Do osteopathic medical students maintain their osteopathic identity in a dually accredited training hospital system?

Ronald P. Januchowski, DO, Edward Via Col- lege of Osteopathic Medicine, 350 Howard Street, Spartanburg, SC 29303.

E-mail address: rjanuchowski@vcom.edu.

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Given the unprecedented growth of the osteopathic pro- fession in the past few decades, osteopathic clinical educa- tion and graduate medical education has been referred to by many terms including “a predicament,” “a quagmire,” and “a challenge.”1 Maintaining a unique osteopathic profes- sional identity during the clinical training years has been difficult given the multiple political and bureaucratic hurdles placed on the system. The importance of maintaining this uniqueness has been stressed in the literature, and pro- grams have been developed to try to attain this goal.2

To maintain the osteopathic uniqueness during under- graduate training, one needs to know what defines the dis- tinctive nature of osteopathic physicians. The 4 basic tenets of Osteopathic Medicine are: (1) The body is a unit; the person is a unit of body, mind, and spirit; (2) the body is capable of self-regulation, self-healing, and health maintenance; (3) structure and function are reciprocally interre- lated; and (4) rational treatment is based on an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function.3 These tenets mirror much of the current concepts of primary care med- icine, and it can be difficult to measure whether a trainee is meeting these tenets. One of the most identifiable features of osteopathic medicine is the use of osteopathic manipulative treatment (OMT). Although not all encompassing of the definition of an osteopathic physician, OMT is seen by some as one of the core tenets of osteopathic medicine.4 Limita- tions in training opportunities for OMT are cited by students as being a factor of its diminished use by graduates from osteopathic medical schools.

It is estimated that there will be more than 5000 gradu- ates from osteopathic medical schools in the 2016 academic year.5 Given this number, this would translate to more than 10,000 medical students requiring clinical rotation positions for their third and fourth years of school. With the growth of osteopathic medical schools in the past few decades, clinical training sites for students have grown to try to meet the demand. A recent survey by the American Association of Colleges of Osteopathic Medicine of its members indicated that the availability of clinical training sites was a cause for concern.5 Because of the limited clinical training sites, many schools are setting up training sites in facilities where there are few to no DO faculty physicians available as preceptors. Other sites are at facilities with residency pro- grams accredited by both the American Osteopathic Asso- ciation and the Accreditation Council for Graduate Medical Education, so-called “dually” accredited sites.

Integration of osteopathic medical students into allo- pathic or dually accredited training sites has been sparsely written about in the literature and there are no studies that garner students’ attitudes or perceptions about the mainte- nance of the osteopathic principles and practices, which define the osteopathic profession.

In this study, we wanted to determine whether students in osteopathic schools who train in a dually accredited hospital maintain their unique identity with respect to the 4 tenets of osteopathic medicine. We also sought to better delineate students’ feelings about sustaining their osteopathic unique- ness and the ability of a system to better meet the needs of these osteopathic students.

‌Methods

‌Study setting and population

This was a prospective qualitative study and there were no racial or ethnic limitations for participation.

Spartanburg Regional Medical Center (SRMC) is affili- ated with the University of Pikeville–Kentucky College of Osteopathic Medicine, the Edward Via College of Osteo- pathic Medicine, and the Georgia Campus of the Philadel- phia College of Osteopathic Medicine. As such, 9-11 stu- dents are accepted in their third year of school for 2 years of

their core clinical clerkship training. In addition, students in their fourth year of medical school come to SRMC for elective rotations in Family Medicine from osteopathic schools across the country. On average there are 7-10 os- teopathic medical students on elective rotation in any given month.

Spartanburg Family Medicine Residency Program is du- ally accredited by the Accreditation Council for Graduate Medical Education (ACGME) and the American Osteo- pathic Association (AOA). There is a blend of graduates with Doctor of Medicine (MD) and Doctor of Osteopathic Medicine (DO) degrees in the program that work closely with the osteopathic students during their time in the pro- gram. The majority of the teaching faculty as well as the hospital physicians are MDs; however, one third of the Family Medicine residents, with whom the students closely work, are DOs.

‌Study protocol

We invited all third- and fourth-year osteopathic medical students to voluntarily participate in monthly focus groups. The purpose of the discussion was explained and partici- pants were assured that all comments would remain anon- ymous to anyone other than the moderator. We also assured the students that comments made would not be part of any future assessments of their performance. After giving their written informed consent, participants were assigned a num- ber by which their comments would later be identified. This number was random and did not carry forward if the student participated in a future group. The same moderator con- ducted the focus group meetings using open-ended instigat- ing questions each month. The moderator had leeway to follow the discussion pattern as students directed and did not have scripted questions to ask. Discussions were audio- recorded and transcribed by a third party. The moderator also took notes during the discussion to supplement the transcriptions. See Table 1 for initial interview guide ques- tions.

Two of the investigators independently reviewed the transcripts, and a coding framework was derived using grounded theory methods.6 Specifically, the narrative text was broken up into individual ideas or themes. The codes were compared, any discrepancies resolved, and the codes combined into a final code. The transcripts were then re- coded using the final code. A repeated mention of the same idea by the same participant during a single context was counted only once. A sample population was coded by a third independent reviewer, which allowed for concurrence in data abstraction and theme development.

‌Data analysis

The number of occurrences in the transcripts for each general theme was determined to estimate the importance of the idea among the students. They were arranged in de- scending order of popularity and tabulated.

1. What are your thoughts on the tenets of osteopathic medicine?

   1. How did the tenets of osteopathic medicine influence you to choosing osteopathic medicine as a career?

   2. What were your expectations for training before coming here?

   3. What do you feel makes a “good” osteopathic physician?

2. How do you feel that your experience here has influenced your identity as an osteopathic physician in training?

   1. What are your thoughts on what makes a training site “good”?

   2. Do you feel that this training site met the needs of an osteopathic medical student?

   3. Did you feel comfortable using your DO skills in the current rotation?

3. As an osteopathic medical student, how do you feel your identity is different (or the same) as an allopathic medical student?

   1. What are your expectations of how your DO skills work in a system along with your MD colleagues?

supervisor comfort. The basis of these themes was analyzed by each of the reviewers providing a ranking of each of the themes based on each mention of the theme in the tran- scripts. Table 1 outlines the ranking of each of the themes along with the text fragments used to develop the themes. Listed next are the top 3 themes mentioned by students with salient points, both positive and negative, for those themes.

‌Teamwork

‌Results

Fourteen students completed the focus group discussions and mentioned 6 main themes in the transcriptions that they felt related to maintenance of their osteopathic identity. The themes that correlated between the reviewers were support- ive, opportunities, teamwork, holistic, time constraints, and

Teamwork was the theme mentioned most frequently in the transcripts. Some of the students focused on the positive nature of teamwork in maintaining osteopathic identity (Ta- ble 2).

I see that maybe we have a different roll to fill, that we have something else in our toolbox that we can contribute. That we can teach other physicians and medical deliverers these skills and share that perspective. Goes back to that whole teamwork thing.

Being part of the larger team highlighted positive differ- ences for some.

That I think I recognize that there are two perspectives on delivering medicine and gives me more opportunity to learn from different people with a different point of view. That’s nice.

The teamwork theme also had some neutral or negative effects on the osteopathic identity.

As part of the team, even identity wise—I mean, I can’t speak for everyone— but even I don’t identify myself as [an] osteopathic medical student versus a medical student.

‌Opportunities

The students identified that exposure to excellent training opportunities with both MDs and DOs would expand their breadth as osteopathic physicians. They focused on their ability to have hands-on time to practice the principles of osteopathic medicine and implement the tenets taught to them in the classroom to include osteopathic manipulative medicine (OMM) skills.

Such as a couple of weeks ago, I was able to use Spencer’s technique, which is [a] shoulder manipulation technique for someone who complained of shoulder pain. And because my attending was a DO, he was willing for me to do it.

The opportunity for a student to be the teacher was part of the learning experience. Although the students worked with their MD colleagues, their role was that of educators of osteopathic medicine, thereby strengthening their osteo- pathic identity.

I was with an intern, who was an MD, and she actually consulted me on the problem. We went back and saw the patient and I worked on the patient for a little while and actually got to teach her something. She was very receptive. I haven’t worked with her in quite some time but she probably uses that now, just from the way she was talking to me about it. So that to me kind of helps me keep my identity that as an osteopathic physician, that people are asking me questions about something I learned that they didn’t have the opportunity to learn. And the fact that, I know that osteopathy, manipulations and those things, are a lot of times used in the clinic, but this was not in the clinic, it was in the hospital, so there are opportunities to use some of the things we’ve learned other places than clinic.

‌Supervisor comfort

The role of the supervising physician was the third top theme recognized in the groups. This was seen as a positive theme in many of the participants’ comments.

I think they are getting more comfortable. We do the noon conferences once a month. They do the OMM conference and we just had one last week. Most of the MD students and residents were up here learning and were like “that’s all you have to do. Oh that’s all it is.” And they get more com- fortable when they see it and they are like “I can do it too, that’s not a big deal” . . . once they see it . . . and it will take time . . . but they are doing it. They are integrating it in. At noon conference, the MD residents get a chance to see what we are doing so they are not really scared of it or they are not really timid. We do it on them and they say “oh that does feel better, oh that does make a difference.”

I haven’t run across any situation where I wouldn’t feel comfortable and I’m always supervised. Every time I’ve performed OMT, I’ve been supervised by a DO who was able to show me pointers and stuff I hadn’t seen or tech-

niques I haven’t seen. So it was a good learning experience and so I felt comfortable.

It was also seen as a negative theme when the supervisor had a lack of comfort with OMT or time.

It takes, like, just getting comfortable in the situation. To, like, take the time to know how much time you need. You don’t want to, like, be late for somebody who’s above you and make them late for the person above them. We don’t want to make everybody else late.

I think our DO skills are limited when we are with an MD resident because if we ask them if it is okay for us to do a certain technique with them not having that knowledge, or that level of comfort, with that technique, they will not allow us to do it because they do not know what we are doing.

‌Conclusions

Osteopathic medical students have many opportunities to train in various locations across the country. In hospitals associated with large academic medical centers, however, maintaining the osteopathic uniqueness in the third and fourth years can be a challenge.7 Given the results of our study, we believe that osteopathic medical students can maintain their unique identity while training in a dually accredited system, even with a majority of MD physicians as preceptors. Providing an environment in which teamwork is encouraged and opportunities for OMM are recognized and supported will aid in maintaining the osteopathic cul- tural identity. Introducing MD preceptors to the tenets of osteopathic medicine, and involving them in OMM work- shops may increase their comfort level in supervising os- teopathic medical students during their clinical clerkships. There are limitations to this study. First, the small num- ber of students interviewed may not represent the opinions of osteopathic students across the country. Only 2 schools were represented by the interviewees. Second, the majority of osteopathic clinical training takes place in community- based hospitals.7 Indeed our study was performed in a community-teaching hospital as opposed to a large aca- demic medical center. This may have affected our results because large academic institutions are usually affiliated with allopathic medical schools whose philosophy differs from the osteopathic tradition. A national survey, based on our findings, would help address this question. Also, stu- dents may have participated in more than one discussion group. This may have led to bias, but we feel this bias would have been minimal given the open-ended nature of the

discussion as directed by the moderator.

The osteopathic medical students that were interviewed seemed to define their osteopathic uniqueness in regards to their ability to do OMT. There was some mention of the tenets of osteopathic medicine sparingly mentioned in the interviews. Given the way students defined their unique-

ness, it is possible for osteopathic medical students to main- tain their unique identity in a dually accredited training hospital system. As described in our study, students have certain feelings of the “right” educational experience they receive. We believe that a dually accredited system high- lights differences in osteopathic and allopathic training but can also serve to unite the medical profession into a com- mon goal-oriented process. As one author so aptly stated, “You don’t have to be a DO to embrace the osteopathic philosophy—you just need a willingness to consider it.”8

‌References

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