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Associate Professor of Medicine/Division of Pulmonary and Critical Care, Patient Safety Officer, Program Director, AOA Internal Medicine Residency Director, Pulmonary Care Unit Nassau University Medical Center East Meadow, NY

To the Editor:

To quote folk singer Bob Dylan's 1964 hit, ".. .the times they are a-changin'."

In the past, I have been fortunate to have had several letters to the editor published in JAOA—The Journal of the American Osteopathic Association challenging the routine granting of AOA credit under Resolution 42 (A/2000), the so-called hardship exception.^1,2 This AOA resolution allows osteopathic graduates who choose to enter non–AOA-approved residency training programs to seek AOA approval for that training.

Graduates of colleges of osteopathic medicine have become a highly desirable "commodity" in Accreditation Council for Graduate Medical Education (ACGME) residency training programs.³ In fact, in my home state of New York, more than 50% of graduates from the New York College of Osteopathic Medicine of New York Institute of Technology (NYCOM/NYIT) in Old Westbury go directly into ACGME-accredited residency programs.⁴ Many NYCOM/NYIT graduates are now accepted into the very best programs in New York State.

When I graduated from NYCOM/NYIT in 1983, only a handful of new osteopathic physicians were considered for even mediocre allopathic programs. Clearly, the success of the profession—as measured by the desirability of our graduates—is now outstanding.

In contrast, hundreds of funded positions in residency training programs approved by the American Osteopathic Association (AOA) remain unfilled.⁴ This fact puts the future of AOA-approved residency training programs in jeopardy because programs that don't fill their funded positions can lose them—and can also eventually lose their accreditation status.

Another reason for maintaining—and even expanding—AOA-approved residency programs is the likely increased competition for residency positions by an increased number of allopathic graduates. As Tod Ibrahim,⁵ Executive Vice President of Alliance for Academic Internal Medicine, wrote earlier this year in his quarterly update for Academic Internal Medicine Insight:

Responding to concerns about an impending shortage of physicians, the Association of American Medical Colleges (AAMC) last February reversed a decade-long policy and now promotes a 15% expansion in the first-year class size at US medical schools. This change caused the largest percentage gain in overall first-year enrollments in nearly 30 years. Sources indicate that AAMC will increase its recommended expansion from 15% to 30% in the near future.

A substantial increase in allopathic medical graduates, along with an increasing number of osteopathic medical graduates,⁴ will continue to increase demand on a limited number of residency positions, be they AOA approved or ACGME accredited. Without AOA programs to "fall back on," our osteopathic graduates may be unable to find the residency positions required to continue their careers.

Based on these factors, I join Bradley H. Werrell, DO, in his October 2005 letter to the editor ("The `Big DO.'" 2005;105:442–443), when he notes the "irony" of not allowing allopathic trainees (MDs) to apply to AOA-approved residency training programs. Although Dr Werrell suggests that "our profession offer MDs some type of certificate of added qualification[s] in osteopathic principles and practice by [completing] qualifying coursework... [allowing] MDs to participate in osteopathic residency programs." Indeed, given the current circumstances, it makes little sense to discriminate against allopathic applicants based solely on the type of medical school they attended.

Let me be clear, however, that I believe that allopathic graduates should be allowed to compete for AOA-approved residency positions only when those positions have not been filled by osteopathic graduates through the AOA match. Separate application deadlines for osteopathic and allopathic candidates would ensure that osteopathic graduates retain "first crack" at all AOA-approved residency positions.

Furthermore, I would recommend that, at the conclusion of trainees' AOA-approved residency periods, each osteopathic program director be required to certify that each resident—both osteopathic and allopathic—has developed competency in osteopathic principles and practice.

It is also important to note that, as an increasing percentage of AOA-approved residency training programs are based at nonosteopathic hospitals and the number of purely osteopathic hospitals continues to dwindle,^6,7 it is increasingly problematic to eliminate allopathic graduates autocratically from consideration for these residency positions. Given that the osteopathic medical profession relies on support from a multitude of allopathic physicians to help train osteopathic residents, how can we possibly deny consideration to allopathic trainees for our programs?

Furthermore, in the creation of new AOA-approved residency training programs, how can a program director expect to get the support of mostly allopathic medical staff to start a new AOA-approved residency training program when allopathic graduates would be ineligible to apply? From personal experience, I can assert that this scenario is a very difficult situation to find yourself in. At the graduate medical education committee level, it is extremely difficult to make a convincing argument for a new AOA-approved program—especially when there are osteopathic trainees in just about every ACGME residency program in the same hospital.

Following is one specific example I would like to provide. I am the director of medical education for osteopathic and allopathic medical residents (and a rotating internship) at a predominantly allopathic institution on Long Island. We have a total housestaff of 300; of these, 60 are osteopathic physicians. I have substantial support from hospital administration and clinical department chairs to develop AOA-approved residency training programs in several attractive specialty areas, such as obstetrics and gynecology as well as cardiology.

Because these proposed programs could not consider allopathic applicants, however, there is also major political opposition—even from those who otherwise support osteopathic graduate medical education. I have been asked repeatedly why allopathic graduates would be ineligible to apply for these new programs. And, yes—before you can pose the question I know you have ready—there has been considerable interest expressed in an osteopathic cardiology fellowship from a number of allopathic medical residents currently in enrolled in our internal medicine residency program.

It makes sense for us to work collaboratively with our allopathic colleagues on tort reform legislation,⁸ limits on resident work hours,^9,10 and Medicare reimbursement for graduate medical education.⁴ I would like to suggest that now might be the time for the osteopathic profession to reconsider its restrictive approach to residency training programs.

Although there is no doubt that osteopathic physicians were discriminated against in the past—and perhaps some still are in certain programs today—two wrongs do not make a right.¹¹ The survival of AOA-approved residency training programs, ironically, may depend on opening the doors to allopathic applicants.

For those of us trying to fill our residency programs with quality physicians, this idea deserves serious consideration. And besides, isn't it true that even A.T. Still started out as an MD?

References
1. 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-a. Accessed April 17, 2006.

2. Steier KJ. In opposition to Resolution 42 [letter]. JAm Osteopath Assoc. 2004;104:314–315; discussion 315. Available at: http://www.jaoa.org/cgi/content/full/104/8/314. Accessed April 17, 2006.

3. American Osteopathic Association's Commission on Osteopathic College Accreditation–Executive Committee and the Subcommittee on Osteopathic Educational Elements. Report of the AOA Commission on Osteopathic College Accreditation–Executive Committee and the Subcommittee on Osteopathic Educational Elements: Resolution 274 (A/2004) "Match participation and rotations with osteopathic physicians, proposed requirements for osteopathic." Paper adopted at: Annual Meeting of the AOA House of Delegates; July 15–17, 2005; Chicago, Ill.

4. Obradovic JL, Beaudry SW, Winslow-Falbo P. Osteopathic graduate medical education. J Am Osteopath Assoc. 2006;106:59–68. Available at: http://www.jaoa.org/cgi/content/full/106/2/59. Accessed April 17, 2006.

5. Ibrahim T. More paradoxes to consider [EVP update]. Acad Intern Med Insight. 2006;4:3–4. Available at: http://www.im.org/AAIM/Pubs/Insight/Spring2006/EVPupdate.pdf. Accessed April 19, 2006.

6. Cummings M. The pull toward the vacuum: osteopathic medical education in the 1980s. J Am Osteopath Assoc.1990; 90:353 –362.[Abstract]

7. Pandeya NK. Same as it ever was [letter]. J Am Osteopath Assoc. 2005;105:128–129. Available at: http://www.jaoa.org/cgi/content/full/105/3/128. Accessed April 17, 2006.

8. Maine Medical Association. Coalition medical liability reform bill is printed as LD 1378. Maine Med Weekly Update. March 21, 2005. Available at: http://newsmanager.commpartners.com/mainemed/issues/2005-03-21.html. Accessed April 17, 2006.

9. Zonia SC, LaBaere RJ 2nd, Stommel M, Tomaszewski DD. Resident attitudes regarding the impact of the 80-duty-hours work standards. J Am Osteopath Assoc. 2005;105:307–313. Available at: http://www.jaoa.org/cgi/content/full/105/7/307. Accessed April 17, 2006.

10. Foresman BH. Resident-physicians' duty hours: perceptions and cultural expectations in medicine [editorial]. J Am Osteopath Assoc. 2005;105:305–306. Available at: http://www.jaoa.org/cgi/content/full/105/7/305. Accessed April 17, 2006.

11. Gevitz N. The DOs: Osteopathic Medicine in America. 2nd ed. Baltimore, Md: The Johns Hopkins University Press; 2004.

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