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Where Is The Data On Residency Education Standards?

The proposed changes to the Council on Podiatric Medical Education (CPME) Document 320 will profoundly affect the entire profession, not just podiatric surgical residencies. Final changes must move the podiatric physicians closer to the ultimate goal of equivalency to our allopathic and osteopathic colleagues. Collaboration with key stakeholders to critically debate and modify this significant manuscript must occur with the strategic plan of aligning with the Accreditation Council for Graduate Medical Education’s (ACGME) policies and procedures for graduate medical education training. 

One proposed modification causing much consternation within the podiatric profession is reducing the biomechanical exam minimal activity volume (MAV) from 75 cases to 50 cases.1 The essential role of biomechanics is the basis of treating the underlying etiology (the “why”) of any lower extremity pathology (the “what”). I require the residents whom I serve as residency director at Ascension St. Vincent Hospital in Indianapolis to perform a minimum of 125 biomechanical exams, 50 more than required by CPME.

A significant difference between ACGME and CPME is competencies versus MAVs. The ACGME moved away from MAVs to clinical competencies. For example, orthopedic surgeons must perform only 30 knee arthroscopies and hip fractures to meet MAVs for these categories.2 These procedures are foundational for any type of orthopedic practice. The difference from CPME’s MAV of 60 first ray procedures, foundational procedures for most podiatric physicians, demonstrates the difference in resident education approach between the two organizations.3 The residency director and residency committee must certify the resident achieved core competencies, not that the resident just met MAVs.2

According to CPME 320, resident activity for each logged procedure as first assist or second assist require direct supervision by an attending physician for both biomechanical exams and surgical cases.3

Surgery is one thing but direct attending observation of a resident doing a full biomechanical exam is another. Regarding biomechanical cases, CPME 320 states the following:

“This activity includes direct participation of the resident in the diagnosis, evaluation, and treatment of diseases, disorders, and injuries of the foot, ankle, and their governing and related structures by biomechanical means. These experiences include, but are not limited to, performing comprehensive lower extremity biomechanical examinations and gait analyses, comprehending the processes related to these examinations, and understanding the techniques and interpretations of gait evaluations of neurologic and pathomechanical disorders.”3

How do residents best learn surgical biomechanics and functional biomechanics? Is the current methodology the optimal learning technique? Why 75 biomechanical cases? Why do I require 125 biomechanical cases? Why aren’t 50 biomechanical cases enough? This topic has no evidence of support for any of these questions. It seems as if the profession is taking a paternalistic approach to this much-discussed topic. Maybe we should be asking our podiatric surgical residents what they think. Perhaps we should follow the lead of the ACGME. 

Our residency program decided to survey podiatric surgical residents about the topic of biomechanics. The plan is to assimilate the data and publish the results to potentially provide some insight to guide the thought process.

Accordingly, please disseminate the survey (https://www.surveymonkey.com/r/ResidencyBiomechanics) to residency directors and residents. Obtaining viable data is essential to provide useful information to key stakeholders as they consider the proposed CPME 320 modifications. The clock is ticking on this topic as CPME moves forward to incorporate these residency education changes permanently.

Dr. DeHeer is the Residency Director of the St. Vincent Hospital Podiatry Program in Indianapolis. He is a Fellow of the American College of Foot and Ankle Surgeons, a Fellow of the American Society of Podiatric Surgeons, a Fellow of the American College of Foot and Ankle Pediatrics, a Fellow of the Royal College of Physicians and Surgeons of Glasgow, and a Diplomate of the American Board of Podiatric Surgery.

References 

1. Council on Podiatric Medical Education. CPME 320 and 330 revision in progress. Available at: https://www.cpme.org/residencies/content.cfm?ItemNumber=29729&navItemNumber=15094 . Accessed December 1, 2020.

2. Holmboe ES, Edgar L, Hamastra S. The Milestones Guidebook. 2016 ed. 3-16. Available at: https://www.acgme.org/Portals/0/MilestonesGuidebook.pdf. Accessed October 1, 2019.

3. Council on Podiatric Medical Education. Standards and requirements for approval of podiatric medicine and surgery residencies. Available at: https://www.cpme.org/files/CPME%20320%20Updated%20May%202020%20%2D%20DP%20Edit%2012%2D2020%5F1608320338618%5F5.pdf . Published July 2018. Accessed January 19, 2021.

Additional References

4. Shapiro J. Orthopedic versus podiatry MAVs. Practice Perfect. Available at: https://podiatry.com/news/346/Practice-Perfect-700-Orthopedics-Versus-Podiatry-MAVs . Published March 30, 2020. Accessed January 19, 2021.

Comments

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One of the problems with the requirement for performing biomechanical exams is the lack of clarity for how the information is interpreted and implemented into a treatment plan for the patient. Are these exams performed only to implement foot orthotic therapy? Are these exams ever conducted before major reconstructive flatfoot surgery? If the resident performs an exam, what is their role in participating in the treatment , and how is their performance evaluated? Shouldn't the biomechanics and pathomechanics be an essential component of every pre-surgical work-up? Instead of debating numbers, we should provide more clarity to these requirements.

Thank you for the comment, Doug. I completely agree with your comments. The setting the resident is seeing the patient complicates matters. In my private clinic, the patient is there to see me so as long as the resident and I agree on things all is fine. If we disagree, ultimately it is my responsibility to provide care and I am held responsible. In my experience as a residency director and a faculty surgeon for two different residencies, much of this learning centers around pre-op, intra-op, post-op, and clinic discussions with the resident to explain my thought process and question the learner on their thought process. It is certainly challenging and I appreciate your thoughts on the topic.

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