This study included an initial survey and evaluations from each educational session, which were not deemed human subject research by the NCH institutional review board and did not require approval. 

An anonymous survey was created using Survey Monkey (SVMK, Inc.) and sent to all 141 residents at NCH (12 ORT residents, 40 IM-Peds, five categorical DO residents, and 84 MD categorical residents) in June 2017 with three reminder emails each sent two to three weeks apart. The survey was designed by associate residency program directors (A.R., E.Z.) who had completed a training course at either the Pediatric Academic Societies Annual Conference or the Association of Pediatric Program Directors Conference before developing the survey. The questions were not based upon previously published surveys and included both multiple choice and free-text responses. The full survey is included in Appendix 1. At the time of the initial survey, the dually-accredited program was transitioning into the ORT. The survey included separate sections for MD residents (Section 2), DO residents in the ORT (Section 3), and DO residents in the categorical training program (Section 4). The MD residents were asked 11 questions (two preliminary questions and nine questions in Section 2 of Appendix 1) that were primarily focused on resident perceptions of OMT before coming to NCH and at the time of the survey. These items queried overall knowledge, thoughts about the efficacy of OMT, OMT referral patterns, and interest in learning more about OMT. Of the 11 questions, 10 were multiple choice, and one was free text. The non-ORT DO residents were asked eight questions (two preliminary questions and six questions in Section 3 of Appendix 1) about the importance of continuing their osteopathic education during residency and how the presence of a dually-accredited program/ORT affected their desire to learn and use OMT. Seven of the eight questions were multiple choice format, and one question allowed free text. The residents in the dually-accredited program/ORT were asked nine questions (one preliminary question and eight questions in Section 4 of Appendix 1) regarding their perceptions of the program’s support of their osteopathic skill development and whether they had adequate opportunity to educate their MD and non-dual DO peers on the value of osteopathic medicine. Two of the questions were free text format, and seven questions gave multiple choice answers. The survey was completed in June 2017 to ensure that all residents had at least a minimum of one academic year with their dually-accredited/ORT colleagues. 

Since the survey demonstrated a general desire from the MD residents to learn more about OMT, several ORT residents, in conjunction with the ORT associate program directors, developed four educational sessions held during the 2018 to 2019 academic year. These sessions were incorporated into the standing noon report (clinical case discussion) series and conducted by ORT residents in their third year of training. They incorporated OMT into the diagnosis and treatment plan for each case and occasionally provided a live demonstration of osteopathic techniques. The tenets of osteopathic medicine provided a framework for the instruction of MD and non-ORT DO residents. ¹⁰ The cases addressed common pediatric problems such as constipation, torticollis and plagiocephaly, mechanical low back pain, and musculoskeletal chest pain that may benefit from the addition of OMT to traditional medical management. Each case also included a review of the basic tenets of osteopathic medicine and the referral process to our OMT clinic. This information was incorporated into a template presentation that could be used for future lectures by ORT residents. An anonymous, 10-question paper survey was distributed after each session. These surveys were developed by an ORT resident leading the initiative (E.B.) and included nine multiple choice questions and one question allowing for a free text response (Appendix 2). The questions were similar to those on the initial survey, concerning referrals to osteopathic-specific care and their impressions of these osteopathic-focused lectures. Residents, medical students, and faculty attended the noon report; thus, surveys were obtained from all three groups and all data was included in the results. There was no formal count made of residents, students, and faculty in attendance at each session, nor was there record of those present for multiple sessions. The researchers did not provide a survey to ORT residents, as they were excluded from completing it. 

A total of 59 of 141 (41.8%) residents responded to the initial survey. Of these, 44 (74.5%) were MD residents, 10 (16.9%) were DO residents in the dually accredited program, and 5 (8.5%) were DO residents in the categorical program. A total of 44 of 124 (35.4%) MD residents completed the survey. The survey was completed by five (100%) of the DO residents in the categorical program and 10 (80%) of the residents in the dually accredited program. Results for the 44 MD residents who completed the survey are included in Tables 1 and 2. 

Of the 44 MD residents, 29 (65.9%) provided free-text responses, and 15 (34.1%) opted not to respond when asked, “Since being at NCH, what are your thoughts about OMT and osteopathic care?” Each of the 29 residents who responded stated that they would refer a future patient for OMT/osteopathic-specific care. The most common conditions for which they would refer included musculoskeletal system (MSK)-related issues (18 residents; 62.1%), headaches (three residents; 10.3%), and plagiocephaly (one resident; 3.4%). Several respondents mentioned OMT’s use in patients with chronic pain. Twenty-five of 43 MD residents (58.1%) stated that they would be interested in learning some basic OMT skills. Finally, one of the MD residents commented that being a resident at NCH “significantly changed my perception of DO physicians in general-I see them as similar to myself except with more skills than an MD has.” 

Four noon conference sessions were held with a combined total of 140 attendees. Because of the nature of our scheduling, a given resident would most likely attend only one or two of these sessions. Regarding the attendees, 76 (54.2%) were medical students (the actual breakdown of MD or DO student was not asked, but, in general, NCH has a mix of two-thirds MD students and one-third DO students at lectures); 48 (34.2%) were MD residents in our program; 10 (7.1%) were non-ORT DO residents in our program; three (2.1%) were MD faculty members, and 3 (2.1%) were unknown. The overall responses were similar from session to session, so the data from all four sessions are presented in aggregate. When asked if they found the educational session beneficial, 138 (98.5%) replied, “yes.” When asked if they would refer a patient for OMT, 132 (94.2%) replied, “yes.” When asked about their prior knowledge and comfort with the potential use of OMT for the case presented, the results were: one (0.7%) “no knowledge,” 97 (69.3%) “some but not familiar with details,” 28 (20%) “OK knowledge,” and 14 (10%) with “strong knowledge.” After attending the session, the results were: zero (0%) “no knowledge,” 52 (37.1%) “some but still not familiar with details,” 75 (53.6%) “OK knowledge,” and 13 (9.3%) with “strong knowledge.” Table 3 demonstrates the pre- and postsession knowledge base of participants. 

Although the ORT is a small part of our overall pediatric training program, it seems to have had a significant impact on MD residents’ understanding of OMT and their belief that OMT is an efficacious treatment strategy. Additionally, a significant percentage of MD residents showed a desire to learn more about OMT and were receptive to initial demonstrations of OMT during the educational sessions. This finding is consistent with previous literature regarding MD resident and faculty attitudes toward osteopathic-specific care. 

As far as any of the authors are aware, these four educational sessions were the first osteopathically-focused didactic series presented to the entire residency program in program history. Informal, single-session presentations had been completed previously about 10 years prior as part of the resident noon conference series. About five years prior to the series presented in this article, a grand rounds presentation was given at Nationwide Children’s Hospital on osteopathic manipulative medicine. Since the initial survey occurred before the educational series, having the ORT residents embedded into the larger programs allows for the inherent sharing of their knowledge and expertise. The ORT residents are strongly encouraged to do OMT in both clinic and inpatient settings, so other residents potentially had prior exposure. 

There are several limitations to this study. First, the initial survey response rate was low overall (41.8%) among all residents and particularly low (35.4%) amongst MD residents, which may have introduced bias toward residents who were already more knowledgeable about or interested in OMT. Although the results from the educational session evaluations showed that most of the attendees viewed OMT as a valid treatment option, those results may be biased if the MD residents and faculty members who completed the surveys had existing positive opinions regarding OMT. This bias may be limited, though, as noon conferences are required educational sessions for all available residents at NCH regardless of interest in OMT. Faculty attendance is optional, though encouraged, at noon conferences, and typically represents a variety of backgrounds. Resident attendance at educational sessions was limited by clinical rotation schedules, which did not allow for consistency regarding which residents were present for each session. Another variable, which was not formally assessed, is the impact of rotating students from Ohio University Heritage College of Osteopathic Medicine on the MD residents. However, one could argue that an osteopathic medical student’s utilization of OMT on their rotation would be under the direction of osteopathic residents and faculty and less likely to impact MD residents. Though it was not specifically studied, the presence of the ORT may make a substantial impact on medical student education. Lastly, the session evaluations were completed immediately after the presentations, so the long-term impact is unknown. 

Based on these results, our program is working on several initiatives to increase knowledge about OMT among our non-ORT residents. These initiatives include (1) having more OMT-focused case reports completed by our ORT residents, (2) developing short didactics about OMT basics that the ORT residents can share with their non-ORT colleagues, (3) developing a more formalized way to incorporate our non-ORT DOs interested in OMT into our ORT curriculum, and (4) most importantly, allowing our ORT residents to do more OMT in all clinical settings, since it has been theorized that this role-modeling is what has been most effective. We also need to assess how long the knowledge obtained by MD residents is retained after completion of the education sessions. 

Further studies should be designed to better delineate the educational session survey responses from osteopathic and allopathic medical students, residents, and faculty. This was a limitation of the current study and could be easily corrected in future studies. Separating those responses would provide more clarification about the true impact of these sessions. Other goals of future studies should be to assess the long-term retention of osteopathic knowledge by MD residents and to evaluate the long-term effect on MD referrals to an OMT provider based on their exposure to an ORT. Future projects may also look at the effect of an ORT on the education of MD and DO medical students. 

For our training program, a significant limitation in increasing the osteopathic presence in the hospital and residency program is the limited number of DO faculty members. Of the nearly 850 faculty physicians involved in teaching the pediatric residency, 6% are osteopathic physicians. ¹¹ Even fewer faculty at Nationwide Children’s Hospital practice osteopathic treatment techniques in their clinical practice. At the time of this study, there was only one faculty member performing OMT in clinical practice. The limited number of osteopathic faculty restricts the osteopathically-focused clinical opportunities for ORT residents and for the entire program. If this number could be increased, it may allow MD residents opportunities for direct clinical exposure to OMT. As demonstrated in the 2019 Osteopathic Medical Profession Report from the American Osteopathic Association, ¹² there continues to be drastic growth for the osteopathic profession, with DOs representing 11% of the American physician population. Ohio currently has the seventh highest number of practicing osteopathic physicians in the United States, with 5,695 DOs in practice, representing 5.4% of all osteopathic physicians in the US. ¹² Our program hopes to capitalize on this growth and increase osteopathic presence in years to come. 

In the ORT program at NCH, we have experienced barriers to practicing OMT as described in previous literature, including time constraints on the part of both trainees and faculty members, lack of research demonstrating a clear benefit of OMT in a wide variety of clinical situations, and physician insecurity with OMT skills. ¹³ Despite these barriers, if other residency programs have osteopathic residents and faculty with enthusiasm for OMT, we feel that MDs would be willing and eager to learn about osteopathic medicine. 

Despite a relative lack of formal education about OMT for non-ORT residents, the presence of a small, passionate group of ORT residents has left an impact on their colleagues. This study shows preliminary data regarding efforts to highlight the clinical use of OMT in pediatric patients. Our small OMT educational series suggests that even brief exposure to osteopathic principles can enhance the knowledge of MD residents, medical students, and faculty. Although further research is needed to fully capture the benefit of educational sessions about OMT for MD colleagues, our approach may be adaptable for programs with or without similar osteopathic influences. 

Abbreviations: DO, osteopathic physician; MD, allopathic physician; NCH, Nationwide Children’s Hospital. 

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Abbreviations: DO, osteopathic physician; MD, allopathic physician; NCH, Nationwide Children’s Hospital; ORT, osteopathic recognition track.