Special Communication  |   July 2007
Getting “Beyond the Barriers” in Reforming Osteopathic Medical Education
Author Notes
  • From the Georgetown University School of Medicine in Washington, DC, and the Philadelphia College of Osteopathic Medicine in Pennsylvania. Ideas from this paper were presented at Founder's Day Address at the A.T. Still University-Kirksville (Mo) College of Osteopathic Medicine on September 23, 2005. 
  • Address Correspondence to John R. Gimpel, DO, MEd, Vice President for Clinical Skills Testing, National Board of Osteopathic Medical Examiners, 101 W Elm St, Suite 150, Conshohocken, PA 19428-2075. E-mail: 
Article Information
Medical Education / Curriculum
Special Communication   |   July 2007
Getting “Beyond the Barriers” in Reforming Osteopathic Medical Education
The Journal of the American Osteopathic Association, July 2007, Vol. 107, 270-275. doi:10.7556/jaoa.2007.107.7.270
The Journal of the American Osteopathic Association, July 2007, Vol. 107, 270-275. doi:10.7556/jaoa.2007.107.7.270

As the healthcare needs of the United States change, some leaders at colleges of osteopathic medicine and osteopathic graduate medical education programs have embraced one very important and timeless goal: to prepare future physicians to meet society's health needs. These medical educators have made significant strides toward moving “beyond the barriers” to effect curricular reform and quality improvement at their institutions. Some of the barriers to osteopathic medical education reform are addressed in this article, which recommends allowing curricular evolution and faculty development; expanding clinical learning and teaching; breaking down departmental walls; integrating osteopathic principles and practice; reevaluating admission requirements of colleges of osteopathic medicine; and eradicating the unspoken and, ironically, often detrimental culture of medicine, which can be contrary to compassionate patient care and healing.

Changes in the demographics of the population in the United States are inevitable. For example, in 2006, nearly 8000 baby boomers turned 60 each day, and that number continues to grow.1 In the same year, 43.8 million Americans did not have health insurance.2 And recently, the US life expectancy reached an all-time high of 77.9 years.3 
To meet society's expanding healthcare demands, medical schools and residency training programs need to revaluate how they teach, train, assess, and cultivate future physicians and recent graduates.4-7 Although there has been increasing concern in how the healthcare community will respond to the challenge, medical education reform may prove to be a viable— and vital—solution.6-18 It is encouraging to see many medical educators and directors at osteopathic residency programs embrace this challenge by addressing the need to revisit and revamp osteopathic medical education.8,19-22 Their action and demands for continued improvements in osteopathic medical curricula had no doubt influenced the 2006 OHF [Osteopathic Heritage Foundation] Osteopathic Medical Education Summit, sponsored by the American Association of Colleges of Osteopathic Medicine (AACOM) and the American Osteopathic Association (AOA), which emphasized the need to evaluate, develop, and expand medical education—particularly osteopathic graduate medical education (OGME).23 
There have been numerous curricular opportunities— and challenges—in continuous quality improvement in medical education at the nation's 23 fully accredited and operating colleges of osteopathic medicine (COMs)24 as well as in the nation's many osteopathic and allopathic residency programs.7,10,11 Unfortunately, those involved with strategic planning and facilitating change in both curricular and extracurricular areas of medical education often encounter barriers25 akin to the resistance encountered by osteopathic medicine's founder, Andrew Taylor Still, MD, DO, when he first used osteopathy to diagnose and treat patients with dysfunctions of the musculoskeletal system.26,27 
Mandate to Change
It is no wonder that those calling for medical education reform have grown to include healthcare professionals (eg, physicians, medical students, and residents); healthcare organizations (medical schools and hospitals); accrediting, certifying, and licensing authorities; and professional societies and organizations. Although each of these bodies is a stakeholder in the future of our nation's healthcare,7,12-14 perhaps the largest stakeholder is the public—our patients—58% of whom, in a public opinion survey,28 responded that “poor training of health professionals” is a “very important” cause of medical errors. 
In response to the growing concerns, various groups have contributed to an increasing number of position papers and collaborative reports4-7,14-17 and projects10,11 during the past 20 years with strikingly similar recommendations for significant educational reform in medical schools and residency programs. A sampling of the reports and projects are listed in the Figure. 
Although these documents vary in regard to scope and focus, the resounding demand for change in medical education is unmistakable. These landmark reports and projects have generated much discussion in the form of articles13,18 and faculty meetings and national conferences.14,23 Some educators have effected significant change at their institutions8,13,14,19,29 while others have tweaked courses,20-22,30 attempted to cut lecture hours across the board,30 piloted or added additional innovative coursework (sometimes as the result of available external funding),13,15,20,21,31 and started or expanded standardized patient programs,32 but often not without encountering barriers to implementing significant reform.8,13,14,18-22,29-32 
Collaborative reports, position papers, and projects listed by the corresponding consensus group. The various groups listed have reported the need for medical education reform.
Collaborative reports, position papers, and projects listed by the corresponding consensus group. The various groups listed have reported the need for medical education reform.
Barriers to Successful Reform
A recent study by Carole J. Bland, PhD, et al25 reviewed a number of articles regarding how to bring about successful curricular reform. This study,25 which evaluated curricular change in the general topics of medical education and higher education, reported several key elements to implementing successful curricular change. 
In relation to the study by Bland et al,25 and in my own experience with medical education reform at a number of osteopathic and allopathic medical schools and residency programs, I have observed the following recurring barriers to curricular change, particularly as they pertain to osteopathic medical education. 
The Skeptics
Faculty and administrators commonly resist proposals for medical education reform with an “If it ain't broke, why fix it?” rebuttal. These skeptics will cite a track record of excellent board scores, anecdotes that “residency programs love our graduates,” and surveys of graduates and residency program directors that indicate all is well in osteopathic medical education.14,25,33,34 There are many educators who refute the evidence in favor of reform6-18 by pointing to the global ratings of medical students' “clinical years” (ie, clerkship grades) to show that graduates are well versed in patient-physician communication, physical examination skills, and other core clinical skills (eg, medical-history taking, physical examination, basic clinical procedures).14,25,33-35 Another common argument against medical education reform is a lack of major studies that prove curricular change will lead to better educational outcomes. The results of small-scale studies,36-39 though promising, are difficult to apply globally to all medical education curricula. 
Such arguments assume that board scores and clerkship grades indicate that the existing system is maximally effective. However, as with a number of clinical questions, sometimes the best guidance comes from smaller case studies and expert consensus. In addition, the growing literature on medical education will help leaders gain further support for—and therefore encounter fewer barriers to—integrating the best educational tools into their programs.29 
Faculty Development and Teaching
Faculty resistance to medical education reform can be a result of competing priorities, inertia, and an organization's under-valuing of faculty development.25 Well-rounded medical educators who value learning—not just teaching—and who are skilled and comfortable with facilitating learning in small-group settings appreciate the assessment process. These educators know that it is an important aspect of evaluating not only the knowledge, skills, and attitudes of the students, but also the curriculum and entire educational program itself.29 
In addition, multiple-choice examinations should not be used exclusively to evaluate students' knowledge. Used appropriately, a combination of multiple-choice examinations and simulation-based educational and evaluative methodologies can provide formative and summative assessment across the continuum. This approach emphasizes improved quality of care and patient safety.9 Faculty development at the most successful institutions also includes aligning appropriate rewards for improved teaching equal to those offered for basic and clinical research and clinical production (ie, revenues generated from patient care) as a necessary prerequisite to educational reform. This barrier may be a smaller hurdle for COMs,7,12 however, because most COMs have considerably less of a research infrastructure than do their allopathic counterparts.40 
The Flexner Report
A major restriction to instituting improvements in undergraduate medical education is ongoing dependence on the Flexner Report41 of 1910—despite its decrepitude and the author's lack of any considerable clinical experience. At a time when diagnostic methods in the practice of medicine are improving almost daily, Flexner's work continues to be used as a key diagnostic tool in medical education.42-44 Although Flexner himself emphasized the need for educators to establish and maintain a relationship between laboratory and clinical experience for medical students,41 I wonder whether the fostering of the separation of preclinical and clinical medical education are now impeding the development of a more student-centered, competency-based curriculum.29 Isn't it time to move beyond Flexner? 
Since 1980, many reports have called for students to have clinical exposure earlier in their training,7,11,14,16 and some from day 1 of medical school.45,46 Some groups advocate for more involvement of basic science faculty in years 3 and 4 of the medical school curriculum.46 But simply adding a number of lecture-based clinical courses into years 1 and 2, and a few basic science lectures into years 3 and 4 falls significantly short of the more integrated approach recommended by most of the experts.7,11,14,16 Band-Aid approaches may also be obstructing the creation of cohesive curricula. 
Although Flexner did not advocate abandoning ambulatory or outpatient medical education in the clinical curricula,41 most medical schools began to emphasize hospital-based training in the 20th century. While many osteopathic medical schools never espoused (either by design or necessity) the hospital as the predominant site for the clinical years, they did balance hospital-based clerkships with office-based, ambulatory clinical rotations.14 Today, getting “beyond the hospital” is a preeminent agenda item for many medical schools and residency programs46 as they attempt to adjust to the major changes in inpatient care that have significantly affected hospital-based clerkships and residency training programs.9,7,13 Shorter hospital lengths of stay and the resulting chaos of patient admissions; advances in outpatient care for common clinical problems; and hospital closings have added to the inherent challenges of providing quality medical education programs through hospitals.12 The lack of continuity of care31,46 and subsequent inability of students to build relationships with patients likely have negatively affected students' learning, satisfaction with educational programs, and career choice. 
In response, many medical schools are now attempting to provide more quality clinical experiences for their students by ensuring educational equivalency across a larger and more diverse array of ambulatory clinical training sites (ie, chronic care, urgent care, and emergency facilities).14 Standardized patients and mechanical simulator programs, which are increasingly used in the teaching, learning, and assessment of students' basic science knowledge and clinical skills,19 are helping to fill some of these gaps,19,35 reduce medical errors, and assure the public of the medical profession's proficiency in providing the best healthcare possible.4 
Creation of educational partnerships with assisted-living facilities, community health centers, and other institutions as well as consideration for providing reimbursement to clinical teachers may be necessary to reduce many schools' reliance on volunteer faculty and maintain quality in clinical education.7,9 One additional consequence of the “2 + 2” curricular model, in which students' first 2 years of medical school consist of laboratory sciences and the second 2 years relate to clinical sciences,31 particularly at some COMs, is a focus on curriculum as pertaining to years 1 and 2 predominantly, with very little change to years 3 and 4 of medical education. With the exception of students' increased exposure in clinical ambulatory settings and a greater number of allopathic medical schools including required clerkships in family medicine, there has been little substantial change to the clinical curriculum at most schools in the past several decades.15,47 
The total dependence on time-based courses in undergraduate and graduate medical education programs and clinical clerkships may also be a barrier to medical education reform.29 In response, the traditional teacher-centered structure, whereby curricular content and students' knowledge acquisition was the driving force, is now being rivaled by the student-centered, competency-based training model, which emphasizes learning from real-world application of clinical knowledge.29,48 The Harvard Medical School (Boston, Ma) Medical Education Reform Initiative, a longitudinal pilot program, in which third-year students follow patients and families over time with interdisciplinary “clerkships,” fosters continuity of care and patient-student relationships. The program may also represent an educational innovation that should be widely exported elsewhere.31 
Curricular Isolation Between Departments
Another barrier to medical education reform is the disjunction in curricular content that occurs in department-based courses when educators do not make significant attempts to integrate and build on each others' lectures and workshops.25 There are a number of success stories from COMs where curricular changes20,21 have allowed faculty to get “beyond the department.” 
Osteopathic Principles and Practice
Fragmentation in coursework, clerkships, and residency programs is often evident in the teaching of osteopathic principles and practice (OPP) and manipulative medicine.8,49 While this may be understandable in certain dually accredited residency training programs, it is puzzling (especially to students) when it occurs on campus. The impact of even one educator who has “lost” his or her skills in palpatory diagnosis and osteopathic manipulative treatment (OMT) can have a profound effect on aspiring osteopathic physicians.50 Perhaps with the increasing global acceptance of the osteopathic medical profession,51 curricular initiatives can be refocused to integrate the distinct elements of OPP throughout all 4 years of medical school and into OGME programs.23,52 
College Requirements and Admissions
While curricular reform receives most of the attention, there are key cocurricular and extracurricular areas that, should they be addressed, can help prepare medical students to meet the healthcare needs of society. For example, if the goals of COMs are to educate physicians to be compassionate and committed to service and to practice a holistic approach to medicine, why is it that COMs require extensive undergraduate hours in inorganic and organic chemistry, physics, and basic sciences, but few schools require more than a course or two in the humanities or social sciences? According to the admission requirements posted online, only six of the 23 fully accredited osteopathic medical schools report requiring any college coursework in the behavioral sciences.53 Physicians must be competent in the sciences, but it seems to me that the “science” of humanity is also important. If osteopathic physicians are oriented to consider the relationship between structure and function and the neuromusculoskeletal system, why is it that not a single osteopathic medical school requires prerequisites in anatomy or neuroscience?53 (Edward Via Virginia College of Osteopathic Medicine in Blacksburg requires six additional semester hours of science courses. Anatomy, biochemistry, genetics, and physiology are “strongly suggested.”53) 
As COMs look to increase the diversity in the applicant pool,54 the profession will likely need to reach out to students from underrepresented groups at the grade school and high school levels to attract those who historically come from educationally or economically disadvantaged backgrounds. 
In addition, medical students' increasing debt loads, particularly at COMs,14 is significantly affecting the career choices of our profession's graduates.14 I hope the next Osteopathic Medical Education Summit will address this worsening problem by implementing ways in which students determine their specialty independent of the educational debt they incur. 
Lack of Osteopathic Research
For years, leaders in the osteopathic medical profession have called for an increase in osteopathic research at COMs.55 Mean-while, an overabundance of research scientists has threatened the financial viability of a number of the allopathic academic health centers.12 It seems prudent for osteopathic programs to align their research goals with areas that complement their missions. Some areas would include OMT, informatics, inter-disciplinary teams, management sciences, health services research, and educational outcomes.48,56,57 
The Unspoken Culture of Medicine
Perhaps the most challenging barrier to successful medical education reform is the hidden culture of medicine, which has been described as competitive, unemotional, hostile to human error, and otherwise contradictory to compassionate care and healing.58 We sometimes hear, “That's the way I was trained,” or witness “old school” pedantic and patronizing teaching methods that are not appropriate in the modern education setting. Rachel Naomi Remen, MD,58 for example, describes how medical students are taught to view “a genuine human connection” between a patient and a physician as “unprofessional.” To allow students, residents, and faculty to redefine the culture of medicine, educators must restructure learning environments and expand humanities requirements. In addition to emphasizing students' longitudinal continuity-of-care relationships with patients, these could be the most promising medical education innovations to emerge in our lifetime. 
There has been some real movement in getting beyond the barriers to real quality improvement in all aspects of both osteopathic and allopathic medical education curricula and graduate medical education programs.25 Osteopathic medical education programs, with faculty members who are committed to teaching and who traditionally focus on creating quality clinical experiences in medical education for their students,45 foster a “hands-on” approach in the first semester, including palpatory diagnosis and a better understanding of the musculoskeletal system. These attributes, which are indispensable to osteopathic medical education, are what the American Association of Medical Colleges and most medical schools are now striving to incorporate into their curricula.59 
The real excitement, however, comes from witnessing leaders at COMs and OGME programs that have summoned up the courage to move above and beyond the barriers to medical education reform and embrace one very important and timeless goal: preparing future physicians to meet society's health needs. Curricula that address the unprecedented aging and cultural diversity of the US population place emphasis on knowledge, skills, and values in geriatrics and cultural competence.8 Continued improvement and outcomes evaluation will help these institutions and our profession rise above and beyond the current state of medical education. 
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Collaborative reports, position papers, and projects listed by the corresponding consensus group. The various groups listed have reported the need for medical education reform.
Collaborative reports, position papers, and projects listed by the corresponding consensus group. The various groups listed have reported the need for medical education reform.