BTK Osteopathy - edited

Hi, welcome to another episode of Behind the Knife. Today we are sitting down with recent president of the American College of Osteopathic Surgeons, Dr. Kristin Conrad Schnetz, about the role of osteopathic principles in surgical training and the future of osteopathic accreditation. Osteopathic education and surgery has undergone significant changes, especially with the transition to a single graduate medical education accreditation system in 2020.

Despite initial concerns about equitable access and representation, studies have highlighted increasing competitiveness of osteopathic medical students in surgical residency matches and comparable outcomes between allopathic and osteopathic surgeons, affirming the quality of osteopathic training. Dr.

Conrad Schnetz is a practicing general surgeon in Northeast Ohio. She's the program director of the General Surgery Residency Program at South Point Hospital and Vice Chair of Education of the Digestive Disease Institute at Cleveland

Clinic. I am Pooja Varman. I am a general surgery resident and surgical education research fellow at Cleveland Clinic.

PhD Education Scientist for the Department of General Surgery. I'm Jeremy Lippman. I'm the DIO and director of GME Cleveland Clinic. Welcome Dr. Conrad Schnatz and thanks so much for being here. Yeah, thanks for having me. I'm very excited to be here. I'm very appreciative. Let's start off by talking about what does it mean to be an osteopathic surgeon?

I think it's going to depend on who you ask, but for me, especially in a program where we really employ our osteopathic principles and practice curriculum. Being an osteopathic surgeon really means approaching the surgical patient as a person not just trying to figure out what the disease process is, but really understanding all of the psychosocial background issues,

structural issues that may be contributing to the disease process, and really trying to navigate the patient and they're presenting symptoms and complaint with the whole picture.

Surgery is just one way of helping our patients and having the extra tool in our toolbox really is really helpful and what does that mean? I'll give you a brief example about that. I have a number of patients that I feel like land in my office and I'm like, this person was meant to come to me, but I had a patient who came to me who was 67 years old and he had been putting off retirement for just over a year.

And the reason he was putting off retirement is because he was told that he had a left lower quadrant hernia that needed to be fixed. He had seen three other surgeons and when he came to me I took his history and something that had happened to him, he had pain in the left lower side. He hadn't

been able to lay on his stomach for years.

And I asked, you know, what, what happened? Did you fall? Did you have a car accident before that started? And the patient had had a fall and had landed on his left side. just before that. And so he's had this chronic left lower abdominal and lower back pain and he had come to me to get his hernia fixed.

But when you look at the imaging, the reason why no surgeon had operated on him is because he didn't have a hernia. But he had clearly this protrusion of his left lower quadrant and when you did a structural exam, his entire left hemipelvis was elevated compared to the right. And so I was able to refer him to one of our osteopathic neuromuscular medicine docs who worked on him for an hour.

He came from Michigan. So they, they got him in on the same day, thankfully, worked on him for about an hour and he was able to leave on his stomach by the time he left. Ended up not needing

surgery. We got him plugged in with an OMM doc up in Michigan and he was able to retire. So. Just small things like that, being able to approach the patient as a whole person, really understanding how structure equals function, and being able to, you know, solve issues for the patient.

That may not always need surgery. Now, that's a great story and a real nice description of how that can work. But you brought up a couple of things that maybe you could provide some background on. So, OPP, we hear about that, osteopathic principles in practice, versus ONMM, the osteopathic neuromuscular medicine.

What's the difference? Can you just provide a little bit of a framework for people who may not be familiar? So osteopathic principles and practice are basically the guiding principles for us when we're approaching patient care. In osteopathic medicine, there are four tenets. The first tenet is

that the body is a unit.

The second part of that is that the person is a unit of body, mind, and spirit. So it takes in all of those aspects with the patient. The second tenet is that the, the body is capable of self regulation and self healing as well as maintenance. The third is that structure and function are reciprocally, reciprocally interrelated.

And I think you heard me say that a little bit earlier. And then the fourth tenant is that rational treatment can be based upon taking all of these things in, into consideration. And so that takes all of the traditional medical training that we get as well as the surgical training that I have received.

along with the osteopathic training. And you can take all of that into consideration when approaching the patient to come up with a really comprehensive plan for them. So those are the main principles that any one can approach a patient with given the, the proper training. Osteopathic neuromuscular medicine is

essentially the specialty where you're really focused on doing osteopathic manipulation.

And I, the way I would equate it is we all do general surgery and then we go off to do some sort of subspecialty to really hone in on a specific skill set. And when osteopathic students graduate and they go on into their training once they're done with their training, they can go to do ONMM. As a fellowship the other option is to do it primarily as a residency training program.

So anyone who's graduated from a residency program with, with the proper requirements of having that background in OMM can go on to do an osteopath neuromuscular medicine program. year or two to really hone in on those skills and really specialize on the delivery of osteopathic manipulation. I can tell you as a general surgeon my osteopathic manipulation skills, and I do do some manipulation for my patients.

It

really helps with post op breathing pain. But my skills are limited. So once I have a patient like the one I described earlier, I'm not going to be able to fix that. So I refer those patients to our ONMM docs here at the Cleveland Clinic. So you mentioned obviously residency training and the OPP principles.

How do you incorporate that then into the residence training so that they could potentially go out and do that when they're done? There, it's multi, multi factorial. We have a wonderful, wonderful director of osteopathic education, Dr. Corey Bavoli Waters, Before she came along, we had Dr. Katrina Rakowski, two big names in the osteopathic profession, but both of them really helped us create a curriculum that's very, very strong.

Our residents do skills labs twice a year where we

have a curriculum that's focused on general surgery topics. Last year, for instance, we did one on the sternum and chest after thoracotomy. We did breast as well. So there are different topics that we cover over a five year period, and we learn the technical skills that are associated with that.

At the end of the year, our residents are actually tested on those technical skills through an OSCE incorporated into that is the coding and billing that is associated with OMM. It's very comprehensive. The second thing that we have is an osteopathic grand rounds. Where our, we just finished ours and the general surgery program where the topic was treat yourself.

So our residents actually learned a lot of different techniques that they can do for themselves whether they're in the O. R. Or they're on call at night, and they need to do certain techniques maybe to relieve some cervical spine pain. things like that. The other thing that we do is we incorporate in our journal clubs, which

We have we cover three journal articles that really pertain to guidelines high impact articles for general surgery and different types of specialties.

But we always have one article that focuses on OPP related topics, whether that's the psychosocial aspect of care for our patients different osteopathic manipulation techniques that are available for patients for post op ileus, or maybe in the trauma literature. I know shout out to Dr.

Gerard Balthazar, who's at NYU Langone, he's doing a lot of that in the trauma population. So, really just taking a hard look at The different literature that's out there and recognizing what needs to be done moving forward. So it's, it's definitely multifactorial. The second thing that I would say is a big component of this is the, the residents that we recruit from medical school.

The students who we tend to try to attract are those

who really feel a strong relationship with the osteopathic principles and practice. There are, are A number of students who don't feel as strongly so we're really trying to recruit people who will continue to help us create a culture of really prioritizing that in the curriculum.

So it sounds like a lot of the foundational principles for osteopathic practice are really learned during medical school. If there is an allopathic trained surgeon who wants to learn how to incorporate some of these skills into their practice, do they have to go back to medical school? Is there another path to formally learning about these principles?

Thankfully, the, the trainees do not have to go back or even, you know, An allopathic trained physician or surgeon who's out in practice do not have, they do not have to go back to medical school to learn osteopathic principles and practice as well as osteopathic manipulation.

Nearly every state has a state osteopathic society in Ohio.

Ours is the Ohio Osteopathic Association. There are also local societies here in Cleveland. We have the Cleveland Academy of Osteopathic Medicine. So there are a number of local osteopathic societies as well that offer courses for novice learners for allopathic physicians who are trying to learn the skills that they need to learn.

And I'll be quite frank with you when I and then I went into practice. I did not do osteopathic manipulation. I certainly approached patients with the osteopathic principles in practice outside of manipulation, but I Really lost those skills and the only manipulation really that I was doing was for my partners if they had a headache or something like that.

So I, when I came back to South Point to run the residency program, I knew that osteopathic recognition was something that I really wanted to pursue through the ACGME. So I actually went to the Cleveland Academy of Osteopathic Medicine and took the novice course

to learn, relearn the basic skills that I needed.

It's just like anything else. So I had to go back and learn those skills and there are certain, say you wanted to go back and do an O& MM fellowship there are certain, and each fellowship is going to be different, but there are certain requirements for having a certain number of hours. or experiences in manipulation before you pursue that type of formal training.

But if you wanted to get familiar with that the state societies, the local societies, and even national societies through the American Academy of Osteopathy, or even the American Osteopathic Association. There are a number of other organizations that offer, you know, beginner courses for learning how to do osteopathic manipulation.

That's great to hear. Hopefully some listeners may get interested and want to engage in that. Shifting gears a little bit, we know that some surgical residency programs specifically exclude DO

applicants. So why is that? What is some misinformation they have? It leads into this practice and how can we correct them?

I think if you ask a lot of DOs they would say that in general there's a, there's a bias against us. And then that begs the question, why, why is there a bias? I, I choose to believe that it's, it's blissful ignorance. You know, we're now in a single accreditation setting. And so our students are applying to all of the same programs that our allopathic colleagues are applying to as well.

And the reality is, is the programs that have been traditionally looking at allopathic candidates have had a certain set of criteria that they've been looking at. And our osteopathic students have a somewhat different set of criteria. Specifically, their licensing examinations. You know, a lot of our osteopathic medical schools are not linked to

necessarily a tertiary you know, academic center.

They don't have a ton of partnerships, so a lot of our students are doing community and role based rotations, so they are not getting a lot of the same experiences that our allopathic counterparts are. I will say, with that, another type of thing example of ignorance is even here in the Cleveland Clinic, which I, I hope is the vice chair of education to try to help people, educate people.

Interacting with some of our fellowship directors, even within surgery they don't understand that even though our program has osteopathic recognition, that our Residents are graduating as ACGME accredited trained surgeons, so they still see it as something different. And so really trying to just break down some of those barriers.

This is an extra added portion of the curriculum that other people aren't getting in their training

programs. And our program is meeting the same requirements just like anybody else. So if you have any surgery resident applying to the fellowship, those trainees are graduating from an ACGME accredited program today.

It wasn't like that, obviously, not too long ago, but it's like that today. So I think that that's some misinformation from the fellowship program leadership side. But then also, I think the, the main piece of the blissful ignorance is the, this concept of COMLEX versus USMLE. Our students take the COMLEX.

I think that that's a very unfamiliar exam. And it's not because you know, it's not, there's no motivation necessarily to really sit down and look at the blueprints, understand what the scoring is when you have this other licensing exam that they can sit for and they're now being required to sit for.

We're hoping to change that. A group of us Dr. Gene Tindella. And Dr. Jack

Boulay with the NBOME along with a couple of us have been working with Dr. Daniel Dent through the American Board of Surgery to come up with some data to show the program directors in general surgery, you know, what, what a decent COMLEX score looks like so that the, our students aren't having to sit for two exams and having to pay for two exams.

So you mentioned a couple of things that I want to try and get you to expand on here. Let's start with the first one and that's the whole idea of the osteopathic recognition from the ACGME. What does that confer to a general surgery program to have that recognition? The added benefit is that the, the approach to patient care is really strong in the way of delivering osteopathic principles and practice.

I think that I will say that you that just like I was saying before, if you're, if you lose those skills, if you don't use those skills, you're going to going to lose them and having the osteopathic

recognition is a way of basically holding us accountable for really making sure that we're delivering that, that curricula in a very structured format.

I will say that having ECGME osteopathic recognition, having gone through the application. Ensuring the curriculum meets the standards. Our curriculum is stronger than it's ever been. So I can tell you that our patients appreciate the care that they receive in, in the way that, in the way that they receive it.

It's sometimes difficult for them to expand on, on how it's different, but they will explicitly tell us that it is. Our patients appreciate osteopathic manipulation, especially on the inpatient setting for our post op patients. When we can consult our O& M colleagues or even do some osteopathic manipulation ourselves for post op pain, ILEUS, things like that, the patients, every single one of them that has received it has

really benefited from it.

I think if you don't have osteopathic recognition, it's very easy to let those things slide. So really, It's a, it's basically keeping your commitment to delivering the curricula surrounding osteopathic principles and practice that are needed, especially in these very, very impressionable years of general surgery residency training.

And I think that certainly can make or break somebody's perception or attitude or even pride around continuing to deliver care in those ways once they graduate and go into practice. And I think it's important to note that a program that has osteopathic recognition goes through the usual accreditation process for their specialty and then takes on an entirely separate supplementary accreditation process for osteopathic recognition.

So for any program directors out there who are listening, these are programs that have elected to go through two review committees, two full

processes with the ACGME. So it's in no way detracting. It's only supplemental to what they're already doing. Yeah, I, I'm glad that you mentioned that. I think it is a lot of work and I think unless you're a program director, who's gone through filling out the application meeting with the with the program, going through all the citations, trying to implement change and just going through all of those All of those requirements and then having to do it a whole second time is a testament to the commitment to delivering that curricula.

It's a lot of work, but to us it was very important to make sure that we're continuing to make sure that our trainees are receiving that osteopathic education. And I know Dr. Lipman, you can attest to this you know, going through all of this, you know, the osteopathic recognition committee is also Very steadfast in ensuring that everybody's meeting the requirements.

I sit on the

osteopathic recognition committee. So I know that for a fact and Yeah, so I am very appreciative that you actually bring that up You've mentioned single accreditation a number of times. Maybe you could provide a little more background about that. You know, in June 2020, ACGME established a single accreditation system for allopathic and osteopathic programs.

What was that? What happened? What's been the impact? Yeah, sure. So previously for osteopathic candidates, you could apply either through the American Osteopathic Association, There was a Match to Match into AOA Approved Residency Programs. And those were specifically designed for DO students applying into residency or you could apply through the ACGME, the NRMP route.

A vast majority of trainees applied through or students applied through the

AOA. The, the whole push, my understanding of the whole push of the single accreditation was to try to get us in line so that we had one single accrediting body so that everybody's meeting similar requirements. But additionally on the osteopathic side, a big push was this.

For this was to ensure that our DO students once and trainees once they Graduate from their training programs if they wanted to pursue fellowship They were qualified to do that and I'll give you an example since I graduated from an AOA approved residency I did not qualify to do ACGME approved fellowship training the way that I was able to be trained is I trained outside of the ACGME outside of the ACGME in a non ACGME spot and I had to apply to get that training approved so that I could sit for my board

exam.

So it was certainly more hoops that I had to jump through than some of my allopathic colleagues. So I think from our side, it was a push to ensure that our trainees had equal opportunity for pursuing fellowship training as well. I will say that through the transition, Our, our specialties and as you know, osteopathic, the osteopathic profession is, is primarily primary care focused.

But there are a number of us who pursue specialty training, and our specialty programs, a number of our programs got shut down and I can tell you for, from a general surgery standpoint, a large part of those programs got taken over by allopathic, program directors. So a lot of, a lot of data is out there.

Some of it is ours. Looking at what has happened with the number of spots over time, what's going on. We knew that we were going to probably take a little bit of a hit up front with the number

of DO students matching into surgical specialties. But our hope was that with the more program leadership learns about what a DO student is.

That those numbers would continue to, to meet, you know, an equitable amount percentage wise compared to our allopathic counterparts. Now there in large part are obviously going to be much much fewer, or there are going to be fewer DO students who match into surgical specialties compared to our allopathic counterparts just because there are fewer DOs than there are MDs.

But at the same time, we were hoping that the, the match rates would at least be comparable. So the number of people who are applying versus those who, who actually match would start to kind of be more equitable. So we're seeing some strides go, moving in that direction. So it is, it is optimistic and hopeful for us.

But that's basically what, what has

happened on our end. And a number of those. Those previously AOA approved spots that were preserved specifically for DOs were are now, are now being taken by MDs, which is completely fine and appropriate. We just have to get our DO students up to snuff so that they can be qualified to match in and then also teach our program leaders about what a DO student is so that they can recognize the, the quality.

That comes with their training. The other thing I kind of alluded to earlier was the Comlex and the USMLE. There's a lot of talk now about the students taking two exams and having to pay for two exams, but in large part the vast majority of students, even before single accreditation, took both exams because if you didn't match and the AOA matched you still had the opportunity to match in an RNP match.

So a vast majority of the students and did take both exams

previously. It's just much more apparent now that we have single accreditation. I just want to ask a little bit of a controversial question. So you have this one accrediting body now who's an appetite to have equal representation among different specialties, and yet to have osteopathic recognition is this very significant added layer of work.

Do you feel like that's discouraging programs from maintaining their osteopathic identity or putting up barriers for students to learn osteopathic principles and practices and training? I would say having osteopathic recognition certainly requires a number of resources. We are extremely privileged at the Cleveland Clinic, especially South Point Hospital.

To have an O& M residency, we have a handful of O& M physicians who help us deliver our

curriculum. But if you're at a hospital that didn't have as strong of an O& M presence, But you still were meeting the requirements for delivering you know, education pertaining to osteopathic principles and practice under the auspices of the AOA.

You know, it was, it was at least achievable to do it in the, in those spaces. The ACGME, I think there's, there are, I think when people think of obtaining the osteopathic recognition, they think of having to have this really robust O& MM program. And like I said, we're very privileged to have that here, but it's not necessarily, you don't necessarily need, That to obtain osteopathic recognition.

It's I think in large part has to do with the leadership and the faculty that are Associated with the program and if they're motivated to be

able to create a curriculum to deliver it that's pertaining to that specialty I know for instance at Doctor's Hospital. Dr. Alyssa Pastorino. She's the director of osteopathic education and the General Surgery Residency Program Director there.

She maintains a large part of the curriculum for that, and she does not have formal O& MM training. So, it is possible but I think people see the resources possibly as a barrier, but it is possible to do it even without a really strong, robust O& MM program. You were the 2023 2024 president of the American College of Osteopathic Surgeons.

What goals did you have when you started in that role? What did you accomplish and what did you learn? To answer the question bluntly to begin with, and then I'll go through and give you some background, my goal was to inspire individuals to come back

to the organization and really be a part of the transformation.

And what does that mean? The American College of Osteopathic Surgeons was started by a group of surgeons who really the foundation was educational. When we were board certified, graduating from an AOA approved residency program, in order to maintain your board certification, you had to have AOA approved.

And the only place that you could get that was from the American Osteopathic Association. But the primary CMEs offered through AOA were primary care. So a group of surgeons got together and started the American College of Osteopathic Surgeons in order to have a space where we could focus on surgical education.

So that's one of the main pillars of the college is to really ensure that we're continuing to deliver a solid educational program that includes. Education on

osteopathic principles and practice. With that being said, when you were a graduate of an AOA approved residency program, you essentially had to be a member of the college during the residency because the college was the organization that assessed and made recommendations to the AOA whether or not a program was in good standing.

And they were the ones who monitored your caselogs and whether you were meeting requirements to graduate. So you had to become a member. When I took over as president, you do not have to be a member. So this was something that we were also going through, you know, coming out on the back end of single accreditation.

So really trying to ensure that we're doing our due part to continue to offer a space for community. That's one of the biggest things that the college offers for me outside of my own professional development. It offers a space, you know, once a year I get to be among a thousand other osteopathic surgeons who have kind of

lived a similar path to me.

And so it was really important to me that in single accreditation that we continue to kind of pave the way and really create opportunity for our students who are coming through. That's one of my big passions to make sure that It's not as big of a fight to get the training and the recognition that you need that I had to fight for and the people whose shoulders we stand on had to fight for.

So the biggest thing for me was to inspire other DO surgeons to come back to the table to say like, Hey, this single accreditation, this transition can either make us or break us. How are we going to pull together and, and make it? And so that was my goal was to inspire individuals to. to be a part of the change.

Alright, let's put your prognostication glasses on and think about what could potentially be happening for the future of osteopathy and surgery. That way in 20 years you can come back and listen to this and be

like, see, I was totally right. Yeah, I think in 20 years, I'm hoping some of our graduates from our, our programs that have osteopathic recognition go out and are either running programs or APD or core faculty somewhere and are starting osteopathic recognition within those programs.

I think this is going to have to be probably more of a grassroots effort, especially in the specialties. And so creating and recruiting individuals who really care about it and feel a strong relationship, going back to what I was saying at the very beginning. So that they can learn the curriculum development, how we're doing things, and that way when they go out into practice, if they are teaching, and the hope would be that they would that they're continuing to grow our footprint over time.

So, that certainly is, is a goal of mine, and I'm hopeful that that will, that will continue. But yeah,

hopefully in 20 years the footprint might not be huge, but even if we can double the number of programs that have osteopathic recognition, or even, you know, get to 15 or 20. That would be really ideal, especially when we had, you know, over 50 general surgery residency programs previously under AOA.

It would be really great. That's a really lovely vision. We always conclude by asking for an educational sign out. What are three takeaways you'd like listeners to have from our conversation today? The first takeaway are the four tenets of osteopathic medicine and what the difference is between osteopathic principles and practice in O& MN.

Reminder that the first tenet is the body is a unit, the person is a unit of body, mind, and spirit. The second tenet is that the body is capable of self regulation, self healing, and maintenance. The third tenet being structure and function are reciprocally interrelated. And the fourth tenet being that rational treatment is based on the previous three and

taking all three of those into consideration when treating the patient.

Osteopathic principles and practice are Delivering care to the patient using those tenants and then ONMM is the specialty training that goes with really focusing on osteopathic manipulation and anybody can pursue that after they finish an ACGME accredited residency. The second thing that I would say is that DO students are qualified.

They know that they have to, they have to go above and beyond. Don't be afraid to take a look at them. Data, hopefully, will be coming out soon so that you'll be a little bit more in the know about what the Comlex is and what a good Comlex score, at least on the Comlex Level 2, is when evaluating our applicants.

And the third one is that I'm hopeful that our trainees will go out and continue to teach others. And I'm hopeful that our students will, you know, remain proud to be a

osteopathic physician when they're, when they're really pursuing a career of general surgery. Thank you very much, Dr. Conrad Schnitz, for this conversation with us today.

This was really incredible, very enlightening. Really appreciate your taking the time to meet with us. For those that are interested in pursuing more education for themselves about OPP and ONMM, We'll make sure some resources are available in the link, and you can keep in mind that the founder of Osteopathy, A.

T. Stills, was allopathically trained. I appreciate you mentioning that. Yeah, no, I am very appreciative that you guys had me today, and hopefully those who are listening learned a little bit about the, the DO side of medicine, and, yeah, if you're all interested, please feel free to reach out. I'm happy to get you connected in any way that I can.

Thanks again. Thank you.