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Special Communication  |   January 2020
2019 United States Osteopathic Medical Regulatory Summit: Consensus, Recommendations, and Next Steps in Defining Osteopathic Distinctiveness
Author Notes
  • From the National Board of Osteopathic Medical Examiners in Conshohocken, Pennsylvania (Drs Gimpel and Shaffer and Ms Turner); Covenant Health Systems in Lewiston, Maine (Dr Belanger); University of North Texas Health Science Center in Fort Worth (Dr Knebl); A.T. Still University in Kirksville, Missouri (Dr LaBaere); the American Association of Colleges of Osteopathic Medicine in Bethesda, Maryland (Dr Shannon); the American Osteopathic Association (Ms Shears and Dr Williams); and the Federation of State Medical Boards in Euless, Texas (Dr Steingard). 
  • Financial Disclosures: None reported. 
  • Support: Financial support for this work was provided by the Osteopathic Heritage Foundations and the Osteopathic Founders Foundation, with additional financial sponsorship provided by the American Osteopathic Association, the American Association of Colleges of Osteopathic Medicine, and the National Board of Osteopathic Medical Examiners. 
  •  *Address correspondence to John R. Gimpel, DO, MEd, President, National Board of Osteopathic Medical Examiners, 101 W Elm St, Ste 150, Conshohocken, PA 19428-2004. Email: jgimpel@nbome.org
     
Article Information
Medical Education / Graduate Medical Education
Special Communication   |   January 2020
2019 United States Osteopathic Medical Regulatory Summit: Consensus, Recommendations, and Next Steps in Defining Osteopathic Distinctiveness
The Journal of the American Osteopathic Association, January 2020, Vol. 120, 35-44. doi:https://doi.org/10.7556/jaoa.2020.005
The Journal of the American Osteopathic Association, January 2020, Vol. 120, 35-44. doi:https://doi.org/10.7556/jaoa.2020.005
Abstract

Background: Osteopathic distinctiveness is a result of professional education, identity formation, training, credentialing, and qualifications. With the advancement of a single graduate medical education (GME) accreditation system and the continued growth of the osteopathic medical profession, osteopathic distinctiveness and professional identity are seen as lacking clarity and pose a challenge.

Summit: To achieve consensus on a succinct definition of osteopathic distinctiveness and to identify steps to more clearly define and advance that distinctiveness, particularly in professional self-regulation, a representative group of osteopathic medical students, residents, physicians, and members of the licensing, GME, and undergraduate medical education (UME) communities convened the 2019 United States Osteopathic Medical Regulatory Summit in February 2019. Key features of osteopathic distinctiveness were discussed. Growth in the profession; changes in health care delivery, technology, and demographics within the profession and patient communities; and associated challenges and opportunities for osteopathic medical practice and patients were considered.

Consensus: Osteopathic medicine is a distinctive practice that brings unique, added value to patients, the public, and the health care community at large. A universal definition and common understanding of that distinctiveness is lacking. Efforts to unify messaging that defines osteopathic distinctiveness, to align the distinctive elements of osteopathic medical education and professional self-regulation across a continuum, and to advance research on care and educational program outcomes are critical to the future of the osteopathic medical profession.

Recommendations: (1) Convene a task force of groups represented at the Summit to develop a succinct and consistent message defining osteopathic distinctiveness. (2) Demonstrate uniqueness of the profession through research demonstrating efficacy of care and patient outcomes, adding to the public good. (3) Harmonize GME and UME by beginning to align entrustable professional activities with UME milestones. (4) Convene representatives from osteopathic specialty colleges and certification boards to define curricular elements across GME, certification, and osteopathic continuous certification. (5) Build on the Project in Osteopathic Medical Education and Empathy study.

In 2018, leaders from the American Osteopathic Association (AOA), the American Association of Colleges of Osteopathic Medicine (AACOM), and the National Board of Osteopathic Medical Examiners (NBOME) engaged representatives in planning meetings for the 2019 United States Osteopathic Medical Regulatory Summit, which was held February 28 through March 1, 2019. The primary goal of the Summit was to discuss professional self-regulation and what patients expect of the profession as it sets its standards for osteopathic medical practice. Consensus emerged to develop an action plan that would draft and solicit profession-wide input for a single statement that defines osteopathic distinctiveness to secure the future of the distinctive practice of osteopathic medicine as a choice for patients. The Summit included osteopathic medical students, osteopathic residents in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), osteopathic physicians (ie, DOs), members of licensing boards, graduate and undergraduate osteopathic medical educators, and public members. 
Previous summits resulted in alignment on the importance of osteopathic distinctiveness and a focus on assuring patients that DOs are highly qualified by merit of graduating from colleges of osteopathic medicine (COMs) accredited by the AOA Commission on Osteopathic College Accreditation (COCA) and passing valid, osteopathically distinctive assessments for licensure. To meet the profession's societal responsibility for self-regulation,1 participants in past summits believed that osteopathic distinctiveness is critical. Osteopathic distinctiveness results from years of education and training—starting with undergraduate medical education (UME). This formation continues throughout one's career, from assessment through graduate medical education (GME), licensure, board certification, and continuous professional development. 
Objectives
The 2019 Summit's objectives were as follows: 
  • ■ Review and discuss self-regulation for osteopathic medicine to ensure high quality, osteopathically distinctive care for patients.
  • ■ Understand how osteopathic distinctiveness contributes to professional identity formation and collaborate to enhance partnership in self-regulation.
  • ■ Focus on the importance of osteopathic distinctiveness in professional self-regulation in securing osteopathic care for patients.
Identification of blind spots, opportunities, and challenges in fulfilling the group's collective professional self-regulation responsibilities were critical to the Summit's success. A key question considered was, as one participant put it, “What do we want our profession to look like a decade from now?” 
Summit Structure
Throughout the Summit, participants engaged in facilitator-led cogitative exercises and large group discussions. In addition, Summit participants responded to workbook exercises, which were used to validate Summit findings. To guide the discussion, the Summit began with presentations on current trends and challenges across the osteopathic medical profession: UME and GME, accreditation, assessment, licensure, board certification and continuing medical education, and patient engagement. In addition, an outline of the research compendium of publications highlighting the distinctiveness of osteopathic medicine was distributed to attendees for reading in advance of the meeting. The compendium listed 127 articles with brief summaries and key findings of the identified articles. The compendium was compiled by members of the Summit planning group and speakers, and articles were grouped by topic area (eg, osteopathic medical training, empathy in osteopathic medical practice, efficacy and safety of osteopathic manipulative treatment). 
Topics explored during the Summit included the following: 
  • ■ COM growth and continued expansion of the applicant pool
  • ■ changes in COCA standards and the evolving practice of osteopathic medicine
  • ■ the transition to a single GME accreditation system (single GME) for GME under which all DOs and MDs will train, with opportunities to choose residency programs with osteopathic recognition
  • ■ support for osteopathic licensing examinations, including the American Medical Association policy recognizing equality for the Comprehensive Osteopathic Medical Licensing Examination-USA (COMLEX-USA) and the United States Medical Licensing Examination (USMLE) uses by residency program directors and acceptance of COMLEX-USA for licensure
  • ■ changes to ACGME Common Program Requirements that recognize osteopathic board certification as equivalent to certifications awarded by the American Board of Medical Specialties
  • ■ trends and changes in osteopathic board certification, osteopathic continuous certification, and AOA membership
What Makes Osteopathic Medicine Distinctive?
Karen J. Nichols, DO, MA, vice chair of the ACGME Board of Directors, opened the proceedings by providing an overview of the osteopathic medical profession and offering her perspective on osteopathic distinctiveness. Nichols’ presentation highlighted trends in the profession—rapid growth, a younger profession with more female representation, higher concentration in primary care compared with MDs, and changes in board certification.2 She discussed 5 areas of distinctiveness that, to her, distinguish the profession from allopathic physicians (ie, MDs): 
  • (1)
    use of an osteopathic lens—how DOs look at medical and scientific facts, provide care, and engage patients
  • (2)
    osteopathic manipulative treatment (OMT)—a visible tool for palpation, diagnosis, and treatment
  • (3)
    osteopathic philosophy3—the 4 tenets: the person as a unit of body, mind, and spirit; the innate capability for self-regulation; the importance of structure and function relationships; and the rational treatment being based on the first 3 tenets
  • (4)
    empathy4—not exclusive to DOs, but emphasized, taught, tested, and built into UME
  • (5)
    an osteopathic culture that emphasizes communication skills and a whole-person perspective
Nichols emphasized that the osteopathic medical profession and culture brings together scientific and humanistic dimensions with emotional intelligence, embracing empathy and understanding. 
What Patients Want—A Public Member's Perspective
Susan I. Belanger, PhD, MA, RN, NEA-BC, system ethicist, leader, and educator, and public member of COCA, presented perspectives on the power of positive patient interactions. Belanger stressed that patients look for knowledgeable health care providers with expertise who listen, allow time for questions, encourage expression of concerns, interact with them outside the room, spend the time needed, validate their feelings, and are trustworthy. With experience in nursing and hospitals, Belanger remarked that DOs are recognized for the osteopathic whole-person approach to care. Her presentation concluded with a compelling personal story about the advantages of an osteopathic medical approach to care. 
Distinctiveness in Osteopathic UME
Stephen C. Shannon, DO, MPH, former AACOM president and chief executive officer, discussed the role of UME and trends and forecasts in COM enrollment, applications, and graduates. Shannon commented that COM enrollment has doubled over the past 10 years as a result of increases in both the number of osteopathic medical students and new COM locations.5 A growing student body presents ongoing challenges and competition for clinical education opportunities and increased competition for GME placement. 
Questions and comments arose about how COMs admissions processes can preserve a unique culture and about the distinctive element of extensive coursework at COMs involving osteopathic principles, hands-on diagnosis, and OMT. A primary care orientation for third- and fourth-year students, with some clinical rotations in the preceptorship model and ambulatory practice environment, was emphasized as critical for preserving osteopathic culture. Studies demonstrating empathy among DOs,6-9 communication skills of DOs,10,11 outcomes generally favoring primary care specialties, and a track record of DOs serving in underserved areas12 are important measures regarding osteopathic distinctiveness. The large-scale, longitudinal Project in Osteopathic Medical Education and Empathy (POMEE13) study of the nation's COMs is underway. 
Distinctiveness in COM Accreditation Standards
Janice A. Knebl, DO, MBA, chair of COCA, gave an overview of the authority that COCA has in accrediting the COMs through the US Department of Education and reviewed current COCA statistics. She described osteopathic distinctiveness in the current COCA standards,14,15 highlighted proposed revisions, and discussed specific elements that ensure osteopathic distinctiveness, as well as those that present challenges. The challenges largely result from the unprecedented COM and enrollment growth accelerated by success in a model that produces competent physicians who are meeting the health care needs of underserved regions of the United States and specialty areas of need. 
Osteopathic Board Certification—A Changing Landscape
Daniel G. Williams, DO, former vice president of AOA Certifying Board Services, and Albert H. Yurvati, DO, PhD, Executive Director of the American Osteopathic Board of Surgery, spoke about AOA board certification for osteopathic physicians. Williams discussed shifting trends in specialization. With more osteopathic physicians training in ACGME-accredited residency programs, many choose to pursue American Board of Medical Specialties board certification rather than through the AOA. 
In response to increasing diversity in practice patterns, the AOA is continuing to explore offering more than 1 certification pathway. Offering additional pathways will not only help attract more DOs, but also open up AOA certification to MDs. With significant pushback from physicians regarding requirements for Osteopathic Continuous Certification, the AOA is continuing to modify its program.16 Several boards17,18are moving toward continuous assessment as an alternative to high-stakes recertification examinations required at long multiyear intervals. 
Osteopathic GME and the Single GME
Robert S. Juhasz, DO, MACOI, an ACGME Board member, outlined the ACGME's oversight role in GME with respect to the transition to the single GME in 2020.19,20 The AOA and AACOM are now members of the ACGME Board of Directors, and DOs have been appointed to most residency review committees, as well as other leadership roles.21 Leaders at the ACGME have emphasized the incorporation of osteopathic principles and traditions into the larger system, and ACGME standards have been modified to reflect the acceptance of osteopathic qualifications,22,23 such as AOA board certification and COMLEX-USA. 
Thus far, as DOs compete for ACGME residencies, overall placement rates for DO graduates remain excellent (greater than 98%24). The single GME established a process for programs to achieve osteopathic recognition.25 Programs with this distinction allow DOs to train in residencies that reinforce osteopathic principles and practice. Juhasz told Summit attendees that the ACGME “doesn't want you to become us…we want you to change us. What if we exposed all in medicine to osteopathic medicine?” 
Richard J. LaBaere II, DO, MPH, an ACGME Institutional Review Committee member and former president of the Assembly of Osteopathic Graduate Medical Educators, added to this discussion with an overview of the osteopathic GME learning environment and updated ACGME common program requirements that acknowledge and accept DO credentials. LaBaere urged the group to consider osteopathic-specific assessment, scholarly activity, and mentoring, with outcome measures to assess and improve the success of the osteopathic GME system. 
Assessment of the Distinctive Practice of Osteopathic Medicine
Dana C. Shaffer, DO, NBOME Board chair, spoke about COMLEX-USA, which features an evidence-based design for the distinctive practice of osteopathic medicine.26 This licensure examination for DOs is considered valid in all 50 states and by the American Medical Association, the ACGME, the Federation of State Medical Boards (FSMB), the AOA, and others. In referring to an October 2018 article on enhancing COMLEX-USA,27 the editor-in-chief of the FSMB's Journal of Medical Regulation described the evidence-based design of COMLEX-USA as: 

… a good example of how medical examiners can update their assessment systems to stay ahead of the curve of change … [and] help medical regulators make sound, balanced decisions as they continue their work in protecting the public and ensuring quality in medical practice, keeping our patients safe.28

 
To address perceptions of disadvantage or to compete for residency positions, many osteopathic medical students elect to take USMLE Step 1, Step 2 (clinical knowledge), or both in addition to taking COMLEX-USA. This practice has increased as the single GME transition nears completion, with more than 50% of DO students taking at least 1 part of the USMLE.29 Summit participants discussed the undue burden for DO students and its potential to erode the emphasis on the osteopathic approach to patient care in educational programs, which could affect the quality of medical care that patients receive from DOs in the future. 
Osteopathic Medical Licensure
Scott A. Steingard, DO, FSMB Board chair, provided a perspective on state-based physician licensure in the United States and the universal recognition of 2 medical licensing examination pathways, COMLEX-USA for DOs and USMLE for MDs. The FSMB published its “Pathway to Licensure”30 diagram that demonstrates licensure requirements and licensure renewal information for US-trained DOs, US-trained MDs, and international medical graduates. Steingard noted that DOs are very active in the FSMB and on state medical boards. He also discussed the Interstate Medical Licensure Compact,31 a relatively new, voluntary pathway that enhances license portability for physicians seeking expedited licensure in multiple states. Steingard reported that predictive validity research32-36 by the NBOME and the FSMB demonstrates a strong correlation between successful completion of COMLEX-USA and a lower likelihood of state medical board disciplinary action. 
Results
Summit attendees agreed that osteopathic distinctiveness is important to the profession. Patients seeking care from DOs should be confident that these physicians have demonstrated at least minimal competence via valid qualifications for providing osteopathic medical care. In Summit discussions, the consensus was that osteopathic distinctiveness is strongest in UME and competency assessment for licensure. 
As DOs seek licensure, enter GME, and move on to practice and partake in continuing medical education, it was generally agreed that there is less consistency in that distinctiveness overall (Figure 1). Thomas Cavalieri, DO, immediate past-chair of the AACOM Board of Deans, noted that the uniqueness of osteopathic medicine enhances health care. He told the group that “it is incumbent on us to improve care for patients nationwide.” 
Figure 1.
Percentage of participants in the 2019 United States Osteopathic Medical Regulatory Summit who rated very high or somewhat high levels of osteopathic distinctiveness by professional sector (N=38). Abbreviations: CME, continuing medical education; GME, graduate medical education; UME, undergraduate medical education.
Figure 1.
Percentage of participants in the 2019 United States Osteopathic Medical Regulatory Summit who rated very high or somewhat high levels of osteopathic distinctiveness by professional sector (N=38). Abbreviations: CME, continuing medical education; GME, graduate medical education; UME, undergraduate medical education.
Public members and student participants pointed out that there remains confusion as to what that distinctiveness is. Students describe the practice of osteopathic medicine with different nomenclature from that used by experienced DOs, and even osteopathic organizations offer different definitions or use similar language to mean different things. There remains a need for a universal statement that defines that distinctiveness and clarifies what it means to be a DO. 
It was suggested that the definition focus on the fact that DOs are selected for, trained in, assessed on, and practice in a manner that connects with their patients’ body, mind, and spirit in order to partner with patients to promote and maintain health. Osteopathic physicians use all rational biomedical treatment approaches but receive additional training in nonpharmacologic approaches such as OMT37 to best improve their patients’ health. Barbara Walker, DO, president of the North Carolina Medical Board and past president of the American Association of Osteopathic Examiners, told the group, “We find health, look at strengths, and build on it. Be proud of the fact that we can do more for our patients, and promote it.” 
Growth in the profession was a second major focus of the discussions. Many attendees agreed that the profession is at a crossroads driven by growth, the single GME for GME, and demographic, technological, and cultural changes. When asked whether the profession can support growth, attendees said that the number of COMs and medical school graduates is not currently balanced and that it will continue to grow even more with the expected continued rise in total COM enrollment through 2030 (Figure 2). 
Figure 2.
Forecasted growth of total enrollment in US osteopathic medical schools, 1968-2030.
Figure 2.
Forecasted growth of total enrollment in US osteopathic medical schools, 1968-2030.
Concerns were expressed about faculty development, the number of DOs qualified for academic leadership positions, and lack of exposure to DO role models in clinical training and GME. Tyler King, OMS IV, national president of the Student Osteopathic Medical Association, pointed to rapid growth of the profession and the need to have more sessions to hear more voices to maintain quality. Lori Kemper, DO, MS, chair of the AACOM Board of Deans, remarked, “None of us can do everything, but all of us can do something. Each of us can make a commitment to step forward.” In a summative exercise, most agreed that the osteopathic medical profession as a whole would improve significantly in the next 5 to 10 years (Figure 3). 
Figure 3.
Percentage of participants in the 2019 United States Osteopathic Medical Regulatory Summit who predicted change in the osteopathic medical profession in 1, 3, 5, and 10 years (N=30).
Figure 3.
Percentage of participants in the 2019 United States Osteopathic Medical Regulatory Summit who predicted change in the osteopathic medical profession in 1, 3, 5, and 10 years (N=30).
Considerable discussion about misinformation about the single GME transition for GME and the importance of professional identity formation ensued. There was a sense of urgency that it is more important than ever to come to a consensus on the precise definition of osteopathic distinctiveness and what it entails. Shaffer expressed the challenge as the need to “define ourselves by who we are today, and not what we used to be.” Students and residents spoke about the importance of advocating for the qualifications of DO students with GME program directors. They noted the confusion that arises with mixed messages at COMs and among resident program directors regarding osteopathic qualifications. 
Recommendations
After concluding the discussions at the Summit, attendees brainstormed recommendations to advance a cohesive statement of osteopathic distinctiveness. A consensus group recommendation was made to convene a task force of groups represented at the Summit, with possible additional entities, to develop a succinct message defining osteopathic distinctiveness. 
The task force would rely on data to help refine a position statement and the cohesive message of osteopathic distinctiveness for the profession to meet the “quadruple aim” of improving the health of populations, enhancing the experience of care for individuals, reducing the per capita cost of health care, and attaining joy in work.38,39 
Additional recommendations discussed by the group put forward during the Summit, to be considered further by the task force and at the next summit, included the following: 
  • ■ Demonstrate uniqueness of the profession through research showing that the profession generates good outcomes, enhances care, and adds to the public good.
  • ■ Harmonize UME and GME milestones40; begin to align entrustable professional activities41 with UME milestones.
  • ■ Convene the AOA Bureau of Osteopathic Specialists and specialty colleges to define curricular elements across GME, certification, and OCC.
  • ■ Build on the POMEE study4 and use the data to determine characteristics that are relevant to admissions criteria and student selection and continued enhancement of education programs.
Several participants stressed that in addition to collective action, steps could be taken within osteopathic organizations to better define, strengthen, and reinforce osteopathic distinctiveness. Organizations should explore opportunities to do this. Suggestions include: 
  • ■ Promote a positive osteopathic clerkship/clinical rotation experience and/or mentorship to encourage osteopathic professional identity and competency formation.
  • ■ Ensure osteopathic culture and professional identity formation throughout UME by (1) setting COCA standards that reinforce osteopathic culture and professional identity formation; (2) focusing on student selection, using data to identify the best candidates to become osteopathic physicians and building the culture from them; (3) providing excellent faculty role models; and (4) ensuring that COMLEX-USA maintains a strong osteopathic identity and competency-based focus.
  • ■ Internally examine language used in communications and activities within COMs and other organizations to achieve greater consistency.
Moving Forward
After the Summit, attendees received a copy of the complete research compendium,42 a document identifying 127 scholarly articles that support osteopathic distinctiveness across the education continuum and into practice in a number of areas. Attendees also received a post-Summit survey to evaluate attendee experience. 
All of the representatives present agreed that the 2019 Summit would likely affect their organization's strategic planning processes. Summit attendees rated the experience favorably overall and emphasized the importance of action steps to be taken following the discussions at the Summit. 
In June 2019, the first meeting of the task force was convened to evaluate Summit findings and discussions and to begin developing a succinct message defining osteopathic distinctiveness. It is anticipated that a fourth Summit will be convened in 2020. 

“Nobody knows what you do; define your story and tell us who you are. What you do is wonderful.”

—Sue Belanger, PhD, MA, RN, NEA-BC

 
Acknowledgments
We thank the following individuals for their contributions to this work: Bill Mayo, DO; Geraldine T. O'Shea, DO; Robert C. Cain, DO; Kevin M. Klauer, DO, EJD; and Dennis M. Powell. In addition, we recognize the editorial support of Gerri Mahn, MLIS, and Alanna Witowski. 
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Figure 1.
Percentage of participants in the 2019 United States Osteopathic Medical Regulatory Summit who rated very high or somewhat high levels of osteopathic distinctiveness by professional sector (N=38). Abbreviations: CME, continuing medical education; GME, graduate medical education; UME, undergraduate medical education.
Figure 1.
Percentage of participants in the 2019 United States Osteopathic Medical Regulatory Summit who rated very high or somewhat high levels of osteopathic distinctiveness by professional sector (N=38). Abbreviations: CME, continuing medical education; GME, graduate medical education; UME, undergraduate medical education.
Figure 2.
Forecasted growth of total enrollment in US osteopathic medical schools, 1968-2030.
Figure 2.
Forecasted growth of total enrollment in US osteopathic medical schools, 1968-2030.
Figure 3.
Percentage of participants in the 2019 United States Osteopathic Medical Regulatory Summit who predicted change in the osteopathic medical profession in 1, 3, 5, and 10 years (N=30).
Figure 3.
Percentage of participants in the 2019 United States Osteopathic Medical Regulatory Summit who predicted change in the osteopathic medical profession in 1, 3, 5, and 10 years (N=30).