Peska, Don N. DO, MEd; Opipari, Michael I. DO; Watson, D Keith DO
Osteopathic medicine has experienced significant growth in the number of accredited colleges and graduates over the past decade. Anticipating that growth and recognizing a responsibility to provide sufficient opportunities for quality postdoctoral training, the American Osteopathic Association created a national network of educational consortia to meet the needs of those graduates. These osteopathic postdoctoral training institutions (OPTIs) were to provide enhanced capability for the development and accreditation of new programs, quality oversight, and access to academic resources for their members. In this article, we discuss the history and accomplishments of OPTIs towards achieving those goals.
A Brief History
For the nearly two decades that preceded 1995, osteopathic medical colleges experienced consistent growth in total enrollment and, hence, the number of graduates seeking postdoctoral training.1 Historically, osteopathic graduates relied on the availability of community-based training programs in private hospitals. Many had fewer than 200 operational beds, and few had formal academic affiliations with the graduates’ medical colleges other than providing rotation sites for student clerkships. In a 1986 commentary on osteopathic postdoctoral education, Dr. Alvin Dubin,2 then chairman of the Bureau of Professional Education at the American Osteopathic Association (AOA), characterized the system as a “tradition of apprenticeship training” that struggled to maintain a satisfactory level of quality. As the number of graduates was increasing, the number of AOA-approved training hospitals began to diminish through closures or mergers with larger hospital systems.3 In response and by necessity, osteopathic graduates increased their search for training opportunities in programs approved by the Accreditation Council for Graduate Medical Education (ACGME), not only in specialties that were few in number in traditional osteopathic hospitals but in primary care specialties as well. In this shift, many training positions in AOA-approved programs were left unfilled. As the number of graduates exceeded the number of available positions that the AOA approved, the AOA was forced to develop new policies to recognize graduates who had completed ACGME training as possessing equivalent credentials to those of graduates from osteopathic programs.3
Through its Department of Educational Affairs, the AOA provides oversight to all aspects of osteopathic education in the United States. Such constituent agencies as the Commission on Osteopathic College Accreditation, the Bureau of Osteopathic Education, and the Bureau of Osteopathic Specialists are responsible for accreditation of colleges, approval of postdoctoral training programs, and the integrity of specialty certification, respectively. While these various entities remain at appropriate arm’s length from the parent organization, the United States Department of Education recognizes the AOA as coordinator of their activities for accreditation purposes. Acknowledging responsibility to its graduates as well as an obligation to sustain the availability of osteopathic health care to the public, the AOA sought a strategy that would facilitate the growth and development of new training programs to meet an anticipated increasing demand. The AOA further saw this period as an opportunity to transform osteopathic graduate medical education by strengthening its academic foundations and establishing a new formal structure to ensure a uniform and consistently high level of quality to all participants.
In 1995, in a special education issue of The Journal of the American Osteopathic Association (JAOA),4 the chairman of the Council on Postdoctoral Training (M.I.O.) provided the osteopathic community with the objectives (quoted below) of a new entity, the OPTI, that would bring about this transformation.
* Develop a single standardized system of reviewing and approving institutions for sponsoring osteopathic postdoctoral training. This standardized system will apply to all sponsoring institutions, whether hospitals, colleges, traditional osteopathic hospitals, or traditional allopathic hospitals with AOA accreditation status. The OPTI replaces the previously used hospital accreditation with the newly developed educational accreditation. Hospital accreditation assesses the quality of patient care, while the educational accreditation assesses resources available for quality medical education. It is inappropriate to continue to base educational training potential on hospital facility and care standards.
* Introduce well-recognized essentials of academics into osteopathic clinical training programs. These academic standards include the formation of a clinical faculty, professional growth and development of that faculty, development and use of a curriculum, functional educational evaluation, self-evaluation of the program by the institution, requirement of a critical mass of trainees and programs within an OPTI, and the integration of Osteopathic Principles and Practice into all training programs of the OPTI.
* Assure continuation of federal and other funding levels for osteopathic GME programs by quality enhancement due to incorporation of recognized academic standards. Graduate medical education funding from federal sources will soon be significantly affected, and any federal subsidy of GME that does occur will likely be based on demonstrated quality stratification or ranking as measured by accepted standards.
* Assure reasonable stability of an institution’s commitment and education program, in an era of increasing instability of community hospitals. An increasing number of programs have been lost because of hospital closings, sales, or mergers, and, as a result, have adversely affected trainees.4
By 1999, all osteopathic postdoctoral training programs would be required to become affiliates of one of the several OPTIs that were forming. (This schedule was realized.) Each OPTI would include at least one college of osteopathic medicine, a critical element that would foster academic excellence in the programs and ensure a continuum of osteopathic medical education. In describing the development of the Centers for Osteopathic Regional Education, one of the first such organizations, Meyer et al5 characterized the Ohio-based consortium as “facilitating collaboration” between the college of osteopathic medicine and postdoctoral programs and bringing “the expertise of curriculum, faculty development, evaluation, research and scholarly activity” to its members.
To the present day, the OPTI vision has endured and the structure and operational standards of OPTIs are little changed. At this writing, the 18 existing OPTIs have sustained the link between the colleges and the postdoctoral community. Where such decisions to collaborate address individual needs, more than one college may provide academic resources to a single OPTI. In addition to their intended (and required) role in providing oversight of quality and accreditation standards for graduate medical education, several OPTIs are active participants in managing student rotations at their member institutions on behalf of their member college(s). Where distance may hinder adequate delivery of academic resources to a training site, modern communications technology has closed the gap with teleconferencing and distance learning.6 Over time, the organizations have each developed unique strategies to share intellectual assets and accomplish the purpose of the original vision.
Ensuring the integrity of the infrastructure has been accomplished through accreditation standards for graduate medical education set by the AOA. No osteopathic postdoctoral training program can be approved if it is not affiliated with an OPTI. Each OPTI is required to adhere to standards of accreditation specifically for OPTIs and is regularly inspected to ensure compliance.7 But the intent of OPTI goes beyond structure and function. The original objectives articulated in the 1995 JAOA article have been reached in form. Whether the concept has provided facility for growth and has transformed osteopathic graduate medical education in a manner that promotes and secures quality education warrants a search for measurable outcomes. We discuss these two objectives below.
The data thus far are not sufficient to support an outright declaration that the OPTI program is the sole independent determinant of program growth. The time period since the establishment of the OPTI model in 1999 has seen a number of influences on graduate medical education. Among these were changes in the prospective payment system from the Centers for Medicare and Medicaid Services (CMS). New program development in new facilities has been encouraged by capping the number of approved reimbursable positions in existing hospitals and health centers. Changes in U.S. immigration policies may have influenced the expected availability of international medical graduates (IMGs) in the recruitment pool, causing programs that historically relied on IMGs to look toward osteopathic graduates to fill vacant positions. The growth in the number of AOA-approved training programs was not uniform across all specialties, which may reflect changes in students’ orientation toward future careers in medicine. As primary care programs went wanting for qualified candidates, more ACGME programs adopted dual accreditation, a growth strategy initiated by the AOA in 1985.8 These programs hope that providing both ACGME and AOA credentials would attract osteopathic graduates by enabling them to sit for certification by either the AOA or the ABMS (or both) on completion of their residencies. Indeed, despite waning interest in primary care in MD-granting programs, the growth rate for osteopathic family practice programs following OPTI development is similar to that seen for all osteopathic programs combined (Figure 1). It should also be noted that much of the growth seen in the number of osteopathic graduate training programs and positions has come through dual accreditation. In many instances, this practice provides no net gain in the number of training positions available.
Nevertheless, through their regional presence, the OPTIs are positioned to advance educational initiatives with both old (historically osteopathic) and new partners, an opportunity that may elude a nationally centralized authority. The OPTI is able to streamline the application process for new programs by providing experienced preparation and review of supporting documents before submission. This has enabled the AOA to adopt policies that require a decision on a completed application within 90 days of receipt. Where such applications are made from existing ACGME-approved programs, initial inspection is deferred to the OPTI, further accelerating the approval process.
Promoting Quality Education
The distinctiveness of the OPTI model, however, is in what it is expected to provide in quality oversight and member services. Identifying quality metrics in graduate medical education frequently focuses on those few outcomes that are objectively measurable. In-service examination scores, certifying board passage rates, and resident satisfaction are among the most common. The variables that influence these outcomes are numerous, as is the diversity in the students, faculty, and facilities that constitute the postdoctoral community. Consumer groups and government agencies have pressed for higher and uniform standards in health care and the training of its future providers. All participating entities are expected to meet or surpass these standards irrespective of their individual attributes. For this and, perhaps, other valid reasons, standards in postdoctoral education have become rather prescriptive. Each OPTI is charged with assuring the compliance of its member institutions (and their training programs) with these standards.7 Adding yet another layer of oversight may not seem a dependable way to advance quality. But the practices associated with this supervisory role are not entirely bureaucratic or cluttered with additional paperwork. Unlike that provided through the inspection processes of the AOA and the ACGME and their associated specialty colleges and residency review committees, this oversight is both peer-driven and part of an ongoing, interactive learning organization. An OPTI-based osteopathic graduate medical education committee (OGME) is at the heart of each consortium, promoting program development and improvement. The OPTI is further structured to provide the resources that may be needed to correct any emerging deficiencies, a practice that in some ways distinguishes its purposes from those of the national accrediting committees and councils. As a matter of course, the OPTI does receive the in-service examination scores of residents in its member programs and, as an accrediting and quality intermediary, receives program-specific data regarding passing rates from the specialty certification boards. Adding to these data, the OPTI solicits feedback from residents and faculty regarding program conduct, as both are represented on the central OGME committee. Also represented on the committee are program directors, directors of medical education, designated institutional officials, deans, and hospital administrators. This committee composition promotes communication and collaboration rather than competition between participating facilities. The structure allows the OPTI to promote curricular changes and program intervention where needed and without the delays that are common to many national inspection programs.
Is It Worth the Effort (and Cost)?
Membership in an OPTI is not free. Nor is accreditation of an OPTI, which is dictated by the AOA and is part of a structured fee schedule that is common to all 18 OPTIs. Nor does the cost of OPTI membership replace fees already charged by the AOA for applications, inspections, and annual program renewals. Each OPTI satisfies the cost of its own business plan through its own fiscal structure, and assessments vary greatly from one to the other. For several, much of the cost of operations is borne by the member medical college or colleges, which find value in the access to student rotations at the member hospitals. Others operate more independently and provide a rich network of management and academic services. The AOA maintains no official database of these charges. With training sites able to seek membership in any OPTI, seldom has the cost been an issue, and most site affiliations follow regional or historic partnerships.
While OPTIs provide external oversight as a means of assuring the compliance of their programs in advance of accreditation visits, there is no clear evidence that approval intervals have lengthened as a result of OPTI participation. It has been our experience that OPTIs have provided assistance in meeting accreditation standards for dually accredited member institutions in advance of both AOA and ACGME (Residency Review Committee) inspections. To the extent that programs do have fewer deficiencies at the time of inspection, longer approval periods can be expected.
There are other intangibles to be considered in assessing the value of OPTIs. Program consolidation and reorganization in an ever-changing landscape of hospital acquisitions, mergers, and closures are readily facilitated by an OPTI.9 In one such instance, 53 residents displaced by the sudden closure of a member hospital were resettled within one week. The OPTI was able to coordinate communication between its other members, other facilities around the state, the AOA, and the ACGME while meeting with the residents within hours of the announcement that operations were being suspended. The OPTI was uniquely positioned to have knowledge of potential training opportunities and of the needs of the residents. It possessed the operational capacity to secure the necessary applications, permits, and CMS clearance to effect the transfers. Adding to the administrative requirements, the OPTI also marshaled assistance from the local medical societies to help residents and their families with relocation costs and the sudden lapse in health insurance (D.N. Peska, associate dean for educational programs, University of North Texas Health Science Center/Texas College of Osteopathic Medicine, personal communication, August 2008). This unfortunate circumstance provided a demonstration of value and services that may only have been available from an organization with a strong local presence and intimate knowledge of its partner institutions and the regional medical community.
Where Are OPTIs Going?
As the concept of OPTI passes the 10-year mark of full implementation, the strategy appears viable and enduring. Issues of added cost surface from time to time, but growth in the number of participating hospital affiliates has diluted that cost within most OPTIs. There are as of this writing 18 independent OPTIs. Consolidation of two or more OPTIs may emerge as a strategy to control cost and maximize shared resources. Still other OPTIs are likely to be established as facilitators for the graduate and undergraduate clinical needs of new colleges that are in development. In its review of the required standards for OPTI accreditation completed in 2007, the Council of Osteopathic Postdoctoral Training Institutions recommended changes to further strengthen the responsibilities that OPTIs have to ensure compliance and quality in graduate medical education.7 Creating advances in the application of competency-based curricula, faculty development, and resident research are just a few of the domains in which each OPTI must actively engage with its partner institutions. The OPTIs remain responsible for monitoring the several quality outcome measures that are available as well as developing other such internal measures. Representatives of the OPTI are expected to visit all member training sites at least annually and to maintain a dialogue with residents regarding their learning, their trainers, and the environment in which it all takes place. In turn, the AOA will continue to require annual summaries of OPTI activities in support of its members, and all communication between the AOA or specialty affiliates and the training programs will be made available to the OPTI as well. These actions suggest that the osteopathic community is thus far satisfied that OPTIs have become sources of strength and accountability to a graduate medical education infrastructure that was greatly weakened in the years that immediately preceded their inception.
A Still-Evolving Model
Maintaining uniform standards for excellence through national accreditation has been a long-standing strategy for medical education in the United States. Decentralization is not unique to OPTIs, as there are several regional accrediting agencies in place for higher education in other disciplines. Even in health care, where community standards may be thought of in terms of a national or international perspective, state medical boards operate independently of one another, often with varying requirements for licensure or certification of facilities. OPTIs do not seek to create regional disparity but, rather, to facilitate the implementation of best practices that are in accord with national standards of accreditation. They go further in their responsibilities by committing the resources needed to ensure implementation of these practices. We believe that OPTIs’ complementary responsibilities for both implementation and oversight have allowed facility and quality in the growth and development of osteopathic graduate medical education. The model is still evolving, and its effectiveness will continue to be studied.
The authors would like to thank Ms. Terri Lischka, manager, OPTI Clearinghouse, American Osteopathic Association, for providing statistical data used in the preparation of this article.