08/17/2022    Allen Jacobs, DPM

ABFAS vs. ABPM

The ABPM surgical CAQ question is emblematic, not
unique, to the “surgical certification” issue in
podiatry. For many years this profession has
offered alternatives to ABPS now ABFAS for
“certification” in foot and ankle surgery. Whether
such alternative “certifications “have been
accepted for credentialing at the local level is
another matter. Additionally, our profession has
accepted 2 levels of “recognized” certification,
foot and rear foot ankle. Therefore, the concept of
“party qualifying” a podiatrist for surgical
privileging is neither a unique nor recent concept.

The issue is to what extent should an ABPM member
be trusted to provide surgical services, and who
should determine the extent of those privileges. A
gastroenterologist may perform an endoscopic
examination but not a bowel resection. A general
dentist may perform extractions or uncomplicated
root canals but not a mandibular osteotomy. A
general practice veterinarian may perform knee
ligament repair on your doggy, but not a hip
replacement. An interventional cardiologist may
perform an angioplasty or stent placement, but not
perform a femoral popliteal artery bypass.

Surgical skill provision is inherent to the
practice of podiatry, including primary care
podiatry. Other health care providers in medical,
dental, and veterinary medicine have generally
determined the breath of surgical procedures which
may be expected to be safely provided by “non-
surgical” specialists. It is time that podiatry
follows this path. I have seen 3rd year residents
who can scope an ankle, reduce and fixate a pilon
fracture, yet cannot do a P and A.

Ultimately, this matter should be settled for the
trust placed in the DPM degree by the public. An
INDEPENDENT committee should evaluate these
concerns and make appropriate recommendations. The
CAQ should then be accepted and supported by ABFAS,
not as certification, but rather an acceptance that
qualified primary care podiatrists are capable of,
and should be allowed certain reasonable surgical
privileges

In my opinion, officers of the APMA, ABPM, and
ABFAS should not participate directly in such a
committee. The issue is too important for shall I
say “political creep” to occur.

This issue is potentially decisive to our
profession at many levels. It should be
appropriately and expeditiously addressed in a
responsible manner.

Allen Jacobs, DPM, St. Louis, MO

Other messages in this thread:

---

08/18/2022    Timothy Ford, DPM

ABFAS vs. ABPM (Allen Jacobs, DPM)

My colleague and friend Dr. Jacobs is spot-on
regarding podiatric medicine and surgery residency
(PMSR) training. Having the opportunity to evaluate
many programs in the past 20 years, I can tell you
there is a vast difference between programs.
Although CPME 320/330 provides common requirement
institutionally and program wise there is a clear
difference in residency training across the
country. This is a particularly true when it comes
to academic medical centers and community
hospitals, not just in training but in overall
institutional monitoring of residency programs.

Academic institutions often have 100+ residency and
fellowship programs they oversee, whereas community
hospitals may have only a PMSR at their facility. A
critical component of medical education involves
interaction with other residents and fellows in
various specialties which enables valuable
interdisciplinary learning to be achieved. This is
particularly true with complex patients where
various services discuss treatment plans to best
treat a patient. Academic and large medical centers
can afford this opportunity to our residents and a
push to develop more programs at these centers are
long overdue.

Like Dr. Jacobs, I also believe we place too much
emphasis on surgery and not enough in medicine. The
residency model we chose is podiatric medicine and
surgery, so shouldn’t we be more active in medicine
and its subspecialties like rheumatology,
endocrinology, wound care, and cardiology to just
name a few! We graduate residents who believe they
are “foot and ankle surgeons” and “fellowship
trained foot and ankle surgeons” but not podiatric
physicians and surgeons. We may be the only
profession where instead of your degree by your
name the statement of “fellowship training foot and
ankle surgeon” is a new title under your name. Why
are we always trying to split our profession—-guess
what we all have the same degree! My orthopedics
foot and ankle surgeons (I have 10 in Louisville
alone) say nothing about their fellowship(s) other
than in their resumes—some have 3 or more
fellowships so listing them all under their name
would be time consuming to say the least.

ABPM CAQ in podiatric surgery - I find it
fascinating that there is this much concern about a
CAQ. The ABPM has made it very clear that it is not
certifying anyone in podiatric surgery only the
ABFAS can do this. However since podiatric surgery
is absolutely a part of podiatric medicine the ABPM
has every right to provide a certificate of added
qualification (CAQ) to their board certified
members.

Interestingly, I have heard not one complaint about
our growing number of non-CPME fellowships by the
ACFAS or others. These fellowships are not Approved
by CPME or accredited by any governing body. The
ACFAS is not an accrediting body for our
profession, CPME is!

WE talk about protecting the public and confusion
with various verbiage like a CAQ in podiatric
surgery yet no one has once criticized the ACFAS
for its “recognized” fellowships. Since these are
not CPME approved fellowships who exactly is
protecting the public and monitoring these
fellowships— in short no one. Why isn’t the ABFAS
(and the APMA and ABPM) concerned about the
training and granting of “certificates” to these
non-CPME fellowships who now tout themselves as
“Fellowship trained foot and ankle surgeons” .

Finally, a comment on board certification—we as a
profession need to have one single board that
certifies us. As a double boarded Podiatric
physician (and a fellow of the ACFAS and ACPM) I
can tell you this division of podiatric medicine
and Surgery is unsustainable! As a person who is
the chief of the medical staff at a university and
a member of the credentialing committee for almost
17 years, I can say board certification is only one
component in credentialing your surgical skills,
surgical numbers, infection rate, OR time per
procedure and patient time to D/C days are even
more important!

The reality is that podiatric physicians and
Surgeons play a critical role in our healthcare
system we just need to be UNIFIED and embrace our
chosen profession. Stakeholders from CPME, APMA,
ABPM, and ABFAS need to find common ground and
understand that division within our profession
imparts a poor perception to not only the public
but to the overall medical community.

Timothy Ford, DPM, St. Matthews, KY

---

08/16/2022    Allen Jacobs, DPM

ABFAS vs. ABPM (Jeffrey Kass, DPM)

The suggestion that all 3-year residencies provide
an equal surgical experience is simply not true.
There are differences in training, ability, or the
desire to perform advanced surgical procedures of
the foot and ankle among individuals within the
same residency programs. Many, but not all, of the
residency and fellowship graduates in podiatry are
extraordinarily capable. It is one thing to perform
skin and nail surgery, uncomplicated hammer toe
surgery, “lump and bump” surgery. It is quite
another to perform TARs, treat complex ankle
fractures, perform Charcot’s joint deformity
reconstruction, manage a pilon fracture, utilized
advanced orthoplastic techniques.

These, Dr. Kass, are the reasons that legitimate
board certification in surgery is necessary. Not
all podiatrists, 3-year residency or not, are
created equally. There is no perfect certification
process. However, with that understanding, and
knowing that a podiatrist may be charged with the
evaluation and management of complex pathology,
some mechanism should be in place as a reference
point for the public and credentialing bodies to,
as best as possible, that an individual seeking to
provide such care has subjected themselves for
evaluation by their peers, who therefore will
attest to their proven capabilities.

My focus on this debate may differ from most. It is
my belief that the MEDICINE portion of PMSR is
largely ignored in residency training. There is in
my opinion too much emphasis on “podiatric surgery”
(ie-foot and ankle surgery for those of you who
find the term podiatrist uncomfortable). I recently
saw a web posting by a new first year student at
Kent State proudly announcing that he is now on his
way to becoming a surgeon. Not a podiatrist. A
surgeon.

I believe we must revitalize primary care podiatry.
It is fun. I is needed. It is rewarding is all
meanings of the word. Residents spend their time
going from OR to OR, ASC to ASC. We need to upgrade
training and exposure in primary care podiatry. My
least profitable day each week in my day in the OR.
Frankly, as I have aged, I enjoy my office care
more and more. Every week is a bit of vascular
disease, rheumatology, dermatology, gait analysis,
fall risk evaluation, non-operative orthopedics,
radiology, pediatrics, geriatrics, neurology, wound
care, physical therapy.

Students and residents should be assigned to the
offices of representative and successful primary
care podiatry practitioners (how’s that for
psychotic alliteration). We need to stop the
charade that we are somehow equivalent to the MD
model. I for one believe that we should align more
with the dental or veterinary model. Define what
surgical procedures a primary care podiatrist
should be expected to be capable of performing.
Leave the triple arthrodesis, PER IV fractures,
calcaneal fractures, TTC arthrodesis to the
surgeons. Where do we draw that line? We need to
discuss this. The single 3 year PMSR is 90% S and
10% M.

Think about it. Most honest educators (and
students) will tell you the college clinics are
somewhat weak in terms of pathology seen. Third and
fourth year spend a great deal of time on hospital
rotation, where they see surgery and disease
critical enough to warrant hospitalization. The see
a strong ACFAS, and not to be insulting but
realistically a ACPM three steps down from this.
They see state and regional seminars with large
sessions covering surgery related topics, while
medical topics are restricted to corporate
sponsored infomercials. It is the reality of what
our profession has become.

In my opinion, medicine associations and boards
have no authority to confer ANY recognition of
surgical competency. The recent announced position
papers of ABFAS, CPME, ACFAS, I believe support
this position. The profession, in order to maintain
any semblance of credibility and trust, must reject
the suggested CAQ in surgery proposed by the ABPM.
Instead, we should increase education and build
prestige in primary care podiatry.

Allen Jacobs, DPM, St. Louis, MO

---

08/15/2022    Lawrence Oloff, DPM

ABFAS vs. ABPM (Allen Jacobs, DPM)

The last published statement concerning the CAQ by
the board ABPM is incredulous. To put in writing
that a test that is designed to measure competency
is too difficult for its constituency, so they are
going to create a test that accepts a lower level
of competency is pretty disturbing. And to use
gender reasons, as one of the reasons to popularize
that stance is beyond disturbing. I believe one of
the purposes of board credentialing is to protect
the public, yet this seems to have been discarded.

The gripe here seems to be that a lot of the
members seem to be concerned that the bar to pass
the surgery boards is too high. I can appreciate
that stance, but not one that takes to lower
standards by another board whose members want a
less intense examination. Tackle the problem of the
pass rate. Is the test too hard, or is the
education between residencies too disparate. Don’t
try and find a walk around solution that lowers
Podiatry. It not only lowers a standard but also
creates another rift in a small profession.

The statements by Dr. Jacobs are right on.
Residencies are not all created equally. Perhaps
the failure rate is related to these discrepancies.
Look at those issues. No one, neither the
profession nor the public is served by lowering
standards. As a residency director, I have always
fully endorsed membership in both boards. It is
going to be very difficult to support APBM with
their recent position statements. I think the ABPM
Board members should feel embarrassed by the
statements they have put in writing. I was
embarrassed for podiatry just by reading them.

Lawrence Oloff, DPM, Burlingame, CA

---

08/15/2022    Steven Kravitz DPM

RE: ABFAS vs. ABPM (Jeffrey Kass, DPM)

Dr. Kass makes some good, interesting points
regarding certification. However, that does not
negate any of my comments made previously which
were simply made to provide historical background
as to why lifetime certification is no longer
accepted in allopathic or podiatric medicine.
Limited timed certificates that require
recertification are the standard. Indicated in my
original article, recertification was established
as a method to demonstrate the physician has kept
up-to-date (since being originally certified) with
the current standards of practice. This is a
response to the medical knowledge base which is
said to now double every seven years.

Lifetime certificates do not provide a method to
reassess the “current” knowledge of the
practitioner. Recertification was designed to do
that. This has nothing to do with ethics and does
not evaluate the actual quality of care but assess
the knowledge base involved in passing the
certification process. Physicians, hospitals,
medical centers, credentialing committees and the
public (which has access to Certification
information) can have a guideline as to the current
knowledge of the practitioner involved. I am not
arguing how well that is accomplished with the
current methodology, but simply providing
perspective as to the perceived purpose of the
process.

Historically certification was initially
established to indicate a high level of achievement
in the knowledge of the specific subject area above
that required for daily practice. Originally, it
was developed to give credit to the top 10% - 15%
of those practicing and were taking the exam at
that time. Since that time, it has been changed and
now is a required credential for many insurance
carriers and most if not all hospitals in the
United States and other related wound healing
centers etc.

Dr. Kass’s comment that certification in podiatry
should be removed and that three-year residencies
be the substitute for that is incredulous and
notwithstanding, if implemented, would have
negative impact on podiatry. Podiatrists practice
in allopathic hospitals and medical centers. We
practice in their “house”, and these are standards
that they have placed to be part an active the
medical staff. Like it or not, certification is
part of mainstream medicine and to deviate from it
is not practical, realistic and will be on the
table for the foreseeable future. Dr. Kass and
others may question the value of certification but,
that does not change the reality as to how this
process is fully integrated as a required
credential.

Steven Kravitz DPM, Winston Salem, NC

---

08/09/2022    Steven Selby Blanken, DPM

ABFAS vs. ABPM

I have been in practice 30 years. At the time, I
completed two one-year residency programs, one in
POR, and the other PSR. Within 3 years upon
completion of my training, I decided to get double
boarded by the then ABPS in foot surgery and ABPO
in foot and ankle orthopedics. At that time, only
around 5-10% of the field was double certified.
Eventually, ABPS turned into ABFAS, and ABPO
turned into ABPOPPM, then ABPM. At some time in my
career, the ABPM offered "lifetime" status with no
expiration for most of its members who went from
ABPO to ABPOPPM. However, for some odd reason,
they grandfathered everyone but people in my board
certification year (1995).

I wrote letters in protest to that board on why my
year was not grandfathered like the years just
below me. They didn't have the best answer in the
world. Months later, I received a new certificate
stating on the bottom that my expatriation date
was now labeled as "lifetime". Therefore, I
thought I had accomplished my goal and was very
happy until a couple years later. I started
receiving notices that my certification was
expiring and I need to pay the dues and take start
the re certification again. I ignored it, then
year 9 came by and got the letter again, then a
final notice to take it in year 10. I called the
board asking them what is going on and quite
honestly what came out of their mouths really
surprised me and shocked me. They told me the new
certificate I received months after my appeal was
given to me by accident!

Really, when I got the letter, there was no
follow-up stating soon thereafter that there was a
mistake. They told me I had to remove it from
walls and stop using it. I was disgusted with
their approach towards me and decided that ABFAS
(ABPS) is what I needed and got me to where I
needed to be. I quit my association with ABPM and
quite frankly, they should refund all my dues due
to their fiasco that caused this issue. Now I see
this statement from ABFAS, for which I am fully
behind, and really didn't know that ABPM has gone
down to another lower level. This is another
division in our field and feel that there needs to
be some type of hearing to settle this issue.

Steven Selby Blanken, DPM, Silver Spring, MD