During the 2013 AOA Match in February, 60% of the traditional rotating internship programs filled fewer than half of their positions. And more than 20% of these programs filled none of their openings.
Many of the rotating internship slots are being filled post match by those who didn’t snag their desired residencies, whether AOA-approved or accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Once required of all osteopathic medical graduates, the traditional rotating internship has become largely a last resort—but not entirely.
In specific states and for certain specialties, the stand-alone internship remains a viable, though not mandatory, first year of training.
In addition, some states still license DOs who have completed just a rotating internship. But long gone are the days when such physicians could go into general practice, with board certification now normally required to participate in health insurance plans and obtain hospital privileges. Nevertheless, some solely internship-trained DOs have set up cash-based osteopathic manipulative medicine practices, to the consternation of those who are board certified in neuromusculoskeletal medicine and OMM.
Moreover, osteopathic physicians who plan to pursue laboratory research or administrative rather than clinical positions sometimes curtail their training after a one-year internship. And some DOs choose to do a traditional internship for personal reasons, such as a spouse’s location or re-entry into the profession after the birth of a baby.
Because the requirements and pathways for osteopathic medical training have become so varied and complex, confusion abounds over the role of the traditional rotating internship.
“Many osteopathic medical students have misconceptions about traditional rotating internships and are getting poor advice at their schools,” says John D. Parmely, DO, the program director of the AOA-approved general surgery residency at Botsford Hospital in Farmington Hills, Mich.
While younger members of the profession are perplexed about its purpose, many experienced osteopathic physicians lament the traditional internship’s decline because being well-rounded historically has been a hallmark of the DO difference.
“A lot of us think that the loss of the rotating non-specialty-tracked internship has been detrimental to the profession,” says Adam B. Smith, DO, the president of the American College of Osteopathic Surgeons. “We now have less-rounded physicians, whether they are going into surgery, internal medicine, pediatrics or any other specialty. If these young specialty-trained DOs are presented with any clinical challenges outside of their comfort range, they don’t have anything to fall back on. And they are less able to communicate with other specialists.”
“The job of a DO traditionally has been to be a doctor first and a specialist second,” adds Dr. Parmely. “We became complete physicians through the rotating internship. That’s part of what made us different from MDs.”
In their heyday, rotating internships also allowed DOs more time to choose their specialty. Dr. Smith argues that osteopathic medical students today are forced to make important career decisions too early. Because they need to schedule fourth-year rotations in desired residency programs in order to be seen, students must select their specialty by their third year. As a result, Dr. Smith contends, more DO graduates are making choices they later regret.
Devoted mostly to audition rotations in a particular specialty, the fourth year no longer provides osteopathic medical students any breadth of clinical training, Dr. Parmely points out. This further erodes DOs’ distinctiveness, he says.
Devolving with the times
Arguably, no one misses the required traditional rotating internship more than Michael I. Opipari, DO, the former longtime chairman of the AOA Council on Postdoctoral Training.
“The rotating internship for me was an extremely valuable year when I trained back in the 1960s,” Dr. Opipari remembers. “Even though I went into an internal medicine residency, I loved having experience in the operating room, in delivering babies and taking care of newborns, and in other areas because it helped me to become a better overall physician.”
Even more important, according Dr. Opipari, the traditional internship year was one of maturation for the young osteopathic physician. “You matured in terms of being able to talk to patients and their families and you came to understand clinical decision-making at deeper level,” he says. The stand-alone internship bridged the gap between the fourth year of medical school and residency.
But changes in health care and DO students’ expectations and interests forced the AOA to modify OGME, says Dr. Opipari, who spearheaded the restructuring of the first year of OGME, implemented by the AOA in 2008.
The MD world eliminated a mandatory rotating internship more than 30 years ago, at a time when the vast majority of DOs still were entering general practice right after completing a rotating internship. But as general practice evolved into the board-certified specialty of family medicine, requiring three years of residency, and as many states began requiring more than a year of training for licensure, the traditional osteopathic internship lost its luster, Dr. Opipari explains.
Because they had to complete an extra year of training beyond that expected of MDs, osteopathic medical graduates began to bypass AOA-approved training in favor of ACGME programs.
“In the late 1990s, we saw that our students were becoming less enchanted with our traditional rotating internship,” Dr. Opipari says. This is when student debt load began to increase significantly and DO students increasingly started pursuing higher-paying non-primary-care specialties to offset escalating educational costs.
“We started seeing more and more DOs leaving our profession for the allopathic world, which is why we developed specialty tracks and eventually shortened our training requirements,” Dr. Opipari says.
Fallbacks and end-arounds
But the traditional rotating internship lives on.
“Right now, the biggest group of people who take the rotating internship are those who did not match successfully into their desired specialty,” Dr. Opipari says.
Shaun Notman, OMS IV, is a case in point. In this year’s AOA Match, he failed to secure a coveted residency in orthopedic surgery, one of the most competitive specialties. So he will serve a traditional osteopathic internship at a Miami-area hospital that plans to start an orthopedics residency. If he doesn’t match into this residency program or it doesn’t get established soon enough, he will try to match either into an emergency medicine residency or into a family medicine residency followed by a sports medicine fellowship.
“Statistically, it is difficult to get into an orthopedic surgery residency from a rotating internship, so you need to have a backup plan,” says Notman, who attends the Nova Southeastern University-College of Osteopathic Medicine in Fort Lauderdale, Fla..
Unlike many fourth-year osteopathic medical students who don’t match into their first-choice specialties and end up scrambling for open spots, Notman matched into his rotating internship. “My wife and I matched as a couple,” he says. His wife will serve her family medicine residency at the same institution, Larkin Community Hospital in South Miami, Fla.
With young DOs determined to balance career and family, the rotating internship can provide needed flexibility.
Brian M. Fishman, DO, decided to do a one-year traditional internship at University Hospitals (UH) Richmond (Ohio) Medical Center to avoid having to spend three years away from his wife, a pediatrician who is in her first year of a three-year fellowship in St. Louis.
“We have been married for three years and together for 12 but have yet to live in the same city for more than three months at a time,” Dr. Fishman says. “I didn’t want to risk another three-year commitment and have us both end up in different cities. Since she was applying from residency and I was applying from medical school, we couldn’t match as a couple, and there was no guarantee that we would end up in the same locale.”
Luckily for Dr. Fishman, he has matched from his internship into a residency at Des Peres Hospital in St. Louis. But like many who match from rotating internships, he will not receive full credit for his first OGME year.
Dr. Parmely, however, worries about osteopathic physicians who opt for a stand-alone internship simply because of family matters or convenience. “These DOs spend six figures getting a professional degree, and they have to make a living when they finish,” he says. “So not making a commitment to a residency doesn’t make sense. You are supposed to make a commitment to yourself to get training so you can get a job and pay back what you owe.”
Moreover, many who enter rotating internships end up disappointed. Dr. Fishman points out that four DOs training with him chose the internship because it had been a pipeline to the highly competitive dermatology program at UH Case Medical Center in Cleveland.
“For some time, Case’s dermatology program took four MDs and two DOs a year. Doing a traditional year at UH Richmond guaranteed you an interview at Case,” Dr. Fishman says. “And each year, Case typically took one of our interns into its derm program. But this year, not one of the UH Richmond interns got into the Case derm residency. In general, Case seems to be accepting fewer DOs into its residency programs.”
The director of medical education at Broward Health Medical Center in Fort Lauderdale, Fla., Natasha N. Bray, DO, says that her six-position rotating internship program fills first and foremost because Broward has a dermatology residency, with three available positions a year. Second, the internship program draws trainees because Florida is one of the four states requiring DOs to complete an AOA-approved first year of training to practice.
“Our derm residents, however, don’t always come out of our traditional internship program,” Dr. Bray says. “This year, one is coming from our internship program, one is coming out of a year of research, and one is coming out of a family medicine residency program.”
Besides the Broward intern going into dermatology, one intern will do research, three are going into ACGME-accredited physicial medicine and rehabilitation programs, and one is entering a military residency in flight medicine.
“Those who should do a traditional rotating internship are a rapidly shrinking pool,” says Gary L. Knepp, DO, the director of osteopathic medical education at Methodist Medical Center in Peoria, Ill., which has dually accredited family medicine and psychiatry residencies but no longer a stand-alone internship. “The only medical students who should look at such an internship are those who want to enter a specialty that still requires a preliminary internship or transitional year.”
Methodist’s family medicine program would consider a candidate who has done an osteopathic rotating internship at another institution.
“But we have a strong enough family medicine program that we fill our slots in the first year,” Dr. Knepp says. “It’s a rare year that we have any second-year slots available, though sometimes people leave due to academic problems or health problems or because they change to a different specialty.”
Many students who do rotating internships end up having to repeat their first year when they land a residency, which can create funding problems because the Centers for Medicare and Medicaid Services does not like to finance what it considers gratuitous years of training, Dr. Knepp says.
And rotating interns often have difficulty securing residency positions.
“Many of these physicians have something in their backgrounds that prevented them from getting their first-choice residency when they tried to match in their fourth year of medical school,” Dr. Knepp explains. “So if they do an internship and then try to match, now they are up against the cream of the next year’s class. And as the number of residency positions has tightened, while the number of DO graduates has increased dramatically, the competition gets stiffer the second time around.”
Rather than being viewed as positive additional experience, the rotating internship frequently is regarded as detrimental, especially if the intern does not score well on Level 3 of the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA), Dr. Knepp says.
In part because of the stigma of mediocrity now associated with those in traditional internships, as well as funding challenges, Botsford will not consider rotating interns for its competitive AOA-approved general surgery residency.
“In my opinion, the person who does a traditional internship is damaged goods,” says Dr. Parmely. “I value the concept of becoming a complete physician first, but the reality is that we have a compressed timeline to train general surgeons and only a certain amount of dollars from the government.
“We do not accept any transfers into our five-year residency program. If you do a traditional internship, you have lost a year of training that you can’t repeat because of CMS funding restrictions.”
Richard LaBaere II, DO, the president of the Association of Osteopathic Directors and Medical Educators (AODME), says it is often unclear even to DMEs whether CMS will fund all or part of a repeated year of training.
Pursuing a rotating internship may be appropriate for individuals hoping to enter a specialty with a required preliminary year, says John Bulger, DO, the chief quality officer for Geisinger Health System in Danville, Pa. But a traditional internship, he argues, is generally not the best choice for someone who did not match into a desired, highly competitive specialty.
“There are instances in which DOs who couldn’t get into a specialty did a rotating internship and eventually got into it. But this probably happens less than 10% of the time,” says Dr. Bulger, the AODME’s immediate past president. “In my opinion, those who don’t match would be better off trying to get into an unfilled program in family medicine, internal medicine or pediatrics. At least they would be on a path to certification from the beginning.” If these residents remain interested in the more competitive specialty, they can try to get into it later, after building some credentials and credibility.
But it is a long shot for the unmatched to snare coveted spots the next year.
“If you are a middle-of-the-road applicant, doing a traditional internship will not make you a shining star,” Dr. LaBaere says. “You will be competing against a whole new class of super-qualified people the following year. So it is risky to put all of your eggs into that basket.”
For help in making such career decisions, Dr. Parmely advises osteopathic medical students to find mentors who are involved in OGME, not just in clinical medicine. “Many surgeons and other physicians who are out in practice but not in a teaching program have no idea what it takes to get a residency in the new millennium,” he says.
Several white papers have been written on the AOA traditional internship and the ACGME transitional year, Dr. Bulger points out. “The current thinking is that residents should be in a continuous path to certification from the beginning of training,” he says. “Each specialty should decide what the first year should look like. In some specialties, that initial year resembles the rotating internship.”
Dr. Smith, however, would like to see the traditional internship brought back as a requirement for all specialties. “It would be beneficial if every DO would have that broad-based training,” he says. “But I don’t see this happening because of dollars.”
Dr. Bray also sees value in the traditional internship. But it is not feasible to mandate it once again, she says.
“We’ve surveyed our residents, and the average debt load at the time of completing their residency is $250,000 to $350,000,” Dr Bray says. “Adding a year to their training would not be appropriate from the standpoint of cost utilization and resource management. You would actually be taking away a productive year from that physician’s career.
“To meet health care needs and address the physician shortage, we need to get DOs out into practice sooner rather than later.”