Discussion
A general lack of awareness of DOs and OMM exists within the Chinese community in New York City’s Manhattan Chinatown. Survey participants did not recognise the osteopathic profession, especially among the elderly. Statistically significant factors contributing to this lack of knowledge include age, English proficiency and education. Compared with similar studies in the past, this study found the gap in minority osteopathic familiarity even greater than previously noted, with less than one in five participants indicating knowledge of OM.17 In the decennial OSTEOSURV 1998, 2000 and 2010, Asians are presumably included in the category of ‘other (including >1 race)’ and ‘non-Hispanic’, leading to a gross simplification and lack of targeted data for the Asian population in America.3 12 15–17 Current research has also focused primarily on osteopathic recognition in European settings, with minimal attention in Asian communities based in Asia or the USA.27 28 Numerous studies have validated the need for disaggregated data as a way of dissecting health trends and practices within Asian communities.13 14 29 While this study was unable to definitively determine a sole cause, exploring the numerous factors such as linguistics and history can provide some context for lack of osteopathic awareness and potential barriers to outreach.
Age (18–29), English-language proficiency (self-identified fluency) and education level (college graduate) were statistically significant in exploring whether the participants had knowledge of DOs and OMM. Adults younger than the age of 30 demonstrated a statistically significant relation with knowledge of what an osteopathic physician does in comparison to adults older than the age of 60, contrary to previous research done that imply the opposite.24 With an ever-increasing number of osteopathic physicians entering the workforce coupled with shifting trends in healthcare consumption, the under 30 age demographic can be a future area of expansion for the OM profession as this generation straddles the divide between separation and assimilation in broader models of acculturation.15 25 27 English language proficiency additionally demonstrated a statistically significant relation with knowledge of what a DO does in comparison to adults without English language proficiency due to the linguistic and historical nuances that separate and unite allopathic and OM.27 28 Unsurprisingly, to coincide with English language proficiency, educational status, particularly those having a college degree, also showed statistical significance in knowledge of DOs and OMM, compared with adults without a college degree, which is a common socioeconomic factor that correlates with higher health literacy and self-advocacy to explore alternative options such as DOs and OMM.14 29 Despite the lack of statistical significance in other demographic categories on DO and OMM knowledge, it is important to acknowledge their potential influence and impact in patient knowledge and choice.
Under the auspices of A.T. Still MD, DO, OM was founded in 1874 as an alternative to allopathic medicine.1 In the same time period, modern medicine, commonly referred to as ‘Western’ medicine, arrived in China at the end of the 19th century after its defeat in the Opium Wars.30 Backed with interventional therapies and single drug pharmaceuticals, modern medicine supplanted more conservative traditional remedies and healers.31 With modernisation of medicine, semantic genericization of medical classifications and terms resulted in an inability to capture the difference between osteopathic and allopathic medicine.30 31 For example, in the Chinese spoken dialects and unified written system, there are no characters or conventions for describing OM vis-à-vis allopathic medicine. On presentation to a patient, an osteopathic physician would identify themselves as yi-sheng (醫生), which is exactly how an allopathic physician would identify. When translating the term ‘osteopathic’, numerous sources use gu-ke (骨科) which means ‘of, or relating to the study of bones’, which can be confusing and misleading as orthopaedics and other bone specialties use the same term. A viable solution could be the use of zheng-gu (整骨) for osteopathic, which when translated, means ‘whole-bone’ and is more representative of the its meaning. In order for the community to adopt this, however, it would require more outreach to transition to common vernacular.
A conceivable challenge to awareness is the lack of osteopathic medical schools in Asia.32 Osteopathic medical schools are predominantly located in the USA, with physicians graduating with full practice rights in relation to their allopathic counterparts. Conversely, in non-American osteopathic medical schools, graduates are osteopaths, who solely perform OMM.3 33 This dichotomy complicates perception of OM, as demonstrated in international licensure. A prime example is seen in Taiwan, in which their licensing board translates ‘osteopathic physician’ as ‘bone doctor’, which is the same as a chiropractor. In an effort to educate the international community regarding the capabilities of American-trained osteopathic physicians, numerous initiatives have been started, ranging from partnerships between osteopathic medical schools and hospitals in Asia to the International Primary Care Educational Alliance’s China Project, which trains physicians in China on osteopathic family medicine.34–36 International licensure and practice rights continue to be a priority for the American Osteopathic Association, leading to partnerships with the Osteopathic International Alliance and the Bureau of International Osteopathic Medicine, and resulting in recognition by the United Nations and increased practice rights in countries such as South Korea.3 37
This multilayered approach and contextual/nuanced view are needed if osteopathic awareness is to occur in Asian, and by extension, ethnic minority communities that lack exposure to the field. In this study, those who had no knowledge of OM would not see a DO for LBP relief and while most participants would see their primary care doctor/family care doctor, this does not preclude the possibility of that physician also being an osteopathic physician. For example, there are several osteopathic physicians at the Charles B. Wang Community Health Center, which is based in the heart of Manhattan’s Chinatown. It is conceivable that some of the participants have an osteopathic physician as their primary care doctor, but do not distinguish between the two entities.38–40 The lack of differentiation compounded by whether or not the osteopathic physician decides to practice OMM at patient visits may result in the possibility of clinical care that is indistinguishable from allopathic physicians. Furthermore, participants also indicated they would see a chiropractor for their LBP. Due to the historical roots of chiropractic, many of the techniques share similar mechanisms to OMM.41–43 Coupled with similar nomenclature in the Chinese language, future studies could assess the effectiveness of OMM demonstrations/pamphlets on the willingness to see a DO.
With the broad implications on osteopathic awareness in the Chinese community, there are several limitations in this study. Manhattan’s Chinatown is but one of several high-density areas for the Chinese community in New York City, which may not be a true representation of osteopathic awareness in the large community. Furthermore, surveys were conducted midday which may fail to capture Chinese community members that are working or not in the area. It was also difficult to assess whether age and osteopathic awareness trends were skewed by immigration status, as almost all participants over the age of 60 had immigrated to America. This could suggest a correlation between lack of osteopathic awareness and immigration status, further affirming that many immigrant minority communities have little to no exposure to OMM and DOs. Future studies may explore the relationship between immigration status and osteopathic awareness, comparing multiple Chinese communities across New York City at varying times of day, or comparing osteopathic awareness across other Asian communities with a qualitative or mixed-method study.44 45