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An anesthesiologist at the Univeristy of Alabama comments on our profession.
I recently had the opportunity to listen to AOA president John A. Strosnider, DO when he visted WVSOM from the Kentucky school...and he seemed very against what George Mychaskiw, DO, one of the chairs of anesthesiology from the Univeristy of Missisippi is trying to suggest here.
Go ahead and give the letter a read. I don't think Strosnider is interested in what Mychaskiw is trying to suggest. I get the feeling there is a war in the osteopathic profession between those who want to stay primary care orientated vs those who want to go all out on the specialty fields.
It seems as if on one side you have Strosnider who is dead set against any change and will not negotiate with osteopathic physicians who went to an allopathic residency program, and those who are advocating that the AOA try to bring back those "lost sheep" or so I once heard.
After listening to Strosnider speak at our school I don't think he's willing to negotiate on any of the points Mychaskiw raises.
http://www.jaoa.org/cgi/content/full/106/5/252
I recently had the opportunity to listen to AOA president John A. Strosnider, DO when he visted WVSOM from the Kentucky school...and he seemed very against what George Mychaskiw, DO, one of the chairs of anesthesiology from the Univeristy of Missisippi is trying to suggest here.
Go ahead and give the letter a read. I don't think Strosnider is interested in what Mychaskiw is trying to suggest. I get the feeling there is a war in the osteopathic profession between those who want to stay primary care orientated vs those who want to go all out on the specialty fields.
It seems as if on one side you have Strosnider who is dead set against any change and will not negotiate with osteopathic physicians who went to an allopathic residency program, and those who are advocating that the AOA try to bring back those "lost sheep" or so I once heard.
After listening to Strosnider speak at our school I don't think he's willing to negotiate on any of the points Mychaskiw raises.
http://www.jaoa.org/cgi/content/full/106/5/252
JAOA Vol 106 No 5 May 2006 252-302
Will the Last DO Turn Off the Lights?
GEORGE MYCHASKIW, II, DO, Vice Chairman, Professor of Anesthesiology, Surgery, Pediatrics, and Physiology/Biophysics
Department of Anesthesiology, University of Mississippi School of Medicine Jackson, Miss
To the Editor:
I have read with interest the continuing debate concerning osteopathic graduate medical education (GME) and the future of the osteopathic medical profession.112 My story in relation to this debate is not unique. In fact, I think it is typical of the majority of graduating osteopathic physicians.
As a medical student in 1986, I was advised, "Go to the best residency you can find, regardless of whether it has an allopathic or osteopathic affiliation." I selected an internship and residency with an allopathic affiliation, knowing that I was obtaining quality GME while sacrificing practicing in states in which an American Osteopathic Association (AOA)-approved internship and AOA certifying board examination are required for licensure. My rotating internship at the Hospital of St Raphael in New Haven, Conn, and my subsequent residency at the Yale-New Haven Hospital were not approved by the AOA. Thus, I was unable to take part 3 of the National Board of Osteopathic Medical Examiners (NBOME) licensing examination (the precursor to the Comprehensive Osteopathic Medical Licensing ExaminationUSA). Instead, I took the allopathic Federal Licensing Examination.
The "inadequacy" of my clinical training in the eyes of the AOA prohibits me from being licensed as an osteopathic physician in those states that require an AOA-approved internship and the NBOME exam. Nevertheless, I function quite well today in an entirely allopathic world. Although I have maintained my AOA membership and I try to be active in the Mississippi Osteopathic Medical Association, I am invisible in the eyes of the AOA, except for my yearly membership dues check.
Were the experience I describe here limited or isolated, it would not be important. However, I believe that my experience is typical of today's graduating osteopathic physicians, many of whom choose to enter allopathic GME programs.13 If we are all invisible to the AOA, what does this say for the future of the osteopathic medical profession? If there were a nationwide initiative today similar to the one that offered conversion of doctor of osteopathic medicine (DO) degrees to doctor of medicine (MD) degrees in California in the 1960s,14 how many DOs would be left?
In my view, there are several factors that, if not corrected, will ultimately result in the death of the osteopathic medical profession as we know it. These factors include the following:
Failure to objectively evaluate the quality of osteopathic GME. It is interesting to note that the growth of osteopathic undergraduate medical education has been inversely proportional to that of filled GME positionssuch that there are now more osteopathic internships available than there are graduates willing to fill them.15 As the number of AOA-accredited hospitals shrinks, more and more osteopathic residencies are served in allopathic medical institutions.13,16,17 These residency programs may or may not have dual accreditation by the AOA and the Accreditation Council for Graduate Medical Education (ACGME).
In addition, osteopathic GME programs tend to be in relatively small facilities, which may be sufficient for osteopathic residents in primary care programs but not for residents in other specialties. For example, the complexity of an anesthesiology residency requires the presence of a large tertiary- or quaternary-care medical center. Indeed, the ACGME Residency Review Committee limits anesthesiology residency training in small hospitals by requiring residents to serve substantial amounts of time in complex critical care environments.18 These kinds of allopathic training programs do not need dual accreditation.
The ACGME is also moving toward integrating internships into the residency continuum.18 Although this will happen slowly, it is a sure sign that the traditional rotating internship is going away. Whether this is a good thing is highly debatable. It is, nevertheless, going to happen.
For many graduating osteopathic medical students then, there is no real choice but to enter residencies at large allopathic medical centers if they wish to pursue specialties in areas other than primary care. (Even primary care may be better taught in the large medical centers.)
Having highly trained subspecialists is important to the future of the osteopathic medical profession. If we remain satisfied with only primary care physicians, the allopathic medical profession will view DOs as little more than glorified nurse practitioners. The osteopathic medical profession needs to embrace osteopathic subspecialists, regardless of their residency affiliations.
Inadequate and nonrigorous osteopathic specialty board certification processes. In the casual opinion of many in the allopathic world, the AOA specialty boards are widely considered to be "easier" and less credible than the allopathic certifying boards. I previously thought that this attitude was just "sour grapes" on the part of the allopathic medical profession. During the last several years, however, I have concluded that this MD opinion of the AOA boards may be accurate. I have personally encountered several osteopathic physicians who, after completing allopathic residency training, were unable to pass the allopathic board examinationsthough they were able to pass the osteopathic board exams with ease. In all of these cases, these osteopathic physicians were viewed by their allopathic colleagues as unworthy of board certification.
The allopathic boards are the gold standard for residency training certification. Following my medical training, I had no intention of pursuing anything but this credible and universally accepted credential. The AOA needs to seriously re-evaluate its board-certification process.
Overemphasis of osteopathic manipulative treatment (OMT). It may be heresy to put this forth, but OMT is vastly overemphasized by the AOA. The practice of OMT is important in osteopathic medical education and in the practices of some osteopathic physicians, but it is not necessary for many other osteopathic physicians. Osteopathic medicine and osteopathic principles do not start and end with OMT.
The steadfast position of the AOA regarding the practice of OMT is as shortsighted as if the American Medical Association were to hold digital subtraction angiography as one of the foundations of allopathic medical practice. The AOA needs to realize that, in and of itself, OMT does not make one an osteopathic physician. A true osteopathic philosophy of practice is a far deeper thing, involving a holistic, patient-centered approach to care and excellence.
Our residency training program at the University of Mississippi School of Medicine seeks out and actively recruits osteopathic medical graduates not because of their abilities in OMT, but because we know that they are consistently exemplary residents who can be relied on to provide our patients with safe, thorough, and compassionate care. Indeed, most of our chief residents, who are selected for their clinical and administrative skills, have been DOs. This has nothing to do with their abilities to perform OMT. In my practice of pediatric cardiac anesthesiology, I do not use OMT. I do, however, practice osteopathic medicine, and I believe that I offer my patients a philosophy and method of care that compares favorably with that offered by allopathic physicians.
I consider my patients to include the parents of the children to whom I am administering an anesthetic for high-risk procedures. If anything is a hallmark of an osteopathic physician, I believe it is a compassionate, holistic, and respectful approach to caring for our fellow human beingscoupled with an honest appraisal of the limitations and potential of pharmaceutic, surgical, and osteopathic interventions.
Failure to welcome all osteopathic physicians. Those of us DOs who trained in allopathic GME programs and who practice in the allopathic world are increasing in number and may very well be the majority of practicing DOs in the United States. We are proud of our profession and identity, though we are largely ignored by the AOA. We are successful clinical and academic practitioners and leaders in many fields. It is foolish for the AOA to treat us as if we do not exist. The AOA should take the "big tent" approach to the osteopathic medical profession and welcome all DOs as active participants with emotional investment in the success of the profession.
I suggest that the AOA create a committee to explore these issues and find ways to welcome back the DOs, like myself, who love the profession more than it loves us.
This is the reality. If the situation I've described in this letter does not change, there will be fewer and fewer DOs involved in the AOA and in national advocacy of osteopathic medicine. In time, DOs and the AOA will disappear entirely, leaving the DO degree as an academic curiosityor as an MD degree with different letters behind the graduate's name.
Follow up letter by Mychaskiw:
GEORGE MYCHASKIW, II, DO, Vice Chairman and Professor of Anesthesiology, Surgery, Pediatrics, and Physiology/Biophysics
Department of Anesthesiology University of Mississippi School of Medicine Jackson, Miss
I very much appreciate Dr Reeves' thoughtful comments regarding my letter in the May 2006 issue of JAOAThe Journal of the American Osteopathic Association. I am pleased to know that his experience with the American Osteopathic Board of Neurology and Psychiatry has been favorably different from my experiences with the American Osteopathic Board of Anesthesiology. It is not unreasonable to expect that there will be substantial variation among the American Osteopathic Association (AOA) specialty boards, especially given the low numbers of physicians certified by these boards in some specialties.2 In this regard, the standards of the member boards of the American Board of Medical Specialties (ABMS), the organization that represents allopathic medical specialty boards,3 may be more consistent than those of the corresponding osteopathic boardssimply because of the large number of allopathic physicians in practice.
Unfortunately, it is nearly impossible to definitively answer the question of osteopathic vs allopathic specialty board quality, because no systematic head-to-head comparison has ever been performed. Thus, we are left with anecdotal reports, including those illustrated by Dr Reeves and me.
The large number of allopathic residency positions, coupled with a dwindling number of osteopathic hospitals and fewer filled osteopathic residency positions, makes the ABMS certification the de facto standard.46 Dr Reeves is quite correct that sole osteopathic board certification may be a hindrance in the allopathic academic world. Even more disturbingly (based on personal communications I've had with leaders in many allopathic medical schools), the DO degreein and of itselfis a hindrance in an academic career. These attitudes are changing and not universal among allopathic institutions, but the tiny number of DOs who are department chairs or deans in allopathic medical schools testifies to the veracity of the generalizations.
Following the publication of my letter in the May 2006 JAOA, I was gratified to receive numerous letters from DOs around the United States expressing solidarity with and support of my views. Most of these letters were from specialists and subspecialists in such areas as pediatric neurosurgery, histopathology, and neurology. To a one, they all expressed doubts about osteopathic graduate medical education (OGME) and certification, frustration with the AOA and the "official" osteopathic world, and a deep support for and belief in osteopathic medicine, despite the fact that few of them practice osteopathic manipulative treatment (OMT) in their practices.
The strength and future of the osteopathic medical profession lie in the continued undergraduate education of competent, caring, and superior osteopathic physicians. A cadre of highly trained specialists and subspecialists is essential in this endeavor. We cannot, nor should we even try to, compete against the programs in massive allopathic medical centers that have large patient volumes, sophisticated and expensive technologies, and substantial research funding. Rather, I believe we should encourage graduates of colleges of osteopathic medicine to enter these allopathic programs. These student DOs could then go on to demonstrate the quality of osteopathic medical education, pass the ABMS boards, and return to the AOA and the osteopathic medical profession, making us all stronger in the process. In the specialties beyond primary care, it is difficult to make a case for the existence of separate osteopathic board examinations.
I have corresponded with John A. Strosnider, DO, the current president of the AOA, about these matters. I am once again calling on the AOA to open a dialogue with osteopathic physicians who have trained in and function in the allopathic world. We support our profession and its philosophynot for political reasonsbut because it represents good patient care. But we need to do a better job in letting the general public know that we are not just family doctors, but also pediatric cardiac anesthesiologists, neurosurgeons, histopathologists, and cardiologists.
The May 20, 2006, cover of Newsweek magazine featured a photograph of Richard Jadick, DO, with the huge, blaring title, "He Saved 30 Lives in One BattleHero M.D.The Amazing Story of the [Iraq] War's Most Fearless Doctor."7 Of course, the title should have read, "Hero D.O." Although Newsweek got his medical degree wrong, Dr Jadick stands as an example of the strength and future of osteopathic medicine. When Dr Jadick conducts battlefield surgery in Iraq, he is not using OMT, but he is still practicing osteopathic medicine. Similarly, when I administer anesthesia to a neonate undergoing surgery for hypoplastic left heart syndrome or when my DO neurosurgical colleague is clipping an aneurysm, we are not using OMT but we are still practicing osteopathic medicine. Isn't it finally time for us to all come together?
