Current Principles In Ensuring A Well-Rounded Residency Experience

These residency directors share how residents can enhance their experience by having a balance between surgical cases and rounding, performing more post-op follow-up care, and taking more elective rotations.

Q:

At times, have you seen residents so focused on getting the required surgical case numbers that they may not be spending as much time on other components of the residency program? In a recent blog, a DPM observed that residents are driving back and forth so much to different facilities to get their surgical case numbers that they may not be able to spend as much time rounding on hospital patients. How would you address these kinds of issues?

A:

Lawrence DiDomenico, DPM, FACFAS, notes his residency program strives to focus the residents’ attention on the important details and nuances of surgical cases, rather than volume. More specifically, Dr. DiDomenico emphasizes that residents learn the indications for given surgical procedures and how to determine the best surgical option given the patient’s diagnosis or condition. Additionally, Dr. DiDomenico and his colleagues will review what procedure is most predictable in allowing a good long-term follow-up.

Dr. DiDomenico feels residency directors, attending physicians and residents bear responsibility to stay focused on the "how, why and what" of surgical procedures.

“Just performing a surgical procedure (as a technician) does not create a good resident,” says Dr. DiDomenico. “There needs to be a much deeper thought process to the given condition and procedure.”

Dr. DiDomenico argues that just because an attending does a procedure, the resident should not accept the procedure selection as being the "best procedure." As he asks, does this procedure provide the patient the best and most predictable long-term outcome?

“It is very important that each resident explore this thought process and respectfully challenge each attending as to why they chose a particular procedure. I believe it's the resident's responsibility to obtain necessary information from each attending surgeon,” says Dr. DiDomenico. 

Lawrence Fallat, DPM, FACFAS, notes his residency program is well rounded as the residents not only cover numerous amounts of surgical cases but also balance that time with rounding and seeing patients in the clinic setting. Dr. Fallat says his program provides enough cases/procedures to exceed the minimum requirements to ensure competency. Therefore, surgery numbers are not something he is concerned about.

“While some residents become very capable in performing a procedure with a certain number of cases, others may require much more hands-on training to achieve the same level of competency,” explains Dr. Fallat.

With this in mind, Dr. Fallat has kept the residency slots at his program to a certain number even though there is enough volume to support required minimal procedure numbers for additional residents.

“Our goal is to graduate residents who are “as capable at surgical correction of a hammertoe as they are at open reduction and internal fixation of ankle fractures and total ankle replacements,” points out Dr. Fallat.

David Bernstein, DPM, FACFAS, says his residents spend an entire day at one of three hospitals that they regularly rotate through. He notes residents round in the morning before surgery, are involved in inpatient consultations after surgery and also cover the emergency department. If residents have any free time, Dr. Bernstein says they visit the wound care center at that same hospital.

Dr. Bernstein says his program has two other surgery training facilities, a surgery center and an inpatient hospital. At this surgery center, he says there have consistently been three to six cases daily to justify the 45-minute drive. The residents only attend the other hospital, also a 45-minute drive, for midfoot and rearfoot surgical procedures, according to Dr. Bernstein. He says the goals are to minimize driving and have the residents stay at one hospital through the entire day.

Dr. Fallat adds that his residents cover four hospitals and one surgical center, all within a 15- to 25-minute drive from the main hospital. Since the participating medical centers are within close geographical areas, he says the time spent driving to the different facilities does not adversely affect the residents’ training.

In today's environment of multiple facilities and locations, Dr. DiDomenico notes most residents are driving from facility to facility to obtain the surgical cases. He says this can be time-consuming and unfortunate because residents quickly lose focus as their time becomes so limited.

Q:

Are residents in your program allowed or encouraged to do post-op follow-up with patients? Have you encountered any restrictions at different facilities in regard to what residents are allowed to participate in when it comes to post-op care? If you have encountered residency restrictions at certain hospitals, what steps have you found helpful to address these situations?

A:

“Twenty years ago, I realized that although our residents were excellent surgeons, they had no idea what was involved in the workup of a surgical patient or their postoperative course,” says Dr. Fallat.

Therefore, Dr. Fallat developed a clinic where residents are fully involved in patient care from start to finish. This includes patients who have had elective surgery, trauma surgery and reconstructive surgery. Residents perform the history and physical, formulate a diagnosis and treatment plan, and present their case to the attending faculty, notes Dr. Fallat. He says the faculty will then evaluate the patient and modify or approve the treatment plan. Then he says the resident will administer the treatment and follow the patient in subsequent visits to determine the effectiveness of the treatment and manage patient complications.

In this clinic, Dr. Fallat says residents provide “full continuity of care, which will better prepare them for their future independent careers. We have not encountered any restrictions at certain hospitals and have worked for many years with administration to make our clinic into what it is today.”

All of Dr. Bernstein’s podiatry residents are encouraged to follow up with postoperative care in the attending’s office. His program has no restrictions when it comes to residents being involved with postoperative care. Dr. Bernstein says all residents also are scheduled to rotate through the different attending podiatrists’ offices in their second and third year.

Likewise, post-op follow-up is mandatory in Dr. DiDomenico’s program and he says it should be mandatory in other residency programs.

“A resident cannot just ‘cut and run,’" emphasizes Dr. DiDomenico. “The resident will never learn comprehensively if he or she does follow up with a patient postoperatively.”

In order to be a good foot and ankle surgeon, Dr. DiDomenico says the resident must learn how to manage multiple facets of the postoperative course, including patient expectations, post-op pain, potential complications, socioeconomic issues, allowable work return, etc. He emphasizes these “very real issues” are very important to patients, their careers and their families.

Additionally, Dr. DiDomenico says the resident should be learning how to bill appropriately for postoperative care. As with most foot and ankle surgery, he says patients should be involved with setting up postoperative rehabilitation and directing the care of physical therapy, bracing, etc.

“The resident must learn and be able to be able handle and manage all of these issues and more,” maintains Dr. DiDomenico. 

Q:

Does your program¹s yearly schedule allow for electives? If so, are electives flexible from year to year? If one of your residents expresses an interest in a certain area of podiatry like wound care, would you allow him or her to spend more time in the wound care center, assuming the resident meets his or her required educational assignments? Can you recall a recent example in which this was helpful for a current or former resident in deciding on a more specialized career path?

A:

Dr. DiDomenico’s program allows for elective rotations. Noting the program’s flexibility, he personally tries to accommodate all residents’ needs once residents have obtained the needed rotations in order to satisfy Council on Podiatric Medical Education (CPME) requirements and hospital requirements.

Although Dr. Fallat’s residents complete all of their mandatory rotations, he says there is time in the schedule for electives. His residents’ surgical volumes vary from week to week so there are days with availability in the mornings and afternoons. During those times, he notes there is opportunity for the residents to seek other desired educational opportunities. Recently, one of Dr. Fallat’s residents wished to spend more time on an orthopedic rotation and he received approval for this due to the flexibility of the schedule. Another resident was interested in the details of billing and coding because she thought it would be helpful in her job next year, and Dr. Fallat says this resident shadowed a DPM in a private clinic to learn this information.

Dr. Bernstein notes third-year residents have time built into their schedules to pursue electives in other rotations such as diabetes, neurology and research. He says third-year residents can also spend extra time in any of their core rotations such as geriatric care, pediatrics, sports medicine, wound care, podiatric surgery and trauma. One of his recent graduates expressed an interest in performing more trauma surgery so Dr. Bernstein was able to see that this graduate was involved in all trauma cases during this chosen elective.

Dr. DiDomenico acknowledges that not all residents want the same thing and not all residents have equal skill levels. For example, Dr. DiDomenico says if a resident does not have the surgical skill for major reconstructive surgery, the resident and director should identify this deficiency and help the resident get more exposure in a different area of the field so he or she can excel in that area.   

Dr. DiDomenico stresses the importance that all residents who complete a residency program should be fully educated in all aspects of the lower extremity. He notes that some training programs do not fully educate and expose many colleagues to all facets of the foot, ankle and lower extremity pathology and treatment.

For example, you may have a surgeon, for example, who is well trained on forefoot procedures but has not received sufficient training on hindfoot and ankle procedures. As a result, Dr. DiDomenico says some of his colleagues are not able to have a detailed, in-depth conversation with another colleague regarding an area of concern outside their expertise. He says the fault lies not with the graduating resident in this case but with the system and residency programs overall.

Dr. DiDomenico believes it is the residency program director’s first obligation to provide a complete, full and robust educational program, and then subsequently tailor the specifics of the educational program to an individual resident’s needs.

“We call our profession the specialist of the foot and ankle, but many are not educated with the entire scope of the practice. I believe this hurts the profession,” notes Dr. DiDomenico. “I have no problem with those who do not want to practice the entire spectrum of the field. However, I do believe it is imperative that each DPM is well versed in all aspects of the foot and ankle. If an individual chooses to specialize in a certain area of the field, he or she should also possess confidence and have the ability to participate in an intellectual conversation regarding all conditions of the lower extremity.”

Dr. Bernstein is the Director of the Podiatric Residency Program at Bryn Mawr Hospital in Wayne, Pa. He is a Fellow of the American College of Foot and Ankle Surgeons.

Dr. DiDomenico is in private practice at Ankle and Foot Care Centers in Youngstown, Ohio. He is the Section Chief of the Department of Podiatry at St. Elizabeth Hospital in Youngstown, Ohio. Dr. DiDomenico is also the Director of Fellowship Training of the Reconstructive Rearfoot and Ankle Surgical Fellowship and Residency Training at Northside Hospital in Youngstown, Ohio. He is a faculty member of Heritage Valley Health Systems in Beaver, Pa. Dr. DiDomenico is a Fellow of the American College of Foot and Ankle Surgeons.

Dr. Fallat is the Director of the Podiatric Surgical Residency at Beaumont Hospital-Wayne in Wayne, Mich. He is a Fellow of the American College of Foot and Ankle Surgeons.