How To Combat The Residency ‘Shortage’

Ron Raducanu DPM FACFAS

I drive around from office to office a lot. When I drive, I think. Dangerous, I know. Lately though, the primary thing on my mind is this residency “shortage” and what in the world we can do to overcome this immense burden on our youngest colleagues.

My heart goes out to them. You know why? I was there. My first go at a residency through the match process was a gut wrenching failure. I remember that feeling well. You break out into a cold sweat. You feel dizzy and nauseous, turn white and feel like passing out. I remember it that well. At the time, not everyone got surgical residencies and I wanted to be a surgeon.

So rather than turn tail and head back to Canada, I first scored a primary podiatric medicine residency in the scramble. Then I was successful in obtaining a surgical residency but at the time, there were programs for guys like me who had a year. They were called “advanced level” programs and had required a year of training to apply. I got one of those without entering into the match so by October of my first residency year, I was set.

Let’s flash forward 14 years (oh my, has it been that long?). Now, if someone enters podiatry school, he or she is virtually assured to be a surgeon. Well, I’m going to be the first to say it. Is that necessarily a good thing? Should everyone be a surgeon? Does everyone entering into podiatry school have the skill to one day wield a knife in the operating room? I am pretty sure the answer to that question is no. So what do we do? We have everyone out there in our profession talking surgery. If you do score a residency, you are a surgeon. What if you don’t? That is the issue at hand.

Everyone is pointing the finger at the schools. “You take too many students!” “You should tighten up your entrance qualifications and make it harder to get in!” Let us explore that for a second. For argument’s sake, let’s say that we have a stable number of residencies (which isn't exactly the case) and the schools cut back to take just as many students as there are programs. That would increase tuition as the schools still have bills to pay and if there are fewer students, someone has to foot the bill, right? “Our student debt is going up!” Hmm … well, do you want a residency or not?

The next issue becomes, what happens when some of the students do not pass their boards? It is impossible to guess with any accuracy whatsoever how many of those students will pass because no matter how “passable” you make the test, some people will fail (unless you outright give away all the answers, but we don’t want to do that, right?).

So now we have some unfilled slots for residency. Well, the pendulum swung that way already and led to residency programs and slots closing. So how do you balance this swinging pendulum? One year, you have just enough residencies but then the following year, too many people fail the boards and now there are some spots that the sponsoring institutions can’t fill and they lose their Medicare funding for that spot.

Oops, now we are back to where we started. It happens that quickly. Once the sponsoring institutions lose that spot and the money gets yanked, they are not so willing to apply for that spot again when there is an overload of students looking to get trained. And here we are.

“Generate more residencies!” The preceding is why it is not that easy, see. Also, if you want to generate a brand new spot, the sponsoring institution has to invest the initial front money to train the residents. Medicare wants these programs to “show them the money!” Medicare wants this hospital to pay for the first round of residents before it will retroactively compensate the place and then decide if it will continue to pay. Risky, huh? A resident costs about $250,000 total to train or something like that.

Do you see how this may present a bit of a challenge? Not only that but students seem a little gun shy about applying for a new program that has not proven itself. I understand that some students would rather take the risk of not matching than take a risk in a new program. Crazy!

What Happens To Those DPMs Who Don’t Get Residency Slots?

Now that we somewhat understand the challenges with generating and maintaining a residency, let us talk about the residents who do not get a residency. It is heartbreaking and in today’s age of Charcot reconstructions and ankle replacements, it gets doctors to really question whether they made the right decision to go into podiatry and also, how in the world they are going to cover all that debt. These are legitimate concerns, I would think, no?

Believe it or not, I think we can look to our past for a solution. Not everyone was going to be a surgeon. They knew this so they prepared for it. Not everyone today going through residency will become a surgeon. The wise ones who graduate from residency will estimate their skills and hopefully understand that perhaps they shouldn’t go or won’t enjoying being in the operating room. There are some of these people out there right now. They have great training but they are not surgeons. They exist. Believe me. How are we preparing for those not getting a residency? We are not and that is a crying shame.

There is only one pathway. Although I understand the need to advance the profession and that having three years of training will unify us (even though it really hasn’t … reconstructive rearfoot/ankle surgery, anyone?), there is still that nagging concern that most states require one year of residency before they will grant a state license. The conundrum is that we don’t offer one-year residencies anymore.

So what gives? It’s three years or no years? Bad news. What do the “no years” podiatrists do? How are they going to pay back their loans without the ability to practice their art?

Does Every Incoming DPM Want To Be A Surgeon?

To back up a bit, does everyone who gets into podiatry school want to be a surgeon? Do they? Do we know this for sure? Would they be happy not being surgeons? I think the answer to this question is yes. The goal is that everyone can make a living, not that everyone can fix bunions. Right? Right! Well, how do we make sure that happens?

Once again, the answer comes from our past and is already in our present. To make sure everyone can make a living, podiatrists have to have one year of training, right? They have to have that so they are free to go anywhere in the United States and practice their art. Why can’t we make that happen again? I think we can and should. There is a place for non-surgical podiatrists in our midst. We haven’t gotten that fickle to think this is not the case, right?

We already have a means to make that happen but we have not yet reached the ultimate endpoint. There are preceptorships out there but they don’t have standardization, and don’t really give their participants anything that can be used to prove proficiency. That needs to change pronto. Would it roll back to my days of a primary podiatric medicine residency? It sure would. So what? We don’t need five or six different kinds of residencies like we used to have. We need two: three-year surgical programs (with reconstructive rearfoot/ankle programs for all, thank you very much) and one-year programs to grant those who want it or need it to actually make a living. Wouldn’t that be great?

Some people may actually choose this route. Imagine that: The podiatrist who doesn’t want to be a surgeon. Blasphemy.

The way to make this happen is to allow volatility and flexibility to those who want to offer it. There must be a curriculum for residents outside the hospital setting. There must be hospital work but not paid for by the hospital. Well, who is going to run that? The American Podiatric Medical Association (APMA) can. In a recent audio program, we learned that the APMA has a $10 million emergency budget fund (surplus?). When confronted with this figure, John Mattiacci, DPM, who was one of the participants of the program, very astutely asked, “Isn’t this an emergency?” Well it kind of is, isn’t it?

Looking Toward A Potential Solution

What I propose is this. The APMA starts a program that will identify prominent private practitioners or big groups in every large community who would be willing to train a colleague for one year. They would have an established curriculum and work toward a certificate that will allow these practitioners the ability to obtain a license to practice in any state. Eventually, this might even shift the paradigm to allow them to do basic hospital work and get on insurances. This would be kind of like a podiatric family practitioner.

Let us put our egos aside for a moment and realize that we don’t want bitter colleagues out there who cannot make a living and default on their student loans. We want us all to grow as a health profession with happy people. It will take a shift in thought for us. This is not going backwards, it is taking care of our own. We are not the mighty surgeons if our colleagues are starving.

I think this kind of thing can eventually take off. Not everyone wants to be or needs to be a surgeon. This will give podiatrists an option. Some people don’t think they need three years of residency to survive as a podiatrist, perhaps? Ultimately, even if you wanted to be a surgeon, at least if you do this and don’t match a second time, you have the option to practice and feed your family, right? These types of practitioners are who we need. Eventually, we will supersaturate with the “Super Surgeon” and then what?

Before everyone takes me to task and screams, “They couldn’t make it! They didn’t get a residency for a reason!,” there are some good people in every graduating class who would make wonderful practitioners but slipped through the cracks. When I did not match, I felt I was one of them. I got a shot because I had the option to complete one year of training, which led to a certificate that, had I not gotten a surgical residency, I could have then used to make a living. Do such podiatrists deserve never to see the inside of a private practice because of it? Even if that is the case, they made it through school and paid their tuition. I do really believe it is unfair to hang these podiatrists out to dry at this very vulnerable time in their careers.

So let’s do it. Let’s work with the Council on Podiatric Medical Education (CPME) to develop a type of one-year certified program that will at least give our colleagues the option to survive after their schooling and after one more year of “training.” I think we will eventually find a way without the APMA to fund these positions, whether local state societies help with this or an endowment fund is created. Private practitioners are doing it on their own with preceptorships, which are great but right now, there is nothing to make sure our colleagues can survive on their own without scoring a three-year surgical program. Let’s change that up.

Are you with me?

Comments

Simplest answer? Graduate less students that are higher caliber. The problem is none of the colleges want to be the one that has to close, cut back or do with less. Very sad to graduate with 250G in student loans and nothing to do, no chance of loan payback? Many of these kids are given unrealistic expectations from the start and then it is too late. This is a lot of money and the best years of your life to give up for so much uncertainty in a profession with a perpetual identity crisis.

This residency shortage can make podiatry extinct as a profession because less people will apply to podiatry schools once they hear of the podiatry residency shortage. It is just a matter of time that this dilemma will be common knowledge to many pre-med undergrad students, despite the PR strategy of the podiatry school recruits (who will not mention the podiatry residency shortage anyway).

Allopathic medical schools always have a residency for every MD graduate every year, which boosts more enrollment into their schools every year.

If podiatry school faculty and administration think that they are immune from the podiatry residency shortage, they are mistaken. This problem can actually threaten their careers too, not just the podiatry students graduating.

The big danger of podiatry residency shortages is that it will actually harm the podiatry schools in the United States. Less enrollment, the employment of faculty and administrative personnel in these podiatry schools will be threatened. Do podiatry schools realize this? They better! Jobs in these podiatry schools are on the line too, not just the well-being of podiatry graduates.

If most states require at least one year of residency in order to grant a podiatry license, then why not institute one-year post graduate residency programs only for those podiatry graduates who did not match with a three-year residency in CRIP or in scramble? I think this should be the next move for CPME and APMA.

It looks like many teaching hospitals that are sponsored and approved by COTH will not open up more new three-year podiatry residency programs because such hospitals either 1) do not feel a need for it or 2) they do not have enough money or 3) both reasons. So it makes sense to enforce the one-year residency for the graduates who did not get matched with a three-year program. COTH-approved teaching hospitals could find these one-year programs more affordable to sponsor.

Offer these one-year podiatry residency programs along with the unmatched three-year residency programs during the scramble period only, not the CRIP period. The scramble period would be over quicker since there is a program for every unmatched podiatry graduate.

Thus every podiatry graduate will have a residency, either a one-year or a three-year program by the time the podiatry school graduation ceremony arrives.

I like your idea of offering one-year programs only after the match very much. I seriously think the powers that be need to consider this immediately.

Thanks for the input.

You are welcome Dr. Raducanu.

In addition, I think that there should be one-year residency programs also for the PREVIOUS podiatry graduates who did not get a residency as well from the Classes of 2009, 2010, 2011, and 2012 with the current Class of 2013 during the scramble period. Think about it. These previous graduates are one to four years out in the real world since they graduated and still without a residency. I wonder how many of them are out there? What is the exact number?

I really don't think the answer to the problem is infiltrating the health care community with under-trained podiatric physicians. You aren't really helping them, patients or the podiatric profession as a whole.

The problem stems from the schools. There is a complete disconnect with schools and residency programs. There should be a cap that all schools need to follow and that cap should be based on the available residency positions. Of course, there will be fluctuation but it is far better than having many, many students in limbo. The easiest way to fix the number of students is to stop making the admissions standards so ridiculously low. Yes, there will be good doctors that were never good students, but in general, a 3.5 GPA student will make a better physician than a 2.5 GPA student. Honestly, it is laughable how easy it is to get into podiatry school. With residency training, expectations increased and medical standards increased. It is only common sense to increase the expectations of incoming students.

There is no simple fix for the current students who don't have a residency position. But making it easier to practice medicine is FAR from the answer. This is much bigger than a small bump in the road. A major overhaul is needed. I suggest we start with some of the schools taking 100+ students and graduating 50.

I disagree with you.

I feel that there is a place for those practitioners that only have one year of training, and that doesn't necessarily mean they are under-trained. As I've explained, there will always be those left out for a variety of reasons. There ARE good students/doctors who just fall through the cracks.

I firmly believe that if you can make it through the curriculum, you deserve a shot at practice and making a living. Regardless of the entry requirements (which I also feel are too low), if you can make it through, you should be able to at least make a living at it.

I've trained medical residents, and believe me, the personalities are no different than what you think we deal with with the low entrance requirements.

I'm unfortunately in the scramble and I thank Dr. Ron Raducanu as well as everyone else who is posting about the shortage. I'm surprised no one in the scramble has replied to any of these posts. It's also frustrating seeing that there was only about a two-week discussion on PM News and then this post.

What's even more frustrating is that I've been to about two conferences, spoke to many podiatrists and found most of them to be surprised that there is an actual scramble. 104 or 1, we are real people with lives and we're doing everything we can to get a residency position.

Every day I wake up, I check my email for any replies, then the CASPR website, and CPME.org. I do this throughout the day about 100 times. Any program that has available positions and comes up on the CPME/CASPR site makes me jump. I read as much as I can about the program, write a letter of intent, send in my application materials, and then I check the people I know to see if they have any connection and beg them to call on my behalf. I've been doing this since March 20th.

At first, there was hope because there were about 30 programs still scrambling but in a little more than a week almost all 30 went red. Less than a handful of programs emailed me back stating they just filled the position and the majority just left me alone to check the CASPR site for updates. Around 10 programs opened since the scramble and now they are all red. I've been so close in obtaining three positions but missed out to another colleague. Oh well, at least I achieved a career goal and am now a doctor?

What keeps me going? I have a family that I need to support, around $250,000 in debt that I have to take care of; not to mention maxed out credit cards from mailing in all my applications and driving/flying to visit places. Four years ago, I was told this was medicine's secret profession and that our university matched 100% of its grads. I did my best to take it one day at a time and learn as much as I could, working and studying countless of hours. I'm tired and beat but I'm still giving my all, waiting to jump on something that will bring me closer to a residency spot. It's been over two months already since match day. I know for a fact I'm not the only one feeling like this and I know some of my other colleagues have it worse.

I'm not blaming anyone. I'm not complaining. I'm just doing all that I can to obtain a residency spot.

I'm so sorry to hear of your struggles. I've been there and know how heartbreaking it can be. Stay strong.

Gee, so things are no different than 30 years ago. Keep paying those dues to our wonderful leaders.

Very much has changed in 30 years. Open your eyes.

I agree with PM. A very large number of DPMs have no clue what is going on and have no idea of the environment the students are entering. The APMA must do a better job educating current practicing DPMs. It has been a shame to hear some older DPMs say "I didn't get a residency and I made it just fine." They clearly do not understand the current environment of healthcare. Thankfully, those who were educated in that day and age are slowly but surely retiring out of the profession, and we will be better for it.

I am sad to read these comments. Those "older guys" laid the foundation for who we are and what we are allowed to do in the operating room and hospitals. Some of the "older guys" still train residents and train them very well. Some of them trained me and I am glad for it as they had much to teach and even today, we all have much to learn from them.

Them retiring will be a blow to us if we don't remember our history and their role in it. Be wise, not spiteful. They faced many challenges so we could progress as a profession. Never forget that.

Thank you Ron.

I was fighting for privileges and breaking down hospital doors throughout the 1980s and even 1990s way before it was unusual "NOT" to have a podiatrist on staff. Could any of these hot shot young guys do a closing base wedge and akin in the office under local in a 10 x 10 treatment room/surgical room without a residency? I don't think they could even imagine the fortitude it took but we didn't have an option until the walls came tumbling down, state by state, community by community.

I see these clueless white lab coat monogrammed pods with their three years of training all the time who think it was always possible to sit around some doctors' lounge and rap with other docs.

That is so funny! Most of the new pods know nothing about our past and really don't care. That;s fine but I wonder now if was really worth busting my a** for them after reading student2015 comments.

I apologize for sounding arrogant and yes, we are VERY thankful for the docs who came before us and made possible the great training we receive today. It was not my purpose to sound entitled. However, it is very frustrating to have students with $250,000 in debt and be told that they will be just fine without a residency and to just chip and chip the debt away. Regardless, I apologize and I thank you for doing what you had to do to get us where we are today.

Thanks young bro. Absolutely no big deal. Actually, rank and file pody including myself agrees with you 100%. You guys can't go out and hustle, learn, assist, etc ... because you can't even get a state license in most states without the three-year program. That is where the political component and national agenda messed things up. Hell, I'd be way more ticked off than you or any other student or grad stuck in that situation. It is absolutely insane and when I read of a dean saying stuff like life isn't fair sometime or nothing is guaranteed, give me a break! Good luck and never be afraid to talk to older guys because you never know who can help you.

Which group of podiatrists benefited more from the CPME?

1. Podiatrists that were matched and obtained residencies

2. The podiatrists that were not matched and did not obtain residencies.

Why can't CPME approve of immediate programs that are similar to and

not federally funded to allow for everyone to have some sort of

in hospital training? Can't this be done in Pennsylvania and Connecticut, states that do not require residency training for licensure? If this were done, wouldn't non-matched podiatrists also benefit by CPME approving a different model training program?

Why can't any licensed podiatrist that is not matched then be able to join a hospital if the podiatry chiefs at those hospitals removed residency requirements and board certification requirements for membership?

Then unmatched podiatrists could first assist at and then eventually become surgeon of record at specifically delineated privileges such as toenail surgery. They could obtain peer recommendations.

Why can't CPME approve of such non-formal, in-hospital training programs if peer recommendations are gotten, confirming a non-matched podiatrists' competence at independently performing procedures?

Would podiatrists who are already matched benefit from CPME accepting a non-formal training program? Perhaps not. But why not have some immediate in-hospital training by all unmatched podiatrists willing to travel get licensed in PA and Connecticut and join hospitals that have podiatry chiefs that advocate for their right to join by eliminating residency requirements? There are probably a lot of podiatry chiefs and residency directors out there in PA and Connecticut that are trying to figure out how to help the unmatched podiatrists. Why not start by encouraging medical staffs to amend bylaws to allow for unmatched podiatrists to join the staffs?

There you have it. Non-formal, in-hospital training without worrying about needing a certain number of cases for such non-formal training to occur. If anyone can say this will take away from cases of those who are already matched, I would disagree and say that every podiatrist
that is able to get licensed in PA and Conn should be entitled to some sort of ability to upgrade their skills, not just those who got matched. If they could get licensed and upgrade their skills in the office, at least they are going to the hospital and saying hey look I want to upgrade my skills to a further high level.

What is the possible result? Even if one can upgrade their skills to say performing an
implant surgery with grommets in one hospital after say six years of "non-formal"
training, then there still may be hospitals with medical staffs that have screening
baseline criteria of residency training.

I personally feel these minimal residency screening
criteria for hospital membership and state licensure should be
abolished as soon as possible. If PA and Connecticut can allow podiatrists to become
licensed, other states have no right in my opinion to have minimal residency screening
criteria. My rationale is that if someone 25 years ago took a residency training program,
how can that program, if possibly outdated and unrelated to current competence, be accepted
by a state licensing board as meeting minimal screening criteria? I believe the
states should abolish all residency screening criteria for licensure as soon as possible.

Why can't podiatry chiefs at hospitals in PA and Connecticut be contacted and have them request that the medical staff amend bylaws to allow for hospital membership for all podiatrists
that get licensed as soon as possible?

I am hopeful that every state will change their laws as soon as possible to allow for
the licensure of all podiatrists that are not matched.

Disclaimer: These are my personal opinions and are not any form of legal advise.

Sadly Dan, this is not likely to happen. It's a huge step backwards for medicine as a whole and to our profession.

If anything, I think all states will eventually go to requiring at least one year of postgraduate training to allow licensure for ANY medical professional. I do believe that this IS in the best interest of the public to have these requirements in place but as a profession, we have to mold to this rather than have the system mold to us.

Dear Ron,

I bet if you were not able to get that residency training, you probably would not say it is a huge step backwards for our profession. My ideas are a huge step forward for those who cannot get matched.

If states require one year of postgraduate training to allow license for any profession, this is not protecting the public all the time because outdated training taken 20 years ago is not current training and how can this relate to current competence? If minimal screening criteria do not relate to current competence, is this discrimination occurring against a group of non-residency trained podiatrists? If yes, does this practice depart from any federal anti-discriminatory legislation? Is discrimination against any group of non-residency trained podiatrist in the public interest if outdated training of 20 years ago is accepted as meeting state criteria?

Ron, if you were not residency trained, would you still agree that all states will eventually go to requiring at least one year of postgraduate training to allow license for ANY medical professional? I do believe that this IS in the best interest of the public to have these requirements in place but as a profession, we have to mold to this rather than have the system mold to us.

Dan

Dan,

Podiatry is a very small profession within medicine as a whole. The requirements are for medical professionals of all kinds.

Also, those who don't get training are still in the minority. My idea is to help them within the system AND the profession. Once again, why ask the system to change when we can change how we do things internally to conform?

It's not hard. It just takes effort and an investment to want to help these people out.

Ron

I couldn't agree more with this article. I am one of the podiatry graduates from 2013 who "fell through the cracks." I was lucky to find a preceptorship with a great podiatrist this year and I have reapplied for match. I have driven over 11,000 miles this year visiting residency programs just to keep my foot in the door. I would love to become a surgeon but it would be great to have the option to practice podiatry in an office setting, pay back my student loans, and feed my family (I have a wife and two children) without a three-year residency. I have had a wonderful experience with my preceptorship this year but still feel like I am a glorified medical assistant, and I don't feel like I'm any closer to being a licensed podiatrist. At this point, I would definitely go for the one-year training if such an option existed.

Hi Ron,
I read your article and I was wondering if you could tell me a little more about the one-year "advanced level" program and how you got it? Is it sort of like a "1-year residency program"? I would also like to ask you if you happen to know if such a program still exists today. Thanks in advance!

Jessica

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