The Ability to Self-Govern: The Accreditation of the Osteopathic Medical Colleges by

the American Osteopathic Association

Core Principle 14. The U.S. Department of Education's and the former Council
on Postsecondary Accreditation's decisions to recognize AOA accreditation of
medical colleges.

Leslie Mae-Geen Ching, DO

OGME-1, Doctors Hospital Family Practice Residency
Columbus, OH

Word Count: 2,998

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Introduction
The number of colleges of osteopathic medicine (COMs), osteopathic medical
students, and Doctors of Osteopathic Medicine (DO) in practice have been
consistently growing since the 1960s. At that time, the osteopathic merger into the
allopathic “Medicinae Doctor” (MD) degree in California galvanized the profession to
fight to defend its existence. In recent years, the growth of the profession has been
exponential. This paper will briefly examine the history and current state of
osteopathic undergraduate and postgraduate education in order to look at the
results of the American Osteopathic Association’s (AOA) ability to accredit the
osteopathic colleges.

Brief History of the Role of the AOA

The AOA1 was established in 1897, only five years after the first osteopathic
medical school, the American School of Osteopathy in Kirksville, Missouri, opened
its doors. The AOA served to protect the interests of the profession on a national
basis. Prior to that, individual groups would have to lobby individual state
legislatures for practice rights (Gevitz, The DOs: Osteopathic Medicine in America,
2nd edition 2004). To protect practice rights, the osteopathic profession had to
establish a legitimate accrediting body to oversee schools and a legitimate licensing
process to protect the public. As a result, by 1923, 46 states had passed osteopathic
practice laws and 27 states had independent osteopathic licensing boards. Also by
that time, most states had legislation that allowed the AOA to accredit osteopathic
schools (Gevitz, The DOs: Osteopathic Medicine in America, 2nd edition 2004).
These were all major landmarks in the process of becoming an independent and
self-governing profession.

History of College Accreditation

In 1952, the United States Department of Education (US DOE) acknowledged
the AOA as being the accrediting agency for osteopathic colleges (United States
Department of Education 2010). This acknowledgement means that the AOA is
recognized as “being a reliable authority regarding the quality of education or
training offered by the institutions or programs they accredit” (United States
Department of Education 2010). Several private, non-governmental accrediting
bodies that would later approve the AOA accreditation of osteopathic colleges
included the National Commission on Accrediting (NCA), the Council on
Postsecondary Accreditation (COPA), and the Council on Recognition of
Postsecondary Accreditation (CORPA) (AOA, COCA 2010). Notably, the Liason
Committee on Medical Education, the accrediting body of allopathic medical schools,
was also first recognized by the US DOE in 1952 (United States Department of
Education 2010).
There have been several college accrediting bodies within the AOA
throughout its history: the Committee on Education in conjunction with the

1 The original name was the American Association for the Advancement of
Osteopathy (Gevitz, 2004).
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Associated Colleges of Osteopathy until 1930, the Bureau of Professional Education
and Colleges, from 1930 to 1960, the Bureau of Professional Education from 1960 to
2004, and the Commission on Osteopathic College Accreditation (COCA) since 2004
(AOA, COCA 2010).
The first college inspection was done in 1903; inspections have been
occurring at varying intervals since then (AOA, COCA 2010). The process of
accreditation and inspection has been an emphasis of the profession since its
earliest days. It is only through rigorous accreditation that the public can be certain
that the colleges that are training their future physicians have implemented a
standard set of academic and clinical expectations into curricula.

Accreditation Process
COCA is the current accrediting body for the AOA. There are 17 voting
members of COCA, appointed by the President of the AOA. These include one private
school dean, one public school dean, two educators from the colleges, one director
of medical education, one hospital administrator, three public members, and eight
members-at-large who are also members of the AOA (AOA, COCA 2006).
There are several levels that a new school must go through to become fully
accredited by COCA (AOA, COCA 2010). The first level is the application, during
which the applicant will receive the paperwork it requires. The second level is pre-
accreditation, which requires the completed paperwork, a feasibility study by a
nationally recognized accounting or management firm, and an on-site visit by COCA.
The applicant school can keep this status for five years, but it cannot accept or
recruit new students during this time.
Provisional accreditation is the next level in the process. The applicant school
has to submit an updated feasibility study, documentation of adequate clinical
training sites, and have an on-site visit by COCA. At this point, the applicant school
can state that it is “provisionally accredited” and accept new students. During the
time that it is provisionally accredited, the school must submit a self-study report
annually. Before it graduates its first class, the school will have an accreditation visit
by COCA. Then two things can happen: either the school attains accreditation status
or it does not. If the former occurs, the school’s accreditation status is reviewed on a
seven-year cycle, or sooner if so required. If the school does not attain accreditation,
the provisional accreditation status is ended by COCA and the school is essentially
defunct.
The goals of the accreditation process are many, and can be reviewed by
interested parties at the COCA website2. One important piece of accreditation since
the earliest days of accreditation has been that the school must show osteopathic
distinctiveness in its curriculum (AOA, COCA 2010). Many of these standards are, by
necessity, fulfilled more in the gestalt as opposed to more hard and fast rules. For
example, there is no rule saying that an Osteopathic Manipulative Medicine (OMM)
department3 must have a designated number of DOs who practice a relatively

2 http://www.aoacoca.org
3 Or the equivalent; e.g., Osteopathic Principles and Practice.
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advanced level of OMM per number of students.
One could argue that the domain of osteopathic distinctiveness is the most
important function of an osteopathic medical school and, by extension, the most
important function of COCA. It is during osteopathic medical school that students
are taught the philosophy and appropriate use of OMM. Everything in osteopathic
postgraduate education is built on those four years (and in many situations, only the
first two years since many schools do not have good osteopathic curricula in the
clinical years4). In those four (or two) years, the osteopathic medical student must
be exposed to the unique advantages of the osteopathic profession and reasons for
osteopathic medical approach. Otherwise, there may be cohorts of medical school
graduates who have no idea of why being “osteopathic” in approach is significant
and what doing so could accomplish.

Osteopathic Colleges Through the Decades

The AOA has estimated that at the current rate of expansion, there will be
100,000 DOs in practice by 2020 (AOA 2009). To put this in some perspective, in
1980, DOs made up only 3.8% of the physician workforce in the United States
(Shannon 2010). In 2008 DOs made up 6.7% of the physician workforce in the
United States, compared to foreign medical graduates, who made up 24.2% of the
workforce (Shannon 2010).
It is somewhat instructive to examine the exponential growth of the COMs
and practicing DOs in recent decades. In 1935, there were six schools and 8,265 DOs
in active practice (Gevitz, The DOs: Osteopathic Medicine in America 1982) (AOA
2009). In 1955, there were still only six schools and 11,912 DOs in active practice
(Gevitz, The DOs: Osteopathic Medicine in America 1982) (AOA 2009). As Norman
Gevitz, PhD, has noted, the California merger in 1962 was a galvanizing force in the
osteopathic profession, causing many disparate groups to consolidate forces and
establish a stronger profession. Part of this movement included establishing more
schools and thus ensuring more osteopathic physicians (Gevitz, The DOs:
Osteopathic Medicine in America, 2nd edition 2004). In 1975, over a decade after
the California merger, there were nine schools and 14,321 DOs in practice (Gevitz,
The DOs: Osteopathic Medicine in America 1982) (AOA 2009). In 1985 the
momentum had continued and there were fourteen schools and 22,540 DOs in
practice (AOA 2009). Expansion of schools into branch campuses began in the
1990s with the advent of the Arizona College of Osteopathic Medicine of
Midwestern University, which was a branch campus of the venerable Chicago
College of Osteopathic Medicine. As a result, in 2005, there were twenty-three
campuses and 56,512 DOs in practice (AOA 2009). Just four years after that, there
were twenty-eight campuses and 67,167 DOs in practice (AOA 2009). And currently

4 For a recent review of student opinions regarding OMM in medical school at

one school, please examine: Quinn T, et al, “Attitudes and Confidence Levels of
Fourth-Year Osteopathic Medical Students towards Osteopathic Manipulative
Medicine,” American Academy of Osteopathy Journal 20, no. 3 (September 2010): 23-
28.
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in 2010, there are currently thirty campuses with more in the preliminary stages of
accreditation (AACOM 2010).
It is truly a staggering achievement to have added so many schools and
physicians to the profession within a few short decades. For most of the early
decades of the osteopathic professions, there were six consistent schools: Kirksville,
Des Moines, Chicago, College of Osteopathic Physicians and Surgeons (in California,
which would be converted to the University of California-Irvine medical school),
Kansas City, and Philadelphia. In a space of roughly four decades, the osteopathic
profession has added approximately four times that number of colleges or branch
campuses. In comparison, there had not been an allopathic school that opened in the
US for the past 20 years until this year (Whitcomb 2010).

Osteopathic Postgraduate Education Through the Decades

With all of these new osteopathic medical school graduates, where are they
all going for postgraduate education? For many decades, a majority of osteopathic
physicians would do the traditional osteopathic rotating internship and then go into
practice as a general practitioner. As late as 1950, a survey of osteopathic medical
students published by the Journal of the American Osteopathic Association revealed
that only 13% of them intended to enter a residency program after internship year.
Only 25% intended to be board-certified in a specialty (Mills 1951).
In comparison, in 2009 there were 762 AOA-approved residency programs
(AOA 2009). There were 5,399 DOs in AOA-approved residencies and internships.
However, there were 7,237 DOs in Accreditation Council for Graduate Medical
Education (ACGME) residency programs, which are allopathic residency programs
(AOA 2010). Not surprisingly, many of those DOs in ACGME residencies were in
residencies without similar AOA residency positions. One good example of this is in
Pediatrics. In 2008-2009, there were 171 funded positions in AOA residency
programs, of which 130 were filled, in addition to 40 “special-track” interns. In that
same time span, there were 656 DOs in ACGME residencies (AOA 2010). In
Neurology in 2008-2009, there were 52 funded positions in AOA residencies and 31
residents. In that same time period, there were 114 DOs in ACGME residencies (AOA
2010).
Interestingly enough, there are residency specialties where there is a surplus
of positions in AOA residencies but not enough residents to fill them. Internal
Medicine, for example, had 1,128 funded positions in 2008-2009 in AOA residencies.
However, there were only 672 residents, in addition to 214 “special-track” interns.
In comparison, there were 1,296 DOs in ACGME Internal Medicine residencies in
2008-2009 (AOA 2010). In Family Practice, there were 1,836 funded positions in
AOA residencies, with 1,077 residents and 221 “special-track” interns. There were
1,374 DOs in ACGME Family Practice residencies, a roughly equivalent number to
the number of DOs in AOA residencies (AOA 2010).
There are several important questions germane to osteopathic postgraduate
medical education. One is: why do many osteopathic medical school graduates
choose ACGME residencies? One important factor is geographical: 10 states have
83% of the AOA-approved residency spots (Shannon 2010). Other factors might be

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the limited number of AOA-residency spots or perceived lack of prestige of AOA
residencies. In fact, in a 2004 survey of fourth year osteopathic medical students,
66% chose to practice allopathic or governmental residencies (Teitelbaum 2005).
Stated reasons of this group for choosing an nonosteopathic residency were: better
training (40%), osteopathic program not available in their preferred geographic
area (33%), more career opportunities (30%), family considerations (26%),
specialty training not available in an osteopathic program (25%), and shorter
training period (13%).
Another question is: why do many osteopathic residencies in Family Practice
and Internal Medicine have fewer residents than they have funded spots? In
addition to the previous reasons, especially in Internal Medicine, with the emphasis
on fellowships, a graduate from an AOA-approved residency might have less
perceived “market value” than one from an ACGME-approved residency. In point of
fact, in a survey of second year DO residents, 31% of those in ACGME-accredited
residencies reported reputation of the institution as being a factor in their decision,
as compared to 12% of AOA-accredited residencies (Teitelbaum 2005).
An interesting result Howard S. Teitelbaum, DO, MPH found in analyzing the
results of his surveys of osteopathic medical students and residents were that those
choosing to go to an osteopathic residency were significantly more likely to report
an osteopathic physician as a role model. Not surprisingly, these residents were also
more likely to value osteopathic principles and practice. There are probably some
osteopathic medical students who are more likely to accept osteopathic philosophy,
just as there are probably some others who are less likely. However, can we teach
the people who are not already motivated either way the value of an osteopathic
approach to health and disease and thus make them more likely to seek further
instruction in this? If we could do so, we could probably make osteopathic
residencies more desirable.

Current Controversies in Osteopathic Education

There are several controversial subjects in osteopathic education today. One
is whether AOA-approved residencies should accept MDs. A tangential question is
whether teaching OMM to non-DOs should be encouraged. These questions, among
others, were discussed in a point-counterpoint format at the Medical Education
Summit II that was held in Chicago, Illinois from November 10-12, 2007 (AOA and
AACOM 2007-2010).
It has been axiomatic in the osteopathic profession that osteopathic
residencies should only accept osteopathic physicians. William D. Strampel, DO, the
Dean of the Michigan State University College of Osteopathic Medicine made several
points in support of this stance (Strampel 2007). He questioned the practicality of
certification of MD candidates in osteopathic residencies. He also pointed out that
giving a “crash course” in OMM would belittle the osteopathic approach, since it is
not “some manual medicine techniques we add on to an allopathic educational
program.”
Kendall Reed, DO, the Dean of the Des Moines University College of
Osteopathic Medicine, delivered the counterpoint (Reed 2007). He cited the number

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of filled osteopathic residency positions being 49% in 2007. He contrasted this with
a study published in the JAOA in 2005 (Allee BA 2005), which showed that 89% of
the surveyed allopathic residents in dually accredited programs felt that OMM was
effective for somatic dysfunction, 78% were interested in CME, and 43% were
interested in OMM integration into their program. Dr. Reed argued that providing
osteopathic residency positions to MDs would preserve the positions’ funding, raise
public awareness of osteopathic medicine and how it differs from allopathic
medicine, increase AOA membership, and strengthen the specialty colleges. He
advocated for a single system of graduate medical education in conjunction with the
ACGME.
Of note, the AOA House of Delegates voted in July 2010 to study the issue of
accepting MDs into AOA residency program5. It remains to be seen what will occur.

Conclusion
The ability of the AOA to accredit the colleges of osteopathic medicine is
nothing short of crucial to the cohesiveness of the profession: it is at the college level
where much of the foundation for osteopathic philosophy and practice is
established. Perhaps it is not a coincidence that in recent years, with fewer
osteopathic physician role models to influence how osteopathic medical students
view their profession, osteopathic residencies have had a harder time finding
residents to fill their positions. In light of the often acrimonious relations between
allopathic and osteopathic physicians, it is a rather bitter irony that a number of
allopathic residents seem to be more interested in osteopathic manipulation and the
holistic aspects of osteopathic philosophy than some DOs themselves!
Given this situation, what are the solutions? Certainly there are no quick
fixes. The conundrums of undergraduate education in the colleges are themselves
almost Herculean. Are there too many schools and too many students or not enough
DOs willing or able to be academic and clinical faculty members? Given the limited
number of DOs with the ability or desire to teach OMM, is it even feasible to have
quality instruction in osteopathic philosophy and practice?
Regarding osteopathic postgraduate education, the question of why so many
graduates of osteopathic medical schools choose ACGME residencies should be
addressed. Again, the reasons are legion, ranging from geography to availability of
residency positions to relative reputation of the programs. It is simply more
prestigious to go to some ACGME programs in some specialties. However, the
osteopathic profession could address how to make the majority of the osteopathic
residencies better in quality and more appealing. There is a proportion of the
population that will always value the osteopathic approach more highly and
preferentially choose it. The question is how to attract the students in the middle.
Part of the answer undoubtedly lies in undergraduate medical education, with more

5 For further thoughts, please see MR Berkowitz, "Admitting Allopathic

Physicans to Osteopathic Graduate Medical Education Programs: the Case for
Competency-Based NMM/OMM Training in OGME," American Academy of
Osteopathy Journal 20, no. 1 (March 2010): 6.
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osteopathic physicians acting as role models and stronger osteopathic curricula
throughout all four years. We must also be willing to look at new approaches, such
as the question of admitting MDs into AOA-approved residencies. There are many
practical issues with this but perhaps it is an idea worth exploring. Of note, the
admixture of the two medical professions already occurs in many locations with
dual accreditation.
Residency training and practice as an osteopathic physician are all based on
the education one receives at the undergraduate level. These colleges are accredited
by the AOA and thus, by the profession as a whole. Each of us gives our imprimatur
to every school and so, in a sense, every school is answerable to each one of us.
COCA is the official accrediting body of the profession but each individual DO is
unofficially partially responsible for making sure the standards of the profession are
being met. As the Osteopathic Oath reads, “To my college I will be loyal and strive
always for its best interests and for the interests of the students who will come after
me” (AOA 2003-2010). It is not just one’s school of osteopathic medicine or specialty
college that this refers to, but the College of Osteopathic Medicine in the broadest
sense.

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Acknowledgements
The author would like to thank William J. Burke, DO, FACOFP, for his review of this
paper. She would like to express sincerest gratitude to the faculty, staff, and
colleagues at the Doctors Hospital Family Practice Residency for their kindness and
support which is not only evinced in designated intern support meetings. To the
faculty, staff, and colleagues at Doctors Hospital, many thanks for their support and
kindnesses (especially in the middle of the night) and belief in the osteopathic
approach combined with the most appropriate medical and surgical management.
She would also like to thank Richard G. Schuster, DO, for his constant and insightful
mentorship, as well as the many DOs she is proud to have learned some aspect of
osteopathic medicine from.

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