Welcome to the final installation in our Practice Perfect residency education series. This week, we’ll focus on surgical training. Despite the fact that there are more than 200 podiatric residencies in the United States, there seems to be relatively little focus on this part of podiatric education in our literature. In the past, when I attended residency faculty development meetings at conferences, I’ve been disappointed by the relatively low attendance. I’m not sure if the Western Foot and Ankle Conference or the APMA National Conference have residency education meetings, but I would suggest they be added on if not, since ACFAS and PRESENT both put on quality residency education meetings. Of all parts of our national conferences that should receive heavy, standing-room-only attendance, it should be those parts dealing with resident education.

Moving on to today's topic, it’s important to first consider the goal of surgical training, which is to create proficient foot and ankle surgeons. In Part 1 of our series, I commented about minimum activity volumes and their deficiency in determining the quality of graduating residents’ surgical skills. Some volume of surgical cases is important for residencies (no one really knows how many, and it actually varies by individual based on a number of factors), but the other side of this is about assessing actual competence, and here we have Competency-Based Medical Education (CBME). Let’s talk about the fundamental principles of CBME and then apply those principles to a podiatric surgical training scenario.

First, some definitions. What’s the difference between competence and competency?Competence is the state or quality of being adequately or well qualified, capable, and effective¹. Essentially, one is competent if they are able to successfully complete a particular task.

Competency is a “knowledge, skill, or attitude that enables one to effectively perform the activities of a given occupation or function to the expected standards of an occupation”¹. In order to prove competence in a task, one must demonstrate mastery of multiple competencies.

CBME has gained significant ground in the last several years in the allopathic medical community, culminating in the ACGME’s Milestones and Next Assessment System for residency and fellowship training. CBME revolves around four primary themes²:

Assessment is a very large part of this process, with advocates pushing for objective assessment testing of actual skills, rather than simply waiting for a specific time to pass (36 months in the case of podiatric training) or simple volume. Here is a list of principles we may apply to what our podiatric surgical training should look like:

Here’s a hypothetical scenario of an improved training method for teaching a resident how to do an Austin bunionectomy, allowing them to practice, gain practical experience, all the while incorporating assessment into the process.

The resident first performs multiple simulations of the major components of the procedure. The resident has already performed 15 – 20 cadaveric simulations of incisions and dissections on various parts of the lower extremity. In this current simulation, the resident performs 20 chevron osteotomies on saw bone models with the attending surgeon watching. The surgeon provides immediate feedback on improvements for each session, and they discuss skills such as hand placement, negative pressure, saw control, cutting the apex of the osteotomy appropriately, and fixation placement. After each osteotomy, the attending asks the resident to reflect on how it went. They discuss concrete actions for the resident to improve, and repeats this process 19 more times. At the end of the process, the attending “certifies” this resident to move on to actual patients.

The resident then performs an Austin bunionectomy on an attending’s patient as is currently done. After the case, the surgeon provides immediate constructive feedback. Then the resident goes back to the cadaver lab with an attending surgeon and they perform the Austin bunionectomy again, this time with an emphasis on comparing how the live human case went with what is happening with the cadaver procedure. The resident is then “certified” again to continue performing Austin bunionectomies on live patients.

At a later date, the resident takes a standardized assessment that is consistently administered across the United States. Since all residents are required to take this test, someone who receives a passing grade has demonstrated knowledge, skills, and behaviors. This consistency would allow the podiatric profession to clearly demonstrate to all stakeholders that we are, in fact, competent to perform the procedures we advertise. The added benefit to this method is that expertise – a somewhat higher level of mastery – could be incorporated into the assessment by simply adding that aspect into the grading rubric.

The major disadvantages to this method is the amount of time, resources, and potential cost of resources to do this properly. This is a major hurdle, even if our leadership decides it is the best training method. Clearly, the national adoption of this method, though possible, would require a lot of work and quality leadership. I’ve seen podiatrists working together to accomplish great things, and this, my fellow educators, is the next great thing for our profession – if only we can see it.