Residency Rap

Good day again fellow residents. I hope everyone is doing well, especially you seniors with your job search. A quick reminder to the chief residents to send in your responses for the Chief Resident Round Table. I’ll give you another two weeks to respond. As a reminder the questions are as follows:

• What is it like to be a chief resident at your program?

• What are some of the dynamics of the residents and attendings you work with?

• How many residents are in your program?

• How do you stay organized while balancing your personal time and work?

• What’s your educational/didactic program like?

• Do you think being chief offers an advantage when looking for jobs?

• Do you receive any extra financial or other compensations?

• What do you like and dislike about the position?

• What hints or tips do have for future chief residents?

It’s finally starting to warm up here in Michigan, which puts me in a spring mood after returning from the ACFAS conference in Las Vegas. Speaking of the conference, I noticed an underlying theme that ran through the lectures. It started with the debates I mentioned in the prior Rap issue and continued during the conference, insinuating itself into my thoughts during workshops and later lectures. This isn’t a new idea. Indeed, during our residencies this topic comes up every day when we discuss both conservative and surgical treatments. This underlying current is standard of care.

I know; you’re thinking, “So what? This isn’t new. What bug got up Shapiro’s butt?” Here’s my bug: there just is NO true standard of care. I’d say this is pretty important concept in medicine considering the current litigious state of our society, and all of us (not only the seniors) will be dealing with it soon enough.

You might argue standard of care does exist, and it is based on what the average doc in the community performs. Or is it the state? Or perhaps the current trends in the specialty? But who decides these “current trends?” Is it local? Is it national? Some of our best national speakers are doing edge-of-the-envelope work, outside of what the average podiatrist does. Should this be standard of care? Performing a McBride for just about all bunions was standard of care before our “current trend” of metatarsal osteotomies and structural correction. Within your own communities, even your own residency programs, I’ll bet you can find many different ways of approaching the same pathologies or procedures, with little consensus. As residents we have a unique perspective on this, seeing many ways to approach the same problem. Take Stage II PTTD, for instance. How many ways are there to skin this cat? Does anyone agree how to treat this?

And what about the lawyers out there, just waiting to demolish the “rich doctor.” God forbid you perform outside of the “standard of care,” and you have a complication. How do we protect ourselves from these vultures? And where do the ACFAS clinical practice guidelines fit in to all this? In my opinion these guidelines are a good start, but they’re so vague they don’t really say anything.

I’m generating more questions than I can answer, but here’s my take on this. The current evidence based medicine movement will, in the future, assist in providing somewhat standardized treatments, borne out through effective research. This will take some time, though, because our research, especially the surgical side, is not where it needs to be. Once this is established, then the clinical practice guidelines will have some teeth. For now we have to do what’s best for our patients using our superior training, experience, and continued education. However, I actually think “standard of care” is a fallacy because there are often many legitimate ways to treat the same problem. If you get 10 podiatrists in a room and ask them what procedure is best for bunions you’ll probably get 11 different answers!

What’s your opinion? Is standard of care real, a pipe dream, or fodder for the lawyers? Write in with your views.

As with all PRESENT publications, all issues of Residency Rap will be stored on the PRESENT  website, so if you miss an issue or you want to refer back to a prior issue, it'll be at:

http://www.podiatricresidency.com/residencyrap/