12/01/2022 Rod Tomczak, DPM, MD, EdD
The DPM/MD Controversy
The controversy concerning a degree change has
been simmering for years and Podiatry Management
has done an excellent job documenting both sides
of the debate. While the arguments continue to
simmer, podiatric educators have not input much
lately. And now that the podiatry colleges have,
for the most part, joined universities that grant
MD or DO degrees, would these institutions condone
a degree change or tolerate a podiatry college
becoming a dual degree granting institution?
Some years ago, when I was a professor at the Des
Moines school and Leonard Levy was the dean, we
instituted a five-year program to grant a DPM/DO
dual degree. During the second semester of the
first year, the Commission on Osteopathic College
Accreditation put an end to our experiment. We
were told that either the medical students were DO
or DPM students. The dozen or so students who were
in the experimental program were given the option
of picking which college they wished to remain
matriculated in. All but one student opted for the
DO college.
Not easily frustrated, we came up with the idea of
administering a step I practice exam the DO
students took after year 2 to the DPM class of
1995. Since the DPM students took the same
classes and course exams as the DO students, we
thought our DPM students would compare favorably
with the DO students. To our disappointment, our
DPM students did not test well and we did not
publish the results. In all fairness, our
students knew their performance on this test meant
nothing and they did not prepare for it like they
might have for the podiatry step I examination.
But it should also be mentioned that we chose the
top 15 students in the DPM class to sit for this
mock exam.
So why don’t these individuals in favor of a
degree change get together, form a consortium and
start a school granting an MD in podiatry or a
DPM/MD degree since we know the DO community did
not want a combined degree? Since our
institutions (DPM) are already accredited or in
the process of becoming accredited, the new school
will have to adhere to the MD criteria for
accreditation. If the new school does not apply
for accreditation a plethora of problems await the
graduates. Unaccredited schools may not sit for
the MD USMLE national boards necessary for
licensing. There is also a strong possibility
that our own (DPM) Council on Podiatric Medical
Education may not grant initial accreditation
meaning the graduate may indeed hold two degrees
but not be able to become licensed in either
discipline.
In order to achieve candidate status, this new
school which will offer an MD degree must submit a
$25,000 application fee. In order to move along
in the application process, there are multiple
sight visits by LCME which is recognized by the US
Department of Education as the accreditation
organization for MD schools. Should the new school
wish to forego recognition by LCME, students would
not be eligible to receive loans. Loans are not
extended to students matriculated in non-
accredited programs. A successful application for
school candidate status must include proof of
economic solvency. This runs into the millions
depending on the institution’s status and size.
There are no students or even advertising for
students so money must be from the institution
itself or the consortium. Usually the faculty
must be on board and salaried so that if granted
application status, the candidate school must be
in position to create numerous self-studies and
generate a curriculum which would have goals and
objectives vastly different than a DPM curriculum.
Of course this faculty must be paid a full salary
with no income being generated.
Before the program can be advertised and students
interviewed, clinical affiliations must be
secured. This is different than the physical
plant itself. LCME is speaking to clinical
affiliates in this section, specifically third and
fourth year hospital core rotations and the
advanced sub-internship and elective rotations.
The third and fourth years must be spelled out
along with core competencies and learning
objectives. The institutions offering these
rotations must be JACHO approved and there must be
an acceptable patient to student and clinician to
student ratios so the learning experience is not
diluted. A strong affiliation agreement is
required.
An experienced, diverse, well published faculty is
necessary. LCME is looking for both MD and PhD
faculty to teach basic science and clinical
correlations of the basic sciences. Preferred
faculty are recognized authorities in their field
which is narrow in scope. A PhD in Biochemistry
would teach in his/her field of expertise such as
the insulin glucagon interaction rather than the
whole of Biochemistry. One clinician might ideally
be an authority n end organ di Perhaps an
ophthalmologist would concentrate on Diabetic
Retinopathy, diagnosis, treatment and prevention.
A publication record in refereed journals, post-
doctoral and post residency fellowships are a
plus and grant experience are sought after
qualities for faculty candidates.
The LCME Data Collection Instrument obtainable at
www.lcme.org is a 105 page outline of questions
that must be satisfactorily answered. Most
submissions total over 1000 pages when completed.
Two extremely germane areas of inquiry delve into
why this particular school is necessary and are
there any areas that exhibit conflicts of
interest. Ironically, The Council on Podiatric
Medical Education mirrors the accrditation process
for colleges of podiatry. It’s difficult for a
reason. In order to ensure the highest quality
education, every nook and cranny has to be
examined prior to advertising the school and
accepting the first student. There are multiple
stages along the way to accreditation and the
process is continuous.
Why is an as of yet unnamed DPM/MD program really
necessary? Will it generate fields of new
knowledge that will benefit patients? Is there
something that will be opened up to someone having
both degrees that is not now available to the
holder of just one of these? Will an MD
orthopedic surgeon fellowship trained in foot and
ankle know more or be of greater value to the
general public than a podiatrist with a three year
residency? Better yet, of what particular use is
a DPM with a three year residency and an MD degree
than the DPM with a three year residency without
an MD degree?
Will a dual degree holder be more attractive to
pharmaceutical companies manufacturing type 2DM
medications because that person can treat Diabetes
not just its manifestations in the foot. Will a
dual degree holder treat Diabetic ketoacidosis?
Will MDs trained in endocrinology be shut out of
research monies which will now be diverted to
podiatrists? Will podiatrists suddenly be working
in the MICU taking care of research patients
suffering from Diabetic ketoacidosis.
Will students be eligible for increased loans over
an extended length of education? What used to
take four years now takes at least five and to
what defined benefit? Will podiatrists finish a
three year podiatric residency then move into an
internal medicine residency competing with newly
graduated MD alone physicians?
Don’t get me wrong, I am all for podiatrists who
want an MD degree to earn one. I have one. When I
lost the ability to practice podiatric surgery I
went through three years of intense depression and
acting out. I couldn’t believe I lost the ability
to practice what I truly loved. Teaching ranked
right after surgery but clinical teachers are
expected to see patients and operate. The next
best came as the opportunity to open MD schools
and I helped open schools around the world. All
went through the same rigor which at times felt
ludicrous. Why did people need to see the size of
our bank account or why did the local sandwich
shop need to write a letter telling everyone why a
new school was needed?
The faculties of these new schools were all PhDs
and MDs; there were no podiatrists. When podiatry
schools open, the faculty consists of PhDs, DPMs,
and one or two MDs or DOs. At a minimum to grant
an MD degree, the faculty and the curriculum of a
DPM school would need to be changed. Having been
involved with podiatry, osteopathic and allopathic
curriculum committees, I can tell you it’s easier
to move a grave yard than it is to change a
curriculum. Incentives would need to be created to
make a faculty appointment attractive at a DPM
college where budgets are extremely tight. You
don’t see today’s podiatry school faculties
chiming in on either side of the debate. I think
they realize that no matter how much it is
desired, the change is impractical and literally
impossible in a system like we have now.
I have no fear that today’s podiatry student could
successfully navigate the MD curricula at the
medical schools I have been in touch with. Of
course it’s possible to make the curriculum so
difficult most MD students would have a hard time
graduating, but what’s the purpose in doing that?
We all know that most of the podiatry we use every
day we learned in our residency anyway, but the
idea of a podiatry school only granting MD degrees
then opening a certain number of podiatric
residencies to these MD graduates is open to
numerous problems at a state level where MD
graduates have an unrestricted license. Will
these MD graduates complete a podiatry residency
but then have a restricted license?
What really scares me is podiatrists, in the quest
to become MDs will lose their identity and
ultimately we lose the profession. There will be
no physicians who care for feet until in a couple
hundred years a new Dr. Scholl is born and we
start all over again. A well known Reformation
author wrote, “Be who you are and be that well.”
There is no question that as a profession we are
the best. Our schools and residencies make sure
we are exposed to the materials and techniques
that ensure we are the best and will continue to
be the best at what we do. Manipulation used to
distinguish DOs from MDs. That’s not the case
much anymore. DOs are not who they once were.
Now it’s a case of accepting who we are. I don’t
think it’s a case of the profession as a whole
being willing to accept who we are, but the
individual accepting who he or she is, reveling in
the training they receive at prestigious
institutions and proudly carry the torch that has
been passed.
The grass is not necessarily greener on the MD
side of the fence than it is on the DPM side.
There are disagreements and arguments over how
much time should be allotted to each system and
discipline when the curriculum committee meets.
We laugh at a grudge developing because an extra
hour is allotted to neuro-ophthalmology but has to
be taken away from acoustic neuromas. I’ve seen it
happen. I personally think that as a profession we
need to be who we are, and be it well.
Rod Tomczak, DPM, MD, EdD, Columbus, OH
