In February 2014, the American Osteopathic Association (AOA), the American Association of Colleges of Osteopathic Medicine (AACOM), and the Accreditation Council for Graduate Medical Education (ACGME) agreed to a single accreditation system for graduate medical education (GME).
1 This agreement could provide an opportunity for the osteopathic medical profession to advance its mission of promoting osteopathic distinctiveness and to improve osteopathic medical education during the clinical and postgraduate years.
2 Review of the historical relationship of the osteopathic and allopathic professions and some current factors affecting medical education can inform the direction our osteopathic leaders and educators should take.
Osteopathic medical education forged and enjoyed a collaborative relationship with allopathic teaching hospitals and physicians during the past 30 years.
3, 4 Over the past decade, more than 60% of graduates from colleges of osteopathic medicine (COMs) pursued their GME training in ACGME-accredited residency programs.
4 Historically, more than half of the funded ACGME primary care residency positions went unfilled by allopathic medical graduates.
4 To fill these open residency positions, osteopathic graduates were increasingly enrolled in allopathic primary care residency programs.
5 One hundred fourteen dually accredited family medicine residency programs were created, which accounted for nearly half of the 241 family medicine residencies accredited by the AOA.
6 In 2010, the Council on Graduate Medical Education's 20th report
7 called for at least 40% of the physician workforce to practice primary care. Responding to the call, medical schools accredited by the Liaison Committee on Medical Education increased class sizes and planned 16 new schools for an expected 31% enrollment growth by 2017 compared with 2002.
8 This recent growth followed 30 years of relatively stable numbers of allopathic graduates entering the ACGME match.
8
Simultaneously, enrollment at COMs has grown both in number and in class size.
9, 10 Numbers of COMs' first-year enrollees more than doubled from 3043 in 2001 to 6636 in 2014.
10 Since 2002, the number of COMs has expanded from 19 to 42 colleges, branch campuses, and additional locations in 28 states in the 2015-2016 academic year.
9, 11 Increasing competition for residency positions from both osteopathic and allopathic graduates is a major concern for the future of the osteopathic medical profession.
9
In the 2014 National Residency Match Program, 611 osteopathic participants were initially unmatched.
8, 10 This number of unmatched osteopathic medical students has led to concerns about the difficulties of obtaining residency training for osteopathic graduates. Despite fears that recent growth in osteopathic and allopathic graduates will soon outpace combined osteopathic and allopathic GME residency positions, Salsberg
12 blogged that enough GME positions are available to keep up with current growth for at least 10 years. However, concern remains about the number of osteopathic and allopathic graduates who do not find a position in the National Residency Match Program.
12
Teng et al
13 found that osteopathic trainees value their osteopathic identity and intend to use osteopathic manipulative treatment (OMT) in their practices. They call for improved osteopathic medical education during the clinical years to foster continued osteopathic identity.
11 Osteopathic medical students report minimal mentorship in OMT and insufficient opportunity to practice their osteopathic manipulative skills during the third- and fourth-year clinical rotations.
13 Despite the encouraging statistic that more than 93% of osteopathic medical students express an interest in OMT,
13 a decreasing number of osteopathic physicians (ie, DOs) use OMT in their practices.
14 At least 25% of practicing DOs report no use of OMT.
14 Furthermore, the more recent the date of COM graduation, the lower the reported use of OMT.
14
Maintaining osteopathic distinctiveness is a priority of the AOA.
2 During the past several decades, allopathic medical education, especially in family medicine, has incorporated patient-centered, holistic curricula.
5 Some experts contend that the remaining clear distinct differences between osteopathic and allopathic training are the use of OMT and the enhanced focus on musculoskeletal diagnostic skills achieved through osteopathic training.
5,11,15 Osteopathic residents are less likely to use OMT when they are trained in allopathic institutions without DO mentors.
14 Graduating medical students and residents in allopathic settings report a lack of confidence in managing musculoskeletal complaints and desire more instruction in manual techniques.
16 Promoting osteopathic curricula in hospitals employing and training DOs can be beneficial to both osteopathic and allopathic physicians.
16 Allopathic physicians (ie, MDs) develop more favorable attitudes toward OMT and the osteopathic profession in a mixed-staff setting and learn to recognize OMT as a viable treatment option.
16 However, additional research is warranted to determine the attractiveness of osteopathic candidates to allopathic program directors, and likewise the importance of OMT, to practicing DOs. This research can direct the profession's leadership in decision making as the single GME accreditation system is implemented.
In addition to maintaining osteopathically focused residency programs and creating workshops to allow MDs to become competent in OMT, development of new osteopathic curricular tracks in current ACGME-accredited residency programs is 1 potential area of focus for the AOA. These tracks would focus on allowing osteopathic graduates to hone their OMT skills during residency training, and the track could be extended to allopathic graduates who have completed an outside OMT training certification process. Incorporating osteopathic curricula into institutions that train osteopathic medical students and residents alongside allopathic graduates will allow students much needed access to continued osteopathic mentors and training.
12, 16 Osteopathic residents need opportunities to maintain their osteopathic identity and hone their OMT skills.
16 The 114 current dually accredited family medicine residency programs
6 testify to the fact that strong osteopathic graduates are attractive to allopathic family medicine residency programs. Providing inexpensive, easily implemented osteopathic curricula could be a viable solution for allopathic programs hoping to attract the best osteopathic residents.
In the current system, the administrative tasks and certification requirements in a dually accredited program were often duplicated,
13 resulting in unnecessary time, effort, and cost to maintain accreditation requirements. However, under the new single GME accreditation system, there will be no additional application fees for GME programs with osteopathic tracks (R.A. Cain, DO, e-mail communication, March 2015). Although it is possible that additional costs may occur in creating an osteopathic-focused learning environment under the requirements of osteopathic recognition, to combat the potential financial barrier to programs seeking osteopathic focus, there is no intention for the requirements to cause increased costs (Cain). Effective osteopathic curricula or tracks will continue to foster osteopathic distinctiveness while enhancing learning opportunities for osteopathic graduates and qualified allopathic graduates without the financial challenges currently faced by dually accredited programs.
The osteopathic medical profession is at an important crossroads. Promoting and developing osteopathic principles and practice among students and residents must remain a priority. It is our duty to develop curricula that can be easily and inexpensively implemented within an allopathic setting. Exposure to DO mentors who use OMT would benefit osteopathic medical students rotating within the hospital during their clinical years as they hone their skills and learn to effectively incorporate OMT into a practice setting. Likewise, MDs could learn and benefit from exposure to osteopathic principles and training. These changes could be a win-win-win for our profession, medical education for DOs and MDs, and our patients. (doi:10.7556/jaoa.2015.040)