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Original Contribution  |   May 2020
Osteopathic Manipulative Medicine Practice Patterns of Third-Year and Fourth-Year Osteopathic Medical Students: An Educational Research Project
Author Notes
  • From the Department of Family Medicine, Preventive Medicine, and Community Health (Dr Snider) at Kirksville College of Osteopathic Medicine (Student Doctor Couch); and the Department of Research Support (Ms Bhatia) at A.T. Still University in Missouri. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Karen T. Snider, DO, ATSU-KCOM Department of Family Medicine, Preventive Medicine, and Community Health, 800 W Jefferson St, Kirksville MO 63501-1443. Email: ksnider@atsu.edu
     
Article Information
Medical Education / Osteopathic Manipulative Treatment
Original Contribution   |   May 2020
Osteopathic Manipulative Medicine Practice Patterns of Third-Year and Fourth-Year Osteopathic Medical Students: An Educational Research Project
The Journal of the American Osteopathic Association, May 2020, Vol. 120, 293-302. doi:https://doi.org/10.7556/jaoa.2020.048
The Journal of the American Osteopathic Association, May 2020, Vol. 120, 293-302. doi:https://doi.org/10.7556/jaoa.2020.048
Abstract

Context: Colleges of osteopathic medicine (COMs) are required to provide hands-on osteopathic manipulative medicine (OMM) training during clerkship years, but this can be challenging given that students are in a variety of clinical sites and often train with allopathic physicians.

Objective: To identify student OMM practice patterns documented on required OMM practice logs detailing 10 OMM treatments each semester as part of a 3-semester third- and fourth-year clerkship curriculum and to determine whether these practice patterns varied by supervisor type (osteopathic vs allopathic) and semester.

Methods: The OMM practice logs from 2 class years were retrospectively reviewed for patient and supervisor characteristics and OMM treatment details. Semesters included 2 third-year semesters and an extended fourth-year semester.

Results: Between July 2015 and March 2018, 1018 OMM practice logs were submitted detailing 10,150 treatments involving 4655 clinical (45.9%) and 5474 volunteer (53.9%) patients. Logs contained up to 10 treatments per log; 26.0% included only clinical patients, 17.4% included only volunteer patients, and 56.6% included both. Significantly more clinical patients (1708 [36.7%]) were treated during the first semester of the third year than the other 2 semesters (P<.001). The supervisor's credentials were identified as an osteopathic physician for 6639 treatments (65.4%) and an allopathic physician for 768 (7.6%). No difference was found in the proportion of clinical to volunteer patients supervised by osteopathic or allopathic physicians (P=.34). Neuromusculoskeletal complaints accounted for 10,847 (90.7%) chief complaints, and nonneuromusculoskeletal complaints accounted for 1115 (9.3%). The most commonly treated body regions were the thoracic (6255 [61.4%]), cervical (4932 [48.4%]), and lumbar (4249 [41.7%]). More body regions were treated on clinical patients than on volunteer patients (mean, 2.7 vs 2.6, respectively; P=.04). Commonly used techniques were muscle energy (6570 [64.5%]); high-velocity, low-amplitude (4054 [39.8%]); soft tissue (3615 [35.5%]); balanced ligamentous tension/indirect techniques (2700 [26.5%]); and myofascial release (1944 [19.2%]).

Conclusion: More than 80% of students documented OMM practice on clinical patients for their required OMM practice logs. Both osteopathic and allopathic physicians provided supervision. Chief complaints and types of osteopathic manipulative treatment used were consistent with current clinical practice. Areas identified for enhanced didactic education included OMM for nonneuromusculoskeletal complaints.

The third- and fourth-year osteopathic medical school clerkship curricula involve didactic education and clinical training in the form of clinical clerkship rotations. These rotations occur in a variety of specialties at inpatient and outpatient clinical facilities. Most colleges of osteopathic medicine (COMs) use several clerkship sites, typically in different geographical areas to ensure a sufficient number of preceptors to provide students with clinical training in required specialties, such as family medicine, internal medicine, general surgery, emergency medicine, and obstetrics and gynecology.1 The inherent difficulty of multiple clerkship sites, as well as training with real patients and a variety of clinical preceptors, is that each student receives slightly different training during their clerkship years. 
The American Osteopathic Association Commission on Osteopathic College Accreditation's (COCA) COM Continuing Accreditation Standards require that all students receive supervised hands-on osteopathic manipulative medicine (OMM) training in each year of the curriculum (Element 6.6).2 Studies3-6 have shown that supervised OMM training in clinical settings and during the clinical years improves student confidence with OMM and fosters the intent to use OMM in future clinical practice. The geographical and preceptor variabilities of multiple clerkship sites create challenges to ensure that all students receive OMM training. This challenge is compounded by COCA's COM Continuing Accreditation Standard Element 6.10, which states that only 1 of the required specialty clerkships in the third year must be completed under the supervision of an osteopathic physician (ie, DO).2 This requirement minimizes the required clinical training with DO supervisors to only 1 clerkship in the third year.2 As such, these COCA requirements allow a large portion of the third-year and fourth-year clerkship training to occur under the supervision of allopathic physicians (ie, MDs). Osteopathic medical students who train with MD preceptors may receive less training in the unique components of the osteopathic approach to patient care, such as OMM.7-9 The reduced exposure to osteopathic patient care may negatively affect students’ attitudes toward the use of OMM in future practice.10-12 
To ensure a basic level of consistency in the didactic education for the osteopathic approach to patient care, the A.T. Still University Kirksville College of Osteopathic Medicine (ATSU-KCOM) developed the Advanced Osteopathic Principles and Practice (OPP) curriculum. The Advanced OPP curriculum is a 3-semester curriculum delivered during the third and fourth years of osteopathic medical training. Semesters 5 and 6 occur during the third year, and semester 7 spans across 3 quarters of the fourth year. The curriculum involves online didactic training and assessments and a required OMM practice log during each semester. The OMM practice log is a list of up to 10 supervised OMM treatments that the students are required to complete each semester. Ten OMM treatments are required to be documented for full credit for the practice log assignment. The OMM treatments can involve either clinical or volunteer patients and may take place in either didactic or clinical settings. All recorded treatments must be supervised by a licensed physician who manually signs the log to verify their supervision. The supervisors may be the student's preceptor or another physician involved in their clinical or didactic OMM education and may include resident physicians. As part of the log, students are required to submit basic de-identified information about each treatment. 
To investigate whether students were waiting until the end of each semester to complete their 10 required OMM treatments, we investigated the timing of their OMM treatments in each semester. The OMM practice logs were expected to reveal the depth and breadth of the OMM practice of the students as a whole. Ultimately, we hope to benefit future students by identifying areas in OMM education during the clerkship years that were either exceptional or needed additional focused OMM education. The purpose of the current study was to identify OMM practice patterns among the students as documented on OMM practice logs and to determine whether these practice patterns varied by supervisor type and semester. 
Methods
The current study used a retrospective study design. The OMM practice logs for the Advanced OPP curricular semesters 5, 6, and 7, completed by third-year and fourth-year osteopathic medical students from the ATSU-KCOM classes of 2017 and 2018, were reviewed. Logs were in either .pdf or .jpg format and had been submitted to the online educational software platform Blackboard. De-identified data from the logs were manually entered into an Excel (Microsoft) spreadsheet and included the Advanced OPP semester number (5, 6, or 7), date of treatment, type of patient (clinical vs volunteer), sex and age of patient, patient's chief complaint (≤3 categorized by organ system or body region), body regions treated with OMM (1-10), osteopathic manipulative treatment (OMT) techniques used, core clerkship site, and degree of the supervisor (DO or MD). The current study assessed practice patterns of students at 33 core clerkship sites in 9 states: Arizona, Illinois, Kansas, Michigan, Missouri, New Jersey, Ohio, Pennsylvania, and Utah. When the degree of the supervisor was not recorded by the student, we searched for the supervisor's name in the clerkship geographic region to obtain the data. When the search could not identify the supervisor's degree, the degree was recorded as unknown. Practice logs submitted by means other than Blackboard, such as through email, were excluded from the study. The current study was reviewed by the A.T. Still University-Kirksville institutional review board and found to be exempt. 
Statistical Analysis
Descriptive statistics were compiled on the student's class year, Advanced OPP semester number, type of patient, age and sex of patient, patient's chief complaints, body regions treated with OMM, OMT technique types used, and degree of the supervisor. A χ2 test was used to determine whether the relative frequency of the type of patient (clinical vs volunteer) varied with the degree of the supervisor. An equal number of clinical patients were expected to be treated during each semester, so we expected that 33% of the total number of clinical patient treatments would occur during each semester. A binomial test of proportion was used to test whether the proportion of clinical patients differed between semesters. Data for the number of body regions treated were not normally distributed, so a nonparametric Wilcoxon rank sum test was used to determine whether the number of body regions treated with OMM differed between clinical and volunteer patients. The timing of the OMM treatments in each semester was determined using a binomial test of proportion to determine whether the proportion of treatment dates varied during the first third, middle third, and last third of each semester. All data analyses were performed using SAS version 9.4 (SAS Inc.). P<.05 was considered statistically significant. 
Results
Practice logs were submitted between July 2015 and March 2018, and 1018 logs were reviewed. On average, 170 logs were submitted each semester. Of the 1018 practice logs, 265 included only clinical patients (26.0%), 177, only volunteer patients (17.4%), and 576, a mix of clinical and volunteer patients (56.6%). Therefore, 841 practice logs (82.6%) included the treatment of 1 or more clinical patients. Up to 10 OMM treatments could be documented, and 987 logs (97.1%) were submitted documenting the 10 OMM treatments required for full credit on the assignment. The ratios of clinical to volunteer patients for the students who documented 10 treatments on their OMM practice logs are presented in Table 1. 
Table 1.
Ratio of Clinical-to-Volunteer Patients for Third- and Fourth-Year Osteopathic Medical Students Documenting 10 Osteopathic Manipulative Treatments on Practice Logs (N=987 Practice Logs)
Logs per semester, No. (%) (within semester)
Clinical-to-volunteer ratio 5 6 7 Total logs, No. (%)
10: 0 54 (16.6) 63 (19) 60 (18.1) 177 (17.9)
9: 1 19 (5.8) 15 (4.5) 15 (4.5) 49 (5.0)
8: 2 28 (8.6) 20 (6.0) 12 (3.6) 60 (6.1)
7: 3 22 (6.8) 22 (6.6) 18 (5.4) 62 (6.3)
6: 4 27 (8.3) 17 (5.1) 24 (7.3) 68 (6.9)
5: 5 39 (12.0) 24 (7.3) 19 (5.7) 82 (8.3)
4: 6 26 (8.0) 22 (6.6) 23 (6.9) 71 (7.2)
3: 7 19 (5.8) 19 (5.7) 27 (8.2) 65 (6.6)
2: 8 20 (6.2) 15 (4.5) 17 (5.1) 52 (5.3)
1: 9 10 (3.1) 16 (4.8) 10 (3.0) 36 (3.6)
0: 10 61 (18.8) 98 (29.6) 106 (32.0) 265 (26.8)
Total semester logs 325 331 331
Table 1.
Ratio of Clinical-to-Volunteer Patients for Third- and Fourth-Year Osteopathic Medical Students Documenting 10 Osteopathic Manipulative Treatments on Practice Logs (N=987 Practice Logs)
Logs per semester, No. (%) (within semester)
Clinical-to-volunteer ratio 5 6 7 Total logs, No. (%)
10: 0 54 (16.6) 63 (19) 60 (18.1) 177 (17.9)
9: 1 19 (5.8) 15 (4.5) 15 (4.5) 49 (5.0)
8: 2 28 (8.6) 20 (6.0) 12 (3.6) 60 (6.1)
7: 3 22 (6.8) 22 (6.6) 18 (5.4) 62 (6.3)
6: 4 27 (8.3) 17 (5.1) 24 (7.3) 68 (6.9)
5: 5 39 (12.0) 24 (7.3) 19 (5.7) 82 (8.3)
4: 6 26 (8.0) 22 (6.6) 23 (6.9) 71 (7.2)
3: 7 19 (5.8) 19 (5.7) 27 (8.2) 65 (6.6)
2: 8 20 (6.2) 15 (4.5) 17 (5.1) 52 (5.3)
1: 9 10 (3.1) 16 (4.8) 10 (3.0) 36 (3.6)
0: 10 61 (18.8) 98 (29.6) 106 (32.0) 265 (26.8)
Total semester logs 325 331 331
×
Patient and supervisor characteristics are presented in Table 2 by semester. Of all patients, 5548 were females (54.7%) and 4592 were males (45.2%). Most patients were aged 18 to 39 years (5683 [56.0%]). A total of 10,150 separate OMM treatments were documented. Of these, 4655 were performed on clinical patients (45.9%), 5474 on volunteer patients (53.9%), and 21 were not specified (0.2%). The majority of practice logs submitted included treatment of both types of patients, and these treatments were documented in all 9 states. The total number of clinical patient treatments (4655) was unevenly distributed across the 3 semesters. Students documented 1708 clinical patients treated by third-year students in semester 5, which accounts for 36.7% of the 4655 clinical patients treated. When compared with the 1509 (32.4%) clinical patients treated by third-year students in semester 6 and 1438 (30.9%) treated by fourth-year students in semester 7, the proportion of clinical patients treated in semester 5 was higher than the projected 33.3% (P<.001). 
Table 2.
Patient Demographics and Supervisor Degree From Osteopathic Manipulative Medicine Practice Logs of Third- and Fourth-Year Osteopathic Medical Students
Semester, treatments No (%)
Characteristic 5 6 7 Total
Patient type
 Clinical 1708 (16.8) 1509 (14.9) 1438 (14.2) 4655 (45.9)
 Volunteer 1648 (16.2) 1868 (18.4) 1958 (19.3) 5474 (53.9)
 Unspecified 9 (0.09) 2 (0.02) 10 (0.1) 21 (0.2)
Patient sex
 Male 1520 (15.0) 1569 (15.5) 1503 (14.8) 4592 (45.2)
 Female 1845 (18.2) 1800 (17.7) 1903 (18.8) 5548 (54.7)
 Unspecified 0 (0) 10 (0.1) 0 (0) 10 (0.1)
Patient age, y
 0-17 195 (1.9) 196 (1.9) 120 (1.2) 511 (5.0)
 18-39 1779 (17.3) 1954 (19.3) 1950 (19.2) 5683 (56.0)
 40-59 899 (8.9) 770 (7.6) 831 (8.2) 2500 (24.6)
 ≥60 492 (4.9) 459 (4.5) 505 (5.0) 1456 (14.3)
Supervisor
 DO 2084 (20.5) 2291 (22.6) 2264 (22.3) 6639 (65.4)
 MD 94 (0.9) 270 (2.7) 404 (4.0) 768 (7.6)
 Unknown 1182 (11.7) 818 (8.1) 721 (7.1) 2721 (26.8)
 Missing information 5 (0.1) 0 (0) 17 (0.2) 22 (0.2)
Total patients 3365 (33.2) 3379 (33.3) 3406 (33.6) 10 150

Abbreviations: DO, osteopathic physician; MD, allopathic physician.

Table 2.
Patient Demographics and Supervisor Degree From Osteopathic Manipulative Medicine Practice Logs of Third- and Fourth-Year Osteopathic Medical Students
Semester, treatments No (%)
Characteristic 5 6 7 Total
Patient type
 Clinical 1708 (16.8) 1509 (14.9) 1438 (14.2) 4655 (45.9)
 Volunteer 1648 (16.2) 1868 (18.4) 1958 (19.3) 5474 (53.9)
 Unspecified 9 (0.09) 2 (0.02) 10 (0.1) 21 (0.2)
Patient sex
 Male 1520 (15.0) 1569 (15.5) 1503 (14.8) 4592 (45.2)
 Female 1845 (18.2) 1800 (17.7) 1903 (18.8) 5548 (54.7)
 Unspecified 0 (0) 10 (0.1) 0 (0) 10 (0.1)
Patient age, y
 0-17 195 (1.9) 196 (1.9) 120 (1.2) 511 (5.0)
 18-39 1779 (17.3) 1954 (19.3) 1950 (19.2) 5683 (56.0)
 40-59 899 (8.9) 770 (7.6) 831 (8.2) 2500 (24.6)
 ≥60 492 (4.9) 459 (4.5) 505 (5.0) 1456 (14.3)
Supervisor
 DO 2084 (20.5) 2291 (22.6) 2264 (22.3) 6639 (65.4)
 MD 94 (0.9) 270 (2.7) 404 (4.0) 768 (7.6)
 Unknown 1182 (11.7) 818 (8.1) 721 (7.1) 2721 (26.8)
 Missing information 5 (0.1) 0 (0) 17 (0.2) 22 (0.2)
Total patients 3365 (33.2) 3379 (33.3) 3406 (33.6) 10 150

Abbreviations: DO, osteopathic physician; MD, allopathic physician.

×
The documented degrees of OMM treatment supervisors included 6639 DOs (65.4%) and 768 MDs (7.6%); degree was not specified for 2721 treatments (26.8%) (Table 2). Both DOs and MDs supervised the treatment of more volunteers than clinical patients (2907 [43.8%] clinical and 3720 [56.0%] volunteer vs 323 [42.1%] clinical and 445 [57.9%] volunteer, respectively). There was no difference in the proportion of clinical to volunteer patients whose treatment was supervised by DO or MD supervisors (P=.34). 
Chief complaints are categorized in Table 3. The 10,150 student treatments included up to 3 chief complaints for each treatment; 11,962 complaints were recorded in total. Neuromusculoskeletal complaints accounted for 10,847 chief complaints (90.7%), and nonneuromusculoskeletal complaints accounted for 1116 chief complaints (9.3%). Thoracic or lumbar neuromusculoskeletal complaints (4744 [39.7%]) were the most common chief complaint, followed by cervical (2293 [19.2%]) and upper extremity (1232 [10.3%]) neuromusculoskeletal complaints. The most common nonneuromusculoskeletal complaints were gastrointestinal (371 [3.1%]) and lower respiratory (231 [1.9%]) complaints. 
Table 3.
Frequency Distribution of Documented Chief Complaints Categorized by Organ System and Body Region from Osteopathic Manipulative Medicine Practice Logs of Third- and Fourth-Year Osteopathic Medical Students (N=10150 Treatments)
Chief complaint category Frequency, No. (%)
Neuromusculoskeletal
 Thoracic or lumbar region 4744 (39.7)
 Cervical region 2293 (19.2)
 Upper extremity region 1232 (10.3)
 Hip/pelvis region 744 (6.2)
 Head region 712 (6.0)
 Lower extremity region 710 (5.9)
 Rib or chest wall 286 (2.4)
 Nonspecific or generalized 126 (1.1)
Nonneuromusculoskeletal
 Gastrointestinal 371 (3.1)
 Lower respiratory 231 (1.9)
 Other, uncategorized 231 (1.9)
 Ear, nose, or throat 180 (1.5)
 Cardiac 62 (0.5)
 Urogenital 30 (0.3)
 Psychiatric 10 (0.1)
Table 3.
Frequency Distribution of Documented Chief Complaints Categorized by Organ System and Body Region from Osteopathic Manipulative Medicine Practice Logs of Third- and Fourth-Year Osteopathic Medical Students (N=10150 Treatments)
Chief complaint category Frequency, No. (%)
Neuromusculoskeletal
 Thoracic or lumbar region 4744 (39.7)
 Cervical region 2293 (19.2)
 Upper extremity region 1232 (10.3)
 Hip/pelvis region 744 (6.2)
 Head region 712 (6.0)
 Lower extremity region 710 (5.9)
 Rib or chest wall 286 (2.4)
 Nonspecific or generalized 126 (1.1)
Nonneuromusculoskeletal
 Gastrointestinal 371 (3.1)
 Lower respiratory 231 (1.9)
 Other, uncategorized 231 (1.9)
 Ear, nose, or throat 180 (1.5)
 Cardiac 62 (0.5)
 Urogenital 30 (0.3)
 Psychiatric 10 (0.1)
×
The students could treat somatic dysfunction in up to 10 body regions per treatment. The average number of body regions treated in a single treatment was 2.7. Frequency and percentage of the treated body regions are presented in Table 4. The most commonly treated body regions were the thoracic (6255 [61.6% of treatments]), cervical (4932 (48.6%]), and lumbar (4249 [41.9%]) body regions. Differences were found in the number of body regions treated between clinical patients (mean, 2.7; median, 3; mean rank score, 2509.0) and volunteer patients (mean, 2.6; median, 3; mean rank score, 2430.3 (P=.04). 
Table 4.
Frequency Distribution of Documented Somatic Dysfunction Body Regions Treated From Osteopathic Manipulative Medicine Practice Logs of Third- and Fourth-Year Osteopathic Medical Students (N=10150 Treatments)
Somatic dysfunction body region Frequency, No. (%)
Thoracic 6255 (61.6)
Cervical 4932 (48.6)
Lumbar 4249 (41.9)
Pelvis 2272 (22.4)
Head 2270 (22.4)
Sacrum 2019 (19.9)
Upper extremity 1787 (17.6)
Lower extremity 1702 (16.8)
Ribs 1422 (14.0)
Abdomen 402 (4.0)
Table 4.
Frequency Distribution of Documented Somatic Dysfunction Body Regions Treated From Osteopathic Manipulative Medicine Practice Logs of Third- and Fourth-Year Osteopathic Medical Students (N=10150 Treatments)
Somatic dysfunction body region Frequency, No. (%)
Thoracic 6255 (61.6)
Cervical 4932 (48.6)
Lumbar 4249 (41.9)
Pelvis 2272 (22.4)
Head 2270 (22.4)
Sacrum 2019 (19.9)
Upper extremity 1787 (17.6)
Lower extremity 1702 (16.8)
Ribs 1422 (14.0)
Abdomen 402 (4.0)
×
The types of OMT techniques used by the students are presented in Table 5. The most commonly used techniques were muscle energy (6570 [64.7%] of treatments); high-velocity, low-amplitude (HVLA) (4054 [39.9%]); balanced ligamentous tension/indirect techniques (3865 [38.1%]); soft tissue (3615 [35.6%]); and myofascial release (1944 [19.2%]). 
Table 5.
Frequency Distribution of Documented Osteopathic Manipulative Treatment Techniques From Osteopathic Manipulative Medicine Practice Logs of Third- and Fourth-Year Osteopathic Medical Students (N=10150 Treatments)
Technique Frequency, No. (%)
Muscle energy 6570 (64.7)
High-velocity, low-amplitude 4054 (39.9)
Balanced ligamentous technique/indirect 3865 (38.1)
Soft tissue 3615 (35.6)
Myofascial release 1944 (19.2)
Counterstrain 1499 (14.8)
Articular 1383 (13.6)
Lymphatic techniques 910 (9.0)
Still technique 730 (7.2)
Osteopathic cranial manipulative medicine 641 (6.3)
Facilitated positional release 441 (4.3)
Visceral 261 (2.6)
Functional technique 157 (1.6)
Ligamentous articular strain 123 (1.2)
Integrated neuromuscular release 96 (1.0)
Other 68 (0.7)
Table 5.
Frequency Distribution of Documented Osteopathic Manipulative Treatment Techniques From Osteopathic Manipulative Medicine Practice Logs of Third- and Fourth-Year Osteopathic Medical Students (N=10150 Treatments)
Technique Frequency, No. (%)
Muscle energy 6570 (64.7)
High-velocity, low-amplitude 4054 (39.9)
Balanced ligamentous technique/indirect 3865 (38.1)
Soft tissue 3615 (35.6)
Myofascial release 1944 (19.2)
Counterstrain 1499 (14.8)
Articular 1383 (13.6)
Lymphatic techniques 910 (9.0)
Still technique 730 (7.2)
Osteopathic cranial manipulative medicine 641 (6.3)
Facilitated positional release 441 (4.3)
Visceral 261 (2.6)
Functional technique 157 (1.6)
Ligamentous articular strain 123 (1.2)
Integrated neuromuscular release 96 (1.0)
Other 68 (0.7)
×
The timing of the OMM treatments during an individual semester was unevenly distributed. Students completed 2614 OMM treatments (26.3%) in the first third of the semester, 3701 (37.2%) during the middle third of the semester, and 3634 (36.5%) in the last third of the semester. Because of schedule variability for a small number of students, 201 treatments (2.0%) were completed outside the normally scheduled semester. Of treatments completed during the semester, the proportion of treatments completed in the first third of the semester was significantly less than the projected 33.3% (P<.001). 
Discussion
Results of the current study suggest that more than 80% of clerkship students at ATSU-KCOM are receiving experience treating clinical patients with OMM. Studies3,4,6 have shown that clinical exposure to OMM has been significantly associated with student confidence when performing OMM in a clinical setting. In the current study, more than half of OMM treatments were performed on patients aged 18 to 39 years. This finding is consistent with students treating other students during hands-on OMM didactic training. While practicing on volunteers is a good way for students to maintain OMM skills, clerkship education should strive to provide all students with clinical training opportunities. The current study found that only 36.5% of the OMM treatments occurred in the last third of each semester, indicating that students were not waiting until the last minute to complete their practice log treatments. 
Semester 7, which occurred during the fourth year, had the lowest percentage of clinical patients and the highest percentage of MD supervisors. These findings may be the result of COCA's current COM accreditation requirement Element 6.10, which does not require clerkship training with a DO during the fourth year.2 These findings may also be the result of students completing audition rotations during their fourth year in preparation for application to residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). While the ACGME does not publish the percentage of DO program directors in ACGME-accredited residency programs, actively licensed DOs account for only 7.8% of specialty board-certified physicians.13 Therefore, the majority of the residency directors for ACGME-accredited residency programs with whom the students are auditioning are likely allopathic physicians. The true effect of MD supervisors on OMM education could not be reliably assessed given that the degree of more than 25% of supervisors was unknown. Future versions of the practice log will require better identification of the supervisor's credentials to further study the impact of MD supervisors on OMM education. Additionally, future studies could assess the level of supervision, such as passive observation, in comparison with active hands-on teaching and its impact on OMM practice patterns. 
Any licensed physician can supervise students’ OMM treatments. Although not analyzed in the current study, some of the supervisors were resident physicians. This finding is noteworthy because the Center for Medicare and Medicaid Services allows resident physicians to supervise students,14 and the ACGME requires osteopathically recognized residency programs to provide opportunities for residents to teach osteopathic principles.15 Residents fulfill a valuable role in the teaching of students, and students have responded favorably to resident teachers in a variety of specialties in clinical and didactic settings.16-18 To better understand the role of residents in the clinical and didactic OMM education of medical students, future versions of the OMM practice log will allow identification of resident physician supervisors. 
The current study found that thoracic, lumbar, and cervical chief complaints were the most commonly documented complaints by students on their OMM practice logs. This finding is consistent with previous studies indicating that OMM was most commonly used in clinical practice for the treatment of lumbar, thoracic, and cervical pain.19-22 The current study also found that students most commonly used muscle energy, HVLA, balanced ligamentous/indirect, soft tissue, and myofascial release techniques in their OMM treatments. These findings are consistent with the types of OMT commonly used by first- and second-year students during informal OMM practice and by physicians in clinical practice.19,23,24 In a study by Langenau et al,25 students reported most commonly using myofascial/soft tissue (43%) and muscle energy (16%) techniques during the clinical encounters of the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) Level 2-PE examination. For the safety of the standardized patients, HVLA techniques are not permitted on the COMLEX-USA Level 2-PE examination since these patients would have to receive the same HVLA techniques to the same body region by up to 12 examinees on the same day.25,26 
Gastrointestinal complaints, such as constipation, were the most commonly reported nonneuromusculoskeletal chief complaints in the current study, but they accounted for only 3% of the total number of recorded chief complaints. Treatment of the abdomen occurred during less than 4% of treatments, and visceral techniques were documented for less than 3% of treatments. Given the large evidence base for OMM in the management of gastrointestinal and other nonneuromusculoskeletal complaints,27-32 these results suggest that this topic is an area where additional OMM education is needed within clerkship training. 
A major limitation of the current study was that the OMM practice logs were not inclusive of all of the OMM being performed by the students. For example, students completing a single 2-week osteopathic neuromusculoskeletal medicine rotation may have participated in 10 times the number of OMM treatments recorded on the OMM practice log during that period. Ideally, practice logs would capture all OMM performed by the students and therefore may yield different results from the current study. Another limitation was that the OMM treatment data were not verified by the authors. An assumption was made that data were logged correctly and verified by supervisors. The number of chief complaints per treatment was not analyzed because of the variability in specificity provided for the chief complaints. For example, a student may have recorded back pain as a single chief complaint while another may have recorded both thoracic pain and lumbar pain as 2 chief complaints. Furthermore, the practice logs did not record what rotation the student was on at the time of the treatment or the specialty of the supervisor. Variability in the frequency of clinical and volunteer patients between clerkship sites was not analyzed because of the variability in the number of students at each site and in each state between the 2 class years. 
Despite these limitations, the data collected likely represent actual trends in OMM practice patterns for this group of osteopathic medical students. At least 25 of the 33 clerkship sites in the current study also hosted osteopathic medical students from other COMs. Because of the shared training experiences, our data are likely representative of OMM practice patterns of clerkship students from these other COMs as well. To further elucidate this line of research, future studies could compare longitudinal practice log data with regional clerkship educational practices, choice of residency type, and future use of OMM in clinical practice. 
Conclusion
The required OMM practice logs that were part of the students’ third- and fourth-year Advanced OPP curriculum provided insight into the depth and breadth of the OMM practice of osteopathic medical students. Our results suggest that students are receiving practice using common OMT techniques for the musculoskeletal conditions most commonly treated with OMM in clinical practice. More than 80% of students had practice treating 1 or more clinical patients each semester, and more than 45% of all treatments were on clinical patients. We identified than semester 7, which occurred during the fourth year, had the lowest percentage of clinical patients and the highest percentage of MD supervision. These findings suggest that osteopathic medical students may be receiving less training in osteopathic principles during their fourth year. We also identified a need to develop strategies to ensure clinical OMM training for all students and for more education on the use of OMM for nonneuromusculoskeletal complaints. Future longitudinal studies of student OMM practice logs may be able to indicate the impact of a structured didactic curriculum on OMM practice patterns, the role of resident physicians in OMM education during the clerkship years, and the long-term impact of how OMM experiences correlate with future use of OMM in residency and clinical practice. 
Acknowledgments
We thank Deborah Goggin, MA, ELS, scientific writer in the Department of Research Support at A.T. Still University, for her editorial assistance. We thank Jody Peterson, administrative assistant at A.T. Sill University Kirksville College of Osteopathic Medicine, for her assistance in entering log data. 
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Table 1.
Ratio of Clinical-to-Volunteer Patients for Third- and Fourth-Year Osteopathic Medical Students Documenting 10 Osteopathic Manipulative Treatments on Practice Logs (N=987 Practice Logs)
Logs per semester, No. (%) (within semester)
Clinical-to-volunteer ratio 5 6 7 Total logs, No. (%)
10: 0 54 (16.6) 63 (19) 60 (18.1) 177 (17.9)
9: 1 19 (5.8) 15 (4.5) 15 (4.5) 49 (5.0)
8: 2 28 (8.6) 20 (6.0) 12 (3.6) 60 (6.1)
7: 3 22 (6.8) 22 (6.6) 18 (5.4) 62 (6.3)
6: 4 27 (8.3) 17 (5.1) 24 (7.3) 68 (6.9)
5: 5 39 (12.0) 24 (7.3) 19 (5.7) 82 (8.3)
4: 6 26 (8.0) 22 (6.6) 23 (6.9) 71 (7.2)
3: 7 19 (5.8) 19 (5.7) 27 (8.2) 65 (6.6)
2: 8 20 (6.2) 15 (4.5) 17 (5.1) 52 (5.3)
1: 9 10 (3.1) 16 (4.8) 10 (3.0) 36 (3.6)
0: 10 61 (18.8) 98 (29.6) 106 (32.0) 265 (26.8)
Total semester logs 325 331 331
Table 1.
Ratio of Clinical-to-Volunteer Patients for Third- and Fourth-Year Osteopathic Medical Students Documenting 10 Osteopathic Manipulative Treatments on Practice Logs (N=987 Practice Logs)
Logs per semester, No. (%) (within semester)
Clinical-to-volunteer ratio 5 6 7 Total logs, No. (%)
10: 0 54 (16.6) 63 (19) 60 (18.1) 177 (17.9)
9: 1 19 (5.8) 15 (4.5) 15 (4.5) 49 (5.0)
8: 2 28 (8.6) 20 (6.0) 12 (3.6) 60 (6.1)
7: 3 22 (6.8) 22 (6.6) 18 (5.4) 62 (6.3)
6: 4 27 (8.3) 17 (5.1) 24 (7.3) 68 (6.9)
5: 5 39 (12.0) 24 (7.3) 19 (5.7) 82 (8.3)
4: 6 26 (8.0) 22 (6.6) 23 (6.9) 71 (7.2)
3: 7 19 (5.8) 19 (5.7) 27 (8.2) 65 (6.6)
2: 8 20 (6.2) 15 (4.5) 17 (5.1) 52 (5.3)
1: 9 10 (3.1) 16 (4.8) 10 (3.0) 36 (3.6)
0: 10 61 (18.8) 98 (29.6) 106 (32.0) 265 (26.8)
Total semester logs 325 331 331
×
Table 2.
Patient Demographics and Supervisor Degree From Osteopathic Manipulative Medicine Practice Logs of Third- and Fourth-Year Osteopathic Medical Students
Semester, treatments No (%)
Characteristic 5 6 7 Total
Patient type
 Clinical 1708 (16.8) 1509 (14.9) 1438 (14.2) 4655 (45.9)
 Volunteer 1648 (16.2) 1868 (18.4) 1958 (19.3) 5474 (53.9)
 Unspecified 9 (0.09) 2 (0.02) 10 (0.1) 21 (0.2)
Patient sex
 Male 1520 (15.0) 1569 (15.5) 1503 (14.8) 4592 (45.2)
 Female 1845 (18.2) 1800 (17.7) 1903 (18.8) 5548 (54.7)
 Unspecified 0 (0) 10 (0.1) 0 (0) 10 (0.1)
Patient age, y
 0-17 195 (1.9) 196 (1.9) 120 (1.2) 511 (5.0)
 18-39 1779 (17.3) 1954 (19.3) 1950 (19.2) 5683 (56.0)
 40-59 899 (8.9) 770 (7.6) 831 (8.2) 2500 (24.6)
 ≥60 492 (4.9) 459 (4.5) 505 (5.0) 1456 (14.3)
Supervisor
 DO 2084 (20.5) 2291 (22.6) 2264 (22.3) 6639 (65.4)
 MD 94 (0.9) 270 (2.7) 404 (4.0) 768 (7.6)
 Unknown 1182 (11.7) 818 (8.1) 721 (7.1) 2721 (26.8)
 Missing information 5 (0.1) 0 (0) 17 (0.2) 22 (0.2)
Total patients 3365 (33.2) 3379 (33.3) 3406 (33.6) 10 150

Abbreviations: DO, osteopathic physician; MD, allopathic physician.

Table 2.
Patient Demographics and Supervisor Degree From Osteopathic Manipulative Medicine Practice Logs of Third- and Fourth-Year Osteopathic Medical Students
Semester, treatments No (%)
Characteristic 5 6 7 Total
Patient type
 Clinical 1708 (16.8) 1509 (14.9) 1438 (14.2) 4655 (45.9)
 Volunteer 1648 (16.2) 1868 (18.4) 1958 (19.3) 5474 (53.9)
 Unspecified 9 (0.09) 2 (0.02) 10 (0.1) 21 (0.2)
Patient sex
 Male 1520 (15.0) 1569 (15.5) 1503 (14.8) 4592 (45.2)
 Female 1845 (18.2) 1800 (17.7) 1903 (18.8) 5548 (54.7)
 Unspecified 0 (0) 10 (0.1) 0 (0) 10 (0.1)
Patient age, y
 0-17 195 (1.9) 196 (1.9) 120 (1.2) 511 (5.0)
 18-39 1779 (17.3) 1954 (19.3) 1950 (19.2) 5683 (56.0)
 40-59 899 (8.9) 770 (7.6) 831 (8.2) 2500 (24.6)
 ≥60 492 (4.9) 459 (4.5) 505 (5.0) 1456 (14.3)
Supervisor
 DO 2084 (20.5) 2291 (22.6) 2264 (22.3) 6639 (65.4)
 MD 94 (0.9) 270 (2.7) 404 (4.0) 768 (7.6)
 Unknown 1182 (11.7) 818 (8.1) 721 (7.1) 2721 (26.8)
 Missing information 5 (0.1) 0 (0) 17 (0.2) 22 (0.2)
Total patients 3365 (33.2) 3379 (33.3) 3406 (33.6) 10 150

Abbreviations: DO, osteopathic physician; MD, allopathic physician.

×
Table 3.
Frequency Distribution of Documented Chief Complaints Categorized by Organ System and Body Region from Osteopathic Manipulative Medicine Practice Logs of Third- and Fourth-Year Osteopathic Medical Students (N=10150 Treatments)
Chief complaint category Frequency, No. (%)
Neuromusculoskeletal
 Thoracic or lumbar region 4744 (39.7)
 Cervical region 2293 (19.2)
 Upper extremity region 1232 (10.3)
 Hip/pelvis region 744 (6.2)
 Head region 712 (6.0)
 Lower extremity region 710 (5.9)
 Rib or chest wall 286 (2.4)
 Nonspecific or generalized 126 (1.1)
Nonneuromusculoskeletal
 Gastrointestinal 371 (3.1)
 Lower respiratory 231 (1.9)
 Other, uncategorized 231 (1.9)
 Ear, nose, or throat 180 (1.5)
 Cardiac 62 (0.5)
 Urogenital 30 (0.3)
 Psychiatric 10 (0.1)
Table 3.
Frequency Distribution of Documented Chief Complaints Categorized by Organ System and Body Region from Osteopathic Manipulative Medicine Practice Logs of Third- and Fourth-Year Osteopathic Medical Students (N=10150 Treatments)
Chief complaint category Frequency, No. (%)
Neuromusculoskeletal
 Thoracic or lumbar region 4744 (39.7)
 Cervical region 2293 (19.2)
 Upper extremity region 1232 (10.3)
 Hip/pelvis region 744 (6.2)
 Head region 712 (6.0)
 Lower extremity region 710 (5.9)
 Rib or chest wall 286 (2.4)
 Nonspecific or generalized 126 (1.1)
Nonneuromusculoskeletal
 Gastrointestinal 371 (3.1)
 Lower respiratory 231 (1.9)
 Other, uncategorized 231 (1.9)
 Ear, nose, or throat 180 (1.5)
 Cardiac 62 (0.5)
 Urogenital 30 (0.3)
 Psychiatric 10 (0.1)
×
Table 4.
Frequency Distribution of Documented Somatic Dysfunction Body Regions Treated From Osteopathic Manipulative Medicine Practice Logs of Third- and Fourth-Year Osteopathic Medical Students (N=10150 Treatments)
Somatic dysfunction body region Frequency, No. (%)
Thoracic 6255 (61.6)
Cervical 4932 (48.6)
Lumbar 4249 (41.9)
Pelvis 2272 (22.4)
Head 2270 (22.4)
Sacrum 2019 (19.9)
Upper extremity 1787 (17.6)
Lower extremity 1702 (16.8)
Ribs 1422 (14.0)
Abdomen 402 (4.0)
Table 4.
Frequency Distribution of Documented Somatic Dysfunction Body Regions Treated From Osteopathic Manipulative Medicine Practice Logs of Third- and Fourth-Year Osteopathic Medical Students (N=10150 Treatments)
Somatic dysfunction body region Frequency, No. (%)
Thoracic 6255 (61.6)
Cervical 4932 (48.6)
Lumbar 4249 (41.9)
Pelvis 2272 (22.4)
Head 2270 (22.4)
Sacrum 2019 (19.9)
Upper extremity 1787 (17.6)
Lower extremity 1702 (16.8)
Ribs 1422 (14.0)
Abdomen 402 (4.0)
×
Table 5.
Frequency Distribution of Documented Osteopathic Manipulative Treatment Techniques From Osteopathic Manipulative Medicine Practice Logs of Third- and Fourth-Year Osteopathic Medical Students (N=10150 Treatments)
Technique Frequency, No. (%)
Muscle energy 6570 (64.7)
High-velocity, low-amplitude 4054 (39.9)
Balanced ligamentous technique/indirect 3865 (38.1)
Soft tissue 3615 (35.6)
Myofascial release 1944 (19.2)
Counterstrain 1499 (14.8)
Articular 1383 (13.6)
Lymphatic techniques 910 (9.0)
Still technique 730 (7.2)
Osteopathic cranial manipulative medicine 641 (6.3)
Facilitated positional release 441 (4.3)
Visceral 261 (2.6)
Functional technique 157 (1.6)
Ligamentous articular strain 123 (1.2)
Integrated neuromuscular release 96 (1.0)
Other 68 (0.7)
Table 5.
Frequency Distribution of Documented Osteopathic Manipulative Treatment Techniques From Osteopathic Manipulative Medicine Practice Logs of Third- and Fourth-Year Osteopathic Medical Students (N=10150 Treatments)
Technique Frequency, No. (%)
Muscle energy 6570 (64.7)
High-velocity, low-amplitude 4054 (39.9)
Balanced ligamentous technique/indirect 3865 (38.1)
Soft tissue 3615 (35.6)
Myofascial release 1944 (19.2)
Counterstrain 1499 (14.8)
Articular 1383 (13.6)
Lymphatic techniques 910 (9.0)
Still technique 730 (7.2)
Osteopathic cranial manipulative medicine 641 (6.3)
Facilitated positional release 441 (4.3)
Visceral 261 (2.6)
Functional technique 157 (1.6)
Ligamentous articular strain 123 (1.2)
Integrated neuromuscular release 96 (1.0)
Other 68 (0.7)
×