Jarrod Shapiro, DPM Practice Perfect Editor Mountain View Medical & Surgical Associates, Madras, Oregon

Fellowships: The Future of
Advanced Podiatric Education?

The practice of medicine is becoming increasingly specialized and competitive. In the past, it was easy for a general practitioner to graduate from residency, “hang their shingle,” and start practice. Similarly, a “general practitioner” was capable of handling almost all medical issues that came his way, to the satisfaction of patients and the larger medical community. It was the standard for GPs to deliver babies and do minor surgery. As time progressed, the practice of medicine has changed significantly. Increasingly, the internal medicine and family practice physicians must rely increasingly on specialists to provide a higher level of appropriate and more focused care to their patients. Clearly, this trend has been beneficial to podiatry, and the trend has occurred throughout medicine. Gastroenterology, oncology, infectious disease, and many other fields have grown out of the increasingly complex and comprehensive body of knowledge that has accrued over Medicine’s long history. It is simply too difficult for any one doctor to effectively treat every disease process that comes along. Specialists are essential.

	Tonight's Lecture is Appropriate Use of Negative Pressure Wound Therapy in Diabetic Foot Wounds; David Armstrong, DPM, MSc, PhD.

The Rising Trend

I find it fascinating that, not only are specialties growing but even subspecialties.  Look at orthopedics for example.  Many orthopedists now subspecialize in anatomical body areas (hand, foot, knee, spine, hip, etc) and disease processes (trauma and oncology, for example).  Similarly, podiatry appears to be increasingly moving in this direction.  We’re seeing more and more wound care, geriatric, sports medicine, podopediatric and reconstructive subspecialists, among others. 

And with this rise in podiatric subspecialties, we’re seeing a rising trend in postgraduate fellowship programs at which podiatists can get the specialized training that they need.  Each time I look, I find increasing numbers of fellowship programs.  Thus far, I have found fellowships covering the following areas: wound care, sports medicine/biomechanics, reconstructive foot and ankle surgery, limb salvage and preservation, dermatology, and research.  There’s even a new practice management fellowship.  Fellowships are available throughout the country at various locations. 

Try a MiniFellowship

Just as with fellowships, we’re also seeing a rising trend in “minifellowships” which usually last from 4 to 6 weeks, covering topics such as external fixation.  Several of these minifellowships are available internationally. 

How Much Is Too Much?

I applaud those who desire to obtain further training, as well as those who supply this extra training.  As with any educational pursuit, teaching a fellow is a labor of love that requires a special person.  But is there a point when one has received too much training?  Is it possible that some of the training becomes extraneous?  Some might argue that our residencies should be providing that comprehensive training that should prepare us for practice life.  Is there something wrong with residency training that we need these fellowships?  What about postfellowship income?  Is it significantly greater than those without fellowships? 

Let's Look at the Pros and Cons

Here are the general benefits and disadvantages of fellowships as I see them. As a doctor who has not undergone fellowship training, I cannot speak for any specific program and welcome comments from anyone, either involved in this type of training or those who have undergone fellowships in the past.

If one agrees with my list, the benefits outweigh the disadvantages for those willing to put in the time and effort.  One must consider, though, that this may be not only an investment of time but also of money.  During my first year of practice, I made a little over $100,000 (after base salary plus bonus).  The average fellowship pays around $50,000/year.  If I had done a fellowship, I would have lost $50,000.  If I had done a 2 year fellowship, I would have lost well beyond $100,000.  Would the salary differential after completion of the fellowship have made up for the difference?  Probably not.  For the podiatry resident intent on getting out into the work force and “starting their life”, this is not the best choice.  For that new doctor who is willing to put in the time and effort, to gain advanced training that may distinguish him/her from general practice podiatrists in the community, the fellowship may be worth that monetary investment.

Where To Go From Here

So, where does that leave us?  Fellowships are increasing in number, complexity, scope of practice, and visibility.  The sophistication of educational experiences are outstanding for those fellows I have spoken with.  Fellowships are here to stay and represent the future of advanced podiatric education.  But some issues still remain.

What about Accreditation?

One large question has to do with accreditation.  As of June 2009, the Council on Podiatric Medical Education (CPME) certified only seven programs.  Where does that leave the other fellowship programs, many of which are excellent?  Some argue for and some against accreditation.  My personal bias is towards requiring accreditation, for the simple reason that education always requires oversight.  A certain level of standardization must be present or we can never be certain of the quality of the fellowship. 

I have a couple of other suggestions for those involved with fellowships.  I would push for a significant increase in the salaries of fellows.  $50,000/year may work for a resident, but to attract more potential candidates, fellowships must make their 1-2 year time period less of a sacrifice.  Fellowships should be located in larger cities and within large hospital systems, to allow the greatest chance for involvement with the full medical community.  Somehow – and I have no good suggestion here – those who have done an accredited fellowship should make considerably more income once in practice than those of us who have not done one.  As a final suggestion, I’d like to see more minifellowships, centered on those in practice who desire to gain further skills in a specific niche area.  Let’s reimburse those of our physician leaders who take the time to continue to advance our profession in a medical community of continually increasing subspecialization.  Good luck to our next crop of fellows.  We applaud your hard work and dedication.

Keep writing in with your thoughts and comments or our eTalk discussion forum on PRESENT Podiatry and start or get in on the discussion. We'll see you next week. Best wishes!

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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