Osteopathic medicine has arrived at a crossroads. The transition to a single accreditation system (SAS) for graduate medical education (GME), which will conclude in 2020, has created uncertainty about the training of osteopathic physicians (ie, DOs) and consequently the future of osteopathic medicine. One reason for the uncertainty is that the Accreditation Council for Graduate Medical Education (ACGME), which has been responsible for accrediting only allopathic (ie, MD) programs, will become the sole accrediting body for
all residency programs.
1 Also, although both medical education models have used physician competencies as a framework for the training of students and residents, the competencies are defined differently by DO and MD accreditation systems. Allopathic programs use a set of 6 core competencies defined by the ACGME.
2 The osteopathic competencies have similar names, but the definitions reflect osteopathic principles and practice (OPP), and the set includes a seventh, distinctly osteopathic competency.
3
Resolving these discrepancies has been a priority in establishing the SAS. For example, the ACGME has designated an Osteopathic Recognition Committee (ORC), which has defined distinctively osteopathic criteria for GME programs seeking to attain Osteopathic Recognition.
4 However, residencies that admit DO graduates will not be required to use these guidelines if the program does not have Osteopathic Recognition. Whether programs not seeking Osteopathic Recognition will accommodate osteopathic competencies, and how their decision will affect DO graduates, remains unknown.
4
In our view, the current measures to promote Osteopathic Recognition in the SAS are insufficient to protect a distinctively osteopathic approach to medical practice, particularly among DO graduates in residency programs that do not seek the additional recognition. The American Association of Colleges of Osteopathic Medicine (AACOM) has addressed this issue by embedding osteopathic considerations within the framework of the 13 Entrustable Professional Activities (EPAs) developed by the Association of American Medical Colleges (AAMC) to define MD student readiness to enter residency.
5,6 Although we applaud and enthusiastically embrace this effort, we also believe that the adoption of a distinctively osteopathic EPA—proposed in the following paragraphs—would help both MD and DO educators recognize and nurture the unique attributes and skills that DO graduates can be expected to bring to patient care. It would also enhance the profile of osteopathic distinctiveness in the context of the SAS.
Discrepancies in DO and MD Competencies?
Differences in the use and assessment of competencies, not only between DO and MD programs but also within MD programs, was a key factor in the development of the SAS.
7 Medical educators have long sought ways to standardize the implementation of physician competencies by basing assessment of competency attainment on directly observable and consistent standards. The ongoing concern that MD and DO competencies are different was illustrated when the ACGME determined that only physicians trained in ACGME-accredited programs were eligible for ACGME fellowships. It was posited that evidence of attaining the requisite competencies would not exist for physicians trained in non-ACGME programs.
8 The possibility that graduates of residency programs accredited by the American Osteopathic Association could be denied access to ACGME-accredited fellowships led to negotiations that resulted in the announcement of the SAS.
1,7,8 Concurrent innovations to resolve discrepancies and promote consistency in the assessment of competence include the ACGME milestone project
9 and the development of EPAs by the AAMC.
6
Ensuring Osteopathic Competencies in the SAS
As undergraduate medical educators working in a college of osteopathic medicine, we focus on preparing students to meet expectations for entering residency. We use the 7 osteopathic core competencies as a guide because we expect our graduates to have a strong osteopathic identity and to be competent in osteopathic skills as well as osteopathic thinking
. At the same time, it is our responsibility to respond to residency programs’ expectations of our graduates. We believe that as lists of observable and assessable tasks that include every “essential clinical activity that defines the profession,”
10 EPAs will be useful to identify the attainment of competence that underlies the performance of definitively DO activities and will therefore facilitate communication between colleges of osteopathic medicine and residency programs regarding student readiness.
5,10,11
We are not alone in the view that EPAs will constitute an important curriculum tool to aid in the transition from undergraduate to graduate programs. The importance and utility of EPAs in the assessment of DO competence is evident in the new, competency-based blueprint and accompanying documentation developed by the National Board of Osteopathic Medical Examiners for its licensure examination series.
12 The importance of EPAs is also evident in the 13 EPAs published by the AAMC to characterize MD student readiness for residency training.
6,8,13 Importantly, each EPA in the guide is accompanied by a listing of underlying physician competencies selected from the 6 core allopathic competencies.
Missing from this guide are distinctively osteopathic definitions of the physician competencies, as well as distinctively osteopathic EPAs, such as being entrustable to perform osteopathic structural examinations or obtain informed consent to perform osteopathic manipulative treatment. It is therefore evident that while the 13 listed activities may be applicable to every medical student, they do not include every essential clinical activity that defines the practice of osteopathic medicine. Therefore, they are an insufficient guide for DOs in residency programs that do not have Osteopathic Recognition.
DO and MD Competency Components: An Analysis
We performed an analysis that illustrates this point. Using a data table available on the AAMC website to align osteopathic competencies with MD competencies,
14,15 we compiled a list of DO competency components referenced by the allopathic EPAs. We then counted and computed the frequency with which each osteopathic competency was referenced (
Figure 1). The 7 osteopathic competencies comprise 332 components; 240 components were referenced at least once, and many were referenced multiple times, resulting in a total of 1269 references. The osteopathic competency most frequently referenced in the allopathic EPAs was OPP, which we believe reflects that osteopathic principles are embedded in all aspects of medical care.
Using the same dataset, we identified 92 components (28%) of the osteopathic competencies that were incompletely or not at all referenced.
Figure 2 shows a selection of these components.
Where We Go From Here
AACOM has begun to remedy the lack of distinctively osteopathic competencies by embedding essential osteopathic skills as they align with each of the 13 allopathic EPAs in
Osteopathic Considerations for Core Entrustable Professional Activities for Entering Residency.
5 For example, EPA 1, “Gather a History and Perform a Physical Examination,” features “Identify, describe, and document abnormal physical exam findings, including osteopathic structural findings (e.g. somatic dysfunction, TART, etc.).”
5
This approach assumes that all physicians have a clear understanding that osteopathic medicine is more than a list of skills. It does not provide sufficient context for faculty unfamiliar with osteopathic medicine to effectively assess whether the skills are
used osteopathically—that is, used to find cause and health and to understand the relationship between structure and function. Osteopathic medicine entails an approach to patient care that relies on a philosophy and reasoning process to inform the application of distinctive skills. While we value the work of AACOM, we suspect it could negatively affect entrustment decisions. For example, in the AACOM draft of EPA 4, “Enter and Discuss Orders and Prescriptions,” the entrustable student is described as “able to synthesize the information at hand from the patient's history, physical exam,
including the osteopathic structural exam [italics added], and review of existing studies.”
5 Without additional context regarding the osteopathic reasoning behind performing the structural examination, faculty members who are not osteopathically trained may be challenged to make an appropriate entrustment decision. Furthermore, embedding osteopathic considerations within each EPA, as it is in AACOM's EPAs,
5 requires an educator to synthesize a picture of OPP from a fragmented list of skills scattered throughout a 68-page document.
We believe the interrelationship of osteopathic philosophy, reasoning, and practice, is the heart and foundation of the osteopathic tradition. Our findings (
Figure 1 and
Figure 2) and the work of AACOM lead us to conclude that while the framework of EPAs for MDs is appropriate for DO graduates, it does not describe a single, definitively osteopathic professional activity through which full competence in OPP can be demonstrated. To address this problem, we recommend national adoption of an osteopathic EPA.
We have drafted an osteopathic EPA, “Integrate Osteopathic Principles and Practice into Clinical Practice,” which consists of a concise, holistic description of osteopathic professional activity (eAppendix). Our proposed EPA follows the model of the AAMC and includes osteopathic pre-entrustable and entrustable behaviors and vignettes. It describes an approach that includes procedures, which are important, but it places osteopathic reasoning and principles in the forefront because many DOs who never use osteopathic manipulative treatment techniques are still dedicated to the osteopathic philosophy. We believe that adopting such an EPA nationally, whether or not it is the one we propose, would promote reliability in entrustment decisions by providing context for the embedded osteopathic considerations. A discreet, stand-alone EPA would also facilitate locating osteopathic content.
Effects and Limits
At the Touro University College of Osteopathic Medicine-CA, we use EPAs in a learner-directed third-year course in which students target specific EPAs for development, including the osteopathic EPA. Students self-assess using a “rubric of entrustability.”
16 They then direct their own growth by targeting a higher level of entrustability to achieve by the end of the course, and faculty members provide narrative feedback on their progress. Our aim is for this program to generate outcome data on the osteopathic EPA while promoting a stronger understanding of the utility of EPAs among faculty and enhanced readiness for residency among students.
We recognize that a single tool cannot be expected to resolve all of the uncertainties presented by implementation of the SAS and different core competencies. The benefits of an osteopathic EPA can only accrue if it is used, and accreditation standards do not currently compel the use of any EPAs. Programs that do not apply for Osteopathic Recognition will not be compelled to evaluate osteopathic entrustability. Even if the use of EPAs was required and an osteopathic EPA or osteopathic considerations embedded within each EPA were adopted, use could be limited by the inconvenience of having to consult separate documents for DO and MD residents. We also recognize that our proposal for an osteopathic EPA was developed by a single school and has not been vetted nationally.
Conclusion
Osteopathic medicine is a different way to practice medicine. Adopting an osteopathic EPA would offer all stakeholders, from students to both DO and MD program directors, a rich, useful, holistic description of osteopathic distinction that might otherwise be reduced to a list of skills that are fragmented and ultimately lost in a lengthy document. An osteopathic EPA would illustrate distinctively osteopathic practices that residency directors should expect from DO graduates while providing a streamlined tool to directly identify entrustability with the skills and philosophy of osteopathic medicine.
17 Perhaps most importantly, we believe the national adoption of an osteopathic EPA could hold the space for osteopathic distinctiveness in residency programs that do not seek Osteopathic Recognition.
Editor's Note: To view the proposed EPA in the eAppendix, which is available online only, access this article at JAOA.org.
eAppendix.
Proposed Osteopathic Entrustable Professional Activity (EPA), including pre-entrustable and entrustable behaviors by competency components (bolded items are proposed by the authors) and pre-entrustable and entrustable vignettes. The layout, format, and design of this proposed EPA are modeled after the Association of American Medical Colleges’
Core Entrustable Professional Activities for Entering Residency: Curriculum Developers’ Guide.
6
Pre-Entrustable Learners
Expected behaviors for a pre-entrustable learner
The learner at this level uses a template or screening examination for osteopathic diagnoses. He or she is unable to integrate osteopathic reasoning into choice of history and physical examination findings and differential diagnosis. He or she is aware of anatomic relationships that are spatially obvious and bases osteopathic examination and treatment on these basic relationships rather than on an understanding of normal anatomy, physiology, and the interrelated nature of structure and function. The learner offers osteopathic manipulative treatment (OMT) but is unable to offer evidence or explanation for why it would be useful beyond basic understanding such as pain reduction or alignment of musculoskeletal aberrations. Documentation of findings and treatment lacks specificity.
Vignette for a pre-entrustable learner
Justin is currently working with the in-patient internal medicine team and is completing morning rounds. His first patient of the day is Mr. Thompson, a 75-year-old man admitted 2 days ago for pneumonia. Justin begins by reviewing Mr. Thompson's vital signs and morning laboratory results in the computer, as well as the current medications.
Justin then goes to Mr. Thompson's room for further evaluation. He begins by asking him how he is feeling, if he has had improvement of his cough, any if he has any pain, discomfort, or associated symptoms. Mr. Thompson notes that he is feeling a little better, though he is still coughing a lot and intermittently feeling feverish and that his appetite has not yet returned. He has some mild lower rib pain on the right side that has been present since the coughing started.
Justin then proceeds with a physical examination, including a general evaluation, mental status evaluation, listening to lung fields, listening for heart sounds in all 4 positions, observing skin for color, checking capillary refill, and palpating proximal and distal pulses. He checks the cervical and axillary lymph nodes. Additionally, he palpates the T2-T6 thoracic region looking for somatic dysfunction representing viscerosomatic reflexes. He notes some hypertonicity in the thoracic paraspinal region.
Justin reviews the patient encounter with Mr. Thompson with his attending physician. He appropriately organizes and presents the history and physical examination findings. He describes the somatic dysfunction found in the thoracic region as “Hypertonic paraspinals from T2-6 bilaterally” and that it may represent a viscerosomatic reflex. Justin's attending asks him why he would want to use OMT in a patient with pneumonia, and he has difficulty outlining why it would be helpful other than it may help decrease sympathetic tone via the viscerosomatic reflex. Justin's attending asks if there is any research support for the use of OMT in patients with pneumonia, and Justin is unsure. Justin's attending is supportive of the use of OMT and would like him to perform it on the patient.
Justin and his attending return to the patient's room, and Justin chooses to perform soft tissue technique after contemplating other technique choices, such as high-velocity, low-amplitude (HVLA). He decides against HVLA because of Mr. Thompson's level of illness and age. He begins the technique and the patient asks, “What are you doing?” Justin replies that he is performing OMT and it will help him to feel better. The patient allows the treatment to continue. When he is finished, Mr. Thompson expresses gratitude for the “massage,” and he and Justin discuss his physical examination and laboratory findings and what they indicate for Mr. Thompson.
Justin returns to the medical record and documents his note including the somatic dysfunction of “thoracic hypertonicity” found on physical examination. Additionally, in his plan, he notes that OMT was performed to the thoracic region.
Entrustable Learners
Expected behaviors for an entrustable learner
The learner at this level is able to routinely apply the four tenets of osteopathic medicine to the gathering of data and development of a diagnostic plan and in application of a treatment. Having retained sufficient understanding of normal anatomy and physiology, the learner is able to integrate and link current findings to prior clinical experiences and understanding of how structure and function are interrelated. Osteopathic physical examination is accurate and reported using appropriate anatomic or medical terms. Using best evidence and language appropriate to the listener, including the patient or health care team members, the learner is able to explain the reasoning for and use of OMT. The learner can prioritize, based on the urgency of the patient setting, which aspects of osteopathic history, physical examination, and treatment are most appropriate. The learner knows his or her limitations and appropriately seeks help or refers for other care.
Vignette for an entrustable learner
Justin is currently working with the in-patient internal medicine team and is completing morning rounds. His first patient of the day is Mr. Thompson, a 75-year-old man admitted 2 days ago for pneumonia. Justin begins by reviewing Mr. Thompson's vital signs, morning laboratory results, and current medications. Justin then goes to Mr. Thompson's room for further evaluation. He begins by asking him how he is feeling, if he has had improvement of his cough, and about associated symptoms, including if he has any pain or discomfort. Mr. Thompson notes that he is feeling a little better, but he is still coughing a lot and intermittently feels feverish. His appetite has not yet returned, and he has some mild lower rib pain on the right side that has been present since the coughing started.
Justin then proceeds with a physical examination, including a general evaluation, mental status evaluation, listening to lung fields, listening for heart sounds in all 4 positions, observing skin for color, checking capillary refill, and palpating proximal and distal pulses. He checks the cervical and axillary lymph nodes. Additionally, he palpates the T2-T6 thoracic region looking for somatic dysfunction representing a viscerosomatic reflex. He notes some hypertonicity in the thoracic paraspinal region as well as some segmental dysfunction. Justin examines the ribs and finds the right first rib elevated and the right ribs 4-6 exhaled. He also notes diaphragm restriction on the right, the cervicothoracic junction rotated right, as well as a tender Chapman point on the right between the first and second rib.
Justin reviews the patient encounter with Mr. Thompson with his attending physician. He appropriately organizes and presents the HPI and the physical examination under which he describes the somatic dysfunction found in the thoracic region, ribs, and diaphragm. In his assessment and plan he describes to his attending how treating these areas will help address viscerosomatic reflexes (thoracic spine), adequate respiration (ribs/diaphragm), and decreased pain by addressing rib motion, as well as adequate lymphatic and vascular flow by treating the diaphragm and thoracic inlet. Justin's attending asks if there is any research on using OMT in patients with pneumonia, and Justin states he knows of several published in the JAOA and can pull them up for review. Justin's attending is supportive of the use of OMT and would like him to perform it on the patient.
Justin and his attending return to the patients' room. He chooses to perform soft tissue and balanced ligamentous tension models of treatment after contemplating other technique choices, such as HVLA. He decides against HVLA because of Mr. Thompson's level of illness and age. Before beginning OMT, he discusses with Mr. Thompson what he has found on physical examination and how he believes OMT may help. He outlines risks and benefits of the procedure and asks if Mr. Thompson would like to consent to treatment. Mr. Thompson consents, and Justin performs OMT to address the somatic dysfunction. When he is finished he checks in with Mr. Thompson to see how he is feeling and counsels him on what to expect after treatment. He then discusses the physical examination and laboratory findings and what they indicate for Mr. Thompson.
Justin returns to the medical record and documents his note, including the following somatic dysfunction: THORAX: T3ERSr, T5ERSl, hypertonic paraspinals bilaterally T2-6, right diaphragm restriction, right respiratory Chapman point, cervicothoracic junction rotated right; RIBS: right rib 1 elevated, right ribs 4-6 exhaled, T/L junction rotated right. He finishes his assessment and plan with a procedure note including consent, reason for treatment, type of treatment, body areas treated, patient response, and posttreatment follow-up.
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