Comparison of MD and DO in the United States

In the United States, physicians (medical doctors) who practice medicine hold either the Doctor of Medicine degree (MD) or the Doctor of Osteopathic Medicine degree (DO).[1] Other than DO medical students learning osteopathic manipulative medicine, the medical training for MDs and DOs is indistinguishable.[2] MD and DO physicians complete conventional residencies in hospitals and training programs, are licensed in all 50 states, and have rights and responsibilities that are identical.

Today, U.S. osteopathic physicians (DOs) are fully licensed, patient-centered medical doctors. They have full medical practice rights throughout the United States and in 44 countries abroad.[3] A Doctor of Osteopathic Medicine (DO) is different than an osteopath: a DO is a physician, while an osteopath is not.[4]

Background

In 2005, Jordan Cohen, MD, the president of the Association of American Medical Colleges (AAMC) stated:

After more than a century of often contentious relationships between the osteopathic and allopathic medical professions, we now find ourselves living at a time when osteopathic and allopathic graduates are both sought after by many of the same residency programs; are in most instances both licensed by the same licensing boards; are both privileged by many of the same hospitals; and are found in appreciable numbers on the faculties of each other's medical schools.[5]

The American Medical Association's current definition of a physician is "an individual who has received a 'Doctor of Medicine' or a 'Doctor of Osteopathic Medicine' degree or an equivalent degree following successful completion of a prescribed course of study from a school of medicine or osteopathic medicine."[6]

Demographics

Medical training

There are significantly more MDs than DOs, though the share of DOs is increasing.[7] Of first-year medical students matriculating in 2015, 25.4% (7,025 students) entered DO medical programs and 74.6% (20,631 students) entered MD programs.[8] The Association of American Medical Colleges projects that from 2015 to 2020, first-year DO student enrollment will increase by 20.5% versus a 5.3% increase in MD students.[8]

Of the 829,914 physicians actively practicing in the United States in 2013, 7.3% hold a DO degree, 67.4% hold an MD degree granted in the U.S., and 24.2% are international medical graduates.[7] The percentage of physicians that hold a DO degree varies by specialty, with the greatest representation in Family Medicine/General Practice (16.5% of general practitioners), Physical Medicine & Rehabilitation (13.6%), and Emergency Medicine (11.3%).[7] 8.3% of residents and fellows in medical training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), which accredits all MD residency programs, hold a DO degree.[7] 54% of DO graduates enrolled in post-doctoral training are in ACGME programs.[9]

Geographic distribution

The geographic distribution of both MD and DO physicians is not uniform. As of 2012, the states with the greatest ratio of active physicians holding a DO degree versus active physicians holding an MD degree were Oklahoma (20.7% of physicians), Iowa, Michigan, Maine, and West Virginia. During the same year, the states with the greatest ratio of active physicians holding an MD degree versus a DO degree were Louisiana, Washington, D.C., Massachusetts, Maryland, and Connecticut.[10] The states with the greatest per capita number of DO physicians are Maine, Michigan, Pennsylvania, Oklahoma, and Iowa. The states with the greatest per capita number of MD physicians are Washington, D.C., Massachusetts, Maryland, New York, and Connecticut.[10]

Trends

The sex and racial distribution of DOs and MDs are similar.[11] Between 1980 and 2005, the annual number of new MDs remained stable at around 16,000. During the same period, the number of new DOs increased by more than 200% (from about 1,150 to about 2,800).[12] The number of new MDs per 100,000 people fell from 7.5 to 5.6, while the number of new DOs per 100,000 rose from 0.4 to 0.8.[12]

A 2012 survey of students applying to both U.S. MD and DO schools found that 46% were admitted only to a DO school, 9% were admitted only to an MD school, 26% were admitted to both, and 19% were not admitted to any medical schools.[13] Geographic location was the top reason given by both DO and MD students for choosing the school in which they enrolled.[13] The college's approach to learning and teaching and the college's reputation were highly ranked by respondents attending DO medical schools.[13]

Cultural differences

Patient interactions

Some authors describe subjective distinctions in patient interactions. Avery Hurt writes, "In actual practice, the variations between the two types of physicians are often so slight as to be unnoticeable to patients, and a day in the life of each can appear indistinguishable. But the differences are there, subtle but deep."[14]

Several studies have investigated these differences. A study conducted during 2003-04 analyzed patient visits to general and family medicine physicians in the U.S., including 65 million visits to DOs and 277 million visits to MDs. It found that there was no significant difference between DOs and MDs with regard to time spent with patients and preventive medicine services.[15]

A small study of 18 physicians compared patient interactions and found that osteopathic physicians were more likely to use patients' first names and to discuss the social, family and emotional impact of illnesses.[16] For example, 66% of DOs discussed a patient's emotional state, compared with 32% of MDs. Only four of the 26 characteristics tested resulted in a statistically significant difference between the DO and MD patient interactions.

Self-characterization

A Harvard study conducted during 1993-94 found significant differences in the attitudes of DOs and MDs. The study found that 40.1% of MD students and physicians described themselves as "socioemotionally" oriented over "technoscientific" orientation. 63.8% of their DO counterparts self-identified as socioemotional.[11]

One study of DOs attempted to investigate their perceptions of differences in philosophy and practice between themselves and their MD counterparts. 88% of the respondents had a self-identification as osteopathic medical physicians, while less than half felt their patients identified them as such. The study asked respondents to identify points of philosophical and practical difference between DOs and MDs; no more than 1/3 of respondents could agree on any single such point of difference.[17]

Self-identification

As the training of DOs and MDs becomes less distinct, some have expressed concern that the unique characteristics of osteopathic medicine will be lost.[18] Others welcome the rapprochement and already consider modern medicine to be the type of medicine practiced by both "MD and DO type doctors."[19] One persistent difference is the respective acceptance of the terms "allopathic" and "osteopathic." DO medical schools and organizations all include the word osteopathic in their names, and such groups actively promote an "osteopathic approach" to medicine. While "osteopathy" was a term used by its founder AT Still in the 19th century to describe his new philosophy of medicine, "allopathic medicine" was originally a derogatory term coined by Samuel Hahnemann to contrast the conventional medicine of his day with his alternative system of homeopathic medicine.[20][21] Today, the term "allopathic physician" is used infrequently, usually in discussions relating to comparisons with osteopathic medicine or alternative medicine. Some authors argue that the terms "osteopathic" and "allopathic" should be dropped altogether, since their original meanings bear little relevance to the current practice of modern medicine[22][23]

Medical education and training

Medical schools

The Liaison Committee on Medical Education (LCME) accredits the 144 U.S. medical schools that award the MD degree,[24][25] while the American Osteopathic Association (AOA)'s Commission on Osteopathic College Accreditation (COCA) accredits the 33 osteopathic medical schools in 48 locations in the U.S. that award the DO degree.[26]

Michigan State University, Rowan University, and Nova Southeastern University offer both MD and DO accredited programs.[27] In 2009, Kansas City University proposed starting a dual MD/DO program in addition to the existing DO program,[28] and the University of North Texas explored the possibility of starting an MD program that would be offered alongside the DO program.[27] Both proposals were met with controversy. Proponents argued that adding an MD program would lead to the creation of more local residency programs and improve the university’s ability to acquire research funding and state funding. Opponents argue that adding an MD program could cause the DO program to lose its identity and drain resources from the established osteopathic program.

61% of graduating seniors at osteopathic medical schools evaluated that over half of their required in-hospital training was delivered by MD physicians.[29] Overall, osteopathic medical schools have more modest research programs compared to MD schools, and fewer DO schools own a hospital.[30] Historically, osteopathic medical schools had associations with osteopathic hospitals, which were usually small, rural, community based hospitals.[31] However, in 1990s and 2000s, economic and regulatory pressures caused many small hospitals, including most osteopathic hospitals, to either close or join larger hospital networks.[31][32]

Osteopathic medical schools tend to have a stronger focus on primary care medicine than MD schools.[30] DO schools have developed various strategies to encourage their graduates to pursue primary care, such as offering accelerated 3-year programs for primary care, focusing clinical education in community health centers, and selecting rural or under-served urban areas for the location of new campuses.[30]

Osteopathic manipulative medicine

Many authors note the most obvious difference between the curricula of DO and MD schools is osteopathic manipulative medicine (OMM), a form of hands-on care used to diagnose, treat and prevent illness or injury and is taught only at DO schools. As of 2006, the average osteopathic student spent almost 8 weeks on clerkships for OMM during their third and fourth years.[33] The National Institute of Health's National Center for Complementary and Integrative Health states that overall, studies have shown that spinal manipulation can provide mild-to-moderate relief from low-back pain and appears to be as effective as conventional medical treatments.[34] In 2007 guidelines, the American College of Physicians and the American Pain Society include spinal manipulation as one of several treatment options for practitioners to consider using when pain does not improve with self-care.[35][36] Spinal manipulation is generally a safe treatment for low-back pain. Serious complications are very rare.[34] A 2001 survey of DOs found that more than 50% of the respondents used OMT (osteopathic manipulative treatment) on less than 5% of their patients. The survey was the latest indication that DOs have become more like MD physicians in all respects: fewer perform OMT, more prescribe drugs, and many perform surgery as a first option.[37] One area which has been implicated, but not been formally studied regarding the decline in OMT usage among DOs in practice, is the role of reimbursement changes.[38] Only in the last several years could a DO charge for both an office visit (Evaluation & Management services) and use a procedure (CPT) code when performing OMT; previously, it was bundled.[38]

Student aptitude indicators

Some authors note the differences in average GPA and MCAT scores of those who matriculate at DO schools versus those who matriculate at MD schools. In 2015, the total enrollment for MD programs and DO matriculants are 20631 and 7025, respectively. the average MCAT and GPA for students entering U.S.-based MD programs were 31.4 and 3.70,[39] respectively, and 27.33 and 3.55 for DO matriculants, although the gap has been getting smaller every year.[40] DO medical schools are more likely to accept non-traditional students, who are older, coming to medicine as a second career, etc.[41][42]

DO medical students are required to take the Comprehensive Osteopathic Medical Licensure Examination (COMLEX-USA) that is administered by the National Board of Osteopathic Medical Examiners (NBOME). This exam is a prerequisite for DO-associated residency programs, which are available in almost every specialty of medicine and surgery. DO medical students may also choose to sit for the USMLE if they wish to take an MD residency[43] and about 48% take USMLE Step 1.[29] However, if they have taken COMLEX, it may or may not be needed, depending on the individual institution’s program requirements.[44][45][46]

USMLE pass rates are as follows for the indicated years: Step 1: 93% DO and 94% MD (2014–15); Step 2 CK: 92% DO and 94% MD (2013–15); Step 2 CS: 90% DO and 96% MD (however, only 62 DO students compared to 20,190 MD students were evaluated for Step 2 CS in 2013-15); Step 3: 83% DO and 98% MD (however, only 23 DO students compared to 17,864 MD students were evaluated for Step 3 in 2015. In 2014, the pass rates were 100% for DO with 27 takers and 96% for MD with 21,224 takers).[47]

Residency

Currently, the American Osteopathic Association (AOA) accredits all DO residency programs and the ACGME accredits all MD residency programs. Graduates of both DO and MD medical schools are eligible to apply to ACGME-accredited residency programs through the National Resident Matching Program (NRMP). As of 2014, 54% of DOs in post-doctoral training are enrolled in an ACGME-accredited residency program and 46% are enrolled in an AOA-accredited residency program.[9] The most common reason (72%) given by DO graduating seniors choosing an ACGME residency or AOA/ACGME dually-accredited program was a more suitable geographic location.[29]

Since 1985, a single residency training program can be dual-accredited by both the ACGME and the AOA.[48] The number of dually accredited programs increased from 11% of all AOA approved residencies in 2006 to 14% in 2008, and then to 22% in 2010.[49] In 2001, the AOA adopted a provision making it possible for a DO resident in any MD program to apply for osteopathic approval of their training.[50] The topic of dual-accreditation is controversial. Opponents claim that by merging DO students into the "MD world," the unique quality of osteopathic philosophy will be lost.[18] Supporters claim the programs are popular because of the higher prestige and higher resident reimbursement salaries associated with MD programs.[51]

Over 5 years starting in July 2015, the AOA, AACOM, and the ACGME will create a single, unified accreditation system for graduate medical education programs in the United States.[52][53] This will ensure that all physicians trained in the U.S. will have the same graduate medical education accreditation, and as of June 30, 2020, the AOA will cease its accreditation functions.[53]

Resident specialty choice

There are notable differences in the specialty choices of DOs and MDs. One study attributes this to a difference in the 'cultures' of their medical schools, concluding that the "practices and educational structures in osteopathic medical schools [DO] better support the production of primary care physician."[11] According to one survey, 54.6% of deans of MD medical schools reported that training future primary care physicians was more important to their institutions than training future specialist physicians, compared with 100% of DO medical school deans.[11]

Steps to licensure

MD DO
Standardized admissions examination Medical College Admissions Test (MCAT)
Medical school application service AMCAS/TMDSAS AACOMAS/TMDSAS
Years of medical school 4
Medical Licensing Exams (MLE) USMLE required
COMLEX required
USMLE optional
Residency
(Current)		 MD (ACGME) One must be selected:
DO (AOA)
MD (ACGME)
combined DO/MD
AOA approval of an ACGME program[50]
Residency
(After June 30, 2020)		 ACGME
Board certification MD medical specialty boards Either DO or MD medical specialty boards

Continuing medical education

To maintain a professional license to practice medicine, U.S. physicians are required to complete ongoing additional training, known as continuing medical education (CME). CME requirements differ from state to state and between the American Osteopathic Medical Association (DO) and the American Medical Association (MD) governing bodies.

Professional opportunities

There are currently more MD schools than DO schools offering medical training in the United States. However, the DO medical profession is expanding rapidly, with approximately 1 in 4 medical students now entering a DO medical school.[8] Both DOs and MDs have the option to train and practice in any of the medical specialties and sub-specialties. One exception is the Neuromusculoskeletal Medicine specialty which is available to DOs who have first completed a one-year AOA-approved residency.[54]

Both degrees are recognized internationally as a medical degree. Accredited DO and MD medical schools are both included in the World Health Organization’s World Directory of Medical Schools.[55] DOs are recognized and accepted by international medical organizations such as Doctors Without Borders.[56]

See also

References

  1. ↑ "What is a DO?". American Osteopathic Association. Retrieved 20 Dec 2014.
  2. ↑ Dennis L. Kasper, Eugene Braunwald, Anthony S. Fauci, Stephen L. Hauser, Dan L. Longo, J. Larry Jameson, and Kurt J. Isselbacher, Eds (2012). "Complementary and Integrative Health". Harrison's principles of internal medicine. (18th ed.). New York: McGraw-Hill. ISBN 978-0071748896.
  3. ↑ http://www.aacom.org/become-a-doctor/about-om/US-vs-abroad
  4. ↑ Wu, Siu (April 2012). "A Brief Guide to Osteopathic Medicine" (PDF). AACOM. Retrieved June 5, 2016.
  5. ↑ Cohen, Jordan. "Following in Flexner's Footsteps". American Medical Association. Retrieved 14 July 2012.
  6. ↑ "H-405.969 Definition of a Physician". American Medical Association. Retrieved 27 Sep 2015.
  7. 1 2 3 4 "2014 Physician Specialty Data Book" (PDF). Association of American Medical Colleges.
  8. 1 2 3 "Results of the 2015 Medical School Enrollment Survey" (PDF). Association of American Medical Colleges. Retrieved 18 May 2016.
  9. 1 2 "2014 Osteopathic Medical Profession Report" (PDF). American Osteopathic Association.
  10. 1 2 "2013 State Physician Workforce Data Book" (PDF). Association of American Medical Colleges. p. 19. Retrieved 1 September 2015.
  11. 1 2 3 4 Peters AS, Clark-Chiarelli N, Block SD (1999). "Comparison of Osteopathic and Allopathic Medical Schools' Support for Primary Care". J Gen Intern Med. 14 (12): 730–9. doi:10.1046/j.1525-1497.1999.03179.x. PMC 1496864Freely accessible. PMID 10632817.
  12. 1 2 Salsberg E; Grover A (2006). "Physician workforce shortages: implications and issues for academic health centers and policymakers". Acad Med. 81 (9): 782–7. doi:10.1097/00001888-200609000-00003. PMID 16936479.
  13. 1 2 3 "2012 Applicants to U.S. and Offshore Medical Schools" (PDF). American Association of Colleges of Osteopathic Medicine. Retrieved 2 Nov 2014.
  14. ↑ Hurt, Avery (Feb 2007). "Inside osteopathic medicine's parallel world". The New Physician. American Medical Student Association.
  15. ↑ Licciardone JC (2007). "A comparison of patient visits to osteopathic and allopathic general and family medicine physicians: results from the National Ambulatory Medical Care Survey, 2003–2004". Osteopath Med Prim Care. 1: 2. doi:10.1186/1750-4732-1-2. PMC 1805772Freely accessible. PMID 17371578.
  16. ↑ Carey TS, Motyka TM, Garrett JM, Keller RB (July 2003). "Do osteopathic physicians differ in patient interaction from allopathic physicians? An empirically derived approach". J Am Osteopath Assoc. 103 (7): 313–8. PMID 12884943.
  17. ↑ Johnson SM, Kurtz ME (December 2002). "Perceptions of philosophic and practice differences between US osteopathic physicians and their allopathic counterparts". Soc Sci Med. 55 (12): 2141–8. doi:10.1016/S0277-9536(01)00357-4. PMID 12409127.
  18. 1 2 Zeigler, Jennifer (April 2004). "Osteopathic residencies struggle to keep up with the growing number of DO grads". The New Physician. 53 (3).
  19. ↑ "Medical/Neurosurgical Glossary". Northern California Neurosurgery Medical Group. Retrieved 27 Sep 2015.
  20. ↑ Berkenwald A (1 February 1998). "In the Name of Medicine". Ann Intern Med. 128 (3): 246–250. doi:10.7326/0003-4819-128-3-199802010-00023. Retrieved 27 Sep 2015.
  21. ↑ Whorton JC (2004), Nature Cures: The History of Alternative Medicine in America, New York: Oxford University Press, pp. 18, 52, ISBN 0-19-517162-4
  22. ↑ Gundling K (9 November 1998). "When Did I Become an "Allopath"?". Arch Intern Med. 158 (20): 2185–2186. doi:10.1001/archinte.158.20.2185. PMID 9818797. Retrieved 27 Sep 2015.
  23. ↑ Jarvis WT (1 Dec 2000). "Misuse of the Term "Allopathy"". National Council Against Health Fraud. Retrieved 27 Sep 2015.
  24. ↑ "Medical Schools". Association of American Medical Colleges. Retrieved 27 Sep 2015.
  25. ↑ "Medical School Directory". Liaison Committee on Medical Education. Retrieved 27 Sep 2015.
  26. ↑ "Osteopathic Medical Schools". American Osteopathic Association. Retrieved 31 March 2016.
  27. 1 2 Hedger, Brian (April 27, 2009). "Texas university explores offering an MD degree in addition to its DO program". American Medical News. Retrieved 5 July 2012.
  28. ↑ "Fired medical school president had been pushing big changes". Joplin Metro. December 25, 2009. Retrieved 30 June 2012.
  29. 1 2 3 "AACOM 2014-15 Academic Year Survey of Graduating Seniors Summary" (PDF). AACOM. 2015. Retrieved June 5, 2016.
  30. 1 2 3 Chen C; Mullan F (June 2009). "The separate osteopathic medical education pathway: uniquely addressing national needs. Point.". Acad Med. 84 (6): 695. doi:10.1097/ACM.0b013e3181a3dd28. PMID 19474535.
  31. 1 2 Hilsenrath PE (Sep 2006). "Osteopathic medicine in transition: postmortem of the Osteopathic Medical Center of Texas.". J Am Osteopath Assoc. 106 (9): 558–61. PMID 17079525. Retrieved 27 Sep 2015.
  32. ↑ Shannon SC; Teitelbaum HS (June 2009). "The status and future of osteopathic medical education in the United States". Acad Med. 84 (6): 707–11. doi:10.1097/ACM.0b013e3181a43be8. PMID 19474542.
  33. ↑ Krueger PM; Dane P; Slocum P; Kimmelman M (June 2009). "Osteopathic clinical training in three universities". Acad Med. 84 (6): 712–7. doi:10.1097/ACM.0b013e3181a409b1. PMID 19474543.
  34. 1 2 "Spinal Manipulation for Low-Back Pain | NCCIH". National Institutes of Health National Center for Complementary and Integrative Health. 26 Jan 2015. Retrieved 27 Sep 2015.
  35. ↑ Chou R; Qaseem A; Snow V; Casey D; Cross T; Shekelle P; Owens DK (2 October 2007). "Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society". Ann Intern Med. 147 (7): 478–491. doi:10.7326/0003-4819-147-7-200710020-00006. PMID 17909209.
  36. ↑ Chou, R; Huffman, LH (2 October 2007). "Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.". Ann Intern Med. 147 (7): 492–504. doi:10.7326/0003-4819-147-7-200710020-00007. PMID 17909210. Retrieved 24 August 2012.
  37. ↑ Johnson SM, Kurtz ME (2001). "Diminished use of osteopathic manipulative treatment and its impact on the uniqueness of the osteopathic profession". Acad Med. 76 (8): 821–8. doi:10.1097/00001888-200108000-00016. PMID 11500286.
  38. 1 2 Snider KT; Jorgensen DJ (Aug 2009). "Billing and coding for osteopathic manipulative treatment". J Am Osteopath Assoc. 109 (8): 409–13. PMID 19706830.
  39. ↑ "Table A-16: MCAT Scores and GPAs for Applicants and Matriculants to U.S. Medical Schools, 2006-2007 through 2015-2016" (PDF). American Association of Medical Colleges. Retrieved 30 March 2016.
  40. ↑ "AACOMAS Matriculant Profile: 2015 Entering Class" (PDF). American Association of Colleges of Osteopathic Medicine. Retrieved 30 March 2016.
  41. ↑ "Osteopathic Medical College Information Book" (PDF). American Association of Colleges of Osteopathic Medicine. 2016. p. 19. Retrieved 27 Sep 2015.
  42. ↑ Madison Park (June 13, 2011). "Never too late to be a doctor". CNN News. Retrieved December 17, 2011.
  43. ↑ "Eligibility for the USMLE Examinations". United States Medical Licensing Examination. Retrieved 27 Sep 2015.
  44. ↑ Sarko J; Svoren E; Katz E (Feb 2010). "COMLEX-1 and USMLE-1 are not interchangeable examinations". Acad Emerg Med. 17 (2): 218–20. doi:10.1111/j.1553-2712.2009.00632.x. PMID 20070273. Retrieved 27 Sep 2015.
  45. ↑ Chick DA; Friedman HP; Young VB; Solomon D (Jan 2010). "Relationship between COMLEX and USMLE scores among osteopathic medical students who take both examinations". Teach Learn Med. 22 (1): 3–7. doi:10.1080/10401330903445422. PMID 20391276.
  46. ↑ "Information for Program Directors". National Board of Osteopathic Medical Examiners. Retrieved 27 Sep 2015.
  47. ↑ "NBME 2015 Annual Report" (PDF). National Board of Medical Examiners. 2015. Retrieved June 5, 2016.
  48. ↑ Hayes OW (November 1998). "Dual approval of a residency program: ten years' experience and implications for postdoctoral training". J Am Osteopath Assoc. 98 (11): 647–52. PMID 9846049.
  49. ↑ Burkhart, DN; Lischka, TA (April 2011). "Dual and parallel postdoctoral training programs: implications for the osteopathic medical profession.". J Am Osteopath Assoc. 111 (4): 247–56. PMID 21562295.
  50. 1 2 Bulger JB (Dec 2006). "Approval of ACGME Training as an AOA-approved internship: history and review of current data". J Am Osteopath Assoc. 106 (12): 708–13. PMID 17242416.
  51. ↑ Terry RR (August 2003). "Dually accredited family practice residencies: wave of the future". J Am Osteopath Assoc. 103 (8): 367–70. PMID 12956249.
  52. ↑ "Single GME Accreditation System". Accreditation Council for Graduate Medical Education. Retrieved 31 August 2015.
  53. 1 2 "The Single GME Accreditation System". American Osteopathic Association. Retrieved 31 August 2015.
  54. ↑ "Neuromusculoskeletal/OMM". Northeast Regional Medical Center. Retrieved September 2, 2015.
  55. ↑ "World Directory of Medical Schools". University of Copenhagen. Retrieved 5 July 2012.
  56. ↑ "Work in the Field: FAQ". Doctors Without Borders. Retrieved 2 Nov 2014.

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