Letters to the Editor  |   July 2007
COM Accreditation: The Flexner Report Revisited
Article Information
Medical Education / Graduate Medical Education
Letters to the Editor   |   July 2007
COM Accreditation: The Flexner Report Revisited
The Journal of the American Osteopathic Association, July 2007, Vol. 107, 246-277. doi:10.7556/jaoa.2007.107.7.246
The Journal of the American Osteopathic Association, July 2007, Vol. 107, 246-277. doi:10.7556/jaoa.2007.107.7.246
To the Editor: Recent articles1-3 have made alarmist references to a predicted shortage of primary care physicians in the United States. If that forecast is accurate, I am concerned about how the osteopathic medical profession will respond to the challenge. After all, approximately 59% of DOs practice in primary care specialties.4 
Osteopathic physicians are respected by the public and our allopathic counterparts as fully licensed physicians at a level previously unheard of,5,6 with full practice rights in 44 countries.7 Osteopathic medicine is certainly expanding, with 23 colleges of osteopathic medicine (COMs) offering instruction at 26 campuses in the 2007-2008 academic year (K. Miskowicz-Retz, PhD, written communication, June 2007). Moreover, the numbers of COMs and DOs are anticipated to increase.8 However, the direction in which the profession expands may, ironically, take us back 100 years. 
At the end of the 19th century, American medical education was dramatically different from what it is today. Many medical schools existed, but they had few admissions criteria and nonstandardized curricula. Many schools were owned by physicians and other investors and had no connection to established universities.9 Those schools operated more for profit than education.9 
In 1908, at the request of the American Medical Association's Council on Medical Education, the Carnegie Foundation for the Advancement of Teaching commissioned a survey of US and Canadian medical schools.10,11 Abraham Flexner, a professional educator, surveyed 155 medical schools in 18 months10,11 and issued a report in 1910,9 which has shaped American medical education into what it is today.10-12 
Flexner criticized the proliferation of proprietary schools, which had limited laboratory and hospital facilities and were staffed by part-time faculty. The profit motive of these schools was particularly distasteful to Flexner, who wrote, “Such exploitation of medical strangely inconsistent with the social aspects of medical practice. The overwhelming importance of preventive medicine, sanitation, and public health indicates that in modern life the medical profession is an organ differentiated by society for its highest purposes, not a business to be exploited.”9 In response to Flexner's critique, all for-profit medical schools were closed by 1930.10 
The new Rocky Vista University College of Osteopathic Medicine (RVUCOM) in Parker, Colo, is the ultimate expression of how far the osteopathic medical profession has fallen. Now that it has received preaccreditation status by the American Osteopathic Association's Commission on Osteopathic College Accreditation (AOA COCA), RVUCOM is on its way to becoming the first contemporary for-profit medical school—osteopathic or allopathic—in the United States in nearly 100 years. 
This institution is a for-profit, limited liability corporation,13 and I am concerned about the potential conflicts of interest of some of the people affiliated with it. For example, the “chancellor” of RVUCOM14 is also president and chief operating officer of the for-profit American University of the Caribbean School of Medicine in Cupecoy, St Maarten, Netherlands Antilles, though he resides in Coral Gables, Fla, where he is also a real estate investor.15 He is also a board member and treasurer of the International Association of Medical Colleges, a recently formed association of offshore colleges that aims to set up its own accreditation standards for foreign medical schools as an alternative to the Liaison Committee on Medical Education (LCME).16 In addition, one of the RVUCOM trustees serves as clinical dean for the American University of the Caribbean School of Medicine.17 
It appears that COCA may be permitting what the LCME has thus far prevented—a for-profit medical school on US soil. Is this damaging precedent being set in an attempt to address a predicted primary care shortage—or to make money? It is very disturbing that COCA, under its second requirement for preaccreditation, permits the incorporation of a COM as “either a nonprofit or for-profit corporation.”18 
And what of the COCA standard titled “Research and Scholarly Activities,” which states, “The COM must make contributions to the advancement of knowledge and the development of osteopathic medicine through scientific research”?18 How much funding is going to be reinvested into research in a for-profit medical school? How much research and funding would a for-profit COM receive from the National Institutes of Health? Even the most modest research endeavor requires $1 million in start-up funding, $2 million in endowment, and 5000 to 10,000 square feet of laboratory space (J. Zhang, MD, PhD, oral communication, August 2005). 
Please correct me if I have missed something, but I can find no record of any published research or funding at the for-profit Caribbean medical schools. Colleges of osteopathic medicine are already widely criticized for relying on tuition to finance operating expenses rather than research.19 For-profit ventures will only decrease the profession's credibility in this regard. How interested are these investors going to be in the principles and practice of osteopathic medicine, aside from the fact that we are allowing them to enter a new profitable venture? 
By virtue of our success as a small but elite group of physicians providing superior, holistic care to our patients, DOs have gained national and international recognition and credibility.7 Our reputation cannot be sacrificed, not only for the sake of the profession but also for the sake of our patients. The United States will need more physicians in the future, but we should not substitute quality for quantity. To retain its credibility as the guardian of the osteopathic medical profession, the AOA should take the following steps immediately: 
  • Establish an independent council to reevaluate COCA standards, membership, and procedures. The standards set by COCA should be at least equivalent to the standards of the LCME.
  • Commission a neutral party to conduct a 21st-century survey of osteopathic medical education, including graduate medical education (GME) and continuing medical education (CME).
The University of Arizona College of Medicine, for example, recently expanded its Phoenix campus in response to the state's increased need for physicians and to increase the number of the college's GME programs and clinical opportunities.20 In the osteopathic medical profession, however, we seem to be less concerned about GME and CME. 
Opportunities in CME for COM graduates are limited and hampered by the anachronistic policies of the AOA. In September 2006, an anesthesiology grand rounds was presented at the University of Mississippi School of Medicine in Jackson on using osteopathic manipulative treatment (OMT) in postoperative pain management by the osteopathic manipulative medicine coordinator from a large COM. The AOA refused to grant category 1A CME credit to participating osteopathic physicians because the University of Mississippi School of Medicine is not an AOA-accredited CME sponsor.21 So osteopathic physicians, attending a lecture on OMT given by a prominent DO, could receive category 1 credit from the AMA for the lecture, but only category 2 credit from the AOA. Only after the DOs who participated in the lecture submitted extensive, time-consuming paperwork to the Mississippi Osteopathic Medical Association were the DOs eligible to receive category 1 CME credit from the AOA's Division of CME. 
  • Establish a council to represent the interests of DOs who have undergone Accreditation Council for Graduate Medical Education (ACGME) training. As the number of DO graduates matching to osteopathic GME programs declines (49% of graduates matched in 2003, while 44% matched in 2005),22,23 DOs who train in ACGME programs make up an evergrowing majority of this profession. In fact, the number of graduating DOs exceeds the availability of osteopathic internship and residency slots. In 2005, only 2652 AOA-approved osteopathic internship positions existed for the 2826 graduating osteopathic medical students.23 However, there seems to be little desire among these graduates to obtain osteopathic GME: In the same year, only 1228 (44%) of 2826 DO graduates matched to osteopathic internships.23
  • Recruit members for these new councils from outside AOA committees' standard participants. The frequent recurrence of a dozen or so names on the list of our various committees suggests the “fox guarding the henhouse” to an outside observer.
There is a difference between growth and responsible growth. Our COMs and the rest of the osteopathic medical profession should grow, but we must adhere to the strictest standards. Has COCA abrogated its responsibility? The AOA's own written standards permit for-profit schools.18 Although funding of scientific research has increased at COMs in recent years,24,25 we rely on osteopathic postdoctoral training institutions for GME.26 
In 1910, American medical schools were for profit, they were unaffiliated with universities, they did not require laboratory work or dissection, and they were staffed by part-time local physicians whose own training left something to be desired.8 Does this description sound familiar? 
In 2007, the government and other payers play significant roles in regulating medicine, which was not the case in the fee-for-service turn of the century. If the osteopathic medical profession does not act aggressively to align itself with current trends, the government may step in and do it for us. It is not beyond the bounds of reason to envision a future in which DOs who underwent ACGME training and obtained allopathic board certification are converted to MDs on a nationwide scale, much like the California merger threatened to expand to other states in the early 1960s.27 And if that should happen, the graduates of hastily accredited for-profit COMs may find their practice rights revoked. 
It is 1910 all over again, and our response needs to be as serious as was the response of osteopathic and allopathic medical colleges' of that time, or osteopathic medicine will perish. It is ironic that now, as the osteopathic medical profession reaches its potential zenith, it is in its greatest danger of unintentional collapse. 
 Editor's Notes: A response letter from Ronnie B. Martin, DO, Dean of RVUCOM, is scheduled to appear in the August 2007 issue of JAOA—The Journal of the American Osteopathic Association.
 The chancellor of RVUCOM was shown this letter and declined to comment.
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