Awareness and interest in osteopathic manipulative treatment in allopathic medical students

Context: Osteopathic manipulative treatment (OMT) is utilized by clinicians to diagnose and treat a variety of musculoskeletal conditions including acute and chronic pain, and other medical conditions. Previous studies have examined attitudes of allopathic (MD) residents toward OMT and have implemented residency-based curricula; however, literature is lacking on the attitudes of MD students toward OMT. Objectives: The objective of this study was to determine MD students ’ familiarity with OMT and to evaluate their interest in an elective osteopathic curriculum. Methods: A 15-item online survey was electronically sent to 600 MD students at a large allopathic academic medical center. The survey assessed familiarity with OMT, interest in OMT and in participating in an OMT elective, educational format preference, and interest in pursuing primary care. Educational demographics were also collected. Descriptive statistics and Fisher ’ s exact test were utilized for categorical variables, and nonparametric tests were utilized for the ordinal and continuous variables. Results: A total of 313 MD students submitted responses (response rate=52.1 %), of which 296 (49.3 %) responses were complete and utilized for analysis. A total of 92 (31.1 %) students were aware of OMT as a modality in treating musculoskeletal disorders. Among the respondents who indicated “ very interested ” in learning a new pain treatment modality, the majority: (1) observed OMT in a prior clinical or educational setting (85 [59.9 %], p=0.02); (2) had a friend or family member treated by a DO physician (42 [71.2 %], p=0.01); (3) were pursuing a primary care specialty (43 [60.6 %], p=0.02); or (4) interviewed at an osteopathic medical school (47 [62.7 %], p=0.01). Among those interested in developing some OMT competency, the majority: (1) were pursuing a primary care specialty (36 [51.4 %], p=0.01); (2) applied to osteopathic schools (47 [54.0], p=0.002); or (3) interviewed at an osteo-pathic medical school (42 [56.8 %], p=0.001). A total of 230 (82.1 %) students were somewhat or very interested in a 2-week elective course in OMT; among all respondents, hands-on labs were the preferred method for delivery of OMT education (272 [94.1 %]). Conclusions: The study found a strong interest in an OMT elective by MD students. These results will inform OMT curriculum development aimed at interested MD students and residents in order to provide them with OMT-speci ﬁ c theoretical and practical knowledge.

In 1972, all US state governments recognized the Doctor of Osteopathic Medicine (DO) degree as equivalent to that of their allopathic (MD) counterparts [1]. Although there has been equivalence in licensure and attendant privileging opportunities since then, the DO degree remains distinct through its osteopathic philosophy, application and practice of osteopathic tenets, and performance of osteopathic manipulative treatment (OMT) [2].
Whereas OMT is taught to all students in osteopathic medical schools, allopathic medical students and residents are rarely exposed to these techniques. This is a missed opportunity because MD students could, as part of their training, develop improved comfort with osteopathic philosophy and some of the medical conditions assessed and treated by OMT, as well as improved musculoskeletal physical diagnosis and pain management skills. In a previous study of 249 MD and DO students who were primarily DOs (66.3 %) and White/Caucasian (81.0 %), DO students reported being more comfortable with musculoskeletal physical examination skills compared to MDs (57.1% vs. 26.8 %), and 91.9 % thought that their education prepared them well for the musculoskeletal portion of licensing examinations (compared to 63.4 % of MD students) [3].
The opportunity for shared skill sets among MDs and DOs is growing; the American Osteopathic Association (AOA) became a member of the American Council of Graduate Medical Education (ACGME) in 2014 [4]. The creation of a single accreditation system for graduate medical education has dramatically enhanced the potential of collaborative effort. Furthermore, MDs can now participate in residency osteopathic recognition (OR) programs.
Many DOs believe that OMT education for MDs can help increase awareness of and confidence in OMT knowledge and skills, and can lead to more referrals and improvement in patient care [5]. In a study of 381 osteopathic and allopathic family medicine residents (60.9 % of which were MDs), 70.9 % of MD resident learners were interested in OMT [6]. Exposure to OMT has been implemented in allopathic residency programs; some exposure to OMT has been reported in small program evaluations [7][8][9][10]. In one such report, 9 of 16 military MD family medicine residents found the establishment of an OMT clinic to be important to their training [8]. In a similar report of residents in an allopathic family medicine residency program, five DOs found the clinic helpful with integrating OMT into resident schedules, maintaining skills, and patient care [7]. After a 1-month OMT elective, all five MD family medicine residents reported that the elective had access to regular teaching, precepting, and independent decision making, and that expectations and goals were reasonable and achievable [10].
There is little literature related to interest in OMT among MD students prior to residency. In 2022, Ellson and colleagues reported on the challenges of creating a curriculum for premedical students by comparing in-person to virtual educational delivery platforms for a seminar series to increase appreciation for osteopathic medicine [11]. In the post-session analysis, 52 students from the first session and 61 students from the second session provided feedback on preferences, with neither in-person nor virtual being effective in increasing the understanding of osteopathic medicine [11].
The aim of this survey study was to assess awareness of, and interest in learning, OMT among the students at an allopathic medical school. Among those interested, we also assessed preferred mode of content delivery (hands on lab, clinical rotation, etc.). We hypothesized that MD students would be both aware of and interested in OMT. We also hypothesized that interest and awareness of OMT in MD medical students at our institution would be associated with prior exposure to OMT or DO physicians, prior application or interview at an osteopathic medical school, and interest in a career in primary care.

Methods
This study was reviewed and approved by the Penn State College of Medicine Institutional Review Board (STUDY#11809) and determined to be exempt. All participants in this study read a summary explanation of research prior to participation in the survey. Completion of the survey implied voluntary consent to participate in the research and approval of their information to be utilized and shared in publication. As an incentive, respondents were given the opportunity to enter a random drawing for one of five $25 gift cards. The study was unfunded, and trial registry was not applicable.

Design
The authors (A.D., T.O., and J.P.), assisted by a survey design expert (see Acknowledgements), designed the survey tool utilizing an iterative approach. Survey items were reviewed with the entire study team and pilot-tested with eight medical students who provided verbal feedback during a 1-h focus group to refine the survey.

Population
The inclusion criteria included all medical students (approximately 600 students) at the two campuses of the institution.

Measure
The 15-item survey took approximately 5 min to complete (Table 1). A definition of OMT was provided after the questions about OMT awareness (after Item 10). This was intentional because giving the definition prior to the awareness questions may have influenced their answer choices. However, giving students the definition of OMT prior to the questions about interest ensured a common understanding of the term to improve the accuracy of responses. Educational demographics included year in medical school, intention to go into a primary care specialty, and if they were on the MD/PhD pathway.

Procedures
The survey was available from July 24, 2019 to August 24, 2019. Students were invited to take the survey via email containing the link to the online survey hosted in REDCap [12]. Information and invitation to the survey were also posted to a private social media (Facebook) group, where our institution's medical students can post and share information. A summary of the study was provided prior to taking the survey. One reminder email was sent after 2 weeks.

Analysis
Data analysis was performed by AB utilizing the R statistical program [13] version 2.2 and summary package [14] (version 1.7.0), and included descriptive statistics, Fisher's exact test for categorical variables, and nonparametric tests for the ordinal and continuous variables. Awareness of OMT (aware and not aware) was defined as having "heard" and "read" about OMT. Interest in learning OMT (not interested, somewhat interested, and very interested) was defined as: interest in learning new tools to diagnose and treat musculoskeletal pain conditions, referring to a qualified provider for OMT, developing competency in performing OMT, and participating in a 2-week elective in OMT.

Results
The survey was distributed to all 600 medical students: 174 first-year, 172 second-year, 170 third-year, and 84 fourthyear students. The fourth-year medical student class was smaller because one site did not yet include a fourth-year class at the time of survey distribution.

Discussion
This study found that approximately one-third of MD students at our institution are aware of OMT, but the majority reports interest in learning about OMT, including taking a 2-week elective course in OMT. Students are more likely to be interested in learning OMT if they have had previous exposure to OMT, have a friend or family member with previous exposure to a DO physician, are pursuing a primary care medical field, or have interviewed at an osteopathic medical school.
This study assessing osteopathic interest among MD students is unique; previous studies have surveyed DO students [3], or DO and MD residents [7][8][9][10]. Similar to MD family medicine residents [7][8][9][10], our MD students also expressed interest in OMT education. Our study also reported a strong preference for OMT delivery through handson labs, with online learning being the least preferred.
The strengths of this survey include a high response rate [15] as well as good representation across all years of medical  students. The main limitation is its survey of students in a single medical school, limiting generalizability. However, as a large academic medical center, our institution may share characteristics with similar institutions. The current project suggests that other institutions may benefit from conducting their own survey. Another limitation is that we did not provide unique links to students; therefore, we could not track whether a student took a survey more than once. MD students who had applied to DO schools may be better informed regarding osteopathic medicine, therefore the responses regarding osteopathic interest potentially may have been affected by this subset of students who had applied to osteopathic schools prior to MD school matriculation. MD students at our institution reported interest in learning osteopathic principles and techniques, which serves as a rationale for residency programs to pursue osteopathic recognition (OR). Any residency program considering pursuit of OR would likely find the results of this study pertinent to their MD residents. While our program was limited to a 2-week rotation per institution allotment, other medical institutions may benefit from a longer timeline, which can increase interest and exposure to OMT training. The authors do not currently have plans to expand on this study; rather, it has encouraged and informed the design of an introductory 2-week OMT elective curriculum for MD students.

Conclusions
At a mid-Atlantic allopathic academic medical center, we found evidence of low exposure but high interest in learning about osteopathic medicine and OMT among medical students. The project has encouraged and informed the design of an introductory 2-week OMT elective curriculum for MD students. These data may inform OMT-related policy or coursework at other allopathic medical schools.
Acknowledgements: The authors would like to thank Carol Weisman, PhD (Distinguished Professor Emeritus in the Department of Public Health Sciences at Penn State College of Medicine) for providing survey design advice and mentorship during the development of the survey. The authors also thank the medical students who helped pilot test the survey. Research funding: None reported. Author contributions: All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors contributed to the analysis and interpretation of data; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.