Letters to the Editor  |   May 2005
Promoting Active Engagement with Osteopathic Principles and Practice in Interns and Residents
Author Affiliations
  • Robert A. Cain, DO
    Department of Internal Medicine
 Grandview Hospital
 Dayton, Ohio
    Program Director
Article Information
Medical Education / Being a DO / Graduate Medical Education
Letters to the Editor   |   May 2005
Promoting Active Engagement with Osteopathic Principles and Practice in Interns and Residents
The Journal of the American Osteopathic Association, May 2005, Vol. 105, 236-237. doi:
The Journal of the American Osteopathic Association, May 2005, Vol. 105, 236-237. doi:
To the Editor: I believe the specialty of internal medicine has been particularly neglectful of promoting training in osteopathic principles and practice (OPP) during the 36 months that we have our residents as a “captive audience.” As the director for the internal medicine residency program at Grandview Hospital in Dayton, Ohio, I have struggled with the question of how to reintegrate osteopathic precepts with osteopathic practice. 
Many osteopathic internal medicine programs are currently struggling to figure out how they will incorporate the required American Osteopathic Association (AOA) core competency for osteopathic principles (as shown in Required Element 3 of Core Competency 1 on the American Osteopathic Association Program Director's Annual Evaluation Report1) into their curriculum. This struggle seems odd, however, as OPP is the cornerstone of the osteopathic medical profession. 
Looking back, it occurred to me one day that during my years of postgraduate training, I had never been specifically asked to present structural examination findings or to describe my plans for using osteopathic manipulative medicine to treat a patient. Isn't that odd? 
When I was a pulmonologist in training, I was asked, for example, to report breath sounds in a patient with chronic obstructive pulmonary disease or to report abdominal findings for a patient with gastrointestinal bleeding. I was never asked to report the one component of physical examination findings that is supposed to be common to every patient seeking the care of an osteopathic physician. 
Of course, this is not to say that every osteopathic internal medicine residency program fails to focus on this particularly osteopathic aspect of patient care, but I am suspicious that the number of osteopathic interns and residents who can say their training provided a different experience from my own is rather small. 
In response, I have recently added two questions for housestaff during patient presentations. On the surface, they are rather simple questions, but their long-term implications can be profound: 
  • What did you find on your structural examination? and
  • What do you want to do about that?
The first time osteopathic interns and residents are asked about structural examination findings, they are very nearly surprised. Typically, the first time, they don't have much of an answer. The second time isn't much different. However, the third time they are asked this question, the results are usually quite different. 
In fact, the third time osteopathic interns and residents are asked about structural examination findings, not only are they ready to answer the question—they often begin offering information before being asked. 
I think the answer is simple—expectations. Residents are expected to report wheezing. They are expected to report abdominal tenderness. Rarely are they expected to report rib motion in a patient with pneumonia. 
The second question, about what to do in response to the findings, of course, automatically follows a response that indicates pathology during the structural examination. 
These two questions, when used consistently, reset expectations among interns and residents and let them know that those in the profession expect that they will incorporate OPP at the same time that they provide the best of standard care. 
As a practicing pulmonologist, I find that the respiratory system is a perfect model for demonstrating structure-function relationships to students and for using the tools we were taught during our first years of osteopathic medical school. 
What made this methodological shift so important to me? I believe that, as a profession, we need direction. I believe that the best possible outcome for the future of our chosen profession will come from rediscovering our roots. 
Our patients want comprehensive, quality healthcare. I believe that using the particular tools that make us osteopathic physicians will help us deliver that kind of exemplary care. 
For nearly 15 years, I had lost sight of that goal. Had it not been for a serendipitous encounter with Edward G. Stiles, DO, Professor and Chairman of OPP at Pikeville College School of Osteopathic Medicine in Kentucky, I might never have found it again. A lengthy conversation with Dr Stiles in June 2003 set in motion the machinery necessary for personal (and professional) change. 
The conversation with Dr Stiles was an “osteopathic epiphany” for me, providing the mental link that allowed me to actively bring OPP back to my medical practice—and, as a result, back into Grandview Hospital's internal medicine residency program. Dr Stiles reminded me that structure-function relationships are part of a continuum between health, injury, and disease—they are not isolated events to be separated from the whole. Osteopathic manipulative treatment is not a stand-alone therapy; it is part of a treatment plan that maintains health and promotes healing. 
It now saddens me that it took so long to discover what I always knew—that osteopathic physicians have something more than our allopathic colleagues to offer patients. 
Sometimes small changes make a big difference. Perhaps these two questions will do much to move the profession toward “provid[ing].. .students with scientific evidence and validation of core OPP in action by personal example,” as Drs Juhl and Ostrow called for in their recent letter to the editor (“Faith Versus Evidence: The Real Question in Osteopathic Medicine?” 2005;105: 126–128). 
By setting new expectations for osteopathic interns and residents, by adding these two simple questions to our interactions with them, perhaps we will also set in motion the machinery that will allow us to complete the vision of our founder, Andrew Taylor Still, MD, DO, who believed that the objective of the physician is to find health because anyone can find disease. 
If we are successful in doing so, the osteopathic profession will make an even bigger difference in the future of healthcare delivery. [American Osteopathic Association Web site]. Program Director's Annual Evaluation Report: Core Competency Compliance Program (CCCP) Part III. Postdoctoral Accreditation: Postdoctoral Internship and Residency Standards and Procedures. Available at: Accessed June 16, 2005.