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Medical Education  |   September 2005
American Osteopathic Association Commitment to Quality and Lifelong Learning
Author Notes
  • Dr Tunanidas was the 2004-2005 chairman of the Department of Educational Affairs for the American Osteopathic Association (AOA) and a member of the Conjoint Committee on Continuing Medical Education (CME). Dr Tunanidas was also a member of the AOA's Board of Trustees from 1999 to 2005. Dr Burkhart is the director of the AOA's Department of Education. 
  • Address correspondence to Diane N. Burkhart, PhD, Director, Department of Education, American Osteopathic Association, 142 E Ontario St, Chicago, IL 60611-2864. E-mail: dburkhart@osteopathic.org 
Article Information
Medical Education / Professional Issues / Graduate Medical Education
Medical Education   |   September 2005
American Osteopathic Association Commitment to Quality and Lifelong Learning
The Journal of the American Osteopathic Association, September 2005, Vol. 105, 404-407. doi:10.7556/jaoa.2005.105.9.404
The Journal of the American Osteopathic Association, September 2005, Vol. 105, 404-407. doi:10.7556/jaoa.2005.105.9.404
Abstract

The American Osteopathic Association (AOA) initiated programs to enhance quality for 54,000 doctors of osteopathic medicine (DOs) practicing in the United States. Seven core competencies are required in undergraduate and graduate medical education standards. They include osteopathic philosophy and osteopathic manipulative medicine, medical knowledge, patient care, professionalism, interpersonal or communication skills, practice-based learning, and systems-based practice.

The AOA Clinical Assessment Program (AOA-CAP) is a quality-improvement tool for physicians to evaluate the safety of patient care. Osteopathic residents and practicing physicians measure the quality and safety of patient care using evidence-based standards through an AOA-supported, Web-based architecture. Alternative models for recertification, including a Maintenance of Certification (MOC) process, are under review by the AOA, the Bureau of Osteopathic Specialists (BOS), and osteopathic certifying boards. The BOS establishes and maintains standards for the various osteopathic certifying boards and oversees matters of policy, jurisdiction, and standards review. The American Osteopathic Board of Emergency Medicine is the first osteopathic board to adopt a MOC process.

The goals of the AOA's continuing medical education (CME) program are continued excellence of patient care and improvement of health and well-being of individual patients and the public. The AOA agrees that CME will play a critical role in recertification and continual assessment of physician competence. The AOA believes that proposed activities of the Conjoint Committee on CME and quality initiatives of the osteopathic profession are in tandem with goals and quality initiatives of the AOA.

The Osteopathic Profession
There are over 54,000 doctors of osteopathic medicine (DOs) practicing in the United States in 2005. Osteopathic physicians are licensed to practice in all 50 states, and practice rights have recently become available in Canada as well.1 Twenty colleges of osteopathic medicine, located in 21 states, together have an enrollment of nearly 10,000 students. The American Osteopathic Association (AOA) serves as the primary certifying body for osteopathic physicians and is the accrediting agency for all osteopathic medical colleges and healthcare facilities. The osteopathic profession offers 227 approved internship programs and 596 approved residency training programs. While osteopathic medicine has a full range of specialty training, the majority of osteopathic physicians practice in the fields of family practice, internal medicine, and emergency medicine.1 

Editor's Note

The following article is being published simultaneously by and in cooperation with The Journal of Continuing Education in the Health Professions (JCEHP) under the same title (J Continuing Educ Health Prof. 2005;25[3]197-202).

The present article analyzes the implications for the osteopathic medical profession of a report issued by the Conjoint Committee on Continuing Medical Education (CME) titled “Reforming and repositioning continuing medical education.” That document can be accessed at the JCEHP Web site: http://www.jcehp.com/vol25/2503_CMEReport.pdf.

The American Osteopathic Association (AOA) was one of 13 organizations that participated in drafting the Conjoint Committee on CME report. Among the organizations that worked with the AOA to draft the document are the sponsors of JCEHP: the Alliance for Continuing Medical Education, the Society for Academic Continuing Medical Education, and the Association for Hospital Medical Education. Other participating organizations included the American Medical Association, the Federation of State Medical Boards of the United States, the Accreditation Council for Continuing Medical Education, and the Council of Medical Specialty Societies.

At the time “Reforming and repositioning continuing medical education” was drafted, the AOA's representative on the Conjoint Committee on CME was Amelia G. Tunanidas, DO, who was then a member of the AOA board of trustees. The AOA's current representative on the committee is AOA Trustee Carol L. Monson, DO. The following article was edited by the staff of JAOA—The Journal of the American Osteopathic Association only to the extent necessary to make it consistent with JAOA style.

 
Osteopathic physicians who complete osteopathic residency training programs are eligible for osteopathic board certification. Primary certification is available in 18 medical specialties. Osteopathic boards also offer specialized certifications (certificates of special qualification and added qualification) in numerous subspecialty areas.2 
AOA Quality Initiatives
The AOA has initiated programs designed to enhance quality at all levels of its “continuum of osteopathic education.” The AOA supports seven core competencies, the first being “osteopathic philosophy and osteopathic manipulative medicine (OMM).” Osteopathic medicine is a complete system of medical care with a philosophy that combines the needs of the patient with the current practice of medicine, surgery, and obstetrics, emphasizing the interrelation between structure and function that appreciates the body's ability to heal itself. 
Figure.
Multidimensional and comprehensive change is being introduced to the American Osteopathic Association's many medical education programs.
Figure.
Multidimensional and comprehensive change is being introduced to the American Osteopathic Association's many medical education programs.
Osteopathic philosophy is a concept of healthcare that embraces the unity of the living organism's structure (anatomy) and function (physiology). Osteopathic philosophy emphasizes the following principles: 
  • □ The human being is a dynamic unit of function,
  • □ The body possesses self-regulatory mechanisms that are self-healing in nature,
  • □ Structure and function are interrelated at all levels, and
  • □ Rational treatment is based on these principles.
In addition to competency in osteopathic philosophy and OMM, the AOA's core competencies include medical knowledge, patient care, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice. The AOA competencies are identical to those adopted by the Accreditation Council for Graduate Medical Education; however, osteopathic philosophy and OMM influence the content of all the core competencies in osteopathic medicine. For example, osteopathic philosophy requires that residents and physicians demonstrate evidence that preventive medicine is part of the treatment plan for patient care, that the patient's family is involved in decision making (communication skills), and that osteopathic manipulative treatment (OMT) is documented in the treatment plan (practice-based learning). 
Requirements for the core competencies in both undergraduate and graduate medical education have been placed in the predoctoral and postdoctoral “basic documents and standards” and are assessed through the AOA inspection process.3,4 They are being introduced on an incremental basis so that programs can develop quality curricula, teaching methods, and evaluation tools. The timeline for implementation of the core competencies in postdoctoral programs is as follows: 
  • Year 1: July 2004
     
    • □ Osteopathic philosophy and OMM
    • □ Medical knowledge
  • Year 2: July 2005
     
    • □ Patient care
    • □ Professionalism
    • □ Interpersonal and communication skills
  • Year 3: July 2006
     
    • □ Practice-based learning and improvement
    • □ Systems-based practice
Every osteopathic specialty college has revised its basic documents to include requirements for the core competencies, and all training program inspections require a review to demonstrate whether programs are successfully implementing core competencies, based on the schedule. At this writing, all programs are tracking on schedule. 
The AOA's Bureau of Osteopathic Specialists (BOS) is the authoritative body that establishes and maintains standards of specialization for the various osteopathic certifying boards. The BOS oversees matters of policy, jurisdiction, and standards review. The BOS is coordinating its efforts with the AOA's Council on Osteopathic Postdoctoral Training (COPT) as each of the core competencies is implemented at the postgraduate level. The BOS Standards Review Committee will evaluate how the seven core competencies are being incorporated into each board's certification process, beginning with the third cycle of review from the time this policy was approved. 
AOA Clinical Assessment Program
The AOA Clinical Assessment Program (AOA-CAP) is a quality-improvement tool for physicians in training to evaluate the safety of their patient care in the ambulatory setting.5 This type of program introduces physicians to active participation in quality-improvement activities during their graduate medical education. The AOA-CAP developed several guiding principles for the program, including the use of information technology to drive the program. This resulted in the development of an AOA-supported, Web-based architecture that provides key components to participating programs and physicians. The program is a retrospective evaluation of care delivery within measure sets, and standardized materials are used for institutional review. Data are abstracted directly from patient medical records and analyzed via this Web-based program. National standards used for the AOA-CAP include: 
  • ▪ National Committee on Quality Assurance Health Employer Data and Information Set measures
  • ▪ Center for Medicare and Medicaid Services
  • ▪ Doctors Office Quality Initiative
  • ▪ Joint Commission on Accreditation of Healthcare Organizations core measures
The AOA-CAP is a tool to provide osteopathic residency programs and, eventually, practicing physicians with an approach to measuring the quality and safety of care osteopathic physicians and residents provide to their patients, using evidence-based standards. As sets of measures pertinent to the conditions, these tools are organized around clinical conditions such as diabetes mellitus and hypertension. The AOA-CAP incorporates continuous quality improvement into graduate medical education and the practice of osteopathic medicine. The AOA-CAP is of interest to maintaining competence because of its strong emphasis on quality measurements and quality improvement. 
Clinical Assessment Program measurements of quality easily could be added as a component of board certification and recertification. The BOS is monitoring the progress and effectiveness of the AOA-CAP to assess how it might be integrated into the AOA recertification process. 
The American Osteopathic Board of Emergency Medicine (AOBEM) is the first osteopathic board to adopt and implement a Maintenance of Certification (MOC) process. “Continuous Certification in Emergency Medicine” was developed as an alternative model to traditional recertification. Several osteopathic boards are evaluating and considering alternate competency-assessment models, but only AOBEM has placed theirs into action at this time. 
Presentations on alternative models, including MOC, are under review by the AOA, the BOS, and osteopathic certifying boards. There are four components to an MOC process: professional standing (licensing), lifelong learning and self-assessment, demonstration of cognitive expertise (examination process), and practice performance assessment.6 American Osteopathic Association leadership fully supports initiatives that will lead to new models that can enhance physician competence and encourage excellence in practice. 
Osteopathic Continuing Medical Education
It was not until the late 1970s that US state legislatures and licensing boards mandated continuing medical education (CME) for licensure and that US boards required CME for recertification.7 Since that time, medical professionals and government agencies have recognized CME as an essential component to maintain physician competence and enhance patient care. Growing concern for patient safety, escalating medical and malpractice costs, increasing intervention from government and other regulatory agencies, and a better educated and interested public have prompted AOA leaders to evaluate the state of osteopathic CME in meeting the needs of physicians and, ultimately, in influencing the quality of patient care. 
The goals of the AOA's CME program are the continued excellence of patient care and improvement of the health and well-being of the individual patient and the public.8 The purpose of the osteopathic CME program is the growth of medical knowledge, refinement of skills, and deepened understanding and integration of osteopathic principles and practice throughout the process of knowledge growth and skill refinement.8 Continuing medical education is considered part of the osteopathic “continuum of education” that includes predoctoral education, postdoctoral training, and the board certification and recertification process.4 The AOA develops, reviews, and evaluates the policies and role of osteopathic CME and the assessment of physician competence through its Council of Continuing Medical Education, COPT, Bureau of Osteopathic Education, and the BOS. 
Organized medicine is advancing with new initiatives and a system that will promote quality physician performance and patient confidence in healthcare providers.9 Research shows that the quality of patient care is variable and inconsistent,10,11 that updating physician skills and knowledge is better accomplished through more interactive teaching methods,12,13 and that the impact of CME toward the enhancement of patient care should be evaluated.12,14 Consistency of quality care may be rectified through restructuring and strengthening the existing CME system. Reform of osteopathic CME will need to focus on the physicians' abilities to maintain the highest skills necessary to deliver timely, cost-effective, and efficient healthcare to their patients. Osteopathic CME providers should offer physicians CME based on the highest level of evidence that explains what works best in a learning environment and that optimally addresses the physicians' needs. 
The AOA believes CME will play a critical role in the recertification process and the continual assessment of physician competence, particularly in light of the movement toward outcome-based CME.15 Including the BOS and the AOA Board of Trustees, all AOA education-related councils, committees, and bureaus were asked to respond to the Conjoint Committee on CME report, “Repositioning and Restructuring CME,”16 and to report back to the chair of the AOA Department of Educational Affairs. 
Responses from the AOA education committees have been favorable. There is universal agreement that CME should focus on the physician-learner, facilitating appropriate learning for optimum patient care. Effective CME should support the physician in his or her professional activities, assessing professional and educational needs, evoking professionalism, motivating physicians as learners, enhancing the quality of care, and producing measurable outcomes. There is agreement that changing the face of osteopathic CME to outcomes measurement will present many challenges; however, many of the changes required already are in motion, as licensing boards, accreditation programs, and federal agencies impose new policies and regulations. 
To determine the strategic goals and objectives of osteopathic CME in the immediate and more distant future, the AOA's immediate past president, George Thomas, DO, appointed a task force on CME in February 2005. The task force represents members from the BOS, predoctoral education, the Council on Continuing Medical Education, and osteopathic affiliates who sponsor and provide osteopathic CME programs for osteopathic physicians. Osteopathic leaders and CME professionals are actively supporting changes to promote the development of quality osteopathic CME programs and lifelong learning opportunities for osteopathic physicians. The AOA believes that the proposed activities of the Conjoint Committee on CME and quality initiatives of the osteopathic profession are in tandem with goals that will ultimately result in quality patient care, where physicians not only participate in the process of learning but also leave educational activities with evidence of their skills verified and with confidence in their ongoing professional competence and knowledge. 
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Figure.
Multidimensional and comprehensive change is being introduced to the American Osteopathic Association's many medical education programs.
Figure.
Multidimensional and comprehensive change is being introduced to the American Osteopathic Association's many medical education programs.