Abstract
In January 2006, the inaugural Osteopathic Heritage Foundation Medical Education Summit was held to address key issues confronting the osteopathic medical profession, particularly the physician workforce, student recruitment, and the funding of postdoctoral programs. Building off of the draft statements from the first summit, the Medical Education Summit II addressed issues specifically related to osteopathic graduate medical education. The authors provide a brief outline of the summit process, describe the outcomes from both meetings, and discuss the future goals of osteopathic medical education.
Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. 1
One of the goals for osteopathic medical education has been to “grow” the influence of the profession within the larger establishment of the US and international healthcare workforce.
2 Ultimately, the osteopathic profession hopes to provide the benefits of osteopathic philosophy and care to an ever-increasing number of patients.
3
The passage of the Balanced Budget Act of 1997,
4 which was proposed with the hope of controlling Medicare spending, caused a funding crisis for graduate medical education (GME) programs,
5 particularly in the osteopathic setting.
6 The premise for this legislation was to limit the number of GME positions funded by the Centers for Medicare and Medicaid Services and to create “bottleneck” control of the number of US-trained physicians based on a projected surplus of US physicians.
4 However, 2004 and 2005 projections indicated that prior assessments were erroneous and that, in fact, a severe shortage of physicians for US healthcare needs will occur by 2020.
7,8
At the same time that this shortage was predicted, osteopathic medical education was undergoing a series of important changes. For example, several new colleges of osteopathic medicine (COMs) were in development, graduates of existing COMs were increasingly choosing allopathic residency programs,
9 and more COM graduates were choosing higher paying specialties rather than traditional primary care specialties to manage their debt, most often incurred for tuition expenses.
10 Meanwhile, the American Association of Medical Colleges announced a recommendation to increase their class sizes by 15% to 30% to address the projected physician shortages.
11 All of these factors created further concerns about the availability of OGME positions and the quality of the osteopathic educational infrastructure and applicant pools.
12
After reviewing these growing concerns, the Board of Trustees (BOT) of the American Osteopathic Association (AOA) passed a resolution in July 2005 that a medical education summit be held (Resolution 43 [A/2005]—Osteopathic Graduate Medical Education—Healthy Profession 2015, Call for Professional Growth In). This resolution prompted leadership at the American Association of Colleges of Osteopathic Medicine (AACOM) and the AOA to appoint the Medical Education Summit (MES) Steering Committee. With the generous support of the Osteopathic Heritage Foundation (OHF), the AOA, and AACOM, the OHF MES was officially launched.
Medical Education Summit Steering Committee
In preparing for the summit, the steering committee, which included representatives from the AOA BOT, AACOM, and the American Osteopathic Directors of Medical Education (AODME), was charged with the following:
Build a comprehensive strategic model of responsible growth in osteopathic medical education
Conduct a thorough analysis of the benefits, detriments, and outcomes for the osteopathic profession with respect to continuing a separate osteopathic match versus adoption of a single joint match (ie, osteopathic and allopathic) as proposed by AOA student groups
Consider and evaluate the requests of “emerging states” for variance from published standards for establishing OGME programs
In addition, more than 80 issues were forwarded to the committee by the AACOM Board of Deans and the Society of Medical Educators, the AOA House of Delegates and BOT, the AODME, and the Osteopathic Medical Educators Council (now the Bureau of Osteopathic Medical Educators),
13 as well as the recommendations published in the osteopathic medical education study.
12 The steering committee deliberated extensively to consolidate the more than 80 topics into 25 rank-ordered items that fell into the following four themes: (1) workforce,
7,8,14,15 (2) recruitment,
16,17 (3) funding,
10,18-20 and (4) quality
21-24 (
Figure 1).
To determine who would participate in the summit, the steering committee selected a broad cross-section of the osteopathic profession's constituent groups: students and residents, medical educators from both osteopathic undergraduate medical education and OGME, chairs of the AOA Department of Education committees, officers of the Commission on Osteopathic College Accreditation (COCA), and public members (eg, chief executive officers of hospitals, public advisors to AOA accreditation bodies). Inclusion was based primarily on functional roles that individuals held in their respective organizations. Despite the committee's best attempts at inclusiveness, invitations were limited to meet budgetary and logistic constraints and encourage collaboration among attendees.
13
The steering committee researched relevant topics related to primary areas of concern and then created and distributed a reading list of articles, many of which are referenced in the present piece. These resources were selected to highlight salient features and provide a common background for discussion. In addition, both the AOA Department of Education and AACOM provided substantive data for use and review where and when it was available.
Inaugural Medical Education Summit
The inaugural OHF MES—later known as MES I—was held January 26, 2006, through January 29, 2006, in Chicago, Ill. Presentations on physician workforce, osteopathic recruitment, and OGME funding were given by nationally recognized experts. After each presentation, the 70 participants were divided into groups of seven to eight people to deliberate on the challenges relevant to the respective topics and to propose statements for the summit to adopt as consensus statements. Each breakout session was moderated by a trained external facilitator overseen by a steering committee member. For each major topic, the groups were “remixed” to provide maximum dialogue among individuals and to promote a collegial exchange of ideas.
13
For the topic of quality in medical education, participants met in separate focus groups to describe their particular viewpoints about the definition of quality as it relates to osteopathic medical education. Key phrases and concepts defined in these sessions will be used in a large, multisite survey to better understand how students, residents, and even the public view the quality of our medical education programs. Pilot surveys are currently being tested for statistical validation.
A total of 65 recommended consensus statements were forwarded for deliberation and further discussion during the final MES I session.
25 The final session was conducted according to ground rules established by the steering committee early in the planning phases. An electronic audience response system (Turning Point; Turning Technologies LLC, Youngstown, Ohio) was used to tally audience responses (ie, “yes” or “no”) on each individual statement. A 75% consensus vote was required for adoption of the statement as a “Summit Consensus Statement.” If an individual statement did not meet 75% on the first vote, alternate language was incorporated to best meet participants' recommended changes. A second vote was then taken with the incorporated changes. If a 75% vote was not reached, the statement was moved to a “parking lot” for further study or referral to subsequent summits.
Outcomes
The
2006 OHF Medical Education Summit: Consolidated Consensus Statements25 reflects all 65 statements considered by summit participants. Sixty-one of the statements reached a consensus level of 75% on either the first or second attempt. This striking number of approved consensus statements has proved invaluable to the profession during the past 24 months. Questions concerning opening new COMs, quality standards, and other “boiling points” have been answered, and actions have been predicated on the consensus points determined by this process. Critics will rightfully argue that many of these statements are “no-brainers.” Nonetheless, they stand as a public declaration of a common professional will around key issues.
The 61 approved statements were regrouped in preparation for the second medical education summit, and a tracking system has been devised to follow action plans. The ongoing MES I progress report, which is being prepared for Web posting (Joyce L. Obradovic, MA, RDH, oral communication, January 2008), will extensively reference documents and accomplishments to date.
Figure 2 outlines the progress on several of the consensus statements within the context of these accomplishments.
26 Additional substantive plans have been put into action since the June 2007 report,
27 and many of them have origins or links to the consensus statements beyond what has been previously reported.
Now we can move to meaningful and purposeful decisions for critical questions in which agreement has not yet been reached. The following statements reflect the four unresolved issues
25:
Should COCA accreditation standards for approvals of class size increases for existing schools and class size approvals for new schools be restricted to available linked first-year OGME postdoctoral positions?
Should the “osteopathic philosophy” be redefined in light of current trends and evolution of the profession? Specifically, should allopathic physicians be allowed to train in OGME settings?
Should the AOA, the American Osteopathic Board of Specialists, and the American Board of Medical Specialists move toward parallel programs and away from dual programs by discussing equivalent recognition of AOA certification as an entry qualification to train in American Council on Graduate Medical Education (ACGME) subspecialty programs as soon as possible?
Should the AOA develop policies that will allow osteopathic graduates of either AOA or ACGME postgraduate programs to obtain positions (eg, osteopathic directors of medical education, deans of COMs) and licenses in some states that are currently open only to those osteopathic physicians who are trained in AOA programs?
These questions were added to the topics and issues to be deliberated during the second medical education summit.
Medical Education Summit II
Because the four statements that did not reach consensus were substantially related to OGME, the Medical Education Summit II (MES II) Steering Committee was charged with assessing issues related specifically to OGME. As a result, the research completed by the steering committee and the reading materials provided to attendees before the summit focused on literature and data relating to OGME and its milieu. As it did with the first summit, the steering committee again restricted participants, this time to approximately 100 members of the profession in official capacities representing all stakeholders in OGME issues, including students, residents, and new “physician-in-practice” leaders. Of the MES I participants, only those directly involved in OGME were invited to participate in MES II.
The steering committee performed a detailed analysis of all aspects of OGME and divided the topics into the following three components:
Global issues—How do we ensure that OGME maintains the essence of what makes it osteopathic?
Resources and structure—How do we ensure that there are sufficient resources and an appropriate structure for the GME needs of osteopathic medical students?
Specialty mix—How should the profession deal with the aspects of specialty mix (ie, students gradual trend toward choosing medical specialties rather than traditional family practice specialties) that influence or are influenced by OGME?
The steering committee prepared question sets for each of these three topics and identified the main controversy in each topic.
Funding for MES II, which was held November 10, 2007, through November 12, 2007, in Lombard, Ill, was generously provided by the AOA, AACOM, the OHF, the Osteopathic Founders Foundation, and the Osteopathic Institute of the South. The summit kicked off with an introduction of the issues and the pertinent history, followed by presentations by nationally recognized experts in each of these areas. These experts delivered a provocative set of point/counterpoint presentations on each controversial topic. Participants also benefited from the general reactions and overview of two noted experts: Barbara Ross-Lee, DO, and David Leach, MD. Dr Ross-Lee, the vice president of health sciences and medical affairs at the New York Institute of Technology in Old Westbury, spoke about the changes in the profession in the bigger context of our history and where the profession can go. Dr Leach, the recently retired director of the ACGME, spoke about the unique nature of the osteopathic profession in the context of the type of medical care the public needs and deserves.
For MES II, groups were divided into a series of three breakout sessions to identify solutions and approaches, analyze barriers and facilitators, and develop action plans, respectively. Each breakout session had nine groups—seven to eight people in each group—and, like MES I, was moderated by a trained external facilitator overseen by a steering committee member. The final breakout session used the affirmed concepts to develop action plans.
At the conclusion of the development of the action plans, the entire group prioritized those plans. Summit participants were asked to vote only for items not yet in progress. In addition, participants were clearly instructed that concepts resulting from MES II would be advisory to the two governing boards (ie, the AOA and AACOM).
Outcomes
During the MES II, the following three overarching concepts were clarified and approved:
Global issues—The osteopathic medical profession will study, define, and maintain OGME as a separate and distinct system, which at its essence is osteopathic. We will identify what we do best and reformulate OGME based on the needs of the 21st century.
Resources and structure—The osteopathic profession will work to provide sufficient resources and an appropriate structure for the GME needs of COM graduates.
Specialty mix—The osteopathic primary care focus as exemplified in osteopathic medical education is essential to meet societal needs.
The structural overview of MES II, in which these three concepts fall, is provided in
Figure 3. After the summit adjourned, the steering committee met to further analyze and assign oversight of the recommendations. However, because there was some overlap, several action plans were combined.
In addition, based on the number of priority votes for each area by summit participants, the concept areas were categorized by priority (ie, low vs high. All concept areas were forwarded to the appropriate bodies (ie, implementation groups already in place). By providing this information to the appropriate groups, MES II has provided affirmation of the work set in motion by MES I.
The work product was sent to the steering committee by electronic mail for final vetting and then submitted to the AOA and AACOM for approval. The steering committee was advised that if there were differences of affirmation votes between the two association boards, the two executive committees would meet in an attempt to adjudicate any identified differences. The the AOA Executive Committee and the AACOM Board of Deans vetted the work products on December 1, 2007, and December 10, 2007, respectively. Action plans that did not achieve consensus were vetted by joint leadership on February 6, 2008. Following that approval, plans were put in place for action plan assignments and for the steering committee to provide ongoing oversight.
Comments
It is clear that MES I set the stage for “evidence-based decisions” about policy—provided that the meaningful data requested by the participants is forthcoming from the AOA and AACOM. The groundwork has been laid to move forward with policy action plans based on consensus not previously possible.
Like any good investigation, each summit uncovered more questions—all of which demand further refinement and study as well as additional action plans. Our progress will become more difficult with each level of questioning as we approach our individual core values and beliefs about who we are as osteopathic physicians and what our profession really means to international healthcare. Questions and decisions like these cannot be reliably answered with emotion, unreasoned judgment, or tradition. Instead, they demand robust data and information that has been thoroughly scrubbed of bias.
The oft-repeated theme of many groups who reported their proposed statements at MES I was “we need reliable data, which are not being collected or are not available.” This point has been reinforced in conversations with Howard S. Teitelbaum DO, PhD, MPH (oral communication, June 2006), author of the well-known osteopathic medical education study.
12 To address the problem of absent data regarding osteopathic medical education highlighted during the summits, an organized entity for the conduct of educational research for the osteopathic medical profession should be created.
12
Conclusion
The first summit was successful in many ways far beyond the 61 statements that emerged as “compass points.” First, the steering committee grappled with a diverse set of topics and issues, determining which ones to deliberate and whom to invite to participate in the discussions. Second, AOA and AACOM administrative personnel came together as never before to work in tandem for a common product. Third, the educational leadership of both organizations came together in a unified way to deliberate very difficult questions with purpose and integrity. The second summit was able to build on the sound foundation of MES I and proceed to the next level of questions and issues related to OGME.
The summits have initiated a common public articulation of educational direction on growth, promotion of tougher accreditation standards, and a purposeful path for producing highly qualified osteopathic physicians for the future. This process continues in a way that is unique to the osteopathic medical profession. Because of our size, our focus, and our commitment to the heart of what our profession has to offer, we can bring all the stakeholders and players to the table and hammer out the issues facing us. The challenge may be daunting, but our charge is worthy of the work.
Dr Watson was chair of the Osteopathic Heritage Foundation Medical Education Summit, which took place January 26, 2006, through January 29, 2006, in Chicago, Ill. Dr Nichols is a member of the
JAOA Editorial Advisory Board and the American Osteopathic Association's Board of Trustees, and she was the chair of the Medical Education Summit II, which took place November 10, 2007, through November 12, 2007, in Lombard, Ill.
We are honored to have been asked to serve as the chairs for the summit events and are likewise humbled and proud of the accomplishments we achieved as a profession in the process.
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