10/06/2023    Rod Tomczak, DPM, MD, EdD

Is Podiatry in a State of Disequilibrium?

I’ve been thinking about the recent posts in PM
News and I recalled two old movie titles and how
they seem to fit the current state of affairs in
our profession. One movie is called Ad quid
venisti and is translated from the dead Latin as
“Why are you here?” The other is Quo vadis? And is
translated from the dead Latin language as “Where
are you going?” I use the word dead on purpose.
The plots of the movies aren’t important, but the
titles are.

I get confused trying to come up with answers to
these two questions and find myself in what Piaget
called a state of disequilibrium. I’m not sure
what the answers to those two Latin questions are
as they apply to podiatry. I wonder if anyone can
answer the questions with any degree of certitude.

I remember when I was first exposed to podiatry
and accompanied a couple podiatrists in their
offices as they saw patients. They would ask the
patient why they were there and as the patient
answered, the podiatrist would pull a nail nipper
out of the pocket of the jacket commonly worn by
barbers or dentists and cut the patient’s toenails
as the patient described what we would now call a
chief complaint. Fifty some years ago “shortening
up the toenails” was just a given regardless of
the chief complaint. There was no consent, no
sterile instruments, just a gratis service that
was taken for granted.

Fast forward 55 years and we have three-year
residency trained podiatrists who may tack on an
extra year fellowship in a subspecialty and yet we
discuss what procedures we are certified to
perform. Many procedures are learned in a virtual
reality situation or at least on a cadaver that
doesn’t bleed.

Ironically, some podiatrists worry about losing
nail care to some nurses who are certified, or so
it seems, by a podiatrist while some podiatrists
are applying external fixators to complex ankle
fractures. These fractures may look similar, and
we are quick to classify them according to one of
the systems we have learned, but those honest
podiatrists who have done many will be quick to
say that no two are identical. The drawings may
be, but the real fractures are different.

If I have four years of training in foot and ankle
surgery, should I be worried about losing nail and
callus patients to a board-certified nurse, or
should I hire a certified advance practice nurse
to work in my office? Is the bottom line strictly
economics and I don’t want to lose the income to
an independent practitioner? Is this thinking the
same we secretly think the orthopedic surgeon is
using to keep us from advanced surgical
procedures. Are we just worried about a bottom
line. The orthopedic surgeons are not going to cut
toenails themselves.

On the other hand, are we limiting what members of
our profession can do based on what the
accreditation folks say is the proper number of
ORIF ankle fractures one needs to perform as a
resident before they can perform them
independently after their residency? Just because
there were 20 ankle fractures repairs on the
record during the residency review committee
accreditation visit one year doesn’t mean there
will be 20 the next year.

During the last few years, I have run into board
certified or board eligible well-trained
podiatrists who no longer want to operate. As
long as someone else is ultimately responsible for
the patient and an unwanted outcome leading to an
unhappy patient the resident will operate on
anyone and can hardly wait to get that procedure
in the log-book. I remember a mini-external
fixator for metatarsal osteotomies floating around
in the early 1980s. It was chic but there was no
clear advantage over a couple screws. The
residents wanted to put these on patients, but
cooler, saner heads prevailed. I’m not sure
anyone can predict which residents with great
hand-eye coordination will not want to stand alone
and answer for their actions, but those who don’t
want the responsibility quit operating. God bless
them if they want to cut toenails and trim
calluses, padding an IPK and dispensing orthotics.

Are we wasting three-year residencies on these
DPMs? A primary care physician may not know how
to perform a total hip replacement, or they may
have even fainted in the operating room as a
student, but they know when their patient needs a
total hip and they are not afraid to refer the
patient to the total joint surgeon knowing that
surgeon is not going to assume management of the
patient’s hypertension and high lipids.

How much training is too much? How many boards do
we need to protect the public? Are people who
performed questionable procedures gradually
retiring and leaving the profession in young
ethical hands? The podiatrists who kept nail
nippers in their jackets are probably gone, but
they were the foundation of what we have today.
“Why we are here?” and “Where we are going?”
should be answered in our mission statement and
everything we do should flow from that mission
statement. Otherwise, the profession will be like
Latin, a dead language.

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

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