To the Editor: 

I commend Cynthia S. Kelley, DO, on her learned article "Impact of the Single Accreditation Agreement on GME [Graduate Medical Education] Governance and the Physician Workforce" in the July issue of The Journal of the American Osteopathic Association.¹ I call it learned because it is an erudite analysis of the arrangement plus it includes a reasonable discussion of some of the negative aspects of the single accreditation system. 

I have been privileged for the past 70 years to personally observe and play an active role in the slow but steady progress of our profession toward full equality. That does not make me smarter or authoritative but merely gives me broad experience. And this negotiation may be a step forward for our profession. 

However, I would like to add some thoughts about the political (that is, organizational and management) aspects, a must because they will eventually determine the success of the project. That immediately brings forth concerns about cost and risks. That all of our graduates will be attending Accreditation Council for Graduate Medical Education (ACGME) residencies is very attractive—no, astounding. But we must stop to ask first, "What is the cost? What are the risks?" These are the questions one would ask in any contract situation—one that would be posed by our attorneys when we present any proposition to them. Financial costs may be known only to our negotiators, and they have not said. There are possible costs of time, effort, effects on memberships—and Kelley¹ has discussed several of them. 

One major risk that rears its ugly head immediately is the prospect of a strengthening call from some quarters for a merger with the American Medical Association. At several episodes in our history, circumstances have arisen that prompted such an uprising among a small minority of our osteopathic physicians (ie, DOs)—always ready to seek that goal. Among other instances, the California episode was followed by a little surge in this activity. But, in spite of the single GME agreement's advantages, it creates another potential battle for us to fight. 

The old cry of "Why do we need 2 separate medical professions?" may reappear and become, "NOW, why do we need 2 separate medical professions? There is very little difference between us." My answer is a question saved from years past: "Considering Macy's and Bloomingdale's carry much of the same merchandise, service much of the same segment of the public, and often have similar pricing, why do they have to be separate?" 

To be clear, I am unalterably opposed to such a merger. We have come a long, long way from almost obscurity to almost equality in status; we have always had equality in ability and service. All that fine progress was achieved without selling our birthright or being forced into joining some special group or society. 

According to the agreement, the ACGME will make the AOA and the American Association of Colleges of Osteopathic Medicine member organizations. Each member organization is entitled 2 representatives on the Board of Directors; thus, there will be 4 designated DO representatives—2 each from the AOA and the American Association of Colleges of Osteopathic Medicine—on the ACGME Board of Directors. Assuming total integrity on the part of the present negotiators, could different personnel, in 5 years or 10, just eliminate those positions or the DOs? 

There are hidden risks all around us and we cannot always discern them or prevent them or forecast them. One danger that has surfaced in other situations is being seduced by false promises. In one instance that I was able to observe, both sides to a merger-like agreement seemed to be satisfied. But a couple of years later, one of the negotiators bragged, "Boy, did we put it over on them, by promising...." Fortunately for both sides, that empty promise did not disrupt the unity and both groups fared well. But those incidents, even though relatively rare, could always be disruptive. 

In a single GME system, the goal is admirable and outstanding. But always—that means always—we must be guarded, careful, alert, and on an unrelenting lookout for stumbling blocks when the promises seem greatest. And that means every step of the way! 

We have struggled long to rise from near-obscurity to unbelievable growth and to an enviable position in medical circles; we did it all by dint of producing numbers of competent DOs providing excellent medical care to the public. Essentially, we "pulled ourselves up by own bootstraps." I am proud of what we have done. Now, we are facing another administrative situation with "prospects" of another milestone achievement. But manholes are still there; we must exert every human effort to avoid them. (doi: 10.7556/jaoa.2014.168)