This one is for all of the Residency Directors slogging through hours of resident log verifications every month. Resident logging, as it turns out, is a highly important part of both residency training, and, unbeknownst to most of us in practice, to the podiatric profession in general.

Remember back to when you first graduated residency and were requesting surgical and staff privileges at your local hospitals? For many of us – especially during those years in which there were a bunch of different residency designations (PPMR / POR / PRR / PM&S 24 / PM&S 36) – we had to explain to our referring providers and hospitals exactly what we were trained to do. Our logs were the only documented proof we were trained to do various foot and ankle procedures.

The same is true today. Documentation of training remains highly important, and it is for this reason that proper logging is an integral and - dare I say it – frustratingly significant aspect of residency training. As a program director, I spend a significant amount of time reviewing and verifying my residents’ logs. As a result, I’ve come to appreciate certain issues in reference to our logging rules and would like to make a few observations and suggestions regarding residents' logs.

Recently, I had the opportunity to attend the Council on Teaching Hospital’s (COTH) yearly education event during the residency interviews in Frisco, Texas. I found this event, which focused mainly on the logging process, to be highly beneficial because of my own tribulations verifying my residents’ logs.

During the recent Chino Valley Medical Center residency accreditation on-site visit – at which we thankfully did very well – one of the on-site team’s recommendations was for me to improve my log verification process. As it turns out, though I verify my residents’ logs each month according to the rules, I was allowing inadvertent mis-categorization of certain procedures. Fragmentation (the residency equivalent of unbundling a surgical procedure) and mis-categorization are the most common logging errors made by most programs.

A Few Observations and Suggestions Regarding Residents’ Logs

This brings me to my first observation. As a director, I have very few resources at my disposal with which to educate myself on the process. Podiatry Residency Resource (the national logging service used by almost all programs) has three short videos about the use of their website and nothing on logging rules. There exists a Proper Logging of Surgical Procedures document that is mildly helpful, but leaves a lot of information out. It focuses mostly on what procedures can and cannot be logged concurrently. The only other resource – outside of the COTH educational meetings, which vary yearly by topic – is word of mouth from other directors. Given the number of basic questions asked during the recent COTH event, I can tell you I’m not the only one in the dark on some of this. If directors are expected to correctly verify logs and educate their residents on correct logging, there should exist a comprehensive written resource detailing all methods. In fact, if they turned the lecture I heard into a written document, it would be very helpful to us all.

This brings us to a more controversial issue: the logging rules themselves. The current rules appear somewhat inconsistent. For example, a triple arthrodesis is logged as one procedure while a hammertoe with plantar plate repair is logged as two separate procedures. Both of these surgeries treat a particular pathology, let’s say predislocation syndrome versus end stage adult acquired flatfoot, respectively. Despite one primary entity being treated, these procedures are logged differently. This inconsistency creates an unnecessarily complex system.

Fragmentation – One Procedure or Multiple Procedures

During the meeting, the speaker seemed to indicate three primary explanations for how cases are determined to be separate versus part of one larger procedure. These were the “skill set” of the procedures, the “pathology treated,” and “choice of fixation.” When logging an Austin and Akin surgery performed concurrently, for example, these are logged as two different procedures because the “skill set” is different for each procedure. However, repairing a bimalleolar ankle fracture is logged as one procedure (rather than lateral malleolar and medial malleolar ORIF), because the resident is fixing one ankle fracture (one pathologic entity) and the “skill set” is the same. Similarly, applying a static external fixator is, according to the COTH representative, not logged as a separate procedure because it is simply a method of fixation, just the way choosing screws to fixate something is just the method of fixation.

When I asked the speaker if there exists a document that explains the rationale behind the logging rules, I was told there was none, and these rules had been created over many years. Where is the accountability in that? Our decision-makers should be required to document their reasoning behind important rules and regulations. Instead, we have a subjective system that appears to exist at the whim of a few rule makers.

I understand the concern with fragmenting cases and making it look like our residents are doing more procedures than they really are, and we don’t want to turn logging into a free for all. However, our residents’ logs should demonstrate their acquisition of skills, not the number of cases they’ve done. For every surgery, we should ask the question, “Are there different skills needed to perform these procedures?”

Here are a few changes I would make based on this more consistent system. A triple arthrodesis would be three separate procedures because performing this procedure demonstrates all the skills necessary to perform each of the joint fusions separately. If I can do a triple arthrodesis I can do a subtalar fusion, a talonavicular fusion, and a calcaneocuboid fusion, each in isolation. Applying an external fixator system is more than simply a method of fixation and is, in fact, a completely different skill set than the primary procedure and should be its own separate procedure. For instance, doing an ankle fusion with screws and then applying an external fixator are very different skills. Similarly, performing a Lapidus and then doing an Austin are also separate skills sets and should count as two procedures. In the same way, a Lisfranc joint fusion should rightly be counted as one procedure because completing fusions of each of the joints covers the same skill set.

In our evidence-based medical practice environment, it’s time our podiatric logging system became more objective, transparent, and rational. Instituting these changes can only make administering our residency training programs easier and more effective.