In this article, I recount how private colleges of osteopathic medicine (COMs) have rapidly and fundamentally restructured themselves, beginning in the 1990s. Their new organizational model de-emphasizes many of the characteristics that distinguish allopathic medical schools of today. I will explain how the private COMs have carved out their own niche in medical education and created a new model compatible with their institutional strengths and weaknesses and related to their economic, educational, and human resources.
Private Colleges of Osteopathic Medicine until 1990
Five current private COMs trace their roots back to the early 20th century. There were several other osteopathic medical schools during that period, but they either closed, merged with extant COMs, or, in one case, converted into an allopathic medical school.1 Four of the five were located in the Midwest. A second dramatic wave of new COMs started in 1969 and ended in 1979. During that decade, ten new COMs were founded, six of them public and four of them private. With this growth, osteopathic medicine, through its medical colleges, planted firm roots throughout the country and became a national rather than just a regional force in medicine. The third wave began in 1992 with the founding of five new private COMs, the most recent being the Edward Via Virginia College of Osteopathic Medicine. In 2002, the American Osteopathic Association (AOA) granted this newest COM provisional accreditation and allowed it to open with an inaugural class of 150 students in September 2003. Currently there are a total of 20 COMs, 14 of which are private but data presented in this article are reflective of the 13 private COMs.
Before 1990, the oldest COMs could have been described as hybrids between pre-Flexner proprietary medical schools and contemporary academic health centers.2 From the proprietary perspective, the COMs offered small, single-institution/single-degree programs and were heavily dependent on tuition dollars to sustain their educational mission. The basic science faculty spent most of their time in the classroom, whereas research productivity, the pursuit of grants, and publications were of limited and secondary importance. Full-time clinical faculty existed, but in small numbers. Commonalities shared with academic health centers include the existence of a teaching hospital associated with the COM and a commitment to patient services. A highly motivated clinical faculty, although generally voluntary, practiced in the community, admitted patients, and taught students, interns, and residents. The COM-owned teaching hospitals supported the clinical education of their students and functioned as centers for postdoctoral training. The curricula of these COMs shared many common features with those of their allopathic counterparts, with the exception of specialized training in osteopathic manipulation and a greater clinical emphasis on primary care.
The second wave of new COMs that began in 1969 evolved with a somewhat different organizational structure. The six state-supported COMs were established on the community-based educational model and were managed in the same manner as other allopathic medical schools within their respective states. Public COMs functioned and were evaluated by the same standards applied to allopathic medical schools accredited by the Liaison Committee on Medical Education (LCME) in terms of their efforts to achieve academic status, medical service to their community, research productivity, and the demands placed on full-time faculty. As the private COMs began to implement new organizational structures, the divergence between the public and private COMs became increasingly evident.
The four private COMs founded between 1977 and 1979 differed in important ways from the older osteopathic medical colleges. These new COMs were started without a COM-owned teaching hospital, and three of the four colleges were either founded as—or soon became—a college of another private educational institution with an entrepreneurial orientation. Although basic science education was provided on campus in the traditional manner, clinical experiences were organized in a much different way.
In general, allopathic medical schools limit core clinical rotations to a base teaching hospital and a select number of neighboring affiliate hospitals. By contrast, osteopathic COMs historically relied on the network of osteopathic community hospitals for clinical education. These institutions became saturated as new COMs continued to be formed and as class sizes swelled. New private COMs faced the critical need to identify additional training locations. The result was that core clinical rotations increasingly occurred quite distant from campus and in varied educational settings. Such locations included physicians’ offices, publicly funded clinics, and smaller community hospitals new to academic medicine. Private COMs proved unable to assume full responsibility for oversight of the third- and fourth-year curriculum and depended heavily on local arrangements, such as integrating osteopathic medical students into clerkship programs designed primarily for allopathic medical students and the extensive use of volunteer community faculty for various clinical rotations. Acceptance of less control over clinical education had many inherent educational drawbacks, but it did produce positive economic benefits. Private COMs collected tuition, paid negotiated amounts to both their clinical training sites and their adjunct faculty, and reduced their direct supervision of clinical education.
Faced with a rapidly changing hospital environment, the five oldest private COMs began to either sell or close their teaching hospitals during the 1980s. Once out of the hospital business and with dispersed clinical faculty, these COMs had little choice other than to pursue the same strategy of outsourcing clinical education that had been pursued by the newer private COMs. As a direct result, competition for affiliate sites increased and new accreditation policies were formulated to address shortages of osteopathic postdoctoral positions. By 1990, the private COMs, both old and new, were structured, organized, and operated in similar ways.
The Imperative to Grow
Starting around 1990, private COMs exhibited distinct patterns of growth characterized by four identifiable traits: (1) increased class size; (2) diversity of health-related programs; (3) expansion; and (4) limited involvement in graduate medical education. Collectively, these steps taken by private COMs represented a new direction in the formulation of a unique educational model for the training of health care professionals.
The private COMs found that the quickest and easiest way to grow was to increase class size. Until 1998, AOA accreditation standards were quite lax in this area: “...the number of students that can be supported by the education program of the COM are [sic] the responsibility of the COM.”1 Taking full advantage of this opportunity, private COMs started to accept more students. Applications to osteopathic medical school rose steadily from 1991-1996, and private COMs found it difficult to resist the temptation of accepting more students into their programs. For example, the New York College of Osteopathic Medicine had 574 medical school students in 1990; 12 years later, in 2002, that number had increased to 1,136, an increase of 98%.3,4 In terms of student enrollment, the most aggressive private COM was the Lake Erie College of Osteopathic Medicine. It first opened its doors in 1993 with an inaugural class of 61 students and in 2002 its medical school enrollment was 721.4,5 Overall, and inclusive of four new COMs, enrollment of students in private osteopathic medical colleges jumped from 4,817 in 1990 to 8,972 in 2002.3,4 Presently, five of the ten largest medical schools in the United States, in terms of entering class size, are private COMs.4,6
Since 1990, private COMs evolved in one of two ways. One group of private COMs formed institutions that offered more than a single degree and became health science universities. The freestanding private COMs obtained regional accreditation and changed names to reflect their new university status. The colleges in the second group, each of which was already a college of an existing private university, became the engine for developing new health-related programs within their institutions. Both groups expanded their educational missions to include new professional degree and allied health programs. Among their collective accomplishments since 1992, private COMs established five new colleges of pharmacy; nine physician assistant, eight physical therapy, and five occupational therapy programs; six Masters in Biomedical Sciences programs; and degree programs in dentistry (two), veterinary medicine, podiatric medicine, optometry, audiology (two), nursing (two), plus a wide variety of other allied health programs. Close attention was given to the development of new programs with a potential for high enrollment that could be accommodated without major capital investment and the need to provide direct patient services and full-time clinical faculty. New programs were favored that had curricular and accreditation requirements that allowed for the joint instruction of students from different programs in the same basic science courses, to maximize faculty use.
Expansion is another characteristic of the new educational model pursued by private COMs. Once private COMs maximized their growth potential in one geographical area, replication was sought in another part of the country. Leading the way in this direction was the Chicago College of Osteopathic Medicine. In the early 1990s, it developed the Chicago College of Pharmacy and the College of Allied Health Professions with programs for physician assistants and for physical and occupational therapy, and changed its name to Midwestern University. In 1995, Midwestern University created a new campus outside of Phoenix, Arizona and established the Arizona College of Osteopathic Medicine, a new college of pharmacy, and allied health programs that are like those it operates in Illinois. This expansionist approach was deemed successful and profitable; soon other private COMs moved to develop branch campuses and to reproduce their existing programs.
In the pursuit of rapid growth and expansion, private COMs reordered priorities. Nowhere is this shifting emphasis more evident than in their approach to clinical and postdoctoral education. Basic tenets of their educational model include keeping the number of full-time clinical faculty low, avoiding ownership of clinical facilities, and nominal involvement in the provision of patient services. Without their own teaching hospitals, private COMs outsourced clinical education. For example, one private COM located in the Midwest boasts that its medical students can take core clinical rotations in fifteen different states.7Their immediate challenge was to squeeze more students into existing clinical training sites and to identify new opportunities for clinical education to accommodate all of their health-related programs. The pressures of rapid growth, when combined with the practice of outsourcing clinical education, stretched private COMs’ oversight of their curricula, generated greater variability in educational quality, and reduced their control over clinical education.
In shifting priorities, private COMs retreated from the concept of the medical schools providing an educational continuum between pre- and postdoctoral education. While the private COMs introduced significantly larger numbers of students into the educational pipeline, most private COMs made nominal attempts to create postdoctoral training opportunities for their graduates. For example, the four private COMs established in the 1990s are expected to graduate 399 students in 2003. Yet between them, their collective development of new AOA-approved residency programs can accommodate a maximum of only 93 of these graduates.8 By shying away from engagement in postdoctoral education, at the internship level but especially at the residency level, private COMs overwhelmed the osteopathic postdoctoral educational system and created the expectation that programs accredited by the Accreditation Council for Graduate Medical Education would absorb their increased number of graduates. In the process of reinventing themselves, the private COMs have chosen not to commit significant resources to clinical and postdoctoral education and to more narrowly define their educational focus to the first two years of medical school.
Medical Education and Economics
Since 1990, the distinguishing characteristics of private COMs are closely tied to the economics of medical education. They have backed away from the most expensive and financially risky activities. In the process they have created their own niche that is an offshoot from the mainstream. Few of the private COMs have invested above minimal levels in efforts to distinguish themselves in areas of research, postdoctoral education, patient care services, publications, clinical education, faculty reputation, or grant support—all things that enhance institutional status but are costly investments.
In 1995, private LCME-accredited medical schools derived only 6% of their total revenues from tuition and fees.9 By comparison, private COMs, with 70% of their total revenues dependent upon tuition and fees, have concentrated on cost sharing between programs, income generation through tuition, high student volume, and spreading risk among several educational programs.10 The result is a group of medical schools that concentrates its efforts on campus-based education for the first two years and leans heavily on the contributions of clinicians to provide the experiential component of the curriculum quasi-independently from the COM. The private COMs demonstrated the ability to plan and implement effectively, respond quickly to changing environments, and to diversify their educational and financial base. Outcome performance indicates that graduates of private COMs and their associated health-related programs fare well on professional and state licensing examinations and the institutions themselves continue to meet specialized and regional accreditation requirements.
The challenges facing private COMs are quite different from those of allopathic medical schools.11 Future expansion becomes increasingly difficult and more costly. With enrollment numbers at all-time highs, opportunities to further increase class size are limited. The professional and allied health programs that best fit their educational model are already up and operating. Other new programs are a bigger challenge because they have limited enrollment potential, require a substantial financial investment in physical plant and faculty resources, and do not offer short-term profitability. The primary option for continued growth appears to be the creation of branch campuses and the duplication of existing programs.
The greatest vulnerabilities of private COMs include a heavy dependence on tuition revenue; increased demands by affiliates and adjunct faculty; misjudgment of societal demand for their graduates; and avoiding a negative public perception of their educational model. Private COMs will be the first institutions affected adversely in any significant enrollment downturn. Given the high cost of medical education, prospective qualified students having a choice of programs (discounting the elite private medical schools) will predictably select public over private medical schools because of lower tuition costs. In choosing between two private institutions with comparable tuition costs, students can be expected to select the one with the strongest academic reputation. The private COMs have high tuition rates, large class sizes, and their educational model is not designed to compete against others in terms of academic status. With a heavy dependency on tuition revenue, private COMs that sustain a downturn in enrollment have few options to offset these losses.
It is also not certain that private COMs can continue to count on the educational contributions of their adjunct clinical faculty without changes. The private COMs’ dependence upon their training sites for clinical education has never been greater, while costs associated with medical education continue to increase. These training sites will be looking to COMs to share a larger portion of tuition revenues as an offset. While the private COMs have formulated a bare-bones, pragmatic way to train osteopathic physicians, they also run the risk of encountering a negative public perception that focuses less on educational outcomes than on how different private COMs the are from traditional medical schools.
Private Colleges of Osteopathic Medicine Today
In many ways, the 1990s were successful for the private COMs. They pursued strategies that fueled rapid growth and took advantage of opportunities that presented themselves. One such advantage comprised the AOA accreditation standards. On paper, the LCME and the AOA accreditation standards for medical schools are quite similar, but there are major differences in the strictness of interpretation. Private COMs enjoy considerable freedom to experiment with novel approaches, and partly because of this, the process of starting a new COM or branch campus requires a comparatively modest investment of financial and human resources. A second opportunity was the strong surge in applications for programs in the health professions between 1990 and 1996. It allowed the private COMs to expand and justify the need for more COMs. The 36% decline in applications to osteopathic medical schools experienced between 1996 and 2001 did not deter the private COMs from accepting any fewer students.10 To the contrary, entering class sizes continued to increase. Compared with 1990, the private COMs are now larger and stronger, more educationally diverse, able to display an impressive array of new buildings on their campuses, and reflect an air of confidence about the future.
These advances of the private COMs have come at a price to others. For years the AOA has committed itself to maintaining an independent and viable system of postdoctoral education and certification. The activities of the private COMs, devoid of joint planning with the AOA, now threaten this educational system. Without the private COMs generating new AOA-approved postdoctoral programs to match their growth, the AOA had to stretch its postdoctoral standards to become more inclusive and to open up a dialogue with the ACGME that will, in the long run, reduce its independent educational status and identity. The trend of COM graduates’ bypassing osteopathic postdoctoral programs for ACGME programs is already evident, and the osteopathic profession is losing its firm grip over postdoctoral education and its certification process.12
For the near future, private COMs seem secure in their niche. It appears the ACGME has the capacity to train its increased number of graduates, especially if there is a decline in the number of international medical graduates training in the United States. The LCME has granted provisional accreditation status to only one new medical school since 1985, leaving growth of U.S. medical schools as an osteopathic issue. Taken as a whole, the dramatic changes of the 14 private COMs has had an overall minor impact on the 125 LCME U.S.-accredited allopathic medical schools because they do not compete in the same arena for faculty, research dollars, patient services, and academic and educational resources. The private COMs managed to reduce the process of training osteopathic physicians to basic essentials and to form partnerships with clinical facilities. As an evolving educational model, the private COMs have undergone a remarkable transformation in a brief period, and bear watching for future developments and to assess their long-term viability.