In November 2009, the Council on Podiatric Medical Education (CPME) released proposed revisions to the CPME publication 320, Standards and Requirements for Approval of Residencies in Podiatric Medicine and Surgery.  Since its release, comments and recommendations have been widely circulated, including those regarding the continued requirement for residents to meet Minimum Activity Volume (MAV) for podiatric cases and procedures.

The current values for the MAVs as published in CPME 320, were chosen arbitrarily with no basis of evidence to justify their inclusion.  There is no valid data to support the practice of using a set number of procedures to determine surgical competency.

I propose that we modify the method in which we determine surgical competency by employing Verification of Surgical Competency through Direct Observation (VSCDO), while eliminating the MAV “Procedure Activities” requirement from CPME 320.  By doing so, residents would be more motivated to learn and perfect their skills, programs would be able to direct surgical procedures to residents who need them, and the CPME would be able to collect and analyze data that has never been available before.

Details of my proposal, Raising Questions About The Use Of Minimum Activity Volume With CPME 320, can be found at www.podiatrytoday.com.

Joe,

You beat me to this topic.

A question was asked of the CPME board members at the 2nd weekend meeting regarding the validity of MAV's for competency. One of their board members, an ABPS member, stated to the audience that there was, in fact, NO evidence to backup repetition as a basis to judge competency.

I believe that MAV's are an antiquated method no longer of value. Direct observation of residents to judge competency does have published articles supporting its' use. As such this is the only method we should be using.

The final rewrite of CPME320 should eliminate MAV's altogether.

What about the use of videotapes. These should be used.

standard disclaimer: do not rely on this opinion or any of the opinions at the following website listed above, but
consult with a licensed health care attorney in your state.

Danny

podiatrist1@optonline.net

Dr. Chaskin,

You are correct, video taping qualifies as an acceptable method of Direct Observation, as does the use of remotely monitored videocams.

I do not doubt that the CPME policy revamp on residency education/approvals is in part due to diminished cases that come through many residencies for a multitude of reasons. Diminished reimbursements, economic impacts on patients leaving work, demagraphic shifts to podiatrists that "opt out" of surgery, etc. Minimal activity volumes (MAVs) require the individual to gain proficiency through repetition. Verification of surgical competency through direct observation (VSCTDO) may be the "new" "see one, do one, teach one" in my younger days as a resident. My point is that MAVs (with appropriate documentation) or VSCTDOs are just parameters to determine accreditation of a podiatric residency....our patients use these parameters to accredit us....Just a thought!

Because we grew up culturally with MAV's does not mean we have to keep it. Orthopedic surgeons, whom we chose to emulate have never had numbers as evidence of anything. Their position is that after five years of residency, and scrubbing on every part of the body eventually makes you competent to approach any orthopedic operation. Numbers with us has not proven anything about competency, and creates a situation of pressure to get the numbers, thereby killing the effectiveness of their non podiatric surgical roatations, as they leave them early or don't attend at all to get into the OR. Residents all over the country tell me about this problem, even though residency directors are hesitant to discuss this. When I have discussed it in open forum, I only hear "not in my program."  Now we are going to implement a Vision 2015, with larger numbers in a mandated PSR-36 for board eligibility. But while we were visioning, a group of 50 or so seniors at our colleges found themselves with no residency slot in the recent "NON-Match." No talk of this on Present. WHY? Vision 2015 is about uniformity and parity, but we are too close to 2015 and too far away from being able to implement it fairly to our own graduates. Removal of the MVA requirements solves this problem with the stroke of a pen.

Bryan Markinson

Dr. Markinson bings up an interesting point here. To repeat what he said....Orthopedic surgeons "after five years of residency, and scrubbing on every part of the body eventually makes you competent to approach any orthopedic operation."

Having spent seven years in the UT Health Science Center Department of Orthopedics I had that same feeling, at least that was until one of my orthopedic colleagues approached me to take over a bunion procedure for him. Why would he want me to do that, I asked him?

The reason?

In all five years of his orthopedic residency, he had never once - NOT ONCE - scrubbed a bunion case. I was surprised but he wasn't. He said it was pretty rare for an orthopedic resident to do routine foot cases. Most of their cases, he explained were big joints - hips, shoulders, knees - and traumas, these days.

The numbers requirements are however working against us, as we do no thave enough spots to train our graduates when we are again mandating the training for board eligibility. The numbers certainly are meaningless when it comes to parity, as we do more but get paid less than those who do not have numbers requirements in many instances. The observation model works to eliminate this obstacle and by decreasing the numbers requirements by a small amount we can train a lot more graduates.  Simply put, the orthopedic training experience is more compelling to insurers and legislators, than our superior numbers requirements are. Always has been. Always will be. And the more we slap our backs, the more we get eaten for lunch. We must protect our students from shelling out for an education and then being told that those of us practicing already expect them to have a three year program to become certified, but "sorry no program. NUMBERS IS THE PROBLEM. REMOVING THEM IS THE SOLUTION.