Nick Salupo enrolled in Marian University's first class of osteopathic medical students almost by accident. But now he sees a purpose to it. "The faculty wanted us to help in what they were building. There was a sense of ownership," said Salupo, who earned his DO degree in May 2017. He is beginning a family practice residency in Indianapolis, not far from the campus of the expanding Franciscan university. "It had a small liberal arts vibe to it, but it was a medical school," he said.
Founding a new medical school is a huge undertaking, but in the past decade, two Catholic universities have taken that plunge. Both Marian University and University of the Incarnate Word, in San Antonio, have chosen to create osteopathic schools. The osteopathic integrated treatment of body, mind and spirit fits the mission of both universities; so does the emphasis on primary care. Also, neither university's medical school maintains a research program or a teaching hospital, representing savings in startup and operational costs.
Doctors of osteopathic medicine are physicians and surgeons licensed to prescribe drugs and to practice medicine in the same specialties as doctors of medicine. Osteopathic medical training is similar to allopathic (MD) medical training, but DOs receive additional education in physical manipulation of the body and take a more holistic approach to treating patients.
An osteopathic doctor examining a patient with a particular health problem, said Donald Sefcik, DO, dean of Marian's osteopathic school, is trained to realize that "a person has multiple other organs, and a family dynamic, and a socioeconomic overlay, and a financial burden. Everything is affected by that diseased organ."
HOLISTIC GENERAL PRACTICE
At University of the Incarnate Word, the first class of future DOs arrived on campus in July 2017, but planning began in 2014.
Choosing to start an osteopathic school "felt like it matched our mission to concentrate on producing more health care providers for south Texas and for underserved communities," said Denise Doyle, interim president of UIW. "It's associated with holistic general practice or family practice, which is more likely found in rural areas or areas of high need. It's totally compatible with Catholic social teaching."
More than simply creating new medical schools, the two universities are trying to alter the entire health care ecosystem of their surrounding areas. They have seen the statistics showing that students are more likely to enroll in medical schools close to home; to seek postgraduate residencies not far from their medical school; and to go into practice not far from their residency.
Doyle said that UIW already has worked with surrounding hospitals and clinics to create new residency positions. Four years will elapse before any UIW medical graduates can fill those slots, but the school wants opportunities waiting for them in areas that need their services.
"We want to attract doctors to stay in rural areas or along the border, where there are a lot of needs that are unattended to," she said.
The university also plans to open an osteopathic manipulation clinic, which San Antonio currently lacks. Learning to use their hands to diagnose and treat is an important part of osteopathic practice, and the clinic will give students literal hands-on practice in those skills.
Unlike the majority of the nation's 48 osteopathic school sites, Marian and UIW are both located in large cities. But underserved populations in need of medical care exist in both rural and urban settings, and both schools are committed to addressing needs where they find them.
Addressing the needs of South Texas also means thinking about language skills. "It's pretty hard to go to medical school and become fluent in Spanish at the same time," Doyle noted wryly. But the university's optometry and pharmacy schools have a program in place, which the osteopathic school may adopt, to teach Spanish medical terms. Also, she noted, 60 percent of UIW's student body is Hispanic, and she expects that a significant number of UIW undergraduates will eventually enroll in the osteopathic school.
GROWING IN NUMBER
Osteopathic medical graduates of U.S. universities can go into any medical specialty — although a significant majority choose one of the primary care fields. Robyn Madson, DO, MPH, FACOFP, was hired to be the first dean of UIW's School of Osteopathic Medicine. Madson said that 8 percent of practicing U.S. doctors will be osteopaths in 2020, but by 2030 the figure is projected to rise to 30 percent.
Because neither UIW nor Marian is affiliated with a teaching hospital, both schools have created partnerships for students to do rotations in existing local hospitals — and also, crucially, with primary care practices. Statistics indicate medical students who have plenty of role models for primary care will be more likely to choose internal medicine, family medicine or pediatrics for themselves, and those are the medical fields that are struggling the most to fill demand.
Marian's default preparation was for primary care physicians, Salupo said. "There was never pressure to say that good doctors should become neurologists. We had strong mentors and good doctors to look up to."
"We talked from Day One about the interconnectedness of the human body and its ability to heal itself," Salupo said. "My formal medical education seemed so well thought out, I don't know how you'd do it otherwise."
Family practice, Salupo said, "excites me, the idea of seeing a little bit of everything. It's a great way to view our shared humanity, to hear people's stories and be part of their healing process. It's humbling to be part of people's lives in that way."
Most rural Indiana counties have far fewer physicians than they need, which hurts families and the economy, said Dan Elsener, Marian University's president. The school collaborated and raised funds from local hospitals that wanted a reliable supply of primary care physicians, and it has established 60 partnerships with health-care institutions ranging from major hospitals to small rural clinics. Also, Elsener said, the state offers some tuition reimbursement to medical students who commit to practicing in Indiana after graduation.
"If you want to practice the entire spectrum of health care, go to more rural areas," said Sefcik. "You have the opportunity to be a more holistic doctor in rural areas of this country."
All students at Marian, he said, do rotations in underserved areas, whether rural or urban. He added that he is lobbying for Marian to admit more students from rural backgrounds, since they already understand the areas and are more likely to return there as fully qualified doctors.
Sefcik, who in 2016 came to Marian from Michigan State University's osteopathic school, is Catholic and resonates with the school's values of "peace, justice, the dignity of the individual, responsible stewardship." But, he added, "we have students of many faiths. We don't force Catholic or Franciscan values on anyone."
UIW's Madson previously helped start a new osteopathic school at Pacific Northwest University in Yakima, Washington. She thought she was ready to take a break, but the opportunity to start a new school in a faith-based environment was too tempting to pass up. Although she is not Catholic, she said she appreciated "the freedom to discuss spiritual issues in the context of health care." The osteopathic approach realizes that "it's not just about their body. They're a being with components of body, mind and spirit," and families, jobs, crises and wellness habits all need to be a part of treatment decisions, she said.
"The students and faculty are of all faiths," Madson said, "but they understood when they came here that faith was going to be discussed. Patients are going to ask deep existential questions, and we have to be prepared to deal with them."
Having been in on the creation of two medical schools, Madson said, "the blank slate is a myth." In UIW's case, the school is surrounded by a big city with large populations of poor and Hispanic residents, which is why the university chose to place the school in a severely underserved neighborhood. The school has hired 70 faculty to teach the incoming class of 150; when those students graduate in four years, the projection is that 130 faculty will be on staff.
One advantage UIW has in starting fresh is that it can avoid creating the silos many conventional medical schools are trying to pull down — a whole-person curriculum will be a feature from the start. Also, Madson said, the physical facilities are designed to encourage students and faculty to mingle.
An integrated curriculum means that students do not take separate classes on mental or spiritual health. "There's a thread to it throughout," Madson said. If, for instance, a diabetic patient's leg needs to be amputated, students would learn to take a spiritual history and "understand that a part of the health care team is the chaplain." And sometimes a spiritual crisis manifests as, or goes along with, physical illness.
Looking at the patient's social context is another important aspect of an osteopathic education. For example, Madson said, a low-income patient diagnosed with asthma doesn't just need medicine — he or she also needs an air conditioner. Although no one organization exists to address such needs, UIW is working to form networks of social agencies in San Antonio that might be able to help.
That approach adds the thread of public health to the tapestry; Madson said it is becoming something that medical students learn as part of their education, rather than going back to school to study it later.
Marian graduated its first class of osteopathic physicians in May 2017, but planning and commitments began eight or nine years ago. Elsener said that the university has expanded during his 16 years at the helm and has added programs to serve needs in Indianapolis and rural Indiana. The school considers whether any potential new program will meet a need, whether it fits the Franciscan mission, and whether it will work economically.
"When those three things can work, we jump on it," he said. "It helps our school, and it helps the world."
For more than a century, Indiana had only one medical school, which in recent times has not been enough to meet the state's need for doctors. But Marian saw no reason to duplicate Indiana University's MD program, and the osteopathic approach fit with the school's mission.
"DO rang out perfectly clear," Elsener said. "It was super clear that this was the place to be."
Marian raised $162 million for the project, which also included new facilities for its existing nursing school plus money for an endowment. Starting in the midst of the Great Recession actually helped in a way, Elsener said, because construction companies were so eager for work that the building costs came in at about $6 million under the initial estimates.
The Marian facility includes a chapel across from the main lecture hall, and Elsener described how the school's healing mission aligns with Franciscan values. As well as body, mind and spirit, the osteopathic approach acknowledges economic and psychological factors. "We see the whole and not differences," he said.
Doyle, who served as UIW's provost and chancellor before becoming the acting president, compared starting a medical school to building a house: "You have to get the right people and the right plans before you can live in it. It's a very expensive project for us as an institution, because we're employing people long before we have students paying tuition."
The university spent between $50 million and $60 million to start the school, she said, which included some money to fund new residency opportunities in partnership with federally funded clinics for high-risk populations.
Describing Marian's first DO graduation day earlier this year, "There's hardly anything like that feeling," Elsener said. "You work that hard for something for that many years, it was a big deal." Sefcik said that 65 percent of the class is doing primary care residencies, and 39 percent stayed in Indiana.
His four years as a Marian student created "a family that I don't think any of us expected to develop," Salupo said. "It was a wild ride that I wouldn't change for anything."
DAVID LEWELLEN is a freelance writer in Glendale, Wisconsin, and editor of Vision, the newsletter of the National Association of Catholic Chaplains.
Copyright © 2017 by the Catholic Health Association of the United States
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