I’ve often wondered why the academic portion of residency training is given such small attention considering its importance. When people speak nationally about our podiatric residency programs we hear about “Minimum Activity Volumes” versus “Competency-Based Training” and which surgical procedures count as one versus two independent procedures in residents’ logs. Yet we hear very little about what the best academics would be for residents.

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“What would be the BEST academic program for Residents ?”

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In fact, the Council on Podiatric Medical Education (CPME), our august body of accreditors for the podiatry colleges, residency programs, fellowships, and continuing medical education provides very little instruction to Residency Directors. Here’s what the CPME requires of residencies in sections 6.7 and 6.8 of the CPME 320 document, the bible of residency education¹:

Boil this down and you have one academic activity per week and one journal club per month. That’s it. Not a heavy requirement.

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“Residency Directors are given very wide latitude by the Council on Podiatric Medical Education as to what they should teach and how they should teach.”

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But more importantly, these instructions do not address how we should actually educate podiatric residents, ie, what specific evidence-based methods are most effective. Similarly, there is no mention about the best ways to teach our residents how to perform surgery. Rather, there is a clear emphasis on number and types of procedures.

If you were to read through the document, focusing on what is unstated as well as stated, you would see the following philosophy about what appears to be important to the CPME:

Do you have a problem with bullet number two? Is that unfair to the CPME? Perhaps a little. However, I would argue that CPME appears to imply the major importance of surgical volume as a stand-in for competence, despite their statement that residencies should be “competency-based.” In what universe does volume of cases equal competency? Not this one.

Now, I don’t have a major problem per se with the nonspecific nature of CPME’s requirements. It is laudable that our accrediting body wants to give residency educators some freedom to structure their programs as they desire based on available resources. However, I would like to see them take a stance on what methods are most appropriate and recommend best academic practices. As an example, the CPME has already published a document guiding educators on what constitutes an appropriate biomechanical encounter. It specifically describes what components are necessary and even provides concrete examples of quality and poor biomechanical examinations. Why can’t this occur for the entire academic education of residents? Would it really be that hard to educate residency faculty on best practices without being proscriptive? I don’t think so.

Residency Directors can be Educated on Best Educational Practices

I think it is possible to elucidate the evidence-based teaching methods we should be utilizing to train our residents and perhaps even use them to create a more thoughtful system of resident surgical and academic education. Let’s talk about just a few pieces of evidence that might help us with this.

Some Evidence that Should Guide Us

The first piece of evidence comes from the work of one of my partners at Western University, David Sholfer, DPM. He did a national survey of residency directors and residents looking to find preferences in aspects of their training. He found that both directors and residents thought the use of more procedural assessment tools would be beneficial. Direct feedback immediately following surgery was considered to be the most valuable learning resource by residents.² The important aspect of this research supports the idea of deliberate practice – procedural skills are greatly improved with focused, specific practice that receives detailed constructive criticism in a timely fashion.

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“Direct feedback immediately following surgery is considered to be the most valuable learning resource by residents”

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The educational practice structure is also important. Should residents be taught procedures in parts or all at once? This is termed ‘part’ versus ‘whole’ task training.³ Think of this as a resident doing a complete surgical procedure from start to finish (whole task training) rather than focusing on a specific skill during the procedure and the attending doing the rest (part task training). Dubrowski and colleagues studied trainee learning of a bone plating technique and recommended that a task with multiple complex steps be performed in order in one sitting (whole task training). However, if part task training is necessary then it is better to arrange the steps in random order.⁴

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“‘Whole Task Training’ vs ‘Part Task Training’ should be considered based on the complexity of the skills being taught.”

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Simulation training is also an important part of residency training and is enhanced by an understanding of the Fitts-Posner Three Stage Theory of Motor Acquisition. In this model a new learner goes through three stages, consisting of a cognitive stage (with erratic performance of the task), an integrative stage (performance is more fluid), and an automation stage (movements are fluid and precise with little thoughtful effort).⁵ Considering this model, it is clear that simulating complex surgical skills would be best for novice learners, progressing them into live procedures as they enter the later stages.

An educational philosophy that considers these concepts and others together would emphasize a staged teaching method rather than the current volume of cases paradigm. This would, of course, require a more preplanned and formalized education structure (that incidentally lends itself closer to a true competency-based format) than the more random minimum activity approach. I think it’s time for a clinical practice guideline or consensus statement to be published in the Journal of Foot and Ankle Surgery (since our residencies are all surgical) that reviews the best evidence on resident education, recommending certain methods over others, indicating the levels of evidence, and including resources for educators to apply to their programs.

In the next couple of weeks, I’ll spend time discussing specific residency scenarios and optimum methods based on these principles. We’ll review what a highly effective journal club would look like as well as clinical and surgical education. Stay tuned for more!