Evaluating the rationale of the osteopathic internship.

To the Editor: As a fourth-year student at the West Virginia School of Osteopathic Medicine, Lewisburg, I had to choose between pursuing an American Osteopathic Association (AOA)–approved or an Accreditation Council for Graduate Medical Education (ACGME)–accredited residency program. Interestingly, my decision to pursue an ACGME-sponsored position has been met with some resistance. Therefore, I would like to explain the reasoning behind my choice, as well as examine some of the conventional views that have governed osteopathic medical education. In a recent meeting with our institution’s dean of students, I was asked whether I was going to complete an osteopathic internship. I replied that I was not and was informed that as an osteopathic physician who had not completed an AOA-approved osteopathic internship, I would not be eligible for licensure in West Virginia, Florida, Pennsylvania, Oklahoma, and Michigan. I asked whether there were any incentives—as opposed to penalties—in seeking an AOAapproved internship. None was offered. As readers might imagine, the dean’s urging to consider spending another year of general rotations to satisfy an arguably outdated piece of legislation was a confusing proposition. My question to him was this: Why would an organization, namely the AOA, as well as the entire osteopathic medical profession, that has worked so hard to establish equal practice rights for osteopathic physicians throughout the United States and beyond, remain committed to a self-imposed policy that limits those very rights of practice? As concerns the underserved populations of the aforementioned states (rural and otherwise), one must ask why the osteopathic medical profession wishes to enforce legislation that prevents osteopathic physicians from helping those who need it most? With respect to those who initially drafted the policy, the logic is difficult to understand in today’s medical climate. Paradoxically, it is to the credit of the AOA that osteopathic physicians are now able to pursue nearly any specialty they choose. Given that most transitional yearlong programs are an extension of the clerkship experience, I wanted to know what was so unique about the osteopathic internship that required such a mandate. Most students interested in subspecialty training must complete between 1 and 3 years of general internal medicine, making an extra year of required rotations through the areas of pediatrics, obstetrics, and surgery unnecessary. This is not required for those interested in pursuing areas other than primary care. I explained to the dean that I would consider adding an extra year to my training if the osteopathic internship provided something extra in terms of education, such as a solid foundation in osteopathic manipulative medicine (OMM). At this point, most AOA residency programs do not. In some areas of the United States, osteopathic physicians have traditionally been a cornerstone in primary care, and many osteopathic medical schools are still oriented toward this goal. The subject of OMM raises other questions. Why, for instance, does the osteopathic medical profession insist on maintaining exclusive rights to such a valuable mode of therapy? Maintaining exclusive rights to OMM only seems to further contradict the stated goal of equal practice rights within the medical profession. Consider a scenario in which an osteopathic physician had developed penicillin. Could he or she have withheld such valuable treatment in good conscience? It is worthwhile to consider that what was appropriate a century ago may not be appropriate today. It is difficult to understand, given the current medical climate, why the AOA continues to support legislation that discriminates against the osteopathic physicians they represent. Without clear educational advantage, a mandated osteopathic internship as it exists today promises only to limit the scope of practice for osteopathic physicians. Such an internship will further promote what is largely an artificial distinction between osteopathic training programs and those of our allopathic colleagues.