Perceived Value of Osteopathic Recognition

Osteopathic Recognition (OR), as a designation of the Accreditation Council for Graduate Medical Education (ACGME), commits accredited programs to teach and assess osteopathic principles and practice at the graduate medical education level.¹ OR allows doctor of osteopathic medicine (DO) opportunities to maintain osteopathic distinctiveness² and allopathic residents and faculty to gain new diagnostic and treatment skills. In July of 2020 the ACGME became the sole accrediting body for US residency programs, including programs formerly accredited by the American Osteopathic Association (AOA).³ Over the past 20 years accreditation has transitioned from dual accreditation in 1999 to a single accreditation. ⁴ Recent commentary in Family Medicine highlighted the importance of incorporating osteopathic training in family medicine,⁵ yet little is published on the difficulty of attaining or the value of OR. The only survey of family medicine PDs regarding OR was conducted in 2015.⁶ The importance of osteopathic trainees to family medicine is clear from the 2021 match results: of 4,493 medical students and graduates matched to family medicine residency programs, 36% (1,623) were US allopathic medical school (MD) seniors and 32% (1,443) were osteopathic medical school (DO) seniors.⁷ This compares to 21% of family medicine positions filled by DOs in 2016.⁸

Our study aimed to assess program directors’ perception of difficulty in obtaining OR and its perceived value for programs with, considering, or reporting no interest in OR accreditation.

The study questions were part of a larger survey conducted by the Council of Academic Family Medicine Educational Research Alliance (CERA) and the American Academy of Family Physicians Institutional Review Board approved them in 2020. The methodology of the CERA Program Director Survey is described elsewhere in detail.⁹ We collected data from September 23, 2020 to October 16, 2020. Following 14 demographic questions, 37 questions were asked on five topics (pediatrics in FM, racial justice, social determinants of health, COVID disruption of training, and Osteopathic Recognition). The 312 returned surveys resulted in an overall response rate of 50.0% (312/624). For the OR questions, 89.7% (280/312) of the responding PDs provided answers for an effective response rate of 44.8% (280/624).

As with previous CERA program director surveys, ¹⁰ the respondents appear to be representative of US family medicine PDs. Of particular importance to the topic of osteopathic training, the percentage of programs in our sample with OR is similar to that reported by ACGME among FM programs. ¹¹

Of 280 PD respondents, 30.4% (85/280) were not considering applying for OR; 24.6% (69/280) had OR status; 45.0% (126/280) expressed interest in applying (3.6% had applications pending, 10% were considering applying, and 31.4% would apply if resources were available). As shown in Table 1, of 73 PDs who had experience applying for OR, in responses to the question “how smooth was the transition to the new ACGME process for Osteopathic Recognition?”, 28 (38.4%) found it “very smooth,” 30 (41.0%) found it “a little bumpy,” while 28 (38.4%) found it “very smooth,” and 15 (20.5%) found it “very bumpy.”

Perceptions of PDs on the value of OR status and Osteopathic Principles and Practice (OPP) are displayed in Table 2, with significant differences found between those with OR status, with interest in OR, or with no interest. PDs found value in OR for recruiting residents. Value of OPP was also reported for both instruction and patient care. For example, in answer to value in “enhancing patient satisfaction and fostering health promotion,” 87.0% (60/69) of programs with OR felt OPP was “somewhat or very valuable” compared to 77.0% (97/126) expressing interest in OR, and 44.7% (38/85) of programs not considering OR.

The impact of the single accreditation process that has unified ACGME and AOA family medicine programs has yet to be fully explored. In a 2017 health policy commentary Ahmed et al reflected on the need to document these future changes in the profession.¹² A recently published study in Family Medicine reported on the growing proportion of DO residents.¹³

Working with programs considering OR, the authors have frequently been asked about the value of OR. In this study we asked questions related to its value as well as a question about the difficulty in attaining OR status. We found that a majority of program directors with or considering OR perceived value in having OR for recruiting osteopathic medical students. A significant number of PDs with OR or an interest in OR also found the distinction valuable for recruiting allopathic graduates. Interestingly, regardless of OR status or interest, PDs reported that including osteopathic practice in their residency clinic was valuable for instruction and for patient care. With the number of family medicine programs increasing, there are proportionally fewer MD graduates of US schools per family medicine program. OR and OPP instruction may be of particular importance as the specialty looks to place graduates into rural areas, where historically many DOs practice.¹⁴

The limitations of this study include a 45.0% response rate among programs and not all recipients answered all questions, however this is similar to most other published CERA PD studies. In this study we were unable to distinguish programs that were previously (1) AOA only, (2) dually approved by AOA and ACGME, or (3) ACGME programs that did not have AOA accreditation and now have sought OR. Therefore, conclusions cannot be drawn about a relationship between previous accreditation and challenges in achieving OR. In our sample only 73 PDs answered our OR accreditation difficulty question. Survey questions regarding value for instruction and patient care referred to osteopathic principles and practice rather than the OR designation itself. Lastly, the CERA format essentially excludes asking qualitative questions, a limitation when assessing perceptions of value.

Responding program directors perceive value in OR status for recruiting osteopathic students as well as value in osteopathic principles and practice for patient care. PDs reporting on the process of applying for OR largely found it to be without many bumps, yet a large number of programs that have an interest in OR have yet to apply. While the term “bumpy” is nonspecific and awkward, in pretesting we found that term to be commonly used by PDs. Further research is needed to explore whether this refers to achieving OR status or to the accreditation administrative process or both. Research is also needed to further quantify the value of OR status and OPP as well as to understand the impact of unified GME accreditation on osteopathic distinctiveness. In our study three-fourths of family medicine programs have obtained or are considering OR accreditation. With increasing numbers of osteopathic medical students entering family medicine residency and increased MD resident exposure to osteopathic principles and practice in OR programs, what changes will we see in the perceived value of OR? Our findings may provide reference points for further study regarding the value versus cost of OR and of OPP instruction and their impact on the culture of family medicine.