In 2006, definitions of dual and parallel programs were added to the Accreditation Document for Osteopathic Postdoctoral Training Institutions and the Basic Document for Osteopathic Postdoctoral Training⁴ glossary of terms, as follows: 

A key difference between dual and parallel residency programs is that trainees who complete dual programs have the option to become board certified by the AOA, the American Board of Medical Specialties (ABMS), or both, while trainees who complete parallel programs are eligible to become AOA board certified only. 

Other differences exist in how the training programs are structured. Trainees in dual and parallel residency programs must follow guidelines and requirements identified by the AOA.⁴ In dual programs, osteopathic residents are fully integrated in training with allopathic residents. Parallel programs can be fully integrated (similar to dual programs) or may operate partially or completely independent of the allopathic program. The trainees may work side-by-side with their allopathic counterparts, but they have their own didactic programs, different rotations, and fewer interactions with allopathic residents and faculty within the hospital. 

The statistics provided for dual and parallel programs in the following sections are based primarily on data provided through the AOA Trainee Information, Verification, and Registration Audit (TIVRA) reporting system. As stated elsewhere,⁵ data on programs, number of trainees, and approved positions may change throughout the year as a result of decisions and actions of the AOA Council on Osteopathic Postdoctoral Training and the Program and Trainee Review Council. 

There has been unprecedented growth during the past 3 years in the number of ACGME training programs seeking dual AOA/ACGME programs and positions. For the 2008-2009 academic year, as of December 2008, there are 150 approved dual programs with 1716 approved positions. Of the 150 programs, 146 are actively training DO residents with 1692 active positions (ie, trainees are or were training in the program). The number of filled positions in 2009 are not yet available. 

By contrast, there were only 90 approved training programs in the 2005-2006 academic year, of which only 57 were active (Table 1). Of the 936 approved positions in the 2005-2006 academic year, 649 approved positions were in active programs, but only 272 training slots were filled with osteopathic trainees. However, in the 2005-2006 academic year, most of the nonactive programs had been newly approved and would become active the next academic year. 

Many osteopathic medical specialties have approved dual programs, as listed in Table 1. Few specialties (ie, forensic pathology, preventive medicine and public health, and general surgery) offer only parallel programs, as described in the next section. 

Family practice sought approval for the greatest number of dual programs and positions (90 and 1011, respectively) followed by internal medicine (26 and 321) and pediatrics (14 and 186). 

The number of dual programs has had the most rapid growth during the past 10 years (Table 2). Before 2000, a total of 36 dual programs were established. From 1990 to 1999, an additional 30 new dual programs were approved, averaging 3 new programs per year. From 2000 to 2008, 119 new dual programs were approved, averaging 13 per year. Therefore, 77% of all new dual programs were developed and approved during the past 9 years. 

Dual programs have been advantageous to both the AOA and the ACGME. Primary care ACGME programs, particularly family medicine, have not been successfully filling with allopathic seniors from US allopathic medical schools. In 2008, the National Resident Matching Program (NRMP)⁶ reported that 90.6% of ACGME family medicine training positions had filled through the NRMP Match, but only 44% of the available positions were filled with current US allopathic medical school graduates. The remaining 47% of the positions filled with international medical graduates (IMGs) that were non-US citizens (19%), IMGs that were US citizens (15%), osteopathic medical students (10%), and previous allopathic graduates (3%). The remaining 9% of available positions may have matched through post-Match activity, but these data are not published. 

Another percentage of osteopathic medical graduates and IMGs have entered ACGME programs by signing contracts outside of the NRMP Match. This practice is prohibited by both the AOA and ACGME for their own graduates,^7,8 yet the NRMP has defended its position to allow osteopathic and IMG students to continue signing such contracts (NRMP, written communication, May 2006). 

Dual programs are attractive to many osteopathic medical students. A 2005 survey-based study⁹ reported that senior osteopathic medical students who preferred dual accreditation did so because such programs “would allow board certification by ABMS-recognized boards” (43%), “would offer better educational opportunities” (39%), and “would offer more specialties” (34%). There is no empirical data or research to demonstrate that the quality of ACGME programs is better, but because more ACGME programs exist, there is greater access to specialties that are unfilled. 

The first parallel program was introduced in 1958. However, parallel programs did not gain ground until the 1990s, when the growth of parallel programs built gradually from 1996 through 2005. Since then, only 1 new program has opened (Table 3). 

In 2006, there were 19 approved parallel training programs with 149 approved positions. Of these programs, only 11 were active with 42 trainees at that time. By comparison, in 2009 there are only 5 programs with 37 approved positions. However, only 3 of these parallel programs are active with 19 trainees. 

Family practice and internal medicine had the highest number of positions (29 each) in parallel programs in 2006. Obstetrics and gynecology had 18 positions, followed by orthopedic surgery with 16 positions. Today, there are only 12 parallel positions in family practice, 11 in internal medicine, 10 in general surgery, 3 in preventative medicine and public health, and 1 in forensic pathology. Obstetrics and gynecology and orthopedic surgery have no parallel positions in 2009. 

Many parallel programs have closed as a result of financial considerations, while others became dual programs. Clearly, parallel programs are not gaining popularity with students or institutions. 

Compared with specialties' traditional training programs in the 2007-2008 academic year, fill rates are higher in dual programs for neurology, obstetrics and gynecology, internal medicine/pediatrics, pediatrics, physical medicine and rehabilitation, psychiatry, and sports medicine (Table 4). The difference is substantially higher in internal medicine/pediatrics, neurology, physical medicine and rehabilitation, psychiatry, and sports medicine. In the aggregate, however, the fill rate for dual programs is 37% compared to a 44% fill rate in traditional programs. 

The most concerning aspect of AOA/ACGME dual programs is that the number of designated AOA slots may be reduced or dropped, therefore reducing the total number of available AOA training slots in the future. This concern is particularly relevant for dual programs in primary care specialties. 

Osteopathic trainees who complete residency training in dual programs have the following four options for board certification: 

The osteopathic medical profession hopes physicians who complete AOA/ACGME dual training will elect to maintain their connection to the profession by becoming board certified by the AOA or the AOA and the ABMS. 

Between January 2000 and April 2006, 545 residents completed training in dual programs. Of those osteopathic physicians (DOs), 230 (42%) elected to become exclusively AOA board certified in their specialty, and 127 (23%) elected to become board certified by both the AOA and the ABMS. Thus, a total of 357 DOs (66%) from dual programs became AOA board certified. However, 150 (28%) became exclusively ABMS board certified. The remaining 38 DOs (7%) had not yet received board certification. 

Between January 2000 and July 2008, the total number of DOs who completed training in dual programs rose to 837 (Table 5). However, a smaller ratio of these DOs obtained AOA board certification: 333 (40%) elected to become exclusively AOA board certified in their specialty and 159 (19%) became board certified by both the AOA and the ABMS, compared with 42% and 23%, respectively, in 2006. Thus, a total of 492 DOs (59%) from AOA/ACGME dual programs had elected to become AOA board certified, compared to 66% in 2006. As of January 1, 2009, a total of 261 DOs (31%) from dual programs elected to become exclusively ABMS board certified. Sixty-six individuals (8%) have not yet completed the requirements for board certification. Because many DOs in new dual programs have not yet completed their training, the number of DOs electing AOA board certification is expected to increase for this population. 

Although DOs who completed dual programs and elected AOA board certification have not been surveyed yet, such a study could provide meaningful information on the various reasons DOs elect AOA board certification when it is an option. Certainly, AOA certification has advantages. For example, DOs from dual training programs may elect AOA board certification if they plan to become osteopathic program directors, who are required to be AOA board certified.⁴ Alternatively, DOs who elected dual programs over independent ACGME programs may have done so because they were committed to the osteopathic medical profession in the first place, therefore choosing AOA certification over (or in addition to) ABMS certification. 

In addition, internal medicine, one of the more “popular” specialties, requires 80% of graduates (averaged for 3 years) in each AOA-approved program to take the certifying examination of the American Osteopathic Board of Internal Medicine.¹⁰ However, only 39% of trainees who have completed training in internal medicine dual programs are AOA board certified at this time. The American College of Osteopathic Family Physicians has a similar requirement in which 90% of trainees in each program must take the certifying examination within 5 years of training completion.¹¹ 

The various aspects of DOs who complete dual programs will continue to be monitored. It will be particularly important to find if physicians who initially become board certified by both the AOA and ABMS will elect to recertify in one or both. More information will become available after recertification data become available on DOs who have completed dual training. In the meantime, AOA membership among DOs who complete dual programs and elect ABMS board certification only can provide preliminary data. As of December 2008, 92 (35%) of the 261 DOs who are only ABMS board certified in their primary specialty are AOA members. In addition, of the 66 DOs who have not yet sat for board certification, 49 (74%) are AOA members (Table 6). 

The cost of most hospital residency training has been funded through the US Centers for Medicare and Medicaid Services (CMS). One of the many provisions of The Balanced Budget Act of 1997 to reduce government spending was placing “caps” on the number of funded positions in hospitals or institutions with existing residency programs.¹² Training positions—or slots—for AOA/ACGME dual programs were primarily carved out of existing ACGME accredited program positions originally slotted for allopathic residents. 

Hospitals have the flexibility to move slots between specialties and back and forth between the AOA Match and the NRMP. That is, if slots do not fill through the AOA Match, they can be transferred back to the NRMP for allopathic or osteopathic participants. Hospitals or institutions in which no programs exist or those in underserved rural or urban communities can be awarded new funded slots from the CMS. There has been one effort by the CMS to reallocate funded positions to hospitals with demonstrated needs. At present, CMS funding is difficult to obtain, but with physician workforce shortages predicted as early as 2015,¹³ many influential groups have asked the CMS to reconsider its position.^14,15 

As previously described, osteopathic medical students believe the option of becoming board certified in their specialty by the AOA, ABMS, or both is a distinct advantage in selecting dual residency programs.⁹ In addition, the quality of ACGME training programs is perceived to be higher by many students and other members of the osteopathic medical profession.^9,16-18 

Osteopathic students and professionals also perceive that the public believes ACGME training is better or has more status or recognition.⁹ Osteopathic trainees may believe that in training with allopathic physicians, they will gain a higher level of acceptance by allopathic peers and patients.⁹ However, in reality, no evidence exists that ACGME training programs are higher quality. In fact, the AOA has similar processes and systems to the ACGME to ensure the quality of training programs.^4,19 In addition, patients rarely know where their physicians completed training. 

Although it may not be an issue to students during recruitment, an AOA-approved internship is required for DO licensure in five states: Florida, Michigan, Oklahoma, Pennsylvania, and West Virginia. Therefore, graduates will be eligible for licensure if they train in traditional, dual, or parallel AOA-approved training programs. 

As of January 2009, 41% of all dual programs are located in these five states. While this percentage may seem high, 49% of all AOA-approved residency programs are also located in these five states. Pennsylvania has the greatest number of dual programs (19%), followed by Michigan (13%), New York (12%), and Illinois (9%).⁵ 

Graduates of osteopathic medical schools who think they will never be interested in working in any of these states should be aware that more than 2000 graduates have sought approval for ACGME training as an AOA-approved internship through Resolution 42 (A/2000, Approval of ACGME Training as an AOA-Approved Internship). This option is currently the only pathway available to DOs who completed ACGME training programs to become eligible for licensure in those five states. Trainees who complete dual and parallel programs are never limited to where they can practice in the United States throughout their professional careers. 

To hold osteopathic leadership positions (eg, COM deans, directors of medical education, program directors), DOs are required to be AOA board certified.^4,20 Resolutions 42 and 56 are two pathways that provide opportunities for ACGME-trained, ABMS–board certified DOs to become eligible for AOA board certification. Resolution 56 (A\2004), Certification of ABMS–Board Certified DOs, is available to DOs who finished residency at least 5 years before application. Approximately 200 DOs have applied for certification through Resolution 56 in the past 4 years. 

When graduating DOs demonstrated they were well prepared to enter ACGME residencies, allopathic training programs began aggressively—and successfully—recruiting osteopathic medical graduates, particularly in primary care. With the planned 30% increase in enrollment at US allopathic medical schools, causing an additional 5000 student enrollment by 2015,²¹ the osteopathic medical students these programs have welcomed may be maintaining the CMS capped positions for ACGME programs. 

There is some uncertainty regarding how open these programs will be to DOs when US allopathic medical students need positions currently occupied by osteopathic trainees. If this situation occurs, the osteopathic medical profession will need to be prepared for the influx of students that will turn to AOA programs. The Medical Education Summits, which were held in 2006 and 2007 and were co-sponsored by the AOA and American Association of Colleges of Osteopathic Medicine, have been addressing this issue in combination with other workforce concerns.²² 

In the meantime, the osteopathic medical profession has gained a substantial number of CMS-capped training slots through the development of dual and parallel programs. Though the slots are flexible and can be either AOA or ACGME designated slots, AOA positions would have suffered a greater loss if they had not become available at all. Maintaining these osteopathic slots may be challenging if dual programs decide to regain these training positions for US allopathic graduates. 

Many osteopathic leaders believe that osteopathic postdoctoral training is superior to ACGME training for osteopathic medical graduates because they receive continued training and education in osteopathic principles and practices.²³ Dual and parallel programs provide DOs with the opportunity to continue this training and enjoy the advantages they perceive are available from training in recognized AOA/ACGME programs. So far, based on the success of dual programs, it appears to be a winning solution for the profession and many graduates. 

Completion of a parallel program would ensure that trainees continued in the osteopathic medical profession throughout their career. Although AOA board specialties would likely prefer greater development of parallel programs leading exclusively to AOA board eligibility, it appears efforts to develop parallel programs are not going to be a strategy for most institutions, as evidenced by the reduced number of parallel programs in recent years. 

AOA board specialties depend on recruiting new graduates to maintain viability for the specialty. Physicians in each osteopathic specialty volunteer their time to create curricula for the specialty, teach students and trainees, participate in certification examination development, and hold leadership positions in the profession representing the specialty. There are many ACGME-trained osteopathic physicians who contribute to the profession in osteopathic leadership positions. Osteopathic physicians who trained in ACGME programs may apply through Resolution 42 or 56 to become eligible for AOA board certification, which is required to be a program director in most specialties and to participate in a number of leadership positions.^4,20 

An AOA/ACGME dual program can fill its AOA-approved slots and then attain additional DOs through the NRMP Match. Although the program is dually accredited, it does not necessarily mean the DOs are in approved positions and eligible for AOA board certification at the end of training. This can be confusing to DOs in ACGME slots who complete the same program as DOs in approved AOA slots. Unless the program increases its number of approved slots or the trainee is approved by submitting an application for approval through Resolution 42, the trainee will not be able to attain a license in the five states requiring the approved AOA internship. To the benefit of these students, the AOA approved a policy (Resolution 39 [M/2006]—Resolution for Program Approval for Residents Training in a Dual Track Program at the Time of AOA Approval) that if an ACGME program becomes AOA approved, any DO currently in the program is eligible for full AOA approval of their training. 

There are additional costs and responsibilities to programs that are dually accredited through the AOA and ACGME. They must pay required AOA and ACGME fees, become a partner in an Osteopathic Postdoctoral Training Institution (OPTI), and are subject to standards and requirements for maintaining approval of both regulatory bodies. They also have to provide registration data, submit reports, and go through site reviews for both the AOA and ACGME. However, the payoff—the ability to maintain CMS-funded slots, meet hospital staffing needs, and fill slots with preferred US physicians²⁴—has been rewarding for these programs. Unfortunately, if dual programs found they could fill programs with allopathic US seniors, many might cancel their AOA-approved slots. 

While dual programs have benefited the osteopathic medical profession, reliance on the continuation of dual positions could present a risk. If a substantial number of dual programs and positions close to DOs, the profession must be prepared with enough residency training opportunities for its graduates. This would be easier to achieve if CMS funding would become easier to attain. Both the osteopathic and allopathic professions are encouraging CMS to lift caps on funded slots to ensure there will be a sufficient number of physicians in the workforce to provide quality care to patients (Carlo J. DiMarco, written communication, March 2009).^14,15,25