What Courses Should Be Eliminated From Podiatric Medical Education?

Healthcare consumers should have a high degree of confidence that their doctors have met a “common standard” of core competencies to provide medical and surgical care within their scope of practice. DPMs do not currently meet this common standard according to the Joint Task Force of orthopaedic and podiatric surgeons.

This task force recently published a resolution proposed for the upcoming American Medical Association (AMA) House of Delegates (HOD). This resolution was developed and agreed upon by the American Academy of Orthopaedic Surgery (AAOS) and the American Orthopaedic Foot and Ankle Society (AOFAS) as well as the American College of Foot and Ankle Surgeons (ACFAS) and the American Podiatric Medical Association (APMA).¹ A Joint Task Force of orthopaedic surgeons and podiatric surgeons from these four organizations clearly state in the resolution that, in order for patients and referring doctors to have the same “high degree of confidence” in DPMs as they do with MDs and DOs, DPMs should be required to receive sufficient education and training to take and pass all three parts of the United States Medical Licensure Examination (USMLE).¹

Until DPMs meet this requirement, the resolution implies that current practicing podiatrists do not meet the prevailing acceptable standard in order for patients as well as referring physicians to have the same confidence as they do with MDs and DOs.¹ One can verify this when reading the following section of the American Medical Association (AMA) Resolution A-21, soon to be introduced to the AMA House of Delegates (with important phrases in bold italics):¹

“Whereas, patients, as well as referring physicians should be able to have the same high degree of confidence that Doctors of Podiatric Medicine (DPMs) have also met this common standard as they provide medical and surgical care to patients within their scope of practice; and

“Whereas, to accomplish this goal, and be considered physicians, DPMs should be required to receive sufficient education and training to take and pass all three parts of the United States Medical Licensure Examination (USMLE).”

In the white paper titled “Improving the Standardization Process for Assessment of Podiatric Medical Students and Residents by Enabling Them to Take the USMLE,” written by the Joint Task Force of Orthopaedic Surgeons and Podiatric Surgeons, it is implied that public trust in DPMs is contingent upon DPMs successfully passing the three-part USMLE:²

“To be considered physicians, DPMs should take and pass the three-part USMLE. Following the model of MD and DO graduates, meeting this common standard along with the successful completion of state licensure requirements is essential to maintaining public trust.”

Therefore, since the two largest organizations representing the profession of podiatry in the United States (ACFAS and APMA) mutually agree that additional examination requirements for graduating students and residents will have to be made in order to meet a common standard established by allopathic and osteopathic doctors, and to maintain public trust, sweeping changes will be necessary in order to address a recognized deficiency.

Specifically, I believe the curriculum at the schools of podiatric medicine will have to undergo substantial modification in order for podiatric medical students to successfully pass all three parts of the USMLE. We as a profession would never want podiatric medical students to perform poorly in comparison to their counterparts at allopathic and osteopathic medical schools when taking the USMLE. Our leaders have lobbied long and hard to have podiatric medical students take this exam, and it is assumed that these same leaders have a high level of confidence that the outcome will be successful when comparing the pass rates of podiatric medical students with allopathic and osteopathic medical students.

However, further scrutiny reveals that currently, podiatric medical students will face significantly disadvantages compared to allopathic and osteopathic medical students in terms of overall education and training necessary for successful passage of all three parts of the USMLE.

During the years 2008 through 2014 I served on the Podiatric Medical Education Committee at the California School of Podiatric Medicine (CSPM) at Samuel Merritt University. For the last three years of that six-year term, I was chairman of that committee and participated in curriculum planning along with the entire faculty at CSPM. During that time, I was acutely aware of the pressure on all of the schools of podiatric medicine to revamp their entire curriculum to mirror allopathic and osteopathic medical schools. Much of this was part of “Vision 21^st Century,” spearheaded by the APMA to hopefully solidify physician and surgeon status for podiatrists throughout the country.³

Many of the changes made in the standard podiatric curriculum over the past 15 years in favor of duplicating allopathic medical education resulted in the elimination of courses in biomechanics.⁴ Now, as we evaluate what will be necessary to change the podiatric medical school curriculum to ensure the success of students passing the USMLE, we will realize that previous changes were insufficient and more sweeping changes will need to be made, which ultimately may mean the end of all of the schools of podiatric medicine, as I will outline below.

To prepare medical students for successful passage of all three parts of the USMLE examination, one needs only to look at the essential elements of that examination itself. The USMLE website describes the three parts of the examination as “steps” rather than parts.⁵ In the first part, or Step 1, of the USMLE, the examination focuses upon “sciences basic to the practice of medicine, with special emphasis on the principles and mechanisms underlying health, disease, and modes of therapy.” Step 2 evaluates “an examinee’s ability to apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision and includes emphasis on health promotion and disease prevention.” Step 2 CK “ensures that due attention is devoted to principles of clinical sciences and basic patient-centered skills that provide the foundation for the safe and competent practice of medicine under supervision.”⁵

I have no doubt that with moderate or even minimal changes in their education during the first three years, most podiatric medical students are in a good position to pass Steps 1 and 2 of the USMLE exam. However, it is the final part, or Step 3 of the USMLE examination where significant change in the podiatric curriculum will need to be made to assure success in passing. As stated on the USMLE website (with important phrases in bold italics):⁵

“Step 3 assesses whether you can apply medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine, with emphasis on patient management in ambulatory settings. It is the final examination in the USMLE sequence leading to a license to practice medicine without supervision. The Step 3 examination devotes attention to the importance of assessing the knowledge and skills of physicians who are assuming independent responsibility for providing general medical care to patients. Step 3 content reflects a data-based model of generalist medical practice in the United States. The test items and cases reflect the clinical situations that a general, as-yet undifferentiated, physician might encounter within the context of a specific setting. Step 3 provides a final assessment of physicians assuming independent responsibility for delivering general medical care.”

Currently, my research supports that podiatric medical students are at a severe disadvantage compared to allopathic medical students in their education and training to successfully pass Step 3 of the USMLE. One can easily appreciate this when comparing the curriculum of CSPM with that of the David Geffen School of Medicine at UCLA.^6,7

At CSPM, students take many courses and participate in many clinical rotations not required of the allopathic medical students.⁶ Consider that in their second year at CSPM, podiatric medical students take courses in radiology, podiatric medicine, podiatric surgery and biomechanics. In their third year, students at CSPM take additional courses in podiatric surgery and biomechanics as well as dermatology and podiatric trauma.

In comparison, medical students at UCLA take no formal courses after the first year.7 Instead, during the second and third years, students are immersed in seven core clinical rotations including surgery, medicine, pediatrics, obstetrics and gynecology, neurology, psychiatry and family medicine. In their final year, medical students at UCLA take elective clinical rotations as well as a “Capstone Course” described as “ensuring their preparedness for clinical practice as interns, providing closing educational statements on important topics that will be ubiquitous during early clinical practice, and permitting the development of deeper conversations about topics of interest.”⁷ One must assume that the thrust of that course is preparing the medical students for passing Step 3 of the USMLE.

Since allopathic medical students do not have to take formal courses in podiatric medicine, podiatric surgery, biomechanics and radiology, they are certainly at an advantage to focus on gaining all the skill and knowledge possible from seven core clinical rotations, multiple elective clinical rotations as well as a final Capstone Course preparing them for general medical internship. All of that experience is critical to successful passage of Step 3 of the USMLE.

So which courses will podiatric educators eliminate from the current curriculum to enable the substitution of clinical rotations in general medicine that mirror the scope of education of allopathic medical students? At the same time, one must ask if our podiatric medical students are going to be required to take and pass all three steps of the USMLE, will they still be required to take and pass all three parts of the American Podiatric Medical Licensing Exam (APMLE)?

In my opinion, if the changes needed for the curriculum at schools of podiatric medicine are implemented, podiatric medical students will not be able to pass the current form of the APMLE and, in reality, could question why they would ever need to take that exam.

In my opinion, all courses not currently offered by allopathic medical schools will need to be eliminated from the curriculum of podiatric medical schools in order for podiatric medical students to compete fairly for successful passage of all three parts of the USMLE exam. In so doing, all current podiatric medical schools will have to become allopathic or osteopathic medical schools, in my opinion. Essentially, that is what will need to happen in order to satisfy the requirement set forth by the Joint Task Force of Orthopaedic Surgeons and Podiatric Surgeons whereby the DPM degree will meet the same common standard and will maintain the same public trust currently established by those with an MD or DO degree.

All of these changes are necessary under the potential assumption that currently, DPMs do not maintain the same standard for medical and surgical care of patients as MDs and do not have the same public trust as MDs and DOs. Do you agree with that assumption made by the Joint Task Force of Orthopaedic Surgeons and Podiatric Surgeons?

Dr. Richie is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. Dr. Richie is a Fellow of the American College of Foot and Ankle Surgeons, and the American Academy of Podiatric Sports Medicine. Dr. Richie is the author of a new book titled "Pathomechanics of Common Foot Disorders," which is available from Springer at https://www.springer.com/us/book/9783030542009 .

Disclaimer: The views and opinions expressed are those of the author(s) and do not necessarily reflect the official policy or position of Podiatry Today or HMP Global, their employees and affiliates. Any content provided by our bloggers or authors are of their opinion and are not intended to malign any religion, ethnic group, club, association, organization, company, individual, anyone or anything.

References

1.   Joint Task Force of Orthopaedic Surgeons and Podiatric Surgeons American Medical Association Resolution A-21. Available at: https://www.acfas.org/uploadedFiles/_ACFAS_Home/Health_Policy_and_Advocacy/Policy_Statements/Joint%20Task%20Force%20Resolution.pdf

2.   Joint Task Force of Orthopaedic Surgeons and Podiatric Surgeons – White Paper. Improving the Standardization Process for Assessment of Podiatric Medical Students and Residents by Enabling Them to Take the USMLE. Available at: https://www.acfas.org/uploadedFiles/_ACFAS_Home/Health_Policy_and_Advocacy/Policy_Statements/Joint%20Task%20Force%20White%20Paper.pdf

3. American Podiatric Medical Association. Vision 21^st Century Objectives. Available at:  https://www.apma.org/AboutUs/content.cfm?ItemNumber=4471

4. Richie D. Proposed CPME 320 changes may dramatically reduce required biomechanics cases in residency training. Podiatry Today DPM Blog. Available at: https://www.podiatrytoday.com/blogged/proposed-cpme-320-changes-may-dramatically-reduce-required-biomechanics-cases-residency . Published Dec. 2, 2020.

5.  United States Medical Licensing Examination. Available at: https://www.usmle.org/.

6. Samuel Merritt University. Doctor of Podiatric Medicine. Available at:  https://www.samuelmerritt.edu/programs/doctor-podiatric-medicine .

7. UCLA David Geffen School of Medicine. Our new curriculum. Available at: https://medschool.ucla.edu/our-curriculum.