Osteopathic Family Physicians Research Articles

Integrating Behavioral Health and Primary Care

Osteopathic family physicians embody the philosophy of whole-person care, including using a biopsychosocial approach to incorporate mental health into patient care. The creation of the Behavioral Health Integration Collaborative increased support for a system-level adoption of whole-person care in primary care settings. With the increase in both mental health symptoms and diagnoses among Americans, and the increasing support for integrated physical and behavioral healthcare in the primary care setting, this paper shares various approaches, as well as challenges to, adapting integrated care in the primary care office. This includes reviewing best practices for implementing this care approach. The two leading models for integrated care are the Primary Care Behavioral Health (PCBH) model and Collaborative Care model (CoCM). Both models include clinically embedding licensed mental health professionals into the primary care setting, thus increasing access to colleagues with this specialized approach. The PCBH model utilizes a warm hand-off approach, resulting in a collaboration between physician and mental health provider in the care of the patient. The CoCM focuses on a registry of patients who are overseen by a behavioral health manager with treatment decisions guided by a consulting psychiatrist. Blended models are also emerging to better suit the needs for different practices and the patient populations they serve. Challenges to full implementation include acquiring buy-in from practice leadership, hiring appropriately trained mental health providers, and defining billing and coding procedures.

Parental Leave: What Do Physician Societies Provide for Their Employees?

Parental leave yields significant health benefits for parents and children. While many medical associations endorse parental leave, it is unknown what parental leave they provide for their employees. To assess parental leave policies of national physician societies for their employees including paid versus unpaid and parity between birth mothers and non-birthing parents. A cross-sectional analysis in 2023 examined parental leave policies of national physician societies, including the American Medical Association (AMA), American Osteopathic Association (AOA), and six specialty societies: American College of Obstetricians and Gynecologists (ACOG), American College of Osteopathic Obstetricians and Gynecologists (ACOOG), American Academy of Pediatrics (AAP), American College of Osteopathic Pediatricians (ACOP), American Academy of Family Physicians (AAFP), and American College of Osteopathic Family Physicians (ACOFP). Examination of policies included: duration, whether paid or unpaid; qualifications before receiving benefit; and whether non-birthing, adoptive, and foster parents were covered. Among the eight societies surveyed, two (25%) did not disclose their policies (ACOG, ACOP), and one (12.5%) lacked a policy (ACOOG). Of the remaining five, two (40%) offered paid leave (AMA, AAP), while three (60%) provided unpaid leave in line with legal requirements (AOA, AAFP, ACOFP). Benefits for non-birthing parents mirrored those for birth mothers, although the AMA offered birth mothers enhanced benefits. Only a minority of surveyed physician societies provide paid parental leave. Physician societies should consider providing paid parental leave for their employees and making their policies publicly available to promote and model the benefit of paid parental leave.

The Biomechanical Links Between Pelvic Floor Dysfunction and Testicular Pain: A Clinical Review

Chronic scrotal content pain affects 100,000 men in the United States annually. Up to 50% of these cases do not resolve by following conventional treatment algorithms and are deemed to be idiopathic. There is little peer-reviewed literature supporting the specific cause and effect relationship between pelvic floor dysfunction and chronic scrotal content pain. Additionally, the specificity of the physical exam in these types of patients is not present in the literature. Overall, the literature is deficient in proposed treatment algorithms that address the large number of cases that are deemed to be idiopathic. Patients presenting with chronic scrotal content pain may benefit from an osteopathic diagnostic and treatment approach. In these types of patients, we recommend osteopathic manipulative therapy (OMT) or pelvic floor manual therapy prior to surgical intervention. This conservative approach may reduce the large portion of cases that aredeemed to be idiopathic. The emphasis on structure and function within osteopathic medical education places osteopathic family physicians in a unique position to be able to properly diagnose and treat this type of pain. Since most cases of chronic scrotal content pain are initially addressed in the primary care setting, it is important for osteopathic primary care physicians to remain vigilant in considering musculoskeletal dysfunction when evaluating these types of patients. This clinical review is underscored by a unique case presentation of a male collegiate athlete who helps demonstrate the larger gap that is present in the literature on male pelvic floor and scrotal content pain.

Combating Poor Mental Health in Emergency Responders: Helping Emergency Responders Overcome (HERO) Act

Suicide rates are alarmingly higher among emergency responders than the general public, and it is estimated that 30% of first responders develop behavioral health conditions compared with 20% in the general population. Emergency responders experience their share of work-related stresses, but mental health problems in this demographic are often under-reported. For example, only 40% of suicides committed by emergency responders are reported. Amid these issues, there is a lack of best practice guidelines for mental health treatment among emergency responders. Hence, the stage is set for legislation to focus on improving mental health among emergency responders.
 The Helping Emergency Responders Overcome (HERO) Act seeks to improve mental health among emergency responders through improved detection, prevention, and treatment, ultimately leading to decreased rates of suicide. The HERO Act would implement data systems to capture rates and risk factors related to suicide, establish behavioral health and wellness programs within emergency responder departments, and implement evidence-based best practices to identify, prevent, and treat post-traumatic stress disorder in emergency responders.
 Osteopathic family medicine physicians play a crucial role in screening and managing poor mental health among their patients. Caring for the body, mind, and spirit is a core tenet of osteopathic medicine; therefore, osteopathic family physicians are uniquely positioned to help emergency responders overcome their mental health struggles. Given the prevalence of emergency responders who receive care from such physicians, and the value osteopathic medicine can offer this population, we encourage the profession to contribute to discussions surrounding the HERO Act.

Covid-19 Fatigue: Diagnosis and Treatment for the Osteopathic Physician

The novel coronavirus disease 2019 (COVID-19) has given rise to a global pandemic, as well as a multitude of long-term sequelae that continue to perplex physicians around the world, including in the United States. Among the most common and impactful long-haul symptoms experienced by survivors is COVID-19 fatigue. This review will use long COVID-19, post-acute COVID-19 syndrome (PCS), and Post-Acute Sequelae of COVID-19 (PASC) as synonymous terms to refer to the chronic symptomatology; chronic fatigue associated with PASC will be referred to as COVID-19 fatigue. While the knowledge and research on the exact pathophysiological mechanisms involved in the disease is still limited, parallels have been drawn between fatigue as a component of long COVID-19 and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Current studies suggest applying principles of pathophysiology, diagnosis, and treatment similar to those for ME/CFS in order to aid in managing chronic fatigue in COVID-19 survivors, particularly in the primary care setting. The osteopathic family physician can use the proposed pharmacologic agents, along with osteopathic manipulative treatment (OMT), as therapeutic modalities that can be tailored to each patient’s unique case. Nevertheless, research on proven successful treatments is still scarce. For that reason, it is essential that COVID-19 fatigue is recognized early, especially since its longitudinal impacts may be debilitating for many. This review of the available literature on COVID-19 fatigue aims to help provide quality care and lessen the disease burden experienced by patients.

2022 ACOFPCA Research Abstracts and Poster Competition

This issue of the Journal of Osteopathic Family Physicians of California (JOFP-CA) features abstracts from the posters presented at the 2022 American College of Osteopathic Family Physicians of California Convention and Scientific Seminars (ACOFPCA’46), which took place on Saturday, July 30, 2022.

Leveraging Primary Care, Public Health and Social Context During the COVID-19 Response Within a University Setting: Considerations for the Osteopathic Family Physician

The COVID-19 pandemic placed a spotlight on both the successes and the needs across the spectrum of the healthcare system. The trusting, enduring relationships developed within the primary care setting served as an important foundation on which to build response strategies throughout the pandemic. Early detection and testing, implementation of telehealth, delivery of continuous comprehensive care, and vaccine education and administration are all key areas where primary care and public health systems successfully served patients and community. Emerging national research from the COVID-19 pandemic experience has also demonstrated the reduction in COVID-19 infection and death rates through the synergy between primary care, public health and social factors, emphasizing once again the critical role these services play and the importance of developing integration strategies for the future. In particular, the COVID-19 experience within the university setting served as a key example of this integration and synergy in action. As osteopathic family physicians, these experiences can serve as lessons learned toward embracing the opportunity afforded by our unique training, expertise and commitment to the osteopathic philosophy.

Identifying Multisystem Inflammatory Syndrome in Children After COVID-19 Infection

Introduction: Since its discovery, the novel coronavirus disease 2019 (COVID-19) has evolved into a global pandemic that has affected millions. The pediatric population was once thought to be mostly spared from the SARS-CoV-2 virus. However, a severe hyperinflammatory sequela of the virus known as multisystem inflammatory syndrome in children (MIS-C) has since been identified and poses a great risk to pediatric morbidity and mortality. The goal of this manuscript is to clarify and characterize MIS-C as a diagnosis, including current management and future considerations. Methods: A thorough literature search was performed using Google Scholar and PubMed databases for articles published January 2020 through August 2021. Results: A two-tiered diagnostic approach was created for any pediatric patient presenting with fever and an epidemiologic link to SARS-CoV-2. The mean age at time of diagnosis was 9.3 years old, with 56.8% of patients identifying as male and the majority identifying as either Hispanic (36.5%) or Black (35.1%). Common signs and symptoms included fever, cough, tachycardia and tachypnea. Current treatment recommendations included IVIG, glucocorticoids, and aspirin, with the more severe cases needing hospitalization and immune modulator therapy. Discussion: MIS-C is a serious and potentially fatal sequelae after COVID-19 infection in the pediatric population. Much is still unknown regarding the long-term effects of MIS-C. Further emphasis should be placed on identifying definitive treatment and preventative strategies. Osteopathic family physicians are the primary providers for many of the patients who may present with signs and symptoms of MIS-C, and familiarity with the workup and treatment can help improve care.

The Predictive Value of the Residency AOBFP In-Service Exam, Produced and Administered by ACOFP.

Board certification is acknowledged as the mainstay for ensuring quality physician-delivered health care within medical specialties. The American College of Osteopathic Family Physicians (ACOFP) administers the American Osteopathic Board of Family Physicians' (AOBFP) In-Service Examination (ISE) to provide residents and program directors with a formative examination to assess competency and preparation for successful completion of the AOBFP certifying examination (CE). Unique assessment processes are integral to monitoring development of the osteopathic family physician throughout training and into practice, and to verify their competency for the safety and protection of the public. This study sought to investigate whether performance on the AOBFP ISE predicted performance on the AOBFP CE, and thereby successfully equipped residents to safely enter medical practice. In 2020, data from 1,893 PGY-1 through PGY-3 residents (2016-2018), whose ISE scores could be matched with scores on the AOBFP initial board CE, were analyzed for this study. Correlations among ISE administrations across 3 years of postgraduate medical education were in the mid-to-high .6 range; the ISE scores correlated with CE scores in the mid .4 to high .5 range. Less reliable measures of positive predictive value were 0.99, and sensitivity was 0.91. Results suggest that ISE administrations during residency training are effective in developing remediation strategies for subsequent successful CE performance. The inclusion of osteopathic principles in the AOBFP CE necessitates inclusion of osteopathic content in resident training exams like ISE.

Asthma medications in schools: a cross-sectional analysis of the Asthma Call-back Survey 2017-2018.

Asthma is the most common chronic disease affecting children in the United States. Goals for asthma management include symptom control, the ability to maintain a normal activity level, and minimizing adverse events. The objective of this study is to analyze the number of children with asthma that are permitted to carry medications at school and without an asthma action plan. In this study, we analyzed the Center for Disease Control and Prevention (CDC) Asthma Call-back Survey (ACBS) to assess the prevalence of children in school allowed to carry medication and with asthma action plans. Utilizing the sampling weights provided, we estimated population prevalence by age group and urbanicity. Results showed that, overall, 34.8% of students reported they were not allowed to carry asthma medications in school. Specifically, nearly 51% of children ages 5 to 9 and 33% of children ages 10 to 14 were reported not to be allowed to carry medications at school. Further, 58.2% of children did not have a written asthma action plan. Reported urbanicity was not significantly associated with access to medication at school (p=0.46) or having an asthma action plan (p=0.57). In our study, more than one-third of students were not permitted to carry asthma medications and nearly three-fifths did not have a written asthma action plan. Therefore, we recommend partnerships between schools, healthcare professionals, students, and osteopathic family physicians to increase access to asthma action plans and medication in schools.

Osteopathic manipulative treatment use among family medicine residents in a teaching clinic.

Osteopathic Principles and Practice (OPP), including osteopathic manipulative treatment (OMT) is the core foundation of the education provided by osteopathic medical schools. Multiple studies performed over the past 25years have demonstrated that a dwindling number of osteopathic physicians utilize OMT in their practice, despite 95% of osteopathic family physicians perceiving OMT as an effective treatment modality. The objective of this study is to quantify how often OMT is being performed by residents in an osteopathically recognized family medicine training clinic and to identify the perceived barriers to performing OMT. Fifteen family medicine residents were given access to an anonymous written survey for three 2week periods. The survey allowed them to input the total number of patient encounters for their half clinic day, the encounters in which OMT was perceived to be appropriate, the encounters in which OMT was performed, and the reasoning for encounters in which OMT was not performed. Surveys were collected anonymously, and data were input into a datasheet in which results were calculated. A total of 101 survey responses were collected for a total of 304 patient encounters. OMT was performed in 5/304 (1.6%) encounters, yet it was perceived to be appropriate in 60/304 (19.7%) encounters. The primary documented reason that OMT was deferred was due to time constraints (42/50 responses, or 70.0% of the encounters in which OMT was deemed appropriate). This study highlights time as the main reason OMT is deferred by residents in a teaching clinic. This provides insight into potential interventions in a training clinic to increase the use of OMT by family medicine residents.

Childhood obesity: An approach to individualized treatment

In the United States, obesity prevalence has surpassed alarming rates and reached epidemic proportions with increased body mass index and poor diet being among the top causes of morbidity and mortality. Approximately 18.5% of children in the United States have obesity. Childhood obesity is associated with medical conditions such as cardiovascular disease, type 2 diabetes mellitus, asthma and musculoskeletal disorders among other conditions. It is also associated with an increased risk for discrimination and bullying. The goal of treatment in the pediatric and adolescent patient with overweight or obesity is to develop healthy habits and lifestyle patterns which will hopefully persist into adulthood in order to prevent future adverse health outcomes, improve quality of life and improve body image and self-esteem. Osteopathic family physicians are well suited to provide the needed comprehensive care, taking a holistic, patient-centered treatment approach including nutrition, activity and behavior. While therapeutic lifestyle changes are the primary focus of treatment, the provider must also consider socioeconomic factors, mental health, treatment of comorbidities and familial factors when determining treatment. This article aims to summarize the risks and consequences of childhood obesity as well as outline the approach the osteopathic family physician can take to assessment and treatment of the pediatric patient with obesity.

Insomnia diagnosis and management: an osteopathic approach

Insomnia affects a large percentage of American adults and is among the most commonly treated medical conditions in the outpatient clinical setting. The psychological, medical and financial impact of insomnia is substantial. Research indicates that pharmacologic treatment is associated with significant risk, and clinicians should consider other modalities including cognitive behavioral therapy before prescribing medications for the treatment of insomnia. Other complementary treatments including yoga, stress management and traditional Chinese medical therapies are promising, but more research is needed.
 The osteopathic family physician plays an important role in diagnosis and management. An osteopathic approach to patient care is highly beneficial and includes a multifaceted evaluation when taking a patient history and osteopathic manipulative treatment (OMT) to balance autonomic tone and correct associated somatic dysfunction.

Adult Hearing Loss: Applying the Five Models of Osteopathic Medicine to Diagnose and Treat

Hearing loss is a common complaint with extensive cognitive, physical, emotional, social and financial implications. Many adults are expected to present with varying degrees of hearing loss by the age of 60 to 69 years old that can be classified according to the cause into conductive, sensorineural and mixed. There can be associated symptoms, like tinnitus, vertigo and otalgia and/or abnormal behaviors such as social withdrawal and difficulty with interpersonal communication. Somatic dysfunctions can accompany hearing troubles and range from fluid problems such as fluids accumulation in the middle ear, lymphatic congestion of the head and neck, and structural dysfunctions in the eustachian tube, neck musculature, thoracic spine, ribs and the cranial rhythmic impulse in addition to other neurologic dysfunctions such as sympathetic hyperactivity and viscerosomatic changes. In this review, we provide several suggestions that may assist the osteopathic family physician in identifying the various causes behind the hearing loss, especially life-threatening or quality-of-life limiting causes. We will also provide an effective treatment addressing the cause of the hearing loss presentation and associated somatic dysfunctions, alone or in conjunction with other appropriately trained health care providers, based on the understanding of the five models of osteopathic medicine and how they can apply toward the anatomical and physiological components of adult hearing loss.

ACOFP Member Survey on Physician Wellness and Preventative Measures for Protection

The current medical landscape highlights that physicians are experiencing an unprecedented epidemic of burnout. National studies show that at least 50% of physicians practicing in the United States are experiencing this harmful, detrimental disorder. This not only leads to personal consequences but potentially adverse patient events. As studies suggest, family medicine physicians are at the highest risk. To evaluate the impact of this effect on its current members and to establish strategies to promote wellness, the American College of Osteopathic Family Physicians (ACOFP) appointed a Task Force on Physician Wellness. Data was collected by a voluntary internal survey between March 21 and April 7, 2019, distributed to all ACOFP members. A total of 133 members completed the survey. Nearly half (47%) of respondents admitted to experiencing burnout symptoms. The factors that influenced burnout the most were the burden of non-clinical/administrative work and the inefficient/burdensome electronic medical record. The most protective elements to combat burnout are having a supportive spouse/partner/family member and recognizing the meaning of their daily work. A transition must occur to focus on health instead of the disease of our physicians. Individual and organizational attention must be placed on the physical, mental and social well-being of physicians. In the creation of this task force, ACOFP has begun to create educational references, provide live CME and generate conversational networks for physician support.

Non-Allergic Rhinitis with Osteopathic Treatment Techniques

Rhinitis is generally classified as allergic or non-allergic and is differentiated from conditions that mimic symptoms of rhinitis. This article reviews the non-allergic forms of rhinitis highlighting signs, symptoms and diagnosis. An in-depth overview of osteopathic treatment options for the head and neck are outlined to assist osteopathic family physicians in providing symptom relief to their non-allergic rhinitis patients.

The Ehlers–Danlos Syndromes

An Osteopathic Family Physician will encounter hypermobile patients. Hypermobility is a symptom of many of the subtypes of the Ehlers Danlos Syndromes (EDS). With the updated classification system (the 2017 International Classification of the Ehlers-Danlos Syndromes) it is important for the osteopathic family physician to become familiar with the EDS patient. The classification system identifies 13 subtypes of EDS.1 Of these 13, 12 have a recognized genetic basis. Hypermobile EDS (hEDS) has a clinical diagnosis criteria checklist (Figure 1, page 29). There is opportunity for the osteopathic family physician community to help diagnose and treat the EDS population. This article seeks to have the osteopathic family physician become familiar with the Ehlers-Danlos Syndrome, and provide an overview of all of the subtypes of EDS, including hEDS and discusses signs, symptoms, and risks associated with the syndrome.

Preventing Premature Weaning: Management Options for Common Lactation Conditions, Including OMT

The benefits of breastfeeding are well established. The World Health Organization and the Centers for Disease Control and Prevention recommend that mothers breastfeed infants for at least one year, but most children are not breastfed that long because of many factors. Breastfeeding mothers face many challenges to continued breastfeeding, including medical conditions that arise during this period, such as postpartum depression and lactational mastitis. Because of a perceived lack of consistent guidance on medication safety, it can be difficult for the family physician to treat these conditions while encouraging mothers to continue breastfeeding. The purpose of the current review is to summarize and clarify treatment options for the osteopathic family physician treating lactating mothers. We specifically focus on the pharmacological management of contraception, postpartum depression, and lactational mastitis.

Comparative Analysis of the American Board of Family Medicine and American College of Osteopathic Family Physicians In-Training Examinations.

Family medicine residency programs accredited by the Accreditation Council for Graduate Medical Education and the American Osteopathic Association typically require their residents to take the American Board of Family Medicine's In-Training Examination (ITE) and the American College of Osteopathic Family Physicians' In-Service Examination (ISE). With implementation of the single accreditation system (SAS), is it necessary to administer both examinations? This pilot study assessed whether the degree of similarity for the construct of family medicine knowledge and clinical decision making as measured by both exams is high enough to be considered equivalent and analyzed resident ability distribution on both exams. A repeated measures design was used to determine how similar and how different the rankings of PGY-3s were with regard to their knowledge of family medicine as measured by the ISE and ITE. Eighteen third-year osteopathic residents participated in the analysis, and the response rate was 100%. The correlation between ISE and ITE rankings was moderately high and significantly different from zero (rs=.76, P<0.05). A Wilcoxon signed rank test indicated that the median ISE score of 62 was not statistically significantly different than the median ITE score of 71 (Z=-0.74, P=0.46, 2-tailed). The lack of a difference on statistical analysis of ISE scores and the ITE scores of the PGY-3 residents suggests that the cohort of osteopathic residents in family residency programs and the cohort of residents in ACGME-accredited programs seem to be of comparable ability, therefore there is no clear justification for administering both examinations.

Association Between Performance on COMLEX-USA and the American College of Osteopathic Family Physicians In-Service Examination.

The primary goal of residency programs is to select and educate qualified candidates to become competent physicians. Program directors often use performance on licensure examinations to evaluate the ability of candidates during the resident application process. The American College of Osteopathic Family Physicians (ACOFP) administers an in-service examination (ISE) to residents annually. There are few prior studies of the relationship between the Comprehensive Osteopathic Medical Licensing Examination of the United States of America (COMLEX-USA) series and formative assessments of residents in training. We explored the relationship between performance on COMLEX-USA and the ACOFP in-service examination to offer support on the use of licensing examinations in resident selection. In 2016, performance data from the COMLEX-USA and the ISE were matched for 3 resident cohorts (2011-2013, inclusive; N = 1384). Correlations were calculated to examine the relationship between COMLEX-USA and ISE scores. Multiple linear regression models were used to determine if performance on COMLEX-USA significantly predicted third-year ISE (ISE-3) scores. Findings indicated that correlations among performance on COMLEX-USA and ISE were statistically significant (all P < .001), and there was strong intercorrelation between COMLEX-USA Level 3 and ISE-1 performance (r = 0.57, P < .001). Performance on the COMLEX-USA Levels 1 and 2-Cognitive Examination significantly predicted performance on the ISE-3 (F(2,1381) = 228.8, P < .001). The results support using COMLEX-USA as a part of resident selection in family medicine. Additionally, program directors may use performance on COMLEX-USA to predict success on the ISE-3.