02/24/2020    Joseph S. Borreggine, DPM

What Kind of Podiatrist Do Today's Residents Want to Be? (Alan Sherman, DPM)

This survey does not surprise me one bit. Why
wouldn't a graduating doctor of podiatric
medicine (DPM) want to be a "foot and ankle
surgeon" instead of just a general podiatrist?
It seems to me that it has nothing to do with
what a podiatrist is trained "to do", but what
a podiatrist "can do". This debate will
continue to linger as long as there are
“podiatrists who perform foot and ankle
surgery” versus “foot and ankle surgeons who
are podiatrists.”

This clash has been a divisive situation in our
profession going all the way back to the early
1940's when podiatrists were organizing groups
like the American College of Foot and Ankle
Surgery and then in the late 1970s establishing
the National Board of Podiatric Surgery (NBPS),
then renamed the American Board of Podiatric
(ABPS) and now is called the American Board of
Foot and Ankle Surgery (ABFAS) which completely
eliminated the word "podiatry" completely. This
change truly reflects what a duly trained
podiatric surgeon does.

This reason for these organizations was because
our profession opined at the time that were a
select few of us that were "trained" by other
"surgical" podiatrists and/or select few
orthopedic surgeons that were befriended by the
profession to "train" DPMs on how to do foot
and ankle surgery. Back then, there was not any
prerequisite for post-graduate residency
programs to obtain a DPM license and if there
were, then it was few and far between. This
step was not necessary to practice podiatric
medicine because once the DPM degree was
obtained, then all you needed to do was hang
your shingle and have at it. But, to some this
was not enough and hence the need to
incorporate surgery into profession became a
mission.

This is when podiatry branched off into two
paths: non-surgical and surgical podiatrists.
Unfortunately, podiatrists back then had a
rough time getting on staff at hospitals and
let alone getting paid by insurance companies.
However, once insurance benefits were being
paid to podiatrists for foot surgery, then the
quandary was still the issue of hospital
privileges. Hence, most DPMs began to perform
foot surgery in their offices after this was
established considering not having hospital
privileges.

Once the momentum started to move toward
podiatrists performing foot ankle surgery, then
a small number of podiatric surgical
residencies were established. But, still very
few DPMs back then had formal and proper
training in the foot and ankle surgical arena.
This limited population of podiatrists
recognized that they had a special talent that
most in the profession did not have and moved
to start changing the educational curriculum to
include surgical lectures complimented by
internal and external program surgical training
(which made up 18 months of the 4-year degree).

And yet, this still did not fill the void left
after graduation to properly train podiatrists
in foot and ankle surgery because of the
different post-graduate residencies that varied
in length (12 or 24 months), training
(rotating, podiatric orthopedic, or podiatric
surgical), and where the DPM was trained
(podiatry office, clinic or hospital). And even
still, there were DPMs who never participated
in a post-graduate residency and either went
onto practice or found a preceptorship position
with an established DPM so they could become
well versed in podiatric practice. Meanwhile,
these separate and disjointed paths led to this
growing division in the profession.

This division was fueled by the "haves and have
not" philosophy that was percolating through
the profession at that time. This was
exacerbated by the lack of post-graduate
training, different state license requirements,
and the continuing growth of this elite group
of well-trained podiatric physicians that
developed a special fraternity within the
profession. With that said, this group grew the
membership ranks of both the ACFAS and the
formerly named ABPS.

This fraternity of podiatric surgeons
eventually developed new group of podiatrist in
1972 “The Podiatry Institute” (shortened name
from the original) which was a founded for the
purpose of advancing podiatric medical
education through seminars, workshops,
publications and audiovisual media. There were
other organizations like this that filed that
void in hopes to help provide the needed
education and surgical training that most
podiatrists lacking at the time.

Even with this happening in the profession,
there was still those DPMs that did not have
the ability to be a part of these surgical
organizations either due to preference,
financial reasons or just did not want to
perform foot surgery. However, there were those
DPMs who recognized the financial advantages of
performing foot surgery since Medicare and most
health insurance companies were not
discriminating against podiatrists versus
orthopedists based on fee schedules.

Hence, a select group of DPMs decided to forgo
any training in traditional foot and ankle
surgery and strictly perform foot surgery in
the office by implementing a new type of
surgical technique called “Minimal Incision
Surgery” or MIS. This, unfortunately continued
to divide the profession now into two different
arms of foot surgery. And, this created not
only conflict within the surgical realm of the
profession but put created a tremendous
onslaught of criticism from the orthopedic
profession seeing the post-op complications and
deleterious results caused by MIS. This was an
era of podiatry that took many years to resolve
and recover from since the media had gotten
involved creating bad press.

Podiatry had to resolve all these issues caused
by a yet unresolved and uncertain education and
post-graduated training problem facing the
profession. Over time, this matter was resolved
through CPME changing and updating the
curriculum in all the schools and requiring a
standard three year post graduate surgical
training program for all graduating DPMs. Most
hospitals require board certification in foot
and/or ankle surgery for a DPM to obtain
privileges and state license requirements also
made changes to reflect the post-graduate
surgical training before a license code be
obtained. Hence, podiatry had to conform or
else.

Evolution has occurred for the better in the
podiatric profession, but still we face battles
with orthopedic prejudice, but with time this
will most likely disappear. The pioneers of
this profession had the foresight and knowledge
to get us where we are today. Moreover, with
the continued training in the field of foot and
ankle surgery and increasing and expanding the
educational curriculum to reflect who we are
and what we actually do maybe someday the
podiatrist will be considered the “physician”
that we have rightfully earned.

Hopefully, someday there no longer be an issue
“who we are and what we do” if somehow in the
not so distant future we will have the
compliment of “full scope” and an “unlimited
license” to practice podiatry in any way that
we see fit. But, on can dream, now can’t they?
So, “To be or not to be” that is the question
or is it really?

Joseph S. Borreggine, DPM, Port Charlotte, FL

Other messages in this thread:

---

02/19/2020    Lawrence Oloff, DPM

What Kind of Podiatrist Do Today's Residents Want to Be? (Alan Sherman, DPM)

I believe this dialogue about “advanced foot
and ankle vs. general practice podiatrist”
espoused by Dr. Sherman misses many key points.
It bothers me that after all the progress that
I have seen our profession make, there are
still advocates that want to have our
profession take two steps back. I have been
involved with podiatric medical education for
forty plus years and continue to do so today as
a residency director. These are my
observations.

Completing residency does not force its
graduates to perform advanced surgery, or for
that matter any surgery at all. The extent of
ones practice is purely up to the discretion of
each graduate of a residency program. Residency
just allow its graduates to provide basic
competency in the care of their patients, both
as generalists and as surgeons. Finishing a
residency is just the beginning of obtaining
competency as a practitioner. It takes a
lifetime to hone in on those skills. Fellowship
programs exist for even more advanced training,
allowing one fast track ones interest in
surgery of that is what is desired.

Residency education has changed since Dr.
Sherman and I were residents. It takes a year
to complete all the core requirements mandated
by CPME. That core year is rightfully dedicated
to providing basic building blocks of education
in medicine and its sub-specialties that are
deemed important to us being competent as both
generalists and as surgeons. That leaves two
years to obtain focused competency on the foot
and ankle. Is it really wise to dilute that
training further?

The last thing we need is further division in
our small profession. Allopathic medicine
judges us by their standards, not by our
standards. Some orthopedists do more surgery
then others. Do they divide their residences
into two types? That is a practice decision one
makes once they are done with their education.
I would also say that leaving the decision as
to how much training is necessary based on
resident perspectives is a bad idea. Even
though well-intentioned, these residents might
have a much different perspective if asked that
same question years from now.

Lawrence Oloff, DPM, Redwood City, CA