A cross-sectional analysis of pathology exposure across COCA-accredited osteopathic medical schools: Gaps and opportunities in pathology undergraduate medical education

Abstract

Osteopathic medical schools emphasize a holistic approach to patient care, integrating Osteopathic Manipulative Treatment (OMT) with traditional medical education. Unlike allopathic (MD) programs, which focus heavily on biomedical sciences, osteopathic (DO) programs place additional focus on the musculoskeletal system and primary care. Clinical training in DO programs often takes place in community-based medical centers, which typically lack specialized resources, such as pathology departments, limiting exposure to certain specialties. Pathology education in osteopathic schools varies widely, with some schools integrating pathology into foundational sciences through lectures, case-based learning, and histopathology labs. However, clinical clerkships offer inconsistent pathology exposure, compounded by limited partnerships with specialized pathology labs. A study of 61 accredited osteopathic colleges revealed variability in pathology faculty, with some schools lacking pathologists entirely. Additionally, only 12% of these colleges had pathologist deans. From 2021 to 2024, only 1.06% of DO students matched into pathology residency, though the percentage of pathology positions filled by DO applicants increased from 9.8% to 16.7%. This variability highlights the need for curriculum reforms and stronger collaboration with pathology departments to ensure equitable and thorough pathology training. Addressing these gaps is crucial for preparing osteopathic physicians to provide holistic and effective patient care.

Introduction

An historical overview of osteopathic and allopathic medicine

Osteopathic medical schools (OMSs) emphasize a holistic approach to patient care, focusing on treating the whole person rather than just the symptoms. This is a major difference between osteopathic and allopathic training programs. OMSs incorporate Osteopathic Manipulative Treatment (OMT), which involves hands-on techniques to diagnose, treat, and prevent illness or injury. In addition to standard biomedical training similar to all allopathic programs, the emphasis on preventive and primary care that has historically been exclusive to osteopathy is now becoming more common in many allopathic curricula. The classic osteopathic curriculum also emphasizes the musculoskeletal system and its role in overall health, whereas allopathic programs have focused more on a traditional biomedical approach, concentrating heavily on medical science, diagnosis, and treatment without the additional OMT component.¹

Osteopathy originated as a form of alternative medicine that emphasizes the interrelationship between the structure and function of the body. Overall, osteopathy aims to address the root causes of health issues by considering the whole person and promoting the body's innate ability to heal itself. The five primary tenets of osteopathy are:

• 1.The body has the ability to heal itself: Osteopathy believes that the body possesses its own healing mechanisms and seeks to facilitate this natural process.
• 2.The body is one unit: Osteopathy views the body as an interconnected whole rather than a collection of separate parts. It examines how different parts of the body are related and how imbalances in one area can affect overall health.
• 3.Structure and function are interrelated: Osteopathy focuses on the relationship between the structure of the body (bones, muscles, and tissues) and its function (movement, circulation, and nervous system). Improving the structure can lead to better function, and vice versa.
• 4.The role of the musculoskeletal system: Osteopathy places particular emphasis on the musculoskeletal system (bones, muscles, and joints) and how dysfunction in this system can affect other parts of the body.
• 5.Treatment through manual techniques: Osteopathic physicians use hands-on techniques such as manipulation, massage, and stretching to diagnose and treat patients. The goal is to restore balance and mobility in the body to promote healing.²

Allopathic medicine, previously known as conventional or Western medicine, is the dominant form of medical practice in the United States and many other countries. It was originally based on the principles of using medications and treatments to combat and suppress symptoms of diseases.^3,4 Some key characteristics of allopathic medicine include:

• 1.Focus on treating symptoms: Allopathic medicine typically focuses on managing and treating specific symptoms of diseases using pharmaceutical drugs, surgeries, and other interventions.
• 2.Evidence-based practice: Allopathic medicine emphasizes the use of scientific research and clinical trials to guide medical decision-making and treatment approaches.
• 3.Specialization and sub-specialization: Allopathic medicine often involves specialization in various medical fields, such as cardiology, neurology, oncology, and others. Physicians may undergo additional training to become experts in specific areas of medicine.
• 4.Emphasis on technology and diagnostic tools: Allopathic medicine relies heavily on advanced medical technologies, imaging techniques, and laboratory tests to diagnose and treat diseases.
• 5.Disease-focused approach: Allopathic medicine typically addresses diseases as discrete entities that require specific treatments, rather than considering the whole person or underlying causes of illness.

Overall, allopathic medicine is characterized by its use of medications, surgeries, and other conventional treatments to address health issues. It is the dominant model of healthcare in many countries and is often the first choice for individuals seeking medical care for a wide range of conditions.

Growth of osteopathic medicine

Osteopathic medicine in the United States dates back to the late 19th century with the founding of the first osteopathic medical school by Dr. Andrew Taylor Still.⁵ Osteopathic physicians (DOs) emphasize a holistic approach to healthcare, focusing on the interrelationship between the structure and function of the body. Osteopathic physicians traditionally trained in osteopathic residency programs (ORPs)⁶ that were accredited by the American Osteopathic Association (AOA) and would therefore enter the AOA Match. These programs emphasized osteopathic philosophy and principles in addition to traditional medical training. Notably, the AOA Match did not offer residency training in pathology.^4,7 The Main Residency Match (MRM) offered residency training in pathology, making it the only option for DO students pursuing pathology.⁴ While the distinction between allopathic (MD) and osteopathic (DO) medicine remains, with each having its own philosophical approach, residency training has become increasingly similar. More osteopathic physicians are entering the MRM to train in allopathic residency programs (ARPs), which are accredited by the Accreditation Council for Graduate Medical Education (ACGME), highlighting the growing convergence in clinical training despite the foundational differences in medical education.⁶

ACGME unified accreditation system

In 2014, the ACGME implemented a single accreditation system that allowed DOs to train in ACGME-accredited programs alongside MDs.⁸ This marked a significant step toward the integration of allopathic and osteopathic GME accreditation and created more flexibility for residents to pursue training in programs of their choice. Instead of two separate allopathic/osteopathic match programs, all applicants entered a single National Resident Matching Program (NRMP), with the exception of a select few specialties. The unified GME accreditation system aimed to standardize training and evaluation processes, improve coordination and collaboration between MD and DO programs, and enhance the quality and consistency of graduate medical education across all specialties. The history behind unified GME accreditation reflected the changing dynamics of medical education and the increasing collaboration between the allopathic and osteopathic medical communities in the United States. This convergence marked a significant milestone in the evolution of medical training and had the potential to shape the future of healthcare delivery in the country.

Since the implementation of the unified accreditation system, DO and MD physicians practice alongside each other, both striving to provide high-quality healthcare for their patients. Both DOs and MDs are fully licensed and recognized to practice medicine in the United States and internationally.⁹ Each can specialize in any area of medicine, although pathways to certain specialties may differ slightly due to residency program preferences.

Overview of osteopathic medical school accreditation

The Commission on Osteopathic College Accreditation (COCA) is an entity within the American Osteopathic Association that is responsible for accrediting colleges of osteopathic medicine. The functional body of the COCA is composed of 21 members who ensure that these institutions meet specific standards of quality and effectiveness in their educational programs. By doing so, COCA plays a crucial role in maintaining high standards in osteopathic medical education, thereby contributing to the overall quality of healthcare provided by future osteopathic physicians. As of July 2024, COCA accredits 41 colleges of osteopathic medicine (COMs) across 66 sites in the United States (Table 1 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50^,51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90^,91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139, 140, 141^,142, 143, 144, 145, 146, 147, 148, 149, 150, 151, 152, 153, 154, 155, 156, 157, 158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 168, 169, 170, 171, 172, 173, 174, 175, 176, 177, 178, 179, 180, 181, 182, 183, 184, 185, 186, 187, 188, 189, 190, 191, 192^,193, 194, 195, 196, 197, 198, 199, 200, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, 223, 224, 225, 226, 227, 228, 229, 230, 231, 232, 233, 234, 235, 236, 237, 238^,239, 240, 241, 242, 243, 244, 245, 246, 247, 248, 249, 250, 251, 252, 253, 254, 255, 256, 257, 258, 259, 260, 261, 262, 263, 264, 265, 266, 267, 268, 269, 270, 271, 272, 273, 274, 275, 276, 277, 278, 279). In total, these accredited osteopathic colleges provide education to about 36,500 medical students. At present, there are 36 fully accredited COMs.²⁸⁰ There are a total of 18 “additional locations”–defined by COCA as a geographically distinct location with the same curriculum, faculty, and budget as the parent COM.²⁸¹ There are a total of 7 branch campuses, which have a separate faculty, administration, and budget from the parent COM.²⁸¹ There are 5 COMs that are pre-accredited.²⁸⁰

Table 1.

COCA-accredited DO programs and pathology data. Collected from July 22, 2024–September 25, 2024.

School	Pathologists (MD/DO) in leadership positions (Yes/No) (n = 61)	Separate/specific pathology department (Yes/No) (n = 43)	Preclinical electives offered (Yes/No) (n = 43)	Pathology or related preclinical elective (Yes/No) (n = 43)	Elective or selective rotations in OMS-III (Yes/No) (n = 43)	How are pathology clerkships categorized (n = 43)	Specified curriculum for pathology clerkship (Yes/No) (n = 43)	Number of pathologists (MD/DO) on faculty (n = 61)	% of students matching into pathology	Pathology interest group (Yes/No)
Alabama College of Osteopathic Medicine10, 11, 12, 13	Yes	No	No	N/A	Yes - Elective	Other/general elective	No	1	2024: 1.1% 2023: 0.0% 2022: 0.67% 2021: 1.3%	No
Arkansas College of Osteopathic Medicine14, 15, 16, 17, 18	No	No	No	N/A	Yes - Elective	Other/general elective	No	2	2024: 1.5% 2023: 2.3% 2022: 0.70% 2021: 0.75%	Yes
A.T. Still University Kirksville College of Osteopathic Medicine19, 20, 21, 22	No	No	Yes	No	Yes - Elective	Other/general elective	No	0	2024: 0.64% 2023: 0.64% 2022: 0.58% 2021: 1.2%	Yes
A.T. Still University School of Osteopathic Medicine in Arizona23, 24, 25	No	No	No	N/A	Yes - Elective	Not defined	N/A	1	2024: 0.0% 2023: 0.72% 2022: 2.7% 2021: 0.99%	No
Burrell College of Osteopathic Medicineb26, 27, 28, 29	No	Yes	No	N/A	Yes - Elective	Not defined	N/A N/A	2 (campus not specified)	2023: 3.0%	Yes (campus not specified)
Burrell College of Osteopathic Medicine- Floridac30, 31, 32, 33	No							Campus not specified	N/A ¦	Campus not specified
California Health Sciences University College of Osteopathic Medicine34, 35, 36	No	No	No	N/A	No	Other/general elective Specialty elective	No	2	2024: 0.0%	Yes
Campbell University-Jerry M. Wallace School of Osteopathic Medicine37, 38, 39, 40	No	Yes	No	N/A	Yes - IM/Surg selective only	Other/general elective	Yes	1	All graduated students: 1.0%	Yes
Des Moines University College of Osteopathic Medicine41, 42, 43, 44	No	No	Yes	Yes	Yes - Elective	Other/general elective	No	2	2024: 0.99% 2023: 1.5% 2022: 0.45% 2021: 0.48%	No
Idaho College of Osteopathic Medicine45, 46, 47, 48	No	No	Yes	No	Yes - Elective	Other/general elective	Yes	1	2024: 1.3% 2023: 2.0% 2022: 3.6%	Yes
Kansas City University College of Osteopathic Medicineb49, 50, 51, 52, 53, 54, 55	No	Yesa	No	N/A	Yes - Elective	Pediatrics Pathology (separate category)	Yes	2	2024: 1.2% 2023: 1.8% 2022: 2.3% 2021: 1.6%	No
Kansas City University College Osteopathic Medicine-Joplinc56	No							2		No
Lake Erie College of Osteopathic Medicine- Erieb57, 58, 59, 60, 61, 62, 63, 64	No	No	No	N/A	Yes - Elective	Medical selective Surgical selective	No	2	2024: 0.88% 2023: 0.63% 2022: 0.63% 2021: 0.38%	Yes
Lake Erie College of Osteopathic Medicine at Elmirac65	No							0		No
Lake Erie College of Osteopathic Medicine at Seton Hillc66	No							0		No
Lake Erie College of Osteopathic Medicine-Bradentond67	No	No	No	N/A	Yes - Elective	Medical selective Surgical selective	No	4		No
Lincoln Memorial University-DeBusk College of Osteopathic Medicineb68, 69, 70, 71	No	Yes	No	N/A	Yes - Elective	Not defined	N/A	1	2024: 2.1% 2023: (First year with Knoxville graduates) 1.6% 2022: 1.3% 2021: 0.96%	No
Lincoln Memorial University-DeBusk College of Osteopathic Medicine Knoxvillec72,73	No							1		No
Liberty University College of Osteopathic Medicine74, 75, 76, 77, 78, 79, 80, 81	No	No	Yes	No	Yes - Elective	Not defined	N/A	2	2024: 1.4% 2023: 0.0% 2022: 0.7% 2021: 1.5%	Groups not listed
Michigan State University College of Osteopathic Medicineb82, 83, 84, 85, 86, 87, 88, 89, 90	Yes	No	Yes	Yes	No	Nonsurgical elective	Yes	1	2024: 1.5% 2023: 1.5% 2022: 0.69% 2021: 0.0%	Yes
Michigan State University College of oOsteopathic Medicine at Macomb University Centerc91	Yes							0		Yes
Michigan State University College of Osteopathic Medicine at Detroit Medical Centerc92	Yes							0		Yes
Marian University College of Osteopathic Medicine93, 94, 95, 96, 97, 98, 99	No	No	No	N/A	Yes - Elective	Not defined	N/A	1	2024: 0.0% 2023: 2.9%	Yes
Midwestern University/Arizona College of Osteopathic Medicine100, 101, 102	No	Yes	Yes	No	Yes - Elective	Other/general elective	No	3	2022: 1.9%	No
Midwestern University/Chicago College of Osteopathic Medicine103, 104, 105, 106	No	Yes	Yes	No	Yes - Elective	Other/general elective	No	4	2024: 0.0%	No
Nova Southeastern University Kiran C Patel College of Osteopathic Medicineb107, 108, 109, 110, 111, 112, 113	No	No	Yes	No	No	Other/general elective	No	0	2024: 0.82% 2023: 1.7% 2022: 0.47% 2021: 1.4%	No
Nova Southeastern University Kiran C Patel College of Osteopathic Medicine - Clearwaterc114	No							0		No
New York Institute of Technology College of Osteopathic Medicineb115, 116, 117, 118, 119, 120	No	No	Yes	No	No	Pathology (separate category)	Yes	2	2024: 0.79% 2023: 1.0% 2022: 0.26% 2021: 0.48%	No
New York Institute of Technology College of Osteopathic Medicine at Arkansas Statec121,122	No							0		Groups not listed
Oklahoma State University Center for Health Sciences College of Osteopathic Medicineb123, 124, 125, 126	No	Yes	Yes	No	No	Not defined	N/A	4	2024: 0.65% 2023: 0.93% 2022: 1.98% 2021: 0.0%	No
Oklahoma State University College of Osteopathic Medicine - Cherokee Nationc127	No							0		No
Ohio University-Heritage College of Osteopathic Medicineb128, 129, 130, 131, 132, 133, 134, 135	No	No	Yes	No	Not specified	Not defined	N/A	1	2024: 0.43% 2023: 0.42% 2022: 0.42% 2021: 0.44%	Yes
Ohio University-Heritage College of Osteopathic edicine - Clevelandc136	No							0		No
Ohio university-Heritage College of Osteopathic Medicine - Dublinc137,138	No							0		Yes
Philadelphia College of Osteopathic Medicineb139, 140, 141, 142, 143, 144, 145, 146, 147, 148	Yes	Yes	Yes	No	Yes - Elective	Not defined	N/A	2	2024: 1.56% 2023: 0.74% 2022: 1.24% 2021: 2.62%	Yes (campus not specified)
Philadelphia College of Osteopathic Medicine-Moultriec149, 150, 151, 152	No							2	2024: 0.0% 2023: 1.96%	Not specified
Georgia Campus-Philadelphia College of Osteopathic Medicined153, 154, 155, 156, 157, 158	No	No	Yes	No	Yes - Elective	Not defined	N/A	2	2024: 0.0% 2023: 2.73% 2022: 2.48% 2021: 0.0%	Not specified
Pacific Northwest University of Health Sciences College of Osteopathic Medicine159, 160, 161, 162, 163	No	No	Yes	No	Yes - Elective	Surgical selective	Yes	1	2024: 0.0% 2023: 1.6% 2022: 0.7% 2021: 1.5%	No
Rowan-Virtua School of Osteopathic Medicineb164, 165, 166, 167, 168, 169, 170, 171	No	No	No	N/A	Yes - Elective	Not defined	N/A	1 (Campus not specified)	2024: 1% 2023: not listed 2022: 1.45% 2021: 0.82%	Yes (campus not specified)
Rowan-Virtua School of Osteopathic Medicine - Sewellc172	No							Campus not specified	N/Ae	Campus not specified
Rocky Vista University College of Osteopathic Medicineb173, 174, 175, 176, 177, 178, 179, 180	No	No	Yes	No	Yes - Elective	Other/general elective	Yes	3	2024: 1.43% 2023: 1.29% 2022: 0.63% 2021: 0.65%	Yes
Rocky Vista University College of Osteopathic Medicine - Southern Utahc181, 182, 183, 184, 185	No							1	2024: 0.83% 2023: 1.52% 2022: 0.81% 2021: 2%	Yes
Rocky Vista University - Montana College of Osteopathic Medicine§186, 187, 188	No	No	Yes	No	Yes - Elective	Not defined	N/A	1	N/Ae	No
Sam Houston State University College of Osteopathic Medicine189, 190, 191, 192, 193, 194, 195, 196, 197	No	No	No	N/A	Yes - Elective	Other/general elective	Yes	2	2024: 1.45%	Yes
Touro College of Osteopathic Medicineb198, 199, 200, 201, 202, 203, 204	No	No	No	N/A	Yes - Elective	Not defined	N/A	2	2024: 0.0% 2023: 0.0% 2022: 0.0% 2021: 0.0%	Yes
Touro College of Osteopathic Medicine - Middletownc205, 206, 207	No							2	2024: 0.81% 2023: 0.0% 2022: 0.0% 2021: 0.0%	Yes
Touro College of Osteopathic Medicine - Great Fallsc208	No							2	N/Ae	Groups not listed
(TUCOM) Touro University College of Osteopathic Medicine-CAb209, 210, 211, 212	No	No	Yes	No	No	Not defined	N/A	1	2024: 1.61% 2023: 0.73% 2022: 1.54% 2021: 1.65%	No
(TUNCOM) Touro University Nevada College of Osteopathic Medicined213, 214, 215, 216, 217	No	No	Yes	No	Yes - Elective	Not defined	N/A	3	2023: 1.85% 2022: 1.74% 2021: 1.45%	Yes
University of the Incarnate Word School of Osteopathic Medicine218, 219, 220, 221, 222, 223, 224, 225, 226, 227	Yes	No	No	N/A	No	Pathology (separate category)	No	3	2024: 2.08% 2023: 2.52% 2022: 0.0% 2021: 1.54%	No
University of New England College of Osteopathic Medicine228, 229, 230, 231, 232	No	No	No	N/A	Yes - Elective	Surgical selective	No	1	2021: 0.57%	No
University of North Texas Health Science Center/Texas College of Oosteopathic Medicine233, 234, 235, 236, 237	Yes	No	Yes	No	Yes - Elective	Other/general elective	No	1	2024: 1.32% 2023: 0.48% 2022: 2.24% 2021: 0.0%	Yes
University of Pikeville-Kentucky College ofOsteopathic Medicine238, 239, 240, 241, 242	No	No	Yes	No	No	Medical selective	No	0	2024: 0.0% 2023: 0.0% 2022: 0.83% 2021: 2.17%	No
Edward Via College of Osteopathic Medicineb243, 244, 245, 246, 247, 248, 249	No	Yes	Yes	No	Yes - medical/surg selective only	Medical selective	Yes	1	2024: 0.92% 2023: 0.0% 2022: 0.0% 2021: 0.0%	No
Edward Via College of Osteopathic Medicine - Auburnd250,251	Yes	Yes	Yes	No	Yes - medical/Surg selective only	Medical selective	Yes	1	2024: 1.04% 2023: 1.02% 2022: 0.95% 2021: 1.75%	No
Edward Via College of Osteopathic Medicine - Carolinasd252,253	No	Yes	Yes	No	Yes - medical/surg selective only	Medical selective	Yes	1	2024: 2.27% 2023: 2.88% 2022: 0.0% 2021: 0.92%	No
Edward Via College of Osteopathic Medicine - Louisianad254,255	No	Yes	Yes	No	Yes - medical/surg selective only	Medical selective	Yes	1	2024: 1.46%	No
William Carey University College of Osteopathic Medicine256, 257, 258, 259, 260	No	No	Yes	Electives not listed	No	Not defined	N/A	1a	2022: 1.20%	No
Western University of Health Sciences/College of Osteopathic Medicine of the Pacificb261, 262, 263, 264, 265, 266, 267, 268, 269, 270, 271	No	Yes	Yes	No	Yes - Elective	Other/general elective	Yes	3	2024: 3.26% 2023: 0.95% 2022: 1.87% 2021: 0.65%	No
Western University of Health Sciences/College of Osteopathic Medicine of the Pacific - Northwestc272	No							1		No
West Virginia School of Osteopathic Medicine273, 274, 275, 276, 277, 278, 279	No	No	Yes	No	Yes - Elective	Medical selective	No	3	2024: 0.0% 2023: 0.57% 2022: 2.14% 2021: 0.60%	Yes

COCA: Commission on Osteopathic College Accreditation; DO: osteopathic; MD: allopathic.

^aWebsite not updated-number may be inaccurate.

^bParent COM.

^cAdditional location.

^dBranch camp.

^eInaugural class not graduated.

The COCA accreditation standards outline the credentials required for faculty that teach at both the clinical and preclinical level. There are currently no accreditation standards that address credentialing requirements for faculty that specifically instruct in the discipline of pathology in the preclinical years.²⁸² Also, as pathology is not regarded as a core rotation specialty, there is no mention of “pathologist” or “pathology” anywhere in the COCA standards. This is not unique to osteopathic education, as the Liaison Committee on Medical Education (LCME) similarly lacks language to this effect.²⁸³

The Continuing Accreditation Standards outlined by the COCA stipulate that “A COM must have a mechanism to review and approve credentials of physician faculty that have never been board certified or are not board eligible by the AOA or American Board of Medical Specialties (ABMS) at noncore rotations sites. All nonphysician faculty in the patient care environment must have demonstrated appropriate qualifications in their disciplinary field.”²⁸¹ Because pathology is not a core rotation specialty, elective rotations in pathology may be delivered or administered by pathologists that are not required to be board certified or board eligible, and their qualifications are vetted by the individual COMs.

Per AACOM's website featuring a general guide for the four-year curriculum, pathology is highlighted as a core course in the foundational first year of medical school but is not included in the clerkship curriculum.²⁸⁴

The need for discourse on pathology education in osteopathic medical schools

There is limited literature discussing pathology curriculum in osteopathic medical schools. Osteopathic medical students (DOs) typically receive pathology exposure through various parts of their medical education, although the extent and format can vary among different osteopathic medical schools. In recent years, the preclerkship curriculum in osteopathic medical schools has transitioned to an integrated approach where pathology is incorporated into the foundational sciences curriculum,⁸ as have some allopathic medical schools.^284,285 This can occur through didactic lectures in organ-based courses, or as case-based and/or problem-based learning, as pathology is covered in relation to disease processes and clinical correlations.²⁸⁶ Sometimes this is supplemented with a histopathology or gross pathology lab where students examine examples of tissue digitally under the microscope and correlate it with gross anatomy. Of note, students may learn pathology alongside, or even integrated with, subjects like anatomy, physiology, microbiology, and pharmacology. Additionally, a case-based learning approach has been utilized to teach students to analyze clinical cases and integrate pathological principles. This aids in understanding the manifestation of diseases and their underlying or interrelated causes. However, students may not recognize pathology as a standalone specialty or body of knowledge. Furthermore, such courses at DO programs are not always taught by pathologists, but more often curated by a course director with a PhD. As a result, students may not understand what distinguishes “pathology” content among other pathophysiology courses, and may not begin to understand why or that it is even a medical specialty. Nearly every medical specialty interacts with pathology in some way, from ordering labs to sending frozen sections. A holistic approach to healthcare requires a holistic education, which requires pathologists in the conversation.

Outside of the preclerkship curriculum, there is more variability in regards to pathology exposure. Core clinical rotations at MD and DO programs typically include internal medicine, surgery, family medicine, pediatrics, emergency medicine, obstetrics/gynecology, and psychiatry. Clinical training environments are a defining difference between DO and MD programs. In contrast to many MD programs that offer clinical rotations at affiliated, large university hospitals or academic medical centers, DOs more commonly receive clerkship experience in community hospitals and outpatient settings. Community hospitals are healthcare facilities that primarily serve the medical needs of the local community. They are generally not involved in medical education or research, although some may offer training opportunities for medical students and residents.⁶ Because community hospitals tend to be smaller with fewer physicians, each osteopathic medical school is typically affiliated with several community hospitals to maintain one-on-one education between the preceptor and the medical student. While community hospitals and clinics can provide a broader range of hands-on experiences in primary care settings, DO students often lack more specialized medical experiences.

Although some students may be able to schedule a rotation with community pathologists, there is little guidance on the objectives of these clerkships without a defined curriculum. Additionally, some community hospitals may not have a pathologist on site. As such, pathology might not be as prominently featured during clinical clerkships as other specialties, potentially leading to gaps in comprehensive understanding of a practicing pathologist's roles. Addressing this requires systematic efforts, including curriculum reforms and collaborations with pathology departments to ensure well-rounded pathology education for osteopathic medical students.

Despite the limited exposure, the number of pathology residency positions filled by osteopathic applicants (both seniors and graduates) has been increasing dramatically, from 34 of 476 filled spots (7.14%) in 2011 to 102 of 621 filled spots (16.4%) in 2024.^4,287,288 It should be noted that the number of osteopathic students matching into PGY-1 positions has also increased over this time period.⁴ Still, this raises the question: Why are more DOs choosing pathology and how are they obtaining pathology experiences?

With the rising interest in pathology, there is a need for osteopathic medical schools to reflect on curriculum and devise ways to support pathology interest among medical students.

Materials and methods

A search engine query was performed using google on July 22, 2024 to gather information from the COCA website regarding accreditation standards and accredited osteopathic medical schools in the United States. The COCA standards were reviewed and searched for the terms “pathologist” and “pathology.” A total of 66 osteopathic medical schools were identified. Each medical school was assigned to reviewers (PP, MH, AB, and MH) to gather information for the following items from July 22 to September 7, 2024: Medical school name, location, class size, curriculum catalog and manual, and specialty of medical school leadership. For preclerkship related information, reviewers searched each respective program for preclerkship electives and how many offered preclerkship electives in histology or pathology, preclerkship curriculum and pathology integration, pathology course directors and their credentials, and the number of pathologists who work for the medical school. For clerkship items, the reviewers explored the overall required clerkship curriculum, pathology elective course offerings, how they were classified (surgical/nonsurgical/other), time allotted for electives, location of clerkship rotations. Presence or absence of a pathology interest group was also documented. We also obtained statistics on the COMLEX 1 and COMLEX 2 pass rates and match rates of students into pathology. The percentage of DO applicants entering pathology from 2021 to 2024 was also obtained from the National Resident Matching Program (NRMP).²⁸⁸

IRB exemption statement

Institutional Review Board (IRB) review is waived for this study, as it does not involve human subjects as defined by federal regulations. The study focuses on evaluating educational practices and perceptions within medical institutions, and the data being collected will not involve any personal identifiers or private information. As such, this research involves aggregate educational data and is categorized as exempt from IRB oversight under the applicable federal guidelines for educational research.

Results

A total of 36 fully accredited COMs across 61 campuses were identified, as seen in Table 1. Eighteen “additional locations” (ALs) were identified and will be excluded, as indicated. Forty three of the 61 programs were specified as either parent or branch campuses, each with a distinct curriculum. The average class size was 169 students (range: 59–300+). Thirteen percent of COMs had pathologist Deans. The average number of physician pathologist faculty per COM was 1.49 (range: 0–4). Of the 57 COMs that specified which campus hosted the faculty pathologists (as applicable), 79% had physician pathologists on faculty (45/57). The campuses without physician pathologists received their instruction from either parent-campus remote instructors, PhDs, DVMs, or, in one case a registered dietician. Thirty percent of COMs (excluding ALs) had Pathology Departments, none of which were associated with ACGME-accredited pathology residency programs. One COM has an associated pathology assistant program. Sixty-five percent of COMs (excluding ALs) offered preclerkship electives, but only 7.1% of these offered a pathology preclerkship elective. Thirty-eight percent of COM campuses had a pathology student interest group. Twenty percent of COMs (excluding ALs) do not offer elective clerkships during year three, and two of these programs do not have physician pathologists leading the preclerkship pathology education. Thirty percent of COMs (excluding ALs) had a specific curriculum for pathology clerkship electives.

Data regarding specifics of pathology clerkship elective offerings at affiliated hospitals was limited. The average percentage of each DO class matching into pathology from 2021 to 2024 was 1.06% (range: 0–3.6%), excluding programs whose inaugural class has not graduated (Fig. 1). There is an overall national increase in DOs entering the pathology field, from 9.8% in 2021 to 16.7% in 2024, per the NRMP (Fig. 2). This data includes both “seniors” and “graduates,” which the NRMP differentiates by the applicant's year of graduation. Notably, there were 59 accredited COM locations in 2021 and 66 accredited (including 5 pre-accredited) COM locations in 2024 (Fig. 3).

Fig. 1.

Average percentage of each graduating class (2021–2024) matching into pathology among accredited US-based osteopathic medical schools.

Fig. 2.

Percentage of anatomical and clinical pathology residency positions filled by DO seniors and graduates (2021–2024). Data adapted from: National Resident Matching Program, Results and Data: 2024 Main Residency Match®. National Resident Matching Program, Washington, DC, 2024. Permission to publish was granted by the National Resident Matching Program (NRMP) in accordance with its data use and publication policies. DO: osteopathic.

Fig. 3.

Number of DO programs opened in the US (2014–2024). DO: osteopathic.

Four parent COMs and two associated additional campuses have consistent above-average pathology match rates for the past three to four consecutive years: Idaho College of Osteopathic Medicine (whose inaugural class graduated in 2022), Kansas City University (KCU), including the Joplin campus; Lincoln Memorial University-DeBusk (LMU), including the Knoxville campus, and Touro University Nevada College of Osteopathic Medicine (TUNCOM). Each of these COMs has physician pathologists on faculty that are present at each campus. Idaho and KCU both have specified pathology clerkship elective curriculum. TUNCOM and Idaho both have pathology student interest groups. KCU and TUNCOM have more than the average number of physician pathologist faculty per COM, with two and three at each campus, respectively.

Discussion

Since no COM hosts an in-house pathology residency, osteopathic medical students already have less interaction with pathology residents than many of their allopathic counterparts. Furthermore, this research highlights the variability in preclerkship and clerkship pathology exposure between the COMs. While preclerkship instruction from nonphysician pathologists has clear educational value, it lacks the opportunities for mentorship, career advising, and professional networking that are only available through physician pathologist instruction. Clerkship rotations with community pathologists are an important opportunity for medical students to understand how pathology interacts with every medical specialty. However, all COMs have multiple hospital training sites of varying sizes, opportunities, and pathology department structure; consequently, clerkship pathology exposure has an even greater degree of variability. Nine out of 43 COMs do not offer elective clerkships during the third year of medical school and two of these programs do not have physician pathologists on faculty. As such, medical students at these programs may not have the opportunity to connect with a physician pathologist until their fourth year of medical school, leaving little time to gain technical exposure before application season begins. Given this variability, many osteopathic medical students are left to cultivate their own pathology exposure if they want to create longitudinal relationships and connections early in their training. One avenue for this cultivation is through student interest groups which, through faculty sponsorship, can provide important mentorship and guidance for students interested in the field.²⁸⁹ There are barriers to pursuing this avenue as well, however, as only 38% of COM campuses have a student interest group.

Osteopathic medical schools have traditionally sought to create primary care physicians in high-need areas. Supporting students interested in pathology and establishing a robust, longitudinal pathology curriculum through medical school would not be a shift from this mission. Rather, excellent primary care physicians need to have a thorough understanding of their interplay with pathology and laboratory medicine. As such, high-quality medical education requires more pathology exposure. This may be accomplished in multiple ways without completely overhauling the COM's department structure. First, recruiting adjunct faculty to provide even a few pathology lectures would allow medical students to gain mentorship and an understanding of what a career in pathology entails. Second, allowing pathology clerkship electives to fulfill certain graduation requirements would expose more students to the field and allow them to understand how pathology intersects with their chosen specialty. This may be achieved by, for example, classifying pathology as a “specialty selective” if a COM requires a certain number of these “specialty selectives” for graduation. This would also recognize and legitimize pathology as a medical specialty. Third, allowing online pathology elective clerkships would further improve exposure, particularly for those students who are at a rural site without an onsite lab and perhaps do not have the financial means to apply for away/visiting student learning opportunities. While some COMs understandably do not allow online electives offered through outside institutions, utilizing existing resources to create an approved online elective is possible. Online pathology modules have been implemented in some institutions, such as Western University of Health Sciences.^264,290,291 It is worth mentioning that online electives would not provide students with a “hands-on” experience, which would be disadvantageous for those seeking a career in pathology. Specifically, a potential letter of recommendation writer would not be able to comment on the student's technical skills in pathology. Finally, educating those directly involved in career advising on the resources and scholarships available to interested students, as well as on the nuances of pathology residency, would alleviate some of the stress experiences by third- and fourth-year medical students, particularly during application season.

Interestingly, the percentage of each DO class entering pathology has stayed relatively stable from 2021 to 2024 (Fig. 1), while the percentage of pathology residency positions filled by DO applicants from 2021 to 2024 has increased (Fig. 2). This discrepancy is likely due to the increase in DO programs, and thereby an increase in DO applicants for PGY-1 positions. It would be reasonable to conclude that the presence of physician pathology faculty impacts whether students choose to enter pathology, particularly when considering the programs with an above-average proportion of their graduating class entering pathology and the program's characteristics. Future studies could further explore whether there is a statistically significant correlation between physician pathology faculty and above-average pathology match rates per class. The percentage of US MD graduates entering pathology in 2020 was only 1.18%; as such, future studies could similarly evaluate allopathic medical school exposure to pathology.⁶

Conclusion

This study was limited by the public availability of curriculum details, residency placement information, and updated faculty and staff information advertised by the medical schools. For a more specific discussion on the preclerkship pathology curriculum, the syllabi and course structure would need to be publicly available and evaluated for each program. Future studies could accomplish this by requesting this information from the COMs directly. This study is the first of its kind to examine the pathology exposure in osteopathic medical schools, and it has revealed the variability of available opportunities for these medical students. Given this, it would be prudent for osteopathic medical schools to examine their curriculum and consider how they frame pathology as a unique medical specialty, if necessary.

Author affiliations and relationships

The authors have no affiliations, collaborations, or relationships that could be perceived as influencing the work. Additionally, there are no dual roles or competing responsibilities.

Funding

The article processing fee for this article was funded by an Open Access Award given by the Society of ‘67, which supports the mission of the Association for Academic Pathology to produce the next generation of outstanding investigators and educational scholars in the field of pathology. This award helps to promote the publication of high-quality original scholarship in Academic Pathology by authors at an early stage of academic development.

Declaration of competing interest

AB discloses that they served on the COCA committee. This role may be perceived as a potential conflict of interest; however, steps were taken to ensure that their committee involvement did not influence the study's design, analysis, or interpretation.