06/18/2015    Joseph Borreggine, DPM

Independent Practice is Dead

http://healthworkscollective.com/andy-
salmen/290846/4-barriers-private-practice-med-
school-graduates

This article states it plainly, "Independent
medical practice is dead." I find the found the
following statement in this article quite
disturbing, but also true:

1. Medical students are responding to external
pressures that are reshaping the medical industry
and radically changing doctors' relationships
with their patients.

2. Younger doctors see salaried positions as ways
to get predictable hours and to help them
overcome their student loan debts. They see the
stability of salaried positions as a benefit.

3. In short, regulatory and administrative
hurdles, escalating malpractice costs, and
declining reimbursements from insurers have all
made it difficult for doctors to develop their
own medical practice management
systems...Clearly, bureaucratic and regulatory
burdens are causing physicians to abandon the
medical practice management systems they might
want to develop in favor of large, impersonal
hospitals

I would like to see further discussion on this
topic in podiatry in your publication. I am
highly concerned that there may be a podiatry
"underground" touting "untruths", hyperbole, and
false fabrication of facts about the profession.
But, deeply hidden in these "tirades of
injustice" are morsels of what is actually
happening.

I believe that the trustees of this profession
may have also lost touch of what is actually
going on in the "podiatric trenches". With the
information in this article above, and others
like it, forecasting the future of medicine, we
cannot continue to ignore what is happening all
around us. But rather, be more proactive and use
all the necessary available tools available to
avoid or prevent any further crises that limit or
inherently affect the practice of podiatry.

With the podiatric residency crisis still quite
apparent, the depletion of podiatric school
applicants and now, the waning number of
graduates I believe that this profession may
rapidly seeing the end of its "glory days". We
are slowly being excluded, if included at all,
from all the important parameters of health care
delivery that are a part of the impending
"reform". Our autonomy in medicine is in
jeopardy. The fact is we do not have the respect
that we should after being a part of health care
over the last century. Our identity needed to be
defined as “physician” equal to our allopathic
counterparts long before now and ability to have
"full licensure" is a must now more apparent than
ever.

We have always have had purpose in medicine. Our
main objective has and always has been to provide
quality and expert foot care, but somehow we have
squandered our best asset. We decided many years
ago that general foot care was not enough for us
and therefore, we had to obtain the ability to
perform foot and ankle surgery. We opined need
needed to expand our scope so we could be
"recognized" as "real doctors". And with that,
part of our profession has literally seceded from
us and disavowed itself from what we actually do
most of the time; provide foot care. This was our
death knell and hence, we became the medical
profession of "have and have nots".

Still to this day, we still provide general foot
care. This defines us to who are; “foot doctor or
podiatrist” This activity take up a majority of
the time to what we do all day. It truly is the
mainstay and the financial security of most
podiatric practices. With the need to cut costs
in health care, even that is slowly being taken
from us by the advent of foot care nurses who are
RN’s trained in our field of expertise. This is
all because we have found this service to be
lesser than who we are and what we actually are
supposed to be doing.

The struggle with maintaining this identity with
an alter ego of “foot and ankle surgeon” is
confusing. Not only is it confusing to our
medical colleagues, but more importantly to the
public we serve. How many times have we all
heard, “I did not know you did surgery?” This
failure is truly rooted in was our inability to
train our graduates at the same surgical skill
level as compared to our orthopedic colleagues.
The evolution of podiatric residencies over the
last forty years has final led to a required
three year surgical residency for all graduating
podiatrists.

Podiatric surgical training quells by comparison
to the orthopedic training that includes
internship a three year residency and then a two
to three year fellowship. This has been the way
it has been done for years, but our profession
slowly figured that out in the last 5 years or
so. But, even with that said, podiatry still is
not a uniform nationally in its requirements
regarding licensure and residency training. This
is also very concerning especially when you
compare us to other allopathic specialties in
regards to these same parameters.

There are other schisms that further divided us.
These dichotomies include titles such as wound
care specialist, sports medicine doctors, and
diabetic foot doctors, and the like, but we are
no longer one voice. There are many voices fueled
by the huge number of professional organizations
and societies in our profession that represent
each one of those voices. The problem is that we
are DPM's; doctors of podiatric medicine who all
should want the same thing, but alas, we do not.

The medical profession has specialists within the
medical field who are all unified each in their
own separate purpose. They are not splintered
into separate groups within a specialty wanting
for other or things which have nothing to do with
their sole purpose. Their goals are defined and
their identity is never in question. We have much
more to do and many more hills to climb before we
will ever reach the place that we want to be.
Meanwhile, as this internal battle rages on in
the podiatric profession, the healthcare delivery
system marches on with or without us. Will it
really matter whether or not we exist in the
future? That choice lies in our hands, but before
we make that decision we need to be fully
informed on all the fact of what hurdles lie
ahead as whether there actually is a future in
podiatry.

Joseph Borreggine, DPM, Charleston, IL

Other messages in this thread:

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06/19/2015    Cosimo Ricciardi, DPM

Independent Practice is Dead (Joseph Borreggine, DPM)

I read with great interest the sentiments and
analysis of the profession detailed by Dr.
Borreggine and others regarding the challenges we
face as a profession. Salient, no doubt,
describing a side of the story which, quite
frankly I am sick of hearing. Comparisons are
made in terms of sweeping generalities using “we
as a profession” as if we all adhere and are
bound by the same analysis of despair.

Yes, podiatry is faced with challenges. We are
doctors in a never ending cycle of change and
rebalance. A cycle which has continually morphed
into a new challenge and a new way to see the
current situation in podiatric medicine as griped
in an unsolvable morass. Problems which are
shared in the majority of instances by our
medical colleagues.

Yes, I agree our professional institutions are
not doing what I, and many of my colleagues feel
needs to be done to best serve the profession.
Must I remind the reader which national
organization is most vocal in the push to
universal coverage, EHR and ICD10 transition? It
was not the APMA. Our allopathic colleagues face
the same problems with their professional
associations if not worse.

Yes, employment in a larger group has appeal.
However, I speak very often with younger and
seasoned podiatrists who would not think of
trading the liberty of self -determination of
their practice or partnership for the security of
employment at the will of another entity. I’ve
seen physicians, both podiatric and allopathic
who have joined large groups, multispecialty
groups and hospital employment only to be “fired”
in lieu of a less expensive replacement.

Yes, there are health care providers who are
rendering foot care. They are also some who are
rendering general medical care, cardiac care,
emergency care, and all matters of health care
delivery. Its medicine.

Our fight is in providing care above the
standard, above the bar and exceeding patient
expectations consistently. Proving yourself the
expert, again and again, not just calling
yourself one.

The barbarian at the gate has been there my
entire career: Residency shortage, Declining
reimbursement, increased competition, regulatory
issues, rising malpractice, MD/DO designation, on
and on and on, the same song over and over for my
15 years. The fight is not against the barbarian
at the gate but against apathy, inaction and
focus on the external at the expense of the
internal, significantly more changeable.
By no means whatsoever do I diminish the
significant hurdles we face. Nor do I disregard
the points made by others. Someone, however, must
speak the balance.

I look around and I see a plethora of bright,
talented, young podiatrists as the go to provider
for pathologies 20 years ago we couldn’t touch,
holding positions of importance of which an older
generation dreamed. Eighty percent of our
profession practice in groups of 3 or more. Large
multi-office practices are flourishing and
podiatry is consistently ranked in the top
professions. Napoleon Hill said that you are the
average of the 5 people with whom you spend the
most time. I acknowledge the barbarian at the
gate, but I refuse to hang out with it.

Cosimo Ricciardi, DPM, Crestview, FL

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06/19/2015    Robert D. Phillips, DPM

Independent Practice is Dead (Joseph Borreggine, DPM)

I read with interest the comments by Dr. Joseph
Borreggine. Unfortunately, I feel that he is
equating podiatric practice with private
podiatric practice. As a teacher in the College
of Medicine at the University of Central Florida,
and also a teacher in the family practice
residency of a local hospital, I can say that the
golden age of medicine is over.

Medical students are incurring ever increasing
debt in going to school and struggling to pay off
that debt afterwards. Insurance companies have
almost totally interjected themselves in what
used to be the doctor-patient relationship –
which included both the medical relationship as
well as the financial relationship. Ever more
time is being wasted in administration of
medicine instead of learning and practicing
medicine.

More podiatric physicians seem to be interested
in the proper coding for a bunion surgery than in
selecting the right bunion surgery for the right
patient. More time is spent in filling out EMR
records than in actually laying hands on patients
and in educating patients. Anyone who interviews
medical (or podiatry) school applicants knows
that the number one answer, when asked why they
want to go into medicine (or podiatry), is
“Because I want to help people.” At the end of
the grueling debt ridden roller-coaster
schooling, the new physician is often asking
themselves, “Why did I go into medicine?”

Salaried positions are becoming ever more popular
with physicians of all specialties, to alleviate
some of the stress of the burden of the huge
debt.

With record numbers of private practice MDs and
DOs also selling their business to work for
salary for large corporate health institutions,
podiatric physicians are caught in the same bind.
This is not a fight of podiatry against big
medicine, as Dr. Borreggine would have us
believe, it is a fight for survival by all
practitioners of medicine.

The survival of podiatry as a specialty really
depends on our ability to penetrate these huge
multispecialty health institutions. Podiatry is
much more acceptable by medicine when our other
specialist colleagues have daily interaction and
are sharing patient responsibilities. It becomes
financially beneficial then to include the
podiatrist, not exclude him/her. I hope to see
many more podiatric physicians join with our MD
and DO partners in the new medical institutions
and not try to go it alone.

Robert D. Phillips, DPM, Orlando, FL