

These same professors and practitioners that claim separate but distinct have failed to show the distinctiveness because the research models they have been using to do so, are not capable of measuring the desired information. This is a common flaw found in unsuccessful research in all the sciences. In using a reductive reasoning approach these same researchers have also missed the target due to the fact that the measures are not parameters of health but of disease. This problem of not showing our distinctiveness has become so large that the ACGME merger has been proposed and renaming largely unopposed “except in principle” by many. The reason for its continued success so far, has been that  the distinctiveness of the profession has not been successfully defended because there is lack of proof of distinction. (see the wiki article on this as one readily accessible condensation of the argument for the merger ( http://en.wikipedia.org/wiki/Osteopathic_medicine_in_the_United_States ).  This has been accepted as proof that there is no difference. Any student of pure logic knows that this conclusion though it may be correct in the end result is not in fact a valid proof. In essence it says if we don’t see it, it does not exist. In that light we can see there is a potentially grave error in our scientific thought process about this that needs exploration prior to taking action on a topic that has huge potential influence on the practice of Osteopathic Medicine.

So the question for this group is, What is the difference, the distinction of an osteopathic education or an osteopathic thought process?

Correctly, our educational forefathers described this perfectly and yet we have not yet even sought to prove the principles suggested. There is an underlying principle and/or discipline of thought that seeks to address a difference in patient perception and patient interaction. This is essentially a discretely different issue that is measurable through a different approach to research. Salutogenesis and its application is exactly one such research paradigm that addresses this very specifically. It’s basic concept was introduced to the medical research community in 1977 (Antonovsky) although its foundational ideas go back in history to ancient greek writings. These principles were the underlying thoughts behind Dr. Stills proclamation of Osteopathy as a distinct and separate philosophy of practice that should someday underlie the physician/patient interaction across the entire medium of healthcare delivery. (A.T.Still Philosophy and Practice) The ACGME merger is precisely anti that movement when it’s plan of execution is examined and in view of the Allopathic vs. Osteopathic distinction, this makes sense for the AMA to present it in this way.

Their educational deficiency in knowing and understanding the basic Osteopathic Principles and Practice paradigm allows this approach to appear logical and even inescapable.

The promoters (from both sides) of this format for our initiating this along sought and fought about merger has been couched in the above thought process in order to move it forward amongst our professional ranks. Fighting it has lacked evidence because it has not been measured effectively. Providing that Evidence fto declare our distinctiveness and clarify this for all of our professional world exists in the Salutogenic model which is by design focused on health and not pathology. the definitions of the salutogenic model are outlined rather well in a masters thesis on the salutogenic research model presented by Barbara Buch 2006.

The general known concept of Pathogenesis [pathos, gr.] = suffering, disease; genesis [gr.-lat.] = origin (Funk and Wagnalls, 1977) – the origin of disease – which still is the base of medicine and its research nowadays, opposites the newer concept of Salutogenesis [salus, salutis, lat.] = health (Funk and Wagnalls, 1977) – the origin of health. Health, according to the WHO is the condition of complete physical, mental and social well-being (WHO, 1946, cited in Doubrawa, 1995). The concept of Salutogenesis aims on finding and examining factors which are responsible for the formation and the maintaining of health, as the healthy pole of a health-dis-ease continuum (see below). In this context the concepts of Pathogenesis and Salutogenesis are not opposed to each other, they are meant to supplement each other. “Salutogenesis makes a fundamentally different philosophical assertion about the world than does Pathogenesis. It directs us to study the mystery of health in the face of a microbiological and psychosocial entropic reality, a world in which risk factors, stressors, or ‘bugs’ are endemic and highly sophisticated [….] that open systems, no less than closed systems, were characterized by immanent forces of entropy” (Antonovsky, 1996, p. 171).

Dr. Still taught his students to “seek health, anyone can find disease.” This is the core distinction to be measured. What has eluded us in evaluation has been  building the bridge between using basic science as a fundamental process of understanding the normal and looking at treatment processes as mechanism that interact with a system that is working hard to return to a homeostatic norm. These concepts receive a great deal of lip service in undergraduate training but loose their front and forward positioning as training continues into the hospital programs. Our basic scientists are sidelined for clinical sciences instead of being integrated into understanding of how the unity of the human system reacts as a whole system not just the parts. This is one of the original tenets of Osteopathy.

The Body is a Single Dynamic Unit of Function

This movement away from basic sciences is admittedly an artificial distinction from a science perspective but in practice what occurs is a shift from thinking about balance in homeostatic systems to an analysis of pathologic symptomatology. this was expressly prohibited in the A.T. Still model of thinking about the human condition. Even the recent changes in evaluation methods for coding have promoted the isolation of health from the pathologic or the disease approach to healthcare that predominates in the allopathic model. The entire ICD-9 – ICD 10 language system and even MeSH terminology is based in and actually managed by, pathology language. Even the people who control the language being permitted to enter the United Medical Language System are pathologists and their codification process is to use a “tree of pathology” in order to structure the language in a defined way.   We need this process to continue, but it does not have the capacity to measure health, qualify or qualify. It says that, the absence of disease is health. That is a very different thing from the Osteopathic concept that is inclusive of the mind, body, spirit connection and the diagnostic system we use that helps us get outside verbal language and into the language of interactive physiology we call Osteopathic diagnosis and treatment.  Osteopathy Practitioners (irrespective of the letters after their name) use placatory interactions to access the well being of the individual in it’s physiological expression of homeostasis for that individual.

The basic  sciences are focused on normal and in theory, health in Osteopathic colleges. The OMM departments use that language to describe and train students to palpate what is normal and to cultivate normalization or return to homeostatic balance. They begin with the musculoskeletal system and are supposed to extend this into an understanding and usage of the same principles as they begin to collect Physical data from patients in their advancing career through hospital education and into practice. They are not initially focused on pathology. They are encouraged to incorporate  their 2nd year pathology education into their homeostatic balance assessment process as a part of the advanced OMM training they are to receive through their 3rd and 4th year curricula. The pathology lectures can then be re-integrated in morbidity and mortality rounds or in morning conferences where educators can elicit these connections from their clinical experiences with them.

Structure and Function are Interrelated

Normalization is the goal, stopping the disease or healing is a property of restoration of homeostasis toward the normal and is a unique property of the individual.

The Body Possesses Self-Regulatory and Self-Healing Mechanisms

How we as deliverers of health care get there involves an integrative and complex set of ongoing and repetitive assessments as treatment progresses using both the disease model and the health model as our guide posts.

Homeostasis is a system every physician interacts with and contends with but Osteopathic thinkers in the post graduate environment, place this concept to the fore in problem solving.

Rational Treatment is Based on Applying These Principles

Sometimes this thought process is evident to the casual but educated observer even when the practitioner is not aware they are using it. This is frequently seen by other professionals as a skill called “being a skilled diagnostician”.We even teach it in Osteopathic Principles and Practice courses as bringing the health of the system to bear on the problem, or in A. T. Stills specific expression, “seek the health and let the system do the rest”.

So, the challenge here to this group is to first ask the following questions which are major issues in our political and health environments as we speak. What we need is to develop a pedagogical approach to the promotion of research around each question based o the distinctions of Osteopathic Medicine and Osteopathic Patient care. We should share what we talk about here with the research community at the AOA Council on Research (COR), the AAO Louisa Burns Osteopathic Research Committee (LBORC) and the Foundation for Osteopathic Research and Education:

What other distinctive characteristics of Osteopathic thinking and action are observable in our profession and can we enumerate them?

Which of these are worth preserving for the future of healthcare delivery and for the benefit of patients health and sense of well being?

How can we measure these characteristics.

How can we measure the effects of these characteristics in our patient population?

How can we measure these Characteristics in our professional programs across all specializations?

How can we measure these characteristics in our undergraduate training programs?

And if we can successfully measure these, how can we improve their formal delivery in educational forums at all levels from COMs to post graduate CME programming?

These concepts and observations have been made and confirmed, thought about and acted upon, percolated and evaluated for over 20 years in exposure to Osteopathic concepts in undergraduate, postgraduate and in professional interactions. Our distinctiveness is clearly assessable and is uniquely sought after in complex cases even from members of our profession who are retired and called back into service to help others do what we do, Think differently, measure differently and succeed often where others fail.

Please let this be the beginning of a deep and thorough discussion. It is what A. T. Still asked of us to do and so have so many others before us some of whom you may know or recall, normal Gevitz among the best known today.

William Garner Sutherland, Ada Strand Sutherland, John Martin Littlejohn, Louisa Burns, Paul Kimberly,  Robert Kelso, William L. Johnston, Anne Wales, Robert Fulford, Irvin M. Korr, J.S. Denslow, Darryl A. Beehler, John H. Burnett and Mary M. Burnett, Max T. Guttenson and so many others along with the many living Osteopathic Researchers today, have sought to move Osteopathy to more fully illuminate the Osteopathic Profession and it’s Distinctiveness.

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Charles Smutny DO, FAAO

Neuro-musculo-skeletal Medicine Licensed & Board Certified Physician/Surgeon NY

Director of Residency Education and OMM Assistant Professor: RETIRED

Assistant professor of OMM/NMM New York Institute of Technology College of Osteopathic Medicine: RETIRED

Professor of Anatomy and Physiology now @ SUNY Suffolk, Brentwood, NY

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