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JAOA/AACOM Medical Education  |   September 2018
Osteopathic Distinction, One Student at a Time
Sharon Obadia, DO
Author Notes
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Sharon Obadia, DO, A.T. Still University, School of Osteopathic Medicine in Arizona, 5850 E Still Cir, Mesa, AZ 85206-3618. Email: sobadia@atsu.edu
     
Article Information
Medical Education / Being a DO / Graduate Medical Education
JAOA/AACOM Medical Education   |   September 2018
Osteopathic Distinction, One Student at a Time
The Journal of the American Osteopathic Association, September 2018, Vol. 118, 607-609. doi:https://doi.org/10.7556/jaoa.2018.134
The Journal of the American Osteopathic Association, September 2018, Vol. 118, 607-609. doi:https://doi.org/10.7556/jaoa.2018.134
As the graduate medical education landscape shifts, culminating in 2020 with the completion of the transition to a single accreditation system for graduate medical education,1 osteopathic medical students participating in the National Resident Matching Program will not have the option of residency spots that the American Osteopathic Association has historically provided.2 In this increasingly competitive environment for residency program positions, osteopathic medical students may wonder how they can stand out during their core, elective, and audition clinical rotations so that residency program directors will view them as desirable candidates and want them to rank their program first in their chosen specialty. 
This is a seminal moment for the osteopathic medical profession. It is incumbent for teachers of osteopathic medical students, whether they are core faculty members at colleges of osteopathic medicine or preceptors at clinics or hospitals, to provide strong role modeling and guidance for osteopathic medical students that will encourage them to be emboldened to accentuate the unique attributes that an osteopathic physician (ie, DO) can bring to patient and community health care. This confidence will help them to shine during their clinical rotations. 
In 2014, the Association of American Medical Colleges established core entrustable professional activities (EPAs) for entering residency with the intent to guide medical schools in competency-based preparation of students for their first day of residency (Table).3 In 2016, the American Association of Colleges of Osteopathic Medicine (AACOM) published “Osteopathic Considerations for Core Entrustable Professional Activities (EPAs) for Entering Residency,” 4 which aligns each core EPA with specific osteopathic core competencies.5 It is imperative that these competency-based osteopathic considerations are emphasized by teachers of osteopathic medical students by modeling behavior, such as taking medical histories, performing physical examinations, and treating patients, and by fostering the concept that, as a product of an osteopathic education, these students bring distinct value to any residency program. In ensuring that osteopathic medical students confidently display their osteopathic distinctiveness and understand that they bring unique contributions to preceptors when offering the osteopathic approach to patient care, teachers of osteopathic medicine will be assisting them in matching successfully to their desired residency programs. 
Table.
Core Entrustable Professional Activities (EPAs)3
EPA Description
1 Gather a history and perform a physical examination
2 Prioritize a differential diagnosis following a clinical encounter
3 Recommend and interpret common diagnostic and screening tests
4 Enter and discuss orders and prescriptions
5 Document a clinical encounter in the patient record
6 Provide an oral presentation of a clinical encounter
7 Form clinical questions and retrieve evidence to advance patient care
8 Give or receive a patient handover to transition care responsibly
9 Collaborate as a member of an interprofessional team
10 Recognize a patient requiring urgent or emergent care and indicate evaluation and management
11 Obtain informed consent for tests and/or procedures
12 Perform general procedures of a physician
13 Identify system failures and contribute to a culture of safety and improvement
View Large
Table.
Core Entrustable Professional Activities (EPAs)3
EPA Description
1 Gather a history and perform a physical examination
2 Prioritize a differential diagnosis following a clinical encounter
3 Recommend and interpret common diagnostic and screening tests
4 Enter and discuss orders and prescriptions
5 Document a clinical encounter in the patient record
6 Provide an oral presentation of a clinical encounter
7 Form clinical questions and retrieve evidence to advance patient care
8 Give or receive a patient handover to transition care responsibly
9 Collaborate as a member of an interprofessional team
10 Recognize a patient requiring urgent or emergent care and indicate evaluation and management
11 Obtain informed consent for tests and/or procedures
12 Perform general procedures of a physician
13 Identify system failures and contribute to a culture of safety and improvement
×
To encourage osteopathic medical students to develop their osteopathic clinical reasoning skills and spotlight osteopathic principles and practice in alignment with the osteopathic considerations within each EPA, teachers must continually advise them to take the following actions: 
  • ■ To provide care that incorporates your patient's body, mind, and spirit, take time to learn the patient's story so that you can understand the reality in which the patient lives and how his or her circumstances may have contributed to their current condition. This understanding includes taking a thorough social history that incorporates questions that address your patient's social determinants of health, such as “Have you been without a home at any time in the past year?” “Can you safely walk in your neighborhood?” and “How do you get your medications?” Only then will you be able to work with that patient to create a successful plan of care for addressing his or her chief complaint. (EPA 1)
  • ■ Take ownership of obtaining and refining your clinical reasoning skills beginning on your first day of medical school. For each simulated or real patient you encounter, incorporate your knowledge of osteopathic principles and basic science concepts with the patient's social and medical history and physical examination findings, along with laboratory and diagnostic test results, to determine the cause of each symptom. (EPA 2, 3, and 7)
  • ■ From the first week of medical school, ask your physician teachers to describe their clinical reasoning processes to you when working through a patient presentation to formulate a differential diagnosis. Ask your DO teachers how osteopathic principles and practice are incorporated into their processes. Remember that your training as a student becoming a physician is an apprenticeship model. Learn as much as possible from each physician's process. (EPA 2)
  • ■ When on clinical rotations, take the initiative to ask your physician teachers, residents, and interns if you can orally present patients to them. Be concise and efficient in your oral presentations. Ensure that pertinent aspects of your patient's story are included to demonstrate that you are incorporating the whole person into your clinical reasoning process, not solely the clinical condition. When presenting physical examination findings, especially highlight osteopathic findings that demonstrate the relationship between structure and function when there is clearly a malalignment of the 2 that is relevant to the patient's clinical condition. Also, ask these mentors to review your notes on the patient's history, physical examination findings, SOAP (subjective, objective, assessment, plan) note forms, and progress notes with you. Ask your DO teachers to provide feedback on your documentation of osteopathic structural examinations and osteopathic manipulative medicine procedural notes. Push yourself to write notes on your patients, even if it has not been asked of you. The consistent practice of writing notes on and orally presenting findings will continually hone your clinical reasoning skills.6 (EPA 2, 5, and 6)
  • ■ Know your osteopathic physical examination techniques, especially for musculoskeletal examinations. These examinations are the bread and butter of the osteopathic medical profession. Your non-DO teachers, residents, and interns can look to you for expertise in the diagnostic evaluation of the spine, as well as the upper and lower extremities. They may ask your advice on the performance and results of shoulder and knee examinations. You will have expertise in these areas well before the end of your second year of medical school. Be confident and show off your skills. (EPA 1, 2, and 12)
  • ■ Be an ambassador of the osteopathic medical profession. Be empowered to offer to perform an osteopathic manipulative treatment (OMT) to your physician teachers when you feel it can help a patient. As an osteopathic medical student, you bring added value to every patient encounter when taking the initiative in offering to demonstrate how OMT may help in the care of a patient. The AACOM website houses rich resources7 that COMs use as faculty development guides to enable allopathic physician teachers of osteopathic medical students to supervise the performance of basic OMT procedures. Refer your preceptors to these resources if they are unfamiliar with OMT procedures. (EPA 12)
  • ■ Remember that OMT is, as Andrew Taylor Still, MD, DO, wrote, the extension of “the touch of the soft hand of kindness”8(p459) to those in need. A simple occiptioatlantal decompression or thoracolumbar kneading and stretching may ease a patient's body, mind, and spirit. (EPA 12)
  • ■ Keep in mind that you are continuously being evaluated during clinical rotations. Draw on your strengths as an osteopathic medical student to consistently demonstrate the utmost professionalism9 and collegiality when interacting and collaborating with members of the health care team, including front office and ancillary staff. In 2016, 70% of residency program directors from all specialties cited “Evidence of Professionalism and Ethics” as an important factor in selecting applicants to interview.10 (EPA 9)
Conclusion
In this increasingly competitive era of graduate medical education, teachers of osteopathic medical students are strongly urged, through emphasis on the osteopathic considerations for core EPAs,4 to encourage and empower students to be osteopathically distinct on every clinical rotation. This distinction will enable students to make strong and lasting impressions that will move their physician teachers to offer interviews for residency program positions and write positive comments on end-of-rotation evaluations. These accolades can then be transferred as direct quotations into the students’ Medical Student Performance Evaluations, which are closely reviewed by residency program directors in their selection of students during the match process.10 Each osteopathic medical student is a future colleague, and the future of the osteopathic medical profession is in their hands. 
Acknowledgment
I thank Frederic N. Schwartz, DO, for his editorial support. 
References
Allopathic and osteopathic medical communities commit to a single graduate medical education accreditation system [press release] Accrediation Council on Graduate Medical Education website. http://www.acgme.org/portals/0/PDFS/Nasca-Community/SingleAccreditationRelease2-26.pdf. Posted February 26, 2014. Accessed November 11, 2017.
Single GME student FAQs. American Osteopathic Association website. https://www.osteopathic.org/inside-aoa/single-gme-accreditation-system/Pages/single-gme-student-faqs.aspx. Accessed February 8, 2018.
Core Entrustable Professional Activities for Entering Residency: Curriculum Developers’ Guide. Washington, DC: Association of American Medical Colleges; 2014. https://members.aamc.org/eweb/upload/Core%20EPA%20Curriculum%20Dev%20Guide.pdf. Accessed July 26, 2018.
Osteopathic Considerations for Core Entrustable Professional Activities (EPAs) for Entering Residency. Chevy Chase, MD: American Association of Colleges of Osteopathic Medicine; 2016. https://www.aacom.org/docs/default-source/med-ed-presentations/core-epas.pdf?sfvrsn=10. Accessed July 26, 2018.
Osteopathic Core Compe­tencies for Medical Students. Chevy Chase, MD: American Association of Colleges of Osteopathic Medicine; 2012. http://www.aacom.org/docs/default-source/insideome-2012TB3/corecompetencyreport2012.pdf?sfvrsn=0. Accessed July 26, 2018.
Diemer G, Salt J, Rebbecchi T. Using progress notes to assess clinical reasoning. Acad Intern Med Insight. 2012;10(3):16-17.
Heath DM, King H, Morris W, Kirsch J, Schwartz F. Training MDs to Supervise DO Students Performing OMM. Bethesda, MD: American Association of Colleges of Osteopathic Medicine; 2016. https://www.aacom.org/docs/default-source/med-ed-presentations/top10ppt.pdf. Accessed November 11, 2017.
Still AT. Autobiography of Andrew T. Still. Kirksville, MO: published by the author; 1897:459.
Swick HM. Toward a normative definition of medical professionalism. Acad Med. 2000;75(6):612-616. [CrossRef] [PubMed]
Results of the 2016 NRMP Program Director Survey. Washington, DC: National Resident Matching Program; 2016. http://www.nrmp.org/wp-content/uploads/2016/09/NRMP-2016-Program-Director-Survey.pdf. Accessed July 26, 2018.
Table.
Core Entrustable Professional Activities (EPAs)3
EPA Description
1 Gather a history and perform a physical examination
2 Prioritize a differential diagnosis following a clinical encounter
3 Recommend and interpret common diagnostic and screening tests
4 Enter and discuss orders and prescriptions
5 Document a clinical encounter in the patient record
6 Provide an oral presentation of a clinical encounter
7 Form clinical questions and retrieve evidence to advance patient care
8 Give or receive a patient handover to transition care responsibly
9 Collaborate as a member of an interprofessional team
10 Recognize a patient requiring urgent or emergent care and indicate evaluation and management
11 Obtain informed consent for tests and/or procedures
12 Perform general procedures of a physician
13 Identify system failures and contribute to a culture of safety and improvement
View Large
Table.
Core Entrustable Professional Activities (EPAs)3
EPA Description
1 Gather a history and perform a physical examination
2 Prioritize a differential diagnosis following a clinical encounter
3 Recommend and interpret common diagnostic and screening tests
4 Enter and discuss orders and prescriptions
5 Document a clinical encounter in the patient record
6 Provide an oral presentation of a clinical encounter
7 Form clinical questions and retrieve evidence to advance patient care
8 Give or receive a patient handover to transition care responsibly
9 Collaborate as a member of an interprofessional team
10 Recognize a patient requiring urgent or emergent care and indicate evaluation and management
11 Obtain informed consent for tests and/or procedures
12 Perform general procedures of a physician
13 Identify system failures and contribute to a culture of safety and improvement
×