03/11/2024    Rod Tomczak, DPM, MD, EdD

A Short History of Podiatric Discontent and Frustration (Michael Uro, DPM)

I could not be more pleased than I am with the
responses from Drs. Uro and Jacobs. I have never
met Dr. Uro, but I’ll posit the two of us would get
along famously. Dr. Jacobs was one of my trainers
when I was a resident and we have been good friends
from the first day. When I taught in Des Moines he
graciously took all levels of students, inspiring
all of them to become excellent clinicians. When I
had to make podiatric relevant decisions, I always
thought WWJD, but refused to wear a bracelet
advertising such.

I applaud Dr. Uro for having the courage to say he
would not recommend podiatry to a college student
today, in spite of the fact he loved the profession
for 45 years. This begs the question why he would
not recommend something he thinks was so
remarkable. I can only postulate, and I may be
wrong, that he is not fond of the changes he has
seen and the direction we are going. There is no
debating that this new generation has not seen the
early days of chiropody evolving into podiatry and
how they locked arms to strive for the common good.

When we graduated, we were reveling in our first
fervor, finished training and excited to practice.
In 1979 I was buying a practice of a podiatrist who
had a procedure named after him, Larry Frost, DPM.
A real mensch who had my hospital privileges before
I set foot into Michigan, a license just before
that, and an office staff that had been with him
since I was in high school. He took me to the men’s
lounge at the country club that sported a Donald
Ross golf course and introduced me to the Monroe,
Michigan policy makers since Frost was a past Mayor
of the city.

And then in 1984 things changed. Ford Motor Company
decided to use preferred providers, and although I
was board certified, the area Michigan political
podiatrist who was not board certified became the
preferred provider. This all happened because
podiatrists were operating on one hammertoe at a
time, stringing out patient disability over a year.

I lost more than half my practice. Suddenly, I was
one of the have nots, a without and but with plenty
of time on my hands. I had come to realize I
wanted to teach at a podiatry school, to form new
podiatrists, the next generation which would enjoy
being podiatrists like I did. Now I got to teach
and practice and I figured we at the new school
would be endeared, commended and celebrated by the
city’s and state’s podiatrists. Instead, I learned
the school was visualized as a preferred provider
no better than the Michigan preferred providers who
took all the patients.

This was about 40 years ago and podiatrists began
to bad mouth one another over economic issues,
always the bottom line. We went out of our way in
Iowa to make amends and build bridges, sponsored
and spoke at state seminars. We tried to turn out
graduates better than we were. We were not afraid
if the next generation was better than we were.
But the students realized there were not enough
surgical residencies to go around and suddenly 22
year old students were talking about board
certification and reimbursements. They saw
advertisements for jobs that publicized board
certified or board eligible only openings. This was
a run-away freight train that somehow had grasped
the rich imaginations of students no matter how
much we tried to quell their worries. We were in
the middle of producing a new generation of
podiatrists some of whom would have a hard time
repaying loans.

Yes, we have passed the torch, and as John McRae so
eloquently stated in the poem “In Flanders Fields,”
“To you with failing hands we throw the torch, be
yours to hold it high. If you break faith with us
who die, we shall not sleep.” We wanted to be sure
the next generation held the torch high, an analogy
for preserving all we have gained as a profession.
Excuse us if you sometimes see us as helicopter
parents, because somehow the good old days and the
podiatrists who populated those days are gone and
well, we shall not sleep.

Allen Jacobs, DPM asks you and me if we are
functioning in the absurd wasteland Waiting for
Godot. Allen is not asking if you are making a
living, let alone becoming rich. He is not asking
if you are able to keep your kids and partner in
designer clothes. Absurdity is a product of an
existential belief that if we have not created real
meaning to our existence, that existence is absurd.
The evolution of chiropody to podiatry occurred
when podiatry and podiatrists learned what could be
done when a scalpel is turned 90 degrees from
parallel to the skin to perpendicular.

This movement brought with it a myriad of questions
that have been plaguing the profession since the
partial rotation of the scalpel. Although the
profession has gained the right to do this, does
every member enjoy that right to operate or is it a
privilege bestowed on a few? Obviously this is an
ethics question and quite honestly a difficult one
that podiatry has tried to avoid. Not to make a
decision about this question is to make a decision.
The status quo prevails. Immanuel Kant is the
champion of “rights-based ethics.”

Kant famously put forth his Categorical Imperative
which states we should not subscribe to any
principle of action (or ‘maxim’) unless we could
will it to be a universal law. His second
formulation of this imperative is that we should
treat other people as ends in themselves and not
merely as means to our own ends. We can postulate
this means not everyone should be operating or that
we should operate to generate a lucrative income.
It’s not the end that’s important but the path or
means to the end, our intentions and it should
apply to everyone in that particular case.

The opposite ethical position was originally put
forth by Fletcher in 1966 and titled “Situation
Ethics” and he stated that an action was neither
good nor bad but the outcome determined whether
they were moral or immoral. If the surgeon has
good results the action of operating is determined
to be good if that action of operating is based on
a purity of intention. So, whatever obtains the
most good for the most people should be considered
the optimum utilitarian choice of action. The last
podiatry lawsuit was settled employing a
utilitarian ontogeny.

What made most people pleased was that no one was
taxed any more money, but no one on either side of
the compromise was happy. Minimal incision
surgeons got board certified but with an asterisk
on their certificate. ABPS surgeons complained the
Ambulatory Surgeons called themselves board
certified but had not navigated the same hoops and
hurdles as traditional surgeons.
Will the next dispute be settled employing a
utilitarian philosophy separate from utilitarian
ethics or will the constituents sitting around the
table weigh right versus wrong in a true
existential matter?

The core idea of existentialism is that we are free
to choose. In fact, we are condemned to choose and
thereby create our essence. Everything we do
involves a choice, from getting out of bed in the
morning to going to the office and deciding who is
a surgical candidate, to getting into bed at night.
Some have argued there is no existential ethic but
rather is a moral view where anything goes. Quite
the contrary, we make our choices based on our own
moral platform.

We, and I specifically mean we as podiatrists are
more than trench coated, Gauloises smoking, coffee
drinking, foot doctors sitting on the Left Bank of
the Seine arguing who should be board certified to
no one satisfaction. Instead, since we value our
own freedom to choose, we must also value everyone
else’s freedom to choose. We may not agree, but we
respect their right to choose.

And this brings us to an unrefined suggestion on
how to possibly solve the same old question of
board certification but on the newest time around.
Podiatry could run a complex survey of the
profession concerning the board certification
questions. Not simply, “Do you believe there
should be one board for podiatry?” but, a series of
questions, the answer to one leading to the next
question in the next series, perhaps a week away.
These questions are not fabricated as of yet but
may lead the profession to evaluate how board
eligibility is decided, how many cases are needed
in a residency to become eligible, should everyone
be taking a surgical in-training exam, If one is
board eligible should office cases count toward
certification, can a young podiatrist complete a
non-surgical residency then complete a surgical
fellowship logging a required number of cases?

What do you think about a boarded surgeon observing
you operate? Frost came to the operating room with
me when I started to observe and report to the
staff. The Dean of the medical school stopped by
to see me operate on my first patient at Ohio State
University. One set of questions leading to another
set with the desired end being a suggested
resolution of this age old question that the
profession has chosen, not the hand full of trench
coated, Gauloises smokers sitting on the Right Bank
of the Chicago River making decisions for the
entire profession.

This multi-part survey would be open to any
podiatrist with an NPI number or a special ID for
residents, however, a podiatrist must answer the
first and every subsequent question to remain in
the survey. The unique NPI must be entered with
every series of questions. To not answer a question
disqualifies a podiatrist. When the survey starts,
we answer as a profession, some who identify as
haves, some as have nots.

The profession answers each question ‘Yes ‘or ‘No’
or perhaps ‘I don’t know’ hopefully with an eye on
the future of the profession. It may be scary to
think about the outcome, but the outcome will be
utilitarian and profession wide, not made by a
handful of individuals imposing their wishes on the
profession. There is no inquisition, no trial, no
lurching toward the carotid, just an authentic
gleaning of information about how 45 or 50 years of
a profession sees itself in light of today’s
healthcare arena. Just maybe the data generated
might be useful.

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

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