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10/24/2019 Leonard A. Levy, DPM, MPH
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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