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LETTERS

As the premier scholarly publication of the osteopathic medical profession, JAOA— 7. negative intrathoracic pressures
The Journal of the American Osteopathic Association encourages osteopathic physicians, from chronic obstructive pul-
faculty members and students at colleges of osteopathic medicine, and others monary disease and obstructive
within the healthcare professions to submit comments related to articles pub- sleep apnea
lished in the JAOA and the mission of the osteopathic medical profession. The
JAOA’s editors are particularly interested in letters that discuss recently published Treatment, evidence, and prognosis
original research. are discussed adequately by Dhar and
Letters to the editor are considered for publication in the JAOA with the under- coauthors,1 and the conclusions they
standing that they have not been published elsewhere and that they are not simul- offer are sound. However, what is
taneously under consideration by any other publication. lacking for me in the article is an insight
All accepted letters to the editor are subject to editing and abridgement. Letter and approach to this issue based on
writers may be asked to provide JAOA staff with photocopies of referenced mate- osteopathic medicine.
rial so that the references themselves and statements cited may be verified. I suggest that osteopathic physi-
Readers are encouraged to prepare letters electronically in Microsoft Word cians consider three additional factors in
(.doc) or in plain (.txt) or rich text (.rtf) format. The JAOA prefers that readers e-mail the care of patients with diastolic heart
letters to jaoa@osteopathic.org. Mailed letters should be addressed to Gilbert E. failure:
D’Alonzo, Jr, DO, Editor in Chief, American Osteopathic Association, 142 E Ontario
St, Chicago, IL 60611-2864. 䡲 Sympathetic hypertonia to the heart
Letter writers must include their full professional titles and affiliations, com- driven by somatic dysfunctions of
plete preferred mailing address, day and evening telephone numbers, fax numbers, the upper thoracic spine and ribs—
and e-mail address. In addition, writers are responsible for disclosing financial asso- An overfunctioning of the sympa-
ciations and other conflicts of interest. thetic nervous system could con-
Although the JAOA cannot acknowledge the receipt of letters, a JAOA staff tribute to the problems listed above as
member will notify writers whose letters have been accepted for publication. numbers 1, 2, and 5.
Mailed submissions and supporting materials will not be returned unless letter Decades of osteopathic medical
writers provide self-addressed, stamped envelopes with their submissions. research have documented the patho-
All osteopathic physicians who have letters published in the JAOA receive physiologic consequences to the heart
continuing medical education (CME) credit for their contributions. Writers of from somatic dysfunction in the
original letters receive 5 hours of AOA category 1-B CME credit. Authors of pub- upper thoracic spine. Most of these ill
lished articles who respond to letters about their research receive 3 hours of cate- effects are mediated through hyper-
gory 1-B CME credit for their responses. sympatheticotonia, as noted by
Although the JAOA welcomes letters to the editor, readers should be aware that Robert C. Ward, DO,7 as well as by
these contributions have a lower publication priority than other submissions. As Michael L. Kuchera, DO, and
a consequence, letters are published only when space allows. William A. Kuchera, DO.8 Louisa
Burns, DO, DScO,9 reported on “car-
diac changes following certain ver-
Osteopathic Approach to Diastolic thought to be caused by the heart’s tebral lesions,” and Irvin M.
Heart Failure inability to contract and eject.2-6 The Korr, PhD,10,11 provided much excel-
authors1 credit this deficit in diastole to lent research on the relationships
To the Editor: the following factors: between somatic dysfunction, the
I read with interest the article by Sunil autonomic nervous system, and end-
Dhar, MD, and colleagues,1 in the April 1. increased passive stiffness organ damage.
issue of JAOA—The Journal of the Amer- 2. abnormal active ventricular relax- It seems a shame to have osteo-
ican Osteopathic Association. This article ation pathic practitioners of cardiology so
represents an expansion of the medical 3. changes in calcium metabolism and underinformed about the many
profession’s thinking about cardiac adenosine triphosphate availability decades of osteopathic medical
insufficiency. As the article suggests, 4. degenerative changes in the research directly applicable to cardi-
diastolic heart failure—an inability of myocardium caused by age ology.
the heart to relax, dilate, and fill—may 5. myocardial ischemia
account for half of the cases previously 6. changes in the extracellular matrix (continued on the next page)

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LETTERS

䡲 The internal contours of the infe- posterior diameter of the lower thorax, Dangers of For-Profit Education:
rior thorax—My observations sug- and enhancement of diaphragm More Than Just Words
gest that if the sternum is “too close” mobility—all of which are obtainable
to the spine as a result of kyphosis, through osteopathic manipulative To the Editor:
pectus excavatum, or internal rota- medicine—can provide additional, syn- The letters of Peter B. Ajluni, DO,1 and
tion of each hemithorax, the diastole ergistic clinical benefits to patients with Ronnie B. Martin, DO, 2 in the
will be inadequate because of the diastolic heart failure. October 2007 issue of JAOA—The
physical constraints of the available Shouldn’t osteopathic medicine be Journal of the American Osteopathic Asso-
space for the heart to expand its dias- about more than back pain? ciation dismiss the for-profit status of
tolic volume. The heart cannot Rocky Vista University College of
expand further into diastole when Thomas Michael McCombs, DO Osteopathic Medicine (RVUCOM) in
Assistant Professor
wedged between the anterior tho- Touro University College of Osteopathic Parker, Colo, as a mere difference in
racic spine and the posterior sternum. Medicine–California “tax status,” compared with nonprofit
Vallejo
This structural constraint could con- colleges of osteopathic medicine. The
tribute to the problems listed on the References implication of these letters—both of
previous page as numbers 2 and 4. 1. Dhar S, Koul D, D’Alonzo GE Jr. Current concepts in dias- which were responses to an earlier letter
tolic heart failure. J Am Osteopath Assoc. 2008;108:203-
209. Available at: http://www.jaoa.org/cgi/content
of mine3—is that the term “tax status”
䡲 The respiratory diaphragm—The /full/108/4/203. Accessed July 31, 2008. is just a legalistic technicality that is
right side of the heart is attached to 2. Senni M, Tribouilloy CM, Rodeheffer RJ, Jacobsen SJ, important only on an obscure line of a
Evans JM, Bailey KR, et al. Congestive heart failure in
the superior surface of the diaphragm. the community: a study of all incident cases in Olmsted corporate 1040 tax form.
As the diaphragm descends during County, Minnesota, in 1991. Circulation. 1998;98:2282- In fact, nothing could be further
2289. Available at: http://circ.ahajournals.org/cgi/content
inspiration, the heart is widened while /full/98/21/2282. Accessed July 31, 2008. from the truth. The tax status of a school
being carried inferiorly. Absent this 3. Kitzman DW, Gardin JM, Gottdiener JS, Arnold A, is critically important in defining the
widening, diastole must be reduced, Boineau R, Aurigemma G, et al. Importance of heart overall philosophy and mission of that
failure with preserved systolic function in patients > or =
contributing to the problem listed on 65 years of age. CHS Research Group. Cardiovascular school—and it goes to the heart of what
the previous page as number 2. Health Study. Am J Cardiol. 2001;87:413-419. is wrong with for-profit education.
I have treated several patients in 4. MacCarthy PA, Kearney MT, Nolan J, Lee AJ, Prescott Dr Ajluni1 is quite correct in his
RJ, Shah AM, et al. Prognosis in heart failure with pre-
congestive heart failure that served left ventricular systolic function: prospective cohort assertion that there are many socially
responded immediately to improved study. BMJ. 2003;327:78-79. Available at: http://www minded for-profit corporations, but the
.bmj.com/cgi/content/full/327/7406/78. Accessed July 31,
diaphragm function, with visible 2008. comparison of a medical school with
reductions in their dyspnea and 5. Vasan RS, Larson MG, Benjamin EJ, Evans JC, Reiss CK, such a corporation (eg, Dell Inc), or even
Levy D. Congestive heart failure in subjects with normal
edema. It is possible that their heart versus reduced left ventricular ejection fraction: prevalence
with a for-profit hospital, is as invalid as
failure was primarily diastolic in and mortality in a population-based cohort. J Am Coll Car- comparing the proverbial apples and
diol. 1999;33:1948-1955.
nature, and using osteopathic manip- oranges. A school’s mission should be
6. Aurigemma GP, Gottdiener JS, Shemanski L, Gardin J,
ulative treatment to enlarge the avail- Kitzman D. Predictive value of systolic and diastolic func- the education of its students, whereas a
able space for diastole was sufficient tion for incident congestive heart failure in the elderly: the for-profit corporation’s mission should
cardiovascular health study. J Am Coll Cardiol. 2001;37:
for symptom relief. 1042-1048. be the maximization of profit for its
7. Rogers FJ. An osteopathic perspective on cardiology. In: investors.
Perhaps heart failure will eventu- Ward RC, ed. Foundations for Osteopathic Medicine. Socially minded corporations
2nd ed. Philadelphia, Pa: Lippincott, Williams & Wilkins;
ally be understood to result from a con- 2003:358-363. engage in charitable activities because
tinuum of causes, with inadequacies of 8. Kuchera ML, Kuchera WA. Osteopathic Considerations such acts are good business. The general
systolic forces and diastolic spaces both in Systemic Dysfunction. Kirksville, Mo: KCOM Press; public will always see a responsible cor-
1990:53-73.
contributing to cardiac insufficiency. 9. Burns L. Cardiac changes following certain vertebral
porate member of the community as
Wouldn’t it be ideal for the osteopathic lesions [Louisa Burns, DO, Memorial]. In: Beal MC, ed. being more worthy of its business. In
1994 AAO Yearbook. Indianapolis, Ind: American
medical profession to lead the way in Academy of Osteopathy; 1994:195-204.
the end, such a public perception will
such research, contributing to standards 10. Peterson B, ed. The Collected Papers of Irvin M. Korr, boost the corporation’s bottom line. No
of care by demonstrating our unique Vol 1. Colorado Springs, Colo: American Academy of for-profit corporation would engage in
Osteopathy; 1979.
approach to medicine? charitable activities at the expense of
11. King H, ed. The Collected Papers of Irvin M. Korr,
I encourage the osteopathic med- Vol 2. Indianapolis, Ind: American Academy of Osteopathy; profit—that is, there comes a point at
ical profession to explore these sugges- 1997. which the goodwill gained by chari-
tions. Research may prove that reduc- table activities is no longer exceeded by
tion of upper thoracic somatic the secondary increase in revenue. At
dysfunction, expansion of the antero- that point, charitable activities stop. To

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do otherwise in a for-profit environ- for the graduates of RVUCOM, the first medicine—aside from the fact that its
ment would be irresponsible. for-profit medical school in the dean for clinical medical sciences is an
Both for-profit and nonprofit insti- United States since 1930.5 osteopathic physician.10 This same indi-
tutions must produce a high-quality Other for-profit medical education vidual is also a member of RVUCOM’s
product to stay competitive in the mar- ventures have been attempted in the board of trustees.9
ketplace. However, the difference United States in recent years. In 1999, In a strict business sense, given the
between these two types of institutions Ross University School of Medicine, a popularity of the MD degree, investors
lies in their use of excess revenue. In the for-profit allopathic institution on the would most likely prefer to open allo-
case of a nonprofit medical school, all Caribbean island of Dominica, planned pathic medical schools rather than
excess revenue is returned to the insti- to open a branch campus near osteopathic medical schools, if that were
tution and used to improve its facilities, Casper, Wyo, under the same clarion possible.
expand its programs, and engage in calls sounded by RVUCOM—meeting The LCME is aware of the prece-
research to increase the existing body of the needs of underserved rural com- dent set by RVUCOM and is currently
medical and scientific knowledge. Fre- munities in the Rocky Mountain West.6 considering the issue of for-profit edu-
quently, these endeavors realize no short- Through the efforts of the Liaison cational initiatives in the context of its
term reward for the school and would be Committee on Medical Education present standards (B. Barzansky, PhD,
viewed as fruitless in the for-profit world. (LCME), the American Medical Asso- written communication, August 2007).
Yet, valuable medical discoveries are ciation, and the Natrona County Med- Nevertheless, there is no evidence to
often built on years of seemingly incon- ical Society, this initiative was vigor- support the concept of for-profit edu-
sequential basic science research. ously fought and defeated—despite the cational institutions as superior to or
Thus, it is fair to ask, where will a ostensible support of “many local physi- more efficient than nonprofit educa-
for-profit medical school draw the line cians” and politicians.6 At the time, tional institutions.11 Furthermore, there
in conducting research? This is a matter plans called for the Wyoming campus is speculation that for-profit medical
of simple economics: to make a profit to be accredited under the auspices of education will not provide students
and generate a return to its investors, a the home campus on Dominica, rather with an opportunity for a complete
for-profit medical school is likely to than the LCME.6 experience of humanity, profession-
divert funds that could otherwise be Despite Dr Martin’s2 liberal use of alism, and ethics—factors that are
used to engage in the aforementioned the LCME as an example of an accred- ingrained in the nonprofit model of
research activities, while at the same iting body, the LCME standards state medical education.11
time maximizing price (ie, tuition) to that a medical school should be a non- For osteopathic medicine, the dan-
competitive market levels. profit institution.7 Although this pro- gers of for-profit education are very
For-profit medical education is an vision in the LCME standards is not an real. Regardless of whether RVUCOM
anathema to the larger medical com- outright prohibition against for-profit provides an education equal in quality
munity. Most for-profit medical schools medical schools, it still is a long way to the nonprofit model, there has been
exist in impoverished, legally permis- from the explicit statement by the Com- no cogent argument put forth as to why
sive locales, such as the Caribbean mission on Osteopathic College Accred- the osteopathic medical profession—
region, to exploit the desires of indi- itation (COCA)8 that an osteopathic which has struggled for more than a
viduals who are willing to pay a pre- medical school can be either a for-profit century to establish its credibility and
mium in tuition—and sacrifice educa- or nonprofit institution. gain acceptance—needs to take this
tion quality and personal credibility—to Florida-based businessman and real step. I believe that the individuals who
become physicians. Certainly, many estate investor Yife Tien, BSc, and his invested in RVUCOM have jeopardized
students who graduate from Caribbean wife are the sole owners of RVUCOM.9 our profession—and, thus, our
for-profit schools become qualified and There is no reason why, were business patients—merely to turn a profit.
respected physicians in the US medical to decline, the RVUCOM campus could As the “baby boom” generation
community—but such results happen not be converted overnight into another enters retirement, the United States faces
in spite of, rather than because of, their office park in the rapidly growing a healthcare challenge heretofore
medical schools. The graduates of for- Denver metroplex. unseen. The “perfect storm” of an aging
eign for-profit medical schools typically The American University of the population, expanding and costly med-
struggle to gain acceptance into Caribbean, which was established by ical technology, and decreasing fiscal
US residency training programs, and and is owned by Mr Tien’s father9 and resources is looming as a threat to the
they frequently must settle for less desir- for which Mr Tien himself has served as economy and national security of the
able or unwanted residency slots.4 Con- chief operating officer, has no tradi- United States.
sidering these realities, I am concerned tional connection to osteopathic
(continued on page 458)

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(continued from page 367) http://www.jaoa.org/cgi/content/full/107/10/425. Accessed Dr Mychaskiw and I agree that
July 31, 2008.
there are substantial problems with the
2. Martin RB. RVUCOM: striving to meet the needs of
In the face of these serious prob- the osteopathic medical profession [letter]. J Am current healthcare system in the
lems, it is difficult to justify the estab- Osteopath Assoc. 2007;107:426-428. Available at: United States. In this regard, it should
http://www.jaoa.org/cgi/content/full/107/10/426. Accessed
lishment of for-profit medical schools in July 31, 2008. be pointed out that organizations like
the United States under the guise of 3. Mychaskiw G. COM accreditation: the Flexner report the one that employs Dr Mychaskiw
osteopathic medicine. When the health- revisited [letter]. J Am Osteopath Assoc. 2007;107:246- are classic examples of a healthcare
247,277. Available at: http://www.jaoa.org/cgi/content
care funding crisis occurs, as it /full/107/7/246-b. Accessed July 31, 2008. delivery system centered around aca-
inevitably will, what is going to get cut 4. Crosby PJ, Cannon RE. International medical schools demic and tertiary care medical centers
first—the large nonprofit medical for US citizens: considerations for advisors and prospec- with reliance on tertiary care medical
tive students; 2004. National Association of Advisors for
schools (providing patient care, educa- the Health Professions Web site. Available at: specialists. Such systems—which tend
tion, and research) or the smaller for- http://www.naahp.org/resources_ForeignMed_articleflat to reward procedures (eg, quadruple
.htm. Accessed July 31, 2008.
profit medical schools (generating 5. Beck AH. Student JAMA: the Flexner report and the
coronary artery bypass grafting, aggres-
income for real estate investors)? standardization of American medical education. JAMA. sive cancer management at the end of
2004;291:2139-2140. Available at: http://jama.ama-assn
In summary, the “tax status” of a .org/cgi/content/full/291/17/2139. Accessed July 31, 2008.
life) rather than concentrating on access
medical school is more than just words. 6. Stewart A. The regulated doctor shortage. Consumer to timely primary care, wellness, pre-
It goes to the very heart and philosophy Health Journal [serial online]. February 2004. Available at: ventive care, and quality of life—are
http://www.consumerhealthjournal.com/articles/regulated-
of a medical school—much more so doctor-shortage.html. Accessed July 31, 2008. systems designed for failure. This is
perhaps than a mission statement, as 7. Accreditation standards: current standards, latest addi- precisely the kind of approach to health-
required by COCA. Although we live in tions to standards, and standards awaiting approval; care that has led the United States to
June 2007. Liaison Committee on Medical Education
2008 rather than in 1910, when educa- Web site. Available at: http://www.lcme.org/standard.htm. impending crisis.
tional theorist Abraham Flexner5,12 Accessed July 31, 2008. Nevertheless, it is hard to conceive
issued his report critical of for-profit 8. Commission on Osteopathic College Accreditation. how the establishment of Rocky Vista
Accreditation of Colleges of Osteopathic Medicine: COM
medical education, some things do not Accreditation Standards and Procedures. Chicago, Ill: University College of Osteopathic
change and, indeed, should never American Osteopathic Association. Available at: http: Medicine (RVUCOM) or any other new
//www.osteopathic.org/index.cfm?PageID=acc_predoc_disc
change. Considering the healthcare laimer. Accessed July 31, 2008. medical school—regardless of tax
challenges facing the United States in 9. Martin RB. Addressing for profit status: a message status—could have a direct effect on
from the chief academic officer and dean; 2007. Rocky
the 21st century, the words of Vista University College of Osteopathic Medicine Web site.
this dysfunctional healthcare system or
Mr Flexner5,12 resonate as strongly today Available at: http://www.rockyvistauniversity.org on the aging and uninsured popula-
/for_profit.asp. Accessed July 31, 2008.
as they did a century ago: tions of the United States. It almost
10. AUC directory: clinical medical sciences—deans. Amer-
ican University of the Caribbean Web site. Available at: seems as if Dr Mychaskiw is implying
Such exploitation of medical educa- http://www.aucmed.edu/aboutauc/directory.htm. Accessed that the last 40 years of healthcare policy
tion is strangely inconsistent with the May 19, 2008.
in the United States have been the result
social aspects of medical practice...the 11. Croasdale M. First for-profit med school nears approval.
American Medical News [serial online]. October 1, 2007. of the establishment of RVUCOM in
medical profession is an organ dif- Available at: http://www.ama-assn.org/amednews 2006. In that vein, I am surprised that
ferentiated by society for its highest /2007/10/01/prsc1001.htm. Accessed July 31, 2008.
the impending disasters projected to
purposes, not a business to be 12. Flexner A. Medical Education in the United States
exploited. and Canada. New York, NY: Carnegie Foundation for result from global warming have not
the Advancement of Teaching; 1910. Available at: http: also been credited to the recent estab-
//www.carnegiefoundation.org/files/elibrary/flexner_report
Dr Martin2 maintains that RVU- .pdf. Accessed July 31, 2008. lishment of RVUCOM.
COM is “...the right school in the right Dr Mychaskiw uses speculation to
location at the right time, created for Responses describe what RVUCOM may or may
the right reasons.” I respectfully dis- In his most recent letter to the editor, not do to provide for its students—
agree. George Mychaskiw II, DO, continues without commenting on or having
to express a deeply convicted personal direct knowledge of the quality of our
George Mychaskiw II, DO position on the evils of for-profit edu- programs, facilities, faculty, or cur-
Professor and Vice Chairman cation, as he has before in JAOA—The riculum—or of our established com-
Department of Anesthesiology
Chief of Anesthesia Journal of the American Osteopathic Asso- mitments to public service. He acknowl-
Blair E. Batson Hospital for Children ciation (2007;107:246-277). However, he edges that RVUCOM will graduate
University of Mississippi School of Medicine
Jackson is not able to present facts to support competent osteopathic physicians.
his position. Rather, Dr Mychaskiw However, he also feels that RVUCOM
References chooses to make his points through con- may jeopardize all patients of DOs by
1. Ajluni PB. Nonprofit and for-profit COMs: investing in
the future of osteopathic medicine [letter]. J Am
jectural attempts at linking together dis- embarrassing the osteopathic medical
Osteopath Assoc. 2007;107:425-426. Available at: parate and unrelated events. profession.

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I do not understand how compe- involved in all aspects of student edu- integral part of our mission and
tent osteopathic physicians who pro- cation. Our clinical education program vision—and it coincides with the strong
vide access to high-quality healthcare exposes students to community-based commitment to excellence that we
for medically disadvantaged patients experiences with excellent university- expect from our students, faculty, and
are an embarrassment to the osteopathic credentialed faculty, in addition to a all those associated with RVUCOM.
medical profession. But, of course, challenging hospital-based curriculum. If RVUCOM is to grow and expand
Dr Mychaskiw is entitled to his opinion. Students rotate during their third year as a university, as currently planned, the
Dr Mychaskiw also implies that of medical school in community and resources for this success must come
when the impending healthcare underserved settings with primary care from our own efforts. We will not be able
funding crisis occurs, for-profit educa- providers—before they make their res- to go to government agencies or other
tional institutions and their students idency choices. This approach allows funding resources to obtain an endowed
will suffer. However, he neglects to the students to be exposed to the pro- auditorium, a standardized patient lab-
explain that RVUCOM provides access fessional opportunities and rewards oratory, or a clinic building. Instead, we
to an osteopathic medical education for provided by such disciplines as family will have to fund such infrastructure
our students and to expanded medical practice, pediatrics, internal medicine, improvements out of that “excess rev-
services for the public without using public health, and women’s health. The enue” to which Dr Mychaskiw refers.
scarce state or federal funding resources. community-based experiences of our As Dr Mychaskiw is surely aware,
If all medical schools followed our students also include required rotations research in the United States is not
model, think of the billions of dollars in osteopathic manipulative medicine funded principally by the “excess rev-
currently directed to support medical designed to strengthen their apprecia- enue,” or “profits,” of medical schools.
schools and faculty that could be freed tion and use of the profession’s distinct These meager funds would not sup-
up to provide healthcare for millions philosophy. port the level of commitment that is
of “baby boom” retirees, patients In addition, RVUCOM has other required to expand medical knowledge
without health insurance, and other public service requirements and oppor- and support medical research. At
individuals without appropriate access tunities for students, ranging from local RVUCOM, we are committed to
to healthcare. and in-state to international medical expanding medical knowledge and
Dr Mychaskiw deemphasizes the experiences. The “shadowing” experi- contributing to research. Our faculty
fact, or entirely misses the point, that ences of our students throughout their will be expected to develop research
no institution can be successful without first 2 years of medical school are pre- projects and concepts and compete for
operating an efficient business model, dominately in community and public grants to support these research efforts
producing a high-quality product, health settings. Such experiences from extramural sources (eg, state and
maintaining the support of its customer encourage students to maintain the federal governments, private founda-
base, and meeting the expectations of spirit they expressed when entering tions), just as faculty at other medical
society. These necessities apply to all medical school—the spirit of wanting to institutions compete for such funds. As
other current medical schools as well make a difference in the lives of people Dr Mychaskiw knows, research grants
as they apply to RVUCOM. and to serve individuals who are dis- obtained from these sources are very
As a for-profit institution, we will advantaged and in need of healthcare. specific regarding how the funds can
have fewer excuses if we do not meet It is not merely our students who be used. The funds cannot simply be
these expectations. We will not be able will provide service to our community. added to “profits.” They must be fully
to blame any shortcomings on state In another example of our public service accounted for and used as intended to
budget cuts, increased expenses, or lack commitments, many members of our support the research and the researcher.
of student preparedness. We are and faculty have agreed to work with sev- In other words, RVUCOM is required
will continue to be responsible for our eral local schools to foster the interests to play by the same rules as any other
own outcomes—and we are prepared of young students in the sciences and medical research institution.
to deal with that reality. medical professions. Other RVUCOM I acknowledge that the education
At RVUCOM, we are confident of faculty members provide leadership for of our osteopathic medical students;
the professional performance of our the osteopathic medical profession the careers of our faculty; and our ser-
graduates because we have planned through the American Osteopathic vice to the profession as well as the cit-
and engineered our educational sys- Association and affiliated organizations. izens of our state, region, and nation
tems and curriculum to make their suc- We are proud to hold our commit- represent the primary missions and
cess possible. We provide our students ment to service up to public scrutiny goals of RVUCOM. At this point in our
with strong role models in osteopathic because striving to improve the lives development, research is not our prin-
primary care. These role models are of those with whom we interact is an ciple vision. Only time will tell if and

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how this aspect of our work may be served. Unlike Dr Mychaskiw, I such as the 53-person Jacuzzi at one
change in the future. believe there is room for and a need for large state university.3
In my more than 30 years in the both for-profit and nonprofit models in These kinds of wasteful decisions
osteopathic medical profession, I have educational establishments. on deployment of resources can be
found that it is not the research that suf- I continue to believe that RVUCOM made in nonprofit and for-profit orga-
fers at many medical schools. Instead, it is the right school in the right place at nizations. It is leadership—not the tax
is the schools’ commitment of resources the right time for our osteopathic med- code—that will be the key determinant
and faculty to teaching, public health, ical students and for the citizens of Col- of an organization’s character and
and public service that often becomes orado and the western United States. spending habits.
downgraded. I have heard, in my pri- History will judge which one of us is I must say that, after receiving and
vate conversations, many a dean lament correct in our beliefs. responding to several communications
that the education of his or her students from Dr Mychaskiw,4,5 I am struck by
and the support of core faculty are fre- Ronnie B. Martin, DO, RPH his lack of understanding of the factors
Chief Academic Officer and Dean
quently overlooked under our current Rocky Vista University College of Osteopathic Medicine that drive commercial free-market busi-
medical school system, in which the Parker, Colo nesses. Profits are generated by a com-
“holy grail” consists of the income gen- pany because satisfied consumers value
erated by the medical specialists on fac- I am disappointed with the most recent the company’s products or services;
ulty (who typically practice more than letter from George Mychaskiw II, DO. find those products or services to be
they teach), the hospital, and the He has mischaracterized my earlier available at prices that are acceptable;
research grants. These considerations letter to the editor,1 in which I cautioned and are willing to purchase products
often take priority over the education of against a priori condemnation of an or services from the company. When
the students. institution simply because of its for- these factors are no longer met, con-
At RVUCOM, by contrast, we profit or nonprofit tax status. sumers seek other sources to fulfill their
believe that our primary obligations are Tax status determines a number of needs.
to the education of our students and financial considerations for an institu- This system of checks and balances
the advancement of our faculty. We tion, including the allowable methods of is not perfect, as recent scandals in the
have acted and will continue to act with raising funds, the tax treatment of financial markets demonstrate. Never-
these primary obligations foremost in received revenues, and the distribution theless, any institution of higher edu-
mind. of those revenues. The main point noted cation that no longer meets the needs of
We recognize that we have an obli- in my previous letter1 was that the lead- its potential students will survive only
gation to consider “social conse- ership of any organization is a larger with great difficulty and at great cost—
quences,” more so than does a private determinate of that organization’s char- regardless of its tax status.
manufacturer or a corporate operator acter than is its tax status. Despite In his current letter to the editor, Dr
of hospitals because we are engaged in Dr Mychaskiw’s lengthy correspon- Mychaskiw intimates (I believe) that
the business of preparing medical stu- dence, I still hold this conviction. research is important at colleges of
dents to serve and advocate for Dr Mychaskiw naively heralds the osteopathic medicine (COMs). I cer-
improvements in the lives and health- blanket superiority of nonprofit insti- tainly agree with this point. However,
care of others. Our commitments to ser- tutions of higher learning by claiming COMs need to devote appropriate
vice, professionalism, and humanity that all excess revenue at such institu- amounts of their limited resources to
are reflected in the ways in which we tions is used to improve facilities, research. As with any other activity,
have designed our curriculum, selected expand programs, and engage in research is not immune to the law of
our students and faculty, and dedicated research. However, Dr Mychaskiw fails diminishing returns. Throwing money
our resources. to mention that the nonprofit approach at research, or any other activity, can
I respect Dr Mychaskiw’s commit- can be wasteful—in a number of ways be wasteful. Likewise, using tuition at a
ment to his beliefs and his willingness that have previously been documented. nonprofit COM to finance a pharmacy
to engage in debate on this subject. Crit- For example, universities across the or veterinary school is not necessarily
ical examination is required to improve United States have been known to use the best use of that COM’s funds. We
any process—and all of us wish for excess revenues to fund large salary must all rely on our leaders to make
improvement in the health of our citi- and staffing increases and to build lux- prudent spending decisions.
zens and in the healthcare system of urious facilities.2 Many universities have Because markets are imperfect, we
our country. Dr Mychaskiw and I purchased impressive athletic facilities put safeguards in place to help them
diverge regarding how the needs of and opulent student unions that are far function appropriately. The accredita-
medical students and patients can best more ostentatious than functional— tion standards developed by the Com-

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mission on Osteopathic College Accred- pathic Association. Dr Davidson’s anal- into the allopathic medical profession.
itation (COCA) 6 require COMs to ysis of education at colleges of osteo- This assimilation would be a tragedy
“make contributions to the advance- pathic medicine is “right on the money” because there are many unique aspects
ment of knowledge and the develop- for the most part. In my experience, of osteopathic medicine that are of great
ment of osteopathic medicine through however, the failure of osteopathic med- value to patients.
scientific research.” Thus, it is the ical students to learn how to apply As a side note, I have recently learned
responsibility of COCA (leadership osteopathic principles and prac- that the University of North Carolina at
again) to ensure that all COMs and tice (OPP) and osteopathic manipulative Chapel Hill (UNC-Chapel Hill) is con-
branch campuses uphold these stan- medicine (OMM) in clinical settings is a ducting a randomized controlled trial on
dards in a financially appropriate result of an almost total lack of follow- the efficacy of craniosacral therapy in the
manner—regardless of their tax status. through once students get into their treatment of patients with migraine
As leaders of the osteopathic med- externships—and ultimately into post- headache.2,3 The principal investigator in
ical profession, we must accept that graduate training. this trial is an MD neurologist, while the
there are times when people reach a If none of my attending osteopathic coinvestigators are MDs and researchers
point at which they agree to disagree physicians had taken the time to show with PhDs, and the individual providing
and move on. This is such a time. me how to apply my theoretical knowl- manual therapy is a registered nurse who
edge of physiology and pharmacology received training at the Upledger Institute
Peter B. Ajluni, DO to actual clinical situations, I would (K.R. Faurot, PA, MPH, oral communi-
Orthopedic Surgical Physicians Pc
Clinton Township, Mich never have been able to make a correct cation, May 2008).
diagnosis or to prescribe the indicated It is amazing to me that the osteo-
Editor’s Note: Dr Ajluni served as the treatment—pharmacologic or other- pathic medical profession is not more
2007-2008 President of the American wise. I use OMM daily in my practice of aggressively pursuing studies of the kind
Osteopathic Association. physical medicine and rehabilitation, taking place at UNC-Chapel Hill,2,3 espe-
but my application of OMM is possible cially since evidence-based medicine is
only because of the strong one-on-one now becoming the “coin of the realm.”
References mentorship provided to me during my Lastly, I want to thank Dr Davidson1
1. Ajluni PB. Nonprofit and for-profit COMs: investing in
the future of osteopathic medicine [letter]. J Am externship and postgraduate training. and all the other mentors out there who
Osteopath Assoc. 2007;107:425-426. Available at: http:
//www.jaoa.org/cgi/content/full/107/10/425. Accessed
Frankly, all the practical knowledge are keeping the flames of OMM
July 31, 2008. I have regarding OMM was gained burning, and who have taken the time
2. Vedder R. Going Broke by Degree: Why College Costs through my own initiative—that is, by to pass on their knowledge to me and
Too Much. Washington, DC: AEI Press; 2004.
3. Winter G. Jacuzzi U? A battle of perks to lure students.
using most of my elective time to rotate many others.
New York Times. October 5, 2003. Available at: with DOs who could show me how to
http://www.nytimes.com/2003/10/05/education/05COLL David C. Hogarty, DO
.html?ex=1380686400&en=99710f7b868c35b9&ei=5007
use my hands to make an osteopathic Kirksville (Mo) College of Osteopathic Medicine-
&partner=USERLAND. Accessed July 31, 2008. diagnosis and provide osteopathic A.T. Still University, Class of 1999
4. Mychaskiw G II. COM accreditation: the Flexner report manipulative treatment. There need to Goldsboro, NC
revisited [letter]. J Am Osteopath Assoc. 2007;107:246-277.
Available at: http://www.jaoa.org/cgi/content /full/107 be more formal supports for osteopathic References
/7/246-b. Accessed July 31, 2008. medical students who want to learn to 1. Davidson SM. OMM education vs “real world” medicine
5. American Osteopathic Association daily reports blog. [letter]. J Am Osteopath Assoc. 2008;108:87-89. Available
Various comments by George Mychaskiw II, DO. Available
use their hands. Such formal supports
at: http://www.jaoa.org/cgi/content/full/108/2/87. Accessed
at: http://blogs.do-online.org/dailyreport.php?itemid may even help prevent those students July 31, 2008.
=30#comments. Accessed July 31, 2008.
with only marginal interest in OMM 2. University of North Carolina at Chapel Hill School of
6. Commission on Osteopathic College Accreditation. Medicine, Department of Physical Medicine and Reha-
Accreditation of Colleges of Osteopathic Medicine: COM from completely abandoning it long bilitation. Suffering from Migraine Headaches? Help us
Accreditation Standards and Procedures. Chicago, Ill: before they get into residency training. learn more by participating in this research study: Mag-
American Osteopathic Association. Available at: http: nets and Craniosacral Therapy for Migraine [brochure].
//www.osteopathic.org/index.cfm?PageID=acc_predoc_disc The bottom line is that the osteo- Chapel Hill, NC: University of North Carolina at Chapel Hill;
laimer. Accessed July 31, 2008. pathic medical profession wants to have 2006.
it both ways. We want parity with our 3. Craniosacral therapy in migraine: a feasibility study.
ClinicalTrials.gov Web site. Available at: http://www.clinical
Keeping the Flames of OMM MD colleagues, but we also want to stay trials.gov/ct2/show/NCT00665236. Accessed July 31, 2008.
Burning a distinct profession. In the “real world,”
most of us practice allopathic medicine Election Year’s First Shot
To the Editor: with a little OPP occasionally thrown in. Over the Bow: Reforms Needed
I am writing in response to the letter My fear is that unless we, as a profes-
by Stephen M. Davidson, DO,1 that sion, commit in practice to doing things To the Editor:
appeared in the February issue of differently than our MD colleagues, we What do former presidents of the
JAOA—The Journal of the American Osteo- will eventually become fully assimilated American College of Osteopathic

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Family Physicians (ACOFP), like me, the US Congress is making an effort physician, office location, characteris-
do in our spare time? We think of ways this year to advance national health- tics of the hospital where the physician
of revising the healthcare system in the care reform legislation.4,5 The presi- provides care, personal preferences of
United States. I hope that the readers dential candidates have also committed family members, recommendations of
of this letter can use the ideas that I offer themselves to achieving healthcare friends, and cost considerations. A
both personally and professionally. I reform.4 As a past president of the patient should always be guaranteed
know that the Osteopathic Political ACOFP, I call on our nation’s elected the ability to make these decisions for
Action Committee (OPAC) uses ver- leaders to find common ground so that him- or herself. No one knows better
biage similar to the ideas in this letter on all Americans can be assured of the fol- than the individual patient the special
a daily basis,1 and I thank OPAC for its lowing: circumstances that make any physician,
ongoing efforts to support reform. hospital, or healthcare plan the “best”
It is fair to say that the United States ▫ healthcare coverage that is retained choice. It is important that individuals
has the best healthcare system in the regardless of employment, economic have the power to make these decisions
world. We have the best-educated status, and health condition based on what they perceive to be the
physicians, widespread availability of ▫ choice of physicians and health insur- best option for themselves and their
superb technology, and the finest hos- ance plans families.
pitals. National polls continue to affirm ▫ medical decision-making by patients Healthcare plans vary widely in
that Americans are satisfied with their and physicians, rather than by gov- their provisions. Some plans may limit
own physicians and the services they ernment administrators or insurance patient choice in physicians and hospi-
provide.2 Yet, there is growing dis- clerks tals. Other plans may cost patients more
comfort with the costs, structure, and ▫ high-quality healthcare money out of pocket. Patients should
direction of this system.2 It is clear that have the right to select from all qualified
the US healthcare system faces critical All Americans should have health- healthcare plans that are available in
problems. care coverage at all times for a standard their areas, including fee-for-service
More than 40 million Americans set of benefits. Coverage should con- plans, health maintenance organiza-
have no health insurance coverage.3 tinue even if policyholders lose their tions, preferred provider organizations,
Individuals may not have health insur- jobs, change state of residence, or exclusive provider organizations, and
ance for a number of reasons. For become ill. Coverage for all Americans benefit payment schedule plans. Guar-
example, they may have preexisting can be achieved through a variety of anteed access to all qualified healthcare
medical conditions; their employers approaches. Such approaches may plans will ensure that people are able to
may not provide coverage; or they may include a requirement that employers choose the mix that is best for them.
be between jobs and currently unem- pay a percentage of the insurance pre- Today’s healthcare marketplace is
ployed. Lack of insurance may cause mium for their employees and their increasingly characterized by for-profit
an individual to delay seeking needed families, and a requirement that indi- corporations and large managed care
care for a medical condition that is viduals obtain insurance coverage—or organizations, many of which are taking
readily treatable. at least pay a portion of the premium aggressive actions to control the
Millions of other Americans face through the use of health savings delivery of healthcare services and
the problem of having to stay in mun- accounts. reduce their costs. Although efforts to
dane jobs simply because their There is no single best mechanism cut costs are appropriate and desirable,
employers provide decent health insur- available for achieving universal health excessive concern for costs can inter-
ance. Still other people face financial insurance coverage. In all instances, fere with the availability and delivery of
ruin because of devastating healthcare however, the government has an obli- health services to patients, thus dimin-
expenses that their insurance plans may gation to pay for coverage when ishing the quality of those services.
not cover. People may be worried that employers and individuals need assis- After any reform of the healthcare
their health insurance coverage is not tance. Congress must work with all system, patients need to be able to work
adequate and that healthcare expenses interested parties to decide the appro- with their physicians to make decisions
will edge out other family necessities. priate balance of responsibility (ie, regarding the medical treatments that
Furthermore, even if an individual is employer, individual, and government) are best for them. All too often today,
now adequately insured, there is a pos- in paying for such universal coverage. insurance company clerks or govern-
sibility that such coverage will not We all should be able to select our ment administrators interfere with or
always be there for that person. These own physicians. These individual delay the medical treatment decisions of
problems must be solved! choices are and will continue to be influ- patients and physicians. For this situa-
As a physician, I am pleased that enced by the professional skills of the
(continued on page 464)
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(continued from page 462) In conclusion, through the years, I medical student at Des Moines (Iowa)
have greatly appreciated the impor- University—College of Osteopathic
tion to change, physicians must be able tance of ACOFP’s political work on Medicine (DMU-COM). I am inclined to
to act jointly in their relations with behalf of the osteopathic medical pro- agree with Dr Lisowsky’s intended
insurers. Current antitrust laws pro- fession and the “mothership,” the point that osteopathic medical students
hibit physicians from engaging in col- American Osteopathic Association. I are not being encouraged to pursue
lective bargaining with private insur- am especially proud of efforts by careers in primary care. In fact, my
ance companies or government Marcelino Oliva, DO, chair of the experience thus far has been more in
insurance agencies.6 Legislation needs ACOFP’s Committee on Federal Leg- the realm of, “You can do anything as
to be enacted to allow physicians to islation, and Ray Quintero, the a DO now. All specialties are open to
negotiate for themselves and their ACOFP’s director of government rela- you.”
patients with insurance companies and tions. I urge JAOA readers to show their Of course, all specialties are open
the government. support for these efforts by thanking to DOs now, and this has happened as
Patients and their physician repre- these hard-working individuals and by a result of the outstanding work and
sentatives should have a say about contributing to OPAC. effort of so many osteopathic physi-
issues that affect healthcare quality. cians during the past century. In addi-
Patients should also have all the infor- Martin J. Porcelli, DO, MHPE, PhD tion, recent efforts of the osteopathic
Family Physicians and Surgeons
mation they need to be able to easily Pomona, Calif medical profession to focus on physi-
compare physicians, other healthcare President, 2003-2004 cian availability in underserved areas
American College of Osteopathic Family Physicians
providers, and healthcare plans are to be commended. For example, last
regarding value, quality, and patient References August, DMU (including DMU-COM)
satisfaction. 1. Key issues. American Osteopathic Information Associ- and the University of Iowa in Iowa City
ation—Osteopathic Political Action Committee Web site.
Instead of government and insurer Available at: http://www.osteopathicpac.org/key_issues announced the formation of several
control over healthcare decisions, a pri- .html. Accessed July 31, 2008. health education centers in our state.3
2. Langer G. Health care pains: growing health care con-
vate/public partnership should be cerns fuel cautious support for change; October 20, 2003.
These centers will serve as a network to
established to develop a national ABC News Web site. Available at: http://abcnews.go.com recruit and retain healthcare profes-
/sections/living/US/healthcare031020_poll.html. Accessed
quality-assurance program for health- May 21, 2008.
sionals, including osteopathic physi-
care. The goal of such a program would 3. Paddock C. 47 million Americans without health insur- cians, in rural Iowa. My school also has
be to strengthen existing efforts of the ance, Census report; August 29, 2007. Medical News loan repayment options available for
Today Web site. Available at: http://www.medical new-
private sector to promote quality stan- stoday.com/articles/80897.php. Accessed July 31, 2008. students who decide to practice in state
dards and the appropriate use of health 4. Salisbury D. The rocky road through Congress; May 12, after residency training.4,5
2008. Human Resource Executive Online Web site. Avail-
services. able at: http://www.hreonline.com/HRE/story.jsp?story
However, these efforts are indirect
It is important that elected officials Id=93450456. Accessed July 31, 2008. and somewhat ineffective. In the com-
hear from concerned constituents before 5. Arvantes J. Health care reform: Senate bill may provide munications I have received as a stu-
starting point to fix health care system; April 25, 2008.
voting on any legislation reforming the American Academy of Family Physicians Web site. Avail- dent member of the American Osteo-
US healthcare system. I strongly able at: http://www.aafp.org/online/en/home/publications pathic Association (AOA), American
/news/news-now/government-medicine/20080425
encourage readers of JAOA—The Journal wydenbill.html. Accessed July 31, 2008. College of Osteopathic Family Physi-
of the American Osteopathic Association to 6. Guadagnino C. Antitrust primer for physicians; March cians, and the Student Osteopathic Med-
2001. Physician’s News Digest Web site. Available at:
write their senators and representatives http://www.physiciansnews.com/spotlight/301.html.
ical Association, it seems that the
and urge action on health system Accessed July 31, 2008. impetus behind any promotion of pri-
reform. In corresponding with con- mary care is related to concurrent polit-
gressional representatives on this matter, Increase Efforts to Promote ical efforts to improve Medicare reim-
be sure to emphasize that any mean- Primary Care bursements and student loan repayment
ingful reform would include healthcare programs for DOs. Although such polit-
coverage that is retained regardless of To the Editor: ical endeavors are necessary, they, again,
employment, economic, or health status; In regard to the letter by Taras fail to recruit students to primary care
freedom of choice in physicians and Lisowsky, DO,1 titled “Pushing bodies practice.
health insurance plans should be through COMs,” and the response by I do not doubt that the AOA and
retained; medical decision-making is Diane N. Burkhart, PhD, 2 in the the COMs have considered how best
reserved for patient-physician interac- March issue of JAOA—The Journal of to promote the fact that DOs can pursue
tions, rather than by government admin- the American Osteopathic Association, I any medical specialty while also pro-
istrators or insurance clerks; and high- would like to share my experiences and moting primary care as a noble, rele-
quality healthcare. thoughts as a first-year osteopathic vant, and economically feasible career

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choice. I’m sure that balancing these 5. DO scholarship information: loan repayment programs. issues that are learned prior to medical
Des Moines University Web site. Available at: http://www
two objectives is a difficult task. After .dmu.edu/fa/scholarship_info/do/. Accessed July 31, 2008. school.
all, our profession does need to address 6. Opportunities: osteopathic medical internships and Furthermore, taking a yearly ethics
the problem of rising student loan debt residencies. American Osteopathic Association Web site. examination before obtaining a state
Available at: http://opportunities.osteopathic.org
coinciding with stagnant primary care /index.htm. Accessed July 31, 2008. medical license will not change poor
physician income, especially in light of 7. Schierhorn C. Slumping OGME piques educators at medical behaviors either. Efforts to elim-
Summit. The DO. February 2008:22-28. Available at:
declining Medicare and Medicaid reim- https://www.do-online.org/pdf/pub_do0208training.pdf. inate “bad medicine” need to begin
bursements. Accessed July 31, 2008. with recruiting efforts—and factors
More importantly, however, we beyond Medical College Admission
need primary care DOs promoting their Eliminating Bad, Bad Medicine: Test scores need to be considered. A
chosen career path one-on-one with stu- Problems With P4P Initiatives written examination with the question,
dents in the COMs—asking students “True or False: Can washing your
to shadow them and discussing eco- To the Editor: hands prior to and after seeing a patient
nomics, lifestyle, and other aspects of The special communication by reduce microbial spread?” is useless.
primary care with them. Robert G. Locke, DO, and Malathi Srini- That question would never weed out
We also need directors of osteo- vasan, MD,1 about pay-for-perfor- the non-handwasher because even a 5-
pathic primary care residency programs mance (P4P) initiatives, in the January year-old child would know how to
to promote their programs in the issue of JAOA—The Journal of the Amer- answer it correctly.
COMs. In addition, we need more of ican Osteopathic Association was thought- Rather than improve the behaviors
these residency programs in locations provoking. I believe, from a patient’s of bad physicians, the P4P initiatives
where students actually want to live perspective, that aspects of P4P initia- have the potential to create serious
during training. tives may seem useful, but I question problems for good physicians. As a
For example, my home state of Col- their application in actual clinical prac- patient, I see the P4P initiatives taking
orado, considered to be a desirable loca- tice. away a good physician’s ability to prac-
tion by many students, currently has For example, the P4P initiatives, on tice medicine because the initiatives
no osteopathic medical residency pro- paper at least, may seem helpful for may have the effect of turning practi-
grams in any specialty.6 I have already certain practices, such as those with tioners into administrators—adminis-
looked at which specialties have allo- clinics that are operated as “cattle calls” trators who follow rules, regulations,
pathic medical residency programs in (ie, “fast-food medicine”); those with and by-laws to the detriment of a
Colorado, and I know from conversa- physicians who have terrible people patient’s unique medical issues, or who
tions with other students that residency skills (ie, bad bedside manner); those use a one-medicine-fits-all approach.
location often plays a role in specialty that re-use syringes2; and those with It is true that checklists can be very
selection.7 physicians and other healthcare useful in any profession. For example,
Combined, the actions taken to providers who fail to wash their hands a report presented at the annual
address these issues could turn the page before and after patient interactions. meeting of the American Society for
and get more DOs into primary care. In reality, however, the P4P initia- Microbiology in New Orleans, La, in
tives are not going to make “non-hand- May 2004, showed that 46% of the neck-
Richard W. Rapp, OMS II washers” suddenly start washing their ties worn by physicians at the
Des Moines (Iowa) University—College of Osteopathic
Medicine hands. Hand-washing is something you New York Hospital Medical Center of
learn as a student in elementary school Queens contained large quantities of
References —not as a practicing physician. Neither Staphylococcus aureus and other infec-
1. Lisowsky T. Pushing bodies through COMs [letter]. will the P4P initiatives make those tious microorganisms.3 Thus, one item
J Am Osteopath Assoc. 2008;108:105. Available at:
http://www.jaoa.org/cgi/content/full/108/3/105. Accessed physicians with bad bedside manner on a useful checklist in hospitals and
July 31, 2008. develop better people skills; these are clinics would prevent physicians from
2. Burkhart DN. Response [letter]. J Am Osteopath Assoc. skills that you either have or do not wearing neckties. However, checklists
2008;108:105-106. Available at: http://www.jaoa
.org/cgi/content/full/108/3/105-a. Accessed July 31, 2008. have prior to matriculation. and similar quality-improvement ini-
3. DMU, U of I receive millions to improve Iowans’ health In short, the P4P initiatives are not tiatives can be overly complicated,
care access, awareness [press release]. Des Moines, Iowa: going to prevent bad physicians from resulting in possible adverse effects on
Des Moines University; August 28, 2007. Available at:
http://www.dmu.edu/communications/index.cfm?NewsID practicing fast-food medicine, re-using the quality of patient care.4
=184. Accessed July 31, 2008. syringes, or transporting patients when If the P4P initiatives are intended
4. Osteopathic forgivable loan program; January 2007.
Iowa General Assembly Web site. Available at:
not medically necessary in an effort to to establish a new standard of care (as
http://www.legis.state.ia.us/lsadocs/SC_MaterialsDist/2007/S increase “billable hours.” All those real- mandated checklists), why not just use
DMAS007.PDF. Accessed July 31, 2008.
world situations encompass ethical a software program to fulfill the pur-

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pose of the initiatives and determine tious microorganisms, such as methi- mandated payment refusals will change
the medical necessities for each patient? cillin-resistant S. aureus (MRSA). Medi- unhealthy patient behaviors.
In computerized medical assess- care officials recently announced that Should there then exist a report card
ments, patients would answer ques- they plan to stop paying for 13 common for patient healthcare performance in
tions about their medical needs, and— conditions typically caused by hospital which a patient’s efforts at good self-
based on patient responses...and the errors.5 Some of these errors can obvi- care determines his or her costs for
assumption that the questions were ously be prevented, but others, such as healthcare? Should this report card
answered truthfully—the software MRSA infections, cannot. As with the include factors such as how well a
would produce a clinical diagnosis and P4P initiatives, Medicare’s “Hospital 13” patient manages diseases with a genetic
appropriate prescription. plan5 ignores the realities of clinical basis, such as type 1 diabetes mellitus?
If the P4P initiatives could truly practice. The Medicare plan implies that It needs to be kept in mind that a
assess clinical observations, the US Food all microbial infections are hospital- successful medical healthcare system
and Drug Administration (FDA) would acquired or hospital-generated. How- consists of approximately 10% medical
not need expert committees to analyze ever, this is misleading because one- guidance and 90% patient effort—not
preclinical, clinical, and postmarketing third of MRSA infections are the other way around. Consequently,
data on drugs and medical devices. community-acquired.6 Does hospital the P4P rating system makes a huge
Instead, the FDA would rely on a soft- protocol now need to dictate that all and erroneous assumption that med-
ware program like the one described patients head toward the laboratory to ical soundness takes a back seat to a
to accurately evaluate a drug or medical get tested for MRSA before treatment— patient’s whims.
device based on inputted data. This similar to the way some hospitals screen Another issue highlighting the inad-
hypothetical scenario, of course, is not every pregnant patient for drug use? equacy of the P4P initiatives is related to
realistic because no software program I also take issue with the value of lack of patient options. For example,
could adequately substitute for the the patient satisfaction scale reported there are clinics in some areas of the
years of practical experience repre- in the article by Drs Locke and Srini- United States that are the only ones in
sented by physicians in their clinics or vasan.1 Is the patient satisfaction scale, town—and thus the only healthcare
on FDA expert committees. which is likely to become the corner- option for patients. Yet, some of these
I agree with the majority of the stone of P4P evaluations, really a true clinics may provide terrible healthcare.
DO survey respondents that P4P ini- measurement of medical care quality? How would the P4P initiatives improve
tiatives would not appropriately cap- For example, how is a physician the care of patients in such clinics?
ture the quality of their work.1 Medicine supposed to help a patient who has been Years ago, I went to a physician
is referred to as being “practiced” for a diagnosed with chronic obstructive pul- whose arrogance created a poor patient-
reason, and practicing medicine does monary disease but refuses to stop physician relationship. As a patient, I
not mean that every patient’s medical smoking? What about those patients decided to never return to that physi-
needs are the same. In addition, the sta- who are not proactive with their health- cian, regardless of the degrees and cer-
tistical significance found in an aca- care, yet expect the physician to fix their tifications displayed in his office. I now
demic study may not translate usefully problem(s) quickly with a pill? have a primary care physician—an
into a physician’s private clinical prac- Presuming the physician does not osteopathic physician in family prac-
tice. Conversely, an excellent patient- “cave in” to a patient’s medically irre- tice—who, from my perspective, is
physician relationship will not trans- sponsible requests, the smokers and pill excellent in all aspects of clinical prac-
late into a checklist item that can be seekers will undoubtedly rate the physi- tice. I plan to keep her as my primary
given to a poor physician to automati- cian poorly—thus skewing the results of care physician even if she changes her
cally change his or her terrible skills that physician’s patient satisfaction scale practice location (provided that she
(whatever they might be) into the skills rating—and seek a second opinion. agrees to still be my physician, of
of a great physician. No P4P initiatives Obtaining a second medical opinion is course), regardless of P4P initiatives or
will change the behaviors of those not inherently bad, but seeking a second her patient satisfaction scale scores.
physicians with questionable ethics or medical opinion for the wrong reasons I follow (as in the 90% patient-effort
poor medical-business practices. is dangerous. part referred to above) my physician’s
The P4P initiatives are not It has been stated anecdotally that medical recommendations and advice
grounded in the realities of clinical prac- about 80% of the US healthcare budget (the 10% medical-guidance part) to
tice. Many physicians who practice is consumed by the effects of five behav- ensure that my healthcare path is pro-
good medicine and many hospitals that ioral issues: smoking, alcohol consump- ceeding according to our plan (encom-
use quality-assurance checklists still tion, lack of exercise, poor nutrition, and passing 100% medical healthcare).
have patients who test positive for infec- stress.7 No P4P initiatives or Medicare-
(continued on page 468)
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(continued from page 466) spirituality curriculum development 7 studies; less heart disease and better
and program evaluation become avail- cardiac outcomes in 7 of 11 studies;
A mutually respectful relationship able.1 We strongly agree with their con- reduced blood pressure in 14 of
between a competent physician and a clusion. In addition, we believe it could 23 studies; lower cholesterol levels in 3
responsible patient is ultimately the be argued that spiritual aspects of of 3 studies; reduced cigarette smoking
only way to achieve quality healthcare. patient care are a fundamental part of in 23 of 25 studies; increased exercise
The P4P initiatives will never replace osteopathic medical care. in 3 of 5 studies; and improved sleep in
that, as they place all the responsibility A number of studies have demon- 2 of 2 studies.4
on physicians and none on patients. strated the value of religion and spiri- In addition to being a growing area
tuality to the physical and mental health of research, religion/spirituality is
Richard McDonald, JD, PhD of patients,2-4 making it clear that a high becoming a crucial part of modern med-
Senior Principal Scientist
Product Development Associate Director proportion of patients rely on religious ical practice. Increasing evidence sug-
GenoVar Diagnostic beliefs to help them cope with their gests that religious beliefs influence
Pahrump, Nev
health problems. In fact, more than patients’ medical decisions and that reli-
References 60 studies have examined the role that gion/spirituality becomes even more
1. Locke RG, Srinivasan M. Attitudes toward pay-for-per- religion plays in helping people deal important to patients as they face the
formance initiatives among primary care osteopathic
physicians in small group practices. J Am Osteopath Assoc.
with such diverse conditions as diseases specter of serious illness.5
2008;108:21-24. Available at: http://www.jaoa.org/cgi of the heart, lungs, and kidneys, as well Many patients desire their physi-
/content/full/108/1/21. Accessed July 31, 2008.
as AIDS, amyotrophic lateral sclerosis, cians to consider their spiritual needs on
2. Thousands may be infected by Vegas clinic; March 5,
2008. USA Today Web site. Available at: http://www arthritis, cancer, chronic pain, dia- an equal basis with their physical health,6
.usatoday.com/news/health/2008-03-05-hepatitis- betes mellitus, and other illnesses.2 and many want clinicians to ask about
vegas_N.htm?loc=interstitialskip. Accessed July 31, 2008.
According to Harold G. their religious beliefs in times of serious
3. A doctor’s necktie can be hazardous to your health. The
Caregiver’s Hotline [serial online]. 2004;1(7). Available Koenig, MD, MHSc,3 codirector of the illness. 7 The Joint Commission on
at: http://caregiver.nowis.com/news/article.cfm?UID=172. Center for Spirituality, Theology, and Accreditation of Healthcare Organiza-
Accessed May 15, 2008.
Health at Duke University Medical tions now requires that certain patients
4. Kuehn BM. DHHS halts quality improvement study:
policy may hamper tests of methods to improve care. Center, among 445 patients who were in inpatient behavioral healthcare pro-
JAMA. 2008;299:1005-1006. consecutively admitted to general grams be given an assessment that
5. Neegaard L. Hospitals, errors to get more expensive. Las
Vegas Journal. February 19, 2008:1A,5A.
medicine cardiology and neurology ser- “includes the client’s religion and spir-
6. Worcester S. Chicago-area hospital system takes on vices at Duke, nearly 90% reported itual orientation.”8
MRSA. Ob Gyn News [serial online]. 2005;40(18):19. Avail- using religion to some degree to cope The proposed tenets of osteopathic
able at: http://download.journals.elsevierhealth.com/pdfs
/journals/0029-7437/PIIS0029743705710302.pdf. Accessed with their conditions. Similarly, more medicine offered by Rogers and col-
July 31, 2008. than 40% indicated that religion was leagues9 indicate that spirituality should
7. Deutschman A. Change or die. Fast Company [serial the most important factor that kept be an important part of the osteopathic
online]. May 2005(94). Available at: http://www.fast
company.com/magazine/94/open_change-or-die.html. them going.3 approach to treatment. The first tenet
Accessed July 31, 2008. Koenig and McCullough4 note that states the following:
more than 700 studies have examined
Spirituality is Fundamental to the relationship between patients’ reli- A person is the product of dynamic
Osteopathic Medicine gious beliefs, well-being, and mental interaction between body, mind, and
health—with nearly 500 of these studies spirit. The human body functions as
To the Editor: demonstrating a beneficial association a unit, integrated such that no part
truly operates independently. Alter-
In the April issue of JAOA—The Journal between religion and better mental
ations in the structure or function of
of the American Osteopathic Association, health, greater well-being, and lower any one area of the body influence
Elizabeth K. McClain, EdS, and col- levels of substance abuse. Koenig and the integrated function of the net-
leagues1 reported that osteopathic med- McCullough4 also summarize research work as a whole. A comprehensive
ical students generally receive 2 to from numerous investigations that approach recognizes the integral roles
20 hours of instruction on spirituality found beneficial effects of reli- of body, mind, and spirit in health
and religion, and that approximately gion/spirituality on patients’ physical and disease. [emphasis added]
55% of all colleges of osteopathic health outcomes.
medicine (COMs) have some form of Among the findings of these inves- In view of this tenet, it would seem that
spirituality-in-medicine program in tigations, religious beliefs and activities there is little question that addressing
place. The authors concluded that it is were associated with improved spiritual issues related to a patient’s ill-
important that more information immune functioning in 5 of 5 studies; ness should be an essential part of the
regarding methods of medical schools’ reduced death rates from cancer in 5 of osteopathic approach to treatment.

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In describing why physicians 8. Joint Commission on Accreditation of Healthcare Orga- ization by osteopathic physicians that
nizations. 2008 Standards for Behavioral Health Care.
should consider spirituality to be an Oakbrook Terrace, Ill: Department of Publications, Joint the symptoms of fever and cough
integral part of the practice of medicine, Commission Resources; 2008:215. exhibited by patients with influenza—
9. Rogers FJ, D’Alonzo GE Jr, Glover JC, Korr IM, Osborn
Dr Koenig5 stated, “...because doing so GG, Patterson MM, et al. Proposed tenets of osteopathic
symptoms that MDs addressed phar-
is part of whole person health care. medicine and principles for patient care. J Am Osteopath maceutically with aspirin and cough
Assoc. 2002;102:63-65. Available at: http://www.jaoa
Simply treating a medical diagnosis or .org/cgi/reprint/102/2/63. Accessed July 31, 2008.
suppressants—were actually the
a disease, without considering the immune system’s protective responses
person with the disease, is no longer Rise and Shine, Rhinorrhea to illness. In the language of evolu-
acceptable.” tionary biology, those symptoms were
The need for additional education To the Editor: defenses that were expressed because
regarding religion/spirituality for The article by Nicholas L. Rider, DO, they conveyed a survival benefit that
trainees in osteopathic medicine is evi- and Timothy J. Craig, DO, 1 in the was lost when they were suppressed. In
dent. We believe that the 2 to 20 hours September 2006 issue of JAOA—The the language of sports, hobbling your
of didactics currently provided at Journal of the American Osteopathic Asso- defense means the other side scores.
COMs may not be sufficient to address ciation, about long-acting ␤2-agonists Most triggers for asthma are recog-
this topic. However, we acknowledge and inhaled corticosteroids, shows the nized in the nose. The “one airway
that it may be problematic to fit addi- benefits of standard therapy in the treat- hypothesis” posits that when the
tional training into the extensive cur- ment of patients with asthma. At the immune system recognizes a substance
riculum already in place at COMs. same time, however, the article raises in the nose (ie, upper airway) that could
Thus, we encourage further dialogue questions in my osteopathic-oriented cause greater problems in the lungs
on religion and spirituality among mind about the wisdom of using (ie, lower airway)—where the body’s
members of the osteopathic medical intranasal steroids to put the immune defenses are less robust—the system
profession. system “to sleep.” protects the lungs by constricting the
In the September 2006 edition of connection between the two airways.6
Roy R. Reeves, DO, PhD The DO, the late John A. Stros-
Associate Chief of Staff for Mental Health
This constriction is one of the actions
G.V. (Sonny) Montgomery Veterans Affairs Medical nider, DO,2 (2006-2007 President of the of histamine as it triggers the washing
Center
Professor of Psychiatry and Neurology
American Osteopathic Association) defense that is rhinorrhea. Both
University of Mississippi School of Medicine encouraged us to remember our roots. common sense and ultramicrographic
Jackson
One of the issues that helped me decide studies point to the fact that histamine’s
Anthony R. Beazley, MDiv to pursue osteopathic medicine as a action in triggering rhinorrhea is just
Staff Chaplain career was the success rate of osteo- as much of a defense as is a fever or a
G.V. (Sonny) Montgomery Veterans Affairs Medical
Center pathic physicians in treating patients cough.7
Jackson, Miss with influenza after World War I. Just as blocking other evolutionary
According to the United States Centers defenses handicaps our ability to deal
References
1. McClain EK, McClain RL, Desai GJ, Pyle SA. Spirituality
for Disease Control and Prevention,3 with threats, stopping rhinorrhea risks
and medicine: prevalence of spirituality-in-medicine the mortality rate of patients with an increase to nasal-related problems.
instruction at osteopathic medical schools. J Am Osteopath
Assoc. 2008;108:197-202. Available at: http://www.jaoa
“Spanish flu” who were treated with The up to 20-fold increases that have
.org/cgi/content/full/108/4/197. Accessed July 31, 2008. conventional medical therapy was more been reported in hospitalizations for
2. Koenig HG. An 83-year-old woman with chronic ill- than 2.5%, while records reported at asthma stem from the early 1970s.8 That
ness and strong religious beliefs. JAMA. 2002;288:487-
493. the time suggest that the mortality rate was the same time at which antihis-
3. Koenig HG. Religious attitudes and practices of hospi- of patients who were treated by osteo- tamines and decongestants were made
talized medically ill older adults. Int J Geriatr Psychiatry.
1998;13:213-224.
pathic physicians may have been as low available on an over-the-counter basis—
4. Koenig HG, McCullough ME, Larson DB. Handbook of as 0.25%.4 and the same time at which these med-
Religion and Health. New York, NY: Oxford University Even if the statistics then reported in ications were advertised on television
Press; 2001.
5. Koenig HG. Religion, spirituality, and medicine: research
the JAOA4 were not entirely accurate, and supplied in bulk for physicians to
findings and implications for clinical practice. South Med J. the difference in outcomes for osteo- give to needy patients. Although this
2004;97:1194-1200.
pathically treated patients versus allo- sequence of events does not satisfy the
6. King DE, Bushwick B. Beliefs and attitudes of hospital
patients about faith healing and prayer. J Fam Pract. pathically treated patients was still likely logic of causality, it should at least raise
1994;39:349-352. to have been significant. the question of causality.
7. Ehman JW, Ott BB, Short TH, Ciampa RC, Hansen-
Flaschen J. Do patients want physicians to inquire about
As Harold I. Magoun, Jr, DO, 5 If the osteopathic medical profes-
their spiritual or religious beliefs if they become gravely pointed out in a letter in the sion is serious about looking to its roots,
ill? Arch Intern Med. 1999;159:1803-1806. Available at:
http://archinte.ama-assn.org/cgi/reprint/159/15/1803.
October 2004 JAOA, this difference in we ought to look at treatments that
Accessed July 31, 2008. outcomes probably centered on the real- honor the natural defenses of the

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immune system and observe how the house staff occurred, and each can- severe reaction noted in Dr Birchem’s
doing so would impact the incidence ister of Hurricaine (20% benzocaine) case report.1
and severity of asthma. Then, it is likely, (Beutlich LP Pharmaceuticals, In addition, research suggests that
we would not have to put our immune Waukegan, Ill) topical anesthetic aerosol even if the duration of spray is consis-
systems to sleep with steroids. spray was tagged with a fluorescent tent, there can be considerable vari-
pink sticker that displayed the following ability in the delivery of the active ingre-
Alonzo H. Jones, DO text: dient in Hurricaine depending on the
Common Sense Medicine
Plainview, Tex orientation of the canister (ie, vertical
Excessive doses can cause methe- vs horizontal) and the degree of full-
References moglobinemia. Only one half-second ness of the canister.2 Because Exacta-
1. Rider NL, Craig TJ. A safety of long-acting ␤2-agonists spray is recommended with one
in patients with asthma. J Am Osteopath Assoc.
cain dispenses a metered dose, the pos-
repeat if necessary. Not recom-
2006;106:562-567. Available at: http://www.jaoa.org sibility of overdosage is lessened with
/cgi/content/full/106/9/562. Accessed July 31, 2008. mended for use for pharyngitis or
tonsillitis.
this medication.
2. Greenwald B. Back to the future: John A. Stros-
nider, DO, challenges the profession to remember its
roots. The DO. September 2006:32-40. Carol L. St George, DO
Both Hurricaine and Cetacaine Chief of Staff and Vice Chairman
3. Taubenberger JK, Morens DM. 1918 influenza: the
mother of all pandemics. Emerg Infect Dis [serial online]. (14% benzocaine) (Cetylite Industries, Department of Surgery
Memorial Hospital
January 2006. Available at: http://www.cdc.gov/ncid Pennsauken, NJ) topical anesthetic York, Pa
od/EID/vol12no01/05-0979.htm. Accessed July 31, 2008.
aerosol spray formulations are safe
4. Smith RK. One hundred thousand cases of influenza
with a death rate of one-fortieth of that officially reported when used appropriately. However, References
under conventional medical treatment [reprint]. January overdosing with Hurricaine and Ceta- 1. Birchem SK. Benzocaine-induced methemoglobinemia
1920. J Am Osteopath Assoc. 2000;100:320-323. Avail- during transesophageal echocardiography. J Am
able at: http://www.jaoa.org/cgi/reprint/100/5/320. caine may occur when house staff Osteopath Assoc. 2005;105:381-384. Available at:
Accessed July 31, 2008. expose patients to these topical anes- http://www.jaoa.org/cgi/content/full/105/8/381. Accessed
5. Magoun HI Jr. More about the use of OMT during July 31, 2008.
influenza epidemics [letter]. J Am Osteopath Assoc.
thetics for a longer time than recom-
2. Khorasani A, Candido KD, Ghaleb AH, Saatee S, Appavu
2004;104:406-407. Available at: http://www.jaoa.org mended by the manufacturers. SK. Canister tip orientation and residual volume have
/cgi/content/full/104/10/406. Accessed July 31, 2008. significant impact on the dose of benzocaine delivered by
In early 2007, York Hospital
6. Grossman J. One airway, one disease. Chest. 1997; Hurricaine spray. Anesth Analg. 2001;92:379-383. Avail-
111(2 suppl):11S-16S. Available at: http://www.chest switched from Hurricaine to Exacta- able at: http://www.anesthesia-analgesia.org/cgi/content
journal.org/cgi/reprint/111/2_Supplement/11S. Accessed cain (14% benzocaine) (Healthpoint Ltd, /full/92/2/379. Accessed July 31, 2008.
July 31, 2008.
Fort Worth, Tex) topical anesthetic
7. Svensson C, Andersson M, Greiff L, Persson CG. Nasal
mucosal endorgan hyperresponsiveness. Am J Rhinol. aerosol spray (G.D. Moffett, JD, written ED Physicians Beware When Using
1998;12:37-43. communication, August 2007). Because OMT for Patients With Motor
8. Crater DD, Heise S, Perzanowski M, Herbert R, Morse of the lower concentration of benzo-
CG, Hulsey TC, et al. Asthma hospitalization trends in Vehicle Injuries
Charleston, South Carolina, 1956 to 1997: twenty-fold caine in Exactacain versus Hurricaine,
increase among black children during a 30-year period. this switch further reduced the risk of
Pediatrics. 2001;108:E97. To the Editor:
methemoglobinemia in patients. Each I read the original contribution by
More on Benzocaine-Induced canister of Exactacain features a fluo- Tamara M. McReynolds, DO, and
Methemoglobinemia rescent pink sticker with the following Barry J. Sheridan, DO, titled “Intra-
text: muscular ketorolac versus osteopathic
To the Editor: manipulative treatment in the man-
I am writing in response to the case WARNING!!! Excessive doses of ben- agement of acute neck pain in the emer-
zocaine from Exactacain Spray may
report by Sandra Kaye Birchem, DO,1 gency department: a randomized clin-
lead to methemoglobinemia. DO
published in the August 2005 edition NOT exceed the recommended dose
ical trial” in the February 2005 issue of
of JAOA—The Journal of the American of three metered sprays, with one JAOA—The Journal of the American Osteo-
Osteopathic Association. repeated application as necessary. pathic Association (2005;105:57-68) with
Situations of benzocaine-induced This product is not intended for use a bit of apprehension. After rereading
methemoglobinemia, similar to the one in the treatment of sore throat! this study, I believe a few comments
described by Dr Birchem,1 arose in 2001 are in order.
at York Hospital (York, Pa) in several The JAOA has performed a useful First, I congratulate the authors for
patient-care areas, mainly related to service in making its readers aware that undertaking the challenge of finding a
endoscopy cases in the emergency Hurricaine and Cetacaine must be used better treatment for patients who have
department. with great care. However, it is impor- a problem that is “a real nuisance” to
Instead of immediately removing tant that readers understand that it is the emergency department (ED) physi-
the medication from the formulary, an the duration of application with these cian—spinal pain, manifested in this
aggressive program of education for topical anesthetics that often creates the particular setting as neck pain.

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My main concern with the study by for serious legal and financial conse- Although not specifically stated in
Drs McReynolds and Sheridan, how- quences to osteopathic physicians in the discussion of methods used in our
ever, relates to the statement, “The this setting. For those osteopathic physi- study,1 we used the criteria of the
majority of patients (58%) had cervical cians practicing in a clinical setting sim- National Emergency X-Radiography
strain resulting from a motor vehicle col- ilar to that of Drs McReynolds and Utilization Study (NEXUS)3,4 to clini-
lision.” In the study group receiving Sheridan (ie, an ED teaching hospital), cally clear the cervical spine. These cri-
osteopathic manipulative treatment the level of physician awareness of legal teria are: absence of tenderness at the
(OMT), there were 18 (62%) subjects with consequences is always high. Thus, posterior midline of the cervical spine;
injuries caused by motor vehicle acci- OMT is likely to be used for only select absence of a focal neurologic deficit; a
dents. In the study group receiving patients, and the odds of an adverse normal level of alertness; no evidence of
ketorolac tromethamine, there were outcome from OMT would be small, intoxication; and absence of a distracting
16 (55%) subjects with this type of injury. as the authors point out. This might not injury.3,4
Depending on the exact mechanism be the case, however, in other kinds of In NEXUS,3,4 34,000 blunt trauma
of injury, a small subset of patients in ED settings. patients were evaluated by cervical
motor vehicle accidents may harbor The concept of using OMT in the spine imagining in 21 EDs nationwide.
injuries to the neck that are not readily ED setting is worthy of further study. Of these patients, 818 (2.4%) had cer-
apparent in plain film radiographs. However, obtaining a computed tomo- vical spine injuries. The study’s criteria
Even if the findings of a patient’s phys- graphic scan or magnetic resonance were 99.0% sensitive for identifying all
ical examination are normal and there imaging of the patient’s spine prior to cervical spine injuries and 99.6% sen-
is no neurologic complaint (eg, radi- the use of OMT would be a wise diag- sitive for identifying clinically signifi-
culopathy), there may still be structural nostic adjunct and safeguard. cant cervical spine injuries.4
problems that could be a contraindica- It is with such low-risk patients that
tion to OMT. Facet joint fractures of the Stephen A. Fletcher, DO we believe OMT can be provided safely
Associate Professor and Chief
cervical spine may be so subtle that they Division of Pediatric Neurosurgery
without the need of cervical computed
are diagnosable only after imaging The University of Texas Medical School at Houston tomography (CT). We do not consider
using computed tomography. In such our study results to be “broadly appli-
cases, there could also be an associated Response cable,” but rather applicable to only a
laminar fracture. Furthermore, some We thank Dr Fletcher for his letter in carefully selected population of patients
ligamentous injuries may not be response to our article in JAOA—The in the ED.
apparent in lateral cervical films. Such Journal of the American Osteopathic Asso- We acknowledge that plain film
injuries may be noticed only with the ciation1 regarding the use of osteopathic radiography does not allow visualiza-
assistance of magnetic resonance manipulative treatment (OMT) in the tion of every cervical spine injury sus-
imaging. Days or weeks after the ini- emergency department (ED) setting. tained as a result of blunt trauma. The
tial trauma, patients with these injuries We hope the JAOA‘s readers were risk of neurologic disability and poten-
may describe only “neck pain.” not left with the misimpression that OMT tial litigation from missing an occult
The diagnostic complexities associ- is broadly applicable in the ED setting— unstable cervical spine fracture exists—
ated with patients who were in motor particularly with respect to patients who regardless of whether OMT, medica-
vehicle accidents raise a number of were in motor vehicle accidents (MVAs), tion, or no treatment is provided to the
questions. For example, should patients as was Dr Fletcher’s concern. patient. A prospective observational
involved in motor vehicle accidents be We used an extensive list of exclu- study by Mower et al5 found that occult
excluded from clinical studies of OMT sion criteria in our study.1 For trauma unstable injuries (ie, injuries that were
because of possible legal ramifications patients (including patients in MVAs), not identified on plain radiographs)
to the investigating physicians? Also, we excluded those with individuals were missed infrequently with the use
why add the ED physician to the list of who had substantial trauma, distracting of plain film radiography. These missed
candidates for possible future litigation injuries, neurologic deficits, alcohol injuries represented only 0.4% of all
in these situations, which are already intoxication, or other factors that pre- injuries and occurred in only 0.015% of
primed for legal action? cluded a reliable physical examination. all blunt trauma presentations (ie, fewer
Some readers of the article by Average “fender-bender” MVAs were than 1 in every 6500 screening evalua-
Drs McReynolds and Sheridan may not considered “substantial trauma” in tions) in that study.5
have been left with the impression that our study.2 Cervical radiographs were Patients in EDs who are at high risk
OMT is broadly applicable in the ED obtained if there was a history of (eg, with altered mental status, multi-
setting. Such an impression has the trauma and the patient could not be system injuries, neurologic deficits, or
potential to throw the door wide open cleared clinically. intoxication) should be evaluated by

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CT. Computed tomography should also ence—should make exceptions to such References
be used if a patient’s plain film radio- guidelines for individual patients. No 1. McReynolds TM, Sheridan BJ. Intramuscular ketorolac
versus osteopathic manipulative treatment in the man-
graphs are deemed to be inadequate, decision-making tool should replace agement of acute neck pain in the emergency depart-
suspicious, or definitely abnormal—or the clinical judgment of a physician in ment: a randomized clinical trial. J Am Osteopath Assoc.
2005;105:57-68. Available at: http://www.jaoa.org/cgi
if clinical suspicion of injury continues the care of individual patients. /content/full/105/2/57. Accessed July 31, 2008.
despite a normal radiograph result. We are unaware of any studies sug- 2. Shekelle PG, Coulter I. Cervical spine manipulation:
In cases where ligamentous injuries gesting—as Dr Fletcher implies—that summary report of a systematic of the literature and a
multidisciplinary expert panel. J Spinal Disord. 1997;10:223-
are suspected, we agree with physicians who practice in ED teaching 228.
Dr Fletcher that the use of magnetic res- hospitals have higher levels of aware- 3. Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective
onance imaging (MRI) and/or flexion- ness of legal consequences than do cervical spine radiography in blunt trauma: methodology
of the National Emergency X-Radiography Utilization
extension films should be considered. physicians who practice in other ED Study (NEXUS). Ann Emerg Med. 1998;32:461-469.
Unfortunately, routinely obtaining an settings. All physicians should realize 4. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker
MI. Validity of a set of clinical criteria to rule out injury to
MRI in the ED is not currently feasible that safety is of paramount importance the cervical spine in patients with blunt trauma. National
at most institutions. As MRI becomes for all patients—regardless of the clin- Emergency X-Radiography Utilization Study Group [pub-
lished correction appears in N Engl J Med. 2001;344:464].
faster and more readily available, how- ical setting in which that care is pro- N Engl J Med. 2000;343:94-99. Available at: http://content
ever, its use may become commonplace vided. .nejm.org/cgi/content/full/343/2/94. Accessed July 31, 2008.
in the ED setting. We believe that the use of OMT in 5. Mower WR, Oh JY, Zucker MI, Hoffman JR; for the
NEXUS Group. Occult and secondary injuries missed by
Because of high direct medical costs the ED provides physicians with plain radiography of the cervical spine in blunt trauma
and potential risks to patients of radia- another powerful therapeutic tool that patients. Emerg Radiol. 2001;8:200-206.
tion-induced malignant thyroid cancer, can and should be used in the correct 6. Rybicki F, Nawfel RD, Judy PF, Ledbetter S, Dyson RL,
Halt PS, et al. Skin and thyroid dosimetry in cervical spine
a CT scan should be used only when it clinical setting. Patients in EDs with screening: two methods for evaluation and a compar-
can be fully justified after appropriate acute neck pain should be given (or not ison between a helical CT and radiographic trauma series.
AJR Am J Roentgenol. 2002;179:933-937. Available at:
clinical stratification with decision rules. given) OMT based on clinical criteria http://www.ajronline.org/cgi/content/full/179/4/933.
The thyroid gland is exposed to approx- and evidence-based medicine—not on Accessed July 31, 2008.⽧

imately 14 times more radiation during physicians’ fears of litigation.


cervical CT scanning (26 mGy) than
during plain film radiography Tamara M. McReynolds, DO
Department of Emergency Medicine
(1.8 mGy).6 Carl R. Darnall Army Medical Center
It is important to keep in mind, Fort Hood, Tex
however, that decision rules are only Barry J. Sheridan, DO
guidelines, not absolute requirements. Brooke Army Medical Center
Fort Sam Houston, Tex
If necessary, physicians—drawing on
their own clinical acumen and experi-

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