ORIGINAL CONTRIBUTION
Do Osteopathic Physicians Differ in Patient Interaction
from Allopathic Physicians? An Empirically Derived Approach
Timothy S. Carey, MD, MPH; Thomas M. Motyka, DO;
Joanne M. Garrett, PhD; Robert B. Keller, MD
Colleges of osteopathic medicine teach osteopathic principles, which provide a different approach to and interaction with patients than principles taught in allopathic
medical schools. The authors examined whether osteopathic primary care physicians’ interactions with patients
reflect the principles of osteopathic medicine when compared with allopathic physicians’ interactions.
The principles of osteopathic medicine were adapted
to elements that could be measured from an audio
recording. This 26-item index was refined with two focus
groups of practicing osteopathic physicians. Fifty-four
patient visits to 11 osteopathic and 7 allopathic primary care
physicians in Maine for screening physicals, headache,
low back pain, and hypertension were recorded on audiotape and were dual-abstracted.
When the 26-item index of osteopathic principles was
summed, the osteopathic physicians had consistently
higher scores (11 vs. 6.9; P = .01) than allopathic physicians, and visit length was similar (22 minutes vs. 20 minutes, respectively). Twenty-three of the 26 items were used
more commonly by the osteopathic physicians. Osteopathic physicians were more likely than allopathic physicians to use patients’ first names; explain etiologic factors
to patients; and discuss social, family, and emotional impact
of illnesses.
In this study, osteopathic physicians were easily distinguishable from allopathic physicians by their verbal
interactions with patients. Future studies should replicate
this finding as well as determine whether it correlates
with patient outcomes and satisfaction.
From the University of North Carolina at Chapel Hill, where Dr Carey is a
professor in the School of Medicine and Dr Garrett is associate director and
professor in the Departments of Medicine and Social Medicine, and from the
Maine Medical Assessment Foundation, where Dr Keller is executive director
and an orthopedic surgeon. Dr Motyka is in private practice in Chapel Hill, NC.
This study was supported by funding from the American Osteopathic
Association.
Address correspondence to Timothy S. Carey, MD, MPH, The Cecil G.
Sheps Center for Health Services Research, 725 Airport Rd, CB No. 7590, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7590.
E-mail: [email protected]
M
ore and more physicians in the United States, especially those in primary care, are graduates of colleges
of osteopathic medicine. Osteopathic physicians generally
practice in parallel with the more numerous graduates of
allopathic medical schools. However, osteopathic medicine
comes from a distinctly different professional tradition. The
first school of osteopathic medicine was founded by Andrew
Taylor Still, MD, DO, in 1892 in Kirksville, Missouri. There are
currently 20 colleges of osteopathic medicine in the United
States.1 Approximately 5% of physicians in the United States
are graduates of colleges of osteopathic medicine, accounting
for more than 100 million patient visits annually.2,3 In the
past, relatively little empiric research has examined ways in
which osteopathic physicians differ from allopathic physicians
other than by using osteopathic principles and practice, which
include osteopathic manipulative treatment (OMT).
However, the tradition of viewing osteopathic medicine
as a distinct profession is deeply rooted within the culture of
colleges of osteopathic medicine. We took advantage of an
ongoing cohort study, the Maine Osteopathic Outcomes
Study (MOOS), to examine whether a distinctive characteristic of osteopathic medicine might be that osteopathic physicians have different communication patterns than allopathic
physicians.
Osteopathic principles, initially elucidated by Dr Still,
include the unity of the body; self-regulatory and self-healing
systems; the relationship between structure and function;
and a rational treatment approach.4 These initial, broadly
based treatment principles have been modified in the twentieth century. There remains an emphasis on a structural
approach: “the osteopathic principles of practice,” which
osteopathic medical educators believe demonstrate distinctive differences between osteopathic and allopathic physicians. These revised principles of osteopathic medicine include
the following:
Osteopathic medicine is the practice of rational medicine
based on the medical sciences.
Osteopathic medicine treats the individual as a whole.
Osteopathic medicine recognizes the body’s ability to be
self-regulating and self-healing.
Osteopathic medicine acknowledges the structure-function interrelationship.
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ORIGINAL CONTRIBUTION
Osteopathic medicine endorses the use of OMT.
Osteopathic medicine emphasizes a close and personal
relationship between physician and patient.
Osteopathic medicine recognizes that health care requires
intelligent collaboration between the lay public and physicians.
Osteopathic medicine relies on all recognized modalities
of medical services.
Osteopathic medicine emphasizes disease prevention.
Osteopathic medicine endorses the application of all services of modern scientific medicine that are needed to
meet the needs of all people.5
Osteopathic philosophy has continued to develop since
the inception of this study. Recently revised statements of
osteopathic principles would not have influenced physician
behavior in this study and were not in existence for use as the
basis of this investigation.6
We operationalized these principles into draft items that
could be identified during typical physician-patient encounters. We then sought to validate these operationalized osteopathic principles by determining whether they could be measured during physician-patient treatment visits. Rather than
attempt to examine all aspects of physician-patient communication during office visits, we chose to examine those components of verbal interaction that we thought would most
likely identify differences between the two medical professions. Our hypothesis was that osteopathic physicians would
use these verbal interactions more than allopathic physicians.
Methods
We conducted two focus groups with experienced osteopathic
physicians in Philadelphia and Florida. Participants in the
focus groups (6 to 8 physicians per group) were not connected
with the primary data collection for the cohort study or the
study of physician-patient communication in Maine. The
physicians in the focus groups, recruited through local colleges of osteopathic medicine and professional societies, were
osteopathic physicians, practiced primarily in primary care, and
saw patients greater than 50% of the time spent practicing.
Recruitment started with a lead letter followed by phone
contact. Each group discussion lasted 2 hours. The focus groups
worked with the investigators (T.M. and T.C.) in operationalizing the modern osteopathic principles into items that could
be measured during audiotaped office visits. Content from
the first focus group was used to inform the discussion in the
second focus group, leading to a list of candidate items. Each
osteopathic principle was mapped to a physician-patient interaction. For example, “recognizes the body’s ability to be selfregulating and self-healing” maps to items “physician discusses what patient can do to improve own condition” and
“discusses body’s self-healing ability or reassures that condition will improve on its own.”
We excluded spinal manipulation from the communica-
tion list, as few allopathic physicians perform OMT, and OMT
is considered a treatment modality, not a communication tool.
We were interested in identifying distinguishing characteristics of osteopathic practice other than OMT. The list of candidate items was shared with several experts in osteopathic
medicine (eg, associate deans, curricular directors) and was
refined based on their comments. Pretesting was performed at
the internal medicine and family practice clinics at the University of North Carolina at Chapel Hill—the six patients
pretested resulted in minimal change in the study process.
We conducted our study using a subset of volunteer
physicians participating in the MOOS. The MOOS is a prospective cohort study of acute low back pain in patients seen in primary care osteopathic and allopathic practices in Maine. The
study of physician-patient communication was separate from
the data collection of the cohort study.
The physician participants (N 18) were told that we
were examining communication characteristics of the two
professions, but they were not informed of emphasis on osteopathic principles or which behaviors we were studying.
Patients were asked at the beginning of their visits whether they
would allow us to audiotape the visits. If willing, they signed
an informed consent form, and the tape recorder in the room
was activated. The research protocol was approved by the
institutional review board. An omnidirectional microphone was
used for clarity. A total of 54 audiotapes were obtained from
11 osteopathic physicians and 7 allopathic physicians. Four
types of visits were eligible for taping: acute low back pain,
headache, hypertension, and health maintenance. These conditions were chosen to represent a range of visits that are most
consistent with osteopathic intervention (back pain) to those
least consistent with osteopathic intervention (health maintenance).
The audiotapes were sent to the University of North Carolina at Chapel Hill. Two reviewers (one research assistant, one
physician) abstracted each audiotape using an explicit form,
addressing communication characteristics of interest. Each
reviewer listened to each tape twice. The two abstractions
were performed independently. Differences between abstractors were resolved at adjudication meetings, and tapes were
reviewed a third time if necessary.
The data were entered and analyzed in a blinded fashion.
Abstractors and data analysts did not know which tapes came
from osteopathic physicians and which came from allopathic
physicians. In a global assessment, abstractors were asked at
the end of each audiotape abstraction process to assess whether
they thought the physician was an osteopathic or an allopathic
physician.
Statistical analysis was performed using a standard
package (Stata, Stata Corp, College Station, Texas). Tests for
means and proportions were adjusted for the “cluster effect,”
as each physician contributed more than one interview to the
evaluation. The individual items were examined separately and
summed to create a draft index.
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Carey et al • Original Contribution
ORIGINAL CONTRIBUTION
Table 1
Patient Characteristics
Visits to
Osteopathic
Physicians
(N = 32)
Visits to
Allopathic
Physicians
(N = 22)
Women, %
72
77
Hypertension visits, %
19
27
Low back pain visits, %
31
27
Headache visits, %
25
23
Health maintenance, %
25
23
Results
Demographic characteristics of the 54 patients (32 patients of
osteopathic physicians and 22 patients of allopathic physicians) are provided in Table 1. Typical for primary care, most
(70%) of the patients were women. Average number of physician years in practice was 11.7. Distribution of the four diagnoses (hypertension, low back pain, headache, health maintenance) among the osteopathic and allopathic groups was
similar. Average length of visit determined by timing the
audiotape was similar between the two professions, but slightly
longer (22 minutes vs. 20 minutes) in the osteopathic group.
This difference was not statistically significant.
We could determine from the tapes when OMT was used
during the visits. The osteopathic physicians used OMT for
visits other than back pain. Osteopathic manipulative treatment
was used in 1of 8 general examination visits, 2 of 6 hypertension visits, 4 of 8 headache visits, and 9 of 10 back pain visits.
Table 2 indicates the 26 items that were coded as being present or absent in the audiotapes. The number of subjects analyzed is less than 54 for some of the variables, as some of the
visits were for preventive care and, therefore, no complaint was
specified. Twenty-three of the 26 items were used more commonly by the osteopathic physicians compared with the allopathic physicians. Four comparisons reached statistical significance. Exact P values are provided when the test of
significance was less than or equal to .05. Even among many
of the items that did not reach statistical significance, the trend
indicated more use of the behavior by the osteopathic physicians compared with the allopathic physicians.
The only communication characteristics that appeared
not to be used more by the osteopathic physicians were patients
using the physicians’ first names (not done by either profession); touching the patients, but not during the examination
(probably not reliably assessed, given the measurement method
using audiotapes); discussing medical literature with the
patients; and discussing health issues related to work. Only one
item, discussion of the medical literature, had a trend toward
greater use in the encounters with allopathic physicians. As
these assessments were based on audiotapes, it was difficult
to determine when the patient was being touched and when
not; this was included as an exploratory variable.
Statistical tests were conducted for each comparison,
taking into account that the data reflected a clustered sampling design, ie, the patients were clustered within physicians
(this design effect must be accounted for in statistical testing).
We call the overall results the osteopathic principles of practice index (OPPI).
For those patients who had complete responses to all
items as being present or absent, we were able to assemble an
index of responses indicating osteopathic behavior. Of the 26
candidate items, the osteopathic physicians had an average of
11 positive responses, and the allopathic physicians had an
average of 6.9. This difference was statistically significant (P .01) even after accounting for the cluster effect of having multiple patients per physician.
In an exploratory analysis, we examined the diagnosis-specific scores. We expected that the osteopathic behaviors would
be more evident in the mechanical diagnoses (headache and
low back pain) than for hypertension. Although the numbers
were small, the index scores for low back pain and headache
(12.6 and 10.1, respectively) were higher than for hypertension
(9.5). The allopathic scores within each of these diagnoses
were similar (low back pain, 7.2; headache, 7.2; hypertension,
6.5). When we summed the available items within the general
medical examination patients, we also found that patients of
osteopathic physicians scored higher on the index than patients
of allopathic physicians (9.5 vs. 6.8, respectively).
Physician gender has also been demonstrated to influence communication.7 We found that summary scores were
similar between male and female allopathic physicians (6.6
and 7.5, respectively), but that male osteopathic physicians
had higher scores than osteopathic female physicians (11.9
vs. 7.6, respectively). Such interactions should be examined in
future studies. Our sample size was too small to examine
interactions across physician and patient gender and specialty.
Figure 1 demonstrates the average score for each of the 18
physicians. While the osteopathic physicians did have higher
scores than the allopathic physicians, there was some overlap,
as some allopathic physicians had scores similar to osteopathic
physicians. The one outlier osteopathic physician with a low
score was based on a single interview.
We asked the abstractors to estimate whether each physician they were listening to was an osteopathic physician or an
allopathic physician. In some cases, blinding was not possible
because OMT was performed. When physicians were osteopathic physicians, the abstractors were correct approximately
90% of the time. When the physicians were allopathic physicians, the abstractors were correct 70% of the time. That is,
30% of the time, both abstractors thought physicians were
osteopathic physicians when they were allopathic physicians.
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ORIGINAL CONTRIBUTION
Table 2
Comparison of Osteopathic Physicians’ and Allopathic Physicians’ Patient Interactions
According to Osteopathic Principles of Practice
Visits to
Osteopathic Physicians
(N = 32)
Visits to
Allopathic Physicians
(N = 22)
P
.03
Discuss preventive measures specific
to the complaint (N = 41)
79
47
Discuss general/unrelated health measures
88
73
Discuss family/social issues unrelated to health
66
55
Discuss health issues in relation to family life
56
32
.01
Discuss health issues in relation to social activities
38
14
.05
Discuss health issues in relation to work
53
55
Discuss patient’s emotional state
66
32
.02
Physician uses patient’s first name
31
9
.05
Patient uses physician’s first name
0
0
28
18
3
0
Review of systems includes unrelated areas (N = 41)
71
53
Examination includes unrelated areas (N = 41)
54
24
Asks “Anything else I can do for you?”
or equivalent
19
9
Asks “Do you have any questions?”
or equivalent
38
14
Prescribes no medications (including over-the-counter
medications)
38
14
Recommends herb/nutritional/physical or other
non-drug alternative medications, not including
osteopathic manipulative treatment
59
45
Discusses what patient can do to improve
own condition
69
55
Physician discusses body’s self-healing ability or
reassures that condition will improve on its own
19
5
Physician discusses musculoskeletal cause or consequence
related to patient’s condition
63
32
History included musculoskeletal review of systems
66
50
9
18
Inquires about alternative modes of therapy patient
may have used
25
14
Asks for patient’s opinion on cause of problem
19
9
Asks for patient’s opinion about treatment
13
14
Explains cause of problem or reasoning behind treatment
50
36
Mean total of ‘yes’ responses (total = 26)
11
6.9
Physician discusses his or her personal experience,
not including professional experience with
other patients
Touches patient but not during examination
Discussion of literature or scientific basis of treatment
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.01
Carey et al • Original Contribution
ORIGINAL CONTRIBUTION
20
20
Mean Score
15
15
10
10
55
00
DO (n = 24)
MD (n = 17)
Provider Type
Figure. Mean scores for each physician on the osteopathic principles
of practice index, based on 41 observations with some overlap in
points.
Discussion
Our index items indicating characteristic communication styles
of osteopathic physicians were derived from the theoretical
basis of osteopathic principles. Using focus groups of practicing osteopathic physicians and experts in the field, we operationalized these theoretical constructs to communication characteristics that could be identified using audiotaped interviews.
Our findings indicate that osteopathic physicians seem to use
communication characteristics with their patients that are similar to theoretically derived osteopathic principles and that
distinguish them from allopathic physicians. Our findings
provide some initial validation that osteopathic principles distinguish osteopathic physicians from allopathic physicians,
not just in terms of training but also in terms of the content of
communication between physician and patient.
These communication characteristics are clearly not unique
to osteopathic physicians. Allopathic physicians commonly
used these same communication techniques, and several allopathic physicians in our study had OPPIs similar to those of
the osteopathic physicians in our sample.
We had hypothesized that the osteopathic index would be
highest in back pain, intermediate in headache, and lowest in
hypertension. Hypertension is less of a “mechanical” or “structural” diagnosis compared with headache and back pain, and
we thought that the osteopathic behaviors would be less manifested. Our data support this, indicating that more mechanical diagnoses were somewhat more likely to be associated
with communications congruent with osteopathic principles.
The strengths of our study are that our abstraction instrument was theoretically based and that our subjects (physicians) were blind to the items in which we were interested.
While the physicians were told that we were studying “communication” between physicians and patients, the exact types
of communication were unknown to the subject physicians.
Our study does have several limitations. Osteopathic
manipulative treatment was used with some patients, which
would have indicated to audiotape reviewers that it was an
osteopathic physician they were hearing. Our sample size was
small: 54 physician-patient encounters across 18 physicians. Our
generalizability to the US population of osteopathic physicians is limited in that the study physicians all practiced in a
single state (Maine) and most osteopathic physicians were
graduates of a single college of osteopathic medicine. Therefore, it is possible that the osteopathic principles may be more
or less manifest in other parts of the United States with more
heterogeneous physician populations. However, informal discussion with medical educators indicates that osteopathic
principles are consistently emphasized in osteopathic undergraduate medical education. The osteopathic physicians in
our study used OMT for multiple diagnoses, perhaps indicating special interest in this particular group in the manual
treatment aspects of the osteopathic medical profession.
Results of our study indicate that communication patterns differ between osteopathic physicians and allopathic
physicians. We cannot correlate these communication patterns with improved clinical outcomes or differences in patient
satisfaction. Other components of the MOOS focus on the difference in treatment patterns and outcomes of the care of acute
low back pain. This work represents the first time that communication patterns have been evaluated between these similar, but distinct, medical professions. Our hypothesis that
osteopathic physicians have different communication patterns
did receive limited support in this small study. Future work
should have larger sample size, stratify by physician gender
and years in practice, examine physicians from multiple colleges of osteopathic medicine, and correlate communication
patterns with patient satisfaction.
By examining different communication patterns with
patients, osteopathic and allopathic physicians can learn from
each other with the goal of improved medical care of all
patients.
During the latter half of the twentieth century, the osteopathic medical profession was sometimes ambivalent regarding
its level of distinctiveness from allopathic medicine in ways
other than the use of OMT.8,9 Given that other health care
practitioners (physical therapists, doctors of chiropractic) use
manipulative therapy and that some allopathic physicians are
beginning to use manual treatment in practice, basing a distinct
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ORIGINAL CONTRIBUTION
profession only on OMT might be called into doubt.10 Our
finding of different communication patterns, which adhere
to the theoretical basis of osteopathic principles, reinforces the
notion that osteopathic physicians represent a profession that
can be distinguished from allopathic physicians.
Osteopathic physicians seem to have a communication
style with patients that is more personal and somewhat more
holistic in that issues relating to family, social activities, and
patient emotions seem to be more commonly incorporated
into visits. Additional research examining the presence of
other distinguishing features of osteopathic and allopathic
medical practice and their implications regarding patient outcomes of function, satisfaction, cost, and use can further illuminate this important and little-studied area.
3. Osteopathic Medicine and Managed Care. Chicago Ill: American Osteopathic
Association; 2001. Available at: http://www.aoa-net.org/Consumers/mgdcare.htm. Accessed June 10, 2003.
References
9. Gallagher RM, Humphrey FJ, Micozzi MS, eds. Osteopathic Medicine: A
Reformation in Progress. New York, NY: Churchill Livingstone; 2001.
1. Osteopathic Medicine. Chicago, Ill: American Osteopathic Association;
2001. Available at: http://www.aoa-net.org/Consumers/omed.htm. Accessed
June 10, 2003.
2. AOA Fact Sheet. Chicago, Ill: American Osteopathic Association; 2001.
Available at: http://www.aoa-net.org/Consumers/omed.htm. Accessed June 10,
2003.
4. Ward RC, ed. Foundations of Osteopathic Medicine. Baltimore, Md: Williams
& Wilkins; 1997.
5. Sirica CM, ed. Osteopathic Medicine: Past, Present, and Future. New York,
NY: Josiah Macy Jr Foundation; 1996: pp63-69.
6. Ward RC, ed. Foundations of Osteopathic Medicine. 2nd ed. Philadelphia,
Pa: Lippincott Williams & Wilkins; 2002.
7 Roter DL, Hall JA. How physician gender shapes the communication and evaluation of medical care. Mayo Clin Proc. 2001;76:673-676.
8 Gevitz N. The DO’s: Osteopathic Medicine in America. Baltimore, Md: John
Hopkins University Press; 1982.
10. Johnson SM, Kurtz ME. Diminished use of osteopathic manipulative treatment and the consequent impact on the uniqueness of the osteopathic profession. Acad Med. 2001;76(8):821-828.
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Carey et al • Original Contribution