Dec-10

CPME Adopts Three-Year Residency Standard

By Brian McCurdy, Senior Editor

The Council on Podiatric Medical Education (CPME) recently approved residency changes that spell an end to the two- and three-year PM&S-24 and PM&S-36 programs. Starting July 1, 2011, podiatric residency programs will consist of a standard three-year Podiatric Medicine and Surgery Residency (PMSR) program.

   The CPME 320 document notes that completion of the PMSR program leads to certification by the American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM), and being certified in foot surgery by the American Board of Podiatric Surgery (ABPS). In addition, the council says residencies that can provide a sufficient volume and diversity in reconstructive rearfoot and ankle (RRA) procedures may grant an added RRA credential and subsequently lead to RRA certification with the ABPS.

   Podiatrists may fulfill their PMSR requirements primarily in a healthcare institution approved by the Centers for Medicare and Medicaid Services (CMS) as opposed to being limited to institutions accredited by the Joint Commission or the American Osteopathic Association, according to the CPME 320 revisions.

   The CPME notes that during the two-year process of deliberations over residency requirements, it received over 150 written comments on the residency changes. The council has tentatively scheduled presentations on the CPME changes at meetings including the New York Clinical Conference, the American Podiatric Medical Association (APMA) House of Delegates, the Midwest Podiatry Conference and the APMA Annual Scientific Meeting.

   Michael Lee, DPM, the President of the American College of Foot and Ankle Surgeons (ACFAS), notes that the ACFAS has for years been advocating the move to a three-year residency standard.

    “Standardization will ensure, on paper at least, that all podiatric surgeons are equally trained,” says Dr. Lee, who is in private practice in Des Moines, Iowa. “The next big step is the standardization and quality of the programs. This is a huge step for professional parity but work remains.”

   Gary Rothenberg, DPM, feels the new residency model is very similar to the current PM&S-36, although he acknowledges that the existing two-year programs either need to increase volumes and rotation opportunities, or they will fold.

    “The changes clearly reflect the desire to standardize podiatric medical education through a time metric but as we all know, quantity does not equate to quality,” says Dr. Rothenberg, the Director of Residency Training and an Attending Podiatrist at the Miami Veterans Affairs Healthcare System in Miami. “There are very few changes that I can tell that speak to the ‘quality’ of education we are providing.”

   The de-emphasis on minimum activity volumes (MAV) and a re-emphasis on evaluation of competency is “the greatest challenge of the new document,” according to Jeffrey Robbins, DPM.

    “MAVs are patient care activity requirements that assure that the resident has been exposed to adequate diversity and volume of patient care,” Dr. Robbins cites the CPME 320 document as saying. “MAVs are not minimum repetitions to achieve competence … It is incumbent upon the director of podiatric medical education and the faculty to assure that the resident has achieved a competency, regardless of the number of repetitions that it takes for the given resident.”

   This statement implies that residency directors must engage in faculty development to ramp up direct observational skills and early recognition of resident deficiencies in knowledge, skills and non-cognitive elements, according to Dr. Robbins, the Director of Podiatry Service for the Department of Veterans Affairs Central Office and the Chief of the Podiatry Section at the Louis Stokes Cleveland Veterans Affairs Medical Center. Additionally, he notes that residency programs will need to emphasize self-learning skills and lifelong learning attitudes to both residents and faculty.

    “I think these changes will increase the level of quality of our programs and elevate the profession’s standing in the world of public health,” says Dr. Robbins.

How Will Residency Requirements Continue To Evolve?

Since the residency documents are reviewed every few years, Dr. Robbins anticipates the necessity for further changes as the practice of medicine evolves in the future. He advocates having a single profession with one certifying body that establishes criteria for residency training and board certification.

    “The current system of competing interests results in too much consternation, confusion and alienation,” opines Dr. Robbins. “From my perspective of 36 years in the profession, we have seen tremendous growth and development. We have much left to do but I am confident that those in positions to influence change will act in a responsible and positive manner.”

   The ACFAS encourages the CPME to maintain or increase the minimum activity volume requirements that protect the quality and quantity of the residency training experience, according to Dr. Lee. He adds that the ACFAS has started a Recognized Fellowship Initiative, which offers “a symbol of quality” to post-residency fellowships.

Is There Enough Emphasis On Biomechanics In Residency?

For Dr. Lee, the balance between surgery and biomechanics “is adequate and representative of the profession as a whole.” As he notes, surgical planning and techniques go hand in hand with a knowledge of biomechanical principles.

   In contrast, Dr. Robbins says for too long, podiatry has “regarded surgery as the primary component of our programs to the detriment of medicine and biomechanics.” Dr. Robbins says it does not help that the field of biomechanics is abstract with competing theories clouding the picture and frustrating residency directors and practitioners. He feels it would be helpful to have a consensus on what components of biomechanics every program should use as benchmarks.

   Furthermore, Dr. Robbins suggests that residency directors have an evidence-based guide on what a complete lower extremity biomechanical examination should specifically include. “There are a number of practitioners and residency directors that do not routinely do, nor see any value, in complete biomechanical examinations. This is not a justification for removing biomechanics,” he says. “On the contrary, it is a call to action for the guardians of this specialty.”

   Dr. Rothenberg believes there is an overall emphasis on surgical management of foot and ankle disease. At the Miami VA, he and his colleagues see a diversity of pathology and offer patients a variety of treatment options, both surgical and non-surgical. He feels the strengths and weaknesses of residency programs are mostly based on the leadership of the given program. Dr. Rothenberg says it is up to students to find the program with the strengths to help them achieve their professional goals.

Laser Gets FDA Clearance For Onychomycosis

By Brian McCurdy, Senior Editor

Podiatric physicians may now consider laser therapy as part of their armamentarium for patients with onychomycosis. The Food and Drug Administration (FDA) recently granted 510(k) approval for the PinPointe™ FootLaser™ (PinPointe USA), noting that the device is “indicated for use for the temporary clearance of clear nail in patients with onychomycosis.”

   In the opinion of Adam Landsman, DPM, PhD, the FDA clearance of the PinPonte FootLaser is an important step and conveys that the FDA understands that onychomycosis is a disease that can be controlled. As he says, the data provided on behalf of the PinPointe FootLaser supports the claim that this device can clear nails with onychomycosis but time will tell if laser treatment ultimately cures the condition.

   Dr. Landsman says the research, including his 2010 study in the Journal of the American Podiatric Medical Association, shows that laser treatment is comparable to the oral medications at producing clear nails. (See “New Study Shows Efficacy Of Laser Therapy For Onychomycosis” in the July 2010 issue or https://www.podiatrytoday.com/july-2010 .)

   PinPointe USA data reportedly shows that after one treatment with the laser, 68 to 81 percent of patients with onychomycosis experienced an increased clear nail at six and 12 months, and 81 percent of all patients had “sustained improvement” at 12 months.

    “Patients seem to be strongly in favor of a treatment that does not require daily use of a pill for 90 days because when you eliminate the pill, you also eliminate the risk for drug interactions or liver injury,” says Dr. Landsman, an Assistant Professor of Surgery at Harvard Medical School in Cambridge, Mass. “In comparison to the topical treatments, the efficacy of the laser appears to be dramatically better.”

   Dr. Landsman has discovered that patients are seeking out the PinPointe laser, particularly after other modalities have failed to resolve onychomycosis.

   However, he does note disadvantages of laser treatment, including costs and the inconvenience of having to go to a doctor’s office for treatment. He adds that the technology is relatively new so “the long-term persistence of outcomes remains unknown.

    “Regardless of the treatment modality used, recurrence of onychomycosis within five years after completion of treatment is very high. This begs the question, ‘Are we truly curing onychomycosis or are we controlling it?’” asks Dr. Landsman.

New 5th Generation Cephalosporin Gets FDA Approval For MRSA

By Brian McCurdy, Senior Editor

A new injectable cephalosporin has entered the mix of antibiotics available for complicated skin and skin structure infections (cSSSIs). The FDA has given its approval for ceftaroline (Teflaro, Forest Laboratories) to treat cSSSIs including methicillin resistant Staphylococcus aureus (MRSA).

   Mark Kosinski, DPM, cites the potential of ceftaroline to be a “very useful new drug” in cSSSIs in which MRSA is a concern. He cites the strength of the data in the CANVAS 1 and 2 studies, which found ceftaroline to be at least as active as vancomycin against MRSA, as well as the FDA Anti-Infective Drugs Advisory Committee’s 18-0 vote to approve the new agent.

   Ceftaroline has a spectrum of activity against methicillin susceptible S. aureus (MSSA), MRSA, vancomycin intermediate S. aureus (VISA) and vancomycin resistant S. aureus (VRSA), notes Dr. Kosinski, a Professor in the Division of Medical Sciences at the New York College of Podiatric Medicine. He notes the antibiotic has gram-negative aerobic activity similar to that of third generation cephalosporins, as well as good activity against gram-positive anaerobes such as Clostridium perfringens. However, he says ceftaroline has essentially no activity against gram-negative anaerobes including Bacteroides fragilis.

   Are there gaps in antibiotic coverage for infections? Dr. Kosinski sees a need for a new oral antibiotic with high bioavailability, a long half-life and activity against MRSA, gram negatives and anaerobes including B. fragilis.

    “Exactly where ceftaroline will figure in the ever growing pack of anti-MRSA drugs remains to be seen but will probably depend on cost, efficacy and side effects,” comments Dr. Kosinski, a Fellow of the Infectious Diseases Society of America. “Time will tell as we gain more experience with the drug and more clinical studies are done.”

   For further reading, see the Podiatry Today blog, “Will the FDA-Approved Ceftaroline Be Promoted To Podiatry?,” by Warren Joseph, DPM, at https://bit.ly/bOnrPr .