Although podiatry residents have opportunities for significant advancement of their skills, they also face daunting challenges that may not be receiving adequate attention in residency programs. Drawing upon their experience, these authors suggest a number of areas for improvement in residency programs, including research opportunities, business education and coaching on leadership skills.
Future residents and program directors in podiatric residency training programs will face certain challenges as healthcare undergoes profound changes. How they manage these challenges in a rapidly changing healthcare environment will be critical.
Those programs wishing to remain viable must provide residents with the opportunity to adapt and become successful in the future. We will have to provide our residents with the knowledge and skill to work their way through these new challenges.
Not so long ago, residents prepared for the business of private practice by memorizing a few ICD-9 and CPT codes. Virtually every graduating podiatric resident would go into private practice. Some would go into solo practice while others might join a group.
However, this is no longer the case. Although our graduates continue to enter group practice, very few go it alone. Additionally, our graduating residents now take positions with “super groups,” multispecialty groups, hospitals or healthcare systems, academic centers, orthopedic groups, vascular surgery groups, wound care centers, etc. Furthermore, some of our graduates pursue fellowship training.
The opportunities for our graduates continue to grow. These opportunities have made entering the workforce much more complex. During my early years as a program director, a resident would ask me to “take a look” at a five-page contract on her behalf. Now residents ask me if I can recommend a competent healthcare attorney to review a 50-page document.
I have come to realize that our residents are unprepared to navigate their way through discussions regarding contract negotiation. Our residents have limited exposure to business and practice management. They do not understand compensation packages, bonus structure, retirement plans, non-compete clauses, etc.
Several years ago, a graduating resident would discuss her contract with the physician with whom she was joining practice. Now residents are negotiating with a MBA health executive who represents the hospital, group, practice, etc. Our residents just do not speak the same language. This can result in frustration, uncertainty and poor decision making, not to mention adversely affecting their financial well-being.
Maybe we need to consider some type of deliberate business training to help residents through the difficult and complex process of securing employment upon graduation. Whereas our training programs have made tremendous strides in clinical and surgical training, we have been somewhat lacking in preparing our graduates for business.
We need to help our graduating residents become financially successful. They will have huge loans to repay, families to support and be practicing in a more competitive and complex healthcare environment. Some formal business education would provide a higher comfort level and greater confidence for our graduating residents as they move forward into practice. This might also expose our residents to other opportunities such as healthcare administration. Furthermore, business education might better prepare our graduates to take a meaningful role within the medical community in promoting quality and safety, and in containing healthcare costs.
Advances in podiatric medicine and surgery are dependent on the creativity and innovation of individuals who have the foresight and commitment to investigate, develop and implement new technologies to improve patient care. We need to have research and research training in podiatric residency training programs. Podiatric residents should be exposed during their clinical training to the process of creativity and innovation that is the basis of research.
Research is the lifeblood of every scientific organization and ours is no exception. Residents should participate in research, not necessarily to become researchers or academic practitioners, but rather to foster critical thinking. Research is the tool that validates who we are and keeps us relevant in the healthcare conversation. This is especially true as the healthcare environment becomes more competitive.
Barske and Baumhauer recently reviewed literature published on the foot and ankle.1 The authors focused on 117 articles in seven North American podiatric and orthopedic journals, including the Journal of the American Podiatric Medical Association and the Journal of Foot and Ankle Surgery. They concluded that Foot and Ankle International, an orthopedic journal, published higher quality studies with a higher level of evidence in comparison to podiatry journals. Furthermore, they state that MDs produced the majority of published clinical foot and ankle research.
Baumhauer is a foot and ankle orthopedist and the article, which was published in Foot and Ankle International, is somewhat self-serving. Nonetheless, the message is clear. Our competitors clearly understand the value and importance of research.
The demand for maximum quality care in combination with the need for prudent use of resources has increased pressure on physicians to ensure that clinical practice is based on sound evidence. Therapeutic advances, an exponentially increasing volume of research data and increasing expectations from patients and third-party payers to provide the best possible care place high demands on physicians to provide care that is based on the best current evidence. Podiatry research needs to contribute to this growing body of evidence. This should begin in our residency training programs.
Our profession needs an organization that can fund seed and starter grants for pilot experiments exclusively for residency programs. Although the American College of Foot and Ankle Surgeons (ACFAS) has a program somewhat like this, the grant money is open to all ACFAS members.
Our biggest dilemma in developing a research culture is limited resources. Political, socioeconomic and cultural changes have increased financial pressures on those hospitals that support graduate medical education.
Many barriers exist. With the rising cost of doing business, we often focus on increasing our clinical productivity to help offset rising costs and declining reimbursement. Many of us involved in residency education just do not have time to dedicate solely to research. This in turn affects our mentorship and modeling relative to research. We currently provide dedicated research time to our second- and third-year residents to focus exclusively on research. This has worked out rather well.
Furthermore, we have formalized our research process to make it more conducive for our residents to participate in research. Those programs located within larger academic health centers can utilize resources provided through the institutional review boards, graduate medical education committees or research departments.
Residents enter their training programs with excitement and enthusiasm. All of them want to participate and contribute to the research process. However, they need direction and structure, which the program director and faculty should ultimately provide. Without direction, their enthusiasm will soon wane.
We need to increase the number of formal DPM and PhD programs, such as the combined degree program at Rosalind Franklin University. These combined degree programs educate physician-scientists who will be able to conduct high-level research, apply for National Institutes of Health grants, etc. We have several PhDs who have later become DPMs and vice-versa.
However, we need a program that students can enter and consider a career in research. We need to promote and encourage these types of programs, not to mention making them affordable. We also need to guarantee these graduates obtain residency positions that allow them an opportunity to conduct quality research.
The future leaders of our profession will begin their leadership training during their residency. I am sure there are certain individuals who are “born to lead” and leadership qualities seem to develop naturally for them.
However, there are very few people who fit this category. Although most residents have some baseline skills, some are naturally better at it than others. People can learn, develop and hone leadership skills. Unfortunately, our residents do not really have time to study leadership skills and it is difficult to find time to include leadership training in our curriculum. The traditional leadership mode (hierarchical, intimidating, etc.) is no longer considered a successful approach and is not tolerated in a clinical setting.
Rather, our residents must understand the importance of leadership qualities such as fairness, consistency and predictability. They must learn how successful leaders seek input, spread authority, treat people with respect, do not dictate and challenge those around them. Our future American Podiatric Medical Association leaders and state association presidents will be trained through our residency programs. The future American Board of Podiatric Surgery, ACFAS, and American Board of Podiatric Orthopedics and Primary Podiatric Medicine leaders will also come through our training programs. We will also be training future program directors and hospital administrators, not to mention community leaders.
Maybe we should consider formal leadership training in our residency programs. This could be something as simple as a lecture series or required reading. We certainly have the opportunity to serve as role models for our residents but is that enough? Maybe our residents need to understand that they are preparing for something more than just practice. They need to develop leadership skills that will serve them, their families, their communities and their professional development for the rest of their lives.
A major issue that will eventually affect the entire profession is our student indebtedness. Medical students are graduating with an average indebtedness of $180,000. This is before residency training and possible student loan forbearance.
Residents need education on ways to develop a strategic approach to managing their debt. Residents must learn appropriate tax saving ways to apply for loan deferments, how to lock into reasonable rates of repayment, how to explore loan forgiveness programs offered by the federal government or individual states for public service, and how to search for new programs being offered by the government.
For example, a new income-based repayment plan is under consideration that mixes loan forgiveness and a repayment plan according to your income. However, residents cannot be expected to gain this knowledge on their own. They have a large number of clinical and academic responsibilities that consume their time.
We need to consider implementing an educational program during residency training to help them navigate through this cumbersome process in a timely manner. This could be a standard program offered through the Council on Teaching Hospitals (COTH) or some other similar organization. Otherwise, our graduating residents risk making uneducated financial decisions that will adversely affect their professional lives in later years.
Our residency programs have made significant progress in clinical training. The entire profession has benefited from these advances in residency training. The future is bright for our graduates as they are better prepared and have greater employment opportunities than any previous generation of graduates from our residency training programs.
However, they will face challenges in a competitive healthcare environment that can adversely affect their professional growth and the continued growth of podiatry. We need to consider implementing programs that provide greater business acumen, deliberately provide leadership skills, emphasize the need for research and provide direction and advice in dealing with student indebtedness. These changes will keep our residency training programs thriving in the future.
Dr. Catanzariti is the Director of Residency Training in the Division of Foot and Ankle Surgery at The Western Pennsylvania Hospital in Pittsburgh. He is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Mendicino is affiliated with Pinnacle Orthopedic Associates in Salisbury, N.C. He is a Fellow and Past President of the American College of Foot and Ankle Surgeons.
1. Barske HL, Baumhauer J. Quality of research and level of evidence in foot and ankle publications. Foot Ankle Int. 2012; 33(1):1-6.
For related articles, see “Current Directions In Podiatric Education” in the October 2009 issue of Podiatry Today or “What Does The Future Hold For Podiatric Surgeons?” in the June 2010 issue. For other articles from the archives, visit www.podiatrytoday.com.