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The implementation of a comprehensive sleep medicine program requires the participation of health care providers from different clinical departments or hospital services. The following is a schematic showing the different services offered in a sleep medicine program for adults (age >18 years) with suspected or proven sleep disorders.This diagram (created by Edward C. Mader, Jr., MD) applies only to adults with suspected or proven sleep disorders. Abbreviations used: OSA=obstructive sleep apnea, CPAP=continuous positive airway pressure, BiPAP=bilevel positive airway pressure, APAP=autotitrating CPAP, PSG=polysomnography, MSLT=multiple sleep latency test, MWT=maintenance of wakefulness test, OCST=out-of-center sleep testing, HST=home sleep testing. BST=bedside sleep testing, PFTs=pulmonary function tests, UPPP=uvulopalatopharyngoplasty.----------------------------------1. CLINICAL SERVICESIn practice, the different sleep disorders can be categorized as A-type or B-type. B-type sleep disorders (B=breathing) include those disorders in which the main problem is a disturbance of breathing. This category includes obstructive sleep apnea (OSA), central sleep apnea (CSA), and various sleep hypoventilation syndromes. A-type sleep disorders (A=aside/apart from breathing) includes all other disorders that do not belong to the B-type category. It is therefore practical to have two different types of clinics: a sleep medicine clinic and a sleep apnea clinic.Sleep Medicine Clinic (SMC). This will serve patients with a suspected sleep disorder, patients with a known A-type sleep disorder, and patients with both types of sleep disorders where the A-type disorder is more significant because the B-type disorder is either very mild or controlled with current treatment. All new patients with an undiagnosed sleep disorder should be seen in the SMC first. SMC evaluation includes history-taking, physical exam, and various data collection tools such as the sleep questionnaire, the Epworth sleepiness scale, and the sleep log or diary. Risk factor assessment and OSA screening will also be performed. If necessary, the patient will be referred to the sleep apnea clinic (see diagram), to an appropriated specialist, and/or to the sleep lab for a formal sleep study. SMC patient care includes drug therapy, patient education and counseling, and follow-up to monitor response to treatment.Sleep Apnea Clinic (SAC). This will serve patients with suspected or proven OSA or other B-type sleep disorder. OSA screening may have been done already in the SMC or by the referring primary care physician or specialist. Rapid OSA and breathing assessment is performed in the SAC. The decision is made whether a portable monitoring (OCST/HST) or formal sleep study should be performed. Auto-titrating CPAP (APAP) can also be offered if warranted. The application of positive pressure devices (CPAP, BiPAP, APAP) and out-of-center sleep testing (OCST) or home sleep testing (HST) devices will be done in the SAC. Other SAC services include mask fitting and pressure titration, patient instructions, data retrieval, and interpretation, compliance assessment, and counselling.Primary care services (e.g. risk factor management, treatment of obesity) and other specialty services (e.g. psychotherapy, pain management) are important components of sleep medicine.----------------------------------2. LABORATORY SERVICESA number of laboratory procedures will be available for making a definitive diagnosis of a person’s sleep disorder. Polysomnography (PSG) remains the gold standard for diagnosing most sleep disorders. Portable monitoring is increasingly being utilized and some portable devices have been validated for clinical use as cheaper alternatives for diagnosing OSA when indicated.Sleep lab testing is required to diagnose certain sleep disorders. Standard sleep studies that are performed in the sleep lab include polysomnography (PSG), multiple sleep latency test (MSLT), and maintenance of wakefulness test (MWT).Polysomnography (PSG) is recorded at night while the patient is asleep in a specially designed bedroom. If the baseline PSG demonstrates significant apneas, CPAP titration is performed in the sleep lab. In this case, the PSG is called a split-night study.Daytime nap studies, MSLT and MWT, are performed during the day preferably after the PSG. MSLT is the gold standard for determining the presence of excessive daytime sleepiness and for demonstrating REM sleep intrusion. It is usually needed to diagnose narcolepsy and other causes of primary hypersomnia. Daytime nap studies have also become a standard job requirement to exclude excessive daytime sleepiness when constant alertness is required for job safety (e.g. truck driving).Portable monitoring is performed outside the sleep lab using a portable recording device. It is often considered synonymous with out-of-center sleep testing (OCST) or with home sleep testing (HST). The portable device is applied to the patient by the respiratory technologist in the sleep apnea clinic. Bedside portable monitoring can also be performed in hospital patients with medical conditions that preclude sleep lab testing.If OSA is confirmed by OCST, an auto-titrating CPAP (APAP) can be applied to determine the CPAP pressure that will be therapeutic. A negative portable study however does not rule out OSA and other breathing disorders. In this case, formal PSG is warranted. If a condition is present where APAP is contraindicated (e.g. severe cardiopulmonary diseases), CPAP titration must be completed in the sleep lab.Another portable sleep monitoring method, called actigraphy, uses a movement sensor worn on the wrist. It is a low cost study that is useful for diagnosing sleep fragmentation and circadian rhythm disorders. It can be applied in the sleep medicine clinic or in the sleep lab.Other laboratory tests are required in some patients with sleep disorders. These studies are offered by different departments including (but not limited to) pulmonary medicine (pulmonary function tests), neurology (electromyography, electroencephalography, epilepsy monitoring), cardiology (Holter monitoring, echocardiography), ENT (laryngoscopy), and gastrointestinal medicine (esophagoscopy).----------------------------------3. SERVICE PROVIDERSSleep medicine is a multidisciplinary specialty. A comprehensivesleep medicine program will require participation primarily from neurology and pulmonary medicine, but also psychiatry, ENT, dentistry/oral surgery, bariatric surgery, cardiology, primary care, and other medical specialties. Sleep centers must have trained and qualified personnel including sleep medicine specialists, sleep technologists, respiratory therapists, behavioral sleep specialists, nurses, and other allied health personnel.There are currently about 70 sleep medicine fellowship programs in the US that are accredited by the Accreditation Council for Graduate Medical Education (ACGME). Each year, there are approximately 200 new sleep specialists graduates and approximately 1,400 physicians who pass the American Board of Medical Specialties (ABMS) sleep medicine board examination.Still, many communities lack access to board-certified sleep specialists and the appropriate diagnostic studies. The greatest bottleneck remains to be trained and certified sleep technologists. Traditionally, technologist training has been on-the-job but recent initiatives have led to the establishment of college-based sleep technology training programs and the formalization of on-the-job training through the AASM-sponsored Accredited Sleep Technologist Education Program.----------------------------------TY4DA2A Emmanuel Fabella, MD.

Q. Does it matter where I go for med school if I want to be a psychiatrist?A. All medical schools in the US are accredited and you would get a good education from anyone of them. You would also be able to match into Psychiatry from any school. Your competitiveness will hinge on your USMLE scores, AOA membership, class rank, LORs, research etc.Psychiatry is chosen by a select few and is less competitive. But the majority of students change their specialty choices several times during the course of training. You should not choose your medical school based on your current interest in Psychiatry. At the moment, psychiatrists are in demand. And they are the least likely to be sued frivolously.PsychiatryOverview of the SpecialtyPsychiatrists specialize in the prevention, diagnosis and treatment of psychiatric disorders including mental, emotional and behavioral disorders and in the common medical and neurological disorders that relate to the practice of psychiatry.Training RequirementsTraining consists of a minimum of four years of postgraduate education. There were 211 psychiatry residency training programs accredited by the ACGME for 2014/15 that offered 1,353 categorical/advanced positions.Subspecialty/fellowship training following completion of a psychiatry residency training program is available in addiction psychiatry, child and adolescent psychiatry, forensic psychiatry, geriatric psychiatry, pain management, psychosomatic medicine, hospice and palliative medicine, and sleep medicine. Detailed information about the scope of these subspecialty training programs, number of positions offered, and length of training is available in the AMA's online database, FREIDA.Best Global Universities for Psychiatry/PsychologyThe fields of psychiatry and psychology deal with the study of the mind and behavior. Topics include applied, biological and organizational psychiatry and psychology, as well as the identification and treatment of psychiatric disorders. These are the world's top universities for psychiatry and psychology, based on their reputation and research in the field.#1 Harvard University United States Cambridge, MA#2 King's College London United Kingdom London#3 Stanford University United States Stanford, CA#4 Yale University United States New Haven, CT#5 University of California--Los Angeles United States Los Angeles, CA#6 Columbia University United States New York, NY#7 University College London United Kingdom London#8 University of California--San Diego United States La Jolla, CA#9 Tie University of Pennsylvania United States Philadelphia, PA#9 Tie University of Pittsburgh United States Pittsburgh, PA#11 Duke University United States Durham, NC#12 University of Toronto Canada Toronto, Ontario#13 University of Oxford United Kingdom Oxford#14 University of Michigan--Ann Arbor United States Ann Arbor, MI#15 University of Cambridge United Kingdom Cambridge#16 Johns Hopkins University United States Baltimore, MD#17 Washington University in St. Louis United States St. Louis, MO#18 University of California--Berkeley United States Berkeley, CA#19 University of Minnesota--Twin Cities United States Minneapolis, MN#20 New York University United States New York, NYRigorous psychiatry training helps medical students relate with their future patients, experts say.By Ilana Kowarski, Reporter | March 27, 2017, at 9:30 a.m.Experts say that the prevalence of mental illness means that every future doctor needs a solid foundation of psychiatric training during medical school. (BRUCE AYRES/GETTY IMAGES)A serious mental illness can be costly. According to the National Institute of Mental Health, U.S. workers lose nearly $200 billion in wages every year when mental health problems interfere with their ability to work."There's a huge need and a lot of good that people can do in this field," says Dr. Brett Kaylor, chief resident in psychiatry at Augusta University in Georgia.Medical school professors and practicing physicians say that every medical student needs rigorous training in the fundamentals of psychiatry during medical school, even those who do not intend to specialize in psychiatry after medical school.Here are three reasons why experts say it is essential to attend a medical school that offers a comprehensive introduction to psychiatry.[See data on the global shortage of mental health care providers.]1. Future doctors should be prepared to treat patients who suffer from a mental illness. Experts say no matter what a medical student's career plans are, he or she will most likely encounter many patients with mental health concerns as a physician. According to statistics from the National Alliance on Mental Illness, nearly a fifth of U.S. adults cope with a mental illness in a given year. Experts say it is difficult to provide this large segment of the U.S population with effective medical care without understanding their psychiatric condition and its impact on their overall health."The brain is a complicated organ, and these are complicated diseases that have a major impact on other organs," says Dr. Joe Parks, medical director for the National Council for Behavioral Health and professor at the Missouri Institute of Mental Health at University of Missouri—St. Louis.Parks says that training in psychiatry is particularly important for medical students who plan to focus on primary care or internal medicine. "Psychiatric illnesses are the most common illnesses that a general practitioner runs into," Parks says. "They are the most common cause of disability."Parks says that all medical students should have at least six weeks of clinical rotations in psychiatry and ideally eight weeks. "Choose medical schools that have longer psych rotations," he says. "Four weeks is not adequate."2. Psychiatry offers important lessons on how doctors can establish strong relationships with patients. Experts say that clinical training in psychiatry teaches medical students how to empathize with patients even when they are being difficult, which is a transferable skill that medical students can apply throughout their careers as doctors.“At the core of all medicine, no matter what specialty you are dealing with is the patient – the person," says Dr. Jeffrey Lieberman, a professor of psychiatry and chair of the psychiatry department at Columbia University. "There needs to be the ability to develop a rapport and a therapeutic relationship with the person."Lieberman, who is also the psychiatrist-in-chief at New York-Presbyterian University Hospital of Columbia and Cornell, says that training in psychiatry is one of the best ways for medical students to learn how to communicate effectively with their patients. "It'll help you no matter what you do," he says.Kaylor of Augusta University says psychiatry requires doctors to relate to patients on a personal level. “It offers a much deeper connection to people and what’s meaningful to them than some other specialties.”[Explore how medical school education is changing.]3. Psychiatrists are in demand. According to a 2016 report from the Association of American Medical Colleges, there is a severe shortage of psychiatrists in the U.S. The report showed that 2,800 additional psychiatrists are needed to fulfill the current level of demand for mental health services.Because of this national shortage, there are often more seats in psychiatry residency programs than there are applicants for those programs, except for elite psychiatry residency programs, Lieberman says. This means that a medical student who opts to specialize in psychiatry has a higher chance of matching with a residency program than if he or she chose a different specialty, he says.Another benefit of studying psychiatry during medical school and setting the stage for a psychiatry career, experts say, is that there are an abundant number of jobs in this field."One pleasant surprise about psychiatry is that the job market is unbelievable," says Dr. Edward Zawadzki, a private practice psychiatrist in South Florida. "You can pick up and go anywhere in the country and get a respectable job."Caveat: Psychiatrists rarely get sued!Ilana Kowarski covers graduate schools for U.S. News. You can reach her via email at [email protected] in U.S. Medical Students’ Specialty Interests over the Course of Medical SchoolAll Class of 2003 medical students at 15 US schools were invited to complete 3 questionnaires, at first year orientation (1999), orientation to clinical rotations/wards (typically between the second and third years), and senior year (2002–2003). Several interesting findings emerged. First, the most common specialty choices among freshman students were pediatrics (20%) and surgery (18%), and the 2 specialties least likely to be chosen were psychiatry (1%) and preventive medicine/public health (1%).Students may enter medical school relatively familiar with some disciplines, such as pediatrics and surgery (and thus having a high level of interest in these areas), but may be less familiar with other disciplines, like psychiatry and preventive medicine. In addition, stigma, perceived lack of prestige, and inadequate inclusion in the premedical undergraduate curriculum could account for this initial low level of interest.Second, while there was some stability in specialty choice, most students changed their specialty choices, either by the time of ward orientation or by senior year, regardless of the initial specialty interest. When changing to another specialty, a non-PC specialty was the most likely new choice. Less than one third of those initially interested in PC remained interested at all 3 time points, compared to more than two thirds of those initially interested in non-PC. Consistent with earlier reports, only 20–45% of medical students ultimately choose the specialty that they had been initially most interested in.Most students do not ultimately choose the specialty they originally prefer, and that the direction of change is typically away from PC. Students wanting a high-prestige career were more likely to be interested in a non-PC specialty than a PC specialty at all 3 time points, and almost half of students reported that prestige was important.Specialty decisions often change during residency, and a substantial portion of physicians change specialties after entering practice, caused in part by general dissatisfaction with their choice because of lifestyle incompatibility and negative practice experiences.Dissatisfaction by specialty regarding specialty choice/medical career choice.A source of dissatisfaction is the likelihood of malpractice claim regardless of merit, by specialty.

In short, some of it.to answer this properly however, one must understand that [22] Osteopathic physicians (DOs) are the legal equivalents and, in most cases, are the professional equivalents of medical doctors. Although most DOs offer competent care, the percentage involved in dubious practices appears to be higher than that of medical doctors. For this reason, before deciding whether to use the services of a DO it is useful to understand osteopathy's history and the practical significance of its philosophy.Cultist RootsAndrew Taylor Still, MD (1828-1917) originally expressed the principles of osteopathy in 1874, when medical science was in its infancy. A medical doctor, Still believed that diseases were caused by mechanical interference with nerve and blood supply and were curable by manipulation of "deranged, displaced bones, nerves, muscles—removing all obstructions—thereby setting the machinery of life moving." His autobiography states that he could "shake a child and stop scarlet fever, croup, diphtheria, and cure whooping cough in three days by a wring of its neck." [1]Still was antagonistic toward the drug practices of his day and regarded surgery as a last resort. Rejected as a cultist by organized medicine, he founded the first osteopathic medical school in Kirksville, Missouri, in 1892.As medical science developed, osteopathy gradually incorporated all its theories and practices [2]. Today, except for additional emphasis on musculoskeletal diagnosis and treatment, the scope of osteopathy is identical to that of medicine. The percentage of practitioners who use osteopathic manipulative treatment (OMT) and the extent to which they use it have been falling steadily.Osteopathy TodayThere are 20 accredited colleges of osteopathic medicine and about 44,000 osteopathic practitioners in the United States [3]. Admission to osteopathic school requires three years of preprofessional college work, but almost all of those enrolled have a baccalaureate or higher degree. The doctor of osteopathy (DO) degree requires more than 5,000 hours of training over four academic years. The faculties of osteopathic colleges are about evenly divided between doctors of osteopathy and holders of PhD degrees, with a few medical doctors at some colleges. Graduation is followed by a one-year rotating internship at an approved teaching hospital. Specialization requires two to six additional years of residency training, depending on the specialty. A majority of osteopaths enter family practice.The American Osteopathic Association (AOA) recognizes more than 60 specialties and subspecialties. AOA membership is required for specialty certification, which forces some practitioners to belong to the AOA even though they do not approve of the organization's policies. Since 1985, osteopathic physicians have been able to obtain residency training at medical hospitals, and the majority have done so. Since 1993, DOs who completed osteopathic residencies have also been eligible to join the American Academy of Family Practice, which had previously been restricted to MDs or DOs with training at accredited medical residencies [3].Osteopathic physicians are licensed to practice in all states. The admission standards and educational quality are a bit lower at osteopathic schools than they are at medical schools. I say this because the required and average grade-point averages (GPAs) and the Medical College Admission Test (MCAT) scores of students entering osteopathic schools are lower than those of entering medical students [4,5]—and the average number of full-time faculty members is nearly ten times as high at medical schools (714 vs. 73 in 1994) [5]. In addition, osteopathic schools generate relatively little research, and some have difficulty in attracting enough patients to provide the depth of experience available at medical schools [6]. However, as with medical graduates, the quality of individual graduates depends on how bright they are, how hard they work, and what training they get after graduation. Those who diligently apply themselves can emerge as competent.In January 1995, a one-page questionnaire was mailed to 2,000 randomly selected osteopathic family physicians who were members of the American College of Osteopathic Physicians. About half returned usable responses. Of these, 6.2% said they treated more than half of their patients with OMT, 39.6% said they used it on 25% or fewer of their patients, and 32.1% said they used OMT on fewer than 5% of their patients. The study also found that the more recent the date of graduation from osteopathic school, the lower the reported use [7].The percentages of DOs involved in chelation therapy, clinical ecology, orthomolecular therapy, homeopathy, ayurvedic medicine, and several other dubious practices appear to be higher among osteopaths than among medical doctors. I have concluded this by inspecting the membership directories of groups that promote these practices and/or by comparing the relative percentages of MDs and DOs. listed in the Alternative Medicine Yellow Pages [4] and HealthWorld Online's Professional Referral Network. The most widespread dubious treatment among DOs appears to be cranial therapy, an osteopathic offshoot described below.AOA HypeMany observers believe that osteopathy and medicine should merge. But osteopathic organizations prefer to retain a separate identity and have exaggerated the minor differences between osteopathy and medicine in their marketing. According to a 1987 AOA brochure, for example: (a) osteopathy is the only branch of mainstream medicine that follows the Hippocratic approach, (b) the body's musculoskeletal system is central to the patient's well-being, and (c) OMT is a proven technique for many hands-on diagnoses and often can provide an alternative to drugs and surgery [9]. A 1991 brochure falsely claimed that OMT encourages the body's natural tendency toward good health and that combining it with all other medical procedures enables DOs to provide "the most comprehensive treatment available." [10] Such statements are consistent with a 1992 AOA resolution that defines osteopathy as:A system of medical care with a philosophy that combines the needs of the patient with current practice of medicine, surgery, and obstetrics and emphasis on the interrelationships between structure and function and an appreciation of the body's ability to heal itself [11].A 1994 AOA resolution describes osteopathy as "a complete system of health care and as such is much more holistic than medicine in the classic sense." [11].The American Osteopathic Association's web site glorifies Andrew Still and asserts that osteopathic medicine has a unique philosophy of care because "DOs take a whole-person approach to care and don't just focus on a diseased or injured part." I consider it outrageous to imply that osteopathic physicians are the only ones who regard their patients as individuals or who provide comprehensive care or pay attention to disease prevention. Another AOA web document states:Osteopathic physicians frequently assess impaired mobility of the musculoskeletal system as that system encompasses the entire body and is intimately related to the organ systems and to the nervous system. Using anatomical relationships between the musculoskeletal and these organ systems, osteopathic physicians diagnose and treat all organ systems [12].This statement strikes me as the same sort of baloney chiropractors use to suggest that somehow their attention to the spine will have positive effects on all body processes. Spinal manipulation may produce pain relief in properly selected cases of low back pain [13]. However, OMT has no proven effect on people's general health.Chelation TherapyChelation therapy is a series of intravenous infusions containing EDTA and various other substances. Proponents claim it is effective against atherosclerosis and many other serious health problems. However, no controlled trial has shown that chelation therapy can help any of them. Chelation therapy with EDTA is one of several legitimate methods for treating cases of lead poisoning, but the protocol differs from that used inappropriately for other conditions. To its credit, the AOA has adopted a negative position statement on chelation therapy:WHEREAS, chelation therapy utilizing calcium disodium edetateis currently labeled by the Food and Drug Administration and recognized by most physicians as medically acceptable only in the management of acute or chronic heavy metal poisoning; now, therefore, be itRESOLVED, that pending the results of thorough, properly controlled studies, the American Osteopathic Association does not endorse chelation therapy as useful for other than its currently approved and medically accepted uses. Adopted 1985, revised and reaffirmed, 1990, 1995 [11].The 1998 member referral list of the American College for Advancement of Medicine (ACAM) , the principal group promoting chelation therapy, identifies about 400 MD members and 121 DO members who list chelation therapy as a specialty. These numbers strongly suggest that the percentage of osteopathic physicians doing chelation therapy is about four or five times as high as the percentage of medical doctors doing it. Curiously, Ronald A. Esper, DO, of Erie, Pennsylvania, who was AOA's president in 1998, is an ACAM member and does chelation therapy.tPractitioners of "cranial osteopathy," "craniosacral therapy," "cranial therapy," and similar methods claim that the skull bones can be manipulated to relieve pain (especially of the jaw joint) and remedy many other ailments. They also claim that a rhythm exists in the flow of the fluid that surrounds the brain and spinal cord and that diseases can be diagnosed by detecting aberrations in this rhythm and corrected by manipulating the skull. Most practitioners are osteopaths, massage therapists, chiropractors, dentists, or physical therapists.Cranial osteopathy's originator was osteopath William G. Sutherland, who published his first article on this subject in the early 1930s. Today's leading proponent is John Upledger, DO, who operates the Upledger Institute of Palm Beach Gardens, Florida. An institute brochure states:CranioSacral Therapy is a gentle, noninvasive manipulative technique. Seldom does the therapist apply pressure that exceeds five grams or the equivalent weight of a nickel. Examination is done by testing for movement in various parts of the system. Often, when movement testing is completed, the restriction has been removed and the system is able to self-correct [14].Another Upledger brochure states:The rhythm of the craniosacral system can be detected in much the same way as the rhythms of the cardiovascular and respiratory systems. But unlike those body systems, both evaluation and correction of the craniosacral system can be accomplished through palpation.CranioSacral Therapy is used for a myriad of health problems, including headaches, neck and back pain, TMJ dysfunction, chronic fatigue, motor-coordination difficulties, eye problems, endogenous depression, hyperactivity, attention deficit disorder, central nervous system disorders, and many other conditions [15].The Upledger Institute also advocates and teaches "visceral manipulation," a bizarre treatment system whose practitioners are claimed to detect "rhythmic motions" of the intestines and other internal organs and to manipulate them to stimulate healing [16].British osteopath Robert Boyd, who developed a variant he calls Bio Cranial Therapy, claims that it is "extremely helpful" for "chronic fatigue syndrome (CFS); varicosity and varicose ulcers; tinnitus; bladder prolapse; prostate disorders; Meniere's syndrome; cardiovascular disturbances including hypertension, angina; skin disorders (psoriasis, eczema, acne etc); female disorders (dysmenorrhoea, PMS (PMT), menorrhagia etc); arthritis and rheumatic disorders; fibromyalgia and heel spurs; gastric disorders (hiatus hernia, ulceration, colitis); asthma and a range of bronchial disorders including bronchiectasis and emphysema."The theory underlying craniosacral therapy is erroneous because the cranial bones fuse by the end of adolescence and no research has ever demonstrated that manual manipulation can move the individual bones [17]. Nor do I believe that "the rhythms of the craniosacral system can be felt as clearly as the rhythms of the cardiovascular and respiratory systems," as is claimed by another Upledger Institute brochure [18]. The brain does pulsate, but this is exclusively related to the cardiovascular system [19]. In a recent study, three physical therapists who examined the same 12 patients diagnosed significantly different "craniosacral rates," which is the expected outcome of measuring a nonexistent phenomenon [20].Osteopathic web sites that espouse cranial therapy can be located by using Google's Advanced Search to lok for "cranial osteopathy" and "Sutherland." The most illuminating source I have found (which no longer appears to be posted) was The Cranial Letter, published quarterly by the Cranial Academy, a component society of the American Academy of Osteopathy. The Summer 1993 issue stated that the Cranial Academy had 989 members. Other issues contained case reports stating that cranial therapy can cause knee pain to disappear within a week (Summer 1992), cure hives (Summer 1993), improve the mental condition of Down syndrome patients (May 1995), and correct crossed eyes (May 1996).The percentage of osteopaths using cranial therapy is not high, but it apppears to be deeply entrenched within the profession. Many of the osteopathic colleges teach it, and the American Osteopathic Association treats it as legitimate. At least 15 of the 88 items listed in the AOA's 1996 list of "Osteopathic Literature in Print" were written by Sutherland, Upledger, or others who appear to advocate cranial therapy [21]. And in 1998, the AOA's continuing education calendar listed a 40-hour cranial osteopathy course it cosponsored with the American Academy of Osteopathy, which is a practice affiliate of the AOA.In 2002, two basic science professors at the University of New England College of Osteopathic Medicine concluded:Our own and previously published findings suggest that the proposed mechanism for cranial osteopathy is invalid and that interexaminer (and, therefore, diagnostic) reliability is approximately zero. Since no properly randomized, blinded, and placebo-controlled outcome studies have been published, we conclude that cranial osteopathy should be removed from curricula of colleges of osteopathic medicine and from osteopathic licensing examinations [17].The Bottom LineI believe that the American Osteopathic Association is acting improperly by exaggerating the value of manipulative therapy and by failing to denounce cranial therapy. If you wish to select an osteopathic physician as your primary-care provider, your best bet is to seek one who: (a) has undergone residency training at a medical hospital; (b) does not assert that osteopaths have a unique philosophy or that manipulation offers general health benefits; (c) either does not use manipulation or uses it primarily to treat back pain; and (d) does not practice cranial therapy.ReferencesStill AT. Autobiography —with a history of the discovery and development of the science of osteopathy. Reprinted, New York, 1972, Arno Press and the New York Times.Gevitz N. The D.O.'s: Osteopathic Medicine in America. Baltimore, 1982, The Johns Hopkins University Press.Gugliemo WJ. Are D.O.s losing their unique identity? Medical Economics 75(8):201-213, 1998. (Clarification regarding AAFP membership published in Medical Economics 75(14):21, 1998.)Doxey TT, Phillips RB. Comparison of entrance requirements for health care professions. Journal of Manipulative and Physiological Therapeutics 20:86­91, 1997.Ross-Lee B, Wood DL. Osteopathic medical education. In Sirica CM, editor. Osteopathic Medicine, Past, Present and Future. New York, Josiah Macy Jr. Foundation, 1996, page 95.Jones DE. Allopathic (M.D.) versus osteopathic (D.O.) medical Schools: Views of a basic scientist with experience in both. Cardiovascular Concepts Web site, accessed 5/21/99.Johnson SM et al. Variables influencing the use of osteopathic manipulative treatment in family practice. Journal of the American Osteopathic Association 97:80-87, 1997.Alternative Medicine Yellow Pages. Puyallup, Washington. Futurer Medicine Publishing, Inc., 1994.Osteopathic medicine: A distinctive branch of mainstream medical care. Undated brochure, distributed in 1987. Chicago: American Osteopathic AssociationWhat is a D.O.? (Brochure) Chicago: American Osteopathic Association, 1991,AOA Position Papers, Aug 1996. In AOA Yearbook and Directory. Chicago: American Osteopathic Association, Jan 1997, pages 565-588.Position Paper on Osteopathic Manipulative Treatment (OMT) & Evaluation and Management services. Part II: The Standard of Care for Osteopathic Manipulation and the E&M Service. AOA web site, September 1998.Gunnar BJ and others. A comparison of of osteopathic spinal manipulation with standard care for patients with low back pain. New England Journal of Medicine 341:1426-1431, 1999.Discover CranioSacral Therapy. Undated flyer distributed in 1997 by the Upledger Institute.Upledger CranioSacral Therapy I. Brochure for course, November 1997.Visceral manipulation. Upledger Institute Web site, accessed Aug 15, 2001.Hartman SE, Norton JM. Interexaminer reliability and cranial osteopathy. Scientific Review of Alternative Medicine 6(1):23-34, 2002.Workshop catalog, Upledger Institute, 1995.Ferre JC and others. Cranial osteopathy, delusion or reality? Actualites Odonto-Stomatologiques 44:481-494, 1990.Wirth-Pattullo V, Hayes KW. Interrater reliability of craniosacral rate measurements and their relationship with subjects' and examiners' heart and respiratory rate measurements. Physical Therapy 74:908-16, 1994.Osteopathic literature in print, October 1996. In AOA Yearbook and Directory. Chicago: American Osteopathic Association, Jan 1997, pages 756–757Dubious Aspects of Osteopathy