You are starting a residency...

[deleted1149159]

Other than what the CPME requires, how would you structure it? What would you consider to be the "must haves". I'm not talking numbers, either. Let's assume the numbers are there, and that is not a concern. I'm also not talking rotations, because, for better or worse, those are mostly set in stone. BUT you do have a choice of "elective" type rotations.

Let's create something as a template. What've you got?

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[air bud]

Cadaver lab once a month

 

[DYK343]

Other than what the CPME requires, how would you structure it? What would you consider to be the "must haves". I'm not talking numbers, either. Let's assume the numbers are there, and that is not a concern. I'm also not talking rotations, because, for better or worse, those are mostly set in stone. BUT you do have a choice of "elective" type rotations.

Let's create something as a template. What've you got?

Residents get the knife but also get the knife taken away if they didnt prepare (or create a danger ot patient)
Too many programs the residents watch and retract.
Learning is doing.
I want residents soon but not 100% ready to turn over the knife. When Im ready I will have residents.

This will be a good thread.

 

[deleted1149159]

Residents get the knife but also get the knife taken away if they didnt prepare (or create a danger ot patient)
Too many programs the residents watch and retract.
Learning is doing.
I want residents soon but not 100% ready to turn over the knife. When Im ready I will have residents.

This will be a good thread.

In my residency, I was not given the knife until I could assist flawlessly. It worked.

 

[DYK343]

In my residency, I was not given the knife until I could assist flawlessly. It worked.

In my residency I did a lapidus (at least 75%) my first day. Attending actually did the osteotomies. So maybe I did 50%?
I walked out of that program well trained.
That said if I wasnt prepared or a danger they took the knife quickly.

 

[deleted1149159]

In my residency I did a lapidus (at least 75%) my first day. Attending actually did the osteotomies. So maybe I did 50%?
I walked out of that program well trained.
That said if I wasnt prepared or a danger they took the knife quickly.

No doubt some attendings are more willing to give over the knife right away. It is important to have a good mix of those that do, and those that expect a little more. I was trained by some brutal attendings who had very high expectations. I responded well in that environment. Some wouldn't. I consider I had excellent training.

 

[deleted1149159]

Cadaver lab once a month

This would truly be amazing.

 

[DYK343]

No doubt some attendings are more willing to give over the knife right away. It is important to have a good mix of those that do, and those that expect a little more. I was trained by some brutal people who had very high expectations. I too walked out of the program well trained. I responded well to that environment. Some wouldn't.

For sure. Not every program is for every person. Some want their hand held. Some want independence.

I remember my cheif calling me the night before I was gonna start and telling me "youre covering Dr X youre doing a lapidus make sure youre prepared"

I walked in there prepared. I did the case. Thats how residency should be. Maybe not day 1. But thats how it should be.

 

[deleted1149159]

For sure. Not every program is for every person. Some want their hand held. Some want independence.

I remember my cheif calling me the night before I was gonna start and telling me "youre covering Dr X youre doing a lapidus make sure youre prepared"

I walked in there prepared. I did the case. Thats how residency should be. Maybe not day 1. But thats how it should be.

Sounds like you were precisely where you belonged and made the most out of your days as a resident. Which is something everyone should strive for. Well done, sir.

 

[PeaJay]

Cadaver lab once a month

I guess my residency was blessed. We had an on campus cadaver lab with 20+ specimen every year. Scheduled cadaver labs and you could schedule extra time over nights/weekends.

I would have attendings that are scrubbed an attentive. An resident is there to learn tips/tricks and finer points not fumble through a procedure on a live human.

 

[DYK343]

Sounds like you were precisely where you belonged and made the most out of your days as a resident. Which is something everyone should strive for. Well done, sir.

I miss residency. It was a blast. Long hard hours. But I miss it. I have the upmost respect for the people who trained me. Amazing people in that program.

 

[DYK343]

Attendings that know how to dissect a research paper. Not take as face value. Journal discussions beyond "this paper says X" are very important for a resident to phish out BS data.

 

[air bud]

I guess my residency was blessed. We had an on campus cadaver lab with 20+ specimen every year. Scheduled cadaver labs and you could schedule extra time over nights/weekends.

I would have attendings that are scrubbed an attentive. An resident is there to learn tips/tricks and finer points not fumble through a procedure on a live human.

Yes mine had a cadaver lab monthly too. 1st years 1 week, 2nd the next and 3 the next. 4th week was do whatever you want.

 

[Weirdy]

Attendings that know how to dissect a research paper. Not take as face value. Journal discussions beyond "this paper says X" are very important for a resident to phish out BS data.

This is also largely dependent on the residents you get.
Some come in with more research experience than others.

It is important, whether on or off service rotations, that you push or encourage them to use evidenced based practices to question and continually evolve current treatment standards.

On the flipside, it is also important that if they come to you with an idea that is evidence based, you are open to trying it.

The residents need to understand they can back up what they do with both experience and the most up to date literature.
Even more so they need to be well read if they will be representing podiatry to their off service rotations who have no idea what a DPM does.
That is the only way you can change the minds of other departments- and most of the time you can't.

They may be able to encourage the surgery resident in the same year as them to trust your podiatry department.
The other department heads will never change their minds.
But at least you may be recieving some decent consults from off service department residents.

 

[air bud]

Fully stocked bar in the residents office. It works trust me.

 

[deleted285117]

More off-service medicine rotations... I think too many residencies are tunnel vision with podiatric surgery.

 

[diabeticfootdr]

Any rotation can be valuable or worthless. So it's important to find the right outside/off-service faculty. Resident feedback will really help with that.

Here are my pearls on some off-service rotations:
ED: Make sure it's in the main ED not urgent care
Vascular: New 320 only mandates 2 weeks. This should be 1 month at least.
Wound Care: Not required in 320, but there is so much to learn about wounds when you're treating wounds above the ankle with a good wound doctor.
HBOT: If you have the option, all residents should leave with their 40-hour UHMS certificate. That will open the door for them at hospital-based wound centers. Right now, just our fellows get this.
Path/Micro: This is actually a great rotation at UT. Our residents see all the foot/ankle pathology and micro with the lab PhD. Bonus if you can get the residents to talk pictures of stuff and present it back to everyone else.

Academics:
Make them really structured and make them early in the morning. We do academics at 6 AM almost every day. It causes some complaining at first, but the early morning is the only part of your day you control.
We do Teaching Floor Rounds on M/Th 6-730 AM
Resident/Fellow/Faculty Lectures on T 6-7 AM
Grand Rounds Wed 6-7 AM
Journal Club is in the evenings

If residents want to go to a conference, they should have to present a poster. They often don't know the secret that you can present the same poster at several meetings.

Some industry sponsored workshops (local or travel) are actually very helpful. They bring in well-known faculty and have great equipment. You learn more than just about the company's products.

 

[diabeticfootdr]

Also, explain to residents that when they're off-service, they're a representation of you and an ambassador of the profession of podiatry. When you find friendly orthos, vascular, etc in your career, they often tell you: "oh, podiatrists rotated with us during residency and they were good".

Especially off-service in the ED. Residents can find some good trauma or other cases and ask the ED faculty if they can consult podiatry. ED cares mostly about 1 thing ... how quickly can I get this foot/ankle problem out of a bed. If you're a part of that solution, it will result in more consults and experience for the residents.

 

[AttackNME]

Cadaver lab once a month

I guess my residency was blessed. We had an on campus cadaver lab with 20+ specimen every year. Scheduled cadaver labs and you could schedule extra time over nights/weekends.

I would have attendings that are scrubbed an attentive. An resident is there to learn tips/tricks and finer points not fumble through a procedure on a live human.

How did your programs manage to pull this off with cadaver labs? I would have loved access to dissection practice in residency, it was hard to come by, our pathology lab granted us very limited access, lots of red tape that I couldn’t get through and my attendings didnt help push through for us

 

[PeaJay]

How did your programs manage to pull this off with cadaver labs? I would have loved access to dissection practice in residency, it was hard to come by, our pathology lab granted us very limited access, lots of red tape that I couldn’t get through and my attendings didnt help push through for us

The program I trained at has a training center on campus that has mock operating rooms (lights/arthroscopes/fluoro/ect) literally set up like the ORs in the hospital. Think ACFAS scopes facility but smaller. The program as part of the budget would buy training limbs every year and we would use them 3-4 times before we needed to dispose. This is on top of any industry limbs that were brought in.

It is amazing what can happen when the hospital/training program treats residencies as a recruitment tool and not a means to make money.

 

[AttackNME]

The program I trained at has a training center on campus that has mock operating rooms (lights/arthroscopes/fluoro/ect) literally set up like the ORs in the hospital. Think ACFAS scopes facility but smaller. The program as part of the budget would buy training limbs every year and we would use them 3-4 times before we needed to dispose. This is on top of any industry limbs that were brought in.

It is amazing what can happen when the hospital/training program treats residencies as a recruitment tool and not a means to make money.

Amazing, is that shared with other programs? Or built just for the podiatry program? How was it funded? I haven't been to ACFAS scopes course but from the social medial photos it seems nice and expensive. Do you guys have access to scope equipment at that lab?

 

[air bud]

We had a super old scope but still got to play around with dry scoping stuff.. And a mini c arm. Industry sponsored everything. So we would do a Stryker 1st mpj fusion. Considering not a part of a large academic center kind of crazy we were able to have a cadaver lab like that....this wasn't even in a basement or anything. Like a normal medical building. Then again we had a bar in the office too....

I remember most just dissecting and getting a better understanding of the anatomy. I still do this when I go to industry labs. When we are all done playing with their upcoming total ankle lapiplasty, I just dissect **** and to remind myself what the plantar plate looks like. Or the relationship between the TNJ and STJ during a medical double approach

 

[PeaJay]

Amazing, is that shared with other programs? Or built just for the podiatry program? How was it funded? I haven't been to ACFAS scopes course but from the social medial photos it seems nice and expensive. Do you guys have access to scope equipment at that lab?

The center is owned by the hospital. It is meant for all the residencies and students. If industry wanted to have a lab with us they would have to rent the facility (this is where they cover costs). We are a campus for medical and PA students. Medical residents do some trauma courses and work on chest tubes there. It is mostly for the OMFS, general surg, and podiatry residents. We had some old fixation sets that were retired along with a bunch of discarded screws that we would re-use.

We had access to essentially anything we have in the OR scopes and all….we had some of the old radio frequency wands that didn’t brick themselves after one use.

 

[deleted1149159]

Attendings that know how to dissect a research paper. Not take as face value. Journal discussions beyond "this paper says X" are very important for a resident to phish out BS data.

This was my role at the residencies I participated in. And will be again.

 

[Feli]

I think that podiatry's biggest stumbling point in residencies is that the vast majority of DPM residency directors are not hospital employees (they work in or own PP, MSG, ortho, etc).

That's just not the case in MD residencies where well over 80% of directors are hospital employees full time, often at large university/teaching hospitals. The get a comfortable salary and can still consult on the side if they want... but it's assured that their primary focus is the program.

The situation with a DPM running a program while also running a PP or working in one while also drawing a moderate salary to run a program creates a situation where any time spent on the program is time away from where they make the real money: seeing patients in their office and running the biz. It also makes most other program attendings the competition of the director's group. All of that is a conflict of interest to best teaching... no matter how diligent the director might try to be.

It is a situation that's starting to sloooowly change with more podiatry directors being FTE of the teach hospital, but it's a definite issue. Also podiatry training programs often end up sponsored by whatever hospital the PP director and their group tend to go to, not necessarily a large teaching hospital. In fact, the large Univ and teaching are typically your mediocre programs since those have ortho teaching programs taking a lot of the good F&A stuff, esp trauma.

In an ideal world, we'd have skilled hospital employ DPMs directing programs a at large teaching or univ hospital so they could focus on the program and its quality and research. They'd also work in cooperation with ortho, but that's obviously a very rare thing to see and a work in progress. I mainly tried to seek out programs like this, but they are much tougher to find than they should be.

...The other BIG problem is that there are too many podiatry residency programs where the director and most/all attendings just aren't very well trained or doing much complex surgery and real RRA recon (not just "diabetic RRA"). That's a cycle that perpetuates and it's an obvious function of the the high variability in the quality of our programs. The VAs are the easiest example and they were a quick bail out (to make 3yr training for all grads), but are most of them really good residencies in terms of case volume, diversity, no MD/DO residencies sponsored, typically no research support, etc? Many community hospital programs are similar concerns. We will see more of the same (low quality, watering down programs) with the new schools pushing for more residency spots created in a hurry.

 

[deleted1149159]

I think that podiatry's biggest stumbling point in residencies is that the vast majority of DPM residency directors are not hospital employees (they work in or own PP, MSG, ortho, etc).

That's just not the case in MD residencies where well over 80% of directors are hospital employees full time, often at large university/teaching hospitals. The get a comfortable salary and can still consult on the side if they want... but it's assured that their primary focus is the program.

The situation with a DPM running a program while also running a PP or working in one while also drawing a moderate salary to run a program creates a situation where any time spent on the program is time away from where they make the real money: seeing patients in their office and running the biz. It also makes most other program attendings the competition of the director's group. All of that is a conflict of interest to best teaching... no matter how diligent the director might try to be.

It is a situation that's starting to sloooowly change with more podiatry directors being FTE of the teach hospital, but it's a definite issue. Also podiatry training programs often end up sponsored by whatever hospital the PP director and their group tend to go to, not necessarily a large teaching hospital. In fact, the large Univ and teaching are typically your mediocre programs since those have ortho teaching programs taking a lot of the good F&A stuff, esp trauma.

In an ideal world, we'd have skilled hospital employ DPMs directing programs a at large teaching or univ hospital so they could focus on the program and its quality and research. They'd also work in cooperation with ortho, but that's obviously a very rare thing to see and a work in progress. I mainly tried to seek out programs like this, but they are much tougher to find than they should be.

...The other BIG problem is that there are too many podiatry residency programs where the director and most/all attendings just aren't very well trained or doing much complex surgery and real RRA recon (not just "diabetic RRA"). That's a cycle that perpetuates and it's an obvious function of the the high variability in the quality of our programs. The VAs are the easiest example and they were a quick bail out (to make 3yr training for all grads), but are most of them really good residencies in terms of case volume, diversity, no MD/DO residencies sponsored, typically no research support, etc? Many community hospital programs are similar concerns. We will see more of the same (low quality, watering down programs) with the new schools pushing for more residency spots created in a hurry.

I agree with you 100%.

I have been trying to change much of this for many years. I approached Eastern Virginia Medical School about my joining them as a hospital employee, and doing exactly what you are talking about, about a fifteen years ago, before I left that area. They declined. And then, when the major hospital system (Sentara) did eventually absorb a podiatry group, the group wanted nothing to do with the residency program, the way I heard it.

I did something similar in Southern New Jersey when Jefferson took over the Kennedy system. I met with multiple Administrators to try to gauge the interest in starting a "Jefferson Podiatry Group" to then absorb the residency, but they were uninterested. Why would they be? They were getting the funding without the headache. There were also some deep seated political issues at stake as well concerning a certain Ortho group that had Jefferson in their pocket and hated us.

As far as the "real" RRA cases...I agree as well. Problem is, there are residencies out there that are being run by doctors that are either towards the twilight of their careers, and are relying on some of their young associates to do those cases, or the programs are run by doctors barely out of residency, and without board certification, yet. There are very few programs that have the middle ground of those dedicated to teach AND supremely trained. I am not one to do the major RRA stuff anymore. Been there, done that. Now I will have someone more than willing to take those cases and also refer me the bread and butter that I prefer. And I'm not board certified in RRA. Back in my day, if you weren't trained by Jack Schuberth or Rob Mendicino, you barely had a prayer in hell to pass that test. Only about 30% of people who sat for it, passed it. Then a whole slew of others that couldn't get the cases to get to the oral portion of the exam. Then again, when there are attendings in RRA programs who aren't even board certified by the ABFAS, it makes you wonder.

 

[DYK343]

Residents have a working relationship with ortho/gen surg and vasc. Strong radiology and ER rotation. Can learn a lot from other professions.

Peds specialist. Not someone who just dables in it.

As much as I hated academics its super important. Group read texts. Journal review. Radiology rounds monday morning for cases that week. Especially important for radiology is MRI review with residents. Make them explain the MRI in detail/pathology they see.

Making senior residents round on straighforward I&Ds /diabetic stuff early AM then making them round again 2nd time same patient with attending present is a waste of the residents time.

Ideally centrally located program/not a lot of commuting. Driving/traffic is lost time.

Pre/post op clinic. See complications.

High volume. Most of the procedure we do are really not that difficult. Where high volume comes into place is #1 to establish confidence and efficiency. But whats most important with high surgical volume is the more cases you do the more intra op complications you will encounter. When the surgery goes as planned its easy. When a major complication happens its not so easy anymore. TH\hats were high volume comes into play.

Strong hospitalist/medicine and ICU rotations. Medicine training (at least where I went to DPM school) could really be improved upon. Gotta really hammer in understanding of surgical appropriateness for patients.

CME for conferences.

Pay a living wage. 401k.

Billing and coding. No tricks. Just basic stuff.

Spending at least a half day a week in a wound healing center.

Varying exposure to different cases. If the attendints all only do lapiplasty and thats it then the resident is doomed. Gotta be confident and know how to do a lapidus with cross screws, staple, and or plate. Its OK to have some newer stuff. That keeps residents exsposed to new products. But they need to be able to bail themselves out if there is a problem. with the new hot jigs they making

Axe toxic attendings/staff. Toxicity will eventually ruin any program. Ive seen toxicity break up two programs close to where I trained. Screaming at the top of your lungs and throwing instruments is not someone who should be training. OK to be angry and firm but not toxic.

I think the most important thing is backing your residents. Network for them to help them find employment. Stay in touch even after they graduate. Develop lifelong relationships.

 

[deleted1138023]

I would make sure that the residents do all my clinic/OP notes and see all my new consults. that would be my first priority when starting a program.

 

[ExperiencedDPM]

I don’t know if your plan is to start a program, become a residency director or simply improve a pre existing program.

I personally think there are far too many incompetent residency directors who don’t have the skill, knowledge or surgical armamentarium to run a program.

Although attendings will vary in all of the above, someone running a program should have a very strong surgical armamentarium, very strong academic background and should be well versed on current trends and technology.

Anyone who does not meet all of those qualifications is doing a dis-service to the residents and is doing it for an ego boost and a couple of extra bucks.

The greatest issue with residency training today is unqualified directors in my experience and opinion.

 

[deleted1149159]

Residents doing the entire case because the attending is not capable of doing so it not teaching. Certainly some value short term for residents getting to cut, but long term not beneficial.

You just described half the attendings I worked with in my three years of residency. I do agree with you.

 

[deleted1149159]

I don’t know if your plan is to start a program, become a residency director or simply improve a pre existing program.

I personally think there are far too many incompetent residency directors who don’t have the skill, knowledge or surgical armamentarium to run a program.

Although attendings will vary in all of the above, someone running a program should have a very strong surgical armamentarium, very strong academic background and should be well versed on current trends and technology.

Anyone who does not meet all of those qualifications is doing a dis-service to the residents and is doing it for an ego boost and a couple of extra bucks.

The greatest issue with residency training today is unqualified directors in my experience and opinion.

100% Agree.

The other issue is that some stay directors for way past when they should. It's a power issue for them, and they don't want to let go. There should be some kind of "term limit" built into the CPME guidelines, but seeing as how the same generation that won't let go are also the ones who wrote the book for the CPME guidelines, it's no surprise we are in this situation. This BS I keep hearing that the younger ones don't want to take over these programs is just that. BS. I'm also not sure how it became a thing that Residency Directors didn't need to be Board Certified by the ABFAS anymore. How can someone run a surgical program without that credential? And how does someone fresh out of residency, with no real world practice experience become the Director of a surgical RRA program? My view is that it takes some years to get your surgical legs and some time in practice before you can train someone to be an effective practitioner. Learning to do surgery is just 1/4 of the way there.

I think it's important that a Residency Director is a strong leader and has a strong crew that can cover what you are describing. A few of us are talking about starting a program, and between us, I personally think we have that compliment of skills amongst us. I am not strong in the very complex rearfoot procedures, like frames, IM rods and skin/muscle flaps. We have someone that is. We all lean strongly to the academic side, and we all keep up on the latest trends. We are especially sensitive to trends that should be followed and others that shouldn't. Like the resurgence of MIS and that Bunion sling thingie. No thanks.

 

[deleted1149159]

Residents have a working relationship with ortho/gen surg and vasc. Strong radiology and ER rotation. Can learn a lot from other professions.

Peds specialist. Not someone who just dables in it.

As much as I hated academics its super important. Group read texts. Journal review. Radiology rounds monday morning for cases that week. Especially important for radiology is MRI review with residents. Make them explain the MRI in detail/pathology they see.

Making senior residents round on straighforward I&Ds /diabetic stuff early AM then making them round again 2nd time same patient with attending present is a waste of the residents time.

Ideally centrally located program/not a lot of commuting. Driving/traffic is lost time.

Pre/post op clinic. See complications.

High volume. Most of the procedure we do are really not that difficult. Where high volume comes into place is #1 to establish confidence and efficiency. But whats most important with high surgical volume is the more cases you do the more intra op complications you will encounter. When the surgery goes as planned its easy. When a major complication happens its not so easy anymore. TH\hats were high volume comes into play.

Strong hospitalist/medicine and ICU rotations. Medicine training (at least where I went to DPM school) could really be improved upon. Gotta really hammer in understanding of surgical appropriateness for patients.

CME for conferences.

Pay a living wage. 401k.

Billing and coding. No tricks. Just basic stuff.

Spending at least a half day a week in a wound healing center.

Varying exposure to different cases. If the attendints all only do lapiplasty and thats it then the resident is doomed. Gotta be confident and know how to do a lapidus with cross screws, staple, and or plate. Its OK to have some newer stuff. That keeps residents exsposed to new products. But they need to be able to bail themselves out if there is a problem. with the new hot jigs they making

Axe toxic attendings/staff. Toxicity will eventually ruin any program. Ive seen toxicity break up two programs close to where I trained. Screaming at the top of your lungs and throwing instruments is not someone who should be training. OK to be angry and firm but not toxic.

I think the most important thing is backing your residents. Network for them to help them find employment. Stay in touch even after they graduate. Develop lifelong relationships.

The saddest thing for me is when I see residents being treated in a toxic manner, and then they turn out to be a toxic attending. If you hated how you were treated, make a change for the better in yourself.

The issue with "firing" a toxic attending is that the hospital makes money on these attendings. And really, you can't prevent any doctor from bringing cases to a hospital. Most residencies rely on community attendings to make their numbers. It's certainly a difficult issue to address.

 

[ExperiencedDPM]

100% Agree.

The other issue is that some stay directors for way past when they should. It's a power issue for them, and they don't want to let go. There should be some kind of "term limit" built into the CPME guidelines, but seeing as how the same generation that won't let go are also the ones who wrote the book for the CPME guidelines, it's no surprise we are in this situation. This BS I keep hearing that the younger ones don't want to take over these programs is just that. BS. I'm also not sure how it became a thing that Residency Directors didn't need to be Board Certified by the ABFAS anymore. How can someone run a surgical program without that credential? And how does someone fresh out of residency, with no real world practice experience become the Director of a surgical RRA program? My view is that it takes some years to get your surgical legs and some time in practice before you can train someone to be an effective practitioner. Learning to do surgery is just 1/4 of the way there.

I think it's important that a Residency Director is a strong leader and has a strong crew that can cover what you are describing. A few of us are talking about starting a program, and between us, I personally think we have that compliment of skills amongst us. I am not strong in the very complex rearfoot procedures, like frames, IM rods and skin/muscle flaps. We have someone that is. We all lean strongly to the academic side, and we all keep up on the latest trends. We are especially sensitive to trends that should be followed and others that shouldn't. Like the resurgence of MIS and that Bunion sling thingie. No thanks.

The term “we” is used a lot in your reply. Unfortunately, if you do get a program up and running there can only be one effective director. And that one director in my opinion, should be proficient in all aspects of foot, ankle and rearfoot procedures.

Realistically egos always end up causing issues when multi DPMs are involved. And let’s be honest, most of us believe we are more skilled and more academic than may be reality.

 

[deleted1149159]

The term “we” is used a lot in your reply. Unfortunately, if you do get a program up and running there can only be one effective director. And that one director in my opinion, should be proficient in all aspects of foot, ankle and rearfoot procedures.

Realistically egos always end up causing issues when multi DPMs are involved. And let’s be honest, most of us believe we are more skilled and more academic than may be reality.

As much as I agree with you, finding someone proficient and dedicated to run a Residency is one in a million. I personally find that a Residency should be a melting pot of attendings, and the Director, more of a figure head than an all encompassing guru of all things. Directors have many administrative duties as well. Something someone dedicated to providing supreme training may not be very well suited to.

Let's say I decide to start up a residency. I'm Board Certified in Foot Surgery, do plenty of bread and butter forefoot and rearfoot procedures, have been very academically involved, and also am very familiar with the ins and outs of the CPME and the minutiae of what they want to see in residencies. Should I be disqualified from being a Director because I'm not RRA certified and don't do external fixators and TARS? Even if there is an attending in this future residency that only does that and is very proficient at it, but doesn't want the administrative burden of being the Director? Serious question.

 

[DYK343]

The saddest thing for me is when I see residents being treated in a toxic manner, and then they turn out to be a toxic attending. If you hated how you were treated, make a change for the better in yourself.

The issue with "firing" a toxic attending is that the hospital makes money on these attendings. And really, you can't prevent any doctor from bringing cases to a hospital. Most residencies rely on community attendings to make their numbers. It's certainly a difficult issue to address.

Totally agree. Certainly is difficult to address fundimentally and legally.

But I know of 2 decent/good programs no longer here due to inner toxicity. Its gotta be stomped out.

 

[deleted1149159]

Totally agree. Certainly is difficult to address fundimentally and legally.

But I know of 2 decent/good programs no longer here due to inner toxicity. Its gotta be stomped out.

I know of many programs over the years that fizzled because of inner toxicity as well.

This issue is a political one. The toxic one or ones at the top have inroads which led them to the position. They hold on to that position with an iron fist, and the higher ups vouch for them despite their toxicity. Threats are made when things start to fall apart, ("I'm going to take my cases somewhere else and all my cronies will follow!!!") and the higher ups don't confront them, but let the problem escalate. Attendings bail because they just don't want to deal with it, and the residents suffer.

I've seen this at least a dozen times in my 20+ years. Instead of these programs calling these toxic people's bluffs out, or outright ejecting them from the program, they hold on to them, which furthers the toxicity. Also, when I've seen hospitals take out the trash, the programs gets clobbered for a few years, by rumors and naysayers. "That program will never be the same without XYZ." And those XYZ were the toxic ones!

This is one of the reasons I think there should be "term limits" for Residency Directors, and it should be written in the CPME Bylaws. Another blog I intend to write.

 

[DYK343]

I know of many programs over the years that fizzled because of inner toxicity as well.

This issue is a political one. The toxic one or ones at the top have inroads which led them to the position. They hold on to that position with an iron fist, and the higher ups vouch for them despite their toxicity. Threats are made when things start to fall apart, ("I'm going to take my cases somewhere else and all my cronies will follow!!!") and the higher ups don't confront them, but let the problem escalate. Attendings bail because they just don't want to deal with it, and the residents suffer.

I've seen this at least a dozen times in my 20+ years. Instead of these programs calling these toxic people's bluffs out, or outright ejecting them from the program, they hold on to them, which furthers the toxicity. Also, when I've seen hospitals take out the trash, the programs gets clobbered for a few years, by rumors and naysayers. "That program will never be the same without XYZ." And those XYZ were the toxic ones!

This is one of the reasons I think there should be "term limits" for Residency Directors, and it should be written in the CPME Bylaws. Another blog I intend to write.

Nailed it!

 

[air bud]

At this point I agree everything needs to be 3 years. You don't like it? Very simple you don't have to become a podiatrist. And if you decide you don't want to do surgery, at least you got the training. You are still better of with that knowledge base than a 1 year trained would be. And the profession is better for it. There has to be some form of standardization. Yes, you just spend 2 years and debt accrued for a longer period of time...but guess what that is the risk you took by going to podiatry school. As we have covered extensively, there are a million other ways to be a part of the healthcare system.

 

[deleted1149159]

I’m just playing devil’s advocate, because I have a different perspective than you.

You state that you have been “very academically involved”. I’m not sure if you owned a practice, worked for a practice, a hospital, MSG, ortho group, etc. But I’m just curious what role you were in where you were “very academically involved”? Was it a school, quality residency program, hospital, etc.?

I’m not trying to bust stones, but when someone says they are very academically involved, and wants to run a program, I think that the statement needs clarification.

You said you practiced in South Jersey and I’m not sure if that means south of Trenton, the Atlantic City area, etc. Regardless, I know of no strong sought after residency programs south of Trenton.

I believe the director NEEDS to be academic and a strong and complete surgeon. The attendings can have an array of skills but the captain of the ship should be the doc with the strongest credentials.

Otherwise in my opinion, you’re (meant in the third person and not meaning you) just creating another mediocre program. And we already have way too many mediocre and less than mediocre program. There are some programs in NY that are downright scary.

I look at what I consider the top programs and they have strong directors. You can’t make chicken salad out of chicken sh-t. And that happens too often in our profession.

Don’t settle for mediocrity just to get a program started. Find THE best and brightest to be the director and play a strong role in that program for diversity.

I apologize if you think this is personal, but it’s not. I’ve been involved in the past with reviewing and visiting programs, and it’s scary what I saw.

I admire anyone who wants to be involved with a program, but raise the bar as high as possible so your program isn’t another sub par training program.

Absolutely not taking it personally. I understand exactly what you are saying and thank you for saying it.

Suffice it to say, I have much more experience with critical thinking exercises, actual scientific research, evidence based medicine evaluation, epidemiology and the scientific method than your average bear. I've been in academia in some form my whole career. Teaching residents from all specialties in the first half of it. I've also done it all in the OR, except Ankle Implants. And now, I chose to give the "bigger stuff" to the younger practitioners. Can I still do it? If I had to, yes. Should I be doing it? Well, I don't think I should anymore. So I don't.

We can agree to disagree about what the Captain of the ship needs. The crewman are the ones that drive the ship, not the Captain. The Captain deals with the day to day BS and directs the ship. But yes, he also knows how to drive the ship if he has to. As I've said, I've been training residents my whole career. Both in the OR, and academically, out of it. Happily I've made a nice network of practitioners out there that I worked with when they were residents over the last couple of decades. I think if you asked them, they would say they learned a lot from me. And I can also say I learned a lot from them.

I totally hear you. And yes, I do think we have different perspectives. And that's okay.

 

[deleted1149159]

This will not happen. Because having 1-year residency trained pods will damage "reputation" of 3-year residency or fellowship trained pods. It will just reinforced already established idea among MDs that podiatry is not standardized and cannot be takes seriously. Biggest argument orthos bring up is huge variation in podiatry training. The idea behind everyone having 3 years of residency training is to benefit those who are actually doing more complex surgeries and seek respect. Its obvious that not everyone needs 3 years to practice as PP podiatrist with minimal to no surgical practice.

It's already a mess. There is so much variety in residency training. It would be impossible to decide which programs must become 1 year and which will stay 3 years long. Plus, I am sure, many 3-year programs will still suck and produce grads not being able to pass ABFAS boards. Problem will still be there.

I believe, programs have to stay 3 year long. CPME or whatever organization is responsible for residency training should strictly standardize training. Those programs that can't meet the requirements after so many years must shut down. All grads must have similar training. And if they decide later on they don't want to do surgery or certain procedures, that's their choice/problem. But programs should not suffer in quality just because their director is lazy, not committed, doesn't like surgery, etc.

It seems that nobody wants to fix the system. Many are just taking advantage of the others

So how would you fix it?

 

[deleted1149159]

At this point I agree everything needs to be 3 years. You don't like it? Very simple you don't have to become a podiatrist. And if you decide you don't want to do surgery, at least you got the training. You are still better of with that knowledge base than a 1 year trained would be. And the profession is better for it. There has to be some form of standardization. Yes, you just spend 2 years and debt accrued for a longer period of time...but guess what that is the risk you took by going to podiatry school. As we have covered extensively, there are a million other ways to be a part of the healthcare system.

I understand what you mean, but only partially agree. Giving everyone the training means some who shouldn't use it, will. And those are the ones you read about. And make us look terrible. This happens in other surgical specialties as well, but we have limited avenues to make a change. If an MD or DO doesn't have what it takes to become a Surgeon, but matches with a surgical residency, they can eventually move to a different specialty and make a career of it. I know of many like this. Once in their surgical residency, they either realized they hated it, or were so bad at it, it was "suggested" they vacate their spot and go do something else. One of my close friends back when did this. Went from Surgery to ED, and became an incredible ED Doc.

Right now, if a podiatry resident is atrocious with his or her hands, what do you do? You push them through because you have to. And that's bad for everyone.

 

[AttackNME]

This will not happen. Because having 1-year residency trained pods will damage "reputation" of 3-year residency or fellowship trained pods. It will just reinforced already established idea among MDs that podiatry is not standardized and cannot be takes seriously. Biggest argument orthos bring up is huge variation in podiatry training. The idea behind everyone having 3 years of residency training is to benefit those who are actually doing more complex surgeries and seek respect. Its obvious that not everyone needs 3 years to practice as PP podiatrist with minimal to no surgical practice.

It's already a mess. There is so much variety in residency training. It would be impossible to decide which programs must become 1 year and which will stay 3 years long. Plus, I am sure, many 3-year programs will still suck and produce grads not being able to pass ABFAS boards. Problem will still be there.

I believe, programs have to stay 3 year long. CPME or whatever organization is responsible for residency training should strictly standardize training. Those programs that can't meet the requirements after so many years must shut down. All grads must have similar training. And if they decide later on they don't want to do surgery or certain procedures, that's their choice/problem. But programs should not suffer in quality just because their director is lazy, not committed, doesn't like surgery, etc.

It seems that nobody wants to fix the system. Many are just taking advantage of the others

Sounds like you want to keep everything 3 years because it sounds better on paper. But that is causing a lot of the problems. Imagine how much better your training would be if some of your coresidents elect to do a 1 year program and you get to scrub more cases?

 

[air bud]

I understand what you mean, but only partially agree. Giving everyone the training means some who shouldn't use it, will. And those are the ones you read about. And make us look terrible. This happens in other surgical specialties as well, but we have limited avenues to make a change. If an MD or DO doesn't have what it takes to become a Surgeon, but matches with a surgical residency, they can eventually move to a different specialty and make a career of it. I know of many like this. Once in their surgical residency, they either realized they hated it, or were so bad at it, it was "suggested" they vacate their spot and go do something else. One of my close friends back when did this. Went from Surgery to ED, and became an incredible ED Doc.

Right now, if a podiatry resident is atrocious with his or her hands, what do you do? You push them through because you have to. And that's bad for everyone.

If only there was a way to be more selective about who gets a Podiatry education....🤔

 

[de Ribas]

So how would you fix it?

1. Do not ruin what's already there. By not opening new schools and not increasing class sizes.

2. Standardize residency training. I am not sure how MDs achieved standardization across their residency programs. At some point they had to implement stricter rules for all programs. I think we need to take that step even if we close bunch of programs down. Someone needs to sit down and develop a standardized curriculum for residency programs and make sure it is implemented. Standards should be similar across certifying board(s), residency training and pod schools and organizations like CPME. Everyone has to be on the same page. Standards need to be raised higher. Way higher. Obvisoisly, residencies do not hit a target if majority can't get board certified. No surprise other specialties think we are a joke.

3. Systematize Residency Training. Being on non-podiatry rotations I have realized how good AGME works with the hospitals, directors, faculty so everyone knows what they need to teach and what to expect at each milestone. Residents know exactly what MD students must do on their rotations. Everyone is involved in student and resident education. It seems as the whole hospital is involved with training their residents. Resident and student pictures are all over the hospital. Rules, expectations, flow charts, protocols are posted throughout the hospital regarding MD/DO residents. Podiatry is usually not included. The whole continuum of education and training for MD/DOs is obvious. Their adminsitration works well support that as well.

Podiatry residents act more like assistants to pods seeing inpatients, writing OR and clinic notes, helping prep OR, suture at the end, place splints, seeing post-ops, placing orders. Basically act like Ortho PAs. Not a lot of teaching. Academics are mediocre at best. No set curriculum, no standardization, no systematic approach to training. In contrast, MD residency has a systematic approach to their academics and to a whole training process. A lot of emphasis is placed on board prep. No surprise why so many pod fail boards, because barely any program teaches well and spends time preparing pod residents for boards.

4. Change the culture. There is too much division. Stop the division. Podiatry is probably the smallest healthcare profession and probably has the most division. Many are taking advantage of their own. This one is toughest. Since system just recreates the product.

5. Stop taking everyone with a pulse. If profession will be changed, it will be changed by the type of people it recruits and accepts. We can't be selective at all if we have 700 applicants for 600 seats. We need to decrease enrollment asap. I have seen so many students who have no business being in medical profession and doing surgery.

 

[de Ribas]

Sounds like you want to keep everything 3 years because it sounds better on paper. But that is causing a lot of the problems. Imagine how much better your training would be if some of your coresidents elect to do a 1 year program and you get to scrub more cases?

I don't think everyone needs 3 years if some would eventually end up not doing surgery at all. But then podiatry is already so small of a profession that any more division and fraction will be damaging.

I would rather standardize the profession, raise quality of training, make it more rigorous, make it on par of MD/DO education hopefully achieving better scope, rights in the distant future. If that happens, it could possibly attract higher caliber candidates and then the system will just sustain itself. At this point with variability in training, there is variability in pay, scope, respect, etc resulting in low and poor applicant pool.

But I also do not think we need to increase class sizes or open new schools.

 

[AttackNME]

Most of us cannot meet these standards that I think we want. It’s like when we started mandating a 3 year residency, well the attendings running those programs did what they could with what they were trained. Our profession isn’t associated with MD/DO and so even the very concept of having residency and standards is relatively new. Our identity as a podiatrist is in flux. Increasing standards of current programs can happen and here’s a couple thoughts

1. Incentivize the hell out of it. If we truely value this, we need to put our money where our mouth is and pay program directors more. Have a limited term, and allow for voting of new directors. Because with only the few of us that are truely qualified to teach, we need them to actually want to deal with the politics and paperwork of running a program

2. How about the residents who decide they don’t wanna do surgery or are terrible at it? How will that affect our image as a community of only podiatrists who do surgery? If it’s surgery or bust, how do programs protect themselves from a class action lawsuit from those screwed by this strict pro-surgery profession that left them with no option and heavy financial debt? It makes so much sense per @Dr.Ron to include 1 year programs, it gives an out for the resident and the program who find them incompetent for surgery. That is a direct internal filter that will only increase the quality of a 3 year trained podiatrist

 

[DexterMorganSK]

Do you all think it makes any difference in resident training if Podiatry is a consulting team vs. an admitting team at a hospital?

I agree with everyone that stated that there needs to be more academics and PD involvement daily. During my externship months, many of the programs were residents run, and that IMO leads to inadequate training. There needs to be some supervision from the PD, either for academics, research, etc.

 

[ExperiencedDPM]

Do you all think it makes any difference in resident training if Podiatry is a consulting team vs. an admitting team at a hospital?

I agree with everyone that stated that there needs to be more academics and PD involvement daily. During my externship months, many of the programs were residents run, and that IMO leads to inadequate training. There needs to be some supervision from the PD, either for academics, research, etc.

It absolutely makes a difference. There are too many directors who are in it for themselves. Free labor in their office, free labor on the floors in the hospital, free labor with consults, etc.

I started a residency many years ago. It was a lot of work and little reward. Too many attendings didn’t want to teach, they only want scuts to do their dirty work. I basically sustained the program on the cases I booked. There was no commitment from my peers. I even had a stipend that I put back into the program. My colleagues let me down and wanted to take but not give.

 

[DYK343]

Nandos Peri Peri is the best spicey wing sauce.

Salt/pepper wings minumum 2hrs (overnight is best)
1st Fry wings at 250 degrees for ~10 min. Heat to 275 because temp will drop once wings added.
Remove and cool 20 min
2nd Fry wings at 375 degrees (heat to ~400 temp drops) for 5-10 min (once golden brown)
Throw some nandos sauce on there and toss away.
10/10. Juicy inside. Crispy outside. Guarenteed best wings you've ever had.

I typically add some beef tallow to the oil. Maybe 10% tallow 90% neutral oil. Never go full Tallow. If you do I'll be doing your TMA.


.....Anyone remember DoctaZero? There were at least 10-20 handles under different names. What was the website? Podiatry post? There was one before podiatry post. 10 years ago we got weekly questions about it. Incoherent rants here and the website. Obvious to identify.


Edit: due to deleted posts this now seems random. But I do encourage you to try the wings.

 

[deleted1149159]

Do you all think it makes any difference in resident training if Podiatry is a consulting team vs. an admitting team at a hospital?

I agree with everyone that stated that there needs to be more academics and PD involvement daily. During my externship months, many of the programs were residents run, and that IMO leads to inadequate training. There needs to be some supervision from the PD, either for academics, research, etc.

I have mixed feelings about the admitting team thing. I'd personally prefer to be a consultant. It comes with less liability that way.

And yes, supervision is absolutely necessary. This is part of the thing I was talking about, about toxicity. It also comes down to liability. If you are billing for seeing a patient in the hospital daily, and you don't, which could be easily verified by residents, that can land you in a whole lot of trouble. Also, if there is a residency clinic, there has to be an attending there. Especially if there is some form of billing going on. A program in TX got slammed with this.