Abstract
With the commitment on the part of the American Osteopathic Association, the American Association of Colleges of Osteopathic Medicine, and the Accreditation Council for Graduate Medical Education to transition to a single graduate medical education accreditation system by 2020, a legitimate concern exists about the future of pediatric residency training that maintains an osteopathic focus. The authors describe a dually accredited pediatric residency program at one of the nation’s largest children’s hospitals, which may serve as a potential model of how to integrate a robust osteopathic-based education into a general pediatric residency program.
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) announced an agreement to create a single graduate medical education (GME) accreditation system, a transition process that would be finalized in 2020.
1,2 However, at least 1 question remains: Will it still be possible to have osteopathic-focused training programs at larger pediatric training institutions that have historically been ACGME training sites? In the past, such programs have been created by means of dual accreditation (ie, meeting both ACGME and AOA GME requirements), but these dual programs will no longer exist after the creation of a single GME accreditation system.
In the present article, we describe our dually accredited pediatric residency program, which we believe has successfully integrated an osteopathic-focused training program into one of the largest US children’s hospitals—a hospital with an extensive tradition of a strong ACGME-accredited program. Our dual pediatric residency program may serve as a useful model for designing and implementing osteopathic tracks into the single GME accreditation system.
Description of the Program
The program is housed at 2 institutions in Columbus, Ohio: (1) Doctors Hospital, a 213-bed tertiary care facility—one of the largest osteopathic training institutions in the United States with more than 160 residents in training—and (2) Nationwide Children’s Hospital (NCH), a 420-bed tertiary care center with more than 1 million patient encounters (admissions, clinic visits, emergency department visits, etc) per year and with approximately 150 pediatric residents and more than 100 pediatric subspecialty fellows in training.
The NCH hosts 3 pediatric residency programs: an ACGME-accredited categorical pediatric program (33 residents per year), an ACGME-accredited internal medicine-pediatrics program (10 residents per year), and a dually accredited pediatric program (4 residents per year).
The residents at the NCH have 13 rotations of 4-weeks duration per year (termed
educational units in ACGME guidelines).
3 Residents in the dually accredited program (or dual pediatric residents) spend up to 33 of the 39 educational units in the same rotations and experiences as the categorical pediatric residents, working side-by-side and inseparably from the categorical pediatric and internal medicine-pediatrics residents. The dual pediatric residents have the same number of elective months as the categorical pediatric residents, with 6 units of time unique to the dual program replacing an additional emergency medicine rotation, 4 “extra” (above the ACGME requirements) inpatient rotations, and 1 additional month of outpatient clinic. The dually accredited program has several unique aspects, including AOA intern and osteopathic manipulative medicine (OMM) requirements.
AOA Intern Requirements
During their first year, our dual pediatric interns complete a rotation (3 educational units) in obstetrics-gynecology at Doctors Hospital, emergency medicine at Doctors Hospital, and pediatric surgery at NCH. Although our dual interns see many adult patients during the first 2 rotations, their experiences are focused on obtaining more education and exposure that will help them develop as pediatricians. For example, the dual pediatric interns spend more time in postdelivery care and working with lactation specialists than do the other interns (primarily obstetrics-gynecology and family medicine interns) during the obstetrics-gynecology rotation. The focus in the surgical rotation is developing the clinical acumen needed to be a good pediatrician, with dual pediatric interns spending a larger percentage of time in surgical clinic or conducting surgical consultations (eg, evaluation of acute abdominal pain in the emergency department).
OMM Requirements
The OMM requirements consist of 2 educational units plus ongoing time throughout the 3 years of residency. A multi-tiered approach is used to teach OMM.
In every educational unit, all of our dual pediatric residents attend a 4-hour session devoted to teaching OMM. This session consists of a lecture describing osteopathic manipulative treatment (OMT) techniques for a particular body region, followed by hands-on table training and practice. In addition, the dual pediatric residents attend an annual OMM retreat (8 hours in duration) during which an OMM-trained expert focuses on several specific OMT skills. The program invites expert faculty, often from outside Doctors Hospital and NCH, to conduct the training.
The dual pediatric residents are required to take the American College of Osteopathic Pediatricians–sponsored Principles of OMT course (5 online classes as a minimum). During their second year of residency, dual pediatric residents have a rotation devoted to OMM. During this rotation, the residents spend 6 half days per week working alongside faculty in a general pediatric OMM clinic (3 half days per week), a pediatric sports medicine clinic that provides OMT (1 half day per week), and a family medicine/sports medicine clinic focusing on OMM (2 half days per week). The annual continuity clinic rotation provides dual pediatric residents the additional opportunity to attend 1 of the half-day general pediatric OMM clinics weekly.
Also, during their second year of training, the dual pediatric residents rotate with the attending physician in the pediatric division at the Ohio University Heritage College of Osteopathic Medicine in Athens. This rotation occurs with attending physicians who incorporate OMM into their daily practice. The rotation focuses not only on development of OMM skills but also on developing familiarity working in a rural setting and providing both inpatient and outpatient care.
Other Requirements
During their third year, our dual pediatric residents may spend 4 weeks (1 educational unit) at 1 of the following sites (some of which may be repeat rotations): a local tertiary level neonatal intensive care unit, the Ohio University Heritage College of Osteopathic Medicine, a rural teaching hospital in central or southern Ohio, an OMM clinic, or a block conducting research, preferably related to OMM.
In addition, the dual pediatric residents have a number of experiences unique to their training. For example, they have their own continuity clinic, which also houses the general pediatric OMM clinic. They also have their own journal club. Although the articles discussed are often the same as those covered by categorical pediatric residents, the dual residents at times discuss an article specific to osteopathic training. The program also provides funding for residents to attend at least 1 of the annual American College of Osteopathic Pediatricians meetings.
Finally, dual pediatric residents are expected to complete a research project during their training, per AOA requirements.
4 The research is chosen by the resident and does not have to be related to OMM, though OMM research projects are common.
Outcomes
To date, 32 residents have graduated from the program, of whom 19 went into primary care and 13 into fellowships. The fellowships chosen varied, and nearly all fellows were accepted into their first- or second-choice program. For the current third-year class, 2 dual pediatric residents have been accepted into pediatric hematology/oncology fellowships, 1 will be entering primary care, and 1 will be practicing general pediatrics in a rural setting in California.
Thirteen of the 14 graduates who have taken the American Board of Pediatrics board examinations passed on the first attempt, and the 14th passed on the first retry. Twenty of our graduates have taken the American Osteopathic Board of Pediatrics examinations with a 100% pass rate. To our knowledge, none of our residents have taken both of the board examinations, though several of our current seniors plan to take both.
For the past several years, each of our dual pediatric residents have had an abstract accepted and presented at least once during their 3 years in the program.
Next Steps
Expansion of the OMM Experience
With the revised ACGME and AOA training requirements focusing on the individual development of a resident,
3 each of our residents will be asked before their OMM rotation to identify 1 or more OMT techniques in which they want to be proficient. The goal is to have our residents learn OMT skills that they can use in their practice—regardless of the type of practice. For example, we envision dual pediatric residents entering neonatology choosing to focus on OMT techniques specific to treating infants, such as techniques for managing plagiocephaly or feeding disturbances.
Starting in academic year 2015-2016, all of our second-year residents will take a weeklong course on osteopathic cranial manipulative medicine. Eventually, we hope to expand both our general pediatric OMM clinic and pediatric sports medicine clinic so as to allow for an even broader clinical experience for our dual pediatric residents. The goal is to have 8 to 9 half days of OMM clinic available each week to our residents, expanding the experience during their OMM rotation but also during their annual continuity clinic rotations.
Expansion of OMM Research
As noted earlier, each of our dual pediatric residents during their second-year OMM rotation have time to conduct scholarly work related to OMM. The goal is to have our residents think critically about pediatric OMM research and how to build upon it. Although not all residents will be interested in OMM research, the program is committed to providing all of the residents with the statistical and study design expertise needed to successfully complete a research project.
Summary
The dually accredited pediatric residency program was developed to provide interested graduates of osteopathic medical schools an excellent pediatric training experience at one of the largest pediatric hospitals in the United States, complete with opportunities to pursue and expand their unique ability to perform OMM. The central Ohio area has a rich history of osteopathic training,
5 so this program was seen as a logical extension.
As a result of the dedication of the 2 hospital administrations, the devoted faculty, and a great group of residents who are proud of their osteopathic training, the outcomes of our program have been excellent. We have trained residents going into primary outpatient pediatric care, we have trained residents going into (and some already completed) fellowships in a multitude of pediatric subspecialties, and—most importantly—we have trained residents to have very specific skill sets who will be poised to advance the field of osteopathic medicine in pediatrics.
We value the contribution of osteopathic training in pediatric residencies. We hope that our program can be seen as a model of how to successfully train residents interested in maintaining their osteopathic identity while being part of a large children’s hospital residency program.
References
Allopathic and osteopathic medical communities commit to a single graduate medical education accreditation system [news release]. Chicago, IL: American Osteopathic Association; February 26, 2014.
Miller CP.
A Second Voice: A Century of Osteopathic Medicine in Ohio.
Athens: Ohio University Press; 2004.