A landmark announcement came in March 2014, with the American Osteopathic Association (AOA), the American Association of Colleges of Osteopathic Medicine (AACOM), and the Accreditation Council for Graduate Medical Education (ACGME) jointly announcing their memorandum of understanding (MOU) aimed at a consolidated graduate medical education (GME) system. I am going to give a synopsis that merges frequently asked questions, press announcements, and discussions from both houses.

What Does This Mean for GME?

There are a great number of questions regarding what this actually means. Essentially, participation in a single accreditation system ensures quality, promotes consistency and efficiency, and strengthens the medical profession as a whole. It does not mean that DOs are no longer learning osteopathic principles or that the MD and DO professions are uniting. The rumor mill has been fraught with “the end is nigh” for osteopathic medicine, which quite frankly is very wrong and shortsighted. What this MOU really means is that the two groups agree that a single standard for quality and consistency is in the best interest of both entities as they look forward to future changes in health care. A unified voice on GME access and funding issues strengthens the influence of all physicians for advocacy on GME issues in Washington, DC, as well as on state and local levels. Everyone agrees that the Affordable Care Act will increase the need for primary care physicians, and yet GME slots and Medicare dollars remain frozen. As partners in GME, we become a much more powerful advocacy group with a nonconflicted voice.

 Furthermore, a single accreditation system preserves access to training programs for DOs wanting to transition into an ACGME program after their first year of accredited training, plus strengthens the ability of the ACGME to have more primary care and rural residency training programs. The ACGME has been better at creating specialty programs, whereas the AOA has been better at meeting primary care needs and those of rural America. Uniting the two GME systems brings the best of both worlds together. This provides access to numerous fellowship programs for DOs and numerous primary care programs for MDs. There are MDs who will want to do a residency that was historically osteopathic for myriad reasons, such as to acquire extra training in physical medicine, but I imagine another will be location. If you are an MD and your family is from Metropolis, your parents live in Metropolis, your spouse wants to live in Metropolis, and the only radiology residency in Metropolis is the former osteopathic residency at Metropolis General, then it may quickly find its way to the number-one spot on your match list.

Implications for Educators and Students

How will this impact educators? A contentious issue exists for most DO-trained residency directors in that residency directors in the new combined system will have to be ACGME-trained or paired with an ACGME director for an undetermined time. Many DO directors see this as a slight to their training and acumen, but it is really just to ensure a smooth transition to a unified system. Norman Vinn, DO, president of the AOA, provided an excellent analogy: “If you were a manager at Microsoft and the director of Windows 7 and went to work for Apple, chances are that you would be paired up with someone who knew the Apple system for a while until you knew their system well. It isn’t about whether Windows 7 was inferior to Apple or whether your training at Microsoft was equivalent but rather about knowledge of how the system operates.” There will be many bumps in the road that will be worked out by a plethora of task forces or committees. In my tenure in the government, politics, and medicine (principal deputy assistant secretary for health affairs and deputy chief medical officer and chief of space medicine for NASA, etc.), I have yet to see a perfect policy from the get-go. They all get tweaked over time as you discover unintended consequences or challenges.

 After implementation, all training programs will be ACGME-accredited. Osteopathic principles will not be thrown out with the bathwater; in fact, just the opposite will happen. Osteopathic principles will be recognized and codified in the single accreditation system, and there will be training programs with an osteopathic dimension under ACGME accreditation. A Neuromusculoskeletal Review Committee and an Osteopathic Principles Review Committee will be developed. Osteopathic primary care programs have been routinely filled and serve the rural communities well, with osteopathic medical school graduating 50 percent or more of physicians headed to primary care. The ACGME will not want that to disappear; nobody wants that secret sauce of minting primary care physicians to disappear.

The questions I get from medical students usually center around the match and board examination. The match is administered by the National Residency Match Program (NRMP) and not the ACGME. Consequently, this is an issue that can be resolved only when NRMP claims a seat at the table. However, if all programs are considered ACGME-accredited, a system with one match seems inevitable. Regarding the examination process, I am sure students would prefer to have a single exam.

Examinations are in multiple parts, and some cover distinct content. It is doubtful that those exams (COMLEX and USMLE) will merge anytime soon. Even if they do merge years down the road, a grandfather clause will be necessary to catch those who are part way through either examination process, and there will need to be at least an additional component for the DO students to test them on distinct osteopathic principles and practice. Conversely, if MDs seek a DO residency, an examination to test them on those distinctive principles will be necessary as well.

 DOs have had one unfair advantage over their MD counterparts: they could do either an AOA or ACGME residency, whereas the MDs could only train in an ACGME residency program. That will also change. DO and MD graduates will have access to ACGME-accredited training programs, including those with an osteopathic principles dimension. Prerequisite competencies (recommended by the new Osteopathic Principles Review Committee) and a recommended program of training for MD graduates may be required for entry into programs that have an osteopathic principles dimension, especially in primary care and physical medicine and rehabilitation. The same will apply to international medical graduates.

Osteopathic principles are becoming less foreign and are already being incorporated into many allopathic institutions. Most folks assume that manipulation is the hallmark difference between the two professions. This is a common misconception. Manipulation is something that DOs learn for sure, but the bulk of the differences are philosophical: that the body is a unit and the holistic approach to the patient, nutrition, and preventive medicine in addition to the manual medicine component. More and more of the allopathic schools and residencies are incorporating nutrition, holistic approaches, empathy training, and preventive medicine into their curriculums. In some respects, the entire approach to patient care, and the health care system itself, has begun to embrace and adopt many of the osteopathic principles.

Power in a United Front

The single system presents an opportunity to advocate, especially with members of Congress, for appropriate public support for funding the best-trained future physician workforce. As efforts are taken to cut GME funding, the single accreditation process is a clear reflection of the collaborative work being done by the AOA, AACOM, and ACGME to remove any perceived inefficiencies of maintaining two accreditation systems. Improving GME, with a focus on achieving demonstrated quality improvement, will produce the greatest benefit.

This epic endeavor also should break down old walls that separated the two professions. A DO who did an ACGME residency will no longer be ostracized by the osteopathic community, and an MD who has extra training in holistic patient care will no longer be seen as “on the fringe.”

We may find we have more in common than we thought, and our focus will then be on patient outcomes rather than initials and inconsequential differences. The letters behind your name or the organization that accredited your training program do not translate to the bedside. Patients need competent, caring physicians, and this new system is on track to produce them.

Dr. Polk is dean of the College of Osteopathic Medicine at Des Moines University in Des Moines, Iowa.