Residency Insight -- A PRESENT Podiatry eZine

Back to Basics

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

Over the years, I've worked with a great many students and residents – from Boston to Des Moines to Phoenix. Many of you reading this e-zine spent time in my office, clinic, or hospital making rounds and visiting patients. That is where the real learning takes place. It's quite difficult to make the transition from your second or early third year classroom experience to the clinical setting, where you actually have to put all those facts you've learned (or regurgitated) into practice. Remember all the hours of studying microbiology, physiology, anatomy, pharmacology, and pathology? All that memorization? Well, it was done for a purpose – to lay a foundation upon which to build your clinical experience and acumen. As a Clinical Dean in Des Moines, it was my job to train the very green students, just coming out of the second year, to be clinicians. It was quite painful – for them as well as myself- but very rewarding by the end of that first clinical year, when many turned into budding clinicians (and almost doctors) . My favorite method of teaching is the Socratic Method- just ask questions that the students should know and wait for their answers – if they have any. Yes, many thought I was terribly cruel to put them on the spot that way But I really thought that this was the best way to get them to think like clinicians- to put that knowledge stored way in the back of their brains to some good use- something that would actually benefit their patients!

My most vivid memory was in a clinic and we were treating a patient for a wound whose culture returned an isolation of Staphylococcus aureus. Thinking that this was a fairly important organism for a student doctor to know how to treat, I asked my third year student to name five possible ways that she would treat an infection caused by this pathogen. And then I waited for an answer- without prompting or cajoling, or pushing. I just waited, to give her time to think and come up with a few selections (even 3 would have been fine). I was mortified when the tears started streaming down her face in lieu of even one antimicrobial agent! She had as big an impact on me as I'm sure I did on her! I felt rather terrible to be sure. But after our calm discussion thereafter, I was quite sure that she would never again forget how to treat a staph infection (and I was quite sure that I didn't ever want to make young ladies cry like that again!) .

It was then that I first realized that students don't generally grasp the importance of the basics of medicine (and podiatric medicine) : microbiology, anatomy, physiology, pathology, and pharmacology. But ask them about bunion surgery or ankle fracture classification and they can step right up to the plate! So I ask, where are the priorities here? Shouldn't doctors be well versed in the basics of medicine before they learn the complexities of surgery? Do they have more surgery courses (or hours) than microbiology or pharmacology? I cannot answer this for sure at this point, but they certainly seem to know more about surgical procedures than they do about medicine (and frequently biomechanics) . My current and past residents (and students) will chuckle when I pose the question: "How would you treat a Stenotrophomonas maltophilia infection?" This has been a favorite for years and it is a rare day indeed when a student ever gets this one right, yet we do see this organism quite frequently in our patient population. (The answer is trimethoprim/sulfamethoxazole by the way) . I continue to ask my 3rd and 4th year students (and residents) my staph aureus question. And I'm still amazed at how few of them can actually give me an immediate 3 or 4 possible choices. (I haven't even gotten to Scopulariopsis brevacaulis yet!) . But they can almost invariably name five or ten different bunion operations! Where are the priorities? When a 4th year student 4 months away from becoming a doctor cannot name 5 ways that he/she might treat a common infection during the first month of their residency, I start to wonder where the focus has been in their training? Shouldn't they become doctors and physicians before becoming podiatric surgeons?

Very few students or residents can name more than one dermatologic marker of diabetes mellitus and fewer can remember how necrobiosis lipoidica diabeticorum is spelled or even pronounced. Very few can recognize that the varus deformity subsequent to the amputation of the 5th ray has something to do with the loss of the peroneus brevis insertion. Few realize that the primary dorsiflexor of the ankle is the EHL and not the Anterior Tibial muscle. (We haven't even talked about RANK, RANKL, OPG, and NF kappa beta) . The point is that somehow we are missing the importance of the basics; obfuscated by the glamour of the quest to become a reconstructive podiatric surgeon (the goal of most students and residents in Podiatry) .

We need to reset our course and emphasize the basics in the didactic and clinical training of students. Yes, they need to know something about surgery and surgical principles for their boards. But learning surgery, for the most part, should come in residency training. Isn't that the way it usually works? I have been blessed with absolutely wonderful residents who manage very complex medical patients with a good deal of skill (and I'm sure many sleepless nights on call) . Their first year is spent practicing their skills as clinicians and doctors — with little emphasis on surgery, due to the demands of their program requirements. It is extremely gratifying to see them develop into fine physicians – often receiving the complements from our Medical staff. After the subsequent two years of concentrated surgical training in all aspects of foot and ankle reconstructive surgery, they become qualified and experienced to handle any problem that comes their way. Their experience and capabilities far surpass my own at that stage of training. Nonetheless, they too have had to go through the fires of learning the basics of how to assess and manage a myriad of medical problems and situations. (And they've all been subject to the same queries mentioned above when they were my students) .

I doubt that this will change – it hasn't done so in the last thirty years, despite all the rhetoric and advances we've made as a profession. My plea is that students will indeed learn the basics first – and well. Master the medical and basic science areas before jumping into the surgical arena, so that medical comorbidities and complications can be better managed before and after the operations. And never forget the importance of knowing at least five ways to treat a staph aureus infection�

Best regards,

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

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