Taking A 360-Degree View On Fellowship Training

APMA Immediate Past President, Dennis Frisch, DPM, made it a point for the APMA Board of Trustees to always consider the unintended consequences of our decisions. I learn something from every President I serve under as a Trustee. Dr. Frisch’s encouraging of us to take a 360-degree view of our deliberations was undoubtedly one of the more valuable lessons for me.

I personally do not believe that the potential unintended consequences of podiatric fellowship genesis by the American College of Foot and Ankle Surgeons (ACFAS) Recognized Fellowship initiative were taken into consideration.¹ Before this initiative, there was a handful of Council On Podiatric Medical Education (CPME)-accredited podiatric fellowships.² The CPME governing document for podiatric fellowships is CPME 820. This document states, “A podiatric fellowship is an educational program that provides advanced knowledge, experience, and training in a specific content area within podiatric medical practice. Fellowships, by nature of their specific content concentration, seek to add to the body of knowledge through research and other collaborative scholarly activities.”³

With three-year podiatric residencies becoming the standard, I am not sure of the impetus for the rapid expansion in the number podiatric fellowships. I am confident the ACFAS Fellowship Initiative was an integral component but on the other side of the coin, more and more residency graduates are seeking fellowship training. Is this because of the significant increase in available fellowships or has an increase in demand resulted in more fellowships? I do not know which is correct but intuition tells me an increase in the number of fellowships led to an increased interest from graduating residents.

In discussing fellowships with another residency director, he made a profound comment. He said, "Fellowships are not to learn how to do a neuroma surgery because of inadequate residency training. Fellowships are for specialized training and research." I agree as it seems that too often fellowships are being used to supplement residency training. If fellowships are primarily being used to enhance residency training, this leads to an entirely different conversation that needs to occur.

Furthermore, ACFAS recognition means the fellowship meets ACFAS' defined requirements but ACFAS is not a recognized accreditation body.⁴ The CPME is the only recognized accreditation body in podiatry that can approve a fellowship program. 

In the interest of full disclosure, I started an international foot and ankle surgery fellowship program several years ago, focusing on diabetic limb salvage in Haiti. I applied for ACFAS recognition but the application was not approved due to concerns regarding the international component. I understood and accepted the decision. However, I thought the international part provided a unique learning opportunity for potential fellows.

I am asked frequently about fellowships by students/externs and residents. My answer is always the same: "If you are looking for specialty training within podiatric medicine and surgery like diabetic limb salvage, pediatrics, dermatology or trauma, a fellowship is an excellent pathway to expand your educational experience." Numerous university-based, research-centered, specialized training fellowships exist.

My concern about the unintended consequences of the explosion in fellowships is the effect they could have on residency training. When both a resident and a fellow are scrubbing on a case, my experience is that the fellow gets priority. The resident ends up assisting on the case instead of doing the case. This situation is still a learning opportunity although any surgeon will say you learn by doing. The residents are not “doing” on cases in which a fellow is involved. I know of outstanding podiatric physicians that do not work with residents, only fellows. When my colleagues that only scrub with fellows make this choice, the negative impact on the resident's educational experience compounds. Not only are the residents unable to participate in the case but critical interaction with a podiatric physician with significant experience and knowledge is lost.

Additionally, I have observed that industry sponsors many fellowships. Conflict of interest is an essential topic in medicine and proper disclosures are imperative. Fellowships rarely disclose corporate relationships.

Do these unintended consequences result in weakened residency training and subsequently necessitate additional fellowship training? Is this a self-fulfilling prophecy? The profession needs to honestly examine the role of fellowship training with a 360-degree view. We must not allow fellowship to simply become a fourth or fifth year of residency training.

References

1. American College of Foot and Ankle Surgeons. Recognized Fellowship Initiative. Available at: https://www.acfas.org/fellowshipinitiative/. Accessed September 5, 2019.
2. Council on Podiatric Medical Education. List Of Approved Fellowships. Available at: https://www.cpme.org/fellowships/content.cfm?ItemNumber=2441&navItemNumber=2246. Published July 2019. Accessed September 5, 2019.
3. Council on Podiatric Medical Education. Standards And Requirements For Approval Of Podiatric Fellowships. Available at: https://www.cpme.org/files/FileDownloads/CPME%20820%205-07.pdf. Published July 2007. Accessed September 5, 2019.
4. American College of Foot and Ankle Surgeons. Minimal Criteria for an ACFAS Recognized Fellowship. Available at: https://www.acfas.org/fellowshipinitiative/. Published October 2018. Accessed September 5, 2019.