Letters to the Editor  |   July 2012
Thinking Osteopathically
Author Affiliations
  • Bruce A. St. Amour, DO
    Emergency Medicine Residency Director, St. Mary Mercy Hospital, Livonia, Michigan
Article Information
Medical Education / Graduate Medical Education
Letters to the Editor   |   July 2012
Thinking Osteopathically
The Journal of the American Osteopathic Association, July 2012, Vol. 112, 465-466. doi:
The Journal of the American Osteopathic Association, July 2012, Vol. 112, 465-466. doi:
To the Editor: 
“Thinking osteopathically.” 
I am not sure what that means. As an emergency physician, does that mean I think holistically about my patients? Does it mean I engage the body's inherent self-regulating mechanisms? Does it mean I use forms of manipulative medicine? If thinking osteopathically ends with these tenets, then so will the osteopathic medical profession. There is nothing unique about manipulative medicine; chiropractors and physical therapists use it every day. The other basic tenents of osteopathic medicine are even less uniquely ours. Also, our training is not of our own design. 
As an educator, I am aware of the strides we have made to elevate the skills and knowledge, as well as the numbers, of osteopathic trainees. But most, if not all, of the recent advances in our teaching have been borrowed from the Accreditation Council for Graduate Medical Education (ACGME). In fact, when you look at the ACGME methods, you will see the American Osteopathic Association (AOA) adopting the same approaches and standards 3 years later. For example, in 2001, the ACGME introduced the 6 core competencies in its Outcome Project.1 In 2004, the AOA came up with 1 core competency of its own.2,3 In 2003, the ACGME established new duty hour restrictions,4 and ours were established in 2006.5 
I'm not against the ACGME's practices, but I would like to see something come from our own house—from our own brains and will. As it is, we are neither the same as, nor different from, the ACGME … imitation poorly done, timid, and slightly behind. We can compete to be the 800-lb gorilla, or we can evolve to use tools. 
The ACGME and AOA both require written yearly criteria for residents to meet before they can advance to the next level of training. These criteria are appropriate, because they help prevent physicians from advancing in their training before they have demonstrated competency. But these plans do not offer any motivation to enter an AOA-approved internship or residency training program. We have set up minimum criteria without allowing those who meet the standards early to enjoy the fruits of their accomplishments. 
It would be valuable to begin thinking about doing away with time-based training (ie, you are done after you have put in your time) and replacing it with competency-based training (ie, you are done when you demonstrate adequate knowledge and experience). Some residents would complete their training sooner; others would require more time. How long does a PhD program take? It takes as long as necessary—until the PhD candidate proves that he or she has obtained the required knowledge and skills. The structure of our training should be focused on the desired end result: qualified osteopathic physicians. 
Learners in a competency-based training program might be able to—and would have some motivation to—learn faster, work harder, and complete the training sooner. Competency-based medical training is a tempting alternative to ACGME-style training, while maintaining the levels of knowledge and experience required by the AOA. In competency-based medical training, osteopathic residents would still be required to pass certification examinations and to have a minimum of patient exposures, but they would do so at their own pace—not the pace of tradition. 
Thinking osteopathically, or thinking for ourselves? 
Stewart MG. Core competencies. Accreditation Council for Graduate Medical Education Web site; 2001. Accessed June 6, 2012.
Core competency compliance program (CCCP) part III. American Osteopathic Association program director's annual evaluation report. American Osteopathic Association Web site. Accessed June 6, 2012.
AOA Core Competency Development Task Force, AOA Core Competency MAP. Core competency compliance program (CCCP) part II: references. American Osteopathic Association Web site. Accessed June 6, 2012.
Resident duty hours in the learning and working environment, comparison of 2003 and 2011 standards. Accreditation Council for Graduate Medical Education Web site. Accessed June 6, 2012.
American Osteopathic Association. The Basic Documents for Postdoctoral Training. Chicago, IL: American Osteopathic Association; Rev BOT July 2011. Accessed June 6, 2012.