Rethinking The Podiatric Residency Education Model

William Halsted, MD, FACS at Johns Hopkins University School of Medicine developed the initial residency education model in 1889 based on the German pyramidal system.¹ The shark tank-like approach to postgraduate medical education guaranteed a single resident would reach the pyramid's peak but this left the remaining surgery residents undertrained.²  Edward D. Churchill, MD, FACS, developed a rectangular model at the Massachusetts General Hospital in Boston in 1938 in response to growing dissatisfaction with the Halsted model.³ The Halsted model, for example, began with eight surgery residents and dismissed four after the first year. One of the remaining four would advance to the house surgeon with the other three left in training indefinitely with no guarantee of becoming staff surgeons.¹ The Churchill model remains intact today.⁴ 

Postgraduate podiatric medical education has transformed immeasurably since the historic 1956 advanced or primary weekend courses at Civic Hospital in Detroit under the supervision of Earl G. Kaplan, DPM. Thousands of podiatric physicians around the country flocked to Detroit for an unprecedented educational experience in podiatric medicine and surgery. These courses eventually led to a formal podiatric surgical residency at Civic Hospital. Initially, the surgical residency program was six months in length and expanded to one year in 1969.⁵ 

The evolution of residency education continues to propel the profession forward to equivalency with our allopathic and osteopathic colleagues.

According to the Council on Podiatric Medicine and Education (CPME), "The podiatric medicine and surgery residency is a resource-based, competency-driven, assessment-validated program that consists of three years of postgraduate training in inpatient and outpatient medical and surgical management. The sponsoring institution provides training resources that facilitate the resident's sequential and progressive achievement of specific competencies."⁶

Are we employing the optimal methodology to accomplish the stated goals of postgraduate education for podiatric physicians? 

The transformation of the residency educational experience continues to evolve across all specialties. Earlier this year, the COVID-19 pandemic resulted in a profound reduction in case volume. The Council on Podiatric Medicine and Education decreased both the case and procedure minimum volumes for the graduating residency class of 2020 and may potentially do so for additional classes. Taking full advantage of each surgical learning opportunity becomes even more essential under these circumstances. 

Cognitive apprenticeship described by Collins and subsequent authors consists of six principles currently used in medicine with well-documented results.^7-12

1. Modeling. The student watches the teacher complete a task 
2. Coaching. The teacher observes the student complete a task and offers suggestions and feedback. 
3. Scaffolding. The teacher provides learning support to the student that ranges from brief lessons to physical learning tools, such as simulations. 
4. Articulation. The teacher uses methods to encourage the student to verbalize his or her thought process explicitly as he or she completes a task.
5. Reflection. The student compares his or her skill level, and ability to complete a task to that of the teacher. 
6. Exploration. The teacher guides advanced students to develop their solution to a problem or method of completing a task.

Junior residents gravitate to modeling, coaching and scaffolding while articulation, reflection and exploration resonate with more senior residents.⁸ Podiatric residencies currently informally employ portions of cognitive apprenticeship during the educational process. Full incorporation of all six principles in the training of podiatric surgical residents will maximize the educational experience. 

Utilizing the cognitive apprenticeship model in a podiatric surgical residency for a Lapidus bunionectomy would go as follows.

1. Modeling. The first-year resident watches the attending surgeon do a Lapidus procedure.
2. Coaching. The first-year or second-year resident performs a Lapidus bunionectomy while the attending surgeon provides direction and feedback.
3. Scaffolding. The attending surgeon holds a cadaver lab so residents can learn to perform a Lapidus procedure in a controlled, low-pressure environment.
4. Articulation. The attending surgeon asks the second-year resident to call out the next steps for a Lapidus bunionectomy as he or she performs the procedure.
5. Reflection. The attending surgeon has a third-year resident provide feedback for him or herself after completing a Lapidus procedure.
6. Exploration. The attending surgeon offers little to no input as a third-year resident completes a Lapidus procedure.

High-impact postgraduate training is possible with an evidence-based approach to education. Multimodal teaching that combines practical experience and academic guidance employing the cognitive apprenticeship model is the recipe for success. 

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, and a Fellow of the American College of Foot and Ankle Pediatrics. Dr DeHeer is also a Fellow of the Royal College of Physicians and Surgeons of Glasgow, and a Diplomate of the American Board of Podiatric Surgery.

References

1. Grillo HC. Edward D. Churchill and the "rectangular" surgical residency. Surgery. 2004;136(5):947-952.
2. Mohebali J. First-place essay – reform: reformation of current surgical residency and fellowship training is the best solution. Bulletin of the American College of Surgeons. Available at: https://bulletin.facs.org/2014/11/first-place-essay-reform-reformation-of-current-surgical-residency-and-fellowship-training-is-the-best-solution/ . Published November 1, 2014. Accessed September 15, 2020.
3. Pellegrini CA. Surgical education in the United States: navigating the white waters. Ann Surg. 2006;244(3):335.
4. Tober DG. What's important: the social contract between surgeons and residents is still relevant. J Bone Joint Surg. 2020;102(15):1376-1377.
5. Kanat IO, Neilson D, Kaplan G. History of the nation’s first podiatric hospital and residency program. APMA News. 2006;27(5):48-52.
6. Council on Podiatric Medical Education. Standards and requirements for approval of podiatric medicine and surgery residencies. Available at: https://www.cpme.org/files/CPME/CPME%20320%20Updated%20May%202020.pdf . Published July 2018. Accessed September 15, 2020.
7. Collins A. Cognitive apprenticeship. In: Sawyer RK, ed. Cambridge Handbook of the Learning Sciences. Cambridge, England: Cambridge University Press; 2006. 
8. Butler BA, Butler CM, Peabody TD. Cognitive apprenticeship in orthopedic surgery: updating a classic educational model. J Surg Ed. 2019;76(4):931-935.
9. Ong CC, Dodds A, Nestel D. Beliefs and values about intra-operative teaching and learning: a case study of surgical teachers and trainees. Adv Health Sci Educ Theory Pract. 2016;21(3):587–607. 
10. Olmos-Vega F, Dolmans D, Donkers J, Stalmeijer RE. Understanding how residents' preferences for supervisory methods change throughout residency training: a mixed methods study. BMC Med Educ. 2015;15:177. 
11. Stalmeijer RE, Dolmans DH, Snellen-Balandong HA, van Santen-Hoeufft M, Wolfhagen IH, Scherpbier AJ. Clinical teaching based on principles of cognitive apprenticeship: views of experienced clinical teachers. Acad Med. 2013;88(6):861–865. 
12. Stalmeijer RE, Dolmans DH, Wolfhagen IH, Scherpbrier AJ. Cognitive apprenticeship in clinical practice: can it simulate learning in the opinion of students? Adv Health Sci Educ Theory Pract. 2009;14(4):535–546.