Letters to the Editor  |   March 2005
“Hardship Exception” Is Necessary
Author Affiliations
  • Edward Zawadzki, DO
    Mount Sinai School of Medicine–Cabrini Medical Center
 Manhattan, New York
    Psychiatry Resident
Article Information
Medical Education / Graduate Medical Education
Letters to the Editor   |   March 2005
“Hardship Exception” Is Necessary
The Journal of the American Osteopathic Association, March 2005, Vol. 105, 124-126. doi:
The Journal of the American Osteopathic Association, March 2005, Vol. 105, 124-126. doi:
To the Editor:  
I have been reading JAOA—The Journal of the American Osteopathic Association these past few months with particular interest in the debate surrounding the current state and future direction of requirements for osteopathic internships. Frankly, it is time to stop the ineffectual pedantic dogma being sent down from those DOs viciously defending a system that is simply not supported by those most important to the future of the profession: students. 
In his January letter to the editor (“Rebuttal Regarding the `Hardship Exception.'” J Am Osteopath Assoc. 2005;105[1]:4–5), Dr Steier expresses disdain for the “routine granting of American Osteopathic Association (AOA) credit for non-AOA–approved internships and residencies under Resolution 42 (A/2000), the `hardship exception.'” 
As a psychiatry resident reading this letter, I am first inclined to ask what the motivation behind such feelings and behavior might be. 
The institution at which Dr Steier is a program director, Nassau University Medical Center in East Meadow, NY, requires that any osteopathic medical student applying for a second-year postgraduate residency position (PGY-2), including allopathic (MD) positions, complete an AOA internship at his hospital (NYCOMEC, e-mail [policy statement], January 2005). 
Of course, a hardship application requesting that credit be given for internships completed at other institutions is reportedly available. One wonders if Dr Steier is as opposed to this hardship application as well. 
Considering the internship match rate at Nassau University Medical Center this year left 18 unfilled osteopathic internship slots,1 the motivation becomes more clear. 
Such tactics serve only to artificially inflate the still-low osteopathic internship match rates while creating additional demands on newly graduated osteopathic medical students. Neither result fosters a love in osteopathic medical students and residents for osteopathic graduate medical education. 
I would go so far as to say that Resolution 42, even as it now stands, fails to properly address the needs of many residents whose chosen specialties have very specific and very different requirements. For this reason, I argue that the hardship exception applications should rightfully have a high approval rate. 
Psychiatry, for example, requires 6 months of inpatient psychiatric unit care; 2 months of neurology; and 4 months of internal medicine, family practice, and/or pediatrics in the first year of residency (PGY-1).2 Some psychiatry residencies do not have accommodations for such requirements (eg, no pediatrics or family practice department). Considering the fact that there are only 4 osteopathic psychiatry residency programs in the United States (Michigan, 2; New Jersey, 1; Pennsylvania, 1) with a combined total of 28 positions,3 it is conceivable that many potential psychiatry residents would not be able to, or would not want to, go to any of these institutions for whatever personal reasons they may have. 
When one combines this dearth of opportunity in osteopathic institutions with the fact that fiercely competitive fellowship positions often require residency training at prestigious institutions, it is no wonder many osteopathic medical students choose to attend the more plentiful and long-established Accreditation Council for Graduate Medical Education (ACGME) residency programs. 
Resolution 42 demands that the resident “complete all AOA-approved traditional internship requirements within the ACGME program.”4 This requirement is often impossible to fulfill. Completion of these requirements would in some cases prevent residents from fulfilling the requirements for licensure application for their own specialties. 
If this is not bad enough, the bylaws demand that these and other requirements be completed within the first year of postgraduate training.5 Some would argue that because psychiatry, for example, allows one to enter as a PGY-2, the osteopathic medical student should therefore complete an AOA internship and then apply to PGY-2 positions in psychiatry. This is extortionate. With the mounting debt that osteopathic medical students face,6,7 it is unreasonable to expect residents to feel comfortable tacking on an additional year of training, losing one year of salary equivalent to $50,000 to $250,000, with arguably minimal benefits. 
Assertions like those made in the November 2004 edition of JAOA by Dr Clark (“Osteopathic Medical Training: Developing the Seasoned Osteopathic Physician.” J Am Osteopath Assoc. 2004;104[11]:452–454), that he had just as much knowledge (if not perhaps a little more) after completing his internship as those now completing full residencies, are preposterous and only signify an out-of-touch attitude that is sadly prevalent in the existing osteopathic guard. 
In fact, Dr Clark begins his letter by berating Dr Smith for originally referring to himself as an “MS” (medical student), rather than an “OMS” (osteopathic medical student), making the false analogy that osteopathic medical school is akin to a business and that the designation OMS brings with it product recognition. 
I say that if osteopathic medicine is a business, then it has largely failed in its marketing campaign. Despite more than 100 years of the existence of our profession, the vast majority of people in the United States still has no idea what a DO is.8 Insisting that osteopathic medical students refer to themselves as “OMS” will do nothing to improve this low level of awareness about osteopathic medicine among the public. 
To take the business analogy a step further, a business must listen to its stockholders when they demand change. Osteopathic medical students in this scenario are the new stockholders. Results over the past few years show poor AOA internship match statistics.9 Basically, our “product” isn't being bought. The truth is that those wishing to pursue ACGME residencies do so for a reason, and they should not be viewed as the enemy or ostracized from the osteopathic community. 
The truth is that almost half of osteopathic medical students do not want to attend AOA internship programs, as evidenced by the recent 52% participation rate for osteopathic internship slots.9 
In fact, even the term “internship” is now found to be degrading and old-fashioned and has, in fact, been eliminated from the ACGME lexicon. The term “intern” brings with it only the reminder that one is a subservient underling. In addition, in today's common understanding of the word, it also often means “unpaid” or “marginally knowledgeable,” and possibly conjures images of morally questionable characters begging for recognition in “the real world.” Once again, the osteopathic profession seems reluctant to change or modernize in even this small matter. 
It appears as though the current generation of osteopathic medical students and residents are choosing not to obsess over the differences between MDs and DOs, but rather focus on our similar yet distinct roles as leaders of the healthcare profession—choosing to be included rather than alienated from our allopathic colleagues. If this means training in an allopathic residency for whatever reason, that decision should be respected. Imposing unreasonable restrictions on osteopathic graduates will only further divide the profession, and that is something we truly cannot afford. [American Osteopathic Association Web site]. 2005 Match results. Available at: Accessed March 22, 2005.
ACGME [Accreditation Council for Graduate Medical Education Web site]. Program requirements for residency training in psychiatry. Available at: Accessed March 22, 2005.
Opportunities [American Osteopathic Association Web site]. Opportunities: internship and residency positions. Available at: Accessed March 22, 2005.
Board of Trustees for the American Osteopathic Association. Approval of ACGME training as an AOA-approved internship [resolution 42]. Meeting Agenda: A/2000. July 2000. Chicago, Ill: American Osteopathic Association; 2000:44 . [American Osteopathic Association Web site]. ACGME training: helpful hints (resolution 42). Available at: Accessed April 7, 2005.
Zonia SC, Stommel M, Tomaszewski DD. Reasons for student debt during medical education: a Michigan study. J Am Osteopath Assoc. 2002;102:669–675. Available at: Accessed March 18, 2005.
Weinberg AM. Lessons in financial health and debt management for young physicians: loan consolidation programs, loan deferments, and tax savings. J Am Osteopath Assoc. 2002;102:545-548,551-554. Available at: Accessed March 18, 2005.
Licciardone JC, Herron KM. Characteristics, satisfaction, and perceptions of patients receiving ambulatory healthcare from osteopathic physicians: a comparative national survey. J Am Osteopath Assoc. 2001;101:374–385. Available at Accessed March 31, 2005.
Natmatch [National Matching Services Web site]. Statistical summary by college. Available at: Accessed March 22, 2005.