Osteopathic medical education has evolved significantly since it was founded more than 100 years ago in the United States. In recent years, a number of trends in socioeconomics, medical education, the regulatory environment, and health care have resulted in major changes to the separate system of osteopathic medical education and practice that had arisen by the mid-20th century. The increasing integration of the osteopathic and allopathic medicine’s training and practice systems, coupled with the current growth spurt in osteopathic medical colleges, is causing an increased focus on the future of osteopathic medicine in the United States.
Osteopathic medicine was established in 1874 as an offshoot of 19th-century allopathic medicine by Dr. Andrew Taylor Still, a Missouri practitioner and Civil War surgeon. He concluded that the medical practice of his day was ineffective and sometimes harmful to the patient, and he developed an alternative philosophy and methodology, which he called osteopathy.1–2 Still started the first school of osteopathy in Kirksville, Missouri, in 1892, and during the next two decades, his students (known as doctors of osteopathy, or DOs) went on to establish other schools of osteopathy in Des Moines, Chicago, Kansas City, and Philadelphia. The graduates of these schools concentrated their practices in small towns and rural Midwestern states, frequently establishing their own hospitals, and eventually spreading osteopathic practice to other areas of the country.2
By the mid-20th century, after surviving years of criticism in the early part of the century,3 osteopathic practitioners had established their status as fully recognized physicians in the United States,4 and osteopathy had evolved into osteopathic medicine. Public health and scientific progress in the diagnosis and treatment of diseases and the reforms of the post-Flexner era led osteopathic schools to fully incorporate the biomedical and clinical sciences into their curricula. The traditional rotating internship year after graduation developed into full residency programs, and graduate medical education (GME) training enabled osteopathic graduates to specialize in practice areas that mirrored many similar changes in allopathic medicine. By World War II, osteopathic physicians were licensed for a full scope of practice in the majority of states, and by 1973 in all states. At the end of the century, there were 19 colleges of osteopathic medicine graduating 2,300 students per year, and there were 42,000 practicing osteopathic physicians in the United States and abroad.5–8
Status of Osteopathic Medical Education
Since the 1960s, the curricula of osteopathic medical schools have closely mirrored those of allopathic schools, with a focus on the biomedical and clinical sciences in the first two years followed by clinical training in the specialties of internal medicine, obstetrics–gynecology, pediatrics, family medicine, surgery, emergency medicine, psychiatry, geriatrics, radiology, preventive medicine, and public health. A basic course in osteopathic manipulative medicine during the first and second years was and remains a required element of all college curricula, with clinical training in this aspect of osteopathic practice continuing in the third and fourth years in the context of specialty rotations and clinical training environments.9
In recent decades, the academic environment of osteopathic medical education has changed. During this period, college accreditation requirements were tightened, with greater emphasis on faculty sufficiency, heightened focus on the clinical training environment, and a requirement for research to be a part of the mission of all colleges. A variety of curriculum innovations were adopted in many osteopathic medical schools. Small-group, problem-based, and/or individualized learning tracks replaced or augmented the traditional lecture-based curriculum.10 Greater emphasis was placed on the integration of the basic and clinical science instruction in the first two years. The use of standardized patients and simulation for instruction and evaluation was implemented, and competency-based curriculum requirements were established as accreditation standards in both osteopathic undergraduate and GME.11 In addition, research opportunities for students have expanded, and many schools offer combined degree programs (DO/MPH, DO/PhD, DO/MBA, etc.) that are being utilized by a growing number of students.12
Other significant changes were also occurring in the educational environment of osteopathic colleges. Between 1970 and 2008, most osteopathic colleges developed, or became part of, larger universities that had other colleges and/or health professional education programs, and regional accreditation in addition to program accreditation became the norm.13 From 1970 to 1995, six state-sponsored osteopathic colleges were established in Michigan, Oklahoma, Ohio, Texas, New Jersey, and West Virginia.2,8
During these years, osteopathic colleges also spread beyond the traditional Midwest and Mid-Atlantic regions. Osteopathic physicians settling throughout the United States facilitated the establishment of additional osteopathic medical schools. The number of osteopathic colleges gradually grew during the 20th century, from the initial 5 to 19 by 2000.2,8 Early colleges tended to be stand-alone schools developed by groups of enterprising osteopathic physicians with a focus on training primary care physicians for solo practice, frequently in rural and underserved areas. The mission-like focus (frequently explicitly expressed) on primary care has been a hallmark of osteopathic medical education.
Since 2000, a significant growth spurt has been underway in osteopathic medical education as nine new schools and branch campuses developed and many existing schools expanded their class sizes (see List 1 and Figure 1). First-year class size grew from 2,927 in 2000 to approximately 4,200 in 2008 (nearly 30%). By 2008, nearly one in five medical students in colleges accredited in the United States were attending osteopathic medical colleges. By 2012, first-year class size in existing colleges is expected to exceed 5,200 (see Figure 2). This expansion was fueled by the growing concerns about impending physician workforce shortages, the resources of existing schools, the history of osteopathic medical schools’ potential to increase primary care physician supply, and the entry of osteopathic graduates into the mainstream of the health care system. At this writing in February 2009, there are currently 25 osteopathic medical colleges and 3 branch campuses in 22 states, with several additional schools under consideration. The growth in the number and size of schools has also been facilitated by growth in the applicant pool of students. Between 2002 and 2007 the number of applicants grew 81% (from 6,384 to 11,459), and the ratio of applications to positions available increased from 2.05 to 2.6. Matriculating students’ average MCAT scores and grade point averages (GPAs) have slightly risen as well.14–18
Until the 1990s, most DO graduates trained and practiced in a system that was mostly separate from that of allopathic medicine. This system contained separate osteopathic colleges, hospitals, residencies, and licensure and specialty boards. However, the traditional training venue that linked osteopathic schools and graduates to osteopathic hospitals and osteopathic GME has been altered during the last two decades. In the economic and regulatory environment of that era, most osteopathic hospitals (which tended to be community hospitals as opposed to tertiary care centers) were sold, merged into historically allopathic hospital systems, or closed.19 A closer association with allopathic GME training and traditional allopathic and mixed-staff hospitals resulted, with a shift in clinical training venues so that many osteopathic medical students began to be trained in hospitals with MD faculty and allopathic medical students as well.20 Osteopathic graduates were increasingly welcomed into Accreditation Council for Graduate Medical Education (ACGME) specialty training programs governed by the ACGME, many pursued American Board of Medical Specialties board certification, and practitioners increasingly joined mixed-staff hospitals and specialty practices.21
Until the 1990s, most DO graduates performed a rotating internship year, followed by an osteopathic residency program accredited by the American Osteopathic Association (AOA). Until recently, two thirds of those graduates pursued primary care graduate training and practice.22 Others chose a variety of AOA-sponsored specialty programs (there are currently 52 specialties overseen by 23 specialty societies). In 2007, those AOA programs that contained 5% or more of the 2,989 osteopathic residents in training were family medicine, internal medicine, emergency medicine, orthopedic surgery, general surgery, and obstetrics–gynecology.23
Since 1999, osteopathic graduate medical education (OGME) programs are required to be affiliated with an osteopathic postgraduate training institute (OPTI) as a prerequisite for program approval. OPTIs are consortia that must consist of at least one college of osteopathic medicine and a minimum number of programs and residency positions within each program. To receive AOA accreditation, an OPTI must meet standards on curriculum, research, facilities, and other areas of evaluation and undergo regular inspections. Separate approval is required for individual specialty programs within each OPTI.24 All osteopathic GME occurs within 17 OPTIs, consisting of 21 colleges of osteopathic medicine, 206 hospital partners, and 665 residency programs offering training in 52 specialties.24,25
DO graduates have three pathways to specialty training: (1) matching directly into an ACGME transitional year or residency program, (2) matching into an AOA internship and residency track, or (3) performing an initial AOA internship year and then matching into an ACGME residency. Licensing requirements in five states require at least one year of AOA-accredited OGME for licensure (Pennsylvania, Michigan, Florida, West Virginia, and Oklahoma). In recent years, there have been a growing number of GME programs (mostly in primary care) with dual (90 programs) or parallel (19 programs) approval by both the AOA and the ACGME. In addition, there has been a shift in the selection preference, with an increasing number of graduates matching directly into ACGME programs and fewer staying within osteopathic programs for their entire specialty training. In 2007, 60% of the 11,140 DOs in postdoctoral programs were in ACGME residencies and fellowships, and only 49% of available OGME residency slots were filled.23
The increasing trend of DO graduates selecting ACGME specialty training can be explained by a number of factors, including
* Increased numbers of students receiving their third and fourth years of clinical training in institutions with allopathic training programs
* The number of osteopathic college graduates increasing faster than the slots available in AOA training programs
* A higher proportion and number of DO graduates selecting non-primary-care specialties, and fewer options for AOA training in these specialties
* Lack of available AOA programs in many areas of the country, and personal factors dictating desired location for postgraduate training
* Increased numbers of AOA programs either being dually approved with their ACGME counterparts or existing in parallel within the same institutions
* Loss of the traditional pathway of DO graduates with the breakdown of the historically separate training, hospitals, and practice system
* The perception by some DO graduates of a lower quality of training in AOA programs
* Active recruiting of DO graduates by many ACGME programs.10,26
The issues surrounding GME for osteopathic medical school graduates are complex and entangled in public policies concerning GME funding, future health care workforce training in general, and specific developments in osteopathic medical education. In the future, the limitations on available specialty training programs may collide with the growth trends in the number of osteopathic medical school graduates combined with that of U.S. and international allopathic medical school graduates seeking specialty GME training in the United States.
The Future of Osteopathic Medical Education
Osteopathic medical education is at a significant point in its development in the United States. In recent decades, osteopathic medicine has generally achieved parity with allopathic medicine. The simultaneous movement away from osteopathic medicine’s traditionally separate training and practice systems, when coupled with its rapid growth, has created a sense of crisis as to its future. The rapid rate of growth has raised questions as to the availability of clinical and basic science faculty and clinical resources to accommodate the increasing load of students. Many members of the profession believe that the continuum of training, from osteopathic college through osteopathic GME, is necessary to maintain the essential qualities of practice that distinguish osteopathic from allopathic physicians.27 Key elements of the philosophy underlying osteopathic training have traditionally included holistic, patient-centered, preventive, and health-versus-disease-focused care within a primary care context. Most recognize, however, that these approaches to health care are present in allopathic medical education as well. The adaptation of very similar competency-based educational requirements in both allopathic and osteopathic undergraduate education and GME is evidence of increasingly similar approaches.
Osteopathic manipulative medicine (OMM) training, however, clearly distinguishes the two. Many in the osteopathic profession believe that this element of diagnosis and treatment, which receives significant time in the osteopathic medical college curriculum, is lost by students and graduates who are not receiving clinical training in systems in which it is an important element of practice.28–29 Therefore, there is an increased focus on the need for OMM training in the osteopathic educational continuum. How likely will graduates be to develop and use these skills in their care of patients if they do not receive a continuum of clinical education by osteopathic physicians who are teaching and utilizing those skills in their own care of patients? Several trends buttress concerns in this regard: (1) the growing utilization of allopathic faculty and clinical training affiliations with hospitals in which allopathic medical student and ACGME training is prevalent, (2) the decreasing numbers of osteopathic graduates choosing primary care specialties (where these skills are most utilized), (3) the growing number of graduates choosing ACGME training as opposed to AOA specialty programs, and (4) the reported decrease in the utilization of OMM by osteopathic practitioners.30
Another aspect of concern about the place of OMM in osteopathic medical education has been a recognized lack of sufficient research into the biomedical mechanisms and clinical efficacy of this modality of practice. Over the last decade, research into these questions has become a priority within the profession and has gained momentum at many osteopathic colleges. A particular focus of these efforts was the founding of the Osteopathic Research Center at the University of North Texas Health Science Center College of Osteopathic Medicine in 2002 (with funding from National Institutes of Health and a variety of osteopathic organizations and institutions) to foster nationwide collaborative research on these questions.31
Leaders from osteopathic medical schools, OGME, the AOA, and others have discussed many of these concerns in summits held in 2006 and 2007. These meetings raised questions and developed a number of recommendations aimed at assessing and considering changes in osteopathic medical education in light of these issues.32 The extent to which this process will redefine or restructure osteopathic medical education remains to be seen. The future of osteopathic medical education and, ultimately, the profession itself will be an outcome of a variety of social and economic forces, the result of the scientific assessment of the efficacy of OMM and other distinguishing aspects of osteopathic practice, and the response of its leadership and organizations to the challenges it confronts.
The authors would like to acknowledge the research assistance of Huy Luu, predoctoral osteopathic medical student at the University of North Texas Health Science Center College of Osteopathic Medicine, and Tom Levitan, vice president for research and application services at the American Association of Colleges of Osteopathic Medicine.
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