M.D.s and D.O.s Today

Jerome Tobis, MD, interview by Michael Seffinger, DO

at his home in Newport Beach, California
April 26, 2006

Dr. Seffinger: Dr. Tobis would you introduce yourself and tell us who you are and where you were born and grew up, your background and how you became involved with the osteopathic profession.
Dr. Tobis: I am Jerry Tobis, a physician at the University of California at Irvine, the College of Medicine. I was born on July 23, 1915 which makes me 90 going on 91. I was born in Syracuse, New York and raised there until 13 years-of-age when the depression affected my family’s economic status and we moved to Brooklyn, New York, where I went to New Utrecht High School in Brooklyn and then on to the City College of New York which has since become a university. I graduated in 1936 from City College with a Bachelor’s degree. I graduated from Chicago Medical School in 1943 and took an interesting internship at Kinickerbocker Hospital in New York City following which I entered the United States Public Health Service and was assigned to Brookhaven, Mississippi, to treat venereal disease with the use of physical modalities such as fever. This significantly influenced my decision to go into the young specialty of Physical Medicine and Rehabilitation which is concerned for the use of physical agents – heat, cold, electricity, among other modalities. I completed my residency after the war in 1948 at the Bronx V.A. Hospital; subsequently, I became a young chairman of the Department of Physical Medicine and Rehabilitation at New York Medical College. In 1960 I was invited to become the Chief of Physical Medicine and Rehabilitation at Montefiore Hospital with a professorship at Albert Einstein Medical School both in the Bronx, New York. In 1969 just prior to my going on a sabbatical to Sweden, I was invited here to be interviewed for the young medical school that had become part of the University of California at Irvine, having been an old medical school in Los Angeles, which was the former osteopathic school of the California College of Medicine. While I was on sabbatical in Sweden, I was informed that I had been chosen as the Chairman of the new Department of Physical Medicine and Rehabilitation at Irvine. At that time the hospital was the county hospital, Orange County Medical Center. I was somewhat intrigued by the fact of the school’s history because in my specialty of Physical Medicine and Rehabilitation, musculoskeletal manipulation was part of our training. I had taken a fellowship at Columbia University related to physical medicine and had the opportunity to take a course in musculoskeletal manipulation with a noted English Osteopath, a Dr. Mennell.
Dr. Seffinger: He was an MD, John Mennell?
Dr. Tobis: John Mennell the Father. John Mennell the son I also know. I think he was an MD, but the father was an osteopath living in England and he had come to Columbia University, which then had a Department of Physical Medicine chaired by a Dr. Snow. I was impressed with Dr. Mennell’s skills and thought manipulation appropriately should be part of the armamentarium of my specialty. At the time I was interviewed for the position, little if any mention was made of osteopathy by either the Dean – Dr. Warrn Bostick or the Associate Dean – Dr. Tom Nelson, both of whom interviewed me on several occasions. Once I arrived and setup the developing program I had an opportunity to meet people who had already been appointed from the Los Angeles College of Osteopathic Physicians and Surgeons.
Dr. Seffinger: You mean the ones that used to be faculty members at the old college COP&S?
Dr. Tobis: Yes, in physical medicine.
Dr. Seffinger: In physical medicine like Dr. Andrews?
Dr. Tobis: Yes, Dr. Andrews and there were others. So I became better acquainted with them and in fact when I took over the residency that had existed at the V.A. Hospital in Long Beach I included in the curriculum lectures and demonstrations of musculoskeletal manipulation. It must have been at the end of 1970 that I met Forest Grunigen, a leading figure in the 41st Medical Trust, who had been a prime mover in establishing the merger of the osteopaths who wished ot become MDs. Fory and his wife and my wife and I developed a social relationship and met on several occasions and they visited this very home in which I am sitting. I also had opportunity to visit Fory at his home up in Los Angeles at that time. Subsequently, Fory emphasized the great interest he had in determining the efficacy of musculoskeletal manipulation. He knew that I had a great interest in clinical research. He told me about the 41st Trust and that there was a capital sum of money that was intended to be used for research. I subsequently applied for a grant in the early years of the 70s and was funded by the 41st Trust for some five or six years, I believe. So that we could conduct a randomized study on the efficacy of “osteopathic manipulation” a term that Fory encouraged to differentiate it from chiropractic manipulation. That study resulted in several publications including a monograph which I co-authored with Fred Hoehler, a statistician who worked in the study. The influence of Dr. Mennell convinced me that obtaining objective data to validate the efficacy of musculoskeletal manipulation was a very significant undertaking. The question that was asked, Did I notice that there was something unique or different about DOs in the osteopathic profession?, that answer is difficult for me. I do not recall any special characteristic that differentiated them from allopathic physicians. Those that I came in contact with both through the study where we were recruited former osteopaths who lived in this area to server as manipulators as well those who continued to be on my faculty and were the remaining faculty from the Los Angeles COP&S. Incidentally, through the 41st Trust where I attended several meetings, initially with Warren Bostick, Mr. Hufstedler, and Fory Grunigen and other leaders of the former osteopathic profession including Dorthy Marsh.
Dr. Seffinger: What year was that?
Dr. Tobis: That probably was in the latter half of the 70’s, like 76, or 77. Although I must have met these people earlier in order to get the funding for our study, it probably had to be approved by the Executive Committee of the 41st Trust.
Dr. Seffinger: Now what was Mr. Hufstedler doing at that time?
Dr. Tobis: He was a senior partner in a prestigious law firm in L.A.. The meetings were held in Los Angeles in his offices on the top of a downtown skyscraper.
Dr. Seffinger: And the purpose of those meetings was what?
Dr. Tobis: Well, it was often a routine meeting of the 41st Trust.
Dr. Seffinger: I see – those were members of the 41st Trust Executive Committee?
Dr. Tobis: Right, and I was invited first to share my interest in carrying out a randomized study, then subsequently to report on the progress we made on the study, and reapplying in subsequent years for continued support…
Dr. Seffinger: and those studies were done with somebody like Dr. Kammerman, for interest, doing manipulation?
Dr. Tobis: I didn’t meet Dr. Kammerman until later years through the County Medical Society. I had no contact with him in terms of musculoskeletal manipulation.
Dr. Seffinger: So you found other people to do the manipulation at the time?
Dr. Tobis: Yes.
Dr. Seffinger: That were around Orange County that were DOs, that became MDs that still did manipulation?
Dr. Tobis: Right.
Dr. Seffinger: and that was not related to the studies done with, who was that, in 1981 or so or 1980 was there another person that was helping you, Buerger or someone?
Dr. Tobis: Oh, Alfred Buerger, yes, he was the coordinator for the study. His name was spelled B-u-e-r-g-e-r. He had a PhD in neuroscience.
Dr. Seffinger: As far as I know that was the first osteopathic manipulation randomized, single-blinded clinical trial done in America.
Dr. Tobis: To my knowledge that’s correct. Curiously, I only heard about the merger of the osteopaths to become MDs in a peripheral way when I was interviewed for the position of Chairman. I realized that the school had come from Los Angeles and that it was a political move done by influential legislators in Sacramento. I gathered that the University of California chose to accept the osteopathic school when Warren Bostick became the Dean of the new California College of Medicine. Apparently the chancellor at that time, Dan Aldrich felt that facilitating the integration of the school in Los Angeles into the campus at Irvine would accelerate the speed which a medical school could be established on this campus. He was in support of that decision. What was your role in the history of osteopathy in California? I really had no role in that merger and it was because of my academic professional status that I became involved with many former osteoapaths.
Dr. Seffinger: But you were the person that carried out one of the missions of the 41st Trust which was a byproduct of the merger agreement and that was to investigate the efficacy of manipulation in particular osteopathic manipulation.
Dr. Tobis: That is correct. What events were you personally responsible for that had an impact on this profession? I would say that to the extent this study in which I was involved influenced the scientific evaluation of musculoskeletal manipulation – to that extent did I have an impact, but I would also wish to emphasize that I still feel that musculoskeletal manipulation is a meaningful therapeutic intervention in selected cases and that I feel it is part of the training of a physiatrist to be familiar with this and to use these skills in selected cases. In my own medical practice I have employed manipulation at times. What were your responsibilities, goals, challenges, failures and increases in your career within and outside the osteopathic profession....
Dr. Seffinger: Successes in your career within and outside of the osteopathic profession.
Dr. Tobis: Well I must say that most of my career has been unrelated to osteopathy or musculoskeletal manipulation. My research has involved a multitude of subjects from cerebral palsy children, to spinal chord injury, to stroke and aphasia, and hemiplegia. I have published some four monographs on different subjects including cardiac rehabilitation, brain injury, as well as on manipulation.
Dr. Seffinger: Didn’t you write a book or edit a book about the validation of manipulation?
Dr. Tobis: Yes I did in collaboration with Alfred Buerger.
Dr. Seffinger: What was the name of that book?
Dr. Tobis: I have copies of it here and I will be glad to show it to you. How were you able to accomplish your goals? - by working assiduously with excellent collaborators to whom I must give a great deal of credit. Who were your supporters? I always felt Forest Grunigen was a staunch supporter, but in the latter part of my studies, I felt that his support waned.
Dr. Seffinger: So we were talking about the research that you did here regarding osteopathic manipulation and receiving funds from the 41st Trust Fund and you were working with Alfred Buerger and wrote a book about the validation of manipulation and then he left the school. Did you have other plans to do further studies in manipulations in the 1980s?
Dr. Tobis: Yes I did. I was invited to consider appointment to the Board of the Chiropractor School in Whittier and although I never became a director on the board, I attended several of their meetings. In the process I got to meet several of their faculty and one, a Dr. Hsieh who is an acupuncturist, chiropractor and physical therapist. He developed a grant proposal with several people including Dr. Hong from my department who is a physiatrist, Dr. Allen Adams who was a chiropractor and I think a Vice President at that time of the chiropractic school and Dr. Hoehler, the statistician and myself. We did a study with funding from the Public Health Service on which technique for the relief of sub acute low back pain – comparing musculoskeletal manipulation, physical therapy and a home study program as a control. The outcome of that study which was based on both improvement and function, but also cost analysis was that the home study was the most cost effective of all the modalities that were employed.
Dr. Seffinger: You mean the home back exercises? Which was the best modality?
Dr. Tobis: The home study was self instruction and participation in some lectures.
Dr. Seffinger: Self-study educational group?
Dr. Tobis: Yes, it was a program that I think originally was developed by a prominent Swedish orthopedist named Alf Nachemson.
Dr. Seffinger: Oh, Alf Nachemson. Pause…Okay, we want to correct the titles of the monographs. First of all this is a book called Musculoskeletal Manipulation. Evaluation of the Scientific Evidence, by Jerome Tobis, MD and Fred Hoehler, PhD. This was published in 1986, and around the same time you had Approaches to the Validation of Manipulation Therapy.
Dr. Tobis: I think that antedated this.
Dr. Seffinger: That was in about 1985 or earlier, by Jerome Tobis, so those two books…You also had a book that was titled, The Neuro Physiologic Aspects of Rehabilitation Medicine with Al Buerger and Jerome Tobis; This was based on Preceedings of an International conference I had organized on that subject. The Evaluation and Management of the BrainDamaged Patient, by Jerome Tobis and Milton Loweanthal; and Cardiac Rehabilitation, by Lenore Zohman and Jerome Tobis. Now this was the first cardiac rehabilitation text in America back in 1970, correct?
Dr. Tobis: That is correct. IT has been translated into three or four different languages.
Dr. Seffinger: Okay. And this is where you talk about the pathophysiological basis of exercise training for cardiac patients, right?
Dr. Tobis: Correct.
Dr. Seffinger: Which is very prominent now-a-days. Okay, that brings us up to date. You were talking about the research studies you were doing with Dr. Hsieh. Do you want to continue on that?
Dr. Tobis: Well that was published subsequently in the journal SPINE probably five years ago.
Dr. Seffinger: Do you remember your major…
Dr. Tobis: It seems to me that there were several publications on that and I can provide you with my curriculum vitae which lists over a hundred publications.
Dr. Seffinger: Excellent, were you able to show the effectiveness or efficacy of manipulation through these research studies through the years or contrarily the lack of efficacy?
Dr. Tobis: Not directly. The study with Dr. Hsieh did show that patients were helped with musculoskeletal manipulation which in that case was carried out by chiropractors. However, when it came to cost effectiveness, the cost benefit was less satisfactory with physical therapy or manipulation than a home study or education program.
Dr. Seffinger: Yes, of course because their personal attention you have time it takes for the therapist or the chiropractor to work on the patient. Office visits are more costly.
Dr. Tobis: It was a sophisticated study because not only did we take into account the cost of therapies, but also the return to employment and the lost days of work, the cost in salary and income were also incorporated into the formula.
Dr. Seffinger: Excellent. Do you know of research that has taken off from those studies that other people have reproduced or have gone further based on your initial studies.
Dr. Tobis: There was a chap who was very interested in low back pain up at the University of Washington, in the school of medicine.
Dr. Seffinger: Deyo?
Dr. Tobis: Deyo, yes, he has published extensively on low back pain, but I have not kept up with the recent literature.
Dr. Seffinger: Do you remember a time when the school here was interviewing Murray Goldstein, a DO from NIH, for neurological diseases and stroke. The Institute of Neurological Diseases and Stroke to come here to work to start an institute research around 1980 were you involved with that?
Dr. Tobis: I was not involved with that although I had the opportunity to meet Dr. Goldstein on a few occasions. I believe once out here, but on a few occasions I met him at NIH where I was on several committees at varying times in my career. But at one time it seemed to me there had been some discussion going on with Ralph Gerard who had been a Vice Chancellor for Academic Affairs here at UCI, a prominent neuro scientist who was interested in musculoskeletal manipulation. In fact I believe one of my books is dedicated to him.
Dr. Seffinger: It could be with The Approaches to the Validation book. Were you involved at all with the development of the St. Mary’s Spine Center in San Francisco?
Dr. Tobis: No.
Dr. Seffinger: Do you know about that?
Dr. Tobis: Peripherally I had heard about that. That was at St. Mary’s Hospital?
Dr. Seffinger: Did you mentor anybody that went into research in manipulation over the years?
Dr. Tobis: To some extent I think I had a modest role in the career of Dr. John Hong who has been a professor in my department.
Dr. Seffinger: Hong?
Dr. Tobis: H-o-n-g. He became especially interested in myofascial pain and worked with David Simons who was a successor to Janet Travell.
Dr. Seffinger: Is he still here?
Dr. Tobis: He is still on the faculty, but he shares his time between Taiwan and our department. He comes about every six weeks and spends several days here in the department and sees patients.
Dr. Seffinger: Does he do research?
Dr. Tobis: Yes, he continues to do research. His main interest has become myofascial pain.
Dr. Seffinger: Okay. As far as advice looking back on your career and your interactions with DOs as well as DOs that became MDs and then working with research in manipulation of both osteopathic and chiropractic types what kind of advice do you have for future allopathic as well as osteopathic medical students in training in terms of how you feel manipulation fits into their careers in the future?
Dr. Tobis: I feel that manipulation is a valuable modality for patients with low back pain, especially of acute and sub-acute duration. I feel it is less effective for chronic pain lasting more than three months. I feel that those trained in osteopathy as well as those trained in physical medicine and rehabilitation should gain the skills that have been described over the years in numerous publications. And to be aware that it is available.
Dr. Seffinger: Okay. Are there any particular documents that you have that would be helpful, historical documents that you would like to contribute to the project that we are working on?
Dr. Tobis: I don’t think I have such documents as I have indicated in this interview. My feelings are that I have had a modest impact on one aspect of the osteopathic profession and its history here in California.
Dr. Seffinger: IS there anybody else that we should contact that was instrumental in the historical development of osteopathic medicine in California that we have not yet contacted? Were you involved with the development of the new school in Pomona or the school in Vallejo, the osteopathic college there at all or any interaction with those people?
Dr. Tobis: No I haven’t been.
Dr. Seffinger: Okay. Is there anything else you would like to talk about or discuss in relation to osteopathy in California that we haven’t touched upon yet?
Dr. Tobis: I don’t think so.
Dr. Seffinger: Just for your information, that study that you did in 1980 or 81 that was published the first randomized, single-blinded clinical trail on manipulation of the lumbar spine with osteopathic manipulation, that study was much talked about within the osteopathic research profession and there was a good decade worth of discussion on about how to design an osteopathic clinical trail and whether one technique should be utilized or a series of techniques or whether there should be a limitation on the way the osteopathic physician should be applying techniques and they went round about and finally created another clinical trial that was finally published in the New England Journal of Medicine on low back pain, sub acute low back pain, where they purposely designed that the osteopathic physicians could use whatever techniques they felt necessary for that particular patient at that time based on the structural findings and the history of the patient and the response of the treatment in direct contrast to the research designed that was first used and so even though you didn’t see a repetition of the study later which you then found was an evolution of research design manipulation in the osteopathic profession that was based upon you foundation work, see.
Dr. Tobis: What year was that published?
Dr. Seffinger: That was in 1999. It took them a good ten years maybe eight years to develop it and run it and analyze the data. It took a long time to get that study…
Dr. Tobis: Where was it…
Dr. Seffinger: It was done in Chicago. IT was published…the author was Gunnar Anderssen, MD and Robert Kappler was the DO amongst several other people. Gunnar is G-u-n-n-a-r and Anderssen is A-n-d-e-r-s-s-e-n.
Dr. Tobis: At which university?
Dr. Seffinger: It might have been through Rush Medical Center. I can get a copy of that for you if you are interested.
Dr. Tobis: I would be interested.
Dr. Seffinger: It was a recent low back pain manipulation study on chronically back pain done by some osteopathic physicians in Texas and they did medical analysis of the three studies, your study, this one that was done in Chicago a decade or so later and then this other study a decade after that it was in Texas on different stages on back pain in osteopathic manipulation and those are the only three studies done in America. There was one done in England prior to that a decade before that – so what we have is these kinds of clinical trials done few and far between may be one per decade, not very much.
Dr. Tobis: By the way, one of the consequences of my experience with these studies is that I invited prominent musculoskeletal manipulators like Dr. Maigne from France. He was in this country and I had him come visit us to talk about his techniques and also a Dr. Dvorak from Czechoslovakia who was especially interested in manipulation studies.
Dr. Seffinger: Did you interact with them in designing research studies or discussion?
Dr. Tobis: It was simply for discussion.
Dr. Seffinger: Well it sounds like you have had an exciting career, a very prominent career and a very successful career.
Dr. Tobis: Thank you very much.
Dr. Seffinger: It’s been a pleasure and an honor to have this opportunity to interview you and hear about your life and your involvement not only the osteopathic profession, but with the school here and with the specialty of physical medicine and rehabilitation. Thank you very much.