ABPM Issues Their Position Statement on the Current Consideration of Changes to Podiatric Residency Education - Commentary
The Council on Podiatric Medical Education (CPME) is currently involved in a re-evaluation and consideration of modifications to CPME 320, STANDARDS AND REQUIREMENTS FOR APPROVAL OF PODIATRIC MEDICINE AND SURGERY RESIDENCIES, which is the document which defines and regulates podiatric residency programs. The American Board of Podiatric Medicine (ABPM) and the American Board of Foot and Ankle Surgery (ABFAS) have been asked to participate in this process as well as other interested parties. ABPM released their recommendations in the form of a position statement on Wednesday evening and I had a chance to thoroughly read and review them today.
After consideration, it is clear to me that ABPM did an excellent piece of work that will contribute greatly to the work that CPME has ahead of it in its consideration of how podiatric residency programs should be structured and run in the years ahead to best meet the needs of the profession and the public that it serves. I see the potential for some very positive change to come out of this hard work that ABPM has done. Kudos to the ABPM Board of Directors and leadership for this great contribution to the growth of the podiatry profession.
I wish to make a few comments on a few of the position statements.
Position #5 - The terminology referring to the specialty of “podiatric orthopaedics and primary podiatric medicine” should be changed to “podiatric medicine” throughout the Council documents.
YES! The arcane and obscure term, “podiatric orthopaedics and primary podiatric medicine” should be retired and heretofore replaced by the term, “podiatric medicine”. That is an important improvement in my eyes, not at all trivial.
Position #6 - There should be a single residency training program, three years of length, in podiatric medicine and surgery.
I understand ABPM’s desire to keep residency training uniform and standardized on the PMSR model, and that since 98% have met the criteria for the added RRA qualification, ALL should meet that requirement and the distinction eliminated. My issue continues to be the lack of opportunity for diversity among the PMSR programs. We need podiatrists who emphasize different sub-specialties in their practices. I think we need residency programs that emphasize different sub-specialties as well. ABPM didn’t address the wasted time spent by residents and directors/attendings in training the 30% of residents who intend to be general practice podiatrists in advanced foot and ankle surgery, when they don’t intend to be advanced foot and ankle surgeons. That we train all residents in advanced foot and ankle surgery is perverse. Maybe they believe that this is not the right time to tackle this issue. I believe it will need to be tackled moving forward and that this is a particularly good time to address it.
Position #8 - Residency program competencies and resident evaluations should be based on milestones and not minimum activity volumes (MAVs).
I would like to learn more about Milestones as the method to determine competency. The two terms seem synonymous. It’s remarkable that the APMA BOT has already endorsed this (See Appendix A). Kudos to them. But there is no purpose in adopting this method if MAVs remain. The two systems for quality assurance are redundant. The CPME 320 guiding statement, “Resource-based, competency-driven, assessment-validated” doesn’t require MAVs. They were overkill and should be relegated to history. More autonomy should be given to residency directors to determine which residents achieve which competencies. This grading by directors is just one more peer review step along the path to board certification. I personally wouldn’t mind if residents left their program with a check list, a report showing exactly what milestone they reached and which ones they didn’t during their three-year training program. How much more responsible can a residency director be than to make these decisions and create this report?
Position #12 - Podiatric Clinic and Office Encounters should not be reduced and should be documented and enforced similar to all other required competencies.
I agree with ABPM in regard to increasing the emphasis on clinic and office-based encounters. The fundamental fact that podiatric practice is an office/clinic-based practice has been under-emphasized in the past 30 years in our drive to become hospital-based surgeons. The current MAV for Podiatric clinic/office encounters is 1,000, or about one patient encounter a day during the three years of residency. It should be much higher. I searched CPME 320 for the standards for providing office/clinic based encounters, and all I found was the MAV of 1,000 and under section 6.1, the description of the PMSR curriculum, Paragraph A, Section 4, “Formulate and implement an appropriate plan of management, including: Direct participation of the resident in the evaluation and management of patients in a clinic/office setting.” Under section 6.3, they go on to limit it, “Twenty percent is the maximum proportion of residency education that is acceptable to be conducted in a podiatric private practice office-based setting.” This does leave open the possibility of more encounters in a hospital-based clinic, if one exists. I think we share this imbalance issue in our residency programs between hospital inpatient vs clinic outpatient with other specialties like orthopedics, ENT, neurology. I just think exposing podiatric residents to patient cases from first encounter to resolution should receive greater emphasis, because that is fundamentally what we all do in practice.
That’s about all I have to say, except to affirm that I support the efforts of ABPM, ABFAS, and CPME in continuing to evolve the standards of education in the podiatry profession to best meet the needs of the profession and the public that we serve.