 I just want to let people know that next week's lecture is not going to be Victoria's Suite, because Victoria wanted to come at a later date. But I just want to let the people on this call know that it's going to be Sydney Halperin, who's going to talk about research ethics related to her work that she's done on people who were involved in the hepatitis experiments. So she is a former U of I faculty, now retired, but has published a recent book. So next week's lecture is going to be that. I just wanted to let people on this call know so. But to get today's talk started, it's my great pleasure to introduce my friend and colleague, Dr. Norm Gevitz. The title of the talk is What is Past as Prologue? The Future of Osteopathic Medicine. Norm Gevitz is a medical sociologist, historian, and academic administrator. He has written numerous books and papers on the history of medicine in the United States and is best known for his book, D.O.'s Osteopathic Medicine in America, where he discusses the history of the profession of osteopathic medicine in the United States. Norm Gevitz studied political science at NYU, graduating with a Bachelor of Arts in 1970 and then a Master of Arts in 1971, where he moved to the University of Chicago where he studied sociology, earning a PhD in 1980. He is currently Senior Vice President of Academic Affairs and Chief Academic Officer at AT Still University, the founding institution of Osteopathic Medicine. Previously at the New York Institute of Technology, College of Osteopathic Medicine, Dr. Gevitz was a professor of history and sociology in the Department of Family Medicine. While there, he also served as Director of Academic Medicine Program. Before going to New York, he was professor and chair of the Department of Social Medicine at Ohio University College of Osteopathic Medicine. He has served twice as the commencement speaker for AT Still University, Kirksville College of Osteopathic Medicine, and in 1996, that institution awarded him an honorary doctor of Humane Letters. His three books include Osteopathic Medicine in America, Beyond Flexner, Medical Education in the 20th Century, and Other Healers, Unorthodox Medicine in America, published by Johns Hopkins in 1990. It is my great pleasure to introduce today's speaker, Dr. Norman Gevitz. Thank you very much, Mindy. I have now traveled full circle. It has been 48 years, 1974, when as a graduate student sociology at the University of Chicago, that I began my research on the social history of osteopathic medicine in the United States. My interest in osteopathic medicine was purely circumstantial. I had a friend who was about to receive his MD degree from a Chicago medical school. He called and asked if I wanted to play tennis, and I met him at the courts on campus, which were being used at the time. So while waiting for a court to open, I started a conversation about one of my interests in sociology, which was occupational role duplication. Occupational role duplication occurs when two or more occupations or professions compete for services in the same subject area, such as both lawyers and accountants doing tax preparation. Since my friend David was soon to graduate medical school, I extended the topic to include health disciplines or specialties. I started peppering him with questions. I asked him, what were the boundaries of ophthalmology and optometry since both could do refractions? At the time, optometrists wanted to dilate the eyeballs so that they could determine if their patient had any underlying conditions they should be aware of. The American Medical Association vigorously fought this expansion of what the optometrists scope of practice. I next asked about where oral surgeons that his dentist stopped compared to the scope of head and neck surgeons. I followed that with podiatrists vis-a-vis orthopedic surgeons. At the time, podiatrists were restricted to the foot up to the ankle, but some podiatrists were lobbying the Illinois legislature to be able to extend their scope of practice to the knee, and some wanted to go to the thigh, a case of professional gangrene, I joked. My friend David answered all the questions I posed and then said, don't ask me to tell you the difference between an MD and a DO. And I looked at him with a blank stare and said, what's a DO? And he responded, an osteopath. And I said, what's an osteopath? And David looked at me funny and said, a DO is like an MD. They're fully licensed to practice medicine and surgery. They have their own schools, their own hospitals, medical societies, their own journals. They are like us, but different. In addition to medicine and surgery, they practice spinal manipulation and I don't really wanna talk about it anymore. Well, at that point, the tennis court came open and we played our match. A few days later, I thought about our conversation. And I remember how surprised I was that I had never heard of a DO or an osteopath. After all, I was a graduate student at the prestigious University of Chicago. I asked some of my UFC classmates and a few professors if they ever heard of DOs or osteopaths and all of them replied negatively. I thought that strange. Eventually during a trip to Regenstein library, I tried looking up in the card catalog. Yes, I'm dating myself for something about DOs and on that particular visit, I was unsuccessful. At that point, I thought my friend David had played a practical joke on me. There were no such things as a DO. Nevertheless, I had one final resource, an old edition of an encyclopedia Americana. And in there, I found an entry on osteopathy. And although outdated, it roughly affirmed what my friend David had told me. One item in particular caught my attention. It said that one of the existing osteopathic schools was located in Chicago. I next reached for the phone book and there it was, the Chicago College of Osteopathic Medicine. And amazingly, it was then located in Hyde Park, just five blocks north of the University of Chicago campus. But at this point, I was intrigued. The next day, I traversed the five blocks north and was admitted into the library of the Chicago College of Osteopathic Medicine. There I discovered the complete run of the Journal of the American Osteopathic Association, which commenced publication in 1901. I first looked at the issues from 1974. And although in no way was I medically trained, it looked like a regular medical publication, in part because of the extensive drug and surgical supply advertisements. Most of the articles appeared to be straightforward discussions of medical conditions and how they might be treated through pharmacology and or surgery. There were a small number of articles which included manipulative treatment in the discussion and a few standalone articles on distinctive osteopathic palpatory diagnosis and manipulative treatment. After reading these issues, I turned to 1901, the beginning of the journal and found something quite different. All the articles were on the philosophy of osteopathy, palpatory diagnosis and manipulative treatment of given conditions. There was a nod to surgery in some cases where manipulation alone was insufficient and a course of negativity to the contemporary pharmacopoeia. That visit to the library led me to ask two basic questions. First, how did osteopathy transform itself to osteopathic medicine in the space of less than 75 years? And second, why would DOs and osteopathic medicine socially invisible? Upon further visits to the Chicago College of Osteopathic Medicine Library, I added a third question. How over the years had this small profession withstood the efforts of the American Medical Association first to crush it and then to amalgamate it? The more I visited the library, the more sure I was that this subject would be my doctoral dissertation. Even more bountiful to me in terms of resources was that the American Osteopathic Association was headquartered in Chicago and was the repository of the largest library and archives of the profession. I believe the sheer lack of social visibility of the profession led the executive director of the association to allow me, a stranger, to do research there in the hopes of me producing an objective portrait of the profession. The head of my doctoral dissertation was the well-known sociologist Odin Anderson. And I was fortunate to engage Lester King, MD, a distinguished historian with an appointment at the Fish Fine Center and who at the time was senior editor of the Journal of the American Medical Association. My dissertation took six years to complete and another two years before the Johns Hopkins University published the DO's Osteopathic Medicine in America as my first book. Since 1982, the DO's has undergone two revisions, the first published in 2004 and the most recent in 2019. In all editions, I've striven to paint awards in all portrait of the profession, believing that as a non-DO, I can provide an independent perspective identifying both the positives and the negatives. For 12 years in my career, I had a full-time appointment at an allopathic medical school, the University of Illinois, Chicago, and rose from assistant to full professor. For the last 25 years, I've been at osteopathic medical schools and now occupy a senior leadership position. Still, I've tried to hold fast to the original concept of being of independent judgment. Outside my institution, I am not currently viewed by osteopathic leadership in a positive light as my stated views on the future of the osteopathic profession, which I will discuss today, differ substantively and significantly from theirs. To understand the future prospects of osteopathic medicine, I believe as an historian that it is essential to understand its past. In the time allotted me, I can only give a thumbnail sketch, which I've often done at osteopathic medical school, white coat and commencement ceremonies across the country. By encapsulating more than 100 years of history into seven generations, each with a particular challenge to overcome, I can give you, particularly those of you who are unfamiliar with the subject, a rough and admittedly simplified sense of the profession's evolution. The first generation faced the challenge of innovation. Andrew Taylor still the founder of osteopathy was schooled in a medical system that relied on bloodletting, arsenic, antimony, alcohol, morphine and mercury as therapeutic agents, a system which likely more often killed than cured. To meet this challenge, he devised an alternative system which relied on palpatory diagnosis and manipulative treatment and whose philosophy was rooted in the body having the ability to heal itself. In 1892, he established the American School of Osteopathy in Kirksville, Missouri. Within six years, he had 700 students in attendance simultaneously. The second generation faced the challenge of institutionalization, organized medicine of stills day vehemently opposed this new system and fought every effort to propagate it. Yet this generation of DOs established schools, clinics, state and national associations successfully lobbied for protective licensure laws won court battles and convinced MD groups much to their surprise that osteopathy was no passing, fad or fashion. The third generation faced the challenge of scope of practice. AT still endorsed anesthetics, antiseptics, antidotes and minor surgery, but he was opposed to vaccines, serums and drugs that had been demonstrated to be of value. For over 25 years, DO struggled over the issue of what diagnostic and therapeutic tools they should teach and employ until finally in 1929, the American Osteopathic Association permitted the schools to teach the broadest scope of practice. The fourth generation faced a challenge of standards. From 1935 to 1960, this profession schools, unlike their MD counterparts, had to lift themselves up without government or philanthropic support to upgrade their admissions requirements to improve their laboratory training and widen their students' clinical experiences to gain greater equivalency with their MD counterparts. The fifth generation faced the challenge of equality. As DOs and MDs came closer together in their scope of practice and college standards, some DOs thought an amalgamation of the two professions was desirable. And in California, there was a merger between the state medical and osteopathic societies where DOs were awarded academic MD degrees, which the state legislature sanctioned for use only in California as a basis for practice. However, the rest of the DO profession vowed to remain independent. And one of the side effects of this merger was that the federal government and other states recognized the DO degree as equivalent to the MD degree and as a result, DOs won each and every subsequent battle to gain unlimited practice rights and entry into the armed forces as physicians. In addition, DOs now obtain external federal and private grants gained entrance into allopathic residency programs. The sixth generation faced the challenge of expansion. After the California merger, the profession sought to grow. There existed just five DO granting colleges in 1962. 60 years later, there are 38 osteopathic medical schools with 59 sites with more than 30,000 students currently in attendance. Today, osteopathic medicine is the fastest growing segment of the US physician population. This past year, 25% of all United States medical school graduates were DOs. Now, lest I be accused of writing a wiggish history of upward positive progress, each of these challenges, although met, came at a considerable cost to osteopathic identity and professional autonomy. In the beginning, DOs could claim that they were radically different from MDs in their belief system and the use of diagnostic and therapeutic means. As I noted at the beginning of this talk, except for a few classes of drugs, antiseptics, anesthetics and antidotes, DO relate them back into position and wait until normalcy returned to the distant body parts so affected. AT still referred to this approach as find it, fix it and leave it alone. No patient of a DO confused him or her with being an MD. But over time, with DOs deciding that palpatory diagnosis and manipulative treatment had limited beneficial effects. And as they wanted to be regarded by the public as complete physicians, DOs expanded the curriculum to incorporate more training in pharmacology and surgery. And consequently, less time devoted to the distinctive original osteopathic approach. As DOs try to convince their patients and the public that they were complete physicians, a growing number of DOs hid the fact that they were DOs by identifying themselves in their signage and stationary as Dr. So-and-so without indicating their degree. And they, including DOs who did properly identify themselves sharply reduced or dropped the utilization of manipulative treatment in their management of patients. Indeed, surveys of general practitioners in the 1950s revealed that DO general practitioners far out prescribed their MD counterparts. With respect to professional autonomy, for many of their legislative gains, they had to give up their autonomy. Early in the 20th century, many state legislatures created independent osteopathic licensure boards to ensure that MD licensing boards did not prevent DO schools from gaining state approval or individual DOs from being licensed. But with DOs seeking to become licensed as complete physicians, the legislatures merged MD boards into single and DO boards into single composite licensing boards. Thus they could not maintain complete control over their own licensure. Osteopathic medical schools as a result became required to remit certain benchmarks, not of their own making in their admission standards, breadth of their curriculum, and clinical training. As DOs began to lobby legislatures for greater scope of practice rights, the AMA invoked the consultation clause against them as they had done against homeopathic and eclectic medical practitioners in the 18th and the mid 19th century. The AMA leadership argued that it was unethical, see I'm bringing ethics into this discussion, that the AMA decided that it was unethical for regular practitioners to associate in any way with practitioners of a medical cult. And in the early 1920s, osteopathic practitioners who held both a DO and MD degree had to choose under which degree they would need to identify themselves. If they decided it would be an MD degree, they had to completely cut off all relationships with their osteopathic friends and colleagues. The consultation clause was also utilized to bar any DO from hospital appointments, even at public hospitals. In one important respect, this inclusion from the hospitals as well as medical societies served to create social and professional solidarity in the osteopathic profession as DOs and their supporters built their own hospitals and DOs were now limited to joining their own professional groups. However, with the completion of the California merger in 1962, the walls of professional separation between the two professions began to come down. State medical societies were given the right to decide from themselves whether professional interaction with DOs were ethical and outside of the deep South, most state medical societies abandoned their cultist designation for DOs. Consequently, osteopathic physicians increasingly found themselves courted by allopathic hospitals. And once the American Medical Association permitted DOs to enter their approved internship and residencies later under the auspices of the ACGME, the process of assimilation started to accelerate. DOs started to join the AMA and state medical societies. More DOs depart or the entirety of their postdoctoral training in ACGME programs eclipsing the number who strictly did their training in osteopathic hospitals. With there being less barriers to joining MD hospital staffs, DO hospitals began to close or began merging into hospital chains in the 1980s and 1990s. In the last 10 years, when I address osteopathic medical students, I tell them that they constitute part of the seventh generation of DOs and they face the challenge of distinctiveness. With DOs and their schools so similar in many respects to MDs and their educational institutions, the only rationale that I see for them to maintain an independent existence is to practice distinctively. It is ironic that in the early 20th century, when there were perhaps only a few thousand DOs in practice that a greater percentage of Americans likely knew what the difference was between a DO and an MD than do they today. This is because except for the differences in degree title, there is very little that distinguishes the two types of practitioners. The osteopathic profession's desire for independence must be rooted in maintaining practice differences which benefit patients. My analysis based on clearly discernible trends suggests that this challenge may not be met by this generation. The original raison d'etre of the osteopathic profession is the belief that DOs think differently or distinctively about the meaning of health and disease and incorporate unique diagnostic and therapeutic tools for the benefit of their patients. Yet since the 1920s, surveys of DOs show a decreasing reliance on manipulative treatment in the overall care of patients. Based on one recent study, 95% of all DOs surveyed responded that they either do not use manipulative means to address patient problems or use them only occasionally. More DOs say they agree with the philosophical tenets of osteopathic medicine but I would argue that a philosophy without a distinctive approach to patient management signifies a hollowness in that philosophy. Even if osteopathic students are enthusiastic about their training in palpatory diagnosis and manipulative treatment in the first two years of the curriculum, this material plus the opportunity to practice these skills usually come to a relative halt during the last two years of undergraduate training. The great majority of osteopathic students are precepted by MDs who do not have the background in osteopathic diagnostic and treatment procedures and therefore feel uncomfortable supervising students in a subject they do not know. Often though, I hear stories from osteopathic students about how an MD preceptor gives them permission to treat a patient osteopathically based upon the rationale given with good results obtained but these are isolated anecdotes without a continuity of practice skills deteriorate particularly when there are pharmacologic tools available to address the same problems. And within the last eight years an inflection point on the road to assimilation was reached, I believe when national osteopathic groups the American Osteopathic Association and the American Association of Colleges of Osteopathic Medicine agreed to join the ACGME in what is called the single accreditation system for graduate medical education. Both the AOA and ACOM would become voting members of the ACGME in return for the AOA to transition its internship residency and fellowship programs to become ACGME programs if they met the latter standards. Previously, the ACGME committed itself to what they called the next accreditation system which when instituted would be competency based. The ACGME which previously had no problem in having DOs enter ACGME programs after DOs completed an internship or residency program under osteopathic auspices now determined that the entirety of postgraduate training needed to be under ACGME auspices or DOs could not enter an ACGME program. At first the AOA resisted threatened a lawsuit but after extended negotiations all parties agreed and the agreement was hailed by its proponents in the AOA and AAACOM as quote in the public interest. As part of the agreement, the AOA would no longer accredit internship and residency programs after June, 2020. In some practical respects the single accreditation system has proven to be highly successful. Hundreds of AOA only accredited programs made the transition. ACGME accreditation standards required hospitals to budget considerably more financial resources particularly in spending for additional full-time faculty members and this year current year 99% of senior osteopathic students found PGY1 positions through the match and the SOAP programs. In addition, it appears that because of the single accreditation system a number of residency programs that never before had allowed DOs in their program now accepted osteopathic medical school candidates. DO leaders quite understandably have hailed these results and changes and believe that with all DOs now completing ACGME programs before they go into practice the reputation of osteopathic physicians will be enhanced and as a result the osteopathic profession will become stronger. After the initial agreement was made to join the ACGME I issued a series of papers focusing on what I identified as the unintended consequences of the merger. If the proponents as they said were dedicated to maintaining the professional independence of osteopathic medicine, I argued as a recovering sociologist that this agreement would instead accelerate the profession's demise. I had no quarrel with what the ACGME was trying to accomplish with the next generation accreditation system. Rather my objections were rooted in the AOA and ACOM not thinking of what would likely be the negative outcomes of this agreement for professional independence. The original structural pillars of osteopathic medicine are first the schools which are accredited by the commission on osteopathic accreditation, COCA. Next with the osteopathic hospitals which were accredited by another entity within the American Osteopathic Association as were the internships, residencies and fellowships. Once DOs completed their residencies they were board certified by the respective osteopathic specialty board and then they were eligible to join an osteopathic specialty college. DOs were expected to join the National American Osteopathic Association as well as the respective state osteopathic medical societies. By the time the merger was agreed to these pillars of osteopathic medicine were already undergoing significant erosion. First, a greater percentage of third and fourth year osteopathic students were receiving undergraduate training in allopathic facilities because existing osteopathic hospitals were insufficient. Second, once these students graduated a greater percentage, approximately 60% went into ACGME rather than osteopathic residencies. Third, as congenital MD hospitals sought to attract DOs to their active staff osteopathic hospitals merged with large hospital systems became mixed staff institutions or closed further reducing the number of students training under local osteopathic auspices. Fourth, the great majority of DOs who trained in ACGME programs became allopathically board certified through the American Board of Medical Specialties. Fifth, as a result of their training and certification these graduates joined an allopathic specialty college and did not join the AOA or its component membership societies. Significantly, much of this erosion was masked by the enormous growth of both osteopathic medical schools and graduates. Even though the percentage of students who were no longer undergoing osteopathic graduate training becoming DO board certified joining osteopathic special societies or obtaining membership in national or state osteopathic societies significantly diminished the escalating total number of graduates annually made it appear to many DOs particularly leadership that the profession was growing in all of these areas. So although the percentage was going down the absolute number was still going up. Those osteopathic leaders who championed the single accreditation system merger did not take into consideration the further erosion of the structural pillars of the profession in large part I believe because they did not take seriously the erosion that had already taken place being blinded by the growth in the number of schools and graduates and ignoring whatever else was occurring. Thus, they simply did not believe that the profession could lose its independent status. It is clear to me that the independence of the osteopathic profession is on an accelerating downward trajectory. Consider that now all osteopathic graduates will become ACGME certified. They will go through ACGME programs and will become ABMS certified. They will be joining their allopathic specialty colleges. The AOA argues that many DOs will become double boarded but why? If only one board certification is necessary for hospital privileges and insurance. It is likely that osteopathic specialty colleges will no longer gain an appreciable number of new members and will become repositories for previously AOA boarded graduates only. Similarly, why should osteopathic graduates join the national or state osteopathic societies when they can join the larger and more powerful AMA and state medical societies if they join any medical society at all? As a result, the osteopathic profession will be greatly weakened. And that brings me to the one pillar of that osteopathic leaders think is the strongest and that is the schools. As I noted earlier, they're currently 38 schools with 59 locations. DO graduates constitute, as I said, 25% of all US trained medical graduates in recent years. There are several new osteopathic medical schools planning to open. It is likely that in a few years there will be more than 40 osteopathic medical schools. Osteopathic leadership touts this growth as a sign of success, but here's the problem. Before the single accreditation system for graduate medical education went into effect, I publicly and repeatedly asked the leadership and membership of the American Osteopathic Association in open forums that if they proudly proclaimed that this graduate medical education accreditation merger was a great idea and most tellingly in the public interest, if so, why wouldn't a single accreditation system for both allopathic and osteopathic medical schools be a great idea and in the public interest? To this day, literally, some seven or eight years later I have never received a substantive response. Some osteopathic leaders literally go mute when I ask the question. And some simply reply, no, that won't happen. Well, why wouldn't it? It is a logical conclusion based on prior evidence. Certainly the liaison committee on medical education wants that undergraduate accreditation merger to happen. The AMA and the double AMC want that to happen. And if that does happen, they will likely be carnage. If one reads the accrediting standards of both the LCME and the commission on osteopathic college accreditation coca, they are practically identical. What is, however, very different, isn't in the standards per se, but in the expectations of what is necessary to meet those standards. The two basic models of medical education are substantially different in a number of ways. Since Abraham Flexner's 1910 report, allopathic medical schools obtained vast sums of money through diverse means, philanthropic and state support, as well as clinical practice plans and research grants. Osteopathic schools have been financed essentially through tuition dollars, although six osteopathic colleges established in the late 1960s through the 1970s are state supported. The annual budgets of private and state supported MD granting medical schools dwarf those of public and private osteopathic schools. MD granting schools rely on comparatively large numbers of full-time faculty members who reside in a wide variety of departments. By comparison, DO schools have a comparatively small cadre of full-time faculty. And rather than having several specialty departments, non-primary care specialists are often grouped in departments of specialty medicine because of their small numbers in individual disciplines. Although some state supported osteopathic medical schools have comparative numbers of full-time basic scientists as their allopathic counterparts, the vast number of private osteopathic medical schools which do not have PhD programs have between T20 and 50 basic scientists. Except for a small number of schools, osteopathic colleges do not have a strong research focus unlike MD granting schools which are multiple goals for their students, research, academic leadership, as well as clinical practice, osteopathic schools tend to have a single focus producing strong candidates for graduate medical education and practice, particularly in primary care. Their very high success rate in obtaining GME positions now exclusively in the ACGME system is one important indicator of the quality of osteopathic student training despite the school's lesser funding. Nevertheless, irrespective of osteopathic undergraduate and graduate student performance, most osteopathic schools cannot now meet current LCME accreditation expectations in terms of sources of funding, amount of funding, faculty student ratios, and departmental organization. With both osteopathic and allopathic leaders hailing the early outcomes of the single accreditation system for graduate medical education, it is likely that pressure will build from the LCME, the AMA, and the AMC to merge the two undergraduate accreditation systems. I already know that the AOA has rebuffed at least one effort by the LCME to hold talks, but how long can that refusal last? Every five years, the US Department of Education reviews professional education accrediting bodies to give them what's called deeming authority. We also know there has been an effort within the Department of Education to reduce, where appropriate, a multiplicity of accrediting bodies that do essentially the same thing. The Department of Education is next scheduled to review the AOA's deeming authority in 2026, which gives Allopathic Association's five years of data to demonstrate how successful the single accreditation system has worked and make the case that there is no valid reason why all US medical schools should not meet the same standards, namely theirs. The LCME, for its part, could offer the AOA and AACOM roughly the same deal that the ACGME offered these osteopathic associations on the graduate level. Osteopathic schools would be free to continue their distinctive training and palpatory diagnosis and manipulative treatment, and both the AOA and the ACOM would be added as constituent members of the LCME. Based on their stated position regarding graduate medical education, osteopathic associations have no logical basis for their refusal to join the LCME. However, it is likely they will bitterly fight such an arrangement and given their political strength, both nationally and on the state level, they may successfully forestall such a combination. DOs can successfully argue that osteopathic medical schools under the current AOA accreditation system serve the public interest in six ways. First, osteopathic medical schools, despite their limited resources, produce uniformly qualified candidates for graduate medical education. Second, osteopathic medical schools educate a higher percentage of future primary care physicians than do allopathic schools. Third, DO school graduates are more likely to eventually serve in rural areas where they are needed. Fourth, osteopathic medical schools are trained in distinctive diagnostic and therapeutic means, not taught in MD schools and these means provide DO graduates with an additional set of competencies to provide quality patient care. Fifth, osteopathic medical schools provide a challenge to conventional allopathic wisdom as to how much and what type of resources are actually needed to sufficiently prepare students for graduate medical education. And sixth, osteopathic medical schools by virtue of their limited organizational structure have the capacity to swiftly develop and institute innovative programs to educate their students and to better serve the underserved. Unfortunately, none of these points, however valid, goes to the heart of the question whether logically there should be one or two agencies that accredit US medical schools that produce candidates for graduate medical education. The AOA and ACOM can now utilize their considerable political cloud at the state and federal level to block a single undergraduate medical education system. But as I've shown, the professional pillars of osteopathic medicine, including state and national membership in osteopathic organizations will be diminishing year after year, thus weakening their power to resist. And if the osteopathic profession is unable to stop a single accreditation system from being adopted in 2026 or 2031 or whenever, there are a number of possible scenarios that may play out. First, those schools, state and private, who will be able to raise the additional funding, which is considerable, to meet standards to become LCME accredited, will do so. And over time, as was the case with homeopathic medicine in the first part of the 20th century, when they recognize the AMA as their accrediting body, distinctive osteopathic methods will diminish in the curriculum unless osteopathic researchers are able to clearly demonstrate through randomized clinical trials the benefit of osteopathic manipulative treatment. Second, those osteopathic schools that cannot obtain the funding to become LCME accredited will have the following options from which to choose. First, they can become satellite campuses of existing LCME accredited medical schools. Second, they could use their physical and human resources to switch from training osteopathic physicians to training other health professionals, such as physician assistants and nurse practitioners. Third, some osteopathic colleges could conceivably repurpose their programs to become naturopathic medical schools. Naturopathic medical schools embrace a similar philosophical approach to healthcare and currently teach osteopathic diagnostic and therapeutic techniques to their students. In some states, naturopaths are eligible to be fully licensed in medicine and surgery. Fourth, some of these schools may simply close their doors. A fifth option, namely transforming osteopathic schools into colleges of osteopathy is the least likely option for political and legislative reasons. Current DOs, except for a very small minority embrace the full practice of medicine and they would not want to be confused with and would oppose legalization of a drugless class of practitioners who call themselves osteopaths, whether under a DO degree or its equivalent. Nor would MD groups countenance the legitimation of another iteration of licensed drugless practitioners. That is why the naturopathic group whose schools and practitioners already have legitimation in accrediting body and licensing laws would be a more likely route for some schools and for a minority of US trained DOs who want osteopathy to continue in one institutionalized form or another. But what is likely to happen in the United States is different from what is going on in the rest of the world. The subtitle of this address is what is past is prologue. And despite what is the experience and trajectory of osteopathic medicine in the United States, during the past quarter century, literally dozens of traditional osteopathy schools have sprung up in Europe, Asia, South America, Australia and elsewhere all committed to teaching the fundamental philosophical beliefs and practices of Andrew Taylor still. Just last month, my publisher the Johns Hopkins University Press sent me complimentary copies of my book which was just translated and published in Korean. Apparently I am big in Korea. Each year hundreds of osteopaths from around the world visit the Museum of Osteopathic Medicine located in Kirksville, Missouri. Not the easiest place to travel to and from. Several research articles on the relative benefits of osteopathic treatment have been published by Italian, Japanese, French and other international osteopaths. And unlike early American DOs who sought to expand their scope of practice, these international osteopaths at least so far do not appear to be going in that direction. And rather than oppose conventional medical treatment which early US osteopaths did, these international osteopaths view themselves as complementary practitioners seeking to work with orthodox MDs in providing patient care. When homeopathy ceased being taught in the two remaining homeopathically established medical schools in 1935, many thought that homeopathy itself would die. It didn't. Anyone today going to a Barnes and Nobles bookstore can find several books on homeopathy for the layperson in the health section. And homeopathic remedies in exceedingly large numbers are sold in conventional drug stores, supermarkets and on the internet. However much conventional medicine diminishes or rejects philosophically based ideas of treatment as antithetical to scientific medicine much of the public does not seem to care. And so philosophically based medical movements such as osteopathy or homeopathy are likely to continue in one form or another. Thank you very much. That was terrific Norm. What an interesting and provocative talk. When you described it as warts and all, I think that's absolutely fascinating. Yeah. And you were 100% right about the homeopathies stuff which continues unabated. Absolutely, absolutely fascinating. So listen, I'm going to open it up for questions. Dr. Heckmott, did you want to answer that? You just have to unmute yourself. Thanks so much for this talk. If we go a few centuries back, probably all of them were the same. And so separation became gradually as allopathic became more scientific, then gradually became osteopathy some more and then care of practice. And so became territorial things. Each one had to protect. So for example, if a college student now debates whether to go to the medical school or goes to osteopathy school and not know which one to go if he goes to medicine then after has had several years he's not going to accept osteopathy. On the other side, the same person if he has gone to osteopathy after a while is not becoming because just like if you go to a party after a while we become that party association rather than going to the other party. So if you become interested in truth and science all became blurs off. Like if a society is where everyone was interested in truth, we didn't have to have left party, right party, we were interested in the truth. So as words become scientific then maybe your view will become true that it is only the scientific approach is important rather than whether you call it the DO or you call it medicine or whatever else you want to. Well, medicine as you know is an art as well as a science. And what we've learned particularly is that many, many MDs were adopted positivism as a way of looking at it that only the scientific was important and anything which was not scientific per se was of no value. And in recent decades social scientists particularly historians of medicine look at it from the patient's point of view that what is patients will choose the type of doctor or the type of treatment which is more consonant with their own value set which is more in line with their lifestyle their beliefs and whatever. So for them and healing rather than medicine is important and healing comes in many forms. And so I think what we've done is to realize that we all agree that science is important but increasingly we're giving more attention to patient preferences in terms of what they feel is useful in terms of their point of view and their experiences and what type of healing that they want. And I think that's part of the conundrum and I think that's existed through the centers. I'm gonna see if there is some. So here's from our friend and colleague, Shelly McKellar said, thank you for your great talk. Any thoughts on key individuals as playing high or low profile role in shaping the profession and are there any female practitioners that stand out in your history? Well, I just say currently most deans of osteopathic medical schools now or almost all deans, let me phrase it a different way. Currently there are more female percentage of women who are deans at osteopathic schools are greater than the percentage of females who are deans at MD schools. So women are playing a larger role in terms of the future of osteopathic medicine. And so we're trying at all schools for greater diversity. And so in terms of leadership, it's more diffuse now than it used to be that in the past that it was a small group of individuals in the larger states that basically had control over the politics of the American Osteopathic Association, it's much more diffuse right now. So it's a much more open organization than it used to be. I have another comment in the chat from Rod Sorenson who wrote, as a DO, this was a fascinating historical look at my profession. When in medical school, I truly felt osteopathic training offered an advantage over allopathic training, but in the process of feeling we need to be assimilated, respected, included, fairly treated, whatever, we have embarked on this path that has resulted in exactly the problem you describe. No real unique identity. The question is whether or not this was an inevitable result. Well, in my book, I talk about inevitability when it came to the California merger, because everybody thought that once the California merger occurred, there would be, and this is 1960, 61, that osteopathy as a whole profession would fold and didn't. And so it's always difficult to predict the future. We historians are better at figuring out the past than we are at the future as such. But we do know that there are certain processes at play as a sociologist. I do know in terms of the process of assimilation. And it's not only other medical groups, we know that certain ethnic groups upon coming to, let's say the United States, that with some generations thereafter, that they lose their identity. They mix into the larger group. And certainly there is more contact between DOs and MDs. There are more DOs and MDs practicing together that are at the same hospital, that there is same kind of practice. And as such, people will emphasize the similarities rather than their differences. So, but the professions sometimes or groups sometimes see a need to re-identify themselves as different. And whether that will occur, I do not know, but I look at the trends. And the trends are that with respect to the overall philosophy, there's great belief in the philosophy. There's great belief in the goals of what type of practitioners should be produced and where they should practice. But again, I think that philosophy has to be paired with actual distinctive practice in order to give meaning to a separate identity for that profession. Now, leaders of the osteopathic profession disagree with me. And they say, well, you know, it's not all about manipulation. It's not all about putting your hands on. But it's kind of like tough to argue in terms of where osteopathy was and where it is right now, that what was once a central core of osteopathic practice really doesn't matter any more in terms of osteopathic identity. As a sociologist, I have difficulty with that. Okay, Dr. Bob, you are on deck. Yeah, I think assimilation is an interesting way to frame this because I think of, I wonder if osteopathy is like an ethnic group. And it's kind of assimilated into, you know, the mainstream of medicine. And, you know, I'm Chinese American. I still eat with chopsticks sometimes, but mostly I've gone over to like a knife and a fork, but I still have this kind of ethnic pride in my roots, even though it's not, you know, daily part of my practice. I think that pride still exists of DOs who identify themselves as DOs. I think though that the basic process of assimilation does apply both to ethnic groups who transplant themselves into a different culture. And it is certainly true that what has happened over the years with the demise of osteopathic hospitals, with DOs being eligible to be trained in the same programs as MDs, joining the same societies, that it used to be, and we talk about also social solidarity as well as assimilation. And when DOs were excluded from hospitals, from associations, from graduate training as such, they became cohesive as such, but now all these barriers are disappearing. And so, you know, in one sense, it served the osteopathic organizations to have this great boogeyman, the AMA, that was trying to destroy it. And now that doesn't exist. I had one DO who said to me, and I wish I remember who it was, that at the beginning of his practice, and this goes back 20-something years, he said to me, you know, Norm, at the beginning of my practice, MD groups wanted to strangle me. Now they want to hug me to death. He said, it's the same outcome though. And talking about an independent profession. And this is why, what is the rationale for having an independent profession? And what I tell, you know, my colleagues is that you need to have a rationale. You need to have something that says, what makes you different? It could be pride. DOs are now saying there are a few small studies that show that in terms of interpersonal relationship with patients or empathy, that DOs have been found to be a little more empathetic or a little more interpersonal, or they're able to appropriately touch a patient more. But that's not fundamental. It's an aspect, it's an element. And in and of itself, it doesn't seem to me strong enough necessarily to defend the notion that it should be an independent profession. And that's what the profession is going to be tackling. And part of the answer, as I suggest, has to do with research. Now, the research is very interesting because it's always been equivocal. It hasn't been one way or the other with that. And what, if the body of research could be summarized, all of these controlled randomized clinical trials that are being done, is that there's no difference between an osteopathic approach and an MD approach, which it goes to my point that I made earlier about different ways to healing. It's not that one is superior to another, it's just that from the MD side, it's like, well, DOs have nothing to add. But on the other hand, it's an alternative that seems to have produced the same kind of results as through an allopathic approach. So ultimately it does seem to me that while that doesn't satisfy the DOs who want to show that what they could do is superior to the MD approach, the fact that these results are equivocal and there doesn't seem to be any difference between them gives, if you will, equal validity to what MD colleagues are doing. That's a just different way of healing. And that's what patients are looking for. The amount of money currently that is being spent on unorthodox medicine is greater than that, that is spent by patients on primary care. People want a different approach, particularly for chronic diseases where medicine can offer benefits but not necessarily a cure and patients are looking for something more or something different. And that's a challenge that currently we have and osteopathic medicine stands out at least through its palpidori diagnosis and manipulative treatment, at least having one different approach, alternative approach to patient care. But if DOs aren't utilizing it, then there is no logical basis in my opinion that sustains the idea that independence is necessary. Okay, last question Dana. Well, I'm sorry I have to be the last question but Norm, you seem to equate the profession with manipulation and that if we're not doing manipulation we have no brighter expectation to maintain our independence. And I totally disagree with that. While I am a firm believer in manipulation and utilized it, I'm sure others on this call utilize a lot of manipulation in their practice throughout the years. It's not the be all on the end all. It's the philosophy and you seem to poo poo the whole philosophy of osteopathic medicine and the four tenants. If you look at patient satisfaction surveys, patients will tell you what it is that they want and it's what DOs bring. And they can identify who the DO is and the ND is when they're being treated by two different individuals no matter what they're specially not just primary care, anesthesia, cardiology, orthopedics, patients can identify how they are treated and how they receive their care differently from an MD and a DO irrespective of manipulation. So I completely disagree with your notion that if we're not doing manipulation we have no right or expectation to maintain our distinctiveness. So Dana, I am so glad that you're the last question because basically this is where I disagree with leadership on. And I think Dana your point is consistent with leadership in terms of the role that osteopathic medicine plays. So first of all, I'm not poo pooing the philosophy at all. I'm saying that the philosophy should be tied to practice patterns and DOs are rightly proud of what they believe that they are accomplishing and they feel from patients that patients treat them differently which is something that I said it's a different way of healing. I'm not poo pooing that at all. And so for the existence of osteopathic medicine from the DO's perspective, it is important that DOs have pride in what they do whether they manipulate or not. That's not my argument. My argument is not so much whether you have a right to exist that isn't my argument that you have a right to exist. What I'm saying as a sociologist is I'm looking at the structural factors which underlie any profession. And what I'm saying is that the structural factors that support an independent osteopathic profession are weakening. They're weakening before the signal accreditation merger. They're weakening because if you look at the number of members of the AOA, if you look at those that are being trained through osteopathic auspices which now on the graduate level is nil. If you're looking at in terms of members of professional colleges, if you're looking at those type of factors which I'm doing that osteopathic medicine as a profession is weakening. I'm not saying anything against individual osteopathic practitioners. I mean, I'm proud to be at an osteopathic medical school. I'm proud of our graduates. Whether they do manipulation or whether they don't do manipulation, I know they're doing good out there. If they have professional pride in who they are in terms of what they are doing, that's important. That is important to the idea of identity. But I'm looking at it at a more structural level. And at a more structural level, it seems to me an argument predicated on the fact that on the argument that DOs are more sensitive that the DOs can be recognized for how closely they interact with the patients that they could be recognized by nurses or other practitioners as a little bit different. Whether that is sufficient for the profession itself particularly when those pillars are weakening to maintain itself as an independent profession. That's what I'm arguing. So in one sense, I understand where you're coming from but I'm arguing as a sociologist, I'm not arguing from the standpoint of individual practice, I'm looking at the entire profession. Well, here's the good news is that Dr. Gavits will be back with the ethics fellows at 130 to continue this conversation, which I think was absolutely terrific and on behalf of the McLean lecture series, I'm just gonna wrap it up now and we'll have him log in to continue this conversation later. And I just wanna thank you for a superb, interesting and both educational and a provocative talk that really made us think. So thank you very, very much Norm. We appreciate it. Thank you all.