Andrew Taylor Still and the Mayo Brothers: Convergence and Collaboration in 21St-Century Osteopathic Practice Robert Orenstein, DO

SPECIAL COMMUNICATION

Andrew Taylor Still and the Mayo Brothers: Convergence and Collaboration in 21st-Century Osteopathic Practice Robert Orenstein, DO

orn in Lee County, Virginia, in 1828, function were integrally related and that BAndrew Taylor Still, MD, DO, wit- he could use manual therapy restore nessed the ravages of many of the infec- health.1 tious diseases prevalent in 19th-century Attracted by Dr Still’s successful treat- America while traveling the country as a ment of previously “untreatable” illnesses, boy with his father, who was both a physi- many physicians began to embrace his cian and a Methodist minister. philosophies, adopt his techniques, and sup- At the time, the practice of medicine port the establishment of a new kind med- was a cottage industry with few proven ical practice known as osteopathy. People treatments. Therapies often were con- came from throughout the United States to cerned with ridding the body of disease Kirksville, Missouri, to learn osteopathic rather than returning the body to health. principles and practice. Dr Still shared his There was little standardization or evi- methods with others freely, demonstrating dence-based practice at the time. the benefits of osteopathy in the mainte- As a young surgeon, Dr Still wit- nance of health and the treatment of dis- nessed the inadequacy and lack of scien- ease. In 1892, he established the American tific basis for contemporary medical prac- School of Osteopathy with the primary mis- tice. Dr Still saw osteopathy as a science SPECIAL FOCUS ISSUE sion of disseminating the principles and and philosophy. The science was the practice of this unique form of medicine. understanding of anatomical, structural, Meanwhile, Dr Mayo’s sons, William and functional relationships. The philos- James Mayo, MD, and Charles Horace Mayo, ophy was that by maintaining normal structure, homeostasis MD, (“Dr Will” and “Dr Charlie”) joined the family surgical prac- and health could be maintained. Dr Still grew to understand tice in Rochester with a similar vision—to place the needs of the that illness was more than the interaction of infectious agents patient first. The Mayos believed that delivering the best med- with their hosts; the whole person and his or her family could be devastated by disease. Dr Still was one of several visionary physicians who Osteopathy is an independent system and emerged from rudimentary 19th-century medical practices to can be applied to all conditions of disease. seek improvements in the way healthcare was delivered. In 1863, a frontier surgeon and British emigré named William —Andrew Taylor Still, MD, DO Worrall Mayo, MD, arrived in Rochester, Minnesota, to Osteopathy: Research and Practice (1910) examine Union soldiers prior to enlistment—around the same time that Dr Still was establishing his practice in rural Missouri. Both of these visionaries would champion improve- ical care required that the physician was well educated in the ments in the existing system of medicine by basing it on latest scientific advances. In addition, they believed that a per- more rational and scientific models. sonalized, team approach should be taken to fully unravel the Dr Still envisioned the patient as a complex unit, encom- complexities of caring for an individual patient. passing mind, body, and spirit. He believed that structure and As medical knowledge expanded in the early 20th-century, so too did the Mayo brothers’ vision for this new collaborative approach, later dubbed the Mayo Model of Care.2 Mayo physi- From the Mayo Clinic College of Medicine’s Divisions of Infectious Diseases and cians felt this approach allowed them to provide the best care General Internal Medicine in Rochester, Minn. possible to each patient every day through an integrated Address correspondence to Robert Orenstein, DO, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN 55905-0001. approach. The Mayo Model of Care soon became the model for E-mail: [email protected] all group practices in the United States.2

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And, again, people came from around the country— ations of osteopathic physicians. Unlike the Mayo group prac- and throughout the world—to Rochester to learn from and tice, which grew into a large, integrated model of practice, be treated by physicians at the Mayos’ clinic. osteopathic physicians were scattered across rural and inner- Like Dr Still, the Mayo brothers too went on to establish city urban America, filling the medical needs of underserved a graduate school of medicine to prepare physicians for their communities. model of care. But now, much of the difficult foundational work of building, establishing, and fortifying is complete. The torch is The Mayo Model of Care being passed to today’s young osteopathic physicians, who and the Osteopathic Difference must now accept the new challenges of practicing medicine in From the embers of late 19th-century American frontier 21st-century America using Dr Still’s model of osteopathic medicine, two visionary models of healthcare founded on care. similar principles and honoring the primacy of the patient However, for as much as things change, history bears emerged. Their approaches differed, however. The Mayo important lessons. There are many similarities between our era Model of Care, as noted, emphasizes a team approach to and that of Dr Still’s: an almost–blind faith in pharmacologic solving “a problem”; while Dr Still’s model of osteopathy solutions to treat disease and an overreliance on technology takes an integrative approach attuned to the specific needs of alone to solve health problems. Reports in the media on public the body’s various systems. perceptions of the depersonalization of patient care are all too In the 20th century, these two models diverged, with common.4,5 The increasing complexity of health problems has Mayo physicians developing into an integrated, specialty- resulted in subspecialized care and sometimes disjointed or focused practice while osteopathy remained focused on the piecemeal approaches to the management of disease, with individual. each organ or tissue having its own “caretaker.” As in Dr Still’s era, many patients today no longer feel whole. They find they are longing for someone to treat all of As we grow in learning, we more justly them, not just their symptoms. They wish to avoid therapies appreciate our dependence on each other. that do more harm than good. They want to assert more con- The sum total of medical knowledge is now trol over their own healthcare decisions. All of these broad- based impulses have led to a growth in complementary and so great and widespreading that it would be alternative approaches to healthcare.6 futile for one man to attempt to argue, or any Many within the profession wonder how osteopathic one man to assume that he has even a good physicians will be able to meet the needs of 21st-century working knowledge, of any large part of the patients. What is the role of the osteopathic physician in the 21st century? How will osteopathic physicians demonstrate their unique- whole. ness in a setting where specialized allopathic care is the norm? —William James Mayo, MD There are clear roles and opportunities for osteopathic Quoted in Mayo Clinic Model of Care physicians who remain enlightened by Dr Still’s philosophy of [brochure] patient care, education, and research. It is time, however, to innovatively renew Dr Still’s original model of patient care Mayo physicians would contribute to and disseminate by taking advantage of an opportunity to incorporate some of the most current medical information on recent innovations in the time-tested and popular features of the Mayo Model of patient care, research, and education throughout the 20th cen- Care. tury.2 This single institution extended its reach, becoming the largest private medical group practice in the world.3 Mayo Patient Care Clinic’s focus on continuous improvement and innovation, Although osteopathic physicians are scattered broadly across while adhering to the basic vision of the Mayo Model of Care, the nation, information technology now provides us with the would continue to be the driving force in its long-term success. means to practice as an integrated team to deliver the best At the same time, however, osteopathic medicine began medical care to our patients. Osteopathic physicians serving in facing many unfortunate legal and practice hurdles in its rural areas no longer need to rely on their experiences alone to second century, forcing a generation of osteopathic physicians aid their patients. Today’s osteopathic physicians can access the (DOs) to fight for their identity and practice rights, instead of latest medical research and clinical practice guidelines through concentrating their energies on innovation in research, edu- the Internet. Telemedicine, the use of visual and electronic cation, and patient care.1 technologies, will revolutionize the delivery of care in rural While fostering excellence in patient care, much of the areas and urban centers. Already, this technology has enhanced energy of the osteopathic medical profession has been spent in the delivery of specialty care to rural areas and prisons, allowed rebuilding osteopathic institutions and training future gener- expert interpretation of complex imaging, and has provided

252 • JAOA • Vol 105 • No 5 • May 2005 Orenstein • Special Communication SPECIAL COMMUNICATION new opportunities to deliver timely and expert care to understood that osteopathic physicians must be at the forefront of served populations. Recently, telemedicine protocols have medicine and groundbreaking research, as these changes will been used to enhance vaccination rates in daycare settings, propel approaches to healthcare in the present century. freeing parents from lost workdays. Clearly, Dr Still envisioned osteopathy as more than Through the proper use of information technology, manipulation. He saw manipulation as a tool to impact struc- patients can feel empowered to make more informed health- ture-function relationships and enhance the body’s ability to care choices. Although some may argue that these tools lessen patients’ needs for traditional office-visit interactions with Osteopathy is a science. Its use is in physicians, this trend is mainly serving to change patient- healing of the afflicted. It is a philosophy physician dynamics. Part of the wellness process involves patient empower- which embraces surgery, obstetrics, and ment. All the good intentions of the physician are lost when general practice. An osteopath must be a physicians are unable to motivate patients to participate in man of reason and prove his talk by his their own care. Therefore, physicians should embrace these work. He has no use for theories unless changes as an opportunity to reshape their roles from decision- they are demonstrated. makers to consultants and educators who help patients main- —Andrew Taylor Still, MD, DO tain and restore their own health. Because osteopathic physicians have long understood this role intuitively, they are well Autobiography of A.T. Still (1897) positioned to take the lead in this new information-savvy age. Osteopathic physicians have incredible opportunities for heal itself. Research opportunities exist to understand the basis expansion—in terms of numbers and influence—as medical of these relationships and their impact on patient outcomes. care moves from an organ-specific model to a cellular, molec- Other questions the profession must address are: ular, and genetic model in the coming decades. Scientists con- Ⅲ How does osteopathic manipulative treatment (OMT) affect tinue delving more deeply into the fundamental building the immune response? blocks of humanity. Many of these technological advances Ⅲ What are the roles of various osteopathic manipulative tech- require acts of “splitting”; that is, making pieces of the whole niques on the release of pro-inflammatory cytokines? ever smaller so we can begin to grasp the workings of each part. Ⅲ Can OMT enhance the delivery of various nutrients and “An osteopath,” says Dr Still, “is only a human engineer who pharmacologic agents? should understand all the laws governing his engine and Ⅲ What is the impact of OMT on gastrointestinal motility and thereby master disease.”1 function? As a consequence, humankind will continue to witness Ⅲ How can osteopathic physicians ensure that a person profound breakthroughs in our understanding of the molec- receives the best form of OMT for his or her particular ular and genetic basis of health and disease—and there will be needs? a continued corresponding rise in specialization. However, Osteopathic physicians should also reflect on the general there will always be a great need for someone to bridge the gap, impact of the osteopathic model of care on patient outcomes to translate these advances for daily use, and to integrate them and resource utilization: into comprehensive and compassionate care of the whole Ⅲ Does the delivery of OMT differ among providers? If so, patient. how? Ⅲ Is there a way to standardize the delivery of OMT? Research Each and every college of osteopathic medicine needs to For far too long, research in osteopathic medicine has been become involved in research specifically designed to address all riding in the backseat. Osteopathic research needs to be the of these questions—and they should encourage an environ- driving engine of the profession. Fundamental discoveries in ment where such inquiry can flourish among their students. genetics, molecular biology, pharmacology, and biotechnology will drive the changes in healthcare in the next century. The Education osteopathic medical profession needs to be at the forefront of How can we reenergize osteopathic medical education in the understanding structure-function relationships at the genetic new century? Again, the answers can be found in Dr Still’s prin- and molecular levels—the new frontier for American medicine ciples, posing a new set of questions that will revise osteo- in the 21st century. pathic principles and practice for the new medical and scien- Dr Still was a keen observer and investigator. Though he tific era: lacked the current understanding we have on the immunologic Ⅲ What tools has Dr Still provided that could be shared with and molecular level, he was a visionary with regard to under- future osteopathic physicians? standing the fundamental interactions necessary to help Ⅲ What social, economic, and technological advances can humans maintain their health. He would have readily under- osteopathic physicians use to improve patient health?

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Ⅲ How best should we deal with the complex issues faced The potential to answer all of these questions presents by the chronically ill and elderly? opportunities for the next generation of osteopathic physi- Osteopathic medical schools must continue to provide cians. Indeed, our vision of the future looks as bright as Dr Still’s the tools necessary to our students—and to develop innova- must have looked to him. tive curricula—that will encourage them to begin answering Let’s seize our opportunities! these questions, allowing them to address larger societal needs. References Conclusion 1. Gevitz N. The DO’s: Osteopathic Medicine in America. 1st ed. Baltimore, Clearly the practice of medicine in the 21st century is quite dif- Md: Johns Hopkins University Press; 1982:18. ferent than what Dr Still observed in the 19th century. The 2. Mayo Foundation for Medical Education and Research. Mayo Clinic Model leading health problems facing our nation demand our atten- of Care [brochure]. 2002. MC4270/R0102. Available at: http://www.mayo.edu/ pmts/mc4200-mc4299/mc4270.pdf. Accessed April 15, 2005. tion and action. The burden of chronic disease, cancer, obesity, heart disease, and acquired immune deficiency syndrome 3. Facts about Mayo Clinic in Rochester, Minn, page. 2003 Statistics. Mayo Clinic Web site. Available at: http://www.mayoclinic.org/about/rochester.html. should be a call to action for all in the medical community. Accessed May 11, 2005. Who better to see the full impact of obesity on the whole person—a bariatric surgeon or an osteopathic physician? Who 4. Creticos AP. President’s message. Annual Report, 2000. Washington Square Health Foundation. Chicago, Ill. Available at: http://wshf.org/annual- better to see the total impact of chronic heart disease—an inter- report.html. Accessed May 12, 2005. ventional cardiologist or an osteopathic physician? Who better 5. DeMoro RA. Thoughts on unions [letter]. NurseWeek/HealthWeek [serial to understand how chronic disability affects the structure and online]. August 26, 1999. Available at: http://www.nurseweek.com/let- function of the elderly patient? The answer to all of these ques- ters/99/990823.html. Accessed May 12, 2005. tions is the same: the osteopathic physician, resoundingly. 6. Kurtz ME, Nolan RB, Rittinger WJ. Primary care physicians’ attitudes and Osteopathy can be a model not only for individual patients practices regarding complementary and alternative medicine. J Am Osteopath but for populations and the healthcare system as a whole. The Assoc. 2003;103:597–602. Available at: http://www.jaoa.org/cgi/reprint/ osteopathic medical profession is uniquely positioned to meet 103/12/597. Accessed May 12, 2005. the needs of patients in this new era. Who better to look at the 7. Saxon DW, Tunnicliff G, Brokaw JJ, Raess BU. Status of complementary and role of structure and function on health dynamics in our alternative medicine in the osteopathic medical school curriculum. JAm Osteopath Assoc. 2004;104:121–126. Available at: http://www.jaoa.org/cgi/con- society? Who better to understand how the role of community tent/full/104/3/121. Accessed May 12, 2005. violence, domestic abuse, and the breakdown of family struc- 8. Still AT. Autobiography of A.T. Still [e-book]. 1897. Electronic library: early tures has had an impact on the structure and health of our American manual therapy page. Meridian Institute: Monterey, Calif; 2004. society? Who better to develop an integrated health policy for Available at: http://www.meridianinstitute.com/eamt/files/still3/st3cont.html. the entire nation? Accessed May 12, 2005.

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