06 January 2010

What's in a degree?

I was recently speaking with a longtime friend -- let's call him Barry -- who is a fellow ER doc and a highly accomplished person: an administrator, a policy wonk, and a software developer.  He holds a Master's degree in computer engineering.  He served a term as president of another state's chapter of ACEP.  He has for a long time been a featured speaker in seminars for hospital executives and health care innovators.  Recently, he sold his company and has been interviewing for new positions, mostly at the C-suite level: CEO, COO, CMO, CIO, that sort of thing.  Given his software background he is most juiced about Chief Information Officer opportunities, but his background and operational experience puts him in the running for any of the positions. Sometimes my wife hassles me and asks why I can't be more like him.  "You can bet your life Barry doesn't waste his time blogging," she says.

His doctoral degree, however, happens to be a D.O. -- Doctor of Osteopathic Medicine.

For those who are not tuned in to the medical community, there are two distinct paths to becoming a physician in the US.  The traditional (or conventional or allopathic or whatever you want to call it) way is to get into a traditional medical school and get your MD degree.  The alternate path is to go to an osteopathic school, which to the best of my knowledge is about the same, perhaps a bit less competitive, and covers more or less the same material.  There's more emphasis on body mechanics and some stuff on manipulation that I am completely ignorant of, but the general stuff is more or less the same. 

It is less prestigious, and I gather that there were bitter philosophic differences in the past, but nowadays to a health care consumer or employer there seems to be no distinction, I think.  I've worked with lots of D.O.s, and some of them were great and some stunk, just as with M.D.s.  I've hired D.O.s in the past, and will again.  You hire the person, not the degree.

So when Barry sat down with the recruiting team at a national hospital chain recently, he was astonished to have the first question be this:
"Why would we want to hire a D.O. for this position when there are lots of M.D. candidates who we could hire instead?"
In the general crosstalk that ensued, it was opined by another member of the interview panel that a highly qualified D.O. would be on more or less equal footing with a half-qualified M.D.

Staggering.  At this level, that someone would hold such a bias based on a certain degree, and would have the tactlessness to put it forth so blatantly.

Needless to say, Barry made his case for the D.O.s as civilly as he could manage, concluded that this was not the best organization for him, and proceeded on with his job search.  It is, quite literally, their loss, and a self-inflicted one, at that.

But it nevertheless is an astonishing thing that in this day and age, at such a senior level of management, there are executives with such regressive attitudes and the chutzpah to display them so openly.


  1. While I agree that the decision was hasty, I too would think twice about someone who thought osteopathy was anything like as worthwhile as proper, evidence based medicine.

  2. Emma,

    Why are you so hard on Osteopathy? As I understand it, a DO and MD are pretty much interchangeable except the DO may also offer Osteopathic Manipulative Medicine.

    Chiropractic manipulation, which I understand to be functionally similar to OMM without the additional in depth general medicine background, has made a big difference for me and my chronic back, neck, and joint pain. Neither drugs nor surgery were appropriate or necessary to treat my problems. Diet, exercise, or behavior changes might have prevented some of my problems, but they wouldn't have fixed them once they occurred. Physical manipulation should have it's place. More than anything rigorous scientific study is desperately needed in this area, but that means we need more science not that the underlying premise is flawed.

    While I have not been to a DO (there don't seem to be any nearby), my experience with Chiropractic means I would be willing to if I found one.

  3. When I was a kid, our town had one doctor, a D.O. He was amazing. My brothers were born in 1948 and 1953; I was born in 1955. Back then, men *never* were in the room when women gave birth, but he always thought family should be present, and so we were. He triaged the people in the waiting room instead of having us make appointments, so the hypochondriacs had to wait longer than the people whose toes were bloody and dangling. He made house calls. We knew about the prejudice against DOs, but because he was so wonderful, it probably gave us a prejudice in the opposite direction. Back then DOs were less likely to prescribe medication; now, to me at least, there isn't any discernible difference. Maybe that's why I never like going to doctors--he died in 1967 and no doctor since has been able to measure up to him.

  4. I think I am a bit younger than you, SF, but when I went to medical school, there was a huge difference between MD and DO candidates. I don't know a single person who was accepted into an MD school and went to DO instead. It just doesn't happen. (On an off note, this is why many people would rather have an MD from a Carrib school than a DO from a US school).

    Most good programs/employers overlook it when there are other things to recommend it. (My top 5 med school would take great DOs into its residency program -- as the self-proclaimed Best Medical School, we had nothing to prove. My mid-range residency hated DOs as they thought it made us look uncompetitive).

    However, I think you are wrong to argue that they should be looked at the same on a resume -- it is like going to University of State College versus Ivy Academic Wonderland.

  5. I have to say that the commenter's assumption that there are no candidates who chose DO programs over MD ones is incorrect. I was accepted to both and chose an osteopathic program.

  6. This post lights my fire! :)

    I don't think the word you are looking for is biased, I think the word is IGNORANT...I went to D.O. school because I chose to (yes, I got accepted to all of my MD choices). Then, I did a residency at an MD based hospital (thank God they took me not based on the DO after my name but instead my top board scores and med school rankings and pleasing personality LOL) and of all the MD residents, guess who was chief? Guess who got the most requests to be a patient's doctor?

    Trust me, I'm not tooting my own horn, I just want to show that it IS the person and not the degree. I whole subscribed to the osteopathic approach to medicine and am very active, health conscious, and like the thinking behind some of their practices.

    MDs and DOs live in symbiosis where I am, I hope it catches up where your friend interviewed. He appears very strong on paper and I hope he continues to blaze a trail for the DO name.

    Thanks for this post, Mark...I'm usually a laid-back humble kind of guy, but this one got me.

  7. I think lots of laypeople, such as myself and Emma, haven't really heard of osteopathy, but it sounds like naturopathy or homeopathy and those sound like woo-filled craziness (or water). I'm guessing that's where Emma's response came from.

    I guess folks in the field (the hiring committee) should know better.

    What are the differences a layperson might notice between an MD and an OD in practice? Or would we even notice except the initials after the name?

  8. Y'know, "osteopathy" means something different in the Europe from what it means in the U.S. Causes some confusion in discussions like these. I think the European meaning is something like chiropractic.

  9. I'm not a lay person, as it happens, and I do understand that osteopathy is different from osteopathic medicine in the American sense. Please do explain further though because from a British point of view it's quite difficult to get my head round.

    I still don't believe that osteopathy has any clinical evidence behind it (please correct me if I'm wrong) and while I'm sure that wonderful DOs exist just as rubbish MDs exist, I'd still be dubious about the value of a degree with such an emphasis on osteopathic medicine.

  10. I first heard of osteopathy a few years ago when a friend moved to Maine to get his O.D. From talking with him, my impression at the time was that it was an essentially equivalent little-a alternative to the traditional M.D. There may be a different theoretical focus but in practice and professionalism (regulation, legal responsibility) there was little pragmatic difference. Again, I was assured that osteopathy was not big-a alternative medicine like chiropractic and other magical thinking.

    I agree though, that the interview should be about the person not the degree, at least for someone beyond an entry-level position. My limited understanding is that the medical profession handles the entry-level issue via residency, so with his background I can't understand the ignorance/presumption/assholery that came out in the interview. Sounds like the right answer for the candidate was to politely find an exit and continue the job search with more sensible prospective employers.

  11. DOs take exactly the same courses that MDs take, and then take one additional class called Osteopathic Manipulative Medicine, OMM for short. When DOs started, back in the late 1800s, neither MDs not DOs knew very much about how the body really functions, and the DOs found that some types of manipulation seemed to help their patients. As science uncovered some of the mysteries of the body, both MDs and DOs were quick to follow. In practice, the majority of DOs work exactly the same way that MDs do, using the same diagnostic tools and prescribing the same meds, but they have the extra tool in their box of OMM for some very particular problems, typically muscle and joint pain.

    In short, DOs and MDs are interchangable these days, because their training is identical. The particular doctor matters much, much more than the letters after her name. Maybe this wasn't true seventy years ago, but it has been for the last thirty.

  12. Given the wide variety in quality between individual MDs, I always wonder why people assume DOs are categorically "worse".

    The Osteopathy shtick appeals to me as an athlete and a metabolism geek (skeletal muscle isn't the liver or pancreas, but still), but I kind of wonder if it really ends up playing out the way I'd hope it does.

  13. "The particular doctor matters much, much more than the letters after her name. Maybe this wasn't true seventy years ago, but it has been for the last thirty."

    This point, I agree with for sure.

    Thank you for those last two posts, very interesting.

  14. I think you hit a nerve here. As an ED Director who employs both MDs and DOs I can't agree with you more. It is the person not the degree that matters. My understanding of Osteopathic manipulation is very limited but is in my mind the only difference in training. I can tell you I have seen a DO perform a manipulation in the ER and actually get a chronic back pain patient out of the ED without narcotics, and HAPPY. That alone impresses me.

    I can very distinctly remember an interview with a physician mentor at my undergrad being appalled that I had listed a DO school on my list of possible med schools I would like to attend. He said that I could keep it on the list as a "back up" but with my grades I should be able to get into a "Real med school" I remember being quite appalled at the time and disregarding any further advice from the man.

    It is about time medical professionals grew up and dealt with real issues (remember health care,crowding, babyboomer rush, etc) rather than contrived animosity. We need all the good docs we can get, regardless of the letters following their name.

  15. I think, as is coming through in these comments, this is definitely a generational bias of the past that is taking it´s time in blowing over. As a current med school applicant, I have plenty of friends looking into both programs and know at least one who chose a D.O. program over some quite prestigious allopathic programs. I think that is becoming more of the norm and, like it or not, we will probably have to wait for that to trickle up to the still-biased.

  16. First off, I agree with the above posters that say that the person is more important than the degree, but I wouldn't go as far as to say that MD = DO.

    Students at MD programs have consistently higher GPA's and MCATs than DO programs. Numbers are just one factor in the application process, but looking at the bigger picture this at least suggests that MD students are more competitive than DO students.

    Sure you can bring up a load of examples of great DOs and terrible MDs, but looking at the aggregate MDs win by a small margin.

  17. Steven wrote:

    Sure you can bring up a load of examples of great DOs and terrible MDs, but looking at the aggregate MDs win by a small margin.

    Sure. But I do not hire in the aggregate. I hire individuals. A DO from Denver general who was chief and published three times wins over an MD from East Podunk with no outstanding factors on their CV.

    For that matter, a DO from a well-regarded program with no outstanding factors will probably still outrank that MD from East Podunk. If nothing else, I know they must have been extra good to match at a good residency being a DO.

  18. I'll agree with SF's last comment.

    I do wonder if residency directors have more stringent selection criteria for DOs than MDs.

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  20. I've been treated by many DOs. I used
    to go to the clinic at the local
    osteopathic college (great appointment
    availability, near my job at the time,
    lower cost, and excellent care given
    by professionals who really loved what
    they did). The large group pulmonary
    practice in my area is mainly board
    certified DOs, all of whom are
    phenominally knowledgeable, great
    people. I have never been offered OMM.

    @emma - DOs here generally take a
    residency in their desired field,
    and get much the same training as
    MDs. ISTR reading something about
    osteopaths' training in the EU being
    about the same as chiropractors'.

  21. D.O., UK = Diploma of Osteopathy
    (limited to manipulation only)

    D.O., USA = Doctor of Osteopathic
    (full practice rights in all 50 states, 65% of whom train side-by-side in MD residencies)

  22. This is a great post!

    One of the biggest problems is that people don't know how Osteopathic medical school works.

    OMM (the manipulation class) is one of MANY classes taken during the first two years of medical school (DO schools). The other classes are the same as any other medical school (anatomy, biochem, physiology, microbiology, etc.).

    DO students learn up-to-date, evidence-based medicine. OMM is a small portion of the curriculum, and is NOT taught as the primary therapeutic element. It is a therapy that can be used as a supplement to proper evidence-based medicine. This is why DO's can take the USMLE (MD board exams) and match to MD residencies.

    DO schools are a bit less competitive than US MD schools, but the gap is getting smaller every year. Caribbean MD schools are a bit less competitive than US DO schools, but who cares? All schools graduate great doctors, and that is all that matters.

    I agree with the original post that discrimination based upon a degree is ridiculous, and am glad to see that times are changing.

  23. there's nothing wrong with the administrators. They essentially asked the question

    "Why should we hire you, as a state U grad, when we can hire some Ivy league grad".

    If that question is asked, and it is asked a lot, no one would raise a fuss.

    DO schools consistently have much lower admission standard comparing to allopathic schools.

  24. I happen to be in the process of applying to both MD and DO schools right now. I see nothing wrong with either degree, they both have the same education. As for standards, I have a friend of mine who got an interview to a US MD school with a 3.3 gpa and a 20 MCAT (URM) and has heard nothing back from the DO schools. Also, my uncle is a general surgeon (MD) and his favorite anestheisiologist happens to be a DO. From what he tells me, in the workplace there really is no bias, and if there is, there shouldnt be.

  25. To Emma,

    Do you really think all DO's practice solely on the principles of one class taken during 4 years of medical school? You clearly have no idea of the differences in curriculum between a DO and MD school (one EXTRA class teaching manipulative and palpatory techniques). Would you think twice about an MD having taken an elective course on manipulative medicine or would they instantly become incompetent.

  26. @"Anonymous"

    Of course not. It's the general concept of osteopathy to which I object, and I never mentioned anyone being incompetent. All I said is that I would think twice about someone who believed in osteopathy. I think most of the issue here has arisen from the difference between osteopathy in Britain and osteopathic medicine in the US, which some people have been telling me about. I find that very interesting and I'm grateful for the help of those people who choose to educate rather than jumping to slightly silly conclusions.

  27. "Why should we hire you, as a state U grad, when we can hire some Ivy league grad"

    To turn the argument in a slightly different direction I am in the camp that an Ivy league degree for the most part is an overpriced piece of paper. My state schools cost of attendance is running roughly 5 grand a year. That is versus the 50ish for an ivy league and that is before you buy books, food, housing etc. Of course there are offsetting costs such as scholarships but I would rather hire a state school graduate if they chose between state school and Ivy league because they seem to value money more and in a business that is often priority number 1. (What is the opportunity cost of 200 grand blown with interest over a 40 year working career?) Of course if you want to destroy america, err work in the "premier" banking sector you need that crisp piece of parchment.

    To parlay this into the D.O. versus M.D. argument I am disappointed that most D.O. schools are private. Sure some have affiliations with state schools but this seems to be a Doctor turf war area, denying access etc etc; that could be turned around for the chronic primary care physician shortage that is always a great talking point and little is done about. This is on top of the fact that the D.O. philosophy is supposed to be more patient-centric than the allopathic model, so they in theory push primary care harder.

  28. It seems to me that the problem is people's issues with prestige and ignorance. Many people who put down a D.O. degree on here do so because they don't fully understand the ideas behind osteopathic medicine and therefore don't think it's "as good"(Emma). People compare an M.D. degree to a D.O. as though they are comparing Harvard to a state university. In the U.S. the two are basically the same, they are qualified for the same positions, go through similar training(4 yrs med school, residencies, etc.)and so on. The only real difference is the emphasis on the musculoskeletal system, etc and common principals of osteopathic medicine. They don't just treat the symptoms, they look at the body as a whole. It makes sense if you can open up your mind and give it a chance. Do your research, then form an educated opinion.

  29. I wonder if the DDS's and DMD's have this problem? The PhD psychologists and PsyD's?

    People just can't wrap their heads around the concept of two different medical degrees grounded in two different historical social movements which have more or less converged in scope and practice....

  30. There is a historical issue not mentioned in these posts. In the 1930's MD schools in some parts of the country did not accept Jewish applicants; DO schools did. I grew up with several bright kids whose parents were DO's because of their religion; those kids chose to become DO's to validate the faith those schools had in their parents. They grew up to be excellent physicians with a moral sense that I have always admired.

  31. When my daughter was about to be born, we (brand new parents) interviewed different pediatricians and settled on one who we really liked. She was a DO. A month later, or little girl was born with a rare congenital defect, a defect that is often not even diagnosed for the first year of life. Her pediatrician diagnosed it the first day.

    I read every article the state medical library had or could order on her condition and chose a pediatric neurosurgeon I wanted my baby to see (one who operated endoscopically rather than using traditional methods). Our DO supported our decision, helped us get our insurance to pay for the procedure, worked with the neurosurgeon to prepare our baby for surgery (Epogen every week for six weeks before the surgery), and got us into contact with charities that helped us make the 1,000-mile trip to see the doctor we chose.

    Right now my daughter is five years old. She is at the top of her class, smart, funny, athletic, and the only evidence of her problem in a two-inch scar behind her hairline. I credit our pediatrician, a DO, with saving my little girl. She was both medically skilled and emotionally supportive.

  32. Some little DO facts:

    DO students take the same coursework as MD students. The only difference is that DO students must also learn OMM (at the expense of first year summer vacation). All DO students are taught evidence based medicine.

    OMM (osteopathic manipulative medicine) is a useful analgesic modality. Occasionally it produces dramatic cures (rarely) but most often it is used as a palliative. Some OMM techniques have a growing basis of evidence while some techniques are traditional without much evidence backing them.

    DO students are required to take the COMLEX examinations to graduate with their degree. Many also take the USMLE.

    DO's may apply to osteopathic and allopathic residencies. For allopathic residencies DO students are usually placed within the independent category (above international, below MD).

    Incidently, the allopathic residency program directors that I have spoken to (from programs which have accepted DO candidates previously) generally like DO students applying for their residency slots. The most entertaining reason that I've heard was "DOs know that they're the underdogs so they tend to work harder then the MDs"

    Thanks for the article Shadow

  33. When I see a DO doctor, I wonder to myself if he/she slacked off a little during college or was an older non-traditional applicant. It's the truth. DO students on the average have significantly lower GPAs and MCAT scores. The average MCAT for MD schools is currently 30, for DO schools it's 26. That's about 2/3rds of a deviation, which might be trivial in the scheme of things, or not.

    When recruiting, I consider a DO doctor who has done an allopathic (ACGME) residency to be identical as an MD doctor. However, I consider a DO doctor from an osteopathic (AOA) residency program to be significantly less qualified than the ACGME candidates. And there's good reason for that.

  34. DOs who do osteopathic (DO) residencies and not MD residencies are still at a disadvantage:

    Carolinas Healthcare System (CHS), the largest hospital system in North Carolina, still does not recognize osteopathic post-graduate education. CHS, based in Charlotte, has refused to amend its bylaws despite repeated advocacy attempts on the part of NCOMA and the AOA.

  35. While the point above regarding AOA vs. ACGME accredited graduate medical education may hold true in some cases, I believe that it is dangerous to apply that standard across all specialties.

    The decision of a DO to opt into an AOA primary care residency (IM/FP) is one that I would personally question. A DO who is opting into a primary care residency, or even a specialty such as emergency medicine or anesthesiology, is often considered quite competitive in the ACGME arena pending a solid CV and USMLE score. A cursory view of many university residency programs in these specialties shows a strong representation of osteopathic physicians. The the experiences offered in AOA accredited residencies in such specialties is often, sadly, not up to par with those sponsored by the ACGME and is widely variable across institutions. While this is not always true, it is certainly not as uniform as that in the ACGME arena.

    A place where it is more difficult to make the distinction is in general surgery and the surgical subspecialties. Some of the established and competitive AOA surgical residencies have rotations for their residents at outstanding facilities and train along with their MD counterparts for a large portion of their residency. As well, many graduates of AOA surgical residencies are competitive for many high-level fellowships. In the end, however, I believe that Shadowfax makes a strong point for the fact that hiring of physicians should take place on an individual basis and that the whole business of aggregate numbers and degree competitiveness really makes no difference.

  36. Just a few words from a current DO student. I only applied to a DO school. After researching both MD and DO schools I came to the conclusion that the types of training were equal. The vast majority of DOs go through MD residencies. (For those who don't know. In the US, to become a physician you typically go through 4 years of undergraduate education, 4 years of medical school, and 3-8 years of residency in your specialty of choice. You take the MCAT exam for admission to medical school, the USMLE or COMLEX to graduate medical school, and specialty boards depending on your chosen field. Occasionally physicians will do additional training (called a fellowship) to subspecialize in a particular field. The vast majority at my school take both the USMLE (MD boards) and the COMLEX (DO boards). For my class, the class of 2012, our average MCAT score was a 29. (The same as the state MD school in the same city.) Our average GPA was around 3.6. (Again on par with the national average.) On average we do about the same as the average MD school of the USMLE. The specialty licensing exams are identical for the two degrees. OMT (osteopathic manipulative therapy) is a very small part of the curriculum (which in every other way is identical to MD schools) and is taught as an adjunctive therapy to use in specialized situations. Hope this helps to clear things up a bit for those that are interested.


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