Notes From a D.O. Ophthalmologist

Differences between D.O.s and M.D.s are not as important as what we can accomplish together.

BY SIDNEY KAY SIMONIAN, D.O.

An often asked question: What's the difference between an M.D. and a D.O. ophthalmologist? Some D.O. ophthalmologists would reply: "Practically speaking, very little, or nothing". My own reply, and the intent of this article are to go beyond the "practically speaking" response, and offer another perspective.

Personal History

My osteopathic heritage begins with my father, a 1952 graduate of Kirksville College of Osteopathic Medicine (where osteopathy originated). He received his postgraduate training in orthopedic surgery at the Detroit Osteopathic Hospital, lovingly referred to as the "mecca" of osteopathic specialty training.

My own path started at Michigan State University College of Osteopathic Medicine, followed by an osteopathic internship. Ophthalmology residencies were scarce in the D.O. world when it was my turn to apply — only two openings were available in the entire United States. I was fortunate to have been accepted to the Kresge Eye Institute. Having just married a D.O. ophthalmologist whose medical educational route mirrored that of my father's, I found myself in a unique position to compare the educational experiences and philosophical differences.

Osteopathic principles and philosophy were founded by Andrew Taylor Still, M.D., toward the end of the 19th century. He noted that the medical treatments of the day were killing more people than they were curing.

He felt strongly that the body has an inherent ability to heal itself, and that structure and blood supply are vital to that healing process. He developed manipulative techniques that strive to restore skeletal alignment and improve blood/lymphatic flow throughout the body. One of the many tenets of osteopathic medicine states that the body has the potential to make all substances necessary to insure its health. No medical approach can exceed the efficacy of the body's natural defense systems if those defenses are functioning properly. Teaching the patient to care for his own health and to prevent disease is part of a physician's responsibility.

Today's Model

Today's osteopathic medical education utilizes the core competency model plus an additional competency of osteopathic principles and manipulative treatment. Osteopathic ophthalmology emphasizes the concept of treating eye disease in a holistic context. Patient evaluation should include examination and consideration of the entire medical and psychological picture.

There are about 54,700 osteopathic physicians practicing in the United States, representing 5% to 6% of the total number of physicians (M.D.s and D.O.s) currently delivering patient care. However, D.O.s attend to about 8% of all patient visits in the United States. Over half of all D.O.s are delivering primary care, 15% in underserved/rural parts of the country. By contrast, about one-third of M.D.s deliver primary care. D.O. ophthalmologists comprise about 0.7% of all practicing D.O.s, and about 2.5% of all ophthalmologists in the United States.

There are several thousand D.O.s in the rest of the world, including 4,000 in Great Britain. D.O.s are licensed and fully recognized physicians in all 50 states, and there are currently 25 osteopathic schools of medicine in the United States, with a total enrollment of over 8,000 students.

D.O.s train in all fields of medicine, either through osteopathic training programs or in the allopathic (M.D.) programs. Ten percent of the physicians in the military are D.O.s. Several professional sports teams employ osteopathic physicians. George H.W. Bush's personal physician was a D.O. Prince Charles of Great Britain recently revealed that he is attended by a D.O.

The American Osteopathic Association (AOA) conducts and maintains its own board certification for its members. Many of our members trained in the M.D. world are eligible for M.D. board certification as well. Board certified D.O. ophthalmologists enjoy the status of Fellow in the American Academy of Ophthalmology and the majority of us maintain AAO membership. The American Osteopathic College of Ophthalmology (AOCO) holds a seat on the AAO Council.

Political Action

In the political arena, D.O.s stand side by side with the allopathic leadership, advocating for Medicare reform, promoting the patient-centered medical home model of care, pushing for mandatory physical education in schools to help combat the childhood obesity crisis, and many other critical health care issues.

The AOCO, with its approximate 400 members, is a vocal supporter of the scope of practice initiatives of the AAO and has been recognized for its contributions. As noted, many D.O. ophthalmologists practice in underserved areas. This demographic strength has assisted the AAO in its scope of practice arguments in states such as Oklahoma. Past president of the American Osteopathic Association and ophthalmologist, Phillip Shettle, D.O., was recently honored by the AAO for political leadership. Ophthalmologist leadership continues next year at the AOA level with incoming president Carlo DiMarco, D.O.

In Practice

In Detroit, there are four ophthalmology residency training programs, including the osteopathic program of which I am a part. Our residents interact with those of the allopathic programs on a daily basis, whether it's grand rounds at Kresge Eye Institute, monthly guest lectures at Henry Ford Hospital or subspecialty lectures and rotations with the physicians at William Beaumont Hospital. In addition, Michigan State University links us with other osteopathic ophthalmology programs for monthly on-site didactic programs and weekly Internet conferences.

Our residents receive one-on-one clinical exposure in the private office setting, where they see firsthand how physicians in practice interact with patients. We also maintain a resident training clinic, located in an indigent area of Detroit, where our residents work together, supervised by an attending ophthalmologist. Together, they care for patients with pathology reflecting the health problems of the inner city.

Our residents also participate in the OKAP, with established scoring requirements for graduation. We enjoy a cordial relationship with the other training programs in the city, and our residents receive much of their subspecialty training locally. Many of our graduates have continued their professional education in prestigious fellowships in Detroit and throughout the country.

What's the Difference?

So, with all this said, what are the differences between D.O. and M.D. ophthalmology training? Our curriculum is built on the core competencies identified by both allopathic and osteopathic schools, but the additional competency of osteopathic principles and philosophy unique. In ophthalmology, this may consist of soft tissue techniques to the neck prior to cataract surgery for relaxation.

Equally as relevant is the approach we take with our patients. Osteopathy emphasizes a level of communication based on respect for the patient as a whole. It is our responsibility to treat patients with eye disease, not just the disease. It is a thoroughness of history and examination that then guides the physician and patient together to chart a medical course of action for a particular ocular condition. Sometimes this requires a lengthy conversation. As we all know, if you let patients talk, they are likely to reveal their diagnosis. If you take time to listen, you will also learn about the patient's personality, living situation, financial constraints, and family pressures, all of which may define his/her illness and determine the best course of treatment.

It is in the listening that we learn. It is in the art of asking the appropriate questions that we arrive at a complete diagnosis. Then the emphasis is on communicating with the patient to ensure understanding, as well as giving treatment options and in many cases, hope. I have learned that there are diseases for which we have nothing medical to offer. However, an attitude of compassion on our part can certainly make the patient feel better for having seen us.

And even in ophthalmology, it is this patient-oriented approach that may make us different. Actually, I have met many M.D.s who, I feel, treat their patients with an "osteopathic attitude." The recently-defined core competencies of communication, professionalism, system-based and evidence-based medicine, as well as medical knowledge, are just a renaming of those aspects of patient care that D.O.s have been championing since the days of A.T. Still.

The Projected Shortage

The scope of osteopathic residency training is certainly dwarfed by the size and number of allopathic training programs. We currently have 12 programs scattered throughout the country and graduate approximately 20 ophthalmologists per year.

The predicted shortage of physicians nationwide in the near future has encouraged all medical schools to increase class size. However, with the current government caps on postgraduate funding, the questions are: Where are all of those medical school graduates going to get their specialty training? Who is going to establish new programs or expand existing programs without funding? And how many of our current graduates in ophthalmology are driven to teach residents, with the declining fee schedules and student loan repayments in their immediate futures?

This particular crisis will take health care in this country backwards by decades if new models of post-graduate training aren't available soon. M.D.s and D.O.s have many issues in common. The time has arrived where collaboration of M.D. might and D.O. tenacity could produce some substantial solutions to the healthcare problems we face.

Renewed Passion

In writing this article, I find renewed passion in my own choices of being a physician, a D.O., an ophthalmologist. Living the principles of osteopathy has made my practice unique, and has enriched my life. My career as a D.O. has been met with little of the past discrimination in the history of osteopathy, but often with mild curiosity. Hopefully, with this article, I've satisfied some of this curiosity. I am most proud that my two daughters have also chosen the osteopathic profession. Many thanks to my husband and my residents, who gave me a true sounding board for my answer to the original question. OM

Sidney K. Simonian, D.O., is president of the American Osteopathic College of Ophthalmology and the program director of the ophthalmology residency at St. John Macomb Oakland Hospital, Osteopathic Division of Medical Education. A graduate of the AAO Leadership Development Program, Dr. Simonian established a solo practice in Madison Heights, Mich, in 1981.