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Joint Podiatry Orthopedics Taskforce Part 3 -
The College Perspective
An Interview with Kathleen Satterfield, DPM, Dean WUCPM

Continuing our miniseries involving the Joint Orthopedics and Podiatry Taskforce, I had the pleasure to interview Kathleen Satterfield, DPM, Dean of the Western University of Health Sciences College of Podiatric Medicine (WUCPM). Our ninth podiatric college uses an integrated education model in which podiatry students take courses alongside their DO colleagues, a different method than some of the other podiatric colleges. WUCPM has also been on the front lines of the California Physician and Surgeon Taskforce and is the only podiatric college that has had its students take the CBSE examination, the test allopathic students take to prepare for the USMLE. As a result, Dr Satterfield has a unique perspective on the current Joint Orthopedics and Podiatry Taskforce, and I hope you enjoy her insight as much as I did.

View the entire interview transcript below or a PDF version Here

Residency Summits Online 2021

Jarrod Shapiro, DPM Interview of Kathleen Satterfield, DPM

Jarrod Shapiro: My name is Jarrod Shapiro, the editor of the Practice Perfect Blog. As many of you know, the Joint Task Force of Orthopaedic and Podiatric Surgeons composed of the AAOS, the AOFAS and the APMA, have brought Resolution J21-303 to the American Medical Association. This bill proposes to investigate if the accreditation education and certification processes for podiatry are comparable to those of the MDs and DOs. This obviously has the potential to create controversy in the podiatric profession. So, I'm speaking with individuals who are well placed to understand its potential effects. I'm here today with Dr Kathleen Satterfield, Dean of the Western University College of Podiatric Medicine in Pomona, California. Dr Satterfield has been an integral part of the WesternU CPM since its inception and has been a leader advocating for a 21st century podiatric college education where students receive a full medical and podiatric education. Before we get started for full disclosure, I want to point out that I'm an employee and faculty member of the WesternU CPM. And I'm very proud to work under Dr Satterfield's leadership. Dr Satterfield, thank you very much for joining me today.

Dr Kathleen Satterfield: Of course, thank you.

Jarrod Shapiro: So, the upcoming AMA resolution that advocates for podiatrist's accreditation, education and certification that's being investigated. This must have an effect on colleges and your deanship. So, as the dean of Western University, how do you feel about this movement that's underway?

Dr Kathleen Satterfield: I am probably the one podiatric dean in the country that is a 100% for this. Well, I know that our school was founded on this principle. It was started with the whole mindset that we would educate a student fully in the sense of medicine with the addition of podiatry. And that's still very controversial. I think one of the misnomers about it is that, well, if you teach medicine, you've got to leave out a whole lot of other things. And that is not the case to the extent that the naysayers are telling the world. When I went to school at Des Moines, I took a few classes with the DOs. I took the majority of my classes, though, with my podiatric colleagues. And most of my classes had the word or the prefix podo in front of them, like podogeriatrics or podopediatrics. So, the things that I learned in a diluted fashion in those courses, it's represented in our courses without podo in front of them. So, I really don't think it's a huge leap to where we need to be.

Jarrod Shapiro: So, that Western University has been doing this type of education for some time. Obviously, not all of the schools are doing that or maybe have started moving in that direction yet. So, do you think that having this full medical plus podiatric education is a realistic goal for all of the colleges to attain?

Dr Kathleen Satterfield: Not without severe pain in expense. And I'm a realist, I understand that that is where a lot of the kickback is coming from, if we look at things completely through the correct lens. One of the deans of one of the more traditional colleges that has been around for many decades said to me, "I could do what you're doing." And I agreed he could. He could make his college like ours. But at what expense? You would have to take the curriculum out, reorder it, putting some things into the medicine core. It's nothing different than what the ophthalmologist does. They learn medicine first. They get some of the eye and structures the brain in medical school, and then they really hone in on their specialty in their residency program. I've just never been able to figure out why we're the opposite. It's like, we just get it backwards.

Jarrod Shapiro: So, what would a school have to do to make those adjustments or to revamp that education? Is it something that like that they could retool for or do you think it… like could it eliminate potentially a school out of this type of thing?

Dr Kathleen Satterfield: I think it probably could leave some schools out in the cold. Because what you… the absolute necessary thing is to be aligned with an on-site medical school or at least close enough in proximity that you can have that cross population of professors, the PhDs, and the MDs, the DOs, and the DPMs working together. That's difficult to do if you're on two separate campuses. And it's really difficult to do if you're in two different cities. Some of our podiatric colleges are not aligned with the mainstream medical school. And I think it would be very difficult for them to do. They would have to… you ask what would they have to do? They would have to find a partner. They would have to align and get agreement from that partner to embed the education into the existing medical curriculum. 00:06:03 You have to have a larger faculty than some podiatric colleges do. We have our podiatric specific faculty members, but we also rely on the large mass of faculty that are in our comp colleague's college.

Jarrod Shapiro: So, as a faculty member of one of these colleges myself, I see a lot of that interaction that you mentioned, we teach in the DO college classes for certain things. I've gone as far as teaching kind of cardiology topics as well in my own experience. Do you think that the podiatric medical staff themselves, the physicians who are at those colleges, do you think that that's something that they can adapt to pretty well? I guess the question really is, is it the main leadership of the colleges that might be the challenge? Or is it the podiatric staff that are educating the students themselves?

Dr Kathleen Satterfield: That's a good question. I think the answer is probably as unique as every faculty member is. I have a lot of friends who teach across the country just like I know you do. And some of them are all on board for sharing their knowledge with their DO and MD colleagues, others feel a little uncomfortable about it. And my experience has been that when we offer to teach something in the DO curriculum, for instance, they welcome us there at this institution. But I've worked at three different medical schools and this one is just different in the culture that exists here. And I think it's because our college was started with this in mind, everybody knew going in that this was going to be a partnership. And indeed, they've been a wonderful partner to us.

Jarrod Shapiro: So, it sounds like one really major component to this is having a partner within the MD, DO world to work with for the college. I'm wondering about the curriculum itself. Western University's curriculum is very integrated, the podiatric education is very integrated as well. It's not separated out by biomechanics class, radiology class, etcetera. Do you think that it's possible for schools to you bring in or become partners with a larger university, but maybe maintain a different version of that education, maybe something different from what we at Western University are doing? Is there room for that kind of diversity within this kind of larger, you're training as a medical doctor as well as a podiatrist kind of situation?

Dr Kathleen Satterfield: Yeah. That's a really good question and a good point, because I think that's exactly what exists right now. When I talk about the newer schools, I'm talking about Midwestern Des Moines and Western and soon probably to be the lower Rio Grande Valley UT program. And all of them have integrated the DO and DPM curriculum to a certain extent. I mentioned that when I went to school, it was a few things were integrated in the first year. I don't know what it is today. But we went all in and integrated everything with the exception of OMM and podiatry. So, I'm sure other people have talked about where they learn their specialty, we learn our specialty. The other colleges, the newer colleges have also integrated and yet they find the room to teach podiatry. But on the converse side, there's not a one of us who doesn't say, at one time or another, "We wish we had time to offer more. There's always more." But as I shared with you and our graduates this year, I just love that photo of an article in JAMA that talked about the medical curriculum is just too full, with all of these new discoveries, how can we teach it all? And the article was from 1909. 1909. Okay. So, we're over 100 years past that, and we still have the same problem. I think part of the problem, in my opinion alone is that medical schools sometimes teach to the PhD level, not the clinician level. And I usually go to the AMAs… the AAMCs learn, teach and lead CME event every year. And one of the things that they've been talking about for the past decade is shortening medical school. There's a trial program out where I forget how many schools it's… I don't know, maybe 15 or 20, that have a curriculum that is only three years in length. And they teach in a very specific way geared toward the clinician, and they even geared towards the specialty. So, I see a real synergy with that. There's one that has a pediatric program. So, you go to that medical school if you want to become a pediatrician. And so, they teach their medical students in that three-year curriculum, pretty much how to be a pediatrician. It worries me a little bit to tell you the truth. Because the fellow presenting it said, "We teach them the top 25 most common diseases that they're going to see in the child." And part of me says, "Well, what if I have a child that has number 28?" I want somebody who's going to know number 26 on through a few more. But I bring that up only as a model that we should look at. If you stop looking at how to improve things, wow, somebody who's going to run over you. And if I ask every student that we've had in the last five years, do you want to keep learning? Do you want to advance? They're going to say yes, because that's who we pick to go to school here. They want to continue to improve. They don't want to stop learning on the day they graduate. And I feel as a profession, we owe it to them. Think about surgery, I mean, Larry Harkless was doing surgery in a janitor's closet with a bone saw… or not a bone saw a cast cutter and came out horrible. It came out with an article in JAMA telling about he had no infections. He had good outcomes. And UT looked at that and said, "We can't have you operating in a closet with a cast cutting saw and advertising it." So, you know what, he got into the OR. So, why aren't we, in our generation pushing to get things to move down the field a little further? I was using the football analogy. We need to move the football down the field.

Jarrod Shapiro: Yeah. It seems like the idea of this Task Force that looking into where we are in the different stages of our process is very much in line with by looking at, can we move forward? Can we do those things that you're talking about?

Dr Kathleen Satterfield: Mm-hmm. Yeah.

Jarrod Shapiro: So, Western University's currently, as far as I know, the only podiatric college that has its students take the CBSE examination, the exam that prepares medical students for the USMLE. Can you give us a little bit of background as to why WesternU CPM made the decision to have the students take this examination?

Dr Kathleen Satterfield: Sure. We're currently the only school that does it. In the past, there have been cohorts that did from other schools that took it to see how they would do. And the proponents of doing this will point out that none of us have done overwhelmingly great on these. But we keep trying to train our students to take it and take it seriously. The history was and it's just before my time here, that Larry Harkless and Les Jones previous deans worked with the California Task Force on the Physicians and Surgeons certificate to show the MDs and DOs what our education was like. And I believe it percolated up from that Franklin Medio conversation that, "Well, why don't you… the CBSE, anybody can take it, you and I could take it tomorrow. So, since it doesn't require NBME permission to take it. Why don't we start having our students take it, see how they do?" We've seen how our students do as a baseline. The first year, we did pretty average, below average, I would say. Second year, our students did horribly. The third year, that class was fired up, and they said, "We're going to do better than the previous year." They raised the score, average 17 points, because they took it seriously. So, we've got the trajectory, we know it can be done. There is a I think he's an assistant dean at another college that's very opposed to this. 00:16:05 And he believes that our students cannot pass it in great numbers. And I argued with him recently at AACPM meeting that I have faith in my students that they could. But I believe that they're being held back. One of the biggest things that competes is they take the APMLE in July, after their second year. They're at the height of their knowledge of what we call here, the shared curriculum, the basic science curriculum. So, we have them take the CBSE almost the same time. Obviously, because the APMLE is bigger stakes, they're going to concentrate on APMLE. They give lip service to the CBSE. But I think that until we make it high stakes, the students will not put the work into it that it needs in order to gain a high score. I fully believe that if I had the power to say the CBSE in a lower anatomy section are going to be all you need this year. You don't have to take the APMLE. It'll be substituted by this much harder CBSE plus a lower extremity anatomy module. I believe that we would have high rates of passage on it. I'm not a betting person, but I would be willing to bet on that. Because I know what my student's curriculum is. I know when they're motivated, what they'll do. But I don't have the power to make that call and let one substitute for the other. Our APMLE has not changed very much since I took it or you took it. 00:18:00 It's primarily first order questions, which are fine for recall. It tests knowledge at the level that our profession wants to test. The CBSE tests it's second order questions, which is like putting several first order questions together and having you draw a conclusion, an educated conclusion. And that's the second order. If you can pass that test, a CBSE, you can certainly pass the APMLE. But they're not going to put their energy into it until it guarantees them advancement.

Jarrod Shapiro: Yeah. That's a good point making the stakes a bit higher will definitely motivate the students to actually take that test seriously.

Dr Kathleen Satterfield: That's correct.

Jarrod Shapiro: But some have also argued about the GPAs of incoming podiatry students and MCAT scores in comparison to MD and DOs. And those vary by school, of course too. And I've made the suggestion in the past that when this Task Force, or even at some point when our students are allowed to take the USMLE or if they use the CBSE, that they can't just compare the scores exactly the same, a one-to-one MD student versus podiatry student. Because there are other factors that are involved there. I think of things like that we take the extra classes for podiatry, for example, that our schedules differ to some extent as far as board certification and whether the boards are pass, fail, those types of things, that they're not quite a black and white comparison between the two types of students. So, my kind of advocacy has been to say, "Look at these, but make sure that you know what you're comparing." What would you advise the Task Force in any specifics and how they would interpret the results of what they're looking at when they are actually examining the podiatry world?

Dr Kathleen Satterfield: Absolutely, you bring up a very good point. Because in the first year that we took it, and I said it's below average, it was way below average. And we had one student who would have qualified for a family practice residency with the score that he earned. And that's not a matter of passing or failing. It's a score related to a residency program. Well, the AMA decided to look… and AAMC decided to look at their students and decided choosing a resident based on their basic science knowledge makes no sense whatsoever. Do you want a dermatologist who did great in physio and pharm and hematology and cardiology, but they don't have the ability to do a biopsy? You know what I mean? What about hand skills? What about clinical? So, they wisely have dropped the scoring of that first exam, starting in 2022. And I think about a year or two after 2022 is going to be a reckoning point. I hope I can have my students take it and be compared up through about 2023. Because if we can do that, it's going to be pass, fail, strictly pass, fail for the MDs and DOs who take it at that point. And it will not be at the same level that it is now. The medical world has said that they realize that. Because they're going to be putting their energies into the clinical test instead to be able to earn that residency program. That is the reckoning point for me right now, not what they do on it this summer, or perhaps next summer. But in a couple of years, when the playing field is more level.

Jarrod Shapiro: Yeah. It seems like a bit of an ever-moving bar for us, where we say, "Take this test and compare to how the MDs and DOs are doing." But then, you see these movements to change how these tests are being interpreted. And whether they're scored or pass, fail. That type of thing. I think they have… the Task Force needs to be cautious about how they interpret how we're doing in relation to that bar that I think there needs to be some caution. And that is fine.

Dr Kathleen Satterfield: And I would challenge them. I don't know why… and even with the Task Force, I don't know why they didn't allow us the right that the DOs have. And that is to also be judged by the COMLEX. Most of the colleges that are affiliated with a medical school in a true sense are embedded into a DO curriculum, and not an MD allopathic curriculum. They're similar. They're not exactly the same, not even from school to school, right, allopathic or osteopathic. But it would have seemed that they would have given us the same leeway and right that they gave the DO community. I would hope that maybe somebody at a higher pay grade would bring that forth and consider that as an option. Why would the DPMs have to attain something even more rigorous than our DO colleagues who are doing just fine?

Jarrod Shapiro: Right. That's even a comparison beyond what anybody would expect or even desire at this point.

Dr Kathleen Satterfield: Right. I suspect it has to do with ACGME, now that DOs and MDs are under the ACGME run residency programs. Those DOs they do have to sit for the USMLE as well. So, I guess I get it. They're trying to bring all the… if you're herding cats, you want to get them all together. Right? So, I suspect that's what it is.

Jarrod Shapiro: Right. Right. Absolutely. So, what advice would you give to other schools who may be considering this idea of having their students take the CBSE exam?

Dr Kathleen Satterfield: I think it would be good to visit a school like ours and I would welcome anybody to come and really investigate and see what it really is. Our curriculum is no secret. Our catalogue is on the internet just like every school. What's not online I've learned at the last dean's meeting is every school's GPA. But as I told the other deans our GPA of our incoming cohort is on there, our MCAT scores. And we're welcome to share that. They can look it up online and compare it with their own, if they don't release that publicly. And perhaps that might take some of the fear away, if they are close to what ours is, might put fear in some who don't have that same kind of a cohort that they're educating. But I think a lot of the conversation comes out of opinion and not education. Just educate themselves, it doesn't mean you have to do it, but just come and spend a couple of days with us, look over our curriculum and talk to our block leaders and see how we accomplish it. Before our college started, the word on the street was, "Well, your students will never be able to pass the boards. They will never get good residency programs." And we lead the nation in residency placement. And our students do quite well on the boards. I think you would agree they make us proud every single year.

Jarrod Shapiro: Absolutely.

Dr Kathleen Satterfield: And so, that is no longer an argument. But I think we fear what we don't know, what we're not familiar with. And I don't think anybody would say that they're afraid, but I think they're just unaware of what it really takes. And it's not as onerous as it might seem.

Jarrod Shapiro: So, as a final question, or kind of way to close out our conversation here. I wonder if you might extrapolate a little bit from the handoff between the colleges and the residency programs. Do you think that maybe changes from this Task Force or the idea of being considered physician would have ramifications for residency programs receiving that handoff from the colleges?

Dr Kathleen Satterfield: That's interesting, because we hear two stories from some residency directors, we hear, "Love your students because they critically think they don't just give a rote answer from memory. Their skills are good. Love teaching them, continuing to teach them in the field." And from some residency programs we hear, although it's fewer, "Would appreciate it if your students had more of X or more of Y that I have to fill in. So, they don't want to function like an allopathic or osteopathic residency. They want somebody who comes in ready to pick up a knife or do a cast of a complicated biomechanic examination." I think our students can do that, but they might not… I think sometimes they don't give them a chance. I think they don't give them a chance. And you know this, I get really irritated about the biomechanics argument. Because a couple of years ago, we had like seven people certified in medicine and orthopedics as opposed to some schools that had very few. And yet it was kind of hammered on that we needed more biomechanics. We teach biomechanics in the way we teach it. We don't have separate courses. And I don't know if you've touched upon that. But we teach it, like the patient comes into your office and they don't come in with a sticker on their forehead that says, "I have a biomechanical problem." We teach our students to think out the problem and come to a conclusion of whether it's biomechanical surgical or conservative, whatever. And just because we do something differently doesn't mean we don't do it. And I would just like to say that there's some people in this country who are supporting us in our biomechanics teaching. And they've given some very generous contributions this past year. We're opening up a brand-new 21st century Gait Lab. And we are not teaching the way that I was taught biomechanics. But does that make it bad? Not in my eyes. And I don't think so in our students' eyes. Our students love biomechanics. They can't seem to get enough of it. They're always looking for more. So, I think the arguments that you don't teach X or you don't teach Y. Come, come and see what we teach. And I think you may be a little bit surprised.

Jarrod Shapiro: I think that come and see what we're doing is very much the perspective that the podiatrists who were on the Task Force, the Orthopaedic and Podiatric Task Force are basically saying, "Come and see what we do as podiatrist and what our training and our certification really is like." I think that your perspective on that seems to match the idea of, "Here we are, we're transparent, see what we're doing." And then, we can make a decision into the future. Right? I think that's a very nice coupling of views.

Dr Kathleen Satterfield: I think you're right. And they did that, didn't they? They came and they looked at our curriculum. They looked at some of the residency programs. And you just reminded me of something that one of the other deans from a traditional school said the other day, and I feel his pain. He said, "I have trouble getting general surgery rotations for all of my students. I have trouble getting internal medicine rotations for my students. Where in the world would I get a women's health or a psych rotation?" And I don't know if it's just different here. Or maybe it's because of the connections that the founders of this college had. But we've been able to find those rotations for our students. And so, their experience in their clinical years is very diverse. But I can feel the pain of that other dean. If he's not in an environment where he can obtain those rotations for his students, why in the world would he want to switch to this model? It would make no sense for him.

Jarrod Shapiro: As somebody who came from a college, who at the time was teaching a very, very much that traditional podiatric education where almost to the point where you're a full-fledged podiatrist coming out of school, like almost to that perspective. And then, having to really learn a lot of that the other parts, the medicine parts, maybe even the thought process to some extent, in my postgraduate training, and then becoming a faculty member at Western University, I felt that it wasn't as difficult to absorb this different method as it could have been. And I wonder if maybe some of it is more the fear of something different or change. Yeah. I agree. It's definitely more work. And that you have to… that there's all the paperwork that goes into your objectives and tracking outcomes and those kinds of things. But the teaching itself it doesn't really seem overwhelming. I think maybe if they just gave it a bit of a chance, I don't think it would be as bad as they think.

Dr Kathleen Satterfield: I agree with you 100%. And you make a very good point. When I went to school, I graduated in 1991. And three people in my class of about 75 got a two-year residency, three people. I don't know. Maybe 10 or 15, I'm guessing, got a one-year residency. The rest either got a preceptorship, or they didn't do anything at all, and they went into business. But they had been educated to leave school and be able to do entry level things independently. I think we still do that. We teach the independent things, but at some of the more traditional schools, you're right, they could have hung their shingle out the next day without any input from anybody else and been a competent podiatrist. I'm sure there are 100s of them, maybe 1000s. We older folks are passing away in an alarming rate. But what's the handoff now? The handoff is to three more years of clinical education. Should we be training? Should we be educating today's podiatrist with the same formula that we used in 1960 when the expectation of what they're going to do when they reach that point is completely different? That makes no sense whatsoever. It's like if you bought a car in 1960 and it broke down. Most people could tinker with it in their driveway and fix minor things and get it back on the road. Well, now if you take tinker on your car that you buy today, you're really going to be in trouble because it's all computerized. Right? And so, the handoff is quite different. It's the same in podiatry, we are not training. We should not be educating a podiatrist in 2021 to do what a podiatrist graduating in 1961 was trying to do. There's no comparison. Shame on us if we do that. Shame on us.

Jarrod Shapiro: Yeah. Absolutely. I think that the Task Force will see that things are definitely changing.

Dr Kathleen Satterfield: I hope so. And then, I hope we can level our playing field, so that we're able to grow into them.

Jarrod Shapiro: Dr Kathleen Satterfield, thank you so much for taking the time to talk with us. I think there's a quite a long way left, I think with all of this examining podiatry and the Task Force and see what happens with it. But your perspective is greatly appreciated. Thank you so much for joining us today.

Dr Kathleen Satterfield: Well, thank you for inviting me. I appreciate it.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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