Perceived Importance of Pursuing Osteopathic Recognition in the Single Accreditation System: A Survey of Medical Students, Residents, and Faculty

Methods

After receiving institutional review board approval, the ORTF cross-sectional survey, concerning various aspects of perceived OR importance, was e-mailed to 3 osteopathic cohorts of the SCS at MSUCOM (ie, medical students and residents and clinical faculty in SCS-sponsored residency programs) during February and March 2016. The e-mail, which contained a link to the online survey, was sent to 2937 stakeholders: 1281 MSUCOM students (first- through fourth-year students) and 1075 osteopathic residents and 581 faculty members (osteopathic and allopathic) in 47 member hospitals with more than 200 SCS residency programs. Respondents had to provide informed consent online before they were able to complete the survey. The survey link was active for 1 month, with reminder e-mails being sent to each stakeholder group twice during that timeframe. This instrument was designed for internal strategic planning and was therefore not validated. However, the survey was developed using questions from the previously disseminated AACOM survey⁷ as well as additional items created by the ORTF that were vetted by content experts to establish initial construct validity.

Surveys contained 17 to 19 primary and sub-item questions, with items related to perceived importance of OR, using a standard 5-point, Likert-type ordinal scale, ranging from 0 (“not important”) to 4 (“very important”). Student surveys included 17 items, resident surveys included 18 items, and faculty surveys included 19 items. Survey items included the respondent's role in undergraduate or graduate medical education (ie, medical student, resident, or faculty) and questions related to perceived importance of OR. Respondents identifying as residents or faculty members were asked to provide their program specialty. Respondents identifying as faculty members (eg, program directors, directors of medical education, faculty/adjunct faculty) were asked to complete an additional item relating to perceived barriers to implementing and achieving OR (the ORTF concluded that osteopathic medical students and residents would not have the necessary administrative experience to provide relevant responses). We used the online tool SurveyMonkey, which allowed for anonymous survey submissions and extraction of raw response data.

Residents and faculty members were stratified into 2 program subcategories for sample subgroup analyses: primary care (eg, family medicine, internal medicine, obstetrics-gynecology, and pediatrics) and non–primary care (including “other specialty” and missing data). After generating a series of descriptive statistics and testing the dataset distributional patterns, a series of appropriate inferential multifactor statistical procedures were used to examine overall OR importance differences across cohorts. Additional procedures to test for differences in perceived barrier item scores within the smaller faculty cohort (n=90) with smaller cell frequencies were planned.

After creation of a working dataset, the distributional response patterns were examined using descriptive statistics, cross-tabulation charts, and graphics to guide selection of analytic procedures. Using the SPSS statistical software (version 22; IBM), data were first tested for overall sample normal or non-normal (ie, nonparametric) distributional patterns and homogeneity of variance across sample subgroups. Based on these findings, we used a series of separate (ie, 1 respondent characteristic at a time) nonparametric rank-based Kruskal-Wallis tests²⁰ to examine for differences across ordinal OR importance response categories from sample subgroups observing a 2-tailed α level of .05.

Faculty respondents were asked to complete an additional item regarding the 9 potential perceived barriers or challenges to implementing OR in their respective GME settings. Owing to smaller anticipated faculty cohort cell frequencies (ie, fewer survey scale responses from certain types of faculty), a series of Fisher exact tests²¹ were used to examine faculty for subgroup differences observing a 2-tailed α level of .05.

Results

Perceived Overall Importance of OR

In overview, 497 respondents (68.2%) in the total analytic sample (N=728) indicated that OR was perceived as somewhat important (score of 2), important (score of 3), and very important (score of 4) on the 5-point scale for their respective medical school/residency program training or faculty positions. On this scale, 224 student respondents (80.8%) selected between somewhat important and very important (Table 2).

Table 2.

Perceived Importance of Pursuing OR for ACGME Accreditation: Responses by GME Role (N=728)

	Response, No. (%)
With quality of training being equal, how important is OR or osteopathic competencies to you?	Not Important	Not Very Important	Somewhat Important	Important	Very Important
Osteopathic medical student (n=277)	4 (1.4)	49 (17.7)	97 (35.0)	108 (39.0)	19 (6.9)
Osteopathic resident (n=359)	76 (21.2)	80 (22.3)	87 (24.2)	67 (18.7)	49 (13.6)
GME facultya (n=92)	20 (21.7)	2 (2.2)	11 (12.0)	25 (27.2)	34 (37.0)
Total	100 (13.7)	131 (18.0)	195 (26.8)	200 (27.5)	102 (14.0)

^a Included program directors, directors of medical education, and faculty/adjunct faculty.

Abbreviations: ACGME, Accreditation Council for Graduate Medical Education; GME, graduate medical education; OR, osteopathic recognition.

In terms of specific differences across program specialty, respondents from some residency program types (eg, family medicine, mean rank of 287.0) were significantly more likely to select higher OR importance responses than others (eg, emergency medicine, mean rank of 145.7). Similar results were obtained when comparing primary care with non–primary care residents and faculty (Kruskal-Wallis test: , P<.001) (Table 3 and Figure).

Table 3.

Perceived Importance of Pursuing Osteopathic Recognition for ACGME Accreditation: Mean Score and Rank by GME Role, Program, and Specialty

With quality of training being equal, how important is OR or osteopathic competencies to you?a	n	Mean (SD)	Mean Rank
Program Specialtyc	424
Primary care	175
Family medicine	59	2.6 (1.2)	287.0
Pediatrics	12	2.8 (1.1)	280.3
Internal medicine	66	2.3 (1.3)	238.8
Obstetrics-gynecology	38	2.2 (1.2)	236.7
Non–primary care	249
Surgical specialties	106	1.3 (1.3)	159.9
Emergency medicine	60	1.2 (1.2)	145.7
Other	83	2.0 (1.4)	213.3
Primary vs Non-Primary Cared	394
Primary care	163	2.5 (1.2)	250.9
Non–primary care	231	1.4 (1.3)	159.9

^a Response options were 0 (“not important”), 1 (“not very important”), 2 (“somewhat important”), 3 (“important”), and 4 (“very important”).

^b Included program directors, directors of medical education, and faculty/adjunct faculty.

^c If specialty was reported and the respondent was a resident or faculty member.

^d If specialty was reported, the respondent was a resident or faculty member, and the data were fitted into analytic software.

Figure

Differences in perceived importance of Osteopathic Recognition (OR) between primary care and non–primary care survey respondents (n=382).

Discussion

These findings further document the interest of osteopathic medical students throughout medical school training in pursuing GME programs with OR, as initially published in 2015 by AACOM.⁷ While the AACOM study targeted third-year medical students, the present study demonstrated student interest in both the preclerkship and clerkship years.

In this report, nearly half of osteopathic medical student respondents (127 [46%]) reported that OR was important or very important; less than 2% described OR as not important at all. These findings may provide incentive to program directors and hospital systems as they consider the benefits of seeking OR for their ACGME-accredited residency programs. Resident respondents in this survey reported perceived importance of OR below that of the student and faculty cohorts. While the survey did not seek to explore why differences in perceived importance existed, several potential explanations could be considered.

First, the residents surveyed are currently enrolled in AOA-accredited programs and may not perceive how OR would alter their curriculum. Second, residents may regard the components of OR as not relevant to their specialty. Third, it is possible that some residents find OR less important because they may complete their program before SAS implementation. However, clear differences emerged between residents and faculty members in primary care specialties and those in non–primary care specialties, with the former reporting a greater perceived importance of OR.

Faculty respondents to this survey identified a number of barriers to implementing OR. Two most commonly identified challenges were the administrative burden and the number of required elements for OR. These data may help inform strategies to facilitate curriculum design and assist faculty in operationalizing OR requirements. Another potential barrier identified by faculty respondents was lack of faculty members skilled in OMT. This issue has been described in published reports on strategies to integrate osteopathic training into ACGME-accredited residencies beginning in the early 1990s through 2015.^22-25 In 3 of the articles,^23,25,26 OMT integration led by osteopathic residents was shown to be a successful strategy within ACMGE-accredited residencies. These articles described specific operating procedures, educational goals, objectives, and core competencies for summative evaluations of the integration of osteopathic principles and practice (OPP) and OMT.^23,25,26

After careful review of the OR requirements and milestones, the SCS ORTF designed a conceptual framework that categorized these requirements into 3 overarching OPP competency domains. These were “Biomechanical Competencies” (including OMT), “Health Promotion Competencies,” and “Physician Wellbeing Competencies.” The ORTF then created a list of educational modules, workshops, and resources to support each of these competency components.

Expanding on approaches described in these articles, and incorporating experiences of implementing the 6 published SCS OPP/OMT Integration Workshops,²⁷ an ORTF SCS subcommittee is currently developing an expanded educational model similar to the American Heart Association's Advanced Cardiac Life Support Instructor Manual.²⁸ Following this blended learning model of online didactic instruction with onsite skills practice, participants must be able to successfully complete all requirements to receive an OMT provider completion card. Providing this type of educational model would offer faculty unfamiliar with OMT the assurance that the resident with the OMT completion card met all established requirements of the OMT provider course. It could also provide faculty members who have not recently used OMT an opportunity to brush up on their skills.

Conclusion

Based on these initial results, OR within ACGME-accredited programs is generally valued by sizable proportions of major osteopathic stakeholder groups, although significant differences exist between different types of osteopathic medical students, residents, and faculty. More than 67% of the total respondents and 81% of osteopathic medical students expressed that OR is somewhat important to very important for their overall medical school or residency program training. Pre- and postgraduate educational support structures designed to reduce barriers to OR implementation may help to create more sustainable OR for specialty residency programs. In the future, we plan to examine student cohort and resident specialty differences as well as stakeholder interest in the types of OR educational support modules in greater depth.