PMNews Letters

Click HERE to return to the listing of PMNews Letters

"Unified" Post-Graduate Training (Charles M Lombardi, DPM)

06/11/2012      Robert D Phillips, DPM


I’m a little confused by Dr. Lombardi’s letter. After 33 years in the profession, 20 of which have been spent in teaching undergraduate and graduate podiatry students, I support fully the “one training” paradigm for all podiatric physicians.

From my early days as a representative in the APMA House of Delegates, I voted always against the subdivision of our profession into smaller, more focused residency training programs. The alphabet soup of post-graduate training programs did nothing but confuse the public and other professions as we could not ever really define what a hospital should look for in podiatric applicants.

Just because a podiatrist is trained in all aspects of podiatric surgery and medicine, does not mean that physician has to practice everything they learned. Indeed, after residency, many physicians in all specialties, choose to focus on only one small part of their total training program.

While extensive work has gone into the new CPME 320 document, it should not be considered to be a finished project. I am concerned that the document focuses too much on numbers of activities (MAVs) instead of competence. For example, it is noted that MAV for digital surgery is 80 (which is subdivided into 13 categories) vs. MAV for first ray surgeries is 60 (which is subdivided into 27 categories).

This means that the resident needs to do an average of 6.15 surgeries in each of the digital categories and only 2.22 surgeries in each of the first ray categories. How did ABPS come to this recommendation? Do they consider that digital surgeries are almost 2.76 times more difficult to do, and that residents need to do almost 3 times more digital than first ray procedures to be considered competent? Has anyone ever done any studies on how many digital surgeries it takes the average resident to do to become competent? I brought this up to a leader of ABPS many years ago, and he admitted that the MAV surgical numbers were totally based on resident log averages.

Similarly I am concerned by the definition of “biomechanical cases” and how ABPM came to believe that 75 was the proper MAV. What constitutes a biomechanical case? The CPME 320 notes: “This activity includes direct participation of the resident in the diagnosis, evaluation, and treatment of locomotor disorders caused by congenital, neurological, and heritable factors. These experiences include, but are not limited to, performing comprehensive lower extremity biomechanical examinations and gait analyses, comprehending the processes related to these examinations, and understanding the techniques and interpretations of gait evaluations of neurologic and pathomechanical disorders.”(CPME 320, Appendix A, B3b) What constitutes, and how does a resident log a “comprehending the processes related to these examinations” experience?

How does an MAV of 75 cases (that is only 1 case every fortnight) prepare the practitioner for the number and variety of biomechanical cases that a podiatrist encounters in a daily practice? I see a large number of young three- year trained surgeons, ready to do Evans procedures for flatfoot, that have no idea how to evaluate the subtalar joint axis. Why wasn’t a biomechanical exam required for each of those procedures done in residency? Why do we care more about surgical procedures done, than “surgical cases” which should include the pre-op workup medically, biomechanically and also the followup care, including the post op care and the post-op gait analysis and the orthotic therapy and the medical management of the patient?

I could make similar cases for other areas of podiatric medicine in which the CPME document needs further revisions. However, I do believe that we have bought the “right horse” by making the residency process uniform for the profession. It is now the responsibility of the ABPS and the ABPM to continue to monitor the training programs, and revise the requirements set forth in the 320 document to truly reflect the needs of the profession and the activities that trainees need to do to become truly competent.

Robert D Phillips, DPM, Orlando, FL, Robert.Phillips9@va.gov