What Makes A Podiatric Surgeon?
A podiatric surgeon is a specialist in the treatment of foot and ankle problems. Podiatric surgeons are not medical doctors (i.e registered Medical Practitioners) having instead specialised over their entire graduate and post graduate training and education in studying the foot and ankle in detail, as well as the lower limb and all the associated medical knowledge necessary to safely and expertly diagnose and treat foot and ankle problems.
The training of a podiatric surgeon covers a minimum period of 10 years and commences with a 3 year undergraduate programme. Once a BSc Hons degree in Podiatric Medicine has been completed the podiatrist must work for at least one year in clinical practice before enrolling on a 3 year Master’s degree (MSc) course in the Theory of Podiatric Surgery. Obtaining a podiatric surgery training post is a highly competitive process and begins with a structured interview. If successful, the podiatrist can then commence surgical training.
A podiatric surgeon is trained to assess the patient as a whole and provide a range of non-surgical, medical and surgical interventions. Podiatric surgeons recognise the importance of working in a multidisciplinary network and will at all times work with other health professionals for the advantage of the patient. The clinical performance of the podiatric surgeon is guided by professional standards against which the podiatric surgeon may be judged. Clinical decisions and outcomes are evaluated using a variety of audit measures.
The standards of Podiatric Surgical practice are defined by the Faculty of Podiatric Surgery of the College of Podiatry. The statutory responsibility for the value and standards of practice of all Podiatrists lies with Health Care Professions Council (HCPC). In 2013-14 the HCPC will assume regulatory responsibility for Podiatric Surgeons through all stages of their training and practice1.
While lacking the financial and other resources of the Royal Colleges of Surgery, the local Deaneries of the Royal Colleges and the General Medical Council, the Faculty of Podiatric Surgery has sought to develop a curriculum, training and assessment which has parity with medically trained surgical colleagues 2,3. Podiatric surgery education and training comprises six stages of development.
- Undergraduate podiatry training
- Post graduate education and foundation clinical practice
- Selection for surgical training
- Podiatric surgical training
- Preparation for independent practice
- Continuing professional development
By taking responsibility for all these stages of educational development, the Faculty of Podiatric Surgery, in partnership with the HCPC, provides the essential Quality Assurance Framework to protect patients. The framework also enhances and develops podiatric surgeons by ensuring that their training reflects the needs of patients through including the benefits of developing technology, research and outcomes audit.
This document provides an overview of podiatric surgery training as well as the measures in place to ensure safe and effective practice. Podiatric surgery, while a recent specialty has many aspirations for future development of its educational and revalidation processes which will also be alluded to. Continuing development of podiatric surgical education and training will forever be a core activity for the Faculty of Podiatric Surgery 4,5. Ensuring fairness and transparency for all stakeholders along with effective regulation and validation is a key principle of that responsibility.
Undergraduate Podiatry Training:
Fundamental to the mission of each UK Podiatry School is the preparation of podiatrists competent to start work in the basic foundation year programmes of NHS Podiatry Services. Podiatry students receive a broad education with a diverse curriculum in order to develop themselves as clinicians and professionals. While from the start the emphasis is on the management of lower limb problems, podiatry students are taught to recognise other underlying medical conditions that may impact on their management of the patient’s foot and ankle problem. In recognising the impact that foot and ankle problems may have on the patient as a whole, podiatry students will learn how they may contribute to the multidisciplinary management of the patient whose foot and ankle problem may be just one symptom of a more general illness. The Faculty of Podiatric Surgery supports an Introduction to Podiatric Surgery programme in the final year of the undergraduate programme.
Completion of the undergraduate programme is followed by registration with the HCPC. All Podiatrists must be aware of and follow guidelines laid down by the HCPC both in their professional roles and in their conduct as laid out in the Fitness to Practice guidelines 6 .
Post graduate education and foundation clinical practice
The newly qualified Basic Grade Podiatrist will commence practice in a variety of settings but within a supervised learning environment. These early years of practice will mainly provide experience in the non-surgical management of foot and ankle problems, though they will also practice nail and skin surgery performed under local anaesthetic. Gait analysis, appliance and orthotic treatment, wound care management and delegation to helper grades will also form an important part of the early years of a podiatrist’s career.
Selection for podiatric training
Those choosing podiatric surgery as a career specialty can gain further clinical experience working as a staff podiatrist in a podiatric surgery unit. Such experience is vital in the preparing for the structured interview process. The interview involves a defined panel of members to ensure consistency and fairness. Enrolment on the Master’s degree in the Theory of podiatric surgery usually commences 1-2 years in general practiceand on completion of the postgraduate certificate modules of the Master’s degree the podiatrist can apply for surgical training posts.
Podiatric Surgical Training
Podiatric surgery is a specialty dealing with congenital and acquired disorders of the bones, joints and their associated soft tissues, including ligaments, nerves and muscles. The programme of clinical based training is currently up to 6 years in duration and aims to furnish trainees with the knowledge, skills and attitudes to progress to a Certificate of Completion of Podiatric Surgery Training (CCPST). A CCPST is an essential for appointment to a position as a consultant podiatric surgeon in the NHS.
Podiatric surgery training consists of essential learning and cumulative experience in order to develop clinical and surgical skills, diagnostic ability and decision making. While technical skills are important, the design of a treatment plan implementing non-surgical, medical and ultimately surgical intervention are essential to high quality care.
Completion of a log book containing audit of surgical outcomes and reflection on surgical experience underpins ongoing assessment of the trainees progress and continues beyond training. Each trainee must complete at least one research or audit study of publishable standard, based on the research methodologies taught at undergraduate and Master’s level. This academic activity is vital to develop the skills necessary to ensure a career long contribution to surgical outcomes measurement and research 7 .
In the first and second year of surgical training, the trainee will complement their knowledge of multi-disciplinary team working by engaging in training rotations with anaesthetics, orthopaedics, rheumatology, dermatology and medical specialties. The trainee will also attend other podiatric surgery units in order to gain experience in sub specialty aspects of podiatric surgery including diabetic foot, rheumatoid foot, paediatrics, arthroscopy and minimal incision surgery.
During the second year of surgical training, the trainee is required to successfully complete a clinical exam which tests diagnostic skills and ability to plan a safe, appropriate and effective treatment plan which takes into account all aspects of the patient’s medical history. This leads to Part 1 of the Fellowship in Podiatric Surgery (FCPodS). Throughout the second year, the trainee will continue to develop their surgical technique and other health care skills including team working, communication, teaching and research.
Surgical experience is gained under direct supervision of a registered consultant podiatric surgeon tutor. For every surgical procedure performed, the contribution and the experience gained by the surgical trainee is graded and written feedback is provided by the tutor and included in the training log book.
Final Fellowship exam (Part 2) leading to award of FCPodS
In the third year of surgical training, the trainee will take greater control of all aspects of patient management. They will be expected to perform surgical procedures to a high level of competence including the understanding and management of intra-operative complications. They will be expected to make decisions under pressure and use professional judgement as they prepare for the final assessment - Part 2. This final pass/fail, peer review assessment of the candidates’ technical surgical ability is unique to podiatric surgery with no other surgical specialty performing such an assessment. The Faculty (of Podiatric Surgery) Quality Group – or FQG is responsible for the standards of training and assessment and is overseen by a broader committee with laypeople holding professional experience in education.
Consultant podiatric surgeons registered with an independent examiners panel are appointed by the FQG to the examination board panel on the basis of their academic and educational experience. The examiners will assess the trainee’s knowledge, professionalism, insight and leadership as well as their surgical skills. Successful completion of this practical and oral exam will lead to the award of Fellowship of the Faculty of Podiatric Surgery (FCPodS) by the faculty board for podiatric surgery responsible for surgery to the college of podiatry.
Preparation for independent practice
Specialist Registrar in Podiatric Surgery and award of CCPST.
Specialist registrar posts in podiatric surgery are secured by competitive process of interview and log book presentation. The three year phase of training will allow the podiatric surgeon to gain more experience while working under the indirect supervision of a consultant podiatric surgeon in the operating theatre and leading the team in the outpatient clinic. They will review patients in clinic, investigate and diagnose new patients, manage and treat common complications and organise the patient’s pathway to surgery. The faculty of podiatric surgery has formulated minimum numbers of procedures across a broad range of foot surgery and once again the podiatric surgeon will attend other podiatric surgery centres to gain sub specialty experience. Once experience has been accumulated over a 3 years period the podiatric surgeon may present their log book to the faculty of podiatric surgery. If there is sufficient specified activity, adequate depth and breadth of experience and satisfactory performance as assessed by the consultant tutor, the tutor will submit the application to the regional deanery chair who will make a recommendation to the faculty board. Once this has been approved it is submitted to an independent board of the college for endorsement. This will lead to the award of CCPST taken by a multi-disciplinary group with lay members.
Funding for Podiatric Surgery Training Posts – the current position.
It is estimated that 40% of podiatric surgery training posts are provided with honorary contracts. While this demonstrates the commitment of the podiatric surgical trainees, it also represents significant hardship among health care workers providing quality NHS services. The faculty of podiatric surgery believes that no training post should be unpaid and continues to lobby for appropriate funding and support for training posts.
Consultant Podiatric Surgeon Appointment process
The faculty of podiatric surgery is committed to an open and transparent appointment process within the limitations of NHS Trusts internal regulations and structures.All consultant appointments are made in free and open competition. A consultant podiatric surgeon will be appointed to represent the faculty of podiatric surgery board and will advise the Trust appointments panel which will comprise a local professional lead and a Human Resources representative. The Faculty representative will provide an external view of the process.
Consultant Podiatric practice
Consultant podiatric surgeons are committed to integrated multidisciplinary working across the organisational boundaries of the NHS in order to provide optimum patient care. This will involve working with medically trained general practitioners, consultant anaesthetists, rheumatologists, endocrinologists, vascular surgeons, orthopaedic surgeons and radiologists, as well as nurses, physiotherapists, orthotists, other podiatrists and secretarial and administrative staff. The Consultant will provide outpatient and inpatient care and will also have responsibility for training a specialist registrar and podiatric surgical trainee. Clinical governance, continuing professional development and appraisal are an on-going career long commitment. The consultant is accountable to the Trust’s Medical Director and Chief Executive for maintaining their continuous professional development.
Working alongside Orthopaedics
During 2011 changes to the structure of the NHS created amalgamation of some community services with acute hospital services. This was seen as a valuable opportunity to share wider experience. The faculty of podiatric surgery has noted with encouragement that more podiatric surgeons are sharing common facilities between the community and hospitals. This is an aspiration supported by the College of Podiatry. During 2012 helpful discussions with the key interest groups; The British Orthopaedic Association and British Foot and Ankle Surgery Society commenced and this work will hopefully lead to better understanding for manpower needs of both professions as they work together in an ever increasingly difficult healthcare system where demands are high.
Presently podiatric surgeons employed in the NHS are required to undertake an annual locally agreed professional development review. Over and above the minimum standards that might be required by employers, the faculty of podiatric surgery expects and makes provision for its practising members to participate in 360 multi-source feedback every 3 years. Areas for review will include:
1. Professional performance, knowledge and skills. This includes keeping up to date, by participating in professional development and educational activities as well as taking part in and responding to quality improvement measures, such as audit, appraisals and performance reviews. The podiatric surgeon must recognise and work within the limits of their competence.
2. Communication. It is vital that podiatric surgeons communicate effectively with their patients and other members of the multidisciplinary team.
3. Safety and quality. Podiatric surgeons are encouraged to participate in a national audit tool administered by the College of Podiatry. This allows bench marking of safety and quality against a national standard.
4. Honesty, integrity and probity. A professional attitude requires the podiatric surgeon to show respect to patients and colleagues and treat them fairly without discrimination and with honesty and integrity. At all times the podiatric surgeon will act with the patient’s interest at the forefront of all decisions.
Failure to comply with guidelines for continuing professional development may lead to removal from the register of the HCPC. It is likely that the HCPC may further develop the appraisal process as part of podiatric surgery annotation.
1. Statement on annotation of the Register - Qualification in Podiatric Surgery.
Health Care Professions Council August 2012.http://www.hpc-uk.org/aboutregistration/professions/index.asp?id=3
2. Pitts D, Rowley DI, Marx C, Sher L, Banks T, Murray A. Specialist training in Trauma and Orthopaedics: A competency Based Curriculum 2007, British Orthopaedic Association. https://www.iscp.ac.uk/static/orthocurriculum/Content/15350_Whole_Doc_19.pdf
3.What makes an Orthopaedic Foot and Ankle Surgeon.Robinson AHN, Bendall SP. British Orthopaedic Foot and Ankle Society 2013 [Personal communication with President of BoFAS, Mr Simon Henderson, FRCS and Dean of Faculty of Podiatric Surgery, Mr David R Tollafield FCPodS]
4. Kilmartin TE. Editorial. Fellowship Training: Moving the goal posts. Br. J. Podiatric Med. Surgery 1995 7:60
5. Kilmartin TE, Potter MJ, Prior TD. Fellowships in Podiatric surgery and podiatric medicine: The new system. Podiatry Now. 2004. 7: 17-19
6. What is fitness to practice? Health Care Professions Council 2013.http://www.hpc-uk.org/complaints/fitnesstopractise/
7. Maher AJ, Kilmartin TE. Patient reported outcomes: a new direction for podiatric surgery. Podiatry Now 2010; 13(10) 36-38