When Dr. Michael R. Williams, a Fort Worth native, was accepted to the Texas College of Osteopathic Medicine and an M.D. program several hours away, he made a pragmatic choice: Attend the closer school and be available to help care for his mom.
The decision would mold his course. When the time came to apply for residency programs in the early 80s, Williams typed 141 letters on his typewriter. After a series of interviews, he received a series of answers: No.
He remembers the reason one program gave: Williams was a D.O., not an M.D.
A doctor of osteopathic medicine, or D.O., is a fully licensed physician whose training emphasizes the doctor-patient relationship and the musculoskeletal system, the body’s network of muscles and bones. The degree developed in the late 1800s, more than a century after the first allopathic medical school in the U.S. opened its doors to train M.D.s, or doctors of medicine.
In the ensuing decades, Williams’ journey would include both degrees, as well as the rise and fall of a partnership between the two in the TCU and UNTHSC School of Medicine. In that same period, the differences and tensions between the degrees have shrunk, but misunderstandings linger among the professions and the public.
“Like so many things, this whole (D.O. vs. M.D. issue) was built on blind prejudice, ignorance from both sides,” said Williams, who is now the chancellor of the University of North Texas System. “While I’ll also say, at that time, there were some facts that did justify some of the biases.”
What do the letters stand for?
D.O. — doctor of osteopathic medicine. The Texas College of Osteopathic Medicine at The University of North Texas Health Science Center produces physicians with D.O.s.
M.D. — medical doctor, also called an allopathic doctor. The TCU School of Medicine produces physicians with M.D.s.
The ‘lightning bonesetter’ of Kirksville, Missouri
The Civil War was coming to an end when Dr. Andrew Taylor Still, a military doctor in Kansas, lost three of his children to spinal meningitis. Not long after, his daughter died of pneumonia.
Disillusioned by his failure to heal his family, Still renounced the health care conventions of the time — methods like blistering and purging — and began to shape a new approach to healing. Informed by farming, hunting and faith, Still concluded that the body could heal itself; the purpose of physicians was merely to facilitate that process. They would use their hands, not drugs, to do the work. Still called this practice osteopathy.
His ideas weren’t well-received. Still became a pariah in the communities that had shaped him — the church and the school his family helped establish — and crossed the border to Missouri. There, he advertised himself as a “lightning bonesetter” and eventually garnered acceptance. He launched the American School of Osteopathy in Kirksville in 1892.
When Abraham Flexner, an American educator, published a scathing critique of the American medical system nearly 20 years later, few medical schools osteopathic or allopathic fared well. “The dissecting-room is foul,” Flexner wrote of Still’s school. The facilities overall were “absurdly inadequate” and some professors merely “senior students.”
M.D. programs received similar contempt — Flexner recommended closing many of them, including the Fort Worth University School of Medicine.
The Flexner Report galvanized M.D. schools to standardize, but D.O. programs fell behind — in part because they couldn’t amass enough funding, according to a 2009 article in Academic Medicine. By the 1930s, state licensing requirements were difficult for D.O.s to overcome; it would be 40 more years before they were allowed to practice in all 50 states.
For decades, D.O.s and M.D.s tiptoed different sides of the same line. They had separate colleges, residencies, hospitals, exams and journals. (Beginning in 1946, Fort Worth had an osteopathic hospital; it closed in 2004 — by then the last osteopathic hospital in Texas — because of financial trouble.)
More and more students are becoming D.O.s
These days, the two paths are more difficult to differentiate. Students seeking both degrees complete four years of medical school, take national licensing exams and, as of 2020, train in the same residency programs. In last week’s Match, almost the same percentage of U.S.-trained M.D. and D.O. students were paired with residency programs.
And although M.D.s still make up about 90% of physicians in the U.S., more and more students are choosing a path toward D.O., according to an August 2021 report from the Federation of State Medical Boards. About one in four medical students attend an osteopathic medical school. And, in both Biden’s and Trump’s White House, the presidents selected a D.O. for their personal physician.
The increase in the number of students pursuing the D.O. path reflects the public’s growing desire to take an active role in their health care, said Dr. David C. Mason, a D.O. and professor at the Texas College of Osteopathic Medicine.
“Patients don’t want the only option to be medicine or surgery,” he said. “They’re looking for coaching, they’re looking for guidance.”
In college, Mason enrolled in an internship that allowed him to interact with physicians and medical students in the New Jersey health care system. He still remembers the friendliness and savvy of an emergency room physician, a D.O., he met during the internship, as well as the collaborative approach of a D.O. program nearby. Those interactions shaped his decision to become a doctor of osteopathic medicine.
‘They didn’t care what I was’
After the residency programs rejected Williams, now the chancellor of the University of North Texas System, he shifted course. He earned an M.D. through Ross University School of Medicine, then pursued anesthesia residency programs near home.
When officials at UT Southwestern’s anesthesia residency program questioned Williams’ background, a mentor faculty member vouched for him, he remembers. Williams was accepted, one of the first students with a D.O. to enter the program.
Four years later, he became chief resident — the highest leadership role a resident can take.
“What I learned was, if you practice quality medicine, if you’re willing to work hard, they didn’t care what I was,” he said.
The pushback Williams received came from both medical communities. He remembers receiving a letter from the American Osteopathic Association, chastising him for pursuing residencies at traditionally allopathic programs. The letter implied he had “crossed over the river,” Williams said — he was no longer welcome in osteopathic organizations.
When he looks back, the differences between the programs and people he’s encountered in both medical communities are slim, Williams said. He’s hesitant to generalize; as his own journey made clear, the person matters more than the degree.
At times, however, he glimpses subtleties that showcase the best of both worlds: a sharp inclination toward research in M.D. programs, and a deep understanding among his D.O. colleagues of the healing powers of talk and touch.
“We were taught how to really sit down and show empathy and care for patients and families,” he said. “We were taught the physician-patient relationship was the most important relationship of all.
The physician and the physical therapist
The intimacy of doctor-patient relationships in osteopathic medicine comes, in part, from osteopathic manipulative treatment, a hands-on practice in which the physician gently adjusts, stretches, or applies pressure to the patient’s body. The treatment helps ease tension within the body and encourages the body’s own healing process.
The treatment focuses on the musculoskeletal system, which people use for “doing anything in this world, really,” Mason said. He thinks it’s a system too often overlooked, despite its role in many health concerns. Back pain is one of the most common reasons people visit their family physicians.
As a physician in New Jersey, Mason conducted a comparative study between his treatment of back pain and the treatment provided by his colleague, an M.D. He learned that, if his colleague were to treat back pain, he was more likely to first prescribe pain relievers and muscle relaxants and, later, order an X-ray and physical therapy. On the contrary, Mason’s first decision would be to treat the patient with osteopathic manipulation and later, if necessary, refer the patient to a physical therapist.
For Mason, prescribing medicine was much less common. Instead, he might prescribe exercises for the patient to perform beyond the appointment. “I’m basically acting as the physician and the physical therapist,” he said.
In medical school, D.O. students typically take about 200 hours in osteopathic manipulative treatment, along with their regular coursework. And the treatment works: A 2005 systematic review of related research concluded that osteopathic manipulative treatment significantly reduces back pain.
Although the use of osteopathic manipulative treatment is perhaps the most tangible distinction between the training D.O.s and M.D.s receive, the majority of D.O.s don’t treat their patients with it, according to a 2021 study in the Journal of Osteopathic Medicine. Its use has been steadily declining over decades, mostly because physicians said they don’t have enough time, institutional support or self-confidence in their own proficiency to perform it.
For Mason, though, what distinguishes a D.O. is not osteopathic manipulative treatment, but a commitment to partnering with the patient along a path toward holistic health.
“When you look at the whole picture, now you go, ‘Oh, OK. That’s why the soup tastes different. It’s got all those extra spices in it,’” he said. “You know, it’s not just one thing. It’s a lot of different things that add up to something that’s quite different.”
‘Let’s all just learn from each other’
The tenets of osteopathic medicine
- The body is a unit; the person is a unit of body, mind, and spirit.
- The body is capable of self-regulation, self-healing, and health maintenance.
- Structure and function are reciprocally interrelated.
- Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function.
Source: American Osteopathic Association
Originally a farm girl from Cleburne, Dr. Lesca Hadley grew up wanting to practice medicine on animal patients until she traveled to Guatemala with a family physician in the early 90s. The trip, a medical mission, revealed to Hadley how physicians could care not only for the body, but also for the soul and the community from which the patient came.
When she returned to the U.S., her course changed. She didn’t know much, if anything, about D.O.s back then, so she pursued and received admission to an M.D. program in west Texas. Hadley, an M.D., now serves as an associate professor at the Texas College of Osteopathic Medicine, teaching students who will become D.O.s.
She’s slipped seamlessly into that world. The tenets of osteopathic medicine, which emphasize the unity of a patient’s body, mind and spirit, echo not her M.D. background but her faith, she said.
“When Jesus is healing, he does not just address the physical,” she said. “He also looks at the person from a spiritual angle, as well as the emotional state they’re in and takes all of that into account and heals them in every dimension and every way.”
She’s seen both the benefits and frustrations of being a D.O. The majority practice primary care, a field experiencing a physician shortage — “that’s really what’s needed in health care right now,” she said. On medical missions, it’s not uncommon for her D.O. colleagues to have to explain their degree to people they meet around the world.
Yet, like Williams, Hadley thinks the differences lie less in the degrees and more between the people who hold them. “Each student has strengths and weaknesses,” she said. “And so you put two students together, one of them’s going to know something the other one doesn’t. They can learn from each other.”
She’s seen the enjoyment and sharpening of M.D. students and D.O. students who get to work together. Their relationships offer a lesson: “Let’s all just learn from each other and work together and make the world a better place.”
Alexis Allison is the health reporter at the Fort Worth Report. Her position is supported by a grant from Texas Health Resources. Contact her by email or via Twitter. At the Fort Worth Report, news decisions are made independently of our board members and financial supporters. Read more about our editorial independence policy here.