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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