The impact of osteopathic recognition on multiple medical specialty residencies in a university-based setting

Methods

Results

In total, 38.3 % (18/47) of residents completed the presurvey and postsurvey, while 51.1 % (24/47) completed the presurvey. The residents who only completed the presurvey were excluded from further analysis. None of the residents only completed the postsurvey. Half (50.0 %) of the residents were PGY1 (9/18), and the other half (50 %) were senior residents PGY2 (6/18, 33.3 %) and PGY3 (3/18, 16.7 %). IM residents represented 55.6 % (10/18) of the cohort, but there was fair representation from IM/Peds with 27.3 % (5/18) respondents and FM respondents at 16.7 % (3/18). Before residency, 33.3 % (6/18) of respondents had no experience with OMT. The prior month, 38.9 % (7/18) of respondents performed no OMM. In the postsurvey, 16.7 % (3/18) did not perform OMM in the prior month. In addition, 72.2 % (13/18) of the respondents plan to utilize OMT in their clinical practice after graduation; see Table 1 for complete data and Table 2 for statistical analysis related to this section.

Improvement in confidence was noted across all five areas within the OMM category (Figure 1, Table 2). Osteopathic Principles (Q1, p=0.0036) observed a significant difference in confidence. The Osteopathic Structural Exam (Q2, p=0.1425) and Osteopathic Treatment Plan (Q3, p=0.0635). There is a bimodal distribution regarding the Osteopathic Structural Exam, but overall, the median score increased. Regarding the Osteopathic Treatment Plan, the reported confidence was generally higher. The Indications/Contraindications to OMT in the presurvey question saw an almost even distribution in reported confidence levels. In the postsurvey, the reported confidence narrowed in distribution with an increase in overall median confidence that was not statistically significant (Q4, p=0.3557). The Documentation of Somatic Dysfunction area showed a widening distribution of responses between the presurvey and postsurvey. The median confidence increased but was insignificant (Q10, p=0.779).

Figure 1:

Comparison of the five survey questions in the osteopathic manipulative medicine (OMM) category. Black dots represent individual responses. Dashed lines represent changes between presurvey and postsurvey for each individual. The presurvey is colored red, and the postsurvey is colored blue. The median is noted as the horizontal line within each boxplot. The vertical lines represent the range of data for each survey question.

The Evidence-Based Medicine (Figure 2, Table 2) category showed improvement in confidence across all three areas assessed. The data points in the confidence of Understanding Evidence-Based Medicine showed a narrower spread with a higher median that was not significant (Figure 2, Q5, p=0.1353). There was a widening of data points with a significant difference in confidence regarding completing a Literature Review of OMM (Figure 2, Q6, p=0.02888). For Incorporating OMM Literature into Practice, there was some increase in the spread to higher confidence levels with a minor increase in the median that was not statistically different (Figure 2, Q7, p=0.4023).

Figure 2:

Comparison of the three survey questions in the evidence-based medicine category. Black dots represent individual responses. Dashed lines represent changes between presurvey and postsurvey for each individual. The presurvey is colored red, and the postsurvey is colored blue. The median is noted as the horizontal line within each boxplot. The vertical lines represent the range of data for each survey question.

The Healthcare Delivery category (Figure 3, Table 2) showed variable changes across the areas surveyed. The Shared Decision-Making area showed a widening distribution of points to higher confidence between the presurvey and postsurveys. However, the change was not significant (Figure 3, Q8, p=0.613). The Cost-Effective Care area had a narrowing distribution of data points in the postsurvey compared to the presurvey. The median was relatively unchanged and was not significant (Figure 3 Q9, p=0.5459). The Recognition of Care Barriers area also showed a narrowing in the points’ distribution to higher confidence levels compared to the presurveys and postsurveys. However, the median was unchanged and not significant (Figure 3, Q11, p=0.6264). Regarding the area of Patient Perception to Touch, there was also a narrowing of the distribution of data points to higher levels of confidence between the presurvey and postsurvey. There was a median increase in confidence (Figure 3, Q12, p=0.07415). The distribution widened but remained at lower confidence regarding the End of Life Care. The median confidence was higher in the postsurvey than in the presurvey but was not significant (Figure 3, Q13, p=0.4538).

Figure 3:

Comparison of the five survey questions in the healthcare delivery category. Black dots represent individual responses. Dashed lines represent changes between presurvey and postsurvey for each individual. The presurvey is colored red, and the postsurvey is colored blue. The median is noted as the horizontal line within each boxplot. The vertical lines represent the range of data for each survey question.

An identical short quiz was administered presurvey and postsurvey to assess content knowledge attainment. In the presurvey quiz, 33.3 % (6/18) of residents scored at or below a 60 %. On the postsurvey quiz, 11.1 % (2/18) of residents scored at or below 60 %. The mean quiz scores improved, presurvey quiz (mean=3.67, standard deviation [SD]= 1.14) and postsurvey quiz (mean=4.22, SD=0.65), which was significant (p=0.0313, Wilcoxon signed-rank test).

Discussion

Previous studies have identified a widespread interest in manual medicine with less desire for ongoing instruction [13]. This OR curriculum is voluntary and provides instruction to residents who are interested in learning osteopathic principles. Additionally, research has identified that residents value osteopathic mentors and that the presence of a mentor will likely carry forward the practice of osteopathic principles postresidency [14]. Residents who completed postgraduate training have more positive attitudes toward OMT and are likelier to perform or refer patients for OMT [15]. Any OR curriculum must be accessible to a wide breadth of experience for DOs with formal training in medical school and MDs interested in learning manual medicine. MD residents have stated an interest in learning OMT skills [10]. A study in a pediatric center identified that 58 % of MD residents were interested in learning more about OMT and that residents within OR significantly positively impacted osteopathic perception and practice [11]. Several studies have implemented an osteopathic curriculum for MD residents [7], 11], 16], which improved interest and attitudes toward osteopathic practice. The attitudes of allopathic and osteopathic residents about OMT [9], 13], 14] were assessed, and it was identified that attitudes can be improved with a formal curriculum. Collectively, these studies highlight an improvement in attitudes toward osteopathic practice with the utilization of a formal curriculum and identify increasing interest among allopathic practitioners in learning more about osteopathic principles.

The OR program described here has significantly impacted residents’ understanding of OMT and the belief that OMT is a robust treatment strategy. The survey uniquely implemented the Likert scale to assess resident confidence for level 1 and level 2 osteopathic milestones. The OMM category was found to have the most overall change in confidence, with significant improvement in knowledge of Osteopathic Principles and gains in the Osteopathic Structural Exam and Osteopathic Treatment Plan. Gains in confidence in Osteopathic Principles have been seen in similar studies [8]. Interestingly, there is a bimodal distribution in the Osteopathic Structural Exam, suggesting that survey respondents either felt confident or not confident in performing a structural examination. A further direction for the curriculum could be to continue and refine Osteopathic Structural Exam techniques in the didactic sessions. The study did not observe significant improvement in confidence in the knowledge of Indications and Contraindications to OMT covered in the didactic sessions. Documentation of Somatic Dysfunction did not change either, but this could be because a defined template is utilized in the electronic medical record, which residents are made aware of during orientation. The widening distribution into higher confidence levels shows that some residents improved in confidence. Still, it is difficult to discern if the presurvey confidence was impacted by prior knowledge of the electronic medical record template that residents routinely utilize in practice.

The Evidence-Based Medicine category showed statistically significant increased confidence in performing a literature review related to OMM, likely due to the incorporation of resident-run didactics and the need to complete a literature review to present those didactics. The Understanding of Evidence-Based Medicine did show a higher confidence levels among participants. Evidence-based medicine topics are taught outside the OR curriculum, which may have impacted survey respondents’ confidence. There were no substantial differences in incorporating OMM literature into practice. The curriculum could be enhanced by further incorporating evidence-based medicine practice into the curriculum, which could include formal instruction on conducting a literature review, appraisal of a research study, and incorporation of results of a study into practice.

The category of Healthcare Delivery represented five areas that, for the most part, were taught within the respective curriculum of each residency as opposed to topics directly in the OR didactics. Interestingly, one of the areas, the Patient Perception of Touch, did show a narrowing of the distribution of data points to a higher level of confidence overall. This finding agrees with previous studies that osteopathic medicine makes one more comfortable with touch and interaction with patients [17]. The other areas in the category of Healthcare Delivery included Shared Decision Making, Cost-Effective Care, Recognition of Care Barriers, and End of Life Care, which represents avenues for further curriculum development.

The cohort in this study was mixed, containing both allopathic and osteopathic residents with varying degrees of experience before enrollment. Degree designation was not collected in the surveys, which would have been an interesting data point as allopathic residents can gain knowledge and confidence in OMT principles with training [16]. It would have been interesting to compare the attitudes of allopathic and osteopathic residents about OMT. Future studies should also quantify resident participation in attendance and look at the effect of OR on the education of MD and DO residents. The respondents represent residents at various stages of training and medical specialty. We are one of the first studies to present data from a medicine and medicine-pediatrics cohort, representing 83.3 % of the respondents (15/18). One-third (33.3 %) of the respondents had no experience with OMT, and 38.9 % (7/18) had not performed OMT over the previous month. Overall, OMM is positively perceived by the respondents, with 72.2 % (13/18) planning to utilize the skillset that they are developing in clinical practice postresidency. As the curriculum is further refined, it is essential that residents in an OR curriculum routinely perform OMT and build confidence in osteopathic practice, both of which should be central to any OR curriculum. OR programs bridge the gap between MD and DO residents, offering distinct advantages for both resident groups. OR improves residents’ understanding of OMM, OMT, and treatment plan development. This study suggests that OR may even enhance their comfort with patient interaction based on survey feedback. OR provides a supportive environment for DO residents to refine their OMT skills and practice alongside MD colleagues. This collaborative learning fosters a mutual understanding and potentially influences MD perspectives on OMT’s value, paving the way for a more integrated approach to patient care.

This study has several limitations that affect the generalizability of its findings and call for further research. The small sample size and low response rate limit the generalization of these results to a broader population. Given the sample size, our study was powered to detect a large effect size, or variables that have a large magnitude of difference. A larger sample size would power the study to detect small effects, which may not have been appreciated in this study. Additionally, the study did not distinguish between MD and DO residents’ experiences within the program. Because DOs likely have a stronger foundation in OMT, analyzing the data by primary training would provide a more nuanced understanding of the curriculum’s impact. Furthermore, the absence of a control group from a residency program without OR makes it challenging to isolate the specific effects of the OR curriculum. Residents’ improvements might be due to general residency training rather than the OR program. Incorporating the Clinical Osteopathic Recognition Training Exam (CORTEx), a formative standardized test, might provide further insight into gains in knowledge as participants progress through the curriculum. There is no standardized assessment tool that assesses the OR curriculum’s effectiveness in achieving ORMP milestones. Future research should ensure that the chosen survey instruments are validated for reliability and accuracy in measuring the desired outcomes. Finally, the single-center design limits generalizability because resident experiences and program structures might vary across institutions. Future studies with a larger, more diverse sample, consideration of primary training, a control group, validated surveys, and a multicenter design, are needed to strengthen the understanding of the OR curriculum’s impact on resident education and future practice.

Conclusions

This study shows that OR can enhance the knowledge of resident physicians on OPP. Overall, improvements were seen in confidence, knowledge, and attitudes related to OMM. Most survey respondents intend to incorporate OMT into their practice postresidency. As more residency programs attain OR, ACGME, Commission on Osteopathic College Accreditation (COCA), AACOM, and osteopathic leaders should continue collaborating to design an inclusive osteopathic curriculum to ensure that DO residents maintain their OMT skills and practice them alongside their MD co-residents. We did not directly identify degree designations within this study, which should be a focus of future studies. Further research is needed with a larger cohort in multiple centers utilizing a validated survey to investigate the impact of OR on achieving ACGME osteopathic residency milestones with residents across different specialties and training backgrounds.