Reflecting on 13 Years of Osteopathic Medical Education Leadership

In some respects, it seems like just yesterday that I first walked into the American Association of Colleges of Osteopathic Medicine (AACOM)’s offices. However, the years have flown by and I am now retiring after 13 ½ years as AACOM President and CEO. So lately, I have been thinking back about how much has changed since my early days at AACOM, how fast it has changed, and what feels like a remarkable pace of transformation.

When I arrived at AACOM in 2006, there was no iPhone (I had recently switched to a Blackberry from a Palm Pilot), Netflix movies were rented by receiving discs in the mail, and while email was widely used, formal communications were still primarily written (on paper) and sent via “snail” mail or fax. While we can recognize the environmental changes impacting us individually and as a society over this decade plus, I’d like to reflect specifically upon changes that occurred within the healthcare system, osteopathic medical education, and AACOM.

In 2006, I had just left the University of New England College of Osteopathic Medicine (UNECOM) after serving as Dean and Vice President for Health Services for nearly 11 years. I was excited to get started in this role with, I believed, new opportunities to make a positive and lasting impact. Transitioning from the osteopathic medical education (OME) academic world to the world of Washington, DC—with its thousands of associations, represented by thousands of lobbyists—also came with many challenges in taking over leadership of what was a relatively small association amongst the health professions education community. However, the critical issues of the day included impending and dramatic physician workforce shortages, especially in primary care, a growing chronic disease epidemic, and lack of healthcare access in many rural and underserved communities. I thought that our profession and educational community could have a real and lasting impact on those issues, and OME needed to be elevated to the forefront of discussions among policy makers.

healthcare in 2006 was somewhat different than it is today. In those years, prominent health issues included the potential for a “Bird Flu” outbreak, growing recognition of the obesity epidemic (and its correlation with diabetes and heart disease), and a sharpened focus on patient safety and medical errors. There were also growing concerns about the healthcare system itself, about the many uninsured and underinsured, the lack of equity in healthcare access and treatment, the increasing rate of growth in healthcare spending as a part of GDP (a little over 15 percent then and around 18 percent now), and the lack of coordination and integration of healthcare data, delivery, and care.

Many of these issues are similar or the same today—but there have been important developments. The possibility of serious infectious disease epidemics continues, not only with potential disastrous influenza strains, but the increase in antibiotic resistance and the exotic disease threats recently highlighted by Ebola, the mosquito-borne Zika virus, and expanding tick-borne diseases—all amidst a world being increasingly impacted by climate change.

Access to equitable healthcare continues to be an issue, but the number of uninsured in our population dropped dramatically from 47 million (nearly 16 percent) in 2006 to under 28 million (10.8 percent) by 2016, largely as a result of the Affordable Care Act (ACA). Of course, that progress has been clouded by recent trends that show the percentage of uninsured is again rising (having increased to 13.7% over the last two years). Up to 45% of our population are “underinsured,” and prescription drug prices are growing dramatically. The ACA and subsequent government and non-government initiatives continue to alter the healthcare landscape and there are clearly ongoing issues for our country and its people. But amidst uncertainty, certain trends have continued: greater integration of health systems, implementation of electronic heath records (with associated disruption), concentration of hospital and clinical care systems into ever-enlarging organizations, movement toward value-based payment for health services, a focus on team-based collaborative practice, and the rapid movement toward physicians as both employees and healthcare team members.

The continually evolving healthcare environment is markedly different than that of just 13 years ago, with technological breakthroughs, personalized medicine, greater focus on prevention and healthy lifestyles, digitized medical reference materials, the expansion of federally-funded community health centers, the renewed debate over our health insurance system, and on and on. Physicians who completed their training in 2006 are mostly in their 30s or early 40s today. The system they practice in now is different in many ways from the system in which they trained. And the changing trends are likely to accelerate.

OME has also seen dramatic changes in the past decade, with new schools, innovative curriculum, and more students. The number of osteopathic medical students and colleges of osteopathic medicine (COMs) has doubled, with just under 31,000 students approved for education at 56 locations across the United States—nearly 25% of medical students in the U.S. Remarkably, the number of applicants increased faster than the number of first-year seats, rising from 2.5 applicants/seat in 2006 to 2.9 in 2018.

In 2006, the osteopathic medical education curriculum was focused on patient centered, hands-on, care built on the tenets of osteopathic medicine, and conducted with a community-based and primary care focus. It was benefiting from variation and innovation from college to college. At that time, “competency-based” was the watch word trending across the OME continuum, and there was increasing use of simulation and standardized patients for teaching and evaluation.

Amidst the rapid and positive change happening within the OME community at the time, a broader issue was emerging across the medical education continuum. Concerns regarding the issues of projected physician shortages were mounting, as were growing challenges to clinical education capacity, particularly in graduate medical education (GME), and the impact caused by the GME caps imposed by the Balanced Budget Act of 1997 (legislation drafted based on inaccurate projections at that time of a surplus of U.S. physicians in the early 1990’s).

While our colleges were members of Osteopathic Postgraduate Training Institutes (OPTIs), in which osteopathic graduate medical education (OGME) programs were accredited, there was no accreditation requirement at that time for our schools to be developing graduate medical education programs. These issues led to major concerns about the future of OME, especially given the U.S. MD and DO medical school growth trends and the “bottleneck” control of physician training laid out in the Balanced Budget Act. AACOM and the American Osteopathic Association (AOA), held two OME Summits—the first in 2006—that brought together leaders in osteopathic medical education to collaborate on ways to address the impending physician workforce shortage and associated issues, such as inadequate GME funding. In addition, the two organizations engaged in an effort to envision what osteopathic medical education across the continuum should look like if it was being designed anew and, after a multi-year process, issued a report from a joint ad hoc committee, the Blue Ribbon Commission for the Advancement of Osteopathic Medical Education, "Building the Future: Educating the 21^st Century Physician," in 2013. This document foretold a number of innovations that have subsequently been broadly adopted in medical education in recent years and continue to have an impact on OME.

The work of AACOM with AOA and other entities resulted in a number of recommendations and changes for multiple entities within the osteopathic profession to address issues that would maintain and strengthen OME amidst the environmental changes underway. 

As mentioned, OGME was a concern throughout, with growing numbers of medical students applying to institutions with federally-capped GME position funding. Increasingly, assuring GME opportunities for DO graduates became a focus for our COMs and AACOM, as well as the AOA and other entities outside our profession (e.g., the Veterans Administration, the Council on Graduate Medical Education, the National Academy of Medicine, and others). These efforts expanded along with the increasing recognition of the value of DO graduates at all levels of the healthcare system, both in the delivery of community-based primary care and in other specialty areas.

The AOA and the AACOM member colleges commenced targeted efforts to expand post-graduate training in hospitals and institutions that had not been “capped” because they were new to GME. Osteopathic medical college accreditation standards were modified to require colleges to develop and support the expansion of GME. And, for a number of reasons that I have addressed elsewhere, AACOM joined with the AOA and the Accreditation Council for Graduate Medical Education (ACGME) to develop the Single GME Accreditation System, which is soon to begin its final year of the 2015 to 2020 implementation period.

Much that has occurred over these years relating to osteopathic GME could not have been forecast in 2006. The success of our graduates in the GME matches (98-99 percent placement) and the recognized value that osteopathic medical graduates bring as residents and physicians are a testimony to the OME community’s focus on providing leadership to solve issues that are before us, all while relying on the values and tenets of our profession to maintain our distinctiveness. And of course, this work continues as a strategic priority for AACOM.

AACOM’s office in 2006 was located in Chevy Chase, MD. A major focus was recruitment of applicants and the manual processing of paper applications for our colleges. We also maintained a presence within health profession’s government relations and had undertaken an office of medical education with a focus on convening the COM’s medical educators. We were engaged in managing our relatively new AACOM Annual Conference, and supporting leadership, research and scholarship amongst our members. We had many fewer staff members, and the AACOM logo, brand, and the publications that you know today—including the one that you’re reading now—didn’t exist. We were not present on social media and our website was just celebrating its 10-year anniversary.

Over these 13 years, with the strategic planning and support of AACOM’s governing body—the Board of Deans—and the dedicated work of many staff members, past and current, AACOM has emerged in so many ways as leading osteopathic medical education and providing leadership in health professions education. To cite some examples:

• AACOM collaboration with the AOA Commission of Osteopathic College Accreditation to improve the accreditation system for the nation’s COMs
• Establishment of the AACOM National Academy of Osteopathic Medical Educators
• Development of the AACOM Annual Conference “Educating Leaders” as the premier osteopathic medical education meeting, with a peer-review submission process and abstract publication
• Publication of “ Osteopathic Core Competencies for Medical Students”
• Integration of the Association of Osteopathic Directors and Medical Educators organization into AACOM as the Assembly of Osteopathic Graduate Medical Educations (AOGME) to embrace the full continuum of OME
• Development of the AACOM Leadership Institute with these programs: Senior Leadership Development, Administrative Leadership Development, Women’s Leadership Institute, Osteopathic Health Policy Fellowship, Osteopathic Health Policy Internship, and Training the Osteopathic Professions Core Educators
• Expansion of Government Relations to a nine-person operation with a Capitol Hill office, active engagement in congressional and executive branch advocacy, leadership of important advocacy coalitions, and a focused Annual COM Day on Capitol Hill
• Creating the ED to MED social media advocacy campaign with 18 organizational national partners organized to support key policies needed by our students and colleges in Higher Education Act Authorization
• Expanded facilitation of the numerous Councils that make up a core aspect of AACOM’s community and the initiation of an annual Council Leadership Meeting
• Implementation of an AACOM Staff Diversity Task Force leading to the establishment the new AACOM Council on Diversity and Equity
• Active and growing presence on social media, blogs, and online newsletters
• Development of an AACOM Osteopathic Medical Education section within the Journal of the Osteopathic Association and publication of AACOM Annual Conference Abstracts
• Implementation of an unprecedented multi-year study, The Project in Osteopathic Medical Education and Empathy (POMEE), on empathy within the nation’s osteopathic medical schools
• Creation of a growing online database of information about OME
• AACOM’s participation as a founding member of the Interprofessional Education Collaborative (IPEC)
• With the establishment of the Single GME Accreditation System, AACOM becoming a member organization of the Accreditation Council on Graduate Medical Education (ACGME)
• AACOM membership in the Coalition for Physician Accountability
• AACOM membership in the International Osteopathic Alliance
• AACOM membership in the Pan American Federation of Associations of Medical Schools
• AACOM engagement in multiple National Academy of Medicine (NAM) initiatives, including the NAM Global Forum on Innovation in the Health Professional Education, NAM Action Collaborative on Clinician Well-Being and Resilience and the NAM Action Collaborative on Countering the U.S. Opioid Epidemic
• In collaboration with AOA and the American Osteopathic Foundation, the endowing of a National Academy of Medicine Fellowship in Osteopathic Medicine

And there are many, many more items that could be listed.

In reflecting on where we have come over these years, I know what has been accomplished has involved much work by many people and organizations. I have always cherished the great AACOM staff and the wonderful colleagues with which I have worked within the osteopathic medical education and professional community, and amongst the many colleagues within the greater health professions education and practice community. All of this has been a team effort with a variety of individuals in a variety of organizations teaming up to make positive change happen and bring the principles and culture of OME to the forefront in decision-making. I can see how far we have come in such a short time in a challenging environment.  And, I strongly believe this progress will continue in coming years as AACOM continues its work together to improve the health of the public.