SPECIAL COMMUNICATION

Getting “Beyond the Barriers” in Reforming Osteopathic Medical Education

John R. Gimpel, DO, MEd

As the healthcare needs of the United States change, some revamp osteopathic medical education.8,19-22 Their action and leaders at colleges of osteopathic medicine and osteopathic demands for continued improvements in osteopathic med- graduate medical education programs have embraced one ical curricula had no doubt influenced the 2006 OHF [Osteo- very important and timeless goal: to prepare future physi- pathic Heritage Foundation] Osteopathic Medical Education cians to meet society’s health needs. These medical educators Summit, sponsored by the American Association of Colleges have made significant strides toward moving “beyond the of Osteopathic Medicine (AACOM) and the American Osteo- barriers” to effect curricular reform and quality improve- pathic Association (AOA), which emphasized the need to ment at their institutions. Some of the barriers to osteopathic evaluate, develop, and expand medical education—particularly medical education reform are addressed in this article, which osteopathic graduate medical education (OGME).23 recommends allowing curricular evolution and faculty devel- There have been numerous curricular opportunities— opment; expanding clinical learning and teaching; breaking and challenges—in continuous quality improvement in med- down departmental walls; integrating osteopathic princi- ical education at the nation’s 23 fully accredited and oper- ples and practice; reevaluating admission requirements of col- ating colleges of osteopathic medicine (COMs)24 as well as in leges of osteopathic medicine; and eradicating the unspoken the nation’s many osteopathic and allopathic residency pro- and, ironically, often detrimental culture of medicine, which grams.7,10,11 Unfortunately, those involved with strategic plan- can be contrary to compassionate patient care and healing. ning and facilitating change in both curricular and extracur- 25 J Am Osteopath Assoc. 2007;107:270-275 ricular areas of medical education often encounter barriers akin to the resistance encountered by osteopathic medicine’s Changes in the demographics of the population in the United founder, Andrew Taylor Still, MD, DO, when he first used States are inevitable. For example, in 2006, nearly 8000 baby osteopathy to diagnose and treat patients with dysfunctions of boomers turned 60 each day, and that number continues to the musculoskeletal system.26,27 grow.1 In the same year, 43.8 million Americans did not have health insurance.2 And recently, the US life expectancy Mandate to Change reached an all-time high of 77.9 years.3 It is no wonder that those calling for medical education reform To meet society’s expanding healthcare demands, med- have grown to include healthcare professionals (eg, physicians, ical schools and residency training programs need to revaluate medical students, and residents); healthcare organizations how they teach, train, assess, and cultivate future physicians (medical schools and hospitals); accrediting, certifying, and and recent graduates.4-7 Although there has been increasing licensing authorities; and professional societies and organiza- concern in how the healthcare community will respond to the tions. Although each of these bodies is a stakeholder in the challenge, medical education reform may prove to be a viable— future of our nation’s healthcare,7,12-14 perhaps the largest stake- and vital—solution.6-18 It is encouraging to see many medical holder is the public—our patients—58% of whom, in a public educators and directors at osteopathic residency programs opinion survey,28 responded that “poor training of health pro- embrace this challenge by addressing the need to revisit and fessionals” is a “very important” cause of medical errors. In response to the growing concerns, various groups have contributed to an increasing number of position papers and col- 4-7,14-17 10,11 From the Georgetown University School of Medicine in Washington, DC, laborative reports and projects during the past 20 and the Philadelphia College of Osteopathic Medicine in Pennsylvania. Ideas years with strikingly similar recommendations for significant from this paper were presented at Founder’s Day Address at the A.T. Still Uni- educational reform in medical schools and residency pro- versity-Kirksville (Mo) College of Osteopathic Medicine on September 23, 2005. grams. A sampling of the reports and projects are listed in Address Correspondence to John R. Gimpel, DO, MEd, Vice President for the Figure. Clinical Skills Testing, National Board of Osteopathic Medical Examiners, 101 Although these documents vary in regard to scope and W Elm St, Suite 150, Conshohocken, PA 19428-2075. E-mail: [email protected] focus, the resounding demand for change in medical educa- tion is unmistakable. These landmark reports and projects Submitted February 17, 2006; revision received July 17, 2006; accepted July 18, have generated much discussion in the form of articles13,18 2006.

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and faculty meetings and national conferences.14,23 Some edu- Barriers to Successful Reform cators have effected significant change at their institu- A recent study by Carole J. Bland, PhD, et al25 reviewed a tions8,13,14,19,29 while others have tweaked courses,20-22,30 number of articles regarding how to bring about successful cur- attempted to cut lecture hours across the board,30 piloted or ricular reform. This study,25 which evaluated curricular change added additional innovative coursework (sometimes as the in the general topics of medical education and higher educa- result of available external funding),13,15,20,21,31 and started or tion, reported several key elements to implementing successful expanded standardized patient programs,32 but often not curricular change. without encountering barriers to implementing significant In relation to the study by Bland et al,25 and in my own reform.8,13,14,18-22,29-32 experience with medical education reform at a number of

Osteopathic ▫ American Association of Colleges of Osteopathic Medicine Osteopathic Medical Education in the United States: and American Osteopathic Association Improving the Future of Medicine14 ▫ American Osteopathic Association Report of the Core Competency Task Force: A Report to the AOA Board of Trustees16

Allopathic ▫ American Academy of Family Physicians Rural Practice: Family Medicine Graduate Medical Education Training for Rural Practice ▫ American College of Physicians The Case for Graduate Medical Education as a Public Good The Physician Workforce and Financing of Graduate Medical Education ▫ American Council for Graduate Medical Education ACGME Outcomes Project10 Educational Innovation Project11 ▫ Association of American Medical Colleges Educating Medical Students: Assessing Change in Medical Education. The Road to Implementation. ACME-TRI Report Emerging Perspectives on the General Professional Education of the Physician: Problems, Priorities, and Prospects Educating Doctors to Provide High Quality Medical Care: A Vision for Medical Education in the United States Physicians for the Twenty-First Century: The GPEP [General Professional Education of the Physician] Report ▫ American Medical Association Initiative to Transform Medical Education: Recommendations for Change in the System of Medical Education6

Federal ▫ Health Resources and Services Administration Undergraduate Medical Education for the 21st Century (UME-21) Project

Other ▫ Blue Ridge Academic Health Group The Academic Health Center: Leadership and Performance Reforming Medical Education: Urgent Priority for the Academic Health Center in the New Century ▫ Carnegie Foundation for the Advancement of Teaching Professional Preparation of Physicians9 ▫ Commonwealth Fund Training Tomorrow’s Doctor’s: The Medical Education Mission of Academic Health Centers7 ▫ Institute of Medicine Academic Health Centers: Leading Change in the 21st Century Crossing the Quality Chasm: A New Health System for the 21st Century5 Health Professions Education: A Bridge to Quality To Err is Human: Building a Safer Health System4 Training Physicians for Public Health Careers The Future Health Care Workforce for Older Americans

Figure. Collaborative reports, position papers, and projects listed by the corresponding consensus group. The various groups listed have reported the need for medical education reform.

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osteopathic and allopathic medical schools and residency pro- from patient care) as a necessary prerequisite to educational grams, I have observed the following recurring barriers to reform. This barrier may be a smaller hurdle for COMs,7,12 curricular change, particularly as they pertain to osteopathic however, because most COMs have considerably less of a medical education. research infrastructure than do their allopathic counterparts.40

The Skeptics The Flexner Report Faculty and administrators commonly resist proposals for A major restriction to instituting improvements in under- medical education reform with an “If it ain’t broke, why fix it?” graduate medical education is ongoing dependence on the rebuttal. These skeptics will cite a track record of excellent Flexner Report41 of 1910—despite its decrepitude and the board scores, anecdotes that “residency programs love our author’s lack of any considerable clinical experience. At a time graduates,” and surveys of graduates and residency program when diagnostic methods in the practice of medicine are directors that indicate all is well in osteopathic medical edu- improving almost daily, Flexner’s work continues to be used cation.14,25,33,34 There are many educators who refute the evi- as a key diagnostic tool in medical education.42-44 Although dence in favor of reform6-18 by pointing to the global ratings of Flexner himself emphasized the need for educators to estab- medical students’ “clinical years” (ie, clerkship grades) to lish and maintain a relationship between laboratory and clin- show that graduates are well versed in patient-physician com- ical experience for medical students,41 I wonder whether the munication, physical examination skills, and other core clinical fostering of the separation of preclinical and clinical medical skills (eg, medical-history taking, physical examination, basic education are now impeding the development of a more stu- clinical procedures).14,25,33-35 Another common argument dent-centered, competency-based curriculum.29 Isn’t it time against medical education reform is a lack of major studies that to move beyond Flexner? prove curricular change will lead to better educational out- Since 1980, many reports have called for students to have comes. The results of small-scale studies,36-39 though promising, clinical exposure earlier in their training,7,11,14,16 and some are difficult to apply globally to all medical education cur- from day 1 of medical school.45,46 Some groups advocate for ricula. more involvement of basic science faculty in years 3 and 4 of Such arguments assume that board scores and clerkship the medical school curriculum.46 But simply adding a number grades indicate that the existing system is maximally effec- of lecture-based clinical courses into years 1 and 2, and a few tive. However, as with a number of clinical questions, some- basic science lectures into years 3 and 4 falls significantly short times the best guidance comes from smaller case studies and of the more integrated approach recommended by most of expert consensus. In addition, the growing literature on med- the experts.7,11,14,16 Band-Aid approaches may also be ical education will help leaders gain further support for—and obstructing the creation of cohesive curricula. therefore encounter fewer barriers to—integrating the best Although Flexner did not advocate abandoning ambula- educational tools into their programs.29 tory or outpatient medical education in the clinical curricula,41 most medical schools began to emphasize hospital-based Faculty Development and Teaching training in the 20th century. While many osteopathic medical Faculty resistance to medical education reform can be a result schools never espoused (either by design or necessity) the of competing priorities, inertia, and an organization’s under- hospital as the predominant site for the clinical years, they valuing of faculty development.25 Well-rounded medical edu- did balance hospital-based clerkships with office-based, ambu- cators who value learning—not just teaching—and who are latory clinical rotations.14 Today, getting “beyond the hos- skilled and comfortable with facilitating learning in small- pital” is a preeminent agenda item for many medical schools group settings appreciate the assessment process. These edu- and residency programs46 as they attempt to adjust to the cators know that it is an important aspect of evaluating not only major changes in inpatient care that have significantly affected the knowledge, skills, and attitudes of the students, but also the hospital-based clerkships and residency training programs.9,7,13 curriculum and entire educational program itself.29 Shorter hospital lengths of stay and the resulting chaos of In addition, multiple-choice examinations should not be patient admissions; advances in outpatient care for common used exclusively to evaluate students’ knowledge. Used appro- clinical problems; and hospital closings have added to the priately, a combination of multiple-choice examinations and inherent challenges of providing quality medical education simulation-based educational and evaluative methodologies programs through hospitals.12 The lack of continuity of care31,46 can provide formative and summative assessment across the and subsequent inability of students to build relationships continuum. This approach emphasizes improved quality of with patients likely have negatively affected students’ learning, care and patient safety.9 Faculty development at the most suc- satisfaction with educational programs, and career choice. cessful institutions also includes aligning appropriate rewards In response, many medical schools are now attempting to for improved teaching equal to those offered for basic and provide more quality clinical experiences for their students clinical research and clinical production (ie, revenues generated by ensuring educational equivalency across a larger and more

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diverse array of ambulatory clinical training sites (ie, chronic may be understandable in certain dually accredited residency care, urgent care, and emergency facilities).14 Standardized training programs, it is puzzling (especially to students) when patients and mechanical simulator programs, which are increas- it occurs on campus. The impact of even one educator who has ingly used in the teaching, learning, and assessment of students’ “lost” his or her skills in palpatory diagnosis and osteopathic basic science knowledge and clinical skills,19 are helping to manipulative treatment (OMT) can have a profound effect on fill some of these gaps,19,35 reduce medical errors, and assure aspiring osteopathic physicians.50 Perhaps with the increasing the public of the medical profession’s proficiency in providing global acceptance of the osteopathic medical profession,51 cur- the best healthcare possible.4 ricular initiatives can be refocused to integrate the distinct ele- Creation of educational partnerships with assisted-living ments of OPP throughout all 4 years of medical school and into facilities, community health centers, and other institutions as OGME programs.23,52 well as consideration for providing reimbursement to clinical teachers may be necessary to reduce many schools’ reliance on College Requirements and Admissions volunteer faculty and maintain quality in clinical education.7,9 While curricular reform receives most of the attention, there are One additional consequence of the “2 + 2” curricular model, key cocurricular and extracurricular areas that, should they be in which students’ first 2 years of medical school consist of lab- addressed, can help prepare medical students to meet the oratory sciences and the second 2 years relate to clinical sci- healthcare needs of society. For example, if the goals of COMs ences,31 particularly at some COMs, is a focus on curriculum are to educate physicians to be compassionate and committed as pertaining to years 1 and 2 predominantly, with very little to service and to practice a holistic approach to medicine, why change to years 3 and 4 of medical education. With the excep- is it that COMs require extensive undergraduate hours in tion of students’ increased exposure in clinical ambulatory inorganic and organic chemistry, physics, and basic sciences, settings and a greater number of allopathic medical schools but few schools require more than a course or two in the including required clerkships in family medicine, there has humanities or social sciences? According to the admission been little substantial change to the clinical curriculum at most requirements posted online, only six of the 23 fully accred- schools in the past several decades.15,47 ited osteopathic medical schools report requiring any college The total dependence on time-based courses in under- coursework in the behavioral sciences.53 Physicians must be graduate and graduate medical education programs and clin- competent in the sciences, but it seems to me that the “sci- ical clerkships may also be a barrier to medical education ence” of humanity is also important. If osteopathic physicians reform.29 In response, the traditional teacher-centered structure, are oriented to consider the relationship between structure whereby curricular content and students’ knowledge acqui- and function and the neuromusculoskeletal system, why is it sition was the driving force, is now being rivaled by the stu- that not a single osteopathic medical school requires prereq- dent-centered, competency-based training model, which uisites in anatomy or neuroscience?53 (Edward Via Virginia emphasizes learning from real-world application of clinical College of Osteopathic Medicine in Blacksburg requires six knowledge.29,48 The Harvard Medical School (Boston, Ma) additional semester hours of science courses. Anatomy, bio- Medical Education Reform Initiative, a longitudinal pilot pro- chemistry, genetics, and physiology are “strongly suggested.”53) gram, in which third-year students follow patients and fami- As COMs look to increase the diversity in the applicant lies over time with interdisciplinary “clerkships,” fosters con- pool,54 the profession will likely need to reach out to students tinuity of care and patient-student relationships. The program from underrepresented groups at the grade school and high may also represent an educational innovation that should be school levels to attract those who historically come from edu- widely exported elsewhere.31 cationally or economically disadvantaged backgrounds. In addition, medical students’ increasing debt loads, par- Curricular Isolation Between Departments ticularly at COMs,14 is significantly affecting the career choices Another barrier to medical education reform is the disjunction of our profession’s graduates.14 I hope the next Osteopathic in curricular content that occurs in department-based courses Medical Education Summit will address this worsening when educators do not make significant attempts to integrate problem by implementing ways in which students determine and build on each others’ lectures and workshops.25 There their specialty independent of the educational debt they incur. are a number of success stories from COMs where curricular changes20,21 have allowed faculty to get “beyond the depart- Lack of Osteopathic Research ment.” For years, leaders in the osteopathic medical profession have called for an increase in osteopathic research at COMs.55 Mean- Osteopathic Principles and Practice while, an overabundance of research scientists has threatened Fragmentation in coursework, clerkships, and residency pro- the financial viability of a number of the allopathic academic grams is often evident in the teaching of osteopathic principles health centers.12 It seems prudent for osteopathic programs to and practice (OPP) and manipulative medicine.8,49 While this align their research goals with areas that complement their

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missions. Some areas would include OMT, informatics, inter- 2. CDC National Center for Health Statistics. New CDC report documents percentage of people without health insurance [press release]. Washington, disciplinary teams, management sciences, health services DC: Department of Health and Human Services. June 25, 2006. Available at: research, and educational outcomes.48,56,57 http://www.cdc.gov/nchs/pressroom/07newsreleases/insurance.htm. Accessed June 25, 2007. The Unspoken Culture of Medicine 3. CDC National Center for Health Statistics. Fast Stats A to Z: Death/Mortality. Perhaps the most challenging barrier to successful medical Washington, DC: Department of Health and Human Services; 2004. Available at: http://www.cdc.gov/nchs/fastats/deaths.htm. Accessed June 25, 2007. education reform is the hidden culture of medicine, which 4. Institute of Medicine. To Err is Human: Building a Safer Health System. has been described as competitive, unemotional, hostile to Washington, DC: National Academy Press; 2000. human error, and otherwise contradictory to compassionate 5. Institute of Medicine. Crossing the Quality Chasm: A New Health System care and healing.58 We sometimes hear, “That’s the way I was for the 21st Century. Washington, DC: National Academy Press; 2001. trained,” or witness “old school” pedantic and patronizing 6. American Medical Association. Initiative to Transform Medical Education: teaching methods that are not appropriate in the modern edu- Recommendations for Change in the System of Medical Education. Chicago, Ill; June 2007. Available at: http://www.ama-assn.org/ama1/pub 58 cation setting. Rachel Naomi Remen, MD, for example, /upload/mm/377/finalitme.pdf. Accessed July 17, 2007. describes how medical students are taught to view “a gen- 7. Blumenthal D. Training tomorrow’s doctors: the medical education mis- uine human connection” between a patient and a physician as sion of academic health centers: a report on the Commonwealth Fund Task “unprofessional.” To allow students, residents, and faculty to Force on academic health centers. The Commonwealth Fund. April 2002. redefine the culture of medicine, educators must restructure 8. Ross-Lee B, Wood DL, Mann DD, Portanova RP, Kiss LE, Weiser MA. An osteopathic prescription for medical education reform: part 1. Curriculum and learning environments and expand humanities requirements. infrastructure. J Am Osteopath Assoc. 1997;97:403. In addition to emphasizing students’ longitudinal continuity- 9. Professional preparation of physicians. Carnegie Foundation for the of-care relationships with patients, these could be the most Advancement of Teaching Web site. 2006. Available at: http://www.carnegie promising medical education innovations to emerge in our foundation.org/programs/index.asp?key=1822. Accessed June 21, 2007. lifetime. 10. ACGME Outcome Project: An Introduction. Accreditation Council for Graduate Medical Education Web site. 2005. Available at: http://www.acgme Conclusion .org/outcome/project/OPintrorev1_7-05.ppt. Accessed June 21, 2007. 11. Project program requirements for residency education in internal medicine: There has been some real movement in getting beyond the bar- educational innovations project. Accreditation Council for Graduate Medical riers to real quality improvement in all aspects of both osteo- Education Web site. 2005. Available at: http://www.acgme.org/acWebsite pathic and allopathic medical education curricula and graduate /RRC_140/140_EIP_%20PR205.pdf. Accessed June 21, 2007. medical education programs.25 Osteopathic medical educa- 12. Detmer D, Steen E, eds. The Academic Health Center: Leadership and Per- formance. Cambridge, Mass: Cambridge University Press; 2005. tion programs, with faculty members who are committed to 13. Rabinowitz HK, Bobbott D, Bastacky S, Pascoe JM, Patel KK, Pye KL, et teaching and who traditionally focus on creating quality clin- al. Innovative approaches to educating medical students for practice in a ical experiences in medical education for their students,45 foster changing health care environment: the national UME-21 project. Acad Med. a “hands-on” approach in the first semester, including pal- 2001;76:587-597. patory diagnosis and a better understanding of the muscu- 14. Teitelbaum HS. Osteopathic Medical Education in the United States: Improving the Future of Medicine. Project funded jointly by the American Asso- loskeletal system. These attributes, which are indispensable to ciation of Colleges of Osteopathic Medicine and the American Osteopathic osteopathic medical education, are what the American Asso- Association. 2005. Available at: http://osteopathicresearch.net/data/special- ciation of Medical Colleges and most medical schools are now report.pdf. Accessed June 21, 2007. striving to incorporate into their curricula.59 15. Muller S. Physicians for the twenty-first century. Report of the project panel The real excitement, however, comes from witnessing on the general professional education of the physician and college preparation for medicine. J Med Educ. 1984;59(11 Pt 2). leaders at COMs and OGME programs that have summoned 16. Gallagher H, Cummings M, Gilman D, McNerney J, Mogil C, Piccinini R, up the courage to move above and beyond the barriers to et al, for the AOA Core Competency Task Force. 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