10/19/2023    Rod Tomczak, DPM, MD, EdD

Thoughts on Single Board Certification and Added Qualifications

In his Inferno Dante says the fourth circle of
hell is greed. Greed is worse than gluttony, the
third circle, but better than anger, the fifth
circle. Greed is characterized by never having
enough and we are constantly in search of more.
It doesn’t seem wrong to bring home as large a
salary as possible for a family. We live in a
society that rewards hard work. Maybe the epitaph,
“He worked himself to death.” is not so bad since
it supposedly reflects admirable unselfishness.

A workaholic is a functional member of society, so
we think. But are we practicing beneficence and
non-maleficence toward ourselves? Maybe Charlie
Brown said it best, “All I want is my fair share.”
I begin to worry if there are not enough surgical
cases for me because a non-certified podiatrist is
suddenly the same as a real board certified
surgeon because he or she somehow has an added
qualification. Am I interested in protecting the
public or am I interested in protecting my pool of
potential surgical patients?

As podiatrists would we be satisfied if we all
were paid a salary based on workload? If we adopt
all those different qualifications for board
certified podiatrists, would the sports medicine
qualification be worth the same as rearfoot
surgery and an added trauma qualification? Is
biomechanics as valuable to society as limb
salvage? What if we all bill out hours like
attorneys? And then, are any of these podiatric
sub-specialists worth more to society than an
inner-city high school teacher?

I recently heard a primary care doctor brag about
how many RVUs he generates for the hospital by
sending pre-op patients for Cardiac CT scans. The
PCP’s salary is predicated on how many RVUs he
generates not on workload. Suddenly legal has
become blurred with ethical. If the podiatrist
only corrects one hammertoe at a time, there would
be a lot more RVUs generated over the course of
eight OR visits. This was tried once in Michigan
with the promise to the patient of a year off work
and continuous Percocet.

With all this RVU emphasis we run into the problem
of how often a controlled diabetic really needs to
see a podiatrist for the “prophylactic foot exam.”
If a NP can look at a foot and determine its high
risk or in danger and refer the patient to a
podiatrist if needed, would that be acceptable?
Or does that protocol threaten me and my practice
however much it might be beneficent because I am
profoundly impressed with my education, knowledge,
and experience? Or is it a question of greed? Do
we simply deny our greed or have we become very
good at justifying it? How much of anything is
enough? Maybe a fair share for all is the answer
and eat what you kill philosophy is actually
immoral?

Have we put ourselves into an existential crisis?
By that, I mean could we be facing extinction of
our profession as we know it. Ontario accepts no
new podiatrists. Only chiropodists are licensed,
and podiatry will cease to exist when the last
registered podiatrist retires or passes away. A
DPM who wishes to practice in Ontario will be
registered as a chiropodist. Why? The government
has figured out other health care professionals
can perform a podiatrist’s job at a lower cost to
the government.

In the US, state legislatures have tried to
exclude podiatry from state funded Medicaid.
Nurses can apply substitute skin grafts to
diabetic ulcers and get paid 75% of what a
podiatrist would be paid for the same procedure.
By this time, we should have all learned the
bottom line is economics. The state boards of
podiatry examiners are impotent to change what the
legislature has mandated as the law.

Obviously, the insurance companies have figured
out they can pay the board-certified RN much less
for nail cutting and callous trimming than they
pay a podiatrist. There seems to be someone ready
to step in and perform everything we podiatrists
perform as a profession, and many of those
procedures for less money. They may not perform
the procedures as well, but they complete the task
and may impersonate our credentials. Instead of
contemplating an existential crisis, we might want
to think about an existential ethical approach to
what we do as a profession based on authenticity.
In other words, be who we are and be that well.

Are we currently being ethical in how we wish to
portray our profession? Have we formed an opinion
about “added qualifications” based on potential
monies or greed or do we have the interests of the
public as a priority and the entire profession as
a close second? When our own house is in order,
we will be able to negotiate from a position of a
unified moral high ground. It’s much better to be
authentic than insecure. Insecurity leads to
litigation. In the mid 1980’s podiatry supposedly
endured the lawsuit to end all lawsuits, like WWI
was supposedly the war to end all wars. Many of
the folks involved in the present podiatry
controversies had not reached the age of reason in
1983. At that time MIS was anathema, now it is
the chic surgical method de jour.

Surgeons have attempted to legislate surgical
competence by sitting around a table in a group
discussing perceived proficiency based on numbers
while making sure they themselves have met those
numbers. There are “cosmetic surgeons” performing
plastic surgery cases in surgical centers because
they do not have the numbers to qualify for
teaching hospital surgical privileges. But their
board certification has an added qualification.

After the 1980s lawsuit we all came away pleased
with ourselves and the results. Everyone, again
supposedly, got what they wanted, the plaintiffs
got what they wanted as far as being able to call
themselves board certified while the ABPS surgeons
made sure the MIS surgeons were differentiated and
marginalized. Everyone got the “more” they wanted
and the only injuries to the constituents were
some dislocated shoulders suffered from patting
themselves on the back because they had supposedly
won. ABPS thought MIS would go away with time and
no new MIS surgeons would become board certified
while MIS surgeons could now proclaim themselves
board certified podiatric surgeons.

The real question is whether an added
qualification in surgery or whatever subspecialty
you choose diminishes someone else’s
certification. In the sports medicine department
at Ohio State there are orthopedic surgeons who
complete a five-year residency and there are
family doctors who complete a three-year
residency. Both then complete a one-year
fellowship in sports medicine, one surgical, the
other not surgical. Does the orthopedic surgeon
feel threatened because both use the term
fellowship trained?

Here we are again at the same crossroad. How could
this be if both parties got what they wanted? We
were greedy and we thought about ourselves when
compromising and everyone thought they were a
winner. Everyone except the profession and how
it’s perceived. What did we learn in the last 40
years? We came to understand real compromise
means we all leave the negotiation table somewhat
disappointed but improving society.
Existentialism as a philosophy studies the fact
that we are condemned to make choices and
emphasizes not to make a choice is really making a
choice. But we are free to choose from the
options. Each choice effects who we are as a
person and a profession while creating both a
personal and professional essence. That essence
is what other people and other professions see.

We have digressed into chaos, but as Leonard Levy
used to say, the Chinese character for chaos is
identical to the character for opportunity. We
think we win or lose, but it’s our profession that
wins or loses and podiatry needs to keep that in
focus. Many universities have adopted a slogan
that mimics, “We are Penn State” or whatever
school we represent bubbling with pride in that
institution. We need to be proud to say, “ We are
podiatry.” And not, “We are me.”

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

There are no more messages in this thread.