Recently a post was made in PMNews regarding Board Certification and podiatry. I understand that podiatry chose Board Certification to signify an elite status a long time ago. I'm not here to argue that. I just want to point out that both the osteopathic and the other allopathic profession do not share that same outlook. As we now are making greater strides than ever towards parity [podiatry in my family goes back to 1934] maybe we should bring our concept of Board Certification in alignment with the MD/DO's.

Pretty much all orthopedic surgeons become Board Certified at the completion of their residency programs, not 5-7 years later. Board Certification to most MD's signify a level of competence but not an elite status.  "Certification by the American Board of Orthopaedic Surgery means that the orthopaedic surgeon has met the specified educational, evaluation, and examination requirements of the Board." [ http://tr.im/OqR ]. Elite status is indicated by completion of approved Fellowships and attainment of sub-specialty status. A non-Board Certified orthopedic surgeon has serious issues with competence. 

Why not develop a process where competent residents can attain Board Certification status [Board Certified Podiatrist anyone?] upon completion of their program after appropriate and fair testing [90% or more pass rate]? This won't prevent anyone from achieving Surgical Specialty [biomechanical or whatever] status if they want it, but not all podiatrists have or want surgical practices. In this method, those of us who have already attained Board Certification would keep it, but would be grandfathered as a Board Certified Podiatrist.

This would just eliminate so much confusion among the public as well as our referral sources. "Are you a Board Certified Podiatrist" would be answered with a simple yes or no, not a 5 to 20 minute breakdown of our internecine squabbles. 

What do you think?

Finally somebody said it!!!! I am so sick of the bull crap that we create for ourselves.

Dr Gottlieb is on to something!  I agree with this approach.  We're already doing this with Board Qualified status, so it shouldn't be too much trouble to up the stakes a bit upon residency completion.  I'm all for it!

This should be an INCLUSIVE designation which the vast majority of us would attain.

The REASON that podiatrists have not been considered Board Eligible upon finishing residency, and what has been the "elephant in the room", has been the variability in our residency programs.  10-15 years ago, many programs were simply poor.  With the move to the PM&S model, most if not all of the poor programs have been shaken out.  And if I may make a somewhat self serving observation, the adoption by most podiatric residency programs of PRESENT Podiatry Residency Education Online, with it's standardized weekly lecture series, eZine publications like Residency Insight and Practice Perfect, and peer interactive social networking, has created a uniform across the board improvement in podiatric residency education.  For the first time in my lifetime, I am confident that most residents are getting a firm foundation in podiatric medicine and surgery in residency.  In fact, I think Dr. Gottlieb, Spears and Shapiro are correct, that it is now time to make the move to declare podiatric residents board eligible when they finish an approved PM&S residency program.  I am confident that there is now no more variability in our residency training than any other medical or surgical specialty.  

Frankly, Dr. Gottleib, raises a point that I was unaware of and that I need to do some research on - that MDs/DOs - do not consider board certification an elite status but just an attainment of educational achievement. That's interesting.

I worked in an orthopedic department at UT med school in San Antonio for years and remember those 5th year Ortho residents sweating over that upcoming exam and with a potential failure, the resulting consequences for those waiting jobs or fellowships that they had waiting in the wings.

The fact that they could take the exam at the end of their residency programs was such a bonus, I agree.

But until all of our residency program grads end their programs competent in everything from soup to nuts that a working podiatrist needs to be able to do, THERE IS NO WAY we can turn them loose with a certificate telling the public that they are Board Certified. And I don't see that happening anytime soon.

I agree that board certification should be made more attainable, but with certain considerations in mind. I question whether podiatry "board certification" should have two distinct organizations ABPOPPM/ABPS with a FF and RF subdesignation recognized by the Council of Podiatric Medical Education and the APMA. Or should they be merged into one distinct board? I remember vaguely in years past, this was bandied about. I worry that residents at the conclusion of their training can present cases toward certification. Why? Well should not part of the certification process of the candidate be contingient on decision-making to "select" the procedure and demonstrate post-operative management of the patient. These procedures in many cases were not "selected" by the resident's decision making but by the "selection" of the attending. The post-operative management and follow up is ever rarely done by the resident. Also, I am troubled by an emphasis on one particular board designation for "certification." What about the practitioner who has a generalized practice in podiatry. Better yet, is the practitioner that may be more skilled in implementation of conservative measures to treat patient's symptoms place that practitioner in a disadvantageous position toward obtaining certification. Perhaps a middle road does exist here?....one where you may not need to provide as many surgical cases and yet may have to demonstrate a larger understanding in the treatment of other subfields within podiatry.

The solution is simple and has been for years. Just adopt the Internal Medicine model. You finish your residency, you sit for the American Board of Podiatric Medicine Exam. Period. Want to be ABPS?, then continue and meet their requirements, like an internist must do to become a rheumatologist or gastroenterologist.  It can be done very easily. Then, and only then, will we shake the Board Certficiation monkey off our backs, and ABPS will REALLY mean something!

The ABPS reports that 30-40% of candidates fail the oral exam each year.  The candidates have shown they know the material by having passed the written exam earlier.  Maybe the average 5-7 year  time lag in taking the oral exam allows the candidates to forget academic details.   I was recently visited by a new DPM on his way to begin his residency.  After quizzing him there is no doubt in my mind that he could have passed the written and oral exam right now.  The candidates I have coached on Skype have been 100% successful on the ABPS oral exam.   There are only 40 questions that may be asked on the oral exam, but an infinite  combination of them.    Dwight L. Bates, DPM, DABPS

I agree with everyone's opinions, statements as well as Alan's "elephant in the room analogy."  I have shared my opinion about Podiatric professional unity to past post and will not restate myself again.  

However, I will share an experience from years past for food for thought.  When I was externing years ago and was visiting a certain Podiatrist, that is in my community,  he was very open about some eye raising things.  This Podiatrist did not complete a formal surgical residency program but had significant surgical privileges at his hospital which he was the only one on staff.  On the first day externing, Dr. X explained to me that I should not bother ever trying to work at "his" hospital because as soon as he came on staff, he successfully petitioned to have the bylaws  changed requiring a PSR 24+ residency program to have privileges.  Remember, he did a non-surgical residency.  Needless to say his surgical outcomes are less than optimal and we see a lot of his post-op patients in the office who are not doing so great.

This is what I was refering to in part in a recent post about a minority of doctors needing to reviewed by peer review when possible.  This is an office were the DME products fly out of the door and his practice does not represent a typical Podiatric practice, at least in my opinion.  

Now before we receive post about older Podiatrist being able to do successful surgery that did not do a formal residency program, yes I agree that is possible.  But you do need to grab some post-residency training certification in terms of CME's, labs, seminars, ect. along the way.   I currently cosign for a couple of local Podiatrist to have privileges.  

I am very much in favor of uniform training and certification. 

My two cents.

Karr 

Board Certified Podiatrist is NOT the same as being certified by either ABPOPPM or ABPS nor should it replace those certifications. It would just designate that you are competent to be a podiatrist, analagous to the Internist, just as Dr. Markinson stated. For most of us, that's all we need. For the others that require advanced standing [either for personal or hospital needs] the existing pathways will still exist. To use Dr. Markinson's example, the Endocrinologist is also a Board Certified Internist. Being Board Certified in the broad specialty is just the first step forward  specialization, if the doctor wants to be specialized.

One other positive in Dr. Markinson's proposal is that it maintains the non operative DPM in a positive postion instead of becoming vestigial as the current 3 year surgical programs are fostering.

I have maintained for three decades that biomechanics is what we offer medicine and the public and that we should be billing ourselves as "Closed Chain Specialists" as described by Marvin Steinberg a half century ago.

There is a bright future for the non operative DPM as a biomechanist, wound healer, sports doctor, diabetic specialist who refers to and from surgically oriented colleagues.

Yes, exactly. This is akin to the dental model, one I've envied for awhile.

Hey, wait a minute and check out http://www.medicalpodiatry.com

Just because one is board certified in podiatric surgery does not mean they are board certified in

podiatric medicine. If a patient requests care from a "board certified podiatrist" and visits a

podiatrist board certified in surgery, that podiatrist should make the patient aware that they are board certified in podiatric surgery without being board certified in podiatric medicine and that they are not being seen

by a podiatrist who is board certified in podiatric medicine who may possibly think ot conservative

podiatric medical approaches to a problem. Don't wait for this to come up in a court of law but make

your patients aware of these credentialing issues.

Alan:  I basically agree with your statement. Advancement of post-graduate education in our residency programs has come a long way.   I am a firm believer in having residents who finish their PM&S-36 program be able to sit for board qualification in both ABPOPPM and ABPS boards.  I know that the ABPOPPM board is moving to that model with in-training examinations leading to board qualification and certification on completion of their cases and successful passing of the in-training modules.  Unfortunately ABPS, who provides in-training exams, does not have a process that provides the same goals at this time. 

I strongly believe that there is a great amount of didactic resources both on-line-(PRESENT) and other online resources that provide all podiatric residency programs with the opportunity to have a  level didactic playing field.  This has been a tremendous resource for programs that take advantage of this opportunity.  The clinical Biomechanical  and Surgical Resources are still not equal in all programs, but are definitely improving.  It is CPME and hopefully the revisions in CPME 320 that will provide direction for programs to provide clinical biomechanical and surgical knowledge, skills and judgement to all programs. 

As we look to Vision 2015, it is imperative that universal competency assessments for PM&S-36 training will be attainable for ALL of our programs, so we can graduate competent podiatric physicians and surgeons. 

Marshall

Below is the current ABOS pathway to board certification.  It is really not much different than our model in my opinion.  They have to be in practice for at least 22 months before they are allowed to present their cases for peer review and take their oral examination.  That closely mimics our ABPS model.

I don't think that the board certification in our profession is elite but clearly shows a level of competence.  I think by us having a competent board certification process it bring value to our profession as a whole.

Taken off the ABOS website:

Board certification in Orthopaedic surgery requires that a candidate pass through a multistage process involving completion of an accredited residency, a written examination (Part I), a period of 22 months in practice, peer review, and an oral examination based on the candidate’s own practice (Part II). A surgeon who has passed the Part I written examination and is practicing while awaiting admission to Part II is deemed “Board Eligible”. This term is not appropriate for surgeons who have not passed part I, or who have been refused admission to part II. The limit of Board Eligibility is 5 years; surgeons who have not passed part II within 5 years of taking part I are no longer “Board Eligible”, and must re-take part I before moving on to part II.

As is often the case, individuals are often willing to make important judgments and comments on matters of which they may not have complete, let alone accurate, information.

The entire growth and development of the podiatry profession must be understood when considering the concerns regarding the matter of granting appropriate Board Certification, and not merely the conferring of such certification on any individual or group. Consideration must be given to the future of the entire profession, without such an intense effort and desire to change our professional past. We must live with our history, just as any organization, group, nation or society must deal with their own. The development of the "future" is the only tool we have, as the "past is prologue."

Residency education and training in podiatry stills remains far from "totally equal."  One must not overlook what the APMA, the Council on Podiatric Medical Education, the Boards themselves, the Colleges of course, the residency programs, and all the many organizations and individual contributions that have been made on our behalf. Outstanding progress and advancement has occurred as a result of these combined efforts to best serve our profession, let alone the public that is always the final arbitrator of our professional success.

I am confident that with the passage of time, many of the individual concerns that seem to be so relevant and upsetting to so many of our peers today, will eventually be solved.

But, it is only with the passage of such time, combined with continued efforts directed toward the achievement of recognizable standardization in all of podiatric education and training, that we will arrive, as a profession, at that place where today's perceived inequalities will become artifacts of our past.

But have heart, when that day comes, there will be new and yet unimagined concerns that will appear for our future leaders to deal with, and to overcome.

Irv Kanat

Thank you to Dr. Kanat, you said it beautifully. 
I want to mention a couple thoughts.
Drs. Chaskin and Markinson have brought 2 issues to mind.  I have been reading this thread since day 1 and have to chime in.  

The statement relating the solution has been simple for years; that just taking the American Board of Podiatric Medicine Exam (ABPME) after you finish your residency would solve it.  Well currently, and he has confirmed this with me, the "ABPME" does not exist, yet.  That is what we are talking about.  Therefore, it has NOT been simple for years.  The PMLexus? I don't think that is what he is talking about.  First, because that has not been around for years either; and second, some states are actually requiring that the PMLexus is passed prior to starting a residency program after graduation, which is a different discussion altogether.  I think what was missed is, the simplicity was based on the grandfather clause.  I don't mean to reiterate the history excessively, but the history is what has brought this discussion this far.
2nd: I am for development of a board certification attainable for all podiatrist?  A podiatrist without certification is at risk of greater liability in the courts and we should be looking out for others in the profession who were not given the opportunity of a PSR or the new PM&S36 simply because our rules in the CPME allowed them to get there.  They met the requirements set at that time and therefore should get the backing from the profession.  However, Dr. Chaskin made the point that podiatric medicine vs podiatric surgery could suddenly be looked upon separately in court.  In my opinion, Dr. Gottlieb's idea is the right path and the poll results go right along with it.   Keeping in mind only 16 votes were made from the membership minds on PRESENT.  A devil's advocate am I, perhaps, but you need one in every democratic format or family (my wife being the one in mine. Ugh! 'Got to love her though.).  If I may add to Dr. Chaskin's point, care must be taken to avoid, if at all possible, laying out a board that would send many competent podiatric surgeons to suddenly need an additional board certification in "podiatric medicine" to avoid the newly fueled lawyer's question, "Dr. D (D=defendant), are you board certified in podiatric medicine, making reference Dr. to the boards you just previously recognized, the American Board of Podiatric Medicine (ABPM) or the American Board of Podiatric Orthopaedics and Primary Podiatric Medicine." Answer, "No."  Then, you are in trouble because the 12 minds in the box aren't thinking like you are.  There is always a flip side to every coin.

For such a small profession, we sure do have a lot of "board certification" organizations. I've been told (and it is probably true) that there are more dentists in New York City than the number of practicing DPMs in the entire country. 

I agree with Dr. Sherman that, PRESENT is a wonderful format to have "uniform" knowledge base among the residency training programs across the nation. This was something we couldn't possibly have done before the internet era.

I happen to think that PRESENT should also be the certifying organization in and out of itself; I would be more than willing to hire a newly graduated resident if they have completed 3 year of the PRESENT curriculum, as I can be sure that they have balanced knowledge on every scope of our profession.  

just my 2 cents. KS. 

Hallelujah, Brian. Why oh why, don't the powers that be understand this? I really thought that we had a chance to solve this when the "great crisis" occurred a couple of years ago. But no, we missed that chance yet again.

We need a basic board certification for ALL podiatrists and then from there we can each, to our own desire, seek specialization and further certification. This is something that our allopathic colleagues could understand.

You and I might want to go the route of medicine, a friend of mine wants to specialize in surgery. Whatever. But its our choice.

Thinking about the totality of it,  I still hark back to the argument that Gary Jolly, a well known and well respected surgeon made about "foot function." You have to understand how a foot functions, i.e. biomechanics, or you should never take that patient to the OR, he used to say. You don't get that by just understanding the ABC's of surgery. That takes a true understanding of biomechanics. I guess I'm meandering but I would like to be what he was intellectually - a truly comprehensive thinker. When evaluating a patient he didn't leave anything out. He started out evaluating the patient medically, went through a complete foot function evaluation and lastly, and only lastly, did he do his surgical evauation. That is a comprehensive workup.

In attaining APMA’s Vision 2015 for for self-improvement and achieving parity with allopathic and osteopathic medicine we have to take a closer look at CPME 320 and our board certification process.  Contrary to what some doctors are saying, this "standardization" does not eradicate the variability in our programs. Variability in programs is what makes one program more desirable to a candidate as long as it upholds the standards of CPME.

This also leads to another fundamental problem that needs to be addressed. It is now time to develop a process where competent residents can attain Board Certification upon completion of their program after appropriate testing. Seven years to attain board certification is unacceptable especially since our counterparts in other fields are board certified soon after completion of residency. This just leads to problems on getting on staff at certain hospitals. ABPS and ABPOPPM certification can continue to be a voluntary process. While medical licensure sets the minimum competency requirements to diagnose and treat patients, the podiatry licensing test is actually specialty specific. Board certification merely demonstrates that a physician’s exceptional expertise is in podiatry. It is now time to incorporate these changes as we move forward in podiatry. We have come a long way and there is always room for improvement and betterment of our profession.

I agree board qualification should happen at the end of residency. There should also be inservice exams across the 3 years of residency to monitor progress of residents and individual programs.  These can be written by the ABPS or CPME . It is ridiculous at this point in time to make residents wait 3-5 years. If  a particular program shows  a pattern of residents not passing, that would be a reason to look at its training more closely.

It is criminal that schools have been allowed to increase enrollment beyond the capacity of current residency programs.  Also, students and residents need more time in internal medicine and general surgery. If the goal is to be primary admitting physicians, students need similar amounts of time in medicine and general surgery that MD/DO students get before graduation