Podiatric Medical Articles

[krabmas]

Clinics in pod med and surg this month is Residency Training. If you can gain access this is a really great journal to read to prepare for your interviews and decide what it is you are looking for in a program. I spent a month at UMDNJ and it is one of the best programs I externed at. It may seem as they toot their own horn alot but they really do what they say. Here is the Preface By Dr. Wallace.

Preface
Guest Editor
Any specialty in the medical profession is only as good as its education:
the four years of the professional school and the residency that follows.
Podiatry is no exception. ‘‘The education of the doctor which goes on
after he has his degree is, after all, the most important part of his education’’
[1].
With the above in mind, this issue of Clinics is dedicated to ‘‘Residency
Training.’’ It is the first in this august publication about training the next
generation of podiatric physicians.
The various authors are to be commended for their efforts contained
within. You do not have to be a residency director to find what they compiled
to be worthy of your time to review. Each article is designed to be
short on theory while emphasizing practical steps to accomplish goals.
The articles may just inspire someone to open a new residency program, become
active in a nearby residency, or appreciate what goes into training
a competent podiatrist.
I wish to thank all of the authors, my family, and Ms. Gavenda at Elsevier.
There are two other groups who need mention also. First are those who
painstakingly gave their all to train me. Your efforts have paid off every day
of my career. Second are the residents whom I have been so honored to train. You challenged me to keep up to date and allowed me to step back
and, in turn, be proud of your accomplishments. Thank you!
George F. Wallace, DPM, MBA
Podiatry Service
University Hospital
University of Medicine and Dentistry of New Jersey
150 Bergen Street, G–142, Newark, NJ 07103, USA
E-mail address: [email protected]
Reference
[1] Billings JS. Boston Med Surg J 1894;131:140. In: Manning PR, DeBakey L, editors. Medicine:
preserving the passion in the 21st century. 2nd edition. New York: Springer; 2004:

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[krabmas]

Another ggod read from The Clinics of pod med and surg for pod students to read. It may help you pick the right residency for you. There are a few more articles that I will post over the next few days that are helpful to students when picking a residency. It may even help prospective students pick a podiatry school that will prepare them for the residency that they want.

What Is a Residency? What Is a Resident?

George F. Wallace, DPM, MBA

Podiatry Service, University Hospital–University of Medicine and
Dentistry of New Jersey, 150 Bergen Street, G-142, Newark, NJ 07103, USA


In the early 1960s, Drs. Kildare and Ben Casey were the first house officers
to be depicted in the media. Both were popular figures on television.
Dressed in a white shirt, white pants, and buckskin shoes, they paraded
around the hospital and were involved in many escapades (life and death
scenarios). At that time, a house officer was called an intern.
Fast forward to the early twenty-first century. Now a house officer is
called a resident. Residency is the period after graduating from podiatry
school when a person spends additional years in a hospital learning, for
the most part, surgery and the care of the patient who needs a hospital, albeit
if only as an outpatient. Only hospitals can sponsor a residency program.
Preferably, the hospital is an academic teaching institution. These
have more resources: clinical and didactic as well as a culture that is dedicated
to the teaching of residents. A director of graduate medical education
who oversees an office of the same name is a valuable resource for any residency
director and program.
The Council on Podiatric Medical Education (CPME) accredits each residency
program. The alphabet jargon has led to the residency designations:
Podiatric Medicine and Surgery (PM & S) 24 and 36. Although the numbers
represent the months that are needed for completion, one may take an additional
12 months to complete each.
Upon completion of the PM & S 24, the resident will be competent in
forefoot surgery. With the PM & S 36, he or she will be competent in complex
rearfoot and ankle surgery. It is hoped that these levels enable the resident
to sit for the Primary Podiatric Medical board and either the foot or
the complex rearfoot and ankle board.
Without a residency, there is no entry into the two-board certification
processes. Most states require a residency for licensure. Hospital privileges
are granted based on training (Fig. 1). What Is a Residency? What Is a Resident?
George F. Wallace, DPM, MBA
Podiatry Service, University Hospital–University of Medicine and
Dentistry of New Jersey, 150 Bergen Street, G-142, Newark, NJ 07103, USA
In the early 1960s, Drs. Kildare and Ben Casey were the first house officers
to be depicted in the media. Both were popular figures on television.
Dressed in a white shirt, white pants, and buckskin shoes, they paraded
around the hospital and were involved in many escapades (life and death
scenarios). At that time, a house officer was called an intern.
Fast forward to the early twenty-first century. Now a house officer is
called a resident. Residency is the period after graduating from podiatry
school when a person spends additional years in a hospital learning, for
the most part, surgery and the care of the patient who needs a hospital, albeit
if only as an outpatient. Only hospitals can sponsor a residency program.
Preferably, the hospital is an academic teaching institution. These
have more resources: clinical and didactic as well as a culture that is dedicated
to the teaching of residents. A director of graduate medical education
who oversees an office of the same name is a valuable resource for any residency
director and program.
The Council on Podiatric Medical Education (CPME) accredits each residency
program. The alphabet jargon has led to the residency designations:
Podiatric Medicine and Surgery (PM & S) 24 and 36. Although the numbers
represent the months that are needed for completion, one may take an additional
12 months to complete each.
Upon completion of the PM & S 24, the resident will be competent in
forefoot surgery. With the PM & S 36, he or she will be competent in complex
rearfoot and ankle surgery. It is hoped that these levels enable the resident
to sit for the Primary Podiatric Medical board and either the foot or
the complex rearfoot and ankle board.
Without a residency, there is no entry into the two-board certification
processes. Most states require a residency for licensure. Hospital privileges
are granted based on training (Fig. 1).
E-mail address: [email protected]
0891-8422/07/$ - see front matter  2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.cpm.2006.08.010 podiatric.theclinics.com
Clin Podiatr Med Surg
24 (2007) 1–9
History
The father of the residency program, as we know it today, was Sir William
Osler, MD. He developed the prototype residency complete with bedside
rounds [1]. The various allopathic medical boards recognized the
importance of a residency program, and required one before permitting
the board certification examination to be taken.
The Flexner Report of 1910 established the basic medical school curriculum
that remains, to a degree, to this day. The Selden Report was the podiatric
counterpart.
St. Luke’s and Children’s Medical Center in Philadelphia was the initial
podiatric residency program. The first residents began in 1958 [2]. Residency
programs in this profession now run for at least 2 years. Most are for 3 years,
with a few requiring 4 years for completion.
In 1995, the profession undertook a major structural change in the education
process. Named the Education Enhancement Project (EEP), it was
able to establish parameters (called handoffs) for each stage of the students’
and later practitioners’ education. For example, the podiatric medical
schools were charged with assuring that students who enter a residency program
are competent in certain areas. Likewise, residency programs handed
off a podiatric physician who is competent to enter practice.
The Council on Podiatric Medical Education (CPME) established the
standards against which the residency programs are measured. Representatives
of CPME conduct site visits to assure that the residency programs are
providing the minimal education (didactic and clinical) requirements [3].
A typical rotation schedule is depicted in Box 1. Active participation in all
rotations will lead to richer educational experiences. An active participant
will be afforded opportunities to be hands on instead of just observing.
The more the podiatric resident becomes a ‘‘resident’’ and looses the podiatric
adjective, the greater chance of being a participant in all of the activities
performed by their allopathic counterparts.
Like allopathic medicine, CPME evolved into the competency model in
2003. It stated, ‘‘a residency is a postgraduate educational program conducted
under the control and sponsorship of a hospital or academic health
center. The purpose of a residency is to further develop the competencies of
graduates of colleges and schools of podiatric medicine through clinical and
didactic experiences’’ [3].
Podiatry Medical Residency (PM & S 24/36)
School
State Board
Licensure Hospital Certification
Fig. 1. Podiatric education.
2 WALLACE
Now a residency program is resource based, competency driven, and assessment
validated. A program that is resource based allows the residency
director to develop, within certain parameters, a program that is driven
by the resources that are available at that institution. Competency driven
implies that the resident achieves the competencies that are annotated by
CPME. The skills, attitudes, and knowledge that are gained throughout
the years of training are validated by way of internal and external assessments
[3]. The former include department evaluations; the latter include,
for example, in-training examinations and 360-degree evaluations.
Note that skills, knowledge, and attitudes now will be taught, assessed,
and validated. This represents a new paradigm in residency education. Allopathic
medicine uses similar vehicles for residency education.
The residency program
The setting for any residency program is a hospital that sponsors the program.
There must be sufficient pathology and clinical experiences for any
Box 1. Typical curriculum of Podiatric Medicine and Surgery 36
program as established at University Hospital–University of
Medicine and Dentistry of New Jersey
First year
Internal medicine (2 months)
Medical imaging (1 month)
Pathology (1 month)
Vascular surgery (1 month)
Plastic surgery (1 month)
Emergency room (1 month)
Trauma (1 month)
Podiatric clinic (2 months)
Podiatric surgery (2 months)
Second year
Behavior medicine (1 month)
Podiatric clinic (11 months)
Podiatric surgery (11 months)
Third year
Pediatric orthopedics (1 month)
Sports medicine (1 month)
Podiatric clinic (10 months)
Podiatric surgery (10 months)
WHAT IS A RESIDENCY? WHAT IS A RESIDENT? 3
residents to be trained adequately. CPME has established minimal numbers
in various clinical categories [3].
No residency program can survive without the tireless efforts of a residency
director. This person assumes all of the responsibilities for educating
and validating the residents’ training. Because of the complexity and time
commitment of the director, the sponsoring institution must provide monetary
compensation. Ideally, this is equal to remuneration that is garnered by
the allopathic counterparts. A residency director may find oneself in a situation
that requires conflict resolution. Likewise, the residency director may
need to be ready for almost anything that occurs to, by, or because of a resident.
Negotiating skills may have to be developed and used. The time that is
committed to the residency program is many hours per week, which is divided
among clinical, didactic, and administrative tasks.
Podiatric faculty (attending physicians) complement the residency director.
All act as a team. These individuals are dedicated to providing education
to the residents in any way possible. Education may be in the form
of cases, rounds, or lectures. Supervision is constant. The ability to ask
meaningful, thought-provoking questions (Socratic method) is a part of
the teaching experience. Residents need to be able to think and to apply
their knowledge to clinical settings. The more and diverse experiences that
are encountered, the better the resident. No attending physician should
view residents as mere ‘‘servants’’ who are available for dictating or doing
scut work.
Allopathic faculty are responsible for providing education in the various
rotations that are mandated by CPME. They have to be accepting of podiatric
residency education. The goals, objectives, and evaluations are prepared
in conjunction with the residency director. The best allopathic rotations
are those in which the podiatric residents are treated as any other resident,
with all of the same responsibilities. The podiatric resident should be dedicated
to whatever rotation one is in and not be pulled out for other tasks.
The podiatric and allopathic faculty should participate in education programs
that are dedicated to residency training (ie, educating the educator).
A plethora of sessions in various venues is offered annually for this type of
training. Unquestionably, the faculty, as teachers of adults, are responsible
for imparting didactic, clinical, and technical components of the podiatric
profession.
Residency programs have to be built around traditions. When present,
traditions allow the residency program to function through the years, no
matter the number of residents. An example is having didactic activities every
Wednesday morning at 7:30 AM. The participants know that week in and
week out, come Wednesday mornings at the same time and place, a didactic
experience will take place. This is considered tradition. Numerous examples
can be in place based on each program’s particular needs.
Each year new residents come into the program, some graduate, and
others move into the next year. The new personalities and movement of
4 WALLACE
the others create a unique residency program each year. The residency director
and the faculty have to be aware of this and adapt accordingly. A resident
in the final year, designated as the ‘‘chief resident,’’ keeps the traditions alive.
Residency programs provide an invaluable service: (1) to this profession,
so that it can continue; (2) to the public, which expects any practitioner to
be competent; (3) to the boards, assuring them of applicants meeting their
standards; (4) to the states, which grant licenses to the graduates; (5) to
the hospitals, which will grant surgical privileges to those demonstrating
competency; and, most importantly, (6) to the residents who are hungry
for training at the next level (eg, surgery and other clinical experiences)
that is offered by the sponsoring institution in conjunction with the podiatric
and allopathic faculty.
Finally, what is a good residency program (Box 2)? There is no ranking
by the profession. Unofficially, students may have a way to stack the programs,
but nothing exists on paper. The common denominator of any program
is CPME approval. Without it, the program is on probation, with the
possibility of being closed if deficiencies are not eliminated.
The resident
‘‘You see what you know.’’ - Larry Harkless, DPM
‘‘Surgery is a privilege, not a right.’’ - Donald Green, DPM
‘‘See one, do one, teach one.’’ - Anonymous
A resident is an individual who has graduated from a podiatric medical
school who seeks additional training in a CPME-approved residency program.
The length of the program may be 24 or 36 months. The latter includes
rearfoot and ankle training. Attainment of competency may allow
a resident to stay in the program for an additional 12 months or fractions
thereof.
Synonyms for a resident are a house officer, intern, or PGY. PGY represents
Post Graduate Year and is followed by the year that the resident is in.
For example, a second-year resident would be designated as a PGY-2.
The resident should arrive at the program competent in certain areas, as
promulgated by the EEP and their school. Likewise, the resident graduates
from the program competent in the CPME areas.
In some circles, residents are perceived to be ‘‘cheap labor’’ for the hospital.
Hiring a full-time attending physician in their place is a larger expenditure.
Besides, Medicare, through direct and indirect reimbursements,
assumes some of the cost of residency training. These reimbursements are
calculated based on the hospital’s Medicare census.
An obvious question arises: Are residents students or employees? Or are
they a combination based on what task they are performing? Practically,
they are both. In some institutions, the residents have joined unions. No
matter how one designates a resident, he or she still falls under the category
WHAT IS A RESIDENCY? WHAT IS A RESIDENT? 5
of adult learners. Because of the ever-expanding medical knowledge, a resident
has to become a life-long learner [4]. The residency program is an excellent
milieu in which to initiate life-long learning habits.
The first quote above can serve as the pedestal for the resident. A resident
who is motivated and who has the ability to tap into myriad and diverse
clinical experiences will make it his or her business to be involved as much
as possible. This will expand one’s knowledge base, clinical acumen, and
Box 2. A good residency program:
Meets the CPME requirements
Satisfies the CPME numerical parameters and then some
Has a dedicated residency director and faculty
Provides diverse pathology and surgical cases
Has didactic experiences and the means to discuss cases with the
faculty
Establishes traditions
Trains residents who are competent
Produces residents who score well on the in-training
examinations
Has a large percentage of graduates that passes the various
board examinations
Meets the desires of the residents
Establishes an environment that fosters professionalism, ethical
practices, cost containment, compassion, and life-long learning
Includes alumni who are available for mentoring
Produces residents who realize the significance of their training
and the effort that was expended to provide this training
Trains residents who, in turn, will want to train the next
generation
Is an asset to the profession
Exists when the podiatric residents share equal pay, benefits, and
standing with any allopathic residents in the same institution
Fosters confidence by making sure that the resident participates
actively in podiatric surgery and other rotations, even if faced
with complications
Has attending physicians who realize the sacredness of their task
in life as members of the healing profession training the next
generation
Graduates residents who are able to communicate with
colleagues, staff, and patients
Teaches the tenets of evidence-based medicine that the residents
will continue to use after graduation
6 WALLACE
competency. Examining an acute Charcot foot reinforces any textbook entries
or lectures on the subject. This picture stays with one for a long time
and is recalled easily and applied to the next patient. Never seeing one, the
practitioner has to rely on the printed or spoken word, and is devoid of
any mental picture. It would be folly, however, to assume that one has to
see every possible type of pathology in the most prestigious text before one
is competent.
The residency program has to be challenging. The hours usually are long.
Allopathic medicine has been concerned with the number of hours that a resident
works and it established the 80-hour work rule. This rule was instituted
to decrease sentinel events that may be caused by sleep deprivation.
CPME has made this a suggestion, not a mandate.
No matter what paradigms are in place for podiatric residencies, the
resident wants to be able to obtain surgical training. PM & S 24 and 36
programs have their own requirements in various surgical and clinical
categories that have to be met before graduation (Table 1); however,
Dr. Green’s cogent comment about surgery being a privilege (for a resident)
to perform is mutually understood between the faculty and the resident.
We can laugh at the adage, ‘‘See one, do one, teach one.’’ It is still mentioned
frequently in hospitals. In the twenty-first century with competencybased
learning, the saying is nothing more than a limerick. Conversely,
before the blink of an eye the residency is over. Now the person is an attending
physician and may be teaching! The confidence and competency that are
achieved in the residency program will be passed on to the next generation
of residents.
No one can say that selecting a resident is easy. Trying to determine if the
person will fit in and be able to amass the skills, knowledge, and attitudes to
graduate is a monumental undertaking. With the residency match process,
Table 1
Minimal numbers needed for each category as established by the Council on Podiatric Medical
Education
Clinical experiences PM & S 24 PM & S 36
B & C-level procedures 350 525
C-level procedures
Digital 80 100
First ray 60 80
Other soft tissue foot surgery 45 65
Other osseous foot surgery 40 60
Reconstructive rearfoot/ankle 0 50
Other procedures 0 0
Inpatient cases 50 75
Podiatric clinic/office 750 1000
Podiatric surgical cases 150 300
Trauma cases 25 50
Podopediatric cases 25 25
Biomechanical cases 150 150
WHAT IS A RESIDENCY? WHAT IS A RESIDENT? 7
one has to select more individuals who may fit the requirements of each particular
program. There are no easy answers. What yardstick can one use to
identify characteristics of who will be a good resident? The list in Box 3 definitely
is not all-inclusive.
The future
The knowledge base of medicine, in general, and podiatry, in particular,
is growing rapidly. The faculty at the residency program will have to keep
up with the literature and the newer techniques, which then will be shared
with the residents. No program should stagnate; however, evidence-based
medicine will have to be taught.
Providing CPME’s numbers is good in and of itself. One assumes that
each resident will be competent with those parameters (see Table 1). There
may be a resident who needs more experiences to become competent in any
area. The program must be able to recognize this and supply much more
than the minimum. This is accomplished through frequent evaluations
and direct observations. More than one person has to supply the evaluations.
This may lead to the residency program having multiple hospitals
from which to draw cases. Inpatient experiences also need to be in place.
The requirement for each resident to be involved in research was eliminated
a few years ago. This does not mean that research should not be
Box 3. Characteristics that may identify a good resident
The educational dossier from the podiatric medical school is
consistent with the program’s standards
Motivated, well groomed, professional, ethical, mature, and
interested in furthering one’s education
Realization of the importance of residency education
A team player and able to assimilate into the program
Respectful and compassionate to all
Able to understand the role of a resident
Organized
Recognized as being capable of being taught
Accepts constructive criticism and learns from mistakes
Understands that as a professional will have to be a life-long
learner
Sees the program’s traditions as being an integral part of the
educational experience
Perceived as being able to accept more responsibilities as the
years progress and will be able to teach students and junior
residents
8 WALLACE
encouraged and nurtured. Residency programs need to take the lead on research,
and, thus, bolster the podiatric literature.
In the future, there may be only one type of residency program with a finite
time frame. Standardization would be the norm. The future for residency
programs will depend on: (1) a podiatric and allopathic faculty that
is willing to provide residents with training; (2) students who are willing
to assume the role of a resident; (3) a sponsoring institution providing the
resources for the program; (4) people with a desire to enter podiatric medical
schools to become podiatrists; (5) the profession recognizing the importance
of residency programs and all those who make them a reality; (6) postresidency
employment opportunities that are commensurate with one’s training;
(7) hospitals providing privileges that match the training of the residents;
and (8) the public, which frequents podiatric physicians for foot and ankle
care.
Summary
If the podiatric profession wishes to keep pace with allopathic medicine,
it has to provide competency-driven residency programs. Only with the dedication
of the podiatric and allopathic faculty can this be possible.
References
[1] Engel CE. Medical education in Australia, Great Britain and New Zealand in the 21st century.
In: Distlehorst LH, Dunnington GL, Folse JR, editors. Teaching and learning in medical and
surgical education. Mahwah (NJ): Lawrence Erlbaum Associates; 2000. p. 23–30.
[2] Levy LA. Podiatric medical education and practice. JAPMA 1996;86(8):370–5.
[3] Council on Podiatric Medical Education. CPME 2003;320:25–6.
[4] Medio FJ, Morewitz SJ. Self-directed learning. In: Robbins JM, editor. Primary podiatric
medicine. Philadelphia: W.B. Sanders; 1994. p. 65–80.
WHAT IS A RESIDENCY? WHAT IS A RESIDENT? 9

 

[jonwill]

The thread is reserved for students to post articles pertaining to podiatric medicine and surgery.

 

[Podman]

Thanks for the effort jon!

 

[krabmas]

The thread is reserved for students to post articles pertaining to podiatric medicine and surgery.

you are the bestest

 

[krabmas]

Today's Article about Residency choosing.

Evidence-Based Medicine in Podiatric
Residency Training
Gregg Young, DPMa,b,*
aGeorge E. Wahlen Department of Veterans Affairs Medical Center,
500 Foothill Avenue, Salt Lake City, UT 84148, USA
bUniversity of Utah School of Medicine, University of Utah Health Sciences Center,
500 Foothill Avenue, Salt Lake City, UT 84148, USA
Sackett and colleagues [1] define evidence-based medicine as ‘‘the conscientious,
explicit, and judicious use of current best evidence in making decisions
about the care of individual patients. The practice of evidence based
medicine means integrating individual clinical expertise with the best available
external clinical evidence from systematic research.’’
Several important considerations are necessary when using evidencebased
approaches. First, the information must be tailored to fit the needs
of an individual patient. This includes accounting for the needs, limitations,
and beliefs of the patient, thereby making the patient an active participant in
his or her own care. It also requires that clinicians not only examine the evidence
with regard to the patient’s disease state, but also rate the applicability
of any given piece of evidence to the particular patient. While the results
of a double-blind study is considered the highest level of evidence, it may
need to be discounted if the study group involved patients distinctly different
from the patient under consideration (eg, the study group was made up of
elderly males and the patient is an adolescent female).
Problems with using evidence-based medicine
Evidence-based medicine is often viewed as synonymous with ‘‘cookbook’’
medicine. However, evidence-based medicine is not ‘‘cookbook’’
medicine. Unlike prescribed treatment regimes such as diagnosis related
groups, which are used to control costs, evidence-based medicine is patient-
specific. This means that if the evidence supports a longer stay for a given
* George E. Wahlen Department of Veterans Affairs Medical Center, 500 Foothill
Avenue, Salt Lake City, UT 84148.
E-mail address: [email protected]
0891-8422/07/$ - see front matter  2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.cpm.2006.09.002 podiatric.theclinics.com
Clin Podiatr Med Surg
24 (2007) 11–16
patient, costs would increase but so would the quality of care. Formularies are
an area where a true evidence-based approach can be beneficial for both the
patient and the payer. Unfortunately, way too often cost becomes more important
than the medical evidence and patients are subjected to inferior therapies
and placed on agents with significantly poorer safety profiles than the
other equivalent therapeutic agents. These one-size-fits-all approaches to using
medical evidence have made it much more difficult to teach individuals evidenced-
based approaches because many have already been convinced it is just
another means to control costs and limit therapeutic choices.
Podiatry specific
The use of evidence-based approaches has lagged behind in podiatry.
Probably the main reason for this slow progress is the lack of high-level evidence
(ie, Level I, II-1, II-2, and II-3 [Box 1]) for most diseases of the lower
extremity. Other reasons include a lack of understanding of statistical
methods, which leads clinicians to misinterpret data or believe the erroneous
conclusions of investigators who have used statistics incorrectly. Finally, podiatrists
appear to have an ‘‘in my hands’’ mentality when assessing problems
and when teaching others to assess problems. Podiatrists tend to rate
their own experiences over what medical evidence shows.
The present approach to podiatric education has led to a lack of critical
thinking on the part of students and residents in clinical settings. Overcoming
this lack of critical thinking is probably the hardest step in developing an
Box 1. Levels of evidence
Level I. Evidence obtained from at least one properly randomized
controlled trial.
Level II–1. Evidence obtained from well designed controlled trials
without randomization.
Level II–2. Evidence obtained from well designed cohort
or case-control analytic studies, preferably from more than one
center or research group.
Level II–3. Evidence obtained from multiple time series with or
without the intervention. Dramatic results in uncontrolled
experiments (eg, the results of the introduction of penicillin in
the 1940s) could also be regarded as this type of evidence.
Level III. Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees.
Adapted from Sackett DL, Rosenberg WMC, Gray JAM, et al. Evidence based
medicine: what it is and what it isn’t. BMJ 1996;312(7023):71.
12 YOUNG
effective evidence-based mindset. Faculty members encourage critical thinking
by trying to instill some ‘‘philosophies’’ in trainees. The following are
some examples:
The most likely reason a patient is not getting better is because you have
the wrong diagnosis. Therefore, reassess and stop blaming the patient
and other outside factors for the failure.
Don’t accept things at face value. If someone, even an attending, tells you
something that makes no sense, question it and research it.
Be prepared to answer the question ‘‘Why?’’ If you tell me a patient has
something, needs something, or is being treated in a certain way, be
prepared to justify it based on the evidence or at least as a logical conclusion
drawn from the basic science on the subject.
Almost all diagnoses have underlying complicating factors or causes.
What are they and can you treat the ‘‘diagnosis’’ without addressing
the underlying factors?
Does the evidence apply to this patient? Sure the patient has a Lisfranc’s
fracture dislocation and the evidence says such fractures mend better if
fixated. However, this patient suffered the injury when he fell from his
wheelchair (He is nonambulatory.) and has severe congestive heart failure.
In this case, should the fracture be fixated?
How do we find the evidence?
Researching a topic can be a very time-consuming process. Doing evidence-
based medicine in a high-volume practice requires a streamlined process.
One approach is to limit the use of this technique to ‘‘difficult’’
patients. The problem with this approach, however, is that practitioners
can potentially create these ‘‘difficult’’ patients by doing inappropriate
workup or therapy or by failing to do indicated interventions. For many
conditions, delay in treatment can make therapy more difficult or worsen
the prognosis. Mainly because of these problems associated with delay,
not taking time for research, which evidence-based medicine requires,
should be limited to cases involving patients undergoing maintenance care
for a known diagnosis or to patients being treated for classic presentations
of common diseases. The practitioner should review the state of the art for
these types of care on a periodic basis as opposed to a patient-specific basis.
Obviously, the best time to do the research is at the time of the initial
visit. This is unfortunately also the least practical time. The only way it is
practical is through the use of ‘‘quick’’ reference sources. These sources include
textbooks, practice guidelines, review articles, and what might be
called quick searches. None of these methods are ideal, and they differ to
some extent in strengths and weaknesses.
Textbooks can be kept readily available and can provide summaries of the
state of the art based on either expert opinion or extensive literature review or
EVIDENCE-BASED MEDICINE 13
both. Only those texts that use extensive literature review should be considered.
The use of expert opinion as evidence should be limited to cases where
other evidence doesn’t exist. The major drawbacks to the use of textbooks
are their lack of timeliness and the biases of the authors and editors, which
can lead to omissions or misleading presentations of the evidence.
To be useful, practice guidelines must be updated on a periodic basis. Obviously,
more frequently is better as medicine is changing at an ever-increasing
pace. The most important factor in choosing guidelines is understanding
the process used in developing them. A guideline developed by a small committee
with limited external input is much more likely to have biases built in
than one that has extensive input. The ideal guideline discusses all the relevant
options and provides an assessment of the level of the evidence and the
patient type. In practice, guidelines are rarely ideal, leaving readers to decipher
what approaches are best for a given patient. The availability of guidelines
in podiatry is limited to those produced by the professional colleges.
They suffer from relatively infrequent revision and the paucity of high-level
evidence. This means they rely mainly on expert opinion. For more general
medical conditions, such guidelines as the web-based Up to Date are available.
These are continuously updated and are easy to search.
Review articles are similar to textbooks but usually somewhat timelier.
Such articles can suffer from incomplete literature review and bias on the
part of the authors.
Assessing the relative value of textbooks, guidelines, or review articles is
an important part of the process. First, who are the authors? Do they have
research experience in the area, special training, or other unique qualifications?
If so, what biases might be expected?
Examples of potential bias might include a guideline written by a surgical
organization omitting or understating nonsurgical options, or a review article
written by researchers emphasizing their own work over other research.
Finally, to effectively judge these resources, one must be familiar with the
literature. Have the authors cited all the studies done in the area? If not,
have they at least cited what appears to be the most relevant? After reviewing
the literature, do you agree with their recommendation? Since no quick
reference is going to be perfect, it is more important that you understand the
biases and limitations of those that you use rather than spend time searching
for incrementally better sources.
Quick search is the use of web-based tools to find current information on
the disease of interest. Such sites as Pub Med, for searching the medical literature,
and general search engines, such as Google, can both be used. A
search through the medical literature increases the likelihood of finding reliable
information. However, gaining access to the information is often more
time consuming, expensive, or both. A focused search with a quick review of
abstracts can often provide needed information. This information suffers
from being incomplete in several ways. First, the search must be limited because
of time constrains. This means key articles may be missed. Second,
14 YOUNG
since the full text of many articles is not available or only available for
a price, review is limited to the abstracts, which can be incomplete or misleading.
General searches should probably be used primarily to determine
what type of information the patient may have or obtain so clinicians can
correct any misconception. Additionally these sites can be useful in researching
specific products and product classes for cost and availability.
Ultimately, for a small subgroup of patients, a comprehensive search of
the literature is the only way to effectively assess the patient’s options.
Such a comprehensive search should be undertaken as soon as it is clear
that the patient is not responding as expected to multiple therapies.
Critical reading of the literature is another skill that is underdeveloped in
podiatric medical students. The Podiatric Medical Education program at the
University of Utah School of Medicine, which is the podiatric medical education
program that the author directs, uses three different journal clubs,
each with a slightly different goal, to achieve this competency. The primary
journal club reviews the current lower extremity literature in an attempt to
track the breadth of the relevant literature. All residents and some faculty
members participate. The second club is part of a weekly wound-care conference,
which, in addition to reviewing difficult patients, reviews the literature
on lower extremity wound care. This session brings attention to the
depth and contradictory nature of the literature, as well as its evolution
over time. The third club is ad hoc, usually meeting one or two times per
month, where residents present on topics they were assigned as the result
of patient-care questions. The residents are encouraged to rank both the
level of evidence (see Box 1) and the relative risk (Box 2 [2]) of interventions.
At the Podiatric Medical Education program at the University of Utah
School of Medicine, search techniques are generally reviewed by having the
residents bring their search results to the ad hoc third journal club. Residents
must justify the structure of the search and the reason they picked
Box 2. Grades of recommendations for a specified level
of baseline risk
A1. RCTs; no heterogeneity; CI all on one side of threshold NNT
A2. RCTs; no heterogeneity; CI overlaps threshold NNT
B1. RCTs; heterogeneity; CI all on one side of threshold NNT
B2. RCTs; heterogeneity; CI overlaps threshold NNT
C1. Observational studies; CI all on one side of threshold NNT
C2. Observational studies; CI overlaps threshold NNT
Abbreviations: CI, confidence interval; NNT, number needed to treat to avoid
one unwanted outcome; RCT, Randomized controlled trial.
Adapted from Canadian Task Force on the Periodic Health Examination. The
periodic health examination: 1987 update. Can Med Assoc J 1988;138:626.
EVIDENCE-BASED MEDICINE 15
the particular article they presented. If the search appears to be inadequate, the
attending supervising the journal club will redo the search as part of the teaching
session. The program primarily uses Pub Med (Medline) and encourage
searches using medical subject headings (ie, MeSH terms) and major categories
with various filters, such as filters that limit searches to English-language
material, research studies, or review articles. The use of these techniques normally
yields the most pertinent information with the least time cost. Limiting
searches to on-line abstracts and free full texts on line saves time.
The program encourages residents to use some of the on-line resources
that teach evidence-based medicine techniques and related topics. Box 3 lists
some of those resources.
Summary
Evidence-based medicine techniques are extremely useful tools for educating
residents. Use of these techniques has underscored the need for
much more research in most areas related to podiatry. In addition to enhancing
resident training, evidence-based medicine might improve patient
outcome (More research is needed here, too.). Also, these techniques may
ultimately save time and money by reducing total patient visits, unnecessary
testing, and the use of less-effective therapies.
References
[1] Sackett DL, RosenbergWMC,Gray JAM, et al. Evidence based medicine: what it is and what
it isn’t. BMJ 1996;312(7023):71–2.
[2] Canadian Task Force on the Periodic Health Examination. The periodic health examination:
1987 update. Can Med Assoc J 1988;138:618–26.
Box 3. Web sites useful for teaching evidence-based medicine
 Users’ Guides to Evidence-Based Practice. http://
www.cche.net/usersguides/main.asp
 Definitions of Evidence Based Practice. http://www.shef.ac.uk/
scharr/ir/def.html
 Evidence-Based Medicine. http://www.herts.ac.uk/lis/subjects/
health/ebm.htm
 Clinical Epidemiology for Effective Clinical Practice Online
Tutorial. http://www.intensivecare.com/Tutorial.html
 Center for Evidence Based Medicine. http://
www.cebm.utoronto.ca/
 Evidence-based Medicine Resource Center. http://
www.ebmny.org/thecentr.html
 University of Massachusetts Medical School’s Evidence-Based
Medicine. http://library.umassmed.edu/EBM/
16 YOUNG

 

[krabmas]

Conducting a Meaningful Interview:
Making the Most of a Golden
Opportunity
Jonathan P. Contompasis, DPM
Podiatric Medicine & Surgery-36 Residency, Christiana Care Health System,
P.O. Box 3772, Wilmington, DE 19807, USA
The interview remains a key aspect in the selection and ranking of applicants
to Podiatric Medicine and Surgery (PM&S) residency programs. How
much importance is placed on the interview in the final selection of candidates
is entirely up to each program’s Residency Selection Committee.
Each program should structure the interview to maximize the opportunity
to have meaningful face-to-face contact with each candidate, while promoting
the positive attributes of their facility, curriculum, clinical experiences,
and educational faculty.
Postinterview surveys show that many residency programs do conduct
meaningful interviews and leave candidates with a positive impression and
the feeling that their interest in that residency program is well founded.
There are programs, however, that leave candidates with a less than ideal
feeling about their interview experience, and possibly concerns about their
decision to consider training at that program in the first place.
This article present concepts that may validate that you are conducting
meaningful interviews or highlight areas in your interview process that
might benefit from structural or philosophical changes.
Preinterview decisions
John B. Molidor, PhD, of the Michigan State University, College of Human
Medicine, has discussed some important decisions that need to be made
before the actual interviews take place [1].
What is the primary purpose of the interview that you will be conducting?
Dr. Molidor cites four major purposes of the interview. These are ‘‘to gather
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Clin Podiatr Med Surg
24 (2007) 17–25
information which would be impossible to obtain by any other means; to use
that information in a sound decision making manner; to verify information
on the application; and to recruit candidates into your program’’ (Box 1).
How many interviews will each candidate have? Most programs in podiatric
medicine use one to three interviews that primarily take place over the
Centralized Interview Residency Program (CRIP) weekend.
What interview format will you use? The panel format has always been
popular in podiatric medicine, but some programs are using multiple oneon-
one interviews. Most allopathic medicine interviews are being conducted
with a one-on-one format, but there is some discussion that ‘‘panel’’ interviews
deserve a place in the selection process.
What relative weight will you assign to preinterview information and to
the interview itself? This is a important decision to be made. Some programs
give equal weight to both, whereas other programs give more weight to
Box 1. The four major purposes of the interview
Information-gathering: gather information that is not available
anywhere else. Do not use the interview to gather grades or
test score information if it is available elsewhere. Aim your
interview at obtaining information about such areas as interpersonal
skills, communication styles, and decision-making
abilities.
Decision-making: determine how much weight you wish to give
to the interview. Do all of the candidates who pass the initial
screen come to the interview equally, making the interview
the determining factor? Do all of the candidates have their
academic and interview scores weighted in the final ranking
decision? Structure and design the interview to aid your
selection committee in deciding which candidates that they
wish to rank and how high to rank them.
Verification/clarification: use the interview to verify the accuracy
of the information sent in the application packet. Also, use the
interview to clarify any information on the application that does
not make sense to you.
Recruitment: use the interview as a tool for recruiting candidates
to your program. Done well (especially if you treat the candidates
with dignity and respect), the interview can be a means
to share information easily and powerfully.
Adapted from Molidor JB. Face to face! The care and treatment of the residency
selection interview. In: Reisenberg LA, editor. Guide to medical education
in the teaching hospital. 3rd edition. Pittsburgh (PA): Association for Hospital Medical
Education; 2004. Available at: http://www.ahme.org.
18 CONTOMPASIS
prescreening information, especially when the candidate has served a clerkship
at that hospital or has had the opportunity to visit the facility on one or
more occasions and interact with current residents and staff podiatrists. Still
others believe that after the prescreening is completed and the applicant is
selected for an interview, every candidate is on equal footing and the interview
should be the determining factor in the ranking process.
Determine who has the final say in the ranking of candidates. The Program
Director, Residency Selection Committee, and ideally, one or more
current residents meet and discuss candidates after the interviews are completed.
Determine what methodology you will be using to rank each candidate,
especially when there are more strong candidates to your program
than available positions.
The basics
Although every residency program interviews different than another, it is
important to follow a few basic tenets to maximize the interview experience.
Know thyself
Each PM&S residency program has a structured curriculum plus stated
competencies, goals, and objectives for every rotation throughout the academic
year. The Residency Selection Committee should use this information
plus their first-hand knowledge of the program’s academic and clinical resources
and faculty to determine what applicant might fit best into its current
learning environment.
Know thy applicant
You may not meet the candidate until the actual interview begins; however,
before that moment there is much that you can learn about each applicant.
Weeks before the actual interview takes place the Program Director is
sent an application packet that contains significant information about each
applicant to the program. This packet contains transcripts, letters of recommendation,
listings of awards and honors received, research endeavors,
membership in student organizations, and community service projects in
which the applicant may have participated. It is imperative that the information
in each applicant packet be reviewed, summarized, and distributeddin
a confidential mannerdto each member of the Residency Selection
Committee.
Determine the ‘‘categories’’ you wish to assess during the interview
Some programs conduct academic interviews, with little time allotted
for casual conversation; however, because the value of social interaction
CONDUCTING A MEANINGFUL INTERVIEW 19
is appreciated, they often supplement the formal interview with a social
event during or shortly after the CRIP weekend. Other programs are
purely social in their approach to an interview, and believe that the applicant
packet and perhaps previous contact with the candidate is all that is
needed for them to rank individuals. Of course, other programs are a mix
of these two formats.
Categories that one may wish to assess during an interview include communication
and interpersonal skills, motivation, responsibility, tolerance
and problem solving, decision-making skills, and professional goals.
Generate a list of questions for the interview based upon the categories
that you wish to assess (Appendix). Determine how much time you plan
to spend on each question, and perhaps how much ‘‘weight’’ will be placed
on each answer. The applicants like to see structure, and they need to feel
that you spent as much time preparing for the interview as they did. Do
not forget that the candidates often are ‘‘looking at you’’ as much as
‘‘you are looking at them.’’
Ask your faculty and current residents to identify key characteristics that
they believe are necessary to succeed in your program. A small community
hospital with one or two residents in training may be looking for a completely
different type of individual than might be sought by a large multidisciplinary
teaching hospital with several podiatric residents in each year
of training.
Determine the role each member of the selection panel should play during
the interview
In a meaningful interview, it is the applicant who should do most of the
talking. Do not try to impress the student with how much you know; take
this opportunity to see how much the applicant knows or perhaps try to ascertain
the student’s critical thinking skills and other areas that you wish to
investigate. Remember to allow the student the opportunity to ask any questions
that he or she may have about your program. It may surprise you to
learn about any stereotypes, myths, or misconceptions that may be floating
around about your residency.
Finally, remember, that it is frowned upon whenever a student reports little
opportunity to express oneself fully, whether answering or asking a question
(Box 2).
Learn the rules
It is important that a fair, legal, and appropriate interview take place
(Box 3). Learn what questions you can and cannot ask. Never belittle or dismiss
a candidate and try not to be too casual in your comments or demeanor.
We are professionals and we must conduct ourselves that way
throughout the entire residency selection process.
20 CONTOMPASIS
Develop skill in evaluating the candidates’ responses
Allow time at the end of each candidate’s interview to summarize briefly
among the panel how that particular interview had gone. Take notes and record
your impression of the responses and statements that were given by the
applicant.
Discuss and rank candidates
After all interviews are completed, time needs to be set aside to get input
from everyone on the Selection Committee. Ideally, each committee member
presents information on each candidate in a predetermined standardized
manner.
Box 2. Candidates’ views on the interview process
What candidates like most about the residency interview
process
Interviews with structure and direction
Opportunities to talk with residents
Special requests being met easily and smoothly
Meeting with program director, faculty, and chair (where
appropriate)
Chance to tell their story and talk about their candidacy
Interviewers who are attentive, interested, and prepared
Major complaints by candidates
Interviewers who are late
Interruptions
Interviewers who are unprepared (eg, they did not read
application)
Interviews during which the candidate cannot get a word in
edge-wise
Interviewers asking questions that are inappropriate, in poor
taste, or unlawful
Interviews that are too short or rushed
Interviews conducted in a noisy environment (eg, hard to
establish rapport)
Interviewers who ask, ‘‘What will it take to get you to come
here?’’ or ‘‘Where are you going to rank us?’’
Adapted from Molidor JB. Face to face! The care and treatment of the residency
selection interview. In: Reisenberg LA, editor. Guide to medical education
in the teaching hospital. 3rd edition. Pittsburgh (PA): Association for Hospital Medical
Education; 2004. Available at: http://www.ahme.org.
CONDUCTING A MEANINGFUL INTERVIEW 21
The interview
Not every applicant to your residency program should be granted an interview.
If you have made certain preinterview decisions you should be able
to determine which candidates have the characteristics, experience, and
training that fit best into your program’s learning environment. Although
it is not mandatory that an applicant visit your program before being offered
an interview, students and educational faculty have commented repeatedly
on the advantages of having some first-hand knowledge of the
hospital facility, educational faculty, current residents, and support staff.
Even if Central Application Service for Podiatric Residencies is scheduling
your interview at one or more CRIP locations, you should contact the
candidates that you have selected to interview to give them updated information
on your residency and curriculum. Send them a brochure or your
program’s Web address. Remember that this is a marketing opportunity
and a chance to demonstrate your organizational skill and professionalism.
At the time of the interview, candidates should be shown a copy of your
hospital’s PM&S resident contract, as well as updated information on benefits
and salary. Certainly, any pertinent information about your accreditation
status, hospital, or faculty should be given to the candidates as soon as
it becomes available.
Interviews are conducted best in a room that is neat and professional
looking. Minimize distractions if possible. No food should be evident and
no one should enter or exit the room after the candidate’s interview begins.
Box 3. Conduct a legal interview
The following subject areas (and questions) are illegal and
unlawful:
Marital status (Are you married?)
Questions relating to children or plans for children (Do you
plan to have children during your residency?)
Religion (What are you religious beliefs?)
Ethnicity (What is the origin of your last name?)
Sexual preference (What is your sexual orientation?)
The US Equal Employment Opportunity Commission has a
thorough Web site that can assist you in determining whether
a question is illegal or unlawful (www.eeoc.gov).
Adapted from Molidor JB. Face to face! The care and treatment of the residency
selection interview. In: Reisenberg LA, editor. Guide to medical education
in the teaching hospital. 3rd edition. Pittsburgh (PA): Association for Hospital Medical
Education; 2004. Available at: http://www.ahme.org.
22 CONTOMPASIS
No cell phones or pagers should be in use during the 20 to 40 minutes that
the candidate is in the room. The only file on display should be that of the
candidate who is being interviewed. Anatomic models, textbooks, laptop
computers, radiograph view boxes, and the like should all be on display;
however, leave the newspapers and extraneous materials in your briefcases.
Your interview needs to get off to a good start, with a positive overtone
and good flow. A previously selected committee member should greet and
introduce the candidate formally to the selection committee before the candidate
is seated.
Seat the applicant in a location that optimizes the flow of the interview. A
circular arrangement often is ideal and there are advantages to placing a pad
and pencil in front of the applicant. Some students will use the pad to organize
their thoughts before answering a question; you might view this as
a highly desirable trait for your program.
Consider beginning the interview with a casual remark or question to put
the candidate at ease. Tell the applicant how the interview will be conducted,
and inform him or her what the purpose of the interview is to your selection
committee and how it fits into the selection process. Candidates should
know that time is allotted for them to ask questions about the program
or selection process. Perhaps start with an open-ended question about their
podiatric medical school coursework or an interesting clinical case that they
have encountered.
Remember that specific questions about the ranking of programs or candidates
are prohibited. Be courteous and be fair. Try to see the candidate at
his/her best. Know their applicant packet well and ask questions about specific
papers that they have written or research projects that they are conducting.
The students are expecting these things to be mentioned.
It can be illuminating to learn that a candidate is ‘‘unfamiliar’’ with
a topic that they have written about or a research project with which they
were involved. If an academic question is asked and the candidate struggles
for a correct answer or gives a completely wrong response, do not highlight
or overstate the error. Instead, bring him/her back to the starting point, educate
him/her in a manner that is not condescending, and move on to the
next topic. Give the candidate the opportunity to explain why he/she gave
the response that he/she did. Perhaps he/she misunderstood your question.
Also, remember that the interview is an opportunity to learn much more
about an applicant than just his/her ability to answer difficult questions correctly
or read an MRI accurately. Use the interview to investigate an applicant’s
clinical acuity, thought process, competency, and character.
Decide who on the committee will orchestrate the flow of questions and
responses. It is common for certain topics to be handled by different committee
members, with perhaps the program director making sure that the
time with the applicant is spent wisely. Many members will be silent or
say little during the bulk of the interview; however, these individuals must
stay focused and not appear to be the least bit disinterested. Behave like
CONDUCTING A MEANINGFUL INTERVIEW 23
colleaguesdand without being too informalddemonstrate to the candidate
that your group is enjoying the entire selection process. With few exceptions,
students and residents are the lifeblood of our profession.
Let the applicant ask questions of the group and end on a positive note
and a hand shake. Thank the applicant for being interested in your program
and wish him/her the best in his/her professional endeavors. Residency programs
that are savvy about marketing send an electronic or written message
to the candidate formally thanking him/her for considering their program
and participating in the interview.
Summary
PM&S residency programs have gone through some positive changes recently
in areas of format and curriculum. The men and women who are
trained in our residency programs are the lifeblood of our profession. For
this reason it is imperative that we make every attempt to select candidates
for our programs who have the clinical acuity to fit best into that program.
This article has presented an overview of topics to be considered before,
during, and after a residency interview takes place. With forethought and
structure, you should have the best opportunity to conduct a meaningful interview.
Please do not waste a golden opportunity.
Appendix
For each category that you wish to assess, generate a list of questions
that pertains to that category. The major types of questions
that you might ask are:
Open-ended (‘‘Of the teaching styles you encountered while in
school, which did you like most? Least? Why?)
Critical incident (‘‘Tell me about a time you were misjudged.’’)
Compare/contrast (‘‘Compare your undergraduate experiences
with your podiatric medical school experiences.’’)
Chained questions are where you link your next question to the
responses that the applicant has just provided. For example,
if the candidate has just said that he is interested in being
involved in the community, you could ask about the
community work that he has performed as well as the areas
that he is interested in during his residency. You can keep the
interview moving along just by listening to the applicant and
then forming your next question.
Zoom questions work like a telephoto lens, where you zoom in
or narrow your focus. If the candidate said that he really
enjoyed his internal medicine clerkship, you could zoom in on
the particulars (‘‘What in particular did you like about this
24 CONTOMPASIS
Reference
[1] Molidor JB. Face to face! The care and treatment of the residency selection interview. In:
Reisenberg LA, editor. Guide to medical education in the teaching hospital. 3rd edition.
Pittsburgh (PA): Association for Hospital Medical Education; 2004. Available at: http://
www.ahme.org.
rotation?’’ ‘‘What aspects of the clerkship did you enjoy the
most?’’ ‘‘Why?’’). The intent of zoom questions is to probe
beneath the surface and to go deeper within a category.
Multiple choice questions are where you give the candidate
choices. (‘‘If you could choose only one of the following to
characterize your motivation to go into podiatric medicine,
which one would you choose: [a] hands-on activities,
people component, [c] control of your lifestyle, or [d]
autonomy’’?). The key to good multiple choice questions is
to write them out beforehand and to try to make all of the
choices as equal as possible. One or two multiple choice
questions, per interview, is the right amount.
Hypothetic (‘‘If you could invite three people [no longer living]
to a dinner, who would they be and why’’?). One hypothetic
question per interview is a good number. Try to make the
question plausible and fun.
You should generate a variety of questions for each category.
You also might want to ask approximately the same number
of questions per category. It will help to make your
interviews more interesting, reliable, and enjoyable.
Adapted from Molidor JB. Face to face! The care and treatment of the residency
selection interview. In: Reisenberg LA, editor. Guide to medical education
in the teaching hospital. 3rd edition. Pittsburgh (PA): Association for Hospital Medical
Education; 2004. Available at: http://www.ahme.org/.
CONDUCTING A MEANINGFUL INTERVIEW 25

 

[krabmas]

Teaching During Rounds

Keith D. Cook, DPMa,*, Rachel B. Gutowsky, DPMb

aPodiatric Medical Education, University Hospital–University of Medicine and Dentistry
of New Jersey, 150 Bergen Street, Room G-142, Newark, NJ 07103, USA
bPodiatric Surgery, University Hospital–University of Medicine and Dentistry of New Jersey,
150 Bergen Street, Room G-142, Newark, NJ 07103, USA

When one envisions teaching rounds on a hospital ward he or she may
picture a group of physicians clad in white lab coats huddled outside a
patient's room or standing around a patient's bed discussing the patient's
condition and proposing treatment plans. The group consists of an elder
attending physician, residents of various levels of training, and students.
The students and junior residents usually carry clipboards and attempt to
write down every word that the elder attending physician says, as if it
were the most important information that they ever will learn during their
training. To some degree, this scenario still occurs on a daily basis at major
medical teaching institutions.
It has been the authors' experience that formal teaching rounds rarely occur
within the podiatric community. At major medical centers and community
hospitals it is not uncommon for attending doctors to see their patients
without the residents present or to rely on the residents for daily updates. At
one institution, the senior author was questioned by a resident as to why he
traveled to the hospital to see one patient on a daily basis when most attending
physicians rarely were present in the hospital. Physicians have a responsibility
to care the same for every patient and not just when it is convenient.
One can only image how frightening it must be for the patients when they do
not have daily communication with the doctor who is overseeing their hospital
care.
Somewhere between that traditional picture of allopathic ward teaching
rounds and the practice of many podiatric physicians today, something
has been lost. Teaching during patient rounds serves multiple purposes
with many benefits. Some of the benefits include physician training, the application
of evidence-based medicine (EBM), and improved patient care.

Teaching
‘‘In what may be called the natural method of teaching, the student begins
with the patient, continues with the patient and ends his study with
the patient, using books and lectures as tools, as means to an end'' [1].
Many medical educators have stressed the importance and numerous benefits
of bedside teaching. The resident or student has the ability to learn and
develop history and physical examination skills along with communication
skills. They also have the opportunity to display ethics, professionalism,
compassion, and humanism. Yet despite all of the benefits, in the United
States less than 25% of clinical teaching occurs at the bedside [2].
The Council on Podiatric Medical Education requires a minimum number
of inpatient contacts for a resident to complete a residency program successfully.
Unfortunately, the time spent at the patient's bedside is decreasing
dramatically because of many factors. Rapid patient discharges and less financial
incentive are just some of the reasons why less time is spent at the
bedside. Although conducting ward teaching rounds may be wrought with
obstacles, it remains an essential part of a doctor's hospital activities and
residency learning [3].
A wealth of teaching opportunities exists during ward rounds. Enhancing
the amount of quality time that is spent at the bedside is essential for making
the most of these opportunities [4].
Numerous pieces of literature have been published on this topic. Some
tips to expedite effective teaching rounds and to keep all of the students
and residents interested are listed in Box 1 [5].

Evidence-based medicine
Hospital ward teaching rounds not only provide crucial training with regards
to specific patients, they also are an excellent venue for incorporating
EBM into a residency program's curriculum. Most EBM is discussed in
a journal club or lecture format. By implementing EBM into daily ward
rounds, its applicability to patient care can be demonstrated clearly. It
also reinforces proper diagnostic and treatment protocols.
There are various methods used to discuss EBM during teaching rounds,
and research has proven its effectiveness [7–9]. EBM literature may be distributed
by the attending physician for discussion about a specific pathologic
process or treatment plan. Another method is to require each
member of the team to present patient-based EBM literature if specific questions
arise during rounds. The Internet is another way of obtaining EBM for
discussion; however, one must be careful when using the Internet, because
much of the information is not peer reviewed.
Regardless of the method used, a structured EBM approach to teaching
rounds should be incorporated into every residency program. It has been
28 COOK & GUTOWSKY
shown to affect patient care, change the way that residents treat future patients
who have the same pathology, and enhance the residents' knowledge
about disease processes [8].

Pimping
Pimping, or the serial questioning of trivial information, was referenced
first in 1628 [10]. Generally, the attending physician or senior resident
asks residents or students about little-known facts or data that are irrelevant
to the care of the patient. There are many theories about the reasoning for
the questions, most of which include the insecurity of the senior physicians,
the belittling of students and junior residents, attempts to develop respect
for the attending physician or senior resident, and denting the egos of the
students [10,11]. Obviously, this can be an unpleasant experience for the student
or the recipient resident, with extremely negative effects. The practice of
pimping or asking irrelevant questions to students or residents may include
questions such as:
Why is Prolene suture material blue?
What year was the Keller bunionectomy first described in the literature?
What is the first name of Austin? (after whom the bunionectomy procedure
is named)
Practical pimping can be used when teaching proper treatment protocols.
Questions may include:
What are the appropriate antibiotics for treating open fractures?
Describe Sander's classification for calcaneal fractures.
What ancillary radiographic studies can be used to diagnose occult Lisfranc's
fracture-dislocations?
Pimping, although used less frequently, still occurs as a way of establishing
the academic hierarchy. Modern pimping, when used properly, can be
an effective pedagogical tool [12]. Pimping should be a constructive way
of teaching and not a tool that is used for humiliating.
Practical pimping, or asking pertinent questions to students and residents
about classification systems, medications, significance of diagnostic results,
and treatments, is an excellent way for students to gauge their own level
of knowledge about a particular entity. Any information that is not known
is researched and presented the following day as a form of ‘‘homework.''
This form of adult education has been effective for the Podiatry Service at
University Hospital–University of Medicine and Dentistry of New Jersey
(UMDNJ) for the student who is eager to learn more. Most students are receptive
to this type of learning, because it is pertinent to patient care and
they admit that they have learned ‘‘a lot'' after their time spent at this
institution.

TEACHING DURING ROUNDS 29
Box 1. Tips to expedite teaching and keep students
and residents interested
Preparation. Before teaching any class the teacher should
prepare by reviewing the subject matter. The attending
physician should prepare for rounds in a similar fashion,
by reviewing any unfamiliar disease entity or processes for
discussion at the patient's bedside.
Have a set teaching plan. Although teaching rounds can
be an ‘‘uncontrolled environment'' with unexpected situations
or questions from students and patients, displaying
confidence and following a set plan toward reaching your
pre-established teaching objective goes a long way in
reassuring the patient and student. Do not ever be afraid
to say that you ‘‘do not know.''
State the relevance of each case to the team. Be sure
to reinforce the pertinence of each patient to the teammembers.
Something can be learned on each patient visit that can be
used later in a team member's career. What may be a routine
dressing change can be an interesting teaching point
for a future clinician.
Assign roles to each team member. This is used to prevent
boredom among the team members. It also prevents chaos at
the bedside. Each team member should know who is changing
the patient's dressing when required, who will hand off
supplies, and so forth.
Assign a patient to each team member. Allow students
to take an active part in a patient's care. Having the students
or residents obtain the patient's information (eg, laboratory
values, culture results) and presenting the patient during
rounds fosters a sense of importance
and responsibility.
Always introduce yourself and the team to the patient. It is not
uncommon for patients at large institutions to be visited on
a daily basis by various teams from different specialties.
Although patients may encourage bedside teaching, it can be
overwhelming and confusing as to which team is responsible
for the patient's overall care [6].
Allow for open discussion. Allow the residents and students to
discuss the modalities that are used to reach a diagnosis and
formulate a treatment plan. This type of discussion is
conducted best outside of the patient's room. The discussion
can be confusing for the patient and may leave one
30 COOK & GUTOWSKY

Patient benefits
Involvement in academic medicine can be challenging on many levels.
Academic medicine encompasses daily activities that are not present in the
private sector, from administrative paperwork to organizing lectures and
workshops, to training and evaluating resident and students. The most important
part of any doctor's duties, however, is the care of the patient.
Patient care and outcomes should be the top priority of any physician,
regardless of medical specialty. Improving patient outcomes and satisfaction
rates is dependent, in part, upon daily ward rounds. Patients, as well as family
members, want to be informed of their condition and involved in the
treatment decision-making process. When conducting daily teaching
rounds, the entire team remains well informed and on the same page about
what diagnostic tests are being performed for each patient, along with the
proposed treatment options and expected outcomes.
Daily teaching rounds also allow the attending physician and team the
opportunity to recognize those patients who may require special needs
upon discharge. Early recognition of these patients and immediate
questioning why certain treatment or tests are not being
performed. ‘‘Spoon feeding'' students prevents thought
processes from developing.
Challenge the team without humiliating. Although ‘‘pimping'' has
its place as an effective teaching tool during rounds, and will be
discussed later, professionalism should be maintained at all
times. Remember that the goal as educators is to teach and
guide the students, not to discourage them from learning.
Step out of the limelight. Allow the resident to be
the patient's primary caregiver, of course under the guidance
of the attending physician. A good teacher should be able
to observe the resident's interaction with the patient
and criticize constructively. Communication skills, knowledge,
and attitude all can be assessed. Remember that some
of the best teachers are good listeners as well.
Allow time for questions and answers. Upon the conclusion of
rounds, always ask the team members if they have any
questions, problems, or comments. It reinforces your
commitment to teaching and to the team. It also allows an
opportunity for any forgotten questions or topics to be
revisited.
Reassess your performance. Hindsight is always 20/20. Evaluate
yourself and think about what you may have done differently to
enhance the learning experience for all of the team members.
Remember to institute these changes the next day.
TEACHING DURING ROUNDS 31
consultation with the necessary hospital disciplines helps to expedite treatment
as well as patient discharge. Although reports may vary about the effectiveness
of interdisciplinary rounds on decreasing a patient's length of
stay in a hospital, they have been shown to improve patient outcomes, family
satisfaction, and staff professionalism [13,14].
Although it is recognized that conducting interdisciplinary rounds is not
possible at every institution, it is the senior author's experience that daily
teaching rounds improves communication between hospital services. It
can be extrapolated that unnecessary or repeat diagnostic testing can be
avoided, more efficient and timely treatment can be instituted, and length
of stay can be decreased. The impact that this has on decreasing medical
costs can be seen easily.

Teaching rounds: a resident's perspective
There is a trend in the podiatric profession that has affected residency
training profoundly and has gone unaddressed for too long. The shift in patient
care to ambulatory or nonhospital settings has decreased the opportunity
for consistent student–attending physician and resident–attending
physician interactions regarding patient care and disease processes [16].
It has become increasingly apparent that most podiatric residency programs
operate with directors and assistant directors advising from afar.
Few podiatric training programs have in-house–based attending physicians;
the workload from private practices simply does not allow for close resident–
attending physician contact, and certainly does not allow for daily
structured teaching rounds. This has placed the burden of not only running
a residency program, but also the responsibility of serving as primary instructor
to rotating students, on the shoulders of residents [16]. The importance
of training programs that have in-house teaching rounds as well as
programs that use residents as teachers create an ideal environment where
the symbiotic relationship between teaching and learning flourishes.
At University Hospital–UMDNJ, certain ‘‘traditions'' have been established;
one of these is formal daily teaching rounds. This begins with resident-
run prerounds that consist of the gathering of information, such as
laboratory and culture results, as well as chart review. During this time
the residents direct students on the proper format for writing in-house progress
notes and the gathering of pertinent information by the podiatric service
and other services that are following the patient. After prerounds are completed,
the residents and students meet with attending physicians for radiographic
review of the previous day's postoperative films and emergency
room films from the previous day's and night's on-call resident. This marks
the beginning of the attending physician–guided learning process for residents
and students. The review of films alone creates discussion, and, in
turn, questioning of injury classification systems, patient treatment, complications
and postoperative protocol, and the healing process.

32 COOK & GUTOWSKY
During ward rounds, each patient is presented formally to the group by
a resident or student; this creates an opportunity to develop the skill of presenting
a case in a clear, concise, and organized manner. This process again
sparks discussion of the best treatment protocol to optimize patient care. If
a resident or student wishes to offer an opinion about treatment, and supports
his or her opinion by citing a publication with a foundation in
EBM, this often prompts a change in patient care. The focus on EBM
and staying current with the literature is paramount at this teaching institution;
this creates an environment in which attending physicians and residents
challenge each other with the most recent advances in medical
treatment [18].
Upon completion of formal teaching rounds, multiple learning issues
have been hurtled, teaching points have been addressed, and reading assignments
have been doled out. Most importantly, this process is repeated every
day. The knowledge that is amassed in this small period of time and the
number of people that benefits from this process is optimized. Studies
have shown that students who are exposed to the best teaching faculty
and residents performed better on the end of clerkship board shelf examinations
[17]. In this lies the importance of a consistent organized teaching system,
because it has proven to be the most effective way to educate future
physicians [18]. It is unfortunate that most residency programs have digressed
from this type of teaching model. It is because of this that we
have created an entire generation of podiatric residents and students who
do not see the importance and the value of formal guidance of in-house attending
physicians.
University Hospital–University of Medicine and Dentistry of New Jersey
rounds
The Podiatry Service at University Hospital–UMDNJ has instituted
a structured system for daily teaching rounds. After the residents have prerounded,
the floor attending physician meets with the podiatric surgical
team to review radiographic studies at one of the hospital's computerized
radiology terminals (Fig. 1). The previous day's postoperative radiographs,
as well as all emergency room or admitted patients' radiographic studies, are
reviewed. Literature has shown that radiographic findings can be missed
when reviewed within the excitement, and, sometimes, chaos, of the trauma
bay or emergency room [15]. By reviewing these studies the next day in
a controlled environment, any missed pathology can be addressed with clinical
efficiency. It also provides additional opportunity for discussion about
what type of treatment was instituted and to incorporate EBM treatment
protocols into practice.
Upon completion of the radiology review and discussion, inpatient rounds
commence. The patients are seen in order from the cleanest or least contaminated
wound to the most infected or those who have known multi-drug
resistant bacteria, in the hopes of preventing cross-contamination or infection.
When conducting successful teaching rounds, each member of the
team has a well-defined role for each patient seen.
Before entering the patient's room, a report, including the patient's history,
vital signs, pertinent laboratory results, diagnostic testing, and overall
patient condition, is given to the team by the resident or student who prerounded
on the particular patient (Fig. 2). This is the time when the significance
of diagnostic test results, the effectiveness of treatment, and any
alterations in treatment are discussed. Any future treatment, such as when
the patient is going to the operating room or anticipated discharge date,
Fig. 1. Inpatient rounds at University Hospital–UMDNJ begin each morning with the team
reviewing radiographic studies. All postoperative and emergency room radiographs or diagnostic
studies from the previous day are evaluated.
Fig. 2. Before entering the patient's room, the case is discussed fully by the team. EBM is incorporated
into the treatment plan at this time.
also is discussed at this time. Using this format keeps all team members on
the same page when proposing treatment options to the patient.
This is another opportunity to incorporate evidence-based literature and
medicine into teaching and practice. Practical pimping or relevant questioning
of residents and students can take place at this time. As always, ample
time should be allowed for residents and students to ask questions as well.
Upon entering the patient's room, after appropriate introductions are
made, the person who presented the patient outside of the room is responsible
for performing the dressing change when required. Usually, he or she is
assisted by one or two people and an additional person is responsible for
handing them supplies. Each member of the team is given sufficient opportunities
to examine each wound to analyze the healing process (Fig. 3). The
attending physician writes his or her daily progress notes, in addition to the
resident's daily progress notes, and any further discussion about the patient
can take place.
This process is conducted for each patient. It provides the opportunity
for each member of the team to learn from every patient contact. The senior
author concludes all ward rounds by asking the team if it has any questions,
problems, comments, or suggestions.
Summary
Teaching rounds is a vital part of every residency program and resident's
training. The Podiatry Service at University Hospital–UMDNJ believes in
adult education and encourages the residents to think for themselves. Dictating
patient care or ‘‘spoon feeding'' information to residents and students
is discouraged. Challenging the residents by way of questioning, allowing
Fig. 3. The entire team participates in dressing changes, which allows each member of the team
ample opportunity to examine the patient. Each team member should know his/her assigned
role to be performed at the bedside before entering the room. This prevents chaos and patient
apprehension.
TEACHING DURING ROUNDS 35
them to experience doctor–patient interaction, and managing pathology
during teaching rounds are used to develop highly competent residents.
Following a structured form of teaching rounds on a daily basis promotes
responsibility and fosters independent thinking and intellectual conversation.
Teaching rounds provide an avenue for incorporating EBM into practical
situations and improving patient outcomes.
Teaching rounds are a necessity for any successful residency program. As
physicians we are life-long learners and teachers, and ward rounds provide
an abundant opportunity for both.
References
[1] Osler W. On the need of a radical reform in our teaching methods: senior students. Medical
News 1903;82:49–53.
[2] Shankel SW,Mazzaferi EL. Teaching the resident in internal medicine: present practices and
suggestions for the future. JAMA 1986;256:725–9.
[3] Norgaard K, Ringsted C, Dolemans D. Validation of a checklist to assess ward round performance
in internal medicine. Med Educ 2004;38:700–7.
[4] Mooradian NL, Caruso JW, Kane GC. Increasing the time faculty spend at the bedside during
teaching rounds. Acad Med 2001;76(2):200.
[5] Ramani S. Twelve tips to improve bedside teaching. Med Teach 2003;25(2):112–5.
[6] Lehmann LS, Brancati FL, Chen MC, et al. The effect of bedside case presentations on patients'
perceptions of their medical care. N Engl J Med 1997;336(16):1150–5.
[7] Ozuah PO, Orbe J, Sharif I. Ambulatory rounds: a venue for evidence-based medicine. Acad
Med 2002;77(7):740–1.
[8] McGinn T, Seltz M, Korenstein D. A method for real-time, evidence-based general medical
attending rounds. Acad Med 2002;77(11):1150–2.
[9] Nicholson LJ, Shieh LY. Teaching evidence-based medicine on a busy hospitalist service:
residents rate a pilot curriculum. Acad Med 2005;80(6):607–9.
[10] Brancati FL. The art of pimping. JAMA 1989;262(1):89–90.
[11] Lerner BH. Young doctors learn quickly in the hot seat. The New York Times. March 14,
2006; page F5.
[12] Wear D, Kokinova M, Keck-McNulty C, et al. Pimping: perspectives of fourth year medical
students. Teach Learn Med 2005;17(2):184–91.
[13] Wild D, Nawaz H, Chan W, et al. Effects of interdisciplinary rounds on length of stay in a telemetry
unit. J Public Health Manag Pract 2004;10(1):63–9.
[14] Halm MA, Gagner S, Goering M, et al. Interdisciplinary rounds: impact on patients, families,
and staff. Clin Nurse Spec 2003;17(3):133–42.
[15] Hoff WS, Sicoutris CP, Lee SY, et al. Formalized radiology rounds: the final component of
the tertiary survey. J Trauma 2004;56(2):291–5.
[16] Whittaker LD, Estes NC, Ash J, et al. The value of resident teaching to improve student perceptions
of surgery clerkships and surgical career choices. Am J Surg 2006;191:320–4.
[17] Irby DM, Papadakis M. Does good clinical teaching really make a difference? Am J Med
2001;110:231–2.
[18] Richardson JD. Training of general surgical residents: what model is appropriate?AmJ Surg
2006;191:296–300.
36 COOK & GUTOWSKY

 

[Dr_Feelgood]

Since we have had some recent debate on the qualifications of DPMs I figured I'd post a few articles on the subject.

 

[Dr_Feelgood]

Whither podiatry?

Gary Peter Jolly, DPM

In 1973, Robert Samilson, MD, president of the American Orthopedic Foot and Ankle Society, chose as the topic for his inaugural address “Whither Podiatry? — The Age of Reason.” His speech, in its entirety, was published in The Orthopedic Clinics of North America (1). His presidential address disturbed me when I read it for the first time and it continued to haunt me for many years after. As I prepare to assume the presidency of the American College of Foot and Ankle Surgeons, I have been asked to contribute an editorial. I would like to take advantage of this opportunity to offer a well-deserved, if belated, response to Dr Samilson’s address.

Samilson, acknowledging his reliance on information about the podiatry profession from published data from the late 1960s and early 1970s, observed that surgical training for podiatrists was vastly inferior to that of orthopedic surgeons. He opined that podiatrists should be allowed to perform basic outpatient procedures, providing they are under the supervision of an orthopedic surgeon. Although Samilson’s words may have carried some truth, I was nevertheless personally hurt and offended by them. As a podiatric medical student with a healthy case of self-importance, I reacted to Samilson’s speech by trivializing his observations about my chosen profession. However, with the passage of time, the acquisition of maturity, and an appreciation for the quantum leaps in the training of podiatric foot and ankle surgeons, my feeling toward his essay has changed.

If the truth be told, the profession of podiatry in 1973 was vastly different than it is today. There were glaring differences in both the predoctoral and postgraduate training between podiatrists and orthopedic surgeons. At the time, only a limited number of residencies offered 1 year of training, and even fewer institutions provided an optional second year. By and large, orthopedic surgeons operated in hospitals, whereas podiatrists operated in outpatient facilities and in offices. The case mix of the 2 groups was therefore vastly different, reflecting the differences in their training.

Samilson suggested that, if podiatrists were to become legitimate foot and ankle surgeons, they would have to change the way in which they were educated, and, for this, he offered a model. He suggested that those podiatrists wishing to become surgeons should apply and be admitted to allopathic medical schools, so that on graduation, they could pursue training as orthopedic surgeons. This was quite a revolutionary thought! However, the lack of enthusiasm from the Association of American Medical Colleges essentially doomed this idea.

Although the allopathic community failed to embrace the concept, a response to this challenge arose from within the podiatric community itself, resulting in the development of podiatric foot and ankle surgery as a recognized specialty.

This came to be in 1975 with the founding of the American Board of Podiatric Surgery. For the first time ever, there was a standardized instrument to test competencies in foot and ankle surgery. Recognizing the need for credibility in a harsh sociopolitical environment, the American Board of Podiatric Surgery has been meticulous in the administration of its examinations. Today, Diplomats of the American Board of Podiatric Surgery are, in fact, the only individuals who have ever presented credentials for review and successfully sat for examinations in foot and ankle surgery.

Since Dr Samilson’s inauguration, there have been dramatic changes in the education of DPMs. The curricula of the podiatric medical schools have undergone standardization and radical revisions in content. Graduates of accredited podiatric medical schools are prepared to function competently as house officers in general hospitals during their postgraduate training, and it is now commonplace for first-year residents in foot and ankle surgery to function as completely integrated interns on medical and surgical services. In fact, it is a requirement of the Council on Podiatric Medical Education that all podiatric residencies provide this experience.

Postgraduate training in foot and ankle surgery has moved toward a standard 3-year model, with additional years of fellowship for reconstructive foot and ankle surgery now available. Podiatric surgery residents and fellows train with orthopedic surgeons, and podiatric surgery residents and orthopedic residents interact on a regular basis. I am fortunate to be affiliated with a 3-year surgical residency that also sponsors a postresidency fellowship. My present fellow is in his fifth postgraduate year.

An interesting literary revolution has been taking place in the field of foot and ankle surgery during the past decade as well. Orthopedic surgeons have been submitting manuscripts for publication to the Journal of Foot & Ankle Surgery on a regular basis and podiatric foot and ankle surgeons have had articles published in both Foot & Ankle International and the Journal of Bone & Joint Surgery. In 1973, podiatric literature was not even referenced in orthopedic journals, and that has changed as well. The reality is that the art and science of foot and ankle surgery is shared by both disciplines, and although the pathways to competence may be different, oddly enough they lead to the same place. This is as it should be.

Dr Samilson stated that the public good was at the heart of his concerns, and I now believe that it was. It is my concern as well, and that of the American College of Foot and Ankle Surgeons. How then can we, as interested parties, ensure competence in foot and ankle surgery by those who practice it?

Our specialty is currently being practiced by orthopedic surgeons and podiatric surgeons. Yet only 1 group is actively testing for competence. Perhaps the time has come for all foot and ankle surgeons to submit their credentials and sit for a standardized certification or certificate of advanced qualification. In a recent article, the authors, who were orthopedic surgeons, stated that the exposure to foot and ankle surgery in American orthopedic residencies was found to be anything but standardized (2). How then can an orthopedist’s competence in foot and ankle surgery be assured? It must also be asked whether there is a standardized curriculum for orthopedic foot and ankle fellowships, as there are for podiatric foot and ankle surgery residencies. Are foot and ankle fellowship-trained orthopedists trained as well in the treatment of the diabetic foot as they are in trauma?

On an individual as well as on an organizational level, the protection of the public should be at the heart of our professional activities. Wouldn’t the public be best served by a cooperative effort between the Orthopedic Foot and Ankle Society and the American College of Foot and Ankle Surgeons in the areas of education and credentialing? Aren’t the articles published in Foot & Ankle International and in the Journal of Foot & Ankle Surgery read by all foot and ankle surgeons, whether they care to admit it or not? Despite the historical and political differences, and the mutual suspicions that existed between these 2 groups, the fact of the matter is that they have more in common than that which divides them. Perhaps the time for a meaningful dialogue between our organizations has arrived. Perhaps the Age of Reason has begun.

References

1. Samilson R. President’s address: whither podiatry?—the age of reason. Orthop Clin North Am 1974;5:3-6.


2. Pinzur M, Mikolyzk BS, Aronow M, DiGiovanni B, Mizel M, Pinney S, Saltzman C, Temple T. Foot and ankle experience in orthopedic residency. Foot Ankle Int 2003;24:567-569.

 

[Dr_Feelgood]

Foot and Ankle Experience in Orthopaedic Residency
Michael S. Pinzur, M.D.; David Mikolyzk, B.S.; Michael S. Aronow, M.D.; Benedict F. DiGiovanni, M.D.; Mark S. Mizel, M.D.; Stephen J. Pinney, M.D.; Charles L. Saltzman, M.D.; H. Thomas Temple, M.D.

ABSTRACT

Background: Dedicated orthopaedic residency training in the musculoskeletal discipline of foot and ankle is an important contribution to the development of a well-rounded orthopaedic surgeon. Current residency training guidelines are vague and do not require specific experience or proficiency in this discipline. Methods: A one-page questionnaire on commitment to foot and ankle education in American Orthopaedic Surgery residency training programs was completed by all 148 program directors. Results: Eighty of the programs (54.1%) had a single faculty member dedicated to foot and ankle orthopaedics, while 21 (14.2%) did not have a faculty member with a specific interest or commitment to problems related to the foot and ankle. Fifteen programs (10.1%) did not have a committed faculty member, nor did their residents have a clinical rotation dedicated to foot and ankle. Ninety-six programs (64.9%) had at least one clinical rotation dedicated to foot and ankle. Fifty-two (35.1%) did not. Thirty-three (34.7%) of those programs with a dedicated foot and ankle experience assigned residents during at least two periods of their training. Of those programs with a single foot-specific rotation, the most common year for training was in the PGY3 year (27 of 63, 42.9%). Of the 60 months’ duration of most orthopaedic residency programs, 39 of 96 (40.6%) programs with a dedicated clinical foot and ankle rotation allocated an average of 12 weeks to foot and ankle. Twenty-six (27.1%) allocated less than 3 total months, and 31 (32.3%) allocated 16 to 24 weeks of dedicated foot and ankle experience. Conclusions: Current residency training in the United States does not universally require a commitment to foot and ankle education. A large number of residency programs do not have a faculty member committed to foot and ankle education, and almost one-third have no time specifically allocated to foot and ankle education.

INTRODUCTION

‘‘Foot and ankle orthopaedics is a subspecialty of orthopaedic surgery that includes the in-depth study, prevention, and treatment of musculoskeletal diseases, disorders, and sequelae of injuries in this anatomic region by medical, physical, and surgical methods.’’1 This statement is taken directly from the program requirements for residency education in foot and ankle orthopaedics of the Accreditation Council for Graduate Medical Education in the United States. While there are specific requirements for fellowship training postresidency, this vague statement is all that is available to guide program chairs with respect to foot and ankle competencies. The American Orthopaedic Foot & Ankle Society has recently developed the core competencies deemed necessary for an adequate understanding of the foot and ankle subspecialty.2 In an effort to determine the exposure to the discipline of foot and ankle orthopaedics being experienced by orthopaedic residents in the United States, the Resident Education Committee of the American Orthopaedic Foot & Ankle Society initiated a survey of program chairs.

METHODS

In the fall of 2002, a one-page questionnaire was circulated to the 148 chairpersons of residency programs in orthopaedic surgery in the United States that have been accredited by the Accreditation Council for Graduate Medical Education (Fig. 1). The questionnaire asked for the following information: 1) the number of program faculty with a dedicated interest in foot and ankle orthopaedics, as defined by having foot and ankle encompass at least 50% of their clinical practice; 2) the presence of a clinical rotation dedicated to foot and ankle; 3) the year of training for the foot and ankle experience; and 4) the duration of the foot and ankle clinical experience. Those program chairs that did not return their questionnaires were contacted by telephone.

RESULTS

All 148 program chairpersons responded to the questionnaire. The results are listed in Table 1. Eighty (54.1%) of the responding programs had a single faculty member, while 21 programs (14.2%) did not have a faculty member with a dedicated interest in foot and ankle orthopaedics. Fifteen programs (10.1%) did not have a committed faculty member, nor did their residents have a clinical rotation dedicated to foot and ankle. Ninety-six of the programs (64.9%) had a dedicated clinical foot and ankle experience. Thirty-three of the programs (34.7%) assigned their residents to clinical foot and ankle rotations at multiple times during their training. When residents had a single foot and ankle clinical experience, it was generally in their PGY3 level of training (27 of 63, 42.9%) The total duration of their foot and ankle clinical experience ranged from as little as 6 weeks, to as much as 24 weeks, out of a possible 260 weeks of residency training.

DISCUSSION

It is difficult to dispute the importance of foot and ankle orthopaedics as an important component of curriculum of a residency training program in orthopaedic surgery. This report points out the disparity of commitment to this important discipline in American graduate medical education in orthopaedic surgery. While most programs are in compliance with the spirit of the guidelines published by the Accreditation Council for Graduate Medical Education, many programs offer virtually no exposure to this important discipline. The information derived from this survey offers a substantial opportunity for improvement in orthopaedic graduate medical education. The Knowledge Map and Core Competencies2 are readily available to those programs without a faculty member. It is hoped that this information will point out the important contribution to resident education afforded by an experience in foot and ankle orthopaedics.

REFERENCES

1. Accreditation Council for Graduate Medical Education. 2003. Available at: www.acgme.org.

2. Knowledge Map and Core Competencies for Foot and Ankle. The American Orthopaedic Foot and Ankle Society. 2002. Available at: www.aofas.org.

 

[krabmas]

I would like some info on the requirements for fellowship trained foot and ankle orthopods. does any one have this info? or where to find it?

I do not really care about the general or other specialty trained orthopods and their lack of foot exposure. I think we should compare grannysmith apples with golden delicious apples not apples and oranges.

 

[krabmas]

I started looking for info for my above post:

This is the curriculum for the Mayo Clinic Foot and Ankle Fellowship...

This fellowship offers you a unique opportunity to participate in a team approach to foot and ankle surgery. You will have opportunities to develop your surgical, clinical and problem-solving skills. The Division of Foot and Ankle Surgery sees approximately 650 patients and performs more than 60 surgical procedures each month. Consultants and fellows see patients who suffer from a variety of problems. Complaints range from straightforward examples of painful bunions and interdigital neuromas to complex problems such as post-traumatic avascular necrosis or failed total ankle anthroplasty.

Rotations
Your training will be divided into two six-month rotations. You will spend one rotation with each of Mayo's two foot and ankle surgical consultants. Each will demonstrate slightly different techniques and philosophies of caring for foot and ankle problems. Training with this variation in techniques will help you develop your own approach and give you the confidence needed to handle the unique problems you will encounter in your own clinical practice.

Didactic Training
Clinical conferences, seminars, small discussion groups, a journal club and one-on-on instruction are all integral parts of the program. Grand Rounds in orthopedic surgery is held once each month. On a rotating basis, you will prepare and make presentations about your research interests or a new clinical/surgical technique to the other orthopedic residents, fellows and consultants.

Research Training
Mayo offers outstanding opportunities for you to conduct basic scientific or clinical research. During the fellowship, you will be encouraged to participate in the development of two manuscripts suitable for presentation and/or publication in a peer-reviewed journal.

Call Frequency
Your call schedule will vary by rotation. Mayo Clinic follows the schedule recommendations of the Accreditation Council for Graduate Medical Education.

Evaluation
To ensure that you acquire adequate knowledge and develop your technical skills, your performance will be monitored carefully during the course of your fellowship. You will be evaluated formally by your supervising faculty member after each clinical rotation. In addition, you will regularly evaluate the faculty to ensure that your educational needs are being met.

 

[krabmas]

Here is a link to a list of F and A fellowships: http://www.aofas.org/files/public/2007-08_FA_fellowships_available_2_12_07.doc

Not all of them are a full year. There is at least one that is only 6 months.

Many of them are not accredited by ACGME. Maybe accreditation is not as important in the MD world?

 

[Dr_Feelgood]

Expanding Roles of the Orthopaedic Surgeon
James D. Heckman, MD

Excerpt

Foot Care

Probably the most dramatic example where the specialty of orthopaedics has allowed its scope of practice to decrease is in the diagnosis and treatment of foot disorders. Finding it unattractive, unexciting, or not as rewarding as treating high performance athletes or doing total joint replacement, as a profession orthopaedists have neglected foot care. Because there is a tremendous demand for these services, the fields of podiatry and podiatric surgery have grown rapidly, expanding into the void created by orthopaedic surgeons during the last 3 decades. By providing timely, compassionate hands-on care, podiatrists have established themselves as the predominant providers of basic foot care in the United States. The number of podiatrists is approximately equal to the number of orthopaedic surgeons in the United States.6 Orthopaedic surgeons still remain well educated and trained in the treatment of foot disorders, and should be able to provide very effective care. Current efforts are underway by the American Academy of Orthopaedic Surgeons and the American Orthopaedic Foot and Ankle Society to increase the emphasis on the delivery of foot care services in the orthopaedist's office. In a cost-effective way, this program will create the opportunity for many orthopaedic surgeons to hone their skills and, in conjunction with their office staff, provide a quality and level of foot care that will be very satisfying to the surgeon and the patient. Recovery of those lost aspects of orthopaedic care should be easy and right in line with the goals of orthopaedic surgeons. The few examples listed are merely examples of how the exceptional education and training of the orthopaedic surgeon can be used to recover areas of lost influence and practice to expand the scope of his or her practice. Careful attention given to one's specific local environment certainly can identify other similar avenues.

References
6. Laughlin RT, Hartson JO, Wright DG: Training in foot and ankle surgery. Curr Opin Orthop 7:75–80, 1996.

 

[Dr_Feelgood]

Expanding the Orthopaedist’s Role in the Treatment of Foot and Ankle Disorders
Shepard Hurwitz, MD; and Enyi Okereke, MD

Many opportunities exist and more will become available for expanding the role of orthopaedic surgeons in the treatment of patients with foot and ankle conditions in the United States. The current authors present the main areas of opportunity: giving comprehensive foot care to patients who already are treated by orthopaedic surgeons and the application of advanced scientific biotechnology that will improve outcomes for patients with foot and ankle conditions who currently do not have satisfactory treatment. Orthopaedic surgeons must maintain a high level of commitment in their education and professional availability to patients and primary care physicians to expand their participation in foot and ankle care. Networking with physician and nonphysician primary care providers and volunteering educational services for fellow professionals in the evaluation and treatment of the entire spectrum of foot and ankle conditions is necessary. The general orthopaedist and the orthopaedic foot and ankle specialist can share in the future of treatment of patients with foot and ankle conditions in the United States.

The specialty area of foot and ankle surgery remains a small part (approximately 8% of the surgical volume) of general orthopaedic practice.18 With an increasing number of subspecialty trained foot and ankle orthopaedic surgeons, there is no accepted number of foot and ankle surgeons needed in the United States to provide optimum care and provide for the continued momentum in education and research.5,11,12,25 Moreover, a recent public survey commissioned by the American Academy of Orthopaedic Surgeons4 reported that 79% of the sampled population consider podiatrists as the first physicians with whom they would seek foot care, and the remaining 21% is shared with orthopaedic physicians and physicians who are not orthopaedists. Workforce surveys and public opinion surveys commissioned by the American Academy of Orthopaedic Surgeons are building the foundation for enhancing the involvement of orthopaedic surgeons in caring for foot and ankle conditions in patients in the United States.3,4

The past president of the American Orthopaedic Foot and Ankle Society, in his presidential address noted, “Most of the prevailing trends in operative care of the foot have been pioneered by orthopaedists. Orthopaedists must not let the leadership for the care of this important part of the body slip from the control of traditional medicine”8 Orthopaedic surgery is partly based on providing musculoskeletal care to the community at large, and to those individuals with foot and ankle conditions in particular.10,12 The introduction of new diagnostic and therapeutic procedures will include numerous advances that improve the health and lifestyle of patients with foot and ankle disorders. Progress in orthopaedic imaging (magnetic resonance imaging, realtime ultrasound) and implant hardware has advanced the level of care for patients with difficult foot and ankle fractures, arthrosis, instability, and foot salvage in patients with diabetes. Application of arthroscopy to the ankle, hindfoot, and sinus tarsi have improved certain patient outcomes and reduced the length of hospital stay. Better footwear, orthoses, and rehabilitation currently exist for treatment of patients who are treated as outpatients by orthopaedists and similar improvements have been made in postoperative treatment of patients with painful foot conditions.6 General orthopaedists and orthopaedic surgeons who specializes in foot and ankle should be familiar with the expanding spectrum of treatable conditions that exist in the general population.2,9,10,20

The current authors want to make orthopaedists aware of the potential for increasing their role in caring for patients with foot and ankle conditions in the United States. Opportunities for treating foot and ankle conditions come from patients already familiar to the surgeon because of hip, knee, or other musculoskeletal complaints. Simply examining patients’ feet may reveal the need for surveillance of a potential problem (a patient who recently was diagnosed with diabetes), or a treatable condition that warrants followup (a
runner with tight heel cords and a plantar keratosis). Involvement in foot and ankle care for the geriatric population is a new direction that orthopaedists should follow1, including visiting elder care facilities rather than having the residents of these facilities travel to an office or clinic for simple toenail or skin care.2,17 There will be applications of cartilage implantation or laser capsuloplasty that a general orthopaedist or sports medicine orthopaedist transfers from experience in the knee or shoulder and uses to treat ankle conditions. Increased survivorship of front seat passengers because of automobile airbags will increase the number of patients with difficult foot and ankles fractures who require treatment by an orthopaedists. There also will be a commensurate increase in the number of reconstructive procedures that follow complex fracture care. In the domain of complex fracture care, orthopaedic surgeons provide the majority of care, whereas orthopaedic surgeons rarely treat patients with simple inversion ankle sprains or contusions.

MATERIALS AND METHODS
The authors performed an English language literature review for the years 1966 to 1999 using key words including foot, ankle, surgery, pain, injury, diseases, repair, manpower, practice, orthopaedic surgery and orthopaedic training. Some of the concepts dealing with practice patterns were searched using the MeSH (Medical Subject Heading) medical practice, foot care, foot disorders, podiatric care, and outpatient management. A search of abstracts was conducted from print sources in the American Orthopaedic Foot and Ankle Society scientific programs, the American Academy of Orthopaedic Surgeons annual meeting program, and from Orthopaedic Transactions, which is published by the Journal of Bone and Joint Surgery. Also reviewed was the In Stride newsletter of the American Orthopaedic Foot and Ankle Society and the Bulletin of the American Academy of Orthopaedic Surgeons. An outline of the practice areas that likely will see increasing participation by orthopaedic generalists and subspecialists in the care of foot and ankle conditions was generated. The increase in service will be based on population dynamics, innovations in orthopaedic care, resident education, and continuing medical education after residency.16,20,21

RESULTS
General orthopaedists care for large numbers of foot and ankle problems in patients in the United States,17–19 including trauma, tumors, infection, arthritis, deformity, diabetes, overuse syndromes, and amputation. There are no data that report on the efficacy of orthopaedic evaluation and treatment versus the treatment provided by podiatrists or other physician specialists.7 There are no data to suggest that general and subspecialty orthopaedists differ in their ability to evaluate foot and ankle problems, to treat patients with common and uncommon conditions, to economically expend resources on evaluation and treatment, and to provide acceptable outcomes. The population-based research that exists for foot and ankle care in the United States is limited in scope and is not concerned with medical or surgical specialty.3,4 To expand the orthopaedic surgeon’s involvement in foot and ankle care there should be a commitment to improve the availability of orthopaedic surgeons, to maintain a high level of diagnostic acumen, and to possess the necessary treatment skills.24 The level of diagnostic and surgical skill needed for the treatment of foot and ankle conditions starts in orthopaedic residency and continues in practice with continuing medical education courses throughout the years that a surgeon is in practice.16,21,22 Developing the willingness among general orthopaedists to evaluate and treat patients with foot problems remains the greater challenge.

The education of the general orthopaedist includes a considerable body of knowledge about the human foot and ankle. The basic and biomedical applied sciences needed to understand the function of the foot and ankle begins in medical school and is completed in orthopaedic residency. Residency should provide the knowledge and skills to interpret signs and symptoms of foot and ankle conditions, arrive at a diagnosis, and competently deliver treatment and followup care. Efforts to have a foot and ankle core curriculum in residencies in the United States is underway.16,23 Furthermore, ample continuing medical education opportunity exists for practicing orthopaedists to acquire additional psychomotor skills in foot and ankle care and to update their knowledge of the treatment of patients with foot and ankle conditions.

Population growth curves and level of service based on current rates of service are combined to give a generic impression of the incidence of new foot and ankle problems and the prevalence of existing foot and ankle conditions.17,18 Most publications discuss the number of medical specialists being trained and the numbers of specialists for the national or regional population.9,12,14,25 The areas of orthopaedic subspecialization are not clearly isolated in the workforce projection for the United States in the next 30 years. Foot and ankle specialists are predominantly podiatrists and orthopaedists although an increasing number of physician and nonphysician providers are delivering foot and ankle care to their patients.19 The amount of acute and chronic foot and ankle care provided by primary care physicians (including physician assistants and nurse practitioners) and emergency physicians cannot be found in the literature.

There were 11 literature references to the orthopaedic workforce needs,5,10–12,14,17–20,23,25 and one reference specifically for foot and ankle care.19 None of the abstracts that were scanned referred specifically to the workforce issue of foot and ankle care by orthopoedists or to expanding the role of the orthopaedic surgeon in treating patients with foot and ankle conditions. There were two commentaries of relevance.2,23 and three editorials in which orthopaedic foot and ankle issues were mentioned.11,12,19

DISCUSSION
There are two domains in which orthopaedic surgeons may expand their practice in caring for patients with foot and ankle conditions: existing practice opportunities (Table 1), and future treatments created by technologic innovation in orthopaedic surgery (Table 2). Existing practice opportunities include nonsurgical footcare for healthy adults, patients with diabetes, and elderly patients. Opportunity exists in trauma centers for orthopaedic surgeons to participate in partial foot amputations, burn care of the feet, crush injuries to the lower leg and foot, gunshot wounds of the foot, and foot care for patients with brain and spinal cord injuries. Networking among physicians is an opportunity to let fellow physicians know that there are surgeons who can provide full service care for patients with foot problems. Networking among physicians includes educating others about the services provided by a well-trained and motivated orthopaedic colleague. It is important that physicians who provide musculoskeletal referrals be aware that orthopaedic surgeons are willing to treat patients with bunions or plantar keratosis and patients with arthritis in the knee.

Speaking at hospital or medical societies, patient support groups, or community action groups is important in bringing the issue of foot care to the primary care physician and the healthcare consumer.8 Lectures about preventive and nonoperative footcare for an otherwise healthy individual are helpful means to educate physicians, patients, and the general public about the availability of orthopaedic surgeons as a resource for education, knowledge, and clinical expertise for foot problems. The reputation of orthopaedists is enhanced if they are interested in caring for the entire musculoskeletal system by participating in public meetings during which the diagnosis and treatment of foot and ankle conditions are discussed.23

Effective treatment of foot problems in patients with diabetes requires a combination of operative and nonoperative interventions; both interventions must be exercised timely and skillfully. The goal of foot care in the patient with diabetes is to diagnose and treat those conditions that, if not treated successfully, will lead to amputation or loss of function. If a patient with diabetes requires foot or leg amputation, an orthopaedic surgeon is best suited to perform a reconstructive surgery, to facilitate the prosthetic limb replacement, and to orchestrate the rehabilitation of a patient who underwent amputation.

Many elderly individuals are very active and have good general health, and they may have foot problems that threaten their enjoy ment of the golden years. Others are unable to reach their feet to trim toenails or calluses and have difficulty with foot hygiene. Likewise, poor eyesight or senile dementia may inhibit routine self-care for basic footcare. These are areas of opportunity in which availability of the orthopaedists’ time is essentially all that is needed. The more complex problems associated with poor peripheral vasculature or peripheral nerve dysfunction are more likely to be encountered in the general elderly population, and a well trained orthopaedic surgeon will be able to provide most of the foot care needed.

Future technologies and their biologic applications will drive future opportunity in the evaluation and treatment of patients with foot and ankle disorders by orthopaedic surgeons. This will most probably start with improved joint replacement arthroplasty of the ankle and great toe metatarsophalangeal joint. There will be advances in arthroscopic techniques for conditions of the ankle, subtalar joint and sinus tarsi, midfoot joints, and metatarsophalangeal joints. Endoscopic procedures will be developed for tendon disorders. Endoscopic plantar fascia release and tarsal tunnel release currently are being performed, although the evidence is clearly not available for outcomes compared with open techniques. The application of laser technology and ex vivo tissue cloning are perhaps next in the arthroscopic-assisted treatment of patients with ankle laxity and focal cartilage injury. Biologic measure that can regenerate bone, cartilage, ligament, tendon, muscle, and nerve eventually will be part of the interventional repertoire of a highly skilled foot and ankle surgeon. There will be a need for microvascular techniques to attach various tissues to one another such as regenerate nerve fibers to motor endplates in the muscle, or attach a cloned tendon to the muscle belly.

Orthopaedic residency educates the general orthopaedist well enough to care for most injuries and infections of the foot and ankle. There are approximately 680 newly trained orthopaedists annually in the United States.5,22,25 Each year between 20 and 28 board eligible orthopaedists take a 1-year postgraduate fellowship to gain expertise in foot and ankle problems in adults, and between 15 and 20 take a 1-year fellowship in pediatric orthopaedics and specialize further in the care of foot problems in children.15,22 In addition to orthopaedic subspecialization in foot and ankle, there are podiatrists and nonsurgical physicians who provide footcare, mostly physicians who specialize in family medicine, internal medicine, rehabilitation medicine, and emergency medicine. One model of cooperative footcare is the United States Veterans Administration where podiatrists and othopaedists staff the foot clinics. Another cooperative model is a medical center, such as the Joslin Diabetes Center (Boston, MA), where special attention is given to footcare in patients with diabetes. In these clinics the services of podiatrists, orthopaedists, endocrinologists, and vascular surgeons are combined with technical and special nursing support staff.13,19

The incidence and prevalence of foot injuries and illness is keeping pace with population growth, so the demand for foot and ankle care can be expected to expand as the general population increases. The likelihood of increasing the incidence of foot and ankle injuries exists when there are trends such as greater participation in sports by adolescents, or riskier sports, snowboarding versus snowshoeing, or changes in the status of teenage driving (younger age limits, no driver’s education).

Within the orthopaedic workforce there is a sense that the foot and ankle subspecialist is available for difficult fractures and complex reconstruction whereas the general orthopaedist is available to evaluate and initiate treatment for all patients with foot and ankle problems. There are no specific guidelines that dictate when a general orthopaedist must, or should, refer a patient for subspecialty care. Podiatrists tend to defer to orthopaedic surgeons for operative treatment of foot and ankle fractures or difficult ankle and hindfoot reconstructions. Again, there are no guidelines in most instances when a podiatrist should refer a patient to an orthopaedist. Some orthopaedists have incorporated a podiatrist in their group practice to treat common problems (toenail care, bunions, hammer toes, calluses, heel pain). By contrast, many primary care physicians do not choose orthopaedic surgeons as the first referral for their patients with foot and ankle problems, choosing to treat simple foot problems and refer the patients with more difficult problems to podiatrists. Many simple conditions such as ankle sprains now are treated by physicians who specialize in family medicine or emergency medicine or by nurse practitioners. Patients with common foot problems such as acute plantar heel pain or ingrown toenails are referred to podiatrists by emergency or primary care practitioners. This practice pattern will change if orthopaedists are committed and available as first referral providers of foot and ankle care.

Expanding the role of American orthopaedic surgeons in the treatment of patients with foot and ankle conditions is a subject worthy of attention. The growth of the general populations, the increasing proportion of elderly individuals, and the incidence of foot and ankle trauma are all likely to expand the need for foot and ankle care in the United States. Local factors such as limited availability of foot and ankle care services and scarcity of foot and ankle care providers will present regional opportunities for appropriately trained orthopaedic surgeons. There are opportunities to provide more service to patients that are already known to the general orthopaedist, and there are opportunities being developed by new procedural solutions to old questions. Is there a need to compare the cost and efficacy of similar services provided by family medicine doctors, podiatrists, general orthopaedists, and subspecialty orthopaedists in the care of foot and ankle problems? In terms of cost to payers, the relative value (cost to achieve final outcome per patient) is important. Clearly, the decision of cost versus quality of foot and ankle care will be decided in the public arena by healthcare consumers, and the orthopaedic surgeons in the United States must be available and competent foot and ankle care providers if they are to be competitive. Education, training, competency, continuing medical education, and a proactive willingness to participate in evaluation and treatment are required in caring for conditions of the foot and ankle.

References
1. American Academy of Orthopaedic Surgeons Bulletin: Aging U.S. to Challenge Orthopaedists. Vol 43. Rosemont, IL, American Academy of Orthopaedic Surgeons 20–21, 1995.

2. American Academy of Orthopaedic Surgeons Bulletin: Foot, Ankle Program to Expand Scope. Vol 47. Rosemont, IL, American Academy of Orthopaedic Surgeons 54–55, 1999.

3. American Academy of Orthopaedic Surgeons Bulletin: Marketing in an HMO Market. Vol 47. Rosemont, IL, American Academy of Orthopaedic Surgeons 37–41, 1999.

4. American Academy of Orthopaedic Surgeons Bulletin: Why the Public Doesn’t Use Orthopaedists. Vol 47. Rosemont, IL, American Academy of Orthopaedic Surgeons 21–22, 1999.

5. American Association of Medical Colleges Data Book: Washington, DC, American Association of Medical Colleges 1998.

6. Bowman MW: Treatment of the Foot and Ankle: A Guide for Office-Based Primary Care. Seattle, American Association of Orthopaedic Foot and Ankle Surgeons 1998.

7. Buckingham K, Freeman PR: Sociodemographic and morbidity indicators of need in relation to the use of community health services. Br Med J 315:994–96, 1997.

8. Clanton TO: Presidential Address. American Orthopaedic Foot and Ankle Society. In Stride 12:1–7, 1999.

9. Escarce JJ: Explaining the association between surgeon supply and utilization. Inquiry 29:403–415, 1992.

10. Flynn JM, Fernandez R, Reina RJ: Puerto Rico orthopaedic manpower study. Puerto Rico Health Sciences J 15:269–273, 1996.

11. Gartland JJ: Demand for orthopaedic surgeons. J Bone Joint Surg 79A:1279–1281, 1997.

12. Greer III RB: Predicting the orthopaedic workforce: Part I. Orthop Rev 23:294–296, 1994.

13. Harris RB, Harris JM, Hultman J, et al: Differences in cost of treatment for foot problems between podiatrists and orthopaedic surgeons. Am J Managed Care 3:1577–1583, 1997.

14. Heckman JD, Lee PP, Jackson CA, et al: Orthopaedic workforce in the next millennium. J Bone Joint Surg 80A:1533–1551, 1998.

15. Herndon JH: Subspecialty training during residency and the ideal academic fellowship. J Bone Joint Surg 80A:1836–1838, 1998.

16. Hurwitz SR: Guidelines for teaching the foot and ankle in an orthopaedic residency. Foot Ankle Int 20:272–275, 1999.

17. Lee PP, Jackson CA, Relles D: Demand based assessment of workforce requirements for orthopaedic services. J Bone Joint Surg 80A:313–326, 1998.

18. Praemer A, Furner S, Rice DP: The Economic Burden of Musculoskeletal Conditions, 1995. In Praemer A (ed). Musculoskeletal Conditions in the United States. Rosemont, IL, American Academy of Orthopaedic Surgeons 139–167, 1999.

19. Rudicel S: The orthopaedic/podiatric dilemma. Foot Ankle Int 16:378–380, 1995.

20. Sammarco GJ: Goals reflect society’s widening scope. In Stride 9:1, 1996.

21. Sarmiento A: Education is the key to non-operative care. Am Acad Orthop Surg Bull 47:49–50, 1999.

22. Simon MA: Orthopaedic surgery fellowships: A ten year assessment—Evolution of the present status of orthopaedic surgery fellowships. J Bone Joint Surg 80A:1826–1829, 1998.

23. Smith RW: AAOS, AOFAS join forces on foot care. In Stride 12:1, 1999.

24. Urbaniak JR: Impact of fellowships on orthopaedic surgery residencies, patient care and orthopaedic practice. J Bone Joint Surg 80A:1830–1833, 1998.

25. Weinstein JN, Goodman D, Wennberg JE: The orthopaedic workforce—Which rate is right? J Bone Joint Surg 80A:327–330, 1998.

 

[krabmas]

Expanding Roles of the Orthopaedic Surgeon
James D. Heckman, MD

Excerpt

Foot Care

The number of podiatrists is approximately equal to the number of orthopaedic surgeons in the United States.

References
6. Laughlin RT, Hartson JO, Wright DG: Training in foot and ankle surgery. Curr Opin Orthop 7:75–80, 1996.

This statement is interesting because there are approximately the same number of podiatrists in the entire US as there are orthopedists in NY.

So unless all the orthopedists that practice in the US are practicing in NY then there is something wrong with this statement.

Maybe they meant there are the same number of orthopedic F and A as there are pods?

 

[Dr_Feelgood]

This statement is interesting because there are approximately the same number of podiatrists in the entire US as there are orthopedists in NY.

So unless all the orthopedists that practice in the US are practicing in NY then there is something wrong with this statement.

Maybe they meant there are the same number of orthopedic F and A as there are pods?

I don't know. The article was discussing increasing foot and ankle across the board in orthopedics. I'd be happy to post the entire article if you'd like.

 

[krabmas]

Foreword
Consulting Editor
‘‘Are you a real doctor?’’
‘‘No, but I did stay at a Holiday Inn Express last night.’’
dCommercial paraphrase
I think we have got it all wrong when it comes to our professional image.
I don’t make that statement lightly, and unfortunately it forces us to take
a long, hard look at the product we have made visible to the world.
Recently, I had the immense pleasure of being selected as the Chief Medical
Officer (CMO) of our medical center. Through all of the excitement of
the challenge of the job, I had lost site of the sheer volume of work that went
into being a successful CMO. I find myself juggling the duties of administration
with those of being a podiatrist. Although abbreviated in time, I still
practice podiatry and feel that it is a necessity to remain connected with
my physician brethren at the hospital. After all, it has been my experience
that when a practicing physician gives up the practice and becomes ‘‘just
a suit,’’ other physicians loose confidence in that individual.
When the official announcement was made, there were many accolades,
and it was a time to celebrate both a personal and professional
accomplishment, until. . . We are the County hospital and thus beholden to
the County tax payers. Therefore, we are frequently the target of the Des
Moines Register’s watchdog reporter, and just about anything we do seems
to make the paper. The reporter who covers our institution called the day
after the announcement was made and asked, ‘‘Is he a real doctor?’’
This got me thinking about where we are going and what we are trying to
accomplish as a profession. I have been involved in meetings in which we
argue about who is going to be cutting patients’ toenails, who should be
physically debriding ulcers, should the physical therapist be recommending
or making inserts, and so forthdand we fight vehemently about these items.
I have seen the profession become exclusionary to its own members, almost
gleeful that we are not all one brotherhood under podiatry and competing
against each other rather than working toward a goal of podiatry for all
and all for podiatry (yes, there is a bit of the Three Musketeers in that statement,
but why not?)dand all for the benefit of our patients!
Apart from the internal fighting, what have we done to promote ourselves
to the world? How does the public see us? How do our colleagues in the
allopathic and osteopathic professions see us? If the public and other professionals
see us as ‘‘less than,’’ then isn’t it our fault? How could it not be? No,
I don’t believe that changing our degree is the answerdI believe changing
our image is! And it starts from the get-go. Are colleges of podiatric medicine
preparing their students mentally to be physicians? I’m not talking
about parity in the curriculum with allopathic and osteopathic centers of education;
I’m referring to attitude. Are we a ‘‘systemically shy’’ profession
that passes that insecurity onto our future podiatrists and focuses on the
technical aspects of treatment? I know the answer, and so do many of
you. Do we really take the time to learn from the bright students who have
chosen our profession, or do we ignore their questions with a perfunctory
‘‘That’s the way I’ve always done it’’ type of attitude? In turn, do we push
our students to be physicians in the true sense of the word? By definition,
a physician is a person trained in the art of healing. How simple, yet perfect.
It doesn’t say MD, or DO; it does, however, imply a ‘‘healer.’’
We need to express to the public and professional communities, through
a strongly united profession, that we are indeed physicians, doctors, and
healersdnot show a fragmented bunch of individuals who only care about
the individual and not the whole. Mr. Spock of the Star Trek movies said it
very well: ‘‘The needs of the many outweigh the needs of the few or the
one.’’ There are many positive ways to satisfy one’s ego; just consider the
grateful patients we all have the privilege of treating.
A strong professional presence that clearly defines our mission as one of
caring for the needs of our patients will go a long way toward answering the
question, ‘‘Are we real doctors?’’ This is accomplished by a united effort of
the profession to educate the world about our mission and to present ourselves
as a desirable profession working toward a common goal. Then we
will easily have the numbers of applicants we need to fill our classrooms with
quality students, and we will be graduating a future generation of podiatrists
that will be clearly recognized as ‘‘doctors.’’
Vincent J. Mandracchia, DPM, MSHCA
Department of Surgery
Broadlawns Medical Center
1801 Hickman Road
Des Moines, IA 50314, USAE-mail address: [email protected]OREWORD xiii

 

[krabmas]

Preface
Guest Editor
This issue of the Clinics was somewhat of a challenge to put together. It
struck me as I started to assemble the Table of Contents how difficult and
challenging our profession can be. It also dawned on me how rewarding
our profession can be. Interestingly, I found that the same common thread
makes the challenge and reward one in the same. It leads us to the realization
that although we all label ourselves as specialists, we are also primary
care doctors, ‘‘gatekeepers,’’ and sometimes both. We are the consulting
doctor, yet for the next patient, we are likely to be the only doctor.
This dichotomy that we encounter is exciting yet concerning. We treat
patients medically and surgically, yet many of us prefer to focus on the surgical
education. How many of us read and constantly continue to educate
ourselves in podiatric surgery? Many of our colleagues read one or two
journals, Journal of Foot and Ankle Surgery and Journal of the American
Podiatric Medical Association, and maybe Foot and Ankle International too.
Although I don’t mean to imply that many of our colleagues neglect the
nonsurgical aspect of medicine, there are some who may not place enough
emphasis on it.
We like to look at ourselves as surgeonsdthose who enjoy operating. We
are training the next generation of podiatrists to think surgery as we continue
to mold our profession as the ‘‘specialist of the foot and ankle.’’ That
catch phrase usually implies surgeon in our own minds and hopefully in the
minds of the public and our colleagues of other medical specialties.
However, I offer you the following: how many people think that to be the
‘‘specialist of the foot and ankle’’ we need to understand the foot, ankle, leg,
pelvis, and spine? How about understanding the colon and gastrointestinal
system as medications are ingested? What about the cardiovascular system
and pulmonary system as our patients are under anesthesia? Maybe those
systems are important for the athletes we encounter or any patient as they
breathe in the office and as their heart beats faster during an injection. What
about the diabetic patient whose sugar spikes on a sliding scale, despite
being on insulin therapy in the hospital and then they proceed to develop
an infection that is limb threatening? Have we truly stayed in tune with the
recent changes in antibiotics? Gastric bypass is becoming more and more
common and so is the use of psychiatric medications for off-label use. What
about the aging baby boomers and the disease processes that affect the
elderly patient? Do these affect us? Should we pay attention to this? I mean,
we are the foot and ankle specialist. . .a surgeon after all.
This issue was used to focus attention away from the surgical journals for
a moment in time, to make us look at our education. No, not the education
in school, or during residency when you live in the hospital managing these
patients regularly; this is our everyday life education we do to stay abreast of
the latest medical developments (notice I said medical and not surgical
developments).
This issue of the Clinics is different. This issue is to remind ourselves of
the necessity to read, study, and learn all areas of medicine. All areas, medical
and surgical, apply to the podiatric physician. This issue attempts to emphasize
the importance of medicine because the best surgeons are well versed
in medicine. The best surgeons understand their patient. The best surgeons
are well trained in all systems and know the implications of all systems.
Hopefully the dedicated authors of this issue of Clinics in Podiatric Medicine
and Surgery will be able to bring us all up to date on the latest in medicine
and instill some motivation to stay that way.
‘‘Perfection is not attainable. But if we chase perfection we can catch
excellence.’’
dVince Lombardi
Jonathan M. Labovitz, DPM, FACFAS
3400 Lomita Boulevard, # 403
Torrance, CA 90505, USA
E-mail address: [email protected]
xvi PREFACE

 

[Stafocker]

The following is found at:

http://www.case.edu/med/epidbio/mphp439/Podiatry.htm

***edited due to length******


THE CURRENT ROLE OF PODIATRY IN AMERICA

In the United States of America, a podiatrist is a doctor licensed to practice podiatric medicine and surgery. This branch of medicine specializes in the art and science of treating disorders and injuries of the human foot, ankle, and leg, and in preventive health measures for the public, with a goal of maintaining active ambulation, even in an aging society. “Doctors of Podiatric Medicine are licensed in all 50 states, the District of Columbia, and Puerto Rico, to treat the foot and its related or governing structures by medical, surgical, or other means. The vast majority of states also include ankle care as part of podiatric physicians’ scope of practice”.1 Since this author has 20+ years of experience practicing in the state of Ohio, it seems appropriate to use this state’s law as a fairly representative example. The Ohio Revised Code, Paragraph 4731.51 states: “The practice of podiatric medicine and surgery consists of the medical, mechanical, and surgical treatments of the foot , the muscles and tendons of the leg governing the foot; and superficial lesions of the hand other than those associated with trauma.”.
It is interesting to note the inclusion of the hand which recalls the days when the profession was known as chiropody, before its official name change in 1958. The word chiropody derives from two Greek word roots meaning ‘hand’ and ‘foot’. The name chiropody is still in common use internationally along with podiatry. The title of podiatrist derives from Greek words combining ‘foot’ with ‘healer, or physician’, and is considered more etymologically correct, since there is very little treatment of the hand rendered by the profession.2 The State of Ohio in paragraph 4731.56 O.R.C., authorizes a podiatrist to use the title “physician” or the use of the term “surgeon” “...when the title is qualified by letters or words showing that the holder of the certificate is a practitioner of podiatric medicine and surgery.”.
The scope of modern podiatric surgical practice is very broad and includes all the procedures and techniques which are also employed by the specialty of orthopedic surgery, in so far as they are applied to the foot and ankle. For example, such procedures would include: treatment of open and closed fractures of the foot and ankle using both internal and external fixation; similar pediatric trauma surgery; major arthrodesis of the joints of the foot and ankle; the use of implanted bone stimulators; the reconstruction of pediatric and adult congenital deformities; treatment of feet crippled by arthritis; emergency incision and drainage of significant diabetic foot and ankle infections; amputations of the foot; plastic surgical techniques such as rotational skin flaps and skin grafting; surgery on the major nerves of the foot and leg; and excision of many kinds of tumors from the foot or leg. All of the above procedures are ones which this author has performed and also taught to second and third year podiatric surgical residents over his career of 25 years.
Because these services might be rendered by either an orthopedic surgeon or a podiatrist there is a potential for friction not unlike that which exists where many other surgical specialties overlap. Such types of unhealthy competition may exist where economic considerations prevail, but seem less consequential where all practitioners are simply “trying to get the job done”, and are equally salaried from sources such as the military, the Veterans’ Administration, or large HMOs.
In fairness to orthopedic surgeons it must be pointed out that orthopedic surgeons have postgraduate education and training, i.e. surgical residencies in hospitals, which is more extensive than that required for podiatrists. Orthopedic surgeons frequently spend five to seven years in such residencies and may take additional fellowship specialization in foot and ankle surgery for an additional year.3 The orthopedist has an unlimited license which means that he or she may operate on any bone of the human body, not just the foot and ankle. However, in practice most do specialize in certain areas of orthopedic surgery such as shoulder and hand surgery, back surgery, large joint replacement, sports medicine and surgery, or foot and ankle surgery. Podiatrists, on the other hand, are more likely to have two to three years of surgical residency, although some programs do offer an additional fellowship year, sometimes providing an opportunity to study in Europe with famous orthopedic surgeons on the Continent.4 Most states require at least one year of postgraduate education for a podiatrist, and all podiatric residency programs are designed so that the first year is a rotating medical internship, in which the podiatrist performs in exactly the same capacity as other first-year medical residents.5
While podiatric medicine has matured as a sophisticated medical and surgical discipline, it is nevertheless, a tiny profession. The United States Bureau of Labor Statistics reports that “...podiatrists held about 13,000 jobs in 2002.”.6 By comparison, there are 700,000 physicians in the United States.
The following profile of the American podiatrist of today is abstracted from the 2002 Podiatric Practice Survey as reported to the American Podiatric Medical

Association by Al Fisher Associates, Inc.7 There were 9,392 members of APMA , of which 2,955 (31.5%) responded to a two-page, 30-question survey similar to surveys that were conducted in 1995 and again in 1997.(In which this author participated.) Most (56.6%) podiatrists were still in solo private practice, although the trend compared to 1995 and 1997 is toward more group practices of podiatrists and also participation in multi-specialty groups. The average age of the respondents was 44.9 years of age, reporting 16 years of practice experience. Most were male (86.6%), and white (90.2%), although the trend among younger podiatrists did include many more women and minorities. Most podiatrists had completed a residency program (90.2%), generally in surgery (66.3%). Fully 84.5% reported still having some student loan indebtedness despite being in practice for 16 years. The average student loan debt owed by podiatrists with fewer than three years of practice was $119,773. Most podiatrists were board certified by the American Board of Podiatric Surgery, ABPS, (51.6%) or the American Board of Podiatric Orthopedics and Primary Podiatric Medicine, ABPOPPM, (22%), and 10.7% were certified by both boards.
In 2001, the average podiatrist worked 41.8 hours per week, averaging 101.4 patient visits per week. On average, 77% of their working day was devoted to treating patients, and 23% was required for administration. The foot problems that these doctors were treating divided as follows: 44.8% heel pain, 23.9 fungal nails, 8.9% ingrown nails, other nail problems accounted for 9.9%, and 4.4% of their treatments were devoted to diabetic foot care. It is interesting with regard to this last percentage that 4.4% is the exact figure that the Center for Disease Control and Prevention8 reports as the prevalence of diabetes in the United States.
It is gratifying to this author to note that in 2001 nearly 22% of podiatrists were independently performing their own History and Physical exams for patients whom they admitted to the hospital. This capability was certainly not always the case, and represents the beginning of a fundamental change which the author has very strongly advocated.
In terms of earnings, podiatrists reported a gross income of $276,680 with a net income of $134,415. At least ten percent of podiatrists were earning a net income of more than $250,000. Podiatrists employed in multi-specialty groups received an average salary of $148,786. In order to compensate for declining reimbursements from third party payers, podiatrists increased their patient volume. The sources of this income were Medicare (38.6%), HMOs (21.6%), and fee for service (18.8%). Only a small fraction of the reporting members of the American Podiatric Medical Association were in military service or employed in the Veterans Administration (1.2%).
The above statistics would accurately reflect this author’s practice experience of 20 years in an Ohio city of 80,000 population which was closely bounded by other suburban cities creating a population base of 250,000. ‘Sources of Referral’ was not a survey question, however, this author would expect that the more successful podiatry practices enjoyed a significant physician referral base. In his experience of a practice that grew from the first patient seen in 1985 to well over 12,000 persons served by 2001, this practice benefited by referrals from many (more than 50) primary care physicians and from emergency departments as well.

AMERICAN PODIATRY AND PUBLIC HEALTH

Every branch of medicine has been blessed by certain far-sighted individuals who possessed both the wisdom and the energy to move their discipline into a positive future. Podiatric Medicine was fortunate to be moved toward public health by Marvin W. Shapiro, D.P.M., who believed that “...podiatric medicine’s greatest contribution could come in the field of public health.”.9 In the 1950s and 1960s, Dr. Shapiro and a select few other podiatrists put together exhibits at the American Public Health Association’s annual meetings. Eventually, Dr. Shapiro became the first podiatrist to be awarded fellowship status in the APHA. Several physician members of APHA took notice of foot health as a separate topic of health concern. Foot health was seen as especially critical for older persons. Eventually, Arthur E. Helfand became the second podiatrist to receive the honor of fellowship in the APHA. In 1962, the APHA funded Dr. Helfand’s project, entitled “Keep Them Walking”. This was aimed at the older population, and this three-year study provided important justification for the inclusion of podiatric medicine as a necessary service under Medicare.Ibid,9 In 1970, the American Podiatric Medical Association established a Council on Public Health, bringing together all APMA-related committees, coordinating a public health policy, and helping to foster a growing relationship with the American Public Health Association. All these years of cultivation bore fruit in 1972, at the 100th annual meeting of the American Public Health Association, the Podiatric Health Section was formally created. The section was granted three seats in the APHA’s Governing Council. Podiatric medicine has been an active, contributing part of APHA
since that date. Within the first year, this Podiatry Section was able to formulate and guide
through the Governing Council of APHA a resolution titled “Foot Health and Public Policy”. The Podiatric Section immediately began developing interdisciplinary scientific programs that infused podiatrists’ expertise into major programs of the APHA.Ibid,9
It must be said that the APHA benefited too, from the dynamic leadership of several podiatrists. Dr. Helfand became the chairman of APHA’s task force on malpractice. It was under his guidance that a resolution was adopted by the Governing Council and submitted as the APHA’a policy statement to the National Academy of Sciences hearings on medical injury compensation.10 Association-wide activity by podiatrists did not end there. Podiatrists also took a lead role in representing the APHA in its efforts with the National League of Nursing to accredit home health agencies and community nursing services.
While podiatrists were eagerly contributing their services to APHA, podiatry as a profession was benefiting by the association. Dr. Helfand has said: “No other external organization has opened so many doors for podiatric medicine and made it an equal partner in the development of health policy than has APHA.”.11
In 1975, APHA adopted a statement on the Functional and Educational Qualifications of Podiatrists in Public Health, but it was not until 1983 that the American Podiatric Medical Association formally approved public health as a special area of podiatric medical practice. Although the Podiatric Medical Section of APHA had made great initial strides during the 1970s, and could boast of a membership of over 700, this involvement declined and membership dropped significantly during the next dozen years.
Jeffery M. Robbins, D.P.M. was moved to write in his “Chair’s Message” for the Podiatric Health Section Newsletter, Winter 1998-1999 that: “The Podiatric Health Section has lacked a dynamic agenda in the past.”. There is some evidence that certain presidents of the American Podiatric Medical Association, and their administrations, did not fully understand the role that should be played by podiatrists in improving the Nation’s foot health, and consequently they did not provide an adequate level of support for activities in APHA.12 Fortunately, the APMA presidencies of Dr.Marc Lenet and later Dr. Terence Albright provided excellent support and the Podiatric Health Section increased its membership by over 100 members. Dr.Jeffery M. Robbins was (and remains) director of the entire department of podiatry services for the Veteran’s Administration, and he brought this considerable administrative skill to his chairmanship of the Podiatric Health Section. He worked hard to ensure that foot health, particularly that of diabetics, was included in the goals advocated and published in Healthy People 2010. As podiatry enters the 21st century it appears that it has rediscovered its mandate to improve the Nation’s foot health. In a telephone interview which this author conducted recently with the incoming Chair-Elect of the Podiatric Health Section of the APHA, Patricia Moore, D.P.M., there are exciting plans being made now to create a textbook of podiatric health directed toward an audience of other health professionals, and greater emphasis will be placed on podiatrists participation in other sections of APHA.


A BRIEF HISTORY OF PODIATRY IN AMERICA

Bates has pointed out that although podiatry may have a new name (see elsewhere in this chapter), “...and the recognition of podiatric medicine as a primary care profession is fairly recent,...podiatry, itself, is as old as any other branch of medicine.”. 13 Humans have undoubtedly always suffered from foot problems since evolving to bipedal gait. Indeed, there is written documentation in an Egyptian papyrus of 1500 B.C.A., outlining a treatment for corns. Hippocrates advocated a sensible approach to corns (thick, hard skin which usually forms on the knuckles of the toes). He recommended a simple operative technique and getting rid of the cause (probably tight sandals or boots). There are records of the King of France employing a personal podiatrist, as did Napoleon. In the United States of America, President Abraham Lincoln suffered greatly with his feet and chose a podiatrist named Isachar Zacharie, who not only cared for the president’s feet, but also was sent by President Lincoln on confidential missions to confer with leaders of the Confederacy during the U.S. Civil War.
According to Bates history14, the licensing of podiatrists began in 1895 in New York, and in that year, America’s first association of podiatrists was formed. In 1907 the association began publishing Pedic Items, the first professional journal on podiatry. The American Podiatric Medical Association was formed in 1912, and boasts the highest membership percentage of current medical associations.15
Both traditional allopathic medicine and podiatric medicine required the wake-up call of a formal report to begin moving into the modern era. For medicine this came in the form of the Flexner Report published in 1910 which was initiated by the American Medical Association. The Flexner Report had major impact. Sub-standard medical schools closed, and those that remained became affiliated with universities, admission standards were raised, full-time faculty became the norm, and teaching included work in laboratories and hospitals instead of lectures only. Podiatric medicine had to wait until 1961 for an analogous phenomena with publication of the Selden Commission Report.16 By 1978 all the colleges of podiatric medicine agreed to adopt the exact same requirements as U. S. schools of medicine.
These were watershed events in the history of podiatric medicine because in the words of Leonard Levy, D.P.M., M.P.H., “...they began providing the basis for establishing legitimacy to the call by the profession for parity with medicine.”.17 In 1967 two separate national changes in policy had a significant impact on the development of podiatric medicine. In 1967 Congress amended the Medicare Act of 1965 to include podiatry. This permitted podiatrists to qualify for payment as did the other physician categories: M.D., D.O., D.D.S. This same year, “...the then Joint Commission on Acreditation of Hospitals issued a bulletin permitting hospitals accredited by the Joint Commission on Accreditation of Hospitals to allow qualified podiatric physicians to perform surgery without having a scrubbed-in ‘physician-surgeon’ in the operating room who was a member of the active medical staff.”Ibid,17
The growth of post-graduate training programs for podiatrists was slow. The first residency program was opened in 1958 in Philedelphia at St.Luke’s and Children’s Medical Center.Ibid,17 However, it required another thirty years before all graduating podiatric medical students received residencies.18
Given that podiatry began as chiropody with ‘knife-in-hand’ cutting corns and
calluses, it should not be surprising that most board certified podiatrists are, in fact, board
certified in foot surgery.Op.Cit. The road to a place alongside orthopedic surgery, establishing podiatric surgery as a legitimate specialty area was a long, slow road. One significant step along this road took place in 1942 when the American College of Foot Surgeons was organized. Almost immediately, rigid requirements for membership included both a written and an oral examination.19 A corps of competent podiatric surgeons ( still called Doctors of Surgical Chiropody) lectured throughout the U.S. and trained other surgeons. A State Supreme Court decision in Michigan (Fowler vs. State Board of Pharmacy) gained the right for podiatrists (chiropodists) to prescribe narcotics to relieve the pain of their postoperative patients, thus allowing more extensive surgical operations.
“The renaissance of podiatric surgery occurred with the opening on June 4, 1956 of Civic Hospital in Detroit, Michigan which was the first podiatry hospital in the United States.”Ibid,19 This hospital had 18 beds and a fully equipped operating room. It quickly became a center for postgraduate education and training in the science and art of podiatric surgery, providing alumni who greatly advanced the state of podiatric surgery, often establishing residencies in their hospitals around the country.
Fortunately for podiatric medicine and surgery, two podiatrists at the California College of Podiatric Medicine, Drs. Merton L. Root, and Thomas E. Sgarlato, became intrigued with the pioneering research of Verne T. Inman, M.D., who was unraveling the mysteries of human gait. Both Dr. Root and Dr. Sgarlato began to study the biomechanics and kinesiology of the human gait cycle, including pathological conditions that appeared
in the foot. Both began to lecture widely in this country, greatly helping podiatrists to base both their conservative and their surgical treatments on scientific understandings of the complex patterns of human locomotion.
Podiatric surgeons learned early the great importance of intense postoperative
care, and since many of their surgeries were performed in outpatient settings, an early emphasis was placed on ambulatory care. By 1974, Kaplan could claim in his historical review of podiatric surgery that “...the majority of foot surgery is now being performed by podiatrists.”Ibid,19
Most developed counties have professions of chiropody or podiatry. Many countries have several colleges of podiatric medicine which have welcomed guest lecturers from America podiatrists whose surgical experience has had a leavening effect on the evolution of the profession in these countries. For example the city of Perth in Western Australia is permitting a rapid growth of surgical skills among its podiatrists. This author had the privilege of participating in the surgical training of one Australian podiatrist who came to Cleveland, Ohio through a fellowship program of the Ohio College of Podiatric Medicine. For six months this author guided his surgical fellow through of all the surgeries which were scheduled through his office. Correspondence with the Australian surgical fellow told a story of considerable development of his surgical practice after he returned to his home. However, at that time in the provinces of New South Wales and Victoria, podiatrists still had not achieved the right to prescribe narcotics, relying entirely on their anesthesiologists for this necessary postoperative
service to their patients. And so, step by step, podiatry grows internationally by a winding path not unlike that followed by American podiatry.

CONCLUSION

An ancient healing art has evolved in America to become a highly complex surgical subspecialty. The advances that podiatry has made in the 20th century are unquestionable. Modern American podiatrists with advanced postgraduate training are some of the finest foot and ankle surgeons in the world. However, despite these advances there are some questions that remain.
Some skilled podiatric surgeons wonder if it makes any sense to have a separate branch of medicine for the care of the foot. Such a division has worked well for dentistry, but, perhaps, not so well for podiatry. Podiatry does not stand side by side with medicine as dentistry does. Even a cursory look at medical literature, or medical research, or medical schools will confirm this. These podiatrists can often be found advocating that podiatric medicine be subsumed under the allopathic umbrella. They argue that podiatrists should attend standard allopathic medical schools and then specialize in podiatric surgery , podiatric orthopedics, podiatric primary care, or podiatric public health. This would, they believe, eliminate the confusion that sometimes surfaces regarding a podiatrist’s education and training, and podiatrists’ role in the developing healthcare complex.
Other podiatrists counter that such an abdication would wipe out entirely the special affection which so many patients feel for their ‘foot doctor’. They claim that such a change would lose that body of knowledge which excels at treating human foot problems without surgery! These doctors and educators, including surgeons as well as non-surgeons, lament their impression that as young podiatrists gain more and more years of postgraduate education, and master increasing complex surgical skills, they grow farther and farther away from the core techniques (and values?) that created the enduring and beneficial profession of podiatry. Only time will answer this.

John D. Waddell, D.P.M.
Diplomate, American Board of Podiatric Surgery
Board Certified in Foot and Ankle Surgery
Fellow, American College of Foot and Ankle Surgeons
Board Certified, American Board of Quality Assurance

Please contact me at: [email protected]
to offer criticism and corrections which will be incorporated in future chapter revisions. Thank you.

http://www.case.edu/med/epidbio/mphp439/Podiatry.htm

 

[Boilermaker]

I looked up foot and ankle surgery on wikipedia and it said this:

Foot and Ankle Surgery is the sub-specialty of orthopedic surgery that deals with the treatment, diagnosis and prevention of disorders of the foot and ankle. Foot and ankle surgeons differ from podiatrists in that foot and ankle surgeons have received a medical doctorate and have completed medical school, 2 year surgical internship, 6 year specialty training in orthopedics and an additional 1-2 year fellowship in foot and ankle surgery.

Maybe its correct but It sounds bad. I think of foot and ankle surgery as being a specialty of both.

 

[SportPOD]

I looked up foot and ankle surgery on wikipedia and it said this:

Foot and Ankle Surgery is the sub-specialty of orthopedic surgery that deals with the treatment, diagnosis and prevention of disorders of the foot and ankle. Foot and ankle surgeons differ from podiatrists in that foot and ankle surgeons have received a medical doctorate and have completed medical school, 2 year surgical internship, 6 year specialty training in orthopedics and an additional 1-2 year fellowship in foot and ankle surgery.

Maybe its correct but It sounds bad. I think of foot and ankle surgery as being a specialty of both.

Wikipedia is written by the layperson and not a site endorsed by professionals.

 

[Dr_Feelgood]

I looked up foot and ankle surgery on wikipedia and it said this:

Foot and Ankle Surgery is the sub-specialty of orthopedic surgery that deals with the treatment, diagnosis and prevention of disorders of the foot and ankle. Foot and ankle surgeons differ from podiatrists in that foot and ankle surgeons have received a medical doctorate and have completed medical school, 2 year surgical internship, 6 year specialty training in orthopedics and an additional 1-2 year fellowship in foot and ankle surgery.

Maybe its correct but It sounds bad. I think of foot and ankle surgery as being a specialty of both.

I'm sorry to say that whomever wrote that should go back and check the facts foot and ankle orthopods do 1 year of surgical internship, 4 years of ortho training and 6 months to 1 year of fellowship training.

I refer people to the survey performed by orthopods that showed that at most a foot and ankle orthopod gets 1.5 years of foot and ankle training. While many principles of orthopaedic surgery are universal, orthopods don't really stay "general" b/c you are a jack of all trades and a master of none.

 

[Dave101]

I'm sorry to say that whomever wrote that should go back and check the facts foot and ankle orthopods do 1 year of surgical internship, 4 years of ortho training and 6 months to 1 year of fellowship training.

I refer people to the survey performed by orthopods that showed that at most a foot and ankle orthopod gets 1.5 years of foot and ankle training. While many principles of orthopaedic surgery are universal, orthopods don't really stay "general" b/c you are a jack of all trades and a master of none.

maybe its not being updated because as it look they get the info in wikipedia but I know wikipedia gives exact and correct information.

 

[347932]

... but I know wikipedia gives exact and correct information.

No it does not. It is updated and written by the laymen with very little background checking on the accuracy of the information posted. This continues to be its biggest criticism. Read with caution.

 

[FreshPodStudent]

I looked up foot and ankle surgery on wikipedia and it said this:

Foot and Ankle Surgery is the sub-specialty of orthopedic surgery that deals with the treatment, diagnosis and prevention of disorders of the foot and ankle. Foot and ankle surgeons differ from podiatrists in that foot and ankle surgeons have received a medical doctorate and have completed medical school, 2 year surgical internship, 6 year specialty training in orthopedics and an additional 1-2 year fellowship in foot and ankle surgery.

Maybe its correct but It sounds bad. I think of foot and ankle surgery as being a specialty of both.

This kind of stuff on wikipedia makes me mad. It was probably written by an orthopod. Its annoying that even though we spend 3 years in surgical residencies doing more foot surgery than most orthos do in their career, and then this kind of statement is made. So they imply that a podiatrist isn't a foot and ankle surgeon? ridiculous

 

[nancy609]

I am a podiatry student and also I have foot problem. I know it doesn't match,yah of course. But this is not the topic,topic is how can I do well in my career?