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Are Residencies Really Preparing Doctors For Practice?

The Weil Foot and Ankle Institute is rapidly expanding. We now either own or partner with practices in New York City, Dallas, Maryland, Virginia and Los Angeles in addition to our home base in Chicagoland. With this growth, we are adding podiatric physicians to all of these locations. Accordingly, we have been advertising our positions, receiving résumés, having telephone calls, Skype calls and personal interviews.

I am flabbergasted at how ill prepared many of the applicants are in their ability to secure a job and worse, how they will be able to survive once they get a job. We have graduating residents or recently graduated residents from around the country applying for positions with us so this is not a regional problem.

With the amount of online resources to help guide the creation of these important documents that are the first look at a person, it is surprising that résumés and CVs are so poorly constructed. I have received many that are difficult to read, poorly formatted, not updated, incomplete and just look bad. An introductory letter usually accompanies the résumé/CV. Often the letter appears to be a form letter with an introduction of “to whom it may concern.” This might be okay when sending a resume to a lot of places but in nearly all of the circumstances I am referencing, there has been some connection between the candidate and us prior to receiving this information, and the candidate did not take a few seconds to personalize the letter.

Once I get past the résumé/CV, I will speak to people by phone or preferably Skype or in person. I want to see how well these people can interact and have a discussion. How are they going to represent themselves, their families and ultimately, my organization? Most people actually take the time to look good for this aspect. They will get dressed appropriately and make sure they present themselves well.

I always try to start the conversation with easy to answer questions like, “Tell me about your family,” etc. I want interviewees to relax and not be on edge. I eventually get around to asking about the candidates’ training and try to ascertain where they are in their education process and what they have done to educate themselves. I am most interested in seeing if they have utilized their time during residency well to prepare them for their life after training. Most people think they do not need to learn anything more and that they have learned everything necessary to go into practice and be immediately successful.

I always ask what I think are simple clinical questions. I ask candidates to tell me how they would take care of a patient with obvious plantar fasciitis who has not received any previous care. Not only do some applicants not have an idea of a standard protocol for plantar fasciitis but they really do not know what works and what does not.

Since applicants usually tell me that their residency has completely prepared them for practice, I ask them how to code and bill for the treatments they recommend. Rarely do they have a clue about this aspect of medicine. Usually, they have not been exposed to any billing or coding. At best, they have used a route sheet and have circled the correct billing or coding on a sheet of paper. I ask interviewees how they would bill and code if they started their practice the next week, and usually get a blank stare.

My second question is what candidates would do with someone who wanted surgical correction on a moderate bunion deformity. There is not a right answer to the question but I want to assess how they think and what they would tell the patient. The usual answer I get is a list of two or three options. They usually say they will let the patient decide.

Is that what residency directors are teaching? Treat surgery like a menu at a restaurant and let the patron choose? When pressed, candidates will finally commit to one choice but do not have a solid plan on discussing recovery with the patient. They really do not know how much immobilization is needed for safe recovery and definitely do not know the total time for recovery with the standard answer of complete recovery in six to eight weeks. Asking candidates about billing and coding for a surgical procedure provides the same insight as previously mentioned with respect to heel pain: nothing.

Most candidates had very little exposure to the process of orthotics. They know how to take a mold or scan a foot, but really do not know what kind of device to order, what postings are necessary or what lab they would use. They certainly have not had discussions with patients regarding insurance coverage of orthotics or a cash price. 

All candidates are willing to go out and market themselves. They usually understand that this will have to be part of building their practice. However, when I ask them what they would say to a potential referring physician about why that doctor should refer to them, they really do not have a good answer.

Not that long ago, podiatric residency training became standardized for the better for our profession. Our graduating residents are far better educated in all aspects of medical care than those trained 20 to 30 years ago. Our residents are also exposed to higher-level surgeries across the board and this creates an overall better group of graduates.

However, our residents are not being prepared for real life. How many graduating residents will end up in jobs that provide a full schedule of patients? Very few. How many residents will land jobs that provide all the coding and billing service support? Very few. How many residents will end up with positions that require them to do nothing but surgery? Very few.

Our graduates are coming out with unprecedented loans and debt. They have expectations to pay back that debt and earn a reasonable living. While they may get the technical and academic skills to succeed, are they getting the tools to succeed in real life? In my experience, they are not.

I do not know if most residency attendings feel it is only their responsibility to provide technical and academic training. As a profession, we need to provide more guidance and mentorship to help our graduating residents and young physicians be successful.

At our institution, we have a one-month training program for any new doctor. This training program combines pre-testing on the level of practical knowledge that one has gained through their education. There are classroom sessions teaching clinical guidelines that are evidence-based and standardized for our organization. We provide training in electronic health records as well as coding and billing. New doctors shadow doctors in clinic and in surgery to appreciate how those clinical guidelines are put into use and how to interact with our staff and patients. There are also role-playing sessions to put the new doctors in real life situations so they can practice their “speech.”

We feel like our young doctors have been much more successful since we started this training program. While the training program is time-consuming, it is well worth the long-term benefits for all involved.


Lowell, You are spot on. At my residency program at Phoenixville, the residents spend quite a bit of time in the office with me and the fellow. It is eye opening and typical how poorly prepared nearly all graduating residents are. This became apparent when I began the fellowship program in 2009 and witnessed many of the attributes you mentioned in your blog. Doing hospital rounds, 'running the list', and discussing fluid requirements for patients are just not reality in the daily life of practicing docs like you or I in large orthopedic or podiatric groups. It appears that little to no time is spent discussing the business of the profession and how to succeed in the modern healthcare world we must navigate. It is truly up to us, as residency and fellowship directors, to correct this imbalance in training and spend the time to educate our young doctors to succeed rather than just get by. Many can't tell you when or why they would recommend certain procedures on a patient simply because all they ever did was the procedure itself and never had the opportunity to see the patient prior to scheduling or follow the patient after surgery. It will make all of us better and prevent young doctors from being taken advantage of by prospective employers and the system itself if we require residents to spend the time needed to be better prepared for the 'real world' rather than the false reality of managing inpatients in ad nauseum.

Seems most programs have very inadequate practice exposure and residents are not frequently seeing their patients pre- and post-op. They have good intraoperative ability but the full spectrum of available treatments, especially conservative options, elude them when things don't always go as planned. This is easily remedied as long as you find someone with the wisdom to realize what they don't know and put in the legwork to figure it out. I'd take that person any day over an "experienced" doc, who hasn't picked up a journal or textbook in 20 years.
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