The Osteopathic Recognition Milestones in the Single Accreditation System for Graduate Medical Education

In 2015, a major transition to a single graduate medical education (GME) accreditation system for both US allopathic and osteopathic programs began.¹ Initial steps included the creation of Osteopathic Recognition designation for programs that train learners in the integration of osteopathic medicine into patient care.² The Accreditation Council for Graduate Medical Education (ACGME) Osteopathic Principles Committee confers Osteopathic Recognition upon ACGME-accredited programs that demonstrate through a formal application process a commitment to education in osteopathic principles and practice (OPP).

The Osteopathic Recognition Milestones were developed soon after the Osteopathic Recognition requirements were established. In 2015, osteopathic physicians representing surgical and non-surgical specialties gathered to determine elements of a foundational formative rating system for osteopathic competencies. Their work identified new subcompetencies, which integrated osteopathic principles and practice into the existing ACGME competency areas (Box 1).³

Box 1 The Osteopathic Recognition Milestones²

• Patient Care 1: Osteopathic Principles for Patient Care

• Patient Care 2: Examination, Diagnosis, and Treatment

• Osteopathic Principles for Medical Knowledge

• Osteopathic Principles of Practice-Based Learning and Improvement

• Osteopathic Principles for Interpersonal and Communication Skills

• Osteopathic Principles for Systems-Based Practice

• Osteopathic Principles for Professionalism

The Osteopathic Recognition Milestones have become an essential developmental tool used by all programs with Osteopathic Recognition, regardless of specialty or subspecialty. Today, there are 253 GME programs with Osteopathic Recognition who are using Osteopathic Recognition Milestones to assess learners, irrespective of the physician's professional degree.⁴ Two examples of Osteopathic Recognition Milestones are Milestone Patient Care 1: Osteopathic Principles for Patient Care and Osteopathic Principles of Practice-Based Learning and Improvement.

Milestone Patient Care 1: Osteopathic Principles for Patient Care

This Milestone evaluates the resident's inclusion of osteopathic principles when obtaining a patient's history and performing the physical examination (Figure 1). To achieve the highest developmental level of this Milestone, the learner must demonstrate care that incorporates the 4 tenets of osteopathic medicine to promote health and wellness (Box 2).

Figure 1.

Osteopathic Recognition Milestones: Patient Care 1²

Box 2 The 4 Tenets of Osteopathic Medicine¹

• The body is a unit; the person is a unit of body, mind, and spirit.

• The body is capable of self-regulation, self-healing, and health maintenance.

• Structure and function are reciprocally interrelated.

• Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function.

Osteopathic Principles of Practice-Based Learning and Improvement

This Milestone requires programs to expand the curriculum to incorporate specialty-relevant research in improving the application of the osteopathic medicine 5-model approach to patient care (Figure 2). The 5-model approach of patient care relies on the integration of basic and clinical sciences utilizing the 5 models—biomechanical, neurological, respiratory-circulatory, metabolic, and behavioral.⁵

Figure 2.

Osteopathic Principles of Practice-Based Learning and Improvement²

The development process for the Osteopathic Recognition Milestones created a new framework across all specialties and subspecialties. Historically, osteopathic principles and practice were integrated into competencies in each individual discipline; a coordinated effort for determining commonality across specialties had not occurred. The new Osteopathic Recognition Milestones were designed to emphasize the shared competencies of all physicians integrating osteopathic principles and practice into patient care, while providing flexibility for the different skillsets required among specialties and subspecialties. Thus, the new Osteopathic Recognition Milestones can supplement existing Milestones used to assess competencies of trainees.

The Osteopathic Recognition Milestones standardize key competencies that define the core osteopathic approach and patient care philosophy. Programs can now use a single standard set of metrics to evaluate learners across the graduate medical education continuum (internship, residency, fellowship), across specialty/subspecialty disciplines, and from novice to expert clinician.

The Osteopathic Recognition Milestones emphasize that learners will demonstrate osteopathic patient care principles throughout their training. To meet that goal, the assessment framework for the Osteopathic Recognition Milestones is different from existing Milestones. The ACGME's specialty-specific Milestones are based on the Dreyfus model of skills acquisition, with Level 4 being an expectation, although not a requirement, for graduation. In contrast, the Osteopathic Recognition Milestones are designed to be used on a longer continuum from entry into residency through completion of fellowship. For the Osteopathic Recognition Milestones, a learner is expected to reach Level 2 for completion of the transitional year, Level 3 for completion of residency, and Level 4 for completion of fellowship.

To ensure that the Osteopathic Recognition Milestones are successfully implemented, programs with Osteopathic Recognition are required to have a Director of Osteopathic Education (DOE) who is responsible for leading the osteopathic education program. The program director may serve in the role of DOE or may delegate that responsibility to a member of the program leadership team. DOEs are not required to be board certified in the same specialty or subspecialty as the program itself. This flexibility creates an opportunity for collaborative learning between different specialty and subspecialty programs.

DOEs are tasked with developing assessment tools that measure the integration of osteopathic principles and practice into patient care.⁴ The clinical competency committees (CCCs) for Osteopathic Recognition programs must have representation from osteopathic faculty. These CCCs must evaluate learners with the Osteopathic Recognition in addition to their specialty Milestones. This can occur within the CCC or in a subcommittee that looks specifically at learner development related to the Osteopathic Recognition Milestones. The CCC makes recommendations to the program director and DOE regarding the learner's growth in osteopathic principles and practice.⁶

Milestones 2.0

As described in the supplement to this issue, the Milestones 2.0 process includes an increased focus on the inclusion of all stakeholders—physician faculty, residents, fellows, and non-physicians. As a result of this focus and the single GME accreditation system, the majority of Milestones 2.0 workgroups include osteopathic physicians. As part of Milestones 2.0 process, the Osteopathic Recognition Milestones will soon undergo a review and revision process. The addition of a supplemental guide will improve access to the revised Milestones. When the updated Osteopathic Recognition Milestones are posted for public comment, we urge all physicians, other faculty, and trainees to review them and offer suggestions and insights. Through continued engagement with this process, we can improve the practice and growth of our osteopathic learners along the continuum of lifelong learning.