DIVERSITY: From Snowball to Avalanche: The Challenges Faced by Osteopathic Medical Students in Urology

By: Marne M. Louters, DO, McLaren Macomb, Mt. Clemens, Michigan; Mallory E. McCormick, DO, Henry Ford Hospital, Detroit, Michigan; Megan McMurray, DO, Southern Illinois University, Springfield; Parker G. Adams, DO, McLaren Macomb, Mt. Clemens, Michigan; Meghan Cooper, DO, Mayo Clinic, Rochester, Minnesota; Katie S. Murray, DO, MS, FACS, NYU Langone Health, New York, New York; Helen L. Bernie, DO, MPH, Indiana University, Indianapolis; Jacob W. Lucas, DO, Baylor Scott & White Health, Temple, Texas | Posted on: 06 Apr 2023

In the United States, there are 2 physician degrees: the Doctor of Allopathic Medicine (MD) and the Doctor of Osteopathic Medicine (DO). Osteopathic medicine, in addition to teaching the same tenets of allopathic medicine, also encourages a holistic approach to treating patients, including diagnosing and treating somatic dysfunctions that may contribute to disease processes known as osteopathic manipulative medicine.1 Recently, ACGME (the Accreditation Council for Graduate Medical Education) has stated the 2 medical degrees are to be viewed as equivalent. To support this statement, the allopathic and osteopathic residency programs underwent a merging process that was started in 2015 and was completed in 2020 through the National Residency Match Program.2

Within the American Urological Association (AUA) residency match specifically, there were 11 historically osteopathic programs that participated in a separate match through the American Osteopathic Association. In 2016, all 11 programs were part of the American Osteopathic Association match, but by 2021, all 11 programs participated in a merged allopathic and osteopathic urology match.2 Since then, allopathic students have matched into some of the 11 historically osteopathic urology programs, but it is unknown if osteopathic students are matching into the historically allopathic urology programs at the same rate and frequency.3 Given 25% of medical students attend osteopathic medical schools and that 2.5% of practicing urologists are osteopathic physicians,4,5 the aim of this editorial is to bring awareness to the obstacles and barriers osteopathic students encounter when applying to urology residency and offer potential resources for these students.

Osteopathic students face several barriers when seeking a residency spot in urology. These obstacles accumulate in a “snowball effect” and must be overcome for osteopathic students to be viewed as competitive residency applicants.

In preclinical years, osteopathic students often have limited or no urology exposure. Osteopathic medical schools generally do not have home urology programs, which leads to a lack of urology-specific mentors and research opportunities for students interested in urology. Urology is not a common specialty, so interest groups within osteopathic medical schools seldom exist, further limiting the potential for early exposure. Additionally, osteopathic students applying to competitive subspecialties usually take the USMLE (United States Medical Licensing Examination) board exams in addition to the required COMLEX (Comprehensive Osteopathic Medical Licensing Examination) board exams, necessitating additional time and money (>$1,200) that may have otherwise been used for exposure to urology, research, or other opportunities.

During clinical years, various obstacles impact osteopathic students. Lack of home programs continues to limit mentorship, research, and networking opportunities, which affects the caliber of an applicant’s curriculum vitae and letters of recommendation. Additionally, osteopathic students face variabilities in the quality of their clinical rotations. Many osteopathic schools set their students up in a 1:1 preceptorship model, therefore exposures to working on resident teams in academic settings are often inadequate. This may negatively impact their grasp on clinical and surgical skills, and their future performances on away rotations, or sub-internships.

To strengthen an osteopathic student’s application, they rely on sub-internships early in their fourth year of medical school. Unfortunately, access to sub-internships may be restricted by medical school policies, residency program requirements, and cost. Institutions may charge fees for visiting students, which can be substantially higher for osteopathic students than allopathic students. Given students’ limited exposure to academic settings in their third year as well as inadequate mentorship, they may struggle to shine on rotations compared to their allopathic peers. In addition, because urology has an early match, osteopathic students likely do not have enough time to build their curriculum vitae to the standards of their allopathic cohorts and obtain quality letters of recommendation.

Finally, osteopathic students face difficulties in the application and interview process itself. For the reasons mentioned, osteopathic students may have difficulty obtaining interviews. With the recent change of USMLE Step 1 to Pass/Fail and with more programs using virtual platforms for rotations and interviews, opportunities for osteopathic students to set themselves apart have been eliminated. Furthermore, the recent residency merger means there are no longer protected residency positions for osteopathic applicants. Given the lack of urology exposure in osteopathic medical schools, if osteopathic students go unmatched, their medical school advisors are less likely to have the experience, knowledge, or connections to appropriately guide them through their next steps.

Development of solutions for osteopathic students applying to urology may be daunting, especially when considering the “snowball effect” (see Figure). First, the process to change and to improve the current dilemma requires recognition of the mentioned disadvantages osteopathic students face when applying to urology residency. Second, osteopathic students likely require multiple interventions to facilitate support and growth through medical school, the residency application process, and if unsuccessful in the match, improvement upon their application.

Figure. From “snowball effect.” Highlighting the challenges faced by osteopathic medical students.

Potential solutions are limitless. Large organizations such as the ACOS (American College of Osteopathic Surgeons) and the AUA can work together to increase exposure to urology during medical school, educate osteopathic schools how to guide and mentor their students, and provide networking and research opportunities for osteopathic students. For example, one of the AUA Diversity, Equity, and Inclusion Committee’s aims is supporting the pipeline of medical researchers.6 Osteopathic students should be equally considered for these opportunities given their lack of medical research availability. Similar initiatives should be considered within the ACOS and the urology community using platforms such as Twitter and YouTube. For the 2023 application cycle, a group of volunteer osteopathic urology residents used Twitter to provide 1:1 mentorship and insight into the application process for osteopathic students. YouTube videos presenting the AUA core curriculum and clinical and surgical skills may be beneficial for students to prepare for sub-internships. Access to sub-internships is also of importance for the reasons discussed, and we urge institutions to consider equal access and cost to osteopathic students. This list of solutions is not completely inclusive, rather a starting point to improve osteopathic students’ chances of being exposed to urology by (1) providing support during medical school, (2) obtaining critical clinical and research mentorship, and (3) improving their application when applying to residency.

  1. Shannon SC, Teitelbaum HS. The status and future of osteopathic medical education in the United States. Acad Med. 2009;84(6):707-711.
  2. Accreditation Council for Graduate Medical Education. Transition to a Single GME Accreditation System History. Accessed January 27, 2023. https://www.acgme.org/about-us/transition-to-a-single-gme-accreditation-system-history/.
  3. McCormick ME, Seideman CA. Are We There Yet? Doctor of Osteopathic Medicine students and the Urology Match. J Urol. 2022;208(3):517-518.
  4. Craig E, Brotzman E, Farthing B, Giesey R, Lloyd J. Poor match rates of osteopathic applicants into ACGME dermatology and other competitive specialties. J Osteopath Med. 2021;121(3):281-286.
  5. Association of American Medical Colleges. Active Physicians with a Doctor of Osteopathic Medicine Degree (DO) by Specialty, 2017. Accessed January 28, 2023. https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-doctor-osteopathic-medicine-do-degree-specialty-2017.
  6. American Urological Association. Diversity, Equity and Inclusion. Accessed January 27, 2023. https://www.auanet.org/diversity-equity-and-inclusion.