Mark Cummings

The impact of osteopathic physicians' participation in ACGME-accredited postdoctoral programs, 1985-2006

Between 1985 and 2006, the number of osteopathic physicians (DOs) training in Accreditation Council for Graduate Medical Education (ACGME) postdoctoral (i.e., residency and fellowship) programs increased by 5,352 (419%). In 2006, more than two of every three DOs (6,629 of 9,618) in postdoctoral training were in an ACGME program. The integration of osteopathic physicians into these programs was facilitated by several factors. The most important of these was a noted growth in the number and types of ACGME programs and a consistent number of U.S. MD graduates (USMDs) from schools accredited by the Liaison Committee on Medical Education (LCME). From 1985 to 2006, the number of all physicians in ACGME programs, both DO and MD, grew by 30,365 (41%). DOs were most often selected for specialties less populated by USMDs, chiefly family and internal medicine and pediatrics.Growth patterns in LCME medical schools project an increase in the national class size to accommodate 3,400 more students by 2012, a 21% increase. The development of new colleges of osteopathic medicine (COMs) and expansion in existing ones is expected to generate 5,227 first-year students in 2012, an increase of 1,380 students (36%) over 2006 numbers. The overwhelming majority of these anticipated new COM graduates cannot be accommodated in American Osteopathic Association postdoctoral programs because of limited capacity. As these additional LCME graduates move into their postdoctoral training, educational opportunities for DOs are expected to decline and competition is expected to become stiffer. The window of opportunity for DOs in ACGME programs that opened in the last two decades will gradually start to close.

The irony of osteopathic medicine and primary care.

Osteopathic medicine is strongly identified with primary care. In the past 20 years, several factors have influenced this relationship, resulting in significant changes in the postdoctoral training of doctors of osteopathic medicine (DOs). Growth in colleges of osteopathic medicine spilled over into postdoctoral programs of the Accreditation Council for Graduate Medical Education (ACGME), creating a number of consequences. More than ever, osteopathic physicians are filling voids in ACGME primary care residency positions left vacant by U.S. medical graduates. Many allopathic primary care residencies have created parallel-accredited (American Osteopathic Association/ACGME) programs in hopes of tapping into this supply of DOs. In turn, osteopathic training institutions have shifted their educational emphasis in support of nonprimary care residencies. As a result of these changes, there is a strong element of irony in the underlying reasons for osteopathic medicines link to primary care, why osteopathic training institutions are emphasizing specialty residencies, and the new responsibility of allopathic programs in training the next generation of primary care DOs.

The Predicament of Osteopathic Postdoctoral Education

The growth of colleges of osteopathic medicine (COMs) during the past 20 years has been a catalyst for change and has created new challenges in osteopathic medicine. None of these challenges is more daunting than the task of sustaining an osteopathic graduate medical education (OGME) system that has suffered during this period of rapid development. Notable trends within the osteopathic medicine community since 1990 include allopathic residency programs obtaining OGME accreditation, COM graduates bypassing OGME, repeated major changes in American Osteopathic Association (AOA) accreditation policies, a growing dependence on Accreditation Council for Graduate Medical Education programs to train osteopathic graduates, and a lessening of options for the AOA to effectively direct its OGME system. The predicament is whether COMs can continue to grow without resulting in the demise of the OGME system and a loss of professional identity.

Osteopathic Students' Graduate Medical Education Aspirations Versus Realities: The Relationship of Osteopathic Medicine and Primary Care.

Osteopathic medicine is closely identified with primary care. The mission statements of a majority of colleges of osteopathic medicine (COMs) mention the goal of producing primary care physicians. By far, there are more family medicine and internal medicine residency programs in the American Osteopathic Association graduate medical education (GME) system than programs for any other specialty. In addition, the osteopathic profession is embarking on a new direction to ensure COM graduates are trained as practice-ready primary care physicians. In counterpoint to the osteopathic professions emphasis on primary care, the majority of entering and graduating osteopathic medical students express preferences for residencies in non-primary care specialties. When graduating students confront their GME options, however, they discover their choices for non-primary care specialties are limited. Currently, approximately two-thirds of COM graduates end up in a primary care residency. The creation of a unified GME accreditation system under the Accreditation Council for Graduate Medical Education (ACGME) may further consolidate the osteopathic identity with primary care: Osteopathic training institutions may reduce the number of non-primary care programs they offer, which would allow them to increase enrollment in primary care programs to meet ACGME standards and remain below their Medicare caps. Additionally, in the National Resident Matching Program Match, selection patterns by program directors for competitive non-primary care residencies currently favor U.S. MDs. Therefore, while osteopathic students enter COMs aspiring to careers in non-primary care specialties, they are encountering a GME environment that offers them a shrinking number of alternatives.

How private colleges of osteopathic medicine reinvented themselves.

Starting in the last decade of the 20th century, private colleges of osteopathic medicine (COMs) began to restructure themselves in ways that represent a distinct departure from the past. Their new organizational model de-emphasizes many of the characteristics that distinguish allopathic medical schools today. The new emphasis centers on high enrollment, diversity of health-related programs, formation of universities of health science, expansion, and a retreat from involvement in clinical and postdoctoral education. Such changes reflect an admixture of entrepreneurship, an ability to respond quickly to changing environments, and an insularity that draws them away from traditional forms of clinical and postdoctoral medical education. The private COMs 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. As an evolving educational model, the private COMs have undergone a remarkable transformation in a brief period; they bear watching for future developments and to assess their long-term viability.

Does the osteopathic internship have a future

Since 1984, a new set of realities has generated pressures that are transforming osteopathic graduate medical education (OGME) and forcing it to adapt to changing circumstances. Policy decisions were made that addressed these circumstances, and the impact of these choices moved OGME in new directions. Many of the changes were perceived as positive, but inherent weaknesses were exposed as well. While the appearance and structure of OGME have been significantly altered, nowhere are the changes more apparent than in the traditional osteopathic internship. Compared with 1990, todays osteopathic internship is markedly different in terms of its curriculum, its identity, and its place within residencies approved by the Accreditation Council for Graduate Medical Education. As a direct consequence of decisions made to expand internship opportunities, the traditional osteopathic internship appears destined to vanish as a distinct educational experience.

The Educational Model of Private Colleges of Osteopathic Medicine: Revisited for 2003-2013.

Trends in the development of new private colleges of osteopathic medicine (COMs) described by the author in 2003 have accelerated in the ensuing decade. During 2003 to 2013, 10 new COMs as well as 2 remote teaching sites and 4 new branch campuses at private institutions were accredited, leading to a 98% increase in the number of students enrolled in private COMs. The key features of the private COM educational model during this period were a reliance on student tuition, the establishment of health professions education programs around the medical school, the expansion of class size, the creation of branch campuses and remote teaching sites, an environment that emphasizes teaching over research, and limited involvement in facilities providing clinical services to patients. There is institutional ownership of preclinical instruction, but clinical instruction occurs in affiliated hospitals and medical institutions where students are typically taught by volunteer and/or adjunct faculty. Between 2003 and 2013, this model attracted smaller universities and organizations, which implemented the strategies of established private COMs in initiating new private COMs, branch campuses, and remote teaching sites. The new COMs have introduced changes to the osteopathic profession and private COM model by expanding to new parts of the country and establishing the first for-profit medical school accredited in the United States in modern times. They have also increased pressure on the system of osteopathic graduate medical education, as the number of funded GME positions available to their graduates is less than the need.

AM Last Page: Osteopathic medicine in the U.S.A.

Source: AACOM, Annual Osteopathic Medical Schools Questionnaire, 1967-1968 through 2008-2009 academic years. Past and Future Trends • By 2012, projected first-year COM enrollment is expected to be 5,227, an increase of 937 (22% ) from 2007. • The American Osteopathic Association (AOA) currently accredits 25 COMs and 3 branch campuses, 9 of which were founded after 2000. • Between 2003 and 2007, the number of women in the first-year class increased from 1,662 to 2,142, a 29% jump. The overall gender distribution for the 2007 firstyear class was 47.6% female and 52.4% male.