Desert Foot 2011 is just one week away and it has grown enormously—again. We're looking forward to seeing you all at our new home at the beautiful Arizona Grand, starting next Wednesday, November 16 thru Friday, November 18. The Inaugural Golf Tournament is Saturday, November 19.

Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St, Pomona, CA

Volume or Variety in Residency Training: Which Is More Important?

With the residency shortage and the movement toward standardized undergraduate and podiatric residency education, the classic question becomes increasingly pertinent: which is more important in the experiences had during residency training, variety or volume ? This was a challenging question when I was a resident and was likely an important question for the entire time podiatric training has existed. Truly, it’s an important question, whether we’re talking about surgical cases, history and physical examinations, biomechanical exams, or any number of skills taught during our training. Proponents of either view, variety or volume, have made strong cases in the past. Let’s look at the relative merits of each.

Tonight's Premier Lecture is
Ankle Fractures Made Simple:
by John Schuberth, DPM

Variety Is the Spice of Training

Perhaps a certain amount of volume is important, but variety is pivotal to competency in residency training. The simple fact is that human disease itself is highly variable, and in order to reach competency, our residents and student doctors need to see the full range of human disease, as well as all the faces of disease. Without this, our future physicians will not have an appropriate level of experience when they’re in practice. From the surgical training standpoint, variety is key. Let’s take bunionectomies as a case example. I’m a contemporary resident, in my hypothetical situation, and by the time I’ve reached my 3rd year, I’ve performed 400 Austin bunionectomies but no other types of bunionectomy procedures. I now lack the variety of training to appropriately take care of any patient with a high IM angle or hypermobility. I might be excellent at performing Austins, but I’m now a one trick pony. This would be acceptable if I specialized in bunions with low IM angles… Not likely to happen.

Similarly, if I were to perform 1,000 history and physical examinations on “average” patients for elective surgeries, but never saw a variety of pathologies, I would not be competent to handle the medical conditions of the large number of patients I’m likely to see in practice. Additionally, I would not understand the various manifestations of abnormal pathology if I only examined normal patients.

Variety, then, is the spice of training that provides the all-important perspective that creates competency.

Turn Up the Volume

Ok. So, variety might be important, but what about volume? Volume is also pivotal to competency, and may be considered the other side of the coin. Human skill is honed by repetition. Malcolm Gladwell discusses this concept in his excellent book Outliers. He explains that it takes 10,000 hours to reach the highest level of expertise. He provides a strong argument, reviewing multiple anecdotes as well as research studies that convincingly support this view. According to Gladwell this calculates out to about 10 years.

I look at volume in two ways: number of “cases” (surgical and nonsurgical exposures) and amount of time spent focusing on the particular skills. Let’s look at time first. If it’s true that we need 10,000 hours to reach world-class expertise, then I’ll estimate it takes ½ that time – 5,000 hours – to reach the competency level required for residency completion. Let’s do the calculations. Is 5,000 hours reachable within the standard 3 year residency?

I’m going to estimate the average podiatric resident works an 11 hour day, 6 days per week (I’m figuring in call, giving one day off per week, and ignoring vacation and sick time). This makes a 66 hour work week, 264 hours/month, and 3168 hours/year. In three years, that makes 9504 hours of on the job residency experience. Using this model, our contemporary residents fit not only my 5,000 hour minimum but almost complete Malcolm Gladwell’s 10,000 hours rule for world-class expertise! Based on this, I applaud Podiatry’s movement toward a standard 3 year residency. Of course, I think it’s fair to say that very few residents graduate from their program with world-class expertise. Why is that? I would argue it’s because of the way we actually spend our time in residency.

The other pivotal component to the volume question is number of cases. It’s all well and good to spend 9504 hours at work over 3 years, but that time must be filled with strong educational experiences and, most importantly, deliberate practice2. This entails repetitive practice of specific and focused skills with repeated assessment and feedback. In order for our trainees to deliberately practice, a certain volume of cases (again, surgical and nonsurgical) is necessary. How many actual cases does this translate into? That’s the $64 million dollar question that no one has the answer to. Most likely, the optimal case number depends on several factors specific to the trainee. Additionally, the variety we talked about before is part of this.

Which is it, then? Variety or volume?

I’m going to stay squarely on the fence and say both are equally important. What I’ll say with conviction is that more variety and volume are better than less, but just as importantly, constant and repeated assessment, feedback, remediation, and repetition are integral parts of best residency training. This is why our graduating residents are not world-class experts when they graduate. In fact, the goal of our current training model is not expertise but rather competency. Residency directors, if you’re not assessing specific resident skills and re-educating your residents based on the results of those assessments, then it doesn’t matter how many triple arthrodeses they do. Your residents could be better.

Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum.
Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]