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MEDICAL EDUCATION |
Address correspondence to John B. Bulger, DO, Geisinger Medical Center, 100 N Academy Ave, Danville, PA 17822-1334. E-mail: jbulger{at}geisinger.edu
Context: The policy of the American Osteopathic Association (AOA) on the approval of allopathic residency training has evolved since the mid-1980s, when such a policy became necessary because of the low number of osteopathic medical residency positions compared with the number of students graduating from colleges of osteopathic medicine. Resolution 42 (A/2000), the Approval of ACGME (Accreditation Council on Graduate Medical Education) Training as an AOA-Approved Internship, requires that trainees justify a special circumstance requiring them to seek ACGME-accredited training, and complete all rotational requirements of an AOA-approved osteopathic internship.
Objective: To examine the evolution of AOA approval of allopathic residency training and to present the available data on Resolution 42 as it points to the future of osteopathic graduate medical education (OGME).
Methods: An electronic review of the literature was conducted using Medline, the search engine on the JAOA's Web site, and Google. Bibliographies from relevant articles were used to find related citations, and further searches were done using the names of authors of major articles on OGME. Finally, the AOA's database of Resolution 42 petitions was cross-referenced with the AOA's membership database.
Results: Nine hundred thirty-seven trainees had applied for Resolution 42. Almost two thirds of the applicants were in family medicine and internal medicine residency programs, and most (55%) programs were in six states: New York, Illinois, Ohio, California, Pennsylvania, and Texas. The special circumstance most documented was location preference.
Conclusion: The sustained advancement of the osteopathic medical profession is dependent on OGME and accreditation policy. By regularly assessing the achievements of policies and programs, educators can better shape the future of osteopathic medicine.
The goal of this article is to examine the evolution of AOA approval of allopathic residency training and to provide elected leaders, educators, residents, interns, and students with the available data on Resolution 42 as it points to the future of osteopathic graduate medical education (OGME).
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Background |
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The executive committee of the Council on Postdoctoral Training (COPT) continued to approve "allopathic graduate medical training as an internship if they met the rotational requirements of the osteopathic internship, and had `special circumstances' preventing them from taking an osteopathic internship."11 The number of applicants considered under this rule, eventually standardized as Board of Trustees Resolution 65, was 27 in 1990–1991, 79 in 1992–1993, and 102 in 1993–1994.11,12 Published data are not available for the 1991–1992 training year.
Other changes in educational policy occurred during this period. Beginning in February 1992, through a policy change by the National Board of Osteopathic Medical Examiners, interns became eligible to take Part III of the national licensing board examination even if they were not enrolled in an AOA-approved internship.13 In 1988, the AOA policy for approval of ACGME-accredited residency training changed so that applicants no longer had to show that osteopathic residency positions were unavailable.14 In 1990, residents were no longer required to pay the costs of inspection of their allopathic programs.10 In March 1993, the AOA Board of Trustees eliminated the $150 application fee required for the ACGME-accredited residency approval process.13
At the July 1996 AOA Board of Trustees annual meeting, the COPT proposed that Resolution 22 replace Resolution 65 to streamline the application process.15 Resolution 22 stipulated that approval be granted if there were a special circumstance and if the applicant completed the rotational requirements of an osteopathic internship.15 In the 1996–1997 training year, among the 205 petitions that were received, 27 were approved, 120 were approved pending completion of curriculum, 49 were denied, and 9 were deferred.16 In the 1997–1998 training year, 132 petitions were received: 44 were approved, 50 were approved pending completions of curriculum, 32 were denied, and 5 were deferred.17
In 1998, Resolution 19 replaced Resolution 22.18,19 Resolution 19 did not require an osteopathic curricular component for approval.19 During the 1998–1999 training year, 108 petitions were received under Resolution 19: 31 were approved, 54 were approved pending completion of curriculum, 17 were denied, 4 were deferred, and 2 received no action. In the 1999–2000 training year, 61 additional petitions were received: 19 were approved, 32 were approved pending completion of curriculum, and 10 were denied.18 Resolution 19 was suspended by the AOA Board of Trustees in March 1999.18
At their annual meeting in July 2000, the AOA Board of Trustees passed Resolution 42 as a response to the suspension of Resolution 19 and to address the declining number of funded internship positions and increasing numbers of COM graduates.20 Resolution 42 contained several changes. It applied to current and past trainees, it broadened and clarified the meaning of "special circumstances," it was processed using a one-page application, and it required a commitment to osteopathic principles and practice.20 Jurisdiction of Resolution 42 fell under the COPT executive committee. When the AOA department of education was restructured in 2004, the Program and Trainee Review Committee (PTRC) began to review these cases.20
Published data from the JAOA on Resolution 42 report 46 petitions in 2000–2001, 204 in 2001–2002, 140 in 2002–2003, 204 in 2003–2004, and 274 in 2004–2005.21–25 These data do not differentiate approval of special circumstances from final approval. The applicant's internship is considered to be approved if the special circumstance is accepted and the applicant has completed all rotational requirements of an AOA-approved osteopathic internship (2 months of internal medicine, 1 month of family medicine, 1 month of emergency medicine, and a total of 6 months in those core disciplines and/or general surgery, obstetrics and gynecology, and pediatrics).
Data on Resolution 42 approvals and denials are available in past COPT newsletters that are sent regularly to OGME directors and residency program directors, and are contained in the minutes of COPT and PTRC meetings.26 The term "approval" in these documents signified that the special circumstance was accepted but not necessarily that AOA approval was granted for the residency program, and "complete" indicated final approval. Recent change in policy has clarified this point by reporting approvals pending completion of required curriculum.27 Individual cases are discussed in confidential executive sessions.
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Methods |
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Subsequently, an analysis of the AOA's database of Resolution 42 petitions was undertaken. This database contains demographic information for all applicants, including AOA Number, name, osteopathic college, college state, graduation date, sex, date of birth, residency institution code and name, residency state, specialty, start date, end date, application approval, application completion, and decision date. This database was cross-referenced with the AOA's membership database to obtain the current membership status of all applicants, member type (member vs nonmember), and the membership "paid thru" date.
Last, a representative sample of files was reviewed to ascertain the type of special circumstances listed on the applications. In most instances, this information was evident from the cover letter sent with the application, but occasionally, further review of the file was needed to determine this information.
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Results |
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Colleges of Osteopathic Medicine
The number of applicants from various COMs ranged from 14 (1.5%) graduates
from Michigan State University College of Osteopathic Medicine in East Lansing
and the University of Medicine and Dentistry of New Jersey–School of
Osteopathic Medicine in Stratford to 98 (10.5%) graduates from Kansas City
(Mo) University of Medicine and Biosciences College of Osteopathic Medicine
(KCUMB-COM) (Table 2).
The majority of applicants (54%) graduated from six COMs:
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Location of Residency Program
The applicants' residency programs represented 45 states. Fifty-five
percent of the residency programs were in six states: New York (96 [10.2%]),
Illinois (85 [9.1%]), Ohio (81 [8.6%]), California (64 [6.8%]), Pennsylvania
(64 [6.8%]), and Texas (62 [6.6%]).
Specialty
Of 18 specialties represented in the applications, dermatology and
orthopedic surgery were each chosen by one (0.1%) applicant. Two hundred
ninety-eight applicants (31.8%) were enrolled in family medicine residency
programs and 290 (30.9%) in internal medicine programs, accounting for almost
two thirds of the applications. The other programs represented were pediatrics
(73 [7.8%]), transitional year (61 [6.5%]), obstetrics and gynecology (46
[4.9%]), emergency medicine (43 [4.6%]), psychiatry (37 [3.9%]), internal
medicine/pediatrics (24 [2.6%]), surgery (22 [2.3%]), anesthesiology (15
[1.6%]), physical medicine and rehabilitation (6 [0.6%]), pathology (5
[0.5%]), urology (4 [0.4%]), neurology (4 [0.4%]), family practice/psychiatry
(4 [0.4%]), and radiology (3 [0.3%]).
Special Circumstance
A representative sample of 124 (13.2% of 937) files was reviewed to gain
insight into the circumstances behind the applications. The majority of this
sample (75 [60.5%]) listed "location because of family concerns"
as the special circumstance for the application. Within this group, 31 (41.3%)
applicants specified spousal employment or education, 25 (33.3%) applicants
had other family conditions that did not allow them to be easily mobile, 12
(16%) applicants listed location because the chosen specialties were only
available in a specified area, 5 (6.7%) applicants highlighted a family
illness, and 2 (2.7%) applicants claimed financial concerns.
Specialty choice was the second most common special circumstance listed (21 [16.9%]). The only specialty choice that appeared more than twice in this group was psychiatry.
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Comment |
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The special circumstance for consideration under Resolution 42 must be approved by either the director of the division of postdoctoral training or the PTRC. If this approval is not granted, the decision can be appealed to the Bureau of Osteopathic Education and then to the Board of Trustees. Applicants must provide extensive supporting documentation aimed at justifying their special circumstance. The subjective nature of the process lends itself to differences of opinion among applicants, decision makers, and the profession as a whole. This subjectivity and the multiple layers of appeal explain in part the very high (99%) acceptance rate for the special circumstance.
The subjective acceptance of the special circumstance is balanced by objective measures. The candidate must complete the prescribed rotational curriculum as defined by the AOA at the time of application.28 There is little room for interpretation of this requirement. At the time of the current study, 58% of applicants had been granted final approval, with applications pending completion of the noted curriculum. One applicant in 100 is denied preliminary approval based on a special circumstance, but 20 applicants in 100 fail to complete the prescribed curriculum and thus are denied approval of their ACGME-accredited training as an AOA-approved internship.
The class of 2001 was the first class with full benefit and knowledge of Resolution 42. In this class, 121 (80.1%) of 151 applicants were granted final approval. In the class of 2002, only 71% of applicants were granted approval, and the number continues to decline. At the same time, there has been a steadily increasing number of COM graduates entering ACGME-accredited residency programs.29 The fact that a trainee can apply for AOA approval at any time after beginning training suggests that the annual number of applications will continue to rise.
Further perspective is gained when data from the 937 applicants are compared with the total number of COM graduates. From 2000 through 2004, there were 12,983 COM graduates.19–23 Seven hundred nine trainees began the application process for approval of their ACGME training as an AOA-approved internship, and final approval was granted to 421 applicants. Therefore, 5.5% of COM graduates in the graduating classes of 2000 through 2004 applied for approval, and 3.2% had their applications approved (Table 3).
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A comparison of the 2004–2005 Intern Registration Program data with Resolution 42 data found that the COMs with the highest number of applicants under Resolution 42 also had the highest number of nonmatched and nonparticipants in the 2004–2005 AOA match. This relationship continued when adjusting for number of graduates.19–23 While only 2.8% of Resolution 42 applicants graduated from Pikeville (Ky) College School of Osteopathic Medicine (PCSOM) (ranked 12th), 10.9% of PCSOMs graduates from 2001 through 2004 applied for Resolution 42 (ranked first).
One of the goals of Resolution 42 is to provide opportunities for trainees in states where few OGME opportunities exist. Six states (New York, Illinois, Ohio, California, Pennsylvania, and Texas) represented more than 50% of the applicant training sites and contained 48.6% (1368/2815) of the approved intern positions in 2004–2005.24 One could question whether the original intent of the policy is being achieved. These same six states have the largest numbers of trainees (osteopathic and allopathic) in ACGME-accredited programs, accounting for 46.8% of all ACGME-accredited residency positions.29 In addition, the seven states with the most Resolution 42 applicants (California, Florida, Illinois, New York, Ohio, Pennsylvania, and Texas) are also the seven states with the largest population in the United States according to the 2000 Census.30 Given these observations, this is where one may reasonably expect this data point to fall.
Another goal of Resolution 42 is to provide the option of AOA approval for training in specialties with a limited number of AOA-approved residency positions. Still, almost two thirds of the Resolution 42 approvals were for family medicine and internal medicine programs. Of the applicants who received AOA approval of their programs, 23.0% were in family medicine, and 14.3% were in internal medicine.24 Also, the bulk of COM graduates in ACGME-accredited programs were in family medicine and internal medicine.29 As of August 1, 2004, there were 5675 COM graduates in ACGME-accredited programs, with 1170 (20.6%) in family medicine and 1097 (19.3%) in internal medicine programs.29 Psychiatry and pathology, two specialties with well-documented shortages of AOA-approved residency programs, had 286 (5.0%) and 102 (1.8%) trainees, respectively, in ACGME-accredited programs.28 The experience with Resolution 42 with regard to specialty choice appears to mirror current OGME trends. The policy requirement that applicants must complete the rotational requirements of an osteopathic internship may account for the discrepancies between those in family medicine or internal medicine programs, where those curricular tenets are encompassed in ACGME-accredited training.
It is worth noting the problems in comparing numbers of residents between specialties and accrediting bodies. To compare the total number of residents in a specialty, one should divide by the required number of years in training. In ACGME programs, if there are 75 residents training in family medicine (3-year program) and 100 training in obstetrics and gynecology (4-year program), there are 25 residents in each training year. In OGME programs, the first year of training is an internship and the subsequent years are residency. So when comparing numbers in OGME- and ACGME-accredited programs, the divisors are different. Finally, residents in dually accredited programs are counted in both the AOA and ACGME statistics.
One of the stated goals of Resolution 42 is to encourage osteopathic trainees to "come back" to the AOA as members.31 Although one of the requirements of the resolution is that "The applicant maintains intern/resident membership status in the AOA," at the time of approval, physicians are not required to retain membership after the approval process is finalized. However, most applicants in the current study remained members of the AOA (770 [82.2%] as of December 2005) even after the approval process was finalized (Table 1). It is possible that the proposed inclusive intentions of the resolution play a positive role.
Concerns over data published in yearly JAOA medical education issues have been discussed previously.17,32 These concerns include inaccuracies in the data because of timeliness and different nomenclature in institutional databases. One of the limitations of any review is the accuracy of baseline statistics. This undertaking is no exception.
Much controversy surrounds Resolution 42, and questions remain regarding whether the original intent is being carried out and whether Resolution 42 is good or bad for the osteopathic medical profession. Answers to questions regarding enactment, implementation, and oversight of policies such as Resolution 42 are open to interpretation and viewed from varying perspectives. Open discussion in the light of the data will shape the future of osteopathic training, accreditation, and certification.
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Acknowledgment |
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Submitted April 11, 2006; revision received July 20, 2006; accepted July 21, 2006.
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References |
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2. Zawadzki E. "Hardship exception" is necessary [letter]. J Am Osteopath Assoc. 2005;105:124–126. Available at: http://www.jaoa.org/cgi/content/full/105/3/124. Accessed October 20, 2006.
3. Steier KJ. Rebuttal regarding the "Hardship Exception" [letter]. J Am Osteopath Assoc. 2005;105:4–5. Available at: http://www.jaoa.org/cgi/content/full/105/1/4. Accessed October 20, 2006.
4. Opipari MI. Chairman of COPT concludes debate on "Hardship Exception" [letter]. J Am Osteopath Assoc. 2005;105:53–54. Available at: http://www.jaoa.org/cgi/content/full/105/2/53. Accessed October 20, 2006.
5. Rodos JJ. Missed opportunity for osteopathic medical education [letter]. J Am Osteopath Assoc. 2005;105:441–442. Available at: http://www.jaoa.org/cgi/content/full/105/10/441. Accessed October 20, 2006.
6. Snyder JJ. Jumping through hoops for osteopathic internships [letter]. J Am Osteopath Assoc. 2005;105:443. Available at: http://www.jaoa.org/cgi/content/full/105/10/443. Accessed October 20, 2006.
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19. American Osteopathic Association Board of Trustees.Resolution 22. Revision of special circumstances for approval of ACGME training for the internship year . Chicago, Ill: American Osteopathic Association; February 1998.
20. American Osteopathic Association Board of Trustees. Resolution 42. Approval of ACGME Training as an AOA-Approved Internship. Chicago, Ill: American Osteopathic Association; July 2000. DO Online Web site. Available at: http://www.do-online.osteotech.org/index.cfm?PageID=sir_postdocres42. Accessed October 20, 2006.
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26. Opipari MI. Council on Postdoctoral Training Newsletter. November 2005. Available at: http://www.do-online.osteotech.org/pdf/acc_postdoccoptnwsltr1105.pdf. Accessed October 24, 2006.
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31. Greenwald B. Brand revitalization aims to connect all DOs with AOA. The DO. March2005; 46:34 –40.
32. Cummings M. Graduate medical education: accuracy of AOA's annual data-reporting mechanisms questioned [letter]. J Am Osteopath Assoc. 2005;105:444–445. Available at: http://www.jaoa.org/cgi/content/full/105/10/444. Accessed October 24, 2006.
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