Osteopathic manipulative treatment for the allopathic resident elective: does it change practice after graduation?

Methods

Resident physicians who graduated from the University of Minnesota North Memorial Family Medicine Residency from 2013 to 2019 were sent an email invitation in August 2020 to complete a Qualtrics survey regarding their comfort with caring for patients with back pain, including physical examination, creation of treatment plans, and OMT (Appendix A). The invitation email included the consent to participate in the study, and the responses to the survey were anonymous. The University of Minnesota Institutional Review Board (IRB) determined that the study met the criteria for exemption from IRB review. Financial support for survey distribution was provided through a University of Minnesota Department of Family Medicine and Community Health Education Support Grant.

Questions regarding comfort with performing a physical examination and performing OMT utilized a 0–100 scale (100 being completely comfortable). Frequency questions regarding performing OMT and referrals were categorized as weekly, monthly, less than monthly, and never.

This study was not powered to identify statistical significance, but a research staff member not involved with the residency program analyzed the data, including differences in demographics utilizing one-way analysis of variance (ANOVA) tests (continuous variables) and Pearson chi-square tests (binary and ordinal variables) to identify any areas of marginal significance.

Results

Among emailed graduates, 61.8% (42/68) completed the survey. The five osteopathic graduates who responded were removed from the data analysis. Of the remaining 37 respondents, 27 had completed the OMT for the allopathic elective rotation during their residency training (“elective participants”) and 10 had not (“control group”). See Table 1 for the year of graduation and survey responses.

Half (50.0%) of the control group provide OMT care with a comfort score of 22.6 on a 0–100 scale (100 being completely comfortable, SD 32.7) compared to 66.7% of the elective participants who had a comfort score of 34.0 (SD 21.0, p=0.091). Among the control group, 40.0% regularly refer to a DO provider, compared to 66.7% of the elective participants (p=0.257).

The mean comfort score for performing a physical examination on patients presenting with back pain was 78.7 (SD 13.1) and 80.9 (SD 19.3, p=0.198), and creating a treatment plan was 76.5 (SD 17.9) and 80.2 (SD 19.9, p=0.711), in the nonelective and elective groups respectively.

The most common barrier to OMT care identified was the limited number of DOs (62.2%). Other barriers identified included insurance coverage of OMT care (32.4%), transportation (18.9%), time (18.9%), and cost of OMT care (16.2%).

Discussion

Most allopathic residents have no exposure to osteopathic manipulative medicine as part of their medical education [5]. With exposure to osteopathic principles and OMT, there is an increased interest in learning more about performing OMT and how to apply it [5, 8], [9], [10], [11]. Successfully implemented OMT curriculum for allopathic residents have included both a 1-month [7] and longitudinal design [6]. At our site, the OMT for the Allopathic Resident Elective is 2 weeks in duration and includes required reading, individual hands-on learning with an osteopathic faculty member, and direct patient care including performing OMT with the supervision of an osteopathic physician. These experiences are supplemented with annual OMT for the MD didactic sessions, which include workshops on the treatment of low back pain, tension headaches, and pregnancy-related back and pelvic pain. Our findings that half (50.0%) of MDs who did not participate in the OMT elective continue to perform OMT in their practices speaks to the value that those residents gain from the didactic sessions.

Residents who completed the elective continue to perform OMT at a higher percentage (66.7 vs. 50.0%) with more self-reported comfort, demonstrating that even a short time spent with DOs may lead to a change in future practice. Although there may be a bias among the residents who participate in the OMT elective to provide OMT and refer to DOs, our findings are similar to previous findings stating that the most important curricular component impacting attitudes toward OMT was the ability to work with DO physicians [11]. Further evidence of this attitudinal effect is seen by the referrals of our graduates to DOs, with 66.7% of those who completed the elective regularly referring compared to 40.0% in the nonelective group. Our overall findings are similar to previous surveys that demonstrate that 54% of family physicians commonly recommend spinal manipulation to their patients [12].

Nonpharmacologic therapies are effective for low back pain, and spinal manipulation is among the first-line therapies recommended for patients with low back pain [13, 14]. The importance of educating allopathic residents on the benefits of osteopathic care is high, as only a quarter of allopathic students feel their undergraduate medical training in musculoskeletal education is adequate, causing reluctance to recommend unfamiliar treatments [15, 16]. Our OMT curriculum for the allopathic resident is not aimed at training MDs to perform OMT but rather to increase their ability to care for patients who present with low back pain. This is supported by our findings that our graduates score their comfort high with regard to performing a physical examination on a patient presenting with back pain (80.3%) and creating a treatment plan for these patients (79.2%). The comfort scores for performing OMT are much lower overall, yet those who completed the elective scored higher (34.7) compared to their nonelective peers (22.6).

Limitations in our study include a lack of formal evaluation of the OMT skills of the allopathic residents and that our findings are from one educational site. A further limitation of this study is the small sample size, because those who responded may be more biased toward osteopathic principles and thus responded to the survey request. Implementing standard evaluation tools, validating those at multiple training sites, and increasing the sample size of responses will be needed to generalize educational outcomes moving forward.

Prior to the merger of Accreditation Council for Graduate Medical Education (ACGME), American Osteopathic Association (AOA), and American Association of Colleges of Osteopathic Medicine (AACOM) into a single graduate medical education accreditation system for residency and fellowship programs in the United States, Family Medicine residents at AOA programs identified AOA accreditation as a strength of their programs [17]. Further, program directors at AOA/ACGME programs perceived that the academic and clinical preparation of their DO residents higher than the program directors at ACGME programs [18]. Recent trends demonstrate that DO residents will outnumber MDs and International Medical Graduates in ACGME Family Medicine residency programs in the future [19]. One could argue that this will make training of MDs in OMT unnecessary, yet a recent article illuminated that OMT was only performed on 1.6% of clinical encounters at an Osteopathic Recognized Family Medicine training clinic, while the clinicians perceived that OMT would be appropriate in 19.7% of the encounters [20]. There is much work to be done moving forward to make OMT a more valued and utilized tool within our residency training programs, and exposing our allopathic colleagues is a step in that direction.

Conclusions

Allopathic Family Medicine residents who completed an elective rotation in OMT have a slight increase in the frequency of referring to DOs after graduating. They also have a meaningful increase in comfort performing OMT on their patients who present with back pain when compared to peers who do not complete an OMT elective rotation. With the limited number of DOs being a common barrier to OMT care, more widely implemented training in OMT for allopathic Family Medicine residents may be a reasonable intervention to improve the care of patients presenting with back pain. Residency programs can utilize curriculum developed at other sites for integration of OMT training locally.