DO Grads Report Bias When Applying for Residencies, Survey Finds

Graduates of osteopathic medical schools continue to experience bias when applying for medical residencies, according to a survey by the American Association of Colleges of Osteopathic Medicine (AACOM).

In a survey of more than 3,700 graduating students, 79.1% reported experiencing some form of bias related to their coming from osteopathic medical schools rather than allopathic schools.

Examples of bias included unequal access to visiting student rotation programs; biased comments by interviewers; explicit expressions of preference for MDs rather than DOs during the interview process; and DO residency candidates being required to take and pass the U.S. Medical Licensing Examination (USMLE) even though they had already taken and passed the Comprehensive Osteopathic Medical Licensing Examination (COMLEX), which is the equivalent test for DOs.

“DO students are not required to take the USMLE for licensure,” Mark Speicher, PhD, AACOM’s senior vice president for research, learning, and innovation, said at a press conference Thursday. “However, many residency programs use a USMLE score to determine whether or not a student is suitable for their residency program.”

He pointed out that many DO students have to take both the COMLEX and the USMLE, even though no MD students — either domestic or international — have to take the COMLEX.

Taking this second exam requires considerable extra effort and resources, said AACOM Director of Government Relations Julie Crockett. “Just to sit for the USMLE is over $2,300 and 32 hours of exam time, and some students have to go to [other] states because the test is not administered in their state,” she said, adding that 73% of programs that interview DOs for residency slots require them to take the USMLE, a 30-percentage-point increase from 2022.

“It’s important to note that things are not getting better,” even though it has been 11 years since a unified, single-system graduate medical education accreditation system was launched for allopathic and osteopathic physicians, said Crockett.

In addition to the extra testing requirement, some interactions that survey respondents reported having during the application process included:

• “One attending told me flat out: ‘You people shouldn’t be doing surgery.’ That comment never left me.”
• “I was asked during an interview if I regretted ‘settling’ for a DO school. It was insulting and demoralizing.”
• “After a grueling interview day, the program director ended with: ‘We usually don’t take DOs, but thanks for coming.'”

Despite these issues, this year’s graduating DO students had their best match year ever, with 93.2% of 8,503 DO seniors matching to a residency position, compared with 93.5% of nearly 21,000 MD seniors, according to the National Resident Matching Program (NRMP).

However, “while the overall match was excellent, there are some specialties — orthopedic surgery, neurosurgery, dermatology, and others — where the match rate for DOs has actually declined since single accreditation,” Speicher said, adding that there appeared to be more bias among residency programs participating in the NRMP match compared to other matches. “In the military match, only 22% of our students reported experiencing something that they perceived as bias, whereas in the NRMP match, it was over 60%. So the setting matters and the specialty matters.”

In addition, only 58% of graduating DO students got their “ideal match,” which was defined as getting into the specialty you wanted, getting into one of the top three programs you wanted, and getting a residency in the specialty you plan on practicing later in your career.

Asked by MedPage Today why such bias was still occurring despite decades of DOs practicing in the U.S., Speicher said that while his organization has not investigated that issue, other studies suggest “the stronger the old boys’ network, the stronger the tradition of an academic medical center, the stronger the hierarchy, I think — the more traditional, the more storied the program, you would be more likely to find bias in those specialties.”

Speicher said he didn’t think this problem would go away even as more seasoned residency directors retired. “Many of your practice habits are learned in residency and they stay with you,” he noted. A lot of studies show “that where you’re trained determines how much utilization you have of ancillary services, how much your care costs, and all those kinds of things.”

While there are no studies on this particular topic, “it seems that in addition to practice patterns and practice habits being passed down in residency, it would be possible for these attitudes to be passed down,” he added.

Some members of Congress are trying to address the bias issue, said Crockett. The Fair Access in Residency (FAIR) Act, introduced in the House by Rep. Diana Harshbarger (R-Tenn.) and in the Senate by Sen. Steve Daines (R-Mont.), would require all Medicare-funded graduate medical education programs to report annually on the number of osteopathic and allopathic applicants and accepted residents, and affirm that DO applications and the COMLEX are accepted for consideration if an exam score is required.

“The legislation is very clear that there are no mandates,” said Crockett. “So a residency program can have no DOs or no MDs and be fully compliant. It just requires that the residency programs report on the types of applicants that they’re receiving and the types of applicants that they are accepting.” So far, the FAIR Act has 15 House cosponsors and seven Senate cosponsors.