Elsevier

Journal of Surgical Education

Volume 68, Issue 3, May–June 2011, Pages 239-245
Journal of Surgical Education

2010 APDS spring meeting
A Primer on How to Select Osteopathic Applicants to an Allopathic General Surgery Residency

Presented at the 2009 meeting of the Association of Program Directors in Surgery held in Salt Lake, City, Utah.
https://doi.org/10.1016/j.jsurg.2011.01.001Get rights and content

Introduction

As part of Education Week 2009 in Salt Lake City, Utah, the Association of Program Directors in Surgery hosted a panel discussion addressing the integration of osteopathic graduates into allopathic general surgery residency training programs. This article summarizes this panel discussion and the questions asked by members of the audience.

With an increasing number of osteopathic medical school graduates, applications to allopathic general surgery residency training programs have been on the rise. Additionally, military scholarships are offered to students at both osteopathic and allopathic schools, increasing the percentage of osteopathic graduates seeking general surgery training in allopathic programs with a military affiliation.

The purpose of this work is to provide program directors and faculty members involved with resident selection a primer of information about the expanding role osteopathic physicians, answer potential biases and frequently asked questions about osteopathic applicants and provide practical information on matching osteopathic residents into an allopathic general surgery residency program.

There has been a dramatic increase of osteopathic graduates applying for allopathic general surgical training. The development of multiple new colleges of osteopathic medicine and expansion of already existing schools is expected to generate 5227 first-year students by 2012, which represents an increase of 1380 students (36%) since 2006. By 2016, the number of osteopathic graduates is expected to increase by an additional 62% over current numbers, whereas allopathic medical school growth is projected to increase by only 21%.1, 2 By 2019, it is predicted that 25% of all United States medical school graduates produced annually will be doctors of osteopathic medicine (DOs).1 The residency training of this increased number of osteopathic graduates cannot be accommodated within the American Osteopathic Association postdoctoral training programs and a significant number will enter the allopathic system. Between 1985 and 2006 the number of osteopathic physicians (DOs) training in Accreditation Council for Graduate Medical Education (ACGME) postdoctoral training has increased 419%.1 Currently, only 40% of osteopathic graduates enter osteopathic training programs, whereas 60% enter an ACGME training program.3

Traditionally, osteopathic medical school graduates have entered primary care specialties or rural practice. Between 1994 and 1996, DOs accounted for only 1.2% of graduates entering general surgery residencies.4 However, the number of osteopathic graduates entering surgical residencies is increasing steadily. In a survey of 1882 osteopathic graduates in 2004, the number entering surgical residencies had increased to 9%.5 However, this increase in DOs entering surgical residency may be misleading, as a large number of these may be nondesignated preliminary internships, and the number actually completing the general surgery training is likely far less.

Given this increase in the number of osteopathic graduates and likely increase in those applying to ACGME surgical residencies, general surgery program directors will need a greater understanding of how to select DOs for their training programs.

Dr. Andrew Taylor Still, a Missouri practitioner and Civil War surgeon, established osteopathic medicine as an offshoot of 19th-century allopathic medicine. In 1864, after he and others could not save 3 children with meningitis, he concluded that the medical practice of his day was ineffective. As a result, he developed an alternative philosophy and methodology, which he called osteopathy. The basic precepts of osteopathy are (1) the human person is a dynamic unit of function, (2) the body possesses self-regulatory mechanisms that are self-healing in nature, (3) structure and function are interrelated and mutually interdependent at all levels, and (4) a rational treatment regimen is based on these principles.3, 6

In 1892, Still3 founded the first school of osteopathy in Kirksville, Missouri. Graduates of this school went on to establish similar schools in Des Moines, Chicago, Kansas City, and Philadelphia. Many of these schools or their affiliated campuses are still in existence today.3 After the 1910 Flexner report, allopathic schools moved rapidly to a more uniform educational system, which resulted in better quality and consistency as well as greater alignment with research universities. Osteopathic institutions did not institute these reforms until the 1930s.7 By World War II, DOs were licensed for the full scope of medical practice in most states and in all states by 1973.3

Today, osteopathic students take a basic course in manipulative medicine, but the remainder of the curriculum is essentially the same as an allopathic school. Similar to course and clerkships at allopathic schools, the duration each specific course varies from medical school to medical school. Although the focus of osteopathic schools remains primary care, this is not different from many allopathic schools. Between 1970 and 2008, most osteopathic medical schools have become affiliated with larger universities; there has been greater emphasis on faculty sufficiency and integration of basic and clinical science. Many schools offer combined degree programs, such as DO/MPH, DO/PhD, DO and MBA.3 Today, it is nearly impossible to distinguish a well-qualified osteopathic graduate from a similarly qualified allopathic graduate.

However, there are some differences with respect to Medical College Admission Test (MCAT) scores and overall grade point average (GPA) required for admission, interpretation of national board examinations, quality of the clinical rotations, and faculty and requirements for particular states to practice as a DO. These factors make it difficult for allopathic program directors to select well-qualified osteopathic residents. In addition to having questions about osteopathic applicants, there may also be particular biases against osteopathic applicants and general misconceptions about selecting successful residents that need to be addressed.

As a program director, one of the first obstacles is to recognize potential biases against osteopathic applicants. If one considers the top 10 variables that surgical program directors value in resident selection8 (Table 1), many of these are difficult to interpret for or do not apply to graduates of osteopathic medical schools. Many allopathic program directors are not knowledgeable about the academic quality or requirements of specific osteopathic schools. In addition, only some osteopathic applicants have taken United States Medical Licensing Examination (USMLE) whereas others have only taken the Comprehensive Osteopathic Medical Licensing Examination (COMLEX). Program directors are also vexed by unfamiliarity with the persons writing letters of recommendation.

To add more confusion, many traditional variables used in the selection of both allopathic and osteopathic residents do not consistently predict success as a surgical resident. Traditional cognitive measures, such as USMLE scores,8, 9, 10 medical school grades,11, 12, 13 honors in core subjects,14, 15 or election into Alpha Omega Alpha (AOA)16, 17, 18 do not predict success as a surgical resident. Likewise, other commonly used variables, such as letters of recommendation,19, 20 the dean's letter,21, 22, 23 research,12, 24 extracurricular activities,25 or “audition” electives26 also do not correlate with success as a resident. This is likely because most residents are dismissed from surgical training because of irresponsibility, incompetence, dishonesty, personality issues, or ethical violations.27

The faculty of traditionally allopathic surgical training programs may have some bias against osteopathic applicants. For the program director, it is important to acknowledge this and to understand whether it is justified.

One common bias is that osteopathic graduates are not academically qualified, for if they were qualified, then they would have entered an allopathic medical school. Although there are certainly academically well-qualified college students who find the osteopathic philosophy attractive, there may be some truth to this bias.

When comparing osteopathic medical schools as ranked by MCAT score to the top 100 allopathic schools (Table 2), the best osteopathic school is on par with the 100th ranked allopathic school.28, 29 Additionally, the mean college GPA for those entering osteopathic medical schools was substantially lower than those entering allopathic schools (Table 2).28, 30 The findings by Jolly et al.,31 that 66.6% of osteopathic applicants also applied to allopathic schools, whereas only 14% of allopathic applicants applied to osteopathic schools, further supports this concern. It is not fully known if academic qualifications entering medical school are long lasting enough to influence or predict success as a resident. Given the findings outlined previously that medical school grades, USMLE scores, and election into AOA do not predict success, the concerns about academic qualification may be true but may not be fully justified. The program director and faculty must understand the limitations of academic performance. They must also agree to commit fully to the training of a particular resident, as there is a potential that being biased about academic qualification may have lasting effects on the quality of the training experience.

Another concern frequently expressed by program directors is the lack of familiarity with osteopathic medical schools. This is not surprising when one considers that of 28 osteopathic schools, the mean year founded is 1974 ± 36 years. Eighty-two percent of schools have been founded since 1970, 46% since 1990, and 32% since 2000.31 Adding to this concern is that fact that there are only 108 osteopathic teaching hospitals, two-thirds of which are in only 3 states (Ohio, Michigan, and Pennsylvania), and only 12 hospitals have more than 300 beds.32 The most established osteopathic medical schools are A.T. Still University–Kirksville (1892), Midwestern University–Chicago (1990), Des Moines University (1898), and Kansas City University (1916). Program directors need to be careful as several universities have multiple, geographically distant campuses. Based on the highest average MCAT scores, the following 4 colleges of osteopathic medicine are ranked the highest: Western University of Health Science–Pacific, Midwestern University–Arizona, Midwestern University–Chicago, and Des Moines University.29

Although most program directors may be familiar with scoring for USMLE, medical students and possibly inexperienced faculty frequently misinterpret these examination scores.33 Faculty members often do not know the mean USMLE scores to determine whether a particular applicant is above or below the national mean. The COMLEX score by contrast is relatively easy to interpret. Graduates of osteopathic medical schools are eligible for licensure using the National Board of Osteopathic Medicine Examinations (NBOME). One challenge of evaluating applicants for allopathic general surgery residency programs is interpreting the results of these examinations. The format for the examinations is the same as the USMLE, including 3 parts testing knowledge and 1 testing clinical skills. It should be noted that the NBOME examination, which is known as the COMLEX, also includes questions on manipulative treatment and the core osteopathic principles.34 One challenge with interpretation of the COMLEX examinations is the different scoring system. For levels 1 and 2 of the COMLEX, a minimum score of 400 has been set as passing with an average of approximately 550.34 On the National Board of Osteopathic Medical Examiner website, there is a formula to convert COMLEX scores into percentile scores at the time the test results are released.35 This has facilitated understanding the performance of an individual compared with their peers.

The relationship between USMLE and COMLEX scores is not well described, however, in a study of internal medicine residency applications, scores on these two examinations were strongly related. However, the authors of this study recommend caution be exercised, as there is significant variation in scoring methodology and applicant characteristics when comparing these two examinations.36 An obvious solution to this dilemma is to have a direct comparison of osteopathic applicants with their allopathic counterparts by requiring them to sit for the USMLE. By instituting this requirement, concerns about misinterpretation of COMLEX scores, different testing methodology, and differing examination content would be easily avoided.

Although the difficulty in making direct comparison between allopathic and osteopathic applicants on national examinations may be overcome by the requirement that both groups take USMLE, because osteopathic do not take the shelf examination, it is nearly impossible to make a direct, objective comparison of the specific knowledge attained during a clinical clerkship or basic science course. Program directors face the same problem when comparing applicants from allopathic schools that do not use the shelf examinations. In addition, there is no national standard for type of examination, the weight given to the examination or the clinical experiences for all medical schools. However, the quality of most allopathic schools is better known to the program director, so this is less likely to be a significant problem.

Traditionally, osteopathic education has focused on primary care; however, over the past several decades, this has changed.37 Although the duration of the surgery clerkship varies from school to school, most schools have at least a 4-week rotation. This situation is not substantially different from the de-emphasis of surgery at many allopathic medical schools.

It is in the interest of the program director to attract and recruit the best applicants. If the program directors and faculty have questions or concerns about osteopathic applicants, it is likely that allopathic applicants may share the same biases. As a result, there is a potential that seeing several osteopathic applicants or residents, an allopathic applicant may have concerns about the quality of the residency. No data suggest that having osteopathic residents is a marker of poor quality. In the experiences of each author, there is no evidence that osteopathic and allopathic residents have difficulty integrating or working together.

Even though a program director can correct or address biases through a sustained educational effort, there is no practical way to educate other applicants. One potential solution, should this be a concern, is to have all the osteopathic applicants interview on the same day.

Although DOs were licensed in 1973 to practice the full scope of medicine in all 50 states,3 some states require that a DO complete a traditional rotating internship before licensure. These states are West Virginia, Oklahoma, Florida, Michigan, and Pennsylvania. A traditional rotating internship includes 6 months of a core discipline and must include at least 2 months of internal medicine, 1 month of emergency medicine, 1 month of family medicine, or half a day per week for 46 weeks in an outpatient ambulatory care setting. It also includes exposure to anesthesiology, radiology, and pathology, and the remainder of the clinical time can be up to the choice of the program.38 The military accepts both allopathic and osteopathic graduates and does not have specific quotas for the numbers of each. Military personnel, however, may be granted an exemption from the rotating internship by The American Osteopathic Association. It should also be noted that osteopathic training is not accepted globally; hence, the ability for an osteopathic physician to practice internationally might vary.

Osteopathic graduates of allopathic general surgery residencies can take the American Board of Surgery (ABS) examinations to gain certification in general surgery. ABS data have demonstrated an increase in the number of osteopathic examinees since 1999. According to data provided by Thomas W. Biester, psychometrician at the American Board of Surgery, the average number of osteopathic examinees between 1999 and 2003 were 8 per year. However, between 2004 and 2008, the average number increased to 26 per year. When comparing DOs and MDs between 1999 and 2008, osteopathic diplomats have higher failure rate on the qualifying examination but a similar failure rate to the allopathic diplomates on the certifying examination (Table 3).

Given that allopathic and osteopathic medical schools seem to have at least similar curriculum and that DOs trained in allopathic programs likely had the same residency experiences, the finding that DOs have a higher failure rate deserves subsequent investigation. Although it is generally assumed that osteopathic graduates who seek allopathic training are the “best of the best,” this may not be true. National leaders in osteopathic medicine have made a concerted effort to keep the best osteopathic graduates within the osteopathic system.39 It is also not clear whether this increased failure rate can be attributable directly to the quality of the examinee or the quality of the training program into which they matched. Even though the ACGME and Surgery Residency Review Committee set rigorous and uniform standards for all residencies, there are likely some significant difference between programs. Given commonly held biases against DOs, it is possible that poorer quality allopathic residencies matched more osteopathic graduates. However, no objective data are available to support this. Finally, it is not yet clear that this failure rate is or will be consistent over time.

WSU is a large residency program affiliated with the United States Air Force that finishes 7 chief residents annually. Since 1999, 6 doctors of osteopathic medicine have completed the general surgery residency program. All passed the American Board of Surgery Certifying and Qualifying examinations on their first attempt. Five of these surgeons are United States Air Force officers. The lone civilian surgeon completed a surgical oncology fellowship and has returned as faculty at Wright State University, serving as an associate program director. One of the Air Force surgeons completed a minimally invasive fellowship and also serves as one of the WSU faculty based at Wright Patterson Medical Center. Another recent graduate and coauthor of this manuscript is currently in a critical care fellowship at the University of Southern California. The remaining surgeons have served or are serving as general staff surgeons at a variety of Air Force Bases around the world.

WSU has a robust experience with the osteopathic students applying for general surgery residency because of its affiliation with the military. Applicants apply via either the Joint Services Graduate Medical Education Selection Board or the National Residency Match Program. Approximately 20% of the interviewed applicants are osteopathic students. The osteopathic medical school curriculum is similar to allopathic schools in the preclinical years and focuses primarily on basic science. One key difference between the allopathic and osteopathic medical school experience is training in manipulation. However, the biggest difference between allopathic and osteopathic schools lies in the clinical years, where there is great variability in experience.

A brief survey was sent to 5 osteopathic graduates completing allopathic residencies who graduated from 5 different schools. They were asked how their clinical years were structured, the amount of time allowed for electives, the type of clinical experience (one-on-one apprenticeship vs. being a part of a multilevel team), and how much time they spent in formal teaching hospitals. At 3 schools, all third-year clinical rotations were set by the school at a core facility. Although there was some structure, there was a great deal of time allowed for electives. One individual commented, “we were allowed to go anywhere we were accepted as third and fourth year students but we had to do all the work ourselves to set it up.” The amount of elective time ranged from “all but 8 weeks of the fourth year experience” to “6, four week blocks.” The situation with off-site fourth-year electives is not different from Caribbean or allopathic medical students. Regardless of the type of medical school, arranging fourth-year electives is typically a medical student's responsibility, and most schools have difficulty vetting the quality of each. It is nearly impossible to determine educational rigor of off-site rotations, particularly if those rotations are performed with nonacademic faculty. The same questions regarding the academic quality of an elective clinical experience are in the minds of program directors as they review an applicant's fourth-year schedule. Despite these difficulties, it is incumbent on the medical school faculty to ensure a quality educational experience during all 4 years of undergraduate medical education.

The amount of one-on-one rotations varied by student and skill. In this small sample, at least 1 student spent 6 months in their third year and 6 months in their fourth year in an apprenticeship model. With regard to time spent in teaching hospitals that included a hierarchy of residents and students, the experience ranged from most of the rotations to approximately half of the clinical years.

None of the individuals commented on any difficulty with assimilating into allopathic residency. At least one surveyed individual commented that rotations at teaching hospitals using a hierarchal team model facilitated the transition into their allopathic residency program. Of note, 3 of the 5 individuals surveyed were counseled to take the USMLE examinations to be more competitive for allopathic programs.

At Wright State University, there has been a high rate of success in program completion and ability to obtain desired fellowship by osteopathic graduates. During the interview process, applicants typically are asked about their clinical experiences as a student to determine whether the applicants would fit easily into a large hierarchical, 6-hospital program. Some initial difficulty in the assimilation of individuals who have had a large percentage of their student experience as apprenticeships has been noted but typically resolves by PGY-2. Since 2003, the rotating internship experiences have not been offered to osteopath interns in the program, and this is explicitly told to the applicants during the interview process. However, any of the osteopathic doctors that match into the program are encouraged to apply for the American Osteopathic Association exemptions and approval of their intern year using their intern rotation schedule.

In conclusion, the WSU experience with graduates of osteopathic medical schools has been that they perform as well as their allopathic peers. Within the osteopathic medical school system, a great deal of variability in clinical exposure exists. Understanding this variability during the application process is key to successful assimilation. In the end, based on the WSU experience, top students are top students and top students make excellent surgery residents.

Section snippets

Conclusions

It is anticipated that there will be a rapid increase in the number of osteopathic graduates applying to allopathic surgical residency programs. Although there may be some differences in the characteristics of these applicants when they applied to medical school, there is essentially no difference between well-qualified osteopathic and allopathic applicants. Applicants from both types of medical school have similar educational experiences and perform equally well during residency.

Acknowledgments

The authors would like thank Thomas Biester, MS, of the American Board of Surgery for providing the data on the failure rates of both MDs and DOs on the American Board of Surgery Examinations.

First page preview

First page preview
Click to open first page preview

References (39)

  • M.B. Hahn

    Foreword: osteopathic medicine and medical education in the 21st century

    Acad Med

    (2009)
  • C. Chen

    The separate osteopathic medical education pathway: uniquely addressing national needs

    Acad Med

    (2009)
  • M. Green et al.

    Selection criteria for residency: results of a national program director's survey

    Acad Med

    (2009)
  • K.P. Black et al.

    Orthopaedic in-training examination scores: a correlation with USMLE results

    J Bone Joint Surg Am

    (2006)
  • D.A. Darosa et al.

    Evaluation of a system designed to enhance the resident selection process

    Surgery

    (1991)
  • D.R. Dirschl et al.

    Correlating selection criteria with subsequent performance as residents

    Clin Orthop Relat Res

    (2002)
  • E.E. Erlandson et al.

    Resident selection: applicant selection criteria compared with performance

    Surgery

    (1982)
  • P. Gardner et al.

    Rites of fall: the costs and utility of the internship interview

    J Med Educ

    (1978)
  • Grades as predictors of physicians' career performance: an evaluative literature review

    J Med Educ

    (1973)
  • Cited by (0)

    View full text