As a residency director, I am interested in discussions on either social media or podiatric forums about residency training. Recently, discussions about the importance of a wound care rotation in residency have garnered some debate. Most of those participating in the debate favored the wound care rotation with the primary argument against adding the rotation centered on residents being in surgery as much as possible.1
While the advancement of the podiatric profession over my 30-year career has been multifaceted, a leading factor was the role of podiatry in wound care. Leaders in diabetic foot care like Lawrence Harkless, DPM, David Armstrong, DPM, MD, PhD, and Lawrence Lavery, DPM, MPH, just to name a few, propelled diabetic limb salvage into the forefront of medicine and simultaneously advanced the podiatric profession as well.
The Council on Podiatric Medical Education (CPME) governing document for podiatric residencies is CPME 320. The document lists wound care under medical subspecialties with CPME 320 requiring at least two of the following rotations: dermatology, endocrinology, neurology, pain management, physical medicine and rehabilitation, rheumatology, wound care, burn unit, intensive/critical care unit, pediatrics and geriatrics.2 I can make an argument for any of these rotations as part of the foundation for a comprehensive educational experience.
While reconstructive surgery is probably the primary focus of my career, I worked in a wound care center for several years and continue to work with a diabetic limb salvage program in Haiti. I understand both sides of the wound care rotation argument. Every residency program is different but the discussion is more nuanced than it appears.
In regard to the residency program that I direct at St. Vincent Hospital in Indianapolis, it includes a two-week wound care rotation as part of the off-podiatric service rotations. The program’s inpatient service consists of numerous patients with wounds and infections, and the residents receive extensive education by the attending physicians in the inpatient management of these conditions. Many of these inpatients’ follow-up care occurs in the hospital podiatric clinic so the residents participate in the continuum of care.
Many of the surgeries taking place on the main hospital campus are related to inpatient care. Additionally, one attending working out of the hospital wound clinic does the majority of his wound cases on campus and another attending’s practice consists of a high number of Charcot reconstruction cases, often with various flaps. I do not know the percentage of surgeries related to diabetic limb salvage for the program but the range is probably 20 to 25 percent. For example, one of the third-year residents to date has logged 1,125 procedures, which may have included approximately 280 diabetic limb salvage cases.
My point is that resident education in diabetic limb salvage is more than just a two- or four-week wound care rotation. It is an ongoing educational process throughout the three years. I will acknowledge the variance in program caseloads with some being more diabetic limb salvage-centric than others. I think our program is well balanced and provides a realistic example of the nuanced nature of diabetic limb salvage education.
Another consideration is the journal club/lecture component of the educational process. A balanced educational program will consist of several diabetic limb salvage articles and lectures, inherent to the published literature on the lower extremity. On the first Tuesday of the month, we have morbidity and mortality conferences, often consisting of diabetic limb salvage cases. Even the program academia consists of multiple opportunities for education in diabetic limb salvage.
Should podiatric residency programs have a formal wound care rotation? I think they should, hence the rotation at our program. However, there is more to it than just a two- or four-week rotation. I believe the incorporation of diabetic limb salvage is vital to any well-rounded residency program.
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.
- https://podiatrym.com/search3.cfm?id=126899. Accessed February 25, 2020.
- Council on podiatric medical education. Standards and requirements for approval of podiatric medicine and surgery residencies. Available at: https://www.cpme.org/files/CPME/CPME%20320%20Updated%20June%202018.pdf . Accessed February 24, 2020.
I totally agree with Dr DeHeer. This is a critical element for our place in the evolving world of healthcare and the value based administration of such care. The DPM should be poised to be the quarterback, leading the management of these complex wound patients.