Thematic Analysis of Attitudes Held by a Group of Italian Osteopaths Toward Osteopathic Evaluation, Treatment, and Management in the Neonatal and Pediatric Field: A Qualitative Study.

OBJECTIVE: The purpose of this study was to investigate the attitudes held by a group of Italian osteopaths toward osteopathic evaluation, treatment, and management in the neonatal and pediatric field. METHODS: A thematic analysis with elements of grounded-theory approaches was used. Purposive sampling was used to recruit expert osteopaths in the neonatal and pediatric field. Data were gathered from July 2017 to January 2018 by individual semistructured interviews and transcribed verbatim. A thematic analysis of the data was then performed. The Consolidated Criteria for Reporting Qualitative Research checklist was used to structure the design of this qualitative study. RESULTS: Eight osteopaths participated. Data analysis generated 3 main themes: the role of the osteopath in the collaborative process of care, osteopathic diagnostic-clinical reasoning in the neonatal and pediatric field, and osteopathic treatment in the neonatal and pediatric field. CONCLUSION: The present study highlights that Italian osteopaths may prefer interprofessional and integrative activities aimed at supporting adaptive capacity and resilience for pediatric patients.

The perceptions and experiences of osteopathic treatment among cancer patients in palliative care: a qualitative study.

PURPOSE: This research aimed to explore the perceptions and experiences of cancer patients receiving osteopathic treatment as a complementary therapy when it is used in addition to conventional treatment for cancer pain. METHODS: This qualitative study employed semi structured interviews of cancer patients in a palliative care unit in Lyon, France, who received treatment from an osteopath alongside their conventional cancer treatment. We analysed data using grounded theory and qualitative methods. RESULTS: We interviewed 16 patients. The themes identified through the analysis included a low awareness of osteopathy among the population and an accompanying high level of misconceptions. The benefits of osteopathy were described as more than just the manual treatments with participants valuing osteopathy as a holistic, meditative, and non-pharmaceutical approach. Participants also described the osteopathic treatments as assisting with a range of cancer-related health complaints such as pain, fatigue, and sleep problems. Offering osteopathic treatment at an accessible location at low or no cost were identified by participants as enablers to the continued use of osteopathy. CONCLUSIONS: The findings of this study provides preliminary data which suggests, when delivered alongside existing medical care, osteopathy may have health benefits for patients with complex conditions such as cancer.

Reliability of diagnosis and clinical efficacy of visceral osteopathy: a systematic review.

BACKGROUND: In 2010, the World Health Organization published benchmarks for training in osteopathy in which osteopathic visceral techniques are included. The purpose of this study was to identify and critically appraise the scientific literature concerning the reliability of diagnosis and the clinical efficacy of techniques used in visceral osteopathy. METHODS: Databases MEDLINE, OSTMED.DR, the Cochrane Library, Osteopathic Research Web, Google Scholar, Journal of American Osteopathic Association (JAOA) website, International Journal of Osteopathic Medicine (IJOM) website, and the catalog of Académie d'ostéopathie de France website were searched through December 2017. Only inter-rater reliability studies including at least two raters or the intra-rater reliability studies including at least two assessments by the same rater were included. For efficacy studies, only randomized-controlled-trials (RCT) or crossover studies on unhealthy subjects (any condition, duration and outcome) were included. Risk of bias was determined using a modified version of the quality appraisal tool for studies of diagnostic reliability (QAREL) in reliability studies. For the efficacy studies, the Cochrane risk of bias tool was used to assess their methodological design. Two authors performed data extraction and analysis. RESULTS: Eight reliability studies and six efficacy studies were included. The analysis of reliability studies shows that the diagnostic techniques used in visceral osteopathy are unreliable. Regarding efficacy studies, the least biased study shows no significant difference for the main outcome. The main risks of bias found in the included studies were due to the absence of blinding of the examiners, an unsuitable statistical method or an absence of primary study outcome. CONCLUSIONS: The results of the systematic review lead us to conclude that well-conducted and sound evidence on the reliability and the efficacy of techniques in visceral osteopathy is absent. TRIAL REGISTRATION: The review is registered PROSPERO 12th of December 2016. Registration number is CRD4201605286 .

Addressing Rural Health Challenges Head On.

Providing health care to patients and families living in rural America presents significant challenges, but comes with unique rewards. The physician who chooses a rural life typically cares for an underserved and aging population, which is often less healthy and affluent than its urban and suburban counterparts. At the same time, rural clinicians feel deeply connected to their patients and their communities. Physicians cite strong doctor-patient relationships as a primary motivator to practice in a rural setting, in addition to lower cost of living and slower pace of life1. Those who choose primary care specialties also enjoy the challenge of caring for multiple, interrelated aspects of health for their patients and community. During Kansas City University of Medicine and Biosciences' (KCU) century-long history, we have offered our osteopathic medical students the opportunity to learn in rural areas during the third and fourth years. As our new, state-of-the-art medical school campus opens in Joplin, Missouri, we will build on our commitment to rural health by offering first- and second-year KCU-Joplin students training opportunities in rural settings, and expanding third- and fourth-year rural clinical rotations. The rich experience to learn rural medicine offers the potential to connect medical students, patients and community in new and exciting ways, building on the firm foundation of osteopathic medical training grounded in strong patient-centered primary care.

Developing a clinical teaching quality questionnaire for use in a university osteopathic pre-registration teaching program.

BACKGROUND: Clinical education is an important component of many health professional training programs. There is a range of questionnaires to assess the quality of the clinical educator however none are in student-led clinic environments. The present study developed a questionnaire to assess the quality of the clinical educators in the osteopathy program at Victoria University. METHODS: A systematic search of the literature was used to identify questionnaires that evaluated the quality of clinical teaching. Eighty-three items were extracted and reviewed for their appropriateness to include in a questionnaire by students, clinical educators and academics. A fifty-six item questionnaire was then trialled with osteopathy students. A variety of statistics were used to determine the number of factors to extract. Exploratory factor analysis (EFA) was used to investigate the factor structure. RESULTS: The number of factors to extract was calculated to be between 3 and 6. Review of the factor structures suggested the most appropriate fit was four and five factors. The EFA of the four-factor solution collapsed into three factors. The five-factor solution demonstrated the most stable structure. Internal consistency of the five-factor solution was greater than 0.70. CONCLUSIONS: The five factors were labelled Learning Environment (Factor 1), Reflective Practice (Factor 2), Feedback (Factor 3) and Patient Management (Factor 4) and Modelling (Factor 5). Further research is now required to continue investigating the construct validity and reliability of the questionnaire.

Ideas, properties, and standards of fracture repositioning with osteopathy in traditional Mongolian medicine in China.

OBJECTIVE: To explore the unique ideas, properties, and standards of fracture repositioning with osteopathy in traditional Mongolian medicine in China. METHODS: Based on the natural life concept of "integration of universe and man", osteopathy in traditional Mongolian medicine in China uses the modern principles and methods of physiology, psychology, and biomechanics. Against this background, we explored the unique ideas, properties, and stan- dards of fracture repositioning in traditional Mongolian medicine. RESULTS: Fracture treatment with osteopathy in traditional Mongolian medicine in China is based on (a) the ideas of natural, sealed, self and dynamic repositioning of fractures; (b) the properties of structural continuity and functional completeness; (c) the standards of "integration of movement and stillness" and "force to force". CONCLUSION: The unique ideas, properties, and standards of fracture repositioning with osteopathy in traditional Mongolian medicine in China have resulted in the widespread use of such techniques and represents the future direction of the development of fracture repositioning.

The DREEM, part 2: psychometric properties in an osteopathic student population.

BACKGROUND: The Dundee Ready Educational Environment Measure (DREEM) is widely used to assess the educational environment in health professional education programs. A number of authors have identified issues with the psychometric properties of the DREEM. Part 1 of this series of papers presented the quantitative data obtained from the DREEM in the context of an Australian osteopathy program. The present study used both classical test theory and item response theory to investigate the DREEM psychometric properties in an osteopathy student population. METHODS: Students in the osteopathy program at Victoria University (Melbourne, Australia) were invited to complete the DREEM and a demographic questionnaire at the end of the 2013 teaching year (October 2013). Data were analysed using both classical test theory (confirmatory factor analysis) and item response theory (Rasch analysis). RESULTS: Confirmatory factor analysis did not demonstrate model fit for the original 5-factor DREEM subscale structure. Rasch analysis failed to identify a unidimensional model fit for the 50-item scale, however model fit was achieved for each of the 5 subscales independently. A 12-item version of the DREEM was developed that demonstrated good fit to the Rasch model, however, there may be an issue with the targeting of this scale given the mean item-person location being greater than 1. CONCLUSIONS: Given that the full 50-item scale is not unidimensional; those using the DREEM should avoid calculating a total score for the scale. The 12-item 'short-form' of the DREEM warrants further investigation as does the subscale structure. To confirm the reliability of the DREEM, as a measure to evaluate the appropriateness of the educational environment of health professionals, further work is required to establish the psychometric properties of the DREEM, with a range of student populations.

A validity study of COMLEX-USA Level 3 with the new test design.

CONTEXT: The National Board of Osteopathic Medical Examiners (NBOME) administers the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA), a three-level examination designed for licensure for the practice of osteopathic medicine. The examination design for COMLEX-USA Level 3 (L3) was changed in September 2018 to a two-day computer-based examination with two components: a multiple-choice question (MCQ) component with single best answer and a clinical decision-making (CDM) case component with extended multiple-choice (EMC) and short answer (SA) questions. Continued validation of the L3 examination, especially with the new design, is essential for the appropriate interpretation and use of the test scores. OBJECTIVES: The purpose of this study is to gather evidence to support the validity of the L3 examination scores under the new design utilizing sources of evidence based on Kane's validity framework. METHODS: Kane's validity framework contains four components of evidence to support the validity argument: Scoring, Generalization, Extrapolation, and Implication/Decision. In this study, we gathered data from various sources and conducted analyses to provide evidence that the L3 examination is validly measuring what it is supposed to measure. These include reviewing content coverage of the L3 examination, documenting scoring and reporting processes, estimating the reliability and decision accuracy/consistency of the scores, quantifying associations between the scores from the MCQ and CDM components and between scores from different competency domains of the L3 examination, exploring the relationships between L3 scores and scores from a performance-based assessment that measures related constructs, performing subgroup comparisons, and describing and justifying the criterion-referenced standard setting process. The analysis data contains first-attempt test scores for 8,366 candidates who took the L3 examination between September 2018 and December 2019. The performance-based assessment utilized as a criterion measure in this study is COMLEX-USA Level 2 Performance Evaluation (L2-PE). RESULTS: All assessment forms were built through the automated test assembly (ATA) procedure to maximize parallelism in terms of content coverage and statistical properties across the forms. Scoring and reporting follows industry-standard quality-control procedures. The inter-rater reliability of SA rating, decision accuracy, and decision consistency for pass/fail classifications are all very high. There is a statistically significant positive association between the MCQ and the CDM components of the L3 examination. The patterns of associations, both within the L3 subscores and with L2-PE domain scores, fit with what is being measured. The subgroup comparisons by gender, race, and first language showed expected small differences in mean scores between the subgroups within each category and yielded findings that are consistent with those described in the literature. The L3 pass/fail standard was established through implementation of a defensible criterion-referenced procedure. CONCLUSIONS: This study provides some additional validity evidence for the L3 examination based on Kane's validity framework. The validity of any measurement must be established through ongoing evaluation of the related evidence. The NBOME will continue to collect evidence to support validity arguments for the COMLEX-USA examination series.

The importance of residency program size and location on American Osteopathic Board of Surgery In-Training Examination outcomes.

BACKGROUND: The American Osteopathic Board of Surgery In-Training Examination (AOBSITE) is administered to general surgery residency training programs. Based on findings in allopathic training, we hypothesize that larger programs will outperform smaller programs and that Southern programs will perform lower than other geographic regions. MATERIALS AND METHODS: In this retrospective study, the performance on the AOBSITE was obtained for all of the osteopathic general surgery programs from 2008 to 2012. To test if program size was related to AOBSITE performance, simple linear regression was performed. Geographic differences in median performance between states and US Census Bureau regions were evaluated using Kruskal-Wallis tests. Nonparametric statistics were performed using an α = 0.05. RESULTS: From 2008 to 2012, there were 49 general surgery residency training programs and 2278 examinees evaluated. The median raw performance by general surgery residency training program was 168.0 (IQR [161.8-177.7]). The weighted median standardized performance by general surgery residency training program was 487.8 (IQR [462.8-528.0]). Simple linear regression analyses showed that the slope of the least-square regression line was greater than zero for raw performance (P = 0.048) and standardized performance (P = 0.005). A Kruskal-Wallis test showed that there were no differences in raw performance or standardized performance by US Census Bureau Region or by state (all P > 0.05). CONCLUSIONS: Overall, larger general surgery residency training programs outperform smaller programs on the AOBSITE and that there are no geographical differences in performance by state or region.

Patient reported outcomes in a large cohort of patients receiving osteopathic care in the United Kingdom.

OBJECTIVE: The use of Patient Reported Outcome Measures (PROMs) to evaluate care is being advocated increasingly in clinical settings. Electronic data capture is both resource and environmentally friendly and convenient. This purpose of this study was to test and implement a nationwide system to collect routine PROM data from osteopathic patients using a web and mobile app. METHODS: A prospective study design was used to monitor outcomes of care for patients attending osteopathic clinics. Demographic and service data were collected, the primary outcomes were the Bournemouth Questionnaire and a Global Rating of Change score. Data concerning patients' satisfaction and experience of care were collected also. Data were collected at baseline, one week, and six weeks post-treatment. RESULTS: A total of 1721 patients completed the PROM app questionnaire. The majority (65.8%) of patients who used the PROM app were between 40 and 69 years old with 11% being 70 years and over. At baseline 39.8% of patients reported they'd had their symptoms for 13 weeks or more. Low back pain was the most common symptom (55.8%). Patients reported high scores for both satisfaction and experience of osteopathic care: 88.1% were very satisfied at six weeks post-baseline and 93.5% reported very good experience at six weeks post-baseline. Data from the Global Rating of Change scale indicated that at one week post-baseline 89.1% of patients reported some measure of improvement, and at six weeks this figure rose to 92.8%. The mean sum score for the Bournemouth Questionnaire went from 30.8 at baseline to 13.3 at six weeks post-baseline. This represented a significant and clinically meaningful positive change score of 56.8%. CONCLUSION: The app was well-completed and the data very encouraging. These data will help to form the basis for standards of care for patients attending osteopathic practices.

2019 United States Osteopathic Medical Regulatory Summit: Consensus, Recommendations, and Next Steps in Defining Osteopathic Distinctiveness.

BACKGROUND: Osteopathic distinctiveness is a result of professional education, identity formation, training, credentialing, and qualifications. With the advancement of a single graduate medical education (GME) accreditation system and the continued growth of the osteopathic medical profession, osteopathic distinctiveness and professional identity are seen as lacking clarity and pose a challenge. SUMMIT: To achieve consensus on a succinct definition of osteopathic distinctiveness and to identify steps to more clearly define and advance that distinctiveness, particularly in professional self-regulation, a representative group of osteopathic medical students, residents, physicians, and members of the licensing, GME, and undergraduate medical education (UME) communities convened the 2019 United States Osteopathic Medical Regulatory Summit in February 2019. Key features of osteopathic distinctiveness were discussed. Growth in the profession; changes in health care delivery, technology, and demographics within the profession and patient communities; and associated challenges and opportunities for osteopathic medical practice and patients were considered. CONSENSUS: Osteopathic medicine is a distinctive practice that brings unique, added value to patients, the public, and the health care community at large. A universal definition and common understanding of that distinctiveness is lacking. Efforts to unify messaging that defines osteopathic distinctiveness, to align the distinctive elements of osteopathic medical education and professional self-regulation across a continuum, and to advance research on care and educational program outcomes are critical to the future of the osteopathic medical profession. RECOMMENDATIONS: (1) Convene a task force of groups represented at the Summit to develop a succinct and consistent message defining osteopathic distinctiveness. (2) Demonstrate uniqueness of the profession through research demonstrating efficacy of care and patient outcomes, adding to the public good. (3) Harmonize GME and UME by beginning to align entrustable professional activities with UME milestones. (4) Convene representatives from osteopathic specialty colleges and certification boards to define curricular elements across GME, certification, and osteopathic continuous certification. (5) Build on the Project in Osteopathic Medical Education and Empathy study.

Cynefin Framework for Evidence-Informed Clinical Reasoning and Decision-Making.

Osteopathy (manipulative care provided by foreign-trained osteopaths) emphasizes manual techniques as the cornerstone of patient care. Although osteopathic medicine has been well integrated into traditional health care systems in the United States, little is known about the role of osteopathy in traditional health care systems outside the United States. Therefore, it is incumbent on the osteopathy community to gather evidence in order to practice scientifically informed effective methods. This narrative review outlines the Cynefin framework for clinical reasoning and decision-making and encourages a broadening of the evidence base among osteopaths to promote health in an interdisciplinary care setting. This review also presents the concept of an osteopath's mindline, in which the osteopath combines information from a range of sources into internalized and collectively reinforced tacit guidelines.

Integrating the Principles and Practice of Scholarly Activity Into Undergraduate Medical Education: A Narrative Review and Proposed Model for Implementation.

The osteopathic undergraduate medical education standards have evolved over the past 2 decades to require undergraduate medical student participation in research and scholarly activity. The authors' objective was to review those evolving standards and develop a model for introducing the principles and practice of research that combines core content with experiential learning. They identified fundamental topics pertinent to the research process and herein provide their recommendations for incorporating these topics into the curriculum as self-study, online modules, and team-based and active learning exercises. The authors' proposed educational model would provide an avenue for osteopathic medical schools to meet the requirements for scholarly activity. Increasing students' and residents' knowledge of the research process will lay the foundation for their engagement is research and scholarly activity and their practice of evidence-based medicine.

Single Accreditation System for Graduate Medical Education: Transition Update.

In 2014, the American Osteopathic Association, the American Association of Colleges of Osteopathic Medicine, and the Accreditation Council for Graduate Medical Education agreed to establish a new, single accreditation system for graduate medical education in the United States. This article focuses on recent policy enhancements and modifications to facilitate the transition to the single accreditation system and concludes with a discussion of the current transition planning after the end of the transition period on June 30, 2020.

Connecting patients, practitioners, and regulators in supporting positive experiences and processes of shared decision making: A progress report.

This paper describes a novel approach to explore how regulators, working with patients and practitioners, may contribute to supporting person-centred care and processes of shared decision making in implementing professional standards and reducing harms. Osteopathic patients report high levels of patient care. However, areas of consultations less likely to be rated as high included "fully understanding your concerns," "helping you to take control," and "making a plan of action with you," suggestive of a paternalistic approach to care and a barrier to the effective implementation of standards. This programme explored how to support patients and practitioners to make more explicit what is important to support consultations with better communication in accordance with standards. A series of workshops took place involving approximately 80 participants, which explored and identified practitioner and patient values; these were themed to develop a common framework and tested using case studies. Aspects of what enables or presents a barrier to a positive consultation were further explored with real patient narratives, and a range of resources were subsequently developed, which may support patients and practitioners to make explicit what is important to them in a consultation. A series of approaches and tools were then developed for piloting including patient curriculum vitae; patient goal planner; patient animation to support preparation for an appointment; infographic: a patient poster or leaflet; practitioner reflective tool; and an audio recording to increase awareness and understanding of values-based practice. In conclusion, a range of approaches may help to support patients and practitioners to make explicit what is important to them in a consultation. The next phase of our programme will use a range of methods including cluster sampling, pre-testing and post-testing with the Consultation and Relational Empathy (CARE) measure tool, and interviews and focus groups with users and practitioners to demonstrate impact.

Addressing the ongoing friction between anecdotal and evidence-based teachings in osteopathic education in Europe.

Despite a growing interest in research and the implementation of standards for osteopathic education and practice in Europe, the inter-professional dialogue remains insubstantial. This article calls attention to the continuous challenges of reconciling anecdotal and evidence-based perspectives and offers suggestions on how to address these areas further.

Preparing Osteopathic Students for the Single Graduate Medical Education Accreditation System: Evaluating Factors for Match Success in Emergency Medicine.

INTRODUCTION: With the development of and progression toward a single graduate medical education accreditation system combining the current Accreditation Council for Graduate Medical Education (ACGME) and American Osteopathic Association (AOA) residency programs, the total number of students competing for the same postgraduate training spots will continue to rise. Given this increasing competition for emergency medicine (EM) residency positions, understanding factors that contribute to match success is important to ensure a successful match for osteopathic medical students. METHODS: Our anonymous survey to evaluate factors that led to a successful match was sent out to residents in current ACGME-, AOA-, and dually-accredited programs via the AOA program director listserv and the Council of Residency Directors (CORD) e-mail listserv in 2017. RESULTS: We had 218 responses. Responses showed that osteopathic graduates had less affiliation with EM residencies, their home institutions provided less information regarding standardized letters of evaluations (SLOE), and that successful osteopathic graduates seemed to learn about them while on EM elective rotations. These students also had less direct EM mentorship and were generally unsatisfied with the level of mentorship available. Osteopathic graduates in current ACGME programs were also more likely to have taken the United States Medical Licensing Examination compared to their AOA resident counterparts. CONCLUSION: Osteopathic medical schools can improve their graduates' chances of successfully matching in EM by establishing mentorship programs and educating their students early about SLOEs.

Understanding ACGME Scholarly Activity Requirements for General Surgery Programs in the Era of Single Accreditation and the Next Accreditation System.

Becoming compliant with the Accreditation Council for Graduate Medical Education (ACGME) requirements for scholarly activity and remaining compliant over time requires time and attention to the development of an environment of inquiry, which is reflected in detailed documentation submitted in program applications and annual updates. Since the beginning of the next accreditation system, all ACGME programs have been required to submit evidence of scholarly activity of both residents and faculty on an annual basis. Since 2014, American Osteopathic Association-accredited programs have been able to apply for ACGME accreditation under the Single Graduate Medical Education Accreditation initiative. The Residency Program Director, Chair, Designated Institutional Official, Faculty, and coordinator need to work cohesively to ensure compliance with all program requirements, including scholarly activity in order for American Osteopathic Association-accredited programs to receive Initial ACGME Accreditation and for current ACGME-accredited programs to maintain accreditation. Fortunately, there are many ways to show the type of scholarly activity that is required for the training of surgeons. In this article, we will review the ACGME General Surgery Program Requirements and definitions of scholarly activity. We will also offer suggestions for how programs may show evidence of scholarly activity.

A Mokken scale analysis of the peer physical examination questionnaire.

Background: Peer physical examination (PPE) is a teaching and learning strategy utilised in most health profession education programs. Perceptions of participating in PPE have been described in the literature, focusing on areas of the body students are willing, or unwilling, to examine. A small number of questionnaires exist to evaluate these perceptions, however none have described the measurement properties that may allow them to be used longitudinally. The present study undertook a Mokken scale analysis of the Peer Physical Examination Questionnaire (PPEQ) to evaluate its dimensionality and structure when used with Australian osteopathy students. Methods: Students enrolled in Year 1 of the osteopathy programs at Victoria University (Melbourne, Australia) and Southern Cross University (Lismore, Australia) were invited to complete the PPEQ prior to their first practical skills examination class. R, an open-source statistics program, was used to generate the descriptive statistics and perform a Mokken scale analysis. Mokken scale analysis is a non-parametric item response theory approach that is used to cluster items measuring a latent construct. Results: Initial analysis suggested the PPEQ did not form a single scale. Further analysis identified three subscales: 'comfort', 'concern', and 'professionalism and education'. The properties of each subscale suggested they were unidimensional with variable internal structures. The 'comfort' subscale was the strongest of the three identified. All subscales demonstrated acceptable reliability estimation statistics (McDonald's omega > 0.75) supporting the calculation of a sum score for each subscale. Conclusion: The subscales identified are consistent with the literature. The 'comfort' subscale may be useful to longitudinally evaluate student perceptions of PPE. Further research is required to evaluate changes with PPE and the utility of the questionnaire with other health profession education programs.