Addressing Misconceptions About The Recent Joint Task Force White Paper And Resolution
"Change is the law of life, and those who look only to the past or present are certain to miss the future."- John F. Kennedy1
The American Podiatric Medical Association (APMA), American College of Foot and Ankle Surgeons (ACFAS), American Academy of Orthopaedic Surgeons (AAOS), and American Orthopaedic Foot and Ankle Society (AOFAS) Joint Task Force white paper publication titled "Improving the Standardization Process for Assessment of Podiatric Medical Students and Residents by Enabling Them to Take the USMLE"2 created a healthy discussion on multiple platforms. It is essential to hear concerns from the podiatric community and address them head-on with facts, debunk misconceptions and correct inaccurate statements. I would like to take this opportunity to share my first-hand knowledge to clear up much for the confusion I have observed amongst colleagues.
Resolution 303 in Reference Committee C of The American Medical Association (AMA) House of Delegates (HOD), held June 11-16, 2021, pertains to podiatric medicine and surgery.3 AAOS and AOFAS introduced this resolution, which has the same title as the white paper. The task force members and attorneys for all four organizations rigorously vetted the white paper, which the four associations’ Board of Trustees/Directors then approved. It is yet undetermined if the resolution makes it to the AMA HOD for a vote this session due to limitations associated with a virtual HOD.3
The notion that this white paper/resolution was a surprise and came out of nowhere is simply not true. The topic was introduced at the APMA 2019 HOD as Resolution 4-19 (Directive) and passed unanimously on the consent agenda.4 The resolution was sponsored/co-sponsored by the APMA Board of Trustees, the American Podiatric Medical Students' Association (APMSA) and 26 state podiatric associations. The American Board of Podiatric Medicine (ABPM) and ABFAS also endorsed the resolution. Additionally, Jim Christina, DPM, Executive Director and CEO of APMA, wrote a guest blog on this topic in May 2019.5
Another point of confusion is the potential role of the Liaison Committee on Medical Education (LCME) in schools/colleges of podiatric medicine. The white paper/resolution does not mandate LCME accreditation. The LCME accredits allopathic medical schools.6 The Council on Osteopathic College Accreditation (COCA) accredits osteopathic medical schools.7,8 Osteopathic medical students must take and pass the Comprehensive Osteopathic Medical Licensing Examination (COMLEX), and if the student chooses, they may also take the United States Medical Licensure Examination (USMLE). In 2018, the AMA HOD passed a resolution to "promote equal acceptance of the USMLE and COMLEX at all U.S. residency programs."9 AMA HOD Resolution 302 stated, "AMA policy supports equal access to licensure for graduates of U.S. MD- and DO-granting schools…recommends to state medical licensing authorities that they require individual applicants, to be eligible to practice medicine, to possess the degree of Doctor of Medicine or its equivalent from a school or program that meets the standards of the LCME or accredited by the American Osteopathic Association…"9
The take-away from this precedent is podiatric schools will need to be comparable to LCME standards. Still, the intention is that podiatric medical colleges/schools will remain under the auspice of the Council on Podiatric Medicine Education (CPME), just as osteopathic medical schools remain under COCA.
The next area of misunderstanding is podiatric medical students must only pass all three parts of the USMLE, rendering the American Podiatric Medical Licensing Examination (APMLE) obsolete and thereby losing podiatric-specific education and/or testing. Again, looking at precedent established in making the DO and MD degrees equivalent, this is not true. Osteopathic medical students' education includes osteopathic manipulative medicine (OMM), which is also part of the COMLEX examination.10 As stated previously, AMA established "equal acceptance of the USMLE and COMLEX at all U.S. residency programs."9 Osteopathic students can take both or just the COMLEX. For practicing podiatric physicians electing to pursue a plenary license, a mutually agreed-upon pathway by all four organizations certainly seems like a logical approach. For those podiatric physicians not selecting to pursue a plenary license, nothing changes, including the ability to practice according to their level of education, training, and experience. Podiatric medical school curriculums will be able to continue courses unique to DPM training and still accomplish this goal, as evidenced by the osteopaths.
The concern regarding podiatric surgical residencies being required to meet Accreditation Council for Graduate Medical Education (ACGME) standards is fascinating. As a residency director at a large hospital with numerous residency programs, we indirectly already adhere to ACGME requirements by association. The curious part of this misconception is an utter lack of understanding of ACGME standards. My opinion is clear on this topic from prior blogs, that CPME must align with ACGME moving away from minimal activity volume (MAV) to a competency-based milestone evaluation of residents by a residency review committee led by the residency director.11,12 The recent decision by CPME to reevaluate document 320 resulted from the significant input by key stakeholders demanding a move towards ACGME, not away from it. All ACGME residencies must meet standard program requirements, which are foundational for any residency program and include resident well-being, patient safety, and quality improvement, just to name a few specifics.13 Our residency program recently published the results of a podiatric resident well-being survey in the Journal of American Podiatric Medical Association (JAPMA). The results are alarming, and the profession must immediately improve the situation.14 In addition to standard program requirements, each specialty has program-specific milestones allowing for specialty key stakeholders to guide the educational experience.15,16 ACGME is the only accrediting organization for both MD and DO residency programs.17 If podiatric residencies eventually fall under ACGME, the podiatric community will have the opportunity to produce the program-specific milestones.
Yet another misinterpretation of the white paper/resolution is that non-podiatric physicians will determine what constitutes board certification. The white paper states, "Board certification for DPMs should meet comparable standards as set forth by the American Board of Medical Specialties (ABMS)."18 In orthopedics, the American Board of Orthopaedic Surgery (ABOS) is one of 24 Member Boards of the American Board of Medical Specialties (ABMS).19
"The ABMS works in collaboration with the Member Boards to maintain the standards for physician certification. Its focus is on improving the quality of health care to patients, families, and communities by supporting the continuous professional development of physician specialists. It achieves its mission as an organization by helping physicians achieve their potential as providers of quality health care."
Clarity on this topic becomes evident with a bit of research that ABFAS and ABPM are equivalent to ABOS in this example. The ABOS "Guiding Principles" eloquently state, "Our founding principles have always been, and will always remain, serving the best interest of the public, our patients, and the profession of Orthopaedic Surgery."20 Ditto for podiatric medicine and surgery.
Much consternation exists regarding the word "physician." The "white paper does not address the different uses of the term physician within both state and federal laws and should not be construed as supporting the removal of any rights currently held by DPMs, nor supporting any effort to prevent DPMs from practicing under their title, status, or scope of practice as currently recognized by state and federal law and non-governmental entities."18 The white paper continues by saying, "Furthermore, all four organizations agree that irrespective of their differences with respect to the current definition of the term physician, that DPMs, similar to MDs, and DOs, should not be restricted in their ability to appropriately take care of patients within their respective scope of practice, nor in their access to patients based upon type of insurance."18
The sentiment that podiatric physicians will have something taken away due to this process is hyperbole, reactionary and without merit. All aspects of federal and state government do not classify podiatric physicians as physicians, as exemplified by the profession's fight to change Medicaid (Title XIX) Recognition via The HELLPP Act.21 I served the past five years as Chair of the Legislative Committee, working with APMA staff, Legislative Committee members, and lobbyists to change Title XIX. The VA MISSIONS Act was a historic victory for the profession to classify podiatric physicians in the physicians and dentists category within the Veterans Administration (VA) healthcare system, so congressional precedent now exists.22 The pathway created by the joint task force provides another viable method to rectify all instances where podiatric physicians still face obstacles that a plenary license will eliminate.
The standardization of podiatric residencies to three-year residencies in 2013 took approximately seven years to reach realization. It is unknown how long it will take to implement the joint task force recommendations if the AMA HOD passes resolution 303. The journey to a plenary license begins with the first step of AMA requesting the National Board of Medical Examiners (NBME) to allow podiatric medical students to take/sit for the USMLE. The destination is clear. The starting point is defined. Let's take this historic journey understanding the profession will emerge equivalent to our allopathic and osteopathic colleagues.=
Dr. DeHeer is the Residency Director of the St. Vincent Hospital Podiatry Program in Indianapolis. He is a Fellow of the American College of Foot and Ankle Surgeons, a Fellow of the American Society of Podiatric Surgeons, a Fellow of the American College of Foot and Ankle Pediatrics, a Fellow of the Royal College of Physicians and Surgeons of Glasgow, and a Diplomate of the American Board of Podiatric Surgery.
Disclaimer: The views and opinions expressed are those of the author(s) and do not necessarily reflect the official policy or position of Podiatry Today or HMP Global, their employees and affiliates. Any content provided by our bloggers or authors are of their opinion and are not intended to malign any religion, ethnic group, club, association, organization, company, individual, anyone or anything.
References
1. John F. Kennedy quotes. Brainy Quote. Available at: https://www.brainyquote.com/quotes/john_f_kennedy_121068. Accessed May 18, 2021.
2. Resolution 303. Available at: https://www.ama-assn.org/system/files/2021-05/J21-303.pdf . Accessed May 18, 2021.
3. American Medical Association. Business of the June 2021 special meeting of the AMA house of delegates. https://www.ama-assn.org/house-delegates/special-meeting/business-june-2021-special-meeting-ama-house-delegates . Accessed May 18, 2021.
4. Resolutions Outcomes. APMA News. 2019. Available at: https://www.nxtbook.com/nxtbooks/apma/news_20190506/index.php?startid=25#/p/24 . Accessed May 18, 2021.
5. Christina JR. Getting podiatric physicians access to USMLE testing. Podiatry Today. Available at: https://www.podiatrytoday.com/blogged/getting-podiatric-physicians-access-usmle-testing . Published May 24, 2019. Accessed May 18, 2021.
6. Liaison Committee on Medical Education. Scope and purpose of accreditation. Available at: https://lcme.org/about/ . Accessed May 18, 2021.
7. Liaison Committee on Medical Education. Frequently asked questions. Available at: https://lcme.org/faqs/ . Accessed May 18, 2021.
8. American Osteopathic Association. Commission on osteopathic college accreditation. Available at: https://osteopathic.org/accreditation/ . Accessed May 18, 2021.
9. Murphy B. DO and MD licensing exams should be viewed equally, says AMA. Available at: https://www.ama-assn.org/residents-students/match/do-and-md-licensing-exams-should-be-viewed-equally-says-ama. Published November 14, 2018. Accessed May 18, 2021.
10. Mehta S. Back to basics: what’s the difference between COMLEX and USMLE? Prospective Doctor. Available at: https://www.prospectivedoctor.com/back-to-basics-whats-the-difference-between-comlex-and-usmle/ . Accessed May 18, 2021.
11. DeHeer P. What is the optimal residency training model? Podiatry Today. 2019. Available at: https://www.podiatrytoday.com/blogged/what-optimal-residency-training-model . Published October 4, 2019. Accessed May 18, 2021.
12. DeHeer P. Where is the data on residency education standards? Podiatry Today. Available at: https://www.podiatrytoday.com/blogged/where-data-residency-education-standards . Published January 20, 2021. Accessed May 18, 2021.
13. Accreditation Council for Graduate Medical Education. ACGME Common program requirements (residency).
Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRResidency2020.pdf . Accessed May 18, 2021.
14. DeHeer PA, Wolfe W, Nichols JA, Badell BJ. Podiatry resident wellness: a group survey study. J Am Podiatr Med Assoc. 2021. Available at: https://meridian.allenpress.com/japma/article/doi/10.7547/21-005/464861/Podiatry-Resident-Wellness-A-Group-Survey-Study . Accessed May 18, 2021.
15. Accreditation Council for Graduate Medical Education . Orthopaedic surgery. Available at: https://www.acgme.org/Specialties/Overview/pfcatid/14/Orthopaedic-Surgery . Accessed May 28, 2021.
16. Accreditation Council for Graduate Medical Education. Orthopaedic surgery milestones. Available at: https://www.acgme.org/Specialties/Milestones/pfcatid/14/Orthopaedic%20Surgery . Accessed May 18, 2021.
17. Accreditation Council for Graduate Medical Education. ACGME, AOA and AACOM usher in new era of single accreditation for graduate medical education. ACGME News. Available at: https://www.acgme.org/Newsroom/Newsroom-Details/ArticleID/10568/ACGME-AOA-and-AACOM-Usher-in-New-Era-of-Single-Accreditation-for-Graduate-Medical-Education . Published July 1, 2020. Accessed May 18, 2021.
18. American Podiatric Medical Association. Joint Task Force of Orthopaedic Surgeons and Podiatric Surgeons – White Paper. Available at: https://www.apma.org/files/Joint%20Task%20Force%20of%20Orthopaedic%20and%20Podiatric%20Surgeons%20%2D%20White%20Paper.pdf . Accessed May 18, 2021.
19. American Board of Orthopaedic Surgery. ABMS. Available at: https://www.abos.org/about/american-board-of-medical-specialties/ . Accessed May 18, 2021.
20. American Board of Orthopaedic Surgery. Guiding principles. Available at: https://www.abos.org/about/guiding-principles/ . Accessed May 18, 2021.
21. American Podiatric Medical Association. Federal advocacy. Available at: https://www.apma.org/Advocacy/content.cfm?ItemNumber=26889 . Accessed May 18, 2021.
22. Congress.gov. VA MISSION act of 2018. Available at: https://www.congress.gov/bill/115th-congress/senate-bill/2372/text. Accessed May 18, 2021.
