Residency Insight
Residency Insight -- A PRESENT Podiatry eZine

Robert Frykberg, DPM, MPH
Robert Frykberg,
DPM, MPH

PRESENT Editor,
Diabetic Limb Salvage
 
History, Education, and Mentorship

In this, my first contribution to RI and introduction as Editor for Diabetic Limb Salvage, I hope that the reader will allow me to wax philosophical on my view of what my role should be in this regard. Please bear with me as I ramble on to give you, the Resident-in-Training, my perspective on Podiatric Medical Education, Residency Education, and Continuing Medical Education.  My perspective is based on over 30 years of practice in the private, academic, and Federal settings. Much has changed since I entered my residency in 1976 and, yet, some things have changed little.

In the old days of the 1970’s (before most of you were born) Podiatry was an emerging profession in the best sense of the word.  Although not all of the 400 or so graduates of the five schools could enter Residency Programs (there were simply not enough positions), we were seeing a wonderful expansion in the opportunities available to Podiatrists.  State practice laws were changing to allow for surgical practices in the increasing number of hospitals that granted DPMs hospital privileges.  Accordingly, Podiatry Residencies (usually just for 1 year) were developing across the nation in many of these community hospitals.  There were precious few programs available in major medical centers or University affiliated hospitals at that time. The University of Texas in San Antonio, New England Deaconess Hospital (Harvard), and the University of Chicago Hospital are the few that come to mind.  These were the gems that became highly sought after programs in their day and eventually lead to all the fabulous training programs that we see today. I wish that I had the opportunities that are currently available to new graduates!

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Nonetheless, there was a lack of uniformity in the quality of Podiatric education (it wasn’t called Podiatric Medical Education back then) and certainly in the quality of residency education.  Much of the latter was due to the diverse backgrounds of Residency Directors (many of whom never had residencies themselves) and much less stringent standards for residency education.  Even so, these men and women served as role models and pioneers in our profession; indeed, they paved the way for the expansion of high quality programs that we see today around the nation.  Podiatry Colleges had equally diverse faculty, both in the Basic Sciences as well as in the Clinical Sciences. Some were full-time faculty and most were part time, either with University appointments for the former or private practices for the latter. Some were excellent teachers while others were marginal or ineffective.  In the early seventies there was a move to expedite medical (and podiatric) education by compressing the traditional four year course into three years.  While many students blossomed under this curriculum, many found it too stressful and this program was abandoned after several years. 

What was sorely missing, and I believe is still largely absent from our education, was a concerted effort to teach future doctors how to be critical thinkers and educated consumers of the medical literature.  Ask yourselves how many courses or hours were devoted to epidemiology, biostatistics, or study design? How many courses did you take where the focus was on a critical review of the medical and podiatric medical literature?  How often did your professors rely on current literature reviews to augment their course curriculum and standard textbooks? How often were you assigned recent or classical papers to review to prepare for exams (rather than class notes and syllabi handed down from one year to the next)? Do you know how to review a paper for accuracy, relevance, strengths, and shortcomings? Do you honestly know the difference between a case-control study and a retrospective cohort study or how to interpret the significance of a 95% Confidence Interval?  I certainly did not.  If this is the same for you, how are you going to be able to evaluate the validity of all those articles that you read each month? With evidence based medicine (EBM) the ever present buzz word surrounding our practices, how does one evaluate evidence critically without the necessary skills to do so? Upon the stark realization of our own inadequacies in this regard, many of us have had to go on to graduate school to acquire the ability to the answer the questions posed above.

Having participated in the training of hundreds of students and residents over the years, it is apparent that the desire to learn remains an ever present quality in our young doctors (as it should).  That said, the weaknesses cited above remain consistent from one student class to the next and from one incoming resident class to the next. Probing questions are necessary to engender critical thought, even if the answers given are not quite correct. It is the thought process that is important – the often difficult process of merging didactic knowledge with the clinical scenarios at hand.  I’m sure that many of my former students and residents remember when they were put “on the spot” to answer a basic clinical (or even biostatistical) question and I simply waited for an answer (much to their chagrin). In as much as the answer may or may not have been important, it is always important to know what you don’t know.  That is how we learn – and we are in a profession that requires a lifetime of continual learning.  They call it a “practice” because we never quite get it right and must always be learning new skills and must constantly replenish our knowledge.  And by the way, most of those students and residents who initially resented me for putting them on the spot during their training have long ago realized that they learned from the experience – a “teaching moment” if you will.

So I have always viewed my role as one of mentorship, if not training young doctors by example then at least by using the Socratic Method: teaching by asking questions so they would learn to use their God-given abilities and the knowledge they already possess. To watch students and young doctors grow in their abilities to think and learn, in concert with their abilities to manage very complex patients, is a joy.  Moreover, it is an honor and a gift that keeps giving over and over throughout the years. Seeing your students and residents achieve successes greater than your own is a remarkable blessing – especially when they, themselves, go on to mentor future generations of doctors.

We will revisit this theme in the months and years to come because I believe it is an important one. Learning from the past is the way to avoid making the same mistakes in the future. Similarly, learning from those who have walked in your footsteps years before might offer some insights for you as you begin your careers in a very noble profession.  In closing, I recall the words inscribed on the hallway walls in the Joslin Clinic that I read so often when I was a young Podiatry Resident and eager to conquer the World:

“Live as if you were to Die Tomorrow:  Learn as if you were to Live Forever”

Best regards,

Robert Frykberg, DPM, The VA PACT Experience: Mortality and First Onset Diabetic Ulcer

Robert Frykberg, DPM, MPH
PRESENT Editor,
Diabetic Limb Salvage

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For those of you who don't know, I will be chairing the Desert Foot 7th Annual High Risk Diabetic Foot Conference at the beautiful Fairmont in Scottsdale, AZ on Weds., Nov. 17 thru Friday, Nov. 19, 2010. I encourage you to join me for this state-of-the-art conference. Please hurry though, seating is limited.

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