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Medical Education  |   June 2009
Measuring Awareness, Interest, and Involvement in the Osteopathic Community Through Board Certification: A Survey of DO Residents in ACGME-Accredited Training Programs
Author Notes
  • From the Arizona College of Osteopathic Medicine in Glendale (Dr Scott) and the Scottsdale (Ariz) Healthcare Family Medicine Residency Program (Drs O'Connor and Marlow). 
  • Address correspondence to Shannon C. Scott, DO, Midwestern University, 19555 N 59th Ave, Glendale, AZ 85308-6813. E-mail: sscott1@midwestern.edu 
Article Information
Medical Education / Graduate Medical Education
Medical Education   |   June 2009
Measuring Awareness, Interest, and Involvement in the Osteopathic Community Through Board Certification: A Survey of DO Residents in ACGME-Accredited Training Programs
The Journal of the American Osteopathic Association, June 2009, Vol. 109, 302-311. doi:10.7556/jaoa.2009.109.6.302
The Journal of the American Osteopathic Association, June 2009, Vol. 109, 302-311. doi:10.7556/jaoa.2009.109.6.302
Abstract

Currently, close to 50% of osteopathic medical graduates receive residency training from programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) rather than those approved by the American Osteopathic Association (AOA). As a result, leaders within the osteopathic medical profession have expressed ongoing concerns about the viability of the profession's distinct osteopathic identity. Using a one-page, 12-item survey, the authors queried ACGME-trained family practice residents (N=1354) regarding their interest in formal membership, continuing medical education activities, and specialty board certification options within the osteopathic medical profession. Four hundred twenty-six completed surveys were returned and usable for analysis for an overall response rate of 31.4%. A majority of survey participants indicated an interest “in continuing [their] osteopathic skills and training during residency” (376 [88.5%]), membership in osteopathic organizations and participating in continuing medical education programs (325 [77.2%]), and completing the American Osteopathic Board of Family Physicians certification examination (267 [63.7%]). Unfortunately, actual involvement may be limited by lack of communication or understanding, as in the case of lack of awareness regarding eligibility criteria for AOA board certification (311 [74.2%]). A variety of recommendations are offered to osteopathic organizations to improve involvement in and commitment to the profession among ACGME-trained DOs.

In 1985, the American Osteopathic Association (AOA) reformed its educational policies to allow osteopathic medical school graduates to attend postdoctoral programs accredited by the Accreditation Council for Graduate Medical Education (ACGME).1 That decision was influenced by a growing imbalance in the number of osteopathic medical graduates vs funded osteopathic residency training positions. The action ameliorated pressure in the osteopathic medical field and helped address a nationwide decline in the number of allopathic graduates entering primary care fields, particularly family medicine.1-4 
Since 1985, the number of osteopathic physicians (DOs) entering allopathic residency programs has been rising.1-7 It has been estimated that “more than 50% of new osteopathic physicians receive residency training in programs accredited by the [ACGME] rather than those approved by the [AOA].”8 This shift could mark a new crisis for osteopathic leadership. The integration of osteopathic medical graduates within the larger allopathic community where little or no training is provided to resident physicians in osteopathic medicine's hallmark treatment modality, osteopathic manipulative treatment (OMT), raises concerns that osteopathic medicine is losing its unique role within the healthcare professions.1,2,8,9 But are these residents actually “lost” to the osteopathic community? 
In 2006, the American College of Osteopathic Family Physicians (ACOFP) Residents' Committee formalized discussions regarding the increasing amount of correspondence received from DO residents in ACGME-accredited programs who were interested in becoming board certified through the American Osteopathic Board of Family Physicians (AOBFP). Residents consistently expressed that the process of applying for board examinations required multiple steps that were confusing or contradictory as a result of separate requirements from multiple osteopathic organizations, namely the AOA, ACOFP, and AOBFP. These residents also described frustrating roadblocks in this multi-step process, leading to confusion about how to navigate the system. A pattern appeared in the kind of informational requests made. 
Some residents, when faced with such barriers, indicated anecdotally that they would opt not to pursue AOA board certification—not initiating the process or “giving up” after pathway entry. The feedback received by the Residents' Committee inspired the following question: 

Are DOs choosing ACGME-accredited programs actually losing interest in osteopathic continuing medical education, board certification, and maintaining ties with osteopathic organizations—or are they instead having difficulty finding educational opportunities and support?

 
We hypothesized that many DOs who chose ACGME-accredited programs had not lost interest in osteopathic medicine or their osteopathic roots but were instead encountering unnecessary institutional barriers to continuing their affiliation with the larger osteopathic family. The ACOFP Residents' Committee was charged with investigating this question and hypothesis. 
Literature regarding the attitudes of DOs in ACGME-accredited programs is limited.1,2,8,10 Allee and coinvestigators8 studied the opinions of DOs in selected residency programs. Their results revealed that, “prior to residency,” a high percentage of family practice DO respondents—regardless of training program type—anticipated using OMT frequently or occasionally during residency training (AOA, 96.4%; ACGME, 97.3%).8 In addition, Allee and coauthors8 reported that a high percentage of family practice DO respondents in ACGME-accredited training programs not only believed OMT is an effective treatment modality for somatic dysfunction (97.4%) but also planned to use it at least occasionally after residency (84.2%). Their results could support the premise that osteopathic medical school graduates moving toward allopathic residencies are not abandoning osteopathic philosophy and training. 
Similarly, Rubeor and coauthors2 identified an inverse trend among residents in osteopathic vs allopathic medicine, with family medicine being more frequently pursued by DOs and less so by MDs.11 Those researchers2 credited this phenomenon to the good “fit” between osteopathic principles and practice with the tenets of family medicine. Rubeor and coinvestigators2 further suggested that the desire among DOs in ACGME-accredited programs to continue OMT training may not be realistic due to lack of qualified instruction and supervision in allopathic settings. Additional support for this observation was noted by Hayes1 and the National Resident Matching Program.3,4 
Methods
A one-page, 12-item survey that took 10 to 15 minutes to complete was developed for osteopathic family practice residents in ACGME-accredited, AOA/ACGME dually accredited, and government military programs. Survey statements were designed to assess the degree of awareness and interest residents had in the following: 
  • receiving osteopathic training and mentoring during residency training
  • ongoing membership and involvement in osteopathic organizations, including obtaining AOA approval for their internship year and specialty board certification
  • increased efforts within the osteopathic medical profession to transition more allopathic programs into dually accredited and parallel programs
Survey participants were also asked to assess the adequacy of existing resources and information regarding these topics. 
The demographic data gathered for this investigation were limited to participants' postgraduate training year: PGY1, first year (class of 2006); PGY2, second year (class of 2005); or PGY3, third year (class of 2004). 
Multiple-choice Likert scale responses were provided for 10 survey items: 1, strongly disagree; 2, disagree; 3, neutral; 4, agree; and 5, strongly agree. One fill-in-the-blank item solicited additional comments from survey participants. 
Responses that did not include resident training year were to be discarded and not used in data analysis. Response categories were grouped by scale numbers: 1 and 2, positive response; 3, neutral; 4 and 5, negative. All nonresponses and neutral responses were dropped from calculations and the sample size for that survey item was adjusted accordingly for analysis. 
The survey was approved by the institutional review board of the Scottsdale (Ariz) Healthcare System. With a cover letter that described the nature of the survey, the ACOFP headquarters distributed the instrument in March 2007 on behalf of its Residents' Committee to 1354 US residency programs using the college's database of resident members. Responses were collected for the next 4 months. A follow-up mechanism was not included in the study protocol. 
Responses were logged and calculated with Microsoft Office Excel (2003; Microsoft Corporation, Redmond, Wash). Pearson's χ2 tests were administered to analyze any potential differences in response frequencies among groups. Statistical significance was set with an α level of .05. 
Results
Of the 1354 surveys distributed, 447 surveys were returned for a response rate of 33%. Of those, 426 surveys were complete and usable for analysis for an overall response rate of 31.4%. 
As noted, limited demographic data were gathered from the survey, chiefly postgraduate training year. A total of 146 responses were received from participants in PGY1; 151, PGY2; 129, PGY3. Twenty-one residents did not designate a training year. Although their responses could not be included in data analysis, we found that their answers were statistically consistent with the three group averages. 
The geographic location of each resident was not specifically requested in the survey; however, return addresses, when available, included a geographically diverse collection of states (Table). Survey instructions invited participants to return surveys directly to study investigators at their private practice family medicine clinic in Scottsdale, Ariz, but many respondents (n=152) opted instead to send groups of completed surveys to ACOFP headquarters in Arlington Heights, Ill. Return addresses were unavailable for materials sent to ACOFP headquarters. 
Table
Osteopathic Residents in ACGME-Accredited Postdoctoral Training Programs: No. of Survey Responses by State (N=447)

State

No.
Indiana26
California 22
Pennsylvania20
Texas 17
Illinois16
Wisconsin 16
Virginia15
New York 13
Washington10
Minnesota 9
Arizona8
North Carolina 8
Utah8
Colorado 7
Ohio7
Oklahoma 7
Tennessee7
Michigan 6
Delaware5
Florida 5
Georgia5
Hawaii 4
Iowa4
Maine 4
Oregon4
Rhode Island 4
South Dakota4
Wyoming 4
Arkansas3
Massachusetts 3
Missouri3
Nebraska 3
West Virginia3
Kansas 2
Mississippi2
New Jersey 2
Alabama1
Connecticut 1
Idaho1
Kentucky 1
Louisiana1
Maryland 1
Montana1
Nevada 1
South Carolina1
Unknown* 152
Total
447
 Abbreviation: ACGME, Accreditation Council for Graduate Medical Education.
 *The geographic location of each resident was not specifically requested in the survey; however, return addresses, when available, included a geographically diverse collection of states. Survey instructions invited participants to return surveys directly to study investigators at their private practice family medicine clinic in Scottsdale, Ariz, but many respondents (n=152) opted instead to send groups of completed surveys to American College of Osteopathic Family Physicians headquarters in Arlington Heights, Ill. Return addresses were unavailable for materials sent to American College of Osteopathic Family Physicians headquarters.
Table
Osteopathic Residents in ACGME-Accredited Postdoctoral Training Programs: No. of Survey Responses by State (N=447)

State

No.
Indiana26
California 22
Pennsylvania20
Texas 17
Illinois16
Wisconsin 16
Virginia15
New York 13
Washington10
Minnesota 9
Arizona8
North Carolina 8
Utah8
Colorado 7
Ohio7
Oklahoma 7
Tennessee7
Michigan 6
Delaware5
Florida 5
Georgia5
Hawaii 4
Iowa4
Maine 4
Oregon4
Rhode Island 4
South Dakota4
Wyoming 4
Arkansas3
Massachusetts 3
Missouri3
Nebraska 3
West Virginia3
Kansas 2
Mississippi2
New Jersey 2
Alabama1
Connecticut 1
Idaho1
Kentucky 1
Louisiana1
Maryland 1
Montana1
Nevada 1
South Carolina1
Unknown* 152
Total
447
 Abbreviation: ACGME, Accreditation Council for Graduate Medical Education.
 *The geographic location of each resident was not specifically requested in the survey; however, return addresses, when available, included a geographically diverse collection of states. Survey instructions invited participants to return surveys directly to study investigators at their private practice family medicine clinic in Scottsdale, Ariz, but many respondents (n=152) opted instead to send groups of completed surveys to American College of Osteopathic Family Physicians headquarters in Arlington Heights, Ill. Return addresses were unavailable for materials sent to American College of Osteopathic Family Physicians headquarters.
×
All responses were tabulated. As noted previously, all neutral responses were dropped from our calculations and sample size was adjusted accordingly, as in the case of survey items that were left blank. As a result of nonresponses or neutral responses to survey items, the sample size for each survey item ranged from 386 to 426. 
Among all three groups, a total of 376 residents (88.5%) responded affirmatively that they were “interested in continuing [their] osteopathic skills and training during residency.” In addition, a total of 279 respondents (65.5%) reported that they had been encouraged by their “program's attendings/directors [to] continue [their] osteopathic training during residency.” This trend appeared consistent regardless of postgraduate training year (Figure 1). 
Three hundred twenty-five residents (77.2%) indicated an interest in “becoming a member of ACOFP and participating in CME [continuing medical education] programs.” However, a total of 167 (39.6%) believed they “received adequate resident resource information from the ACOFP during...training.” Once again, this trend appeared consistent across all three postgraduate years (Figure 2). 
Regarding their relationship with the AOA, 320 residents (82.9%) were interested in “obtaining AOA approval for [their] internship year” via Resolution 42 (A/2000), Approval of ACGME Training as an AOA-Approved Internship.12 However, less than half of these individuals (155 [38.5%]) affirmatively stated that they were familiar with the approval process. For this survey item, there was a difference in the responses received by postgraduate training year; 67 PGY3 residents (58.3%) agreed that they were familiar with the AOA's internship year approval process compared to 54 (38.8%) and 34 (22.8%) in PGY1 and PGY2, respectively. 
Among all survey respondents, 267 (63.7%) specified an interest in “completing the [AOBFP] certification [examination],” with 108 (25.8%) “aware of the AOA's eligibility criteria” to take that examination. Once again, a difference in level of awareness was expressed by postgraduate training year: 44 PGY3 residents (34.9%) were aware of eligibility criteria compared to 30 (20.8%) in PGY1 and 34 (22.8%) in PGY2. 
When asked if they “would support increasing efforts by the AOA and ACOFP to transition more allopathic programs into dually accredited or parallel programs,” 399 respondents (93.7%) assented. 
Figure 1.
Select resident responses by postgraduate training year regarding the two osteopathic skills and training items in a one-page, 12-item survey distributed by the American College of Osteopathic Family Physicians (ACOFP) Residents' Committee in March 2007 (n=426). All nonresponses and neutral responses were dropped from calculations and the sample size was adjusted accordingly for analysis.
Figure 1.
Select resident responses by postgraduate training year regarding the two osteopathic skills and training items in a one-page, 12-item survey distributed by the American College of Osteopathic Family Physicians (ACOFP) Residents' Committee in March 2007 (n=426). All nonresponses and neutral responses were dropped from calculations and the sample size was adjusted accordingly for analysis.
In addition, 341 residents (81.2%) specified an interest “in the development of an osteopathic family medicine mentoring program for DOs in allopathic residencies.” Consistent results were achieved regardless of postgraduate training year. 
Finally, participants were asked to “provide any additional comments,” and told to “feel free to use additional space if needed.” Representative comments are provided in the Appendix, organized by topic and reported in a purposefully random order to protect the anonymity of survey respondents. 
According to results from Pearson's χ2 tests (Figure 3), a statistically significant difference was observed among study groups by postgraduate year in training for three survey items. Aside from these three survey items, consistent responses were observed across study groups. 
Comment
Osteopathic family practice residents who provided anecdotal comments in response to our 2007 survey described a frustrating multi-step board certification process that required coordination among several osteopathic organizations, namely the AOA, ACOFP, and AOBFP. They outlined roadblocks and had questions about how to navigate the system and find the right resources to help unravel their perplexity. 
Many residents, when faced with this situation, do not start the process or decline to complete it because of perceived or evident barriers. Considering their increased responsibilities and limited free time during residency training—along with limited guidance from osteopathic organizations—it is perhaps understandable that many lose interest and momentum before obtaining their goal of AOA board certification. 
The results of our survey illuminate some of the barriers to AOA board certification that are faced by osteopathic physicians at ACGME-accredited family practice residency programs. The survey also affords the profession with a tool to consider these residents' attitudes toward membership in osteopathic organizations, CME activities, and board certification options. 
In 2005, Allee and coauthors8 reported a similar percentage of DO residents in AOA-approved (74.1%) and ACGME-accredited (62.2%) programs who indicated a desire for more osteopathic CME opportunities. Their results8 suggested that a majority of DO residents in ACGME-accredited family medicine programs intend to continue developing and using their OMT skills—in addition to maintaining their affiliation with the osteopathic medical profession. 
According to Bulger,9 709 (5.5%) of the 12,983 osteopathic medical students who graduated from 2000 to 2004 submitted applications via Resolution 42 (A/2000) for AOA approval of their ACGME-accredited training. Of these applications, 421 (59.4%) were approved for an overall approval rate of 3.2%. When it is estimated that 50% of osteopathic medical graduates were in ACGME-accredited residency programs, a 5.5% application rate and a 3.2% approval rate are somewhat lackluster. 
Figure 2.
Select resident responses by postgraduate training year regarding the two American College of Osteopathic Family Physicians (ACOFP) items in a one-page, 12-item survey distributed by the ACOFP Residents' Committee in March 2007 (n=426). All nonresponses and neutral responses were dropped from calculations and the sample size was adjusted accordingly for analysis. Abbreviation: CME, continuing medical education.
Figure 2.
Select resident responses by postgraduate training year regarding the two American College of Osteopathic Family Physicians (ACOFP) items in a one-page, 12-item survey distributed by the ACOFP Residents' Committee in March 2007 (n=426). All nonresponses and neutral responses were dropped from calculations and the sample size was adjusted accordingly for analysis. Abbreviation: CME, continuing medical education.
The disparity between the number of osteopathic family practice residents who claim interest in AOA board certification and those who actually obtain it is very important. As previously noted, our survey was distributed during the 2006-2007 academic year, a year in which 11,140 osteopathic physicians were in training: 4511 (40%) in AOA-approved programs and 6629 (60%) in ACGME-accredited programs.5,11 The results of our survey suggest that the majority of DOs at ACGME-accredited programs are interested in membership at osteopathic organizations, CME activities, and board certification options. 
Two hundred sixty-seven such residents who graduated in the class of 2004, 2005, or 2006 and responded to our survey expressed an interest in becoming osteopathic specialty board certified. However, among graduates from 1998 to 2003, an average of 23 per year who completed ACGME-accredited residency training went on to receive AOA board certification (J.J. Sweeney, BA, oral communication, August 2008). Perhaps the gap between these numbers (ie, intention vs reality) can be explained by barriers within the certification process and the limited availability of resources offered through osteopathic organizations. 
Sixty-seven percent of the individuals who were invited to participate in our survey declined to do so. Several possible reasons exist for this lack of response: nonreceipt of the instrument, lack of time, or lack of interest. We believe that the number of residents who did not receive a survey was limited because we used contact information from the ACOFP database. We hypothesize that the majority of potential subjects who declined study participation chose to do so as a result of the time constraints common to physicians in residency training. Nonresponse due to lack of interest in osteopathic medicine is difficult to estimate. However, because the data were analyzed within the population of respondents, we do not consider this lack of response to be a cause for concern regarding bias. Therefore, we did not make adjustments to our statistical analysis. 
As our discussion focuses on DO residents who are most likely to pursue opportunities for continued training, certification, and affiliation with the osteopathic medical profession, it seems likely that data from individuals who either did not receive the survey or were too busy to participate would yield information similar to that reported by our 426 survey participants. However, residents who opted out of study participation as a result of lack of interest in osteopathic medicine would be expected to provide survey responses that reflect this opinion. 
Step 1: Understanding the Process
As of July 2008, the requirements for ACGME internship training approval by the AOA (ie, through Resolution 42 [A/2000]) became more stringent.2,12 Unfortunately, as shown in the results of our survey (Figure 3), lack of awareness—if not confusion—abounds among residents regarding eligibility criteria and program requirements. In particular, the family practice residents responding to our survey anecdotally reported (Appendix) that the confusion engendered by the official guidelines, which they judge to be complex and lengthy, are exacerbated by contradictory “clarifications” provided by AOA staff. Residents are not aware of or do not understand Resolution 42. Thus, it is often at this first step in the process—understanding of eligibility criteria—where attrition begins. 
Figure 3.
Select resident responses by postgraduate training year regarding the four American Osteopathic Association (AOA) and American Osteopathic Board of Family Physicians items in a one-page, 12-item survey distributed by the American College of Osteopathic Family Physicians Residents' Committee in March 2007 (n=426). All nonresponses and neutral responses were dropped from calculations and the sample size was adjusted accordingly for analysis.*Using Pearson's χ2 tests, a statistically significant difference was observed among study groups by postgraduate year in training for three survey items: Item 6, 34.46 (P<.001); Item 7, 8.027 (P<.05); Item 8, 9.463 (P<.01).
Figure 3.
Select resident responses by postgraduate training year regarding the four American Osteopathic Association (AOA) and American Osteopathic Board of Family Physicians items in a one-page, 12-item survey distributed by the American College of Osteopathic Family Physicians Residents' Committee in March 2007 (n=426). All nonresponses and neutral responses were dropped from calculations and the sample size was adjusted accordingly for analysis.*Using Pearson's χ2 tests, a statistically significant difference was observed among study groups by postgraduate year in training for three survey items: Item 6, 34.46 (P<.001); Item 7, 8.027 (P<.05); Item 8, 9.463 (P<.01).
As previously noted, our results indicated that 320 residents (82.9%) were interested in obtaining AOA approval for their internship year via Resolution 42; however, less than half of these individuals (155 [38.5%]) were actually aware of how to complete the process. 
During a 7-year period (ie, July 2001 to December 2008), in all subspecialties including family medicine, a total of 1818 physicians petitioned for approval of their first-year ACGME-accredited postgraduate training.6 Of those individuals, 1520 (84%) received AOA approval.6 An additional 270 (15%) requests have been approved pending the completion of training.6 
Among family practice residents surveyed for the present investigation, if all interested respondents (82.9%) actually applied for AOA approval of their ACGME-accredited postgraduate training, 320 applications under Resolution 42 would be received during the next 3 years. If this number were projected for the next 6 years, the total number of applicants in family practice alone would be double the total number of all specialty applicants. 
The necessity of strengthening osteopathic identification through membership in professional organizations and the pursuit of other professional development activities has been investigated by other researchers.2,10 For example, Hayes10 found that residents who receive AOA approval for an ACGME-accredited internship year have significantly higher rates of AOA membership and medical specialty board certification than DOs whose allopathic residencies have not been approved—a conclusion confirmed by subsequent investigators.2,9 
In the additional comments section of our survey, some residents anecdotally described frustrating contacts with osteopathic organizations. In particular, survey participants noted that staff at osteopathic organizations were not able to locate and orient the resident as to his or her remaining steps in the AOA board certification process. Some residents further commented that staff at osteopathic support organizations actually discouraged them from completing the process, stating that they were “not eligible” or that achieving certification was “too difficult.” Residents described other instances of mis-communication and misdirection as well as their feelings of frustration when trying to navigate the system. 
Additional comments from military residents suggest yet another barrier: lack of automatic AOA recognition for military training. Military residents are likewise required to complete the Resolution 42 approval process. Military residents described the frustration of being advised that their applications required program and internship year approval only after they applied for AOA specialty board certification examinations, causing a 1-year delay in the opportunity to sit for those examinations. 
Step 2: Specialty College Approval
The next step in this process involves obtaining the approval of the relevant specialty college for one's ACGME-accredited residency training program. 
Family practice residents, therefore, are required to apply to the ACOFP for approval. A one-page application (http://www.acofp.org/membership/pds.aspx) is available for this step. 
However brief the process for osteopathic family practice residents may appear initially in this form, this step is complicated by being contingent on the full review of the college's program approval committee. For most specialty colleges, this committee meets in person to review applications for ACGME program approval generally only once per year. Thus, depending on when a resident's paperwork is filed with the specialty college, he or she may need to wait an entire year before the next approval committee meeting. This delay can have a debilitating domino effect on a resident's preparations for board examinations. 
The ACOFP's approval committee usually meets in the spring or early summer. Potential candidates for board certification are encouraged to contact the ACOFP directly by phone at (800) 323-0794 regarding 2010 application deadlines. 
Step 3: Specialty Board Examination
The final steps in obtaining AOA approval for ACGME postgraduate training involve applying, paying for, and often traveling to take an osteopathic medical specialty board certification examination. 
The AOBFP examination is offered to family practice residents twice per year (http://www.aobfp.org/news.html), once at the AOA Annual Convention and Scientific Seminar and once at the ACOFP Annual Convention & Exhibition. The 2009 AOA Annual Convention and Scientific Seminar will be held in New Orleans, La, from Sunday, November 1, through Thursday, November 5 (http://www.do-online.org/index.cfm?au=D&PageId=conv_main). The ACOFP's 46th Annual Convention & Exhibition was held in March. 
By way of contrast, many board examinations offered by the ACOFP's allopathic counterpart, the American Board of Family Medicine (ABFM), involve relatively little travel time or expense for DO residents in ACGME-accredited programs. Board examinations offered by the ABFM are often local, computer-based, single-day examinations, making them an affordable, accessible alternative for budget-limited and time-strapped residents. If an osteopathic family practice resident in an ACGME-accredited program intends to choose between the AOBFP and ABFM examinations, finances and travel costs may be a sufficient disincentive for taking both board examinations. 
In May 2009, a total of 1648 osteopathic physicians (63.2%) from the class of 2003 (N=2607) were board certified (J.J. Sweeney, BA, written communication, June 2009). Less than half of these DO graduates obtained AOA board certification (523 [31.7%]) or dual certification (52 [3.2%]) (J.J. Sweeney, BA, written communication, June 2009). More than half of these graduates (1073 [65.1%]) opted instead to receive certification through the American Board of Medical Specialties (ABMS) alone (J.J. Sweeney, BA, written communication, June 2009). 
At each step, a certain number of residents become discouraged and give up in their pursuit of AOA board certification, despite an initial interest. This high rate of attrition is reflected in the low number of residents (52 [3.2%]) who reported dual certification (J.J. Sweeney, BA, written communication, June 2009). 
Recommendations
Close to 50% of osteopathic medical graduates choose to enter ACGME-accredited residency training programs each year for a variety of reasons,6 many based on geographic preference and a perception that training quality would be better at allopathic institutions.8 Approximately 75% of all AOA-approved internship positions are located in only seven states: Michigan, Pennsylvania, Ohio, New York, New Jersey, Florida, and Illinois.6 
Nevertheless, osteopathic organizations must recognize their unique responsibility to support DOs in ACGME-accredited programs as these physicians continue to pursue osteopathic training in specialties where the profession's resources may be limited—or nonexistent. Many DO residents are opting for the ACGME-accredited pathway because of a shortage in the number of osteopathic training programs; there are simply not enough osteopathic residency slots for DO graduates in many specialties.5,6,8,11 Osteopathic leadership must recruit, provide, and advocate for more osteopathic training site opportunities. 
A streamlined process for residents who are interested in pursuing AOA internship year approval via Resolution 42 (A/2000) would also be beneficial. The guidelines and guidance offered to these DOs should be clear, consistent, and easy to navigate. Part of this effort would include ongoing resident education and communication regarding AOA specialty board requirements, ensuring adherence to measurable osteopathic practice guidelines. It is important for DOs to meet not only required standards of care in their individual medical specialties, they must also inspire confidence within the medical community regarding the quality of the training they received in osteopathic medical school. 
Recommended changes are not limited to those implemented on a procedural level (ie, vis-é-vis requirements for obtaining approval for training). A new spirit of inclusiveness within the osteopathic medical profession could be promoted through enhanced mentoring relationships and greater availability of high-quality osteopathic CME opportunities for residents in ACGME-accredited programs. A network of individuals who will connect with DOs training in specialty areas with few osteopathic resources is recommended. Such efforts would likely increase loyalty to and involvement in the wider osteopathic professional family among these DOs. 
In addition, once a DO has actually completed ACGME-accredited residency training, the osteopathic medical profession has a responsibility to look for ways to keep the doors of communication and professional affiliation open to them. According to the anecdotal comments we received as a result of our survey (Appendix), residents continue to feel discouraged in contacts with their “home base” osteopathic organizations. They report completing ACGME-accredited training often out of necessity and then later feel penalized through the disapproval of DO colleagues—and a cumbersome formal process to obtain training recognition. Addressing the challenge of inclusiveness and expanded opportunity would do much to keep these newly trained DOs in the osteopathic family and strengthen the profession as a whole. 
The addition of high-quality osteopathic CME opportunities accessible to residents in ACGME-accredited programs would be another effective way to promote a new spirit of inclusiveness within the profession. 
Recommendations for future research include expanding the scope of the present study to other medical specialties to explore their unique needs in comparison with those of family practice residents. An inquiry regarding resident preference between the two board certification options (ie, AOA vs ABMS)—with the aforementioned barriers removed—would also be of value. 
Additional information may also be gathered by surveying program directors at ACGME-accredited residency training programs regarding their perceptions of DO resident performance as well as institutional interest in transitioning residency training programs to dual or parallel programs.13 
Conclusion
Our 2007 survey of osteopathic family practice residents who received residency training from ACGME-accredited programs revealed a disconnect between their initial favorable attitudes toward participation in the osteopathic medical profession and their level of involvement and feelings of loyalty toward the profession as measured through participation in professional memberships, CME activities, and board certification. 
Osteopathic organizations are encouraged to investigate the potential ramifications of this disconnect within the profession. A collective focus is encouraged to assist in the retention of new DOs within the osteopathic medical community. Beyond an increase in the number of osteopathic training sites and dually accredited and parallel programs, areas for emphasis include engendering a feeling of inclusiveness toward these physicians through a streamlined residency-training approval process, a mentoring network devoted to strengthening osteopathic affiliation, and improved communications with support staff at osteopathic organizations. 
Just as the body is a unit,14 the osteopathic family is encouraged to look for systemic ways to realign and reengage all its members—including those who completed ACGME-accredited postdoctoral training—to promote the health of the profession as a whole. 
2  
Appendix
Narrative comments from osteopathic physicians (DOs) who completed a one-page survey distributed by the American College of Osteopathic Family Physicians (ACOFP) in March 2007 at the request of that organization's Residents' Committee (N=426). The survey was sent to osteopathic family practice residents in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) as well as those in programs that were dually accredited by the American Osteopathic Association (AOA) and the ACGME, and government military programs.
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Appendix
Narrative comments from osteopathic physicians (DOs) who completed a one-page survey distributed by the American College of Osteopathic Family Physicians (ACOFP) in March 2007 at the request of that organization's Residents' Committee (N=426). The survey was sent to osteopathic family practice residents in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) as well as those in programs that were dually accredited by the American Osteopathic Association (AOA) and the ACGME, and government military programs.
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 At the time of the study, Drs O'Connor and Scott were members of the American College of Osteopathic Family Physicians Residents' Committee and subcommittee chairs for the Osteopathic Physicians in Allopathic Programs initiative.
 
Hayes OW. Dual approval of a residency program: ten years' experience and implications for postdoctoral training. J Am Osteopath Assoc. 1998;98:647-652.
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Figure 1.
Select resident responses by postgraduate training year regarding the two osteopathic skills and training items in a one-page, 12-item survey distributed by the American College of Osteopathic Family Physicians (ACOFP) Residents' Committee in March 2007 (n=426). All nonresponses and neutral responses were dropped from calculations and the sample size was adjusted accordingly for analysis.
Figure 1.
Select resident responses by postgraduate training year regarding the two osteopathic skills and training items in a one-page, 12-item survey distributed by the American College of Osteopathic Family Physicians (ACOFP) Residents' Committee in March 2007 (n=426). All nonresponses and neutral responses were dropped from calculations and the sample size was adjusted accordingly for analysis.
Figure 2.
Select resident responses by postgraduate training year regarding the two American College of Osteopathic Family Physicians (ACOFP) items in a one-page, 12-item survey distributed by the ACOFP Residents' Committee in March 2007 (n=426). All nonresponses and neutral responses were dropped from calculations and the sample size was adjusted accordingly for analysis. Abbreviation: CME, continuing medical education.
Figure 2.
Select resident responses by postgraduate training year regarding the two American College of Osteopathic Family Physicians (ACOFP) items in a one-page, 12-item survey distributed by the ACOFP Residents' Committee in March 2007 (n=426). All nonresponses and neutral responses were dropped from calculations and the sample size was adjusted accordingly for analysis. Abbreviation: CME, continuing medical education.
Figure 3.
Select resident responses by postgraduate training year regarding the four American Osteopathic Association (AOA) and American Osteopathic Board of Family Physicians items in a one-page, 12-item survey distributed by the American College of Osteopathic Family Physicians Residents' Committee in March 2007 (n=426). All nonresponses and neutral responses were dropped from calculations and the sample size was adjusted accordingly for analysis.*Using Pearson's χ2 tests, a statistically significant difference was observed among study groups by postgraduate year in training for three survey items: Item 6, 34.46 (P<.001); Item 7, 8.027 (P<.05); Item 8, 9.463 (P<.01).
Figure 3.
Select resident responses by postgraduate training year regarding the four American Osteopathic Association (AOA) and American Osteopathic Board of Family Physicians items in a one-page, 12-item survey distributed by the American College of Osteopathic Family Physicians Residents' Committee in March 2007 (n=426). All nonresponses and neutral responses were dropped from calculations and the sample size was adjusted accordingly for analysis.*Using Pearson's χ2 tests, a statistically significant difference was observed among study groups by postgraduate year in training for three survey items: Item 6, 34.46 (P<.001); Item 7, 8.027 (P<.05); Item 8, 9.463 (P<.01).
Table
Osteopathic Residents in ACGME-Accredited Postdoctoral Training Programs: No. of Survey Responses by State (N=447)

State

No.
Indiana26
California 22
Pennsylvania20
Texas 17
Illinois16
Wisconsin 16
Virginia15
New York 13
Washington10
Minnesota 9
Arizona8
North Carolina 8
Utah8
Colorado 7
Ohio7
Oklahoma 7
Tennessee7
Michigan 6
Delaware5
Florida 5
Georgia5
Hawaii 4
Iowa4
Maine 4
Oregon4
Rhode Island 4
South Dakota4
Wyoming 4
Arkansas3
Massachusetts 3
Missouri3
Nebraska 3
West Virginia3
Kansas 2
Mississippi2
New Jersey 2
Alabama1
Connecticut 1
Idaho1
Kentucky 1
Louisiana1
Maryland 1
Montana1
Nevada 1
South Carolina1
Unknown* 152
Total
447
 Abbreviation: ACGME, Accreditation Council for Graduate Medical Education.
 *The geographic location of each resident was not specifically requested in the survey; however, return addresses, when available, included a geographically diverse collection of states. Survey instructions invited participants to return surveys directly to study investigators at their private practice family medicine clinic in Scottsdale, Ariz, but many respondents (n=152) opted instead to send groups of completed surveys to American College of Osteopathic Family Physicians headquarters in Arlington Heights, Ill. Return addresses were unavailable for materials sent to American College of Osteopathic Family Physicians headquarters.
Table
Osteopathic Residents in ACGME-Accredited Postdoctoral Training Programs: No. of Survey Responses by State (N=447)

State

No.
Indiana26
California 22
Pennsylvania20
Texas 17
Illinois16
Wisconsin 16
Virginia15
New York 13
Washington10
Minnesota 9
Arizona8
North Carolina 8
Utah8
Colorado 7
Ohio7
Oklahoma 7
Tennessee7
Michigan 6
Delaware5
Florida 5
Georgia5
Hawaii 4
Iowa4
Maine 4
Oregon4
Rhode Island 4
South Dakota4
Wyoming 4
Arkansas3
Massachusetts 3
Missouri3
Nebraska 3
West Virginia3
Kansas 2
Mississippi2
New Jersey 2
Alabama1
Connecticut 1
Idaho1
Kentucky 1
Louisiana1
Maryland 1
Montana1
Nevada 1
South Carolina1
Unknown* 152
Total
447
 Abbreviation: ACGME, Accreditation Council for Graduate Medical Education.
 *The geographic location of each resident was not specifically requested in the survey; however, return addresses, when available, included a geographically diverse collection of states. Survey instructions invited participants to return surveys directly to study investigators at their private practice family medicine clinic in Scottsdale, Ariz, but many respondents (n=152) opted instead to send groups of completed surveys to American College of Osteopathic Family Physicians headquarters in Arlington Heights, Ill. Return addresses were unavailable for materials sent to American College of Osteopathic Family Physicians headquarters.
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Appendix
Narrative comments from osteopathic physicians (DOs) who completed a one-page survey distributed by the American College of Osteopathic Family Physicians (ACOFP) in March 2007 at the request of that organization's Residents' Committee (N=426). The survey was sent to osteopathic family practice residents in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) as well as those in programs that were dually accredited by the American Osteopathic Association (AOA) and the ACGME, and government military programs.
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Appendix
Narrative comments from osteopathic physicians (DOs) who completed a one-page survey distributed by the American College of Osteopathic Family Physicians (ACOFP) in March 2007 at the request of that organization's Residents' Committee (N=426). The survey was sent to osteopathic family practice residents in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) as well as those in programs that were dually accredited by the American Osteopathic Association (AOA) and the ACGME, and government military programs.
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