1. Katharine Chen B.S. – Grewal Orthopedic & Spine Care
2. Peter Boucas Resident Physician – Huntington Hospital Northwell Health
3. Peter White Resident Physician – Huntington Hospital Northwell Health
4. Kanwarpaul Grewal Attending Physician – Huntington Hospital Northwell Health/ Grewal Orthopedic & Spine Care

Abstract

Keywords
Orthopaedic, spine, osteopathic medicine, surgery

Doctors of Osteopathic Medicine (D.O.s) have become overall more prevalent in the healthcare work force. Specifically, the amount of D.O.s in the subspecialty of adult orthopaedic spine surgery have increased. Furthering an understanding of the history of osteopathic medicine and education, as well as the residency and fellowship trainings that follows, allow for a comprehensive overview of the role of D.O.s in orthopaedic spine surgery today.

Introduction
Doctors of Osteopathic Medicine (D.O.s) continue to increase in presence within health care providers. Within the past decade, the profession has grown nearly 63%, with an approximate 300% increase over the last three decades.¹ As of 2021, there are nearly 170,000 osteopathic physicians and students in the United States alone.² These increases translate to D.O.s representation in a vast number of specialties and subspecialties, including orthopaedic spine surgery. 

Overall, the percentage of D.O. physicians within orthopedic surgery has steadily increased from making up 6.85% of orthopedic surgeons in 2013 to about 8.67% in 2019.³ In a parallel manner, there has been an overall upward trend in the percentage of D.O.s performing the three of the most common spine procedures: lumbar decompression and fusion, lumbar laminectomy, and cervical anterior decompression and fusion (ACDF). In terms of lumbar decompression and fusions, the percentage of D.O.s operating increased from 4.95% in 2013 to 5.54% in 2019. D.O. performed cervical ACDFs and lumbar laminectomies have increased by ~1.50% from 2016 to 2019 as well.³ These trend increases can be representative of the relationship between the founding musculoskeletal focus of osteopathic medicine and orthopaedic surgery. In this commentary, we aim to demonstrate the relationship between osteopathic medicine and surgical spine procedures by discussing the history of D.O.s, current training pathways and practices, and the contributing role of osteopathic training in spine surgery.

Osteopathic Training & History
Allopathic and osteopathic medical schools pick from a pool of applicants of similar pre-medical educational backgrounds. The similarity extends further with the first two years of each of the respective medical schools. Both allopathic and osteopathic schools have aligning core curricula, which include courses such as human anatomy, physiology, and microbiology. The difference between allopathic and osteopathic medical schools is the teaching of Osteopathic Principles and Practice (OPP) in osteopathic schools, typically within the third- and fourth-year curricula. OPP integrates osteopathic philosophy, including the four tenets of osteopathic medicine, into the classic teachings of traditional medicine.⁴ Another feature difference between D.O.s and their M.D. counterparts is the additional usage of osteopathic manipulative treatment (OMT). Though it is important to note that OMT has been steadily declining over time. There has been a ~40% decrease physicians who would use OMT on 76-100% of their patients over the last two decades.^5,6  

The origin of these osteopathic teachings began with Dr. Andrew Taylor Still, M.D./D.O. in the 1870s. Dr. Still was the son of a physician, and he followed the same path towards allopathic medicine. As he worked alongside his father, he began to recognize the ineffectiveness of allopathic practices as he observed treatments of the time such as bloodletting and over usage of arsenic, opium, and elixirs. This is the time in which he began to explore alternative ways to understand the complexity of the human body, and more importantly, how to heal it.^7,8 

Through his own ventures of patient care, Dr. Still began to focus on the role of the musculoskeletal system in disease. He believed that the human body could maintain a healthy status if vitalized properly. In other words, he aimed to treat the whole body, and not just the symptoms or the disease. Dr. Still brought this philosophy to teaching by establishing the first osteopathic medical school in 1892 in Kirksville, MO.⁸ Today, there are currently 38 accredited colleges of osteopathic medicine in the United States.

Orthopaedic Residency & Spine Fellowships
Osteopathic physicians have slowly increased their presence in specialties such as orthopaedic surgery and their subsequent subspecialties. From 2015 through 2021, the percent of D.O. applicants applying for orthopaedic residency has increased by 140%.⁹ These numbers may have increased due to the recent merger of the American Osteopathic Association (AOA) and the American College of Graduate Medical Education (ACGME) in 2020.¹⁰ As a result, there is now a single accreditor for both D.O. and M.D. residencies which in turn allows further opportunity for D.O. recognition in orthopaedic surgery and thereby spine surgery. 

Among the classes of orthopaedic residents, over 90% of them pursue fellowship trainings upon residency completion.⁹ According to the Orthopaedic Practice in the US (OPUS) 2018 report, 60% of all orthopaedic surgeons participate within a subspecialty, and 8.3% of those surgeons specialize in the adult spine.¹¹ An orthopaedic spine surgery fellowship is an additional one-year. During that year, spine surgical fellows are ideally expected to complete at least 250 operative cases.¹² 

As the United States population increases, specifically the portion over the age of 65, the patient to physician ratio will decrease. As this is a growing concern, the number of orthopaedic residency training programs have increased by 11 between the years of 2008 and 2018, creating a net of about 106 new residency positions.¹³ Furthermore, there has been a 24% increase in orthopaedic spine fellowships between 2013 and 2017.¹³ For example, in 2022, there were 138 available fellowship positions for orthopaedic spine, in which about 131 were filled.¹⁴

American Osteopathic Academy of Orthopaedics
Orthopaedic spine surgery and osteopathic principles remain in close ties to one another. D.O. orthopaedic spine fellows remain connected to their osteopathic education through the American Osteopathic Academy of Orthopaedics (AOAO). Established in 1941, the AOAO aims to continuously implement fine osteopathic principles and trainings in the treatment plans for orthopaedic patients.¹⁵ Furthermore, AOAO splits into specialty sections, providing a common platform for D.O.’s within the same specialty to further collaborate.¹⁶ And as a national organization, it has been a useful tool to keep with current understandings within the spinal surgery section. 

Conclusion
D.O. representation in orthopaedic surgery and orthopaedic spine surgery has expanded within the last decade. The AOA-ACGME merger in 2020 has further increased the width of potential for future D.O.’s to pursue the subspecialty of orthopaedic spine. As osteopathic medicine has a musculoskeletal focus-based history, there are high hopes for success in orthopaedics.

References

1. AOA. AOA Osteopathic Medical Profession Report 2019. 2019.
2. American Osteopathic Association. AOA Osteopathic Medical Profession Report 2020-2021. 2021.
3. Medicare Physician & Other Practitioners – by Geography and Service – Centers for Medicare & Medicaid Services Data n.d. https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-geography-and-service (accessed May 26, 2022)
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9. Gardezi M, Moore HG, Socci AR, Grauer JN. Impacts of COVID‐19 on orthopaedic surgery residency / spine trainee application trends. North American Spine Society Journal (NASSJ). 2021;8:100088. doi:10.1016/j.xnsj.2021.100088
10. AOA, ACGME and AACOM usher in new era of single accreditation for graduate medical education. American Osteopathic Association. Published June 30, 2020. Accessed June 6, 2022. https://osteopathic.org/2020/06/30/aoa-acgme-and-aacom-usher-in-new-era-of-single-accreditation-for-graduate-medical-education-2/
11. AAOS. AAOS Department of Clinical Quality and Value. 2018. 
12. Dowdell JE, Louie PK, Virk S, et al. Spine fellowship training reorganizing during a pandemic: perspectives from a tertiary orthopaedic specialty center in the epicenter of outbreak. The Spine Journal. 2020;20(9):1381-1385. doi:10.1016/j.spinee.2020.04.015
13. Moore ML, Singh R, McQueen K, et al. Workforce Trends in Spinal Surgery: Geographic Distribution and Primary Specialty Characteristics from 2012 to 2017. World Neurosurg. 2021;156:e392-e397. doi:10.1016/j.wneu.2021.09.073
14. SF Match. Orthopaedic Fellowship Match Report. 2022. 
15. About AOAO | American Osteopathic Academy of Orthopaedics. AOAO. https://aoao.org/about/ (accessed June 14, 2022)
16. Spinal Surgery | American Osteopathic Academy of Orthopaedics. AOAO. https://aoao.org/groups/sections/spinal-surgery/ (accessed June 14, 2022)

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