As stated in The Basic Documents for Osteopathic Postdoctoral Training glossary of terms,⁵ the definitions of dual and parallel programs are as follows: 

As stated previously,¹ 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.⁵ 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 are based primarily on data provided through the AOA Trainee Information, Verification, and Registration Audit (TIVRA) reporting system. As stated elsewhere,⁶ data on programs, approved positions, and number of trainees may change throughout the year as a result of decisions and actions of the AOA Council on Osteopathic Postdoctoral Training (COPT) and the Program and Trainee Review Council (PTRC). 

Positions in the osteopathic medical profession are considered approved, funded, or filled. Approved positions are those that have been approved by the PTRC. These positions are not necessarily funded, and hospitals frequently have more approved than funded positions so that they may move them around to meet the needs of the hospital or offer additional slots in one residency over another based on recruitment in a given year. Funded positions are those that have been offered in the AOA Intern/Resident Registration Program (ie, the AOA Match) for first-year trainees. Once the position is filled the AOA considers this position funded throughout the trainees' entire training program and must be reported through the TIVRA system conducted each year by the AOA Department of Education. 

In 2010, growth of dually accredited training programs and positions rose to be approximately 22% of all approved AOA positions compared to 11% in 2006 and 14% in 2008. The majority of dually accredited training programs are ACGME-accredited programs that carved out slots specifically for the osteopathic trainees. Programs accredited by the ACGME that become AOA approved can maximize funding from the Centers for Medicare & Medicaid Services (CMS) by filling training positions with osteopathic physicians. Primary care positions in particular have not been filled to capacity in either AOA or ACGME programs. In their Twentieth Report (December 2010),⁷ the Council on Graduate Medical Education recommended to the US government that the proportion of US primary care physicians should be raised from the current level of 32% to 40%. Primary care training positions have not been competitive with specialty careers in either the AOA Match or the National Residency Matching Program (NRMP). 

Programs approved by the AOA have also become ACGME accredited to be more competitive for slots with both osteopathic physicians (ie, DOs) and allopathic physicians (ie, MDs). There are new programs, in fact, that have become both AOA and ACGME approved or accredited within months of each other. For the 2010-2011 academic year, as of December 2010, there were 170 approved dually accredited programs with 2098 approved positions (Table 1). Of the 170 programs, 162 (95%) are actively training DO residents with 2056 active positions (ie, DO trainees are or were training in the program). At this time, the number of filled positions for the 2010-2011 academic year is 1188; however, that number will change between this writing and May 31, 2011, when the AOA official census is finalized. 

By comparison, in the 2005-2006 academic year, there were only 90 approved training programs, of which 57 (63%) were active. In the 2008-2009 academic year, there were 150 approved training programs, of which 146 (97%) were active (Table 1). 

For the 2010-2011 academic year, the specialty of family practice has been approved for the largest number of dual programs and positions (98 and 1159, respectively) followed by internal medicine (30 and 403) and pediatrics (15 and 206). 

Rapid growth in dual programs during the past 11 years is demonstrated in Table 2. In fact, 79% of all dually accredited training programs were approved since 2000. Before 2000, 36 dual programs were established. From 2000 to 2005, 58 new dual programs were approved, and from 2006 to 2010, 78 new dual programs were approved. In 2005, the AOA Council on Postdoctoral Training (COPT) approved a new concept whereby training institutions could partner as a consortium. For some programs, this consortia formation has resulted in new relationships with previously unaffiliated ACGME programs that are now dually accredited programs. 

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 graduates from US allopathic medical schools. In 2010, the NRMP⁸ reported that 91.4% of ACGME family medicine training positions had filled through the NRMP Match, but only 45% of the available positions were filled with current US MD graduates. The remaining 46% of the positions were filled with international medical graduates (IMGs) that were not US citizens (17%), IMGs that were US citizens (15%), DO graduates (10%), and previous MD graduates (4%).⁸ The remaining 9% of available positions may have matched through post-Match activity, but these data are not published. For the first time in NRMP history, there were more US graduates who were unmatched in 2010 than there were ACGME funded positions available. 

Based on feedback we have received from program directors at COMs, in 2010, a growing 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 for DO students and the NRMP for US MD students.^9,10 NRMP issued a statement on their website they are reviewing this practice in the coming year with potential intent to require all programs to place available slots in the NRMP Match program.² 

Dual programs are attractive to many osteopathic medical students. A 2005 survey-based study¹¹ reported that fourth-year 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 one reason ACGME programs are attractive to many osteopathic medical students is that more ACGME programs exist, providing DO graduates greater access to competitive specialty programs. 

The COPT has undertaken many initiatives to improve the quality of all AOA-approved training programs, which include the implementation of uniform standards following guidelines developed by a workgroup of the Board of Trustees under the chairmanship of Karen J. Nichols, DO, 2010-2011 AOA president. The Education Policy and Procedure Review Committee (EPPRC) III also developed quality initiatives that were approved in January 2011 or will be reviewed with additional information by the AOA Board of Trustees for approval at the July 2011 Annual Meeting in Chicago, Illinois. Using independent reviewers, developing additional resources for informational technology, and providing additional support to stakeholders for curricular development are a few of the pending recommendations that have been developed through EPPRC III. Dual programs will benefit from these initiatives, if approved. 

Growth in parallel programs has been unpredictable. In the 2005-2006 academic year, there were 19 approved parallel training programs with 149 approved positions; in the 2008-2009 academic year, there were 5 parallel programs with 37 approved positions; and in the 2010-2011 academic year, there are 13 programs with 158 approved positions (Table 3). In 2010-2011, surgery has the highest number of programs and positions (3 programs and 50 positions) followed by family practice (2 programs and 27 positions). Emergency medicine, internal medicine, and anesthesiology each has 1 program with 24, 18, and 16 positions, respectively. Like dual programs, growth in parallel programs is partially the result of recent formations of hospital consortia. 

Compared with training programs that are approved by the AOA only (ie, AOA-approved only programs), in the 2009-2010 academic year, fill rates are higher in dual programs for child psychiatry; gastroenterology; hematology and oncology; internal medicine/pediatrics; obstetrics and gynecology; pediatrics; physical medicine and rehabilitation; and psychiatry (Table 4). In the aggregate, however, the fill rate for dual programs is 54% compared to a 60% fill rate in AOA-approved only training programs. Compared with the 2007-2008 academic year, this is an increase for both groups, as aggregated fill rates were 37% for dual programs and 44% for AOA-approved only programs.¹ This increase in programs and fill rates also demonstrates a substantially greater percentage of filled AOA training positions in general. While dual programs have gained popularity, so have AOA-approved only training programs. In 2010, the AOA filled 84.6% of its first year training program slots overall compared to 69.1% in 2006. 

There is a risk to AOA programs that are AOA/ACGME dually accredited programs, if dual accreditation is only a construct to fill ACGME positions. If these programs determine that they can fill their positions without AOA accreditation, then osteopathic positions and dual accreditation would no longer be desirable. A reduction of dual programs and positions would be detrimental, as 22% of all approved AOA training positions are dually accredited at this time. 

Osteopathic trainees who complete residency training in dual programs have the following 4 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 July 2010, the total number of DOs who completed training in dual programs was 1687 (Table 5)—twice the number reported in our 2009 article.¹ A larger percentage of this group obtained AOA board certification: 852 DOs (51%) became exclusively AOA board certified, and 301 (18%) became board certified by both the AOA and the ABMS, compared with 40% and 19%, respectively, as reported in 2009.¹ Thus, a total of 1153 DOs (68%) from AOA/ACGME dually accredited programs elected to become AOA board certified, compared to 59% in 2008 and 66% in 2006. As of January 2011, a total of 351 DOs (21%) who have completed dually accredited programs chose ABMS board certification only and 183 (11%) have not obtained board certification to date. Many of the DOs currently listed as uncertified will certify at a later date and are considered board eligible, but others will not meet current AOA policy for eligibility. 

There are advantages to obtaining AOA board certification. Osteopathic physicians are required to be AOA board certified if they want to become a dean at a college of osteopathic medicine or a director of medical education or program director in an AOA-approved training program.⁵ In addition, leadership opportunities are available within the specialty board only if you are board certified. Osteopathic physicians who elect dually accredited 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. 

Internal medicine, one of the more sought after 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.¹² However, 59% of trainees who have completed training in internal medicine dually accredited programs are AOA board certified in 2010. 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.¹³ 

The Bureau of Osteopathic Education, the COPT, and other leaders in education are tracking statistics about DOs who complete dually accredited programs and will continue to monitor these trends. It will be particularly important to determine if physicians who initially become board certified by both the AOA and the 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 2010, 120 of the 351 DOs (34%) who are ABMS board certified only are AOA members. In addition, of the 183 DOs who have not yet obtained board certification, 142 (78%) are AOA members (Table 6). 

The cost of most hospital residency training is funded through the 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.¹⁴ 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 have been efforts 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 2015,¹⁵ many influential groups have asked the CMS to reconsider its position.^16,17 

The Patient Protection and Affordable Care Act, signed into law March 2010, included provisions for graduate medical education payments to support community-based training, as follows¹⁸: 

 

The AOA COPT revised its policy to allow OPTIs to become sponsors of such programs in order to meet the requirements for application of these funds. The government will require residency programs to be more accountable in meeting quality measures from trainees to continue receiving future funding. In essence, as stated by Hackbath and Boccuti¹⁹: 

 

As previously described,¹ 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.¹¹ In addition, the quality of ACGME training programs is perceived to be higher by many students and other members of the osteopathic medical profession.^11,20-22 

Osteopathic medical students and medical professionals who influence student choice of training also perceive that the public believes ACGME training is better or has more status or recognition.¹¹ Osteopathic trainees may believe that in training with allopathic physicians, they will gain a higher level of acceptance by allopathic peers and patients.¹¹ 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.^5,23 In addition, it seems that patients rarely know where their physicians completed training. A survey, which was developed in response to the issue of AOA training program quality at an osteopathic Medical Education Summit held in January 2006 and was conducted independently by D. Keith Watson, DO, chair of the Medical Education Summit I, was distributed to 2010 fourth-year osteopathic medical students and will be distributed again to 2011 fourth-year students. Results from this survey are pending the second wave of responses. Whether the quality is better or not, perceived quality is what drives many osteopathic medical students to dually accredited AOA/ACGME programs. 

Although it may not be an issue to students during recruitment, an AOA-approved first year of training is required for DO licensure in 4 states: Florida, Michigan, Oklahoma, and Pennsylvania. Therefore, graduates will be eligible for licensure if they train in traditional, dual, or parallel AOA-approved training programs. 

As of December 2010, 37% of all dual programs and 41% of dually approved positions are located in these 4 states. While this percentage may seem high, 45% of all AOA-approved residency programs and 46% of all AOA-approved residency positions are also located in these 4 states.⁶ Pennsylvania has the greatest number of dual programs (18%), followed by Michigan (16%), New York (12%), and New Jersey (8%). 

Graduates of osteopathic medical schools who think they will never be interested in working in any of these states should be aware that almost 3000 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 4 states. Trainees who complete AOA dual and parallel programs are never limited to where they can practice in the United States. 

To hold osteopathic leadership positions (eg, COM deans, program directors, directors of medical education), DOs are required to be AOA board certified.^5,24 Resolutions 42 and 56 have been the only pathways that provided 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) was amended in 2009 to allow all DOs who are ABMS board certified to apply for AOA board eligibility immediately following residency training. Approximately 300 DOs have applied for certification through Resolution 56 in the past 6 years; 119 have become AOA board certified. Not all applicants will complete the process because they may have not understood that they will have to actually apply and sit for the primary AOA board examination first, not a recertification examination. Many boards have developed hybrid examinations that include a mix of primary examination questions and examination questions that would pertain to someone who has been in practice a number of years. 

The AOA Board of Trustees approved Resolution 29 (A/2010—Approval of ACGME Residency) in 2010. This resolution eliminated the need for ACGME-trained DOs in Option 1 specialties, which start residency immediately after graduation from the COM, to go through Resolution 42 to gain approval of a first year of training. The majority of specialties have elected option 1. Upon completion of an Option 1 specialty, the physician may apply for approval of his entire residency instead. Osteopathic physicians who complete ACGME training in Option 2 and Option 3 specialties continue to need Resolution 42 for approval of their first year of training because these specialties require a first year internship in AOA programs. Duffy and Martinez²⁵ provide more information on AOA approval of ACGME programs. 

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. Leaders in the profession agree the contribution of dually accredited training programs has been positive and should continue to be a strategy to increase the number of available slots to DOs. However, it should not be the only strategy. 

Leadership in osteopathic postdoctoral training believe AOA training for osteopathic physicians is superior to ACGME training because they receive continued training and education in osteopathic principles and practice.²⁶ Dual and parallel programs are required to follow the same standards as all other AOA-approved programs without exception. The success of dual programs is a winning solution for the profession and a growing number of graduates who elect to train in dual and parallel programs. 

Completion of a parallel program would ensure that trainees continue in the osteopathic medical profession throughout their career. Although there were a reduced number of parallel programs reported in 2008, that number has shown an increase, primarily due to the COPT's approval of consortium models. 

Osteopathic 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 29, 42, or 56 to become eligible for AOA board certification, which is required to participate in a number of leadership positions, as previously stated. Unless a trainee expects to need licensure in 1 of the 4 states requiring an AOA-approved first year of training (Florida, Michigan, Oklahoma, and Pennsylvania), application through Resolution 56 will meet the eligibility for AOA board certification and requirements for licensure in all other states. 

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 AOA positions and eligible for AOA board certification at the end of training. Osteopathic physicians in ACGME slots who complete the same program as the DOs in approved AOA slots may find they need to use other pathways to be eligible for AOA board certification. Many dual programs have increased their number of approved training slots to match the number of actual DO trainees in their program to avoid the need for DOs to apply for ACGME program approval. 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 be subject to standards and requirements for maintaining approval by both regulatory bodies. They also have to provide registration data, submit reports, and go through site reviews for both the AOA and ACGME.²⁷ However, the payoff—the ability to maintain CMS-funded slots, meet hospital staffing needs, and fill slots with preferred US physicians²⁸—continues to be rewarding for these programs. 

Accreditation by the AOA may also be an attractive element to MDs seeking residency programs because it provides MDs with diversity of curriculum—specifically, training experience with DO residents from which they may learn osteopathic approaches to clinical issues. Also, a program that must meet the accreditation requirements of 2 organizations could be perceived as inherently superior to one that must only meet the requirements of 1 body. 

The Medical Education Summits, which were held in 2006 and 2007 and were co-sponsored by the AOA and the American Association of Colleges of Osteopathic Medicine (AACOM), have developed several initiatives to address the issue of workforce and sufficient training positions for osteopathic graduates during the past 5 years.²⁹ This team of Summit leaders will complete the recommendations approved at the original summits or place responsibility on appropriate existing structures for programs that require ongoing oversight and review. A new committee has been proposed to continue review of workforce and education issues for the profession starting in 2011. 

The AOA closely monitors the number of filled training slots after the AOA Match and post-Match scramble. There has been a dramatic change in the fill rates of AOA-funded positions. In 2006, 69% of first-year funded training slots were filled by 2814 fourth-year students and 72 previous graduates seeking a different specialty. In 2010, 85% of funded first-year training slots were filled by 3845 fourth-year students and 423 previous graduates seeking a different specialty. Colleges of osteopathic medicine are expected to graduate 4228 students in 2011 and well over 5000 students by 2015.³⁰ It will be impossible to meet the number of funded slots if the profession does not seek growth through dual programs, seeking new programs and positions through hospitals eligible for funding, including opportunities with Veterans Affairs Hospitals and providing support to AOA institutions through new funding initiatives created by the CMS and other funding agencies. 

In 2010, approximately one-fifth of all AOA-approved positions (22%) were dually accredited, compared to 11% in 2006. The number of dual programs has nearly doubled since 2006 (from 90 to 170). Growth in dually accredited fellowships has risen from 14% to 21% in the same 5 years. 

While dual programs have benefited the osteopathic medical profession, reliance on the continuation of dual positions presents a risk. There is cause for concern. Allopathic medical schools in the United States will substantially increase their number of MD graduates in the next 5 years, graduating MD students outnumbered the available training slots after the NRMP Match in 2010, and the number of CMS-funded slots has remained stagnant for existing training institutions. If dual programs decide to close because they can fill their programs with MD graduates—without the added expense of being a dual program—the osteopathic medical profession must have the ability to create sufficient residency training opportunities for its graduates. Both the osteopathic and allopathic professions continue to encourage leaders to lift caps on funded slots. As long as there are empty slots and the belief that the cost to continue funding residency training is too high, there likely will be little support from the US government to raise the funding caps. The AOA has partnered with the AAMC to share data on dual programs so that reports to the government on the workforce are accurate. The focus on producing a sufficient number of physicians in the workforce to provide quality care to patients is a concern of the entire osteopathic medical community.^16,17,31