Abstract
Context: In 1992, the West Virginia School of Osteopathic Medicine (WVSOM) created a task force as part of an institution-wide initiative to integrate osteopathic principles and practice (OPP) across its entire curriculum. The goals of the initiative, which was implemented with the graduating class of 1997, were to create a clearly distinct osteopathic curriculum and preserve the use of osteopathic manipulative treatment (OMT) by WVSOM alumni.
Objective: To evaluate outcomes of the Osteopathic Principles and Practices Integration Project among WVSOM alumni.
Methods: A survey was mailed on a staggered timeline to WVSOM alumni who had graduated at least 5 years earlier. Data from the graduating classes of 1995 and 1996 (preintervention) were compared with data from the graduating classes of 1997 through 2002 (postintervention).
Results: After excluding responses from alumni still in residencies, responses from 52 (41.9%) of 124 alumni in the preintervention group and 155 (40.9%) of 379 alumni in the postintervention group were analyzed. Comparisons of preintervention group to postintervention group, based on the χ2 test, revealed significant improvement in the proportion of alumni who agreed that basic sciences faculty at WVSOM provided exposure to osteopathic philosophy (P=.020); that basic sciences faculty at WVSOM taught OMT (P=.019); and that alumni were exposed to osteopathic philosophy during rotations with DOs (P=.031). Approximately 53% of alumni in both groups reported daily OMT use in treating patients. Posthoc analysis using the McNemar test for correlated proportions revealed that the proportion of all alumni rating themselves as “prepared” in OMT and OPP at the end of the second year of the WVSOM curriculum was 92.7%, significantly higher than the 76.1% rating of preparation at graduation (P<.001).
Conclusion: Survey results indicate that WVSOM's Osteopathic Principles and Practices Integration Project has created a distinctly osteopathic curriculum and has helped alumni maintain use of OMT in clinical practice.
During the past 30 years, numerous authors have stressed the need for curricular reform in osteopathic medical education, having noted a declining emphasis on osteopathic philosophy and osteopathic manipulative treatment (OMT) in osteopathic medical curricula and decreasing or low usage of OMT by osteopathic physicians (DOs).
1-14 In published articles about the extent to which osteopathic medical students, interns, and residents report exposure to OPP during their training and the extent to which practicing DOs perform OMT, authors generally conclude that osteopathic medical education is becoming less distinct from its allopathic counterpart and that use of OMT by osteopathic physicians in practice is declining.
6,10,12,15-29
In 1992, the West Virginia School of Osteopathic Medicine (WVSOM) began an institution-wide initiative called the Osteopathic Principles and Practices Integration Project (OPP Integration Project) designed to integrate OPP across its entire curriculum. The goals of this initiative were to create a clearly distinct osteopathic curriculum at WVSOM and to ensure that WVSOM alumni would continue to use OMT in their clinical practices. In the present study, we report outcomes of the first 6 years of WVSOM's OPP Integration Project based on surveys of alumni.
Previous Findings on OMT Use
Care must be taken when comparing surveys of DOs regarding OMT use, because different surveys tend to vary in their analyzed central characteristics. Among items that might vary from survey to survey are the following:
specialties of DOs surveyed, with greater use of OMT observed among osteopathic family physicians than other specialists
22,24inclusion of DOs still in postgraduate training—who ostensibly have less control over their practice patterns, and, therefore, the extent to which they use OMT, compared to established DOs
time frames evaluated for use of OMT in practice (ie, use in past week, past month, or “ever” vs percent of patients receiving OMT with no time frame specified)
In developing its OPP Integration Project, WVSOM was interested in enhancing use of OMT by all alumni—regardless of specialty—with the goal of increasing daily use of OMT. Thus, previous studies evaluating OMT use by DOs in all specialties were reviewed. Five studies
12,18-22 reported OMT use by osteopathic physicians in all practice specialties, with DOs still in training or not in active practice excluded from analysis. In four of these studies,
12,18-22 respondents were requested to estimate the percentage of patients with whom they used OMT, with no time frame given. The most recent study
21,22 assessed the percentage of DOs providing OMT to specified numbers of patients within the week previous to the survey.
As indicated by the survey results
12,18-20 summarized in
Table 1, the percentage of DOs providing OMT to less than 5% (but more than 0%) of their patients more than doubled from 1993 (27.7%) to 1999 (60.4%), and the percentage of DOs providing OMT to most (75%-100%) of their patients decreased from 12.7% to 2.1% during that period. In one of these studies, Johnson and Kurtz
12 concluded, “The evidence supports the assertion that OMT is becoming a lost art among osteopathic practitioners.”
Table 1
OMT Use by Osteopathic Physicians: Results of Recent Studies Including All Specialties
|
|
DOs Providing OMT to Specified Percents of Patients, No. (%)*
| | | | | |
|---|
Reference
| Year
| 0%
| >0%-<5%
| 5%-<25%
| 25%-<50%
| 50%-<75%
| 75%-100%
|
|---|
| WesternU/COMP18† | 1993 | 54 (25.4) | 43 (27.7) | 63 (39.9) | 21 (13.3) | 11 (7.0) | 20 (12.7) |
| Fry19‡ | 1996 | ... | 28 (29) | 43 (44) | 12 (12) | 6 (6) | 8 (8) |
| Johnson and Kurtz12§ | 1998 | ... | (53.5) | (30.1) | (6.8) | (3.5) | (6.1) |
| Aguwa and Liechty20∥ | 1999 | ... | (60.4) | (24.7) | (8.0) | (2.0) | (2.1) |
| Spaeth and Pheley21,22¶ | 2002-2003 | ... | ... | ... | ... | ... | ... |
Table 1
OMT Use by Osteopathic Physicians: Results of Recent Studies Including All Specialties
|
|
DOs Providing OMT to Specified Percents of Patients, No. (%)*
| | | | | |
|---|
Reference
| Year
| 0%
| >0%-<5%
| 5%-<25%
| 25%-<50%
| 50%-<75%
| 75%-100%
|
|---|
| WesternU/COMP18† | 1993 | 54 (25.4) | 43 (27.7) | 63 (39.9) | 21 (13.3) | 11 (7.0) | 20 (12.7) |
| Fry19‡ | 1996 | ... | 28 (29) | 43 (44) | 12 (12) | 6 (6) | 8 (8) |
| Johnson and Kurtz12§ | 1998 | ... | (53.5) | (30.1) | (6.8) | (3.5) | (6.1) |
| Aguwa and Liechty20∥ | 1999 | ... | (60.4) | (24.7) | (8.0) | (2.0) | (2.1) |
| Spaeth and Pheley21,22¶ | 2002-2003 | ... | ... | ... | ... | ... | ... |
×
It is apparent from reviewing such published data
12,18-22 that the use of OMT by practicing DOs is declining.
Calls for Curricular Reform
In 1975, Korr
2 wrote, regarding an osteopathic curriculum, “it matters much less how the hours are arranged than what
goes on in those hours, individually and collectively.” This opinion gained support in a 1992 study by Miller
6 of attitudes and behavioral intentions regarding OPP among osteopathic medical students. Miller
6 suggested that the total number of OPP hours within the curriculum was not necessarily the key to increased OPP competency.
Several authors have suggested various curricular initiatives to reverse the decline in OMT use, and some implemented initiatives have demonstrated immediate improvement in trainee behaviors regarding OMT.
7,30-37 However, longitudinal retention of these improved behaviors in subsequent practice patterns has not been reported.
In 2007, Gimpel
14 called on all colleges of osteopathic medicine (COMs) to move “beyond the barriers” to effect curricular reform and quality improvement so that future DOs are better prepared to meet society's healthcare needs. Included in his recommendations was the need for integrating OPP across all 4 years of osteopathic medical education and into graduate medical education programs.
14 Such recommendations are incorporated into WVSOM's OPP Integration Project.
Creation of the OPP Integration Document
The OPP Integration Project of WVSOM began in 1992 with the creation of the OPP Integration Task Force (OPPI TF) by WVSOM's dean for academic affairs. It consisted of faculty from both the basic sciences and the clinical sciences, with a member of the OPP faculty appointed by the dean as task force chairperson.
The OPPI TF conducted an extensive institutional internal study to determine where OPP concepts were being taught in the existing curriculum. Evaluations of the current curriculum and recommendations for creating the desired osteopathically integrated curriculum were obtained from WVSOM students, faculty and staff, administrators, and alumni.
Early in this process, the basic sciences faculty members of the OPPI TF asked that the clinical sciences faculty develop an institutional definition of osteopathic medicine, which would then be used to guide the entire OPP Integration Project. After being created by the clinical sciences faculty, this definition was revised and endorsed by the entire WVSOM faculty (Appendix). An advantageous effect of the group process leading to this definition was an increased understanding by the basic sciences faculty that although OMT is important, other osteopathic concepts—such as the body's abilities to self-regulate and heal itself—are also central to osteopathic medicine, and these other concepts could be reinforced by faculty members who are not DOs.
The OPPI TF studied two documents reflecting the work of other organizations toward achieving the goal of integrating OPP into the osteopathic curriculum. These documents were
Core Curriculum for Osteopathic Education,
38 published in 1987 by the Educational Council on Osteopathic Principles of the American Association of Colleges of Osteopathic Medicine (AACOM), and
1986-87 AACOM FOCUS [Funds for Osteopathic Colleges in the United States] Grant Report on “Implementation Strategies for Integrating Osteopathic Philosophy, Principles, and Practices into Osteopathic Instruction,”39 published by Kirksville College of Osteopathic Medicine-A.T. Still University in Missouri.
After reviewing all collected information, the OPPI TF generated numerous recommendations and ranked them based on importance and expected ease or difficulty of implementation. The recommendations were also grouped into three main topic areas: (1) the first and second years of the curriculum; (2) the third and fourth years of the curriculum; and (3) faculty development. One topic area was assigned to each of three subcommittees of the OPPI TF, and these subcommittees were asked to develop recommended timelines for a phased-in implementation plan. The reports of the three subcommittees were combined into a final document, which was submitted to the dean.
The dean approved the concept of the document and passed it to the faculty Curriculum Committee for vetting and support. After the Curriculum Committee revised the document and recommended adoption of the initiative, the document was sent to the entire faculty for their critique and approval. The dean then assigned members of the OPPI TF as continuing members of an Ad-Hoc Committee on Integration of OP&P into the WVSOM Curriculum, which was charged with overseeing the proposed 5-year implementation plan.
The final 1993 OPPI TF recommendations can be accessed on the WVSOM Web site at:
http://www.wvsom.edu/_pdf/OPPIntegDoc93.pdf.
40 It should be noted that the task force recommended no changes in WVSOM's admissions process, which emphasizes recruitment and selection of students who are interested in osteopathic medicine and in practicing in rural areas of West Virginia.
The administrative structure developed at WVSOM to implement and continue the OPP Integration Project deserves discussion. The details of this initiative were not mandated by upper administration. Rather, the initiative was the outcome of a paradigm that was interpreted and implemented voluntarily by the faculty, based on a common vision and recognition of need. The initiative was developed under the watchful guidance of the OPP TF chairperson and with the clear expectation by the dean that all faculty members would be involved in some way in support of the initiative.
Three components of WVSOM's OPP Integration Project were crucial to its success: support from the dean; the role of a committed chairperson who nurtured the project from its beginning through its implementation and evaluation; and the involvement of the faculty from the project's beginning. The depth of faculty involvement is demonstrated by the fact that in 1996, WVSOM's faculty voted to establish the Ad-Hoc Committee as a standing committee of the faculty, with the chair of the Ad-Hoc Committee also serving as chair of the standing committee. This arrangement enabled the OPP Integration Project to be endorsed by vote of the faculty as a committee, with the Ad-Hoc Committee chairperson to be given permanent faculty position.
In 1997, the WVSOM faculty further supported the OPP Integration Project by voting to include assessment of each faculty member's integration of OPP into teaching as part of existing annual reviews for faculty retention, tenure, and promotion.
In 2002, a new academic dean was appointed at WVSOM. The new dean proactively continued previous activities for OPP integration and, in addition, created the position of associate dean for osteopathic medical education and expanded OPP integration into graduate medical education. The new associate dean position was an important step in strengthening the OPP Integration Project, because it provided administrative authority to project leadership to ensure the continuation of the program.
In 2003, the OPP Integration Committee (ie, the standing committee) began granting annual recognition awards to WVSOM faculty members for exceptional integration of OPP into teaching. Awards are given each year to a basic sciences faculty member, a clinical sciences faculty member, and a preceptor who teaches students in the third or fourth years of the curriculum or in the Mountain State Osteopathic Postdoctoral Training Institute. Full-time OPP faculty members are ineligible for these awards.
Implementation of Recommendations
The OPPI TF was of the opinion that a uniquely osteopathic curriculum could not be created without both curriculum revision and extensive faculty development. Therefore, the final recommendations in the OPP integration document
40 were grouped into two major sections: curricular reform and faculty development. Curricular reform was subdivided into recommendations for the preclinical and clinical years of training.
Included within each target goal in the document was a time frame for staged implementation and the name of an office (or offices) responsible for the goal's implementation. The OPPI TF considered its final document
40 to be a guide, noting that time frames and mechanisms for achieving specified goals might need to be altered during the process of implementation.
▪ Curricular Revision—The following recommendations of the OPPI TF were implemented to enhance integrative learning in the first and second years of WVSOM's curriculum:
Institute early clinical exposure in osteopathic diagnosis and OMT. To help accomplish this goal, a free community clinic was created in which second-year osteopathic medical students practice distinctive osteopathic evaluation and treatment with community patients under direct supervision of WVSOM OPP faculty members. This student osteopathic manipulative medicine clinic was established in 1995, for the class of 1997, and has been continuously operating since that time.
41Create a mechanism for lectures and laboratories that outlines osteopathic principles relevant to systemic disease and that integrates these principles into the organ systems-based curriculum. The concept behind this approach was to “build a bridge” for osteopathic medical students to relate knowledge and skills learned in OPP courses to their general medical knowledge learned in the organ systems-based curriculum. Although different formats have been used to achieve this goal, the typical format is either case development with integrated osteopathic components or team-teaching on a clinical condition with both basic sciences and clinical sciences faculty.
Establish “substantive dialogue” between basic sciences and clinical sciences faculty. This recommendation included various methods to foster communications and integrative teaching across disciplines. This goal is achieved, in part, by assigning cross-discipline “advisors.” For example, clinical faculty members are assigned to be advisors for all basic sciences courses, and basic sciences faculty are assigned to be advisors to clinical courses.
Establish multidisciplinary case-study presentations, including osteopathic concepts, within the second-year organ systems-based curriculum.
Resequence the curriculum, where appropriate, to allow for the teaching in temporal proximity of concepts important to understanding osteopathic medicine.
The following recommendations of the OPPI TF were implemented to enhance integrative learning during the third and fourth years of WVSOM's curriculum:
Require that each osteopathic medical student spend a rotation with an osteopathic preceptor who uses OMT in his or her practice. We chose to include DOs specializing in osteopathic manipulative medicine and those in other specialties who regularly integrate OMT into their practices. This requirement has developed into the James R. Stookey, DO, Preceptor Program,
42 in which WVSOM students perform a required OPP rotation in both the third and fourth years of the curriculum.
Recruit preceptors who use OMT in their practices. This recommendation has also been supported via development of the roster for the James R. Stookey, DO, Preceptor Program.
Require each osteopathic medical student to submit an OMT case history describing the integration of OPP into the treatment of a patient in whose management they participated. This recommendation has resulted in WVSOM's OMT Case Study requirement in two family medicine rotations—one in the third year and the other in the fourth year. The student must complete the case study, which is graded by WVSOM clinical faculty, before passing that rotation.
▪ Faculty Professional Development—The following recommendations of the OPPI TF have been implemented to enhance faculty knowledge, comfort, and skill regarding concepts necessary to integrate OPP into their teaching:
Provide on-campus faculty development regarding OPP several times each year. These faculty development classes are generally attended by 60% to 90% of both basic sciences and clinical sciences faculty.
Orient all new faculty and staff to OPP and WVSOM's integration activities.
Provide regular off-campus faculty development, including programs for preceptors and assistant deans in WVSOM's statewide campus system, which delivers WVSOM's third-year curriculum. Some of this faculty development is now provided by the Mountain State Osteopathic Postgraduate Training Institute, the osteopathic graduate medical education consortium in which WVSOM serves as a partner.
43Conduct regular OPP education in WVSOM's continuing medical education programs, targeted to practicing DOs who serve as WVSOM's student preceptors.
Foster collaborative research projects in areas of mutual interest to basic scientists and clinicians.
44-47
Methods
To determine whether WVSOM's OPP integration initiative had an impact on subsequent attitudes and practice patterns of alumni, approval was obtained from the WVSOM Institutional Review Board to conduct confidential surveys of alumni. A 2-page survey was created to gather information on multiple topics of interest, including the following:
alumni perception of their preparation in OMT/OPP in the second year of the curriculum and at graduation
alumni perception of OMT/OPP instruction by basic sciences faculty and clinical sciences faculty
alumni perception of exposure to OMT/OPP during the third and fourth years of the curriculum
type of current clinical practice
approximate number of patients seen daily
approximate number of patients each day with whom OMT is performed
OMT techniques regularly used
reasons for not performing OMT, if applicable
Not all survey items were included in all eight years that the surveys were sent. The present article reports only results of those survey items that were common across all survey years.
Because one of the objectives of WVSOM's OPP Integration Project was to preserve the use of OMT by its alumni—despite the reported decline in the use of OMT by osteopathic physicians nationally
12,18-22—measurement of this outcome could necessarily be obtained only via survey over a long-term period. Therefore, surveys were sent only to those alumni who had graduated 5 or more years previous to the survey, allowing time for the alumni to complete at least 3 years of postgraduate training and to be in practice for approximately 2 years. We reasoned that by that time in their careers, alumni should have developed their own practice patterns, making it possible to determine to what extent OMT would be included in their practices.
Surveys were sent via regular mail to every member of the WVSOM graduating classes of 1995 through 2002—5 to 9 years after graduation. A follow-up letter and survey were sent 1 month later to all members of each class who had not responded. All surveys received at time of data analysis were included in the results of the present study.
In 2003, the survey was administered to all students in the graduating classes of 1995, 1997, and 1998. In 2004, the survey was administered to the graduating class of 1999. In 2005, the survey was administered to the graduating class of 1996. In 2007, the survey was administered to the graduating classes of 2000, 2001, and 2002. Mailing addresses were obtained from the WVSOM Alumni Affairs Office for all graduating classes, and the alumni office was informed of any returned surveys.
For purposes of the present report, alumni survey respondents were categorized into two groups: respondents in the graduating classes of 1995 and 1996, who completed their curricula before implementation of the OPP Integration Project (ie, the preintervention group), and respondents in the graduating classes of 1997 through 2002, who completed their curricula after implementation of the OPP Integration Project (ie, the postintervention group). Favorable responses to survey questions (eg, perceptions of being “very well prepared” and “well prepared”) were combined, as were unfavorable responses (eg, perceptions of being “not well prepared” and “very badly prepared”) to allow for 2×2 comparisons of correlated proportions. As previously indicated, responses from graduates who were still in residency or fellowship training were excluded from analysis.
Data were compiled and verified, and data analysis was conducted using SAS statistical software (version 9.1; SAS Institute Inc, Cary, North Carolina). Categorical data were analyzed with χ2 testing unless an expected cell count was less than 5, in which case the Fisher exact test was used. For comparison of all students' perceived OMT/OPP preparation at end of the second year of the curriculum vs preparation at graduation, the McNemar test for correlated proportions was used. The P value was set at .05 as the level of statistical significance.
Results
Survey response rates for the WVSOM graduating classes were as follows: 1995, 29.5%; 1996, 55.6%; 1997, 42.2%; 1998, 34.5%; 1999, 65.6%; 2000, 41.3%; 2001, 37.3%; 2002, 49.2%. A total of 53 of 124 alumni from the preintervention classes (1995, 1996) responded, for a return rate of 42.7%. A total of 171 of 379 alumni from the postintervention classes (1997-2002) responded, for a return rate 45.1%. Surveys of one preintervention graduate and 16 postintervention graduates were excluded from subsequent analysis because these alumni were still in residency or fellowship training.
The complete sample size of the preintervention group was 52 (representing 41.9% of surveyed individuals in this group) and that of the postintervention group was 155 (representing 40.9% of surveyed individuals in this group)—for a total combined-group sample size of 207. However, some respondents did not answer all items, so response rates on certain individual items were somewhat lower.
Practice Types of Respondents
The types of practice (general practice, family practice, or other primary care vs other specialty) as self-identified by survey respondents are shown in
Table 2.
Table 2
Survey of WVSOM Alumni: Type of Practice Indicated by Respondents (N=207)
|
Respondents in WVSOM Graduating Classes, No. (%)*
| |
|
|
|---|
Survey Item
| 1995-1996
| 1997-2002
| Total No.
| P Value†
|
|---|
| ▪ 4a. Type of current practice | | | | |
| □ General practice or family practice/other primary care | 35 (67.3) | 107 (69.5) | 142 | .77 |
| □ Other specialty | 17 (32.7) | 47 (30.5) | 64 | |
□ Total No.‡
| 52
| 154
| 206
|
|
Table 2
Survey of WVSOM Alumni: Type of Practice Indicated by Respondents (N=207)
|
Respondents in WVSOM Graduating Classes, No. (%)*
| |
|
|
|---|
Survey Item
| 1995-1996
| 1997-2002
| Total No.
| P Value†
|
|---|
| ▪ 4a. Type of current practice | | | | |
| □ General practice or family practice/other primary care | 35 (67.3) | 107 (69.5) | 142 | .77 |
| □ Other specialty | 17 (32.7) | 47 (30.5) | 64 | |
□ Total No.‡
| 52
| 154
| 206
|
|
×
Statistically significant differences were not found in type of practice between alumni in the preintervention group, with 35 (67.3%) respondents in primary care, and alumni in the postintervention group, with 107 (69.5%) respondents in primary care.
Perceived Preparation in OMT/OPP
Results of how well prepared alumni believed they were “to diagnose and treat a patient regarding OMT/OPP,” both as second-year osteopathic medical students and as graduates, are shown in
Table 3.
Table 3
Survey of WVSOM Alumni: Perception of OMT/OPP Preparation During School (N=207)
|
Respondents in WVSOM Graduating Classes, No. (%)*
| |
|
|
|---|
Survey Item
| 1995-1996
| 1997-2002
| Total No.
| P Value
|
|---|
| ▪ 1a. At the end of your sophomore year, how well prepared were you to diagnose and treat a patient regarding OMT/OPP? | | | | |
| □ Very well prepared/well prepared | 45 (86.5) | 147 (94.8) | 192 | .062† |
| □ Not well prepared/very badly prepared | 7 (13.5) | 8 (5.2) | 15 | |
| □ Total No. | 52 | 155 | 207 | |
| ▪ 1b. Overall, by graduation, did you feel that you were adequately prepared to diagnose and treat a patient regarding OMT/OPP? | | | | |
| □ Very well prepared/well prepared | 36 (69.2) | 120 (78.4) | 156 | .179‡ |
| □ Not well prepared/very badly prepared | 16 (30.8) | 33 (21.6) | 49 | |
| □ Total No.§ | 52 | 153 | 205 | |
Table 3
Survey of WVSOM Alumni: Perception of OMT/OPP Preparation During School (N=207)
|
Respondents in WVSOM Graduating Classes, No. (%)*
| |
|
|
|---|
Survey Item
| 1995-1996
| 1997-2002
| Total No.
| P Value
|
|---|
| ▪ 1a. At the end of your sophomore year, how well prepared were you to diagnose and treat a patient regarding OMT/OPP? | | | | |
| □ Very well prepared/well prepared | 45 (86.5) | 147 (94.8) | 192 | .062† |
| □ Not well prepared/very badly prepared | 7 (13.5) | 8 (5.2) | 15 | |
| □ Total No. | 52 | 155 | 207 | |
| ▪ 1b. Overall, by graduation, did you feel that you were adequately prepared to diagnose and treat a patient regarding OMT/OPP? | | | | |
| □ Very well prepared/well prepared | 36 (69.2) | 120 (78.4) | 156 | .179‡ |
| □ Not well prepared/very badly prepared | 16 (30.8) | 33 (21.6) | 49 | |
| □ Total No.§ | 52 | 153 | 205 | |
×
The data indicate that 45 (86.5%) responding alumni in the preintervention group rated themselves as “very well prepared” or “well prepared” in OMT/OPP at the end of their second year at WVSOM, compared with 147 (94.8%) responding alumni in the postintervention group. This difference was not statistically significant.
For the survey item asking about overall OMT/OPP preparation by the time of graduation, 36 (69.2%) responding alumni in the preintervention group, and 120 (78.4%) responding alumni in the postintervention group, rated themselves as prepared. Again, this difference was not statistically significant.
Perceived Classroom and Laboratory Exposure to Osteopathic Philosophy
Table 4 shows alumni responses to the survey question about their perceptions of “classroom [and laboratory] exposure to osteopathic philosophy.”
Table 4
Survey of WVSOM Alumni: Perception of Exposure to Osteopathic Philosophy in Classroom and Laboratory Instruction (N=207)
|
Respondents in WVSOM Graduating Classes, No. (%)*
| |
|
|
|---|
Survey Item
| 1995-1996
| 1997-2002
| Total No.
| P Value†
|
|---|
| ▪ 2a. Classroom/lab exposure to osteopathic philosophy was provided by: | | | | |
| □ Basic sciences faculty | | | | |
| — All/almost all/most professors | 36 (69.2) | 127 (84.1) | 163 | .020 |
| — Few/no professors | 16 (30.8) | 24 (15.9) | 40 | |
| — Total No.‡ | 52 | 151 | 203 | |
| □ Clinical sciences faculty | | | | |
| — All/almost all/most professors | 41 (80.4) | 133 (88.1) | 174 | .170 |
| — Few/no professors | 10 (19.6) | 18 (11.9) | 28 | |
— Total No.‡
| 51
| 151
| 202
|
|
Table 4
Survey of WVSOM Alumni: Perception of Exposure to Osteopathic Philosophy in Classroom and Laboratory Instruction (N=207)
|
Respondents in WVSOM Graduating Classes, No. (%)*
| |
|
|
|---|
Survey Item
| 1995-1996
| 1997-2002
| Total No.
| P Value†
|
|---|
| ▪ 2a. Classroom/lab exposure to osteopathic philosophy was provided by: | | | | |
| □ Basic sciences faculty | | | | |
| — All/almost all/most professors | 36 (69.2) | 127 (84.1) | 163 | .020 |
| — Few/no professors | 16 (30.8) | 24 (15.9) | 40 | |
| — Total No.‡ | 52 | 151 | 203 | |
| □ Clinical sciences faculty | | | | |
| — All/almost all/most professors | 41 (80.4) | 133 (88.1) | 174 | .170 |
| — Few/no professors | 10 (19.6) | 18 (11.9) | 28 | |
— Total No.‡
| 51
| 151
| 202
|
|
×
A significantly higher proportion of responding alumni in the postintervention group (127 [84.1%]) than in the preintervention group (36 [69.2%]) indicated that exposure to osteopathic philosophy was provided by all, almost all, or most of their basic sciences professors (P=.020, based on χ2 test).
For the survey item asking about exposure to osteopathic philosophy by all, almost all, or most clinical sciences faculty, 41 (80.4%) respondents in the preintervention group vs 133 (88.1%) respondents in the postintervention group indicated that they had received such exposure. This difference was not statistically significant.
Perceived Teaching of OMT in the Classroom
Table 5 shows alumni responses to the survey question about their perceptions of classroom instruction by basic sciences and clinical sciences faculty in integrating OMT into practice.
Table 5
Survey of WVSOM Alumni: Perception of OMT Integration Into Classroom and Laboratory Teaching (N=207)
|
Respondents in WVSOM Graduating Classes, No. (%)*
| |
|
|
|---|
Survey Item
| 1995-1996
| 1997-2002
| Total No.
| P Value†
|
|---|
| ▪ 2b. Classroom instruction/assistance in integration of OMT into practice was provided by: | | | | |
| □ Basic sciences faculty | | | | |
| — All/almost all/most professors | 27 (52.9) | 107 (70.9) | 134 | .019 |
| — Few/no professors | 24 (47.1) | 44 (29.1) | 68 | |
| — Total No.‡ | 51 | 151 | 202 | |
| □ Clinical sciences faculty | | | | |
| — All/almost all/most professors | 40 (78.4) | 127 (84.7) | 167 | .305 |
| — Few/no professors | 11 (21.6) | 23 (15.3) | 34 | |
| — Total No.‡ | 51 | 150 | 201 | |
Table 5
Survey of WVSOM Alumni: Perception of OMT Integration Into Classroom and Laboratory Teaching (N=207)
|
Respondents in WVSOM Graduating Classes, No. (%)*
| |
|
|
|---|
Survey Item
| 1995-1996
| 1997-2002
| Total No.
| P Value†
|
|---|
| ▪ 2b. Classroom instruction/assistance in integration of OMT into practice was provided by: | | | | |
| □ Basic sciences faculty | | | | |
| — All/almost all/most professors | 27 (52.9) | 107 (70.9) | 134 | .019 |
| — Few/no professors | 24 (47.1) | 44 (29.1) | 68 | |
| — Total No.‡ | 51 | 151 | 202 | |
| □ Clinical sciences faculty | | | | |
| — All/almost all/most professors | 40 (78.4) | 127 (84.7) | 167 | .305 |
| — Few/no professors | 11 (21.6) | 23 (15.3) | 34 | |
| — Total No.‡ | 51 | 150 | 201 | |
×
A statistically significant improvement was found in the proportion of respondents in the postintervention group (107 [70.9%]) who indicated that they received such OMT instruction from basic sciences faculty, compared with respondents in the preintervention group (27 [52.9%]) (P=.019, based on χ2 test).
For the corresponding survey item on OMT teaching by clinical sciences faculty, differences between the preintervention group (40 [78.4%]) and the postintervention group (127 [84.7%]) were not statistically significant.
Perceived Teaching of Osteopathic Philosophy and OMT in Rotations
Results of alumni responses to the survey item about exposure to osteopathic philosophy and OMT during clinical rotations with osteopathic physicians are shown in
Table 6.
Table 6
Survey of WVSOM Alumni: Perception of Clinical Years/Rotations with DOs (N=207)
|
Respondents in WVSOM Graduating Classes, No. (%)*
| |
|
|
|---|
Survey Item
| 1995-1996
| 1997-2002
| Total No.
| P Value†
|
|---|
| ▪ 3a. For rotations with DOs, exposure to osteopathic philosophy was provided by: | | | | |
| □ All/almost all/most DO rotations | 23 (45.1) | 96 (62.3) | 119 | .031 |
| □ Few/no DO rotations | 28 (54.9) | 58 (37.7) | 86 | |
| □ Total No.‡ | 51 | 154 | 205 | |
| ▪ 3b. Instruction/assistance in integration of OMT into practice was provided by: | | | | |
| □ All/almost all/most DO rotations | 16 (30.8) | 60 (39.0) | 76 | .290 |
| □ Few/no DO rotations | 36 (69.2) | 94 (61.0) | 130 | |
| □ Total No.‡ | 52 | 154 | 206 | |
Table 6
Survey of WVSOM Alumni: Perception of Clinical Years/Rotations with DOs (N=207)
|
Respondents in WVSOM Graduating Classes, No. (%)*
| |
|
|
|---|
Survey Item
| 1995-1996
| 1997-2002
| Total No.
| P Value†
|
|---|
| ▪ 3a. For rotations with DOs, exposure to osteopathic philosophy was provided by: | | | | |
| □ All/almost all/most DO rotations | 23 (45.1) | 96 (62.3) | 119 | .031 |
| □ Few/no DO rotations | 28 (54.9) | 58 (37.7) | 86 | |
| □ Total No.‡ | 51 | 154 | 205 | |
| ▪ 3b. Instruction/assistance in integration of OMT into practice was provided by: | | | | |
| □ All/almost all/most DO rotations | 16 (30.8) | 60 (39.0) | 76 | .290 |
| □ Few/no DO rotations | 36 (69.2) | 94 (61.0) | 130 | |
| □ Total No.‡ | 52 | 154 | 206 | |
×
A significantly higher proportion of alumni in the postintervention group (96 [62.3%]) than in the preintervention group (23 [45.1%]) indicated that they had received “exposure to osteopathic philosophy” in all, almost all, or most clinical rotations with DOs (P=.031, based on χ2 test).
No significant difference was found between proportions of alumni in the preintervention group (16 [30.8%]) and the postintervention group (60 [39.0%]) regarding the extent to which they indicated that “instruction/assistance in integration of OMT into practice” was provided by all, almost all, or most DO rotations.
Use of OMT by Alumni in Practice
Survey results comparing the proportion of alumni who reported daily use of OMT in their clinical practices with the proportion of alumni who reported that they did not use OMT daily are shown in
Table 7.
Table 7
Survey of WVSOM Alumni: Summary of Graduates' Use of OMT (N=207)
|
Respondents in WVSOM Graduating Classes, No. (%)*
| |
|
|
|---|
Survey Item
| 1995-1996
| 1997-2002
| Total No.
| P Value†
|
|---|
| ▪ 4c. Approximate number [of patients seen] each day on whom OMT is performed | | | | |
| □ Use OMT daily | 27 (52.9) | 74 (52.5) | 101 | .955 |
| □ Don't use OMT daily | 24 (47.1) | 67 (47.5) | 91 | |
| □ Total No.‡ | 51 | 141 | 192 | |
Table 7
Survey of WVSOM Alumni: Summary of Graduates' Use of OMT (N=207)
|
Respondents in WVSOM Graduating Classes, No. (%)*
| |
|
|
|---|
Survey Item
| 1995-1996
| 1997-2002
| Total No.
| P Value†
|
|---|
| ▪ 4c. Approximate number [of patients seen] each day on whom OMT is performed | | | | |
| □ Use OMT daily | 27 (52.9) | 74 (52.5) | 101 | .955 |
| □ Don't use OMT daily | 24 (47.1) | 67 (47.5) | 91 | |
| □ Total No.‡ | 51 | 141 | 192 | |
×
In the preintervention group, 27 (52.9%) responding alumni reported using OMT with at least one patient per day. In the postintervention group, 74 (52.5%) respondents reported using OMT with at least one patient per day. This difference in OMT use was not statistically significant.
Comparison of Perceived OMT/OPP Preparation at End of Second Year and at Graduation
Additional analysis was used to examine whether a statistically significant difference existed between the proportion of graduates rating themselves as “very well prepared” or “well prepared” to diagnose and treat a patient regarding OMT/OPP at the end of the second year of the WVSOM curriculum compared with those giving themselves such a rating at time of graduation (
Table 8). Because no statistically significant differences were found in such ratings in comparisons of alumni in the preintervention group vs the postintervention group (
Table 3), all responding alumni from all classes were combined in a single analysis to generate the data in
Table 8.
Table 8
Survey of WVSOM Alumni: Comparison of Perceived OMT/OPP Preparation at End of Second Year of Curriculum and at Graduation, All Classes (1995-2002) Combined, No. (%) (N=207)
|
1b. Overall, by graduation, did you feel that you were adequately prepared to diagnose and treat a patient regarding OMT/OPP
| |
|
|
|---|
Survey Item
| Very well prepared/well prepared
| Not well prepared/very badly prepared
| Total
| P Value*
|
|---|
| ▪ 1a. At the end of your sophomore year, how well prepared were you to diagnose and treat a patient regarding OMT/OPP? | | | | |
| □ Very well prepared/well prepared | 154 (98.7) | 36 (73.5) | 190 (92.7) | .001† |
| □ Not well prepared/very badly prepared | 2 (1.3) | 13 (26.5) | 15 (7.3) | |
| □ Total† | 156 (76.1) | 49 (23.9) | 205 | |
Table 8
Survey of WVSOM Alumni: Comparison of Perceived OMT/OPP Preparation at End of Second Year of Curriculum and at Graduation, All Classes (1995-2002) Combined, No. (%) (N=207)
|
1b. Overall, by graduation, did you feel that you were adequately prepared to diagnose and treat a patient regarding OMT/OPP
| |
|
|
|---|
Survey Item
| Very well prepared/well prepared
| Not well prepared/very badly prepared
| Total
| P Value*
|
|---|
| ▪ 1a. At the end of your sophomore year, how well prepared were you to diagnose and treat a patient regarding OMT/OPP? | | | | |
| □ Very well prepared/well prepared | 154 (98.7) | 36 (73.5) | 190 (92.7) | .001† |
| □ Not well prepared/very badly prepared | 2 (1.3) | 13 (26.5) | 15 (7.3) | |
| □ Total† | 156 (76.1) | 49 (23.9) | 205 | |
×
This analysis, based on the McNemar test for correlated proportions, revealed that significantly more alumni rated themselves as prepared regarding OMT/OPP at the end of the second year of the curriculum (190 [92.7%]) than at the time of graduation (156 [76.1%]) (P<.001). Therefore, these results suggest that rather than feeling that they had become more confident in their OMT/OPP skills after their clinical years, alumni felt they had become less confident.
Comment
Osteopathic manipulative treatment is one of the hallmarks of the osteopathic physician. Because the use of OMT grows out of an understanding and adoption of osteopathic philosophy, imbuing osteopathic medical students, interns, and residents with OPP philosophy and OMT skills during their training will not only enhance the care they provide to their future patients, but is crucial to the future of the osteopathic medical profession.
The comprehensive OPP Integration Project initiated in 1992 at WVSOM was designed to create an academic culture at one COM in which each faculty member was expected to support student understanding of osteopathic philosophy from within the context of his or her discipline. In order for this goal to be achieved, extensive faculty education and a network of support for integrative teaching were provided. In addition, the WVSOM curriculum was resequenced and reallocated so that students' understanding of osteopathic philosophy and OMT would be enhanced—without any increase in curricular time.
A leader for WVSOM's OPP Integration Project was identified, and the dean made clear his expectation that each faculty member would be involved in the program. Furthermore, the WVSOM faculty at large was allowed to develop a process and curriculum to meet the agreed-upon goals.
Alumni survey data document success in some important aspects of WVSOM's OPP Integration Project after its first 6 years, through the graduating class of 2002. This success was achieved with substantial changes in WVSOM's curriculum and faculty development, but no changes in the college's admissions process. The OPP Integration Project resulted in statistically significant improvements in alumni perception of classroom and laboratory exposure to osteopathic philosophy from basic sciences faculty and in alumni perception of exposure to classroom instruction and assistance from basic sciences faculty in integration of OMT into practice. The initiative also resulted in statistically significant improvement regarding alumni perception of exposure to osteopathic principles in rotations with DOs.
The OPP Integration Project did not lead to significant improvement in alumni perception of teaching of osteopathic philosophy or OMT by clinical sciences faculty. Nevertheless, more than three-fourths of all responding alumni indicated that all, almost all, or most clinical sciences professors included instruction of osteopathic philosophy and OMT into their teaching at WVSOM.
In the survey reported in the present study, WVSOM alumni were asked about their daily use of OMT in clinical practice. Although there are no studies in the literature to which our data on this matter can be directly compared, the present study's reported daily use of OMT by approximately 53% of graduates in both the preintervention and postintervention groups appears to be counter to the national trend toward decreasing usage of OMT in osteopathic practice.
12,18-22 While we did not find that WVSOM's OPP Integration Project caused an increase in graduates' daily use of OMT, the baseline daily use of OMT by more than 50% of all WVSOM graduates—and the lack of decrease in OMT use by graduates over time—may indicate that some aspect of the WVSOM educational continuum makes WVSOM graduates more likely to integrate OMT into the care of their patients.
Alumni expressed a statistically significant loss of confidence in their ability to diagnose and treat patients using OMT/OPP between the second year of the curriculum and graduation. However, the vast majority (92.7%) of survey respondents entered their clinical training years confident in their OMT/OPP abilities, and 76.1% of respondents remained confident in their OMT/OPP abilities at the time of graduation. The reduction in alumni self-evaluation of their preparedness in OMT from the second year of the curriculum to graduation may reflect the difficulty most COMs encounter in continuing to foster OPP education in the third and fourth years. This issue has been extensively addressed for the second 6 years of the OPP Integration Project.
In 2002, WVSOM began to develop a statewide campus system for coordination of student education during the third and fourth years of the curriculum. As a part of this system, substantial increases in OPP integration have been implemented during the clinical training years, including extensive faculty development for preceptors and more curricular emphasis on osteopathic manipulative medicine. In addition, WVSOM has strengthened teaching regarding OPP at affiliated graduate medical education sites—a step that could potentially increase confidence in OMT and OPP abilities as graduates enter clinical practice.
As with all studies based on survey data, the present study has the limitation of accepting respondents' reports of their attitudes and behaviors, rather than directly observing the performance of respondents. The study also has limitations associated with having a response rate of less than 100%, as well as possible selection bias by those responding to the survey. However, the same limitations apply to alumni from both the preintervention and postintervention classes, thereby canceling out any potential bias. Until a strategy is developed for obtaining actual medical records of WVSOM alumni, surveys of the alumni may be one of the better mechanisms available for monitoring their perceptions, attitudes, and behaviors.
In future surveys of WVSOM alumni, we hope to be able to compare our data on rates of OMT use with data on OMT use obtained by other authors in regard to various interventions. Future WVSOM alumni surveys will also be used to determine if the OPP Integration Project eventually results in improved confidence in OMT/OPP preparation at graduation and in clinical practice.
Conclusion
The OPP Integration Project at WVSOM was undertaken with clear goals and a long-term perspective: to create a clearly distinct osteopathic curriculum and to preserve the use of OMT by graduates. Comparisons of alumni survey data from graduates before the implementation of the initiative with graduates of the first six classes after implementation of the initiative reveal statistically significant improvements in alumni evaluation of the osteopathic distinctiveness of some aspects of the WVSOM curriculum. In addition, no decrease in graduate use of OMT in practice has occurred over time—with approximately 53% of graduates reporting daily use of OMT in clinical practice. Although a statistically significant decline in survey respondent confidence in OMT and OPP preparation was observed between the end of the second year of the curriculum and graduation, 92.7% of respondents entered their clinical training years confident in their OMT and OPP skills, and more than three-fourths of respondents remained confident at graduation.
The WVSOM's OPP Integration Project is successful at meeting its objectives of creating a clearly distinct osteopathic curriculum and of maintaining OMT use among WVSOM graduates. Future surveys of WVSOM alumni will determine if gains observed in the first 6 years of the OPP Integration Project will continue, and if additional gains will be realized based on the continued maturation and development of the OPP Integration Project.
Copies of the survey instrument are available upon request.
We would like to extend our appreciation to the following individuals who provided support for portions of this project: L. Scott Dean, PhD, MBA, for statistical analysis of the data; Edward Bridges, PhD, for providing careful review of and invaluable suggestions to drafts; and the following individuals who compiled surveys and entered data while serving as WVSOM work-study students: Eric McClanahan, DO; Linda Wilson, DO; Misty Shoemaker, DO, and Amanda Young, OMS II. We would also like to thank WVSOM's graduates for providing helpful feedback to improve the project during its implementation and for participation in surveys. Finally, we thank both past and current WVSOM faculty and administration who worked hard to make the OPP Integration Project a reality.
Korr IM. What `osteopathic medicine' and the `osteopathic concept' mean to me [reprint from 1962]. J Am Osteopath Assoc. 1995;95;706 .
Korr IM. Some thoughts on an osteopathic curriculum. J Am Osteopath Assoc. 1975;74:685-688.
Ward RC. Osteopathic theory: a strategy for curriculum integration. JAm Osteopath Assoc. 1977;76:414-422.
Radis C. Osteopathic education: a student perspective. Osteopath Ann. 1981;9(12):32-36.
Eckberg DL. The dilemma of osteopathic physicians and the rationalization of medical practice. Soc Sci Med. 1987;25:1111-1120.
Miller K. The Use of Osteopathic Principles and Practice: A Study of Osteopathic Medical Students. Final Report. Grant S90-93, September 1992; Arizona State University.
Kasovac M, Jones JM III. Integrate osteopathic principles and practices in postgraduate medical education—now. J Am Osteopath Assoc. 1993;93:118-125.
Gevitz N. `Parallel and distinctive': the philosophic pathway for reform in osteopathic medical education.
J Am Osteopath Assoc. 1994;94:328-332.
http://www.jaoa.org/cgi/reprint/94/4/328. Accessed September 5, 2009.
Nemon BM. Osteopathic medical profession: who are we & where are we going? A student perspective. Am Acad Osteopath J. 1997;7(1):10-15,30-34.
Johnson SM, Kurtz ME, Kurtz JC. Variables influencing the use of osteopathic manipulative treatment in family practice. J Am Osteopath Assoc. 1997;97:80-87.
Johnson SM, Bordinat D. Professional identity: key to the future of the osteopathic medical profession in the United States. J Am Osteopath Assoc. 1998;98:325-331.
Johnson SM, Kurtz ME. Diminished use of osteopathic manipulative treatment and its impact on the uniqueness of the osteopathic profession. Acad Med. 2001;76:821-828.
Shlapentokh V, O'Donnell N, Grey MB. Osteopathic interns' attitudes toward their education and training. J Am Osteopath Assoc. 1991;91:786-802.
Chamberlain NR, Yates HA. A prospective study of osteopathic medical students' attitudes toward use of osteopathic manipulative treatment in caring for patients.
J Am Osteopath Assoc. 2003;103:470-478.
http://www.jaoa.org/cgi/reprint/103/10/470. Accessed September 5, 2009.
Allee BA, Pollak MH, Malnar KF. Survey of osteopathic and allopathic residents' attitudes toward osteopathic manipulative treatment.
J Am Osteopath Assoc. 2005;105:551-561.
http://www.jaoa.org/cgi/content/full/105/12/551. Accessed September 5, 2009.
Western University of Health Sciences College of Osteopathic Medicine of the Pacific. Alumni survey determines OMT use in practice. CompView. Summer1993;XIII(2).
Fry LJ. Preliminary findings on the use of osteopathic manipulative treatment by osteopathic physicians. J Am Osteopath Assoc. 1996;96:91-96.
Aguwa MI, Liechty DK. Professional identification and affiliation of the 1992 graduate class of the colleges of osteopathic medicine. J Am Osteopath Assoc. 1999;99:408-420.
Spaeth DG, Pheley AM. Evaluation of osteopathic manipulative treatment training by practicing physicians in Ohio.
J Am Osteopath Assoc. 2002;102:145-150.
http://www.jaoa.org/cgi/reprint/102/3/145. Accessed September 5, 2009.
Spaeth DG, Pheley AM. Use of osteopathic manipulative treatment by Ohio osteopathic physicians in various specialties.
J Am Osteopath Assoc. 2003:103;16-26.
http://www.jaoa.org/cgi/reprint/103/1/16. Accessed September 5, 2009.
Gamber RG, Kennedy DA, Erickson RC, Moss JA, Hart CM, Zengerle C, et al. Osteopathic manipulative treatment: practice use and opinions of the Texas College of Osteopathic Medicine alumni. Am Acad Osteopath J 1997;7(3):17-19,27.
Johnson SM, Kurtz ME. Conditions and diagnoses for which osteopathic primary care physicians and specialists use osteopathic manipulative treatment.
J Am Osteopath Assoc. 2002;102:527-540.
http://www.jaoa.org/cgi/reprint/102/10/527. Accessed September 5, 2009.
Johnson SM, Kurtz ME. Osteopathic manipulative treatment techniques preferred by contemporary osteopathic physicians.
J Am Osteopath Assoc. 2003;103:219-224.
http://www.jaoa.org/cgi/reprint/103/5/219. Accessed September 5, 2009.
Ray AM, Cohen JE, Buser BR. Osteopathic emergency physician training and use of osteopathic manipulative treatment.
J Am Osteopath Assoc. 2004;104:15-21.
http://www.jaoa.org/cgi/reprint/104/1/15. Accessed September 5, 2009.
Sun C, Desai GJ, Pucci DS, Jew S. Musculoskeletal disorders: does the osteopathic medical profession demonstrate its unique and distinctive characteristics?
J Am Osteopath Assoc. 2004;104:149-155.
http://www.jaoa.org/cgi/content/full/104/4/149. Accessed September 5, 2009.
Mason DC, McElrath S, Penn-Erskine C, Kramer-Feeley V, Pomerantz SC, Cavalieri TA. Practice patterns of osteopathic physicians providing end-of-life care: a survey-based study.
J Am Osteopath Assoc. 2008;108:240-250.
http://www.jaoa.org/cgi/content/full/108/5/240. Accessed September 5, 2009.
Licciardone JC, Nelson KE, Glonek T, Sleszynski SL, Cruser dA. Osteopathic manipulative treatment of somatic dysfunction among patients in the family practice setting: a retrospective analysis.
J Am Osteopath Assoc. 2005;105;537-544.
http://www.jaoa.org/cgi/content/full/105/12/537. Accessed September 5, 2009.
Magnus WW, Gamber RG. Osteopathic manipulative treatment: student attitudes before and after intensive clinical exposure. J Am Osteopath Assoc. 1997;97:109-113.
Danto JB, Kavieff TR. Making a difference: the osteopathic approach lecture series. J Am Osteopath Assoc. 1999;99:168-172.
Shubrook JH Jr, Dooley J. Effects of a structured curriculum in osteopathic manipulative treatment (OMT) on osteopathic structural examinations and use of OMT for hospitalized patients.
J Am Osteopath Assoc. 2000;100:554-558.
http://www.jaoa.org/cgi/reprint/100/9/554. Accessed September 5, 2009.
Chamberlain NR, Yates HA. Use of a computer-assisted clinical case (CACC) SOAP note exercise to assess students' application of osteopathic principles and practice.
J Am Osteopath Assoc. 2000;100;437-440.
http://www.jaoa.org/cgi/reprint/100/7/437. Accessed September 5, 2009.
Mann DD, Eland DC, Patriquin DA, Johnson DF. Increasing osteopathic manipulative treatment skills and confidence through mastery learning. J Am Osteopath Assoc. 2000;100:301-308.
Gamber RG, Gish EE, Herron KM. Student perceptions of osteopathic manipulative treatment after completing a manipulative medicine rotation.
J Am Osteopath Assoc. 2001;101:395-401.
http://www.jaoa.org/cgi/reprint/101/7/395. Accessed September 5, 2009.
Lockwood M, Snider E, Chipman M. Retrospective study of a peer assessment education encounter in the development of osteopathic clinical skills. Am Acad Osteopath J. 2008;18(4):12-17.
Educational Council on Osteopathic Principles, Project on Osteopathic Principles Education. Core Curriculum for Osteopathic Education, Part I. Chevy Chase, MD: American Association of Colleges of Osteopathic Medicine; 1987.
Sublette G, TenBrink TD, Leonard BC. 1986-87 AACOM FOCUS Grant Report on “Implementation Strategies for Integrating Osteopathic Philosophy, Principles, and Practices into Osteopathic Instruction.” Kirksville, MO: Kirksville College of Osteopathic Medicine; 1987.
Steele KM; Ad-Hoc Committee on Integration of OP&P into the WVSOM Curriculum.
Committee on OP&P Integration Into the Entire WVSOM Predoctoral Curriculum Recommendations. Lewisburg: West Virginia School of Osteopathic Medicine; 1993.
http://www.wvsom.edu/_pdf/OPPIntegDoc93.pdf. Accessed September 5, 2009.
Steele KM, Baker HH, Boxwell GF, Steele-Killeen S. Community-based osteopathic manipulative medicine student clinic: changes in curriculum and student confidence levels.
J Am Osteopath Assoc. 2005:105;503-513.
http://www.jaoa.org/cgi/reprint/105/11/503. Accessed September 5, 2009.
Lemley WW, Steele KM, Shires WE, McMahan RM. Evolution of osteopathic graduate medical education: integration of osteopathic principles and practice in postdoctoral training.
J Am Osteopath Assoc. 2007:107;495-501.
http://www.jaoa.org/cgi/reprint/107/11/495. Accessed September 5, 2009.
Jackson KM, Steele TF, Dugan EP, Kukulka G, Blue W, Roberts A. Effect of lymphatic and splenic pump techniques on the antibody response to hepatitis B vaccine: a pilot study. J Am Osteopath Assoc. 1998;98:155-160.
Jackson KM, Steele KM. Osteopathic treatment of asthma: a literature review and call for research. Am Acad Osteopath J. 1999;9(4):23-27.
Dugan EP, Lemley WW, Roberts CA, Wager M, Jackson KM. Effect of lymphatic pump techniques on the immune response to influenza vaccine [abstract]. J Am Osteopath Assoc. 2001;101: 472. P02.