Resolution 42

[group_theory]

The August 2004 edition of the JAOA had an interesting letter to the editor (and response) concerning Resolution 42. (J Am Osteopath Assoc. 2004l104:314-315)

For those of you who don't know, Resolution 42 allows DOs who are doing ACGME internship to apply and get AOA approval for this internship (thus satisfying the requirements for licensure in 5 states, ability to maintain AOA membership, and be board certified in osteopathic specialty boards)

The first post, by Kenneth J. Steier DO, is in opposition to Resolution. The next post, by Michael I. Opipari, is the response.

Perhaps you guys can vote (let your voices be heard), and post comments concerning this issue. This is a serious issue that must be debated, and both side must have their voices heard. We are now members of the osteopathic community and will be future leaders (that is, if we maintain AOA-membership, which if they abolish Resolution 42, those pursuing ACGME residency won't be eligbile). Perhaps if we get a resonable size response (with good arguments), we can forward this thread to those who are in the positions to make judgement (ie Dr. Steier and Dr. Opipari). I am sure both side will like to hear support and criticism of their stances.

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Journal of the American Osteopathic Association
2004;104:314-315

In Opposition to Resolution 42

To the Editor:

Resolution 42 (A/2000), also known as the "hardship resolution," was enacted in 2000, allowing DO graduates to apply for credit from the American osteopathic Association (AOA) during or after completing a non-AOA-approved internship or residency. To qualify, graduates are required to demonstrate a significant hardship due to "unusual or exceptional circumstances." Specific eligibility criteria include physical or mental disability, legal restrictions tying a DO to a certain geographic area, and service in a federally designated health profession shortage area or in a specialty for which no AOA programs exist.

The spirit of this resolution is to allow DO graduates to remain "part of the osteopathic family" if, for legitimate reasons, the student had no choice bt to select allopathic over osteopathic residency training. Applications for approval are submitted to the AOA Division of Postdoctoral Training. Final AOA approval of an application under this resolution satisfies the requirement for an AOA-approved internship and for eligbility for osteopathic specialty certification eligibility.

Unfortunately, there is ongoing wide-spread abuse of this hardship exception. According to AOA records, since 2000, only 4 of 400 applicants for this exception have been turned down, a mere 1% of all applicants. This is despite opposition from Osteopathic Postdoctoral Training Institute (OPTI) leadership, at least in New York and Pennsylvania, to many of these applications, as "groundless" (verbal communication-OPTI leadership). In states where there is a multitude of quality AOA-approved training programs, the routine granting of hardship exceptions is alarming and particularly difficult to understand.

According to osteopathic medical school students, one allopathic hospital in New York reportedly informs DO applicants to their internal medicine residency that Resolution 42 is always available to them and that "all 11 of their DO residents" that applied for the exception have received it. This is despite several competing, fully accredited AOA-approved internal medicine residencies available within miles from this community hospital. Interestingly, this particular facility does not accept DO students for third-year clerkships, while readily accepting allopathic medical students.

A Pennsylvania hospital has even reported that a DO received the hardship exception, though he was offered an AOA-approved fast-track internship position, in the same discipline, at the same hospital! Certainly, this is not what anyone had in mind when Resolution 42 was implemented.

Oliver Hayes III, DO, MHSA, at the Michigan State University College of Osteopathic Medicine, East Lansing, has reported that DO graduates who participate in dually certified AOA/ACGME (Accreditation Council on Graduate Medical Education) programs are as likely as those in AOA-only programs to become AOA certified and AOA members. (J Am Osteopath Assoc. 2004;104:82-86) This important study points out the importance of keeping DOs in AOA-approved training programs, including those that are dually approved.

The blatant abuse of Resolution 42 is a threat to AOA- and dual-approved programs. We are providing ACGME-only programs a recruitment weapon to use against our approved programs. This is tantamount to handing a burglar a weapon, knowing he will use it against you. There are no data that DO graduates granted the Resolution 42 hardship are any more likely to become AOA board-certified, or to become long-term AOA members, than if they were not granted this exception. To the contrary, given this free pass, DO graduates may be even more likely to turn their backs on osteopathic medicine.

The assumption by some that ACGME-accredited programs are uniformly superior is unfounded, especially as many ACGME-accredited programs are based at the same hospital as AOA-approved programs. American Osteopathic Association-approved (or ACGME-accredited) programs with quality issues need to be beefed up or closed. Resolution 42 neither addresses nor solves that problem.

In conclusion, though well-intentioned, Resolution 42 is being grossly overused. Its policy is counterproductive for the osteopathic medical profession and our graduate medical education programs. To build more programs, including dually approved AOA/ACGME programs, with willing partners, this resolution should become more the exception and less the rule. We should immediately suspend this resolution and the process by which AOA credit is granted until this can be studied further and the standards properly enforced. The future of our osteopathic training programs may depend on it.

Kenneth J. Steier, DO, FACOI, FCCP
Corporate Safety Officer
Associate Professor
Director of Pulmonary Care Unit
Director of Medical Education
Program Director, Dual-Approved Internal Medicine Residency
Nassau University Medical Center
East Meadow, New York

Clinical Assistant Dean
New York College of Osteopathic Medicine of New York Institute of Technology
Old Westbury, New York

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[group_theory]

IN RESPONSE

Journal of American Osteopathic Association
2004;104:315

Response

Resolution 42 (A/2000), Approval of ACGME Training as an AOA-Approved Internship, was approved by the American Osteopathic Association (AOA) Boarf of Trustees in July 2000. Currently, 486 applications have been reviewed and acted on by the Executive Committee of the Council on Postdoctoral Training and recently by the Program and Trainee Review COmmittee. This equates to approximately 122 applications reviewed annually since adoption of Resolution 42 by the AOA Board.

Dr Steier is correct in describing Resolution 42 as intending to deal with such issues as students' financial hardships, family situations, and geographic issues due to lack of availability of AOA-approved internship programs. Each application is reviewed separately based on such parameters. Documentations is provided by applicants, though personal documentation of this sort is uncomfortable to request and review. However, the committee has attempted to adhere to this policy. In addition, applicants are required to follow the correct rotational requirements of the AOA-approved internship.

In reviewing data, we find that 374 applicants for Resolution 42 remain in an internship or residency and therefore are not yet eligible to be included in data regarding AOA board certification. In addition, of 243 approved applicants, 189 maintained AOA membership, and of 108 applicants who completed training, 10 are AOA board certified.

Dr Steier writes that Resolution 42 is "grossly overused, counterproductive for the osteopathic medical profession and our graduate medical education programs, and tantamount to handing a burglar your weapon, only to have him use it against you." Let us examine more closely the data regarding DO graduates in the two states mentioned in his letter (New York and Pennsylvania). During all 4 years of Resolution 42 activity, 34 applicants from students in New York in ACGME-accredited programs were reviewed and 32 were approved. During the same 4-year period, 41 applicants from students in Pennsylvania were reviewed and 39 were approved. Thus, those states registered 1425 DOs in ACGME-accredited positions, of which 71 were approved. It appears that these students made a choice to enter ACGME-accreduted programs, as only 5% of them requested AOA approval and the option to remain within the osteopathic family with osteopathic-related options in the future. Should those 5% be criticized and refused consideration over the 95% of osteopathic medical students who never so much as requested AOA approval or presumed to care?

I do not believe Resolution 42 to be counterproductive, and therefore, I do not support suspension of the resolution. While we continue to study further, our students continue to speak and act.

Michael I. Opipari, DO
Chairman
Council on Postdoctoral Training
American Osteopathic Association

 

[Sharky]

That's a good debate. I am more inclined to believe the point of view of Dr. Opipari but the argument against resolution 42 by Dr. Steier sounds more convincing.

I would still support resolution 42 and go as far as to widen the scope of hardships so that more DO students would be able to apply for it. There is no need to shun DO students just because they want to do an allopathic residency. The simple fact is that every year more and more DO students are going that way due to the notion that those programs are better. Whether that is true or not doesn't matter.

Dr. Steier's view is that of the old-school DOs that want to protect their turf and want to stay seperate from the allopathic profession. I'm of the opinion that sooner or later the prevailing view of most DOs and future DOs will be to integrate more with allopathic medicine and that would include supporting such resolutions like #42.

 

[InductionAgent]

Even more important than maintaining Resolution 42, we need to get rid of the stupid requirement of doing an AOA-approved internship in order to practice in the 5 states.

The problem with the AOA is that much like any organization (just look at our political parties), it tends to be the extremists' view that is most represented. So we often have the "I can palpate the cranial rhythm on your 4th toe" fanatics calling the shots and representing us to the rest of the medical world.

I think that if more DOs who complete allopathic residencies would maintain a connection with the AOA and let their voices be heard, the state of its affairs would not be so bad. So in part the mentality of "hell with the AOA, I'm doing an MD residency" is also to blame for the state of things.