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I found this article in the June issue of the JAOA where a DO student challenged the AOA as to why it is important to do an AOA approved internship. There is also a response by a DO chairman.
http://www.jaoa.org/cgi/content/full/104/6/230
http://www.jaoa.org/cgi/content/full/104/6/230
Evaluating the Rationale of the Osteopathic Internship
Adam B. Smith, MSIV
West Virginia School of Osteopathic Medicine Lewisburg, West Virginia
To the Editor:
As a fourth-year student at the West Virginia School of Osteopathic Medicine, Lewisburg, I had to choose between pursuing an American Osteopathic Association (AOA)?approved or an Accreditation Council for Graduate Medical Education (ACGME)?accredited residency program. Interestingly, my decision to pursue an ACGME-sponsored position has been met with some resistance. Therefore, I would like to explain the reasoning behind my choice, as well as examine some of the conventional views that have governed osteopathic medical education.
In a recent meeting with our institution's dean of students, I was asked whether I was going to complete an osteopathic internship. I replied that I was not and was informed that as an osteopathic physician who had not completed an AOA-approved osteopathic internship, I would not be eligible for licensure in West Virginia, Florida, Pennsylvania, Oklahoma, and Michigan. I asked whether there were any incentives?as opposed to penalties?in seeking an AOA-approved internship. None was offered.
As readers might imagine, the dean's urging to consider spending another year of general rotations to satisfy an arguably outdated piece of legislation was a confusing proposition. My question to him was this: Why would an organization, namely the AOA, as well as the entire osteopathic medical profession, that has worked so hard to establish equal practice rights for osteopathic physicians throughout the United States and beyond, remain committed to a self-imposed policy that limits those very rights of practice?
As concerns the underserved populations of the aforementioned states (rural and otherwise), one must ask why the osteopathic medical profession wishes to enforce legislation that prevents osteopathic physicians from helping those who need it most? With respect to those who initially drafted the policy, the logic is difficult to understand in today's medical climate. Paradoxically, it is to the credit of the AOA that osteopathic physicians are now able to pursue nearly any specialty they choose.
Given that most transitional yearlong programs are an extension of the clerkship experience, I wanted to know what was so unique about the osteopathic internship that required such a mandate. Most students interested in subspecialty training must complete between 1 and 3 years of general internal medicine, making an extra year of required rotations through the areas of pediatrics, obstetrics, and surgery unnecessary. This is not required for those interested in pursuing areas other than primary care.
I explained to the dean that I would consider adding an extra year to my training if the osteopathic internship provided something extra in terms of education, such as a solid foundation in osteopathic manipulative medicine (OMM). At this point, most AOA residency programs do not.
In some areas of the United States, osteopathic physicians have traditionally been a cornerstone in primary care, and many osteopathic medical schools are still oriented toward this goal.
The subject of OMM raises other questions. Why, for instance, does the osteopathic medical profession insist on maintaining exclusive rights to such a valuable mode of therapy? Maintaining exclusive rights to OMM only seems to further contradict the stated goal of equal practice rights within the medical profession. Consider a scenario in which an osteopathic physician had developed penicillin. Could he or she have withheld such valuable treatment in good conscience?
It is worthwhile to consider that what was appropriate a century ago may not be appropriate today. It is difficult to understand, given the current medical climate, why the AOA continues to support legislation that discriminates against the osteopathic physicians they represent. Without clear educational advantage, a mandated osteopathic internship as it exists today promises only to limit the scope of practice for osteopathic physicians. Such an internship will further promote what is largely an artificial distinction between osteopathic training programs and those of our allopathic colleagues.
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Response
Michael I. Opipari, DO, Chairman
I am sensitive to the challenges students face in selecting between osteopathic and allopathic programs. Such challenges may involve distinct opportunities related to specialty choices or geographic choices. I am not sensitive, however, to choices made that are based purely on logic that implies that the internship year is a waste of time. Let me explain.
1. You selected the osteopathic medical profession. This means that you made a choice to commit to the philosophy, responsibility, and requirements of the osteopathic medical profession, as established by the American Osteopathic Association (AOA). The internship is one of those requirements.
2. I also meet your rationale with resistance. Your rationale (not your choice) ignores that the osteopathic medical profession, which you chose to grant your degree and to educate you to become a physician, provides an approved training system. This system has been in place for more than 70 years and existed when you entered the profession. More importantly, your chosen profession values the internship year.
3. You ask whether there are incentives associated with the internship. You also question the program's uniqueness, given the requirements of the AOA, as well as the requirements for licensure eligibility in five states. I will give you some incentives:
-A year of bridging and transitioning from classroom to clinical decision-making. Although minimal classroom activity occurs in third- and fourth-year clerkships, independent decision-making in patient care does not occur until the internship year.
-A year of clinical growth and maturation to create a more balanced, professional, and self-assured physician. This is recognized and appreciated in later years.
-A year of added clinical exposure and experience, providing increased medical knowledge and enhancing future residency training.
-A year that provides a final opportunity to integrate the multiple specialties of the rotating internship into a total patient care package. There is significant value in having exposure to specialties other than your chosen residency.
4. I wish to address the issue of your feelings regarding AOA's support of licensure requirements based on the internship. Licensure laws are the exclusive province of each state, not of the AOA. Some states have separate licensing boards, and others have combined boards. The AOA has no control over state policy, as evidenced by only five states having such a law. The AOA educational leadership supports the internship based on the rationale of quality education and not for political or other purposes.
5. The internship does not represent an extra year of training within the osteopathic system. In comparison with allopathic residencies, each of the specialties are equal in duration, with the exception of one, even including the internship. The reason the internship is included in the residency duration is because of the valued significance of that year.
6. Finally, osteopathic manipulative treatment (OMT) is not the only significant or distinctive characteristic of osteopathic medicine. Although vital, OMT is a skill that is based on a profound philosophy of biomechanics, science, and a total approach to the patient. Without this philosophic and scientific basis, as taught and integrated into osteopathic medical education, the mechanical skill of OMT alone offers little. The cultural beliefs of the osteopathic medical philosophy and science form the basis of OMT techniques and skills. Delivery of osteopathic medicine is governed by those beliefs and applications, which we have been taught and which are integrated in all osteopathic medical care, whether the manual skill is used or not.
The Council on Postdoctoral Training and all educational leadership of the AOA have a rational and educational basis for continuing to promote and require the osteopathic internship. It is not based on the licensure requirements of five states in which the AOA has no decision or authority. We are also sensitive, however, to the continuing perception of many students who choose not to participate annually in increasing numbers. As perception becomes reality, and reality drives the emergence of change, we must remain open to that change as demanded by need. But please understand the underlying rationale for the requirement, and be willing to accept this as a loss in your education and training.
Council on Postdoctoral Training American Osteopathic Association
