Guest Editorial: This week we bring you the conclusion of Orthopedic Foot and Ankle Surgeon Dane Wukich of UPMC in Pittsburgh, PA. He offers some great insight into the future of our field and knowing that it would be controversial for both he and us, I very much appreciate the fact that Dane agreed to write this piece. Even more so, I appreciate the way in which Dane presents his points and observations, most of which I agree strongly with. As a member of the AOFAS who is actively involved in training podiatric residents and fellows, Dane clearly does not stray away from a challenge. This week is Part One and we will print Part Two next week along with your comments. Please read below and have a great holiday!
—John Steinberg, DPM, PRESENT Editor
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Dane Wukich, MD
Associate Professor of
Orthopaedic Surgery,
Assistant Residency Director,
Department of Orthopaedic Surgery
University of Pittsburgh
School of Medicine
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Part 2: Podiatry from the Perspective
of an
Orthopedic Surgeon in 2009
Follow this link to read last week's Part 1.
For the field of podiatry to gain universal respect from the medical community, some radical changes must take place. Podiatry schools should educate their students during the preclinical years as a part of an established medical school. Allopathic and osteopathic students who interact with podiatry students at such an early stage will not develop the bias that often comes later in training. My understanding is that this does take place in certain schools, but it is not standard. I have interacted with students from all of the US podiatry schools, and those students who are educated side by side with allopathic or osteopathic medical students feel this is a distinct asset. This has been done with dental students for some time. The DPM degree should be granted from an established university such as several podiatry schools do.
Patients and doctors alike are impressed with places they know and recognize such as Temple School of Podiatric Medicine or the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science. Podiatry students should be trained and expected to pass Parts I, II and III of the USMLE exam just like every other surgeon or medical doctor does. This would involve a formal “intern” year (PGY 1) followed by a minimum of three years of foot and ankle surgery training. The intern year should largely be outside the scope of foot and ankle surgery, concentrating on internal medicine and its subspecialties, general surgery and its pertinent subspecialties and formal rotations in anesthesiology, radiology and pathology. Our orthopaedic residents spend a maximum of three months on orthopaedics during their PGY 1 year, and nine months is devoted to other specialties. My understanding is that a few podiatry programs already do this and they should be applauded for setting the standard. During this formal intern year, podiatry residents would establish relationships with other house officers. Those relationships that are forged during an intern year will go a long way in elevating the respect that talented podiatric residents are due. I have personally witnessed this at the University of Pittsburgh, when our podiatry residents get the opportunity to work with other residents outside the field of podiatry.
If you send your best and brightest podiatrists to rotate with other physicians in training, you will change the prevailing attitudes immensely. No other surgical training program is less than four years, and most are at least five years, not counting fellowship training. Having trained four podiatry fellows over the past four years, I can say with certainty that they have matured immensely during that additional year of surgical training. All of them have worked with me since their PGY 1 year, and I am confident that they would echo my sentiments. During this fourth year of training, they have acted as junior attending surgeons, dramatically improving their skills in the operating room and clinic.
Finally, I would strongly recommend that Podiatric residencies fall under the guidance and supervision of Accreditation Council for Graduate Medical Education (ACGME). The ACGME is a private, non-profit council that evaluates and accredits medical and surgical residencies across the US. It was established in 1981 and its mission is to improve health care by advancing the quality of resident education. It is quite healthy for an outside organization to objectively assess programs. The ACGME member organizations are the American Board of Medical Specialties, American Hospital Association, American Medical Association, Association of American Medical Colleges and the Council of Medical Specialty Societies. Orthopaedic surgeons are certified by the American Board of Orthopaedic Surgery (ABOS), however ACGME works closely with the ABOS.
Standardization of Podiatric residencies needs to take place prior to podiatry gaining the respect that it desires and merits. It is not fair to the young and talented podiatric residents to have several different podiatric boards granting certification. Nor it is fair that the curriculum varies from program to program. The leaders of Podiatry need to establish a formal basic science curriculum that should be followed by each training program. The field of surgery mandates a large base of knowledge, and this fund of knowledge is expanding each year. A comprehensive basic science curriculum should be established that can be completely covered during a three year program, not including an intern year. Topics such as metabolic bone disease, biomechanics, materials and perioperative care should be included. Attending a weekend course on total ankle arthroplasty does not provide any surgeon(orthopaedic or podiatric) with enough knowledge about the material properties of plastics and metal, the concept of soft tissue balancing or the modes of failure of total joint implants. The same is true for workshops on external fixation. Mastery of these techniques takes years of experience under the supervision of a competent mentor, and this is not unique to the field of podiatry.
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