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!
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?
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?
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?