To the Editor: 

The study by Snider et al¹ in the September 2015 issue of The Journal of the American Osteopathic Association examined table trainer-to-student ratios (TTRs), which is a vital component of osteopathic medical education. However, the study design failed to incorporate elements widely recognized as fundamental to the effective teaching of osteopathic manipulative treatment (OMT), thus limiting the conclusions that may be drawn. For example, OMT requires palpatory skills that cannot be taught by a handout or video but rather by repetition and practice under the hands-on guidance of experienced osteo-pathic physicians. Snider et al¹ chose to use a combined Microsoft PowerPoint and video presentation, the limitations of which they acknowledge in their discussion. However, they offer few details about the context of the workshops: What was the level of experience of the table trainers? Was hands-over-hands training offered? How much time was spent at the treatment tables? It is unclear to what extent the study workshops reflected OMT laboratories as they are conducted in colleges of osteopathic medicine today. 

Perhaps most importantly, the study¹ looked at retention after a single workshop. Yet OMT skills—as with all clinical skills—are only honed through repetition. It is difficult to draw a meaningful conclusion regarding TTRs when the learning environment was compromised in these critical ways. The authors note that post-workshop practical assessment scores were higher for the 1:4 and 1:8 TTR groups, but not the 1:16 group. This finding begs the question of whether this disparity might also prove to be the case after OMT laboratories. Since laboratories are conducted weekly, it is reasonable to consider that repetition and consistent study in an environment with lower TTRs may, over the course of the 2 academic years, result in students’ improved practical skills. 

Additionally, it is worth noting that the dropout rate for the 1:16 TTR group was 3 times higher than that for the 1:4 and 1:8 TTR groups. Perhaps, without the close engagement of table trainers, these students simply lost interest. I hope that future research takes these points into account.