Raising Questions About The Use Of Minimum Activity Volume With CPME 320
The Council on Podiatric Medical Education (CPME) has released proposed revisions to CPME 320, which have sparked quite a bit of discussion on residency training. This author raises concerns about the use of Minimum Activity Volume (MAV) to help establish competency and suggests some alternative options.
The Council on Podiatric Medical Education (CPME) recently released proposed revisions to the CPME publication 320, Standards and Requirements for Approval of Residencies in Podiatric Medicine and Surgery.1 Since the release of these proposed revisions, there has been a flurry of comments and recommendations, including a variety of opinions regarding the requirement for residents to meet Minimum Activity Volume (MAV) for podiatric cases and procedures. My recommendations on this topic assume that the reader has some familiarity with residency training and specifically, the current and proposed CPME publications 320.1,2
Currently, Standard 6.10, Section A of CPME 320 dictates MAVs for surgical procedures and cases for PM&S-24 and PM&S-36 programs (see the table “A Closer Look At Current CPME Requirements For Surgery” below). As the standard says, “MAVs are patient care activity requirements that assure that the resident has been exposed to adequate diversity and volume of patient care. MAVs are not minimum repetitions to achieve competence. For some residents, the minimum repetitions may be higher or lower than the MAVs. It is incumbent upon the director of podiatric medical education and the faculty to assure that the resident has achieved a competency, regardless of the number of repetitions that it takes for the given resident.”2
The CPME’s purpose of including minimum activity volume as a requirement for residents is well intentioned. Its definition of MAVs, specifically the statement that MAVs are not minimum repetitions to achieve competence, is universally accepted. However, this statement does not correlate with the requirement for residents to perform a designated volume of procedures in order to achieve competency. Unfortunately, the CPME has once again included MAVs in its proposed revisions to the CPME publication 320.1
The current values for the MAVs as published in CPME 320 are arbitrary choices with no basis of evidence to justify their inclusion. There is no valid data to support the practice of using a set number of procedures to determine surgical competency that would apply to all residents equally. For example, it is inaccurate to state that a resident is incompetent in digital surgery if he or she has only obtained 99 of the 100 minimum number of digital procedures.
What is more troubling with the MAVs is that numbers for a PM&S-24 program are different than those for a PM&S-36 (see the table “A Closer Look At Current CPME Requirements For Surgery” above). A PM&S-24 resident meets the digital surgery minimum volume at 80 procedures while a PM&S-36 resident needs 100 procedures to reach the minimum. Do PM&S-24 residents learn faster? One must consider this question when reviewing the proposed revisions to the CPME publication 320. The CPME has proposed eliminating the PM&S-24 program. The new, three-year residency model utilizes the same MAVs as the existing PM&S-36. Why didn’t the council use the MAVs for a PM&S-24, adding in the Reconstructive Rearfoot and Ankle (RRA) component? It appears that the CPME has determined that the present PM&S-24 MAVs are too low, which suggests that PM&S-24 graduates are incompetent in surgery. What data did CPME base this decision on? Should we rescind certificates from PM&S-24 graduates?
VSCDO: An Alternative Proposal To Minimum Activity Volume
I propose that we modify the method by which we determine surgical competency by employing Verification of Surgical Competency through Direct Observation (VSCDO). Here are some key components to implementing the VSCDO.