The 1985 annual graduate medical education report in the Journal of the American Medical Association (JAMA) identified 1,277 osteopathic physicians (DOs) in postdoctoral (i.e., residency and fellowship) programs of the Accreditation Council for Graduate Medical Education (ACGME) programs.1 Of that number, 606 (47%) were in family and internal medicine residencies. By contrast, the 2006 JAMA report stated that 6,629 osteopathic physicians were in ACGME programs, of whom 2,529 (38%) were in the same two disciplines.2 Several intersecting factors account for these patterns of growth and specialty diversity of osteopathic physicians in ACGME programs between 1985 and 2006. During these 21 years, periods of dynamic expansion in both osteopathic and allopathic medicine overlapped. Interestingly enough, allopathic medicine’s growth happened almost exclusively at the postdoctoral level, whereas osteopathic medicine’s period of rapid development occurred primarily at the predoctoral level. Opportunities were created from which these professions mutually benefited.
The Osteopathic Experience in Postdoctoral Education
We began this article by reporting statistics from 1985 because that year represents a pivotal time for the osteopathic profession. Policies were enacted that allowed colleges of osteopathic medicine (COMs) to serve as sponsors of American Osteopathic Association (AOA) postdoctoral programs.3 Before this time, only AOA-accredited hospitals qualified, and their numbers were stagnant if not declining through hospital mergers, closures, and/or acquisitions. In practical terms, it meant that COMs were given accountability to develop and sponsor new osteopathic postdoctoral programs at hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, including institutions that were already sponsors of ACGME programs. It marked a turning point in reshaping the structure and direction of osteopathic medical education. Instead of a closed system limited to osteopathic institutions, it has evolved into a hybrid inclusive of AOA- and ACGME-accredited programs with the allopathic profession playing an increasingly dominant role.4
Pressure for this policy change stemmed from an early wave of new COMs. There were just 5 COMs in 1969, 9 in 1975, and 15 in 1981. First-year COM enrollment for these same years went from 577 to 1,038 to 1,582 students.5 Efforts to generate new osteopathic postdoctoral programs failed to keep pace, even with the opportunity to create dual or parallel-accredited AOA and ACGME programs. In 1985, the AOA had 1,799 accredited residency and fellowship positions in 30 specialties populated by 1,244 osteopathic physicians.6 The first internal assessment on the critical need for postdoctoral positions occurred in 1985.7 Recognizing the likelihood of an insufficient number of accredited positions, the AOA Board of Trustees appointed a Task Force on Postdoctoral Training to examine its educational needs from 1987 to 1996. The report focused on AOA-accredited internship positions that, at the time, were considered as a required capstone experience for all COM graduates. The first recommendation of the task force was to keep the number of osteopathic internships consistent with class size. A second recommendation was to maintain primary care as the major emphasis for AOA-accredited programs. An implied dependence on the ACGME for residency training was also noted. One consensus statement was that the “osteopathic medical profession should position itself to benefit from the expulsion of foreign medical graduates from allopathic postdoctoral training programs.”7
Despite this awareness of looming postdoctoral shortages, new COMs continued to come online and existing ones expanded, adding more students to the educational system and increasing the dependency on the ACGME to supply training opportunities for DOs. Currently, there are 25 COMs and three branch campuses with a projected first-year enrollment of 5,227 students by the fall of 2012.8 As it stood in 2006, more than two out of every three DOs (6,629 of 9,618) in postdoctoral training were already in an ACGME program.2,9* With the AOA’s limited capacity to train its own graduates, the current assumption is that these additional students will continue to find their educational opportunities in ACGME residencies.
Characteristics of ACGME Postdoctoral Programs: 1985–2006
A simple comparison of postdoctoral trainees in 1985 and 2006 clearly demonstrates the explosion in the number of trainees in ACGME programs. JAMA reported 74,514 residents and fellows on duty in 1985 and 104,879 in 2006, an increase of 30,365 (41%).1,2 Reasons that explain this expansion are less obvious. It is certainly not proportionate to U.S. MD graduates (USMDs) coming out of schools accredited by the Liaison Committee on Medical Education (LCME). In 1985, the number of allopathic medical school graduates was 16,318 compared with 15,926 in 2006.10,11
To fill these additional ACGME-accredited positions, sponsors of postdoctoral programs turned to the only other qualified groups: osteopathic physicians and international medical graduates (IMGs). Using our two-decades benchmark, osteopathic physicians accounted for 1,277 (1.7%–%) of the residents and fellows in ACGME programs in 1985 and 6,629 (6.3%–%) in 2006.1,2 Not only was this a time for increased inclusion of osteopathic physicians into ACGME programs, but this development affected IMGs in much the same way: IMGs accounted for 12,509 (16.8%) of the ACGME residents and fellows in 1985 and 28,176 (28.2%) in 2006.1,2 Without the infusion of DOs and IMGs, the stable supply of USMDs would have sharply curtailed growth in the number of ACGME-accredited programs.
Another noted trend during this 21-year period was the rapid rise in combined specialty and fellowship programs. In 1985, 55 specialty areas for residency and fellowship training were listed compared with 142 in 2006.1,2 The impact of these new programs extended the length of time physicians spent in medical education and contributed to the overall growth in the number of doctors in training. This expansion also points to a definite drift toward increased specialization. In addition, consolidation of several base specialties resulted in fewer but larger programs. In internal medicine, for example, there were 442 accredited programs with 17,832 residents in 1985.1 In 2006, there were fewer programs (386) but more residents (22,099).2 This same trend of creating larger yet fewer programs is noted in pediatrics, anesthesiology, obstetrics–gynecology, psychiatry, and pathology. Other specialties increased their numbers of programs and residents. The most dramatic change is noted in emergency medicine. In 1985, JAMA listed 68 programs and 1,122 residents, whereas its most recent report cites 140 programs and 4,379 residents.1,2 Compared with emergency medicine, family medicine was a distant second, but it too followed the same pattern of impressive growth.
Other specialties remained relatively unchanged or even contracted. It is not surprising that those specialties tend to be the most competitive and selective. Ophthalmology is one example. Profession-wide in 1985, there were 142 programs and 1,561 residents.1 The numbers for 2006 are 117 programs and 1,225 residents.2 Falling into this category are otolaryngology, urology, neurology, plastic surgery, general surgery, thoracic surgery, nuclear medicine, and orthopedic surgery. Despite a 41% growth in the overall number of physicians in training during this 21-year period, these mostly surgical specialties either retrenched or remained relatively unchanged compared with the pace of development in graduate medical education.
Between 1985 and 2006, the resident physician workforce was dominated by five general trends. The number of USMDs remained flat. Osteopathic COMs grew significantly in the number of institutions and students. Postdoctoral positions accredited by the ACGME rose sharply. A stronger emphasis in specialization can be seen in the accelerated growth in new combined specialty and fellowship programs. DO and IMG representation in ACGME programs increased in proportion to the number of new postdoctoral positions. The impact of these trends had many reverberations, including the mix of osteopathic and allopathic physicians training in allopathic medical specialties.
Osteopathic Participation in ACGME Programs
A consistent pattern throughout this period is that USMDs monopolized the most competitive and sought-after residency programs. In 1985, for example, there were 2,817 physicians training in orthopedic surgery; 20 of them were DOs, 46 were IMGs, and 2,751 (98%) were USMDs.1 Of the 3,187 orthopedic surgery residents reported in 2006, 26 were DOs, 73 were IMGs, and 3,087 (97%) were USMDs.2 This heavy concentration of USMDs can also be noted in the residencies of dermatology, neurological surgery, ophthalmology, otolaryngology, plastic surgery, diagnostic radiology, and urology. The USMDs may have decreased as an overall percentage of the number of physicians in ACGME programs between 1985 and 2006, but they did not lose their grip over what are perceived as the most attractive specialties.
In 1985, USMDs represented more than 70% of residents in all base specialties within the ACGME, with the exception of physical medicine and rehabilitation.1 Options for LCME graduates to become more selective coincided with the creation of a larger number of accredited programs. Given these choices, USMDs demonstrated a decided preference for specialties, leaving those related to primary care programs with fewer USMD candidates. In 2006, eight base specialties had fewer than 70% of USMD graduates, with family medicine (46.5%) and internal medicine (50.3%) being at the bottom.2 By and large, USMDs have not been attracted to the newly created combined residency programs, especially those that involve a primary care specialty.2 These career decisions of USMDs have a profound impact on available educational opportunities of DOs and IMGs.
The integration of osteopathic physicians into ACGME programs occurred most often in specialties where there was either a professional affinity, such as physical medicine and rehabilitation and emergency medicine, or in specialties less populated by USMDs. With some exceptions, the ACGME specialties most active in expanding training positions from 1985 and 2006 also increased their percentages of DOs and IMGs. Family medicine offers a good example. In the two decades under consideration, the number of residents on duty in ACGME positions went from 7,276 to 9,456. And, the percentage of DOs who were ACGME family medicine residents in 1985 was 4.4% (318), whereas the 2006 percentage was 14.1% (1,336).1,2
According to the 2006 JAMA report on graduate medical education, osteopathic physicians represented more than 5% of reported residents in 10 specialties.2 Those disciplines support the heaviest concentration (91.4%) of DOs in base ACGME programs. Table 1 highlights the growth in the number of osteopathic physicians in these 10 specialties during the past 21 years. The expansion in residency positions and decreased interest over time by USMDs in family medicine and internal medicine account for the larger number of DOs in these specialties. In other disciplines, such as anesthesiology, neurology, pediatrics, PM&R, psychiatry, and pathology, the osteopathic profession has few AOA-approved residencies of its own. Osteopathic physicians interested in those specialties have limited options other than to pursue training in those ACGME programs in which they have achieved greater acceptance. For example, emergency medicine in the allopathic and osteopathic professions developed simultaneously as a distinct medical specialty in the 1980s. Despite a consistently high percentage of USMDs in this specialty (85.4% in 2006), osteopathic physicians routinely receive strong consideration and currently represent 9% (394) of emergency medicine physicians in ACGME programs.2 In obstetrics and gynecology, the trend showed that in the past 10 years, as the percentage of USMDs decreased, the number of DOs increased.
Although osteopathic graduates have filled a niche within ACGME programs, they have made few inroads into competitive surgical specialties monopolized by USMDs. Osteopathic physicians have experienced increased opportunities in other specialties in which USMDs have shown decreased interest. Although the numbers of DOs and postdoctoral positions within the ACGME have increased in the past 21 years, the pattern of where osteopathic physicians have specialty opportunities to train has changed only marginally over time.
Looming Challenges for Osteopathic Medicine
The ACGME functions primarily to accredit residency programs that train USMDs. Osteopathic physicians and IMGs have the opportunity for selection into these residencies as guests because of the disparity between the number of USMDs and the number of positions in accredited programs. On the other hand, the AOA postdoctoral system, designed specifically to accommodate DOs, has already been eclipsed and overwhelmed by the growth of COMs and by increased student participation in the National Resident Matching Program.12 Now the formerly flat number of USMD graduates entering ACGME programs has become dynamic. In responding to the clarion call for growth, allopathic medical schools are expected to add 3,400 new first-year medical students between 2002 and 2012. Additional growth beyond that number is distinctly possible.13
Assuming no upward adjustment in federal support for postdoctoral training, DOs and IMGs in ACGME programs can expect displacements in the future to accommodate this new cohort. As those students are added to the educational pipeline, the projected number of LCME graduates will be around 18,100 in 2012 and 19,900 in 2016.13 In 2006, there were 24,772 first-year residency positions.2 If the number of ACGME positions remains stable or grows at less than 1% per year, DOs and IMGs alike can anticipate increased competition for a shrinking number of residual residency positions in ACGME programs. The list of specialty programs monopolized by USMDs will become longer, and the numeric gains of DO penetration into several ACGME programs can be expected to decline as osteopathic physicians are gradually displaced by LCME graduates.
The COMs are also ramping up. COMs’ first-year enrollment for the fall of 2012 is expected to be 5,227, an increase of 1,380 students (36%) over 2006 numbers.8 To date, little progress has been noted in identifying new osteopathic postdoctoral positions to accommodate the existing and projected numbers of students. If one assumes a three- to four-year postdoctoral experience, the osteopathic profession will need to identify between 4,140 and 5,520 positions just to handle this growth spurt. With two thirds of osteopathic residents now training in ACGME programs, the overwhelming majority of these anticipated new COM graduates cannot be accommodated within AOA postdoctoral programs and will be looking to ACGME programs for their postdoctoral training.
The osteopathic profession is positioned to fall victim to the pecking order for selection into allopathic postdoctoral programs, for its too-heavy reliance on the ACGME programs to train its graduates, and for the misfortune of experiencing accelerated expansion at the same time that the LCME-accredited medical schools did. The window for integration of DOs to enter into ACGME programs opened in the decades of 1990 and 2000 because of minimal growth in LCME medical schools and rapid growth in the number of ACGME programs and positions. The same window will begin to close gradually, starting in the decade of 2010 because of anticipated stability in the number of ACGME programs and positions and because of the projected mercurial growth in the number of USMD graduates. More LCME and COM graduates will be vying for the same ACGME positions in an environment in which USMDs historically have held advantages over DOs and IMGs. Future osteopathic physicians can expect to encounter an intensified rivalry for ACGME residencies and to become more concentrated in the least competitive medical specialties. As this scenario unfolds, the osteopathic profession will need to directly confront the formidable challenge of providing an adequate supply of postdoctoral positions for its COM graduates.