12/04/2024    Rod Tomczak, DPM, MD, EdD

“I Have Built a Monument More Lasting than Bronze…”

Exegetes agree that when Horace put quill to
papyrus in 23BC he was not writing about Rome, but
rather himself and his poetry as a monument. So
far, he has lasted more than two thousand years
and it looks like he’s still going strong. To
those who had the courage to major in Liberal Arts
it appears he’s good for another thousand at
least. I will not be present to see if he’s still
quoted in 3025. Podiatry is an evolving
profession. Some practitioners remember when we
were called chiropodists. We are a relatively
young group of specialists looking for an identity
amongst the numerous existential pressures that
jeopardize the potential unity and threatens to
tear us into a bunch of splinter groups. Denying
this threat is the worst thing we can do.

I’m willing to bet that podiatric board
certification, the sine qua non of any medical
specialty, will not look like today’s
certification even 20 years from now. There’s a
good chance I won’t be around for that either.
There are people who don’t want to see a change,
especially to a single board. A straw poll in PM
News shows most podiatrists do favor a single
board. Why are there podiatrists who want multiple
boards? It seems to some we need to emulate
exactly what orthopedic surgeons do to earn and
maintain board certification. There’s one inherent
problem with that philosophy.

We are not orthopedic surgeons. Their
certification is fine for them. If you want to do
it their way, become an orthopedic surgeon. Their
profession is built to perform surgery. You cannot
sit there and say podiatry is built exclusively to
operate. Yes, that is one tool in our toolbox, but
not the only tool.

You’ve heard the saying, “If the only tool in your
box is a hammer, the whole world is a nail.” We
are more diverse than just hammers. Forty-eight
percent of the respondents to the recent PM News
poll that asked who the biggest competitive threat
to podiatry is, answered nurse practitioners. The
last time I looked, they don’t operate. Nurse
practitioners don’t want to be doctors or
surgeons. I have two daughters that are advanced
practice nurses, and they do not want to be
podiatrists or physicians.

A little less than twenty percent of the
responders in the poll answered orthopedic
surgeons were the biggest competitive threat to
them. You may not like orthopedic surgeons, but
there is nothing to fear from them and don’t say
weakening our certification processes will give
them ammunition. They don’t care about our
certification process; they are too busy
operating. If you’re thinking foot and ankle
orthopedic surgeons care about our certification
process, I think it’s because they fear us. That’s
why they are making noise with lady-finger
firecrackers.

Should anyone be worried about our board
certification process? Yes, we should. Board
certification means one is minimally qualified to
practice. Minimally qualified. The letter to a
hospital from an orthopedic fellowship director or
a residency director along with board eligibility
suffice for OR privileges for the MDs and DOs.
They have passed their in-training exams. For
podiatrists the way we used to do things just
doesn’t apply anymore. No more than Horace jotting
down his poetic thoughts today with quill and
papyrus. No, as comfortable as he was in 23 BC,
he’d probably use a new $2500 desktop iMac or
something similar today.

For podiatry, we need a board eligibility, board
certification process that satisfies the entire
profession. It must indicate everyone using a
blade perpendicular to the skin is minimally
qualified or no surgical privileges. The new
attending should have a reasonable amount of time
to become board certified. We have in-training
exams. Residents and fellows keep logs. Directors
have the responsibility of seeing they are
accurate, and they should be held accountable not
to rubber stamp documents. Some podiatrists lucky
enough to join an orthopedic practice have
rearfoot and ankle cases fed to them because ABFAS
certification rewards the reimbursements for the
entire practice. The solo practitioner not lucky
enough to find themselves in that catbird position
must look for cases.

I was fortunate to take over a practice in a town
with no orthopedic surgeon and no other podiatrist
who worked regularly in the hospital. The ED
physicians liked me and fed me foot and ankle
cases so that I became boarded as soon as
possible. Others are simply not that lucky. There
must be a vehicle to show they are as minimally
qualified to operate as the lucky podiatrists who
get cases fed to them. This alternative process
must be equal to the current route to surgical
certification in as far as knowledge and
kinesthetic tactile skills are presently
demonstrated. It must be as rigorous or it is not
valid. There is no wiggle room here, none.

Those podiatrists who already have the credential
they want cannot think they “…are higher than the
pyramids regal structures. That no consuming rain
nor wild north wind can destroy…” (Horace’s next
line). There’s always someone on the horizon
poised to take over, be it a smooth Hannibal, a
simply vicious Attila or an unethical Machiavelli.
Every decision maker in this process must be
Plato’s philosopher king who rigorously pursues
truth and possesses true knowledge, not relying on
value judgements, opinions and personal beliefs.
Concepts must be grounded in truth and truth is
what exists in reality. This goes for all parties
involved in the decision-making and the decision
meetings cannot be an after-game Ohio State-
Michigan brawl.

Parties must realize compromise is inevitable to
make true progress. Can a wok, DEI believing
podiatrist think the status quo should be
maintained without violating their convictions and
belief system or are there gross misunderstandings
of fact relative, belief relative and evidence
relative systems? Decisions generated would need
to be moral and ethical resolutions because of
wide spread ramifications. Lack of such is the
basis for the existential threat. There is no room
for not getting involved. To not get involved is
to cast a vote.

So what happens if an alternative, acceptable, and
safe route to certification cannot be generated?
What if ABFAS simply refuses to negotiate since
they believe they are that bronze monument and
feel compromise is unnecessary? This is
unpalatable and untenable because the profession
desires mandatory arbitration and they believe a
single board is still possible. APMA, CPME, and
whatever other alphabet groups are involved in the
decision making process would need to come
together for the future of podiatry and inform
hospitals and surgical centers that ABFAS no
longer is the exclusive certifying board for
podiatry and has no desire to be included in the
profession’s future board certifications. I don’t
like it either.

Should this come to arbitration ABPMS must
construct a cogent and viable alternative plan for
certification. It must be as rigorous as ABFAS is
now, ensuring minimal surgical qualification. No
back door approaches. Years ago, someone from
ACFAS came to observe the surgeons who wanted to
become ACFAS fellows. That’s thinking outside the
box. If someone is as adept at ankle/rearfoot
surgeries, let a yet to be determined surgeon
watch them perform a bimalleolar ORIF or whatever
is decided on.

There are eight “specialties” in the ABMSP
organization. Can a person get certified in all
eight? Even Scouting America (formerly Boy Scouts
of America) requires a certain level of proof of
competence to award a merit badge to sport on a
scouting sash when dressed in uniform. It’s the
responsibility of ABMSP to come up with a
certification process that is acceptable to the
entire profession. It is not ABFAS’s
responsibility to develop tasks and tests to
ensure minimal competence in primary care, sports
medicine and geriatric medicine. But even Scouting
America has strict requirements to earn a badge.
And sadly, like podiatry, they have had to weather
multiple lawsuits.

Since these are all facets of the unpolished
podiatry diamond, perhaps there should be an exam
after residency that tests all these specialties
that are the essence of day-to-day practice. Maybe
the whole paradigm of certification in podiatric
medicine and surgery needs to be re-examined based
on a new mission statement. Just because we have
always done something a certain way does not mean
it is the way things should be today in
preparation for tomorrow. If podiatry really
examines itself in light of a new mission, there
is a chance discovery will result in a lot of
unhappy young podiatrists. The podiatrists who are
rearfoot and ankle certified will want to preserve
the status quo and those who perceive they are on
the outside want the system changed. Let’s be
honest with ourselves. There is more podiatric
diabetic foot care being done than flat foot
reconstructions and malleolar fractures together.
The later are not the Cinderella of podiatry
because they say they are.

When I started podiatry school over 50 years ago,
I had no idea of where it would take me, what the
new potentials would be, what the roadblocks
consisted of and how much effort it would take to
overcome them. Physician assistant applicants must
spend 2,000 hours in patient care before applying
to PA schools. That figures to be fifty 40-hour
weeks, hopefully spending time with different PAs
in different specialties. If there was a
requirement for potential podiatry schools to make
this a necessity, the podiatry schools might balk
at the recommendation fearing loss of potential
students to other medical schools.

In MD and DO schools, I can unequivocally tell you
some students never want to see blood as a
practitioner to the point that a long general
surgical rotation as a third-year medical student
is no longer required. I know of a couple podiatry
students and practitioners who do not want to
operate. Why should they match into surgical
residencies if they know that is not what they
want to do? But, they must graduate a residency
with the ability to speak all facets of the
podiatry diamond and refer to the proper
practitioner.

Those already certified by organizations they want
to be certified by are going to push back. They
will say to themselves we have what we want and it
is the correct process that got us here. This is
analogous to the Catholic Church saying they are
infallible because they say they are infallible,
and that belief is correct because they are
infallible. That’s called circular logic. We are
too smart a profession to succumb to circular
logic. Syllogism logic is more appropriate. Let’s
also remember half the profession wants one
certifying board.

Those wanting the change must come up with an
acceptable route to change, not just a concept.
The whole profession must approve it since we are
all stakeholders and we all must put the brakes on
a break-up that will come without preemptive
action by our profession. We must start paying
real attention to the horizon and quit pretending
there is a red sky every night. I see a red sky in
the morning and it’s time to reef the sails lest
hospitals, surgical centers and insurances do it
for us and to us.

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

Other messages in this thread:

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12/16/2024    Robert Kornfeld, DPM

“I Have Built a Monument More Lasting than Bronze…” (Rod Tomczak, DPM, MD, EdD)

There is no question, and I have been a witness to
this for well over 40 years, that we are supremely
well trained in recognizing and treating foot and
ankle pathology, but we have literally no
training, outside of biomechanics, to understand
the underlying mechanisms of pathology. If we had
this training, this comprehensive understanding of
the human body, we would have much better
acceptance by our MD/DO colleagues and we would be
much better physicians. Functional medicine
provides this in-depth understanding of why a
patient has crossed the morbidity threshold and is
sitting in your office. As doctors, it is our job
to manage the causes prior to treating the
symptoms. Even if your patient improves from what
you did, the unaddressed mechanisms will lead to
new pathology in the future.

If we continue to function as we have, trained in
the foot and ankle but not in the whole body, this
profession will certainly not survive into the
future. But a comprehensive understanding of body
systems, immune burdens, epigenetics, SNPs and
other genetic markers as they relate to the
patient's medical history and review of systems
gives you the information you need to address
these issues.

I have been asked if it is out of our scope to do
this. The answer is definitely no, since they
relate directly to why a patient cannot repair
cellular injury in a timely way or undergo
degeneration in the foot and ankle. Let us not
forget we are licensed to suppress the immune
system (NSAIDS, steroids, etc...), we are licensed
to affect changes in the CNS (narcotic analgesics,
SSRIs, SNRIs, etc.) and all of our prescriptions
involve systemic treatment. They do not go only to
the foot. Case in point, even with a local steroid
injection, blood sugar elevates. So why not
support the patient back to improved health, lift
the immune burdens and then, with a more efficient
immune system, you can apply natural therapies and
regenerative medicines to heal the presenting
symptoms.

I have been practicing functional medicine and
regenerative medicine for decades and I can tell
you after treating thousands of patients this way
that it is true healing. And I would rather be a
healer than a "provider of service" that is
relegated by insurance companies to address the
presenting symptoms and nothing else.

Let's be all we are capable of being. IT'S TIME
FOR A CHANGE OR TIME WILL RUN OUT!

Robert Kornfeld, DPM, NY, NY

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12/12/2024    Rod Tomczak, DPM, MD, EdD

RE: “I Have Built a Monument More Lasting than Bronze…” (Allen M. Jacobs, DPM) From:

Every time I see an Ingmar Bergman film, I’ve
already seen a few times before, like “The Seventh
Seal”, I don’t understand it again, but in a
different way from the previous viewings. So it is
with podiatry and all the issues we are now
facing. I don’t understand these problems again,
but in a different way.

The enrollment at our podiatry schools is
declining as Dr. Jacobs states while we continue
to open more schools with enrollments in each
class numbering in the 20s and 30s while the MD,
DO, PA, and NP programs increase enrollment. I
have two daughters who are NPs. One is a nurse
anesthetist making an unbelievable salary working
four days a week and taking call one weekend day
every couple months. She had an undergrad nursing
GPA of 3.9 and worked as an RN in a level I trauma
center for six years. The other is an advanced
practice nurse with 120 patients in an extended
care facility. She sees every patient once a week
and works one day in an aesthetics spa.

Both make more than I did at the height of my most
productive days. The salary was not the first
reason they chose advanced nursing over podiatry.
They don’t take call like I did and are home for
dinner every night, and don’t have to go to the
ED. The NP has prescribing privileges broader than
I ever did as a podiatrist, and the CRNA uses
medication I had to look up. They work with
patients that are honestly sick, something they
chose to do. Through their work they have gained a
new respect for what podiatry does with diabetics.
They, as providers don’t know if a podiatrist is
board certified.

I think the profession lacks exposure to college
students before they start to apply to healthcare
professions schools. I don’t think the majority of
the public knows what a podiatrist is or how one
gets to be a podiatrist. I was lucky enough to be
exposed before I ever applied to any school. A
podiatrist had me in his office assisting on
forefoot cases. Somehow the premed advisors of
colleges across the country have to be made aware
of our existence. Why can’t the podiatry students
in our eleven schools visit the undergraduate
programs where they went to school and talk us up
as part of their curriculum? They can talk to the
advisors and the students at the same time and
explain who we are. For that matter, young
podiatrists can also visit their colleges. I
really believe there is widespread ignorance of
our profession.

I think Dr. Jacobs and I both see no problem with
a limited license. Your dermatologist isn’t going
to treat anything other than your skin, and they
have no ego problem. In many states, pathologists
can not prescribe anything. Anesthesiologists
can’t treat diseases in most places. They can live
with the fact they put you to sleep and wake you
up. They are not fighting to treat your
hypothyroid. Is it simply because they get to add
MD after their names? Is it because orthopedic
surgeons get paid more than we do for the same
procedures or is there parity? Maybe the moneys
generated from issuing a podiatry seal of approval
or acceptance can be used to research that topic.
Maybe the limited licenses these specialties have,
but are still MDs or DOs can guide us. Instead we
fight over board certification. It’s like a
Bergman film, I don’t understand in a difference
this time, again.

Dr. Jacobs and I agree we are a lot like dentists.
They have different board certifications. There is
also the American Board of General Dentistry.
About 1% of dentists are certified by that
organization. No problems with the dentists who do
not have that shining spotlights on a certificate.
Is your dentist certified? Did you ever look?
Then they have the American Board of Dental
Specialties (ABDS) with four dental specialties.
Does this sound familiar? It recognizes implant
surgeons, oral medicine, orofacial pain, and
dental anesthesiology as specialties. Their
website details in depth what they are required to
do to get certified. There doesn’t seem to be much
of a problem about certification in dentistry. So
why is it a big deal in podiatry? The same Bergman
movie and I don’t get it again.

I think tuition and fees for podiatry schools run
around $65-$75,000 per year. That’s not going to
come down. A $2,000 scholarship by APMA hardly
makes a dent in the overall payback, but there are
a lot of glossy pictures in APMA news about these
scholarships that serve to recruit future APMA
members. What is the ratio of APMA to non-APMA
members out there practicing and do the non-
members think APMA doesn’t do anything? Is
belonging to the APMA worth the cost? Same film
again.

When the Iowa podiatry school opened in the 1980s
it was all about the money. Leonard Azneer, PhD
the president of what was called the College of
Osteopathic Medicine, the second oldest DO school
realized it would cost him virtually nothing more
in expenses to load the DO classrooms with more
students. He decided to start a podiatry school
and put the students into class with the DO
students. At first, the PhDs who taught almost all
the first two years at the Des Moines DO school
using integrated systems courses almost revolted
because they felt they would have to dumb down new
lectures to accommodate the less intelligent DPM
students and prepare a second set of exams that
were less stringent.

Making the DO curriculum less rigorous might
jeopardize the DO students when it came time for
their step I boards. Azneer told the faculty to
change nothing. An integrated curriculum means
that under the title of a cardiovascular system,
the students would be taught cardiovascular
anatomy, physiology, pathology, pharmacology, and
surgery. Most medical schools that use a
lecture/discussion method of instruction use this
curriculum.

The DPM students took the same exams, word for
word as the DO students and did just as well.
Immediately certain podiatrists began to clamor
that if they took the same classes and exams, they
should be granted a DO degree. After the last exam
at the end of the second year, the DO students
left the campus and headed to two years of
hospital clinical rotations that included a third
year of family practice, internal medicine,
general surgery, gynecology and obstetrics,
psychiatry, and emergency medicine. Podiatry
students stayed in Des Moines and went to a year
of podiatry clinics including podiatric medicine,
podiatric surgery, and biomechanics.

That third year makes all the difference in the
curriculum. Sure, some patients brought a grocery
bag full of orthotics and smelly running shoes to
the biomechanics clinic. They complained of a
history of patellar pain that occurred when
running 120 miles per week but disappeared at 115
miles per week. This scenario may qualify as
having a psychiatric component, but it hardly
meets the requirements for a month-long
psychiatric rotation.

During the fourth year, DO students spent more
time in hospitals doing sub-internships and
general medicine clinics with electives in what
they thought they would like their residency to be
in such as neurosurgery. DPM students spent time
in outside hospitals and offices devoting time to
podiatry. There was no need to explore since all
DPM students would be doing a residency in
podiatry.

When DPM schools began to join or merge with large
MD granting universities the idea was to save
money on PhD faculty. The first two years of
podiatry school could be with MD students at no
more cost to the MD programs yet glean more
tuition without additional expenditures. Des
Moines had been doing this for years. In addition,
grant research opportunities might be available to
DPM students and maybe some more hospital clinical
rotations. The Liaison Committee for Medical
Education (LCME) and the American Association of
Medical Colleges (AAMC), the accrediting
organizations for MD programs had other ideas.
Suddenly throwing DPM students into MD rotations
which had MD students, university nursing
students, interns, residents and fellows diluted
the faculty to student ratios and was often
frowned on by MD accrediting agencies.

You can see from our literature there is not a lot
of bench research being done by DPM students at
these universities where PhDs would love to stuff
their portfolios with original papers to bolster
their tenure applications. Students are also busy
getting master’s degrees in public something or
other qualifying a podiatrist to be on a hospital
committee that no MD wants to be on. You can bet
if an MD wanted to be on the committee, they would
be,

With a three-year residency, podiatrists should be
able to understand most of the MD language in the
hospitals and journals plus contribute to a
conversation on the next generation dialysis
machines. We’ve come a long way, but it’s on a
different track than the MDs because of the third
and fourth years in the curriculum. Podiatry is
not built that way. not even in the same universe
or even a parallel universe. But yet we still
think we deserve an MD degree. I have seen this
movie innumerable times and never understand it,
again.

I spent 10 naïve years at the Des Moines school
reveling in the “ignorance is bliss” mushroom
atmosphere. To refresh everyone’s memory, the
mushroom atmosphere is where they keep you in the
dark and feed you organic fertilizer. I even
suggested an “experiment” where a few DPM students
would be on a combined five or six year DO/DPM
plan. A dozen students enrolled in this curriculum
and were well into the first year when the DO
accreditation people and the Des Moines Board shut
the plan down. Eleven out of the twelve students
opted to stay in the DO curriculum. When I
interviewed at Ohio State Medical School, I told
the interviewers I was prepared to come to an MD
school, be on their curriculum committee and chair
the Problem-based Learning tract because I had
done those things in the DPM college at Des
Moines. They hired me anyway.

All in all, it seems we are characters in a never-
ending movie. It is just looped to play over and
over. There is no beginning or end. We are just
waiting. Maybe years of waiting for Godot. The
characters are frustrated and finally realize
Godot will never appear and the only choice is to
hang themselves from that tree and they can’t get
that correct. Or like Sisyphus, don’t give up and
just re-roll the rock up the hill only to see it
roll down. Neo-existentialists assert Sisyphus
finds no purpose in his task but embraces the
rock. He admits to himself he finds no new meaning
in the thousandth time he has seen the movie and
admits he doesn’t understand his task, but still
holds the rock dear. Is this the fate of podiatry
or will someone with a lengthy future in the
profession help redefine podiatry?

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

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12/11/2024    Allen M. Jacobs, DPM

“I Have Built a Monument More Lasting than Bronze…” ( Rod Tomczak, DPM, MD, EdD)

Mark Twain stated “Never argue with stupid people.
They will drag you down to their level and beat
you with their experience “. With specific
reference to the question of wither podiatry,
there are realities which in my opinion are stupid
to ignore. Stupid, meaning lack of common sense.
Why is there a concerning decline in the
application pool to the colleges of podiatric
medicine? That is a reality. Those educational
facilities awarding an MD, DO, PA, NP degree are
overwhelmed with applicants. Why do all these
alternative degrees maintain a broader scope of
practice including diagnostic and therapeutic
interventions than a DPM degree maintains? The
reality is that of education. That is reality.

Those holding a DDS degree may diagnose and treat
within a limited scope of anatomy. Those holding a
DPM degree may similarly diagnose and treat within
a limited scope of anatomy. The reality is that
the education of a DDS or DPM is directed to the
goal of graduating a limited license health care
provider. Puffery suggesting that the didactic and
clinical education of a podiatrist is three or
four courses away from the more global
qualifications of an MD or DO is just that,
puffery that is accepted as realistic only by the
uninformed, I.e.,- stupid people.

Dr. Tomczak references Waiting for Godot. The two
(Estragon and Vladimir) argue in part about what
Godot will look like. As Dr. Tomczak notes, Godot
never appears. The profession must decide what it
believes will best serve the public interest. A
broadly educated health care provider practicing
podiatry or a limited license practitioner
practicing podiatry. Perhaps the former is more in
line with the reality and requirements of
tomorrow’s world, thus requiring a true change in
education. Perhaps this is the reason that the
declining applicant pool to our colleges is
analogous to the canary in the mine. Before we
continue the board certification debate, we must
answer the question: board certification for
what? Einstein noted that “Great spirits have
always encountered violent opposition from
mediocre minds “.

Are we to suffer the fate of Estragon and
Vladimir, or do we conclude this seemingly endless
debate by establishing the future definition of
podiatry and provision of an appropriate
educational experience to support that definition.
There was a time our profession moved on from the
DSC and similar degrees to the DPM degree. Is
another metamorphosis required for the future, or
do we accept the reality that we shall forever
remain a limited license practitioner?

In my opinion, the colleges do an excellent job in
providing the necessary education (together with
the residency/fellowship experience) to produce a
competent limited license practitioner. The
current goal is not to provide an education
qualifying a podiatric student to pass the USMLE.
Nor to graduate individuals misrepresenting their
education, engaged in endless puffery.

Whatever the profession determines it wishes to
be, do so and move on one way or the other. The
second act is ending, and the curtain is about to
come down. Shall we still be talking about moving,
like Estragon and Vladimir, yet never move? I do
know this; I am not stupid, and will not be
dragged down to the level of believing that I am
one gynecology and psychiatry course from being an
MD or DO and being granted a general medical
license. Thank you for the warning Mark Twain

Allen M. Jacobs, DPM, St. Louis, MO

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12/09/2024    Rod Tomczak, DPM, MD, EdD

“I Have Built a Monument More Lasting than Bronze…” ( Allen M. Jacobs, DPM)

I was extremely edified reading Dr. Jacobs’
response to my editorial titled, “I have Built a
Monument more Lasting than Bronze.” I wish more of
the silent majority would join Dr. Jacobs and
myself. It is very edifying to see that we are on
the same page when the question of board
certification is posited. While reading Dr.
Jacobs’ response I could not help thinking about
the play by Samuel Beckett, “Waiting for Godot.”
It was voted the most significant English language
play of the 20th century. It is the perfect
example of existential absurdist theater defying
interpretation but like all good literature
personal interpretation is encouraged, and as it
applies to the number of certifying boards in
podiatry, it is textbook. It is a unspoiled
version of tragic comedy, and an existential
metaphor for the present certification problem.
Should ABFAS refuse to compromise, it is like a
kid taking his football and going home. If ABPM
digs in it heels, and doesn’t compromise, we will
be at the conclusion of “Waiting for Godot.”

Two individuals named Estragon (Gogo) and Vladimir
(Didi) are found on a barren set, except for a
single leafless tree in Act I. They banter angrily
and discuss life and nothing in particular while
they wait for Godot who never arrives. A young boy
appears on set informing the two actors that Godot
will not be coming today, but surely tomorrow.
Gogo and Didi have known each other for fifty
years but still seem to have a love hate
relationship. They agree they will come back
tomorrow to wait for Godot’s arrival.

The next day, Act II finds the two actors on the
same set except for a few leaves on the tree.
Nothing else has changed. Once again after
conversing and bickering a young boy appears on
set and informs Gogo and Didi that Godot will not
be coming today either, but surely tomorrow. The
two men are angered and agree they should hang
themselves from the single tree using Gogo’s belt.
Gogo removes the belt from his pants. Gogo’s pants
fall as the two actors remain motionless. The
lights go down and the curtain closes as the play
ends.

The play is reminiscent of Camus’ “Myth of
Sisyphus.” Both are tragic comedies where one is
forced to laugh at the absurdity of the human
condition and the futility of what we are trying
to accomplish. In Camus’ essay, Sisyphus spends
all eternity rolling a large rock up a hill only
to see it roll back down as he nears the pinnacle.
The absurdity of the two literary works runs
parallel to what we are facing right now with the
two board versus the single board question. The
question has been on the back burner, but it will
soon be brought to the front and the heat turned
up. Of course, both parties think they are
correct. To have two correct answers to this
dilemma is not possible.

At the end of the play, the suicide fails, pants
are down and although the actors agree to leave
the set, they remain motionless. Does this remind
you of anything relevant to the current podiatry
condition? Peter Woodthorpe who played Gogo asked
Beckett one day while riding in a taxi what the
play was about and Beckett replied, “It’s all
symbiosis, Peter; it’s symbiosis.” Does art
imitate life here or does life imitate art? We
have two boards stuck in their own convictions and
at the end of the day are motionless, not budging.
Sisyphus is frustrated because it’s the same task
day after day while Gogo and Didi never get to
meet the solution they are waiting for; Godot.

Let’s say there are 15,000 podiatrists in the
United States. There could be that many characters
in “Waiting for Godot.” There may be 15,000
practitioners named Sisyphus rolling that rock up
the mountain in their office and everyone has the
answer as to when Godot will show up or how to
finally crest the mountain top. Why can’t we work
together as a profession to solve the
certification problem? Is everyone an independent
contractor or do we fall into just two stubborn
verklempt camps?

We keep comparing ourselves to orthopedic
surgeons. As Dr. Jacobs writes, we are more like
dentists in what we do and how we do it. This is
not to disparage our education and training; I
continue to preach we could pass USMLE at the rate
MDs and DOs pass. Our curriculum is targeted
toward podiatry and the practice of podiatry.
Isn’t that ludicrous? No, it’s the way it is for
now. But, if we were to sit for USMLE, we would
teach to USMLE, take USMLE, then rely on our three
year residency and fellowships to teach podiatry.
Novel thought. Podiatry schools would be called
medical schools, we could change the degree and
students would still have to match into podiatry
residencies otherwise, there would be no need for
podiatry schools. After all, didn’t we all learn
more podiatry in our residencies than in podiatry
school? Be honest. But those thoughts are for
tomorrow when Godot will surely be coming.

In the meantime, that’s not the way it is, and a
degree change is going to be a bit more
complicated. So, we need to make the most of what
we have and how we become certified. We must work
together, symbiotically to counter the absurdity.
Everyone’s opinion is worth as much as the next
podiatrist’s. But we don’t hear about the
communities’ solutions. My solution to the degree
granted won’t change the board certification
process. We still have all those subspecialties
under the DPM degree. That’s what we must work
with today and tomorrow when Godot will surely
come. I’m pretty sure if we don’t work together,
Godot will never show up.

Then there will be another tomorrow with no answer
from Godot and then another tomorrow until we make
what Sartre called the ultimate free choice. We
will throw a belt over the tree branch with our
pants down around the ankles we have fought so
fervently for attempting to hang ourselves. What
irony. In one version of the play Gogo and Didi
use a rope that continues to break. Their
solution? They search for a sturdier rope and will
come back tomorrow to hang themselves. Insanity.

In the late 1970s and early 1980s we told people
we were reconstructive foot surgeons. Our job was
to be instrumental in changing the profession from
medical DSCs to surgical DPMs. Maybe we were wrong
trying to roll the rock up the hill for everyone
with a DPM degree.

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

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12/05/2024    Allen M. Jacobs, DPM

“I Have Built a Monument More Lasting than Bronze…” (Rod Tomczak, DPM, MD, EdD)

Hereclitus, the late 6th century BCE philosopher,
stated " you cannot step into the same river twice
". Bob Dylan famously sang " the times they-are-a
changing". Indeed, the flowing river of modern
society and medicine are rapidly changing. Dr.
Tomczak notes in his recent communication in PM
News that it is more likely than not that
yesterdays solutions and answers may not be serve
the podiatric profession, and the public that is
is intended to serve, well in the future. A change
in the board certification process should be
seriously considered.

Dr. Tomczak references the results of two PM
weekly polls. He states that the majority of the
profession favors a one-board solution to podiatry
board certification. He also notes (as did I with
apparent equal surprise) that a recent PM News
poll suggests that podiatrists view foot care
nurses as the greatest potential "threat" to
podiatry.

One cannot help but wonder if the results of such
polls might not be different if taken, for
example, of attendees at an ACFAS annual
scientific meeting. Furthermore, the polls cited
represent less than 10% of all podiatrists. Mark
Twain famously noted " Data is like garbage. You
better know what you are going to do with it
before you collect it ". Twain is further credited
as stating " There are three types of lies. There
are lies, damn lies, and statistics".

In my opinion, the initial question to be asked is
this: is podiatry a surgery first profession,
somewhat analagous to orthopedic surgery? As a
student and later faculty member at PCPM, we had
both a medicine and a surgery department. Anthony
Kidawa DPM was a passionate teacher who emphasized
the need to learn about vascular disorders. Harvey
LaMont may clear the need for a detailed
understanding of dermatologic disorders. James
Ganley, although an accomplished surgeon, inspired
us to understand biomechanics and what I will
refer to as "orthopedic medicine. Inspired
teachers such as Alan Whitney DPM taught us how to
evaluate and manage commonly encountered foot
pathologies. The major seminar of those years, the
Hershey seminar of the Pennsylvania Podiatric
Medical association, had dual tracts, medicine and
surgery.

Concurrently, at PCPM, we observed the growth of
podiatric surgery led by a young brilliant surgeon
named Guido Laporta. Podiatrists, previously
excluded from medical staffs at major hospitals,
began involvement at hospitals with increasing
surgical volumes. Dr. Tomczak states some may
remember the DSC days. I am old enough to be one
of those. I ecall the days of limited podiatric
surgical scope of practices. When we moved our
residency from Lindell Hospital to Deaconess
hospital here in St. Louis, I remember a vascular
surgeon laughing in my face. He stated that there
was no possible way a podiatrist would be awarded
surgical scope of practice at Deaconess, a major
hospital at that time.

Prior to determination of a one or two board
solution, we must first determine what our
profession is. Are we a surgical profession or a
medical profession. I have long maintained that
podiatry is more akin to dentistry, not medicine.
However, with that said look at cardiovascular
disease. Cardiologists do not perform cardiac
bypass surgeries. Electrophysiologists perform
limited procedures but do not perform heart
transplant surgery. There are subspecialties such
as CHF, pediatric cardiac surgery, and so forth.
The difference lies in the extensive addition
training (eg-fellowships) our medical colleagues
receive that podiatrists do not.

There is great diversity in podiatry residency
training. Here is St. Louis, there are many
residents who have absolutely no interest in
performance of "advanced" or major surgeries.
Nevertheless, they are compelled to participate in
such surgeries which are not performed with enough
regularity to ensure competency.

Dr. Tomsczak's opinions are, in my opinion, well
taken. There will will those potentially left
behind. Minimal competency is not equivalent to
incompetent. A legitimate, vigorous certification
is mandatory to ensure the public and the medical
profession that our profession provides safe and
effective care. However, before we establish a
one or two board certification process in the
future, we must first define what a podiatrist is.
One thing is certain: we are stepping into a
rapidly flowing river called medicine and medical
care delivery.

Allen M. Jacobs, DPM, St. Louis, MO