Title: A Review of Osteopathic Practice and Principles Graduate Medical Education
Authors: Priya McBride, MA, OMSII; Jennifer Weaver, MA; Russell Maier, MD, FAAFP
Introduction
Although osteopathic manipulative medicine (OMM) is a large part of pre-clinical education for osteopathic medical students, and a defining feature of osteopathic medicine, it is sparingly practiced in clinic. According to a landmark study by Johnson, Kurtz, and Kurtz, the decline in OMT in practice, is in part due to a de-emphasis of OMT training in graduate medical education (GME). Although opportunities to pursue OPP GME (OGME) are predicted to increase with the introduction of additional Osteopathic Recognition (OR) Accreditation Council for Graduate Medical Education (GME) residencies and colleges of osteopathic medicine (COM), there is no comprehensive review of current OPP GME programs. The goal of the present literature review was to summarize the current OGME research and to inform the future of OGME research.
Methods
The literature review is comprised of peer-reviewed journal articles from CINAHL, Google Scholar, PubMed, and TripPro. Keywords, such as “continuing medical education”, “graduate medical education”, “osteopathic medicine”, “osteopathic manipulative medicine”, “osteopathic practice and principles”, and “osteopathic manipulative treatment”, were used to search the listed databases. Based on their alignment to the above keywords, twenty-five relevant journal articles were identified by the authors to review, and the journal articles to specifically evaluate OGME programs were summarized in the literature review.
Results
In the literature, allopathic and osteopathic healthcare professionals are surveyed on the value of OGME to medicine. In addition, the studies in the literature review critique OMM/OMT training(s) offered to both DO and MD residents.
There are multiple trends in previous OPP GME research. First, the structure of OGME typically consists of both hands-on OMT laboratory work and lecture, and the structure is generally well received by attendees. The ability to learn OMT is valued by both DO and MD residents, and DO mentorship is crucial to encourage DO physicians to continue to practice OMT.
Discussion
It is clear OGME is important to the future of osteopathic medicine, however, the conclusions of current OGME research are not generalizable due to small sample sizes. Instead, a majority of the research is specific to certain institutions. Further research on OGME may want to focus on the long-term impact of OMT/OPP curriculum in residency programs, and the increase or decrease of OMT use by physicians after completion of OGME programs.
Thank you for this presentation, Student Dr. McBride. I have been assigned as one of the judges for this project. In your review of the literature, did you come to any conclusions about what GME programs can do to increase the likelihood of using OMT in practice? Thanks again!
Thank you for the question, Dr. Briggs-Early. Based on the literature review there are a number of barriers to practicing OMT including, limitations of time and space in the clinic to perform OMT. Also, there is a self-reported lack of confidence of physicians to perform OMT. For example, one of the studies I referenced noted 22% of 1,055 physicians reported a lack of confidence in their OMT skills, leading them to forego opportunities to practice it in clinic. Based on the desire of physicians to build confidence in their OMT skills prior to practicing OMT, and number of studies I read looked at components of OMT/OPP curriculum necessary to learn OMT, and, subsequently, to encourage its use in practice. A number of DO residents stated it is important to them to work with DO faculty, to learn to integrate OMT in clinic settings, to learn to bill and code for OMT, and to maintain/practice OMT skills.
Consequently, role modeling by DO mentors on how to incorporate OMT in practice and the continued integration of OMT/OPP curriculum in residency programs to maintain OMT skills was concluded to help increase the likelihood of using OMT in practice. Specifically, directors of residency programs are encouraged to apply for osteopathic recognition (OR) to ensure DO mentors are available to DO residents to demonstrate their use of OMT in clinic.
Thank you for taking the time to listen to my presentation and for your thoughtful question.
Ok great, thank you for this thoughtful and thorough response!
Thanks for this presentation, I am one of your judges. I’m wondering if you found any information as to what types of OGME programs would be valued most by physicians and at what stage of training are they most likely to engage in these activities.
Thank you for the question, Dr. Mapes. Based on the research I reviewed, OGME programs appear to mainly train attendees on the treatment of primary care complaints, such as somatic dysfunctions of the back and neck. For example, in the WVSOM study I referenced, the workshops focused on the diagnosis and treatment of acute arm and neck pain, chest pain, headache, and low back pain. Each of the workshops included a discussion of somatic dysfunctions and OMT techniques relevant to the topics, followed by a hands-on OMT laboratory, taught by graduate teaching assistants and/or OPP faculty. Similar to WVSOM, other OGME programs in literature appear to follow the design of offering OPP/OMT didactics followed by hands-on OMT trainings, and the programs are seen to be of value to those who attend.
Interesting, DO residents at Warren Alpert Medical School of Brown University elected to design an OMM/OMT clinic staffed by allopathic and osteopathic residents to promote OPP curriculum in residency. The residents at Brown University were scheduled to work the clinic twice a month. In addition to the clinic, the DO residents created an osteopathic medicine interest group. The group met primarily to present cases to each other. After the presentation of a case, residents were invited to share their approaches to the patient, including OMT likely to be performed. In evaluations of the Brown University OGME curriculum, the strengths of the program centered on the OMT clinic. Specifically, residents were able to maintain OMT skills, the clinic was a benefit to patients, and the clinic allowed OMM to be integrated in the residency program.
Consequently, it is concluded the types of OGME programs to be of value to physicians are programs that incorporate hands-on OMT practice, allowing physicians in training the opportunity to continue to develop their OMT skills.
Based on the literature review, OGME programs are largely offered to and/or mandatory for first- and second-year residents. Although, the WVSOM program was also open to preceptors, and optionally to third and fourth year medical students, the majority of attendees were residents. I think based on the literature review the opportune time to offer OMT trainings is in the first and second years of residency, when physicians no longer exposed to daily OPP curriculum, are influenced by their DO and MD attendings, and are starting to mold what their practice is going to look like.
Thank you for taking the time to listen to my presentation and for your thoughtful question.
Thank you for your presentation. I am one of your judges. What criteria were used to choose the 11 included articles?
Thank you for the question, Dr. Walser. Because the literature review was completed in partnership with the PNWU Office of Graduate Medical Education, I wanted to include articles in the review that would be able to inform the current work by the Office of GME. In the past, PNWU’s Office of GME hosted OPP workshops and used pre- and post- surveys to assess the efficacy of their workshop to improve OMT knowledge. Based on the design of the OMT workshops at PNWU, I narrowed down the 25 peer-reviewed journal articles I found (using the search criteria mentioned in the presentation) to 11 studies that included survey data. Overall, there is, unfortunately, not a lot of research on OGME, however, I think the gap in literature offers PNWU’s OGME Department the opportunity to contribute largely to this field of research.
Thank you for taking the time to listen to my presentation and for your thoughtful question.