Why Fellowships Are Necessary In Podiatric Foot And Ankle Surgery

Christopher F. Hyer DPM FACFAS

Fellowship training is a bit controversial within podiatric surgery. Some see it as unnecessary and redundant. Others feel it marginalizes the role of residency training. I submit that both opinions are wrong and shortsighted. Let’s look outside of podiatry and review the role of fellowship training.

A one- or two-year fellowship is now standard in most allopathic and osteopathic surgical sub-specialty training. This additional year focuses and hones skills used in a specialty setting, often combining operative, research and practice management experiences. Typically, the operative volume and diversity is on par with what would take years of general training to gain. In addition, those at fellowship centers often are performing complex reconstructive and revision cases as well as developing new, cutting-edge techniques.

Foot and ankle surgery continues to evolve, encompassing more complex surgeries and reconstructions as well as more advanced technologies. Consider the breadth and complexity of what is now performed, from total ankle replacements (TARs) and circular external fixation with limb deformity correction to Charcot limb salvage surgery and cartilage replacement techniques. These require advanced training techniques with high volume exposure to achieve mastery. Specialized centers with areas of concentration allow the fellows to cater their training to specific interests.

If we look to the orthopedic model, the year of fellowship training is not merely an additional year of residency, but instead a specific focus on sub-specialization in the hand, foot and ankle, spine, total joint, etc. This year is structured with hands-on training, research and education and mentoring to advance the physician through this final stage in education. These fellowship-trained surgeons become active members in their respective specialty societies and carry forward and disseminate their training and expertise.

Fellowships have been available to DPMs for several years now but in limited numbers. In my opinion, these numbers are expanding in answer to an increasing demand for this level of specialized training from the general medical community.

If anyone has interest in completing a fellowship after residency training, I would encourage you to review the Web sites for the American Podiatric Medical Association and Council on Podiatric Medical Education (http://www.apma.org/Members/Education/CPMEAccreditation/Fellowships.aspx), and the American College of Foot and Ankle Surgeons (http://www.acfas.org/Students/content.aspx?id=493) for additional information.


If you read Dr. Richie's most current blog (see http://www.podiatrytoday.com/blogged/my-search-new-associate ), I think it may explain why some may have issues with the fellowship trend in our profession.

The examples you give of our allopathic cousins is just. However, those sub-specialties are careers in of themselves. An orthopedist can make a singular career out of doing only shoulder, knee, hip or hand surgery alone. The more medical sub-specialties also have a very distinct niche. Cardiology, Infectious Disease and even the more surgically oriented specialties like Vascular surgery, etc, all lend themselves to singular careers in that sub-specialty.

However, as Dr. Richie pointed out, there are those that do these more specialized podiatric fellowships thinking like the allopaths. However, in private practice, you just can't survive like that in our profession. You have to be comfortable doing everything both in the office and at least the basics in the OR, but many already perform the more complex procedures that are focused on in these fellowships.

I'm all for fellowships. If a resident feels he or she wants to learn more and enhance his or her training, the time to do that is right after residency. What I do question is those that want to do these fellowships to fulfill a niche in a community, even though the niche has been covered for years. I meet new practitioners all the time that did advanced training expecting to walk into a community and be THE guy or gal. That is not a realistic goal. It takes years to foster those types of referral relationships.

I did a lot of podopeds in my residencies and love this aspect of practice. However, if I tried to do only that, I would starve. There is a niche but it can't be the only thing that I try to do.

If you want the extra training, GO FOR IT, but do it for the right reasons. That is to enhance yourself and learn more.

Fellowships are a way for residencies and large medical groups to get a highly trained surgeon at an amazingly low salary. Most I have reviewed pay between $65,000 and $95,000 and require board certification and multiple years of surgical residency.

Other medical professions don't have hands on surgical training during their 3rd and 4th year of medical school and therefore need an extra year to perfect their niche.

I was doing total joint replacements and external fixation my 3rd year of podiatric medical school and perfected my skills during my residency. I feel West Penn and Dr. Gumann's externship programs do a great job demonstrating and preparing students.

I do however agree more input is needed on practice management but see little benefit in doing it during a fellowship.

Dr. Hyer's points are well taken and this type of post-residency training fills gaps that some residency programs have throughout the country. Despite the standardization of the residency models, no two programs are alike in the breadth of training. Sometimes this is state scope speciifc, other times it is faculty dependent. In an era where residency positions are not plentiful, a student may end up having to 'settle' for a program outside the area where he or she desires to practice.

In turn, the resident may not have the exposure to the types of procedures that are demanded by the patient population in the area they choose to practice or may want to join a multi-specialty or orthopaedic practice where the additional training enhances their salary package and/or desirability.

I don't believe DPMs need to seek validation from our MD or DO counterparts by performing a fellowship, but it is this type of additional training that has stimulated physician parity in many hospitals throughout the country. Another example of how fellowship training benefits the resident can be seen in the following situation: A student may take a residency position to train with a surgeon who is known for being an expert in an area that interests him/her but partway into the residency program, the surgeon moves on to another facility leaving a hole in the program that is not perhaps filled by other surgeons. This example does occur in the real world with regularity in recent years and the resident leaving a program and re-starting another is rarely an option.

A fellowship position can fill this void for a resident affected by this hypothetical situation. In any case, having been involved with residency training for over 10 years, I have seen residents graduate who longed for additional exposure to specific areas within our profession that they felt they didn't see enough of.

Regardless of the reason a 3 year trained resident chooses to perform a fellowship, there is no question that the current fellowship positions in this country are preparing our young practitioners better than they ever have before. For this reason alone, our patients will be better off in the future.

Thanks for all the comments. All good points. Lots of angles to discuss with many perspectives.

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