Other Medical Careers Part One: The Most Controversial Article Ever Which Will Cause A Flood of Irate Comments and In Which I Tread Carefully But Obviously Not Carefully Enough

Osteopathic Medicine

My mother, who is from Greece, is visiting us and was amazed to hear that our program is a combined osteopathic and allopathic program.  She had no idea that chiropractors were used in the Emergency Department. In Europe, you see, osteopaths are not trained medical doctors but confine their practice to manipulation and other alternative therapies.  In the United States, however, osteopaths, who are conferred the DO degree (Doctor of Osteopathic Medicine) are fully trained medical doctors and are without exception completely interchangeble with allopathic physicians, those with the traditional “MD” after their names.  The confusion arises because osteopaths are far fewer in number than allopathic physicians and in some states, particularly my native Louisiana, are as scarce as hen’s teeth.  I had never heard of osteopathic medicine before I started applying to medical school.

Osteopathy was founded shortly after the Civil War by Andrew Still, a former Army surgeon, in a reaction to the general quackish and barbaric nature of most medicine at that time.  He developed a theory of medicine that, as it was based on the manipulation of bones, did not require drugs or surgery.  His idea was that manipulation could restore the flow of blood and nervous impulses, the interruption of which he regarded as the cause of most diseases.  Osteopathic Manipulative Treatment (OMT) has grown out of his theories into a treatment modality which is still taught at Osteopathic medical schools. 

I say “still taught” because there is little or no good evidence that manipulation does anything other than make the patient feel subjectively better.  Hell, you can get a topless massage in most cities and even a “happy ending” that probably would make you feel as subjectively better without all of the fanfare and the embarrassing questions about your diet and bad habits.   In light of this there is a considerable sentiment among practicing osteopaths and osteopathic medical students that just as modern medicine has moved away from now discredited but once accepted treaments, it may be time to move away from OMT.  I have asked many osteopaths if they use OMT and a typical answer is, “I’m not a believer.”

Whatever the case, except for several hundred hours of training in OMT  the science and clinical curricula are similar enough between ostepathic and allopathic medical schools that graduation from an osteopathic medical school will lead to full licensure as a physician with no restrictions on your practice or the ability to receive additional fully accredited training.  Not only are there osteopathic residency programs in every recognized medical specialty but osteopaths can apply for allopathic residency positions as well (but not vice versa).

Many pre-meds apply to both types of schools to increase their chances of being accepted.  I didn’t because I’m shallow and didn’t want to explain the initials after my name.  This is actually not a problem in some parts of the country, particularly the upper midwest where osteopathic physicians are well known and respected. 

Some people believe that it is easier to get into osteopathic medical schools and decide to use them as “back up” schools.  This is the conventional wisdom but it’s silly if you think about it.

While the objective qualifications of allopathic matriculants (MCAT scores, GPA) are indeed slightly higher on average than their osteopathich counterparts, generally, if you’re not qualified for admission to an allopathic medical school you will not get into an osteopathic one either.  Sure, the fierce partisans are quick to point out the higher average scores but these are the result of outliers.  Like most things, the subjective qualificatons distribute themselves normally and it is only at the extremes where the curves don’t overlap.  For my part, since I was an average applicant (at least by MCAT scores and BPCM GPA), almost half of osteopathic matriculants had better qualifications.

So think about this before you get too cocky.  If you want to be an osteopath go to an osteopathic school.   If you want to have the MD after your name you’d be better served just applying to more allopathic medical schools and taking your chances.  The best osteopathic schools are also better than the worst allopathic schools and they can afford to be more selective.

Osteopathy, aside from OMT, distinguishes itself from allopathy by purporting to be more patient-centered, viewing as they do the patient holisitically and not in the disjointed manner that allopaths are accused of doing.  There is something to this but not enough to get excited about.  Osteopathic schools push primary care hard and they’re serious about it, not just paying the usual lip service offered by people who wouldn’t be caught dead in primary care.  Despite this (or because of it) many osteopaths specialize and have the same reasons to run screaming from primary care as anybody else.  At our local College of Osteopathic Medicine, the students have related to me that they spend close to eight months of their clinical years on mandatory outpatient and ambulatory clinic rotations which will tend to make pathology look mighty good.

Keep this in mind if you think primary care ain’t your bag.

Osteopathy Disadvantages: Metaphysically, none.  Full-fledged physicians in every specialty from neurosurgery to pediatrics.  However, lingering prejudice in some states might make licensure more complicated (the requirement for an extra intern year for example).  Also the COMLEX is reputed to be more difficult thant the USMLE, not to mention that the regulatory body for osteopathic residency programs is a lot more stringent about absolutely everything. (Paperwork, etc.)

Osteopathy Advantages: The ability to match into both allopathic and osteopathic residency programs.  It’s true that you will have a disadvantage, all other things being equal, in the allopathic match but you won’t in your own and the rest is gravy.  Not to mention that osteopathy has a certain retro coolness factor to it.

92 thoughts on “Other Medical Careers Part One: The Most Controversial Article Ever Which Will Cause A Flood of Irate Comments and In Which I Tread Carefully But Obviously Not Carefully Enough

  1. Well that was sort of anti-climatic as far as controversy goes.

    The first resident I worked with in 3rd year was a D.O.–she was a psychiatry resident. A pretty good one too.

  2. People are pretty touchy about this subject. Just wait, the firestorm is coming.

  3. You were so meticulously careful & fair that I cannot imagine what the hell anyone could object to?

    The only thing that would worry me about an osteopathic degree is if you ever decided to move to the UK, Ireland, Australia etc. would it be more difficult (impossible?) to obtain a license to practice?

  4. Oh Boy I agree with the Administrator….putting this article up is like sticking your hand into a bee hive. But stirring up controversy has its own benefits :)I did residency with my DO colleagues but I never found their fundamentals to be any weaker than MDs. Infact I never knew the difference until I read this article. But they are touchy about being discriminated against. Or for that matter, commented against. Reminds me of sienfield’s “Anti-dentite” or should we call ” Anti-DOite “

  5. Little details…
    *Doctor of Osteopathic Medicine
    *From my limited first hand experience OMT works great for acute musculoskeletal dysfunctions.
    *I’ve heard mixed sentiments regarding USMLE vs. COMLEX difficulty
    *I believe the UK did recently open up practice rights, and it is spotchy with other countries on the ability to practice full, OMT only or not at all.

  6. There is still a ‘battle mentality’ with the older doctors about the osteo vs allo degrees.

    I shadowed a doc who was a DO and when it came time to write up a rec for me (he already agreed to it fairly early on), he dragged his feet about it after I handed over the paperwork.

    When I finally tracked him down (no easy feat when he doesn’t have a direct number or email address), he told me that it was because I was applying to allopathic schools and he was an osteopathic and believed it would hinder my application. In fact, he made it sound like I was sending in the wrong recommendation if I sent in his letter to allo schools. He was an older doc who went to school back in the 1960’s (or 70’s) and I had wanted to have him send my recommendation letter to my school which had a fairly well known allo med school attached to it.

    Later on, I found on my school’s biology website that they suggested under ‘alternative medical careers’, osteopathic medicine, for people who can’t/did not want to go to ‘normal’ med school. So I guess there was reason for some of that fear of anti-DO sentiment that my doc had.

  7. Given that only 69% of DOs pass the USMLE the first time around, I fail to see how the training between allopathic and osteopathic schools can be considered similarly rigorous.

  8. Well, I don’t know if I agree with you about the ‘minimal’ difference between admissions standards. It’s more like 5 points on the MCAT, nearly a full standard deviation, and I’m sorry but that’s pretty significant. And even their GPAs are calculated in a more favorable fashion than allo schools: DO schools let you replace bad grades completely while MD schools average them. Moreover, now they’re allowing people to open FOR PROFIT DO schools, which I consider absurd.

    Most of the DOs I’ve met have been perfectly fine, but the quality control at the AACOM level appears to be lacking and they’re letting new DO schools spring up like weeds without opening new residency programs for all these new DOs, which is just absurd. Obviously it doesn’t affect MDs much, but it’s still kind of dodgy.

  9. i was ready for the fire storm. but, no so much. we have a DO program in our area. they rotate with us. there are good ones and bad ones just like the MD’s. they are better with the basic stuff. if we get all academic with them and start asking for article quotes, there not on the same level. but, i have only a few patients that asked about literature 🙂 so i don’t think that matters so much.

    one thing to point out as far as the match. the DO match is before the MD match. they did this to prevent people from applying to both. (this was per one of my DO residents)

  10. There are alot of people that choose it over allopathic schools. I applied to one allopathic and one osteopathic state school. I got into both and went to the osteopathic one because I liked their emphasis on primary care. I’m about as far away from primary care as you can get now, but it is still to my advantage. All of the primary care DOs means built in referral base and they take care of their specialists.
    Alot of the OMT used now is the realm of the Physical Therapist. Manipulation gets all of the pub, but it is only a fraction of OMT most of the other aspects such as Muscle Energy and Counterstrain make up a large part of the Physical Therapist arsenal.

  11. Pretty fair assessment PB. I’m a D.O. going to Vanderbilt this summer, and I sure as heck won’t be using OMT unless I get into chronic pain (which would mean I would have to kill myself).

    I’ve met great M.D. & D.O.s and terrible ones too. Yes, allopathic schools are more academically selective at admission but sometimes a dude with a 34 MCAT will still go D.O.

    As far as half MDs comment, my schooling was definitely as rigorous as anywhere else in the country. Perhaps different foci during the course, but still rigorous. The educational component is really all dependent on the individual. You can go to Hopkins and dick around and suck just as you can go D.O., study hard and kill both the allopathic/osteopathic boards.

    Over on SDN, insecurity drives the D.O. vs M.D. debates in the pre-med forums. Once you get into school, out on rotations, and into residency nobody cares.

    Oh yeah, many of us are upset with the AOA for their recent opening of schools (among other things).

  12. DO medical students do indeed apply through both matches, at least I know many DOs who claim to have done so. They go through ERAS and if somebody knows the truth of it, please let us kow and I will correct my article.

  13. The thing about the USMLE versus the COMLEX, osteopathic schools may emphasise different things and this is reflected in the 69 percent versus 94 percent USMLE pass rate of DOs versus MDs. But I wonder how well MDs would do on the COMLEX (if they took out the OMT stuff, I mean, which we don’t even touch).

  14. I just matched this year, and had some DO students on a 4th year rotation. It was for Radiology and they were thinking about applying for both DO and MD Radiology residencies (I didnt know there were DO radiology residencies). There was some thing about applying to both though, that if they got into a DO place first, they automatically forfeited an MD place (if they matched into it). So if you really want an MD residency spot as a DO student, you have to take a chance and apply only through ERAS. Or you can cover your bases and do both, but you may have to do take a DO spot even if you got into some fancy MD spot.

  15. DO’s can apply to both matches, and it is true that the DO match occurs before the MD match. And if you match into a DO program, you are simply removed from the MD match before it occurs.

    As I’ve talked to other students, however, going thru both matches is very costly and time consuming, so I believe it is less common than just choosing one or the other.

  16. And I wonder what the actual pass rates for step 1 would be if MD schools didn’t fail 8% of their year 2 class. I’m not saying ALL of them do – I just know of one. Further, you have to look at when schools make their students take step 1. Is it after 3rd year? Bet you’d do a whole lot better then.

  17. PB

    I actually thought the USMLE was a better test b/c it was much better written. The COMLEX definitely didn’t have as much molecular biology or genetics as the USMLE. I would say from talking to friends, that this is related to a difference in the curriculum between allopathic & osteopathic. The COMLEX was a terrible test to try to wade through, when I took it it was a 2 day 800? test.

    mf: Step 1 is almost uniformly taken after 2nd year (to my knowledge). I could not imagine taking it after 3rd year, there is no way that I would have remembered all of the minutia. I took USMLE/COMLEX step 2 after 3rd year; it is a much more clinical exam and thus well suited for that time period.

    To glyph: you are correct, if a D.O. applies to both matches and matches D.O., they are automatically withdrawn from the allopathic match. Hence the reason some, like myself, only apply to the allopathic match. Some apply to both and some apply to the osteopathic match only.

  18. But look, if you really want a specialty and don’t care if it’s DO or MD, you do have two shots at it.

  19. glyph and sp,

    that is the same information my resident gave me. he said the DO match day was done ~1 month done prior to the MD match.

    a had received a number of emails in regards to the likelihood of a DO matching into an otho program. i usually recommend that they stay in the DO system to make it easier on themselves because there still is a lot of bias in the MD community about DO’s. many allo programs won’t even interview DO’s regardless of scores.

  20. I thought you were very fair in your assessment of the osteopathic world. If anything I thought you might have been a little soft. I’m harsh about the difference in applicant pools and I’m only applying DO. I’m doing this because

    1. I think I could get into a better DO school than MD school
    2. I want to go into Internal Medicine (at least for now) – which from what I hear shouldn’t pose a problem if I want to go to an MD program
    3. I think learning OMT only gives me more tools to use, whether they’re proven to work or not.
    4. They seem to push a little more problem based learning than allopaths.

  21. Oh, the only thing that I get a little annoyed about is when people say “oh i want to go to medical school, not DO school.” I should probably get over it and accept that MD came first, thus making DO the alternative.

  22. There is one disadvantage you failed to mention. Surgical (and surgical subspecialty) ACGME residencies are almost off-limits to DOs, thanks to the policies and the mindset of those governing boards. For those that don’t believe me, look up the stats.

  23. A few years out of training I roomed with a DO for about six months and he taught me some OMT. I still use it from time to time. Since I’m an MD, it’s impossible for me to bill with the OMT CPT codes.

    I usually just kick up the E&M code by one level and describe what I did in the notes in such nebulous terms as “range of motion” and “muscular pressure.” Is there anyone else out there who is an MD but does OMT?

  24. :):):) Cmon docs and would be docs…we don’t need polite talk here on this issue…lets get into some cut throat squabble !!!

  25. Well, this is only sort of a disadvantage. There are osteopatic residency spots in (if I’m not mistaken) every surgical specialty. I don’t think that ACGME residencies being effectively off-limits to DO students is AT ALL unfair. MD students are not even allowed to apply to DO residencies, so I don’t see why DO students should be allowed to do the reciprocal. Also, the DO governing body is being completely stupid in allowing new DO schools to spring up like weeds without opening any new DO residency spots. I’m guessing they’re just expecting allopathic residency programs to accept this flood of DO graduates. That’s irresponsible, and I think shutting all (but the very best) DO graduates out of MD residency programs in competitive specialties will force the AOA to either better regulate the number of DO schools/graduates or will force it to actually put resources into developing more DO residencies in the competitive specialties without expecting the ACGME to do all its heavy lifting for it. There are some excellent DO residency programs in surgical specialites and there should be more. Effectively barring DO graduates from competitive MD residencies will (hopefully) force the AOA to actually put resources into taking care of DO graduates.

  26. There are plenty of primary care residency positions that go begging every year and end up filled by FMGs or not filled at all. I’d rather have American doctors (MD or DO) fill those spots. Call me a patriot but there it is. If the new DO schools can put more American-trained doctors in the pipeline, I’m all for it.

  27. Panda, I agree that it is much preferable to have American doctors, DO or MD, fill spots in specialties that typically go unfilled or that typically bring in a copious number of FMGs. I think, however, that DO candidates should not automatically be forced into primary care (or other non-competitive) specialties, which is what will happen with greater frequency as the number of osteopathic medical students increases. I also believe that there is a valid reason for ACGME residency spots in competitive specialties to go to MD applicants over DO applicants (after all, allopathic residencies were created to train allopaths). If the number of DO graduates increases without a corresponding increase in the number of residency spots in competitive specialties, then it will become progressively more difficult for DO students to be trained as neurosurgeons, orthopods, emergency medicine doctors, etc. It’s not the ACGME’s job to help out DO graduates, but the DO governing body should put the effort into expanding the number of residency spots for DOs in competitive residencies if they’re going to accredit new osteopathic med schools. It’s not that I necessarily think that we shouldn’t increase the number of DOs in the country (although there’s reason to believe that we really don’t need an increase in the number doctors according to the Dartmouth Atlas of Healthcare, etc.), but I do think that the AOA should work to make sure that not all DOs are forced into primary care specialties because of a lack of osteopathic residency spots in other specialties.

  28. “although there’s reason to believe that we really don’t need an increase in the number doctors according to the Dartmouth Atlas of Healthcare, etc”

    I thought physician shortages were expected to be critical by 2020 at the current rate of graduates. Where (links?) does this information come from?

  29. Basically, the Dartmouth Atlas was a huge, long-term statistical analysis project that broke the US up into several thousand healthcare areas. They looked at the per capita cost of healthcare and number of physicians in those areas and compared it to the likelihood of surviving various ailments (MIs, hip replacements, etc.) They basically found that the lowest-spending/lowest-ratio-of doctor-to-patient areas had the best outcomes, as evaluated by a number of criteria. Basically, spending more money and having more doctors around (especially specialists) actually makes you worse off, up to a point. I’ve heard Dr. Fisher (one of the people in charge of the study) facetiously, but somewhat accurately, describe the situation thus: “We could send a 1/3 of our [the U.S.’s] healthcare providers to Africa and improve the quality of care in both places.”
    For more info, go here: http://www.dartmouth.edu/~cecs/ismorebetter/is_more_better.html
    At the bottom of that link is a copy of Dr. Fisher’s JAMA paper: http://www.dartmouth.edu/~cecs/downloads/jsc80266.pdf


    “Given the apparent inefficiency of current physician practices, the supply pipeline is sufficient to meet future needs through 2020, with adoption of the workforce deployment patterns now seen among AMCs [Academic Medical Centers] and regions dominated by large group practices.”

    “Research to date, in contrast, indicates that physician workforce levels, particularly of specialists, are not a primary factor in determining health outcomes.”

  30. Basically, the Dartmouth Atlas was a huge, long-term statistical analysis project that broke the US up into several thousand healthcare areas. They looked at the per capita cost of healthcare and number of physicians in those areas and compared it to the likelihood of surviving various ailments (MIs, hip replacements, etc.) They basically found that the lowest-spending/lowest-ratio-of doctor-to-patient areas had the best outcomes, as evaluated by a number of criteria. Basically, spending more money and having more doctors around (especially specialists) actually makes you worse off, up to a point. I’ve heard Dr. Fisher (one of the people in charge of the study) facetiously, but somewhat accurately, describe the situation thus: “We could send a 1/3 of our [the U.S.’s] healthcare providers to Africa and improve the quality of care in both places.”
    For more info, go here: http://www.dartmouth.edu/~cecs/ismorebetter/is_more_better.html
    At the bottom of that link is a copy of Dr. Fisher’s JAMA paper: http://www.dartmouth.edu/~cecs/downloads/jsc80266.pdf


    “Given the apparent inefficiency of current physician practices, the supply pipeline is sufficient to meet future needs through 2020, with adoption of the workforce deployment patterns now seen among AMCs [Academic Medical Centers] and regions dominated by large group practices.”

    “Research to date, in contrast, indicates that physician workforce levels, particularly of specialists, are not a primary factor in determining health outcomes.”

  31. “I say “still taught” because there is little or no good evidence that manipulation does anything other than make the patient feel subjectively better. Hell, you can get a topless massage in most cities and even a “happy ending” that probably would make you feel as subjectively better without all of the fanfare and the embarrassing questions about your diet and bad habits.”

    WOW. The ignorance here is astonishing. (Hey, we really haven’t gotten very controversial in our debate, so here I go, I suppose) Ok, look, we’ve only had evidence-based medicine for maybe 50 years. In that time we’ve been a bit consumed by drugs, antibiotics, surgery, and cancer. Thats where the money goes for research. When it comes to treating muscle aches, chronic lower back pain, edema, hiatal hernias, etc by means not related to the above…the time and money just isn’t there. It has only been last maybe 10 years that some dedicated DOs have really dedicated to getting some research behind this, which is hard to do anyway seeing has how you pointed out, alot of it is based on “how the patient feels.” WHat also makes it hard is the operator. OMM in the wrong hands can be ineffective if not very painful.

    BUT, just b/c the improvement tends to be subjective, that doesn’t mean the principles aren’t sound and purely objective. We KNOW our anatomy. So when a bone is out of place, we precisely put it back in. When a muscle is in a knot, we release it. When their blood pressure is up, we balance the sympahetics and it goes down. We are not just guessing here. We don’t do general massage, we are precise.

    Its easy to say its rubbish when you are not educated on the subject, but I challenge you to have it done. I guarantee I can change your mind. As for the happy ending…I don’t know about that, but many have said my treatments are pretty orgasmic 🙂

  32. Mvmedstudent, first warning. Don’t accuse me or any other commenters of being ignorant. I won’t delete your comment because you are at least making a point. I know a lot more about OMT than I let on but as I am not writing a graduate thesis (which is what people seem to expect) but rather a blog which entertains as well as informs on some broad topics, I’m not going to footnote if that’s what you expect.

  33. I don’t see anything wrong with increasing the number of DO students. More applicants means programs can be even pickier and you turn out a better product. Only those not confident in their own abilities are reluctant to compete.

  34. First of all, I want to apologize if it came off that I was calling YOU ignorant. That is certainly not the case. If I just felt you were a dull person spouting utter bull, I wouldn’t bother.

    Second, I was merely remarking that that particular statement, though it may have been educated, did not come off that way b/c there was nothing backing it up at the time except “I talked to some DOs who say they don’t use it.” Of course, there’s no need for footnotes, c’mon, lets not get ridiculous here. I’m just saying, you did not express knowledge of the theories or any personal experience, yet you were able to compare a skill taught at credited medical school and which I’ve spent a great deal of time cultivating to no greater value than a hand job. How else should one react? Thats a bit rude, and I think its quite reasonable for me to take offense.

    Again, sorry, I meant no personal attack, I just took offense to that one statement and I get a little passionate sometimes. Since you say you do have more experience with it than you let on, I would love to discuss with you any holes in the theory, bad experiences, or negative feelings by fellow DOs.

  35. I propose the following experiment:

    Take two groups of patients with essential hypertension. I’ll even let you pick both groups and they can all be people who you think are hypertensive because of some malalignment of a bone. Manipulate one group and put the other on a course of the usual combination of anti-hypertensives.

    I guarantee the manipulated group’s blood pressure will be unaffected. OMT is an adjunct that adds nothing to the treatment of any condition that is not musckulosleleltal…and I’m giving you a huge benefit of the doubt because it’s only effective for subjective muskulosleletal problems.

    Take my fibromyalgia patients.

    No, seriously, take them.

    On another note, we just try to keep the debate civil on this blog. But cursing and ranting are allowed and I don’t delete comments just because I don’t agree with the sentiments.

  36. Hi,

    Touro University College of Osteopathic Medicine student here.

    Interesting discussion. It’s pretty clear to me that there’s very little “real” difference in going to a DO/MD school at this point. The USMLE pass rate isn’t really that interesting to me. When your a practicing physician, does anyone really care what your USMLE/COMLEX score was? But I understand this is a mega-important thing for some people.

    What I do find very interesting is comparing the AOA and the AMA. The two organizations that sort of “oversee” this professional field. The politics of these two organization is quite different. And some of the specifics about how school get accredited are quite different. There’s something to the fact that so many new Osteopathic school are opening in US and so few allopathic ones are. In my opinion, the Osteopathic accreditation process is much much simpler, less expensive, generally looser. This is a BIG misstep on the part of the AOA is my opinion. By making the process of opening osteopathic school easier, they are sort of shooting themselves in the leg down the road.



  37. Probably wouldn’t work. We don’t treat hypertension musculoskeletally for one thing. We don’t believe its ever caused by a “malalignment of a bone.” We would work on decreasing sympathetics. This clues me in again on your lack of knowledge on the theory of what we do, and I don’t mean that as a personal attack. I used to say drugs were all bad until I came to med school and realized how they work with the body, and how sometimes they are very, very necessary. Like I said before, I would love to discuss theory with you, but you just keep insisting it wouldn’t work with nothing to back up these claims as to how the theories are flawed.

    I know, I know. Lack of evidence. And I’m sure if I say, there is no evidence disproving it either, I’ll get a reply something to the effect of well, we can’t disprove the Easter Bunny. And I’ll say that we CAN prove that all drugs are bad for you in some way but we still use them. Ugh, lets not go down that road.

    All I can say is that there is science backing it up, (which can we talk about sometime if you have the time? if only so you can maybe disprove it, better I find out now right? haha)… and when you completely dismiss it without giving specific reasons why, then you are calling all the thousands of DO’s and researchers and european osteopaths and professors who use it ignorant. And thats a pretty bold claim. You got mad at me for saying your statement was ignorant, can’t you imagine I might try to stand up for myself when you essentially call a whole institution ignorant?

  38. MvMedStudent,
    As a 2nd year DO student I have to say that I’m surprised someone would enter MEDICAL school (DO or MD, doesn’t matter) thinking up front that “drugs were all bad”. 4 years is a big commitment to make if you only believed in what amounts to may 15% of our curriculum. Seriously I thought even the hard core OMM (osteopathic manipulative medicine) gurus believed in things like, oh say… antibiotics.
    Medicine is a big tent and there is a place for almost everyone. However in the context of this discussion, when the only person stepping up to argue about the efficacy of OMM is coming from your angle it makes DOs look like throwbacks and not the mainstream physicians that we are today.
    And to Panda…I’m not even close to being big on OMM but as to your hypertension study you might be surprised. The fact that the study performed as you proposed would never make it past an IRB notwithstanding, OMM administered several times a week might actually do something (by something I mean an itty-bitty drop – probably non significant). As for the mechanism of that change, “normalizing the sympathetics”, relaxation, placebo effect, who knows, but it just might actually do something. Now just smelling your Lasix would lower your BP more but that wasn’t really the challenge was it.

  39. Making the patient subjectively feel better does have therapeutic effects. It is called the placebo effect.


    This effect switches the body from the “fight or flight” state to the “rest and relaxation” state. To optimize survival, under conditions of “fight or flight”, all resources are diverted to (for example) “running from a bear”. Repair of damaged tissues while “running from a bear” is a wasteful and potentially fatal use of resources. Those resources are better spent increasing the running speed until escape is effected. Then (and only then) does the organism have the luxury of repairing damaged tissues.

    That is what the placebo effect does, tell the body’s emergency systems to “stand down”, and divert ATP and other resources to repair.

    I have no doubt that (as you suggest) a topless massage with a “happy ending” would invoke the placebo effect too. Why is it that married people live longer? (it isn’t just that it seems longer), rather regular episodes of affection invoke the placebo effect and turn on repair systems. When that happens frequently, people live longer because their bodies are in better repair.

  40. Mvmedstudent, in his post, said that DOs treat blood pressure with manipulation. As blood pressure varies considerably during the day even in normotensive people, I have no doubt that OMM can transiently lower blood pressure secondary to its no doubt calming effects. But that’s a far cry from saying that it will stay low once the patient gets in his car and is cut off in traffic.

    I also think that OMM is terrific for the “well-being” of the patient so I’m not jumping down anybody’s throat here. It does fit into the DO world view of holistic medicine so I don’t see a problem with people practicing it.

    But the research supporting OMM is sparse and shoddy. Personally, there is no treatment modality that I hold so dear that I wouldn’t give it up if the it was proven to be useless which is not the case with some DOs (not all) and manipulation.

  41. In other words, while I of course care about all aspects of medicine, I just don’t care what people do to, for, or with each other if it is harmless.

    I think things like acupuncture and homeopathy are complete quackery, for example, but since the people who are fleeced can usually afford it, I take a caveat emptor position on most of it.

    Stand by for my article on CAM. And see this article.

  42. daedalus2u,
    I don’t know about married couples but I always figured that married men lived longer because their wives nag and make them go to the doctor when they wouldn’t otherwise.

  43. First off thank you to PB for constructing this article. The people who read your well written blog have most likely learned something about Osteopathy. This is important to me as a DO student when so much misinformation is out there (I mean Newsweek ran an cover story called ‘Hero MD’ on a guy that’s a DO).

    Second, to CholeraJoe, OMT can be billed by MDs although I’m not sure if the specific insurance companies you bill will reimburse for it. I know there are MDs out there billing for this service.

    Third is about research. I entirely agree that we need to show objective evidence for our treatments but I’d like to point out to everyone that a double blind placebo study for OMT is basically impossible. This isn’t meant as an excuse but simply a reminder that it’s impossible to compare these types of studies to the gold standard research methods that work so well with drugs. Research is also expensive and most DO schools don’t get anywhere near the amount of NIH funding as the MD schools so it’s going to take a while to publish some good data.

  44. “Balancing sympathetics”? How do you propose to do that manually? You somehow cause a lasting change in the balance of the autonomic nervous system? If there is ignorance, it’s in thinking that a massage will magically fix high blood pressure. Ugh. I’d rather have Harry Potter’s friend Hermione wave a wand at me than have somebody try to “balance my sympathetics”.

  45. Moose (and others):

    Not sure you are amenable to discussion on this–your mind seems made up–but let me try put the concept of “balancing the sympathetics” into words that don’t sound like metaphysical jibber-jabber.

    If you recall from neuroscience, there are several different reflex pathways that operate at the spinal level. Afferent sensory neurons have been shown to synapse on a variety of targets in the spinal cord including visceral (autonomic) motor efferents. In other words, somatic nociceptive input can activate a direct reflex that increases sympathetic output. People live with these chronic muscle spasms and joints with decreased mobility which cause a constant stream of nociceptive afferent input driving an aberrant sympathetic response. It seems reasonable that if you can eliminate the nociceptive input, you will cause a decline in that reflex mediated sympathetic activity. The tool osteopaths use to relieve muscle spasm and improve joint mobility is OMM. The idea is not to somehow manipulate the sympathetic nervous system, it is to identify and treat any possible structural problems that may be driving that somato-visceral reflex.

    This model, while being based on good basic science, still needs to be investigated in a controlled manner.

  46. One more interesting thought:

    Aside from activating those somato-visceral reflexes, nociceptive input also activates somato-somatic reflexes (causing muscular action to try to minimize the pain) and through ascending pathways it activates the arousal system. Chronic hyper-arousal, probably mediated through cortisol and norepinephrine, has been linked to many disease processes such as diabetes, heart disease, etc. So again, its conceivable that you could create a more favorable setting for improved health by reducing the overall somatic pain a patient is experiencing.

    (Guess who just took their OMM written final and is in the middle of neurosensory system.)

  47. RD- Ya, I know, it was more of an irrational fear at the time. Well maybe a little rational. I watched my mom wither away on chemo. I have since gotten over the fear and am even seriously considering hem/onc.

    Red Beard- Good job. I didn’t think it could be explained in the body of 2 comments, but you have explained the primary theories quite concisely. The only thing I need to clarify was how I treat sympathetics when I said we don’t do it musculoskeletally. I mean, we do technically, but I don’t diagnose an issue within the musculoskeletal system first, as in, I don’t go looking for any tight muscles, rotated vertebra, etc. Instead, in cases where sympathetics are predominant, like in high blood pressure or low blood sugar, I’ll decrease the sympathetics by doing paraspinal inhibition, where deep pressure applied to the paraspinal muscles directly inhibits the sympathetic chain ganglia.

    Panda- Believe me, I too would hold no treatment so dear that if it were disproved I would cling on. If a treatment is shown to do nothing, or there is no science behind it, I don’t add it to my repertoire. –Hey other DO’s, ever heard of Chapman’s points? Explain to me how nodules on ribs correlate to visceral problems and I might bother to do more than memorize them for boards— But really, I’ve found that experience speaks for itself and have thus dropped using many techniques. Like I will never do an HVLA treatment (as in back cracking/popping/whatever) on anyone with hypoglycemic issues. I once did it to a diabetic classmate and his blood sugar plummetted. Scared the crap out of me! However, there are plenty of my friends, and friends of friends, and plain ol’ freeloaders who have had various kinds of muscle tightness, pain, joint issues, etc that they’ve tried everything for. Drugs, surgery, diet, massage, physical therapy, chiropractors. But in those cases, they never got such relief until I treated them (obviously if any of this worked for them, they don’t need me!) If it was just comforting touch, or relaxation, or any other psychosomatic explanation, why didn’t it work with the massage or chiropractor? I’m not posing that to instigate. I’m saying thats literally the question I have posed in my head dozens of times when coming to grips with what exactly I was doing… and the conclusion I come to is that we are exacting some other more specific change than just relaxation of a person’s touch. But then again, even if it isn’t (perhaps they have such utter confidence in me that I’ll cure them that I do…doubtful, haha), I still only use the techniques that consistently provide this relief to people.

    So MDs…I have a semi-unrelated question. As students, we are all twisted and hunched and in pain from studying too much, but we just pop eachother back into place. How do you guys survive?

  48. If this statement were true:

    “This model, while being based on good basic science,…”

    Then this statement would be false:

    “…still needs to be investigated in a controlled manner.”

  49. RxnMan:

    I hate to turn Panda’s blog into an academic disussion, but….

    What I mean to say is the concept of somato-visceral reflexes has been studied in animal models. Here’s one example of that research: (I hope this thing hyperlinks automatically)


    What needs to be studied in a controlled way is the effect of OMM on this process.

    I’m not saying I’m a true believer, I am saying there is a more rational model in development that will hopefully bear fruit.

    Time will tell. In the meantime, its unlikely OMM is going to hurt anybody, being used as an adjunctive to the standard antihypertensive regimen.

  50. Maybe I missed something in my perusal of the abstract (sans any sort of statistics – what does “was usually increased” really mean?), but I think if I pinched your chest, you’d be upset too.

    I’ll tell you that I think using musculoskeletal manipulation to cure biochemical disorders is right up there with homeopathy. My opinion won’t (and shouldn’t) change your practice. If you really want converts, don’t give out theories, and don’t quote a pain study paper and say it proves your point. Get one paper where the authors twist the spine of a test animal (or volunteer), who then develops hypertension, which is then immediately relieved by aligning its spine via OMM methods.

  51. RxnMan:

    You are absolutely right–that is exactly the kind of study that needs to be done.

    You’ve misunderstood my intentions here. Personally, I couldn’t give a rats ass about making converts or proving any point regarding OMM, other than to say some practitioners are beginning to look at it in terms other than nebulous ideas of balancing chi flow or that kind of nonsense.

    Take care man.

  52. I generally agree with most of what you say and my only beef with you is that you don’t provide actual numbers to back up your assertions. The average MCAT for matriculants to DO schools is 24 and the average GPA is 3.4 cumulative. (http://aacom.org/data/cib/06-mcat-gpas.html). 24 is AVERAGE. A score of 24 on the MCAT would effectively rule you out of an MD program at even the worst MD school. MD programs (combined) have an average GPA of 3.6 and an average MCAT of 30. That’s pretty damn significant.

    The fact is, ask MOST osteopathic students, they would rather be at an MD program and the DO program was clearly a back-up. Also fact: MOST DO acceptees would have significant trouble getting into an MD program. So you’re completely wrong when you say it’s because of “outliers” that the averages are skewed.

  53. Great article Panda. I’m about to begin medical school at an osteopathic school this fall and I’m not entirely convinced either way about the effectiveness of OMT. I did however come across this article on webmd.com about chiropractic adjustment of the C1 vertabra and the associated lowered blood pressure in hypertensive patients. I don’t know if this is a similar technique to OMT but the study found that the chiropractic technique was successful while the “sham”/placebo technique did nothing. Granted, this was just a pilot study with N=50, nevertheless, it is interesting. Any thoughts or comments?
    link: http://www.webmd.com/hypertension-high-blood-pressure/news/20070316/chiropractic-cuts-blood-pressure?page=2

  54. Please tell me more about how you “inhibit” the sympathetic chain ganglia by manipulating a surface level of muscles which is above the rib cage, which protects the sympathetic ganglia. That’s a lot of meat to get through.

    I can see how massage or making someone more comfortable could help lessen sympathetic output, but to imagine that the mechanism of high blood pressure is always musculoskeletal misalignment is silly. I won’t even touch the low blood sugar comment, because I’m not sure you understand the biochemistry well enough to understand why I’d make fun of you.

  55. Moose-
    When did anyone here say high blood pressure is caused by misalignment? Or even most of the time? I’ve only ever said it might help with management.

    As for blood sugar, crap, I admit, I misspoke. I originally just replied to Panda with my story about lowering blood sugars but when I decided to expand, I accidentally wrote that. I do realize sympathetics both increase glucose utilization and gluconeogenesis.

    I think its kinda interesting how hard some of you guys try to argue that this is of no value. Its like you are trying to convince yourselves you aren’t missing out on anything.

  56. “I think its kinda interesting how hard some of you guys try to argue that this is of no value.” How hard do you think this is? I’m not trying to convince myself I’m not missing out on something. I would have liked to have learned OMM/OMT once, but now that I have the experience of being in med school I realize I’d rather not take attention off learning the art and science of medicine to learn something that is unproven and frankly seems to me to be more of the “golden cow” of Osteopathy than anything. Your explanations of OMT don’t fit biochemistry or anatomy as I understand them, so until you prove that it can do what you say it can, my assumption is that it can’t. How exactly can you influence an anatomical structure through 2-4 inches of muscle and bone? If I used my fist, I don’t think I could damage the sympathetic ganglia without first breaking the ribs. Yet you think you can “inhibit” them through manipulating the muscle over the ribs over the connective tissue they rest on? Such claims seem much like homeopathy.

    If high blood pressure isn’t caused by musculoskeltal problems (which I agree it’s probably not), how do you think that “fixing” musculoskletal issues will improve it? I admit, I think a regular massage might result in a transient drop in blood pressure, but listening to relaxing music probably would too and be cheaper. A massage therapist is probably cheaper than a DO, so how does your skill set result in value for your patient?

    I don’t doubt that DOs are fine doctors. I’ve met and shadowed some really excellent examples, but they practiced medicine. I’m simply unimpressed with unfounded claims for OMT. Anything you’ve got evidence for, I’m more than happy to keep an open mind on and read your research, but I haven’t seen any presented here.

  57. Hey Moose:

    I don’t think anyone is claiming that musculoskeletal problems are the sole cause of hypertension. What we are claiming is that musculoskeletal problems may play a role in essential hypertension, along with the myriad other commonly cited nebulous factors like stress, sodium, exposure to loud noises, crowding, etc.

    As far as how you might “manipulate” the sympathetic chain physically: The chain runs along the lateral surfaces of the vertebral bodies. Just posterior and invested in the same fascia are the heads of the ribs. Some osteopaths claim that by manipulating the ribs you will be basically moving that fascia and mechanically stimulating the sympathetic chain.

    ***HOWEVER: A study published in JAOA found no significant alteration of sympathetic activity with rib articulatory OMT!!! So this one I DON’T buy into personally. (Sorry, no time to dig up the reference at the moment.)

    As far as being able to manipulate something through 2 inches of muscle and bone…you’ll probably do it several times in your training as an MD when you take a turn doing chest compressions during a code.

    Take care.


  58. Well I see alot of posts from MD’s, DO’s, and their respective students. But I have yet to see a single post from people like me…a patient. So here is my humble perspective.

    OMM is my first choice of treatment. It’s quick, simple, and to the point. I’ve had more than a few physical problems completely resolved with OMM. Chronic headaches, chronic backaches, my trick shoulder, constipation, and my bum knee just to name a few.

    OMM has had a very positive impact on my psychological health. My pain is gone! It hasn’t been covered up with pain pills, it’s just gone. It’s wonderful to not have the pain, and also not have the medicated feeling I got from taking pain pills. WOOT for no medicine head!

    OMM cannot treat everything. Obviously. However, even when OMM cannot directly treat my problem, I’ve found that adding OMM to the proscribed treatment has allowed me to recover from illness much quicker. I’ve also noticed that don’t get sick nearly as often since I’ve been receiving regular OMM treatments.

    OMM has caused me no harm, and I personally have felt it’s benefits. My quality of life has improved since I started receiving OMM regularly, and I think I can make no better argument for the positives of OMM than that.

  59. During chest compressions, aren’t cracked ribs common? Seems a little counterproductive, because I think that would drive up most patients’ bp ; )

  60. I’m sure none of you are “ignorant” as
    MyMedStudent was careful to not insinuate,
    but can’t we just agree to disagree about the
    efficacy of OMM? If I hear one more MD ask for OMM on a silver platter, I’m gonna puke.

    There’s literally hundreds and hundreds of studies, OMM doctors who have private practice have a 6 month to a year long waitlist of patients, the residency program at St. Barnabas is a kick ass program from what I’ve heard… so what’s the problem? If I don’t to believe in Estonia all I gotta do is keep out of Eastern Europe, right?

  61. Did I just walk into a pile of dung by
    putting OMM and Estonia in the same paragraph?
    Strike me down where I sit right now.

    Hey, one day, when I’m all grown up, I’ll be back and give you the “straight dope” on whether OMM works for more than just a neck crick.

    Anybody got some Vioxx?

  62. Yes, US DO’s can now practice in the UK.

    Went DO, love it.

    91%ile on the MCrAP btw 😉

  63. Nice to hear to hear from a patient…look guys, it doesn’t matter what MD’s or DO’s say about OMM/OMT, the fact of the matter is that patients are very satisfied with how it works and there is a very high demand for it,and DO’s are getting paid nicely for doing it…so if I can give patients a sugar pill and they say it cures there pains and they pay more for it and the fact that it does not harm them in anyway then I the heck not…

  64. *anyway then why the heck not…*

    sorry that is what the last line on my previous post should say

  65. OMM is an actual acceptable treatment, whether you may believe it to be a placebo or not…so thats all i am saying

  66. Little difference between MD and DO?

    Last time I checked, DO had an average matriculation MCAT of 24-25, ~3.4 GPA (with grade replacement), while MD schools had around 30-31, ~3.65 (no grade replacement). Statistically, that is about a 1 STD, which is very significant (~70 percentile difference). Fact of the matter is, most students prefer MD over DO because there are more oppurtunities associated with the latter.

    Clinically, the difference between MDs and DOs in the same medical field is one’s personal drive and ambition, but pre-clinical, its a whole different ball-game.

  67. DO: From what I’ve read here, almost sounds like “medically trained chiropractor”, except the bony manipulation has perhaps a little more logic and a lot less superstition behind it.

    What do I care, as long as a competent DO can hold a candle to his/her MD colleague on the wards?

    they spend close to eight months of their clinical years on mandatory outpatient and ambulatory clinic rotations which will tend to make pathology look mighty good.

    As a pathology resident (Australian MBBS), I had to laugh long and hard about this; I despised my hospital internal medicine and outpatient duties, but oddly enough I liked rural general practice.

  68. Lets get the numbers straight here if people are going to talk about them:

    1.) Average DO school gpa are usually 3.4-3.5 (3.6-3.7 MD)
    2.)Average DO MCAT is usually around 24-25 (29-30 MD)

    3.) These numbers only matter if you are seeing large rates of attrition at DO schools, which you dont, which tells me that the students there are perfectly capable. What matters the most are you board scores, evals..etc, which tells me how could a physician is.

    If anyone ever looks at how a DO class looks, you will see a lot of people with very high gpa’s, with average mcats (ie. 3.8/25) or vice versa (3.33/32, so they usually are in a DO school because they didnt do well on the mcats but still high gpa or had lower gpa’s but high mcats. In my experience it’s been the carribbean schools that usually take students who have done poorly in both.

  69. I can only speak for my school, AZCOM, but my entering class had an MCAT of 28 and a GPA of 3.5. We also routinely match at 80%+ MD residencies and with the majority of our graduates entering specialties.

  70. If that AZCOM average is correct that pretty much is equal to UIC, RFU, Loyola, and SIU numbers here in illinois (~29, 3.5-3.6), SO there are a bunch of DO schools with comparable if not better averages than a lot of MD schools, it’s really up to each person to research each individual school instead of categorizing all MD schools are automatically better than all DO schools. S if you really don’t care about the degree designation, I encourage you to research each school because I know of a few DO schools I would take over numerous MD’s.

  71. hey,
    I’m a DO, we rock the boat. It’s cool to have the same adrenaline and pressure-laden roles as MDs and to get asked “what does DO stand for?
    We stay humble.
    Plus we have spent some time exploring sacral edges of our colleagues.
    MDs are too intelligent, many of the really high IQ ones totally, totally SUCK and should be locked in cages with monkeys and placebos.
    I wonder if this will start anything.

  72. PS DO stands for:
    “Done with Osteopathy”.
    “Dent the Occiput”
    “Dream of Ontogeny”
    “Drown the overlord”

    etc etc etc

  73. Hey guys,

    I am a DO student and I must say I was at first very hesitant about OMM. I believed it was effective for musculoskeletal issues but I was not confident regarding the other claims made by OMM physicians. However, as a person suffering from a severe chronic illness with failure of all medication, I turned to OMM as a last ditch resort. I must say it has helped me tremendously. I do not want to get into details to protect my identity (I have a very specific case), but it seems to be working.

    In regards to MCAT and GPA’s for osteopathic medical schools, they seem to be rising for certain schools. Many of them have MCAT’s >26 and GPA’s >3.5. I can speak for two schools….Des Moines University and Philadelphia College of Osteopathic Medicine. I know that DMU’s stats for the Class of 2010 was 3.65 GPA and 27 MCAT. PCOM’s entering stats were 3.6 GPA and 26 MCAT.

  74. Heres another school..

    Michigan State University; College of Osteopathic Medicine

    Science GPA: 3.6
    MCAT: 26
    25% of the class has a MCAT higher than 29.

  75. Patients pick DOs because they have better bedside manner than MDs-at least by reputation. So far my practical experience confirms that. The one MD/phd I saw had nightmarish bedside manner-he should be in a lab not a hospital. Med school screens for scientists, not caregivers. The DO schools come across “softer” and with more emphasis on the whole patient.

    none of my DOs do the joint manipulation but my DO IM guy did figure out a chronic genetic condition in my family by messing with my fingers. He noticed global joint hypermobility which falls into the EDS spectrum of disorders. The diagnosis explained four generations of upperGI pain/chronic fatgue/chronic muscle pain and may underlie some pretty fucked up familial endocrinology. All that by looking at me rather than my medical chart.

  76. The DO and MD degrees are essentially different “brands” of physician training or different “operating systems” for the same hardware. They are functionally equivalent. It all depends upon which group’s marketing propaganda you’re more inclined to believe. Are you more “holistic” or “reductionistic?” Are you more of a “people person” or a “book worm?” Do you consider yourself “non-traditional?” Most of the perceived differences are really a reflection of self-selection factors.

    DO schools may have slightly more generous admission stats, but do 3-4 points on the MCAT or 0.2-0.4 of GPA really make a difference in a code or during a trauma resuscitation? I don’t think so. My experience is that DO’s hang on to their osteopathic roots for reasons mostly sentimental, marketing, and nostalgic. Manipulation and manual treatment probably helps for musculoskeletal disorders. Interesting as physical therapists convert their training programs into doctoral programs—DPT’s—their curricula are looking more osteopathic.

  77. I’m going to be applying to both MD and DO schools. My brother, who’s an MD in the Air Force, was the one who originally suggested DO schools to me (before that I’d never heard of them). As a side note, DO’s are common in the military. Anyways, I wanted to ask you DO’s out there who also applied to both: did that ever come up in interviews at DO schools? Did they ask if you were also applying to MD schools and how did you handle that inevitable question/suspicion that you may have considered their DO school has a “backup”??

  78. Hello,
    I am appling to medical school right now and stumbling randomnly across this web site. Since applying for medical school,as competitive as it is, I found out that there are other medical schools to apply to,that is osteopathic med schools. I have never heard of a DO until now. As long as I do well on the MCAT, I am very glad to know there is a backup plan for me to get into a medical school,i.e., osteopathic medical school.
    Anyway, I have read of possible DO initials changes to MD,DO or MD,O or MD/DO. By the time I graduate, if from a DO school, does anyone know if this will happen?
    If not, does anyone know if any DOs are applying for an MD degree through http://www.DOTOMD.com program?
    Just asking because I would rather have an MD degree instead of DO degree to avoid having to tell people what I am or any discrimination, you know?
    Thanks for any blogs regarding to this.

  79. One way to look at all this is from the perspective of the ‘organization’, and by doing so we have ‘MD’ and ‘DO’, and ‘ND’ etc.

    Another way to look at this is from the perspective of ‘what works’. And if you look at it this way, you then only have ‘medicine for which there is evidence of efficacy’ and ‘medicine from which there isn’t evidence of efficacy’.

    Looking at it this way also demolishes the orthodox vs CAM problem. Who really gives a flying hoot from where it originated, if in the end, a certain treatment is demonstrated to ‘work’.

    And by ‘work’, I mean consistenly shown to be more effective than doing nothing or doing a pretend treatment.

    And if a treatment is shown to ‘work’, then why should it remain ‘complementary’ or ‘alternative’, for that would be illogical. Treatments for which there is suitable evidence of effectiveness should be mainstream.

    For OMM, I do not believe that there is any suitable evidence of effectiveness other than for low back pain. Even though there may be biologically plausible science for why it ‘should’ work, this is not the same as evidence that it ‘does’ work.

    The ‘does it work’ kind of evidence relys on clinical trials of various types and these are underway – particularly at the North Texas Health Science Centre under the leadership of Prof Licciardone.

    So, the answer for OMM is really, ‘watch this space’. And if it turns out that some OMM does actually ‘work’, then, when you come to think of it, it would be unethical for MD’s not to offer it as an evidence based treatment.

    But I’m jumping ahead … the alternative scenario is that it would be unethical for DO’s to keep offering something that doesn’t work.

  80. “there is little or no good evidence that manipulation does anything other than make the patient feel subjectively better.”

    In fact, ‘subjectively’ is actually the only way that someone can feel better. What’s important, though, is exactly why they feel better. Of course, the same standard should apply to all health care intervention, regardless of its origin. Rhoda’s post above says it all.

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