Impact of osteopathic manipulative medicine training during graduate medical education and its integration into clinical practice

Methods

To evaluate the effects of graduate OMM training on OMM use in clinical practice, currently practicing physicians from a variety of fields were asked via survey to provide information pertaining to their training in and practice of OMM. The survey, consisting of 33 questions, was created utilizing the Research Electronic Data Capture (REDCap) software [11] (see Supplemental Digital Material for full survey). Ethical approval was obtained from Phoenix Children’s Hospital Institutional Review Board (IRB-22-089) prior to survey dissemination. The survey was distributed nationally over a 90-day period in late 2022 to osteopathic medical school alumni groups, professional physician organizations, and osteopathic social media groups (see Supplementary Material). The survey responses were anonymous, and no identifying information was collected. A statement was included at the beginning of the survey indicating that completion of the survey constituted consent. Respondents did not receive compensation for completing the survey.

The first portion asked for specifics about OMM use in practice. The survey’s initial question asked about medical degree earned (DO, MD, or other); if the respondents chose “MD” or “other,” they were asked whether formal OMM training was completed (“yes” or “no”). If “no” was selected by non-DO respondents in the follow-up question, the survey ended. If DO was selected in the first question, or if the non-DO respondents marked that they had received formal OMM training, the respondent was able to continue the survey. After the initial training question, the survey asked if the respondent utilizes OMM in their current practice, and if so, further questions on OMM use populated such as: on what percentage of patients is OMM utilized, the driving factor behind utilizing OMM (benefit to patient, desire to apply knowledge, increased compensation, or other), and how they felt their patients responded to OMM treatment (very positively, positively, neither positively nor negatively, negatively, or very negatively). If respondents selected “no” to the use of OMM question, they were asked about their primary reason for not utilizing OMM (lack of time, lack of reimbursement, lack of confidence/proficiency, lack of applicability, lack of institutional support, do not find it to be valuable, or other). The last question in this section asked if they would be interested in providing more OMM if given adequate support/opportunity.

The second portion asked about OMM-specific education. Survey respondents were asked if they completed an OMM fellowship or scholar year during medical school, if they received formal OMM education in residency (e.g., lectures, rotations, or continuing medical education [CME] opportunities) and if they had the opportunity to practice OMM informally during residency (e.g., with co-residents or faculty). Respondents were also asked to provide the percentage of DO attending faculty and DO co-residents within their residency program.

The final portion focused on gathering demographic information. Respondents were first asked about when they graduated from medical school, whether they were board-certified or board-eligible, and the type of certifying body of their board (allopathic, osteopathic, or both). Respondents were then asked about their residency program with questions on what type of residency they completed and which accrediting body governed their program (AOA, ACGME, dually-accredited, ACGME with osteopathic recognition, or other). They were also asked if they completed a fellowship, and if so, what type and whether they received formal OMM education within their fellowship program. Lastly, respondents were asked what specialty they currently practice, whether they practice full- or part-time, and how satisfied they are with their current career (very dissatisfied, somewhat dissatisfied, neither satisfied nor dissatisfied, somewhat satisfied, or very satisfied). Any question with “other” as an option provided an opportunity to specify utilizing a free-type response.

A power analysis was performed prior to survey distribution; a sample size of 174 was needed to have 80 % power for the primary analysis, assuming a significance level of p<0.05. Survey data were analyzed utilizing SPSS software. Descriptive statistics were computed to describe the sample demographic, training, and practice characteristics. Chi-square tests were utilized to make comparisons of categorical (specialty) or binary (fellowship training, and formal and/or informal OMM training) training characteristics as they related to OMM use in current practice (yes/no). Binary logistic regressions were computed to assess the association of continuous training characteristics (i.e., percentage of DO colleagues [attendings and co-residents] in residency and year of medical school graduation) with current OMM use (yes/no).

Results

A total of 451 surveys were collected over a 3-month period. Among these, 73 surveys were excluded due to incompleteness, 3 were excluded due to respondents being non-DOs without formal OMM training, and 76 were excluded due to respondents still being in residency during survey completion. With 152 survey responses eliminated, the remaining 299 surveys were utilized for analysis. A response rate was not able to be calculated due to the convenience nature of the sample.

Among the physician respondents, 201 (67.2 %) were certified by an allopathic board, while 69 (23.1 %) were certified by an osteopathic board and 22 (7.4 %) were dual-boarded. The top three respondent clinical specialties were Pediatrics (n=135; 45.2 %), Family Medicine (n=36; 12.0 %), and Internal Medicine (n=13; 4.3 %) (Table 1). Most (84.9 %) respondents practiced medicine full-time. ACGME-accredited residency programs were the most common (n=195; 65.2 %), followed by dually-accredited (AOA/ACGME; n=49; 16.3 %), AOA-accredited (n=39; 13.0 %), and ACGME programs with an osteopathic recognition track (n=15; 5.0 %). During residency, 92 (30.8 %) respondents had completed formal OMM training, defined as lectures, rotations, or CME opportunities. A total of 170 (56.9 %) respondents practiced OMM informally, and 80 (26.8 %) had both formal training and informal OMM practice during residency. In contrast, 117 (38.8 %) respondents reported neither formal OMM training nor informal OMM practice during residency.

Among the respondents, 101 (33.8 %) reported utilizing OMM in their clinical practice. Specialties with the highest percentage of OMM use were: Osteopathic Neuromusculoskeletal Medicine (NMM; n=11; 100 %), Oncology (n=1; 100 %), Physical Medicine and Rehabilitation (n=4; 100 %), Family Medicine (n=36; 77.8 %), Sports Medicine (n=3; 66.7 %), and Pain Medicine (n=2; 50 %). Perceived patient benefit (93.1 %) was the main driving factor reported for utilizing OMM. Providers reported that patients responded very positively (59.4 %) or positively (38.6 %) to OMM treatments. Primary reasons for not utilizing OMM in clinical practice included a perceived lack of applicability to specialty (36.4 %), confidence or proficiency (22.2 %), or time (17.7 %) (Figure 1). In addition, 101 (33.8 %) of the respondents indicated that they would be interested in incorporating more OMM into patient care if given adequate support and opportunity.

Figure 1:

Responses identifying the primary rationale for not utilizing OMM in current clinical practice.

Those who received formal OMM education within residency were more likely to utilize OMM in their current medical practice (59.8 %) than those without formal OMM education in residency (10.3 %; (χ ² [1, N=209]=58.00; p<0.001) (Figure 2). Respondents who practiced OMM informally in residency were also more likely to utilize OMM in current practice (37.8 %) than those who did not (10.3 %; χ ²[1, N=207]=22.29; p<0.001). Finally, respondents who received formal OMM training during residency were more likely (59.8 %) to utilize OMM in clinical practice than those who only practiced informally (37.8 %; χ ²[1, N=182]=8.81; p=0.003] (Figure 2). Due to the unintentional bias favoring pediatric respondents, the primary analysis was repeated with pediatric respondents removed. Excluding the pediatric respondents, those who received formal OMM education were still more likely to utilize it in their current practice (66.1 %) as compared with those who did not receive OMM education in residency (5.9 %; χ ²[1, N=90]=31.21; p<0.001). Binary logistic regression analysis showed that those who completed a residency program with more DO attendings (b=−0.015, p=0.001) or with more DO co-residents (b=0.010, p=0.012) were also more likely to utilize OMM in clinical practice (Figure 3).

Figure 2:

OMM use in current clinical practice among those who received formal OMM training, practiced OMM informally, or had neither formal nor informal OMM exposure during residency. While formal training in residency resulted in the greatest proportion of current OMM use, responders who practiced OMM informally also reported greater OMM use compared to those without OMM experience in residency.

Figure 3:

The percentage of respondents who reported current OMM use by percentage of osteopathic attending faculty and co-residents in residency. Those with more DO colleagues during training reported greater OMM use in their current practice.

The survey contained respondents who attended training programs both before and after the osteopathic merge into ACGME training programs in 2020. Prior to the merge, training programs were either accredited by the AOA, the ACGME, or dually-accredited by both bodies. After the merge, the programs were all accredited by the ACGME, with those having additional training in osteopathic principles and practice designated with an osteopathic recognition track. Residents who attended ACGME training programs with an osteopathic recognition track were most likely (60.0 %) to utilize OMM in clinical practice, followed by AOA-accredited (56.4 %) and dually-accredited (53.1 %) programs. Differences between these programs were nonsignificant (all χ ²<1, all p>0.10]. Residents from each of these programs were more likely to utilize OMM than those trained in solely ACGME-accredited (22.1 %) programs: ACGME with Osteopathic Recognition Track: χ ²(1, N=210)=10.77; p=0.001; AOA: χ ²(1, N=234)=19.13; p<0.001; and dually-accredited: χ ²(1, N=244)=18.57; p<0.001 (Figure 4).

Figure 4:

The percentage of respondents who reported current OMM use by accrediting body of their prior residency program. Those who trained under programs with osteopathic-specific accreditation (AOA, dual accreditation, and ACGME with osteopathic recognition) reported greater OMM use in their current clinical practice (more than double than that of ACGME alone).

Generally, respondents who did not complete a fellowship were more likely to utilize OMM (38.9 %) than those who did complete a fellowship (23.8 %; χ ²[4, N=299]=35.63, p<0.001). However, when considering OMM-specific education in fellowship, physicians who received formal OMM education in fellowship were much more likely to utilize OMM (90.9 %) than those who did not (15.6 %; χ ²[1, N=101]=30.72; p<0.001). Additionally, respondents who completed an undergraduate OMM fellowship or OMM scholar year as medical students were more likely to currently utilize OMM (70.8 %) than those who did not (30.5 %; χ ²[1, N=299]=16.02; p<0.001). A binary logistic regression analysis of the year of medical school graduation and OMM use in current practice found that respondents who graduated from medical school more recently were less likely to utilize OMM (b=−0.032, p=0.011).

Discussion

The adoption of a single accreditation for GME in 2020 posed a challenge to preserve the unique facets of osteopathic training, such as the incorporation of osteopathic principles and the practice of OMM [7]. A recent study found declining use of OMM in clinical practice among DOs and recommended further investigation into the cause of this decline [5]. While a great deal of time is devoted to the study and practice of OMM in osteopathic medical school, OMM education for DOs during postgraduate training is much more variable. Many residents and fellows receive no formal or informal OMM education following medical school. The present study illustrates the association between OMM education during postgraduate training on OMM utilization in clinical practice. We found that the receipt of formal OMM training during residency and fellowship was associated with the highest rates of OMM use in clinical practice. Informal practice of OMM during residency was also associated with higher rates of current OMM clinical practice as compared to no OMM exposure. Attendance at a training program with a greater percentage of DO faculty and co-residents also corresponded with greater clinical uptake. Notably, more recent graduation from medical school was associated with decreased utilization of OMM. These findings help to elucidate one of the reasons for the declining trend of OMM use after training.

It may seem self-evident that continued OMM education and practice during residency and fellowship would lead to a greater likelihood of its use in clinical practice. However, prior to this study, there was little evidence in the literature to support this claim. Kerr et al. [9] conducted a survey of residents indicating that training in OMM after medical school led to increased OMM practice during residency. However, this work did not comment on whether this trend continued following the completion of postgraduate training. The present study provides such evidence, illustrating that OMM education during postgraduate training also increases OMM utilization in clinical practice.

A minority of survey respondents (30.8 %) reported receiving formal OMM education during residency. Formal OMM exposure, such as structured lectures, rotations, and CME opportunities during GME, likely increases DOs’ knowledge, skills, and confidence in OMM, leading to increased uptake after the completion of training. The previous study by Kerr et al. [9] reported that 67.2 % of resident respondents received OMM training after medical school. This discrepancy is likely due to differing definitions of such training, as well as geographic location bias. Although the previously reported survey had a broader definition of OMM training, including self-directed training, journals, and webinars, we defined formal OMM education as lectures, rotations, and CME opportunities. Furthermore, the data reported by Kerr et al. [9] consisted of only residents in the state of Ohio, where our study encompassed practicing physicians throughout the country.

Notably, 56.9 % of respondents reported practicing OMM informally among co-residents and/or faculty, and 38.8 % of respondents reported neither formal education nor informal practice of OMM. We found that informal practice of OMM during residency, as well as attending a training program with a larger proportion of DO faculty and/or co-residents, led to increased practice of OMM. Informal practice of OMM during training, facilitated by interactions with DO faculty and co-residents, may reinforce the cultural and professional identity associated with osteopathic principles. This ongoing exposure could foster a continued commitment to integrating OMM into clinical care.

The homogenization of GME programs with single accreditation saw the loss of many osteopathic leadership positions within postgraduate education [7], potentially creating barriers to fostering an osteopathic identity during residency and fellowship. Although the proportion of osteopathic physicians in medical practice has increased over the last decade [1], our study showed that recent medical school graduates are less likely to utilize OMM, echoing previous work [5]. This is concerning for those who wish to preserve such practices that distinguish osteopathic care. Following single accreditation, the ACGME developed the Osteopathic Recognition designation to denote programs that meet a specific set of requirements for osteopathic education during GME [8]. Our survey showed that graduates of such programs were more likely to utilize OMM in clinical practice, which lends further support to the notion that continued OMM training in GME leads to increased clinical uptake. Prior to single accreditation, graduates of AOA-and dually-accredited programs were also more likely to utilize OMM compared to those accredited solely by the ACGME; however, AOA-and dually-accredited residencies no longer exist under single accreditation. The value of including osteopathic education in GME is well-documented in the literature. A 2020 study of family medicine program directors noted that the inclusion of osteopathic recognition was beneficial for recruiting medical students and that osteopathic practice within residency clinics was beneficial for both instruction and patient care [12]. Misra [13] outlines the importance of maintaining osteopathic principles at the forefront of medical education and practice, citing their patient-focused nature, which may provide a framework to combat the fragmentation of medical care. However, as of 2022–2023, only 255 of the 13,063 ACGME-approved training programs (<2 %) have applied for or obtained Osteopathic Recognition, with most in family medicine or internal medicine [14]. Our work aims to contribute to the current literature advocating for the importance of osteopathic education in GME, with the hope that more programs will choose to implement it in the future.

Completion of an OMM fellowship or OMM scholar year during medical school is another mechanism to receive additional OMM training. Survey respondents who had completed this training were also more likely to utilize OMM in their clinical practice. This is expected, given that physicians who select this option dedicate this additional training to OMM education and likely have a high degree of interest in its use.

In our survey, 33.8 % of respondents reported utilizing OMM in clinical practice, compared to 43.0 % OMM usage among DOs reported in previous work [5]. The top three reasons that respondents gave for not utilizing OMM were the lack of applicability to specialty, lack of confidence, and lack of time. Previous work has additionally reported barriers of time, confidence, and institutional support [5] but did not include metrics of perceived applicability to specialty. All of those who did utilize OMM reported that patients generally responded positively to the treatments. One might argue that trainees who have a greater initial interest in OMM programs select training programs that offer opportunities for continued training. However, one-third of respondents to our survey indicated that they would be interested in incorporating more OMM into patient care if given adequate support and opportunity. This suggests that many DOs find value in this treatment modality and provides hope for greater uptake of OMM with increased support and postgraduate resources.

Reported specialties that utilized OMM most often included Osteopathic Neuromusculoskeletal Medicine (NMM), Family Medicine, Sports Medicine, Pain Medicine, and Physical Medicine and Rehabilitation. This is not unexpected because these specialties align closely with osteopathic principles due to their focus on primary care and musculoskeletal health. Our findings are similar to those published by Johnson and Kurtz [15], who found that OMM specialists and family physicians utilized OMM most frequently. Kerr et al. [9] also showed that primary care residents utilized OMM more often than residents in surgical and other subspecialties. Respondents to our survey were less likely to utilize OMM if they completed any fellowship, supporting the notion that primary care providers utilize OMM more often than subspecialists. As more osteopathic physicians pursue subspecialty care, the corresponding decrease of DOs in primary care may be contributing to the decline of OMM use in clinical practice.

This study uniquely highlights the crisis surrounding declining OMM use and a potential solution in additional training and ongoing support for practicing physicians following graduation from medical school. If the osteopathic profession wishes to maintain this unique skillset, it is critical to have increased OMM education within GME and greater postgraduate opportunities for OMM education and practice.

Future work should assess the impact of barriers to the practice of OMM, such as time, compensation, and institutional support, with a broader survey study. Such work could then provide the data necessary to conduct interventional work that evaluates the role of OMM training in provider confidence and patient satisfaction. More broadly, additional research into the efficacy of OMM is needed to provide an evidence base for its continued use. Such work will establish a foundation for increasing OMM’s effective use and reimbursement.

Limitations of the current study include a relatively small sample size, with an unintentional selection bias toward pediatrics (45.2 % of respondents). This selection bias likely occurred due to the makeup of the authors’ professional networks within which surveys were distributed given their practice in pediatrics. This overrepresentation could skew perceptions and practices related to OMM, because pediatricians have different training emphases, patient populations, and clinical needs compared to physicians in other specialties. However, even when removing pediatricians from the sample, a significant positive correlation remained between OMM use and formal OMM education during postgraduate training. This indicates the persistence of these relationships with a larger sample size but with greater potential to explore regional variation in training. Recall bias and self-reporting may have also impacted our results, especially with respect to questions surrounding the percentage of DO co-residents and faculty during training, and perceived patient satisfaction with OMM use. The survey focus and sampling methods of this study rendered it susceptible to response and self-selection bias favoring those who practice OMM; however, the rate of OMM use in our survey was slightly lower than the estimates reported in recent literature, suggesting that the impact of such biases were negligible [5]. In order to maintain anonymity, geographic location was not collected as part of the survey; therefore, we were unable to explore regional variations in OMM uptake. Future work could seek to employ more diverse and inclusive sampling methods, such as random sampling or stratified sampling by specialty and geographic location, objective recruitment and data recall from national databases, quantitative measurement of osteopathic trainees and faculty from program data, and querying patients as to the quality of their care with OMM rather than relying on the physician’s perception. Future work to validate these findings should also be considered.

Conclusions

The results of this study underscore the significant impact of both formal and informal OMM education during postgraduate training on the utilization of OMM in clinical practice among DOs. It is evident that DOs who receive comprehensive OMM training during residency and fellowship are more likely to incorporate these techniques into patient care. Additionally, the presence of osteopathic representation in training programs enhances OMM utilization, emphasizing the importance of maintaining osteopathic identity within medical education.

However, the study also confirms a concerning trend: newer physicians demonstrate lower rates of OMM utilization, potentially linked to the integration of postgraduate training under single accreditation and a shift away from primary care. This highlights a critical need for concerted efforts to prioritize ongoing postgraduate OMM education and promoting the leadership of skilled DOs in these programs.

Preserving the unique aspects of osteopathic medicine, including OMM, is essential amid evolving healthcare dynamics. Strengthening professional identity through comprehensive educational pathways and supportive training environments is crucial for the future relevance of osteopathic medicine. These findings call for strategic initiatives aimed at supporting OMM integration, advocating for its recognition, and ensuring sustained prominence in osteopathic clinical practice. Addressing these challenges will help to safeguard the distinctive heritage of osteopathic medicine.