The Why Behind the Establishment of Western University College of Podiatric Medicine

Podiatry was starting to get the attention of the medical world by the 1970s, enough so that the president of the American Orthopedic Foot and Ankle Society used the occasion of his inauguration to address the profession. “Whither Podiatry?” Robert L. Samilson, MD, titled it, and he spent the entirety of the speech, which was later printed as an article in Orthopedic Clinics of North America, to call out the podiatry profession as being inferior to orthopedic surgery. Many took offense at the time, but his words may have had the opposite effect than he would have suspected.

Podiatry was listening closely, and things started happening. Curricula started evolving from what it had been to what it could become. The American Board of Podiatric Surgery was established to test competencies in foot and ankle surgery. The first new school of podiatric medicine in decades was established, in conjunction with an osteopathic medical college using some of its existing curriculum. The variations that existed from college to college started to equalize somewhat. As newer colleges began, there was ever more integration of curriculum with those of existing medical schools. Podiatric medical residents in hospital-based programs found themselves serving as interns on medical and surgical services.

Dr. Samilson's choice of words had been interesting. The word “whither” is an archaic term meaning “to what place” and is commonly mistaken for a similar word, “wither,” which means to shrivel and die. Many wondered which he truly meant. But, wither podiatry did not.

Western University of Health Sciences (WesternU) created a College of Podiatric Medicine (CPM) out of this historical context, to be unlike any other. Founding dean (retired) Lawrence B. Harkless and interim dean of Academic Affairs Lester J. Jones had the unique opportunity of a blank slate. The future home of the CPM was yet to be built, and a curriculum was not yet predetermined. Before a single brick was laid, it was decided that the evolution of what a podiatric medical education could be would be pushed farther than it had been before.

“The curriculum is groundbreaking in podiatric medicine. The podiatric medical students are almost totally embedded with the osteopathic students in the curriculum,” says Harkless. In place of Osteopathic Manipulative Medicine, podiatric medical students take a longitudinal course in podiatric medicine, surgery, and biomechanics.

The school was prepared for the complaints that there wasn't enough podiatric medicine and surgery being offered, but Dr. Jones often gives the analogy with orthopedic surgery. “Where does an orthopedic surgeon learn to be an orthopedic surgeon?” Dr. Jones asks. “He or she learns that profession in their residency program. That's where. This is what we are doing with podiatry.”

The profession of podiatry as a whole had invited seismic change with the Educational Enhancement Project in the 1990s. This considerable undertaking brought together practitioners, faculty, administrators, residency directors, representatives from the various boards, and other stakeholders for a several-year conversation about how podiatric medical education and training could evolve and become more equal to osteopathic and allopathic medicine. It was often a loud conversation, and it was always lively.

In the next decade other, pivotal changes occurred as a result. The alphabet soup of residency programs was reborn, or retired, to become one comprehensive medical and surgical residency program of 36 months in length. Programs housed at surgery centers were closed and moved where possible to hospital-based programs. It was in that atmosphere of acceptance for change that WesternU started considering the addition of a new podiatric medical college.

Curricular Design

The extent of integration with the osteopathic medical school was a bold move, but the methods of teaching the curriculum were as well. Instructional methods are based on academic research and are designed for adult learners. The all-lecture format of traditional didactic education was discarded in favor of case-based teaching, introducing students to the meaning behind the science. Patients came into the classroom to discuss their conditions with the students, explaining not only the symptoms but also how disease affects their quality of life and their families.

That connection with the patient extends into the community, where students perform service learning activities, putting them face to face with patients across Southern California.

WesternU has nine health-care colleges, and it was an ideal setting for an early commitment to interprofessional education, a case-based course. Podiatric medical students meet with their counterparts from veterinary medicine, osteopathic medicine, dentistry, optometry, physical therapy, pharmacology, graduate nursing, and physician assistants to solve the challenges of complex cases dealing with population health issues, such as obesity, diabetes, autism, and others. The students first explore how their specialty may have a role in each case and then interact with students from the other colleges to learn how a patient can best be served by a health-care team rather than by a physician in a professional “silo.”

Team-based learning is a hallmark of education at WesternU, where all classes are student centered rather than teacher centered. This move from the lecture format is often referred to as a move from the “sage on the stage” to the “guide on the side,” or facilitator-assisted groups.

The method has been shown to promote critical thinking skills and the ability to problem solve rather than memorize. Team-based learning uses self-managed learning teams and results in the development of critical thinking and application skills. The key to its success is active engagement, with students researching, via electronic medical resources, to answer questions posed about a case. To ensure that eventually students reach the correct answers, facilitators direct but do not lecture. Another technique—Small Group/Large Group—integrates a traditional didactic encounter followed by team-based learning.

Students are actively assessed in their performance not only with numerical or letter grades but also with competencies in subject areas. Education technology makes it possible to assess each student's individual competency by tagging questions with thematic words ranging from subject matter (biomechanics, renal, lower-extremity anatomy, etc) to broader learning outcomes unique to the profession or to the College (humanism, referrals, research method, etc).

Trends are monitored, by both individuals and classes. Changes can be made to a course that is in progress if students are challenged by a particular subject or outcome.

The shared curriculum was redesigned last year to add more active learning, a year-long anatomical dissection, flipped classroom style, and “Just in Time Remediation.” In the past, students required to remediate were often moved into the next class, to allow them to repeat a course. Now, using the tagged examination questions, faculty can determine if a student has struggled with all subjects in a course or just a single one. For instance, a student might be challenged by physiology but not hematology, pharmacology, and biochemistry. In that case, the student can be remediated quickly in that area of deficiency and continue on with their cohort. This method has brought attrition to a halt and is better addressing the students' needs.

Technology and Medical School Education

Objective standardized clinical examinations help monitor students' clinical acumen, an essential in successfully completing the more than 45 Standardized Patient encounters that each student completes before leaving WesternU.

Standardized Patients are a common medical school teaching tool, and fourth-year podiatric medical students at all nine colleges now are required to pass a Clinical Skills Physical Examination to graduate and begin a residency program. This is a 12-patient examination that requires taking a problem-focused history and performing the related physical examination, then writing a SOAP (subjective, objective, assessment, and plan) note reflecting on the encounter. WesternU students have a 100% pass rate on the Clinical Skills Patient Encounter.

The podiatric medical students are trained to correctly perform all of the examinations that they may be called on to perform in their externships and residencies. This includes those examinations and procedures they may encounter when they are on services outside of podiatric medicine, such as internal medicine, women's health, and general surgery. Specialized Standardized Patients, called Body Teachers, give feedback to students as they learn to perform pelvic, rectal, and breast examinations.

“I don't want their patient on an Internal Medicine hospital rotation to be the first person on whom they have performed one of these exams,” said Kathleen Satterfield, DPM, associate dean for Pre-Clinical Curriculum and Outcomes Assessment. “Their patients deserve a well-trained student, whether they are doing one of these exams or casting for orthotics. This training insures that they are knowledgeable and skilled.”

Procedures that cannot be simulated, such as performing deliveries, are learned on high-fidelity manikins that can be altered to represent different birth situations, such as breach presentation. At least one WesternU graduate found himself in the position of delivering a baby while on an emergency department rotation. The same type of technology is used to teach students how to deal with heart arrhythmias and heart attacks.

Another WesternU graduate surprised DC's MedStar Hospital colleagues when he resuscitated a patient, running the code, and directing the arriving physician-nurse code team. It was only at the end of the successful resuscitation effort that a senior attending noticed the name and degree on the code runner's ID. “I didn't know that podiatrists knew how to do this,” he was said to have remarked, with the young resident proving that yes, WesternU students do. It was an important educational moment for the teaching hospital's staff.

WesternU students have Gross Anatomy, with significant cadaveric dissection through the entire first year. This is now reinforced by using a virtual dissection table (Anatomage, San Jose, California), where students can review anatomical structures and images repeatedly, a task that becomes impossible after structures have been physically dissected. Case studies are entered into the device, and students use active learning techniques to identify motion's effects on anatomy, for instance. Surgeries can be simulated on it with a special scalpel feature that was added, allowing students to reinforce their knowledge of surgical anatomy repeatedly.

The table is housed in the Pumerantz Library, which is the hub for education technology, and a suite has been named Virtual University. Students can use a virtual reality headset (Oculus Rift; Oculus VR, Menlo Park, California) to interact with anatomical structures, performing procedures and visualizing the results in three dimensions. They continue their work on the iPad workstations in the suite, all loaded with proprietary programs from Stanford University School of Medicine, allowing students to further review and learn the information actively.

The latest addition to the University's educational technology and curriculum is ultrasound. WesternU is one of the latest medical schools to integrate the use of ultrasound into the curriculum, much like the stethoscope was integrated more than 100 years ago. All of the students received a SonoSim ultrasound probe simulator (SonoSim Inc, Santa Monica, California) and learned how to use the technology in each discipline. For instance, second-year students in endocrinology receive training to visualize the adrenal glands and then are assessed on their individual technique to isolate and identify abnormalities there.

Education does not stop at the end of the second year with completion of the preclinical years. Third-year students continue their didactic education on Wednesday afternoons throughout that year. Relieved of clinical duties for the afternoon, they work in small groups with a facilitator to continue to learn podiatric-specific knowledge, including biomechanics. The use of technology enhances this learning, with all of the students, regardless of clinical site in Southern California, receiving the same material through teleconference. Again, assessment is performed to ensure that learning is continuing and that each individual student is gaining the knowledge needed to be successful.

Conclusion

WesternU has a 36-year history of successful delivery of health-care education. The recent addition of the CPM continues that tradition with a rigorous education intended to graduate a physician with a specialty in podiatric medicine and surgery. It has been a goal of many, but until there was a university that allowed almost complete immersion in the DO curriculum it remained just a goal.

In California there is a unique opportunity for podiatric medical graduates to qualify for a Physician and Surgeon Certificate, an opportunity unique to California and its law. State leaders are working with osteopathic and allopathic groups to show that podiatric medical graduates from our school are receiving the same education and training. A multiprofessional task force (MD, DO, DPM) continues to gather evidence to prove the point. A part of that evidence will be students' performance on licensing examinations.

Students in podiatric medical programs at the California colleges can sit for an examination that is considered introductory to the US Medical Licensing Examination (USMLE.) If they average an accepted score on the Comprehensive Basic Science Examination, the National Board of Medical Examiners will be petitiioned to allow the colleges to sit for the USMLE on a trial basis.

This is the rigorous test that allopathic and now many osteopathic students take to qualify for graduation and for certain residency programs.

The osteopathic medicine program at Western U has a proprietary board preparation course that tests their students on coursework cumulatively throughout the first 2 years. It has proved very successful in preparing students for the board examinations. The podiatric medical students joined the DO students in taking the cumulative exams in 2017, enhancing their retention. All of these actions offer the profession a historic opportunity for advancement.