The Rule of Three

To the OFP Editor:

Good Morning! I'm Dr. Abend, and I'll be treating you today. I am a DO.

A DO? What's that?

It's the acronym for doctor of osteopathic medicine. I'll be performing osteopathic manipulative treatment as part of my special training and hands-on skills.

Oh, you mean you can prescribe medicine and make referrals?

Yes, I am a fully licensed physician and can prescribe medication and physical therapy and refer patients to different specialists.

What about the chiropractic manipulations you do all the time?

The manipulations I perform are not chiropractic; instead, these are osteopathic and unique to what we do as DOs. They were developed to avoid medication and augment other therapies.

So, you're like a chiropractor?

No, it's the other way around. Chiropractors are like DOs. Most people know what a chiropractor is because they perform hands-on or manipulative techniques, but DOs are a hybrid. It's likened to having a chiropractor and an MD wrapped into one.

This type of conversation happens to me almost weekly when encountering new patients, as it has for the past 30 years of my experience as a practicing osteopathic physician. I usually describe to the patients the current statistics describing the exponential growth of DOs, which now comprises approximately 11% of the U.S. physician population, with 150,000 doctors currently in our ranks and another 25,000 students in medical school training.1 If patients want to learn more, I refer them to the American Osteopathic Association website, specifically for patients,2 or Wikipedia.3,4 When disseminating this information, I carefully avoid using archaic terms such as osteopathy or therapy when describing osteopathic manipulative treatment (OMT). Ironically, due to its MD orientation, one of the best DO descriptions is offered by the Cleveland Clinic.5 With my facile hand manipulations and my explanations to patients, staff and students come readily. If they are willing, I demonstrate my skills and let the results speak for themselves. Although osteopathic practices have been in existence for over 128 years, recently, my conversations with patients had taken an interesting turn at a time when osteopathic physicians did not ask or even need public relations. It was thrust upon us after a curious Rule of Three in 2020. I was reminded of my mother's religious superstition that things always seem to happen in three.

The Oxford Dictionary of Quotations lists third-time lucky in its Proverbs section and says it goes back to the mid-19th century.6 The number three is much more often associated with good luck than bad. There's an old soldiers' superstition, variously said to date from the Crimean or Boer Wars, that it is bad luck to light three cigarettes with one match. That would give any would-be sniper a good sight at a target. However, I have also seen a suggestion about a Russian Orthodox prohibition on lighting the three altar candles with one taper.7

Rule of Three #1: After then-President Donald Trump was diagnosed with COVID-19, I sat watching the October 3, 2020, national television broadcast of the physician press conference outside Walter Reed Naval Medical Center where the then-President was being treated. The cameras focused on the left-hand pocket of Dr. Sean Conley's starched crisp white coat, clearly reading Sean P. Conley, DO, Physician to the President, as he updated the nation on then-President Trump's condition after being admitted to the hospital.8

Rule of Three #2: A short time later, I read an article about then-President-Elect Joe Biden and his physician, Dr. Kevin O’Connor, who is also a DO.9

Rule of Three #3: Then, also in October 2020, NBC News reported Figs®, a manufacturer of medical scrub wear, posted a video advertisement insensitively targeting not just DOs but female DOs by specifically featuring a woman in neon pink scrubs reading an upside-down book titled "Medical Terminology for Dummies."10

Suddenly, osteopathic medicine is taking center stage and in the national spotlight. Evidence of this could be seen after Sean Conley, DO, gave his update from Walter Reed Naval Medical Center. Despite his impressive background—consisting of an undergraduate degree from Notre Dame in 2002, graduation from The Philadelphia College of Osteopathic Medicine, and service in Afghanistan in active duty in the U.S. Navy and attaining the rank of Commander—the media seemed to focus solely on defining osteopathic medicine and DOs. As mentioned above, Dr. O'Connor is now President Biden's physician, a DO, a member of the George Washington University Medical Faculty Associates, a graduate of the New York College Osteopathic Medicine and a decorated flight surgeon and colonel in the U.S. Army.

Once again, the media spent its energy highlighting the osteopathic community. News media sources from all over the U.S., using quotes from leaders in our medical profession, juxtaposed us with our MD counterparts. But their efforts fell far short of the mark. Some news outlets referred to us as holistic and labeled us as osteopaths or delved into politics after a cursory and superficial discourse, thereby further confusing the public.11,12,13 The Atlantic published a well-researched piece with a rich history of the osteopathic medical profession 4 and a little-known Irish publication/newsletter published a piece that described Dr. Conley's osteopathic medical training in some detail.15

With decades of experience, I have provided medical care to thousands of patients as a primary care physician. I’ve also proudly integrated the gift of hands-on skills learned from my medical school training of over 700 hours in Kirksville, notably OMT taught throughout my medical training and beyond. This unique hands-on skill forms the backbone of our profession's deep roots as developed by the founder, Andrew Still, an MD. An American-born physician, Dr. Still sought to improve upon the primitive and barbaric practices of medicine at the turn of the century in the late 1800s/early 1900s. This difference in utilizing our own hands helps heal the human body to support other traditional medical options—such as pharmacologic, interventional and surgical—that I have always championed. For more than a quarter of a century, other types of hands-on arts and sciences, such as physical therapy, chiropractic, massage, and even some sports medicine MDs, have incorporated OMT.16

While 11% of the nation's medical doctors are DOs, less than 10% use their hands and a lesser fraction of those are using their hands- on OMT skills. Moreover, DOs and MDs are generally indistinguishable today because the lines are blurred with the new Accreditation Council for Graduate Medical Education guidelines creating one universal residency matching program. In my opinion, these factors are fostering the public’s misperception of our profession.17

We need to teach and reinforce our medical students and residents how important our hands-on osteopathic skills are to diagnose better and heal our patients. By doing so, we can create the necessary dialogue and recognition our medical profession deserves. The Venn diagram center connects the five clinical models: biomechanical, neurological, respiratory-circulatory, metabolic and behavioral, which form the basis—or root core—of osteopathic principles and philosophy.18 They provide the foundation of the basic and clinical sciences integrated into osteopathic medicine in all 37 osteopathic medical schools in 58 different locations.19

Respectfully Submitted,

David Abend, DO, Assistant Professor, Department of Osteopathic Manipulative Medicine, Rowan University School of Osteopathic Medicine, Stratford, NJ

Board Certified, Neuromusculoskeletal Medicine and Osteopathic Manipulative Medicine Board Certified, Family Practice and Osteopathic Manipulative Treatment