09/08/2023    Lee C. Rogers, DPM

No Wonder There is an APMA Membership Crisis

Dear Dr. Virbulis and Dr. Christina,

APMA’s response on the August 30th CPME/SBRC
Listening Session truly alienated a majority of
American podiatrists. What I heard was a President
proudly asserting that the association was out-of-
touch with its membership and the profession.

The APMA is a trade organization. Its purpose is to
represent every member, and the profession as a
whole. Yet, comments by the APMA President made it
clear that the organization is satisfied with
disenfranchising 2/3 of the profession and allowing
ABFAS, a board that is not transparent with the
profession and engages in DPM-vs-DPM anti-
competition, to gate-keep the door to the OR. It’s
not that these 2/3 of podiatrists are untrained. In
fact, many, if not most of them are surgically
trained at the standards you implemented. It’s that
the profession left them behind with changing
residency models and then closed the door on their
opportunities for board certification - leaving
them with enormous practice challenges and economic
hardships.

What kind of profession have you built where 1/3 of
its members are ineligible for board certification
and must seek certification by a non-CPME-
recognized board (ABMSP)? No MD specialty even
comes close to this. And normally you just stand
idly by while the CPME and ABFAS demean the
training and skills of colleagues without their
credential. But on August 30th, you didn’t just
stand by, you participated in the disqualification
of this 1/3 of the profession.

Then you told ABPM, which certifies another 1/3 of
the profession, to stay in its lane.

The APMA BOT has publicly bemoaned ABPM’s CAQ in
Podiatric Surgery. It should be made known that the
ABPM started testing in surgery because you’re
simply not doing your job. And the CPME/SBRC is
incapable of providing unbiased oversight because
of its own unmitigated conflicts of interest. Board
certification is no longer a luxury that can be
served by an elitist club. It is necessity to
practice and podiatrists needed a fair assessment
in surgery so they can obtain surgical privileges.

Furthermore, EVERY SINGLE SURVEY of podiatrists
reveals (by supermajorities) that they want ONE
BOARD in podiatric medicine and surgery. And what
have you been doing? You’re actively stifling
attempts to foster discussion. You swept the
results of your own certification summit under the
rug. Then you tried to block ABPM from using its
own room for a town hall at The National and, even
worse, you then dissuaded podiatrists from
attending. At the same time, you refuse to
challenge the ABFAS’s excuses for their obstruction
in meeting and collaboration.

So if you wonder why APMA is having a membership
crisis, look no further than the substance of this
email. The APMA leadership is unwilling to
recognize the struggles of the average podiatrist
and you have done nothing to facilitate changes in
policies to aid them.

Do you know which podiatric organization is not
having a membership crisis? The ABPM. In fact, we
are the fastest growing organization in the entire
profession, more than doubling our membership in
the last 6 years. Now with 6,000 diplomates, 75% of
them having finished residency less than 10 years
ago, we are the largest representation of the
future of the profession.

I challenge you re-read APMA’s comments from August
30 and ask yourself, is APMA really advocating for
everyone in our profession? Or are you only
advocating for that 1/3 who benefit from the
elitist system.

To me, the diagnosis is clear. APMA’s membership
crisis is a symptom of its leadership crisis. Only
you can change the prognosis.

Thank you for considering my comments.

Lee C. Rogers, DPM, San Antonio, TX

Other messages in this thread:

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09/15/2023    David Secord, DPM

No Wonder There is an APMA Membership Crisis (Jeff Carnett, DPM)

Once upon a time, there was a podiatrist of some
note who originally hailed from Michigan. After
being mentioned in one of Lee Iacocca’s books
(when he was at Ford Motor), this podiatrist
(unfortunately) moved to the Corpus Christi area.
Mr. Iacocca overheard this podiatrist sitting
behind him, talking to his partner about
capitalizing upon the UAW provision in their
contract which allowed for 6 weeks of paid
convalescent care after foot surgery and how they
would use this to do a digital procedure on a UAW
member.

When they were about to go back to work, another
digit would be done and then, another and so on.
With the extended time off, a number of these UAW
members would actually have other jobs during the
convalescent period and collect two pay checks.
Mr. Iacocca got off the plane, met with the UAW
and wrote podiatry out of the upcoming contract.
My understanding is that a number of people in our
profession lost their practices in the Detroit
area with the loss of UAW coverage.

This same podiatrist then decided to start his own
board (the rather long and tortured name escapes
me.) Due to many actions which are too lengthy to
mention here, this doctor sued the ABFAS, a long
and expensive legal battle ensued, all of us
received a letter informing us of the financial
plight and were asked to consider a donation.
ABFAS won the lawsuit and shortly thereafter, the
doctor who started all of this closed his practice
without notice and was never heard from again.
Auspicious, to say the least.

Those of us who remember this battle remember the
hard feelings and professional debris left on the
side of the road with this internecine battle to
have everyone “board certified” by someone. It was
expensive, accomplished nothing except clogging
the courts and employing attorneys and left us
wondering how long it might be before something
similar occurred. Here we are.

The threatened lawsuit from those who never did a
residency lead to a dilution of the worth of board
certification by the “grandfathering” action.
Anyone outside the profession who wasn’t already
confused became such after hearing that a person
who only did a preceptorship had the same board
certification as a multiple-year, hospital-
trained, multi-specialty rotation resident (and
perhaps, fellowship trained) individual. At this
point, it is a fair guess that the preponderance
of the “grandfathered” board certified have
reached retirement age and are not an issue
anymore. On the horizon is yet another maelstrom
to threaten the board certification status.

Moving to a three-year basis for residency and a
multi-year minimum training standard was made (as
far as I can divine) to bring us up to par with
primary care standards. Eventually moving to a
five-year residency standard is likely to occur in
our future to bring us up to standard with other
allopathic practitioners in the surgical arts.
Adoption of the USMLE is inextricably in our
future in pursuit of parity and a plenary license.
If you’ve never viewed a sample of the USMLE phase
I, II and III exams, I would encourage you to do
so. Sobering, to say the least. Break out the
Harrison’s!

What do we do with the elephant in the room? The
phase of training which was less than two-year
minimum in surgery and—before that—included non-
surgical residencies of different acronyms corrals
a not inconsiderable cadre of our peers. How is a
fair administration of privileges and insurance
panel participation assured when the standard for
adequate training in surgery is now set at three
years? How are these individuals not orphaned by
the progression of the whole?

Heady issues worthy of debate. I’m overwhelmingly
glad that I’m not the one who has to figure this
out, as the Paul Kruszka, DPM debacle was
memorable, damaging to the profession, expensive
and embarrassing.

The issue is still debated and debatable. 1. How
do those who cannot qualify to sit or perhaps pass
the APMA-established high bar to become board
certified overcome the strictures set by insurance
panels and hospital rules for membership? 2. If a
competing board emerges to
allow the outlier to become board certified in our
specialty, how does the profession, the public and
other professions view this level of disarray?

This is the World of Paul Kruszka all over again.
Will it lead to costly litigation again? The
grandfathering of people who didn’t have the
training to achieve board certification, which
dilutes the value of that measure? This is from a
letter I submitted to this listserv on January 11,
2011:

Dr. Fisher: It is interesting that you propose to
board certify people with no hospital-based
training, with the assumption that time served
equals quality training. The specious nature of
this line of thought has intrigued me for some
time, especially in light of my experience with
the practice I purchased from a man in private
practice for 15 years who wanted to move his
family back to the northeast. He did one year of
residency RPR at a Waco, TX Veterans facility
(which was so weak a program that it ceased to
exist 2 years after he finished it). I trained
with at the Graduate Hospital in Philadelphia (the
training facility for those coming out of the
University of Pennsylvania School of Medicine) and
have my certificate for this PSR-36 program from
the
University of Pennsylvania.

So, in juxtaposition, we have a guy practicing for
15 years who did a weak one-year program and a new
practitioner (I had practiced for 2½ years in
Arlington, TX before joining this practice and so
was not completely wet behind the ears) with a 3-
year Ivy-league level residency (one of the top 10
in the nation) put together in an office. This guy
constantly gave me advice on surgical approaches,
techniques and fixation for cases he had never
seen much less done before. His approach to all
this is that his time in clinical practice more
than compensated him and indeed, excelled my
training. Why would anyone with minimal training
completely disregard the training I received,
which included many cases with not only
nationally known plastic, orthopaedic and
podiatric surgeons, but several who are world-
renown?

It is an epiphenomenon I term "uber-ignorance".
This guy has such a stilted level of exposure to
the possibilities of what is out there that he
truly doesn't know what he doesn't know. Let me
clarify. He has no awareness of how poorly trained
he is and has no awareness of his level of
ignorance. Indeed, he 'doesn't know how much he
doesn't know'. I wish I could say this is a rare
occurrence, but it is not. I've been in practice
now for 23 years and my employment history is as
follows:

He worked for a doctor south of Dallas, who never
did a residency, but had been in practice for 20
years. He spent more time advising me on surgical
approaches and fixation than he did paying
attention to the procedure itself. This, in light
of the fact that the cases I was doing (ankle
fractures, Achilles ruptures, lateral ankle
stabilizations, etc.), he had never seen much less
done. He believed that his 20 years in practice
equaled an Ivy-League residency and I should be
asking his advice on cases rather than the
opposite.

He worked for a (now deceased) doctor in
Arlington, TX. This guy never did a residency. Was
board certified in surgery and was the most ham-
handed individual I've ever seen in the O.R. He
also believed that his 23 years in practice more
than equaled a top-flight residency and
constantly gave his input on things he knew
nothing about, deciding that it was the proper
'mentoring thing' to do.

He joined the practice I eventually owned in
Corpus Christi, TX. While I was an associate, the
practice owner hired another associate, as there
was a second practice absorbed and another doctor
was needed to take it over. This guy did a 1-year
residency at a VA facility (medicine)
and 2 years of surgery at a residency outside of
Texarkana. I would think that 3 years of training
would be a pretty good starting point for anyone.
He was hired because he claimed to have ankle
experience. He lied. This guy knows nothing, does
no reading and is no better trained than the other
individuals I've mentioned. He is also much more
dangerous, as he is willing to take on cases he
isn't trained to do (arthroscopy) and neither asks
for assistance on the case or takes any training
or does any reading before doing it, deciding to
'figure it out as he goes'.

I've known doctors who practiced their entire
lives without killing anyone. This guy
accomplished it in his 2nd year of private
practice. My conclusion: There are a number of
well-trained people in our profession and there is
a preponderance of poorly trained people, many who
think they are well-trained and/or believe that
time served imbues knowledge and experience. This
knowledge and experience is only amplified if the
person is willing to constantly note that learning
never ends and investing in journals and books and
reading them and going to seminars (and actually
attending the lectures and listening to them) is
part of the learning process.

None of the doctors I've mentioned has read a
journal, purchased a textbook or gone to a meeting
or seminar (for any other reason than to use it as
a reunion or golf outing) in a number of years.
They are poorly trained (even with several years
of surgical training), are board certified in
surgery in several cases and I wouldn't have them
wash my car, much less do surgery upon me.

Your proposition to offer board certification to
the unwashed masses serves two purposes:

1. allows some parity to those not fortunate
enough to have secured a surgical residency, due
to bad luck, or low numbers available at the time
they graduated.

2. Further denigrates the implicit value of the
board certification effort by offering it (like
the guy in Arlington) to anyone with a pulse.

Do you really think the Ortho guys and pretty much
all the MD community think we are well trained out
of the box? Just the opposite. We may be the only
surgical specialty that is taken one-by-one and no
assumption of our abilities is made on face value.
We have to prove ourselves as we enter a community
by our work. Every ortho guy, plastic guy,
vascular guy,
cardio guy, etc. has the assumption made when they
enter the medical community that they have good
training for what they do. We do not share that
luxury. There is so much variability to the
training level of our practitioners and even among
the surgical residencies themselves that no
assumption could possibly be anticipated from the
medical community on our training level. Rather
than making board certification more common, it
should be more restricted to those who
deserve it. I could not possibly be more opposed
to your proposition to offer this certification to
those who have 'earned it through clinical
practice experience', as the people I've met in
this category are ignorant of their ignorance and
surely do not deserve praise, much less academic
accolades for such ignorance, simply because it
will help sustain them on an insurance plan.

That was back in 2011. We are facing these same
issues again. We will face them again with the
push to establish five years of training to be on
par with other allopaths. We will face it again
with a push to establish the USMLE as the
benchmark towards a plenary licensure. Some sort
of metric needs to be put in place to handle these
situations so that the wheel doesn’t have to be
reinvented over and over again.

David Secord, DPM, McAllen, TX

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09/12/2023    APMA Board of Trustees

No Wonder There is an APMA Membership Crisis (Lee Rogers, DPM)

Comments about APMA’s testimony presented
incomplete and misleading information. APMA is the
greatest advocate for this profession, driven by
the expressed needs of its members. Let’s examine
the facts.

After the APMA bylaws revision adopted by the
House of Delegates in 2020, the Joint Committee
for Recognition of Specialty Boards (JCRSB) was
transferred completely to the Council on Podiatric
Medical Education (CPME). CPME now has a Specialty
Board Recognition Committee (SBRC) responsible for
the initial and continued recognition of specialty
boards. CPME documents 220 and 230 govern this
activity, and an ad hoc committee of CPME is
rewriting these documents. The ad hoc committee
set up a listening session to solicit input from
the interested stakeholders regarding these
documents. There was a process to register and to
request to speak.

The information APMA provided to the CPME SBRC Ad
Hoc Committee was based on the committee’s
specific request about changes to CPME documents
220 and 230. The comments were based on policies
and propositions passed by the APMA House of
Delegates, the governing body of our organization.
APMA is a 501(c)6 professional membership
organization. The delegates are elected by the
state component members to represent their
interests in the governance and policies of the
association. Further, the comments provided to the
ad hoc committee were vetted and approved by the
APMA Board of Trustees.

During the listening session, those who asked to
speak were given three minutes, and speakers were
held to that time. There was also the ability to
submit written comments to the ad hoc committee.
Dr. Virbulis, speaking for APMA, delivered a
succinct statement addressing issues that could be
pertinent to the rewrite of the documents.

Many of the points raised in criticism of APMA’s
testimony are outside the purview of CPME
documents 220/230. A recognized certifying board
could raise these issues to the SBRC for
consideration. Specifically referring to an
alternate pathway to certification by either or
both currently recognized certifying boards would
require a change to the board’s policies and
approval by the SBRC.

Prior to implementation of current rules, there
was a time when an alternate pathway to
certification existed. ABPM, ABFAS, and the JCRSB
all agreed it was important to limit that pathway,
as reflected in the boards’ current policies. From
the ABPM website: “If you completed your residency
prior to 2015 and have never attempted the
certification exam, you are not eligible to sit
for certification.” These are exactly the
physicians Dr. Rogers claims APMA has left behind.

Let us be clear: APMA is not a certifying board
and has no jurisdiction over the certifying
boards, which are independent entities, nor does
it have authority over CPME. CPME’s independent
status is required by the US Department of
Education. The issue of who has access to board
certification is something that the CPME-
recognized certifying boards—ABPM and ABFAS—would
need to work out. Currently, all graduating
podiatric residents have access to both of the
CPME-recognized certifying boards. That is because
of the hard work and foresight of the profession
to develop a three-year residency training model
for all graduating podiatric students. This model
made our educational process comparable to our
allopathic and osteopathic colleagues. But more
importantly, it ended the longstanding issue of
access to board certification because of the type
or length of postgraduate training.

The growth of the ABPM membership is a direct
result of the three-year residency training model
and the fact that graduating residents can become
board-certified very quickly by ABPM. APMA
supports this model; it helps our member
physicians meet the demands of insurance payers
that require board certification to be part of
their panels. Our graduates recognize the value of
ABPM certification, and the increase in ABPM
membership can be directly traced to the change in
the residency model.

APMA is a membership organization, and we work for
our members. Our mission statement: “Defend member
podiatric physicians’ and surgeons’ ability to
practice to the full extent of their education and
training to best serve the public health.” While
we work for our members, our advocacy efforts
benefit the entire profession—members or not.

ABPM and ABFAS are certifying boards that both
have a similar mission of protecting the public
via their rigorous certification processes. APMA
encourages both boards to continue striving to
meet their stated mission, and we hope that one
day they can work through CPME and come together
to collegially discuss the potential of one
certifying board.

APMA Board of Trustees