Tom Takubo, DO, an osteopathic physician and pulmonary critical care specialist, is exasperated and crestfallen.
Since 2017, the West Virginia state senator has questioned why his state has two separate agencies to license and discipline its osteopathic versus its allopathic physicians. Each board has its own rules and standards of practice that vary in at least a dozen perplexing ways. He said it's confusing to patients, it's strange, and constitutes a double standard.
"Why are we working under two separate rules, depending only on where we went to medical school?" Takubo asked during an interview with MedPage Today.
It's an important question.
After all, 37 states and the District of Columbiaopens in a new tab or window -- including large states like New York, Texas, Illinois, and Ohio -- license all their allopathic and osteopathic physicians under one board. That accounts for some 65% of the nation's doctors.
In February, Takubo introduced a billopens in a new tab or window that would combine the two boards to oversee professional conduct for its 9,067 MDs and 1,800 DOs. Though he had strong support from both chambers and the two state boards, he lost his fight. In late March, West Virginia Gov. Jim Justice (R) vetoedopens in a new tab or window that bill. Organized osteopathic associations argued that combining the two licensing agencies would be disastrous for DO autonomy.
Times Have Changed
The origins of osteopathic philosophy 150 years ago were based on a concept that the roots of illness could be found in misalignments of the body's structure, which could be repaired through musculoskeletal correction. Founder A.T. Still eschewed treatment with surgery or drugs, which arguably were much less effective than they are today.
The American Medical Association at one point called osteopathic doctors a "cultopens in a new tab or window," in part because of their training in osteopathic manipulation treatmentopens in a new tab or window (OMT).
Today, those early concepts are long gone. Osteopathic medicine is no longer held with disdain, and DOs' treatment is almost indistinguishable from that of MDs. Although osteopathic medical schools still teach what they claim is a more "holistic" approach to healthcare, DOs' privileges and prescribing practices are virtually identical to the MDs they work alongside in every state.
Indeed, a 2023 studyopens in a new tab or window in the Annals of Internal Medicine found that DOs and MDs delivered similar quality of care for hospitalized Medicare beneficiaries.
And their numbers are growing. About 25% of medical studentsopens in a new tab or window are enrolled in the country's 60 osteopathic medical school campuses, which now graduate between 8,000 and 10,000 students a year, according to the American Osteopathic Association (AOA). In 2023, the AOA counted 148,829opens in a new tab or window actively practicing DOs, and a 2017 report from the group predictedopens in a new tab or window that by 2030, one in five practicing physicians will be a DO.
Also, their graduate training is now essentially the same as that of MDs. In 2015, the AOA turned over its authority to accredit graduate medical education programs to the Accreditation Council for Graduate Medical Education in a merger processopens in a new tab or window that was completed in 2020. Since then, all DOs compete for the same training slots as MDs, and their 2024 match ratesopens in a new tab or window -- 92.3% and 93.5% -- were virtually identical.
So why have two separate licensing boards?
"It's almost inevitable that state licensing agencies would try to consolidate now that there's one accrediting body for postdoctoral medical education," said Norman Gevitz, PhD, senior vice president of academic affairs at the nation's first osteopathic medical school, A.T. Still University in Kirksville, Missouri.
Gevitz, author of a bookopens in a new tab or window detailing the tortured history of osteopathic medicine, said states that created separate osteopathic licensing boards established them "because of the fear of prejudice, that the allopathic physicians would put impediments in the way of their licensure."
And while there is still some discrimination and prejudice -- some MDs believe that it is easier to get into osteopathic medical school than an allopathic school -- times have changed dramatically.
Part of Takubo's reason for wanting to combine the boards was to develop a stronger voice to advocate for better health policies, especially in West Virginia, which is listed as one of the least healthy and most medically underserved states. It could produce more alignment in efforts to reduce lung cancer death and improve other health outcomes. They'd have more clout to work against scope creep, and advocate for better physician pay, especially for those treating the underserved, he said.
His bill called for naming five DOs and five MDs to the board, and most importantly, it would dissolve the discordant standards that Takubo said contribute to an antiquated belief, still held by some, that DO physicians just aren't as good as MDs.
For example:
• In a disciplinary proceeding against an MD, the West Virginia Board of Medicine must see "clear and convincingopens in a new tab or window" evidence of wrongdoing to justify action. In a case against a DO, the West Virginia Board of Osteopathic Medicine needs to find only a "preponderance of evidence." Takubo said the burden of proof difference is like having 80% evidence of medical misconduct versus 51%.
• MDs must take 50 hours of CME for re-licensure every 2 years while DOs need only 32.
• The MD board can issue temporary licenses for applicants who need to start working immediately. It also can issue special administrative licenses for non-practicing clinicians. The DO board has no such capabilities.
• No academic MD can sit on the MD board, but academic DOs can be members of the DO board.
Governor's Veto
But support for the bill was not enough.
It met vehement opposition from the AOA and the West Virginia Osteopathic Medical Association (WVOMA), which feared a loss of autonomy and independence.
WVOMA's executive director, Penny Fioravante, called the bill "a political ploy, "totally unnecessary," and "a political trade with a large hospital system."
Late last month, Justice vetoedopens in a new tab or window Takubo's bill, saying that DOs and MDs "are two separate and distinct" medical doctors. He mentioned opposition from "the osteopathic community."
"I hated that veto letter because he makes it look like DOs are different, that we want to be separate," Takubo said. "But we don't. That's not what we have fought for for so long."
Besides, he added, "What better says that we are now equal than when a DO is signing the license to allow an MD to be a physician?" Justice's veto "set us back decades," referencing a time when osteopathic physicians were held with disdain by their MD colleagues, and their practice was equated with that of naturopaths.
In an interview with MedPage Today, AOA President Ira Monka, DO, said he opposes consolidation of DO and MD licensing agencies in those 13 states. He said it would strip osteopathic physicians of their distinctive training and autonomy, including OMT.
"The allopathic boards don't always have the training to understand how to evaluate the training we have, especially when it comes to osteopathic principles in medicine," Monka said. An AOA media representative was present during the call.
But almost all of the states that combine DO and MD licensing have at least oneopens in a new tab or window, and sometimes two or three, DOs on their boards. Wouldn't they defend an unjustly accused DO?
Not necessarily, Monka said. "We're pretty much outnumbered at the get-go. When you have your own osteopathic board," he said, "the majority is taking care of you."
Much of DOs' fear about being robbed of their autonomy and philosophy, and suffering unfairly at the hands of MD-dominated boards, stems from what happened more than 60 years ago in California, which still maintains separate DO and MD licensing boards.
Essentially, California DOs, who were more progressive and practiced more similarly to their MD colleagues, made a deal with the California Medical Association to exchange their DO licenses for MDs for a $65 fee and one course of study, and most of them did. (See a sidebar on this story hereopens in a new tab or window.)
Some of osteopathic organizations' distrust of MD oversight appears to center on doubts that MDs have enough understanding of OMT, but that concern is rapidly losing relevance. While OMT training is still emphasized in osteopathic medical schools, dozens of DOs interviewed for this story said they rarely if ever perform it, and several studiesopens in a new tab or window have documented how seldom DOs actually use it in practice.
First, many payers won't reimburse for it, the DOs said. Second, the procedure requires time to relax and position the patient, time that is increasingly scarce in busy clinical practice.
Takubo, who also teaches medical students at West Virginia University Health System where he is the executive vice president of provider relations, says he has talked with well over 100 DO students about the state's dual licensing board system and "the vast majority are in favor of combined boards. They felt it would further remove perceived bias and stigma and help them get into competitive rotations.
Charlie Wray, DO, an internist at the University of California San Francisco, thinks there's no reason to have separate boards since there is so little difference today in their delivery of care. He complained that licensing rules for DOs require that they obtain separate and expensive osteopathic continuing medical education (CME), often requiring out of state travel, when he's exposed almost daily to the same course material -- for free -- that qualifies for MDs' CME.
The AOA's Monka acknowledged that many DOs support merged boards, perhaps because they don't know the history, and think parity with MDs would only be enhanced if they were licensed by the same board. "It's really those under 45 versus the ones over 45. That's the number we throw around where the mindset is so different," Monka said.
The New Mexico Merger
Seeing an opportunity for consistency, New Mexico lawmakers recently combined its two boards. State officials and osteopathic physicians acknowledged that the old way wasn't giving its 1,000 DOs the attention their practice of medicine deserved. In that case, the DO board was housed in a different government section that also oversaw the licenses of chiropractors, tattoo artists, and barbers.
Steven Jenkusky, MD, medical director of the New Mexico Medical Board, recalled the history behind that state's 2021 merger of its DO and MD licensing agencies. Discussions had begun years earlier because the state has a relatively small number of DOs and because of concerns the DO board was inefficiently processing licenses. Talks went nowhere because the dean of the state's only osteopathic medical school was adamantly opposed.
But that dean left, and was replaced by "a new dean who was from Texas. The new dean said, 'We have only one board in Texas; I don't see an issue.' And that's what got the ball rolling," Jenkusky said.
Brad Scoggins, DO, past president of the New Mexico Osteopathic Medical Association, said it seemed important that DOs who were the subject of complaints would be investigated by officials who also explored accusations against MDs. "In states with larger numbers, you could make an argument for keeping the boards separate," he said. But in New Mexico, DOs are in leadership roles, chiefs of staff, surgery, and medicine. "Parity has been pretty well achieved."
MedPage Today interviewed DOs from about a dozen states with combined boards from New York to Oregon, and all said that DOs were treated the same as MDs under a combined board.
"It's antiquated," said Marc Price, DO, from Malta, New York. "We learn the same thing from the same books."
"I think it should all be combined into one," said Spencer Nadolsky, DO, of North Carolina. "I also think letters after our names should be somewhat consolidated. If they want to have some difference, it could be 'MDo.' It's confusing to patients!"
Cheryl Clark has been a medical & science journalist for more than three decades.
https://www.medpagetoday.com/special-reports/exclusives/109695
