02/21/2020    Joe Agostinelli, DPM

Should a wound care rotation be a part of residency?

I respectfully disagree with Dr. Peacock’s
comments on doing away with waste of time
rotations and only teaching surgery to our
podiatric residents. I come to this because of
my background as a DPM in the USAF for 23 years
in orthopedic clinics then 13 years in private
practice with a large orthopedic surgical group
as their DPM.

During my first assignment at a USAF hospital
that trained 25 orthopedic surgeons , I quickly
realized the need to become a “good doctor
first “ then a surgeon after that . The four
years of podiatry school gave us the background
in biomechanics, surgery, palliative care, etc.
and the mostly one and few two-year residencies
at the time then trained you as a “foot
surgeon.”

My first chief of orthopedics at the time told
me our problem as DPMs was the lack of
standardization of our post graduate training.
He explained how the initial year of “
internship “ after 4 years of medical podiatric
medical school was vitally important to
ensuring we were “physicians first.” That’s why
the orthopedic residents had a full year of
either internal medicine, or general surgery
with the obligatory rotations needed to
complete your doctorship training. The next 4
years was devoted to orthopedic surgery and the
subspecialties of orthopedic surgery.

Spending three years as a DPM with the
orthopedic residents convinced me early in my
professional career that we needed the various
rotations to treat the whole patient rather
than just their foot! Fortunately, my PSR -12
residency had the required rotations as well as
the podiatric surgery needed as a DPM at the
time, with the more advanced foot and ankle
surgery learned through working with the
orthopedic surgeons early in my USAF career
.What is puzzling to me is when comparing our
DPM 4 years of podiatric medical school then 3
years of post- graduate residency to an
orthopedist’s 4 years of medical school, one
year of internship and then 4 years of
orthopedic surgery.

That’s why I have been supportive of having
“podiatry/podiatric surgery” becoming a
“regional specialty residency” within the
regular medical school/internship/post-graduate
residency model. This would necessitate a
degree change, naturally, with
podiatry/podiatric surgery becoming a true “MD
medical specialty. We only lack the critical
one year medical/ general surgery internship
prior to our 3 year comprehensive DPM post-
graduate residency. We have a total 7 year
process for a fully trained podiatrist
/podiatric surgeon, with a still limited
license versus the 9 years total of a fully
trained orthopedic surgeon without a limited
license.

Without the non-surgical, medical rotations how
can we properly evaluate the whole patient pre-
operatively, intra-operatively and post-
operatively? How do we handle co-morbidities,
complications of surgery, etc. without a
thorough medical background? Do we evolve into
“just being trained in how to perform the
actual surgery” without the requisite
background we could attain by becoming a “good
doctor” first?

Joe Agostinelli, DPM, Niceville, FL

Other messages in this thread:

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02/25/2020    Don Peacock DPM, MS

Should a wound care rotation be a part of residency?

Residents need to be trained in surgery. During
school, we are taught how to assess a patient
from a biomechanical standpoint and how to cast
orthotics. We certainly are taught how to
administer palliative care and even contact
casting. We are taught how to interpret
vascular exams and do rotations through
vascular departments while in school.

We were also taught how to do ingrown nails in
school. I did ingrown nails with phenol
procedures while I was in school. These things
can easily be taught in a busy podiatric
medical school clinic. In our fourth year, we
do rotations through the various disciplines
that we pick or we rotate through podiatric
surgery residencies that perform both in-house
and outpatient procedures and techniques.

We only have the residency years to learn as
much surgery in the foot and ankle as you can.
All podiatric surgical residents should have
scrubbed and performed on a minimum of 1,000
cases before practice begins. Until these
criteria are reached we are spinning the
wheels. It makes no sense. You have to do
surgery in your training and lots of it to be a
trained podiatrist.

There are other things lacking in our
training. Podiatric surgery residents need to
be taught better surgical ways to handle
wounds. Minimally invasive techniques are
scientifically proven to outperform many
traditional techniques for wound healing.

We are not taught any of these techniques in
our surgical residencies. This is a tragedy.
Search the literature for minimally invasive
and percutaneous techniques for the resolve of
ulcerations in the foot.

The fact that we are not teaching minimally
invasive techniques for the purposes of wound
care is absolutely crazy. It's an outright
shame. Very few podiatrists know these
techniques and cannot perform them. Our public
searches minimally invasive procedures and the
awareness is growing by leaps and bounds.

Some are afraid to start this type of training
because of things that happened in the
yesteryear. This is not the case today. We are
dropping the ball and hurting our patients by
not teaching percutaneous and MIS procedures in
the foot and ankle as a part of the residency
program.

Don Peacock DPM, MS, Whiteville, NC

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02/20/2020    Michael M. Rosenblatt, DPM

Should a wound care rotation be a part of residency? (Robin Lenz, DPM)

Robin Lenz, DPM recently wrote a letter
explaining how important wound care issues are
and should be a part of every DPM residency. I
strongly agree. Some years before I retired, I
heard an orthopedist who routinely used
Achilles Tendon lengthening and gastrocnemius
recession to treat very severe diabetic
ulcerations, even for patients with very poor
circulation. He presented sound evidence that
this should be a “part of podiatric care” for
diabetic ulcers. He made the point that DPMs
should be doing MANY more of these than
presently done. He also used some tendon
releases in other tendons, but most of his
surgery was gastroc recession and Achilles
tendon lengthening.

When questioned about malpractice risk for
patients with very poor circulation, he
provided data that showed virtually NO
amputations after his surgeries. I found this
shocking and unexpected.

I had always thought that surgery on diabetics
is rife with malpractice risk and that DPMs
should be wary of attempting it. Perhaps this
should be “restricted” to DPMs, DOs and MDs
associated with a large medical group or
academic environment that would provide deep
pocket back-up. Or so I thought. This
orthopedist strongly disagreed. (We should also
mention that these types of procedures are
available in minimal incision format which
makes them even more attractive.)

This represents a “marriage” between foot and
ankle biomechanics, foot type diagnosis, severe
metabolic disease, ulcerations, and surgery. It
fits together like a jigsaw puzzle. I present
this argument with multiple literature
references:

https://www.podiatrytoday.com/tendon-
lengthening-best-treatment-diabetic-foot-ulcers
Excellent bibliography of references

https://www.researchgate.net/publication/268129
13_Midfoot_Ulcers_Treated_with_Gastrocnemius-
Soleus_Recession

Surgery and ulcer healing in patients with
equinus | Lower Extremity Review Magazine
Excellent discussion of various types of tendon
lengthening procedures. (Very good list of 11
specific references)

I applaud Dr. Lenz for very modern thinking
about diabetic wound care. We are now
graduating thousands of nurse-practitioners and
others who are looking to take on a role in
foot care. Surgery on diabetics and others with
severe lesions are not only very successful
(according to the literature), but also keeps
us firmly planted in a range that is consonant
with our excellent training. It keeps us
relevant.

All indications point to a continued epidemic
of Type II diabetes in our populations. This is
an important arena where podiatrists can
maintain their legitimacy in care we provide to
patients.

Michael M. Rosenblatt, DPM, Henderson, NV

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02/19/2020    Robin Lenz, DPM

Should a wound care rotation be a part of residency?

I work in a 14 podiatrist group, with 4 doctors
dedicated to wound care. We work in 4 wound
care centers. We have residents rotate with us.
podiatry school taught me much of the basics,
but my residency is where I learned the
majority of my wound care knowledge.

The residents rotating through our facilities
learn about gastrocnemius recessions for
plantar forefoot ulcers, Selective plantar
fascial release for IPJ ulcers, flexor and
extensor tenotomies to heal ulcers, peroneus
longus to brevis transfer for plantar first
metatarsal head ulcers and the Level 1 JBJS
evidence behind it, plus the problem solving
skills to surgically offload ulcerations from
feet that have undergone multiple other
amputations. They learn about preserving the
metatarsal parabola or performing other
procedures to reduce wound transfer and
recurrence. They learn that isolated
Gastrocnemius recessions can heal plantar
midfoot Charcot ulcers without extensive
reconstruction.

They learn about instill wound VACs and the
most recent consensus guidelines around those
treatments. They learn that nearly all plantar
wounds can get total contact casts. They learn
about the long list of advanced tissue products
now available as well as split thickness skin
grafts. They see our close interaction with the
vascular surgery, interventional cardiology,
and interventional radiology. They leave the
rotation with a much greater appreciation for
how advanced wound care can be. Without this
exposure, it is easy to consider wound care a
small part of podiatry, while there are a
growing number of podiatrists who are now
dedicated sub-specialists in wound care.

Some podiatrists want to do reconstructive foot
and ankle surgery, some want to be palliative
doctors. Another very rewarding option is being
a subspecialist in wound care and limb salvage,
which is a nice middle ground of advanced
surgical procedures with an exhaustive list of
conservative options. I would never be in the
position I am now without my wound care
rotations.

Robin Lenz, DPM, Toms River, NJ