What Is The Optimal Residency Training Model?

The profession’s steady progress toward equivalency with allopathic and osteopathic medicine consists of foundational changes that must occur to reach the desired outcome. One such foundational change is the governance of podiatric medicine and surgery residency programs by the Accreditation Council for Graduate Medical Education (ACGME). The Council on Podiatric Medical Education (CPME) is the podiatric version of ACGME. Both institutions have similar functions as one can see in the following excerpts from each of the organizations’ websites.  

“The ACGME accredits sponsoring institutions and residency and fellowship programs, confers recognition on additional program formats or components, and dedicates resources to initiatives addressing areas of import in graduate medical education. The ACGME employs best practices, research, and advancements across the continuum of medical education to demonstrate its dedication to enhancing health care and graduate medical education. The ACGME is committed to improving the patient care delivered by resident and fellow physicians today, and in their future independent practice, and to doing so in clinical learning environments characterized by excellence in care, safety, and professionalism.”¹

“The Council on Podiatric Medical Education is an autonomous accrediting agency for podiatric medical education. Deriving its authority from the House of Delegates of the American Podiatric Medical Association, the Council is empowered to develop and adopt standards and policies as necessary for the implementation of all aspects of its accreditation, approval, and recognition purview. The Council has final authority for:

• The accreditation of colleges of podiatric medicine, the approval of fellowships and residency programs, and providers of continuing education.
• The recognition of specialty certifying boards for podiatric medical practice.”²

The standardization of podiatric residency programs to three years was a critical step toward equivalency. The CPME 320 Document is the governing document of podiatric residency programs and is currently undergoing a rewrite. One significant change being considered is the role and significance of minimum activity volumes (MAVs). The CPME states, “MAVs are patient care activity requirements that (ensure) that the resident has been exposed to adequate diversity and volume of patient care. MAVs are not minimum repetitions to achieve competence. It is incumbent upon the program director and the faculty to (ensure) that the resident has achieved a competency, regardless of the number of repetitions.”³

The ACGME has a different approach to residency education. The Next Accreditation System (NAS) was created to answer concerns about graduate medical education (GME). The Next Accreditation System utilized outcome-based principles to create general competencies for residencies in 1999 and the Outcomes Project in 2001.⁴ Subsequent refinement in the outcome-based approach led the Next Accreditation System to develop milestones and clinical competency committees (CCCs).⁴ The change in the educational philosophy for residents resulted in the ACGME moving away from MAVs to competency-based medical education (CBME) in 2013.⁴ In other fields, CBME is termed competency-based education and training (CBET).

Eloquently summarizing the differences between traditional and CBME/CBET learning, Sullivan stated, “In a traditional educational system, the unit of progression is time and it is teacher-centered. In a CBET system, the unit of progression is mastery of specific knowledge and skills, and is learner-centered.”⁵

The methodology to CBME learning includes identification of the six ACGME competencies (Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and System-Based Practice), utilization of benchmarks and milestones to evaluate competencies and performance levels, competency evaluation, and overall assessment of the process.4 One can use milestones to evaluate performance levels within the six core competencies. The milestones are composed of sub-competencies with five levels of achievement based on the Dreyfus model of expertise development.⁶ The milestones for each specialty were developed by a specialty-specific working group. Milestones are not comprehensive in determination of a resident’s level of performance. One is supposed to use milestones in conjunction with multiple other evaluative factors. Orthopedic surgery residents have their own set of unique milestones. Specifically analogous to podiatric residencies, foot and ankle orthopedic surgery fellowships have their own milestones.

Surgical specialties continue to use surgery minimal numbers to ensure residents receive adequate training. For example, orthopedic surgery requires a minimum of 1,000 cases with case-specific requirements accounting for only about half.⁷ This provides important flexibility for the resident to align his or her specific interests with his or her training. For example, if an orthopedic surgeon has an interest in sports medicine during their residency training, he or she may choose to do more of these types of cases above and beyond the minimal case volumes. Those additional sports medicine types of procedures become an excellent head start for his or her sports medicine fellowship. Interestingly, the orthopedic surgery case log rules also state the resident may perform “no more than 3000 procedures.”⁷ I wonder if the maximum number is to prevent resident burnout or procedure inequity among orthopedic surgery residents?

Podiatric residencies are based on MAV patient care activities. Residents are required to have a minimum of 300 surgical cases (additional case activities are required such as 50 trauma cases and 25 pediatric cases) and 400 surgical procedures. In order to ensure diversity in training, five different surgical categories account for 275 of the 400 procedures.³

The current system seems archaic in comparison to the ACGME approach. I attended the Council on Teaching Hospital (COTH) residency director meeting during the Centralized Residency Interview Program (CRIP) interviews this year. Most within the group felt the MAVs should be higher.

Does it really take a podiatric resident 80 hammertoe corrections to be proficient? What if a resident wants to specialize in diabetic limb salvage? Does the resident really need to do 60 first ray procedures? What if a resident wants to go into a biomechanical, non-surgical practice? Should the resident be forced to meet the same requirements? I think these are difficult questions but the ACGME has already deliberated and answered these questions.

I hope the CPME moves toward the competency and milestone model of ACGME. I think the CBME method provides a more accurate assessment of a resident. As CPME rewrites CPME Document 320 and reviews the comments from key stakeholders within the profession, I encourage the committee to make bold changes to this governing document, continuing to move the profession toward equivalency but, more importantly, “improve educational outcomes, and by extension, clinical outcomes, at the level of the individual learner and the program.”⁴

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.

References

1. Accreditation Council for Graduate Medical Education. What we do. Available at: https://www.acgme.org/What-We-Do/Overview. Accessed October 1, 2019.
2. Council on Podiatric Medical Education. About the council. Available at: https://www.cpme.org/about/content.cfm?ItemNumber=2427. Accessed October 1, 2019.
3. Council on Podiatric Medical Education. Standards and requirements for approval of podiatric surgery residencies. CPME Document 320. Available at: https://www.cpme.org/files/CPME%20320%20final%20June%202015.pdf. Updated July 2015. Accessed October 1, 2019.
4. Holmboe ES, Edgar L, Hamastra S. The Milestones Guidebook. 2016 ed. 3-16. Available at: https://www.acgme.org/Portals/0/MilestonesGuidebook.pdf. Accessed October 1, 2019.
5. Sullivan RS. The Competency-Based Approach to Training. Baltimore: JHPIEGO Corporation; 1995. Available at: https://pdfs.semanticscholar.org/0528/76cd22aac2fdfbad1270a47f080813d61c4d.pdf. Accessed October 1, 2019.
6. Batalden P, Leach D, Swing S, Dreyfus H, Dreyfus S. General competencies and accreditation in graduate medical education. An antidote to over specification in the education of medical specialists. Health Affairs. 2002; 21(5):103-111.
7. Review Committee for Orthopaedic Surgery. Orthopaedic surgery minimum numbers. Accreditation Council for Graduate Medical Education.  Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramResources/260_ORS_Case_Log_Minimum_Numbers.pdf.  Updated September 10, 2014. Accessed October 1, 2019.