The Need to Provide a Separate Medically Intensive Podiatric Medicine Residency
Podiatric medicine is specialty that includes a wide variety of knowledge and skills included in its surgical and medical components. Unfortunately, too many members of the profession have stratified it into surgery and routine care. There is a paucity of the profession who concentrate on the numerous medical implications that exist among our patients.
While I think that we are more medically- oriented than dentistry, there are some lessons we can learn from them. They have specialties ranging from periodontia, to prosthetics, to oral and maxillofacial surgery, and several more. Residency and specialty certification is provided to each of these. In no way does this confuse the public, but rather provides a way that the public can have some way to determine the qualifications of the entities that make up dentistry.
There are also so many pathological entities that are related to the pedal extremity that the undergraduate podiatric medical degree, like the case for the MD and DO curriculum, cannot possibly provide its graduates with adequate preparation. The multiple specialties that DOs and MDs have does not in any way result in public confusion.
There is virtually no system in the human body that does not in many instances have manifestations in the pedal extremity. For the most part a large percentage of podiatric physicians believe that we are either surgeons or provide care for local foot problems.
In order to provide care to patients who are experiencing symptoms and/or signs in the foot, it is essential that members of our profession have considerably more time, not only in local foot pathology but also in the many disorders that affect other body systems. While currently we certainly provide limb-saving care to patients with diabetes mellitus, there are so many other conditions that escape the thought process of podiatric physicians because their training has been limited.
There is a desperate need to narrow this gap and to provide adequate medically intensive residency training in podiatric medicine just as there is to provide such training in podiatric surgery.
Leonard A. Levy, DPM, MPH
Other messages in this thread:
11/06/2019 Alan Sherman, DPM
The Need to Provide a Separate Medically Intensive Podiatric Medicine Residency (Charles M Lombardi, DPM )
In Charles Lombardi’s comments on the discussion regarding the need for a separate medically intensive podiatric medical residency, he criticizes certain unnamed people for being schizophrenic, for changing their minds as to whether such a program is needed between 2000 and 2019. To be clear, I am not for such a program. But I would point out that we are all scientists, trained to collect data and draw the best possible conclusions from that data, and that data has changed as podiatric practice and training has evolved in the past 19 years.
The situation is now quite different than it was in 2000. That “certain people” have changed their opinions during those 19 years is not only reasonable, but it is admirable. In fact, those who cling to obsolete opinions in the face of new and changed data are not only unscientific, but they risk becoming obsolete.
Let’s examine the facts. In 2000, the predominant board in podiatry was the “surgical” board, the American Board of Podiatric Surgery (ABPS) which is now known as the American Board of Foot and Ankle Surgery (ABFAS). As a practical matter, certification by the “surgical” board was required to get on a hospital staff, which was required to get on insurance panels, which was required to get paid by patients’ health insurance policies. So all podiatrists had to seek certification in surgery in order to get paid. During these years, the ABPS/ABFAS was doing their job, which was to maintain high standards, while the profession was complaining that ABPS/ABFAS was keeping too many podiatrists from achieving that board certification.
I’m going to be honest here and admit that though I did achieve that certification, I thought this board was getting in the way of many podiatrists’ ability to earn a living. Today, the data has changed and I have changed my mind, for two reasons. First, we have witnessed the rise of the American Board of Podiatric Medicine into a well-run board that certifies in podiatric medicine (i.e. podiatry) and whose certification is generally accepted at hospitals across the country for staff privileges and insurance panels to get paid.
So the rise of ABPM has eliminated the need for every podiatrist to get training in and to do advanced foot and ankle surgery. General practice podiatrists can and are getting boarded by ABPM, getting on hospital staffs, and getting paid by insurance companies. And secondly, I have come the believe that ABFAS SHOULD have very high standards and should be granting certification to only those podiatrists who are truly advanced foot and ankle surgeons, and can demonstrate such to their peers. The reality is that most podiatrists are not that. Not only are most podiatrists not advanced foot and ankle surgeons, we or the public DO NOT NEED them to be advanced foot and ankle surgeons. The trend of ALL podiatrists getting trained as advanced foot and ankle surgeons was DRIVEN by the NEED to be boarded in surgery, and with the rise of ABPM, that need is now obsolete….it is no longer needed.
Advanced foot and ankle surgery should be a sub- specialty of podiatry, and only a subset of podiatrists are needed to populate that sub- specialty. Of course, ALL podiatrists needs to do some surgery, ie. nail surgery, ID abscess, excision soft tissue lesions, arthroeresis. But advanced foot and ankle surgery, ie. ORIF ankle fractures and major trauma, calcaneal osteotomies, rear foot fusions…we just don’t need ALL podiatrists to do these procedures.
With this new set of facts, I believe it’s time to re-assess our needs as a profession as far as post-graduate training and board certification, and to make some adjustments as a profession, as Leonard Levy suggests in his last message on this topic. Follow the growth of any profession and you’ll find that seldom is there long term planning by its institutions and voluntary cooperation among them. Most often, the institutions are separate silos, each with their own goals, personalities, and esprit d corps. When they need to change for the overall needs of the profession, oversight BY THE PROFESSION is needed.
I believe we are at a point in history for our profession when we need oversight of the boards and CPME to assess our needs and plan changes in those institutions to best meet those needs. As a profession, we need to determine not what is best for ABFAS and ABPM and CPME, but what is best for podiatry and how those institutions can best meet the needs of our profession and the foot health needs of America.
There has been a lot of discussion over the past year surrounding these issues, which seems to be rightly focused on: (1) The current model for podiatric residency education and (2) the structure of our boards and the certifications that they issue. There is justifiable confusion in the medical hierarchy as to what a podiatrist is and what certification they should use to ascertain that a podiatrist is certified as a podiatrist. They ask, reasonably, what constitutes THE board certification in podiatry? During the first 19 years of this century, we have created what I call an “emperor’s new clothes” situation where we are telling the medical hierarchy and the public that we are all advanced foot and ankle surgeons, supported by the fact that we are all completing this standardized 3 year surgically focused residency program.
But we know that we are not all advanced foot and ankle surgeons, nor do we need us to all be that thing. Most of us are general practice podiatrists, or focused on one or another sub- specialty of podiatry as their predilections and talents dictate and the fact that all recent grads are completing 3 year surgically focused residency programs doesn’t make them advanced foot and ankle surgeons. Of course, most are not, by choice or circumstances.
In effect, I think our drive to advance the profession and achieve respect, status and all that comes with it, has driven the progress pendulum way past the midline as far as the balance between surgery and podiatry, and what we need now is for it to swing back. The only way that is achievable is by an assessment of our situation and a reconsideration of the structure of our colleges, residency programs and our boards. We need the 21st century equivalent of the Selden Report…an examination of how well the institutions of podiatry are currently serving our needs, where the pain points are, what our needs are predicted to be in the decades ahead, and how best to mold our institutions to best meet those needs.
It is my opinion that our residency programs will need to allow options for some diversity in training, and that we need a merger of ABPM and ABFAS, to the end that we have a single board that offers a single essential certification in podiatry, with sub-specialty certifications in advanced foot and ankle surgery, sports medicine, podiatric dermatology, and any of subs that the profession wishes to offer.
Alan Sherman, DPM, Boca Raton, FL
11/04/2019 Alan Sherman, DPM
The Need to Provide a Separate Medically Intensive Podiatric Medicine Residency (Leonard A. Levy DPM, MPH)
I’m confused by Leonard Levy’s most recent message in this discussion in the October 31, 2019 #6,539 issue, in which he refers to the “highly controversial proposal to have two specialty boards in the podiatric medical profession (i.e., podiatric surgery and podiatric medicine”. It’s not a proposal. We currently have these two specialty boards, ABPS and ABFAS. What we don’t have is two medical specialties. We have two specialty boards that represent one specialty, podiatry, and that structure is what is confusing the public and the medical establishment.
The proposal made by Jeff Robbins, DPM, supported by myself, Joe Borreggine, and now Brent Haverstock, DPM, is that our two specialty boards MERGE and form one board with sub- specialties, including advanced foot and ankle surgery and any other subs that the profession wish to pursue certification in. I am not in favor of closing podiatry schools and becoming an MD…I can’t see that far into the future. But merging the boards is do-able and badly needed.
As far as how to best serve podiatrists in training that do not intend to become advanced foot and ankle surgeons, in order to not waste their time on training in what should be a sub- specialty and to allow them to focus their training in general podiatric practice, I have proposed a dual track 3rd year of residency to get the discussion started.
This would also give the advanced cases to the residents who are most likely to use the training once they get into practice. Another solution is to simple allow more diversity in podiatric residency training, to reduce the constraints of minimum surgical volume standards and allow residency directors to rate graduates upon graduation on the specific competencies that they achieve.
Look, we all know why two boards evolved in podiatry…we needn’t rehash the history. The men and women who founded, built and manage these boards have done a tremendous service for us all and we owe a huge debt of gratitude to them. But it has become untenable and it’s time for the profession as a whole and the boards specifically, to overcome their differences, be adults, acknowledge respect for each other, acknowledge what is best for the profession and MERGE as a single board for the sake of the profession.
Of course it’s going to be complicated…both boards have been operating for over 20 years. They are two separate, mature non-profit businesses. My understanding is they are both financially solvent, have excellent physician and executive leadership, and would only need the will and desire to get this merger done.
ABPM explains its foundation and authority on its website as follows, “The American Board of Podiatric Medicine is recognized by the Joint Committee on the Recognition of Specialty Boards of the Council on Podiatric Medical Education under the authority of the American Podiatric Medical Association as the specialty board to conduct a certification process in Podiatric Orthopedics and Primary Podiatric Medicine.”
Although I can’t find a similar foundation statement on the ABFAS website, I imagine they are similarly recognized by the Council on Podiatric Education under the authority of the APMA. The body that must take on that task is the APMA and I call upon them to do so on behalf of the profession.
Alan Sherman, DPM, Boca Raton, FL
11/01/2019 Robert Kornfeld, DPM
The Need to Provide a Separate Medically Intensive Podiatric Medicine Residency (Leonard A Levy, DPM, MPH)
This discussion is a critically important one. Especially because my professional path brought me to a deep understanding of human physiology, the foundations for health and healing and a never-ending focus on understanding mechanisms of pathology BEFORE symptoms are treated. I pursued a path in functional medicine for foot and ankle pathology because it provides a means to heal pedal pathology AND improve the health of the patient. This has been my path and my passion since 1987 (I am a 1980 graduate of NYCPM). My career has been extraordinarily satisfying because the healing is in medicine, not surgery. Of course there’s a place for surgery, but without a true mechanistic approach to healing, we correct one issue but leave our patients open to future pathology.
Podiatry has always struggled with itself. In our zeal to be accepted as ”real doctors”, we focused on pushing ourselves into hospital operating rooms. Unfortunately, that has not aided us in achieving parity. It has caused an unfortunate shift away from podiatric medicine (even though our DPM degree asserts that is our specialty). I have tried and failed on my own to share my knowledge and expertise with this profession. I ran self-funded seminars but was consistently denied CME credits. I contacted every college of podiatric medicine in years past offering to lecture and was ignored (even by NYCPM, my Alma Mater). And now, after more than 30 years of intense experience in this paradigm and having trained with many amazing MDs and DOs, I am in the twilight of my career (I’m now 65) and it is sad to me that this amazing facet of podiatric medical knowledge and experience will die with me.
Although I’m very proud to say I’m a podiatrist, I have all but divorced myself from this profession after my offers to help up level the profession were disregarded. I believe the word holistic makes many podiatrists feel like they won’t be taken seriously as doctors (which I believe comes from insecurity from an identity disorder). My experience has been quite the opposite. I eventually just gave up and have watched podiatry flounder to find itself a rightful place amongst physicians in this country. I strongly believe it won’t happen until we graduate podiatric medical doctors who understand and apply the principles of health and healing in addition to those who wish to focus on foot and ankle surgery.
If I had one piece of advice for this beleaguered profession, it would be to remember that the foot is attached to a complex human body that has an enormous amount of epigenetic influences on its genome. Training needs to focus deeply and intensively on this.
Robert Kornfeld, DPM, NY, NY
11/01/2019 Brent D. Haverstock, DPM
The Need to Provide a Separate Medically Intensive Podiatric Medicine Residency (Leonard A Levy, DPM, MPH)
It would seem that if podiatry were are to become a branch of medicine (MD/DO) the APMA would have to meet with the American Medical Association (AMA) and the American Osteopathic Association (AOA) to see if there is a desire to see this happen. If there were an agreement the schools of podiatric medicine would have to close. The APMA and AMA/AOA along with the Accreditation Council for Graduate Medical Education (ACGME) would establish appropriate training programs.
I suggest a 5-year commitment to become a podiatric surgeon and 3-years to become a podiatric physician. Podiatric medicine and surgery would have a single certification board with specialist certificates granted as either a podiatrist or podiatric surgeons. Medical students (MD/DO) could consider podiatry or podiatric surgery as their career path. This is the only way to achieve true parity. Suggesting that podiatric medical schools grant an MD/DO is ridiculous. What exactly will podiatric medical students taking the USMLE achieve? How does this begin a to address parity? It demonstrates we have very bright young men and women studying podiatric medicine, but it does nothing to address a restricted license.
Programs offering a DPM/MD or DPM/DO would not achieve what those calling for, parity of podiatry with medicine. Dr. Levy admitted as much with his experience at Nova Southeastern University College of Osteopathic Medicine. DPMs who obtained their DO degree went on to train in other areas of medicine leaving podiatry behind. To achieve the parity that many so badly desire, the entire foundation of the profession must torn down to the ground and built back up.
I agree with Dr. Levy, this is an exciting profession with continued opportunity for growth and establishing ourselves as the primary providers of foot and ankle care.
I don’t agree with the notion that we need an MD/DO degree but rather strengthen the current curriculum in the schools of podiatric medicine and define appropriate tracks of post-graduate training and practice.
Brent D. Haverstock, DPM, Birmingham, AL
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