02/12/2025     Allen M. Jacobs, DPM

Where are Our Thought Leaders? (Ivar E. Roth, DPM, MPH)

Dr. Roth laments his conversation with an
individual in that allegedly, a graduate of a
three-year podiatric residency had never performed
a surgical procedure "skin to skin". He queries
how this is possible.

Community podiatrists do not have an ethical or
legal obligation to allow residents to participate
in surgery on their patients. We must recall that
patient sought the care of the attending, not a
resident. Our first obligation when we participate
in medical education is to always prioritize
patient safety, not the education of the resident.
A community podiatrist may determine that it is in
the best interest of the patient to limit or not
allow a particular residents participation in a
particular case. With that said, PM readers know
there is touch and sense to surgery that must be
experienced and cannot be taught.

There is a "feel" to surgery that can only be
mastered by active participation. While we have an
obligation to our patient, those who consider
themselves to be educators also have an obligation
to society to graduate qualified surgeons who can
safely perform podiatric surgical interventions,
and utilize appropriate judgement in the
evaluation of these patients. Dr. James Ganley
used to say ,"surgeons think in the O.R. or they
do not think at all".

The question is whether the resident will have the
confidence and capability necessary to provide
podiatric surgical services.

In the "old days" podiatric resident education was
based upon the William Halstead, MD "see one, do
one, teach one" model. I have always felt an
obligation to follow the Zwisch model of surgical
education, both during my days as a residency
director and now as a participant attending in our
local residency program. The Zwisch model is
simple: show and tell, smart help, dumb help, no
help. With show and tell, the attending
essentially teaches by thinking out loud, while
performing the key parts of the surgery. A
preoperative discussion and post operative
debriefing offer "teachable moments" for the
resident. Smart help involves being a good first
assistant, guiding the resident through the
procedure. With dumb help you allow the resident
to lead in the OR, offering advice or insight for
technical refinement. No help is self-explanatory,
always maintaining patient safety as the priority.

As attending we strive to impart situational
awareness and good decision making with our
residents. This comes from devoting time to
discussions with the resident before and following
surgeries.

When asked, what do residents actually desire?
They desire honest feedback. They desire focused
learning goals with preoperative case briefing and
post operative debriefing. They desire some degree
of autonomy. They desire the chance to struggle
and work out solutions. You can provide all of
these measures should you choose to do so.

The ACGME core curriculum for surgical residents
includes patient care, medical knowledge, practice
based learning and multiple other worthwhile
objectives.

It has been fascinating to watch the growth of
surgical fellowships, which many you feel are
required following four years of pediatric medical
education, and three years of pediatric residency.
Perhaps the individual with whom Dr. Rothberg is
representative of a larger population of less than
adequately trained individuals?

I was once sitting in the lounge when an internist
popped down next to me. Out of nowhere he saw I
was wearing greens and stated “I don’t need
surgeons to think. I will do the thinking. I just
need them to do a good job at what they do.”
similarly, a rheumatologist once confided in me
“we know that most orthopedic surgeons don’t know
anything about these diseases. All I want them to
do is replace that hip or knee or shoulder and
send me the patient back better than they were
before and without any injury“. When all is said
and done, there are necessary skills that must be
obtained during a surgical residency program.
However, there is an intellectual side to surgery
involving patient assessment, procedure,
determination, interoperative, decision-making,
and post-operative care that also must be learned.

All of you have experience, which is Albert
Einstein once noted is the only true form of
knowledge. You can certainly participate in the
education of a surgical resident by sharing your
experience and knowledge, without necessarily
allowing the resident to perform the procedure if
you feel uncomfortable in allowing the resident to
do so.

In the end, however, there is only so much you can
do. As Charles Lombardi states with regard to
surgical education, “I can teach you how to paint,
but I cannot make you an artist.”

Allen M. Jacobs, DPM, St. Louis, MO

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