Abstract
Context: Despite interest by osteopathic medical students in learning and incorporating osteopathic manipulative treatment (OMT) techniques into their future practices, most students indicate that OMT is rarely or never taught during many clinical rotations.
Objective: To determine whether a mandatory OMT course taken during the third year of medical school would influence students’ exposure to OMT, confidence in OMT, intent to continue developing OMT skills, and plan to provide OMT as practicing physicians.
Methods: A mandatory pilot OMT course was implemented in the 2014 third-year curriculum. A survey was then developed to assess students’ attitudes toward OMT. Surveys were administered to students whose third year was in 2013 and thus had not taken the course (group 1) and to students who had taken the course in 2014 (group 2).
Results: Of the 223 students in group 1, 143 (64%) responded. Of the 213 students in group 2, 112 (53%) responded. Students in group 2 reported greater exposure to OMT compared with students in group 1, higher confidence levels in practicing OMT (61 [54%] vs 71 [50%]), greater intent to continue developing OMT skills, and plan to provide OMT as practicing physicians (91 [81%] vs 94 [66%]).
Conclusion: A pilot course in OMT increased students’ levels of confidence in and intent to provide OMT in their future practices.
In the 2013-2014 academic year, colleges of osteopathic medicine (COMs) graduated approximately 5000 osteopathic physicians (ie, DOs).
1 The American Association of Colleges of Osteopathic Medicine (AACOM) is projecting that in the 2018-2019 academic year, the number of DO graduates will increase to 6000,
1 as 11 new COMs, 3 branch campuses, and 8 remote teaching sites have been established since 2005, bringing the total number of colleges, branch campuses, and additional locations to 42.
2 Although DOs currently comprise 7% to 8% of the practicing physician population in the United States, they are quickly approaching 20% of this population, owing to the exponential growth in DO graduates over the past decade.
1,3 This increase, however, has raised concern about how to preserve a unique osteopathic identity, particularly through the use of osteopathic manipulative treatment (OMT).
3,4
Osteopathic physicians are taught to consider the somatic and visceral functions in patients, and it is this whole-person approach that is considered the distinguishing feature of a DO.
5 Studies
4,6 have found that osteopathic medical students are interested in learning and incorporating the techniques of OMT into their future practices. However, Gamber et al
4 reported that most students indicated that OMT was rarely or never taught during many of their clinical rotations. The study
4 also found that 57% of entering osteopathic medical students were interested in or enthusiastic about OMT, but by the time they finished residency, the percentage had decreased to 34%. Of those surveyed, approximately one-third noted that the clinical rotation years directly influenced their current use of OMT.
4 According to the study,
4 82% of fourth-year osteopathic medical students indicated that their OMT skills were “useful” or “very useful,” but the use of OMT during clinical rotations was reported as “sometimes” or “never” by 65%. Gamber et al
4 reported that obstacles to applying OMT in the clinical setting included lack of time (46%), discouragement of the use of OMT by a preceptor (22%), discomfort with skill level (19%), and lack of interest in OMT (6%).
4 Chamberlain and Yates
7 found that by approximately 10 months into their third year, osteopathic medical students were deciding not to perform structural examinations on a standardized patient with chronic obstructive pulmonary disease, reflecting a change in attitudes toward the use of palpatory skills and OMT early in the clinical training years.
Osteopathic medical students require models of physician behavior to understand what it means to embody osteopathic distinctiveness—in particular, having first-hand experiences with physicians who incorporate OMT into practice. Johnson and Kurtz
5 reported that of 979 responses by osteopathic physicians across all specialties, more than 50% used OMT on less than 5% of their patients. Approximately 70% of family physicians reported using OMT on 5% or more of patients, and 31.3% of specialists used OMT on more than 5% of patients. Chamberlain and Yates
7 reported that 36% of third- and fourth-year medical students were given an opportunity to do an osteopathic palpatory evaluation on 5 to 14 of the required rotations, and 28% were given the opportunity to apply OMT. Nonetheless, Teng et al
3 found that when students are exposed to a mandatory osteopathic manipulative medicine (OMM) course in the third- and fourth-year clinical rotations, their levels of comfort with OMT were favorably influenced.
3
The American Osteopathic Association (AOA) Commission on Osteopathic College Accreditation has maintained high standards for OMT training, practice, and evaluation as required for COM accreditation. In addition, Ching and Burke
8 suggested that by increasing the presence of osteopathic principles and practice in the clinical years, graduates’ interest in AOA residencies would increase. In February 2014, the AOA, the American Association of Colleges of Osteopathic Medicine, and the Accreditation Council for Graduate Medical Education (ACGME) agreed to move forward with a single system of graduate medical education accreditation under the ACGME.
9 It is yet to be determined as to the quality and depth of postdoctoral training that the ACGME residency programs with an osteopathic focus will provide.
It is our aim to help keep osteopathic distinctiveness at the forefront of osteopathic medical education. By implementing a mandatory pilot OMT course in the third year, we sought to determine whether mandatory use of OMT skills during the third year would influence students’ exposure to OMT, confidence in OMT, intent to continue developing OMT skills, and plan to provide OMT as practicing physicians. Based on the findings of Teng et al,
3 we hypothesized that these factors would increase.
To address the current requirements of the AOA Commission on Osteopathic College Accreditation and potentially influence interest in continued osteopathic principles and practice, a pilot course with 2 components was created for all third-year students in 2014. To develop the cognitive skills in their clinical OMM knowledge base, students were required to read 13 select chapters and complete postchapter quizzes from
Somatic Dysfunction in Osteopathic Family Medicine.10 Students could electronically access the text and quizzes remotely at all hours. Quiz questions were taken from the supplemental materials in the textbook, and an average of 5 quizzes per chapter were used. Students were permitted to access the quizzes through an online portal. The passing grade for an individual quiz was 80% or higher, and students were permitted 1 retake per quiz.
To nurture students’ understanding of osteopathic philosophy and encourage development of students’ palpatory and psychomotor OMT skills, they were required to perform 6 OMT encounters per year and create encounter notes for each one. Students were allowed to submit 1 note per clinical rotation. They were encouraged to treat patients with OMT when allowed by the preceptor; however, OMT was not required for submission or acceptance of the note. On the OMT encounter note, students were required to document the presenting medical condition and diagnosis, their thought process on important body regions to evaluate for somatic dysfunction related to the presenting medical condition, the osteopathic structural examination findings, the OMT techniques used (if applicable), the immediate results of the treatment, the plan or follow-up recommendations for the patient, and the preceptor’s signature confirming the encounter. Notes were faxed to the Department of Osteopathic Manual Medicine and were reviewed by DO faculty in the department (K.L.H., D.D.L., and S.V.C.). Timely feedback on the notes was delivered, and students were informed whether their notes were accepted for credit.
Successful completion of the course required the completion of the assigned readings and quizzes and the submission of 6 approved OMM encounter notes (
Table 1).
Table 1.
Grading Protocol for Third-Year Osteopathic Medical Students Participating in an OMT Curriculuma
| OMT Course | Points |
| Reading Assignments |
| Chapters 1, 4, and 5 | 20 |
| Chapters 8 and 14 | 20 |
| Chapter 9 | 10 |
| Chapter 7 | 10 |
| Chapter 10 | 10 |
| Chapters 12 and 18 | 20 |
| Chapter 16 | 10 |
| Chapter 26 | 10 |
| Chapter 27 | 10 |
| Total | 120 |
| Diagnostic Procedures |
| OMM diagnosis and summary #1 | 20 |
| OMM diagnosis and summary #2 | 20 |
| OMM diagnosis and summary #3 | 20 |
| OMM diagnosis and summary #4 | 20 |
| OMM diagnosis and summary #5 | 20 |
| OMM diagnosis and summary #6 | 20 |
| Total | 120 |
Table 1.
Grading Protocol for Third-Year Osteopathic Medical Students Participating in an OMT Curriculuma
| OMT Course | Points |
| Reading Assignments |
| Chapters 1, 4, and 5 | 20 |
| Chapters 8 and 14 | 20 |
| Chapter 9 | 10 |
| Chapter 7 | 10 |
| Chapter 10 | 10 |
| Chapters 12 and 18 | 20 |
| Chapter 16 | 10 |
| Chapter 26 | 10 |
| Chapter 27 | 10 |
| Total | 120 |
| Diagnostic Procedures |
| OMM diagnosis and summary #1 | 20 |
| OMM diagnosis and summary #2 | 20 |
| OMM diagnosis and summary #3 | 20 |
| OMM diagnosis and summary #4 | 20 |
| OMM diagnosis and summary #5 | 20 |
| OMM diagnosis and summary #6 | 20 |
| Total | 120 |
×
Although the percentage of hands-on OMT experiences was reported to be low in the third-year curriculum by students overall, after implementation of the pilot OMT course, students in group 2 reported an increase in exposure to OMT, an increase in confidence in practicing OMT, an increase in intent to continue developing OMT skills, and a plan to provide OMT in their future practices. Although the pilot course could not influence the frequency of patient presentations appropriate for OMT, it did appear to influence the students’ willingness to look for opportunities to observe and participate in OMT.
These results, along with those of Teng et al,
3 support efforts to increase OMT experiences during clinical rotations. It is our hope that by requiring OMT experiences in the third and fourth years of osteopathic medical school, preceptors will develop a heightened awareness of the importance of providing clinical experiences and training in OMT. In a grassroots manner, perhaps this effort will also increase the number of patients that a preceptor decides to treat with OMT.
Surveys are useful to determine the attitudes of a large participant population; however, this method has some research limitations. On average, survey response rates have been found to range from 30% to 55%.
11 Our response rates of 64% and 53% were high. The use of self-reported data by voluntary participants has the potential for bias. Students may have overreported or underreported confidence levels, intent to continue developing OMT skills, or plan to provide OMT as practicing physicians. Similarly, the self-reported data may have been influenced by the participants’ interest level in OMT. To help minimize this bias, all surveys were anonymous and submitted electronically. No points were awarded toward the students’ overall grade for completing the survey. The present study included only students from DMU-COM; therefore, the results may not be generalizable to other COMs, although DMU-COM is similar to many other COMs in that it does not currently require an OMT rotation.
Further research should be conducted to determine whether there is a difference in students’ exposure to OMT, confidence in OMT, intent to continue developing OMT skills, and plan to provide OMT when rotating with DO vs MD preceptors. Future research could also longitudinally track the current respondents into their clinical practice to determine whether intentions to use OMT can predict use in practice. Also, with the results of our survey as a baseline, we are planning to repeat the survey in future years for comparison and tracking.