Osteopathic Physicians in Ophthalmic Medicine
In the challenge to meet the ophthalmic needs of America’s future, allopathic ophthalmologists are finding enthusiastic colleagues in osteopathic medicine.
The history of osteopathy in medicine, including ophthalmic medicine, has been characterized by meeting challenges, gaining recognition and eventually earning integration. Today, hundreds of osteopathic ophthalmologists run thriving practices across the country, often in underserved areas. Many ophthalmologic societies count osteopathic physicians as members and state officers, and the Academy Council itself includes DO representatives. Within osteopathic medicine many ophthalmologists have risen to positions of leadership. Most notable are recent past president of the American Osteopathic Association (the Association), Phillip Schettle, DO, and president-elect Carlo J. DiMarco, DO.
History of Osteopathic Medicine
The story of osteopathic ophthalmology began more than a century ago when Andrew Taylor Still, MD, DO, founded osteopathic medicine in 1874. Dr. Still was dissatisfied with the state of 19th-century medicine. His philosophy at that time focused on the unity of all body parts, identifying the musculoskeletal system as a key element of health. Today, DOs take a “whole person” approach to medicine. They receive extra training in the musculoskeletal system and osteopathic manipulative treatment, a practice in which osteopathic physicians use their hands both to encourage the body’s natural tendency toward good health and to diagnose illness and injury.
The American Osteopathic College of Ophthalmology notes that the formal organization of osteopathic ophthalmologists and otorhinolaryngologists began in 1908 with the establishment of the Eye, Ear, Nose and Throat Section of the Association. The next 80 years would witness many changes within the professional organization, and by 1995, the American Osteopathic Colleges of Ophthalmology and Otolaryngology split into two colleges under the combined umbrella to help members more fully participate in their areas of interest.
A 20th-Century Pioneer
Joseph H. Wyatt, DO, founder of the Detroit Osteopathic Ophthalmology Consortium, has been described as a visionary pioneer of osteopathic ophthalmology. As Wayne F. Bizer, DO, of Ft. Lauderdale, Fla., noted, “Dr. Wyatt’s determination to start a residency program for osteopathic ophthalmologists is remarkable, and the impact of these efforts continues to be felt by several generations of osteopathic ophthalmologists.”
While it may seem that Dr. Wyatt’s birth date—which was Feb. 20, 1920 (2-20-20!)—may have predestined him to become an ophthalmologist, he was originally much more interested in athletics and music. Born in Flora, Ill., he was the quarterback and captain of the high school football team, and served as captain of the basketball team. After graduating and completing two years of pre-med training, Dr. Wyatt attended the Kirksville College of Osteopathic Medicine in Missouri, hoping to become a team trainer. At the time, Missouri had a full medical and surgical license for osteopathic physicians, with a rigorous curriculum and a school year that ran 12 months during the World War II era.
Military policy provided an ironic benefit to the osteopathic medical profession; osteopathic physicians were not permitted to serve the military as medical doctors. “This policy against DOs allowed many DO physicians to remain home and provide health care to the civilian population while the allopathic physicians were inducted into the military,” Dr. Wyatt recalled. “Obviously, this had a very positive impact on the acceptance of osteopathic physicians by the civilian population. Today, DOs are fully credentialed equally with allopathic physicians in all branches of the military.”
A Fascination with Eye Medicine
Dr. Wyatt next secured an internship at the Detroit Osteopathic Hospital (DOH) and became interested in obstetrics. However, since the only obstetrics residency was filled, he took over a general practice in 1944 in Wayne County, Mich., while on staff at the DOH. At this time, Dr. Wyatt experienced a life-changing event: A patient presented with symptoms of nausea, vomiting and severe head pain. He brought the patient in as an emergency and was invited to observe a sector iridectomy on the woman, who had been diagnosed with acute narrow-angle glaucoma. “I was absolutely fascinated by this surgical procedure,” he said. “However, there were three other doctors crowded around the patient, and I couldn’t really see what was going on. So the surgeon, a Dr. Whitney, who was chairman of the ophthalmology department at Henry Ford Hospital at the time, took me back into the locker room after surgery and, at 2:40 in the morning, drew pictures to explain the operation. That is the exact moment when I became interested in ophthalmology.”
However, the quest to become an ophthalmologist at that time was easier said than done. There were no ophthalmology-only residencies in the osteopathic profession, as all of the residencies were in eye, ear, nose and throat programs. One of Dr. Wyatt’s first experiences with educational restrictions occurred when he applied to several allopathic training programs in ophthalmology and was turned away because only graduates of allopathic schools were recognized.
Dr. Wyatt’s search for medical training took him to California, where 12 eye, ear, nose and throat osteopathic physicians were practicing in Los Angeles and had banded together to create a training program. Dr. Wyatt started his training in 1946 at the main teaching facility, the former Los Angeles County Hospital. Cataract surgery was far more complex in those days. It took five minutes or so just to extract the lens in intracapsular cataract surgery, not counting the rest of the surgery time. The drug Zolyse (alphachymotrypsin—used to dissolve zonular fibers) was just coming into prominence. Dr. Wyatt recalled using von Graefe knives to make the famous 180-degree corneal incision. “Surgical gloves were not used in the early period of eye surgery,” he said.
He returned to Detroit in 1948 and attempted to start an ophthalmology-only practice. Yet he could not make a living and reluctantly decided to include ear, nose and throat with his practice for a decade. But as it turned out, this expanded experience did not bother him. “Actually, in retrospect, I think the ear, nose and throat work made me a better ophthalmologist,” Dr. Wyatt said.
Dr. Wyatt said that one of the favorite aspects of his career was corneal transplant surgery. In the early 1960s, he spent two and a half months traveling to 19 countries around the world, meeting and teaching ophthalmologists. Dr. Wyatt and a friend, A. B. Rizzutti, MD, exhibited their skills in corneal transplant, using donor corneas obtained within each country as well as dehydrated corneas.
The Quest for a DO-Ophthalmology Training Program
In the early 1960s, Dr. Wyatt felt ready to tackle a career-long goal: to start an ophthalmology residency program. In 1961, he began the first ophthalmology-only residency in the osteopathic profession. His longtime partner, Patrick G. Murray, DO, joined him in 1962. Dr. Murray made an important contribution to the organization and perpetuation of the residency, Dr. Wyatt said. “And my first resident was Jessie Cardillio, DO, who still practices in Warren, Michigan, and has been very active in resident training for many years,” said Dr. Wyatt.
In the early 1980s, Dr. Murray organized a residency training consortium among some of the hospitals in the Detroit area, basing the DOH residency program in a multihospital consortium.
Michael Rubin, DO, director of the Detroit Osteopathic Ophthalmology Consortium, estimates that close to 100 osteopathic ophthalmologists have graduated from this residency program since its inception in 1961. Dr. Rubin cited some of the aspects of the osteopathic ophthalmology training programs that differentiate them from allopathic medicine training programs. “One of the advantages in the way osteopathic graduate medical education is structured is that the programs are usually based in a community hospital setting, allowing our residents to receive in-depth experience in treating everyday problems,” Dr. Rubin noted. “This is in sharp contrast to residencies based in tertiary centers where the focus is on more complex conditions. In addition, our residents maintain almost a one-on-one relationship with the attending physician, while also caring for their own patients. This allows the resident to learn not just from other residents but also from general and subspecialty-trained attendings.”
Dr. Rubin said there are 61,000 DOs in the United States and about 350 of those are ophthalmologists. There are 12 residency programs nationwide for osteopathic ophthalmologists, and they adhere to a rigorous certification system. “The osteopathic profession takes the board certification process seriously,” said Sidney Kay Simonian, DO, a recent past president of the American Osteopathic Board of Ophthalmology and faculty member of the Detroit program. She explained that after completing all the requirements of the residency program, osteopathic ophthalmology residents begin board certification with a written qualifying exam. After they pass the written exam, an oral certifying exam is administered. “Both exams are closely monitored psychometrically for validity. Content is based on core competencies and standards of practice, and the entire process is overseen by the American Osteopathic Association.”
The Allopath-Osteopath Relationship
Dr. Wyatt would be the first to say that the relationship between allopathic and osteopathic medicine has not been a bed of roses. Gaining acceptance has proved a long and challenging effort. Yet the difficulties never got the best of Dr. Wyatt or his colleagues.
In the 1960s, Dr. Wyatt learned that the Michigan Ophthalmology Society only allowed DOs to join as members for $100, not fellows for $125, because their training was not considered certified. “I declined the acceptance to the Michigan Ophthalmology Society and wrote them a letter saying they could keep my $125 and use it for a good purpose,” Dr. Wyatt said. “I believe that to have accepted a membership without recognition of my DO certification would have been an unthinkable disservice to osteopathic education and the DO certification process.” DOs faced educational barriers on the national level as well. In the 1950s, for example, the Academy’s policy on admission to the Annual Meeting lagged behind the DOs’ educational needs. Around 1955, Adolph Posner, MD, a well-known ophthalmologist from New York, was giving a series of lectures to the DO Ophthalmology Society in Los Angeles, and he asked the DOs in attendance if they would be at the Academy meeting that year. When he learned that DOs were not credentialed to attend, Dr. Wyatt said, “he vowed to change that and told all the DOs in attendance that they could attend the AAO meeting that year as his guests.”
True to his word, Dr. Posner met the DO ophthalmologists, personally escorted them into the Academy and secured their name badges. “Adolph Posner’s place in the history of DO ophthalmology was made that day,” said Dr. Wyatt, “and he enjoys the grateful title of Godfather of Osteopathic Ophthalmology.”
Today, the Academy makes no distinction between certified DO and MD ophthalmologists, Dr. Bizer said. He added that unity is a key theme now among the allopathic and osteopathic ophthalmology communities, with both “maximizing our abilities to make ophthalmology better, to fight common challenges to ophthalmology and to give the best care possible to our patients.”
Challenges Ahead for DOs in Ophthalmology
Dr. Rubin said that the barriers to educational access faced by osteopathic physicians continues to wane. These battles of acceptance have given way to new challenges, specifically, scope of practice issues and the predicted shortage of specialty physicians.
“The biggest challenge is making sure that there are ophthalmologists who can take care of all of us when the time comes,” he said. “The government is predicting a shortage of physicians, and both allopathic and osteopathic medical entities are opening schools and training more students in order to fill this shortage. Yet the big problem is that the government has not seen fit to fund, adequately, graduate medical education, so we have people coming out of medical school but we don’t always have the funding to train them in the specialties that will be needed.”
Both allopathic and osteopathic programs are receiving 20 to 50 applicants for each residency slot. “Until we can find funding, it will be difficult to train the next generation of ophthalmologists to take care of us,” Dr. Rubin said.
He believes that Dr. Wyatt is a pioneer whose work will live forever. “The reason I know that is because the things he taught me, I am teaching to my residents and some of my residents are teaching new residents. He has left a remarkable legacy, as witnessed by the osteopathic ophthalmologists who are improving the quality of life for countless Americans.”
Visit the American Osteopathic Association at www.osteopathic.org.