In July 2011, there were 4159 graduates from US osteopathic medical schools.¹ At that time, more than 50% of ACGME and AOA residencies were in the eastern time zone of the United States.^2,3 The Western University of Health Sciences College of Osteopathic Medicine of the Pacific (WesternU/COMP), in collaboration with the osteopathic postdoctoral training institute (OPTI) OPTI-West, was actively involved in residency development in the Western United States. It assessed the fiscal viability for GME at every hospital in California, Oregon, and Washington and led a strategic initiative to target hospitals with osteopathic leadership, positive financial metrics, and the capacity for quality programs with the appropriate scope, volume, and variety. 

Before the MOU, the development of new osteopathic residency programs was usually achieved at a slow pace as a result of multiple factors, including underrepresentation of osteopathic leadership in many hospital medical staffs. On the basis of my experience as a national consultant for GME financial projections, a role in which I provided consultation to numerous hospitals throughout the United States, the development of osteopathic residencies in medical centers with minimal osteopathic staff leadership is challenging. Osteopathic medicine has been at the forefront of development of primary care graduates in both AOA and ACGME programs. Unfortunately, the political power base of hospital medical executive committees and medical staffs is generally not in primary care, and hospital staffs in the Western United States rarely have more than 5% osteopathic representation (D.A.C., unpublished data). 

Should a hospital's medical staff and administration agree to develop dedicated de novo osteopathic GME programs, they face other substantial impediments, such as the lack of AOA board–certified physicians who comply with osteopathic residency standards. In the Western United States, more than 60% of osteopathic medical school graduates train in ACGME programs.⁴ For many years, these ACGME-trained osteopathic physicians (ie, DOs) were labeled unqualified by the AOA specialty colleges to act as program directors or faculty members at colleges of osteopathic medicine, even though, in my experience, many of these DOs provided osteopathic manipulative treatment and adhered to osteopathic principles and practice. Some AOA specialty colleges provided special exceptions for allopathic physicians (ie, MDs) or ACGME-trained DOs to be program directors or qualified preceptors, but no exception was ever made, to my knowledge, for the allowance of anyone with an MD degree to participate in residency training, which I believe resulted in a number of hospitals not allowing AOA program development. 

To help alleviate this problem, many institutions embedded AOA-accredited residencies into current ACGME residencies, called dual programs, to provide dedicated opportunities for osteopathic medical graduates. Although these programs incurred double the cost and paperwork to meet both AOA and ACGME accreditation requirements, they enabled osteopathic residency standards to reflect ACGME residency standards. Unfortunately, these programs will likely cease to exist after 2015 once the ACGME's requirements take effect, regardless of the AOA's adoption of the MOU. 

In October 2011, the ACGME announced the planned implementation of Common Program Requirements under the Next Accreditation System, in which DOs would be prohibited from entering ACGME-accredited training programs. Shortly thereafter, many ACGME training programs prohibited AOA-trained residents from accessing ACGME fellowships. Although some may have believed that this change would affect a small percentage of osteopathic medical school graduates, in my experience, the change impacted all ACGME training programs nationwide. For example, to my knowledge, ACGME programs in the Western United States began labeling any DO attending physician with AOA-accredited residency training to be “unqualified” to participate in training of ACGME residents, even if the ACGME resident had a DO degree. In addition, the University of California, Davis; the University of California, Irvine; and the University of California, San Diego deemed osteopathic medical students “ineligible” for their programs for audition rotations and stated such on their websites. To my knowledge, WesternU/COMP and the Osteopathic Physicians & Surgeons of California also received reports that other institutions were denying osteopathic medical students access to ACGME programs for audition rotations. 

The efforts by the AOA and AACOM to negotiate with the ACGME regarding the initial proposed MOU halted the rule change—in other words, AOA-trained and AOA board–certified DOs could again be preceptors in ACGME programs. Unfortunately, osteopathic medical student discrimination continued at numerous ACGME training programs in the Western United States, prominately stating on their websites “DOs need not apply,” thus limiting the access of third- and fourth-year medical school clerkships and audition rotations in the University of California system for osteopathic medical students. Touro University College of Osteopathic Medicine tried to gain access for their students for more than 2 years at University of California, Davis without success. 

The Osteopathic Physicians & Surgeons of California, using a multipronged approach, was able to reverse this policy, resulting in the cessation of discrimination against osteopathic medical students in the state of California beginning May 2014. A major factor in reversing the discrimination of osteopathic medical students was the approval of the MOU by the AOA, AACOM, and the ACGME. The MOU has enabled collaborative discussions between the University of California, Irvine and WesternU/COMP for continued collaboration and development of residency training programs. 

The MOU has further strengthened our relationship with Loma Linda University in that its leadership has formally asked WesternU/COMP and OPTI-West to develop GME programs in the Adventist health care system. Since the initial phase of discussion, the MOU has aided in the development of 5 new hospitals in Southern California with more than 12 new programs and numerous others developing over the next 4 years. In addition, 3 new hospitals have received final approval from their senior level administrators and medical staff for at least 20 new programs. 

These hospitals are finally moving forward with applications, due in part to the single GME accreditation system pathway's ability to allow the development of programs that provide access to both MDs and DOs yet maintain osteopathic culture, heritage, and training. One must also credit OPTI-West's leadership and comprehensive approach for success in residency development and operation under a unified OPTI. 

Currently, there are 2988 postgraduate year-1 osteopathic training positions in the United States,⁵ and the number of graduates from osteopathic medical schools is expected to increase to 6000 by 2019.⁶ Unfortunately, on the basis of my conversations with hospital administrators, I believe many of these postgraduate year-1 osteopathic training positions will cease to exist after 2015 regardless of the AOA endorsement of the MOU. 

Those who are against the adoption of the MOU for a single GME accreditation system do not seem to recognize the lack of osteopathic postgraduate training positions for osteopathic medical students and the profession's inability to create enough positions for osteopathic medical school graduates. Further, I believe a rejection of the MOU by the osteopathic medical profession will result in a permanent cleavage of the AOA and the ACGME, and the osteopathic medical school graduates who are currently accessing ACGME programs will likely begin to see those opportunities erode and become nonexistent, just as we had begun to experience in the Western United States 3 years ago with the ACGME Next Accreditation System Common Program Requirements. 

The osteopathic medical profession is at a crossroads. It is up to our profession to decide how our osteopathic culture and heritage will continue in this new paradigm, with the AOA and AACOM as equal members on the ACGME Board of Directors. The new ACGME Residency Review Committees will have osteopathic leadership to ensure that our culture and heritage instilled at our osteopathic medical schools continue in this single GME accreditation system. The osteopathic specialty boards have an opportunity to provide certification to MDs who embrace osteopathic distinctiveness. Osteopathic medical school graduates are well prepared to compete effectively with MD graduates. 

Without the MOU and single pathway for GME accreditation, it is difficult to understand how the osteopathic medical profession will survive. We cannot electively exclude ourselves from active representation on the board of the largest organization of GME in the world yet expect this same organization to continue to accept our medical school graduates.