In residency training, “competency” is the word – the word that generates controversy. Are our podiatric residents competent to practice after three years of training? What is competency and what does it look like? One would think this is an easy question. Just test the resident on something after completing the minimum activity and diversity before they graduate, and you know they are competent. Right?

Wrong. Unfortunately, this concept is a bit more complicated than that. Let’s explore some of the issues associated with competency-based training and see if this is a reasonable direction for us to go as educators of the next generation of podiatrists.

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“Are our podiatric residents competent to practice after three years of training?”

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First, let’s take a quick look at what is currently happening in resident education. According to the CPME 320 document, the rulebook of residency training, the definition of a contemporary podiatric residency is as follows¹:

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The podiatric medicine and surgery residency is a resource-based, competency-driven, assessment-validated program that consists of three years of postgraduate training in inpatient and outpatient medical and surgical management. The sponsoring institution provides training resources that facilitate the resident's sequential and progressive achievement of specific competencies.

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“Our programs are actually based on volume and diversity of cases rather than competency.”

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It seems clear that our programs are resource-based and assessment-validated. However, despite making the statement that a podiatric medicine residency is competency-driven, the reality is different. Our programs are actually based on volume and diversity of cases rather than competency. According to appendix A of the same CPME 320 document¹, our residents are required to accomplish the following before graduation:

A.	Patient Care Activity Requirements	MAV
	(Abbreviations are defined in section B)
	Case Activities
	Podiatric clinic/office encounters	1000
	Podiatric surgical cases	300
	Trauma cases	50
	Podopediatric cases	25
	Biomechanical cases	75
	Comprehensive history and physical examinations	50
	Procedure Activities
	First and second assistant procedures (total)	400
	First assistant procedures, including:
	Digital	80
	First Ray	60
	Other Soft Tissue Foot Surgery	45
	Other Osscous Foot Surgery	40
	Reconstructive Rearfoot/Ankle (added credential only)	50

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“Is it true that completion of 60 first ray procedures makes for a competent surgeon?”

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Do you see anything about competency here? I don’t. Our rules and requirements document that we publish for the world to see states that, in essence, performance of these many surgical cases, office encounters, etc, makes for a competent podiatrist. But is it true that completion of 60 first ray procedures makes for a competent surgeon?

Again, I don’t think so. One resident might actually need 10 first ray procedures to demonstrate competency, while another might need 70. Additionally, doing 60 procedures wrong is still doing 60 procedures poorly. We don’t hit 60 and then all of a sudden, magically, we become competent. Our profession equates volume with competence, and that standard is questionable.

I should point out that the CPME does not explicitly equate these two concepts (that’s my interpretation). The MAV definition from the CPME 320 document is as follows¹:

Minimum Activity Volume (MAV)

MAVs are patient care activity requirements that assure that the resident has been exposed to adequate diversity and volume of patient care. MAVs are not minimum repetitions to achieve competence. It is incumbent upon the program director and the faculty to assure that the resident has achieved a competency, regardless of the number of repetitions.

I read this as a liability-limiting statement that puts the onus on the residency programs to independently find a way to assess competency. In general, I would be ok with this idea, except that the entire purpose of the CPME 320 document as stated is¹:

The mission of the council is to promote the quality of doctoral education, postdoctoral education, certification, and continuing education. By confirming these programs meet established standards and requirements, the Council serves to protect the public, podiatric medical students, and doctors of podiatric medicine.

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“CPME should provide leadership and resources to help programs measure competency. That is the only way to truly make podiatric residency standardized. ”

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If the purpose of the Council is promoting quality, then how does leaving this incredibly important aspect of training up to individual residency programs - providing no guidance - lead to quality and protect the public? Our governing body of podiatric education should provide leadership and resources to help programs measure competency. That is the only way to truly make podiatric residency standardized.

We are also wasting our trainees’ time with the present system. Currently podiatric residents complete the minimum activity volume (MAV) and 36 months of training and are then let out to practice. Again, volume and time-based training occurs rather than actual competency. If our residencies were truly competency-based, then trainers would be able to focus on deficiencies specific to each of our trainees and would use the three years more efficiently and productively. For example, if a resident was determined to be competent in hammertoe procedures and not Lapidus procedures, then the residency director could focus their subsequent efforts to teaching that resident the Lapidus procedures and not waste their time doing more digital surgeries.

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“We need to begin formally taking steps toward true assessment and documentation of competence and stop worrying so much about volume”

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Let me state here a couple of important clarifications. First, accrediting residency programs is a highly complex venture that is easier to talk about than to actually administer. Considering the past quality of residency training and how variable it was, the CPME has done an excellent job creating the current system. Second, any process of improvement has to begin somewhere (MAVs) and move in a progressive fashion (toward competency), and this takes time. Change is never well accepted when it comes all at once, and I would advocate a gradual method of modification. We do, though, need to begin formally taking steps toward true assessment and documentation of competence and stop worrying so much about volume.

With these thoughts in mind, we’ll look next week at what competency-based training would look like. Is this method actually possible and realistic for individual residency programs, and what are the current methods being used to assess competence?