Advocacy to improve access to training opportunities for DO students

The success of the osteopathic medical profession in the past two decades is undoubtedly due in part to the quality of care delivered by the graduates of DO-granting medical schools. DOs also tend to practice in primary care and other much-needed specialty areas, and in rural and other underserved locations. Unfortunately, however, during their clinical education years some DO students encounter barriers to applying to certain hospital systems or programs for elective clinical rotation experiences or residency training opportunities. With one in four entering U.S. medical students now choosing to enroll in a DO-granting medical school, and our societies’ advancements in standing up for diversity, equity and inclusion, there have been a number of successful advocacy efforts in recent years to advance educational opportunities for DO students.

The osteopathic profession advocates for its students and their credentials. Continuous efforts by the AOA, its affiliates and others to increase acceptance of osteopathic medical students and their qualifications, have helped to shine a light on some of the disparities encountered by DO applicants in some settings and to create change.

There have been reports for a number of years of some DO students encountering barriers to their medical education when they apply to visiting clinical rotations through the AAMC’s Visiting Student Learning Opportunities (VSLO) program. DO students have reported higher application or rotation fees, programs that do not accept DO applicants, and programs that don’t accept COMLEX-USA and require USMLE in order to apply. As a result of outreach efforts, a number of clerkship programs have changed their requirements to be more inclusive of osteopathic applicants. Some of the programs that have reported removing barriers for DOs include VSLO programs at Tufts University, Icahn School of Medicine and the Cleveland Clinic.

Though there has been considerable progress for DO students in this area, some academic medical centers still do not accept DO students into their clerkships. Due to concerns during the pandemic, the Coalition for Physician Accountability discouraged away rotations last year and recently announced changes for the 2021-2022 academic year, limiting the number of away rotations available. University of Virginia (UVA) policy restricts electives to students from Liaison Committee of Medical Education (LCME) accredited U.S. and Canadian medical schools and currently does not accept osteopathic or international visiting medical students. With over one-third of medical students in Virginia at one of the state’s two osteopathic medical schools, Liberty University College of Osteopathic Medicine or Edward Via College of Osteopathic Medicine, Virginia Osteopathic Medical Association (VOMA) is working to improve access for clinical education and training for DOs at UVA and other academic medical centers within the state, according to Maria Harris, VOMA executive director.

The National Board of Osteopathic Medical Examiners (NBOME) has been active in advocating with the graduate medical education (GME) community to reduce unnecessary barriers for DO students in their application for residency positions for over 10 years. The osteopathic medical licensing examination, COMLEX-USA, is accepted as a pathway to licensure in all 50 states, territories and D.C. (and required in a number of these jurisdictions), is a graduation standard from all colleges of osteopathic medicine, and is accepted by the majority of residency training and fellowship programs. COMLEX-USA acceptance has expanded since the single GME accreditation system was implemented. However, there are some programs that still ask a DO applicant for a USMLE score, either because they are unfamiliar with COMLEX-USA, assume all DO students take USMLE, or perhaps are unfamiliar with the easy-to-use percentile conversion tools that put numeric scores in context in screening and comparing large numbers of applicants.

And yet some DO students continue experience bias or discriminatory practices when applying for residency positions. While most residency programs accept DO applicants and utilize COMLEX-USA scores as part of a holistic application review process, some programs don’t interview DO applicants or require USMLE examination scores or even score minimums for all applicants. According to FREIDA, the AMA online platform utilized by some students to research residency program demographic data and application requirements, more than 1,000 residency programs report requiring only USMLE in order to be considered for an interview, even if an applicant has completed the comparable COMLEX-USA examination. Not all programs included in the FREIDA database provide information on licensing exam requirements, and when available, unfortunately the information included is often found to be inaccurate or outdated.

NBOME has been working with several state osteopathic associations in an advocacy campaign to increase awareness about osteopathic students and their qualifications, including COMLEX-USA. These efforts target residency programs to help program directors and other staff understand that COMLEX-USA is the required licensure exam and graduation standard for DO students, and, to the extent that licensure exams are used in residency applications, the appropriate and valid assessment for DO applicants. Program directors are often unaware that COMLEX-USA is required for the DO degree, for example, and that the additional stress, financial burden, test prep time, and uncertainty in an otherwise stressful environment for all applicants is unnecessary, unjust and unwarranted. For example, in Indiana, about half of all residency programs listed on FREIDA stated that they accept and train DO residents and use the osteopathic medical licensing examination as part of the review process.

This seemed unfair, and concerning. The Indiana Osteopathic Association (IOA) worked with the NBOME and reached out to programs at the Indiana University School of Medicine that publically list a requirement for USMLE for DO applicants on FREIDA. More than half responded that they do accept COMLEX-USA for DO applicants or are considering doing so in the future. For several remaining programs, the issue remains open, but the GME office indicated that they will study the issue this year.

“We’re so encouraged to work with our colleagues in GME in the state of Indiana,” commented IOA Executive Director Tabitha Arnett.

According to data on FRIEDA, approximately 13% of Virginia’s residency programs have a requirement for USMLE for osteopathic medical students. To improve equity in review of DO applicants, the VOMA is launching a new initiative to get to know GME programs in Virginia and learn how the state association can help. Harris states, “VOMA is committed to improving the situation in Virginia and is planning to visit residency programs in the state to establish relationships with program directors to help relieve barriers to DO applicants. Advocating for opportunities for students and residents is one way we can support future members of our profession.”

“DOs and osteopathic organizations are standing together to advocate for our learners and our patients to bring attention to any and all opportunities for education and to eliminate disparities in opportunities for DOs and DO students,” said NBOME President and CEO John R. Gimpel, DO, MEd, who has been an outspoken advocate for DO students. “Understanding the distinct and valid credentials and experiences of all applicants will contribute significantly to diversifying the educational milieu and improve the quality in our nation’s GME programs and the healthcare system, helping us to collectively take better care of our patients and communities.”