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Department of Anesthesiology, University of Mississippi School of Medicine Jackson, Miss

To the Editor:

I have read with interest the continuing debate concerning osteopathic graduate medical education (GME) and the future of the osteopathic medical profession.^1–12 My story in relation to this debate is not unique. In fact, I think it is typical of the majority of graduating osteopathic physicians.

As a medical student in 1986, I was advised, "Go to the best residency you can find, regardless of whether it has an allopathic or osteopathic affiliation." I selected an internship and residency with an allopathic affiliation, knowing that I was obtaining quality GME while sacrificing practicing in states in which an American Osteopathic Association (AOA)-approved internship and AOA certifying board examination are required for licensure. My rotating internship at the Hospital of St Raphael in New Haven, Conn, and my subsequent residency at the Yale-New Haven Hospital were not approved by the AOA. Thus, I was unable to take part 3 of the National Board of Osteopathic Medical Examiners (NBOME) licensing examination (the precursor to the Comprehensive Osteopathic Medical Licensing Examination–USA). Instead, I took the allopathic Federal Licensing Examination.

The "inadequacy" of my clinical training in the eyes of the AOA prohibits me from being licensed as an osteopathic physician in those states that require an AOA-approved internship and the NBOME exam. Nevertheless, I function quite well today in an entirely allopathic world. Although I have maintained my AOA membership and I try to be active in the Mississippi Osteopathic Medical Association, I am invisible in the eyes of the AOA, except for my yearly membership dues check.

Were the experience I describe here limited or isolated, it would not be important. However, I believe that my experience is typical of today's graduating osteopathic physicians, many of whom choose to enter allopathic GME programs.¹³ If we are all invisible to the AOA, what does this say for the future of the osteopathic medical profession? If there were a nationwide initiative today similar to the one that offered conversion of doctor of osteopathic medicine (DO) degrees to doctor of medicine (MD) degrees in California in the 1960s,¹⁴ how many DOs would be left?

In my view, there are several factors that, if not corrected, will ultimately result in the death of the osteopathic medical profession as we know it. These factors include the following:

Failure to objectively evaluate the quality of osteopathic GME. It is interesting to note that the growth of osteopathic undergraduate medical education has been inversely proportional to that of filled GME positions—such that there are now more osteopathic internships available than there are graduates willing to fill them.¹⁵ As the number of AOA-accredited hospitals shrinks, more and more osteopathic residencies are served in allopathic medical institutions.^13,16,17 These residency programs may or may not have dual accreditation by the AOA and the Accreditation Council for Graduate Medical Education (ACGME).

In addition, osteopathic GME programs tend to be in relatively small facilities, which may be sufficient for osteopathic residents in primary care programs but not for residents in other specialties. For example, the complexity of an anesthesiology residency requires the presence of a large tertiary- or quaternary-care medical center. Indeed, the ACGME Residency Review Committee limits anesthesiology residency training in small hospitals by requiring residents to serve substantial amounts of time in complex critical care environments.¹⁸ These kinds of allopathic training programs do not need dual accreditation.

The ACGME is also moving toward integrating internships into the residency continuum.¹⁸ Although this will happen slowly, it is a sure sign that the traditional rotating internship is going away. Whether this is a good thing is highly debatable. It is, nevertheless, going to happen.

For many graduating osteopathic medical students then, there is no real choice but to enter residencies at large allopathic medical centers if they wish to pursue specialties in areas other than primary care. (Even primary care may be better taught in the large medical centers.)

Having highly trained subspecialists is important to the future of the osteopathic medical profession. If we remain satisfied with only primary care physicians, the allopathic medical profession will view DOs as little more than glorified nurse practitioners. The osteopathic medical profession needs to embrace osteopathic subspecialists, regardless of their residency affiliations.

Inadequate and nonrigorous osteopathic specialty board certification processes. In the casual opinion of many in the allopathic world, the AOA specialty boards are widely considered to be "easier" and less credible than the allopathic certifying boards. I previously thought that this attitude was just "sour grapes" on the part of the allopathic medical profession. During the last several years, however, I have concluded that this MD opinion of the AOA boards may be accurate. I have personally encountered several osteopathic physicians who, after completing allopathic residency training, were unable to pass the allopathic board examinations—though they were able to pass the osteopathic board exams with ease. In all of these cases, these osteopathic physicians were viewed by their allopathic colleagues as unworthy of board certification.

The allopathic boards are the gold standard for residency training certification. Following my medical training, I had no intention of pursuing anything but this credible and universally accepted credential. The AOA needs to seriously re-evaluate its board-certification process.

Overemphasis of osteopathic manipulative treatment (OMT). It may be heresy to put this forth, but OMT is vastly overemphasized by the AOA. The practice of OMT is important in osteopathic medical education and in the practices of some osteopathic physicians, but it is not necessary for many other osteopathic physicians. Osteopathic medicine and osteopathic principles do not start and end with OMT.

The steadfast position of the AOA regarding the practice of OMT is as shortsighted as if the American Medical Association were to hold digital subtraction angiography as one of the foundations of allopathic medical practice. The AOA needs to realize that, in and of itself, OMT does not make one an osteopathic physician. A true osteopathic philosophy of practice is a far deeper thing, involving a holistic, patient-centered approach to care and excellence.

Our residency training program at the University of Mississippi School of Medicine seeks out and actively recruits osteopathic medical graduates not because of their abilities in OMT, but because we know that they are consistently exemplary residents who can be relied on to provide our patients with safe, thorough, and compassionate care. Indeed, most of our chief residents, who are selected for their clinical and administrative skills, have been DOs. This has nothing to do with their abilities to perform OMT. In my practice of pediatric cardiac anesthesiology, I do not use OMT. I do, however, practice osteopathic medicine, and I believe that I offer my patients a philosophy and method of care that compares favorably with that offered by allopathic physicians.

I consider my patients to include the parents of the children to whom I am administering an anesthetic for high-risk procedures. If anything is a hallmark of an osteopathic physician, I believe it is a compassionate, holistic, and respectful approach to caring for our fellow human beings—coupled with an honest appraisal of the limitations and potential of pharmaceutic, surgical, and osteopathic interventions.

Failure to welcome all osteopathic physicians. Those of us DOs who trained in allopathic GME programs and who practice in the allopathic world are increasing in number and may very well be the majority of practicing DOs in the United States.¹⁹ We are proud of our profession and identity, though we are largely ignored by the AOA. We are successful clinical and academic practitioners and leaders in many fields. It is foolish for the AOA to treat us as if we do not exist. The AOA should take the "big tent" approach to the osteopathic medical profession and welcome all DOs as active participants with emotional investment in the success of the profession.

I suggest that the AOA create a committee to explore these issues and find ways to welcome back the DOs, like myself, who love the profession more than it loves us.

This is the reality. If the situation I've described in this letter does not change, there will be fewer and fewer DOs involved in the AOA and in national advocacy of osteopathic medicine. In time, DOs and the AOA will disappear entirely, leaving the DO degree as an academic curiosity—or as an MD degree with different letters behind the graduate's name.

References
1. 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 March 21, 2006.

2. Werrell BH. The "big DO" [letter]. J Am Osteopath Assoc. 2005;105:442–443. Available at: http://www.jaoa.org/cgi/content/full/105/10/442. Accessed March 21, 2006.

3. 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 March 21, 2006.

4. Packer EE. "Opportunities" for improvement [letter]. J Am Osteopath Assoc. 2005;105:443–444. Available at: http://www.jaoa.org/cgi/content/full/105/10/443-a. Accessed March 21, 2006.

5. Cain RA. Promoting active engagement with osteopathic principles and practice in interns and residents [letter]. J Am Osteopath Assoc. 2005;105:236–237. Available at: http://www.jaoa.org/cgi/content/full/105/5/236. Accessed March 21, 2006.

6. 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-a. Accessed March 21, 2006.

7. 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 March 21, 2006.

8. 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 March 21, 2006.

9. Clark RC, Smith AB. Osteopathic medical training: developing the seasoned osteopathic physician [letter]. J Am Osteopath Assoc. 2004;104:452–455. Available at: http://www.jaoa.org/cgi/content/full/104/11/452-a. Accessed March 21, 2006.

10. Hornbeck KL, Opipari MI. DO notes difference between residency programs [letter]. J Am Osteopath Assoc. 2004;104:367–368. Available at: http://www.jaoa.org/cgi/content/full/104/9/367. Accessed March 21, 2006.

11. Steier KJ, Opipari MI. In opposition to resolution 42 [letter]. J Am Osteopath Assoc. 2004;104:314–315. Available at: http://www.jaoa.org/cgi/content/full/104/8/314. Accessed March 21, 2006.

12. Smith AB, Opipari MI. Evaluating the rationale of the osteopathic internship [letter]. J Am Osteopath Assoc. 2004;104:230–231. Available at: http://www.jaoa.org/cgi/content/full/104/6/230. Accessed March 21, 2006.

13. 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.

14. The Historic Background of Osteopathic Medicine. The History of Osteopathic Medicine Virtual Museum Web site. Available at: http://history.aoa-net.org/Osteopathy/text.htm. Accessed March 21, 2006.

15. 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 March 21, 2006.

16. Sinay T. Cost structure of osteopathic hospitals and their local counterparts in the USA: are they any different? Soc Sci Med. 2005;60:1805 –1814.[Medline]

17. Barr P. Final farewell. Osteopathic Medical Center of Texas closes its doors. Mod Healthc.2004; 34:10 .[Medline]

18. Program requirements for graduate medical education in anesthesiology. Accreditation Council for Graduate Medical Education Web site. February 14, 2006. Available at: http://www.acgme.org/acWebsite/downloads/RRC_progReq/040pr708_TCC.pdf. Accessed April 7, 2006.

19. Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2002–2003. JAMA.2003; 290:1197 –1202.[Abstract/Free Full Text]

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