01/03/2025    Rod Tomczak, DPM, MD, EdD

Definition of Podiatry

In 1976,I was beginning my third year of podiatry
school, the United States was celebrating a
bicentennial, Jimmy Carter was running for the
presidency, many of todays practicing podiatrists
were not born yet and Carter gave an incredibly
controversial interview with Playboy magazine that
was published before the election.

In the interview he candidly admitted he had “…
looked upon many women with lust,” and “…committed
adultery in his heart.” After the election he said
these quotes almost cost him the election, but in
reality, he probably edified as many voters as it
alienated. Carter was a Southern Baptist deacon
and was referring to the new testament Gospel of
Mathew where, “ …an offending thought was
equivalent to a consummated adultery.” And, Carter
said, “I have committed adultery many times in my
heart.”


If you look at the banner on the internet edition
of PM News you will notice that the News serves
over 21,000 subscribers daily and many are fervent
readers of the controversy concerning what the
definition of podiatry is. More succinctly, what
procedures should state legislatures allow trained
podiatrists to perform. If there are 6,000
podiatrists in the US, the banner on the
publication suggests another 15,000 non-
podiatrists are reading the newsletter.

I can only imagine what they think when they see
Dr. Roth opining that endovascular procedures
involving the femoral and popliteal arteries are
within the scope of our practice and spinal cord
stimulators that may reduce painful neuropathies
can be legally inserted by trained podiatrists.
Instead of Dr. Roth’s pronouncements costing an
election, I fear they may be alienating our MD
friends or slamming the door on potential MD
friends who become disenfranchised before they get
to know most of us.

The catheter used in an angioplasty is a tool used
to perform the procedure. A hammer is the tool
used to drive a nail. A weekend course in
‘hammering’ does not make one a master carpenter
even though we all have a hammer at home. I use
the same hammer to drive a stage nail as I do a
finish nail. To perform an angioplasty I would
need to perfect my judgement about the maximum
length the an occlusion can be before it shouldn’t
be compressed, is the clot too calcified to be
effectively compressed, am I prepared to insert a
leak proof graft if the angioplasty fails, what
surgical approach should I use, is it better to
attach the proximal end of the graft first or the
distal, where should I clamp the artery to achieve
hemostasis? How do I assess the distal arteriole
runoff to guarantee continuous flow and prevent
back up? The vascular surgeons can recite the
answers to these questions as quickly as the last
four numerals of their social security number.
Podiatrists, I’m not to sure.

Is it worth alienating a real vascular surgeon who
has performed an additional two-year fellowship
after a general surgery residency so I can perform
a couple of these procedure a year? What do I do
when I get into trouble by getting one of the
answers to the above questions wrong? How can I
perform a distal vascular surgery fellowship when
the concept of a fem-pop angioplasty or graft when
needed has been judged to be within the scope of
our practice based upon the opinion of a state
podiatric medical association attorney who is paid
by the state podiatric medical association but not
the legislature?

Intervention into the nervous system is, in my
opinion, even more perilous. What do I tell a
patient when I try to bovie a small arteriole
since I can’t see everything but cauterize the
pudendal nerve because the weekend course was so
long ago I don’t remember, this is my first
patient suitable for this procedure and the
salesperson in the OR is not sure what they’re
looking at? You can use a foot drop brace if the
deep peroneal is obliterated proximally but no one
has a brace if the pudendal nerve is damaged.
Again, why should I alienate another member of the
MD profession who has been good to me and my
cohort of podiatrists so I can make someone
incontinent then ask a real neurosurgeon to fix
it? And once again, how can I learn to use this
modality if the body part it’s being used on is
not within the scope of podiatric practice?

As I stated before, more non-podiatrists read this
newsletter than podiatrists. When the non-
podiatrists read these dubious suggestions, what
can they possibly think? Has some cowboy got an
itchy trigger finger and wants to perform a
procedure that he learned during a weekend course
and has a diploma filled in with a permanent
marker to prove it?

To go about introducing a new and somewhat
questionable procedure, protocol must be followed.
I am not talking about just a new tool, but a new
procedure for podiatry, First, the procedure has
to be clearly defined and approved to be within
the scope of practice for a podiatrist before it
should be taught. Secondly, it must be taught by
experts, not someone who just learned on a cadaver
a couple weeks ago. Third, you must be evaluated
as to operator efficiency and proficiency in
performing the task. Efficiency relates to minimal
waste and effort; proficiency relates to the skill
and expertise acquired. And last, there is no
reason a new operator cannot be monitored by an
established expert.

Let’s make sure that all the readers of PM News
feel comfortable that the legality of a new
procedure has been established for podiatry, the
surgeon is both efficient and proficient as an
operator thus putting the patient, and our
confreres at ease. This makes for full disclosure,
like President Carter.

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

Other messages in this thread:

---

12/21/2024    James DiResta, DPM, MPH

Definition of Podiatry (Allen M. Jacobs, DPM)

If there is one lesson to be learned from these
recent blog entries, whether overtly stated or
implied, and I might add from some of our most
esteemed colleagues is the stupidity of suggesting
that we ought to "stay in your lane". If
podiatrists of my generation stayed in our lane we
would be nowhere. We have come this far because we
were willing to buck the system and work to
improve our profession beyond the instruction we
received. I for one anticipated that those coming
along behind me would expand our scope further and
not be satisfied with the status quo.

If we fail to move this profession forward and
expand our scope to practicing more general
medicine we will be extinct in a very short time.
The walls are closing in on us. Why are we
committing ourselves to being stuck in our lane?
It is unthinkable that our 4-4-3 model of
education has limited us to treating only the
local manifestation of systemic diseases of the
foot and ankle. Can't we tune our medical
education model to provide for the treatment of
systemic disease that we feel comfortable treating
and that can improve upon the lives of our
patients?

This is imperative in today's healthcare arena
especially for our many residency graduates who
don't envision doing complex surgeries and yet
don't want to be existing financially on routine
foot care which is slipping away and frankly can't
support the lifestyle that our graduates were
promised and deserve. What's with all the
resistance?? If we need to increase our residency
programs by an additional year to provide the
clinical experience of primary care for our
graduates, let's do it. I cannot fathom any pre-
med college student choosing a 7 year plus
podiatry education over a 27 month physician
assistant educational program and being out done
by a PA.

This is nonsense. Today NPs can practice with full
authority in 26 states and PAs are gaining ground
in becoming more independent as well. It's just a
matter of time as they as a profession gain more
clinical experience. They have already changed who
they are from physician assistants to physician
associates. No DPM needs to be an all-inclusive
expert in any medical treatment just as no general
practitioner whether NP, MD or DO is expected to
be.

The key is knowing when to refer and treat
collaboratively which is something our profession
already does only too well. If we drive ourselves
any further into this bunker we are going to limit
only the few that can maneuver their way out. What
a selfish mistake that will be.

James DiResta, DPM, MPH, Newburyport MA

---

12/19/2024    Robert Kornfeld, DPM

Definition of Podiatry (Allen M. Jacobs, DPM)

Dr. Jacobs’ definition of podiatry, should it be
the majority opinion, will surely lead to the
death of podiatry. If all we do is look at the
foot, focus on the foot and treat the foot
regardless of the underlying immune burdens (as if
the foot is independent of the body it is attached
to) we will surely be replaced by NPs and PAs in
the coming years. We are already a profession that
is slowly being usurped by these new professions.
Dr. Jacobs and I are from the older generation
that began the battle for parity through better
surgical skills.

But will that sustain us? I say absolutely not. I
feel that our schools need to provide more
comprehensive training in what creates an
inefficient immune system that is part and parcel
of most of the pathology we treat. Are we not
allowed to advance our skills once in practice? Or
are we only allowed to practice what we learn in
school and post-graduate training? Dr. Jacobs
admits that we do treat our patients systemically
but opines that’s only in the direct treatment of
foot pathology. And I opine that a functional
medicine podiatrist is doing just that. Treating
the pedal symptoms by managing the systemic
factors. Just by way of supporting, rather than
suppressing.

Several years ago, I wrote to every school of
podiatric medicine offering to teach what I have
been doing for decades. And sadly, I was ignored
by every single one of them. So, if you want to
sustain the limited thinking of our schools and
continue this antiquated idea of what we, as
doctors, should be able to do for our patients,
then there will be no need for podiatry. The foot
will become the domain of MDs, DOs, NPs and PAs
who are being trained in functional medicine and
will address what must be addressed in order to
actually practice health care. And that, after a
very satisfying and successful career, would
really disappoint me. In my mind, this is
professional suicide.

Robert Kornfeld, DPM, NY, NY

---

12/18/2024    Allen M. Jacobs, DPM

Definition of Podiatry

What is the definition of podiatry? A podiatrist
is educated at the didactic and clinical level to
diagnose and treat disorders of the foot and in
some states the ankle and lower leg. The willful
misinterpretation of the limited scope of practice
of a podiatrist by some DPMs does not justify the
practice of general medicine by a podiatrist.
Example: a patient presents to you with tingling
and burning paresthesia. You rule out local nerve
entrapment. You order electrodiagnostic studies.
The studies demonstrate a peripheral sensory
neuropathy. Or you perform an epidermal nerve
fiber density study. The test is consistent with
small fiber neuropathy.

Now what? This not pathology intrinsic to the
foot. Whatever the etiology, as a podiatrist you
are not educated to proceed with further
evaluation. What if the neuropathy is a
manifestation of an occult malignancy? You then
order screening laboratory studies as you believe
you are qualified (contrary to the intent or
spirit of the DPM degree ) for common causes of
neuropathy. The patient is hypothyroid by
laboratory study criteria.

Now what? Do you prescribe medications to treat
the low thyroid function? Do you practice
integrative/functional medicine to treat the
underlying cause of the hypothyroid dysfunction?

Yes, as William Osler noted over 100 years ago, a
good physician treats the symptoms, a better
physician treats the disease, a great physician
treats the patient who has the disease. Referral
to a qualified health care provider is treatment.

An obese patient has plantar fasciitis. They have
a progressive collapsing foot deformity. A good
podiatrist will treat the heel pain. A better
podiatrist might also initiate pronation limiting
therapies, treat any equinus, inform the patient
that obesity may be a contributing comorbidity.
But a podiatrist is not educated in weight loss
medicine nor functional medicine principles to
manage the cause of the obesity. That is not the
intent of the DPM degree. I’m not suggesting that
you are incapable of knowing how to do so. I am
suggesting that the treatment of obesity or any
underlying functional causes of obesity are not
within the “ spirit “ or possible legal intent on
the DPM degree. I don’t know where the line ends.

Of course anything we do can affect other body
systems. Orthotics or even arch supports can
affect knee or hip or spine function. A prescribed
NSAID can affect renal, cardiac, or other systems
and disturb homeostasis. An antibiotic you might
prescribe for an ingrown toenail may affect the
gut biotome or induce a cardiac arrhythmia.
However, I would be very careful suggesting this
can be interpreted as suggesting that podiatry is
thus more than what it was intended to be. There
are those who would and continue to argue that the
above examples are the very reasons that a DPM
should be severely limited in scope of practice
and prescribing capabilities. Look at the severe
restrictions of our foreign podiatry colleagues.

We must define (and accept ) once and for all what
podiatry is. The classroom, clinical, and post
graduate education of a podiatrist must then
follow to support that definition, whether
surgical on integrative medicine or anything in
between.

Podiatrists are at present limited license health
care providers. Theoretical arguments and
postulations and extrapolations by our professions
“thought leaders “ do not change that reality, no
matter how much you believe you know regarding
medicine.

Knowing when to refer and the limits of your real
knowledge is what will bring you the respect of
your non-podiatry medical colleagues. Staying in
your lane is a clear indication that you know
enough to know what you don’t know. That is the
true hallmark of a well educated health care
provider. Mark Twain said it well; “ It ain’t what
you don’t know that gets you in trouble. It’s what
you know for sure that just ain’t so “.

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

---

07/15/2024    James DiResta, DPM, MPH

APMA Members Asked to Vote on Revised Definition of Podiatry (Kathleen Neuhoff, DPM)

I read with great interest the recent comments
concerning the revised definition of podiatry
specifically as to the removal of the "treatment of
the local manifestation of systemic disease".
Elimination of this phrase is absolutely paramount
for the survival of podiatry. Increasing our scope
by inching our way proximal from the tibial
tuberosity is not the answer.

If we have increased our level of education to that
of a true single track medical school which
provides us an equal foundation to our allopathic
and osteopathic colleagues during our 1st and 2nd
year curriculum in the anatomical sciences and body
systems course of study and we then provide a
carefully planned and more focused series of
clerkships and classes during our 3rd and 4th years
that emphasizes the diagnosis and treatment of
systemic illnesses in addition to surgery and
general podiatry training we ought to be prepared
to do a heck of a lot more than what we are
presently doing in clinical practice. Our graduates
follow their four years of podiatric medical school
with a minimum of three years of residency training
in medicine and surgery.

I would hope that our graduates could move forward
initiating treatment for a condition that may be
delaying a surgery like a UTI. Patients who present
with local manifestation of system illnesses in the
future should expect the podiatrist to initiate
treatment for gout, type II diabetes, hypertension
etc... as this should be the natural scope of
practice for a well-rounded and newly trained
podiatrist. Knowing when to refer and consult with
medical colleagues is paramount but sending all of
these patients out to specialists is neither
necessary, cost effective or in their best
interest. Our resident graduates should be able to
compete with a PA or a NP in following an algorithm
for prescribing these treatments and if not then
something in our training is severely lacking.

It's unfortunate but several of our older
colleagues are holding our newly trained
podiatrists back as they themselves are
uncomfortable expanding their own scope of
practice. We are not training future diabetologists
or neurologists but we can at least initiate
workups and prescribe treatments for common
systemic diseases that we encounter daily. We owe
this to our patients, our profession and our
healthcare system. It's time to let go and move our
profession forward. Once we do this, achieving
parity with our DPM degree or moving our degree to
a DO or MD will be achieved.

James DiResta, DPM, MPH, Newburyport, MA