Philadelphia College of Osteopathic Medicine - Synapsis Yearbook (Philadelphia, PA)

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PROLOGUE: State of the Art In 1974, The New England Journal of Medicine published a special article entitled, Trends in Gradu- ate Medical Education and Specialty Certification (N Engl I Med 290: 545-549, 1974), a tracking study of U.S. medical school graduates. They find, Of the 1960 graduates ... 99 percent entered residency, 86 percent completed residency . . . and 73 percent had achieved specialty certification. In addition, they point out that, The overwhelming motivation for graduate education and specialty certification . . . together with a shortening of formal medical educa- tion, and approva l of the specialty of family practice (1969), warrant the conclusion that during the 1970 ' s, virtually all United States graduates will undertake residency training and seek specialty certification. This report and a recent redefinition of the es- sentials of medical education form a policy statement which affirms that undergraduate medical education prepares the student for further education in a gradu- ate program and not for the independent practice of medicine. Either these conclusions are in error, or we, as osteopathic physicians, must seriously consider our present identity and our presumed usefulness and acceptability to American Society. Our training, which mandates a rotating intern- ship, is conducive to advancement in graduate osteo- pathic residency programs, and is largely directed towards the preparation of primary care physicians whose approach is to be holistic, with concerns not limited to mechanisms alone but also with the indi- vidual and his environment. Our osteopathic medical education includes both a philosophy, which is well known to us, and an assumption that the training of a physician is a process which never nears completion, but which proceeds after didactic, clinical and intern- ship training, with much dependence upon the experi- ence gained from patients at the bedside. There exists opinion that osteopathic medicine adopted this role as primary care clinician when that area of patient concern was abandoned as specializa- tion and ultraspecialization became commonplace among allopathic physicians since the Second World War. Yet, the maturatibn of osteopathic medicine over the past one hundred years has progressed as though it were fed a diet of sound and cohesive ideas rather than having scavenged the remnants of medical opportunity. The concepts with which we have learned to approach a patient are holistic. We now think of a patient as an integrated unit, indivisible into sepa- rate parts. The osteopathic specialist is derived from this fundamental precept. Our philosophy, which as students, we viewed as a catechismal burden, prevents that development of a heart, or gut, or bone specialist. From our midst, only an osteopathic physician may emerge; and as a specialist he may be well versed in cardiology or gastroenterology, etc. Modern osteopathic ideology and practice differ greatly from that which sprang from the doctrines of Andrew T. Still in 1874. Though he utilized drugs and surgery, many diseases were thought due to ab- normalities in or near joints and that the treatment for these diseases is the correction of these abnormalities. By the Mid-20th Century, our pattern of practice had undergone considerable change. We have become eclectic; retaining the concept of the spinal lesion but recognizing that physical, chemical, nutritional, hor- monal and immunologic factors influence the state of health and that improved drugs and contemporary surgical competence are necessary and d esired modali- ties of treatment of many dieases. The modern osteopathic physician has become a unique individual. Borne on the arms of an educa- tional system which diverged from and opposed the prevailing concepts in therapy and diagnosis during its infancy, today osteopathic medicine recognizes an interdependence with allopathic medicine. Medicine has progressed rapidly and effectively in the past one hundred years; diagnostic methods have become exacting; therapeutic modalities have become com- patible with physiologic principles clarified since that time. The osteopathic philosophy is now one which may be played in concert with the precision of allopathic medicine. Our role as primary care physician is fortified by the existence of men in medicine whose work pro- vides research, improvisation and specialization. We are able to employ diagnostically and therapeutically the most excellent from the entire spectrum of medi- cine while at once creating a most intimate relation- ship with our patients. We have become the craftsmen at the level of the object. We are the first physician. As students of osteopathic medicine we have been taxed with the burden of understanding some complexities associated with our profession. Origi- nally, Andrew T. Still created opposition by his refusal to employ many drugs then commonly used. The efficacy of agents then employed is so question- able that his non-pharmacologic therapies were by comparison the sounder. When pharmacologic, bio- logic and synthetic materials improved and became available, the osteopath avidly employed these agents. Undeservingly, he was given a stigmata as only a manipulating therapist. Much of the significance of his earlier non-pharmacologic modality was forgotten. Compare the benignancy of manipulation with an armamentarium of polypharmacy, bleeding, purg- ing, blistering, leeching and puking, in use up to the time of the Civil War. Ouinine was consumed in great quantities for any fever and calomel was used so

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PJ.O.M. LIBRARr widely and incorrectly that symptoms of mercurial poisoning were often confused with the fevers calo- mel was intended to cure. In 1810, Hahnemann published Organon of the Art of Healing, in which he protested against the medical practices of his day and advocated certain principles that became the basis of the homeopathic method of treatment. Among other suggestions, he called for a single remedy preparation and for the minimum dose that will cure. Polypharmacy continued. It involved the use of five to ten drugs in a single preparation. A striking example of this tendency can be illustrated by quoting from a paper published in 1934 on the treatment of pneumonia. 1. Quinine hydrobromide, 25 grains by mouth, repeat in three to six hours. 2. Surgical pituitrin 1.0 cc intramuscularly, every three hours as long as systolic pressure remains below pulse. 3. Tincture of digitalis, 15-30 drops, every three hours if diastolic pressure and respira- tory rate are are within 10 points of each other. This prescription was advocated by a prominent pro- lessor in one of the Philadelphia medical colleges. In 1844, Lea and Blanchard of Philadelphia published a series of lectures on the Practice of Medi- cine by Professor Thomas Watson, of St. John ' s Col- lege, Cambridge, England. He states, I cannot enter- tain a doubt that the withdrawal of a certain amount of blood is, in almost every case, essential to the per- manent control of common acute inflammation at- tended with fever. Dr. Watson says further, I once stood by and saw, not without trembling, a vein in the left arm kept open until four and a half pints of blood issued from it and not until then did the patient become faint. The event of the case justified the bleeding, for the man got perfectly well. This was the prevailing medical mentality which existed at the time that Still dissented from allopathic medicine. An additional complexity we faced as students is the charge that those who enter osteopathic medicine are less qualified and that the educational require- ments are shorter and less rigorous. About 3 years ago, we as a class were engaged in an Anatomy course of twenty weeks and were required to dissect limbs and viscera. Medical schools in Philadelphia had shortened Anatomy to eight weeks and employed pro- sections of limbs. Not many years ago, it is well known, didactic programs of lectures and laboratories entailed four years at PCOM. The public is poorly advised in these matters. Andrew T. Still was a licensed physician in Mis- souri. He served several years as an apprentice to his father who did doctoring, but whose main occupa- tion was minister. Later, he attended lectures at the Kansas City Medical School; it is unlikely that he graduated or obtained the degree M.D. His credentials were not unlike most licensed physicians in the Pio- neer West. In 1876, a medical practice act was approved by the Governor of California. One year earlier, a law was passed in Nevada making it necessary for a phy- sician to exhibit his diploma to the county recorder before he could practice. These three question comprised the examination for licensure for the Territory of North Dakota in 1885. 1. Given a case of diptheria, what precautions would you take to prevent its spread? 2. What is a case of puerperal septicemia? 3. What is a case of typhoid fever? For training, students in 1858 could go to San Francisco where two courses of 18 weeks each were required for graduation. The first medical school in the Pacific Northwest was established in Salem, Ore- gon, in March of 1857, and in July of the same year graduated the first class of three. In 1876 for the best one went to Pennsylvania Medical School. Lec- ture tickets (S20 each) were purchased for the seven courses required per year. A two year stay was re- quired for graduates, while a third year was added in the 1880 ' s. Upon graduation the young doctor pos- sessed a diploma in a tin case, a stethoscope and a 12-inch thermometer. Other schools were required two yearly courses of five months each, followed by two or three years of apprenticeship or preceptorial training with a practitioner (1885) . A diploma could be purchased from the Buchanan School in Philadel- phia. There were many such mail-order diploma agen- cies and medical schools granting diplomas were referred to as diploma mills. President Eliot of Harvard Medical School at- tempted to institute written examinations in 1871. The Head of Surgery, Henry Bigelow is quoted, 1 had to tell him [Eliot] that he knew nothing about the quality of Harvard Medical School students . . . more than half of them can barely write. Of course, they can ' t pass written examinations. (Churchill, E.D. to Work in the Vineyards of Surgery, Harvard University Press, 1958, P. 182). The separation of Medicine into two opposing fac- tions. Allopathic and Osteopathic, is based upon myth. The myth is no more substantiated than that which interposes itself between peoples of different racial origins. Naivete seizes the subtleties within groups and entertains itself with games of superiority, conquest and self-righteousness. Osteopathic medicine obsequiously wore a tatoo of illegitimacy, trying all too hard to outrun the fetid breath of the charlatan. We played the myth upon ourselves. That game is over. You are a physician. G.M.C.