Match season is almost upon us. The fourth year of podiatry school is a very busy time. Students spend one month with programs that they may wish to attend for residency. In that short period of time, they need to decide if they like the program, decide if the program provides appropriate training and determine whether they are a good fit for that program. The unfortunate part is that these decisions are at that stage when one really does not know what to look for in a residency. There are many things that I feel are important from an educational standpoint. Not only are these things important for fourth-year students to assess but staff and attendings should consider gauging these factors in their residency programs as well.
Interpersonal dynamics. A major defining characteristic of a program is how the attendings work with the residents. There are many programs where the residents’ involvement is part of the job description for attending physicians. I find that those who view resident training as an elective option rather than an occupational requirement tend to be much more appreciative of their assistance. When teaching residents is part of one’s job description, the process becomes less and less personal as time goes on. This, in my observation, eventually devolves into a sort of jaded dependence on resident involvement.
This is often noticeable in surgical cases. Every residency has those few attendings that barely let us suture, let alone actively assist in cases. This lack of participation offers little educational value aside from being able to log the case. Attendings that are motivated and enjoy teaching residents are an invaluable resource in a resident’s training.
Another equally important aspect is how the residents interact with each other. Many programs still operate with a very strict hierarchy. This is evident in cases in which first-year residents are treated as inferior, second-year residents are the workforce of covering cases and clinics and the third-year residents run the show. This style of operation leaves residents with feelings of division, distrust and almost regret. Coming from a program that operates more as a collective than a hierarchy, I can honestly say that we accomplish more and function more efficiently.
For instance, at our program, for each level of boards that we take, the residents that just took the exam sit down with everyone else and go over all the topics on which they were tested. This way, we can review more appropriately and everyone can benefit. There is a residency program in my area that still has such a militaristic hierarchical structure that it does not encourage residents to pass down any information after taking board exams. The first-year residents were not even aware when the third-year residents took American Board of Foot and Ankle Surgery (ABFAS) board qualification exams last year and did not receive any insight as to what would be important to study for the National Board of Podiatric Medical Examiners (NBPME) Part III boards this year.
I cannot understand why it is okay for a group of people that work with each other every day to not work together toward the same goal. Working as a unit allows everyone to expand on their strengths and improve on their weaknesses. There may be a topic that I am weak on but one of my first-year residents may be more well-read than I on the subject. It is not a matter of ego. It is a matter of humility.
Educational culture. Another strange issue I have seen at many residency programs is where questions are not met with answers but merely the line; “Hhy don’t you go look it up?” This principle leads to all of us at one point in time acting like we know a subject when we really don’t and not taking anything away from the experience.If someone is asking you a question, he or she is trusting you to answer and share your knowledge. Telling him or her to go and look it up shows that his or her education is not worth your time. It sends a bad message with no overall educational gain.
One last resident interaction issue I see very commonly is a subtle disrespect toward students. At many residency programs, it starts with not even using one’s name and simply referring to him or her as “student,” even when this person is standing one foot away. This perpetuates the notion that the residents are better than the students. Many times, this also insinuates that the student in question is more of a burden than a guest. At our program, we treat our students as guests because that is what they are. They are guests to the program, viewing our daily activities and searching for their future residency spot. I find no reason to belittle them for the simple fact that they are not as far along in the educational timeline as myself. Often times, the students are older than the resident and this can lead to an additional layer of rudeness. We were all students at some point. I think that the residents play a huge role in how a program is perceived by students. Remember that word of mouth is more powerful than anything. If you treat your students in an inferior manner, they will tell everyone they know. This will subsequently affect the perception of your residency program in the future.
Rotation structure. Every residency program has a unique curriculum structure. It appears that the majority of programs have residents complete their non-podiatric rotations in the first year. This is a very common structure. I personally do not necessarily agree with it. We are in school to be a podiatrist. I am not in school to become an internist, an anesthesiologist or a rheumatologist. Spending one’s entire first year off podiatric service essentially turns our three-year surgery residency into a two-year residency. I do understand that we are struggling for parity with our MD and DO counterparts, but I feel that we are doing this at a small cost when it comes to education.
This brings me to the next point. In many residency programs, there are procedure restrictions by year. The most prevalent example is that first-year residents only get soft tissue cases, which are mostly incision and drainage procedures. Second-year residents then get soft tissue and other osseous procedures. Third-year residents gain the privilege of working on rearfoot procedures. This seems extremely inefficient. Essentially, when you get to be a third-year residents, you will just now start doing rearfoot cases. Additionally, you won’t do any smaller cases until you get out of residency. This does not seem like a good idea to me.
Also, from a board preparation standpoint, it is better to gain experience with everything for all three years, especially with successful passing of in-training exams during the third year of residency counting as board qualification for the American Board of Foot and Ankle Surgery (ABFAS).
Work schedules. This is where residency programs differ. Based on my experience as a student as well as conversations with current students and other residents. I find that the differences in residency programs can be pivotal in board pass rates as well as job acquisition. Academic and physical work schedules have a major impact on this.
On average, most podiatric residencies have residents round around 5 a.m. and are instructed to stay at the hospital until approximately 6 p.m. In most cases, this is a gracious underestimation. This has the average resident working about 70 hours a week. I have a hard time understanding why these hours are necessary. In many cases, the residents are there until almost 8 p.m. doing things that could be done during normal business hours. There is this expectation to be extremely busy for all three years of residency. I do not think that adds to our educational experience.
In my observation, most private practitioners end up having a fairly reasonable schedule. Every attending at our program is in private practice. I can tell you that not one of them follows that schedule throughout his or her normal work week. If we as residents can be efficient and get our work done from the hours of 8 a.m. to 4 or 5 p.m., that is reasonable. Overworking causes us to learn less. These hours leave very little time for studying. They also leave very little time for extended learning outside of rounding in clinic. I can tell you from experience that having time during the day to sit down and read a chapter of a textbook or research a topic has been invaluable to my success. Many of my friends are residents and feel they literally have no time to study for boards. They barely get the day off when actually taking the exam. Some still have to show up to work after they finish. I think this is one major thing that needs revamping in our residency programs.
Academics. The academic program varies widely by residency. But all in all, there are only so many things you can cover in the foot and ankle. In my experience, it is not what you cover but how you cover it.
Let me give you an example. When I was a student, I spent a month in a residency program that had a 5:30 a.m. McGlamry review in which residents presented a chapter of material. Let me tell you one thing. At 5:30 a.m., nobody is learning anything. This was an absolute waste of time that had no educational value.
Contrast that with my current schedule where we have an academic meeting on Mondays at 7:30 a.m. and a second academics meeting Wednesdays at lunch for all who are covering cases. We also have ample time during the week for self-study. This has been very effective in terms of our ABFAS board pass rates. People will learn more when given the opportunity to learn rather than then when education is forced upon them.
Career preparation. This may be the most important aspect of residency. After all, what is the point of all of this if you cannot get a job. There needs to be some sort of formal education on the differences between hospital-based and private practice careers. They are structured very differently and have their own pros and cons. These pros and cons are very important to understand before beginning a career search.
The basics of practice management are also important. A basic understanding of concepts like overhead management can make someone very marketable to a practice. Billing and coding can be difficult concepts to master. Inquiring about one’s experience with this topic seems to be one of the most common questions asked by potential employers. This is also one of the least discussed concepts across the board during residency training. We did not go into podiatry just to make money but we need to know how to make a decent living. These career lessons are invaluable and need to be taught before residents are sent out into the world.
Residency training is extremely important. It is up to the faculty of each program to assess their residents’ quality of education as well as their quality of life. Those three years set the tone for a career. I think we need to adapt and improve many of our educational methods to keep our profession moving in the right direction.
Dr. Bishop is a third-year resident at Alliance Community Hospital in Alliance, OH.