In this article, I review the remarkable transformation that osteopathic graduate medical education (OGME) has been undergoing and predict OGME's likely future.
Emphasis on Internship Education
To understand OGME, a distinction must be made between internship and residency training. The osteopathic profession operates under the premise and expectation that every graduate of a college of osteopathic medicine (COM) will complete an internship program approved by the American Osteopathic Association (AOA). This is considered a capstone experience for all doctors of osteopathic medicine (DOs), and rigid accreditation policies are in place to reinforce its importance.1 The AOA's Council on Postdoctoral Training (COPT) focuses its policy efforts on preserving the osteopathic internship and on generating sufficient training positions to match the number of graduates of COMs. Recognition of this emphasis on intern education is essential in understanding the driving force behind OGME.
Reasons for the Present Dilemma
Initial concerns about the osteopathic internship arose in 1983, when it became evident that the profession had an insufficient number of positions to accommodate the increasing number of graduates. In response, the AOA chose, amid considerable controversy, to modify its accreditation standards to permit COMs to develop postdoctoral programs, primarily internships, outside the osteopathic hospital network. For their part, COMs took up the challenge and began in earnest to develop new internship programs. With revised accreditation standards, COMs now had the chance to sponsor postdoctoral programs on their own and set up separate educational networks for pre- and postdoctoral education and, in the process, gain greater oversight.
There were no AOA/ACGME and COM-sponsored internship positions in 1985. But shortly afterwards, such jointly sponsored positions were established, and by 2000 their number had risen to 931.2 Not surprisingly, the primary motivation for ACGME programs to participate in OGME at the internship level was to recruit DOs to fill vacant residency positions. While the osteopathic profession has welcomed allopathic programs' development of internship positions, the consequences may prove detrimental. Most DOs who have entered AOA — ACGME internship programs have blended into the ACGME portion of the residency in the second year of residency and beyond and have effectively departed from the osteopathic educational system.
After 1984, several new patterns related to career choice of COM graduates begin to emerge.
▪ The fastest-growing group and the one of most concern to the osteopathic profession consists of COM graduates who bypass AOA-accredited programs altogether and go directly into ACGME residencies. In the 2002 osteopathic Match, 45.9% (1,212) of all COM graduates did not register to participate.3
▪ The second group is made up of DOs who enter AOA — ACGME-accredited internship programs and continue training in allopathic programs. When taken together, these two groups represent a sizable majority of DOs who start and complete their entire postdoctoral training in ACGME-accredited programs. For the 2001–02 academic year, 4,658 DOs (65%) were enrolled in ACGME-accredited programs.4 The AOA reported 2,499 DOs (35%) in its residency programs for the same period, a number that must be viewed as artificially high because it includes osteopathic physicians counted in both ACGME and AOA reports.5
▪ A third group of DOs gravitates to residencies within the osteopathic hospital network because those residencies offer them realistic opportunities to train in selective surgical specialties.
▪ The fourth group is composed of graduating seniors who take an AOA-approved internship to qualify for a state license and then select an allopathic residency for their specialty training.
▪ Finally, there are those osteopathic physicians, formerly the largest group but now the minority, who seek internship and residency programs at solely osteopathic institutions as their first choice for training. In the 2001–02 osteopathic intern Match program, 698 of the 1,989 funded first-year positions went unfilled. Clearly, recent COM graduates prefer allopathic over osteopathic postdoctoral programs.
The increased presence of DOs in allopathic training programs during the 1980s and 1990s significantly lowered barriers of professional prejudice against osteopathic physicians; they have grudgingly won greater acceptance. The downside is that a high percentage of graduates have capitalized on this acceptance by going directly into ACGME-approved programs, chiefly in primary care. For the year 2001–02, 2,484 DOs trained in family medicine, general internal medicine, and general pediatrics at ACGME-accredited programs, compared with 1,097 DOs at AOA-accredited programs, a number that also includes residents in AOA — ACGME-accredited programs.6
REVISIONS OF AOA EDUCATIONAL POLICIES
The AOA internship in 1989 consisted of required rotational experiences in the following disciplines for the months indicated: Internal medicine (three), surgery (three), obstetrics — gynecology (one), pediatrics (one), and family medicine (one). Three months of electives were allowed. In practical terms, the AOA internship added an additional year of training, compared with the number of years required in most ACGME residencies. In internal medicine, for example, a DO took the one-year internship plus a three-year residency to achieve program completion.
Pressures for Change
With the initiation of combined AOA — ACGME programs, the AOA traditional internship faced new problems. Many of the new combined AOA — ACGME programs awarded credit for not only the AOA traditional internship but, from the side of the ACGME, also for the first year of the allopathic residency. Since the DOs normally continued in the sequential years of the allopathic residency, they were able to reduce their postdoctoral training by one year. More problematic was the fact that osteopathic physicians who followed this educational track became eligible for allopathic but not osteopathic certification. In most specialties, family medicine being an important exception, individuals were consistently one year short of AOA-approved postdoctoral training to qualify for board eligibility.
Understandably, programs that permitted DOs to train in ACGME-approved residencies with AOA approval proved to be extremely popular with graduates. Postdoctoral programs at osteopathic hospitals were at a competitive disadvantage based on years of training alone. In addition, AOA membership and certification status are linked. Osteopathic physicians who are AOA-certified must maintain active membership with the national organization or else they lose their certification status. The prospect of diminished numbers of DOs seeking AOA certification following their post-doctoral training and its potential negative impact on AOA membership generated new incentives for the profession to make further adjustments to the concept of the traditional osteopathic internship.
Responses to Pressures
In 1990, the AOA accreditation process began to eliminate this discrepancy in the number of training years by initiating what are called “track and emphasis internships.” No longer would the concept of a traditional osteopathic internship be a single educational experience. Starting with internal medicine, curricular changes were introduced that incorporated a sufficient number of internal medicine rotations into the first postdoctoral year to count both as an internship and as the first year of residency training in internal medicine. Twelve months of postdoctoral training were eliminated in the educational continuum, and equivalence with the ACGME was achieved. Following the lead of internal medicine, the 1990s witnessed the adoption of track programs by several specialties. In each instance, the first year of post-doctoral training was modified to reduce the educational sequence by one year.
Emphasis internship programs changed curricular content in the first postdoctoral year to create meaningful educational experiences related to the specialty. While there was no reduction in the number of years of training, interns gain additional exposure in their chosen careers. The former experience of a broad-based internship became subsumed by curricular revisions to achieve equivalence in the number of training years with ACGME-approved programs and to provide additional specialty training in the first postgraduate year. With dogged determination, the osteopathic profession preserved the name “internship” even as it became indistinguishable, in terms of curricular design and training exposure, from the first year of most ACGME-approved residencies. Rather than one type of AOA internship, at least 14 different first-year programs are currently possible, with more on the horizon.
In February 1999, additional revisions were made to the definition of a traditional osteopathic internship.7 As a result, the number of required rotations shrunk from nine to five, leaving it to administrative discretion to build in seven months of electives. The new curricular model mandated at least one month, or four weeks, in internal medicine, general surgery, family practice, pediatrics, and female reproductive medicine. Three years later, in February 2002, further revisions were implemented that narrowed the scope of clinical exposure even more.8 Now the only required clinical exposure was in internal medicine (two months), family medicine (one month), and emergency medicine (one month). Dropped from the required list were pediatrics, obstetrics—gynecology, and general surgery; these could be added at the discretion of the program sponsor but were not essential for accreditation. The addition of alternative first-year internship programs and a radical redesign of the curricular structure have diminished its distinction as a unique osteopathic educational program.
The AOA Board's Perspective
The AOA Board of Trustees created its Rotating Internship Task Force to broadly review the value of the osteopathic internship “as a key component of osteopathic medical education and our distinctiveness as a profession.”9 One of the first questions asked was whether the osteopathic rotating internship should be retained. The conclusion reached by the task force in its October 2001 report was that not only should the rotating internship be retained, development of new specialty track and emphasis internships should be encouraged for all specialties.
Another hard question considered was the future or vision of the AOA rotating internship. The recommendation of the task force on this question was more backward-looking than forward-looking. It stated that the “mission of the osteopathic internship program is to provide first-year graduate osteopathic physicians with an in-depth and comprehensive year of postdoctoral and academic experience that provides a base for entry into specialty training.”10 The history of the changes made since 1990 points to a greater focus on specialized training and more narrowly constructed training in the first postdoctoral year. Reductions made in the number and diversity of required educational experiences run counter to the mission of comprehensiveness. The osteopathic internship is no longer the base for entry into specialty training, it is the first year of specialty training.
HARD CHOICES FOR OSTEOPATHIC MEDICINE
Internship policy decisions made in the 1990s and the perception of the osteopathic internship's being a distinctive educational experience are moving in different directions. This dichotomy is reflected in what the osteopathic profession wants the internship to be versus what the internship has become. A number of compelling issues are at stake. As noted above, the AOA continues to identify the osteopathic internship as a unique and distinctive part of its educational system. Maintenance of this notion has important financial and political implications. For example, the federal government, in the Balanced Budget Act of 1997, provides for reimbursement of the AOA internship apart from and in addition to residency training. Separate osteopathic licensing boards in five key states evaluate individuals based primarily on their completion of an osteopathic internship and routinely deny licenses to DOs without this unique experience. As noted above, popular support within the rank and file of senior AOA members for the internship is high.
Four major trends will continue to shape the osteopathic internship. The first is the diminishment of the osteopathic hospital network and a resultant loss of institutions with the best opportunity to create the desired distinctive osteopathic internship program. Second, the character of the osteopathic internship will increasingly model itself as, and be considered the first year of, an allopathic residency program as AOA-ACGME programs continue their growth as sponsors of OGME. Third, continued efforts to add variety and to reduce curricular structure for an osteopathic internship only weaken its identity. Is it possible to call an osteopathic internship a unique educational experience if this internship can take the form of 14 or more alternative programs? Finally, the trend of graduating seniors' going directly into allopathic residencies will go on as long as the distinctions between an osteopathic internship and a first-year residency position in an allopathic residency are blurred.
It is not possible for the osteopathic profession to turn back the hands of time. The period of increased growth at the college level occurred when the osteopathic hospital network contracted. Many ACGME-approved residencies, working in partnership with the AOA, had excess capacity to absorb the ever-burgeoning number of DO graduates. In the process, the AOA made compromises in its accreditation standards to facilitate the development of AOA—ACGME programs. A process of integration is occurring that is pulling the traditional osteopathic educational model closer to the allopathic educational model. The notion of the osteopathic internship is swiftly losing its hold as a capstone experience that occurs immediately following graduation and prior to residency training. In osteopathic circles, the AOA internship is still discussed as being a unique and distinctive program. However, this perception is now more a wish than a fact; the winds of change have created a new reality.