System

DOs provide OMM in the context of a health care system with policies, leadership, and environmental factors that may be more or less conducive to OMM. When interviewees discussed systems issues, they primarily focused on referrals, appointments, and support from peers and leadership. Regarding referrals, interviewees reported that good relationships with DO colleagues help referring providers trust that their patients will benefit from OMM. Several noted that referring providers prefer easy referral mechanisms, standardized order sets, streamlined scheduling, and education on appropriate referrals in order to provide “ease of availability, ease of scheduling” (P03). Clinicians who refer for OMM want “options to refer locally” (P08), and they appreciate having partners in the same practice for internal referral. The limited availability of OMM appointments causes long wait times, “even getting people when you refer into the OMM clinic, it can be a month later” (P09). One family physician who provides OMM stated she doesn’t use OMM as often as she would like because “it takes six months to get into see me” (P13). Many interviewees felt this was much too long, and that the ideal follow-up duration would be only a few weeks.

Several interviewees expressed a desire for autonomy in the amount and duration of their OMM visits; this was seen as a weak point within their practice environment. A family physician observed, “We need to allow for that flexibility of scheduling, and I think that is the biggest barrier” (P13). They reported it is easier to provide OMM during visits scheduled for this purpose rather than incidentally during other visit types, in part because “our schedules are packed” (P12). They use various models for scheduling these visits, such as dedicated half days or 1 appointment per day. If they allowed OMM to be scheduled during any visit, it could quickly overwhelm the schedule. One DO observed they “get so many referrals for osteopathic manipulation that we have to put session limits on them” (P13). The atypical schedules for OMM visits can present problems with centralized schedulers with limited knowledge of OMM referral services, leading to double bookings, visits at the wrong time, or visits that are too short. One family medicine physician lamented, “The time that it would take to really appropriately treat patients and trying to arrange [OMM visits] in a schedule that would fit within our clinic structure” would “be a big hindrance” (P02).

Interviewees who provide OMM valued support from colleagues to discuss cases, validate treatment course, or see patients for OMM when they are out of the office. They also appreciate having a strong regional advocate to represent their needs in leadership discussions. Many interviewees would like to see peer networking opportunities, such as an OMM interest group, to learn useful techniques, discuss patient cases, and advocate for each other. As one said, “It’s helpful to actually have people around us that have a similar background, similar experiences, similar knowledge base… We offer something different than MDs, and it would probably just help us make connections” (P04).

In discussing how leadership affects the decision to use OMM, interviewees wanted their leaders to support physician autonomy and create an environment where OMM can flourish. They reported that their leaders generally allow practice of OMM and were helpful in providing resources such as tables, rooms, and appointments for OMM. However, as 1 interviewee stated, “we are just so woefully over paneled” (P09), and many felt that “there isn’t an ability to necessarily cap their panels” (P03) to reflect the time they spent performing OMM. Interviewees wanted their leaders to facilitate OMM education for health care staff and help spread news of OMM practices through “general education to the masses” (P15). They also hoped their leaders would focus more on recruiting and retaining DOs to practice OMM. One interviewee felt if their leadership would hire somebody “three days a week for family med and one day a week for OMM,” then “we’d get those people here” (P13).

Interviewees were mixed about whether reimbursement limited the amount of time they felt they could reasonably spend performing OMM. One family physician noted “there’s pretty good reimbursement” (P02). This was especially true for procedural specialists such as surgeons. Those who perform OMM reported that billing is easy in the electronic health record, but billing support staff need appropriate training on OMM billing to make sure that coders do not overturn their billing. One physician who provides OMM noted the need to be “diligent in your practice to check the billings happening, your coding’s not getting downcoded” or else “sometimes it doesn’t get billed correctly” (P12).

Capability

Interviewees varied in their self-assessment of their capability of providing OMM. Technical prowess was part of their assessment, but emotional responses appeared to be equally important. Enjoyment emerged as a key factor in the decision to provide OMM. Interviewees who use OMM reported that they enjoy doing it, while those who do not use OMM spoke fondly of times when they used to use it. A psychiatrist who does not use OMM observed that it was nonetheless “a vital part” of their medical school rotations (P01). One interviewee said, “I enjoy doing it, and I think I’m delivering a service that nobody else is delivering here” (P16). However, some reported not wanting to use OMM.

Many interviewees who do not perform OMM cited skill degradation as a primary reason. One family physician recognized they were using OMM “less and less in my practice,” and noted, “I felt my skills were dwindling somewhat” (P09). Training and regular practice were seen as ways to prevent skill loss, maintain stamina, and stay up to date on coding and billing; however, many reported having to rely on funding to attend continuing medical education events. Interviewees who did not feel comfortable with OMM reported they would need further training before resuming practice, and a few expressed interest in this training. “I would like to [use more OMM],” noted one interviewee. “I just haven’t done it in so long I feel that I would need a refresher” (P14).

Quick techniques were seen as especially helpful for busy clinicians. Interviewees described several osteopathic techniques, including fascial distortion model, high-velocity low amplitude and muscle energy. Fascial distortion model (FDM) was highlighted as especially fast, simple, and effective. “I heavily use FDM and then muscle energy and myofascial,” stated one family physician (P13). Rapid technique enabled more frequent treatment, as one physician observed, “Even despite going to 30-mintue visits over the last year and half, I’ve been able to do even more OMT with the direct techniques like FDM and stuff” (P02). High-velocity low amplitude (HVLA) and muscle energy techniques were also highlighted as quick, though not as easy to learn. Many interviewees “don’t feel comfortable” (P02) with high-velocity low amplitude techniques, which were seen as more involved technical skills with greater risk and difficulty. Many interviewees said they value techniques that can be performed during a physical examination.

Utility

Whether or not they provide OMM, many interviewees reported seeing it as a valuable treatment tool that helps avoid use of medications, especially opioids. One interviewee observed, “You will always have stories of people being on like 10,000 medications, getting all these pain medications, and then you will do OMM and then they’re not taking medications” (P04). Interviewees found OMM useful in acute and chronic illnesses, especially for pain. They valued how touching patients through OMM facilitates connection. OMM was offered to patients in all life stages, including pregnant women, children, younger adults, and the elderly. Interviewees reported positive personal experiences with OMM. Many said they use OMM on family members even if they do not use it on patients, such as the general surgeon who mentioned that “I use it at home on my family all the time” (P05).

Interviewees stated clinical specialty was important when deciding whether to use OMM. Subspecialists and primary care DOs agreed that OMM is most useful in primary care practice. One family medicine provider stated, “Primary care is the work horse of who does [OMM] (P09). One psychiatrist noted that, “Obviously, my biggest barrier is that it doesn’t fit into my practice setting and specialty” (P01). While some interviewees who practiced OMM were not in primary care, several agreed that, “If anybody is specializing in anything other than family medicine, or internal medicine, or primary care, then they’re not likely to use it” (P15).

Training

For a few interviewees, the holistic nature of osteopathic medical schools played a central role their decision to choose to become a DO. As one noted, “I only applied to one osteopathic school—one medical school. It was an osteopathic medical school, and it was because of that contextual comprehensive holistic approach to care” (P13). A pediatric neurologist observed, “I liked the idea that it was a little bit more holistic, looking at more preventative factors and the person as a whole” (P14). Many others were attracted by the perceived ease of admission among DO schools relative to MD schools. “Only a handful of DOs truly want to participate in OMT,” observed one participant. “For those people, it’s probably their driving decision to go into the osteopathic field. I think, for some people, it’s just about getting into any medical school they can, and then having to be DO or MD as long as they can become a physician” (P10). This concept was supported by a physician who stated, “The allopathic school put me on a wait list, so then I found an alternative” (P15). Several interviewees described choosing their medical school based off of location, as stated by a participant who stated he picked a DO school because, “Geographically, that’s where I wanted to be” (P06).

Presence of a DO mentor and appeal of the osteopathic philosophy also influenced their choice, such as the general surgeon who stated, “My dad’s partner was a DO, which I didn’t realize he was any different than the MD… I really liked his partner as a person and the way he practiced medicine” (P05). However, some found that their medical school training gave the impression that OMM was separate from mainstream medicine. One family physician noted that, “There was sort of this approach to medical education that was like, here’s medicine, and here’s how to do your physical exam, and here’s how to think about disease processes. Then here’s OMT. The entire process did not really integrate OMT into medicine, and so I had this constant cognitive dissonance between [medicine and OMT]… There were times where it felt like it was pulling me from medicine, and it being part of medicine” (P13).

Several DOs reported receiving adequate OMM training during medical school, which prepared them to treat patients of all ages using various techniques. “I think as a medical student I had great exposure,” remarked one interviewee. “As a fourth-year medical student, I had excellent exposure. I mean, I did it all the time” (P14).

In contrast, the primary training barrier reported by interviewees was inadequate OMM training during residency. As one remarked, “I learned OMM during med school, but I really didn’t do a lot during residency because I didn’t have supervision. It was pretty limited, and it remains really pretty limited” (P08). Another noted that when trainees don’t practice OMM during residency, “They don’t incorporate it or don’t know how to incorporate it” (P07). Alternatively, one interviewee observed that, “If you saw it in residency and you were like, ‘Hey, this really helped in this patient,’ you would use it” (P05).

Attitudes and beliefs

Interviewees reported OMM is not well-recognized by patients in their region, affecting both patient demand and provider perception. Even in their health system, people may not know what a DO is, including non-osteopathic physicians (especially specialists), schedulers, nurses, and leadership. Interviewees reported frequently observing patients and providers comparing OMM with chiropractic. Some interviewees were bothered by this comparison, while others welcomed it. One interviewee noted that when the comparison is brought up, “We get to have a conversation about how OMM is different than chiropractic and what are advantages or disadvantages for that” (P03).

Many interviewees observed that physician attitudes towards OMM tend to be positive, particularly for chronic pain indications. They often express excitement and are eager to refer. Attitudes differ by specialty and tend to improve with education and positive experiences with OMM. Staff wellness events were seen as a way to provide positive experiences and education, as one interviewee mentioned, “If [staff] experience it personally, that might probably help them spread the word” (P04).

Likewise, interviewees who perform OMM reported patients have a more favorable view of OMM when they have experienced it themselves. They stated that some patients seek them out for holistic care. One interviewee observed, “A lot of people come to me knowing what a DO is, because they’ve heard of them or they’ve had experience before, so when I offer [OMM], they’re excited” (P07). Another mentioned, “When you can take the time to really explain what it is you’re doing and why you’re doing it, there’s very few that actually then don’t want to proceed” (P11). Many reported that patients seem to have varying expectations of what OMM can do, such as expecting resolution of pain even when that is not offered.

Interviewees expressed that providers seemed more likely than patients to view OMM with skepticism. A pediatric rheumatologist mentioned, “I think the evidenced-based part is the question mark, right?” (P06) An internal medicine physician added, “There’s some definite fringe things in OMM that probably need to go away. I remember learning about craniosacral therapy when I was in med school. We’re not moving the bones. There’s no good biologic basis for that, so I think we need to get away from some of that stuff that isn’t helping us with our MD colleagues, getting acceptance. Some of that’s in our court as a profession” (P08). This interviewee continued, “The research was crap. Really, it was. It was garbage” (P08).

Resources

Interviewees reported that time and physical resources strongly affected their decision to provide OMM. Performing OMM was seen by interviewees as time-consuming amid busy schedules and diverse patient needs. The addition of OMM was seen as taking time that physicians may not have. “It just always takes more time than any other routine exam that I would do” (P16). “I was contacted before if I wanted to increase my manipulation, I said yes. Did it increase? Did I get more time? No” (P07). “The time that it would take to really appropriately treat patients and trying to arrange those in a schedule that would fit within our clinic structure, I think would be a big hindrance to trying to get something like that going more consistently” (P11).

Interviewees highlighted multiple extra steps involved in OMM, including:

1. Explaining the procedure, getting buy-in, and obtaining consent (this may take more time than the procedure itself)
2. Obtaining additional history
3. Performing the procedure
4. Documenting and coding the procedure

Interviewees felt that they already take care of too many problems; as one said, “I think we’re all overbooked and overworked and it’s hard to see every patient and it’s hard to get to your meetings and then also get home” (P05). Visits for OMM need to be long enough. Many interviewees reported that sessions should be 20–40 minutes depending on the context. Thirty minutes appeared to be adequate for most interviewees. Some reported having to find time for OMM between already-scheduled visits.

Interviewees who perform OMM reported needing access to an OMM table and a large enough room in which to perform OMM. They felt it was important for the table to have adjustable height and preferred tables with a face opening. An adjustable-height table was seen as important for patient and physician comfort. One physician stated that, “It hurts my back to do OMT on [fixed-height] tables” (P04). Also, a clinic requires enough rooms for the number of physicians performing OMM. “The biggest hinderance on that,” noted one DO, “has been we only have one procedure room between myself and [my partner]” (P02).