Saving Osteopathic Family Medicine, Now is the Time to Transform Our Practices
By Jan M. Willcox, DO
Abstract: There continues to be an annual increase in the number of graduates from osteopathic medical colleges; however the decline in the percentage of osteopathic graduates entering family medicine remains a cause for concern. Once considered the backbone of osteopathic medicine, the specialty of family medicine no longer holds the same allure for graduates. Osteopathic family medicine provides a significant contribution to the well being of a community and is best placed to produce an efficient primary care base for society. For family medicine to thrive, the profession must once again broaden the scope of practice, enhance procedural skills training in residencies, and return the prestige for family medicine on our campuses. Osteopathic family medicine residencies that provide training in novel models of care, promoting electronic medical records (EMR) and procedural skills will bring increased financial return and practice satisfaction for their graduates. The data indicate that the time for change is now if we are to remain competitive in recruitment of osteopathic graduates into osteopathic family medicine programs.
Introduction
The recent decline of osteopathic and allopathic graduates entering primary care is a cause for concern for many in the United States.1 Societies such as China have lost their primary care base and find their access to health care diminished while costs continue to rise. As the United States begins the next decade with predicted healthcare workforce shortages, the need for an efficient primary care base is even more vital. Many in the private sector have taken notice as can be seen when the leadership of the American Association of Family Physicians (AAFP) and ACOFP are called upon by IBM, Kaiser and others to find a solution to the decreasing primary care base.5 Effective prevention strategies, efficient chronic disease management and the delivery of primary care services have been realized as integral in maintaining the health of our citizens.5 The contribution family medicine brings to the wellbeing of a country has now been embraced. We now are faced with the question of whether we are training a sufficient number of primary care physicians to meet U.S. needs.
History of Osteopathic Family Medicine and Residency Training
Osteopathic family medicine is a recent specialty from a historical perspective. For many years non-residency trained allopathic and osteopathic physicians enjoyed general practice, caring for the health of families, including newborns and their elderly great-grandparents. The generalist practiced a broad scope of medicine including delivering babies, performing cesarean sections, appendectomies, and tonsillectomies and caring for critically ill hospitalized patients. In the late 1960’s, acceptable training for the general practice of medicine was four years of medical school followed by a rotating internship. The evolution of evidence-based medicine and the increasing scope of the practice of generalists brought about Accreditation Council for Graduate Medical Education (ACGME) family medicine training guidelines in 1967, and family practice became the 20th U.S. medical specialty in 1969.1 Soon osteopathic graduates sought equivalency in family medicine training and the one year osteopathic family medicine residency following internship evolved. In the early 1980s, the total number of osteopathic graduates who entered general practice residencies remained small and most still entered general practice following internship. By the end of the decade; however, the acceptable entry to the practice of osteopathic general practice or family medicine was a one year family medicine residency beyond internship. In 1990, a two year residency training (following a one year internship) was offered as an option to osteopathic graduates entering family practice. In 1993, the American College of General Practitioners in Osteopathic Medicine changed its name to the ACOFP and the board certification changed from general practice to family practice. Later in this decade the expanding scope of family medicine, the body of evidence based medicine, and the demands for parity in training would all help establish a standard completion of a second year of family medicine residency training beyond internship. The difficulty became that the two years of additional training beyond internship for family medicine did not bring about a parity of pay with specialties, or an increase in the funding for services.1
The mid-1990’s began another new trend; osteopathic physicians were readily admitted to allopathic family medicine residency programs. A trend for parallel accreditation for residency programs (AOA and ACGME) soon followed.1 The National Matching Residency Program results demonstrate that less than ten percent of allopathic graduates are seeking family medicine as a career. ACGME family medicine residency directors have become increasingly interested in seeking AOA accreditation for their ACGME residency programs and recruiting osteopathic graduates into their programs. Minimal differences in curricula exist beyond the incorporation of osteopathic principles and manipulation. The seamless integration of osteopathic physicians into the ACGME family medicine faculty is effortless (given the osteopathic physician is often a graduate of the said allopathic program).1
With the trend to accept osteopathic residents into ACGME residency training programs, the profession has seen a decrease in the number of osteopathic graduates participating in the osteopathic residency match. In 2002, there were 2569 osteopathic graduates with 1361 participating in the osteopathic match. By 2003, there were over 5,838 total osteopathic graduates training in ACGME accredited programs compared to the 2,523 training in osteopathic accredited residency programs. In 2005, there were 2,826 new osteopathic graduates with 1,228 entering the osteopathic match (44 percent).2 According to data provided by the AOA, 1424 osteopathic graduates entered these osteopathic internships in 2006 and 1493 in 2007. While in 2007 the total number of graduates entering both AOA and ACGME training programs rose, the percentage entering osteopathic residencies recovered only slightly, to 49 percent, with 1624 entering the NRMP match.
Turning the Trend in Osteopathic Family Medicine Residency Training
By early 2000, the gap in income between the specialist and the family physician was growing. Allopathic and osteopathic graduates began to turn away from family medicine and toward residency programs that led to fields that offered less work hours and higher pay.3 The number of family medicine residency training positions fell from 3,292 in 1998 to 2,983 in 2002, and solely ACGME accredited programs were only 79 percent filled.3 In 2002, the total AOA approved family medicine training positions had grown to an all time high of 1,552, yet only 50 percent of these positions would fill.3 By 2003, it was reported that 47 percent of the 2,650 graduates entered osteopathic residencies and only 215 of 338 internship positions linked to osteopathic family medicine residencies were filled. In 2003, there were a total of 581 residents for the 1,596 family medicine residency positions available.4
Over the past four years, while there has been a decrease in the percentage of all residents entering family medicine, there also has been an actual increase in the total number of osteopathic graduates entering family medicine. In 2006, 450 residents were enrolled in these osteopathic family medicine residency positions, and in 2007 this number rose to 608 residents enrolled in the 1751 approved osteopathic family medicine residency positions.5 Osteopathic graduates continue to enter ACGME approved residency training programs as well. In 2005, 240 osteopathic graduates would enter ACGME-only accredited family medicine programs and 90 entered an AOA/ACGME dually accredited family medicine residency.6 In 2008, according to NRMP match data, 263 osteopathic graduates entered ACGME family medicine residency programs.7
In a 2005 survey of the directors of ACGME accredited family practice residencies, the majority perceived that parallel accreditation would enhance the competitiveness of their program and also increase the overall quality and prestige of osteopathic residency programs.8 This becomes evident when one looks at the increasing number family medicine programs obtaining parallel accreditation. Between the years of 2002-2007, the total number of osteopathic family medicine residencies grew, 35 new programs applied and were approved by ACOFP and the AOA between the years 2005 to 2007, the majority with ACGME/AOA parallel accreditation.8
Osteopathic graduates remain a significant resource for ACGME primary care residencies. The NRMP 2008 data demonstrate 1,339 new osteopathic graduates entering the match, a slight decrease from recent years. The top five residency choices for these osteopathic graduates were: family medicine, internal medicine, pediatrics, obstetrics, and psychiatry.9
Despite the downturn in primary care percentages, in 2007 the majority of osteopathic colleges boasted numbers ranging from 20 percent to 28 percent of graduates entering family medicine.9 In addition, 54.6 percent of deans of allopathic medical schools reported that training future primary care physicians was more important to their institutions than training other specialties, while 100 percent of osteopathic medical school deans reported the same.9
Over the years, students have repeatedly cited the reasons for residency choice to be quality, geographic location, and availability of specialty choice.10 The osteopathic profession; however, has done little to change the distribution of family medicine residencies.10 The majority of all residencies (75 percent) remain in seven states and family medicine follows this distribution.10 Osteopathic colleges have grown to a total of 26 colleges with three branch campuses, and these colleges are located in 24 states. The geographic distribution of residency programs has not followed this growth. While some colleges added new osteopathic residency opportunities to meet the growth of graduates within their state, others have relied on ACGME programs to meet the need. In addition, some established colleges of osteopathic medicine do not consider post-graduate training a responsibility of the college.10
In view of the increasing number of ACGME programs with AOA accreditation, it is not a surprise that students easily find ACGME family medicine residency programs in their desired geographic location more appealing than those the osteopathic profession has to offer, even when program quality is felt to be equal.10
Current Trends in the Practice of Family Medicine
In 2004, 629,000 (67 percent) of the 936,000 physicians in the United States were involved in patient care. According to the AMA Master-file data reported in Academic Medicine,11 The same report identified 226,000 (36 percent) practicing family medicine/general practice, internal medicine, and general pediatrics with 131,040 (14 percent) of those practicing in family medicine or general practice. See Chart 1.
This same article reported 46,800 (5 percent) of all osteopathic physicians practicing patient care with 25,740 (55 percent) in all primary care and 10,553 (41 percent of primary care) in family medicine or general practice. See chart 2.
In a 2008 a nationwide study was performed by the National Center for Analysis of Healthcare Data (NCHAD) at the Virginia College of Osteopathic Medicine. (The prior study from the Robert Graham Center utilized data from the AMA Physician Masterfile in 2004.) The State Medical Boards released data to NCHAD that shows 85,290 practicing osteopathic physicians (including interns and residents) with active licenses to practice in 2008. After removing the interns and residents, it is still apparent that the osteopathic profession could not have grown by over 20,000 in four years. This variation reflects the significant differences found in content and quality of data collected and provided relative to all healthcare workforce professionals in this country, especially relative to their practice site(s) information. The AMA Physician Masterfile updates a percentage of their information on a rolling basis through a survey of a portion of their membership. The information collected by the state medical boards varies and what they provide can be very limited and updated infrequently due to state regulations and/or lack of resources. In addition, the AOA noted this year that a difference in the AOA physician data and AMA Physician Masterfile data existed. According to the data supplied by the state medical licensing boards of all fifty states, the analysis of this data showed 85,290 osteopathic physicians (including those in post-graduate training) currently practicing in the United States, with 24,611 (29 percent) practicing in primary care, and a total of 18,619 (21 percent) in family medicine or general practice.12 See chart 3.
Conclusions
If family medicine is to not only survive but thrive, the osteopathic profession cannot sit back and wait for a health policy change or financing reform. While it is important to lobby for improved funding for family medicine and primary care, in the current financial crisis increased payments for service are not likely to be realized for some time to come.
The osteopathic family medicine profession must present a consistent message to osteopathic medical students that given the appropriate education, family medicine is a field in which they can prosper.
To prosper, residency programs must promote newer models of primary care, such as the medical home model, and teach the use of EMR in practice. In addition, training on in-office technology and for in-office ambulatory procedures must be fundamental to every family medicine residency. Essential to the financial stability of the graduates is the incorporation of ambulatory procedural skills such as dermatology, colonoscopy, bone densitometry, ultrasound, mammography, colposcopy, cardiac stress testing, and minor orthopedics. Training in ambulatory procedural medicine is an excellent source to increase revenues for the residency program and to enhance recruitment. Osteopathic family medicine residencies are well poised to make this change. Osteopathic medical students have over the past decade turned their backs on managed care practices where family physicians become triage experts and the most interesting cases and procedures leave the office. The profession must return family medicine to a broader scope of practice and assure procedural skills that will provide graduates with a rewarding career with a sound financial return.
Residencies must also incorporate allied health care providers such as nurse practitioners and physician assistants in residency training in order to assure future successful practice collaborations. Collaborative practices are essential to meet the needs of the growing population in times of a healthcare workforce shortage.
Osteopathic Post Graduate Training Institutes must improve the geographic distribution of AOA accredited family medicine programs. New osteopathic family medicine residencies must be developed in states where new osteopathic colleges are located and no osteopathic programs currently exist.
Osteopathic colleges must actively engage in the process of enhancing primary care training by supporting the development of new family medicine residencies and by increased efforts to improve the visibility and status of family medicine on their campuses.
It is only through these combined efforts that we will see family medicine once again take the rightful place as the foundation of osteopathic medicine. As big business and insurers are looking for a way to stimulate the growth of primary care, has the time for change ever been better than now?
Acknowledgements: Ann Peton for the maps and data analysis, National Center for Analysis of Healthcare Data, Virginia College of Osteopathic Medicine Blacksburg, VA.
| The following map reflects the distribution of osteopathic family medicine residencies in 2008. |
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| The following map reflects the distribution of osteopathic family medicine and general practice physicians in the United States in 2008. |
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