Ready To Train Or Ready To Practice? Redefining The Goals And Expectations Of Schools And Residency Programs

Here we are again. Another period of graduates outmatching the number of training programs until the powers that be gear up and produce more slots. Let “quality” be the key word this time please.

Also, residency directors, keep in mind that this is the 21st century and let me introduce a concept: “the handoff.” You may have heard of it but apparently expectations are still mired back in the 1960s and 1970s. I hear it from colleagues around the country all of the time, even on these blogs.

“The kids these days coming out of school don’t know anything,” colleagues say. “Why, they can’t even do a hammertoe!”

You know what? They shouldn’t be able to do a hammertoe. They shouldn’t be able to do any surgery. That is for a three-year residency to train them to do. In the 1960s and 1970s, there were states where graduating DPMs could go down the street, hang out a shingle and see their first patient.

That might mean performing a bunion surgery and dealing with a complication, handling a diabetic foot infection or just debriding a neuropathic patient’s onychomycotic nails every three months. The point is that the podiatric medical school had to ensure a handoff at graduation to the public or to the residency programs of a doctor ready to practice but possibly with as much training as he or she was going to receive.

Here is an important question for you: Does that make any sense in 2010? Unfortunately, residency directors are still expecting the same “product,” the ready to practice model. That would be fine except those students come at a price and it denies our profession the ability to reach the goal of the American Podiatric Medical Association’s (APMA) Project 2015.

The amount of knowledge allopathic/osteopathic medical students get now is so much more than what students got in the 1960s, 1970s, 1980s or even the 1990s. To reach the ideal of Project 2015, our students need to receive the curriculum of the MDs and DOs and get an emphasis on the lower extremity.

Will the schools be able to teach them to be foot surgeons as well? It is my personal opinion that this is the job of the residency programs.

What is the handoff of the MD/DO schools? They are learning their procedures once they hit residency. They do the odd, small procedure as students but they learn the majority of their work as residents. Med school is for first and second order learning: knowledge and comprehension. Residency is for third and fourth order: application and analysis.

Maybe it is time for all of the educators, both in med schools and residencies, to do some advanced learning — synthesis and evaluation — and reconsider the handoffs here. It sounds like a revamp of the Educational Enhancement Program (EEP) of the 1990s and to that, I would say “No!”

We do need to make this subject an important part of Project 2015 because frankly, we have this all wrong for the 21st century. We are not producing ready to practice physician surgeons. We should be producing ready to train graduates.
Our residency interviewers continue to perform the “academic interview,” the code phrase for “We don’t want to teach you the contents of your intern year.”

General medical schools conduct social interviews to assess whether candidates will be compatible with the team. They do not ask them to list the essential amino acids while picking up BB-gun pellets with a pair of chopsticks with a non-dominant hand, and then do hand-ties while they recite the citric acid cycle. They know they have the educational foundation they need in order to be clinically trained to become physicians.

Too bad podiatric residency directors are too selfish to realize what Project 2015 offers our profession: real parity with MDs/DOs.

Anonymoussays: November 29, 2010 at 5:24 pm

I totally agree with you on this one. Sadly though, some etiquettes take long to die down and it is a shame for those that get caught up in the nets of the time period. Maybe there is a voice of reason out there. Let us hope so.

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Anonymoussays: November 29, 2010 at 8:38 pm

I find this article quite disturbing to be perfectly honest.

"Vision 2015" is about getting equal training for all graduates (time wise) so it will then be easier to start fighting for a national scope of practice, and then have an easier time with hospital privileging and board certification.

It is a coalition between the CPME and the colleges to try and work together to ensure that all graduates get a residency. It is not just the task of the APMA to magically make more residency positions appear out of thin air.

There is an ongoing push to create more residency positions and more residencies to accommodate more students, but it is far more complex than that. It takes several years to secure these kinds of positions and no amount of waving the magic wand will hasten the process unfortunately.

The "handoff" doesn't work in some situations. It is expected that a podiatric medical student knows the anatomy of the first MPJ to the point where he or she is aware of the basic techniques in performing a bunion procedure. That is why there is a 1st ray surgery lecture series. A close to graduating student should know the anatomy of the toe and the stages of performing a hammertoe release. There should be a basic knowledge of general medicine to know the basics of how to treat a patient medically. These are all prerequisites to the next stage of learning: A podiatric medicine and surgery residency.

If a student can't relate the anatomy to the procedure academically, then where did the "handoff" fail? I've been training residents for years and also work in an allopathic setting. What you are basically saying is that a general surgery resident shouldn't know to avoid the mesenteric artery when doing belly surgery or what to avoid when removing a gall bladder. The TECHNIQUE of the procedure is learned in residency, but the anatomy and fundamentals SHOULD be well known by then by someone interested in pursuing a career in surgery.

If we REALLY want to graduate residents who are ready to practice, the CPME should start devoting a lot more time during residency to practice management, billing and coding. Where is that in the residency curriculum? It is up to some of us as concerned directors and attendings to take up the mantle and teach these residents this stuff. Sure you can do a triple arthrodesis but do you know how to code it correctly so you'll get PAID? Many years ago, this was not a consideration, but these days if you want to eat and pay your loans back, you better know how to bill for your services or you will starve. No question about it.

Lastly, to call any residency director selfish is a real slap in the face. Those of us that devote much of our time to training the next generation of podiatric surgeons usually do it on a volunteer basis and it is not an easy thing to manage. Running a residency is an exhausting and generally rather thankless endeavor. Most who do this ask for no accolades and rarely get them anyway. The most that is generally received is a "thank you" from some of the residents that truly understand and appreciate the sacrifices that are made by those in that position. Most just walk out when their time is up. That is also part of the shortage issues. How many directors just plain burn out and give up when there is no one left to pick up the program? I wonder.

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Anonymoussays: November 30, 2010 at 12:41 pm

Thank you for the dialogue! Let's get talking or nothing will happen.

Blogger 5:11 p.m., I agree that it is sad. Change happens at a crippled snail's pace. You are so correct.

To Blogger 8:11 p.m., I appreciate your comments and your passion. I especially take issue with your comment that "Vision 2015" is about getting equal training for all graduates (time wise).

If that were the case, we could just fill five years, the same length as an ortho residency, with gibberish and be done with it. I know that is not your intent but I'm making a point by taking it to the extreme. What we fill the three years with is what I am concerned about.

I see Vision 2015 as TRULY separate but equal. What did we call it at the summit, "similitude"? The students in school today get an incredible amount of material that we did not just 20 years ago, much less 40 years ago. They learn about the reproductive system in detail, the endocrine system, renal, neuro in depths that we never dreamed of. The knowledge base is so much broader.

A case in point. At teaching rounds this morning at the college where I teach – Western College of Podiatric Medicine – the wrap-up was done on a patient who was presented last week. The patient has cerebral palsy with a longstanding foot/ankle deformity bilateral. In discussing what needs to be done for the patient, a possible undetected cerebral vascular accident was picked up that was previously undiscovered by the neurologist. Why did the podiatry team pick it up? Because they worked up the patient from head to toe, not ankle to toe, and they are trained to do so. That is the education they are getting these days.

It takes time to get that education. It takes four years in med school. In my personal opinion, and it is my personal opinion only, med school should not be spent as a review session for a residency interview. It should be spent learning and not doing the residency program’s job.

You are right. I should not have called residency directors selfish. Some 90 percent are not. And those 90 percent are probably exhausted too because they are working long hours. I could have better phrased my point by saying they are spending their time doing the wrong things.

But hey, you SHOULD be getting PAID! Why aren’t you? Hasn’t the CPME site team made that a strong recommendation? Didn’t that help? I would like to know.

And YES, YES, YES, you are correct Blogger 8:11 p.m.. If you want to eat and pay your loans back, you had better know how to bill for your services or you will indeed starve. Our students were shocked yesterday to learn that they would make more money staying in their office doing procedures with 10-day global periods than soul satisfying surgery at the hospital with a 90-day global. But that is even IF THEY DO BILL IT CORRECTLY?! Life just doesn’t seem fair sometimes, does it?

Thank you for your passionate reply and your service.

Kathleen Satterfield, DPM, FACFAOM

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Anonymoussays: November 30, 2010 at 2:38 pm

I'm poster "8:11".

You are comparing apples and oranges with ortho residencies. You don't mention that ortho foot and ankle fellowships are 6 months long and most get trained by podiatrists (over 80% according to the AMA). Most ortho residents never touch a foot or ankle unless it is trauma related. I don't see how your comparison applies.

Your example of the CP patient is a valid one. We are the foot and ankle experts, but that also means that we need to be acutely aware of the systemic issues that affect foot and ankle pathology. Not a week goes by where this isn't applied in the private practice setting and truly separates the "meh" practitioners from the outstanding ones.

Podiatry school is not a preparation for residency interviews. It is a preparation for private practice AFTER a good residency. The way the interviews are done is for a reason. I've been an interviewer and it amazes me how sometimes the brightest students can't explain their way out of a paper bag when confronted with a real life situation.

It is the integration of the knowledge that is being ascertained. I agree that full integration takes years of residency and practice, but as an interviewer, I'm looking for someone who can present information in a concise way and deliver the semblance of a plan of action treatment wise. Students should know some basic information but if they can't get it out of their head, my job as an educator becomes that much harder. Not impossible, just harder.

In some residencies (I'm not naming names), the attendings are more committed and the CPME has no stipulations for this. Also, the CPME can make any recommendations as far as paying the director they want but I hardly think the CPME will pull accreditation because the sponsoring institution doesn't pay the director. In fact, I know this to be true.

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Anonymoussays: December 1, 2010 at 4:59 pm

Blogger 8:11 p.m.! I was agreeing with you there for a little bit but then you wrote the following words: "The way the interviews are done is for a reason."

Come on! Picking up BB pellets with chopsticks while explaining ankle fracture classifications? That tells me nothing except that this person can eat Chinese food proficiently with their other hand - not what a great doctor he or she is going to be!

I understand that you are "looking for someone who can present information in a concise way and deliver the semblance of a plan of action treatment-wise." That is why the newer schools no longer teach via the lecture system and have turned to case-based learning or problem-based learning. I agree with you that if you "can't get it (knowledge) out of their head, my job as an educator becomes that much harder. Not impossible, just harder."

Where we differ though is that it is my job as a college educator to put that knowledge in their heads, and a whole lot more knowledge than there was 20 or 30 years ago, and I think it is your job as a residency educator to teach them how to do surgery - not mine.

I'm not saying you feel like this but some residency directors do. Some feel students should come out of school already proficient at doing some surgeries. I don't have time to teach them that anymore and neither do my colleagues here. We are too busy teaching them what the modern day curriculum prescribes - a full medical education like the MD and DO curriculum.

I am saying it is the residency program's job to teach them surgery now, unlike what it was 20 years ago when they didn't have to have a residency program. Maybe I didn't say it well the first time and was misunderstood?

Kathleen Satterfield, DPM, FACFAOM

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Anonymoussays: December 2, 2010 at 12:45 pm

Blogger "8:11" here again,

LOL, I know what you mean with the BB pellets and chopsticks and some of the other ridiculous stuff some programs make their applicants do. I walked out of a few of those as a student, and NEVER expect this of anyone I help interview or teach as externs when they come to our program.

I also agree that as a residency educator it is my job to teach residents how to DO surgery, BUT if they don't learn the fundamentals during their tenure in Podiatry School, it is not my job to teach them the basic knowledge they should have graduated with. If a resident can't tell me the difference between the Achilles Tendon and the PTT in the OR (which happened a few times btw), the "handoff" didn't work.

It is the critical thinking I'm after AND the manual dexterity, which a surgeon needs both of in spades if he or she really wants to excel. How would you test for manual dexterity skills in an unobtrusive way during an interview for becoming a surgeon?

As an aside, my brother interviewed for a residency in Plastics way back when (he is an MD) and they asked him to do hand ties while wearing surgical gloves coated in vaseline. We are not the only specialty that have these types of interviews. I was thinking of having them play Halo but this isn't fair to those that aren't video game addicts like me =).

Also as you pointed out, there is much more to learn academically now than 20 to 30 years ago, just like there is much more to teach surgically now then there was 20 to 30 years ago. We are all in the same boat and on the same team. Let's just work together to the common goal of graduating the finest podiatric physicians (academically, medically and surgically) any generation has ever seen. We have the tools and the students.

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