Health system science, yeah!
We’re going to talk about the
structure of healthcare.
We’re going to talk about
how things are set up
so that people can get care,
what kind of care they’re going to get,
and who does what
and how you know what somebody
is going to do.
So this is really an administrative lecture—
how we put things together
and what they mean,
and what they’re supposed to mean
because it’s getting confusing out there.
So osteopathic medicine is a field,
and a philosophy, and a technique.
When we talk about the regulation
of osteopathic medicine –
the standards, the norms, the culture—
we’re talking about a
lot of different things.
So why bother?
Well, if you’re practicing osteopathic
it means you’re an osteopathic physician
or trained in osteopathic manipulative
Typically, the government will
mandate what it means.
There’s some type of regulatory
body that licenses people
that tells you what you should do
if you say you’re an osteopathic physician.
If you say you’re an osteopathic physician,
you’d likely trained in osteopathic
or got additional training
in osteopathic manipulative therapy,
and understand osteopathic
principles and practices.
If you put a sign up on your
store and say, “WTF—
we treat feet,”
people will expect you to treat feet.
If somebody walks into WTF
and someone starts pushing on their belly,
WTF—that’s the feet.
What are you doing pushing on the belly?
Maybe the ankle,
but once you get up to the knee,
you’re not treating feet anymore.
So WTF, if you’re saying you treat feet,
you should be treating feet.
So those are standards we put in place
so that people understand
what they’re getting.
If you say you’re going to a hospital,
do they take care of emergencies
or do they just do certain tests?
You can’t just do what you want to do.
You have to start from where the
person is in front of you,
and the standards in place
will say what kind of care you get
and what kind of language you can
use to describe that care.
You can’t say you’re a foot specialist
and then start focusing on the abdomen.
Then, you’re no longer a foot specialist.
And if you are trained in certain things,
how much training do you need
to do a colonoscopy,
to do a full exam,
or to do a limited exam?
Those are the standards that the
government puts in place
through licensure and regulating bodies.
Osteopathic medicine is a profession
that has developed its own standards
that set its own record
of what every osteopathic physician
knows and can do.
So if you say you’re an
you know to do an osteopathic
which includes the nervous system
and the musculoskeletal system.
You’re good at examining people
and you’ve met a basic standard.
You can name the muscles, you
can treat the muscles,
and you can assess the motion
of the muscles.
and we try and fit it into the whole system
so that even though you’re an osteopathic
manipulative medicine specialist,
or trained in osteopathic manipulative
you can continue on and specialize.
Every DO student learns 7 different
types of manual therapies.
Seven different ways they
can do manipulation
to effect the musculoskeletal system.
Yes, there are over 30 types,
and in residency, you can be trained
in manipulation under anesthesia.
You can be trained in the fascial
or facilitative positional release.
Those are residency level techniques
that you get some exposure to in
osteopathic medical schools
but not entirely.
And what this does is,
when you say you’re an osteopathic physician,
there’s an expectation that you,
at some point in your career,
were trained and were competent
in these therapies.
It also says that when you started an
osteopathic medical school,
you ascribed to a philosophy
that looks at structure and function
and its interrelatedness.
You look at the mind, body and spirit
and treat more than just the
disease in front of you.
You treat the person you’re taking care of,
and all care has to start from the person.
The person is the one who
gives you the history,
they tell you the chief complaint,
they tell you why they’re there,
and that’s where it starts.
The disadvantages to self-developing
is we tend to get very narrow.
We tend to focus on what we’re interested in.
We tend to focus on what we’re good at.
We tend to focus on where
we want people to be
who are calling themselves
but other physicians may disagree.
There’s some overlap
and there’s arguing around the edges.
So in healthcare,
if you’re an institution, you get accredited.
You can say we are a hospital, we
are a medical school,
we are a healthcare facility,
and we’re a health facility
that works to optimize health
and teach in that way.
The accreditation is for institutions.
Certification is when an individual
has met a standard,
completed a course of study,
been assessed and been evaluated.
They can become certified.
Those are the systems in place.
States and federal governments license you.
They will say whether or not you
can do something in public,
whether it’s safe,
and they’ll dictate the edges
of what healthcare is.
So when people come to a physician,
or come to a provider,
they want to optimize health.
They want to be able to do more than
they were able to do before.
They want to feel better, stronger,
and that’s why they’re coming.
What can you do has to be
within the balance
of the science you’re practicing under
or the system you’re working within.
So there’s a difference between what you’re
licensed to do and what you’re paid to do.
If you’re licensed, it means you’ve
satisfied the basic requirements
to get a license for the state to say what
you’re doing makes sense and is safe.
That doesn’t mean someone
is going to pay for it.
Those are determined by other organizations,
and in the US, it’s Medicare
and insurance companies.
Medicare sets a standard for what’s covered
and what will be paid for by Medicare.
Insurance companies can modify it.
They can add or they can take away,
and they work around the edges,
and they play a lot more with more of the
expensive therapies or treatments.
So cancer chemotherapy—
Medicare says it’s covered—
they may give you 3 or 4 options
of what can be done.
Insurance companies can limit that to one
and they say, “we want this one as
the most cost effective.”
For back pain—
do you get manipulation, do you get x-rays,
do you get injections, or do
you get acupuncture?
All of those things are determined
outside of the licensure.
Licensure says you can do it.
It says it is part of what you’re
trained to do.
It is part of what’s safe and it is part of
what’s been studied and approved,
but that doesn’t mean it’s
going to get paid for,
and that’s where Medicare matters
and that’s where the insurance
A monopsony is when you no longer
have true competition.
It’s when you have few basic companies
that control a market,
and because there’s no true competition,
they can dictate what’s covered and what's
not covered and how you move forward.
To understand the structure of education
and how you get able and accredited
and certified to do things,
your institution will be accredited.
In college, there are 6 regional
mostly based on geography.
There’s western states, northern
states, and mid-Atlantic
that initially accredited colleges
in their geographic area.
In today’s day and age,
we’re no longer restricted by geography
and you can have the northern states
accredit a southern school
or the western states accredit
an eastern school,
but their standards are consistent
and there’s a lot of overlap.
The differences were meant to be regional
and to adapt to different realities
in a wide open area of the west
versus a more urban area of the northeast.
That’s how colleges are accredited.
In medical education,
we have different accrediting
bodies for DO schools
which is the COCA,
the Commission on Osteopathic
and the LCME, the Liaison Committee
for Medical Education.
Both of these organizations
accredit medical schools.
They say the medical schools
have a curriculum that fits,
they have a faculty that fits,
and they have the clinical
resources to matter
because one of the hallmarks
of medical education
is that it is education that
takes place outside
of an educational environment.
You’re trained where care is delivered.
You’re trained where people
are being treated
because that’s where you’re going
to see what’s going on.
The assessment piece
is done by the NBOME or the NBME,
the National Board of Osteopathic
or the National Board of Medical Examiners,
and they’re the people who test you
either in person at clinical skills testing
or via computer with online tests,
and they do the assessment
to say you can move on.
In graduate medical education, there
is only one organization
that accredits institutions
and that’s the ACGME,
the Accreditation Council for Graduate
and they’re the people who
are going to make sure
that when you’re in graduate
there is a learning community,
there is a learning environment,
there are people around to teach you,
to oversee you, and to give you feedback,
and if you don’t have the time to learn,
then you shouldn’t be accredited, and
that’s what the ACGME does.
They make sure the standards are there,
other people are there, the oversight
is there, the protection is there,
and that you are going to be safe
to both practice and learn at the same time.
This is different than the
which tell you when you can be certified
as an individual to practice
a certain specialty
and that gives you additional freedoms
to do procedures
and to take care of people
with specific conditions
that may need more specialized care,
more followup, and more interventions.
Internationally, there are
very different systems.
The ECFMG is the organization
that’s going to put the stuff together.
They’re going to evaluate your credentials,
keep your credentials in one place,
and make sure the international medical
school that the person went to
is accredited either by an accrediting
body in their own country
or an international accrediting body
that has standards that are
consistent and observable.
FAIMER is part of the ECFMG that
does help set the standards
and develop the knowledge needed
to understand what is going
on in other countries.
And this is all based on the concept
that medical education should
That if you learn anatomy here,
it’s going to be the same anatomy
that you learn here.
ERASMUS is the European system
to make sure that
things that happen in Belgium
can be done in Germany,
and things that occur in Bulgaria
will mean the same thing it does in Greece.
And that you can move from
one country to another,
and you can transfer from
one school to another.
And if you’ve conquered a field of study,
if you’ve passed a certain
amount of knowledge,
that it’s consistent
and we’re moving toward
and getting it to where we do have
one system of knowledge
that can be obtained in different ways—
some online, some in person—
and the assessment is what matters,
but making sure that it’s interchangeable
In America, this is seen
in the establishment
of an interstate compact.
So if you’re licensed in one state,
and you practice telemedicine,
can you cross over the border?
Can you write a prescription
that will be filled in West Virginia?
Right now, 22 states have
signed an agreement
saying that there is some reciprocity
because while some states say one year of
graduate medical education is enough,
others say you need two,
and others say it might be three.
If you’ve done the most, and you
have completed a residency
and are board certified,
then you’ve met the requirements to be
part of the interstate compact—
to have your license in West Virginia
and work in Nevada or Utah,
to make sure that Arizona and Montana
have some reciprocity.
This is the interstate compact
that the FSMB has been advancing
and the concept of getting
of having one standard and using
systems to share information
and to keep those together.
So the specialty colleges in the
they’re separate from the ABMS
or allopathic world.
Osteopathic specialty colleges
want you to be conversant in osteopathic
principles and practice;
to have the philosophy of a DO;
to understand the mind, body,
and spirit connection;
to work on structure and function
and to start from the individual
in front of you.
They also want you to be trained
with a certain level of expertise
in osteopathic manipulative therapy,
to understand that 60% of the body
is the musculoskeletal system,
and how you treat the musculoskeletal
as both an organ system
and as a biomechanical system matters.
The ABMS specialty colleges
are also ACGME certified as all osteopathic
ones will be by 2020
and they have less stringent requirements
in terms of philosophy
and in terms of musculoskeletal medicine
and the training you get.