Letters to the Editor  |   June 2013
International Health Electives: Strengthening Graduate Medical Education
Author Affiliations
  • Zachary Comeaux, DO
    Professor at the West Virginia School of Osteopathic Medicine in Lewisburg, member representative to the Osteopathic International Alliance, and former president of the World Osteopathic Health Organization
Article Information
Medical Education / Graduate Medical Education
Letters to the Editor   |   June 2013
International Health Electives: Strengthening Graduate Medical Education
The Journal of the American Osteopathic Association, June 2013, Vol. 113, 446-447. doi:
The Journal of the American Osteopathic Association, June 2013, Vol. 113, 446-447. doi:
To the Editor: 
Reading the December 2012 issue of The Journal of the American Osteopathic Association, I was encouraged by the article by Sidney Coupet, DO, MPH,1 on the use of international health electives to strengthen graduate medical education programs. I thought the article was scholarly, cogent, and timely. In reflecting on the subject matter, however, I believe that we in the US osteopathic medical community are overlooking an important element in the global evolution of medicine and culture: parallel to the progressive involvement of US-trained osteopathic physicians and osteopathic medical students in international medical missions and rotations is the rapid evolution of international osteopathy as a cohesive profession. 
The aspects of our education and professional activity that make US osteopathic physicians distinctive are repeatedly scrutinized and debated, and they are perennially evolving. I have formed this opinion after 30 years of participation in faculty discussion, as well as participation in national and international organizations, committees, and associations. This process of self-scrutiny and refinement, which involves deciding what is essentially distinctive about our profession and then improving it by adapting best practices from different streams of the osteopathic profession, is a benefit of participating in the osteopathic medical community. 
For those not well versed in the history or current status of international osteopathy, the 2006 article “A Global Snapshot of Osteopathic Medicine” by Jane E. Carreiro, DO,2 is still largely relevant. Developments in international osteopathy are ongoing, as is evident from the reports of representatives of different countries presented at the March 2013 Osteopathic International Alliance (OIA) Spring Board Meeting in Orlando, Florida. 
Establishment of the OIA in 2004, as well as formation of the now discontinued World Osteopathic Health Organization, initially stemmed from the desire of US-trained osteopathic physicians to be recognized globally and to enhance developments in osteopathic medicine around the world. The creation of these organizations complemented a desire among European osteopaths for recognition and enhancement of both competency and educational standards. Formation of the European Federation of Osteopaths, European Register for Osteopathic Physicians, Forum for Osteopathic Regulation in Europe, and Osteopathic European Academic Network, among other organizations, reflects the wide-spread effort to fulfill this wish. 
So far, these organizations (including the OIA), and their active members, have had a substantial impact on catalyzing the global osteopathic medical profession. Many communities that have had osteopathy and osteopathic medicine introduced by diverse historical routes have reflectively pursued a future with more in common than different. Ongoing consensus discussions among OIA participants in Europe, Asia, and North and South America have led to the development and promulgation of the World Health Organization's Benchmarks for Training in Osteopathy.3 In addition, the OIA, along with its constituent organization members, provides information and support to those implementing osteopathy or osteopathic medical care in new political or cultural settings. 
In discussions of US-trained osteopathic physicians and our professional identity, the elephant in the room remains to be addressed. Although training in osteopathic manipulative medicine is compulsory for all osteopathic medical students in the United States, very few of these students develop everyday competency in this distinctive practice and choose to use it. 
A survey by Allee et al4 showed that 67.9% of osteopathic physicians in American Osteopathic Association–approved family medicine residencies claimed to use manipulation regularly, compared with 39.5% of those in family medicine residencies approved by the Accreditation Council for Graduate Medical Education. In addition, a number of the latter's allopathic peers reported interest in learning osteopathic manipulative treatment.4 However, in another survey of osteopathic physicians in Ohio (a state relatively heavily saturated with osteopathic physicians), 79% of respondents reported hardly ever using osteopathic manipulative treatment; those in specialties reported using none.5 
From personal experience, including teaching abroad, I have noted that the manner of integrating osteopathic principles and practice into a health care setting varies. Foreign-trained osteopathic physicians, however, seem to particularly value these principles and apply them with specific intention and with more passion than many of our US osteopathic medical school graduates. Exposure to foreigntrained osteopathic physicians and their means of integrating manual therapy into clinical practice may spark a renewed interest by US osteopathic medical students and graduates in the uniqueness of osteopathic medicine. It might also inspire them to practice osteopathic medicine with the same intention and passion as foreign-trained osteopathic physicians. 
This conjecture undoubtedly will be dismissed by many individuals who have a false sense of our identity as US-trained osteopathic physicians in relation to our colleagues who are practicing osteopathy in other countries around the world. I believe that exposure to global health care techniques during individual professional development, however, could contribute to an understanding of the real power and potential of maintaining the uniqueness of osteopathic medicine, including the judicious inclusion of manual diagnosis and manipulative treatment as a resource for patients. Reciprocally, such exposure would also offer opportunities to showcase the osteopathic medical profession's potential to integrate osteopathic principles into contemporary full medical practice. 
I suggest that, to some extent, we merge international health electives with opportunities for exposure to international osteopathy. The American Association of Colleges of Osteopathic Medicine and the OIA have initiated small-scale discussions of how to implement more international exchanges into US osteopathic medical education, and individual osteopathic medical schools have taken the initiative to promote such exchanges. No such undertaking is simple, but I believe that this debate would benefit from wider exposure and a discussion of the issues. 
Coupet S. International health electives: strengthening graduate medical education. J Am Osteopath Assoc. 2012;112(12):800-804. [PubMed]
Carreiro JE. A global snapshot of osteopathic medicine. Osteopathic Family Physician News. May 2006;6(5):14-16.
World Health Organization. Benchmarks for Training in Traditional/Complementary and Alternative Medicine: Benchmarks for Training in Osteopathy. Geneva, Switzerland: World Health Organization; 2010.
Allee B, Pollak M, Malnar KF. Survey of osteopathic and allopathic residents' attitudes toward osteopathic manipulative treatment. J Am Osteopath Assoc. 2005;105(12):551-561. [PubMed]
Spaeth DG, Pheley AM. Use of osteopathic manipulative treatment by Ohio osteopathic physicians in various specialties. J Am Osteopath Assoc. 2003;103(1):16-26. [PubMed]