Krueger, Paul M. DO; Dane, Peter DO; Slocum, Philip DO; Kimmelman, Marilyn EdD
Osteopathic medical education is similar to allopathic medical education in many ways, but it is uniquely different in others. State licensing agencies and many hospitals recognize the degrees as equivalent. Admission processes or requirements for prospective students are similar. Curricular content is consistently four years long, divided into two years of basic sciences and two years of clinical rotations. Curricular presentation may vary from traditional lecture-based formats to integrated models stressing case-based and problem-based learning. Medical education in osteopathic and allopathic schools, however, differs in mission, curricular emphasis, and types of faculty.1 The culture of osteopathic medical schools supports students entering primary care careers more than most allopathic medical schools. Dissimilarities in tradition, philosophy, and health care delivery2,3 define differences in the teaching and practice of clinical medicine.
Osteopathic medical education preserves a link between human body structure and function, to promote a more holistic approach to patient care than allopathic physicians education normally does. Osteopathic medicine’s emphasis on primary care, family and preventive medicine, musculoskeletal health, and wellness influences curricula as well as diagnostic approaches. While allopathic clinical training is traditionally done in academic teaching hospitals, osteopathic clinical education places a greater reliance on voluntary faculty at community-based hospitals. Utilizing community-based institutions allows for more extensive exposure to the practice of primary care medicine.4 These differences are dynamically shown at Michigan State University, where osteopathic and allopathic students share faculty resources and classroom experiences during the first two years of medical school but complete their clinical training in different hospital systems.5,6
The clinical training of osteopathic medical students, therefore, differs significantly from allopathic clinical training. Differences emerge from the historical roots of the osteopathic profession, the links to community-based hospital settings, and the professional emphasis on primary care. In this paper, we explore the historical roots of osteopathic clinical training, describe the typical osteopathic clinical preparation, and outline the significantly different methods of delivering clinical training in three osteopathic medical schools: University of Medicine and Dentistry of New Jersey–School of Osteopathic Medicine, Kirksville College of Osteopathic Medicine, and Ohio University College of Osteopathic Medicine.
History of Osteopathic Medicine: Impact on Clinical Training
In 1892, osteopathic medicine began as a reformation movement when Andrew Taylor Still, a country physician, opened the American School of Osteopathy in a small house in Kirksville, Missouri, bought with his personal savings. In contrast, John Hopkins University opened a year later as a medical school with a $7 million endowment. Osteopathic medical schools initially grew rapidly, but then they experienced a post-Flexner decline similar to that of allopathic schools. By 1970, osteopathic physicians were licensed in almost every state, although there were only six osteopathic medical schools: the original five schools—Philadelphia College of Osteopathic Medicine, College of Osteopathic Medicine in Surgery in Des Moines, Chicago College of Osteopathic Medicine, Kansas City College of Osteopathic Medicine, and Kirksville College of Osteopathic Medicine—and Michigan State University College of Osteopathic Medicine, founded in 1969. One significant limitation on the growth of osteopathic schools was their exclusion from federal research dollars until 1956.7 The past four decades have shown increasing growth in osteopathic medical education, from the five original schools in the 1960s to 25 colleges of osteopathic medicine and three branch campuses today.
Osteopathic physicians (DOs) were traditionally excluded from the medical staff of allopathic hospitals, particularly in large institutions. This led to the growth of smaller, community-based hospitals that still play a critical role in the current training of osteopathic students. DOs were not recognized as physicians by the armed forces during World War II. However, many MDs were drafted, and many of their patients went to osteopathic physicians for care. Because allopathic hospitals kept their ban on allowing DOs on staff, increased numbers of patients led to further growth of the community-centered osteopathic hospitals. These hospitals recognized the need for well-trained physicians, not only in primary care but also in specialties. Residency programs were rapidly developed; these programs relied on the volunteerism of attending physicians. The spirit of osteopathic volunteerism not only continues today but also remains an integral part of osteopathic clinical training as a whole. The vast majority of clinical educators within the osteopathic profession express their strong commitment to the ideal of “giving back” by devoting their professional time and energy to the education of their successors without remuneration. For example, in the three colleges of osteopathic medicine we discuss in this paper, 87% of the faculty members have voluntary status; these are supplemented by many other DOs at their affiliate hospitals who do not have faculty appointments.
Historically, osteopathic hospitals were the cornerstone of osteopathic clinical training. These community-based hospitals fit well into the primary care mission of the osteopathic colleges. Although students of osteopathic medicine may have limited exposure to such tertiary services as transplants and advanced neurosurgery in community-based hospitals, they gain extensive experience with common illnesses and procedures.
The Challenges of Rapid Expansion
The rapid growth of osteopathic medical schools, including new schools, new branch campuses, and expansion of existing campuses, has created an additional challenge for osteopathic clinical training. This challenge is shared by allopathic schools, which are also expanding and compounded by offshore medical schools paying hospitals large sums for clinical training sites. The challenge is minimized by the standards of the Commission on Osteopathic College Accreditation (COCA), which require adequacy of clerkship sites before new colleges can begin and before expansion is approved.
A few osteopathic colleges pay hospitals for medical student training; the great majority do not. Some colleges of osteopathic medicine contract with others to offer clinical training opportunities. COCA also requires detailed plans before allowing osteopathic colleges to expand class size. Hospitals with osteopathic graduate medical education programs affiliate with schools to ensure that their programs fill.
The “Typical” Osteopathic Clinical Experience
The American Association of Colleges of Osteopathic Medicine’s 2005–2006 Annual Report on Osteopathic Medical Education, the most current data available, derived data from the annual survey of the 20 colleges of osteopathic medicine operating in those years. The data show the major clinical clerkships required in the third and fourth years are family/community medicine, internal medicine, general surgery, pediatrics, obstetrics–gynecology, and psychiatry. Nineteen of the schools required emergency medicine. Osteopathic manipulative medicine (OMM) is integrated throughout these experiences. An additional rotation in OMM is offered by 33% of those surveyed. The leading rotations are internal medicine (11.1 weeks, or 17.2%), family/community medicine (10.9 weeks, or 16.9%), and pediatrics (9.3 weeks, or 14.4%). The typical osteopathic student spent 7.8 weeks (12.1%) on OMM clinical experiences.
Thus, the “typical” osteopathic medical student does indeed complete a required curriculum that strongly emphasizes primary care. The student averages 50.4 weeks (over 50%) of his or her required rotations in family/community medicine, general internal medicine, pediatrics, and geriatrics. Other leading selections include obstetrics–gynecology, emergency medicine, general surgery, cardiology, critical care, gastroenterology, pulmonary, hematology/oncology, infectious diseases, psychiatry, nephrology, neurology, orthopedics/orthopedic surgery, rehabilitation medicine, rheumatology, and urology/urological surgery8 (Table 1).
Three Osteopathic Medical Schools
University of Medicine and Dentistry of New Jersey–School of Osteopathic Medicine: An academic health center
In 1978, an act of the New Jersey legislature founded the University of Medicine and Dentistry of New Jersey–School of Osteopathic Medicine (UNDNJ-SOM), one of several state-supported osteopathic schools established in the 1970s (starting with the Michigan State University College of Osteopathic Medicine, created in 1969). Like its UMDNJ allopathic sister schools, the Robert Wood Johnson Medical School and the New Jersey Medical School, UMDNJ-SOM functions as a traditional academic medical center with a centralized hospital system.
UMDNJ-SOM’s principle clinical affiliate is the three-hospital, 600-bed Kennedy Health System (KHS), which began when three separate osteopathic hospitals merged in 1981. UMDNJ-SOM is also affiliated with Our Lady of Lourdes Medical Center, a tertiary, 437-bed hospital in Camden, New Jersey. All four hospitals are within a 15-minute drive of the school’s main campus in Stratford, New Jersey. The KHS Stratford Division adjoins the school’s campus. Most of the school’s full-time faculty have hospital privileges at one or both institutions. The system allows all core clinical rotations to have full-time faculty members as clerkship directors. These clerkship directors meet regularly so that learning issues, administrative issues, and learning outcomes can be monitored and continuously improved.
UMDNJ-SOM faces several of the same challenges as other osteopathic medical schools. Despite its large, 211-member, full-time faculty, the school relies on volunteer faculty for training, particularly in selected specialties in its unique first-year family medicine preceptor program. The spirit of volunteerism is challenged by increasing clinical demands on the physicians, yet the tradition persists. Volunteer faculties are not paid; the school finds other ways to value their contributions, such as letters, public recognition, and invitations to school events. Many of these volunteers have faculty appointments and titles. They must complete the same credentialing as full-time faculty members. The American Osteopathic Association (AOA) requires 120 hours of continuing medical education (CME) every three years for all members, and acting as a preceptor for students and residents can account for 60 of these required hours. The school allows volunteer faculty to attend many CME activities at little or no cost.
Maintaining the osteopathic uniqueness in the third and fourth years is also a challenge for UMDNJ-SOM. KHS is now a mixed-staff hospital (53% DO and 47% MD). The staff at Lady of Lourdes Medical Center is predominately allopathic. The school has responded in several ways, including adding a required OMM clerkship in the third year and introducing an in-hospital consultative service in OMM at the KHS. The school is implementing osteopathic learning scenarios, case-based sessions that integrate OMM in each required clinical rotation. Another important response to the challenge is the development of the family medicine preceptor program. This program begins with early clinical experiences in the first year and continues with an eight-week preceptor experience in the third year during the family medicine clerkship. These preceptors are all osteopathic family practitioners, and all use OMM. They receive annual faculty development, including faculty development in OMM, during the annual meeting of the state osteopathic society.
Ohio University College of Osteopathic Medicine: The statewide CORE system
In 1995, the Ohio University College of Osteopathic Medicine (OU-COM) formalized its affiliation with 11 teaching hospitals throughout the state by forming the Centers for Osteopathic Research and Education (CORE). The resulting educational consortium, which has expanded to include 12 teaching hospitals, became the vehicle for delivering the college’s third- and fourth-year curriculum by providing clinical training opportunities for 200 third- and fourth-year predoctoral students from OU-COM and an additional 120–160 third- and fourth-year students from three colleges of osteopathic medicine located in other midwestern states. Third-year students, after ranking their top five choices, are assigned by a proprietary computer program to 1 of 12 base training sites. A board of directors, composed of representatives from the college and member hospitals (which, as of this date, number 24), governs the consortium.
To unite such a dispersed academic administration, the college established the CORE office network. Each member hospital has a dedicated three-person CORE office staff, all employees of the OU-COM. The CORE assistant dean, a DO who holds faculty status with Ohio University through the OU-COM, is responsible for overall supervision of the CORE office and for mentoring and monitoring the professional progress of students assigned to that CORE site. Each CORE site also has an administrator (a master’s-level educator primarily responsible for student scheduling and day-to-day coordination and implementation of the site’s academic program) and an administrative assistant/associate (who provides secretarial support).
Each CORE site unit reports to the central Office of Predoctoral Education, located on the Athens campus and headed by the associate dean and run by the director of predoctoral education. Videoconferencing technology allows the associate dean to meet with the entire group of assistant deans monthly; likewise, the director meets with the CORE administrators once per month. Five times a year, representatives from all CORE offices gather at a central location for a combined meeting.
The CORE Academic Steering Committee consists of educational representatives from each CORE member hospital, including the CORE assistant deans, directors of medical education, the director of CORE research, OU-COM clinical and biomedical department chairs, faculty development directors, and various members of the OU-COM Offices of Predoctoral Education and Graduate Medical Education. This body meets monthly at a central location in Ohio to discuss issues germane to medical education locally, statewide, and nationally.
Student learning outcomes for the clinical training years are monitored in a variety of ways, including computerized pre- and postrotation exams, preceptors’ evaluations of students’ performances using the seven AOA core competencies, and triannual individual progress reports by the CORE assistant deans. The CORE staff consistently attempt to identify students’ professional training ambitions and to guide them to appropriate training opportunities with the CORE consortium. After each rotation, students evaluate the program and preceptor; composite summaries of these evaluations are shared with teaching faculty and appropriate clinical departments on an annual basis. Twice a year, the associate dean for predoctoral education conducts individual site visits to meet with students, CORE office personnel, and teaching faculty. The information and data gathered and exchanged are used to further refine the academic program.
To implement its clinical curriculum, OU-COM relies heavily on the osteopathic tradition of volunteerism. As part of its commitment to these generous supporters, OU-COM provides faculty development and complementary CME opportunities, both centrally coordinated from the Athens campus. In addition, many members of the teaching faculty value their involvement in predoctoral training as part of a recruitment effort for graduate medical programs at their institution.
The multicampus configuration of the consortium challenges the consistency and flow of learning through both the third and fourth years. The learning objectives for the 79 weeks of required and elective clinical clerkships are centrally coordinated and locally implemented, using the organizational structure that includes the Athens-based Office of Predoctoral Education and the CORE offices at each training hospital. With the help of a generous grant from the Ohio Osteopathic Association, OU-COM held a series of retreats that resulted in the creation of a curriculum explicitly devoted to enhancing OMM skills in the third and fourth years. OMM “champions” at each CORE site took the lead in implementing this curriculum and, using such teaching and learning resources as student manuals and instructor PowerPoint presentations, introduced specific training in OMM skills into the formal didactic portion of the clinical years.
The Kirksville College of Osteopathic Medicine: The regional campus system
The Kirksville College of Osteopathic Medicine (KCOM), the descendant of Dr. Still’s original American School of Osteopathy, is a private, community-based medical school and part of A.T. Still University. It provides a classic 2–2 split in medical education, where the first two years are predominately didactic, heavily loaded with the basic sciences and osteopathic manipulative medicine, and the third and fourth year consist of clinical rotations. KCOM’s clinical rotations occur in regions, arranged predominately by state. Currently, KCOM has regions in Missouri, Michigan, Minnesota, Wisconsin, Indiana, Ohio, New Jersey/Pennsylvania, Florida, Arizona, Utah, and Colorado.
Regional deans organize and supervise the student rotations. Learning objectives for these rotations are determined at one of the two annual regional deans’ meetings. KCOM selects a regional dean either through association with the existing structures, such as Ohio University’s CORE, or through an application process directed by the associate dean for clinical educational affairs. The regional dean is paid for part-time service by the KCOM.
The system of regional deans allows the associate dean for clinical educational affairs to maintain vigilance over these geographically diverse sites. Support staff at each site, employed by KCOM, report to the regional dean, handle scheduling and student affairs issues and student nonacademic administration, and enter academic and nonacademic data into a KCOM-wide database. Outcomes from these data, including differences among sites, are tracked by the associate dean.
The majority of these regional sites are hospital based. Some regional sites (Colorado and Utah) are preceptor-based rotations. These rotations are designed to offer extensive experiences in ambulatory medicine. Students are assigned to sites using a lottery method very similar to OUCOM’s. The method is described to students in detail during the admissions process. Hospital rotations are limited to a few months of core clerkships in internal medicine, pediatrics, surgery, and obstetrics–gynecology. The remainder of the time, students follow patients in a hospital setting from the preceptor’s practice.
All students must pass a clinical skills exam at the end of their second year before they are permitted on rotations. They are tested on interviewing skills, physical examination skills, the interpretation of basic diagnostic tools, and their performance in standardized and simulated experiences.
To assess the teaching of OMM, KCOM has developed modules to be presented by OMM fellows and local faculty at each regional campus. These modules are presented on “education days” held regularly, usually monthly, in each of the regions. Currently, KCOM is developing rotations in OMM in each of the regions.
Because KCOM students are at regional campuses throughout the nation, reliable and valid student assessment is a challenge. Each rotation has a predetermined set of explicit learning objectives that are assessed at the end. Students’ progress is monitored using logs, exit objectives lists, postrotation exams, National Board of Medical Examiners (NBME) “shelf exams,” end-of-third-year exams, and NBME end-of-rotation exams. The capstone experience encompasses bringing the entire class to Kirksville for a performance examination that includes testing with standardized patients, high-fidelity human patient simulation, and objective structured clinical examinations. Students are rated on compassion, integrity, communication skills, professionalism, documentation skills, performance of skills, gathering and interpreting histories, and implementation of OMM skills. On rotations, students are required to make two formal case presentations, attend education days, present at two journal clubs, and write one paper of acceptable quality.
Students are also required to take an end-of-rotation examination. The preceptor and the regional assistant dean, the director of student medical education, or their designee, assess each student’s professionalism, compassion, and integrity. Students are also required to pass a performance examination at the end of their third year, structured similarly to the prerotation examination but administered at a higher level of difficulty. Beginning this year, a third part of the assessment will include the use of student portfolios for formative assessment.
The one measure of learning outcomes common to all three schools is the National Board of Osteopathic Medical Examiner’s (NBOME) Comprehensive Osteopathic Medical Licensing Examination (COMLEX). The examinations are “designed to assess the osteopathic medical knowledge and clinical skills considered essential for osteopathic generalist physicians to practice medicine without supervision. COMLEX-USA is constructed medical problem-solving which involves clinical presentations and physician tasks. Candidates are expected to utilize the philosophy and principles of osteopathic medicine to solve medical problems.” The Level 2 examinations are designed to measure clinical skills. The Level 2-CE computer-based examination is a multiple-choice/matching assessment “integrating the clinical disciplines of emergency medicine, family medicine, internal medicine, obstetrics/gynecology, osteopathic principles, pediatrics, psychiatry, surgery, and other areas necessary to solve medical problems.”9
The Level 2-PE examination tests clinical skill in a standardized patient setting. A description of each examination is available at the NBOME Web site (http://nbome.org). The NBOME notes that statistics about student performance in medical disciplines—surgery, obstetrics–gynecology, psychiatry, family medicine, pediatrics, internal medicine, emergency medicine, and osteopathic principles and practice—may not be valid and are, therefore, not included in this paper. The exams are not a perfect outcome measure, because many variables, including admissions criteria, class diversity, and the curricula of the first two years, can have an impact on the scores. Thus, the scores among schools cannot be directly compared, but they do give insight about the clinical training programs at each school.
The results for the last two years are shown in Tables 2–5. First-time takers at all three schools performed above the national mean in the vast majority (90%) of all outcome measure on the two examinations. In some situations, particularly COMLEX Level 2-PE, the difference between pass rates was sometimes two or three students. The overall success of all three schools suggests that all three methods of clinical training can be successful.
In the clinical training of osteopathic medical students, colleges rely on many of the profession’s historical strengths, including a great tradition of volunteerism and a group of strong, community-based hospital affiliates. Osteopathic medical schools overcome the many challenges of clinical training by varying models (academic medical center, statewide core, and regional campuses) and innovative programs (early osteopathic primary care preceptors, 79-week clinical curricula, and preceptor-based affiliates). Despite the pronounced differences between allopathic and osteopathic training, we believe these models can be adapted by our allopathic counterparts as they meet Association of American Medical Colleges’ call to expand their own class sizes.