Who’s Who: Part I

Article two in a series of four discussing the various health professions within the primary/general care space. This post focuses on western medically trained practitioners. Please see Who’s Who: An Introduction for more context.

Conventional Medicine, MDs –  not that it needs much explanation, but these are fully licensed physicians experts in the western medical system – a very systematic and compartmentalized approach to care, predicated on a hierarchy of evidence from scientific studies, with pharmaceutical and surgical interventions as top line therapies.  Its foundation on evidence-based outcomes provides a very necessary structure for how to approach care for the masses and the “average person”, but often has limitations addressing anomalous situations and care needs at the individual level.  Western medicine was born out of the aftermath of the Flexner report in the 1930s that highlighted a need for standardized medical education and treatment – not a bad thing, but in the process it eradicated other established forms of medicine in the US including osteopathy, homeopathy, chiropractic, and naturopathy, and evolved into the one-size-fits-all system it is today.  My personal opinion is that this is a problem; you need only look at the chronic illness and opioid epidemics to understand that not everyone succeeds in this model of care. And, to no fault of the profession itself, the practice of western medicine today is largely dictated by cost-savings to insurance companies, further handicapping providers from providing the patient-centered care that is so desperately needed. There are great MDs, average MDs, and some not-so-great MDs. 

Education: 4 years of graduate studies including 2 years of clinical rotations in inpatient and outpatient care, largely in hospital-based settings, followed by 3 – 8 years of residency and board certification, depending on the medical specialty chosen. Less than 10% of US MD graduates choose to go into general/primary care practice.

Osteopathic Medicine, DOs – up until the mid 20th century, osteopathic medicine was its own body of medicine founded on the philosophy that musculoskeletal function was imperative to the body’s ability to heal itself, and it viewed disruptions to this system as a root cause to many ailments. As such, manual skeletal manipulation was used as a primary treatment to correct misalignment and restore function. In a desire for more respect, recognition, and greater scope of practice (the American Medical Association tried to abolish osteopathic medicine in the 1960s and often referred to the profession as a cult), DOs began to align their curriculums to that of MDs. While a small percentage of the education still involves osteopathic manipulative medicine, the larger profession seems to have more or less eschewed these osteopathic foundations and there is essentially little to no difference from how DOs and MDs practice today. Many medical students apply to DO schools as a back-up option to MD programs, and many apply to them exclusively for the more holistic philosophy that permeates the culture versus that of MDs (I do find the vast majority of DOs to be more open minded than their MD counterparts.)  There are great DOs, average DOs, and not-so-great DOs. 

Education: same as MDs although it includes 200-300 hours of osteopathic education and places an emphasis on primary/general care versus specialization, with residencies spanning 2-3 years. Nearly 50% choose a primary care specialty.

Naturopathic Medicine, NDs – similar to the philosophy of the early DO days, naturopathic medicine operates from the idea that the body functions to maintain its own health but, unlike osteopathic medicine, does not tie this to musculoskeletal health.  Rather, it suggests the ability to heal is influenced by a person’s vitality, a concept influenced by a myriad of things including physical state and emotional wellbeing.  As a very simplistic example, person A is depressed and malnourished while person B is physically and emotionally robust; person B has greater vitality and would likely be able to overcome a common illness with adequate rest while person A might require more support in the way of medication or other interventions. The point of the naturopathic approach is to restore and optimize this vitality so the body is supported in maintaining health. This is a profound, fundamental difference from the conventional model of care.

NDs receive education in western medicine diagnosis and standards of care including pharmaceuticals, but also receive up to 100 more hours in nutrition than conventional programs, 150 hours in behavioral medicine (nearly absent in conventional curriculums), and training in non-pharmaceutical treatment options including botanical medicine, physical medicine, and homeopathy.  In Arizona and Canada, the education also includes acupuncture although the majority of NDs are not acupuncturists unless they are separately licensed as LAcs. Naturopathic medicine is evidence-based but less strictly defined by it than conventional care; many prefer to say evidence-informed as it is used to guide the treatment approach but is not necessarily bound by it, placing the focus more on the individual. Physician status, licensed provider status, and pharmaceutical prescriptive abilities vary by state.  I find many in the field loosely considered MD/DO school but the majority did not (I never did), ultimately choosing naturopathic medicine because it most aligned with their health philosophy.  ND’s are trained in general/primary care and lifestyle medicine and, with a few exceptions, do not practice in hospital or in-patient based settings. There are great NDs, average NDs, and not-so-great NDs.

Education: 4 years of graduate studies including 2 years of clinical rotations based in outpatient, community medical clinics.  No residency requirements at this time (they are privately funded while most MD/DO residencies receive federal funding to operate). Roughly 20% participate in formal 1-3 year residencies with other graduates participating as associates in mentee situations or collaborative clinics in their first years of practice. Nearly all NDs work in a primary or general care setting.

Functional Medicine – functional medicine was born out of naturopathic medicine (it’s founder was a board member of my alma mater – Bastyr University – before going on to coin “functional medicine”) and was created in the early 1990s in response to the growing popularity in holistic care, serving as an additional education resource for those in the MD community that found limitations in their conventional training.  It has since grown and today serves as a general term used by varying types of practitioners who are practicing more holistically. Functional medicine shares similarities to naturopathic medicine but is far less comprehensive in terms of philosophy and education – I’ve heard colleagues refer to functional medicine as “naturopathic medicine 101” and “naturopathic medicine light.” If I am being honest, I do feel the field has appropriated much of naturopathic medicine and without much credit, but it is important that this more holistic concept of health grows and that more of the conventional community embraces it as it is far more helpful than the current state of care that, I argue, is creating more problems than it is solving them.  There are great functional medicine providers, average functional medicine providers, and not-so-great functional medicine providers.

Education:  The main educational body is the Institute for Functional Medicine (IFM).  The IFM offers two to three day seminars – remote or in person – on specific health systems, or full certification with completion of all its modules/seminars and online exam.  Once reserved for MDs, functional medicine programs are now open to all healthcare professionals whether they have a western medical background or not, so if you work with a functional medicine provider know that this does not designate them as a medical doctor.

Chiropractors, D.C. – chiropractic practice originated slightly after osteopathic medicine with a similar philosophy toward health.  After the Flexner report, however, osteopathic medicine took more of an initiative to reform its medical education while the chiropractic cohort did not and they were heavily persecuted for this.  According to the ACA, “Chiropractic is a health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health” with diagnosis through imaging studies and physical exam, and treatment via spinal manipulation techniques, corrective exercises, and lifestyle medicine.  Legal verbiage in many states allow DCs to practice beyond this, ordering and interpreting lab work and managing unrelated disorders with supplements and nutrition advice, a scope of practice that I, at times, struggle with.  There are great DCs, average DCs, and not-so-great DCs.

Education: the doctorate degree level involves 3.3 to 4 years of graduate school covering the basic sciences and clinical education/experience with a primary focus on evaluation and diagnosis of the neuromusculoskeletal system with lesser coursework in other body systems for a total average of 4,200 hours of classroom, laboratory, and clinical internships.

As with all things in life, there is a spectrum of skill among practitioners and a poor experience with one should not characterize an entire profession, hence my reference to great, average, and no-so-great practitioners in each category. All of these professions have a valuable place in healthcare. I also think it’s important to point out again that less than 10% (!) of MDs choose primary care. There is a glaring lack of interest (and, more importantly, lack of money) in serving primary care needs, yet this is where people need the most support and the level at which we can correct downward health trends before they become chronic issues.

For a less colorful summation of these programs you can read the INM’s post on the same topic. Resources used for my information include: jaoa.org, palmer.edu, ifm.org, osteopathic.org, aacom.org, aafp.org

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