02/27/2019 John L. Trench III, DPM
What Term Best Describes Your Professional Title (Alan Sherman, DPM)
I was appalled to read Dr. Alan Sherman's guest
editorial in the January 2019 issue of Podiatry
Management. His proposal, that only 20% of the
profession be trained in "advanced surgery",
while the remaining 80% be consigned to
podiatric medicine and "minor surgery", is
nothing new. Nor is it anything the majority of
the profession, or our patients, want or need.
This proposal is just a rehash of an attempt
made in the late 1980s and the early 1990s, to
strip surgery from the majority of our
profession and to make it the sole, very
lucrative province of a minority, with the
majority of us relegated to serving as referral
sources for that surgery, and a dumping ground
for their toenail trimming and corn and callus
paring.
At that time, I believe the proposal was to
limit it to just 10% of the profession, with the
self-appointed elite who figured themselves to
be part of that 10% debating whether the
majority of us would even be permitted to
perform toenail surgeries and to treat warts
with anything beyond simple topical medications.
That effort generated a tremendous level of
outrage among students and young residents, as
well as many already established in practice.
Many podiatrists and angry students began
communicating with college advisors, warning
them off from sending their charges toward
podiatry. While not the only reason for the
decline in prospective student applications that
podiatric medical schools experienced at the
time, it was certainly a significant
contributor.
That effort to carve up our profession failed
because no one beyond the self- appointed elite
making the turf grab for surgery wanted it, but
unfortunately not before it had done some damage
to the futures of many young men and women. The
"medical podiatrist" is a "specialist" who does
very little that requires a doctor. Almost
everything non-surgical podiatrists do can be
done by mid-level practitioners.
Given the extreme expense involved in podiatric
medical education, it is an inexcusable waste of
financial resources to train new doctors who
will spend their careers doing very little that
requires a doctor, and who will presumably be
expected to refer all of their surgical cases--
and the fees those cases generate--to the
surgical podiatrists.
Dr. Sherman proposes a third year track for non-
surgical podiatry, which he says he believes
most candidates would voluntarily choose. With
all due respect to Dr. Sherman, that is simply
false. There is no legion of podiatric medical
students wistfully wishing for a non-surgical
track that they could pursue. There is no demand
for a non- surgical track. None.
The past history of our profession demonstrates
conclusively that the majority of candidates
would NOT voluntarily select the non-surgical
track, if one were available. Take another look
at the wording of Dr. Sherman's editorial: there
would be nothing "voluntary" about the non-
surgical track. Eight out of ten residents would
be consigned to it, no matter what they
personally wanted. Nor do I agree that such a
track is in the best interests of our patients.
As the Baby Boomers age, they are going to
represent an increased demand for various
surgical interventions, as well as medical and
palliative. Not less. There is nothing that
prevents current podiatrists from limiting their
practices to non-surgical care. The fact that
they do not choose to do so is telling. There is
no wide-spread demand in our profession for a
non- surgical practice model, nor has there ever
been. I disagree with Dr. Sherman's conclusion
regarding the Podiatry Management Quick Survey.
I feel that the results of the survey
conclusively show that the overwhelming majority
of Doctors of Podiatric Medicine consider our
profession to be a combined medical/surgical
specialty. The current three year medical and
surgical residency model recognizes this, and
exists in large part due to the outrage and
backlash the previous attempt to fragment our
profession generated. We are a indeed a combined
medical and surgical specialty--we are both, not
either/or.
If, as Dr. Sherman's editorial would suggest,
surgery is being emphasized to the detriment of
medicine, then increase the emphasis on
medicine, without decreasing the surgical
training. Restore the balance, do not rip the
profession apart. The most common conditions we
all see in our daily practice continue to be
toenail pathology, corns and calluses (and their
biomechanical causes), hammertoe deformities,
hallux abductovalgus deformities, and heel pain,
along with an increasing amount of work
involving lower extremity wounds and skin
conditions including basal cell and squamous
cell carcinoma, melanoma, and other lesions.
These conditions that we all see in daily
practice present plenty of opportunities for
both medical and surgical work. There is no
excuse for trying to strip the surgery from the
majority of us, and consign us to palliative
care, handing out padding, and turning over our
surgeries and the fees they generate to the
elite few this proposal would create.
I have no issue with Dr. Sherman's proposal for
third year tracks in wound care, pediatrics,
sports medicine, or my own addition of
dermatology. Where I disagree with him is on how
those tracks should be structured. I oppose his
attempt to define them as non-surgical tracks.
These new specialty tracks, if created, should
include training in all of the medical and
surgical approaches those patient populations
require.
Insurance company pressures to reduce fees are
undoubtedly a major motivating factor in this
ill-advised proposal rearing its ugly face
again. Restructuring our profession to limit
surgery to just 20% would only serve to protect
and even enhance the incomes of the minority at
the expense of the majority. I think an argument
can be made that not everyone needs to be
trained in reconstructive ankle surgery, or in
performing a triple arthrodesis.
That argument cannot be made, however, for
simple bunion and HAV surgery, hammertoe
surgery, lesser metatarsal surgery, plastic
procedures for wound closure, or digital,
partial ray, and transmetatarsal amputations. I
strenuously oppose Dr. Sherman's proposal, just
as I did the efforts to carve up the profession
and usurp surgical work a minority in the late
1980s and early 1990s.
It is in the best interest of our patients, and
in the best interest of our profession and its
future, to continue to fully train all podiatric
medical school graduates in both podiatric
medicine AND podiatric surgery. Let the young
men and women who graduate from those programs
then tailor their practices to the needs of the
patient populations they serve in their
communities. They will be well educated and
equipped to do so.
John L. Trench III, DPM, Terre Haute, IN
