A Properly Balanced Path Forward for Podiatry -
A Response to "What Kind of Podiatrist Do Today’s Residents Want to Be?"
Alan Sherman DPM’s commitment to the podiatric residency training has been well recognized and appreciated over the years. And I also laud his thoughtfulness in trying to bring more reality into the podiatric training process. In considering his comments in his recent blog, "What Kind of Podiatrist Do Today’s Residents Want to Be? – Survey Results", I believe we have to look at the history of our profession to find out why we are in the current state we find ourselves in. It is important that we not go backwards in trying to solve the current problems.
Podiatry’s Early Development
Podiatry developed outside the framework of the allopathic and osteopathic professions. We were not taken seriously as doctors and did not have access to hospitals until we became surgeons. CCPM, under the leadership of Dr Pierce Nelson, took a giant step forward by establishing a hospital as part of their campus. This started putting economic pressure on the hospitals in their area as foot surgery was seen by administrators as a highly profitable source. Today, podiatrists have become part of a large percentage of hospital staffs throughout the country, providing not only better medical care than ever before, but also providing good financial income for hospitals.
American Board of Foot and Ankle Surgery - First Podiatry Certifying Board
The American Board of Foot and Ankle Surgery (ABFAS) was the first certifying board, which was needed by hospitals to say that those who were doing foot surgery had adequate expertise. Being the oldest board, it became the only option for podiatrists to certify in order to gain hospital access. Podiatrists had to become advanced foot and ankle surgeons to gain any kind of board certification back then. Today the ABFAS is the most powerful certifying board because they have the largest number of diplomates.
Now There is the American Board of Podiatric Medicine
Not all DPMs could become certified by ABFAS simply because they were either by choice or lack of training, not advanced foot and ankle surgeons. For these reasons, the American Board of Podiatric Orthopedics (ABPO) and then the American Board of Primary Podiatric Medicine (ABPPM) were established to increase expertise and certification in those areas that were considered non-surgical. These two boards merged under the name American Board of Podiatric Medicine (ABPM). The ABPM continues to make advances and is greatly increasing its influence by increasing the numbers of podiatrists taking it’s exam and earning it’s certification. As they also require a certain amount of surgical expertise (generally surgical principles, evaluation, complications, medical management, leaving out surgical technique), it is becoming a more viable option to pursue certification by young practitioners and those who want to do some surgery that is of a less complicated nature.
Some Confusion as to Multiple Boards and What Exactly a Podiatrist IS
With the development of two different main boards (and there are some lesser known boards as well), an alphabet soup of podiatric residencies were established. This alphabet soup ended up confusing outside sources as well as dividing the profession into a "haves" and "have-nots." Those students who graduated in the top of the class generally sought out and got the PSR-24 or PSR-36 programs and those at the bottom of the class got the PPMR programs. It created an arrogance by the haves as those who didn't have the PSR-24 or better struggled more to establish strong practices after training. The reasonable course was to create a stronger podiatric profession by having a single 3-year residency program. The establishment of this put many of the small residency programs out of business, many of which had very strong clinical non-surgical training and helped the young physician figure out that a majority of foot problems don't need surgery. The profession, for these practical reasons, continued down the road of emphasizing surgical training and downplaying non-surgical education, we came to accept the myth that our surgeons are our superstars and those who do only minor surgery are less worthy of our esteem. This, of course, is not true.
Two Standardized Residency Formats – RRA and Forefoot, Mostly RRA
With the establishment of a single 3-year residency, there still was a two tier system set up, one leading to certification in rearfoot surgery and one without. However, almost all programs have adopted the RRA tier because it is more difficult to attract top quality students to a program that does not have RRA.
What Determines Competence in Training – Volume of Cases or Determination of Competence by Peers?
ABFAS and CPME continue to set minimum activity volumes (MAVs) for residency education that are not based on any type of evidence, only on average volumes. Who can say that it takes 80 digital surgeries for all residents to become competent in digital surgery, but only 60 first ray procedures to become competent? And only 50 rearfoot surgeries to become competent in all types of ankle trauma and reconstructive surgery? Since ABFAS is the major driving force in the residency model, shouldn’t ABFAS set surgical MAVs based on evidence of competence? In fact, paradoxically, the CPME 320 document which sets the regulations of podiatric residency programs states that our programs are to be Competency-Based while still requiring MAVs, which continues to confuse Residency Directors. Should ABFAS quit demanding a certain number of surgeries during residency training, and instead base certification on demonstrated competence, no matter what the tier of residency training is? Who cares if competence is developed during residency training, during fellowship training or even after several years of working with someone who is very competent? Competence is competence, no matter what the source of training. This would markedly decrease the pressure on residency programs to provide exotic surgeries or even surgeries which will never be utilized in an average practice, and instead focus on developing patient centered competence.
The Rise of ABPM – Proper Recognition of General Practice Podiatric Medicine
ABPM has grown in popularity in recent years because of their offering certification at an earlier stage of the young practitioner's career and their greater emphasis on podiatric medicine. ABPM has set MAVs for biomechanical examinations during the residency program, however any reviewer for CPME will tell you how difficult many programs find in meeting the MAV. This writer has a lecture on this particular forum in how the biomechanical examination helps a surgeon decide on the best flatfoot surgery to perform. If every flatfoot surgery required a biomechanical examination as part of the pre-op workup, the biomechanical exam MAV would be much easier to meet. Likewise if a biomechanical exam MAV was required before any bunion surgery, this requirement would be much easier to meet.
A Proposal - Merge Those Boards, Add Sub-Specialties
Considering these aspects, instead of taking a step backward in time by making more division in the profession by having a two tier residency program, it is time to consider the following proposals:
- ABFAS and ABPM need to consider uniting as a single board. As a single board, various certifications could be offered, including certifications in general medicine, physical medicine, and various surgical options. Practitioners would be able to continually add certifications to their resume throughout their career. The board certifications would be based on demonstrated competence, not on the type of residency one completed. Jeff Robbins, DPM, head of podiatry in the influential Veterans administration, recently called for a merging of the podiatry boards, due to problems he has had getting improved rights and seeking equivalent treatment and benefits for VA podiatrists.
- MAVs for residency programs should be established on evidence, or eliminated in favor of Peer Review by Residency Directors of competency. The profession clamors for evidence based medicine, but who is clamoring for evidence based education?
- Residency programs should become more focused on following patients from pre-op, through workup, through surgery and post-op care. Instead of having MAVs for each little category, MAVs should be set for following patients with various pathologies over a period of time. The current system is now set on training surgical technicians, not on treating patients in a wise and thoughtful manner.
In summary, podiatric medicine has made great strides in the 40 years that I have been part of it. We have solved many problems. Most podiatrists, especially new practitioners, now have access to hospital practice and also board certifications. This is because of the selfless sacrifices of so many of those who have gone before in making the profession better than they found it. Today the trainers of students and residents continue to make the sacrifices of putting the interest of young practitioner’s futures ahead of their own interests. I applaud the efforts of all who do so. Let us continue to work together to make the profession more united and more competent.