02/28/2019 Alan Sherman, DPM
What Term Best Describes Your Professional Title (John L. Trench III, DPM)
Since publishing my two pieces on the “Advanced
Surgery Divide - Is Podiatry a Surgical
Specialty or is Surgery a Sub-Specialty of
Podiatry?” and “A New Direction in Podiatric
Residency Training – Dual Track Third Year”, I
have read only very positive responses and a lot
of personal identification with the issues
expressed. I was waiting for a serious rebuttal,
because as I have acknowledged, this represents
an important identity re-adjustment for
podiatry, and the changing of the structure of
the third year of residency education will be a
challenge.
So I thank John L. Trench III, DPM for providing
an all-out emotional assault on everything that
I observed and proposed, as I look forward to
addressing each of his observation and opinions.
In fact, there are a few issues where we do
agree, and I can assure all who are reading this
that I am no longer in practice, did practice
for 25 years, had a mixed surgical and general
podiatry practice, and no longer have a horse in
this race. I simply want to see the podiatry
profession that I love advance to reach its
fullest potential, and feel that we have
overemphasized surgery to the detriment of the
profession and the public.
Dr. Trench begins by characterizing the divide
as being between podiatrists doing minor surgery
and advanced surgery, but then describes minor
surgery as “a dumping ground for (the advanced
surgeon’s) toenail trimming and corn and callus
paring”. The issue of where the dividing line
should be drawn between the residency training
of advance foot and ankle surgeons and general
practice podiatrists is an essential issue in
this debate, which must be decided by the
profession, but it is my opinion that his
definition expressed here is way off base. It’s
very important what we call this “divide”. It
is NOT non-surgical podiatrists vs. surgical
podiatrists. I have stated repeatedly that ALL
podiatrists must do some surgery. The correct
way to describe the “divide” is general practice
podiatrists vs. advanced foot and ankle
surgeons.
Later in his message, Dr. Trench expresses a
dividing line between advanced surgery and
general podiatric practice that makes more sense
to me. He states, “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. ” I agree 100% that
the surgical and non-surgical treatment of these
conditions should be in the realm of the general
practice podiatrists. He goes on to state, and
again I agree with him, “I think an argument can
be made that not everyone needs to be trained in
reconstructive ankle surgery, or in performing a
triple arthrodesis.” I have consistently heard
from residency directors that only a small
subset of their residents can confidently
perform these types of procedures.
I also want to clear up a misconception that Dr.
Trench repeatedly states. I am not proposing,
nor do I want, any change in the status of
currently practicing podiatrists. I’m not sure
why he thinks his practice or any existing
practice would be threatened at all by this.
This is only about the future. The only change
that I am proposing is a change in the structure
of the 3rd year of residency education.
Dr. Trench incorrectly goes on to state that,
“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.” Yes, they can
do some of it, but certainly not all of it, and
the ultimate question is, to which would you
take your mother or child to? Which does their
job better?
Then he espouses the old trope that we hear so
often from non-surgical podiatrists, that the
money is in the surgery, that podiatric surgery
is the lucrative part of podiatry practice, that
the few advanced surgeons want to keep all the
surgery for themselves and make all the money.
He states, “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.” Those
of us with more level heads who have run
practices for years know that this is just not
true.
I think Jon Hultman, DPM’s articles over the
years showed us most clearly that a general
podiatry practice makes more income per hour
worked than most surgically oriented practices.
The fact is, general podiatry practice is quite
a good business, routinely gets listed in the
top 20 most lucrative professions in the
country, and advanced surgeons only make more
money than general practice podiatrists if they
work their butts off, working very long hours.
His concern that a podiatry education is
expensive and podiatrists new to practice are
saddled with onerous debt is correct, and I am
concerned with this as well. But the fact is,
general practices make more per hour worked than
surgical practices, and provide no less means to
repay that debt than advanced surgical
practices. Period.
Dr. Trench firmly believes that “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.” I don’t think that is even true
as early as podiatry school, but once in
residency, when they begin actually doing
surgery, by their 25th procedure, it’s
abundantly clear to the residents and the
directors which ones have a calling to be
advanced surgeons and which ones aren’t. It’s
also clear which ones have the most talent for
medical management, for patient empathy, for
running a practice. There is so much more to
podiatry practice than surgery.
Frankly, what a podiatry student finds alluring
and aspires to is largely guided by the
leadership of their professors at the schools,
and those in classes ahead of them. It’s my
premise that we as a profession have built an
atmosphere where we lead all students to become
surgeons, and that has been overdone. We should
be leading them all to be great podiatrists, and
those with the best potential to be great
surgeons, to be our advance foot and ankle
surgeons.
And I also firmly believe, and this is a new
idea, that we are discouraging applicants to our
schools who have no interest in being advanced
surgeons, and only have fear that they need to
pretend that they want to be surgeons for 7
years, because that’s what it currently takes to
become a general practice podiatrist.
I’m not trying to hold anyone back here. I’d
like all of us to reach our best potential to be
the best contributors to the profession that we
can be. And I want us all to be happy in our
achievements.
Alan Sherman, DPM, CEO, PRESENT e-Learning
Systems
