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SURF  |   August 2017
Effects of Clinical Exposure to Osteopathic Manipulative Medicine on Confidence Levels of Medical Students
Author Notes
  • From the New York Institute of Technology College of Osteopathic Medicine in Old Westbury. Dr Shapiro is a first-year resident and Dr Defoe is a second-year resident. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Sheldon C. Yao DO, New York Institute of Technology College of Osteopathic Medicine, Northern Blvd, Serota Building Room 126, PO Box 8000, Old Westbury, NY 11568-8000. E-mail: syao@nyit.edu
     
Article Information
Medical Education / Graduate Medical Education
SURF   |   August 2017
Effects of Clinical Exposure to Osteopathic Manipulative Medicine on Confidence Levels of Medical Students
The Journal of the American Osteopathic Association, August 2017, Vol. 117, e1-e5. doi:10.7556/jaoa.2017.105
The Journal of the American Osteopathic Association, August 2017, Vol. 117, e1-e5. doi:10.7556/jaoa.2017.105
Abstract

Context: Training in osteopathic manipulative medicine (OMM) is a unique component of the osteopathic medical school curriculum. Indicators of successful OMM programming include student comfort in explaining and performing OMM as well as confidence in using OMM on future patients. Research on the amount of clinical exposure sufficient to achieve this goal is limited.

Objectives: To gauge the impact of clinical OMM exposure on medical students’ self-assessed understanding of OMM, their ability to discuss, explain, and perform OMM, and their plan to use OMM in their future practice.

Methods: Fourth-year osteopathic medical students were e-mailed surveys before (baseline), during, and after 4 weeks (postrotation) of an elective OMM rotation. Answers were scaled from 0 to 10, with 0 being not at all comfortable/confident and 10 being the most comfortable/confident.

Results: Thirty-five students participated in the survey. A significant mean (SD) increase was found between the baseline and postrotation scores for students’ understanding of OMM principles (1.43 [0.51]; P<.001), comfort discussing OMM principles with patients (1.27 [0.88]; P<.001), comfort with explaining OMM to someone unfamiliar with it (1.32 [0.82]; P<.001), comfort with performing an osteopathic structural examination (2.23 [1.44]; P<.001), and confidence incorporating OMM into future practice (1.86 [0.47]; P<.001).

Conclusion: Increased clinical exposure to OMM increased the confidence of osteopathic medical students in all dimensions surveyed. This observation can help guide the development of undergraduate osteopathic clinical programming as well as standards for entry of allopathic residents into ACGME programs with osteopathic designation.

The ability to use osteopathic manipulative medicine (OMM) in patient care separates osteopathic physicians from their allopathic colleagues.1 Although osteopathic medical students spend approximately 200 hours learning and applying OMM in the preclinical years, a study showed that many students do not use OMM during clinical rotations, nor do they incorporate OMM into their practice as physicians.2 Their reasons included time constraints, discouragement from attending physicians, and discomfort with their skill level.3 Of these reasons, preparation for and comfort with practicing OMM on patients they encounter on clinical rotations can be addressed.4 Objective measures of preparedness are analyzed with OMM practical examinations, as well as by the Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation, which every osteopathic medical student must pass before graduation. Although objective measures may demonstrate that students meet requirements for a nationally determined level of competence, to our knowledge, no evidence exists to relate competence in OMM to rate of OMM use during clinical rotations or in future practice. 
Methods of encouraging students to practice OMM during rotation and to use it in their future practice include exposing them to formal, clinical OMM education and mandating a specific number of OMM encounters during the clinical years of medical school.2,5 Similar to procedural skills like venipuncture and catheter insertion,6 additional clinical exposure to OMM may allow students to develop a greater sense of proficiency and a better perspective on how to use OMM in the clinical setting. 
The purpose of the current study was to examine the effect of an OMM clinical rotation on medical students’ self-assessed understanding of OMM, their ability to discuss, explain, and perform OMM, and their plan to use OMM in their future practice. Currently, approximately half of osteopathic residents are in allopathic graduate medical education programs.7 With the upcoming single accreditation system for all graduate medical education programs, ensuring that osteopathic medical students carry their skills into practice will become increasingly necessary to preserve the uniqueness of osteopathic medicine. The development of undergraduate programming that instills students’ confidence in their OMM skills may help ensure that the principles of the osteopathic medical profession continue to be upheld by future generations of physicians. 
Methods
This study was performed at the New York Institute of Technology College of Osteopathic Medicine (NYIT-COM) with institutional review board approval. Fourth-year osteopathic medical students completing an elective OMM rotation between May 2014 and June 2015 at NYIT-COM were invited to participate in the study using SurveyMonkey online surveys. No compensation or incentive was offered for participating in the study. 
The elective OMM rotation is a 4-week rotation offered only to fourth-year NYIT-COM students. Students receive hands-on OMM training with a preceptor for approximately 15 to 20 minutes per patient, with an average of 6 patients per 4-hour session, and a minimum of 4 sessions per week. They also keep a handwritten log of their patient encounters that is compliant with the Health Insurance Portability and Accountability Act. 
Survey Instrument
Surveys were kept anonymous by assigning each participant a unique study number, and they entered this number on each survey as the sole identifying piece of information. Students were given a baseline survey before the start of the rotation, a follow-up survey after weeks 2 and 3, and a postrotation survey after the fourth and final week. 
The surveys consisted of 2 parts. The first part assessed the quantity of OMM exposure for the given week. The requested data consisted of the number of minutes spent with patients, the number of patient interactions, and the number of patients they treated with OMM. The items in the second part assessed the level of confidence on a scale of 0 to 10 (with 0 being no confidence and 10 being very confident) in (1) understanding osteopathic principles of OMM; (2) discussing the principles of osteopathic medicine with patients; (3) explaining what OMM is to someone who is unfamiliar with it; (4) performing an osteopathic structural examination; and (5) using OMM in their future practice. 
Statistical Analysis
A multivariate test was conducted to determine whether a difference existed between the amount of OMM exposure per week of rotation. A paired t test was used to determine whether a statistically significant difference existed between the baseline and postrotation mean confidence level for all categories. After determining which categories reached statistical significance in their mean change from baseline to postrotation scores, we ran paired t tests between baseline scores and after each week of rotation to narrow the time point during which the change in score became statistically significant. 
Results
Thirty-five of the 37 students in the OMM rotation participated in the study (95% participation rate). Fourteen participants completed all 5 surveys. Twenty-four participants (68%) completed both the baseline and postrotation surveys, which constituted the data used for the primary analysis. Of 33 participants who filled out a baseline survey, 30 filled out at least 1 follow-up survey. The survey response rates for the baseline and 4 weekly follow-up surveys were 89%, 48%, 44%, 36%, and 68%, respectively. 
No statistically significant difference was found in the amount of OMM exposure per week for mean number of minutes, mean number of patient interactions, or mean number of patients treated with OMM (Table 1). 
Table 1.
Descriptive Statistics for Amount of Exposure to OMM During OMM Rotation in Fourth-Year Osteopathic Medical Studentsa
OMM Exposure Week 1 Week 2 Week 3 Postrotation P Value
Min/wk 31.14 (7.39) 27.73 (8.70) 29.17 (9.28) 28.48 (8.45) .17
Patient interactions/wk 1.39 (5.30) 1.73 (6.33) 13.17 (7.82) 9.83 (6.47) .17
No. of patients treated with OMM 1.17 (4.81) 11.26 (6.50) 13.00 (7.84) 9.61 (6.16) .38

a Data are given as mean (SD) unless otherwise indicated.

Abbreviation: OMM, osteopathic manipulative medicine.

Table 1.
Descriptive Statistics for Amount of Exposure to OMM During OMM Rotation in Fourth-Year Osteopathic Medical Studentsa
OMM Exposure Week 1 Week 2 Week 3 Postrotation P Value
Min/wk 31.14 (7.39) 27.73 (8.70) 29.17 (9.28) 28.48 (8.45) .17
Patient interactions/wk 1.39 (5.30) 1.73 (6.33) 13.17 (7.82) 9.83 (6.47) .17
No. of patients treated with OMM 1.17 (4.81) 11.26 (6.50) 13.00 (7.84) 9.61 (6.16) .38

a Data are given as mean (SD) unless otherwise indicated.

Abbreviation: OMM, osteopathic manipulative medicine.

×
A significant increase was found between the baseline and postrotation scores for all categories tested, including understanding of OMM principles (1.43 [0.51]; P<.001), comfort discussing OMM principles with patients (1.27 [0.88]; P<.001), comfort explaining OMM to someone unfamiliar with it (1.32 [0.82]; P<.001), comfort performing an osteopathic structural examination (2.23 [1.44]; P<.001), and confidence incorporating OMM in their future practice (1.86 [0.47]; P<.001) (Figure). These findings translated into a mean percent change of 15.7%, 14.3%, 14.8%, 24.7%, and 20.6%, respectively. After analyzing the increase in score from baseline to each week of rotation, it was found that each category reached a statistically significant change from baseline by week 2 (Table 2). Three categories continued to have statistically significant increases in scores through week 3, and 1 category continued to have a statistically significantly positive change in score on the postrotation survey. 
Figure.
Mean change from baseline to postrotation score in fourth-year osteopathic medical students in an osteopathic manipulative medicine (OMM) rotation.
Abbreviation: OSE, osteopathic structural examination.
Figure.
Mean change from baseline to postrotation score in fourth-year osteopathic medical students in an osteopathic manipulative medicine (OMM) rotation.
Abbreviation: OSE, osteopathic structural examination.
Table 2.
Mean Change From Baseline Score to Each Week of OMM Rotation in Fourth-Year Osteopathic Medical Studentsa
Survey Item Week 1 Week 2 Week 3 Postrotation % Change
Understanding OMM principles 0.29 (1.10); P=.25 0.57 (0.96); P=.01 1.13 (0.63); P=.001 1.43 (0.51); P<.001 15.7 (10.2)
Discussing OMM principles 0.19 (1.25); P=.49 0.62 (0.74); P=.001 0.8 (1.62); P=.08 1.27 (0.88); P<.001 14.3 (10.3)
Explaining OMM to a layperson 0.40 (0.75); P=.028 0.52 (0.98); P<.05 1.31 (0.87); P<.001 1.32 (0.82); P<.001 14.8 (9.5)
Performing OSE 0.81 (1.57); P=.028 1.26 (1.49); P=.002 2.15 (1.28); P<.001 2.23 (1.44); P<.001 24.7 (15.9)
Confidence incorporating OMM in their future practice 1.19 (1.60); P=.003 1.43 (1.01); P=.001 2.00 (0.79); P<.001 1.86 (0.47); P<.001 20.6 (15.8)

a Data are given as mean (SD) unless otherwise indicated.

Abbreviations: OMM, osteopathic manipulative medicine; OSE, osteopathic structural examination.

Table 2.
Mean Change From Baseline Score to Each Week of OMM Rotation in Fourth-Year Osteopathic Medical Studentsa
Survey Item Week 1 Week 2 Week 3 Postrotation % Change
Understanding OMM principles 0.29 (1.10); P=.25 0.57 (0.96); P=.01 1.13 (0.63); P=.001 1.43 (0.51); P<.001 15.7 (10.2)
Discussing OMM principles 0.19 (1.25); P=.49 0.62 (0.74); P=.001 0.8 (1.62); P=.08 1.27 (0.88); P<.001 14.3 (10.3)
Explaining OMM to a layperson 0.40 (0.75); P=.028 0.52 (0.98); P<.05 1.31 (0.87); P<.001 1.32 (0.82); P<.001 14.8 (9.5)
Performing OSE 0.81 (1.57); P=.028 1.26 (1.49); P=.002 2.15 (1.28); P<.001 2.23 (1.44); P<.001 24.7 (15.9)
Confidence incorporating OMM in their future practice 1.19 (1.60); P=.003 1.43 (1.01); P=.001 2.00 (0.79); P<.001 1.86 (0.47); P<.001 20.6 (15.8)

a Data are given as mean (SD) unless otherwise indicated.

Abbreviations: OMM, osteopathic manipulative medicine; OSE, osteopathic structural examination.

×
Discussion
Most participants made positive, though not always statistically significant, improvements in each week of the 4-week rotation. The greatest increase in mean percent change from baseline to postrotation survey occurred in the category of comfort performing an osteopathic structural examination, with an increase of 24.7%. 
The category of confidence incorporating OMM in future practice had a statistically significant improvement in score through the fourth week. For this category, an even greater level of confidence may have been reached if the exposure were continued for more than 4 weeks. Alternatively, for the 3 categories that did not have any statistically significant increase in score after week 3, there may have been a maximum effect of the clinical exposure at that given time point. Alternatively, this observation also suggests that a minimum of 3 weeks is required to see the greatest change in confidence levels. Understanding the quantity of clinical exposure required to reach a given level of confidence in the categories tested can be used by osteopathic medical schools to create new or modify existing OMM clinical rotations. Future studies may attempt to correlate students’ level of self-assessed confidence with an objective measure of their competence. If we can correlate these 2 measures, graduate medical education programs will have evidence to substantiate a specific quantity of OMM exposure and training required for allopathic residents to enter residency programs with osteopathic recognition. 
One limitation of this study is that the students who participated in the clinical rotation did so electively. This baseline interest in practicing OMM may have skewed the overall degree of improvement. If this rotation were a curricular requirement for all fourth-year students, the results may have differed, perhaps showing an even greater improvement in comfort from baseline to postrotation score. Conducting a similar study at an osteopathic medical school for which such a rotation is mandatory may be the optimal way to address this question. Additionally, many participants were not compliant in filling out each survey. Furthermore, the surveys were e-mailed on the Friday of each rotation week but were often not filled out until the following week. Given the nature of survey-dependent studies, recall bias could have played a role in altering the accuracy of the data reported for the previous week of the rotation. 
Conclusion
This study provides evidence that clinical OMM exposure is associated with improved comfort levels of osteopathic medical students in treating patients with OMM. Osteopathic medical schools can use this knowledge to develop osteopathic clinical programming for undergraduate medical education. Additionally, an understanding of the amount of clinical exposure required to instill a given amount of confidence in performing OMM can inform curricular requirements for allopathic medical graduates entering residency programs with osteopathic recognition. Future research may focus on investigating similar parameters in OMM-naive students, such as those in the preclinical years and allopathic students and physicians. 
References
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Johnson SM, Kurtz ME. Diminished use of osteopathic manipulative treatment and its impact on the uniqueness of the osteopathic profession. Acad Med. 2001;76(8):821-828. [CrossRef] [PubMed]
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Teng A, Terry R, Blue R. Incorporating a mandatory osteopathic manipulative curriculum in clinical clerkships: impact on students attitudes towards using OMM. J Am Osteopath Assoc. 2011;111(4):219-224. [PubMed]
Heineman KL, Lewis DD, Finnerty EP, Crout SV, Canby C. Effect of a mandatory third-year osteopathic manipulative treatment course on student attitudes. J Am Osteopath Assoc. 2016;116(4):207-213. doi: 10.7556/jaoa.2016.045 [CrossRef] [PubMed]
Dehmer JJ, Amos KD, Farrell TM, Meyer AA, Newton WP, Meyers MO. Competence and confidence with basic procedural skills: the experience and opinions of fourth-year medical students at a single institution. Acad Med. 2013;88(5):682-687. doi: 10.1097/ACM.0b013e31828b0007 [CrossRef] [PubMed]
Jolly P, Lischka T, Sondheimer H. Numbers of MD and DO graduates in graduate medical education programs accredited by the Accreditation Council for Graduate Medical Education and the American Osteopathic Association. Acad Med. 2015;90(7):970-974. doi: 10.1097/ACM.0000000000000649 [CrossRef] [PubMed]
Figure.
Mean change from baseline to postrotation score in fourth-year osteopathic medical students in an osteopathic manipulative medicine (OMM) rotation.
Abbreviation: OSE, osteopathic structural examination.
Figure.
Mean change from baseline to postrotation score in fourth-year osteopathic medical students in an osteopathic manipulative medicine (OMM) rotation.
Abbreviation: OSE, osteopathic structural examination.
Table 1.
Descriptive Statistics for Amount of Exposure to OMM During OMM Rotation in Fourth-Year Osteopathic Medical Studentsa
OMM Exposure Week 1 Week 2 Week 3 Postrotation P Value
Min/wk 31.14 (7.39) 27.73 (8.70) 29.17 (9.28) 28.48 (8.45) .17
Patient interactions/wk 1.39 (5.30) 1.73 (6.33) 13.17 (7.82) 9.83 (6.47) .17
No. of patients treated with OMM 1.17 (4.81) 11.26 (6.50) 13.00 (7.84) 9.61 (6.16) .38

a Data are given as mean (SD) unless otherwise indicated.

Abbreviation: OMM, osteopathic manipulative medicine.

Table 1.
Descriptive Statistics for Amount of Exposure to OMM During OMM Rotation in Fourth-Year Osteopathic Medical Studentsa
OMM Exposure Week 1 Week 2 Week 3 Postrotation P Value
Min/wk 31.14 (7.39) 27.73 (8.70) 29.17 (9.28) 28.48 (8.45) .17
Patient interactions/wk 1.39 (5.30) 1.73 (6.33) 13.17 (7.82) 9.83 (6.47) .17
No. of patients treated with OMM 1.17 (4.81) 11.26 (6.50) 13.00 (7.84) 9.61 (6.16) .38

a Data are given as mean (SD) unless otherwise indicated.

Abbreviation: OMM, osteopathic manipulative medicine.

×
Table 2.
Mean Change From Baseline Score to Each Week of OMM Rotation in Fourth-Year Osteopathic Medical Studentsa
Survey Item Week 1 Week 2 Week 3 Postrotation % Change
Understanding OMM principles 0.29 (1.10); P=.25 0.57 (0.96); P=.01 1.13 (0.63); P=.001 1.43 (0.51); P<.001 15.7 (10.2)
Discussing OMM principles 0.19 (1.25); P=.49 0.62 (0.74); P=.001 0.8 (1.62); P=.08 1.27 (0.88); P<.001 14.3 (10.3)
Explaining OMM to a layperson 0.40 (0.75); P=.028 0.52 (0.98); P<.05 1.31 (0.87); P<.001 1.32 (0.82); P<.001 14.8 (9.5)
Performing OSE 0.81 (1.57); P=.028 1.26 (1.49); P=.002 2.15 (1.28); P<.001 2.23 (1.44); P<.001 24.7 (15.9)
Confidence incorporating OMM in their future practice 1.19 (1.60); P=.003 1.43 (1.01); P=.001 2.00 (0.79); P<.001 1.86 (0.47); P<.001 20.6 (15.8)

a Data are given as mean (SD) unless otherwise indicated.

Abbreviations: OMM, osteopathic manipulative medicine; OSE, osteopathic structural examination.

Table 2.
Mean Change From Baseline Score to Each Week of OMM Rotation in Fourth-Year Osteopathic Medical Studentsa
Survey Item Week 1 Week 2 Week 3 Postrotation % Change
Understanding OMM principles 0.29 (1.10); P=.25 0.57 (0.96); P=.01 1.13 (0.63); P=.001 1.43 (0.51); P<.001 15.7 (10.2)
Discussing OMM principles 0.19 (1.25); P=.49 0.62 (0.74); P=.001 0.8 (1.62); P=.08 1.27 (0.88); P<.001 14.3 (10.3)
Explaining OMM to a layperson 0.40 (0.75); P=.028 0.52 (0.98); P<.05 1.31 (0.87); P<.001 1.32 (0.82); P<.001 14.8 (9.5)
Performing OSE 0.81 (1.57); P=.028 1.26 (1.49); P=.002 2.15 (1.28); P<.001 2.23 (1.44); P<.001 24.7 (15.9)
Confidence incorporating OMM in their future practice 1.19 (1.60); P=.003 1.43 (1.01); P=.001 2.00 (0.79); P<.001 1.86 (0.47); P<.001 20.6 (15.8)

a Data are given as mean (SD) unless otherwise indicated.

Abbreviations: OMM, osteopathic manipulative medicine; OSE, osteopathic structural examination.

×