Many medical specialists created a surge of new
patients by alerting the public to a possible
catastrophic malady germane to their specialty and
only they are properly trained to handle the
problem. Gastroenterologists are the magicians of
guiding the colonoscopy around flexures and blind
turns, although you can now get a pseudo-
colonoscopy delivered to your front door in a
brown wrapper box. Twenty-five years ago
urologists taught us that PSA was not something to
be considered when picking a bunion procedure and
it was imperative to get one every year or so.
Dermatologists discovered that hydrocarbons caused
a surge in melanomas, and we all needed a biopsy
of that lesion on our back and to be sure there
weren’t additional lesions someone missed, we
better have a dermatologic screening.
What used to e crisis dentistry where you only visited the
dentist when you were in excruciating pain is now
replaced with adult braces and oral implants. And
of course, the orthopedic surgeons have become the
Cinderella surgeons of pain free joints for life.
You can see where I’m going here and I ask you to
think about what we may be creating, be it good or
bad for the profession. I am the first to espouse
to the maxim, “Be who you are and be that well.” I
don’t think that there is any doubt that we are
the gate keepers who run point on diabetic limb
salvage.
But are we limiting ourselves and
becoming diabetic foot doctors in the eyes of the
rest of the medical professions? Are we getting so
good at that aspect of podiatric medicine that
other medical specialties are pigeon-holing us
into the double-edged sword of limb salvage even
if we don’t want to treat those patients? That
aspect, limb salvage is indeed rewarding,
satisfying and beneficial to society, but it is
tedious, patience testing and fraught with danger.
It is so dependent on patient compliance that a
short lapse in strict adherence on the diabetic’s
part can result in a septic patient needing an
amputation to save a life.
There are days full of ulcer patients who are
still smoking and lie to your face about it. They
light up after every candy bar and are on the
verge of sepsis. We as the treaters are condemned
to smell that smell which is not the smell some
want to smell, as the song goes. But you can’t say
“No” to that referring family doctor who has never
seen anything like what this patient has and
naturally they must be seen immediately. This is
really urgent care and as the masters of this
particular crisis we see all too often. We must
muster all the troops needed to handle this
predicament. It is easier to herd a clowder of
cats than to get the interventional radiologist,
endocrinologist, vascular surgeon, internist, and
plastic surgeon in the same space or even virtual
place at the same time.
Maybe we must take this new patient to the OR tonight after sitting down and spending an hour with the family explaining
what might happen if we don’t begin the surgical
intervention during the first inning of our kid’s
softball game that we will miss. The patient ate
on the way to the hospital, but we haven’t had
anything since that protein bar we ate between
patients seven hours ago but not to worry, it has
been supplemented by a couple quarts of coffee.
Some podiatrists may enjoy living like this and
flourish on crisis podiatry, but it’s not for
everyone, especially people on the verge of
burnout. There are those people who like emergency
trauma surgery, usually restricted to Level 1
trauma centers.
As of today, 152 American emergency trauma surgery fellowships have gone unfilled for this year, meaning the vocation is not that desirable. The adrenalin is there, but the quality of life may not be. I’ve been involved in
a couple of 16-hour surgeries. That’s about as
long as it takes to fly from Delhi, India to
Chicago. After the first few hours the fun is gone
and phlebitis starts to settle in. Do all podiatry
practices that concentrate on diabetic salvage
evolve into crisis foot and leg salvage? Once your
reputation gets out there as a wound care maven
are you compartmentalized? Can a young
practitioner, drowning in debt say, “No” to a
referring doctor who wants to help out the new
kid?
If you join a salaried practice, can you say,
“I don’t do that?” MD physicians often do a
fellowship and stick to it? Can a new podiatrist
fellowship trained in limb salvage have the luxury
of doing an occasional lapiplasty and picking the
type of patient they want to see from day one?
Diabetic limb salvage is a hard career fraught
with danger for the podiatrist. There are
podiatrists who supplement their income by
testifying against podiatrists who have patients
that go bad.
We try to save every leg but can’t.
Jealousy still exists in all medicine and some
folks think they should be the only one caring for
serious diabetic limb disease just like some
podiatrists think they should be the only ones to
ORIF tri-malleolar fractures. We have decided each
of us has become the standard of care and we talk
about others behind their back. It is a passive
way of pumping ourselves up if we need it.
When podiatry initially came out of the office and
into the hospital we needed to establish
credibility. Hence board certification as foot and
ankle surgeons with multi-year residencies was
started. I was in that group but can’t remember if
diabetic ulcer cases were accepted for board
certification cases or how much of the orals or
written was dedicated to limb salvage. The board
certification process examined a clean specialty.
Now, we have one board in surgery. The American
Board of Foot and Ankle Surgery.
Podiatrists are devoting a significant part of
their practice to limb salvage and somehow this
sub-specialty needs to become officially
recognized and certified for lack of a better
term. It shouldn’t be a sticker on a diploma.
ACFAS and the schools have issued policies and
algorithms for decision making when surgery is
being considered. Diabetic limb salvage to too
complicated and too fluid for a simple path
analysis to determine levels of debridement or
amputation, let alone what is acceptable. There
are too many tissue substitutes and products on
the market to randomly choose one to use on all
the patients. There are fellowships in shoulder
surgery because the common orthopedic surgeon may
not really understand how the rotator cuff works.
They are board certified orthopedic surgeons, but
there are fellowship trained shoulder
orthopedists. They usually limit their practice to
the shoulders.
Podiatrists who have completed a limb salvage
fellowship and devote most of their practice to
limb salvage should be examined in limb salvage
and guarantee continued mastery by being
recertified in that realm of podiatry. Limb
salvage is too critical to just dabble in. Maybe
there will be one board for podiatry but I think
there should be a recognized Association of Limb
Salvage for those podiatrists who devote their
practice to that sub-specialty and continue to
show their high proficiency in that area. On one
hand, should the limb salvage podiatrist perform
an occasional Lapiplasty?
On the other hand, should the person performing bunionectomies and other reconstructive surgeries on a daily basis save an occasional contaminated diabetic ulcer
debridement till the last case of the day. It’s
time we podiatrists start thinking about how we
podiatrists think about podiatry.
Rod Tomczak, DPM, MD, EdD, Columbus, OH
