Any licensed osteopathic physician can focus his or her practice on osteopathic manipulative medicine. No residency or board certification is required. Indeed, notes Michael A. Seffinger, DO, the immediate past president of the American Academy of Osteopathy (AAO), some DOs straight out of osteopathic rotating internships have set up cash-only OMM specialty practices in wealthy communities and reportedly make $500,000 or more a year working three days a week.
But, generally, those who specialize in OMM have additional credentials and are not in it mainly for the money, which tends to be in the mid-range for medical specialties—more than primary care but less than surgical specialties, says Lisa A. DeStefano, DO, who chairs the OMM department at the Michigan State University College of Osteopathic Medicine (MSUCOM) in East Lansing.
Many OMM specialists feel they have a calling. They devote themselves to learning as much as they can about osteopathic principles and practice over the course of their professional lives to improve the health of their patients, and they seek to share their knowledge with others to raise the quality of health care on a broader scale. Some of these DOs also perform or promote OMM research to advance the profession and enhance patient outcomes.
More than a decade ago, DOs who had five years of practice experience and 500 hours of continuing medical education in OMM could become AOA board certified in the specialty by taking examinations. “Our specialty was the last in the profession to have such a practice track,” points out Dr. Seffinger, who was certified in OMM in this manner. Today, only those who serve a residency in neuromusculoskeletal medicine (NMM) and OMM are eligible for board certification in NMM/OMM.
Such board certification is a prerequisite for chairing an OMM department at an osteopathic medical school or directing a residency program in the specialty, but it does not increase the amount or likelihood of reimbursement for osteopathic manipulative treatment, says Melicien A. Tettambel, DO, who chairs the American Osteopathic Board of Neuromusculoskeletal Medicine, the AOA certifying board overseen by the AAO.
DOs who desire to deepen their knowledge of NMM and OMM to better care for patients and who aspire to OMM-related leadership positions in academia, hospital settings and organized osteopathic medicine should consider an NMM/OMM residency, recommends Dr. Tettambel, who chairs the OPP department at the Pacific Northwest University of Health Sciences, College of Osteopathic Medicine in Yakima, Wash. Osteopathic physicians who simply want to hone their OMT skills or learn new techniques can do so by attending CME workshops and practicing on their peers and later their patients, she says.
In fact, the neuromusculoskeletal designation stems from the need to distinguish the residencies and board certification from skill in OMT, Dr. Tettambel says. Expected to become experts in neuromusculoskeletal function, NMM/OMM residents serve rotations in neurology, orthopedics, rheumatology, pain management, physical medicine and rehabilitation, and other specialties. Although the emphases of each program differ, all residents receive inpatient and outpatient clinical training and have teaching and research obligations.
Four pathways to certification
Becoming board certified in NMM/OMM requires completing one of four residency tracks:
- A two-year program in NMM/OMM following a traditional osteopathic internship.
- A one-year program in NMM/OMM following an AOA-approved residency in another specialty, known as a “Plus One.”
- An integrated three-year program in family medicine and NMM/OMM.
- An integrated three-year program in internal medicine and NMM/OMM.
Those selecting an integrated residency generally plan to become primary care physicians who emphasize but don’t limit themselves to OMM. Those pursuing a two-year NMM/OMM residency right after their internship typically specialize in OMM. Those completing a Plus One residency often do so later in their career and sometimes drop their original specialty in favor of OMM, says Dr. Tettambel, an AOA board-certified obstetrician and gynecologist who for much of her career integrated OMM into her other specialty but currently focuses on OMM.
After completing their residencies, DOs need to pass an oral, a written and a practical examination to become certified in NMM/OMM.
DOs who are certified in NMM/OMM, whatever the route, should not be confused with DOs who are AOA board certified solely by the American Osteopathic Board of Family Physicians in family medicine and OMT. Dr. Tettambel notes that while the AAO would like to see osteopathic physicians in all specialties perform or at least appreciate the value of OMT, NMM/OMM-trained DOs have deeper knowledge of musculoskeletal medicine, more experience applying OMM to a broad range of patients, and more OMM teaching and research experience.
“We are seeing a renaissance of people—patients and MDs especially—who seek DOs who do OMT,” Dr. Tettambel notes. “Yet only a small proportion of DO graduates do manipulation. And those who devote their lives to OMM and are board certified in NMM/OMM tend to be looked down on by our profession’s other specialties.”
With certain exceptions, NMM/OMM residencies often do not fill. Rather than being funded by the federal Centers for Medicare and Medicaid Services, NMM/OMM residencies for the most part are funded by hospitals or osteopathic medical colleges. Some of the programs struggle to maintain their funding amid declining interest among DO graduates and competition from specialty training programs that generate more revenue for hospitals.
Such concerns notwithstanding, osteopathic physicians who train in NMM/OMM point to fulfilling, lucrative careers with plenty of opportunities. More important, patients benefit from the additional knowledge and skills their DOs gleaned during residency.
“Residency-trained specialists in NMM/OMM have the skills and confidence to handle a huge range of conditions afflicting patients of all ages,” notes Dr. Seffinger, who chairs the NMM/OMM Department at the Western University of Health Sciences College of Osteopathic Medicine of the Pacific in Pomona, Calif. “They are able to make a living by about four months after residency via word-of-mouth recommendations from satisfied patients.”
Beyond the basics
“The things we learn in the first two years of osteopathic medical school are important, but they’re fundamentals; they don’t even scratch the surface of OMM,” says T.J. Macari, DO, who is completing a two-year NMM/OMM residency at St. Barnabas Hospital in the Bronx borough of New York City.
Like many DOs who enter these residencies, Dr. Macari had served a fifth-year undergraduate OMM fellowship. Sometimes called OMM teaching assistantships or scholarships, such programs normally offer a stipend and free tuition for the extra year and divide students’ time between teaching in the OPP lab, seeing patients in a clinic, and going on rotations with OMM preceptors.
“Every time you teach someone something, you develop a better understanding of it,” Dr. Macari says, explaining why being a fellow fueled his desire to specialize in OMM. Even more significant, he served a few elective rotations with Hugh M. Ettlinger, DO, the renowned director of the St. Barnabas NMM/OMM residency program, and spent time with several other seasoned OMM specialists. Although Dr. Macari initially thought he would become an emergency physician first and do OMM on the side and a Plus One residency years later, these mentors instilled in him an appreciation for all the specialty involves.
“There was so much more I needed to learn,” he says. What’s more, the hospital rotations opened his eyes to the impact OMM can have on seriously ill patients, and he craved more of this experience.
Dr. Macari applied to do a rotating internship and NMM/OMM residency at St. Barnabas because of the program’s strong clinical reputation, he says. One of just seven two-year NMM/OMM residencies, the St. Barnabas program has six funded positions that usually fill.
Functioning as a consulting service, NMM/OMM residents are in every department in the hospital. “No two days are the same,” Dr. Macari says. “When our day starts off, we’re either in medicine and surgery or pediatrics and obstetrics. If we’re in pediatrics, we start in the nursery at 7 a.m. and treat newborns who were born overnight and the day before. If we’re in medicine and surgery, we’ll write up initial consults for patients awaiting surgery. Once they’re called, we follow up with them each day they’re in the hospital.” Every day, the St. Barnabas NMM/OMM residents also treat outpatients in the hospital’s clinic and attend didactic programs.
While the St. Barnabas program provides intense clinical training, some other NMM/OMM programs place more emphasis on teaching and research, says David C. Mason, DO, the director of the two-year and Plus One NMM/OMM programs at the University of North Texas Health Science Center Texas College of Osteopathic Medicine (UNTHSC/TCOM) in Fort Worth.
Trained originally as a family physician, Dr. Mason feels strongly that all primary care physicians and many other specialists should use OMT and that NMM/OMM residents need to help family medicine, internal medicine and other residents develop their skills. “I see my NMM residents as mentors and liaisons for all of the osteopathic residency programs we have in our OPTI,” he says.
Given that the professionwide Osteopathic Research Center is based at UNTHSC, a strong research culture permeates the university. The NMM/OMM residents must conduct a research project with publishable results, Dr. Mason says.
Just ending her decade-long tenure as the director of MSUCOM’s two-year NMM/OMM residency, Dr. DeStefano championed a scholarly, analytical approach in her program. “I wanted my residents to understand that they were not here to get an education in how to do OMT,” Dr. DeStefano says. “Our goal is for residents in our program to become experts in how the musculoskeletal system works in its normal function—every aspect of it. They are expected to do substantial reading in basic science and understand that there is a lot of reflex neurology involved in the musculoskeletal system.
“Our residency focuses on biomechanics and the underlying rationale for doing OMT rather than the techniques themselves.”
Candidates for MSUCOM’s residency, which has three positions, match in the fourth year of medical school and serve a rotating internship at Sparrow Hospital in Lansing, Mich. Because the program typically fills, it rarely accepts candidates from rotating internships at other institutions, Dr. DeStefano says. Although the number of applicants varies each year, the program has more candidates than open slots.
MSUCOM’s program requires passing but not necessarily high scores on the Comprehensive Osteopathic Medical Licensing Examination—USA (COMLEX-USA). “Applicants don’t have to be brilliant as far as their board scores go,” Dr. DeStefano says. “But they have to be very passionate about function. We prefer individuals who understand our goals and our mission. I look for candidates who aren’t just looking to make a lot of money doing OMT. If they just want to do manipulation, they probably should have gone to chiropractic school.”
Although top board scores are not required, those matching into their first-choice NMM/OMM residencies in 2009 had an average score of 520 on COMLEX-USA Level 1, tying with those matching into AOA-approved neurology residencies, according to a report issued last year by the American Association of Colleges of Osteopathic Medicine.
Most NMM/OMM programs require a dean’s letter and three additional letters of recommendation. When possible, students who are interested in a particular residency should serve one or more OMM rotations at the sponsoring institution, as Dr. Macari did at St. Barnabas. All of the programs prefer known over unknown candidates.
Dr. Mason is most impressed by applicants who have taken CME courses in OMM and cranial techniques throughout all four years of medical school. “Students who take these courses don’t get the CME credit, but they do get the education,” he says. “This indicates to us that they are committed to this.”
The director of the two-year and Plus One residency programs at the Philadelphia College of Osteopathic Medicine, Alexander S. Nicholas, DO, usually favors applicants who were undergraduate OMM fellows and active in the Student American Academy of Osteopathy. “The OMM fellows make the best residents because they’ve already been through everything twice,” he says. “They know all the theories and principles and more than a dozen styles and techniques. These are the individuals who can hit the ground running in our program.”
What irks Dr. Nicholas is the many applications he has received from DOs who have been in practice for decades but haven’t been doing OMT. “They think they can come in and do a Plus One and go out and practice OMM,” he says. “I ask them, ‘Have you done OMT in 20 years? Do you know counterstrain, myofascial release and cranial techniques?’ And they say, ‘No. I figured I’d learn that in the residency.’
“I counter, ‘No, you don’t understand. You’re already supposed to have that knowledge, and I’m supposed to make you better at it in the residency. You’re also supposed to help me teach. If I have to teach you everything, you can’t be very helpful to me in treating my patients.’ ”
In July, Dr. Macari will open a private solo OMM practice in Boston. Because of low reimbursement rates, he is leaning toward not accepting Medicare or insurance, at least initially. “I’m going to try to keep my rates reasonable and see what happens,” he says.
Dr. Mason, who previously practiced in New Jersey, notes that reimbursement rates for OMT vary regionally and are especially low in the Northeast, which is why this part of the country has many cash-only OMM practices. He has found the reimbursement to be much better in Texas, where OMM specialists typically accept insurance.
Having trained at St. Barnabas, Dr. Macari enjoys practicing in hospitals, but he won’t have hospital privileges for a while. “When you apply for hospital privileges as a board-certified internist or obstetrician and gynecologist, for example, experts are always available who can review your credentials. But because so few of us are board certified in NMM/OMM, when you apply for privileges, you are often the only expert and you have to do all of the legwork for the hospital in terms of figuring out what forms they need and how to complete them. It’s not easy paving your own way into a hospital.”
Dr. Macari mistakenly thought he would be able to obtain privileges relatively quickly at a Boston hospital that has DOs on staff who do OMT. “But they are on staff as board-certified family physicians who have OMT privileges,” he says. “They asked me, ‘Are you board certified in family medicine and OMT?’ And I said, ‘No, I just do OMM.’ Silence followed.”
Because of all the paperwork to get privileges, Dr. Macari has put this objective on hold for now. “First, I want to get my practice going until it’s self-sustaining,” he says.
Dr. DeStefano has helped many DOs who trained at MSUCOM obtain hospital privileges, sometimes enlisting assistance from the AOA. “It’s not discrimination on the part of hospitals so much as ignorance,” she says. Because NMM/OMM board certification has no allopathic counterpart, hospitals aren’t sure what it is, she explains.
“There are so few of us in America,” DeStefano notes. “People don’t know who we are.”
But Dr. Macari is hopeful that his practice will thrive. As he builds it from scratch, he will use his downtime to study for the three-part board-certification examination in November. He expects in time to precept students, teach part time at the osteopathic medical school in Maine, and perhaps eventually follow in the footsteps of his mentors.