08/05/2021    Jon Hultman, DPM

We Have Met the Enemy and It Is Us

Taking and passing the USMLE is the true path to
parity. DPMs are the only healthcare practitioners
whose training includes a minimum of four years of
podiatric medical school and three years of
residency training that do not hold a plenary
medical license. Because of this, DPMs are not
considered physicians, are lumped with
chiropractors and optometrists as providers of
optional services under Medicaid, and must
constantly amend state bills to include DPMs
whenever those bills use the term “physician.”
Every advancement that has been made in podiatric
medicine has been considered a victory because it
gave DPMs a benefit or privilege that MDs and DOs
already had. This process has moved us
incrementally closer to MDs and DOs, but in spite
all these small “victories,” this will not win our
“war for parity.”

The only achievable pathways that have been
available for DPMs to attain true parity with MDs
and DOs were to go to LCME accredited medical or a
COCA accredited osteopathic schools to obtain MD or
DO degrees, or to obtain a dual degree by taking
additional years of education at an osteopathic/DPM
school. Interestingly, in addition to more years of
education, these pathways to parity both require
taking and passing either the USMLE or the COMLEX
exam. Once a doctor has obtained a dual MD/DPM
degree, s/he still does not have a medical license.
To obtain a medical license also requires
completion of an ACGME approved residency program.
If a DPM actually wants to practice podiatric
medicine and surgery, s/he also needs to take a
CPME approved podiatric residency.

To avoid these extra years of medical school and
residency programs, a process was begun in
California over ten years ago through the
initiation of a task force that includes the
California Medical Association, the California
Orthopedic Association, the Osteopathic Physicians
and Surgeons of California, and the California
Podiatric Medical Associations. The initial
“impossible” hurdles for this task force to
overcome were (1) the podiatric schools would need
to be accredited by the LCME, (2) the residency
programs would need to be accredited by the ACGME,
and (3) graduates would need to take and pass the
USMLE.

Of course, to be accredited by the LCME, the
podiatric schools would need to become medical
schools. That option was unacceptable. Following
in depth visits by the task force representatives
to the two California podiatric medical schools and
four residency programs, the consensus was that the
sequencing of DPM education was different from that
of MDs and DOS because podiatric students choose
their specialty at the beginning of their
educational process. It was clear that by the end
of the educational process DPMs were comparable to
those in other surgical specialties of medicine.
The end consensus of the members of the California
Task Force was that if the accrediting standards of
CPME were found to be comparable to LCME and ACGME
(which we believe they are), the medical and
orthopedic associations agreed that they would
accept CPME as the accrediting body. The only
requirement left would be to take and pass the
USMLE; however, as it stands today DPMs cannot take
the USMLE. Because access to the USMLE is a
national issue, CPMA submitted the USMLE resolution
to the APMA House of Delegates for action. After
passing, this resolution was subsequently adopted
by the National Task Force consisting of APMA,
ACFAS, AAOS, and AOFAS.

The goal at this point in time is to simply to gain
access to the test.
The pathway to parity that California supports is
the current one being pursued by the National Task
Force. That is: CPME would remain as the
accrediting body for the colleges and residency
programs, no additional years of education beyond
seven would be required, the pathway would be
inclusive so that the USMLE would be an option for
all DPMs who wanted to study and prepare for the
exam, and the DPM degree would become the third
degree to qualify for a plenary medical license –
hence, DPM=MD=DO. The end result is that DPMs
would be included in all statutes where the term
“physician” is used, they would become R1 instead
of R3 physicians under Medicare, their services
would become mandatory under Medicaid, and DPMs
would have true parity with MDs and DOs.

Without seizing this opportunity now, as we go into
the future, DPMs will continue to be considered
“non-physicians” – lumped with chiropractors and
optometrists as optional services under Medicaid,
and because they have a limited license, they will
be doomed to fight battles each and every year just
to retain previous gains or to advance small steps
– one at a time – trying to move ever closer to MDs
and DOs. If you were a college student trying to
decide on a career, would you choose a specialty
that requires seven to eight years of education and
in which, upon graduation, its members would be
considered non-physicians and practitioners of the
only surgical specialty that holds a limited
license?

One question I have for those who oppose this
pathway – especially those who consider themselves
to be visionaries and say they want what is best
for our specialty – is, “What other credible
alternative to true parity do you suggest?” Our
profession has been talking about and working
towards parity with MDs and DOs for my 50-year
history as a DPM, but I have yet to see any other
credible plan on the table that is actually
achievable and has momentum. It has taken us ten
years to get to a point that many in the past have
considered to be impossible. Do we simply abandon
this process, happy with the status quo, for the
next 50 years?

Jon Hultman, DPM, Executive Director, California
Podiatric Medical Association

Other messages in this thread:

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08/09/2021    Eddie Davis, DPM

We Have Met the Enemy and It Is Us (Tilden H Sokoloff, MD, DPM)

Sorry, I am a bit of a latecomer to this discussion
but after reading Barry Block's editorial, “We Have
Met The Enemy and It is Us” as well as Tilden
Sokoloff’s response, more questions arise.

According to the Wikipedia article on the USMLE:
“The USMLE assesses a physician's ability to apply
knowledge, concepts, and principles, and to
determine fundamental patient-centered skills that
are important in health and disease and that
constitute the basis of safe and effective patient
care. Examination committees composed of medical
educators and clinicians from across the United
States and its territories create the examination
materials each year. At least two committees
critically appraise each test item or case,
revising or discarding any materials that are in
doubt. The program intends to provide state medical
boards in the United States with a common
examination for all licensure applicants. However,
as of 2021, physicians with a DO degree do not
require it for licensure.”

There are 3 parts to the USMLE. The third part is
the last step in licensure per the Wikepedia
article:

USMLE Step 3 is the final exam in the USMLE
sequence and assesses whether medical school
students or graduates can apply medical knowledge
and understanding of biomedical and clinical
science essential for the unsupervised practice of
medicine, with emphasis on patient management in
ambulatory settings
.
So those with a DO degree are not required to take
USMLE for licensure. Yes, they have an alternative
exam. DPMs who take USMLE Part 3, still have a
limited license despite taking an exam designed to
determine the ability to practice via an
unrestricted or unlimited license. Dr. Sokoloff
states that “no podiatric physician out of training
for more than the past 10 years will qualify to
take the examinations.” Why? What happens to our
knowledge base after 10 years?

What happens to those who invested in a podiatric
education who are more than 10 years from the end
of training? How are we enhancing the opportunities
of future students by having them take an exam that
does not provide a scope of practice commensurate
with the intent of the exam? Sorry Tilden, but I
am not “kicking and screaming.” I am looking for a
reasoned discussion of the proposed changes and how
that not only benefits future students, but the
profession as a whole.

Eddie Davis, DPM, San Antonio, TX

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08/09/2021    Alan Sherman, DPM

We Have Met the Enemy and It Is Us (Jon Hultman, DPM)

I agree with Jon Hultman on this issue and believe
we as a profession should pursue nationally what
the California Podiatric Medical Association
successfully started in California. Allen Jacobs
raises some valid practical issues that must be
addressed but are not reasons to abandon the
pursuit.

There are times in the evolution of a profession
where bold action is needed, and I believe this is
one of those times. In general medicine, this
occurred in 1910 with the release of the Flexner
Report, calling for the standardization of hospital
based medical education. For podiatry, it was the
Selden Commission Report in 1961. We find ourselves
at a crossroads in 2021.

Reading the comments from our esteemed colleagues
on the issue of the equivalence of our education to
that of MD/DOs, we seem to fall into 3 camps: 1)
The righteously indignant, who feel we deserve to
be recognized already as equivalent, 2) the proud
and entrenched, who feel we should protect the
unique and separate identity of podiatry as a
profession and 3) the progressive realists, who
recognize that equivalence recognition by the
medical hierarchy is only possible by cooperation
with and following the standards set by the MD/DO
hierarchy. I fall into that third camp. They are
not coming to us for recognition. We are coming to
them. If we want our education to be considered
standard, I believe we must follow their rules to
make it standard, and that mean making some
modification to the curriculum of our schools,
culminating with taking the USMLE and its
predecessor exam.

The Joint Task Forces have admirably and capably
gotten this ball rolling, but there have been calls
for greater transparency and inclusion in the
effort. I think what we really need is the 21st
century version of the Selden Commission to oversee
the effort on behalf of the entire profession. It
won’t be easy, as we are not a homogenous group. My
personal feeling is that our diversity contributes
to our richness as a profession and what we have to
offer to serve the foot and ankle health care needs
of the public. But whomever wishes to be heard
should be heard and we need to choose leadership
for this new commission carefully and have
representation from all camps. Personally, I would
like to see the esteemed Leonard Levy join with the
current Task Force, as I don’t think there is a
podiatrist alive who has the experience and the
vision that he has, or is better suited for this
challenge ahead.

Podiatric medical education and practice. 1960s to
the 21st century by Leonard Levy, DPM, MPH
Levy LA: Podiatric medical education and practice.
1960s to the 21st century. J Am Podiatr Med Assoc
1996, 86(8):370-375.

History of podiatric medical education. An update
by C W Gibley Jr. Gibley CW: A history of podiatric
medical education: an update. J Am Podiatr Med
Assoc 1987, 77(8):404-418.

Alan Sherman, DPM, Boca Raton, FL

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08/06/2021    Sabrina Minhas, DPM, James Hanna, DPM

We Have Met the Enemy and It Is Us

We are writing to address the PM News editorial
comments offered on the topic of the APMA endorsed
White Paper and AMA Resolution submitted to the AMA
House of Delegates for its consideration last June.

This is a problem which needs to be examined on two
levels. The first level is an examination of the
“ends”; and the second level is an examination of
the “means.” Dr. Block quotes philosopher George
Santayana in support of the APMA actions. One level
of our concern is that the actions of the APMA are
also burdened by Machiavelli’s; “The ends justify
the means.”

In his editorial, Dr. Block cites three examples of
“opposition” to seminal developments in the
profession of podiatry. The first is the
professional change from the term chiropody to
podiatry. This was accomplished through: “…a late-
night Parliamentary maneuver in 1957 to finally get
it passed.” The second example was the inclusion of
the term “medical” in the association name. Again,
the editorial states that “… delegates
unsuccessfully voted against the inclusion of the
word “Medical.”” The third example was the
development of the three year residency
requirement. The editorial states: “…there was
opposition to mandatory requirements of one, two,
and finally three-year podiatric residencies.”

There is a common thread in each of Dr. Block’s
cited examples. That common thread is that each of
the seminal developments was accomplished in an
open forum of the APMA House of Delegates with
appropriate deliberation and transparency. That
common thread is absent in the current attempt of
the APMA Board and National Task Force’s effort to
gain what they define as “physician” status within
our scope.

The APMA House passed a Resolution, Resolution 4-19
in the 2019 APMA House of Delegates. In
anticipation of it reporting back, that Resolution
only authorized the APMA Board and National Task
Force to continue discussions which had been
initiated by the California Podiatric Medical
Association. Those discussions had involved the
American College of Foot and Ankle Surgeons, the
American Academy of Orthopedic Surgeons, and the
American Orthopedic Foot and Ankle Society. The
stated purpose of including the APMA through the
Resolution was to continue to advocate for the
involvement of the American Medical Association
(AMA) and American Osteopathic Association (AOA)
with the National Joint Task Force.
The operable portion of the Resolution states:

“RESOLVED, That the national joint task force work
with AMA to facilitate discussions with the
National Board of Medical Examiners to allow
podiatric medical students to be eligible to take
the United States Medical Licensing Examination…”

A report on the progress of these discussions was
to be made to the 2020 APMA House.
The 2020 House was a victim of COVID Cancellation.
Further, no mention of these discussions or
progress on Resolution 4-19 was made at the 2021
virtual House of Delegates.
On March 17, 2021 APMA announced that it had
“endorsed” a White Paper entitled “Improving the
Standardization Process for Assessment of Podiatric
Medical Students and Residents by Enabling Them to
Take the USMLE.”
Pursuant to endorsing this White Paper, the APMA
National Task Force caused a Resolution to be
placed before a special meeting of the American
Medical Association House of Delegates which took
place on June 11 through June 16. The AMA
Resolution contains the following “resolve”:

“RESOLVED, that our American Medical Association
study, with report back at the 2021 Interim House
of Delegates Meeting, whether CPME accreditation
standards are comparable to Liaison Committee on
Medical Education (LCME) standards and sufficient
to meet requirements which would allow DPMs to take
all parts of the USMLE.

This Resolution was introduced by the American
Orthopedic Foot & Ankle Society (AOFAS) and the
American Academy of Orthopedic Surgeons (AAOS).
Our position is that the White Paper and the
Resolution terms contain implications which promote
the inference that our training and education are
not at the level of a “common standard” which the
Task Force defines as the USMLE, and improperly
suggests that the sole path to recognition as
Physicians should be passage of the USMLE.

• No disclosure of the content of the White
Paper was made to APMA Stakeholders prior to the
APMA Board endorsing the White Paper.
• No disclosure of the content of the
Resolution was made prior to the Resolution being
submitted to the AMA.
• No discussion took place prior to the
recognition of a “common standard” being defined as
the USMLE in the endorsed White Paper.
• No discussion of podiatric medical school
curriculum was solicited from the Deans prior to
submitting the podiatry school curriculum to the
review of the AMA.
• The White paper states that passing the
USMLE is “…essential to maintaining public trust.”
• The White Paper states that “the care of
patients will be assured by requiring basic medical
education that would allow for qualifying DPMs to
take and pass all 3 parts of the USMLE.”
• The White Paper states that: “To …be
considered physicians within their scope of
practice, DPMs should be required to receive
sufficient education and training to allow them to
take and pass the USMLE.”
• The implications of this White Paper is
that our profession, which has its own educational
structure, curriculum and training, is somehow
inadequate because we have not passed a “common
standard” which was created by and currently
governed by the profession of allopathic medicine;
the USMLE.
We have two separate issues with the actions of the
APMA. One is procedural and one substantive.
Procedurally: The common thread in each of Dr.
Block’s cited examples is missing here. No
explanation to, or review by, any APMA stakeholder
was solicited by the National Task Force or the
APMA Board prior to calling for a “study” by a
third party, the AMA. By endorsing the White Paper
and submitting it to the AMA House, prior to any
membership or stakeholder involvement, the APMA
violated its own governing documents. That is, the
actions of the Board exceeded the authority granted
the Board under the 4-19 Resolution.
Substantively: By endorsing the White Paper, the
Board created new standards for each and every
facet of the Profession without including those
facets of the profession in discussions which
resulted in the White Paper, and advances a policy
in conflict with existing policies pursuing
recognition for podiatrists as physicians.
Additionally, this new standard is defined by and
controlled by a separate health care profession.

Finally, the “…overwhelming majority of
grassroots…” which Dr. Block cites constitutes 63%
of 1056 people responding to the question of
support for Students and Residents taking the
USMLE. This means that 665 respondents were in
favor of a truncated question summarizing this
issue. This is not an “overwhelming majority” of a
universe of over fourteen thousand podiatrists, or
eleven thousand APMA members or the twenty two
thousand subscribers of PM News.

The ends of this APMA effort may very well be
advantageous to the profession; or they may be
detrimental. The annual House of Delegates is the
forum at which that decision is to be presented
debated and decided. The House of Delegates is the
forum at which each of Dr. Block’s seminal examples
was decided. Here, there has been no forum.
Rather, a seminal issue was covertly negotiated,
seminal policies were covertly developed, and
seminal actions taken in the public forum of the
AMA without regard to our own membership and
governance. This is not the manner in which our
profession or Association is to be governed.

Sabrina Minhas, DPM, President PPMA, James Hanna,
DPM, President NYSPMA

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08/05/2021    Allen Jacobs, DPM

We Have Met the Enemy and It Is Us (Tilden H Sokoloff, MD, DPM)

Using phrases such as “those with no vision” or
referring to those in disagreement with the
students taking the USMLE test as “the enemy” serve
no useful purpose. The concerns expressed by those
opposed to the white paper should be considered
seriously as they represent concerns about the
future of this profession.

Dr. Sokoloff consistently refers to the advances
made by the California Podiatric medical
Association. However I do have some questions. Do
the students graduating the podiatry colleges in
California take the USMLE examination? The answer
is no. Are podiatrists in California still
considered a podiatrist with no advanced
delineation of privileges beyond that typical for
podiatry in the state of California? Again, the
answer is no. Are the colleges of podiatry in the
state of California approved by the liaison
committee on medical education which approves
medical schools? The answer is no. Are the
residencies in podiatry in the state of California
approved by ACGME? Again, the answer is no.

Those of us who question the proposition within the
white paper are not anti-growth of our profession.
They are individuals who care very much about this
profession and very much about the DPM degree and
what it represents. Rather than resorting to ad
hominem personal attacks, we should consider
seriously the potential validity of alternate
opinions. Alternate opinions should be respected.

I suggest that those supporting our students taking
the USMLE examination look at the sample questions
available online, as I did. I would ask that you
seriously consider whether or not you believe
podiatry school graduates would successfully pass
this examination.

I suggest you look at the high failure rate for
this examination in foreign medical school
graduates. In order to pass USMLE examination,
significant changes would be required in the
schools of podiatry. So far as I am aware the Deans
of the colleges have never been consulted regarding
the ability to make such changes without
sacrificing basic podiatry training.

More importantly, in the end, what is to be gained
by making substantial changes in our college
curricula, residency training, and fellowship
training if in the end we are still defined as a
podiatrist with limited privileges? Do you actually
foresee the day that a foot and ankle orthopedic
surgeon will refer to a podiatrist as their “total
equal“.

Perhaps a clear understanding of the eventual
benefits oh by our students taking the USMLE should
be better defined

Allen Jacobs, DPM, St. Louis, MO

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08/04/2021    Ira Kraus, DPM

We Have Met the Enemy and It Is Us

There has been much discussion about that there
should have been deliberation by the profession
about the white paper and resolution and whether
access to the USMLE for podiatrists should be
pursued. The reality is that there has been much
discussion and debate about this dating back to
2005, when the resolution known as Vision 2015 was
passed. As a result of that resolution, a task
force was formed to develop a pathway to the stated
goal of the resolution of achieving parity with our
allopathic and osteopathic colleagues by the year
2015.

The task force reported back to the 2006 APMA House
of Delegates. That task forces report included a
section that said (paraphrasing) that ultimately to
achieve parity with allopathic medicine,
podiatrists will need to take and pass the same
examination that the allopathic physicians take,
i.e. the USMLE. That was in 2006. The subsequent
work of Vision 2015 committees discussed the USMLE
and NBPME and how they might possibly interact to
achieve the goal of parity.

The California Podiatric Medical Association began
their work on achieving a Physician and Surgeons
Certificate in California, i.e. a plenary license.
Part of that process included that obtaining a
Physicians and Surgeons Certificate would require
passage of the USMLE. CPMA realized they could not
gain access to the USMLE on their own and when the
national Task Force of Orthopedic and Podiatric
Surgeons was formed they recognized that this could
be the method to gain access to the examination.
They introduced Resolution 4-19 to the APMA HOD
which directed APMA to work with AMA to facilitate
discussions with the National Board of Medical
Examiners (the controlling agent for the USMLE) to
allow podiatrists to be able to take the USMLE.

Resolution 4-19 passed on consent agenda with a
majority of states and organizations signing on as
co-sponsors. So the white paper and AMA Resolution
that came out of the task force was not some sudden
whim of the Task Force members and the respective
boards of APMA and ACFAS, but rather the
culmination of 16 years of work and discussion.

The AMA resolution was simply directed at gaining
access to the USMLE for podiatric students and
graduates of CPME accredited colleges of podiatric
medicine. So despite what has been written, if
access to the USMLE is gained—all podiatrists would
be eligible to take all parts. Granted it might not
be desired and could be difficult for those that
have been out for a period of time, but no one will
be denied access to taking the exam. Also, the
focus on the white paper is misguided. The white
paper is a supporting document for the AMA
resolution and should be read as if you were an AMA
delegate. It was written to convince an AMA
delegate to support the efforts to gain access to
the USMLE. It does not establish any new standard
and it does not state that the current podiatric
medical education is lacking or that there is any
lack of public trust in the current system of
licensing podiatrists.

The ultimate goal of the process would be to have
MD, DO, and DPM degrees seen to be equivalent. On
the federal level this would mean working to change
the classification of podiatrists in Medicare from
the current R (3) categorization to an R (1)
categorization—which currently includes MD and DO.
If R (1) were achieved for podiatry, there would be
no need for the HELLPP Act as podiatrists would
then automatically be defined as physicians in
Medicaid. It is important to note, if this were to
occur, it would include all with a DPM degree
independent of whether they had taken and passed
the USMLE or not.

However, this is simply the first step in the
process—trying to gain access to the USMLE, an exam
that currently we cannot take. Once access is
gained, the profession can determine what steps
occur next and how we move forward from there.

This is for the future of our profession and just
this week the APMSA House of Delegates passed a
resolution in support of this process. The resolved
from that resolution: “Be it resolved; that APMSA
will support the Joint Task Force in a resolution
that would allow podiatric medical students access
to the USMLE.”

Now is the time to move our profession forward.

Ira Kraus, DPM, Past president APMA, Member Task
Force

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08/04/2021    Steven Selby Blanken, DPM

We Have Met the Enemy and It Is Us

I am very concerned about the repercussions that
can occur from this white paper. First of all, it
said APMA approved this, but somehow, most of the
members were not informed. This should have been a
large topic to be discussed by all state societies
prior to presenting to the other boards and
societies. There should have been feedback from
state to state from all members before rendering an
APMA decision.

I am concerned about the drawbacks that can hit existing DPMs over 10 years from training. I am concerned how this can be used against us in malpractice claims where the
prosecution would use this against a charged DPM. I
am concerned how hospitals can limit the procedures
they allow for older DPM's just based on this. I am
curious what PICA has to say about this?
Interestingly, I come from a family of podiatrists,
My grandfather was a DSC and had his degree changed
to DPM. He was a visionary in our field and even
helped the start of PICA and PCPM. He was a DCPMA
delegate for years.

I followed in his footsteps as
I was fortunate to be surgically trained and
certified in Foot Surgery. I even was a residency
director at one time. My son is also a DPM in his
second year of residency with training of the
highest level. So you can see I have some issues
with this coming out to the other societies prior
to all the members discussing this in detail. This
is not a small topic, it is huge.

With no offense to the state of California, but it
does not represent the entire 50 states. I applaud
the effort, but I feel we should reach out to all
of our leaders of our profession, past and present
officers/presidents and discuss this further in a
larger forum. I was at MPMA meeting last week and
was going to vote on something about this topic. I
withdrew my second of the motion because I listened
to a former APMA president's view on the motion and
it was eye opening and very much appreciated. The
Foot and Ankle MDs and the lawyers could a field
day on members in the future if this white paper is
not discussed and modified thoroughly.

Steven Selby Blanken, DPM, Silver Spring, MD