06/13/2023    Rod Tomczak, DPM, MD, EdD

What is the biggest existential threat to podiatry?

the biggest existential threat to podiatry?
For the last 50 years we, ourselves have been the
biggest threat to the profession. I remember being
in school in the early 1970's hearing the
statement, "Podiatry eats its young."

It seems like there is always an intra-podiatry
conflict of some kind. More often than not the
strife revolves around surgery, board
certification, and extent of privileges. We of
vintage age, remember the intra-podiatry lawsuit;
one group of podiatrists suing another group of
podiatrists. Then there was the formation of PPO's
and podiatrists were literally paid per capita to
essentially do nothing for patients. To become a
member of the PPO a podiatrist paid $10,000 to
someone and then as a member was paid an amount
per month for each potential patient enrolled in
the PPO regardless of the treatment extended to
the patient.

Of course, the delineation of privileges fiasco
became a classic humiliation. One practitioner
could operate on the foot and ankle, but someone
who had been operating on the foot and ankle could
now operate on toes and metatarsals unless the
diagnosis was only soft tissue. A ruptured
Achilles was only soft tissue, but that was beyond
the scope of privileges for some but not others.
Surgical logs from a residency would remedy that
problem until people figured out how easy it
became to submit fiction before computerized
records.

Oral examiners had say over who became board
certified. At one time there were observers, then
exam sessions were recorded which turned out to be
a bad idea when the examinee sued because he
thought he had passed and the tape was proof.

Now, of course we have the added qualficationgate.
Somehow, someone judges whether or not someone can
perform forefoot or rear foot surgery and get a
sticker on a diploma saying such. What qualifies
the person judging who gets an added certification
sticker? Can I just get an added ankle
arthroscopy certificate. Maybe I just want to do
something simple like remove a screw from the
medial malleolus. What if the screw breaks? Does
everyone have to be adept at using a screw removal
system?

Of course these examples tend toward the absurd.
It seems like the bottom line is economics, and at
times we are trying to stone each other to death
with popcorn. Walt Kelly said it best, "We have
met the enemy and he is us."

Rod Tomczak, DPM, MD, EdD, Columbus, OH

Other messages in this thread:

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06/14/2023    Steven, Kravitz, DPM

What is the biggest existential threat to podiatry? (Rod Tomczak, DPM, MD, EdD)

Dr. Tomczak points to an age old question that
faces not just podiatry, but all fields of
medicine. There's too often a disconnect between
the pride of being in medical practice, the
economics that drive that practice, and the
realization that all of us have a limitation of
education. At the end of the day the primary focus
must be whatever is best for the patient.

I just had a paper accepted by the Journal of
Wound Care (due October 2023) that addresses this
very issue. It describes a simple vascular
procedure that went wrong, causing a major
complication and nearly a BK amputation. It
exemplifies the point Dr. Tomczak mentioned in his
post that a very simple screw removal can become a
major complication when it breaks.

Do you as a practitioner have all the skills
necessary to handle the complications that can
occur with simple (especially new) procedures. Is
there someone that you can refer to, better
trained or has performed the procedure multiple
times where you may have not. If the procedure is
new -- is there track record for it demonstrating
complications, healing rates, etc.? What's the
cost versus gain for your practice?

A review of literature indicates that for wound
healing 80% of the time Advanced expensive
modalities are used in the treatment of a patient
for healing. Yet Bill Marston 20 years ago
presented a very good paper on Venous ulcers
demonstrated that nearly 95% of the time healed
with simple compression therapy and quality wound
care - "going back to basics". The economic
factors, the pride of being in practice, etc.
drive physicians to sometimes get in over their
head and/or utilize new technologies that are
exciting, inventive, but at the end of the day do
not create better outcomes while simultaneously
increasing costs for the patient and/or the
system, and potential risk to the patient.

The question is huge and not only deals with scope
of practice but more importantly, the morals,
ethics, and the principles of knowing one's
educational limitation's and best available
opportunities for that patient. It's too easy to
lose that in our fast-paced world; we can barely
keep up with the changes.

I will be making presentations with open
discussion at upcoming conferences, "just because
you're able to do it, should you do it?"

Steven, Kravitz, DPM, Winston-Salem, NC