11/27/2024     Rod Tomczak, DPM, MD, EdD

Who Determines the Standard of Care?

The term "standard of care" has been bandied about
recently in a few postings in PM News. One author
seemed to impugn whether the standard of care had
been breeched because a patient had sought
treatment from another podiatrist rather than from
the author because the author of the letter was in
his humble opinion, the standard of care, and if
you read between the lines, also the gold
standard. That is an absurd assertion.

The standard of care, not the gold standard, is
the level at which an ordinary, prudent
professional with the same training and experience
in good standing in a same or similar community
under the same circumstances would perform. This
is not the “average podiatrist since that would
mean half the foot and ankle physicians would not
qualify. The plaintiff must prove the standard of
care was not met by the testimony of an expert in
order to achieve a judgement in favor of the
plaintiff.

My question for the podiatry community is, “Who
decides what the standard of care is and how is it
accomplished?” My question is based on how the
standard of care is generated.

Textbooks are nice sources of old knowledge, but
they usually become obsolete before the ink is dry
in the book. Medical knowledge is exploding and
what was true yesterday may not be true tomorrow.
Often the standard of care is based on research at
a reputable institution and published in a
refereed journal. That means when six cases of
plantar fasciitis are treated in a walk-in clinic
and results published in the Obscure Journal of
Medicine or the Journal of Non-Reproducible
Results these thoughts will not qualify as a
standard of care.

So, who says that the mnemonic acronym RICE is now
obsolete? Rest is no longer advocated for a
sprained ankle and early rehabilitation is
recommended. Is a Lapiplasty the standard for a
high IM and only a high IM bunion? Will the mini
and micro Lapiplasties soon become the standard of
care replacing the original Lapiplasty? At what
stage in the plantar fasciopathy algorithm is an
endoscopic fasciotomy indicated and justified?
The new knowledge needed to answer these questions
is ideally generated at a university or research
institute.

This type of knowledge would seem to hold the
highest level of credibility, especially when
reproduced at a similar venue. A drug company
flier interpreted in court or at deposition by a
big pharma talking head in need of extra cash
rather than someone in search of the truth is not
the standard of care. This is hardly the desired
level of credibility that is sought after and
should be viewed as such. The data should be
reviewed by respected clinicians/scientists and
published in respected journals to become the
standard of care.
T
his best practice scenario is lacking at a couple
steps for we podiatrists. I recently perused this
year’s JAMA and JFAS to see where the published
research was done, and by whom it was done. This
is not, by any means, a criticism of the journals.
Their growth in range and depth are amazing,
especially when compared to articles published
when I was a wet behind the ears podiatrist who
knew mostly everything and what I didn’t know
about podiatry wasn’t worth knowing.
Unfortunately, many of the current authors are
non-American MDs working at universities around
the world. I am not an old-time jingoistic foot
and ankle care giver.

I was a baby boomer exchange student for my junior
year of high school, and in later life I opened MD
schools in Belize, Saudi Arabia and Curacao. I’m
not sure about the answer to the question, “Are
the standards of care for we American podiatrists
being generated abroad or by American MDs?” It
must then logically follow that the institutions
where this knowledge is being generated are not
podiatry schools where we received our degrees.
So, is the standard of care for American
podiatrists being spawned by MDs at MD
universities in the US and around the world?

Faculty at our podiatry colleges and in residency
programs are using articles in our journals
created by MDs, many of them in other countries as
the source to teach young students and residents
what the protocols and standards ought to be. Are
there cultural, socio-economic differences in
those countries or among MDs in large universities
that are making the standard of care bar too high
for the office bound podiatrist trying to make a
living, pay off loans, buy a house, and raise a
couple kids impossible to meet? Is a salaried MD
or DPM at the Best Medical University or an MD in
a country where the economic picture allows the
students to drive a BMW establishing a standard of
care which is impossible for the new podiatrist to
meet?

If there is even a possibility any of the above
are true, how do we fix it? The supply chain of
medical information that results in the standard
of care must be modified to include more input
from our podiatry schools. We are now at
universities with medical schools. I even have a
diploma from Kent State that says I attended the
non-medical school university famous for two
things. The second is its football team ranked 134
out of 134 college football teams. I’ve never set
foot on the Kent State campus. Aside from that
humorous digression, of all the foot and ankle
articles I perused in JFAS only one originated
from a podiatry school, Texas, Rio Grande.
Are we currently affiliated with major
universities for economic or credibility issues?
Or both?

One of the reasons a school becomes a credible
institution is for the research it produces, and
research is historically one of the criteria for
tenure. When researching the review of the
literature for my doctoral dissertation I
discovered an obscure fact. Shortly after WWII
,Case Western University instituted an innovative
integrated medical curriculum that was to become
the model for most US medical schools. OCPM was on
the verge of closing and Case Western offered to
assimilate the failing OCPM. It never
materialized. Hahnemann University College of
Medicine closed because it was originally a
homeopathic school. No matter that it gave up that
affiliation decades ago it could never lose that
reputation. It closed momentarily and became
Drexel College of Medicine and suddenly became
credible.

It really is time for our eleven podiatry schools
to start producing new knowledge and publishing
these research findings, making us the masters of
our own standard of care. As pseudo-alumni of
these medical universities we deserve to know why
this isn’t happening and why we must depend on
outside institutions to determine how we practice.

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

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