Application for Provisional Approval of Residencies in Podiatric Medicine — Canadian Council on Podiatric Medical Education

Podiatric Medicine and Surgery Residency Application for Provisional Approval

This application and supporting documentation must be submitted prior to activation of the residency, at least 9–12 months before the anticipated starting date. RRC and the CCPME require that the program’s director is the individual responsible for submitting all materials to the CCPME related to all application, on-site evaluation, and approval processes. The entire review process for a residency requesting approval may require a period of 12 months from the time an application is received in the office of the Canadian Council on Podiatric Medical Education until the CCPME takes an approval action.

Please submit the application and supporting documents to the CCPME office on two flash drives. Each flash drive is to include this completed form and the documentation in response to questions 9–11 pages 15–16 (supplemental materials) in PDF format, as a single bookmarked continuous document. Hand-written responses and hard copy documentation will not be accepted.

The $1,500 application fee, made payable to the Canadian Council on Podiatric Medical Education, must accompany the application. The application will not be processed until the sponsoring institution submits all required materials, including the application fee.

1. Sponsoring Institution Information

Sponsoring Institution

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Fax

(###)

###

####

Website Address

http://

Date Institution Began Operations

Number of Beds

Does the sponsoring institution also have internships or residency programs other than in podiatric medicine & surgery?

YES

If yes, please list the other programs

2. Co-sponsoring Institution Information (if applicable)

Co-Sponsoring Institution

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Fax

(###)

###

####

Website Address

http://

Date Institution Began Operations

Number of Beds

3. Program Director Information

Program Director Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Fax

(###)

###

####

Mobile

(###)

###

####

4. Administration – List the names and email addresses of persons holding the following staff positions (include professional designations where applicable, e.g. DPM or MD)

Chief Administrative Officer

First Name

Last Name

Designated Institutional Official

First Name

Last Name

Chief of Podiatric Staff

First Name

Last Name

Chief of Medical Staff

First Name

Last Name

Director of Graduate Medical Education

First Name

Last Name

Chief of Surgical Staff

First Name

Last Name

5. PROGRAM INFORMATION (as defined in the CCPME 320)

Type of program

Length of Program

Is the resident required to be licensed?

YES

Number of positions requested per training year

1st/2nd/3rd/4th

Program start & end dates

eg. July 1 - June 30

Resident stipend per year of training

1st/2nd/3rd/4th

6. The following information about the volume of patient care activity should be based on the 12-month period prior to submission of the application. The number of procedures is to include those performed at all facilities utilized by the sponsoring institution (including the sponsor). For secondary institutions or other facilities used, appropriately executed affiliation agreements must exist (and be submitted) to be included in the number of procedures column.

Sponsoring Institution

Co-Sponsoring Institution (if applicable)

Affiliate facility

7. Statistics

The statistics below cover the period from

YYYY

To determine the institutions ability to support the number of requested residency positions, multiply the number of residents requested per year by the Minimum Activity Volume (MAV) requirement per resident. For example: if a program is requesting 2 residents per year (2/2/2), the reported volume of biomechanical cases over a 12-month period should be 150 (75 x 2 ). The Residency Review Committee however, expects the reported volume to exceed the MAV to allow for fluctuations in the availability of cases and resident logging errors.

Podiatric clinic / office encounters (minimum 1000 per resident)

Podiatric surgical cases (minimum 300 per resident)

Trauma cases (minimum 25 per resident)

Podopediatrics (minimum 25 per resident)

Biomechanical cases (utilizing the definition in the CCPME 320) (minimum 75 per resident)

Comprehensive medical histories & physical examinations

Category 1: Digital Surgery (Description (code number))

Enter number of procedures in the box

Partial ostectomy / exostectomy (1.1)

Phalangectomy (1.2)

Arthroplasty (interphalangeal joint [IPJ]) (1.3)

Implant (IPJ) (1.4)D

Diapyhsectomy (1.5)

Phalangeal osteotomy (1.6)

Fusion (IPJ) (1.7

Amputation (1.8)

Management of osseous tumor / neoplasm (1.9)

Management of bone / joint infection (1.10)

Open management of digital fracture / dislocation (1.11)

Revision / repair of surgical outcome (1.12)

Other osseous digital procedure not listed above (1.13)

TOTAL NUMBER OF PROCEDURES (minimum 80 per resident)

Category 2: First Ray Surgery (Description (code number))

Bunionectomy (partial ostectomy / Silver procedure) (2.1.1)

Bunionectomy with capsulotendon balancing procedure (2.1.2)

Bunionectomy with phalangeal osteotomy (2.1.3)

Bunionectomy with distal first metatarsal osteotomy (2.1.4)

Bunionectomy with first metatarsal base or shaft osteotomy (2.1.5)

Bunionectomy with first metatarsal-cuneiform fusion (2.1.6)

Metatarsophalangeal joint (MPJ) fusion (2.1.7)

MPJ Implant (2.1.8)

MPJ Arthroplasty (2.1.9)

TOTAL NUMBER OF PROCEDURES

Category 2: First Ray Surgery - Hallux Limitus (Description (code number))

Chilectomy (2.2.1)

Joint salvage with phalangeal osteotomy (Kessel-Bonney, enclavement) (2.2.2)

Joint salvage with distal metatarsal osteotomy (2.2.3)

Joint salvage with first metatarsal base or shaft osteotomy (2.2.4)

Joint salvage with first metatarsal-cuneiform fusion (2.2.5)

MPJ Fusion (2.2.6)

MPJ Implant (2.2.7)

MPJ Arthroplasty (2.2.8)

TOTAL NUMBER OF PROCEDURES

Category 2: First Ray Surgery - Other First Ray (Description (code number))

Tendon transfer / lengthening / capsulotendon balancing procedure (2.3.1)

Osteotomy (i.e. dorsiflexory) (2.3.2)

Metatarsocuneiform fusion (other than for hallux valgus or hallux limitus) (2.3.3)

Management of osseous tumor / neoplasm (with or without bone graft) (2.3.5)

Management of bone / joint infection (with or without bone graft) (2.3.6)

Open management of fracture of MPJ dislocation (2.3.7)

Corticotomy / callus distraction (2.3.8)

Reision / repair of surgical outcome (i.e. noin-union, hallux varus) (2.3.9)

Other osseous first ray procedure not listed above (2.3.10)

TOTAL NUMBER OF PROCEDURES

TOTAL NUMBER OF CATEGORY 2 HALLUX VALGUS, HALLUX LIMITUS & OTHER FIRST RAY PROCEDURES (minimum 60 per resident)

Category 3: other soft tissue foot surgery (Description (code number))

Excision of ossicle / sesamoid (3.1)

Excision of neuroma (3.2)

Removal of deep foreign body (excluding hardware removal) (3.3)

Plantar fasciotomy (3.4)

Leser MPJ capsulotendon balancing (3.5)

Tendon repair, lengthening or transfer, involving the forefoot (including digital flexor digitorum longus transfer) (3.6)

Open management of dislocation (MPJ / tarsometatarsal) (3.7)

Incision & drainage / wide debridement of soft tissue infection (including plantar space) (3.8)

Plantar fasciectomy (3.9)

Excision of soft tissue tumor / neoplasm of the foot (without reconstructive surgery) (3.10)

Old procedure code – no longer used (3.11)

Plastic surgery techniques (including skin graft, skin plasty, flaps, syndactylization, desyndactylization, and debulking procedures limited to the forefoot (3.12)

Microscopic nerve / vascular repair (3.13)

Other soft tissue procedures not listed above (limited to the foot) (3.14)

Excision of soft tissue tumor/ mass of the ankle (without reconstructive surgery) (3.15)

External neurolysis / decompression (including tarsal tunnel) (3.16)

Total Number of Procedures (minimum 45 per resident)

CATEGORY 4: OTHER OSSEOUS FOOT SURGERY (Description (code number))

Partial ostectomy (distal to and including the talus) (4.1)

Lesser MPJ arthroplasty (4.2)

Bunionectomy of the fifth metatarsal without osteotomy (4.3)

Metatarsal head resection (single or multiple) (4.4)

Lesser MPJ implant (4.5)

Central metatarsal osteotomy (4.6)

Bunionectomy of the fifth metatarsal with osteotomy (4.7)

Open management of lesser metatarsal fractures (4.8)

Harvesting of bone graft distal to the ankle (4.9)

Amputation (lesser ray, transmetatarsal amputation) (4.10)

Management of bone / joint infection distal to the tarsometatarsal joints (with or without bone graft) (4.11)

Management of bone tumor / neoplasm distal to the tarsometatarsal joints (with or without bone graft) (4.12)

Open management of tarsometatarsal fracture / dislocation (4.13)

Multiple osteotomy management of metatarsus adductus (4.14)

Tarsometatarsal fusion (4.15)

Corticotomy / callus distraction of lesser metatarsals (4.16)

Revision / repair of surgical outcome in the forefoot (4.17)

Other osseous procedures not listed above (distal to the tarsometatarsal joint) (4.18)

Detachment / reattachment of the Achilles tendon with partial ostectomy (4.19)

TOTAL NUMBER OF PROCEDURES (minimum 40 per resident)

CATEGORY 5: RECONSTRUCTIVE REARFOOT AND ANKLE SURGERY - ELECTIVE SOFT TISSUE (Description (code number))

Plastic surgery techniques involving the midfoot, rearfoot or ankle (5.1.1)

Tendon transfer involving the midfoot, rearfoot, ankle or leg (5.1.2)

Tendon lengthening involving the midfoot, rearfoot, ankle or leg (5.1.3)

Soft tissue repair of complex congenital foot / ankle deformity (i.e. clubfoot, vertical talus) (5.1.4)

Delayed repair of ligamentous structures (5.1.5)

Ligament or tendon augmentation / supplementation / restoration (5.1.6)

Open synovectomy of the rearfoot / ankle (5.1.7)

Old procedure code – no longer used (5.1.8)

Other elective rearfoot reconstructive / ankle soft tissue surgery not listed above (5.1.9)

TOTAL NUMBER OF PROCEDURES

Can be zero if only a PMSR residency application

CATEGORY 5: RECONSTRUCTIVE REARFOOT AND ANKLE SURGERY - ELECTIVE OSSEOUS (Description (code number))

Operative arthroscopy (5.2.1)

Old procedure code – no longer used (5.2.2)

Subtalar arthroeresis (5.2.3)

Midfoot, rearfoot or ankle fusion (5.2.4)

Midfoot, rearfoot or tibial osteotomy (5.2.6)

Open management of talar dome lesion (with or without osteotomy) (5.2.7)

Ankle arthrotomy with removal of loose body or other osteochondral lesion (5.2.8)

Ankle implant (5.2.9)

Corticotomy or osteotomy with callus distraction of the midfoot, rearfoot, ankle or tibia (5.2.10)

Other elective rearfoot reconstructive / ankle osseous surgery not listed above (5.2.11)

TOTAL NUMBER OF PROCEDURES

Can be zero if only a PMSR residency application

CATEGORY 5: RECONSTRUCTIVE REARFOOT AND ANKLE SURGERY - NON-ELECTIVE SOFT TISSUE (Description (code number))

Repair of acute tendon injury (5.3.1)

Repair of acute ligament injury (5.3.2)

Microscopic nerve / vascular repair of the midfoot, rearfoot or ankle (5.3.3)

Excision of soft tissue tumor / mass of the foot (with reconstructive surgery) (5.3.4)

Old procedure code – no longer used (5.3.5)

Open repair of dislocation (proximal to tarsometatarsal joints) (5.3.6)

Other non-elective rearfoot reconstructive / ankle soft tissue surgery not listed above (5.3.7)

Excision of soft tissue tumor / mass of the ankle (with reconstructive surgery) (5.3.8)

TOTAL NUMBER OF PROCEDURES

Can be zero if only a PMSR residency application

CATEGORY 5: RECONSTRUCTIVE REARFOOT AND ANKLE SURGERY - NON-ELECTIVE OSSEOUS (Description (code number))

Open repair of adult midfoot fracture (5.4.1)

Open repair of adult rearfoot fracture (5.4.2)

Open repair of adult ankle fracture (5.4.3

Open repair of pediatric rearfoot / ankle fracture or dislocation (5.4.4)

Management of bone tumor / neoplasm (with or without bone graft) (5.4.5)

Management of bone / joint infection (with or without bone graft) (5.4.6

Amputation proximal to the tarsometatarsal joint (5.4.7)

Other non-elective rearfoot reconstructive / ankle osseous surgery not listed above (5.4.8)

TOTAL NUMBER OF PROCEDURES

Total Number of Category 5 Elective Soft Tissue, Elective Osseous, Non-Elective Soft Tissue and Non-Elective Osseous Procedures (minimum 50 per resident for PMSR/RRA programs only)

Can be zero if only a PMSR residency application

8. RESIDENCY POLICIES

a. Describe the composition of the committee responsible for interviewing and selecting residents

b. How will the prospective residents be informed of the selection process and the conditions of appointment established for the program?

c. In what format will the institution make available to the prospective resident a copy of the resident curriculum (i.e. bound hard copy, on residency web site, on a USB stick / flash drive)?

d. Will the applicant be charged an application fee? Yes or No. If yes, what amount will be charged? To whom will the fee be paid?

e. Describe the institutions plans for interviewing its first resident(s).

f. When will interviews to select the institutions first resident(s) be conducted?

g. On what date will the sponsoring institution obtain a binding commitment from the prospective resident(s)?

SUPPLEMENTAL MATERIALS

The following items must be submitted on each flash drive (see page 1 of the application). Please refer to the referenced requirements in CCPME 320, Standards and Requirements for Approval of Podiatric Medicine and Surgery Residencies, for further information specific to each required document.

9. Sponsor and Affiliation Agreements: Please provide the following information for the sponsoring institution, including the sponsor and co-sponsor (if applicable), and each affiliated training site (i.e. hospital, surgery centre, private office), For each institution identified, provide copies of accreditation documents and copies of executed affiliation agreements between the sponsoring institution and the affiliates: (Name, City/Province, Accredited by, Percentage of training, Date Affiliation Signed / Effective Date.)

10. Standard 3 - Policies Affecting the Resident

a. Sample copy of the contract or letter of appointment between the sponsoring institution(s) and the resident.

(requirements 3.8 and 3.9)

b. Residency manual that will be distributed at the beginning of the program to residents, faculty and administrative staff involved in the residency. The manual must include at minimum the following components (requirement 3.10):

a) The mechanism of appeal b) The remediation methods established to address instances of unsatisfactory resident performance c) The rules and regulations for the conduct of the resident d) Rotations and competencies specific to each rotation (requirements 6.1 and 6.4) e) Training schedule for the duration of the program. The schedule must relate to the institutions and facilities listed in response to question #6 and to the rotations listed in response to item (d) above. The schedule must also document that the time spent in the rotations in infectious disease plus internal medicine and / or family medicine plus two medical subspecialities is equivalent to a minimum of three full-time months of training (requirement 6.3) f) Schedule of didactic activities (requirement 6.7) g) Journal review schedule (requirement 6.8) h) Assessment documents for all rotations. Assessment documents must identify the rotation, duration and include lines for the dates and signatures of the faculty, resident and program director (requirement 7.2)

c. Certificate, or sample certificate, to be awarded to the resident upon completion of training. (requirement 3.11)

11. Standard 5 - Program Director and Faculty

a. Curriculum vitae of the program director and a statement providing evidence that he / she possesses appropriate clinical, administrative and teaching qualifications suitable for implementing the residency. (requirement 5.2)

b. List of podiatric medical faculty actively involved in the program with educational and professional qualifications of each. For each staff member, list only the name, degree and affiliations with certifying and professional organizations (i.e. ABPM, ABFAS). Additionally, identify which podiatric faculty, if any, are affiliated with other CCPME approved podiatric residency programs. If a faculty member is not certified by a board recognized by the CCPME, please describe the specialized qualifications possessed by this individual that make him / her qualified in the subject matter for which he / she is responsible (requirements 5.5 and 5.6)

c. List of non-podiatric medical faculty involved in the program with educational and professional qualifications of each. For each staff member, list only the name, degree (MD, DO, PhD, etc.) and affiliations with certifying and professional organizations. (requirement 5.6)

Completing this form, the chief administrative officer(s) and the program director confirm the commitment of the institution(s) in providing podiatric residency training.

A typed name in the fields below will constitute a signature.

Chief Administrative Officer

First Name

Last Name

Chief Administrative Officer of co-sponsoring institution, (if applicable)

First Name

Last Name

Program Director

First Name

Last Name

Date

YYYY