THE EVOLUTION OF PROFESSIONAL IDENTITY: THE

CASE OF OSTEOPATHIC MEDICINE

KATHERINE MILLER

Department of Speech Communication, Texas A&M University, College Station, TX 77843, U.S.A.

AbstractÐThe osteopathic medical profession was founded in the late 19th century and has become anaccepted part of the medical establishment in the United States. Throughout its history, the osteopathicmedical profession has attempted to de®ne itself in a way that di�erentiates osteopathy from otheralternative therapies and situates the profession as responsive to the changing health care needs of theAmerican public. This article examines identity within the osteopathic profession by examining theways in which the profession has created, maintained, and changed its identity in its over century-longexistence. The case analysis presented here involves the examination of identity statements culled fromseveral osteopathic data sources. The identity statements represent four speci®c time periods within theosteopathic profession: the founding statements of A. T. Still, statements from 1915 through 1935 whenthe scope of osteopathic identity was expanding, statements from 1954 through 1974 in which the os-teopathic profession dealt with internal and external threats in developing a ``separate but equal'' iden-tity, and recent statements from a osteopathic student web site that illustrate current and future viewsof osteopathic identity. The results of this case analysis highlight the role of the social environment inestablishing and changing professional identity, the importance of an occupational founder in shapingthe articulation of identity, and the tension between identity and practice within the osteopathic medicalprofession. # 1998 Elsevier Science Ltd. All rights reserved

Key wordsÐosteopathy, alternative therapies, professions

INTRODUCTION

The osteopathic medical profession was founded inthe late 19th century and has become an accepted

part of the medical establishment in the UnitedStates. Throughout its history, the osteopathicmedical profession has attempted to de®ne itself in

a way that di�erentiates osteopathy from otheralternative therapies and situates the profession as

responsive to the changing health care needs of theAmerican public. In this construction of identity,

the profession has dealt with the role of a strongand articulate founder, the challenge of expanding

practice and identity, and internal and externalthreats to the profession. This article examines iden-

tity within the osteopathic profession by examiningthe ways in which the profession has created, main-tained, and changed its identity in its over century-

long existence.The understanding of identity within the osteo-

pathic medical profession developed in this article isessentially grounded in a phenomenological or

``folk'' approach to professions. This view can becontrasted with ``trait'' or ``professionalization''

approaches (Brint, 1993) that assume that pro-fessions can be identi®ed in terms of a particular set

of professional characteristics (Millerson, 1964;Kultgen, 1988). Instead, a phenomenological

approach regards the concept of profession as a``folk category'' and suggests that professions mustbe studied through a consideration of the phenom-

enological character of particular professions and of

professions in general (Dingwall, 1976). Within this

approach, ``[o]ne does not attempt to determine

what profession is in an absolute sense so much as

how people in a society determine who is a pro-

fessional and who is not, how they ``make'' and

``accomplish'' professions by their activities, and

what the consequences are for the way in which

they see themselves and perform their work''

(Freidson, 1983, p. 27).

A phenomenological approach to professions

requires a consideration of the discourse through

which individuals de®ne themselves and their work.

Fine (1996) recently took this approach in his study

of organizational rhetorics among restaurant cooks.

He notes that organizational rhetorics are con-

cerned with central and enduring questions of iden-

tity. ``Through occupational rhetoric, workers

justify their work and explain to themselves and

their public why what they do is admirable and/or

necessary'' (Fine, 1996, p. 90). A phenomenological

consideration of professions requires the same

examination of identity and identi®cation accounts.

It is through such accounts that several aspects of

professional identity can be emphasized. First,

identi®cation is not a process in which an individual

assimilates an objective professional identity to a

greater or lesser extent. Rather, it is a process

through which a group of communicators negotiate

an identity for the institution with both internal

Soc. Sci. Med. Vol. 47, No. 11, pp. 1739±1748, 1998# 1998 Elsevier Science Ltd. All rights reserved

Printed in Great Britain0277-9536/98/$ - see front matter

PII: S0277-9536(98)00247-0

1739

and external constituencies (Cheney and Tompkins,1987; Christensen and Cheney, 1994). Further, or-

ganizational identity is not a ®xed concept. Rather,identity is ¯uidÐchanging as an institution movesthrough its life cycle and adapts its culture to in-

ternal exigencies and the external environment.Thus, a comprehensive approach to identi®cationmust consider the ways in which an institutional

community negotiates an identity over time withboth internal constituencies and the larger society.Thus, this essay will consider the ways in which

identity statements regarding the osteopathic pro-fession have evolved over the profession's 125 yearhistory.The osteopathic medical profession provides a

particularly valuable avenue for the study of theprocess through which a profession constructs itsidentity. The osteopathic profession was born in the

relatively recent past. Indeed, extensive statementsof the founder, Andrew Taylor Still, serve as a use-ful starting point for the study of this profession's

rhetorical development. Second, the osteopathicprofession has been forced to deal with a variety ofidentity concerns, both internal and external.

Internally, the profession has struggled with thenature of osteopathic practice and education.Externally, the profession has warded o� threatsfrom mainstream medicine, worked to di�erentiate

itself from other alternative therapies, andattempted to situate itself as responsive to the chan-ging health care needs of the American public.

Thus, this essay will chart the historic developmentof professional identity through a consideration ofthe 125 year existence of the osteopathic medical

profession. This case analysis will be followed bysome conclusions regarding the evolutionary con-struction of a health profession.

A CASE ANALYSIS OF PROFESSIONAL IDENTITY:OSTEOPATHIC MEDICINE

In Doctors: The Biography of Medicine, SherwinNuland (1988) traces the profession of medicine

back to Hippocrates, founder of the Coan Schoolon the island of Cos. He notes (Nuland, 1988, pp.8±9):

It is one of the ironies of history that the academy of Cos,the so-called Coan School, had a rival, situated on theopposite peninsula at Cnidus, which practised a form ofmedicine that was in some ways more like our own thanthat of the physicians of Cos. The Cnidian focus was onthe disease, while that of Hippocrates was on the patient.The Cnidian physicians, like those of today, were reduc-tionists, ®ne-tuners who directed their e�orts to the classi-®cation of the processes of sickness and to exact diagnosis.They sought to know the speci®c local organ disturbancesthat caused the symptoms they so assiduously categor-ized... The Hippocratic physicians saw diseases as eventsthat happen within the context of the life of the entirepatient, and they oriented their treatment toward restor-ation of the natural conditions and defenses of the sick

person and the reestablishment of his proper relation tohis surroundings.

At the turn of the 20th century, the contrastbetween Cnidian and Coan traditions was redrawnin the United States, with osteopathic physicians(D.O.s) following the philosophy of Hippocrates

and allopathic physicians (M.D.s) following theCnidian tradition. Though Nuland notes this as an``irony of history'', it is perhaps even more ironic

that Nuland writes almost 500 pages about the his-tory of medicine with no mention of osteopathy.Osteopathic medicine was founded in 1874 by

Andrew Taylor Still, a licensed ``frontier physician''from Kansas. Still became frustrated with ``oldschool'' medicine and its reliance on medication todeal with illness. His frustration peaked when his

children were wiped out in a meningitis epidemicand traditional treatment could do nothing forthem. At this point he was ``inspired'' to found a

new school of medicine Ð osteopathy (as he put it,``On June 22nd, 1874, I ¯ung to the breeze the ban-ner of osteopathy''). The basic tenets of the osteo-

pathic system today were espoused by Still at thattime: a focus on wellness rather than disease, afocus on treatment of the whole patient, and a

focus on the relationship between the structure andfunction of the body. As practised by Still andother early osteopathic physicians, this system ofhealing involved, almost exclusively, the manual

manipulation of bones and soft tissue with the goalof restoring structural integrity so the circulatory,nervous, and other body systems could function in

a natural and healthy way.When Still found little support for his system in

Kansas, he and osteopathy settled in Kirksville,

Missouri. In the ensuing 20 years, the fame of theosteopathic system of healing spread to the sur-rounding communities, as Still treated individualswith a wide range of ailments that had not

improved through treatment by ``old school''doctors. Arthur Hildreth recounts the early days ofosteopathy in ``The Lengthening Shadow of A. T.

Still,'' waxing eloquently about the sick venturingto Kirksville to partake of Dr Still's treatment(Hildreth, 1938, p. 87):

Kirksville awakened to the fact that through the work oftheir one-time lowly citizen their little city was fast becom-ing world-famous. Its reputation as the home of osteopa-thy was placing Kirksville on the map, so to speak. Oneman, with his hands, was administering a treatment basedupon the theory that disease is caused by structural altera-tions in the body machine, and through correction of suchdefects was curing many deplorable conditions that hadbeen pronounced hopeless in many instances by men ofhigh standing and splendid reputation.

Still founded the ®rst school of osteopathic medi-

cine in 1892. The ®rst class consisted of 17 students,and the curriculum was heavily based on anatomyand physiology with many opportunities to watchthe ``old doctor'' at work in manipulative treat-

Katherine Miller1740

ments. In 1896, Vermont was the ®rst state tolicense D.O.s. In 1897, the American Association

for the Advancement of Osteopathy (later theAmerican Osteopathic Association) was founded.Thus, by the turn of the 20th century, this ¯edgling

profession was starting to gain a foothold as anestablished system of health care.Growth of the osteopathic profession from that

point on was relatively steady and the osteopathicprofession today is a well-established ®xture on theU.S. medical scene. Five and a half percent of all

physicians are D.O.s and 11% of patients are trea-ted by osteopathic physicians. Osteopathic phys-icians are fully licensed in all states and receivetraining as comprehensive as M.D. training. D.O.s

use a wide range of treatment modes, includingthose of ``traditional medicine'' (e.g. drugs, surgery)and manipulation. Over half of today's D.O.s are

primary care physicians, though osteopathic phys-icians also specialize in all areas.Looking backward, osteopathic physicians of

today can marvel at how far they have come in 125years. From a ``lightning bone-setter'' in thenation's heartland has sprung a widely-accepted

profession with full practice rights, 19 medicalschools, and almost 40 000 practitioners. However,today, as throughout the profession's history, osteo-pathy is beset by questions about professional iden-

tity. The problem of identity takes many forms. Atone level, osteopathic physicians must struggle withde®nitions of osteopathy in today's world of health

care. How central is manipulative treatment? Howcentral is primary care? What exactly is holism? Atanother level is the profession's historical struggle

to craft an identity that is both true to A. T. Still'smemory and adaptive to current health care contin-gencies. These concerns lead to the central researchquestion guiding the analyses reported on in this

essay: How has the osteopathic medical professioncreated, maintained, and changed its identity in itsover century-long existence?

CASE ANALYSIS METHODS

Data sources for the case

Data for this case analysis of identity in the os-

teopathic profession were drawn from both primaryand secondary data sources. Secondary data on thedevelopment of the profession and its struggles with

identity were drawn from the literature on the his-tory of osteopathy (e.g. Gevitz, 1982, 1988a,b), theprofessionalization and sociology of osteopathy

(e.g. Baer, 1981, 1984, 1989; Forsyth and Thayer-Doyle, 1990), and from work on alternative medicalsystems in the United States (e.g. Wardwell, 1972;

Gevitz, 1988a,b; Saks, 1995).In addition, primary data were drawn from the

``identity statements'' of individuals within the os-teopathic medical profession. For the purposes of

this case, analysis was restricted to four speci®ctime periods that represent important turning points

in the osteopathic profession and to speci®c state-ments of identity by representatives of the pro-fession. The ®rst set of identity statements

examined considers the founding rhetoric ofAndrew Taylor Still, as represented in his state-ments published in the Journal of Osteopathy

between 1894 and 1910 (see Schnucker, 1991). Thesecond set of identity statements examined rep-resents the coping of the profession with A. T.

Still's death and the profession's expansion as acomprehensive medical system. This period of timeis represented by the addresses of the AmericanOsteopathic Association presidents between 1915

and 1935. The third set of identity statements exam-ined represents a critical period in the profession'shistory in which the role of the profession in the

greater U.S. society was being debated, particularlyvis a vis relationships with the allopathic medicalcommunity. This period of time is represented by

the acceptance speeches of A.O.A. presidentsbetween 1954 and 1974. Finally, the identitystruggles of the osteopathic profession today are

examined through ``on-line'' statements of identityculled from the world wide web. In particular, thestatements of osteopathic medical students found inThe Pulse (http://www.osteopathic.net/pulse) were

considered.Clearly, these identity statements are not all

representative of the ``rank and ®le'' of the osteo-

pathic profession and they are not directly compar-able with each other. However, these various datasources serve particular goals within the case analy-

sis. The statements of American Osteopathic presi-dents and president-elects, for example, are``o�cial'' views of the profession that may not berepresentative of the views of individual prac-

titioners. However, the goal of this analysis is notto consider the connections between individualphysicians and their profession, but to consider the

ways in which the osteopathic profession ± as awhole ± has historically constituted its identity.Following Merton (1982, p. 207), I would argue

that professional associations such as the A.O.A.have developed ``su�cient consensus to be able tospeak authentically and authoritatively on behalf of

the profession''. Second, the statements of currentmedical students ± though not ``parallel'' with thedata culled from presidential addresses ± provide awindow on the future of identi®cation within the

osteopathic medical profession.

Analysis of identity statements

The identity statements outlined above were ana-lyzed by the careful culling of all relevant identity

statements from the data sources, then the consider-ation of themes and categories that linked theseidentity statements. The themes were identi®ed foreach historical period separately, beginning with the

Osteopathy, alternative therapies, professions 1741

earliest period and moving chronologically forward.As identity statements from each historical period

were reviewed, they were considered in light of (1)the nature of the textual statement, (2) the contextin which the statement was made, (3) historical

events and contexts that preceded the statement,and (4) theoretical concepts regarding the socialconstruction of professional identity. Thus, the

analysis involved a hermeneutic ``tacking'' amongtext, context, history, and theory (see Diesing,1991).

CASE ANALYSIS RESULTS

The seeds of osteopathic identity: the rhetoric of A.

T. Still

Osteopathic medicine was born when orthodox

medicine was dominated by ``heroic'' techniquessuch as blood-letting and the use of purgatives suchas calomel. A. T. Still was frustrated with thesepractices of the ``regulars'' both because of their

ine�ectiveness and because of an underlying moralobjection to drug therapy based largely on hisstrong Methodist background (Gevitz, 1988a,b).

Though alternative schools such as homeopathyand eclecticism were available at the time, Stillfound neither of these alternatives satisfying and he

turned his attention to other practices including``magnetic healing'' and ``bone-setting'' (Gevitz,1988a,b). From these inspirations, Still founded theschool of osteopathy in 1874, moved to Kirksville,

Missouri in 1889, and established the AmericanSchool of Osteopathy in 1892. In 1894, Stillfounded the Journal of Osteopathy, a compendium

of views about osteopathy, primarily from the per-spective of those in Kirksville, the profession'smecca. A view of osteopathic identity from the

founder's perspective can be culled from Still's pub-lished words within this Journal.Still's rhetoric was far-ranging, with comments

on speci®c therapeutic techniques, educational goalsfor the profession, legislative progress, and news ofthe day. Many of his comments within the Journalof Osteopathy, however, centered on the nature of

his invention, osteopathy, something that ``standspre-eminently above all things else'' (Still, 1894, inSchnucker, 1991, p. 1).

Though Still sometimes de®ned osteopathy interms of its lexical roots (e.g. ``Greek lexicographerssay it is a proper name for a science founded on a

knowledge of bones,'' Still, 1895, in Schnucker,1991, p. 18), he more often discussed the practice ofosteopathy metaphorically or comparatively. Still's

favorite metaphor was that of the machine. He ®rstargued that humans can best be viewed in mechan-istic ways (Still, 1894, in Schnucker, 1991, p. 11):

It proves that man, or any other animal, is but a machinerun by positive laws of animal life. No well informed anat-omist, can think otherwise for a moment. We ®nd a ma-

chine with all the parts, qualities, and requirements thatperfection means. A complete system of nerves from thebrain to all parts. A complete system of arteries, plowingfrom center to surface, feeding all parts with blood inquality, kind and quantity, just enough, no more, no less,to ®ll the divine law of animal life.

Still then argues that ``disease is the creaking ofthe eccentricities of any or all parts of the machin-ery'' (Still, 1896, in Schnucker, 1991, p. 49) and

that the proper role of an Osteopath is to return abroken machine to working order (Still, 1894, inSchnucker, 1991, p. 5):

They will look you over as an engineer would look overhis engine, to see if it is in running order. If found out of®x, they adjust the machine and start it to running.

Still also de®ned osteopathy in comparativeterms, and his most frequent point of comparison

was the practice of traditional medicine, alsoknown as regular medicine or allopathy. It is inthese comparisons that Still's rhetoric became the

most vituperative. For example, he makes thisdirect comparison (Still, 1894, in Schnucker, 1991,pp. 11±12):

The question is asked often, ``How does Osteopathy com-pare with Allopathy?'' Osteopathy cures, Allopathy kills,teaches you to drink whisky, eat opium, ruin your wholemanhood until you are a total wreck, and makes youashamed to be in society until you get another dose ofmorphine; that you are the most pitiable fool, and the big-gest liar in the country... Osteopathy cures fevers and alldiseases of any climate and sends you home to make a liv-ing for yourself and those dependent upon you. That ishow a truthful comparison stands.

Still's antipathy toward allopathy is almost

always directed toward the use of drugs in the regu-lar's system, and his comments also extend to``homeopathic practice, with its sugar-coated pills''(Still, 1894, in Schnucker, 1991, p. 1). Indeed, Still

makes it clear that there will be no concessions inosteopathy's ``war on drugs'' and he stakes thefuture of the profession on this position (Still, 1896,

in Schnucker, 1991, p. 55):

The ®ght is hot and heavy; blood runs in great rivers fromit. An armistice is called for. A proposition is made inwriting on the walls. The generals of drugs ask us to betails to their kites, and to be friends. They are sent backwith this announcement, that this war is waged for prin-ciple, and no quarter will ever be asked or given until theyconcede to give us equity in all that is honorable, grantingto us all the rights of progress without restraint.

Clearly, then, A. T. Still's founding vision for

osteopathy is one de®ned by opposition to drugsand by a belief in the therapeutic bene®ts of manip-ulative treatment (e.g. adjustment of ``the ma-

chine''). Osteopathy is a pure science that should beunadulterated by drugs or by other ``adjuncts'' ofthe day such as vibrators or electric shocks. Indeed,

Still made this purity foremost when he stated that``[i]f you go out thinking that Osteopathy is a goodaid to medicine, you are using the words of incom-petency'' (Still, 1898, in Schnucker, 1991, p. 172).

Katherine Miller1742

Expanding the scope of osteopathic identity: rhetoricof 1915±1935

In the early part of the 20th century, as A. T.Still reached the end of his life, the profession

struggled with the tension between maintaining anarrow de®nition of osteopathy and expanding theprofession to meet perceived patient needs and to

compete with allopathic physicians. Some earlyexpansions were relatively easy. For example, Stillhimself worked to include obstetrics in osteopathy

by writing a ``full treatise on Obstetrics'' that was``Osteopathic from start to ®nish'' and would``easily go into your vest pocket'' (Still, 1895, inSchnucker, 1991, p. 45). However, other expansions

of osteopathic practice were much more di�cult.Clearly, the most troublesome issue was the in-clusion of pharmacology (known in the early 20th

century as ``materia medica'') into osteopathic prac-tice and education.A. T. Still built the profession of osteopathy on

the base of his opposition to the drugs of ``the regu-lars''. To his death in 1917, Still denounced medi-cation and put little stock in the germ theory ofallopathic medicine. Indeed, the nameplate of a

painting of Still in Kirksville, Missouri recounts hisdying words as ``Tell the Boys to Keep it Pure''.However, in the early 20th century, mainstream

medicine was moving away from some of the nas-tier heroic measures of earlier decades, and manyD.O.s found it di�cult to deny the e�cacy of some

medicinal treatments. Thus, a major thrust of osteo-pathic rhetoric during this period involved theappropriate use of drugs by osteopathic physicians

and the teaching of materia medica in osteopathicmedical schools.Some statements early in this period kept to

Still's staunch opposition to drugs. For example,

Meacham (1916, p. 658) referred to the use of drugsas ``broader osteopathy'' and noted it as ``anotherlittle canker at work''. However, other professional

spokesmen counseled a more balanced perspective(Upton, 1915, p. 637):

There has been some uneasiness over the trend toward theteaching of materia medica in some of the colleges, due toa misconception of the most vital problem a�ecting thefuture of our practice. There is no need for alarm and nodanger to the basic principles on which the practice ofosteopathy is founded. The problem will work itself outslowly but surely to our advantage.

In the 1920s, though, the tide began to turn, and

osteopathic leaders increasingly supported the in-clusion of pharmacology in osteopathic practiceand education, albeit in somewhat indirect ways.

There was a legislative imperative in this shift ±obtaining legal standing for the profession and cer-ti®cation for osteopathic medical schools was

increasingly dependent on a curriculum thatincluded pharmacology. McDonald (1930, p. 15)supported such changes, stating ``[t]he law gives youthe right to treat sick people. Since it does, it can-

not deny you the right to study and use toxicology,anesthesia and emergency narcotics''. However, the

rhetoric of osteopathic spokesmen clearly demon-strates their discomfort with the topic of materiamedica, and leaders used a variety of appeals to jus-

tify this major shift in osteopathic practice and edu-cation. A most telling example of these appeals isincluded in the A.O.A. Presidential Address of

Warren B. Davis in 1931. In his address, Davis(1931, p. 11) moves from staunch opposition ofdrugs to support of materia medica through appeals

that could be labeled, ``know the enemy'' and``some drugs are okay''.

We do not in any way approve of ``entering medicine orsurgery through the back door'' as someone has called it.If any one wants to practice drug therapy let him go to amedical college and be a so-called ``regular''... I do believe,however, that our physicians should be quali®ed for gen-eral practice in every way... Are we afraid to teach ourstudents the nature and properties of drugs because suchknowledge will detract from their faith in osteopathy?Probably all will admit that there is occasionally a time ingeneral practice when a doctor should prescribe somedrug. Would you, if you were the patient, prefer a doctorwho was ignorant of the nature of drugs or a doctor whohad studied the nature of drugs and who knew their sub-stances and their dangers?... The more a physician knowsabout drugs the less he uses them; the more a physicianknows about osteopathy the more he uses it. Therefore, Isay, teach pharmacology that our physicians may have aknowledge of the nature and substances of drugs andteach osteopathy in such a way that the osteopathic phys-ician may know that he has the most e�ective system oftherapy in the world.

Of course, with this shift in belief about the roleof drugs in osteopathy, a clear contradiction arises

with the original vision of A. T. Still. Rhetors ofthe day, however, dealt with this contradiction byrecasting the vision of A. T. Still and reinterpreting

the nature of osteopathic identity. In the speechesof this period, Still's vision of osteopathy was notdiscussed in terms of his anti-drug stance or interms of his ``machine'' vision of the human body.

Instead, references to Still consistently refer to hisstatements about the role of future generations toful®ll the early promise of osteopathy. Riley (1918,

p. 654) harkened back to the founder, stating,``[h]ow oft did he tell us in those days agone, `Ihave just charted the bold outlines of osteopathy:

you boys and girls will have to go on and ®ll in thedetails'. Similarly, Fryette (1919, p. 564) arguedthat ``Dr Still knew that there was more to osteopa-

thy than was taught in those early days. He said:`Now, boys, I have the squirrel by the tail: it is leftto you to pull him out'. Indeed, contradictionsbetween current practice and founding vision could

be clearly justi®ed if Still was seen as someone whomerely glimpsed the possibilities of osteopathyrather than someone who developed core tenets of

the profession (Conley, 1935, p. 557):

To say that the Old Doctor gave us the last word in theapplication of his concepts to the healing art would be ona par with the statement that Benjamin Franklin had

Osteopathy, alternative therapies, professions 1743

exhausted the possibilities of electricity when he touchedhis knuckle to the key attached to the string of his kite.

With this reinterpretation of A. T. Still also camea reinterpretation of the nature of osteopathy.Though there were some references to the import-ance of holism and natural immunity in osteopathy,

the rhetoric during this period shifted largely to ade®nition of osteopathy grounded in the concept of``progress,'' where progressiveness is seen as the

combination of breadth and distinctiveness. Forexample, Purdy (1933, p. 468) stated that ``[t]hefoundation upon which osteopathic education is to

be builded must be comprehensive enough to givethe student a breadth of knowledge commensuratewith the needs of modern thought and advance-ment'' and Conley (1935, p. 560) argued that ``we

must temper the osteopathic concept... to a ¯exi-bility of clinical purpose''. Indeed, even as early as1922, members of the profession were advocating a

progressive and inclusive view of osteopathy(Scothorn, 1922, p. 762):

We must have vision to honor and appreciate everyadvance in the direction of greater ability to cope withhuman ailment. We must have vision to bow to andaccept every demonstrated truth, regardless of whether itcomes from within or without the profession. Our visionof osteopathy should be the vision of a great aggressiveand progressive science that works on and on to bring tolight every method which can bring more happiness andhealth to the world, but is not too proud to acclaim andaccept the truths that others may have demonstrated.

Finally, rhetoric about the ``other school'' ofmedicine also shifted during this time period. No

longer were M.D.s demonized as the creators ofdrug addicts and the killers of children. Instead, amore rational stance is taken in which the medicalcommunity's control in speci®c arenas such as mili-

tary service (Riley, 1918) or school immunizations(Swope, 1925) is criticized. Rhetoric during thisperiod also consistently warned of the dangers of

absorption, often pointing to the fate of homeop-athy and eclecticism. Gilmour (1926, p. 1007) notesthat ``[t]he object lesson furnished by the recog-

nition of homeopathy through almost completeabsorption is too recent and too strong to be disre-garded by the osteopathic colleges and the pro-fession'' and continues a year later (Gilmour, 1927,

p. 18) that ``[we are] well within the danger mark ofan attempt to absorb the distinctive theory of osteo-pathy by the dominant school, just as has been the

case in other instances that were ®rst scorned bythat autocratic body''. However, osteopaths of theday are also chastised to not blame problems on

outside entities such as the AMA and the medicalprofession. Clark (1929, p. 858) says that he is``convinced beyond a doubt that our worst enemy is

in our own ranks, drifting away from osteopathy''and Conley (1935, p. 557) states that ``our greatestmenace lies within our own ranks''. Indeed,Meacham (1916, p. 656) draws on the patriotic

spirit of World War I in arguing that ``the enemy isus'':

I have this to say, if osteopathy is dead it is the liveliestcorpse I have every seen, and if osteopathy ever dies it willbe murdered in the house of its friends. There is not forceenough in the organization of the American MedicalAssociation, there is not force enough in the Congress,there is not force enough in the Central Powers and Alliescombined to kill osteopathy, unless we murder it our-selves.

A ``separate but equal'' identity: rhetoric of 1954±1974

By the mid-1950s, the osteopathic profession had

dealt with many early issues of identity, but wasstill struggling with acceptance in the larger commu-nity. For example, Gevitz (1982) notes that by the

1940s, most D.O.s had begun using the title ``osteo-pathic physician'' rather than ``osteopath'' in amove to improve the status of the profession in the

public eye. The profession continued to ®ght forcomplete rights in all states during this period, andthat battle was ®nally won in 1973 with the passageof a full practice law in Mississippi. In general, the

rhetoric of this time period suggests the ``maturing''of the profession. Professional spokesmen rarelyconsidered the ``details'' of therapeutic practiceÐor

even the details of educational and legislative bat-tlesÐin their rhetoric. Instead, A.O.A. presidentswere increasingly looking outside of the con®nes of

the profession in a consideration of the ``other''school of medicine (e.g. M.D.s and their pro-fessional body, the A.M.A.) and a consideration of

the role of osteopathy in enhancing public welfare.Rhetoric about medical doctors and the A.M.A.

was not new, of course. A. T. Still vili®ed the``regulars'' in his rhetoric, and speeches in the early

1900s criticized the dominance of allopathic medi-cine, though in more measured tones than those ofStill. In the middle of the 20th century, however, a

more ``institutional'' rhetoric is adopted with regardto the A.M.A. and the medical profession.Osteopathy seems more sure of itself, noting that

osteopathic actions ``have won us, ®rst, thousandsof patients and, second, recognition by manygroups'' (Mulford, 1954, p. 2). This con®dence isre¯ected in the nature of comments directly consid-

ering the medical community. Two themes areapparent in these remarks during the 1950s: ®rst,that the osteopathic profession does not need to be

under the ``protective custody'' of the A.M.A. andsecond, that the osteopathic profession is alwayswilling to ``cooperate with all responsible health

agencies, and to discuss with them our mutual pro-blems regarding our common objectiveÐservice inthe public welfare'' (Moore, 1955, p. 2). These

cooperative discussions were instantiated in the``conference committee'' between the A.O.A. andA.M.A. established in 1951 (Gevitz, 1982), an inter-professional group whose purpose was supported in

Katherine Miller1744

several presidential addresses during the early- andmid-1950s. The comments of Morrison (1957, p. 4)

are representative of the general attitude of thistime period:

With regard to other health professions, relations havebeen steadily improving, on the whole. Each group isbecoming more ``scienti®c''Ðthat is, we are all learningthat the vigorous opposition of ideas can be carried on inan atmosphere of mutual respect. Foundations have beenlaid for the highest degree of interprofessional co-operation. And we shall maintain our faith that our policyof willingness to co-operate will eventually result in thesolution of remaining problems.

However, this rhetoric changed dramaticallywhen, in 1961, the California Medical Associationand the California Osteopathic Association

``merged'' (see Gevitz, 1982, for full discussion).This ``merger'' allowed D.O.s licensed in Californiato adopt the ``M.D.'' title and transformed theCollege of Osteopathic Physicians and Surgeons

into an M.D. school, the California College ofMedicine. Naylor (1961), in his PresidentialAcceptance Address following the merger, made

clear some of the lessons learned from the experi-ence. These lessons were in part external onesregarding the medical profession: ``the A.M.A. has

shown bad faith in their dealings with us, and... ifany further progress is to be made they will have torecognize our legitimacy and independence'' (p. 2).

But the lessons were also reprisals of the ``theenemy is us'' theme discussed earlier (Naylor, 1961,p. 1):

What have we learned from our tribulations during thepast year? We have learned, ®rst of all, that this professionhas great strength and that the only way it can bedestroyed is from within. No agency or group of individ-uals outside this profession could have accomplished whatthe leaders of the conspiracy in California accomplished.Their careful plans were e�ective only because they wereable to hide their motives under the guise of helping thisprofession to improve and expand.

This time period was also marked by a largerconsideration of the role of osteopathy in publicwelfare. Earlier rhetoric considered the e�cacy of

osteopathic treatment in individual cases. In con-trast, spokesmen during this time period talkedmore about how osteopathic medicine could betterserve the larger public health needs facing the

United States. In noting that ``what is good fororganized medicine is not always good for theAmerican people'' (Horn, 1970, p. 15) the osteo-

pathic profession de®ned itself as the guarantor of``democracy in the ®eld of health care and medi-cine'' (Hayes, 1966, p. 15). Speeches during this

time period pointed to the leading role the osteo-pathic profession could play in emerging nationaltrends such as group and industrial medicine, pri-

mary care, ecological medicine, and holistic medi-cine.Thus, in the middle portion of the 20th century,

the osteopathic profession was rede®ning itself with

a more broadly construed nomenclature. New termsused to describe osteopathy included complete

(''osteopathy... is our only complete minority schoolof medicine,'' Young, 1959, p. 2), comprehensive(``we have rendered a service... not equaled in its

comprehensiveness by any other school of medi-cine,'' Pearson, 1963, p. 16) and ¯exible (``we pos-sess the wisdom and ¯exibility to innovate and

change,'' Horn, 1970, p. 16). In keeping with thisbroadened perspective, the roots of osteopathy wereas often placed with Hippocrates as with A. T. Still.

For example, Northrup (1958, p. 2) stated that``[t]he roots of the osteopathic profession are buriedin the antiquity of the medical world. The basicprinciples upon which the osteopathic school of

practice was founded are in actuality a restatementof basic concepts of Hippocrates''. Though osteopa-thy did not totally abandon appeals toward distinc-

tiveness, leaders argued that the mature professionof osteopathy could best serve the public withapproaches that were not radical (Heatherington,

1969, p. 13):

The challenge for new leadership, then, is the challenge fora new and moderate voice, a voice that foregoes rhetoricand political slogans and replaces them with wisdom, com-mon sense, and understanding. We, the members of theosteopathic profession, can supply that voice.

Distinction or extinction? The rhetoric of today's os-teopathic medical students

As we enter the 21st century, new classes of medi-cal students are training to become part of the os-teopathic profession. The profession has survived a

variety of crises and is now a well-established ®x-ture on the American medical scene. The rhetoricexplored in the last two sections of this essaydemonstrated the ways in which osteopathic iden-

tity has shifted both in terms of what osteopathicphysicians do, and how osteopathic physicians ®tinto the larger health care industry. In this section,

the comments of current medical students areexplored to consider the present and future of os-teopathic identity. These comments were culled

from a world-wide web site ± The Pulse ± designedto discuss issues of importance to current osteo-pathic medical students.Clearly, osteopathic identity is still a hotly-con-

tested topic. The articles on this web site were fullof debates about what osteopathy is, how it hasdeveloped, how it di�ers from allopathy, how news

of osteopathy should be spread, and whether theprofession has a distinct and independent future.De®nitions of osteopathy proposed by students

tended to be very broad. For example, one studentproposed a 3-point de®nition that included unrest-ricted medical practice, health promotion, and treat-

ment of disease (Steele, 1997). Other studentscommented that the de®nition is ``constantly evol-ving'' (Carlisle, 1997) and that ``an accurate de®-nition of osteopathy may never be born''

Osteopathy, alternative therapies, professions 1745

(Mutscheller, 1997). Indeed, this student summedup this broadened conceptualization of osteopathy

by quoting Wilbur V. Cole's textbook, AnIntroduction to Osteopathic Medicine. Cole statesthat ``Osteopathy is a word that de®es de®nition,

for it actually refers to an organized movement forthe continual reorientation of medicineÐa move-ment within the past, present, and future medical

history''. This is, of course, a far cry from A. T.Still's de®nitions of osteopathy 100 years ago, but itis a conceptualization more in keeping with the

evolving nature of today's world of health care.Questions of identity for today's students often

centered, like in the past, on comparisons with allo-pathic medicine. However, the debate today is

much more personalized than it was in the 1950sand 1960s. Consider the comments of Cain (1997):

Are you tired of hearing them tell you how you are ``justas good as any MD'' so many times that you are begin-ning to wonder if this isn't some kind of brainwashing orfraternity hazing. You ask yourself, ``If I am as good asany MD, why does everyone have to tell me all the time?And not vice versa?'' Where are the pep talks for MDs toassure them that they are as good as any osteopath, chiro-practor, or naturopath.

Students reach a number of conclusions when

making comparisons with allopathic medicine.Some conclude that there are no real di�erencesbetween the two schools (e.g. ``[w]e both try to do

our best for the patient,'' Dotzman, 1997; and ``weall still answer to the same parents born from deathand su�ering,'' Mleynek, 1997). For many, this lackof distinctiveness provides a warrant for a titular

change to initials that include both the concepts of``medical'' and ``osteopathy''. Frequently suggestedinitials include D.O.M., M.D.O., and D.O., M.D.

Though a former A.O.A. president who contributedto the web site noted that the debate about thedegree designation has been going on for several

decades (Kasovac, 1997), the issue showed no indi-cation of abating among current medical students.Other web site contributors, however, were con-

cerned about the abandonment of osteopathic prin-ciples. Marlow (1997) notes that, ``[u]nfortunately,there are those among our ranks who do notembrace the philosophy or principles of osteopathic

medicine,'' and Mott (1997) believes that ``wannabe M.D.s are simply ignoring the principles uponwhich their profession was built''. Mott continues:

Analyzing the current status of health practitioners in theUnited States, one thing is clearÐmedical doctors are thekings when it comes to drugs and surgery, and chiroprac-tors are the masters of manipulation. So where does thisleave osteopathy? With nothing to cling to, and a namethat is no longer ®tting, one can only assume that thedays are numbered for osteopathy in the United States.

This view ± and views advocating complete amal-gamation ± are relatively extreme examples, how-ever. Most writers on the web site took a moremoderate position, and often harkened back to A.

T. Still in o�ering their ideas. Many embraced thetraditional osteopathic principles of wellness and

holism, and argued that manipulative therapy stillhas a role in today's health care arsenal. However,many students also expressed frustration over the

development of the osteopathic profession andtalked about identity qualms that have yet to besettled in the profession's over century-long exist-

ence. One student expressed the tension betweenhistory and current contingencies in a letteraddressed to A. T. Still (``Complete Equality'',

1997):

Dear Dad,

I love you and revere you. I am undyingly grateful to youfor inventing the profession to which I am devoting mylife, but I've got to tell you that you have lousy tastewhen it comes to names. When you invented this pro-fession, why did you have to call it osteopathy?... I realizethat at one time, an osteopath was something quite di�er-ent than an MD, but that is not as true today. In order tosurvive in today's world, we had to change. Our schoolshad to add to their curricula all the elements that arefound in the curricula of allopathic medical institutions.Consequently, D.O.s today prescribe drugs, perform sur-gery, provide every single service that the M.D.s do, andin addition to that, we still o�er that good old osteopathictouch. I bet that sounds pretty good to you. I bet itsounds a lot like what you had hoped the future wouldhold.

In some ways, this student is undoubtedly wrong.The profession is not what A. T. Still envisioned,

and it probably would not look very good to him.Indeed, Still speci®cally disavowed the value of anM.D. with the ``osteopathic touch''. But the osteo-

pathic profession has been without A. T. Still for80 years, and it now must struggle with its identityin a radically di�erent health care environment.

Thus, current students' struggles with osteopathicidentity are just as palpable as those faced by Stilland his students at the turn of the century.

THE EVOLUTION OF OSTEOPATHIC IDENTITY

In a century and a quarter, the professional iden-

tity of osteopathic medicine has changed in substan-tial ways. From A. T. Still's characterization of the``body as machine'', emphasis on manual manipu-lation, and extreme hatred of the drug treatment of

the regulars has emerged a practice much like allo-pathic physicians. In making this transformation,the osteopathic profession needed to come to terms

with the use of drugs and other mainstream modal-ities in treatment, with the threats of eliminationand then absorption by the medical establishment,

and with the role of the profession in a changingAmerican society. Through these changes, the os-teopathic profession has demonstrated a ¯exible

resiliency, a ``bend but don't break'' philosophy.They have changed professional practices and pri-orities. But they have not yielded in their determi-nation to remain a separate (though not

Katherine Miller1746

particularly distinct) profession and in their alle-

giance to philosophical principles such as holism,health, and the relationship between structure andfunction.

Several important insights can be drawn fromthis case analysis. Perhaps most striking is the roleof the environment in the social construction of

professional identity. Osteopathy began in a healthcare ®eld that included homeopaths, eclectic phys-

icians, and ``regular'' physicians. The professionsurvived the ®rst ``shake-out'' at the turn of thecentury, and continued to deal with the animosity

of mainstream medicine. Osteopathy weatheredthese challenges to be faced with the needs oftoday's complicated health care environment and

current trends of holism, prevention, and managedcare. Osteopathy survived because of its general

awareness of the environment and because of itsadaptiveness in the face of these threats. Freidson(1983, p. 28) has argued that if a profession is to

``accomplish'' itself, it ``cannot fail to include takinginto account the conceptions of members of otheroccupations with whom interaction takes place, and

negotiating with them some workable agreement''.Osteopathic medicine did not always ``negotiate''

with other professional groups. However, osteopa-thy was almost always vigilant in its awareness ofother professions and the society at large, and this

vigilance served the profession well.A second notable aspect of this analysis was the

continuing, but shifting, role of a strong founder in

articulating and socially constructing the nature ofosteopathic identity. Andrew Taylor Still simply

does not go away in the discourse of osteopathicmedicine. However, his role in the discussion ofidentity has changed dramatically and changed very

quickly after his death. Still's strident rejection ofdrugs has been all but forgotten. Instead, he is nowrevered for his philosophical positions (which were

not particularly well-articulated by Still himself),for his maverick nature, and for his love of osteo-pathy. Organizational scholars (e.g. Schein, 1985)

have pointed to the importance of the founder inarticulating strong cultural values. This analysis

suggests that the founder's role is equally importantin a profession, but, at least in osteopathy, the in-¯uence consists of tradition and continuity rather

than actual content. This analysis is in line withsocial constructionist positions, as beliefs aboutStill's positions on issues have been ``rei®ed'' and

now serve to inform current conceptions of identity.Finally, this analysis leaves us still with the ques-

tion of osteopathy as a profession. A ``folk pro-fession'' approach would contend that osteopathyis, indeed, a profession, because they see themselves

and talk about themselves as a profession. Theyhave the professional association and other accou-terments that mark them as a profession. However,

the practice of osteopathic medicine is largely indis-tinct from allopathic medicine and the education of

osteopathic medical students is largely indistinctfrom allopathic education. Further, the philosophi-

cal markers of the osteopathic profession ± holism,preventive medicine, relation of structure to func-tion, primary care ±have largely been adopted by

mainstream medicine. The osteopathic struggle forsurvival and success has required the profession tocraft an identity that bears little resemblance to

their founding identity and bears a striking resem-blance to the profession they originally were revolt-ing against. It may be impossible for osteopathy to

craft an identity that justi®es a distinctive and sep-arate profession in the coming century. However, ifthe past 125 years serve as precedent, they may con-tinue to walk the identity tightrope on which they

are true to some philosophical roots and responsiveto a complex health care environment.

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