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AOA’s House of Delegates Reaffirms Support of Osteopathic Competency Assessment for Licensure

September 20, 2022

At the American Osteopathic Association’s (AOA) Annual House of Delegates (HOD) meeting in July, delegates from across the profession of osteopathic medicine reviewed numerous resolutions and enacted policies to help guide the work of the AOA and the future of the osteopathic medical profession.

During this meeting, the HOD supported two key resolutions related to NBOME, COMLEX-USA, and the credentials of DOs and DO students:

Resolution 213—reaffirms the AOA’s position that the only examinations able to fully evaluate the ability and competency of osteopathic physicians for licensure are the examinations developed by the NBOME.

Resolution 200—states that the AOA will work with the American Association of Colleges of Osteopathic Medicine, the American Association of Medical Colleges, the American Council of Graduate Medical Education and other relevant stakeholders to ensure that graduate medical education programs employ a holistic review of all residency candidates, and to consider COMLEX-USA equivalently to USMLE.

“COMLEX-USA is designed to assess the unique ways that osteopathic physicians are educated, trained, and practice,” said John R. Gimpel, DO, MEd, president and CEO of the NBOME. “Its intended purpose is to ensure DOs meet a national standard for licensure, to provide excellent care to our patients. As more and more GME programs use licensure exam results in the application process, we will continue to advocate for the equivalent use of osteopathic qualifications as part of a holistic residency application process. This includes licensure exams, COMAT, AOA Board Certification, and the DO degree itself.

“We welcome the input of the students and residents, as well as DOs in education, regulation and practice roles, as we stand up together in advocating for our distinctive profession and its valid and trusted credentials,” he added.

The discussion around Resolution 213 in particular included a lively debate among osteopathic medical students, osteopathic educators, state licensing representatives, and practicing osteopathic physicians about the need for a distinctive set of licensure assessments for osteopathic physicians.

While a few suggested that combined licensure exam for DOs and MDs (with an additional osteopathic manipulative treatment [OMT] component) would suffice assessing osteopathic competencies, many others disagreed.

The debate centered on the ways COMLEX-USA integrates osteopathic principles and patient-centered cases, how it aligns with the curricular pathways at DO schools, the secondary use of COMLEX-USA in residency applications, discriminatory practices uses by a subset of residency program directors, and the distinctive practice of osteopathic medicine.

Natasha Bray, DO, MSEd, interim dean of OSU College of Osteopathic Medicine—Talequah and NBOME National Faculty chair for COMAT internal medicine, noted concern for any circumstance where the misuse of a licensing exam as a basis for discrimination against DO students but added that a distinctive licensure pathway must be affirmed.

“Our profession must standup for the well-being of our students and against undue hardship (financial and emotional) being placed on our students by an undercurrent of expectation to sit for two licensing examination series,” she said. “However, we must continue to support the licensing pathway for physicians in practice and our responsibility as a profession to self-govern and determine the qualifications for the safe practice of osteopathic medicine.”

Many felt that the AOA and others need to advocate with the ACGME and residency program directors to eliminate discriminatory practices.

Jean Rettos, DO, an associate clinical professor at Ohio University Heritage College of Osteopathic Medicine, testified that the concept of simply adding an osteopathic component to a USMLE-based exam was not the solution for full parity; rather than “changing or diminishing our identity,” it would be better to partner with organizations such as the AOA and ACGME to eliminate biases against osteopathic medical students, leading to equality in the residency application process within the established single accreditation system.

NBOME Board member and longstanding Florida Board of Osteopathic Medicine representative and Florida delegate James Andriole, DO, agreed, testifying that an add-on OMT test is not the answer.

“The only valid exam for osteopathic medical students and residents is the COMLEX-USA. It truly measures what osteopathic medical students are taught, and it ensures the protection of the public by measuring the skills, knowledge, and unique philosophy of the osteopathic physician,” he said. “An add-on exam will not do that and would do nothing to protect the distinctiveness of the osteopathic medical profession.”

To underscore that distinctiveness, Marc Kaprow, DO, immediate past-president of the Florida Osteopathic Medical Association, presented an informal review of the exam blueprints of COMLEX and the USMLE. He explained that words such as “the patient” and “communication” appeared significantly more times in the COMLEX blueprint, and suggested that due to the alignment of COMLEX-USA with the education and practice of osteopathic physicians, that exam is the only valid and trusted instrument to assess osteopathic physicians.

The meeting ended with consensus that both resolutions presented an opportunity for the profession to come together to eliminate biases and discriminatory practices that create hardship for DO students and DOs. The group agreed it was a timely discussion, as the profession continues to grow in both numbers and in its reputation and trust across the house of medicine and with patients.

“Long-term resolve and consistency in policy and action help to preserve the distinctive practice of osteopathic medicine,” said Kevin Klauer, DO, EJD, CEO of the AOA. “The HOD spoke loudly, regarding its commitment to and support of an osteopathically distinct competency assessment for licensure as designed and administered by the NBOME. This commitment is important for all current and future DOs.  However, the HOD recognized the undue burden imposed on osteopathic medical students, expecting them to also take the USMLE series to compete for residency slots. The AOA is committed to advocating for our student colleagues to abolish this unfair expectation.”

Ernest R. Gelb, DO, president of the AOA, added: “Throughout my career, the AOA has partnered with many, including the NBOME, to protect and preserve our distinctive philosophy. I was moved by the actions of the AOA House, as it reaffirmed this charge, honoring our profession and protecting the credentials of all DOs and osteopathic medical students. Our efforts to protect our philosophy must and will be complementary to the needs of our medical students and not at their expense.”