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The DO | In Training | Training Ground

Proposal would limit DOs’ access to ACGME residencies, fellowships

Proposed rule changes announced in early November by the Accreditation Council for Graduate Medical Education (ACGME) would erect barriers to DOs who wish to transfer into ACGME-accredited residency or fellowship programs from AOA-approved internship or residency programs that are not dually accredited.

AOA: ‘We will take any and all steps to resolve this’

The AOA has not stood silently by while the proposed revisions to the Common Program Requirement of the Accreditation Council for Graduate Medical Education (ACGME) have been causing unrest in the medical educational arena. Instead, we are actively working to have these proposed policies recalled or amended so that osteopathic physicians will continue to benefit from additional career opportunities.

AOA President Martin S. Levine, DO, MPH, and I have submitted several letters to ACGME leadership expressing concern about the impact these changes would have on our collective ability to train the physician workforce. We collaborated with a majority of the osteopathic specialty societies to send a joint letter echoing those same concerns as part of our specialty college communication and advocacy plan. Several leading allopathic medical organizations have joined in with their support.

Email communications to directors of osteopathic medical education, DO trainees and osteopathic medical students have rallied professionwide advocacy to prevent the proposed changes from becoming permanent. I have met via conference call with ACGME CEO Thomas J. Nasca, MD, to protest the changes. Furthermore, a meeting of ACGME and AOA leaders is being scheduled for January 2012.

We will take any and all steps to resolve this situation to the benefit of the America’s 78,000 DOs.

—AOA Executive Director John B. Crosby, JD

To be implemented in 2014 or 2015 if approved, one change would restrict ACGME-accredited fellowships to MDs and DOs who complete residencies accredited by either the ACGME or the Royal College of Physicians and Surgeons of Canada. Fear of this change coming to fruition has already started to influence osteopathic medical students’ decision-making, says Mansoor Ali Jatoi, OMS IV, the student representative to the AOA Board of Trustees.

“I’ve had a number of calls from students who are concerned that if they match into an AOA-approved residency, they might not be able to pursue an ACGME fellowship four or five years from now,” notes Jatoi, who attends the Midwestern University/Arizona College of Osteopathic Medicine in Glendale. This is especially true of osteopathic medical students planning to specialize in internal medicine, who often extend their training with subspecialty fellowships, he says.

While he is participating in the upcoming AOA match, Jatoi points out that some students who would prefer to serve AOA residencies because of their commitment to osteopathic principles and practice, program location or connections are now questioning whether that would be a sound career choice in the long run.

Another proposed change to the ACGME’s common program requirements would prevent DOs serving osteopathic internships from transferring into ACGME residency programs unless they repeat their first year of graduate training. This revision would have a major impact on the training options of DOs who intend to practice in Florida, Michigan, Oklahoma or Pennsylvania—states that require an osteopathic internship for licensure.

In addition, four specialties with training programs accredited by the ACGME—family medicine, radiology, anesthesiology and physical medicine and rehabilitation—currently give DOs full credit for serving an osteopathic internship, and many other such specialties give partial credit for completed osteopathic graduate medical education (OGME). The proposed revisions would essentially nullify previously completed OGME, reducing the career choices of DOs in AOA-approved internship and residency programs that aren’t also accredited by the ACGME, according to Stephen C. Shannon, DO, MPH, the president of the American Association of Colleges of Osteopathic Medicine.

The problem isn’t just that these DOs would need to repeat a year of graduate training. Because of funding limits on graduate medical education imposed by the Centers for Medicare and Medicaid Services, “the proposed requirements may deny some physicians access to positions because repeating and then completing residency training may exceed the maximum five years of 100% funding,” wrote AOA President Martin S. Levine, DO, MPH, and AOA Executive Director John B. Crosby, JD, in a letter to the ACGME in November.

Professionwide response

AACOM and osteopathic specialty societies, as well as the AOA, have responded to the ACGME with letters calling for revocation of the proposed rule change, explaining both the impact the new requirements would have on DOs’ graduate medical training and the similarity in standards between AOA-approved and ACGME-accredited residency programs. In addition, many other organizations and individuals, such as residency program directors, have voiced their concerns to the ACGME, Dr. Shannon says.

Jatoi

The student representative to the AOA Board of Trustees, Mansoor Ali Jatoi, OMS IV, has heard from many osteopathic medical students who are concerned that the ACGME’s proposed rule change would adversely affect their career plans. (Photo by Patrick Sinco)

“The ACGME has expressed surprise at the magnitude of the response,” says Dr. Shannon, who remains hopeful that the proposed revisions to ACGME’s common program requirements will be amended.

Comments received by the ACGME will be forwarded to its Council of Review Committee, which will decide whether to make any modifications to the proposed rule at its February 2012 meeting. The amended rule would then be sent to the ACGME Committee on Requirements, which will meet in June. Before making a final decision next year, the ACGME will hold a public hearing during which the AOA, AACOM and other organizations can submit additional testimony.

The AOA has been chronicling the profession’s initiatives to communicate with the ACGME, while AACOM is providing answers to osteopathic medical students’ frequently asked questions about the proposed rule change.

Unintended consequences?

The rule change would affect foreign-trained international medical graduates, as well as osteopathic physicians. “From a number of conversations with people involved in medical education in the U.S., we believe that OGME programs were not specifically targeted for exclusion and that the impact on osteopathic medical training is largely due to unintended consequences,” Dr. Shannon says. “The ACGME did not fully analyze the reaction that would occur to the proposed changes.”

Some ACGME leaders have said they were unfamiliar with the accreditation standards governing OGME, Dr. Shannon adds.

“The ACGME is making no assumptions as to the quality of AOA-accredited residency programs in these new standards,” said ACGME CEO Thomas J. Nasca, MD, in a statement. “It is making an affirmative standard that all residents, regardless of medical school of origin or country of origin, who wish to participate in ACGME-accredited programs must participate in the complete program.”

The proposed rule change would not affect DOs training in the 20% of AOA-approved programs that are dually accredited by the ACGME. If the change is approved, Dr. Shannon expects that many more OGME programs will apply for dual accreditation.

cschierhorn@osteopathic.org

14 Responses

  1. Debra Meness on Jan. 6, 2012, 2:37 p.m.

    The ACGME vs AOA residencies is also a problem who those such as myself who wish to work in Canada. I completed an AOA internship and an AOA family practice residency and am board certified in FP from the AOA in support of a complete osteopathic training tract. As a result, I am unable to get licensed in Canada. I have been infomed that my medical school grades and board scores will be accepted but because I did not complete an ACGME residency I cannot obtain a license in any province in Canada. I now wish I had completed an ACGME residency or at the very least a dual accredited program.

  2. AT Stills on Jan. 6, 2012, 3:16 p.m.

    The ACGME cited its inability to independently verify AOA training. The ACGME is able to independently verify Canadian Training due to the cooperation and transparency of the Royal College of Physicians and Surgeons of Canada.

    The AOA should become more transparent, much like the Canadian body, and allow ACGME observers to monitor the high quality of education in our AOA internships and residencies. The AOA competencies and regulations are identical to the ACGME anyway. Being a graduate of AOA internship and a resident in ACGME, I have first hand knowledge that AOA training meets and exceeds the requirements of the ACGME.

    Such change in policy would allow the ACGME to provide its patients with proof that its residents are competent and safe, while protecting our American population from residents trained in residencies and internships outside the USA where the quality of education is impossible to verify and possibly dangerous to our loved ones.

    Closing the door to outside monitors raises suspicions. Some in AOA government have allowed self preservation tendencies and lobbying by some training programs to influence their decisions.

    Some AOA execs falsely believe that such isolation will “force” osteopathic students into AOA internships and residencies. Well, this is not North Korea or China, and osteopathic students will choose the same AOA residencies with or without AOA Government regulations.

    And any AOA executive who thinks such isolation will protect our AOA training programs is insulting our profession by implying that in a free residency market, our training programs will be ranked last. Such executives should reconsider their AOA membership.

    The AOA executives will have to examine their dedication to the best interest of the osteopathic profession and make the right decision for the profession. This is our opportunity to shine. Let’s welcome transparency in AOA government and allow ACGME monitors to visits once every 3-5 years. Keep AOA representative of the people who pay its member’s salaries.

    AOA execs; feel free to contact me
    aoadoctor@gmail.com

  3. dofellow on Jan. 6, 2012, 4:40 p.m.

    I’m currently doing an ACGME-accredited fellowship after completing a DO residency. My experiences in going through the matching processes, I wish I had completed an ACGME residency. Why? Because many of the programs did not even consider me because I’m a DO (how can I make that assumption? Because I interviewed at some of the most prestigious programs in the country). One may not believe this, but the prejudice of DOs still exists in many of the university programs. For example, I was offered an interview for a fellowship position at an ACGME program, but once they found out that I’m a DO, I never heard from them again. I feel that the only way to truly expand the awarness of DOs is to have the same match date. Many of the top candidates are not matching into ACGME subspecialties (mainly surgical programs) because they match with AOA programs. And I truly feel that the only way to raise awareness is to have top residents get the chance to represent us.
    I’m extremely satisfied with my currently fellowship and training. But in order to prevent the ACGME not to understand the AOA programs, we have to take the first step in raising awareness. Then we can go to the next step to represent AOA residencies.

  4. wmurad on Jan. 9, 2012, 12:13 p.m.

    I would encourage all programs to become dually certified. Teaching opportunities for DOs who have not been trained in ACGME or dually accreditted programs are also effected.I trainied in a AOA only accredited psychiatry program but the ACGME does not recognize my AOA traing and certification, thus baring me from supervising any of their residents. Nor can I do a fellowship in a ACGME program as no ACGME program will accept my AOA training for consideration of their fellowship. With few AOA psychiatry fellowship opportunities I am restricted in advancing my career. Prospective residents knowing this may then consider a ACGME residency tract. It would apear that the ACGME thinks many DO programs are substandard, by becoming dually certified that argument ends. It also then lends itself to ACGME validation of AOA specific trainings, such as manipulative medicine, something that helps both the trainee and the profession.

  5. Robert Swanson, PA-C on Feb. 26, 2012, 12:04 p.m.

    Having worked with many bright, talented, and exceptionally competent D.O.’s in a wide variety of clinical settings, it seems as if the ongoing bureaucratic tendencies of both the ACGME and the AOA will potentially have an unnecessarily negative impact on many practicing D.O. Physicians.

    Hopefully, before this issue becomes an unnecessary crisis of exclusion for many D.O.’s, the ACGME and the AOA will be able to come to a mutually satisfying agreement. Having trained extensively with many M.D. and D.O. residents, it truly seems that the similarities vastly outnumber the differences between Osteopathic Internships and the first year of most Allopathic Residencies. There is plenty of time to specialize in a medical career. As such, it really makes more sense to retain a general medicine/general surgery focus for the first year of ALL D.O. and M.D. residencies.

    Best of luck on a speedy and inclusive success for all D.O.’s and M.D.’s in this ongoing discussion.

  6. Cary Schneider, DO, MPH on April 24, 2012, 4:03 p.m.

    I have not read everything on this topic, and I appreciate
    AOA’s stance and the stance by my college: ACOEP. However, I have not yet seen anything that asks the big question: Why? What is it about AOA training that is turning off ACGME and the lack of ability to get licensed in Canada. What are we doing wrong that gives them the impression our training is inferior? Or, is the issue political in response to AOA programs not being inclusive to MD’s? Should our programs somehow join with ACGME as a partnership, not an adversary? Do we need to do something different? I apologize if this has been answered, but would like to know. Thanks, Cary Schneider,DO,MPH, FAOCEP.

  7. Deja Vu on May 2, 2012, 6:16 p.m.

    Will this discrimination ever end?

  8. Eric E. Shore, DO, JD. MBA on May 4, 2012, 5:05 p.m.

    This is just one more battle that was never necessary and can only serve to frustrate DOs who want training in highly ranked academic programs, want licensure beyond the borders of the US, and divide DO from DO and DOs in general from the remainder of the “Medical” profession.

    AS someone who has trained on “both sides,” I am sure of one thing; there is no significant difference between my AOA approved and ACGME approved training. There was no difference in academic material, philosophy or any other material aspect.

    Surely we can all see that DO and MD training programs need not ever be separated. Simply establish a joint commission on accreditation with the ACGME so that EVERY approved program in the country can be jointly accredited, and the entire problem disappears. Only an anachronistic parochialism on either side would prevent this, and the ultimate outcome would only be to hurt the graduates of DO schools. It will have little effect on anyone else.

  9. Reality Knocking on May 5, 2012, 10:16 a.m.

    This is largely brought on by the AOA’s policies. Open up, be transparent. Let others independently observe and critique our programs. Then it won’t be the big unknown that we currently are.

    DEAR AOA,
    OPEN UP AND BE TRANSPARENT….Then your life will improve.

  10. Satyanarayana G. raju, D.O., PhD., DAOBPMR, FAAPMR on Sept. 2, 2012, 5:56 p.m.

    It appears that the ACGME is undermining the internship/PGY1 training of the OGME programs. This proposal would discourage most of the Osteopathic students to skip the OGME internship/PGY1 where the DOs get more clinical training in OMT. We have some excellent DO physicians practicing OMT which makes us different from MDs. Some of the Allopathic medical schools are including OMT in their curriculum now recognizing the clinical advantage of this unique OMT treatment. This is unfair for the ACGME to treat the DOs with the international Medical Graduates.
    Now, The chiropractic treatment is well recognized and the chiropracters are hired in Federal organizations such as VA medical centers. The DOs practice much more than a chiropractor.

    I hope the AOA will fight for this proposal and need to take any legal action, if needed. All the DOs collectively fight for this unnecessary proposal and stop once for all.

    Thanks for allowing me to express my feelings.

  11. M Verdone, DO on Sept. 28, 2012, 11:55 a.m.

    Clearly a gift wrapped present by the AOA to the ACGME. Read b/t the lines. Less money for residency slots means eliminate potential competitors for those funds. This pissing match can end baldy and I would appreciate it if the AOA would wake up and start representing the best interests of it’s representative society.

  12. David Farrell on Oct. 11, 2012, 6:37 p.m.

    I don’t see what the problem is – the AOA keep telling everyone how special and unique osteopathic medicine is – so why would they want their grads going off to ACGME programs?

    And what about some equality? An MD grad can only apply for ACGME programs and not AOA ones – while DO’s can apply to both.

  13. Student on Oct. 12, 2012, 1:08 p.m.

    Dr. Raju said: “I hope the AOA will fight for this proposal and need to take any legal action, if needed. All the DOs collectively fight for this unnecessary proposal and stop once for all.”

    I’m not sure there is any legitimate legal action that could be taken here. Are MD students allowed to match into AOA programs? Nope. There goes any thought of legal action right out the window. There cannot be double standards if one wishes to be treated equally.

    As for “all DO’s collectively” fighting against the proposal, it appears as if that would be a tough stance to take when most DO’s do not feel the AOA truly represents the collective whole, but rather that of a small subset of DOs. Regardless, the ACMGE does not rely on the AOA to train the graduates it is responsible for. On the contrary, the osteopathic educational system has allowed itself to bloom out of control (yet praise its increased number of grads) without having the proper training set into place. The AOA most definitely relies on its bigger brother; it is not currently capable of training the graduates they are responsible for.

    Just imagine how this appears from an arbitrary perspective. No lawsuit there…

  14. Bart on Dec. 4, 2012, 9:22 p.m.

    This has directly affected me. I have been out in practice a few years after completing my osteopathic orthopedic training and went to apply for a sports fellowship for 2014. I have been told I am not eligible for 2014 but would be eligible for unfilled spots in 2013 due to the policy coming into place in 2014

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