Practice Perfect 714
How Should We Handle the Clerkship Crisis?

For those of us in practice, dealing with the fallout from the coronavirus pandemic has been challenging to say the least. The daily trials involved with taking care of our patients in the midst of an almost unprecedented healthcare crisis rightfully has many of us focused on practice life. But this healthcare crisis has also created challenging situations for our residents and students. Our leaders in national residency requirements have focused on decreasing the burden with actions such as temporarily decreasing the minimum surgical numbers required for graduation, which I applaud.

However, there’s also a major crisis going on with our students. Imagine this scenario. You’re a 4th year podiatric medical student about to start the most pivotal stage of your undergraduate education by clerking at various residency programs around the country. You know these clerkships can make or break your opportunity with the residency program needed to complete your education as a podiatric physician and surgeon. You are about to leave when the coronavirus pandemic hits. Your podiatric college has asked you to sequester at home and not attend your clerkship. This continues for several months while you lose essential hands-on clinical experience. Your podiatric college attempts to supplement these lost opportunities with online education. Education leaders outside the schools such as PRESENT e-Learning help by providing free online educational content to the schools. Despite this supplemental education, nothing can replace your lost face-to-face encounters with patients and their pathology. This situation creates uncertainty for students both in learning important clinical skills and possibly losing the chance to acquire a residency.

4th year clerkship students at podiatry schools across the country are losing essential hands-on clinical experience

Several of our national leaders have begun to think about this situation and consider solutions. One of those leaders is Patrick DeHeer, DPM, a long-time student and resident educator, residency program director, national speaker and communicator, and board member of the American Podiatric Medical Association. His perspective as both a national leader and an individual with skin in the game make him someone to whom we should listen.

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As a residency director and podiatric college associate professor, I too have an opinion on this issue. Let me first add a disclaimer that all opinions stated here are mine alone and do not represent either my employer or PRESENT e-Learning Systems. With that said, and before we get to Dr DeHeer’s suggestions, the American Association of Colleges of Podiatric Medicine (AACPM) and the Council on Podiatric Medical Education (CPME) recently released a joint statement that you can read by clicking here. To summarize, they recommend the following:

Podiatric colleges should:

  • Employ virtual training and online didactics as much as possible.
  • Work closely with students to understand concerns.
  • Communicate with external training programs to ensure education occurs safely for students and patients.
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Regarding residency interviews:

  • Residency programs should plan for residency interviews in January but be prepared for virtual interviews.

Supplemental requirements for students to be ready for the residency application process:

  • Stakeholders should work together to identify modifications to the interview schedules, match dates, and residency start dates.

I applaud these organizations for releasing a statement, but I think it can go further. They place most of the responsibility on the schools, residency programs (which are already doing the actions they recommend), and students rather than calling on the entire podiatric community to help. It would also be good to see more concrete and creative solutions.

Let’s now get to some solutions posed by Dr DeHeer. These are quotes from Dr DeHeer with slight modifications by me for readability.

  1. Move the match submission date back to March to allow for February to become an additional rotation month before the rankings are submitted.
  2. Use the APMA Mentor Network [the program for undergrads considering going to podiatry college] as preceptorships for fourth-year students with unfilled rotations. The schools (AACPM) and CPME/COTH must be flexible in recognizing these preceptorships as accredited rotations. The hands-on experience is so important, and it is being jeopardized, so if there are not enough hospital residency-based externships, let’s use podiatric physicians already committed to the profession through the Mentor Network.
  3. Colleges must be more flexible by allowing students to use unfilled months for preceptorships or to visit residency programs that welcome visitors and not being so black and white about what is considered an approved rotation. During a discussion with the APMSA Class of 2021 Delegates, I asked students what a “virtual externship” is like. One said it consisted of one hour per week of academics and another said it was 5-6 hours per week.
  4. Ask residency programs to allow students to participate in their academic sessions virtually.
  5. Many programs like mine increased the slots per month (I went from four to five students per month - I was increasing from three to four anyway so I actually increased by two).
  6. Apparently 2-week and 3-week rotations were not favored from the CPME/COTH surveys, while a May 2020 AACPM student survey supported shortened rotations. Below is the question and the response.

    Question
    If it is found optimal to shorten clerkship rotations from the current 4-5 weeks, which of these shorter rotations do you prefer (only options presented were 2 and 3 weeks)?

    Answer
       74% of respondents selected the 3-week option
       27% of respondents selected the 2-week option

    Some programs in states with surges are requiring students to do a 2-week self-isolation prior to doing the externships. So, essentially, they are doing a 2-week rotation. Why not just make this an option for all programs to increase the available slots?

I agree with almost all of Dr DeHeer’s comments and suggestions. I would add that with any change, we must remain cognizant of the medical risks to our clerks when working with patients. This risk remains whether clerking at a residency program or doing a preceptorship. We must remain vigilant to protect them during rotations with increased testing, continued education on proper PPE use, and PPE availability.

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Dr DeHeer’s recommendation for a preceptorship is intriguing. Podiatrists in various parts of the country have done similar programs for graduates who were unable to obtain a residency. It’s been done before. Now, we could use this type of program in one-month intervals for those students unable to acquire a clerkship. There are some caveats to this idea, though. First, there must be support from the community for the doctors running the preceptorships. They will need easy assessment forms and rotation goals and objectives as well as clear and efficient instructions on COVID testing, PPE use, and contingencies in case of exposure. They won’t have time to create educational content and will require help. Additionally, this type of training can be highly variable, so it must be made clear that our students are not workers in their practices but rather trainees. If there is concern about the variability of skill acquisition, we can ask the schools to set up clinical skills examinations during the end of the students’ 4th year to confirm their level of competency and remediate deficiencies.

Asking all of the nation’s residency programs that are currently open and accepting clerks to accept an extra clerk is also a good idea as well as an easy fix. My program has added an extra clerk per month just as Dr DeHeer mentioned he is doing. For those programs that don’t feel they can do this, they should keep in mind that each clerk’s experience doesn’t have to be identical to the others. For example, my program currently has three clerks, but only two of them will be able to go to the operating room (we couldn’t obtain clearance at our local hospitals due to the last-minute addition). Now, as much as I’d like all three to gain surgical experience, at least my third student has a clerkship. Isn’t something better than nothing? If every program accepted one more clerk per month, we would largely eliminate this problem.

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There are plenty of other ideas that are possible if we come together as a national community to do something. Our leadership should create a taskforce aimed at generating both solutions and resources. The CPME should ask the schools what they need to help their students and then work in partnership to make that happen. Perhaps temporarily easing restrictions would allow schools to be more flexible with how they work with their students. If our students need more didactic sessions, then let’s create a national online academic conference.

Companies like PRESENT are well situated to run a program like this. They have been providing the online education series for podiatric residency programs for the last 17 years and a similar program for the colleges since March of this year. We should enlist the people who are already doing this type of work to help.

Companies like PRESENT are well situated to run a program like this. They have been providing the online education series for podiatric residency programs for the last 17 years and a similar program for the colleges since March. We should enlist people who are already doing this type of work to help. Many residency programs around the country do didactic sessions weekly. For those programs willing to do so, invite clerks around the country to participate in your sessions. The AACPM could easily set up an online announcement board where residents can post their academic schedules and links. There are so many ideas – it just requires some thought and our community choosing to work together. Statements are good – actions are better.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
jarrod@podiatry.com

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