Current Directions In Podiatric Education

In this roundtable forum of leading podiatric educators, the panelists discuss the challenges of having a DPM/MD curriculum, offer a glimpse into current research initiatives in biomechanics and refute the notion that there are too many podiatry schools.

   With the recent debut of the College of Podiatric Medicine at the Western University of Health Sciences in California, we take a look at current and emerging issues in podiatric education with some of the deans and/or directors of educational programs at the podiatry schools. Without further delay, here is what our roundtable panelists had to say.

   Q: Earlier this year, we did an online poll on the Podiatry Today Web site that asked the question: Are there too many podiatry schools? Nearly 800 people responded to the poll and 65 percent felt there are too many podiatry schools. How would you respond to this seemingly prevalent sentiment in the profession?

   A: All of the panelists disagree with the assertion that there are too many podiatry schools. Vincent Hetherington, DPM, FACFAS, Michael Trepal, DPM, FACFAS, and Robert “Tim” Yoho, DPM, FACFAS, note the findings of the recent workforce study commissioned by the American Podiatric Medical Association (APMA) and published in the July/August 2008 issue of the Journal of the American Podiatric Medical Association (JAPMA).1

   Citing the workforce study, Dr. Hetherington says three key trends require a greater demand for podiatric services now and in the immediate future. In addition to the aging of the population, Dr. Hetherington says there is an increasing prevalence of obesity, which can result in more stress and strain on the feet. The study also points to the increasing prevalence of diabetes and corresponding lower extremity complications associated with the disease, according to Dr. Hetherington.1

   Jeffrey Page, DPM, says these population trends clearly indicate the need for more podiatric physicians.

    “There can be no question that we have too few, not too many colleges of podiatric medicine,” emphasizes Dr. Page. “ … There is a substantial unmet demand that is getting worse.”

   Terence Albright, DPM, concurs. However, he notes that, historically, having more podiatry schools does not necessarily translate into more podiatrists.

    “In 2000, (a total of) 586 students graduated and in 2009, 429 students graduated from our colleges,” points out Dr. Albright. “The perception by my colleagues that increased numbers of colleges means more graduates is erroneous. There may be more colleges but there are fewer graduates compared to almost 10 years ago. Twenty years ago, there were even less colleges but the number of graduates was exceedingly more than today or for that fact 10 years ago.”

   Dr. Hetherington says the aforementioned workforce study says all the existing podiatry schools would have to “nearly triple” the number of graduates in order to keep up with population growth. The study maintains that even more dramatic increases in DPMs would be required in order to meet the expected demand resulting from the aforementioned population trends (aging, diabetes and obesity), according to Dr. Hetherington.1

   Lawrence Harkless, DPM, says the main problems are the visibility of podiatric schools, maldistribution and “the inability of our educational institutions and residency training programs to integrate into the allopathic and osteopathic infrastructure that presently exists.” Out of over 130 allopathic medical schools and 30 osteopathic medical schools, Dr. Harkless says there are perhaps 10 to 12 podiatric residency programs that are “fully integrated” and the certificate comes from the university and not the hospital.

   Dr. Hetherington maintains that several schools are integrated or affiliated with osteopathic and allopathic institutions.

    “All podiatric residencies are already affiliated with either an allopathic or osteopathic institution,” explains Dr. Hetherington. “This is a requirement for graduate medical education (GME) funding.”

   Dr. Harkless advocates aligning colleges with state funded institutions to help ensure no more than 30 to 40 students per class.

    “The infrastructure of these institutions can provide the resources that are necessary to educate across the continuum from student to residency training to entry into private practice,” maintains Dr. Harkless.

   In order to increase the number of podiatry school graduates, Dr. Yoho says the profession must address the “size of the national applicant pool and the availability of residency training programs.”

   Dr. Harkless concurs. He says the shortage of podiatric residency programs is a “health policy issue that should be on the health care reform agenda.” Dr. Harkless says the quality and quantity of the applicant pool, and the number of residency training positions will continue to be significant issues until there is a more united front in the profession to successfully address these obstacles. He suggests that podiatry could take a few cues from the allopathic and osteopathic models.

    “The allopathic and osteopathic infrastructure that presently exist can provide the platform for sustainable growth,” notes Dr. Harkless.

   Q: There has been a lot of debate about having a DPM/MD curriculum. What are the obstacles to this?

   A: “The debate over a DPM/MD curriculum raises the question: Are we a profession much like osteopathic and allopathic medicine, or are we a specialty? My sense is we are both,” explains Dr. Yoho. “Podiatric medicine is a profession (but it is also) viewed as a specialty in the realm of all medical specialties. This is in contrast to allopathic and osteopathic medicine, which include specialties within their professional domains.

    “As a result, there is a philosophical conflict and are we willing to sacrifice our professional identity?”

   Dr. Page says there are key differences between the missions of podiatry schools and those of allopathic and osteopathic medical schools.

    “Allopathic and osteopathic medical schools prepare students to be a generalist who specializes in some branch of medicine or surgery during residency and fellowship. Podiatric medical schools train students to be specialists, who subsequently enter residency to enhance and refine the preparation for specialty practice,” explains Dr. Page. “To grant a MD or DO degree to podiatric medical students would require additions to our crowded curriculum, not to mention the cooperation of our medical colleagues.”

   To that end with the dual degree, Drs. Trepal and Hetherington say there is the challenge of having curriculum that meets the standards of two different accrediting bodies. Whereas the DPM degree is awarded by colleges with curriculum that conforms to the standards established by the Council on Podiatric Medical Education (CPME), Dr. Trepal notes that the MD degree is only awarded by colleges that provide a curriculum conforming to the established standards of the Liaison Committee on Medical Education (LCME), which accredits colleges of medicine.

    “While there is much overlap in the respective curriculum, there remain fundamental differences. I do not believe that any of the current colleges of podiatric medicine qualify for LCME accreditation,” notes Dr. Trepal. “This in no way denigrates the podiatric medical curriculum or implies it is substandard. On the contrary, all of our colleges of podiatric medicine provide an outstanding educational experience. It is simply different, not inferior, and most valuable in its own respect.”

   Dr. Page concurs. At Midwestern University, Dr. Page notes that DO students take six quarters of osteopathic manipulation but they do not have any biomechanics or surgical courses. Dr. Page says the podiatric program offers little training in women’s health. However, Dr. Page says the overall rigor of the podiatric curriculum at Midwestern University is equal to that of the osteopathic program.

    “In fact, DPM students take more credit hours than their DO colleagues,” points out Dr. Page.

   In order to accommodate a DPM/MD curriculum, Dr. Albright says the podiatric medical school offering this program would have to be aligned with an allopathic medical school. Drs. Albright and Yoho maintain that prospective students who are interested in the dual degree would need to qualify for admission to both schools.

   Considering the changes in podiatric medicine at the undergraduate and residency training levels (moving to three years in duration), Dr. Yoho says there should be a study to help determine the functional application of the dual degree with respect to residency training.

    “Would a graduate complete a podiatric residency program versus another medical specialty residency program, or be willing to complete multiple residency programs?” questions Dr. Yoho. “This is a very complex issue.”

   In regard to the steps one would take to obtain a dual degree, Dr. Albright says students would first take the basic science training required to take Step 1 of the United States Medical Licensing Examination (USMLE). During the clinical years, Dr. Albright notes that students would participate in the core clinical training to satisfy the medical degree requirements. Then they would take Step 2 of the USMLE and complete the didactic and specific clinical training required of podiatric medicine and surgery, according to Dr. Albright.

    “It would take about six years to complete the program required for the DPM/MD degree,” explains Dr. Albright. “Then the student would take a three-year residency in foot/ankle and reconstruction surgery.”

   Dr. Hetherington says students would probably need to complete two separate residency programs in order to obtain a viable license to practice with both degrees.

   While the Arizona Podiatric Medicine Program at Midwestern University is exploring dual degree options, Dr. Page says the arduous time commitment and costs to obtain dual degrees would likely limit this pursuit to a few interested students.

    “I believe that there will be little interest in or demand for dual degrees given the additional cost for tuition, the necessity of passing two sets of boards, the requirement of residency training in two disciplines, the need to become board certified in different disciplines, and the continuing education requirements in both professions,” maintains Dr. Page. “This is to say nothing of the opportunity cost of staying in school longer.”

   Dr. Hetherington says the APMA’s initiative to demonstrate parity in the core competencies required for the education and practice of medicine and podiatric medicine is the “appropriate way to address this issue.”

   While Dr. Harkless feels there are no justifiable short cuts to achieving dual degrees, he says the “dual degree program is not difficult to develop.” Dr. Harkless says the natural pathway is through meeting the accreditation standards of both the CPME and the Association of American Medical Colleges (AAMC). If the podiatric medical colleges embraced the AAMC standards (including all pre-clinical and clinical education programs) and accepted the established competencies (including those approved by the CPME), Dr. Harkless says the DPM degree would be equivalent to the MD or DO degree.

   If this occurs consistently across the colleges of podiatric medicine, Dr. Harkless maintains that the American Association of Colleges of Podiatric Medicine (AACPM) could petition for podiatric medical students to take Steps 1 and 2 of the USMLE after the second and fourth undergraduate years respectively and Part 3 of the USMLE at the conclusion of the second year of residency training.

    “This pathway will allow for the licensing boards of all states to award the physicians and surgeons certificate to all podiatric physicians completing this task,” explains Dr. Harkless.

   Q: What is your school doing to improve research in biomechanics and outcome studies on orthotic devices?

   A: Dr. Albright says the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science has been proactive in applied biomechanical research through its Department of Applied Biomechanics and its Center for Lower Extremity Ambulatory Research (CLEAR). James Wrobel, DPM, the Acting Director of CLEAR, recently lectured at a seminar on the evidence behind custom foot orthoses, according to Dr. Albright. He adds that Dr. Wrobel is also the principal investigator on a study of heel pain and orthoses that is funded by the APMA.

   Dr. Albright also notes that CLEAR faculty recently lectured and gave poster presentations at the North American Congress of Biomechanics, and have submitted manuscripts to the journals Gait & Posture and Computer Methods in Biomechanics and Biomedical Engineering.

   At the College of Podiatric Medicine and Surgery at Des Moines University (DMU-CPMS), Dr. Yoho says research efforts have been very productive under the leadership of Vassilios Vardaxis, PhD. The faculty at DMU-CPMS have numerous publications in peer reviewed journals and have presented multiple podium and poster abstracts at state and national scientific meetings, according to Dr. Yoho.

   He notes that DMU-CPMS has received seven national awards over the past three years in recognition of its research efforts. When it comes to biomechanics and orthotics research, Dr. Yoho says the CPMS faculty have recently completed or are currently engaged in over 20 research projects. These projects include:

   • the Des Moines University multi-segment foot model for clinical evaluation;
   • the role of rearfoot mobility in the long-term response to wedge orthosis in medial osteoarthritis;
   • the effect of the foot orthosis on frontal plane moments during gait; and
   • radiographic analysis of Haglund’s deformity in resting and neutral calcaneal stance position.

   In terms of new faculty additions, Dr. Albright notes that the Scholl College recently hired Bijan Najafi, PhD, who was affiliated with the Harvard School of Engineering and Applied Science. He says Dr. Najafi’s research, supported by funding from the National Institute of Health (NIH), has focused on auto feedback for individuals with cognitive impairment as well as research on fall prevention.

   The Ohio College of Podiatric Medicine recently hired Metin Yavuz, PhD, who previously worked with researchers Brian Davis, PhD and Peter Cavanaugh, PhD, D.Sc, in the Biomechanics Lab of the Cleveland Clinic at Cleveland State University. Dr. Hetherington notes that Dr. Yavuz explored the distribution of plantar shear stresses in patients with various foot disorders using a custom device during his doctoral studies.

   According to Dr. Hetherington, Dr. Yavuz maintains that challenges in measuring anteroposterior and mediolateral shear forces in the foot have limited researchers to one-dimensional data that only accounts for vertical shear forces. As a result, Dr. Yavuz feels that “plantar shear forces have been neglected for a long time in foot biomechanics, especially in diabetic foot research.”

   Using a custom Cleveland Clinic pressure shear platform, Dr. Yavuz and his colleagues have been able to assess the distribution of plantar shear stresses in patients with diabetic neuropathy and have published these findings in journals such as Diabetes Care and the Journal of Biomechanics, according to Dr. Hetherington.

   Dr. Hetherington says Dr. Yavuz is currently investigating plantar shear distribution and its relevance to foot ulcers in a large sample study. He is also investigating the potential association between plantar loading profiles and temperature increase under the foot, a theory previously expressed by Paul Brand, MD.

   Dr. Page notes that the Arizona Podiatric Medicine Program at Midwestern University is currently involved in multiple biomechanics research projects with studies on equinus, tendinopathy, sports medicine and diabetes.

   The New York College of Podiatric Medicine (NYCPM) is in the final stages of constructing a gait lab, which will help facilitate sophisticated biomechanical research, according to Dr. Trepal.

    “This has been an area deserving of more attention than it has received in the past,” notes Dr. Trepal.

   Drs. Yoho and Albright also emphasize that students are involved in the research at their respective institutions. According to Dr. Albright, students at the Scholl College were able to do clinical research through a NIH T-35 grant. He says one study is investigating foot orthoses as proprioceptive feedback devices.

   For students at the College of Podiatric Medicine at the Western University of Health Sciences, Dr. Harkless says a principles and practice course will embrace the tenets of basic biomechanical principles to ensure students have a sound fundamental basis to understand normal and abnormal foot function. He adds that the college will have its interdisciplinary faculty who have distinguished themselves in the biomechanics realm engage in research to support and validate theories in biomechanics.

   Q: Do you think the current curriculum prepares the young podiatrist on how to be successful in private practice? Are the students being educated about managed care and insurance contracting?

   A: Drs. Hetherington, Trepal, Yoho and Albright agree that the current mission of the colleges is preparing students to enter post-graduate residency training, not to enter practice.

   Dr. Albright says intensive training in practice management was the norm at the Scholl College in the 1970s and 1980s as the college’s mission then was to prepare students to enter private practice. However, with the advent of multiple residency programs for students, the missions of the colleges changed, according to Dr. Albright. While the Scholl program does include basic course work in practice management, managed care and insurance, Dr. Albright concedes that “the degree of intensity is not the same as it was years ago.”

   Dr. Trepal says attributes and concepts of healthcare delivery and medical economics are presented in various courses and seminars throughout the curriculum at NYCPM.

   Podiatry students at Midwestern University do take a practice management course and a jurisprudence course, according to Dr. Page. Dr. Yoho says students at DMU-CPMS receive formal training in health information technology, medical jurisprudence and health systems and policies. He adds that students are exposed to EMR and introduced to various aspects of coding and billing procedures in the clinical training years. Dr. Page also notes that Midwestern University sponsors extracurricular presentations from successful DPMs to help students learn the paths to practice success.

   When it comes to preparing young podiatrists on how to be successful in private practice, Dr. Harkless says the profession overall “has not performed acceptably in this area.” While the colleges have always offered practice management courses and residency training programs have tried to address this, Dr. Harkless maintains there are no established standards for education in this arena.

   However, he notes that colleges are now being held responsible for developing competencies to address this issue. Dr. Harkless says the podiatry curriculum at the Western University of Health Sciences will involve application of practice management principles and problem solving, and this will include learning about reimbursement for services. The Ohio College of Podiatric Medicine (OCPM) recently modified its curriculum in order to add a practice management course at the end of the year for seniors. Dr. Hetherington says this course was taught by a combination of college faculty and faculty from the American Association of Podiatric Practice Management (AAPPM).

   In a recently announced partnership with the AAPPM, the Ohio College of Podiatric Medicine (OCPM) unveiled the addition of a new practice management curriculum that will be incorporated into all four years of student education at the college. Dr. Hetherington says OCPM is the only podiatric college in the country to offer this to students.

   Dr. Hetherington says the curriculum for the first two years will focus on presentations on topics such as goal setting, time and stress management, and communication skills. In the third and fourth years, Dr. Hetherington emphasizes that there will be more of a focus on interpreting financial reports, financial benchmarks, staff management and marketing strategies.

   Dr. Trepal adds that NYCPM is currently completing an agreement with a neighboring school of medicine to offer a joint DPM/MPH degree to those students who wish to pursue this option.

   Q: How have class sizes changed in recent years?

   A: The class size at the Scholl College has “diminished considerably,” according to Dr. Albright. Prior to the 1990s, Dr. Albright says it was not uncommon to matriculate a class of 150 students. During the early 1990s, Dr. Albright says the Board of Directors at the college foresaw the pending effect of managed care on medical professions and limited the matriculating class to between 90 to 100 students.

    “With the ‘dot com’ era, many health professional schools, including podiatry, experienced a dramatic drop in enrollment,” points out Dr. Albright. “This trend is reversing itself.”

   Dr. Yoho says the average class size for students entering DMU-CPMS in five increments over the past 20 years are as follows:
   1993-1997: 76
   1998-2002: 64
   2003-2007: 38
   2008-2012: 56

   Dr. Page says the class size of the Arizona Podiatric Medicine Program has not changed since the program’s inception in 2004. The class size at OCPM has not changed in recent years, according to Dr. Hetherington. He notes that the Board of Trustees at OCPM set the maximum enrollment of a first-year class at 125 students. This is in accordance with the CPME and the regional accreditation agency, the Higher Learning Commission of the North Central Association of Colleges and Schools, notes Dr. Hetherington.

    “The impression that the colleges can extend their enrollment whenever they choose to is erroneous,” maintains Dr. Hetherington. Drs. Hetherington and Albright note there is currently a moratorium by the CPME on new colleges and the expansion of current class size at existing colleges of podiatric medicine.

   Drs. Harkless, Hetherington and Albright agree that the availability of quality postgraduate training programs is an important factor when it comes to any foreseeable enrollment changes at the colleges.

    “This is a problem that the profession as a whole currently faces,” maintains Dr. Hetherington.

   While Dr. Albright believes the fixed enrollment has benefitted the profession by allowing the colleges to matriculate more qualified students, he does feel “there will never be enough podiatrists to meet the needs of society in the future.”

   Dr. Albright will retire in 2010 as the Dean of the Dr. William M. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine and Science. He has served as the Dean of the college since the merger of the two schools in July 2001. Dr. Albright previously served as the President of the Scholl College from 1997 to 2001, and as Executive Vice President from 1994 to 1997.

   Dr. Harkless is the Founding Dean of the College of Podiatric Medicine and is a Professor of Podiatric Medicine and Surgery at the Western University of Health Sciences in Pomona, Ca. Dr. Harkless was previously a Professor of Orthopedics and the Director of Podiatric Residency Training for 30 years at the University Of Texas Health Science Center in San Antonio, Texas.

   Dr. Hetherington is the Vice President and Dean of Academic Affairs at the Ohio College of Podiatric Medicine in Independence, Ohio. He is a Professor and former Chairman of the Department of Surgery at OCPM. Dr. Hetherington was previously an Associate Dean of Clinical Affairs at the College of Podiatric Medicine and Surgery at the University of Osteopathic Medicine and Health Sciences in Des Moines, Iowa.

   Dr. Page is a Professor and Director of the Arizona Podiatric Medicine Program at Midwestern University in Glendale, Arizona. He previously served as Chief of the Podiatry Division and the Residency Director at the Carl T. Hayden Veterans Affairs Medical Center in Phoenix. Dr. Page was also a Senior Vice President and Executive Dean at the California College of Podiatric Medicine for nearly 11 years.

   Dr. Trepal is a Professor of Surgery, Vice President for Academic Affairs and Dean of the New York College of Podiatric Medicine. He is a Clinical Assistant Professor of Surgery at the New York Medical College in Valhalla, N.Y. Dr. Trepal is also the Section Chief for Podiatry at the Metropolitan Hospital in New York City and is the Section Chief for Podiatry and the Residency Director at Long Island College Hospital in Brooklyn, N.Y.

   Dr. Yoho is a Professor and Dean of the College of Podiatric Medicine and Surgery at Des Moines University in Des Moines, Iowa. He is the Current Chair of the Accreditation Committee of the CPME and is Vice-Chair of the CPME. Dr. Yoho previously served as Vice President of Academic Affairs for DMU-CPMS from 2002 to 2007.

References:

1. Wing P, Forte GJ, Dionne MG, Christina JR. Projections of the supply of and demand for podiatric physicians in the United States, 2005 to 2030. JAPMA 2008; 98(4):330-336.