10/26/2020 Lee C. Rogers, DPM, et al.
RE: An Open Letter to the Council on Podiatric Medical Education
It's time to Finally Make Wound Care a Mandatory
Part of Podiatric Medicine and Surgery Residency
Training
Dear Council on Podiatric Medical Education
(CPME) Residency Ad Hoc Advisory Committee,
As you are completing the arduous task of the
required periodic review and revision of CPME
Document 320,(1) the Standards and Requirements
for Approval of Podiatric Medicine and Surgery
Residencies (PMSR), we wish to applaud your
efforts on the advancement of podiatry residency
training standards over the decades. Today’s
podiatrist is well-trained in surgery because of
your actions and those of other CPME committees
to ensure the standards are being followed.
However, there remains one glaring omission from
the PMSR training in Document 320, last revised
in 2018.
Where is wound care?
Please note our preference would be to refer to
the topic as “tissue repair and wound healing”,
since we don’t just care for wounds, we use a
combination of medicine, reconstructive surgery,
and collaboration with other specialties to heal
wounds. But nonetheless, a podiatrist today could
technically finish residency and not have a
single documented wound care experience.
We believe this is a great disservice to the
profession, the specialty, and to public health.
Let’s review some numbers.
There are 150,000 bunion surgeries per year in
the United States, or 46/100,000 population.(2)
Bunion or first ray procedures are mentioned more
than 25 times in Document 320 with specific
minimum activity volumes (MAVs or case numbers)
to ensure today’s podiatrist has the training to
operate on a patient with a bunion. We think this
is a necessary training exercise for today’s
podiatrist.
The annual incidence of ankle fractures is
187/100,000. Evaluation and repair of ankle
fractures are emphasized in Document 320 and 50
of 300 surgical cases must be documented in
rearfoot and reconstructive ankle (RRA) surgery.
We agree with and endorse this emphasis. (We
acknowledge that about 2% of current PMSR
programs do not offer the added credential in RRA
surgery)
Painful plantar fasciitis, a disease that is
commonly seen by a podiatrist, occurs in
850/100,000 people per year.(3)
Now to put wounds in perspective. There are 6.5
million people with a chronic wound in the United
States alone. That is roughly 1,980/100,000.(4)
If you look specifically at people with diabetes,
it is 8,000/100,000 people who will develop a
foot ulcer annually. Wounds are mentioned 4 times
in Document 320, and 3 of those times it refers
to that training experience as optional or
elective.
A recent Podiatry Management News Survey asked,
“should a wound care rotation be a part of
podiatric residency training?” and 95% of 797
responded “yes”.(5) Similarly, the 2019 Practice
Survey of 1039 DPMs6 reported that 90% of
podiatrists had more than 1 in 10 patients with
diabetes and about half of DPMs had more than 30%
of their patients with diabetes. The same survey
found that about half of podiatrists had more
than 10% of their practice dedicated to wound
care, while about a quarter of DPMs said that
more than 20% of their practice was on patients
with wounds.
We can recite statistics on the prevalence of
diabetes in the US or the annual incidence of
foot problems and their all too frequent sequela
of amputation, but we don’t think that is in
question here. Would you not agree that the
demand for podiatric wound care is only expected
to increase over the next couple of decades?
We are aware of the letter to the Committee from
the Board of Trustees of the American Podiatric
Medical Association dated March 5, 2019
requesting that in addition to comprehensive
surgical training, a PMSR offer increased
training in wound care of the lower extremity and
we whole-heartedly agree.
The Committee and Council have a probate
responsibility to match the training with public
need. The podiatrists’ role, now and in the
future, in caring for the diabetic or ulcerated
foot is vital, and we literally mean vital. The
actions of podiatrists preserve limb and prolong
life. (7–12)
It is imperative that CPME create the same kind
of emphasis on wound care that exists with
elective surgery and trauma, including mandatory
rotations, minimum activity volumes, and training
experiences in other collaborating specialties.
Then we can live up to Standard 6.0 in offering
the podiatric resident training in the breadth of
podiatric health care, especially on a disease
manifestation that is common, costly, and deadly.
Lee C. Rogers, DPM
David G. Armstrong, DPM, MD, PhD
Lawrence A. Lavery, DPM, MPH
Jeffrey L. Jensen, DPM
Matthew G. Garoufalis, DPM
Lawrence B. Harkless, DPM
Barry I. Rosenblum, DPM
1. Council on Podiatric Medical Education.
Document 320: Standards and Requirements for
Approval of Podiatric Medicine and Surgery
Residencies.; 2018. Accessed September 11, 2020.
https://www.cpme.org/files/CPME/CPME%20320%20Upda
ted%20May%202020.pdf
2. LaPointe S. BUNION SURGERY: A Prospective
Clinical Outcomes Study. In: Podiatry Institute
Manual. ; 2001.
3. Analysis of Data on the Prevalence and
Pharmacologic Treatment of Plantar Fasciitis
Pain. Accessed September 11, 2020.
https://www.nccih.nih.gov/research/research-
results/analysis-of-data-on-the-prevalence-and-
pharmacologic-treatment-of-plantar-fasciitis-pain
4. Sen CK, Gordillo GM, Roy S, et al. Human skin
wounds: a major and snowballing threat to public
health and the economy. Wound Repair Regen.
2009;17(6):763-771.
5. Podiatry Management Online Survey: Should A
Wound Care Rotation Be Part of Podiatric
Residency Training? Published February 25, 2020.
Accessed September 11, 2020.
https://podiatrym.com/polls2.cfm?surveyid=332
6. Podiatry Management 2018 Annual Survey.
Published 2019. Accessed September 11, 2020.
https://podiatrym.com/Annual_Survey_report2.cfm?
id=2126
7. Sloan FA, Feinglos MN, Grossman DS. Receipt of
care and reduction of lower extremity amputations
in a nationally representative sample of U.S.
Elderly. Health Serv Res. 2010;45(6 Pt 1):1740-
1762.
8. Skrepnek GH, Mills JL, Armstrong DG. Foot-in-
wallet disease: tripped up by “cost-saving”
reductions? Diabetes Care. 2014;37(9):e196-e197.
9. Rogers LC, Andros G, Caporusso J, Harkless LB,
Mills JL, Armstrong DG. Toe and flow: Essential
components and structure of the amputation
prevention team. J Vasc Surg. 2010;52(3,
Supplement):23S - 27S.
10. Armstrong DG, Boulton AJM, Bus SA. Diabetic
Foot Ulcers and Their Recurrence. N Engl J Med.
2017;376(24):2367-2375.
11. Gibson TB, Driver VR, Wrobel JS, et al.
Podiatrist care and outcomes for patients with
diabetes and foot ulcer. Int Wound J.
2014;11(6):641-648.
12. Conte MS, Bradbury AW, Kolh P, et al. Global
Vascular Guidelines on the Management of Chronic
Limb-Threatening Ischemia. Eur J Vasc Endovasc
Surg. 2019;58(1S):S1-S109.e33.
