Osteopathic manipulative treatment use among family medicine residents in a teaching clinic

Methods

This was deemed to be a quality improvement project and exempt by the University of Michigan Health-West Institutional Review Board (IRB), thus no IRB number was assigned. The project did not require funding, and this was not a clinical trial that would require registry. The consent of study participants was implied by completion of the anonymous survey. Potential study participants were informed of the purpose of the study, the investigators involved, and the predicted duration prior to the surveys being made available.

A survey was conducted over three 2 week periods between the dates of April 2021 and June 2021 among 15 family practice residents, all of whom are in designated osteopathic recognition positions. This was done to ensure variability of resident involvement due to residents rotating on clinic-specific 4 week rotations. Surveys were completed by residents after each half-day in the clinic. Participation was optional. The surveys evaluated the total patient encounters for the session, encounters in which OMT was utilized, encounters in which the physician felt that OMT was appropriate, and reasoning for encounters in which OMT was not performed. The survey template can be found in Appendix A. The surveys were anonymous and placed in a closed box upon completion. These surveys were not previously validated but were developed solely for use in this study.

The data were collected and input into a spreadsheet by the investigators (JF, LZ). Simple calculations were completed based on that data (GC).

Results

A total of 101 survey responses were collected for a total of 304 patient encounters. The raw data on the encounters can be found in Table 1. The total number of encounters in which OMT was performed was 5/304 (1.6% of total encounters), and the number of encounters in which the provider felt that OMT would have been appropriate was 60/304 (19.7% of total encounters). Figure 1 includes a graphic representation of the previously mentioned data. The reason given for OMT not being performed was evaluated against the number of encounters in which OMT was felt to be appropriate, which can be found in Table 2. The highest reported reason that OMT was not performed was due to time restrictions, with the number of responses being 42/50 (70.0% of OMT-appropriate encounters). This was followed distantly by faculty staffing at 3/50 (5.0%), physician comfort at 2/50 (3.3%), patient comfort at 2/50 (3.3%), and finally room/OMT table availability at 1/50 (1.7%). There were several comments made in the “Other” category, which can be found in Table 3. These reasons varied and provided some additional insight into what was behind a decision to defer or not perform OMT.

Figure 1:

Graphic representation of survey responses with the frequency in which OMT was performed or felt to be appropriate shown as the percentages of total encounters.

Discussion

Our survey found that there is a significant discrepancy between the number of encounters that providers felt were appropriate for OMT and the number of encounters in which OMT was performed (19.7 vs. 1.6% respectively). By far, the most common reason OMT was not performed was due to time constraints (70.0%). The “Other” category and the answers in Table 3 ranged from provider-related deferment of treatment to patient choice.

The findings of this survey are consistent with a prior study showing that OMT is being performed on <5% of patient encounters in the outpatient setting [1]. It is also not surprising that time constraints were the top reason that OMT was deferred in our study. Frequently, our residents have told us that time was a reason that they were unable to address all patient concerns with the level of detail that we would prefer as physicians. This also correlated closely with findings among practicing physicians in the study by Healy et al. [5] Our residents have the advantage of supervising physicians versed in OMT integration in family medicine available during their continuity patient time, which correlated with a relatively low report of faculty staffing as a limiting factor at 5% (3/60). Future interventions will be able to be developed with the knowledge that time is the primary limitation in our residents’ utilization of OMT.

This study does have limitations. This is a study conducted by survey, so it was unable to be blinded. The residents were aware that the study was being performed. We attempted to limit any influence that the survey may have on the encounters by ensuring that the surveys were anonymous. Other limitations include the sample size of the study. We anticipated a sample size of 500 patient encounters, and the result was 304 encounters. Contributing factors include patient no-shows and residents not always completing a survey following a clinic session. Due to an initial low response volume, the original data gathering period of two 2 week periods was extended to a third 2 week period. Also, this study was based on self-reported data that could have resulted in recall error from the residents surveyed. Another potential bias is that in our residency program we have residents that focus additional time learning and performing osteopathic manipulation in preparation for a neuromusculoskeletal medicine fellowship. They generally perform OMT more frequently than the other family medicine residents. Finally, this study was performed during the spring of 2021, during the COVID-19 pandemic; therefore, the residents had integrated tele- or virtual visits during their half days and may have sought to limit close contact with patients if possible. The study design did not specifically ask if there were COVID-19–related factors that prevented residents from performing OMT.

The proposed next steps with this project will be for program faculty to introduce an intervention with the goal of increasing residents’ integration of OMT into their continuity patient care. We have opportunities to address both the concern for time as well as residents excluding 78.6% (239/304) of patients due to not considering them candidates for OMT. We did not ask details about the exclusion of patients as OMT candidates, but this is a potential area for further study. We have not yet involved other osteopathically recognized programs at our institution. If we are able to demonstrate improvement with an intervention among our own program, we would also seek to incorporate that intervention among other specialties.

Conclusions

The results of our survey, while not unexpected, are still significant. In a training program that has osteopathic recognition and pursues regular incorporation of OMT in practice, residents are performing significantly less OMT than they perceive to be warranted. This survey study may provide the background needed for changes to a residency curriculum to increase utilization of OMT by residents in the future.