Letters to the Editor  |   March 2011
Author Affiliations
  • John B. Bulger, DO
    Chairman, AOA Council on Osteopathic Postdoctoral Training
    Chairman, AOA Program and Trainee Review Council
Article Information
Gastroenterology / Medical Education / Graduate Medical Education
Letters to the Editor   |   March 2011
The Journal of the American Osteopathic Association, March 2011, Vol. 111, 178-179. doi:
The Journal of the American Osteopathic Association, March 2011, Vol. 111, 178-179. doi:
Dr McCombs has submitted a scathing criticism of American Osteopathic Association (AOA) enforcement of osteopathic college and postdoctoral training program standards. Both predoctoral and postdoctoral activities are sponsored by the AOA. The predoctoral accreditation is regulated by the Commission on Osteopathic College Accreditation (COCA), and the postdoctoral activities are regulated by the Program and Trainee Review Council (PTRC) under the authority and policy oversight of the AOA Council on Osteopathic Postdoctoral Training (COPT). 
Dr McCombs refers to an incident in which a surgical resident failed to respond to a student's question regarding use of osteopathic manipulative medicine (OMM) in treating a patient with postoperative ileus. He implies that the surgical resident's apparent lack of knowledge, understanding, or use of the suggested treatment reflects a general lack of compliance with OMM training standards and a lack of enforcement of these standards in the accreditation process of AOA programs. 
It should be pointed out that the lack of conducting a particular therapeutic element in a trainee's clinical practice has no relationship to the element's level of compliance enforcement in the accreditation site review of the training program. The program accreditation process does not evaluate the use of every element required in the standards by every resident in each case. Accreditation is a validation of compliance with a majority of required training standards. The benefits of OMM and osteopathic principles and practice (OPP) are required to be taught to all residents, as applicable to specific specialties, in every AOA training program. 
A summary of postdoctoral accreditation site reviews begins with development with a set of specialty-specific basic standards (ie, requirements). Multiple standards of general clinical, administrative, procedural, and academic relevance are always included in reviews. The inclusion of standards specific to osteopathic medicine is always required for each specialty. 
In addition, the AOA has incorporated a set of core competencies, in which proficiency must be evaluated annually by program directors. The programs must achieve proficiency in the core competencies by the conclusion of training. The OPP competency, in which OMM is included, is required to be integrated into each of the other 6 competencies of an osteopathic physician. Each specialty college's Council on Education and Evaluation reviews achievement in the core competencies annually. Every single required standard is listed in a Standards Inspectors Workbook (ie, Standards Crosswalk) used by the reviewer and is evaluated as “met” or “unmet.” Patient charts, of cases in which interns and residents have participated in patient care, are reviewed for evidence of structural examination and OMM performance as indicated. 
When OPP/OMM deficiency citations are noted, the PTRC will reduce the continuing approval of the program by 1 full year. For every cited deficiency, a program is required to submit a corrective action plan, which must be approved by the respective specialty college. Then, documentation of implementation of that plan must be submitted within 180 days. This mechanism involves OMM citations as well as any other training citations. Equal compliance is required for osteopathic (ie, OPP/OMM) standards as for any other clinical, academic, or administrative standard. 
Dr McCombs indicates that curricula, sign-in sheets, clinical logs, and chart notes are never requested during site reviews of programs. However, those items are the exact documentation that is always requested for validation of compliance. Dr McCombs also states, “Many leaders in our profession do not use OMM in their own practices or for their own families.... They do not know how to use OMM because their COMs and hospitals did not teach them.” Contrary to this claim, however, if individuals do not use OMM, it is unlikely that a lack of teaching can be blamed. Based on multiple personal observations, we believe it is more likely that these individuals chose not to use OMM as a result of time unavailability, reimbursement issues, or unfavorable regard for OMM. Lack of OMM use in practice is not always related to lack of teaching. 
For the past 12 years, Osteopathic Postdoctoral Training Institutions (OPTIs) have been the required accreditation model for all AOA training programs. All OPTIs include COMs as partners in the educational continuum of osteopathic medical students and residents. Most research and development of OMM teaching modules and methods occurs at the COMs. That exposure is a required element for accreditation of OPTIs, as well as for all of their programs and their trainees. 
The COPT has recently recommended to the AOA Board of Trustees that full-time professional reviewers be employed for all postdoctoral training program reviews. The purpose of this recommendation is to consistently enforce all standards and to validate program compliance through objective documentation. 
In conclusion, not all osteopathic physicians use OMM in their practices, but many do. Those who do use OMM were taught in the same COMs and residency programs as those who do not use OMM. The AOA educational system is a good resource for training. We will always continue to enhance and enforce OMM standards.