After three of Andrew Taylor Still’s children died of spinal meningitis in 1864, the midwestern healer turned against mainstream medicine. Eschewing drugs and surgery, Still gravitated toward the wellness offerings of his era, dabbling in magnetic healing and hydrotherapy, before outlining a philosophy of his own. Drawing from the teachings of his Methodist-preacher father and his own experiences farming on the frontier, Still argued that the body was a self-healing machine. When physical, psychological, and spiritual afflictions interfered, a doctor’s job was to gently return a patient to homeostasis, usually through hands-on manipulation of the spine. Still called this new discipline osteopathy.
While allopathic, or medical, doctors can trace their lineage back to Hippocrates and ancient Greece, osteopathy is a uniquely American tradition, comparable to jazz, says Wolfgang Gilliar, the dean of osteopathic medicine at Touro University, in Nevada. One in five Americans has never heard of osteopathic doctors, according to the American Osteopathic Association, but they are a substantive presence in health care. As of 2017, they quietly account for more than 8.5 percent of all physicians in the United States and 26 percent of first-year medical students. While M.D.s may specialize in ever more complicated fields, many D.O.s are proud generalists, and they’re more likely to serve patients’ most basic health needs as primary-care doctors. They are especially prevalent in rural settings, but one is also in the White House: In 2018, President Donald Trump selected the osteopathic doctor Sean Conley as his physician.
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Today, osteopathic manipulative medicine consists of dozens of manual techniques—many of them also employed by masseuses, chiropractors, and physical therapists. There’s high velocity, low amplitude, or HVLA, a pretzel of trust in which a doctor wraps their arm around a curled-up patient to deliver a quick, popping thrust. Strain/counterstrain, which involves holding a patient’s aching joint in a pain-free position, is so gentle that it can feel like nothing at all. D.O.s also do soft-tissue work, including kneading and stretching; lymphatic techniques, such as pumping a patient like a Shake Weight at 100 beats per second to encourage drainage; and myofascial release, a subtle but sustained pressure on irritated trigger points.
Many patients of osteopathic doctors, myself included, are exceedingly loyal. D.O.s believe that their holistic approach distinguishes their practice from that of allopathic doctors, and although they spend about the same amount of time with patients as other primary-care doctors, they are more likely than allopathic doctors to ask about a patient’s family life in relation to health. For those who respond to it, manipulative treatment can also provide a drug-free form of pain relief—something that the opioid crisis has shown patients desperately need, yet few doctors feel equipped to address. Whether they know the term or not, many Americans want what the osteopathic philosophy promises: a doctor who trusts their self-knowledge and sees them as a person, not a disembodied set of symptoms.
Osteopathic medical schools are still seen as inferior to allopathic ones, and many students apply to D.O. schools only when it’s clear they won’t be getting into an allopathic one. But today, many D.O. practices look no different from those of M.D.s, and the two often work side by side. Data are difficult to come by, but in a 2003 survey, 75 percent of D.O.s said they never or rarely used their osteopathic techniques. Some likely never intended to practice manipulative medicine, while others simply stopped training—and trusting in—their hands after graduation. But osteopathic techniques have filtered into other practices, and osteopathic doctors have assimilated into mainstream medicine—so fully that this year, D.O. and M.D. programs combined their residency programs for the first time.
Growing up, whenever I had the slightest ache, I would climb onto my grandpa’s brown-leather exam table for a treatment. Like his parents and his two older half brothers, my grandpa was a doctor of osteopathic medicine. Born and raised in Iowa, he graduated in 1962 from A.T. Still University, the original osteopathic medical school in the humid hillocks of Kirksville, Missouri. He was an old-school “10-fingered osteopath”—often a pejorative, even then, for D.O.s dedicated to the manipulative tradition, in contrast to the “osteopathic” doctors focused on the future of medicine. As a primary-care physician in the agricultural communities of eastern Washington State, he delivered babies, performed small surgeries, and prescribed medicine. But I remember him best in the exam room he kept at a relaxing half-light, his big hands cupped around the base of a patient’s upturned head.
Osteopathy’s “founding myth,” as Dan Bensky, a D.O. in Seattle, calls it, is set during the 1918 pandemic, when influenza spread through the United States. D.O.s treated more than 100,000 infected patients across the country and only 257 died, according to one 1920 article in an osteopathic medical journal. A century later, even a D.O. can look at this study with reservations, given the notorious unreliability of self-reported data and the profound lack of epidemiological context for the disease. But at the time, the results made osteopathy look appealing to prospective patients, because the mortality rate was drastically lower than what M.D.s were reporting.
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From the moment that Americans began to embrace osteopathy, the medical establishment grew skeptical of its alternative offerings. In 1910, an investigation into the state of North American medical education, the Flexner Report, castigated the field—and homeopathy, botanical medicine, and osteopathy in particular. Medical doctors responded by urbanizing, specializing, and pursuing the evidence-based approach the report demanded. But D.O.s stayed behind to work in primary care and rural medicine, where many lacked the time, money, and high-volume hospitals necessary to pursue systematic scientific research on osteopathic techniques.
This skepticism from the medical establishment meant that it took decades for all 50 states to grant D.O.s the same rights to practice as M.D.s. Not until 1973, after Mississippi finally began licensing its osteopaths, did the last holdout in the United States finally recognize them as physicians. In the decades since, M.D.s and D.O.s have worked in concert, but the evidence base for distinct osteopathic practices remains thin.
Only in the past 20 years or so have researchers begun to rigorously evaluate osteopathic practices. The studies that do exist remain “equivocal,” says Norman Gevitz, a senior vice president at A.T. Still University and author of The D.O.s: Osteopathic Medicine in America. In patients with pneumonia, for example, osteopathic manipulation can reduce the number of days they spend in the hospital. For chronic low-back pain, studies show either no or minimal reduction in pain or disability following a muscle-energy treatment, a highly controlled form of wrestling where the provider and patient push against each other to lengthen tissues. And although one paper indicated that osteopathic manipulation could alleviate low-back and pelvic pain during pregnancy, the intervention was no more effective than a sham ultrasound.
That hasn’t stopped the diffusion of osteopathic ideas into mainstream medicine. Chiropractors, physical therapists, massage therapists, and sports doctors have all utilized osteopathic techniques, Gevitz says. Muscle energy, which a D.O. developed in 1948, and myofascial release, which a D.O. and physical therapist pioneered, are popular among other “professional touchers,” in the words of the poet Diane Ackerman. These strategies are even used by M.D.s, plenty of whom attend continuing-education courses on osteopathic methods. Although research has yet to validate many of these methods, patients continue to seek these treatments. Whether they’re experiencing a real change or a placebo effect, accumulating evidence suggests there’s probably a benefit either way.
Osteopathic doctors are happy to share their techniques, but most could stand to receive a little more credit for their contributions. In recent years, M.D.s have gathered scientific evidence that supports osteopathic claims, but often without referencing those osteopathic origins. For example, D.O.s contend that the growing interest in fascia—tissue that sheaths and supports muscles and organs throughout the body—and the 2012 “discovery” of the glymphatic system, which drains waste away from the brain, both correspond to concepts Still described more than 100 years ago. Some osteopathic doctors feel validated by these developments. For others, the sense of disrespect runs deep. My D.O., whom I visited roughly every three weeks prior to the pandemic, teared up when talking about scientists who say that the glymphatic system was “previously unknown.”
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In the past decade, professional organizations and academic institutions have begun to invest more heavily in osteopathic research. But at this point, the most compelling evidence for the continued practice of osteopathic medicine are the studies showing that, in certain cases, there’s no significant difference in patient outcomes, whether they’re managed by a D.O. or an M.D. It sounds like a low bar, but Gevitz argues it shows that different patients benefit from different kinds of care. Some people hate touch; for others, it’s restorative. “There are different paths to healing,” Gevitz says, and the opportunity to choose is itself important.
My grandfather died of multiple myeloma in 2014, and a few months later, the meniscus in my jaw dislocated. Achy and tired, at one point I Ubered around Seattle looking for a TMJ specialist until, finally, my mom set up an appointment with an osteopathic physician. As the doctor’s big hands cupped the base of my head, I felt like a time traveler coming home.
Still defined the osteopathic tradition, from its inception, in opposition to the mainstream medicine of his day. It was only natural that mainstream medicine shunned osteopathic doctors in turn, relegating them to their own hospitals and refusing to refer patients their way. But today, osteopathic and allopathic doctors are difficult to distinguish, and the curricula at osteopathic and allopathic schools have largely synchronized, because D.O.s and M.D.s must ultimately pass the same licensing exams in order to practice.
“D.O.s are having an identity crisis,” Gevitz says. “Because who are they? What is the rationale for being a separate profession of medicine?”
The two disciplines are only growing closer. This spring, after years of negotiations, allopathic and osteopathic organizations agreed to sort their students into residency programs through a single, unified competency-based system, which evaluates all residents on six domains, including medical knowledge and systems-based practice. Although the majority of the programs are allopathic, some pursued a special osteopathic recognition, which signals their commitment to continuing education on osteopathic principles and manipulative medicine.
For some, this residency looks like another step on the path to self-annihilation. Gevitz predicts that fewer D.O.s will apply for osteopathic licensing or join osteopathic associations when they launch their career. He thinks it’s even possible that administrators will one day use the residency merger to argue for a medical-school merger, too, which many fear would be the end of osteopathic education altogether. But others are optimistic that the new system will ensure that residents get the rigor of the allopathic system while still preserving osteopathic traditions. The merger is already exposing new doctors to osteopathic techniques: Young M.D.s also applied for osteopathically recognized programs. Like the eager chiropractors, masseuses, and physical therapists who came before them, they are open to incorporating physical touch into their practice.
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However osteopathy remains relevant, many patients say it must. Without it, those who rely on manipulative medicine would suffer, their pain harder to manage without the skilled application of osteopathic techniques. And a D.O. disappearance would contribute to the slow and steady homogenization of our health-care system, further constricting the spectrum of care.
Osteopathy could still have a unique role to play in American medicine. At the height of the coronavirus pandemic, in April, when doctors at St. Barnabas, a nonprofit hospital in the Bronx, could hardly hear themselves think over the whirring of the ventilators, a group of osteopathic doctors was determined to keep human touch at the center of their practice. Swaddled in personal protective equipment, Hugh Ettlinger, D.O., and his residents in osteopathic medicine treated 35 infected patients a day. “We were there and we talked to them and we put our hands on them,” he told me.
While other doctors tried to limit their exposure to infected patients, Ettlinger and his team spent 15 to 20 minutes with each person. Using the techniques they learned in school, they sought to ease breathing by manipulating the ribs and spine, and worked to improve the flow of the lymphatic system. “We probably had more bedside contact than anyone else in the hospital,” Ettlinger said. He hopes that this moment could show that osteopathy has advantages that other techniques don’t offer: once again, the D.O.s collected data on their pandemic patients, and intend to publish in the coming months.