At the Intersection of Health, Health Care and Policy Cite this article as: Stephen C. Shannon, Boyd R. Buser, Marc B. Hahn, John B. Crosby, Tyler Cymet, Joshua S. Mintz and Karen J. Nichols A New Pathway For Medical Education Health Affairs, 32, no.11 (2013):1899-1905 doi: 10.1377/hlthaff.2013.0533
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Reform Proposals By Stephen C. Shannon, Boyd R. Buser, Marc B. Hahn, John B. Crosby, Tyler Cymet, Joshua S. Mintz, and Karen J. Nichols
10.1377/hlthaff.2013.0533 HEALTH AFFAIRS 32, NO. 11 (2013): 1899–1905 ©2013 Project HOPE— The People-to-People Health Foundation, Inc.
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A New Pathway For Medical Education
Stephen C. Shannon ([email protected]) is president and CEO of the American Association of Colleges of Osteopathic Medicine, in Chevy Chase, Maryland.
Physician education in the United States must change to meet the primary care needs of a rapidly transforming health care delivery system. Yet medical schools continue to produce a disproportionate number of hospital-based specialists through a high-cost, time-intensive educational model. In response, the American Osteopathic Association and the American Association of Colleges of Osteopathic Medicine established a blue-ribbon commission to recommend changes needed to prepare primary care physicians for the evolving system. The commission recommends that medical schools, in collaboration with their graduate medical education partners, create a new education model that is based on achievement of competencies without a prescribed number of months of study and incorporates the knowledge and skills needed for a twentyfirst-century primary care practice. The course of study would occur within a longitudinal clinical training environment that allows for seamless transition from medical school through residency training. ABSTRACT
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n a changing health care delivery system that purports to be shifting away from disease care and toward a focus on population-based prevention and care management, new models of comprehensive health care delivery, based on interprofessional teams led by primary care physicians, are emerging as an innovative response. For years, evidence1 has shown that the availability of primary care physicians improves health care outcomes2 and lowers costs.3 Unfortunately, most health experts have concluded that there is an inadequate supply of primary care physicians in the United States,4 and this shortage is expected to grow over time.5 The addition of millions of newly insured people through the implementation of the Affordable Care Act will exacerbate shortages.6 Although the demand for primary care services is high, students’ interest in primary care careers has been low7 because of multiple factors, including high student debt loads,8,9 low primary care
Boyd R. Buser is vice president for health affairs and dean of the Kentucky College of Osteopathic Medicine at the University of Pikeville. Marc B. Hahn is president and CEO of the Kansas City University of Medicine and Biosciences, in Missouri. John B. Crosby is immediate past executive director of the American Osteopathic Association, in Chicago, Illinois.
compensation relative to that provided for specialty care, and primary care workloads that impinge upon preferred lifestyles. New models of care may enhance primary care compensation, improve the work environment, and improve the attractiveness of careers in primary care medicine. But the ability to train physicians for these new models is limited.10 Osteopathic physicians are an important part of our nation’s health care system. Today there are 82,500 osteopathic physicians in the United States; 60 percent practice primary care, many of them in rural locations.11 More than 20 percent of US medical students are attending osteopathic medical colleges, benefiting from the community-based, primary care–focused education emphasized by their medical schools, many of which are located in rural areas.12,13 Growth in the number of osteopathic medical schools and students14 and the strong primary care foundation their students receive (Exhibit 1) position osteopathic medical education to play a leaderN OV E M B E R 201 3
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Tyler Cymet is associate vice president for medical education at the American Association of Colleges of Osteopathic Medicine. Joshua S. Mintz is managing partner at Cavanaugh Hagan Pierson & Mintz, in Washington, D.C. Karen J. Nichols is dean and professor of internal medicine at Chicago College of Osteopathic Medicine, Midwestern University, in Downers Grove, Illinois.
Health Affairs
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Reform Proposals Exhibit 1 Trend In Primary Care Physician Production At US Osteopathic Medical Schools, 1995–2007
SOURCE American Osteopathic Association. American Osteopathic Association Masterfile. Chicago (IL): AOA; 2011.
ship role in preparing the physician workforce required to meet the nation’s health care needs.15 As the health care system undergoes transformation, many have called for a corresponding change in the nation’s medical education system. As one leading advocate has said, there is a strong connection between medical practice redesign and medical education redesign.16 Without simultaneous innovation in both, there can be no substantial progress made toward meeting tomorrow’s health care challenges.17 To equip physicians with the skills and attributes they will require to meet new health care system demands, osteopathic and allopathic medical educators and policy makers are rethinking the competencies expected of new physicians and the training process required to achieve them.18 At the same time, the growing cost of medical education is raising challenges for students, institutions, and the system itself,19 and many policy makers are calling for exploration of new methods of curriculum delivery that would reduce the inefficiencies inherent in traditional, time-based educational models.20 Calls for reform abound. The American Medical Association has called for a “transformation” of medical education.21 The Council on Graduate Medical Education has proposed “streamlining physician training, accelerating the time frame for education, improving educational quality, developing new strategies for competency-based education, increasing the number of physicians being trained, and developing new approaches to team-based training.”22 Among a number of recommendations from a recent Josiah Macy Jr. Foundation report is a call for “greater efficiency through adoption of a competency-based approach, and eliminating non-educational experiences and redundancies in training.”23 The Josiah Macy Jr. Foundation has also recom1900
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mended that the Institute of Medicine conduct a review of the governance and financing of graduate medical education (GME)—a call that was later echoed by a bipartisan group of US senators24 and implemented by the Institute of Medicine (whose work is currently under way).25 Calls for change have also arisen within the academic medicine community. Most prominently, a recently published monograph, “Educating Physicians: A Call for Reform of Medical School and Residency,”26 which was timed to coincide with the centennial of the Flexner Report, proposes a number of substantial changes in the way physicians are educated, including early clinical immersion and integrated courses, longitudinal integrated clinical experiences with a focus on out-of-hospital settings, alignment of patient care with clinical education, and standardization of educational outcomes with individual flexibility in learning. The Flexner Report transformed early-twentieth-century medical education, eliminating proprietary medical schools and establishing the biomedical sciences as the foundation of the medical school curriculum.
Reorganizing And Improving Medical Education Against this backdrop of health system transformation, a small group of osteopathic medical education representatives—the Blue Ribbon Commission for the Advancement of Osteopathic Medical Education27—was created by the American Osteopathic Association and the American Association of Colleges of Osteopathic Medicine. It was charged with addressing two critical questions: How can we reorganize medical education to produce physicians who will be able to achieve better health care outcomes for the US population? And how can we improve medical education to produce competent and compassionate physicians more efficiently and effectively? After two years of extensive analysis of the forces described above, input from leading thinkers in health professions education, and commission members’ own research and experiences, the group proposed some fundamental changes in the current medical education model to better prepare physicians to serve and succeed in today’s and tomorrow’s health care environment. In its report27 the commission describes a new “Pathway for Medical Education,” which is designed to produce board-eligible, practice-ready primary care physicians who have the abilities needed for today’s evolving delivery systems. Pathway graduates would be prepared to practice
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in a health care environment driven by concerns about quality and value; imbued with ways to measure those outcomes; and equipped to work in a team-based environment that focuses on patients, families, and communities. The Pathway is defined by five principles. First, it would prepare physicians for primary care practice and focus training on team-based and patient-centered care, incorporating prevention and population health as a means of improving the overall quality and efficiency of care. Second, it would be built on a competency-based curriculum centered on biomedical, behavioral, and clinical science foundations. Outcomes specific to medical education would be established to assess graduates’ readiness for professional practice at multiple points in the physician education continuum. Exhibit 2 offers an initial outline of the proposed competencies. Third, it would be a continuous, longitudinal educational experience. Clinical experiences would begin in students’ first year of medical education and would continue with increasing levels of responsibility throughout the duration of their training. An integrated continuum with a seamless transition between undergraduate and graduate medical education would be established, making it possible to eliminate redundancies and inefficiencies in the medical education process, with anticipated cost reductions and time savings.
Fourth, it would be administered by medical schools in collaboration with GME providers (organizations with authority to offer accredited residency training). Clinical experiences would occur in a wide variety of environments, including both hospital and ambulatory communitybased settings. Community-based sites, such as integrated health systems, community health centers, and large practice groups, would provide optimal environments for clinical continuity of experiential learning in primary care. Fifth, it would include a focus on health care delivery science, including the principles of the high-quality, high-value, outcomes-based health care environment (such as accountable care organizations and patient-centered medical homes); health care team leadership; analytic skills; health policy; health systems planning; health information technology; quality assurance; and patient safety. Imagine a medical school that, in collaboration with its primary care graduate medical education partners, designed a curriculum around these principles. Students would be selected to enter the Pathway program based on the qualities necessary for their success and their commitment to primary care. The educational experience would integrate basic and clinical sciences learning into a longitudinal primary care clinical experience, with individual students taking on increasing responsibilities as they demonstrate a
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Principles in Pathway The Pathway is defined by five principles: (1) focus on team-based, patientcentered care; (2) build on competency-based curriculum; (3) provide a continuous, longitudinal educational experience; (4) be administered by medical schools in collaboration with GME providers, with clinical experiences in a variety of settings; and (5) focus on health care delivery science.
Exhibit 2 New Knowledge And Capacities For The Twenty-First-Century Osteopathic Primary Care Physician Foundational knowledge and associated capacities Osteopathic principles and practices Patient-centered primary care delivered predominantly in communitybased and outpatient ambulatory care environments Role and function of high-quality, high-value delivery models, such as patient-centered medical homes and accountable care organizations Health care management, health care financing, and health policy Systems-based practice and the implementation of quality assurance and patient safety principles and processes Leadership capabilities, including leading an interprofessional health care team and managing change Data management, analysis, and the use of health information technology to facilitate patient care and patient management Principles of population health, including health and wellness promotion, disease prevention, risk assessment, and patient education, and principles of health literacy Principles of aging and communication with the elderly Design and conduct of clinical and educational research, interpretation and application of biomedical and translational research, participation in practice-based research and evidence-based practice, and evaluation of diagnostic tests and therapeutic interventions Competency with diverse populations and environments and alternative health care practices and beliefs
Personal attributes and other behavioral and contextual capacities Leadership and team-building skills, working with a variety of different health professionals, and shared decision making Communication skills, empathy, compassion, open-mindedness, personal adaptability, altruism, patient advocacy, and the ability to share the decision-making process with patients Capacity to employ social and behavioral sciences in medical practice Professionalism and adherence to ethical principles Problem solving and critical thinking Willingness to be integrated into the communities in which they practice Continuity in following up with patients and treating them thoroughly Dedication to quality, performance improvement, and continuous learning model, teacher, and mentor Capacity for self-assessment and critical appraisal and for serving in primary care role
SOURCE Blue Ribbon Commission for the Advancement of Osteopathic Medical Education (see Note 27 in text).
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Reform Proposals readiness to move to the next level. Students would develop mastery of clinical skills and knowledge in a variety of primary care and specialty areas—all targeting the competencies needed for a community-based primary care physician. Progress through medical school and residency training would be assessed based on competency, not time, through a variety of evaluative tools (see online Appendix Exhibit 1 for a description of how the Pathway could work for one hypothetical student).28 The Pathway would produce ready-for-practice osteopathic primary care physicians who were well prepared to serve as leaders of interprofessional health care teams. It is envisioned that a highly qualified and motivated student could complete this education and training program in as few as five years. All Pathway trainees would receive a strong grounding in primary care that would allow them to practice upon completion of the program. Those who later decided to pursue other specialties would be well prepared for continued training.
How Is This Different? It is reasonable to ask how these proposed changes differ from osteopathic medical education’s traditional patient-centered approach and primary care focus, and how the proposed Pathway differs from what exists in allopathic medical education. A traditional medical education, whether beginning in an osteopathic or allopathic medical school, is an eleven-to-eighteen-year journey that normally requires a minimum of a four-year undergraduate degree, four years of medical school, and three years of residency training (the length of time necessary for training in family medicine, pediatrics, or internal medicine— the traditional primary care specialties). For those who choose other specialty or subspecialty tracks, an additional one to six years may be necessary. Medical school is traditionally divided into two years of mostly basic and clinical science learning, followed by an additional two years of mandatory and elective clinical experiences. Both osteopathic medical school and residency training are organized to meet traditional competency standards (Appendix Exhibit 2). Osteopathic medical education has been rooted in primary care since its development and has a traditional holistic approach to health and an emphasis on close physician-patient interaction. Its education system, although more community based, nevertheless has been Flexnerian in its model of curricular content and delivery, as have most allopathic medical schools.15 The new Pathway would reorient the osteo1902
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Osteopathic medical education has been rooted in primary care since its development.
pathic medical educational approach to respond to the changing health care system while maintaining osteopathic medicine’s traditional emphasis on primary care and community-based training. The competencies described by the commission (Exhibit 2) recognize the need for new, team-based expertise to address the complexity of care needs, importance of the broader community environment, importance of integrating information technology with care delivery and quality measures, and need to use new knowledge emerging from health care delivery science in the provision of care. In addition, the Pathway would change a trainee’s progression from a time plus competencybased system of knowledge and skills development, in which a student must complete a certain length of time in a curriculum segment no matter how accomplished he or she might be in the learning objectives associated with that portion of the curriculum, to one in which the accomplishment of competency determines the time it takes to complete one’s training. A person would progress through medical school and residency training as he or she achieves established benchmarks of accomplishment—not when a certain date has arrived. As recommended in “Educating Physicians,” the Pathway would individualize the learning process but result in standardized learning outcomes.26 Because the Pathway model represents a substantial shift from today’s medical education model, it should be piloted by a limited number of medical schools working with their GME provider partners. After a period of assessment and revision, the model’s broader implementation would be possible.
Policy Considerations Although the commission’s work focused on development of the new Pathway, the group recognized that a variety of institutional, accreditation, licensure, governance and board certification, financial, and regulatory issues may need to be addressed for its vision to be realized. Policy considerations include everything from
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The Pathway has the potential to be a disruptive innovator of the current medical school and GME funding mechanisms.
redesigning admissions criteria to identify and select students for Pathway participation to devising and overseeing a system that creates a seamless educational continuum from undergraduate through graduate medical education. Another consideration is ensuring the ability of Pathway graduates to gain licensure and board certification. But among the most critical of the policy issues to be addressed are accreditation and financial considerations. Accreditation To facilitate the development of a seamless amalgamation of undergraduate and graduate osteopathic medical education, the accrediting and certifying agencies of both will need to reassess their standards and agree to collaborate. The Commission on Osteopathic College Accreditation accredits US colleges of osteopathic medicine. The American Osteopathic Association’s Council on Postdoctoral Training accredits US osteopathic GME programs.29 Its Bureau of Osteopathic Specialists certifies osteopathic physicians through the specialty certification board process.30 The Pathway describes a course of study in primary care that could be completed in less time based on demonstrated mastery of competencies. All of the entities listed above currently require mastery of competencies for successful completion but also include a minimum time requirement. Although there are allowances for extended time to master the competencies, there has never been an allowance for completion of study in less than the specified time requirement, based on demonstration of mastery. For example, the Commission on Osteopathic College Accreditation specifies that medical school must be four years in length or equivalent and then lists 130 weeks of instruction as the minimum amount for completion of undergraduate medical education.31 The training standards for the three separate primary care specialties specify a thirty-six-month program, with detailed specifications for length of time in
all pertinent specialty areas.32–34 Board certification is the normal next step for osteopathic physicians who have completed the specified course of time and competency-based study prescribed by the relevant specialty board.35 The commission’s proposed program of study also would lead to board certification based on competencies but without a prescribed number of months of study. That board certification could be offered by the American Osteopathic Board of Family Physicians or a conjoint board composed of two or three of the primary care specialty boards. For pilot Pathway programs to proceed, it would be necessary for all three entities—medical school accreditor, graduate medical education accreditor, and specialty board authority—to agree to make the necessary modifications to enable this innovation. Financial Considerations The Pathway has the potential to be a disruptive innovator of the current medical school and GME funding mechanisms. The current system uses resources from multiple sources, including tuition, state support, scholarships, and Medicare to fund the separate components of a physician’s education and training. However, the commission’s proposed model could lead to a commingling of funds such that appropriate resources might be allocated when needed, not according to any particular time schedule. Thus, to ensure the Pathway’s viability, changes in current graduate medical education funding streams may need to be enabled. The Pathway calls for greater medical school involvement in the administration of GME programs in partnerships with GME-sponsoring institutions. Flexibility in distribution of GME funding to allow it to flow through such partnerships (consortia) would foster creativity in addressing the financial issues related to a shortened length of undergraduate medical education and GME training. Redirecting GME funding to follow the trainee, not the institution (for example, through a voucher system), is another possible mechanism to foster flexibility. Finally, innovative funding models have been developed in a number of states to help address physician shortages. Given the current debate over federal funding levels for graduate medical education, it is reasonable to predict that alternative funding streams will continue to emerge. External funding through both public and private sources should foster testing of pilot programs such as the Pathway.
Next Steps In this article we have presented the commission’s proposal for major reform in the educaNOVEMBER 2013
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Reform Proposals tion of osteopathic physicians—and, if successful, all physicians. It marks a call for a substantial shift, not only toward competency-based assessment and seamless advancement through all stages of medical education but in the curriculum itself, to include the new knowledge and abilities needed for the health care system of the future. It is anticipated that in the coming months and years, new Pathway pilot programs could be initiated within the osteopathic medical education community, but a variety of policy challenges will need to be addressed for this to occur. The authors of this article and other members of the commission are engaging in converThe authors acknowledge the contributions of the following people in the preparation of this article: Thomas Levitan, vice president for research and application services, American Association of Colleges of Osteopathic
sations with accrediting agencies, licensing boards, regulators, and other policy makers to educate them about the new Pathway and assess associated policy concerns. Despite the time it will take to reform the medical education system, the osteopathic profession continues to focus efforts to train a strong physician workforce. Policy questions that could stand in the way of reform must be answered if osteopathic medical education is to maintain its traditional mission of community-based primary care for underserved populations in a changing US health care system.36 ▪
Medicine; James E. Swartwout, associate executive director, American Osteopathic Association; Anna M. Naranjo, executive assistant to the president, American Association of Colleges of Osteopathic Medicine; and
Wendy Fernando, communications and marketing consultant, American Association of Colleges of Osteopathic Medicine.
NOTES 1 Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502. 2 Chang CH, Stukel TA, Flood AB, Goodman DC. Primary care physician workforce and Medicare beneficiaries’ health outcomes. JAMA. 2011;305(20):2096–104. 3 American College of Physicians. How is a shortage of primary care physicians affecting the quality and cost of medical care? A comprehensive evidence review [Internet]. Philadelphia (PA): ACP; 2008 [cited 2013 Aug 30]. Available from: http://www.acponline.org/ advocacy/current_policy_papers/ assets/primary_shortage.pdf 4 Council on Graduate Medical Education. Twentieth report: advancing primary care [Internet]. Rockville (MD): Health Resources and Services Administration; 2010 Dec [cited 2013 Aug 31]. Available from: http://www.hrsa.gov/advisory committees/bhpradvisory/cogme/ Reports/twentiethreport.pdf 5 Dill M, Salsberg E. The complexities of physician supply and demand: projections through 2025. Washington (DC): Association of American Medical Colleges; 2008 Nov. 6 Government Accountability Office. Primary care professionals: recent supply trends, projections, and valuation of services. Washington (DC): GAO; 2008 Feb 12. 7 Which schools turn out the most primary care residents? U.S. News and World Report [serial on the Internet]. 2013 [cited 2013 Aug 30]. Available from: http://grad-schools .usnews.rankingsandreviews.com/
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best-graduate-schools/top-medicalschools/primary-care-residentsrankings?int=1656ec Greysen SR, Chen C, Mullan F. A history of medical student debt: observations and implications for the future of medical education. Acad Med. 2011;86(7):840–5. Sheehy K. 10 medical schools that lead to the most debt. U.S. News and World Report [serial on the Internet]. 2012 May 22 [cited 2013 Aug 30]. Available from: http:// www.usnews.com/education/bestgraduate-schools/articles/2011/04/ 14/10-medical-schools-that-lead-tomost-debt Advisory Committee on Training in Primary Care Medicine and Dentistry. Priming the pump of primary care: ninth annual report to the secretary of the U.S. Department of Health and Human Services and to Congress [Internet]. Rockville (MD): Health Resources and Services Administration; 2012 Feb [cited 2013 Aug 30]. Available from: http://www.hrsa.gov/advisory committees/bhpradvisory/actpcmd/ Reports/ninthreport.pdf American Osteopathic Association. Osteopathic medical profession report [Internet]. Chicago (IL): AOA; 2012 [cited 2013 Aug 30]. Available from: http://www.osteopathic.org/ inside-aoa/about/aoa-annualstatistics/Documents/2012-OMPreport.pdf American Association of Colleges of Osteopathic Medicine. 2012–13 osteopathic medical college total enrollment, by college, by state of legal residence [Internet]. Chevy Chase (MD): AACOM; 2013 [cited 3013 Aug 30]. Available from: http://
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www.aacom.org/data/student enrollment/Documents/2012-13_ COM_TotEnroll_College_State.pdf Association of American Medical Colleges. Table 26: enrollment by U.S. medical school and sex, 2008– 2012 [Internet]. Washington (DC): AAMC; 2012 Dec 17 [cited 2013 Aug 30]. Available from: https:// www.aamc.org/download/321526/ data/2012factstable26-2.pdf American Association of Colleges of Osteopathic Medicine. Trends in osteopathic medical school applicants, enrollment, and graduates [Internet]. Chevy Chase (MD): AACOM; 2012 Mar [cited 2013 Sep 3]. Available from: http:// www.aacom.org/data/Documents/ Trends-apps-enroll-grads.pdf Shannon SC, Teitelbaum HS. The status and future of osteopathic medical education in the United States. Acad Med. 2009;84(6): 707–11. Advisory Committee on Training in Primary Care Medicine and Dentistry. The redesign of primary care with implications for training: eighth annual report to the secretary of the U.S. Department of Health and Human Services and to the U.S. Congress [Internet]. Rockville (MD): Health Resources and Services Administration; 2010 May [cited 2013 Sep 3]. Available from: http://www.hrsa.gov/advisory committees/bhpradvisory/actpcmd/ Reports/8threport.pdf Thibault G. Innovation and the future of health care. In: Proceedings of the Joint AACOM and AODME 2013 Annual Meeting; 2013 Apr 25; Baltimore, MD. Mullan F, Chen C, Petterson S,
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Kolsky G, Spagnola M. The social mission of medical education: ranking the schools. Ann Intern Med. 2010;152(12):804–11. Association of American Medical Colleges. Physician shortages to worsen without increases in residency training [Internet]. Washington (DC): AAMC; 2010 Jun [cited 2013 Sep 3]. Available from: https://www.aamc.org/download/ 150584/data/physician_shortages_ factsheet.pdf Iglehart JK. The uncertain future of Medicare and graduate medical education. N Engl J Med. 2011;365(14): 1340–5. American Medical Association. Initiative to Transform Medical Education: recommendations for change in the system of medical education [Internet]. Chicago (IL): AMA; 2007 Jun [cited 2013 Sep 3]. Available from: http://www.amaassn.org/resources/doc/rfs/itme_ final_rpt.pdf Council on Graduate Medical Education. Letter to Tom Harkin, Mike Enzi, Fred Upton, Henry A. Waxman, and Kathleen Sebelius [Internet]. Rockville (MD): COGME; 2011 Nov 16 [cited 2013 Sep 3]. Available from: http://www.hrsa .gov/advisorycommittees/ bhpradvisory/cogme/Publications/ letter111611.pdf Josiah Macy Jr. Foundation. Ensuring an effective physician workforce for the United States: recommendations for reforming graduate medical education to meet the needs of the public [Internet]. New York (NY): The Foundation; 2011 May [cited 2013 Sep 3]. Available from: http://macy foundation.org/docs/macy_pubs/ Macy_GME_Report,_Aug_2011.pdf Bingaman J, Udall M, Kyl J, Udall T, Grassley C, et al. Letter from senators to the Institute of Medicine [Internet]. Chevy Chase (MD): American Association of Colleges of Osteopathic Medicine; 2011 Dec 21 [cited 2013 Sep 12]. Available from: http://www.aacom.org/resources/e-
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news/ome/archives/2012/2012-01/ Documents/Senate-Letter-to-IOM .PDF Institute of Medicine. Governance and financing of graduate medical education [Internet]. Washington (DC): IOM; [cited 2013 Sep 3]. Available from: http://www.iom .edu/Activities/Workforce/GME GovFinance.aspx Cooke M, Irby DM, O’Brien BC. Educating physicians: a call for reform of medical school and residency. San Francisco (CA): JosseyBass; 2010 Jun. Blue Ribbon Commission for the Advancement of Osteopathic Medical Education. Building the future: educating the 21st century physician [Internet]. Chevy Chase (MD): American Association of Colleges of Osteopathic Medicine; 2013 [cited 2013 Oct 15]. Available from: http:// mededsummit.net/uploads/ BRC_Building_the_Future__ Educating_the_21st_Century_ Physician__Final_Report.pdf To access the Appendix, click on the Appendix link in the box to the right of the article online. American Osteopathic Association. The basic documents for postdoctoral training [Internet]. Chicago (IL): AOA; 2013 May 14 [cited 2013 Sep 3]. Available from: http://www .osteopathic.org/inside-aoa/ accreditation/postdoctoral-trainingapproval/postdoctoral-trainingstandards/Documents/aoa-basicdocument-for-postdoctoraltraining.pdf American Osteopathic Association. Handbook of the Bureau of Osteopathic Specialists [Internet]. Chicago (IL): AOA; 2013 [cited 2013 Sep 3] Available from: http://www .osteopathic.org/inside-aoa/ development/aoa-boardcertification/Documents/boshandbook.pdf Commission on Osteopathic College Accreditation. Accreditation of colleges of osteopathic medicine: COM accreditation standards and procedures [Internet]. Chicago (IL):
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American Osteopathic Association; 2013 [cited 2013 Sep 3]. Available from: https://www.osteopathic.org/ inside-aoa/accreditation/ predoctoral%20accreditation/ Documents/COM-accreditationstandards-effective-7-1-2013.pdf American Osteopathic Association. Basic standards for residency training in osteopathic family medicine and manipulative treatment [Internet]. Chicago (IL): AOA; 2011 [cited 2013 Sep 3]. Available from: http://www.osteopathic.org/insideaoa/accreditation/postdoctoraltraining-approval/postdoctoraltraining-standards/Documents/ basic-standards-for-residencytraining-in-osteopathic-familypractice.pdf American Osteopathic Association. Basic standards for residency training in internal medicine [Internet]. Chicago (IL): AOA; 2012 [cited 2013 Sep 3]. Available from: http://www .osteopathic.org/inside-aoa/ accreditation/postdoctoral-trainingapproval/postdoctoral-trainingstandards/Documents/BasicStandards-For-Internal-Medicine .pdf American Osteopathic Association. Basic standards for residency training in pediatrics [Internet]. Chicago (IL): AOA; 2012 [cited 2013 Sep 3]. Available from: http://www .osteopathic.org/inside-aoa/ accreditation/postdoctoral-trainingapproval/postdoctoral-trainingstandards/Documents/BasicStandards-Pediatrics.pdf American Osteopathic Association. AOA board certification [Internet]. Chicago (IL): AOA; [cited 2013 Sep 3]. Available from: http://www .osteopathic.org/inside-aoa/ development/aoa-boardcertification/Pages/default.aspx Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M. The social mission of medical education: ranking the schools. Ann Intern Med. 2010;152(12):804–11.
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Reform Proposals By Stephen C. Shannon, Boyd R. Buser, Marc B. Hahn, John B. Crosby, Tyler Cymet, Joshua S. Mintz, and Karen J. Nichols
10.1377/hlthaff.2013.0533 HEALTH AFFAIRS 32, NO. 11 (2013): 1899–1905 ©2013 Project HOPE— The People-to-People Health Foundation, Inc.
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A New Pathway For Medical Education
Stephen C. Shannon ([email protected]) is president and CEO of the American Association of Colleges of Osteopathic Medicine, in Chevy Chase, Maryland.
Physician education in the United States must change to meet the primary care needs of a rapidly transforming health care delivery system. Yet medical schools continue to produce a disproportionate number of hospital-based specialists through a high-cost, time-intensive educational model. In response, the American Osteopathic Association and the American Association of Colleges of Osteopathic Medicine established a blue-ribbon commission to recommend changes needed to prepare primary care physicians for the evolving system. The commission recommends that medical schools, in collaboration with their graduate medical education partners, create a new education model that is based on achievement of competencies without a prescribed number of months of study and incorporates the knowledge and skills needed for a twentyfirst-century primary care practice. The course of study would occur within a longitudinal clinical training environment that allows for seamless transition from medical school through residency training. ABSTRACT
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n a changing health care delivery system that purports to be shifting away from disease care and toward a focus on population-based prevention and care management, new models of comprehensive health care delivery, based on interprofessional teams led by primary care physicians, are emerging as an innovative response. For years, evidence1 has shown that the availability of primary care physicians improves health care outcomes2 and lowers costs.3 Unfortunately, most health experts have concluded that there is an inadequate supply of primary care physicians in the United States,4 and this shortage is expected to grow over time.5 The addition of millions of newly insured people through the implementation of the Affordable Care Act will exacerbate shortages.6 Although the demand for primary care services is high, students’ interest in primary care careers has been low7 because of multiple factors, including high student debt loads,8,9 low primary care
Boyd R. Buser is vice president for health affairs and dean of the Kentucky College of Osteopathic Medicine at the University of Pikeville. Marc B. Hahn is president and CEO of the Kansas City University of Medicine and Biosciences, in Missouri. John B. Crosby is immediate past executive director of the American Osteopathic Association, in Chicago, Illinois.
compensation relative to that provided for specialty care, and primary care workloads that impinge upon preferred lifestyles. New models of care may enhance primary care compensation, improve the work environment, and improve the attractiveness of careers in primary care medicine. But the ability to train physicians for these new models is limited.10 Osteopathic physicians are an important part of our nation’s health care system. Today there are 82,500 osteopathic physicians in the United States; 60 percent practice primary care, many of them in rural locations.11 More than 20 percent of US medical students are attending osteopathic medical colleges, benefiting from the community-based, primary care–focused education emphasized by their medical schools, many of which are located in rural areas.12,13 Growth in the number of osteopathic medical schools and students14 and the strong primary care foundation their students receive (Exhibit 1) position osteopathic medical education to play a leaderN OV E M B E R 201 3
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Tyler Cymet is associate vice president for medical education at the American Association of Colleges of Osteopathic Medicine. Joshua S. Mintz is managing partner at Cavanaugh Hagan Pierson & Mintz, in Washington, D.C. Karen J. Nichols is dean and professor of internal medicine at Chicago College of Osteopathic Medicine, Midwestern University, in Downers Grove, Illinois.
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Reform Proposals Exhibit 1 Trend In Primary Care Physician Production At US Osteopathic Medical Schools, 1995–2007
SOURCE American Osteopathic Association. American Osteopathic Association Masterfile. Chicago (IL): AOA; 2011.
ship role in preparing the physician workforce required to meet the nation’s health care needs.15 As the health care system undergoes transformation, many have called for a corresponding change in the nation’s medical education system. As one leading advocate has said, there is a strong connection between medical practice redesign and medical education redesign.16 Without simultaneous innovation in both, there can be no substantial progress made toward meeting tomorrow’s health care challenges.17 To equip physicians with the skills and attributes they will require to meet new health care system demands, osteopathic and allopathic medical educators and policy makers are rethinking the competencies expected of new physicians and the training process required to achieve them.18 At the same time, the growing cost of medical education is raising challenges for students, institutions, and the system itself,19 and many policy makers are calling for exploration of new methods of curriculum delivery that would reduce the inefficiencies inherent in traditional, time-based educational models.20 Calls for reform abound. The American Medical Association has called for a “transformation” of medical education.21 The Council on Graduate Medical Education has proposed “streamlining physician training, accelerating the time frame for education, improving educational quality, developing new strategies for competency-based education, increasing the number of physicians being trained, and developing new approaches to team-based training.”22 Among a number of recommendations from a recent Josiah Macy Jr. Foundation report is a call for “greater efficiency through adoption of a competency-based approach, and eliminating non-educational experiences and redundancies in training.”23 The Josiah Macy Jr. Foundation has also recom1900
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mended that the Institute of Medicine conduct a review of the governance and financing of graduate medical education (GME)—a call that was later echoed by a bipartisan group of US senators24 and implemented by the Institute of Medicine (whose work is currently under way).25 Calls for change have also arisen within the academic medicine community. Most prominently, a recently published monograph, “Educating Physicians: A Call for Reform of Medical School and Residency,”26 which was timed to coincide with the centennial of the Flexner Report, proposes a number of substantial changes in the way physicians are educated, including early clinical immersion and integrated courses, longitudinal integrated clinical experiences with a focus on out-of-hospital settings, alignment of patient care with clinical education, and standardization of educational outcomes with individual flexibility in learning. The Flexner Report transformed early-twentieth-century medical education, eliminating proprietary medical schools and establishing the biomedical sciences as the foundation of the medical school curriculum.
Reorganizing And Improving Medical Education Against this backdrop of health system transformation, a small group of osteopathic medical education representatives—the Blue Ribbon Commission for the Advancement of Osteopathic Medical Education27—was created by the American Osteopathic Association and the American Association of Colleges of Osteopathic Medicine. It was charged with addressing two critical questions: How can we reorganize medical education to produce physicians who will be able to achieve better health care outcomes for the US population? And how can we improve medical education to produce competent and compassionate physicians more efficiently and effectively? After two years of extensive analysis of the forces described above, input from leading thinkers in health professions education, and commission members’ own research and experiences, the group proposed some fundamental changes in the current medical education model to better prepare physicians to serve and succeed in today’s and tomorrow’s health care environment. In its report27 the commission describes a new “Pathway for Medical Education,” which is designed to produce board-eligible, practice-ready primary care physicians who have the abilities needed for today’s evolving delivery systems. Pathway graduates would be prepared to practice
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in a health care environment driven by concerns about quality and value; imbued with ways to measure those outcomes; and equipped to work in a team-based environment that focuses on patients, families, and communities. The Pathway is defined by five principles. First, it would prepare physicians for primary care practice and focus training on team-based and patient-centered care, incorporating prevention and population health as a means of improving the overall quality and efficiency of care. Second, it would be built on a competency-based curriculum centered on biomedical, behavioral, and clinical science foundations. Outcomes specific to medical education would be established to assess graduates’ readiness for professional practice at multiple points in the physician education continuum. Exhibit 2 offers an initial outline of the proposed competencies. Third, it would be a continuous, longitudinal educational experience. Clinical experiences would begin in students’ first year of medical education and would continue with increasing levels of responsibility throughout the duration of their training. An integrated continuum with a seamless transition between undergraduate and graduate medical education would be established, making it possible to eliminate redundancies and inefficiencies in the medical education process, with anticipated cost reductions and time savings.
Fourth, it would be administered by medical schools in collaboration with GME providers (organizations with authority to offer accredited residency training). Clinical experiences would occur in a wide variety of environments, including both hospital and ambulatory communitybased settings. Community-based sites, such as integrated health systems, community health centers, and large practice groups, would provide optimal environments for clinical continuity of experiential learning in primary care. Fifth, it would include a focus on health care delivery science, including the principles of the high-quality, high-value, outcomes-based health care environment (such as accountable care organizations and patient-centered medical homes); health care team leadership; analytic skills; health policy; health systems planning; health information technology; quality assurance; and patient safety. Imagine a medical school that, in collaboration with its primary care graduate medical education partners, designed a curriculum around these principles. Students would be selected to enter the Pathway program based on the qualities necessary for their success and their commitment to primary care. The educational experience would integrate basic and clinical sciences learning into a longitudinal primary care clinical experience, with individual students taking on increasing responsibilities as they demonstrate a
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Principles in Pathway The Pathway is defined by five principles: (1) focus on team-based, patientcentered care; (2) build on competency-based curriculum; (3) provide a continuous, longitudinal educational experience; (4) be administered by medical schools in collaboration with GME providers, with clinical experiences in a variety of settings; and (5) focus on health care delivery science.
Exhibit 2 New Knowledge And Capacities For The Twenty-First-Century Osteopathic Primary Care Physician Foundational knowledge and associated capacities Osteopathic principles and practices Patient-centered primary care delivered predominantly in communitybased and outpatient ambulatory care environments Role and function of high-quality, high-value delivery models, such as patient-centered medical homes and accountable care organizations Health care management, health care financing, and health policy Systems-based practice and the implementation of quality assurance and patient safety principles and processes Leadership capabilities, including leading an interprofessional health care team and managing change Data management, analysis, and the use of health information technology to facilitate patient care and patient management Principles of population health, including health and wellness promotion, disease prevention, risk assessment, and patient education, and principles of health literacy Principles of aging and communication with the elderly Design and conduct of clinical and educational research, interpretation and application of biomedical and translational research, participation in practice-based research and evidence-based practice, and evaluation of diagnostic tests and therapeutic interventions Competency with diverse populations and environments and alternative health care practices and beliefs
Personal attributes and other behavioral and contextual capacities Leadership and team-building skills, working with a variety of different health professionals, and shared decision making Communication skills, empathy, compassion, open-mindedness, personal adaptability, altruism, patient advocacy, and the ability to share the decision-making process with patients Capacity to employ social and behavioral sciences in medical practice Professionalism and adherence to ethical principles Problem solving and critical thinking Willingness to be integrated into the communities in which they practice Continuity in following up with patients and treating them thoroughly Dedication to quality, performance improvement, and continuous learning model, teacher, and mentor Capacity for self-assessment and critical appraisal and for serving in primary care role
SOURCE Blue Ribbon Commission for the Advancement of Osteopathic Medical Education (see Note 27 in text).
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Reform Proposals readiness to move to the next level. Students would develop mastery of clinical skills and knowledge in a variety of primary care and specialty areas—all targeting the competencies needed for a community-based primary care physician. Progress through medical school and residency training would be assessed based on competency, not time, through a variety of evaluative tools (see online Appendix Exhibit 1 for a description of how the Pathway could work for one hypothetical student).28 The Pathway would produce ready-for-practice osteopathic primary care physicians who were well prepared to serve as leaders of interprofessional health care teams. It is envisioned that a highly qualified and motivated student could complete this education and training program in as few as five years. All Pathway trainees would receive a strong grounding in primary care that would allow them to practice upon completion of the program. Those who later decided to pursue other specialties would be well prepared for continued training.
How Is This Different? It is reasonable to ask how these proposed changes differ from osteopathic medical education’s traditional patient-centered approach and primary care focus, and how the proposed Pathway differs from what exists in allopathic medical education. A traditional medical education, whether beginning in an osteopathic or allopathic medical school, is an eleven-to-eighteen-year journey that normally requires a minimum of a four-year undergraduate degree, four years of medical school, and three years of residency training (the length of time necessary for training in family medicine, pediatrics, or internal medicine— the traditional primary care specialties). For those who choose other specialty or subspecialty tracks, an additional one to six years may be necessary. Medical school is traditionally divided into two years of mostly basic and clinical science learning, followed by an additional two years of mandatory and elective clinical experiences. Both osteopathic medical school and residency training are organized to meet traditional competency standards (Appendix Exhibit 2). Osteopathic medical education has been rooted in primary care since its development and has a traditional holistic approach to health and an emphasis on close physician-patient interaction. Its education system, although more community based, nevertheless has been Flexnerian in its model of curricular content and delivery, as have most allopathic medical schools.15 The new Pathway would reorient the osteo1902
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Osteopathic medical education has been rooted in primary care since its development.
pathic medical educational approach to respond to the changing health care system while maintaining osteopathic medicine’s traditional emphasis on primary care and community-based training. The competencies described by the commission (Exhibit 2) recognize the need for new, team-based expertise to address the complexity of care needs, importance of the broader community environment, importance of integrating information technology with care delivery and quality measures, and need to use new knowledge emerging from health care delivery science in the provision of care. In addition, the Pathway would change a trainee’s progression from a time plus competencybased system of knowledge and skills development, in which a student must complete a certain length of time in a curriculum segment no matter how accomplished he or she might be in the learning objectives associated with that portion of the curriculum, to one in which the accomplishment of competency determines the time it takes to complete one’s training. A person would progress through medical school and residency training as he or she achieves established benchmarks of accomplishment—not when a certain date has arrived. As recommended in “Educating Physicians,” the Pathway would individualize the learning process but result in standardized learning outcomes.26 Because the Pathway model represents a substantial shift from today’s medical education model, it should be piloted by a limited number of medical schools working with their GME provider partners. After a period of assessment and revision, the model’s broader implementation would be possible.
Policy Considerations Although the commission’s work focused on development of the new Pathway, the group recognized that a variety of institutional, accreditation, licensure, governance and board certification, financial, and regulatory issues may need to be addressed for its vision to be realized. Policy considerations include everything from
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The Pathway has the potential to be a disruptive innovator of the current medical school and GME funding mechanisms.
redesigning admissions criteria to identify and select students for Pathway participation to devising and overseeing a system that creates a seamless educational continuum from undergraduate through graduate medical education. Another consideration is ensuring the ability of Pathway graduates to gain licensure and board certification. But among the most critical of the policy issues to be addressed are accreditation and financial considerations. Accreditation To facilitate the development of a seamless amalgamation of undergraduate and graduate osteopathic medical education, the accrediting and certifying agencies of both will need to reassess their standards and agree to collaborate. The Commission on Osteopathic College Accreditation accredits US colleges of osteopathic medicine. The American Osteopathic Association’s Council on Postdoctoral Training accredits US osteopathic GME programs.29 Its Bureau of Osteopathic Specialists certifies osteopathic physicians through the specialty certification board process.30 The Pathway describes a course of study in primary care that could be completed in less time based on demonstrated mastery of competencies. All of the entities listed above currently require mastery of competencies for successful completion but also include a minimum time requirement. Although there are allowances for extended time to master the competencies, there has never been an allowance for completion of study in less than the specified time requirement, based on demonstration of mastery. For example, the Commission on Osteopathic College Accreditation specifies that medical school must be four years in length or equivalent and then lists 130 weeks of instruction as the minimum amount for completion of undergraduate medical education.31 The training standards for the three separate primary care specialties specify a thirty-six-month program, with detailed specifications for length of time in
all pertinent specialty areas.32–34 Board certification is the normal next step for osteopathic physicians who have completed the specified course of time and competency-based study prescribed by the relevant specialty board.35 The commission’s proposed program of study also would lead to board certification based on competencies but without a prescribed number of months of study. That board certification could be offered by the American Osteopathic Board of Family Physicians or a conjoint board composed of two or three of the primary care specialty boards. For pilot Pathway programs to proceed, it would be necessary for all three entities—medical school accreditor, graduate medical education accreditor, and specialty board authority—to agree to make the necessary modifications to enable this innovation. Financial Considerations The Pathway has the potential to be a disruptive innovator of the current medical school and GME funding mechanisms. The current system uses resources from multiple sources, including tuition, state support, scholarships, and Medicare to fund the separate components of a physician’s education and training. However, the commission’s proposed model could lead to a commingling of funds such that appropriate resources might be allocated when needed, not according to any particular time schedule. Thus, to ensure the Pathway’s viability, changes in current graduate medical education funding streams may need to be enabled. The Pathway calls for greater medical school involvement in the administration of GME programs in partnerships with GME-sponsoring institutions. Flexibility in distribution of GME funding to allow it to flow through such partnerships (consortia) would foster creativity in addressing the financial issues related to a shortened length of undergraduate medical education and GME training. Redirecting GME funding to follow the trainee, not the institution (for example, through a voucher system), is another possible mechanism to foster flexibility. Finally, innovative funding models have been developed in a number of states to help address physician shortages. Given the current debate over federal funding levels for graduate medical education, it is reasonable to predict that alternative funding streams will continue to emerge. External funding through both public and private sources should foster testing of pilot programs such as the Pathway.
Next Steps In this article we have presented the commission’s proposal for major reform in the educaNOVEMBER 2013
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Reform Proposals tion of osteopathic physicians—and, if successful, all physicians. It marks a call for a substantial shift, not only toward competency-based assessment and seamless advancement through all stages of medical education but in the curriculum itself, to include the new knowledge and abilities needed for the health care system of the future. It is anticipated that in the coming months and years, new Pathway pilot programs could be initiated within the osteopathic medical education community, but a variety of policy challenges will need to be addressed for this to occur. The authors of this article and other members of the commission are engaging in converThe authors acknowledge the contributions of the following people in the preparation of this article: Thomas Levitan, vice president for research and application services, American Association of Colleges of Osteopathic
sations with accrediting agencies, licensing boards, regulators, and other policy makers to educate them about the new Pathway and assess associated policy concerns. Despite the time it will take to reform the medical education system, the osteopathic profession continues to focus efforts to train a strong physician workforce. Policy questions that could stand in the way of reform must be answered if osteopathic medical education is to maintain its traditional mission of community-based primary care for underserved populations in a changing US health care system.36 ▪
Medicine; James E. Swartwout, associate executive director, American Osteopathic Association; Anna M. Naranjo, executive assistant to the president, American Association of Colleges of Osteopathic Medicine; and
Wendy Fernando, communications and marketing consultant, American Association of Colleges of Osteopathic Medicine.
NOTES 1 Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502. 2 Chang CH, Stukel TA, Flood AB, Goodman DC. Primary care physician workforce and Medicare beneficiaries’ health outcomes. JAMA. 2011;305(20):2096–104. 3 American College of Physicians. How is a shortage of primary care physicians affecting the quality and cost of medical care? A comprehensive evidence review [Internet]. Philadelphia (PA): ACP; 2008 [cited 2013 Aug 30]. Available from: http://www.acponline.org/ advocacy/current_policy_papers/ assets/primary_shortage.pdf 4 Council on Graduate Medical Education. Twentieth report: advancing primary care [Internet]. Rockville (MD): Health Resources and Services Administration; 2010 Dec [cited 2013 Aug 31]. Available from: http://www.hrsa.gov/advisory committees/bhpradvisory/cogme/ Reports/twentiethreport.pdf 5 Dill M, Salsberg E. The complexities of physician supply and demand: projections through 2025. Washington (DC): Association of American Medical Colleges; 2008 Nov. 6 Government Accountability Office. Primary care professionals: recent supply trends, projections, and valuation of services. Washington (DC): GAO; 2008 Feb 12. 7 Which schools turn out the most primary care residents? U.S. News and World Report [serial on the Internet]. 2013 [cited 2013 Aug 30]. Available from: http://grad-schools .usnews.rankingsandreviews.com/
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www.aacom.org/data/student enrollment/Documents/2012-13_ COM_TotEnroll_College_State.pdf Association of American Medical Colleges. Table 26: enrollment by U.S. medical school and sex, 2008– 2012 [Internet]. Washington (DC): AAMC; 2012 Dec 17 [cited 2013 Aug 30]. Available from: https:// www.aamc.org/download/321526/ data/2012factstable26-2.pdf American Association of Colleges of Osteopathic Medicine. Trends in osteopathic medical school applicants, enrollment, and graduates [Internet]. Chevy Chase (MD): AACOM; 2012 Mar [cited 2013 Sep 3]. Available from: http:// www.aacom.org/data/Documents/ Trends-apps-enroll-grads.pdf Shannon SC, Teitelbaum HS. The status and future of osteopathic medical education in the United States. Acad Med. 2009;84(6): 707–11. Advisory Committee on Training in Primary Care Medicine and Dentistry. The redesign of primary care with implications for training: eighth annual report to the secretary of the U.S. Department of Health and Human Services and to the U.S. Congress [Internet]. Rockville (MD): Health Resources and Services Administration; 2010 May [cited 2013 Sep 3]. Available from: http://www.hrsa.gov/advisory committees/bhpradvisory/actpcmd/ Reports/8threport.pdf Thibault G. Innovation and the future of health care. In: Proceedings of the Joint AACOM and AODME 2013 Annual Meeting; 2013 Apr 25; Baltimore, MD. Mullan F, Chen C, Petterson S,
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Kolsky G, Spagnola M. The social mission of medical education: ranking the schools. Ann Intern Med. 2010;152(12):804–11. Association of American Medical Colleges. Physician shortages to worsen without increases in residency training [Internet]. Washington (DC): AAMC; 2010 Jun [cited 2013 Sep 3]. Available from: https://www.aamc.org/download/ 150584/data/physician_shortages_ factsheet.pdf Iglehart JK. The uncertain future of Medicare and graduate medical education. N Engl J Med. 2011;365(14): 1340–5. American Medical Association. Initiative to Transform Medical Education: recommendations for change in the system of medical education [Internet]. Chicago (IL): AMA; 2007 Jun [cited 2013 Sep 3]. Available from: http://www.amaassn.org/resources/doc/rfs/itme_ final_rpt.pdf Council on Graduate Medical Education. Letter to Tom Harkin, Mike Enzi, Fred Upton, Henry A. Waxman, and Kathleen Sebelius [Internet]. Rockville (MD): COGME; 2011 Nov 16 [cited 2013 Sep 3]. Available from: http://www.hrsa .gov/advisorycommittees/ bhpradvisory/cogme/Publications/ letter111611.pdf Josiah Macy Jr. Foundation. Ensuring an effective physician workforce for the United States: recommendations for reforming graduate medical education to meet the needs of the public [Internet]. New York (NY): The Foundation; 2011 May [cited 2013 Sep 3]. Available from: http://macy foundation.org/docs/macy_pubs/ Macy_GME_Report,_Aug_2011.pdf Bingaman J, Udall M, Kyl J, Udall T, Grassley C, et al. Letter from senators to the Institute of Medicine [Internet]. Chevy Chase (MD): American Association of Colleges of Osteopathic Medicine; 2011 Dec 21 [cited 2013 Sep 12]. Available from: http://www.aacom.org/resources/e-
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news/ome/archives/2012/2012-01/ Documents/Senate-Letter-to-IOM .PDF Institute of Medicine. Governance and financing of graduate medical education [Internet]. Washington (DC): IOM; [cited 2013 Sep 3]. Available from: http://www.iom .edu/Activities/Workforce/GME GovFinance.aspx Cooke M, Irby DM, O’Brien BC. Educating physicians: a call for reform of medical school and residency. San Francisco (CA): JosseyBass; 2010 Jun. Blue Ribbon Commission for the Advancement of Osteopathic Medical Education. Building the future: educating the 21st century physician [Internet]. Chevy Chase (MD): American Association of Colleges of Osteopathic Medicine; 2013 [cited 2013 Oct 15]. Available from: http:// mededsummit.net/uploads/ BRC_Building_the_Future__ Educating_the_21st_Century_ Physician__Final_Report.pdf To access the Appendix, click on the Appendix link in the box to the right of the article online. American Osteopathic Association. The basic documents for postdoctoral training [Internet]. Chicago (IL): AOA; 2013 May 14 [cited 2013 Sep 3]. Available from: http://www .osteopathic.org/inside-aoa/ accreditation/postdoctoral-trainingapproval/postdoctoral-trainingstandards/Documents/aoa-basicdocument-for-postdoctoraltraining.pdf American Osteopathic Association. Handbook of the Bureau of Osteopathic Specialists [Internet]. Chicago (IL): AOA; 2013 [cited 2013 Sep 3] Available from: http://www .osteopathic.org/inside-aoa/ development/aoa-boardcertification/Documents/boshandbook.pdf Commission on Osteopathic College Accreditation. Accreditation of colleges of osteopathic medicine: COM accreditation standards and procedures [Internet]. Chicago (IL):
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American Osteopathic Association; 2013 [cited 2013 Sep 3]. Available from: https://www.osteopathic.org/ inside-aoa/accreditation/ predoctoral%20accreditation/ Documents/COM-accreditationstandards-effective-7-1-2013.pdf American Osteopathic Association. Basic standards for residency training in osteopathic family medicine and manipulative treatment [Internet]. Chicago (IL): AOA; 2011 [cited 2013 Sep 3]. Available from: http://www.osteopathic.org/insideaoa/accreditation/postdoctoraltraining-approval/postdoctoraltraining-standards/Documents/ basic-standards-for-residencytraining-in-osteopathic-familypractice.pdf American Osteopathic Association. Basic standards for residency training in internal medicine [Internet]. Chicago (IL): AOA; 2012 [cited 2013 Sep 3]. Available from: http://www .osteopathic.org/inside-aoa/ accreditation/postdoctoral-trainingapproval/postdoctoral-trainingstandards/Documents/BasicStandards-For-Internal-Medicine .pdf American Osteopathic Association. Basic standards for residency training in pediatrics [Internet]. Chicago (IL): AOA; 2012 [cited 2013 Sep 3]. Available from: http://www .osteopathic.org/inside-aoa/ accreditation/postdoctoral-trainingapproval/postdoctoral-trainingstandards/Documents/BasicStandards-Pediatrics.pdf American Osteopathic Association. AOA board certification [Internet]. Chicago (IL): AOA; [cited 2013 Sep 3]. Available from: http://www .osteopathic.org/inside-aoa/ development/aoa-boardcertification/Pages/default.aspx Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M. The social mission of medical education: ranking the schools. Ann Intern Med. 2010;152(12):804–11.
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