03/31/2024 Rod Tomczak, DPM, MD, EdD
The MD Accreditation Process
The accreditation process for podiatry schools is a
rigorous endeavor and make no mistake the
maintenance of accreditation, an ongoing process is
no walk in the park either. You will notice that
over the years there has been public debate about
transitioning to an MD degree. Podiatry Management
featured a roundtable discussion some years back
that allowed the deans of each school, six or maybe
7 at the time, to weigh in on the discussion and
explain their viewpoints. Subsequent to that
roundtable, no movement was made toward making our
schools MD granting institutions. There has been
speculation regarding the why nothing changes
although the roundtable was provoked by a ground
swell of podiatrists clamoring for an MD degree.
The first is that our curriculum is not rigorous
enough and would need to be upgraded completely.
Partially true. At the time podiatry schools
taught to the cellular level. Today we are
approaching the molecular level where MD schools
teach. DO school changed their curriculum to the
molecular level to enable their students to perform
well and pass USMLE exams. The podiatry curriculum
is podiatry rich. An MD curriculum is medicine
rich.
Second, we are wanting in faculty numbers and their
quality. We would need many more PhDs and MDs to
qualify as an MD granting institution. PhDs at MD
schools are performing research, securing large
government grants, and publishing in refereed
journals in order to secure tenure. DPMs and MDs
are no different but must also see patients because
part of their salaries is determined by monies they
generate from patient care. There is no gravy
train. All faculty teach, perform research and are
involved in community service in order to attain
tenure. Physicians add patient care to their
requirements for tenure. It is a given that
faculty numbers would have to be increased, and
sorry to say, many DPMs might be replaced by MDs or
significant MDs would need to be added to the
faculty to achieve accreditation.
The United States Secretary of Education has
granted accreditation authority for MD programs to
The Liaison Committee on Medical Education (LCME)
and the American Association of Medical Colleges
(AAMC) to work together to accredit 115 MD programs
in the US and Canada. The Council of Higher
Education Accreditation and the US Secretary of
Education have granted accreditation authority to
CPME to accredit the 11 podiatry schools.
A podiatry school that would wish to grant an MD
degree would have to adhere to the LCME/AAMC
standard for accreditation in order to qualify to
sit for USMLE, the exams that are recognized by all
50 states and territories as the licensing exams.
No one holds a medical license as an MD without
passing all steps of USMLE. LCME and the Secretary
of Education do not, at this point recognize CPME
as a valid accrediting agency to offer an MD
degree, so a podiatry school would have to start at
ground zero and jump through all the hoops to
become an MD granting institution. The steps to
accreditation are as follows: applicant ->
candidate -> preliminary accreditation ->
provisional accreditation -> full accreditation.
In order to achieve an applicant status and move
from one step to another, it must be unequivocally
stated that the dean of the new school must be an
MD. Nothing but an MD will suffice, and there goes
the podiatric identity. The leader of the new
school, even if it is just in transition will
adhere to a general allopathic philosophy. The
process for accreditation can be found by searching
the internet for LCME Accreditation Process
Overview. There are 12 standards that must be met
in each step toward accreditation that will be
repeated and addended for each step of the process
from the initial application for candidate status
through the full accreditation status and in a
modified form for each self-study to maintain LCME
accreditation moving forward. As each step in the
accreditation process is achieved, the submissions
will increase in scope and depth. While the first
modified submission for candidate status may only
be 1,000 pages, the final submission for full
accreditation after a minimum of 4 survey visits
would be much more reiterating what was already
said while adding new material. The format for LCME
accreditation is not unlike CPME accreditation for
a podiatry school, so the process is not foreign to
podiatric administration. Each of the Standards
listed below is elaborated on each step of the
accreditation process and embellished as progress
is made so that the final product will show an
evolution of the college on paper accounting for
the ultimate thousands of pages in the final work
product. As each step is submitted, the LCME
accreditation force may ask for additional material
submitted as an addendum.
It would be remiss not to mention this process is
expensive. The initial application can run to
$50,000 and the cost for each visit by the
accreditation team is paid by the applicant school.
There is also a requirement for a bank account.
The faculty must be in place and paid for a year
prior to students being accepted. Faculty don’t
show up a week before the students. The faculty
will be responsible for achieving each standard and
especially for creating a curriculum. There must
also be an escrow account in the bank to pay the
faculty for at least another year if the status of
the next step is denied and the new college is
appealing or correcting the deficiency in which
case the faculty must still be paid but no money is
being generated from tuition. LCME works on its
own schedule, but the college must adhere to the
same academic calendar the rest of the medical
colleges in America adhere to. Colleges start in
the summer of MS1 and graduate in the spring of MS4
so that newly graduated MDs have a month to move to
the site of their residencies.
12 Standards of the Data Collection Instrument
Standard 1: Mission, Planning, Organization, and
Integrity
Standard 2: Leadership and Administration
Standard 3: Academic and Learning Environment
Standard 4: Faculty Preparation, Productivity,
Participation and Policies
Standard 5: Educational Resources and
Infrastructure
Standard 6: Competencies, Curricular Objectives and
Curricular Design
Standard 7: Curricular Content
Standard 8: Curricular Management, Evaluation and
Enhancement
Standard 9: Teaching, Supervision, Assessment, and
Student and Patient Safety
Standard 10; Medical Student Selection, Assignment,
and Progress
Standard 11: Medical Student Academic Support,
Career Advising, and Educational Records
Standard 12: Medical Student Health Services,
Personal Counseling, and Financial Aid
No two new applications or continuing applications
are identical, nor are they meant to be. This
prohibits boilerplate applications from being
generated and used by multiple applying schools.
Bank statements, resources, certificates of need,
community reactions to candidates’ applications and
levels of commitment differ from city to city.
Affiliation agreements with hospitals are created
by LCME and are standard insuring a level of
compliance with the education and comfort of the
students in mind. Hospitals are required to hire a
fulltime Director of Medical Education.
As the accreditation process moves forward toward
the first full accreditation, prior commitments and
promises cannot be easily changed. The third year
core rotations, totaling 48 weeks in length are
generally spent in the city where the medical
college is situated guaranteeing the students have
easy access to the college administration,
infrastructure, and resources. There can only be
so many medical students for each service. A
service may have a fellow, a couple residents, an
intern, and then 3rd and 4th year students. LCME
makes sure the students are not short changed in
faculty to student ratios while ACGME guarantees
post graduates are not short changed in the ratio.
Should a change occur during the initial
accreditation process, LCME determines whether or
not it is acceptable and if not can it be corrected
in a limited time frame or LCME may place the
accreditation process on hold until the deficiency
is corrected to the satisfaction of LCME.
The first survey visit by LCME occurs after the
pending school has been granted candidate status.
If LCME determines sufficient progress is being
made toward accreditation based on the report from
the survey visit, the school will be granted
preliminary accreditation and may begin accepting
applications for enrollment.
Once the college has been granted preliminary
accreditation and admits a charter class, the
college is required to submit a new Data Collection
Instrument, (the 12 Standards) to gain provisional
accreditation. Another survey visit takes place,
typically when the charter class is at the midpoint
of their second year. If the report of the survey
team convinces LCME the college is complying, the
college may be granted provisional accreditation.
Once the program is granted provisional
accreditation, another Data Collection Instrument
must be completed and submitted to LCME. There is
another survey visit when the charter class is
typically in the early part of their fourth year.
The survey team submits a report to LCME and if
they determine the college is complying, the
college is granted full accreditation for 5 years.
It has taken from 5 to 7 years for the medical
college to go from an idea to candidate status to
full accreditation. So once the podiatry school
has decided it wants to grant an MD degree, it will
take from 5 to seven years before the first MD
degree is granted, and that is with the entire
accreditation process going relatively well.
During the fifth year of full accreditation another
Data Collection Instrument is completed and
submitted to LCME before the next survey team visit
takes place and if LCME determines the college is
complying full accreditation is granted for another
extended period.
Once provisional accreditation is granted the
students will be allowed to sit for Step 1 and Step
2 of USMLE. Successful completion of these exams
is paramount for the MD residency matching program
and state licensure. Every MD must complete at
least a year PGY1 to apply for and receive an
unrestricted license to practice medicine in the
United States. It would be absolutely ludicrous to
put oneself through a rigorous four year MD
curriculum and not receive a medical license.
So now the situation becomes really complicated.
What kind of residency are graduates applying to?
We would be MDs and not qualified to accept a
podiatry residency of any kind. The federal
government funds DPMs to occupy podiatry residency
slots. Where does an MD graduate who wants to
practice podiatry take his or her MD degree to
learn podiatry or foot and ankle surgery? There’s
a simple answer to this question. Do a five year
orthopedic surgery residency then apply to a foot
and ankle fellowship meaning another 500 applicants
to MD orthopedic residencies. As MDs with a one-
year PGY1 one could apply to an unfunded MD foot
and ankle fellowship in which case podiatry will
become what we now criticize most.
We routinely call out orthopedic foot and ankle
surgeons by saying they have no foot rotations as a
student, 2 or 3 months of foot surgery as an
orthopedic resident then a year fellowship. How
can they possibly be better trained than
podiatrists who spend 4 years in podiatry school,
take a 3 year residency in foot and ankle then a
year fellowship in a foot and ankle subspecialty?
We have literally painted ourselves into a corner
because there is no and I mean no wiggle room in an
accredited MD program. Be careful what you wish
for. We have regularly criticized the faculties in
our school with a snide comment like. “those who
can’t teach.” Perhaps they are a lot smarter than
they are given credit for. Perhaps they have
played the tape all the way through or thought the
consequences of changing to an accredited MD
program would have on each person who navigates it.
The graduate of an accredited MD program who
completes a one year PGY1 internship arguably knows
less podiatry or chiropody than the 1922 Ohio
College of Chiropody graduates, as described by
Lawrence Kobak, DPM, JD, in this month’s Podiatry
Management.
I am going to switch to the first person plural
“we” for the rest of this very extended letter,
because we are all in this should we earn real,
accredited MD degrees that are recognized by the
rest of the world. Those Ohio chiropodists had an
8-month curriculum, more than we would have if we
moved to an accredited MD degree. Although there
is some wiggle room in a medical school curriculum,
we cannot forget that USMLE is created by PhDs and
MDs from the other 155 MD schools accredited by
LCME and the preponderance of questions come from
institutions that teach more neuro-ophthalmology
than they do foot pathology. We would have to
forgo the podiatric part of our education in order
to keep up with the general medicine exemplified in
the questions that were sampled in my last post.
So, our students pass Steps 1 and 2. They cannot
take Step 3, the final Step that allows an MD to be
given a medical license in all 50 states until
completing a PGY1 internship which again would be
heavy on general medicine and surgery. Foreign
medical graduates may take step 3 before starting
an internship because this guarantees a hospital
that the foreign graduate will be licensed after
PGY 1 and can work more or less independently. So,
we have graduated from a new school which 6 years
ago was granting a DPM degree but now is offering
an MD degree and we have passed our USMLE boards.
CPME is tasked with accrediting DPM colleges and
cannot interface with programs which graduate MDs
according to the US Department of Education. MD
graduates may not sit for our podiatry boards and
DPMs may not sit for USMLE because only MD
graduates who have navigated an arduous general
medicine curriculum are eligible. If you tried the
sample USMLE questions in my last post will have to
agree they are very difficult based on our
curriculum and if we teach a DPM focused
curriculum, we will not be prepared for that exam.
In an obtuse fashion, MD colleges teach to the test
without specifically teaching to the test just like
DPM colleges teach to a DPM APMLE licensing exam.
But suppose we pass all 3 USMLE parts, complete a
PGY1 and become licensed as MDs. We have
definitely lost our identity as podiatrists. How
much podiatry do we know at this point? Just like
some MDs do not want us to call ourselves
“physicians” we cannot call ourselves podiatrists.
Is there a path to become podiatrists? We would
have to transition podiatry residencies which are
presently restricted to DPMs to MD residencies in
the new MD specialty called podiatry. There would
be a problem with ACGME when only podiatrists teach
MDs. At some point, and I don’t know how one would
propose to the AMA and ACGME that this new
specialty be added to and recognized by the ABMS.
Regardless, of the path needed to follow to create
a new MD specialty called podiatry, I think there
would be some significant push back by the
orthopedic surgeons and particularly by the foot
and ankle orthopedic surgeons. Believe it or not
orthopedic surgeons complain they are losing body
parts to other surgeons. Plastic surgeons are
performing hand surgery, neurosurgeons are
performing spine surgery and primary care
physicians are doing sports medicine fellowships.
Now the new MD foot surgeons, formerly known as
podiatrists, are wanting to become board certified
MD podiatrists who did not complete an orthopedic
residency but decided during their third year of
medical school to become MD podiatrists. All
things being equal, any graduate of an MD program
or an osteopathic medical school could follow this
path to an MD/DO podiatrist, not just graduates of
a former DPM granting institution.
After 4 years of general medical school which is
needed to pass 2 steps of USMLE, then a more or
less general internship known as PGY1, then passing
step 3, we could match into a podiatry residency.
Remember there isn’t much podiatry in our new
medical schools, so we must ask ourselves, should
the almost final path to MD podiatry be a medical
residency which would be 3 years followed by a 1-
or 2-year surgical fellowship or just call it an MD
podiatry surgical residency of 5 years all taught
by DPMs to new MDs? When do the graduates of the
MD/DO podiatry program present a proposal to be
recognized as a valid specialty by the American
Board of Medical Specialties. There is an American
Board of Surgery, but that is one of the 24
specialties included in the American Board of
Medical Specialties, so the Medical Specialties
Board would co-sponsor the proposal to the AMA and
somewhere ACGME would need to be involved.
Unless I follow the Methuselah longevity life path,
I doubt I will live to see the valid path of MD
board certified podiatry come to fruition, but
brothers and sisters rejoice because there is a
path which leads to an MD board certified
podiatrist who would have as much training in
diagnosing and treating medically or surgically
pathology of the foot and lower leg as we do right
this minute, right now. The cost? The next
generation could still call themselves podiatrists,
but would they lose our identity? I wonder how
difficult it was for Maurice Lewi, MD to change the
name chiropody to podiatry somewhere between 1911
and 1919. And did they worry about losing their
identity as chiropodists?
What I know is that today’s podiatry school deans
cannot meet in a secret conclave and decide to
issue the 2025 DPM graduates an MD degree. It just
cannot happen no matter what some of us wish for.
There is a path, and two path’s diverged in a
yellow wood and we must choose wisely.
Rod Tomczak, DPM, MD, EdD
