A New Direction in Podiatric Residency Training – Dual Track Third Year
In a recent poll done by PMNews, only 14% of 928 podiatrists identified themselves primarily as surgeons. Another 24% prefer the term Podiatric Physician and Surgeon. The majority, 62%, preferred names that did not contain the word surgeon.
In a subsequent poll, 1,034 respondents weighed in on the related Question: Is podiatry a surgical specialty or is surgery a sub-specialty of podiatry? Less than a third of podiatrists think of podiatry as a Surgical Specialty.
Barry Block recently wrote an editorial discussing these findings entitled, “ There never has been. And the most highly skilled surgeons should to be doing ”. I have been talking to Barry and many of my colleagues for years about this “identity” issue, and discuss it further in the paragraphs below. The reality revealed by the poll results is that most podiatrists engage in general podiatry practice, and identify themselves as a “Podiatrist” or “Foot and Ankle Specialist”, rather than a “Podiatric Surgeon” or a “Foot and Ankle Surgeon”. While we all do some surgery, we are all doing the same three year residency training programs in which training in surgical skills is highly weighted. The fact is, most of what most podiatrists need to do today and in the years ahead, is not advanced surgery. There are not enough patients needing advanced podiatric surgery to keep all the graduates of our residency programs busy doing surgery.advanced surgery daily, in high volume, to be the best surgeons they can possibly be.
There are not enough patients needing podiatric surgery to keep all the graduates of our residency programs busy doing surgery. The fact is, most of what most podiatrists need to do today and in the years ahead for our patients is not surgery.
The PMNews polls confirm what many of us have been feeling for years - that while we all do surgery, and deserve recognition for the training that we get, the credentials we achieve and the fine work that we do in that discipline, very few podiatrists are primarily advanced surgeons, nor should most podiatrists primarily be advanced foot and ankle surgeons. If we all were primarily advanced foot and ankle surgeons, who would do ALL THE REST of the important work that we do in solving the worlds foot health issues? The volume of medical podiatry, the work we do as physicians, not as surgeons, far exceeds the volume of surgery needed by the public. Shouldn’t podiatric residency training reflect that?
Less than 20% of podiatrists are primarily advanced foot and ankle surgeons, and that seems about right. The public doesn't need more than 20% of podiatrists to fill this role.
I think what the poll is telling us here, and this result is very interesting and I believe, even exaggerated, is that only 14% of us think of ourselves as primarily being surgeons. And I believe some of those responses are aspirational…in that some podiatrists like to think of themselves as primarily surgeons, but are they really spending most of their time doing surgery, or pre and post-op care?
The volume of medical podiatry, the work we do as physicians, not as surgeons, far exceeds the volume of surgery needed by the public. Shouldn’t podiatric residency training reflect that?
Truth be told, is that I believe less than 20% of podiatrists ARE primarily surgeons, even though ALL podiatrists do at least some surgery among all the treatments that they do for their patients. And though surgery is an advanced calling, so too is the treatment of infection, preventative medicine, the non-surgical treatment of trauma (be that trauma acute and forceful, or small and repetitive), and all the other skills we possess and employ to cure disease and relieve suffering. Being a podiatrist, a Foot & Ankle Specialist is an advanced, sophisticated and appreciated calling, as advanced as are our Foot & Ankle Surgeons. One is not higher or lower in the podiatric hierarchy than the other. They are just both different paths. Medical doctors in medical specialties, your neurologists, cardiologists, pulmonologists, don’t feel inferior to surgeons because they don’t do surgery.
Truth be told, is that I believe less than 20% of podiatrists ARE primarily surgeons, even though ALL podiatrists do at least some surgery among all the treatments that they do for their patients.
Why do we have a hierarchy of esteem and self-esteem in podiatry based on how much surgery we do? It’s ridiculous, yet it persists. I believe strongly in the three-year model of residency training, but wouldn’t it be great if after two years, residents that show promise to be in the top 20% of podiatric surgeons continue on to focus their third year on advanced surgery to refine their skills, while the other 80% fill that third year with everything else that podiatrists do? They’d be spending their third year getting training that reflects that balance of work that they’ll be doing in practice. Our most talented surgeons would go on to do one or two-year fellowships in advanced surgery, limb salvage, and trauma care after they complete their third year of surgery focused residency education. And the 80% would complete their residency better prepared to be the best general podiatrists that they can be.
Why do we have a hierarchy of esteem and self-esteem in podiatry based on how much surgery we do?
I believe the needs of podiatrists and patients would be better served by restructuring the third year of our residency training programs. I believe we should be tracking candidates demonstrating the best potential to become advanced foot surgeons into an advanced surgical track. We might want to consider other specialty tracks as well, such a wound care/limb salvage, sports medicine, pediatrics, etc that particular programs would offer third year programs in. The default third year, that I believe most candidates would voluntarily choose, is podiatric medicine, consisting predominantly of continued training in outpatient-based podiatric medicine and non-advanced surgery. Under this plan, in the most practical sense, most podiatric residents would spend their third year refining their skills in the areas of patient care that most podiatrists and patients need, and a smaller carefully select group of residents who show exceptional skills in surgery: hand-eye coordination and manual dexterity, biomechanical analysis, diagnosis, surgical planning, OR tactics, tissue handling, OR leadership, would enter the advanced surgical track, perhaps even doing additional fellowship training in a 4th or 5th year.
A New Direction for the Future to Best Train All Podiatrists
This is the education path that I think would better serve the needs of podiatrists and the podiatry profession overall. Let’s agree on both what podiatry is now and what it should aspire to be in the years ahead. What does the public need and what is our most sustainable position in the medical delivery system? I think that is a profession consisting of most of us that practice primarily office based podiatric medicine with minor surgery and a minority of a carefully selected group of the best surgeons among our ranks doing the advanced podiatric surgery. And I don’t begrudge our podiatric surgical pioneers, our Earl Kaplans, Harold Schoenhauses and Lowell Weil Senior's at all for seeing our future as so surgery centric. In fact, God Bless them for their visions. Their aspirations were accurate and correct, but too narrow-minded. They saw, and trained, and were largely responsible, for the current generation of excellent foot surgeons. And many others joined them, to build the tradition of surgery as such an important part of the practice of podiatry. But this vision should never have sought to include ALL podiatrists, because we don’t need or want all podiatrists to be advanced foot surgeons. We and the public need 80% of podiatrists to be great general practice podiatrists, and we need to regard those podiatrists as worthy of our highest regard. Because they truly are.
I've been gratified to learn that every single reasonable podiatrist whom I’ve discussed this with agrees. I can't help feeling that both the excellent surgeons and the general podiatrists will both feel vindicated once the clear distinction between them is made.
Alan Sherman, DPM
CEO, PRESENT e-Learning Systems