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Growing Pains

OSTEOPATHIC RESIDENCIES STRUGGLE TO KEEP UP WITH THE GROWING NUMBER OF D.O. GRADS.

The New Physician April 2004
Yeah, spring—robins, flowers, young love and all that—but let’s get serious: Spring is when third-years’ thoughts turn from the rotation of the month to residency and the rest of their lives. Melissa Pearce, a third-year at Touro University College of Osteopathic Medicine (TUCOM), is no different. She dreams of a combined program in family practice and osteopathic manipulative medicine that won’t take her far from the San Francisco area home she shares with her husband. The only problem is that the closest program is thousands of miles away in Missouri. There isn’t even a general osteopathic family practice residency within 400 miles of Pearce, despite TUCOM graduating about 100 D.O.s each year.


The number of quality osteopathic residency openings doesn’t even come close to meeting the annual need—a far cry from the allopathic side of medicine, where hundreds of residency positions go unfilled by U.S. medical graduates each year.


The situation has begun a trend in the osteopathic profession that many find disturbing: As the number of D.O. graduates increases, the number of those going on to osteopathic residencies has decreased. The American Osteopathic Association (AOA) is working on finding ways to deal with the problem, and students and residents say any resolution will have lasting effects on the future of their profession.


GROWING PAINS


Compared to allopathic medical education, which saw the first new school in 20 years open its doors three years ago, osteopathic schools are growing at a frenetic pace. The number of osteopathic medical schools has gone from 15 in the mid-1980s to 20 this year, and the number of annual D.O. graduates has increased 36 percent in the last decade.


But as the number of graduates rises, the number of D.O.s in AOA-approved residencies has fallen 30 percent since 1998, despite the fact the profession has added 410 positions during that time. In 2003, about 46 percent of D.O. graduates entered allopathic residencies, according to the American Association of Colleges of Osteopathic Medicine (AACOM).


For some D.O. students like Pearce, the problem is one of real estate: location, location, location. It’s a fact not lost on Dr. Mitchell Kasovac, a past AOA president and director of medical education at Mesa General Hospital in Arizona. “From the osteopathic profession’s standpoint, we’re trying to grow, and we do want that student to go back to their home state for training and to practice,” he says, but he knows the reality is that those opportunities don’t always exist.


A map pinpointing the 20 D.O.
schools would show the profession heavily favoring the Northeast and Midwest, and because of osteopathy’s community-based medicine philosophy (see “What’s Osteopathy, Anyway?” at right), large teaching hospitals with lots of residency options nearby are not the reality. Seventy-five percent of all osteopathic graduate programs are in just six states: Florida, Michigan, New Jersey, New York, Ohio and Pennsylvania, mostly at small, local hospitals. So Pearce and others who spend four years at school building ties to their communities will often find they’ve got to uproot themselves to find an osteopathic residency.


For others, choosing an allopathic residency becomes a decision not of location but of program availability. Dr. David Russo, a second-year physical medicine and rehabilitation resident at the Mayo Clinic in Minnesota, looked at the lone osteopathic offering but settled on allopathic training at Mayo as his first choice. Other specialties have no osteopathic offerings—oncology and occupational medicine had no positions in the 2002 AOA match—while specialties such as preventive medicine and psychiatry have only a few.


The profession also loses training options as the small, community hospitals that often host AOA-approved residencies close or get swallowed up in the current hospital merger trend. In January, tiny Eastmoreland Hospital in Portland, Oregon, closed its doors and shuttered the only osteopathic residency in the Northwest, forcing its 16 residents out of state to finish their training.


Yet other students point to a lack of faith in osteopathic training as a major reason for the declining residency numbers. Ironically, after osteopathy spent years fighting a quack-doctor stereotype, some D.O. students now say they wouldn’t go into an osteopathic graduate program because they’re not as good as the allopathic ones.


Cathy Sims-O’Neil, a third-year at the University of New England College of Osteopathic Medicine (UNECOM), says she won’t consider an osteopathic residency because AOA-trained physicians have to “jump through extra hoops” to gain privileges in some allopathic hospitals, implying they’re not as well trained.“While I am very excited about the integration of manual medicine, I am not impressed with the osteopathic association at large.” She points to the differences between the allopathic and osteopathic licensing exams, calling the Comprehensive Osteopathic Medical Licensing Examination “poorly written.”


“They obviously don’t have the kind of money that the [United States Medical Licensing Examination] folks do. But if they run their residencies any way they run their tests, I’m sorry. I don’t want any part of it,” she says.


Kasovac says he’s aware of these concerns. “I think it’s a reality out there, but I don’t think it’s universal. I would ask, what part of the country are you looking at? Our people have had more clinical practical experience at the end of year one than those in year two and three at the big M.D. programs because [the M.D.s] have to wait their turn.”


AACOM dismisses a lack of faith in the system and says the reason fewer D.O.s are staying within the profession for postgraduate training is because the allopathic programs are recruiting them. “Osteopathic medical schools have a long history of training excellent clinicians. This, coupled with the osteopathic profession’s emphasis on training physicians for primary care specialties who understand the importance of the whole person and the musculoskeletal system to health and wellness, is very attractive to allopathic programs. Additionally, since the tragic terrorist events of September 2001, federal restrictions on foreign medical graduates that can train in allopathic programs have changed, resulting in more openings in allopathic programs,” the association said in a statement.


“We used to say that we were like AVIS—No. 2, but we try harder,” Kasovac says.


DEALING WITH THE DECLINE


The AOA, seeing these trends, convened a task force in 1999 to address the lack of osteopathic options for its students. At first, it contacted hospitals in the states most lacking opportunities and asked administrators if they would be interested in starting D.O. programs. A few came on board, Kasovac says, but the group soon realized a more cost-effective way to increase residency numbers: approach already established allopathic programs and encourage them to apply for AOA accreditation as well. “Looking out there, I see networking between the two programs [as] a very good thing,” Kasovac says. “I’m a graduate from 40 years ago, and the doors were closed to us.”


They’re not anymore. “As D.O.s are accepted into programs, our allopathic colleagues see they are just as well-trained,” says Dr. David Broder, president of the New York College of Osteopathic Medicine (NYCOM) Educational Consortium, an organization of NYCOM and 18 local hospitals.


So the task force approached 800 allopathic programs that had either D.O. faculty members or residents, and since 2000 has had 97 programs in 14 states apply for dual accreditation. The programs must teach the six osteopathic core competencies in the first year under a D.O.’s direction, as well as offer some type of training in osteopathy’s signature procedure—osteopathic manipulative treatment (OMT). For this, the AOA gives graduates credit for an osteopathic internship year, a preliminary training year about half of D.O.s take after graduation. The internship, or transitional year, is required of D.O.s seeking board certification in osteopathy.


The plan has proven popular among D.O. students, many of whom, while shunning wholly osteopathic programs, have sought out dually accredited ones. “I personally chose to only apply to dual-accredited…pediatric residency programs,” says Meredith LeQuear, a fourth-year at NYCOM. She explains that five states require D.O.s to have graduated from AOA-approved residencies for licensure. “Being from South Jersey, a neighbor of Philadelphia…, I would find it frustrating to know I could not practice over the bridges in Pennsylvania. The dual-accredited programs…will hopefully allow me to continue to foster my manipulative skills. I am able to later apply to both osteopathic and allopathic fellowships…without having to process additional paperwork.”


An AOA survey last year of D.O. students and residents found 84 percent of students and 81 percent of residents would be more likely to apply to a program with dual accreditation than to one with only AOA approval.


“Dual accreditation is going to continue to be extremely popular among D.O. medical graduates. It allows them to keep one boot squarely in each world,” Russo says.


Kasovac says he’s convinced the dual-accreditation route is the way to go—starting new programs from scratch just isn’t realistic. “The profession is going to sustain itself. I truly do not feel it’s selling the profession down the river,” he says.


FOSTERING A DIFFERENCE


There is a concern that as more D.O.s cross into the allopathic world, the osteopathic philosophy will get lost in the journey.


“I personally think osteopathic students in allopathic residencies is a bittersweet situation...,” LeQuear says. “Unfortunately, training in allopathic residencies may not afford opportunities to osteopathic doctors to continue to strengthen their musculoskeletal diagnostic or manipulative skills.” She adds, however, that D.O.s will continue to practice according to the profession’s standards regardless of their residency training.


Broder echoes LeQuear’s concerns. “I’m not sure that [osteopathic training is] watered down or lost—it’s more that they don’t have that reinforcement.”


Pearce would agree. “I think the trend away from osteopathic residency programs is bad for our profession. It’s very difficult to develop skill in osteopathic medicine while being precepted by allopathic physicians, though not impossible.”


The secret, many say, to sustaining the profession is in promoting OMT. “That is the difference, and we should take it [to allopathic medicine] and offer it,” Kasovac says. Thanks to an increased interest in alternatives to standard drug therapies, D.O.s are seeing more M.D.s making efforts to learn about OMT—Sims-O’Neil says an M.D. even runs the OMT clinic at one of UNECOM’s clerkship hospitals.


But Russo says osteopathy isn’t embracing OMT the way he’d like it to. “The sad reality is that at most D.O. residencies, there’s not a lot of hands-on treatment going on. Maybe there’s lip service given to it, but there just aren’t a lot of opportunities to practice it, because for the last 100 years we’ve been trying to be more like M.D.s,
so we’ve gotten away from it…. I think the challenge in the next 100 years is to get the message out that we have something different to offer the U.S. health-care system. To do that, you’ve got to build back into programs the osteopathic piece.”


In the meantime, D.O. students give all indications that they will continue to seek out allopathic-affiliated residencies, and Broder says they should. “It’s another route to practice, and D.O.s owe it to themselves to get the best training they can.”
Jennifer Zeigler is a senior writer with The New Physician. Direct comments about this article to tnp@amsa.org.