Osteopathic Principles and Practices in Osteopathic Medical Schools
By Gautam J. Desai, DO
ABSTRACT: Osteopathic education has evolved tremendously since the founding of the American School of Osteopathy by A.T. Still MD, DO on May 10, 1892. Not only has there been remarkable expansion in the number of schools of osteopathic medicine to the current 23 schools in 26 sites1, but there has been an expansion in the breadth and depth of osteopathic curriculum. Osteopathic educators are challenged to devise curriculum that stays true to the basic tenets of osteopathic medicine and in the spirit of Dr. Still, is innovative and pioneering.
Osteopathic curriculum may vary widely from one osteopathic institution to another. The American Association of Colleges of Osteopathic Medicine, through the Educational Committee of Osteopathic Principles (ECOP) is in the process of establishing educational objectives related to osteopathic manipulative techniques for colleges of osteopathic medicine in the United States. This document, scheduled to be released in 2008, was last revised in 1983.2 The development of curriculum requires content experts. The delivery of curriculum requires talented faculty, adequate physical and technologic resources and engaged learners. The process of curricular design is tremendously challenging and the ECOP recommendations should prove helpful to schools of osteopathic medicine.
Currently there are no specific uniform national requirements for OPP education, and no one best method of curriculum delivery, but it has been suggested that the osteopathic profession examine these issues.3 The Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) and the Comprehensive Osteopathic Medical Licensing Examination-Physical Examination (COMLEX-USA Level 2-PE) are national assessments which include OPP topics. The COMLEX-USA Level 2-PE, established in 2004, is a national examination to assess communication, physical examination and OMM skills. Each osteopathic medical student will take this examination prior to graduation. If a student fails the COMLEX-PE they must successfully remediate in order to graduate from KCUMB-COM. Osteopathic colleges may utilize the COMLEX Examination scores to guide their curriculum in addition to other variable factors related to the state of health care in general.
This paper describes the OPP curriculum and assessment at Kansas City University of Medicine and Biosciences College of Osteopathic Medicine (KCUMB-COM). Teaching and assessment of OPP skills and knowledge will also be presented for the purpose of stimulating discussion and thought about the training occurring at different colleges of osteopathic medicine with the ultimate goal of improving education in OPP.
Traditionally, the OPP curriculum had been presented in a course separate from other physical examination courses (Introduction to Clinical Medicine and Fundamentals of Clinical Medicine). As part of the continuous quality improvement, the faculty of the Department of Family Medicine developed a curriculum which sought to integrate the osteopathic examination and treatment into the traditional physical examination and diagnosis curriculum. This new curriculum, Integrated Osteopathic Clinical Skills (IOCS) is the result of that work.
The curriculum at KCUMB-COM features sections (Table 1), most of which are six weeks in length, bases on anatomic and physiologic systems and taught in an integrated manner. For example, the musculoskeletal section, offered in year one, is taught by faculty from all departments including anatomy, family medicine, pharmacology, pathology, biochemistry, and microbiology. This education team provides students with a multidisciplinary approach to instruction. The ICOS curriculum is presented through all of the sections and seeks to provide information related to the particular section, specifically integrating OPP in order to emphasize to students the importance of an osteopathic approach to diagnosis and treatment. The ability to assimilate information gathered from the medical interview and physical examination into a patient assessment and management plan requires a complete skill set, which includes communication skills and physical examination skills.
The osteopathic examination provides much more information that the traditional “orthopedic” or “neurological” examination. The incorporation of OPP into the traditional “physical examination” curriculum offers an approach to teaching that more closely simulates the clinical osteopathic patient evaluation. A complete osteopathic examination includes a comprehensive neuromusculoskeletal evaluation as well as osteopathic evaluation, and framing a curriculum around this philosophy provides the student with a more comprehensive educational experience and will better position them to provide comprehensive patient care on clinical rotations and as osteopathic physicians. Further, this approach is consistent with that of A.T. Still, MD, DO, who taught that structure and function are inextricably interrelated.4 Integrating information is a very difficult medical decision making skill to develop, and students are well served by beginning their medical education with this mindset.
The faculty of the Department of Family Medicine is responsible for the development and delivery of the IOCS curriculum. There are eight DO’s and one MD in the Department who teach full-time. Another osteopathic physician who is retired from practice serves as a part-time adjunct faculty member. All are board certified in family medicine, four have CAQ in sports medicine and three have CAQ in neuromusculoskeletal medicine.
The Department of Family Medicine currently has two OMM Fellows who are year four students at KCUMB and who have been selected to serve a one year Predoctoral OMM Fellowship. Among their responsibilities are assistance with preparation and teaching in the IOCS laboratories. Additionally, they provide year one and year two students with focused tutorial and review sessions and preparation for IOCS assessments.
Second-year students at KCUMB are invited to apply to be teaching assistants in the IOCS laboratories. This is a popular program designed to enhance the knowledge and skills of the teaching assistants and provide peer-to-peer mentoring, which is beneficial to year one students. There are approximately 100 teaching assistants selected annually who are assigned to specific OMT tables in the laboratory. The scheduling of IOCS I clinical laboratory sessions was done to provide for the availability of second year students in the teaching assistant program. The Department considers this a “win-win” situation for the peer mentors/teachers (students as teachers) and the year one IOCS students. The teaching assistants have proved invaluable in the instruction of first year students. They also gain knowledge and skill during what amounts to a “review” for them.
KCUMB-COM year one and two students participate in the campus-based IOCS I and IOCS II courses. As with all student bodies, there is a spectrum of age and skills. The diversity of educational and vocational backgrounds and philosophies related to heath care enrich the learning culture and enhance the educational environment. Year three and four students, on clinical rotations in various areas of the country, are presented with an extended IOCS internet-based curriculum and assessment program. There are 255 students in year one and 262 students in year two programs.
The Educational Council on Osteopathic Principles of the American Association of Colleges of Osteopathic Medicine provides educational resources including Clinical Osteopathically Integrated Learning Scenarios5 and guidelines for curriculum. KCUMB’s program utilizes these resources to establish teaching and assessment goals.
Faculty of the Department of Family Medicine devised a list of core clinical skills, which would prepare the student for year three clinical rotations. Curriculum was framed around these core clinical skills. Resources used in developing this list included Core Curriculum for Osteopathic Principles Education2 and Foundations for Osteopathic Medicine.4
Although one assessment of the knowledge of the students is the COMLEX-USA, KCUMB’s mission is to increase the number of students using OPP in their daily medical decision making as they begin residency as well as when they begin private practice. The goal is to increase knowledge not only for the sake of national boards, but to improve and impact patient care.
The Physiatric Association of Spine, Sports and Occupational Rehabilitation has a list of core neuromusculoskeletal examination skills that is recommended for all residents completing a residency in physical medicine and rehabilitation. Although this is a much more comprehensive and rigorous list that was not specific to osteopathic medicine, it was of particular usefulness as applied to general skills development and assessment strategies.6
The current teaching of clinical and osteopathic manipulative skills is conducted via Integrated Osteopathic Clinical Skills laboratory sessions. The laboratory is a large open room with 68 OMT examination tables, suspended video monitors and a video recording system. The two-hour laboratory sessions are conducted weekly. There are two students assigned to each OMT table. The lead instruction will conduct the session from the stage. The camera is located in a central media room within the laboratory and from which the demonstrations on the stage are broadcast to the monitors. Skeletal models are used to illustrate anatomy and vertebral and joint motion.
IOCS lectures are designed to provide information about neurophysiology, osteopathic concepts, principles and techniques. These are generally one hour in duration and held weekly. The specific lecture topic generally correlates with other lectures in the particular academic section. For example, a lecture on cranial would be presented during the neuroscience section and a lecture on thoracic outlet syndrome presented during the cardiopulmonary section. An Interdepartmental Review session, a lecture-style three-hour format is conducted weekly and includes faculty from various clinical and basic science departments. A case is presented which seeks to provide discussion, which will review the primary topics and concepts presented during the previous week. Students are asked to consider osteopathic findings and which types of OMT would be suitable for a particular clinical scenario. Ten lectures are provided in a comprehensive review of OMT at the end of year two. The specific topics reviewed are presented in Table 2.
An inpatient OMT service, comprised of a lead osteopathic physician, KCUMB OMM Fellows and year three and four students on the KCUMB OMM clinical rotation, providing OMT for hospitalized patients. Patients are referred to this service by KCUMB internal medicine and family medicine physicians. This service meets twice weekly and is designed to offer students an opportunity to develop OMT skills in a hospital setting. This increases exposure to OMT and encourages students to apply knowledge and skills gained in year one and two towards direct patient care.
Prior to starting clinical rotations, all students are given a DVD, which demonstrates OMT techniques, and serves as an additional teaching tool for students on externships. In addition, students have access to a bank of questions about OPP.
KCUMB has increased the number of laboratory assessments for the students. Previously, IOCS practical examinations occurred three times per year. In an effort to better focus the assessment and gain information about student strengths and weaknesses, the number of assessments was increased to six each academic year. The efforts were to devise a schedule and plan that would focus on the assessment of a more narrow range of specific skills (the focus of faculty teaching). The purpose of this is to encourage students to study the material and practice OMT skills regularly, arguably the best way to learn a skill, rather than procrastinate until the examination, which was previously, several months in the future.
There is a reading assignment for each laboratory designed to prepare the student for the session. To encourage preparation for the laboratory, five-question quizzes are given at the beginning of each session to assess knowledge of information provided in the textbooks referenced in the reading assignments. This encourages students to prepare for the laboratory, as the points are counted towards their final grade. The year this was implemented, the bookstore sold out of the Foundations for Osteopathic Medicine text. This is in conjunction with the philosophy of increased practical assessments, and designed to promote frequent reading and assimilation of course materials.
One faculty member is assigned to each of nine testing stations. Each station assesses skills in a particular topic. For example, one may ask the learner to demonstrate OMT or evaluation of a particular joint. Students present in pairs at each station, one serving as “physician” and one as patient. A card is selected by the “physician” which provides instruction for the demonstration of a particular skill, which is assessed by the faculty physician.
A multiple question PowerPoint-based didactic station was developed to assess cognitive abilities. The didactic station consists of slides with varying items, including anatomic and radiographic images, questions about general knowledge and identification of clinical conditions discussed in lectures and laboratory sessions.
A comprehensive Clinical Skills Assessment (CSA) is conducted at the end of year two. This multi-station examination is intended to simulate the experience students will have during clinical rotations with the expectation that the student can conduct a patient interview and comprehensive osteopathic examination. Additionally, students must demonstrate an ability to develop a working diagnosis and management plan. Standardized patients are utilized for the CSA, which provides for the simulation of the clinical encounter.
Previously, students on clinical rotations during years three and four did not have many questions related to OPP. The number of questions for students on all rotations as they pertain to OMT has been increased. Students are now given a pre-test and then required to complete a post-test to ascertain whether an increase in knowledge has occurred. All rotations have content related to OMT incorporated, as well as assigned reading for those sections from clinically relevant texts, such as Foundations for Osteopathic Medicine, Osteopathic Considerations in Systemic Dysfunction, and Clinical Osteopathically Integrated Learning Scenarios. This ensures some exposure to OMT, even if their preceptor does not optimally utilize OMT during that month.
Standardized, national testing of students has begun with the advent of the COMLEX-USA Level 2 PE in September 2004. This examination serves to provide a tool to gauge the performance of each osteopathic college’s students. It measures information gathering, humanistic domain, medical documentation, and osteopathic manipulation. This assessment, similar to the CSA, serves to identify students who may have difficulty integrating the coursework of years one and two, as well as rotations during the third year.
Students also receive assessment of their knowledge of OPP during the COMLEX Parts I, II, and III. While this testing format is not conducive to testing of hands on skills, it serves to encourage students to study, retain, and review the osteopathic concepts taught during their undergraduate osteopathic medical education. These tests are also a powerful motivating factor for students to study.
Osteopathic educators at KCUMB and all osteopathic schools are challenged to provide instruction that not only meets curricular guidelines, but provides for the highest quality patient care. Trends in medical education towards small group-centered learning and the introduction of new technology present opportunities and challenges for educators. OMT and other manual skills are particularly challenging to teach and learn.
Current questions for osteopathic educators include: What is the role of technology in osteopathic education? How may small groups be designed to optimize the development and refinement of psychometric skills? What is the role of peer teaching and assessment? Students have higher expectations for their education at all levels than ever before and schools of osteopathic medicine must exceed those expectations if COM’s are to compete for the highest quality students. The integrated osteopathic curriculum, which emphasizes the utility of OMT for the enhancement of patient care, is an example of curricular innovation. Efforts to improve instruction and enhance learning, through faculty development, the use of varied educational methods to engage students and the practical application of learning science is critical as Colleges of Osteopathic Medicine prepare students for careers in osteopathic medicine.
Dr. Desai is a 1996 graduate of Michigan State University College of Osteopathic Medicine, East Lansing, Michigan. He first received his certification in Family Medicine in 1999. Presently he is an Associate Professor for the Department of Family Medicine, and Physician Educator, Department of Medical Affairs, at Kansas City University of Medicine and Biosciences College of Osteopathic Medicine. His practice in Family Medicine is with University Physician Associates, at St. Joseph Medical Center, Kansas City, Missouri.
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