Are We Giving Away Our Unique Skills In Biomechanics In The CPME 320 Rewrite?

Kathleen Satterfield DPM FACFAOM

Almost every surgeon is able to say a patient’s surgery looks good on the table and on the X-ray film. Then there are those podiatric surgeons who are exceptionally skilled. These surgeons have bragging rights six months after the day of surgery.

What is the distinction between the surgeons? It is an understanding of biomechanics. In a recent Podiatry Today poll (see www.podiatrytoday.com/does-biomechanics-have-sufficient-emphasis-podiatr... ), poll respondents have said it is the one skill that makes podiatrists truly unique and it is that understanding, anatomy in motion, which makes a good surgeon an exceptional one.

However, as a profession, we risk giving away what defines our uniqueness with the proposed rewrite of the CPME 320 document. Section 5.6 reads:

“Podiatric and non-podiatric medical faculty members shall be qualified by education, training, experience, and clinical competence in the subject matter for which they are responsible.

“The active podiatric faculty must include sufficient faculty representation by each board recognized by the Joint Committee on the Recognition of Specialty Boards, or by individuals possessing other specialized qualifications acceptable to the Residency Review Committee.” (The italics are mine.)

The reason given is that some sponsoring institutions have had difficulty enlisting board-certified faculty members to participate in their residency programs. While the document does not specifically mention the American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM), this is the only board with which there is a perceived problem.

Some sponsoring institutions have had difficulty enlisting ABPOPPM faculty for their residency programs. The ABPOPPM diplomates are not always available in the geographic region of the residency program or they are not always on the hospital staff.

Looking At An Alternate Pathway To Certification

There is a simple solution we are overlooking. The question is why did we overlook this? I will leave that for the pundits to answer. The solution came from Marc Benard, DPM, the Executive Director of the ABPOPPM.

As residency programs face the challenge of trying to find trained biomechanists for their residency programs in places as diverse as rural Iowa and Virginia (which will most likely be impossible), there is an opportunity to create an alternate pathway to fill this unique need for well-qualified faculty at our nation’s residency programs.

Closure of the alternate pathway to board certification has lead to a situation in which those who trained under one residency program designation are now unable to access the board certification process of the other American Podiatric Medical Association (APMA) recognized certifying board.

Over the years, some residency faculty members have come to the ABPOPPM wishing to take the certifying examination to satisfy the CPME 320 requirement but could not do so because they had completed a non-qualifying residency type, according to Dr. Benard.

The ABPOPPM requested a variance to the closure of the alternate pathway, specifically for existing faculty of residency training programs, from the Joint Committee on the Recognition of Specialty Boards (JCRSB), which governs this area. The JCRSB declined the request.

We favor using evidence-based medicine when treating our patients. Why wouldn’t we use evidence and objective criteria when building our residency faculty rather than leaving it up to vagaries and bias of individual programs? This flies in the face of the excellent, unbiased design of the CPME’s on-site residency reviews.

At one extreme is the requirement that every program delivers a minimum activity volume of surgical procedures in each category, such as first ray, hammertoes, etc. Now at the other extreme is the recommendation that the individuals who actually train the residents need only demonstrate “equivalent” training or experience in the opinion of their other faculty while the very mechanism recognized by the CPME to assess the competency objectively is ignored.

Can you imagine a podiatric residency program being proposed at a leading academic health science center with only foot and ankle MD orthopedists, a full complement of other healthcare professionals and no podiatrists except a group of ABPOPPM-certified DPMs? Of course not. It would never be approved.

This could happen conversely if the new rewrite goes through. Essentially, you may have a residency program consisting of MDs, complements of other healthcare professionals and no podiatrists except a group of American Board of Podiatric Surgery (ABPS) certified DPMs.

Some of you will say that is different. Please tell me how it is different.

Just as not everyone can be or should learn to be a surgeon, I say that not everyone can be or should be a biomechanist.

If it is the study of biomechanics that sets podiatry apart from other professions, then who are these “individuals possessing other specialized qualifications acceptable to the Residency Review Committee”?

Comments

Many issues exist in this discussion.

Firstly, all podiatric students should graduate with an advanced knowledge of the the bio- and pathomechanics of the foot and ankle. This is both up to the faculty of the colleges and the students to learn and understand the lessons they learned in class and in the clinical setting.

Next, in residency, if the attendings (I am an attending in a PM&S-36) are not teaching the coexistence of both biomechanics and the surgeries they perform, we have a learning deficit here.

No board certification can ever address this. I had 3 years of residency. A PPMR (of which students reading this won't even know what this is) followed by a PSR-24. My attendings in both residencies were excellent in helping me to correlate between what we were doing in the OR and the pre- and postoperative mechanics involved.

Did I take the ABPOPPM certification? No, I didn't for two reasons. One was financial. I just couldn't afford the $1000 dollars to pay to apply for the exam and fly to wherever it was and spend money on a hotel and food just out of residency AND do the same thing for the ABPS. The other was that the hospitals in my community only recognized ABPS certification for hospital privileging.

Am I a biomechanist? Yes. Am I a surgeon? Yes. I don't see how or why there should be a clear line of distinction between one or the other. We as a profession are one AND the other. Unless of course you come from a time when training for surgery was just not available or accessible. If you are not, you didn't learn your lessons the way you should have. Especially in the new day and age of everyone eventually having three years of training.

I am impressed by your training - not one but two residency programs! Your training mirrors what today's young podiatrists should be getting if all things go perfectly. In other words, a mix of medicine, biomechanics and then surgery.

But residencies are in shortage once again and no one will be getting (or for that fact needing) more than one residency program.

The fact that you can say that you are a biomechanist and a surgeon because you took a PPMR and a PSR really makes the point. You had the advantage of training with specialists.

The CME 320 rewrite should ensure that there are STILL specialists training the next generation's specialists as well if we care about their future as much as we cared about ours.

Isn't one of the goals of vision 2015 to have one unifying Board rather than a Medicine/Biomechanics Board and a Surgery Board?

What happens to the Biomechanists then?

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