Letters to the Editor  |   January 2005
Rebuttal Regarding the “Hardship Exception”
Article Information
Medical Education / Graduate Medical Education
Letters to the Editor   |   January 2005
Rebuttal Regarding the “Hardship Exception”
The Journal of the American Osteopathic Association, January 2005, Vol. 105, 4-5. doi:
The Journal of the American Osteopathic Association, January 2005, Vol. 105, 4-5. doi:
To the Editor: I was fortunate to have had my letter to the editor published in the pages of this Journal in August 2004. In that letter, I opposed the routine granting of American Osteopathic Association (AOA) credit for non-AOA–approved internships and residencies under Resolution 42 (A/2000), the “hardship exception” (J Am Osteopath Assoc. 2004;104[8]:314-315). In my letter, I described the documented (at the time) 99% approval rate for the hardship exception as excessive and unjustifiable, especially given the large number of quality AOA-approved residency programs available in many areas. 
My position continues to be that the specific criteria included in Resolution 42 must be vigorously applied; applicants with internship or residency experience that fails to meet the criteria should not be routinely granted AOA-approval for such experience. 
Michael I. Opipari, DO, chairman of the Council on Postdoctoral Training, wrote a response to my letter (published in the same issue) disagreeing with my position. In his response, Dr Opipari provided updated data on the granting of this exception. His data are consistent with the percentages presented in my letter, including a 94% hardship exception approval rate for applicants from New York and a 95% hardship exception approval rate for applicants from Pennsylvania. 
As justification for this high approval rate, Dr Opipari described the discomfort involved in requesting in-depth information from applicants and the large number of osteopathic medical applicants who choose non-AOA–approved programs. The theory, as expressed in his letter, is to keep DOs who choose non-osteopathic training, nevertheless, within the osteopathic “family.” According to Dr Opipari's own data, however, only 9.3% of those applicants granted AOA-approval through Resolution 42 chose AOA-board certification on completion of their residency. This is not, therefore, a reasonable justification. 
I have tremendous respect for Dr Opipari and all he has done for our profession. There is no question as to his dedication and commitment to medical education. On this particular issue, however, I disagree with his position and the rationale behind it and am against the routine granting of the Resolution 42 exception. There is simply no evidence to support his position. 
As a profession, we must consider important questions before coming to a conclusion on this important issue: Is the survival of osteopathic graduate medical education important to our profession? 
Consider what we would do if Accreditation Council on Graduate Medical Education (ACGME)-accredited programs decided to only accept graduates of Liaison Committee on Medical Education (LCME)-accredited schools. (Reminder: AOA-approved residency programs can only accept graduates of AOA-approved schools.) We must also ask ourselves what message we are sending to osteopathic medical students by automatically approving ACGME-accredited training programs as equivalent (or better) than AOA-approved training programs. 
In addition to the 486 hardship applicants I referred to in my original letter, how many other applicants chose ACGME-accredited training, knowing they could always receive AOA-approval through the hardship exception—if they so desired? 
We must also question the implication that there are no substandard ACGME-accredited programs. In fact, a quick review of the ACGME Web site will tell you that there are. 
It is important to acknowledge that by routinely granting this hardship exception, we are not being fair to the many osteopathic medical students who “speak and act” by choosing AOA-approved residency programs and AOA-board certification. That some osteopathic medical school graduates choose non-AOA–approved residency programs does not require us to extend approval to all. 
Finally, what significance does the most recent report from the Council on Graduate Medical Education, which calls for the expansion of class size in LCME-accredited medical schools while, at the same time, acknowledging the continued decrease in the number of graduate medical education positions, hold for our graduates? Is it not our obligation to guarantee that there are AOA-approved residency positions available for our graduates? 
So, informed reader, considering all that has been presented on this subject, do you support the routine granting of the Resolution 42 hardship exception? Given the chance, would you vote for—or against— Resolution 42? Further, do you support a general membership vote on this resolution, as it is currently being (mis)applied? Whatever your opinion, I would strongly encourage you to write to the editor in chief of The Journal on this important issue. 
In conclusion, although well-intended, the Resolution 42 “hardship exception,” should not be used as a rubber stamp for back-door AOA-approval of non-AOA–approved internship and residency programs. Although individual circumstances may warrant use of this exception, a 95% approval rate for a policy that was approved by the AOA's Board of Trustees as only an “exception” is clearly inappropriate. 
Although I respect the individual right of osteopathic medical graduates to choose the residency that best fits their personal goals and will always welcome them as active and vibrant members of the osteopathic community, the survival of AOA-approved residency programs is a higher priority, as it is essential to the survival of our profession. 
The greater good calls for us to honor and actively support and improve osteopathic graduate medical education and respect osteopathic medical graduates who choose AOA-approved residencies and AOA-board certification. 
The criteria set forth in Resolution 42 need to be applied strictly, or the resolution itself needs to go.