Letters to the Editor  |   August 2004
In Opposition to Resolution 42
Author Affiliations
  • Kenneth J. Steier, DO, FACOI, FCCP
    Corporate Safety Officer, Associate Professor, Director of Pulmonary Care Unit, Director of Medical Education Program Director, Dual-Approved Internal Medicine Residency, Nassau University Medical Center East Meadow, New York, Clinical Assistant Dean New York College of Osteopathic Medicine of New York Institute of Technology Old Westbury, New York
Article Information
Medical Education / Graduate Medical Education
Letters to the Editor   |   August 2004
In Opposition to Resolution 42
The Journal of the American Osteopathic Association, August 2004, Vol. 104, 314-315. doi:
The Journal of the American Osteopathic Association, August 2004, Vol. 104, 314-315. doi:
To the Editor:  
Resolution 42 (A/2000), also known as the “hardship resolution,” was enacted in 2000, allowing DO graduates to apply for credit from the American Osteopathic Association (AOA) during or after completing a non–AOA-approved internship or residency. To qualify, graduates are required to demonstrate a significant hardship due to “unusual or exceptional circumstances.” Specific eligibility criteria include physical or mental disability, legal restrictions tying a DO to a certain geographic area, and service in a federally designated health profession shortage area or in a specialty for which no AOA programs exist. 
The spirit of this resolution is to allow DO graduates to remain “part of the osteopathic family” if, for legitimate reasons, the student had no choice but to select allopathic over osteopathic residency training. Applications for approval are submitted to the AOA Division of Postdoctoral Training. Final AOA approval of an application under this resolution satisfies the requirement for an AOA-approved internship and for eligibility for osteopathic specialty certification eligibility. 
Unfortunately, there is ongoing wide-spread abuse of this hardship exception. According to AOA records, since 2000, only 4 of 400 applicants for this exception have been turned down, a mere 1% of all applicants. This is despite opposition from Osteopathic Postdoctoral Training Institute (OPTI) leadership, at least in New York and Pennsylvania, to many of these applications, as “groundless” (verbal communication-OPTI leadership). In states where there is a multitude of quality AOA-approved training programs, the routine granting of hardship exceptions is alarming and particularly difficult to understand. 
According to osteopathic medical school students, one allopathic hospital in New York reportedly informs DO applicants to their internal medicine residency that Resolution 42 is always available to them and that “all 11 of their DO residents” that applied for the exception have received it. This is despite several competing, fully accredited AOA-approved internal medicine residencies available within miles from this community hospital. Interestingly, this particular facility does not accept DO students for third-year clerkships, while readily accepting allopathic medical students. 
A Pennsylvania hospital has even reported that a DO received the hardship exception, though he was offered an AOA-approved fast-track internship position, in the same discipline, at the same hospital! Certainly, this is not what anyone had in mind when Resolution 42 was implemented. 
Oliver Hayes III, DO, MHSA, at the Michigan State University College of Osteopathic Medicine, East Lansing, has reported that DO graduates who participate in dually certified AOA/ACGME (Accreditation Council on Graduate Medical Education) programs are as likely as those in AOA-only programs to become AOA certified and AOA members. (J Am Osteopath Assoc. 2004;104:82-86) This important study points out the importance of keeping DOs in AOA-approved training programs, including those that are dually approved. 
The blatant abuse of Resolution 42 is a threat to AOA– and dual–approved programs. We are providing ACGME-only programs a recruitment weapon to use against our approved programs. This is tantamount to handing a burglar a weapon, knowing he will use it against you. There are no data that DO graduates granted the Resolution 42 hardship are any more likely to become AOA board-certified, or to become long-term AOA members, than if they were not granted this exception. To the contrary, given this free pass, DO graduates may be even more likely to turn their backs on osteopathic medicine. 
The assumption by some that ACGME-accredited programs are uniformly superior is unfounded, especially as many ACGME–accredited programs are based at the same hospital as AOA-approved programs. American Osteopathic Association-approved (or ACGME-accredited) programs with quality issues need to be beefed up or closed. Resolution 42 neither addresses nor solves that problem. 
In conclusion, though well-intentioned, Resolution 42 is being grossly overused. Its policy is counterproductive for the osteopathic medical profession and our graduate medical education programs. To build more programs, including dually approved AOA/ACGME programs, with willing partners, this resolution should become more the exception and less the rule. We should immediately suspend this resolution and the process by which AOA credit is granted until this can be studied further and the standards properly enforced. The future of our osteopathic training programs may depend on it.