Practice Perfect 741
Biomechanics and Residency Training

Recently, there has been increasing discussion about minimum activity volume numbers (MAV) required for podiatric residents, specifically those MAVs related to biomechanical examinations. This is, of course, in response to the recent CPME’s call for public comment about proposed decreases to the required minimum numbers from 75 to 50. I have some thoughts on the subject that I would like to share. 

Before I get started, I will assert at the outset that it is a bad idea to drop the numbers. Decreasing requirements for any competency that is presented to the public is a bad idea. But now let me say that dropping the numbers does not matter at all.

Biomechanics is the foundation of almost everything in podiatry.

I don't mean to sound like a nihilist, as if this topic has no importance. Just the opposite. This topic is actually more important than any change the CPME is proposing. Biomechanics is the foundation of almost everything in podiatry – but we will get to that in a minute. The reason dropping the numbers by 33% does not matter is if you look at the absolute rather than relative impact, you’ll see that we’ve already abrogated this aspect of residency training. Currently, residents were required to log 1,000 clinical encounters with a minimum of 300 podiatric surgeries. That means surgical requirements are 33% of the numbers while biomechanical exams are only 7.5%. That is pitiful. If we were to change the BM exam to 50 (making them only 5% of the 1,000 encounters) that would be equivalent to a change of only 2.5%. Basically, the numbers are already so insignificant that the 33% relative decrease from 75 to 50 will not make a difference to the overall numbers.

Surgical requirements are 33% of the 1,000 clinical encounters, while biomechanical exams, at only 7.5% are already so insignificant that the decrease from 75 to 50 will not make a significant difference to the overall numbers.

This entire issue is a symptom of a larger problem and not a cause. Podiatry as a profession has given up our supposed expertise in foot function to others. Orthopedic foot and ankle specialists know as much biomechanics as we do (their literature has more than ours). This is also true of the physical therapists and PhD researchers. Except for a few bright stars, podiatry is stuck in the 1970s-1980s. U.S. podiatrists argue over whether Root biomechanics is correct, while much of the rest of the world has already moved on. Podiatry turned increasingly toward surgery and away from biomechanics – just like the orthopedists did in the past. Their move away from lower extremity surgery opened a door for podiatrists to become surgeons.

Podiatrists’ turning away from biomechanics opened the door for professions such as physical therapy to enter what was previously our expertise.

Similarly, podiatrists’ turning away from biomechanics opened the door for professions such as physical therapy to enter what was previously our expertise.

Podiatry as a profession has given up our supposed expertise in foot function to others.

The problem, though, is this entire issue is a false dichotomy. As others much smarter than I have said, it is not surgery OR biomechanics. It is surgery AND biomechanics. If you do not know the biomechanical aspects of podiatric surgery, how do you properly choose a procedure? Why is it bunionectomy OR orthotics? Shouldn’t your post-bunionectomy patient wear orthotics after surgery? Did you eliminate the cause of the bunion in the first place with your surgery? (HINT: No!) Do you even know what caused the bunion? Biomechanics is the why and how of podiatry. If you do not know how or why, then how do you know how to treat patients? Do you use some cookbook method your attendings told you to do in residency? Jeez. Get a brain. Pick up a book; read an article. Think for yourself. People like Kirby and Richie have been writing about this stuff for years. Read them.

Biomechanics is the why and how of podiatry. If you don’t know how or why, then how do you know how to treat patients?

Now, what about residents? Leave the MAV numbers alone or change them – it does not matter. Residency program directors should remember they can require whatever numbers they want if they meet the minimums. I require 150 biomechanical examinations for my residents. 

Why is it so difficult to achieve these tiny numbers anyway? Getting my residents to do formalized biomechanical exams is difficult, and that difficulty lies in the charting, not the exam itself. The notes are longer and more laborious, so the residents do not want to do them. We have zero requirements for residents to “prove” they did a particular surgical case other than their names being listed on the op report with the proper procedure name. What would happen to logged surgical numbers if we required residents to turn in op reports with a requirement that they created that op report? I bet the logged surgical numbers would plummet. A chart note with a “full” biomechanical exam is as long or longer than most op reports. Why have such long chart notes? Does this really prove the residents know how to do an exam? In fact, why is the category even “biomechanical exam”? Do you just want them to prove they can examine a patient? Then have them do a test of some sort, such as OSCE, and show you they can do the biomechanical exam. Charting something proves nothing. Templates on electronic medical records has proven that we can cut and paste to create garbage chart notes.

Our trainees should demonstrate and document their understanding of the cause of disease and how to use that understanding to treat patients.

What skills should we look for with this “biomechanical exam”? Our trainees should demonstrate and document their understanding of the cause of disease and how to use that understanding to treat patients. Isn’t that the point in the first place? As an example, diagnosing plantar fasciitis is easy. Post-static dyskinesia and painful palpation of the medial heel. Done. Understanding the cause of plantar fascial strain (forefoot supination relative to rearfoot, obesity, modern surfaces, etc) will create a foundation for treatment paradigms. Wouldn’t a “proper” biomechanical exam note demonstrate a thought process leading to thoughtful treatment? 

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I submit we should eliminate all the current rules guiding the contents of a note and instead require residents to document their biomechanical thought process. This would be applicable for both surgical and nonsurgical situations. Notes would be more concise, residency directors could stop worrying about this during program site visits, the process would be simpler for everyone, and we can all stop focusing on some proscribed physical examination that has questionable validity in the first place. We should simplify the process to eliminate the residency logging problem. Then we can focus on the real problem: podiatry’s carve off biomechanics as a major part of the profession. That is an issue that demands discussion.

Best wishes.

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

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