01/11/2025 Rod Tomczak, MPM, MD, EdD
Ethics of Belief
It’s always in vogue to criticize the colleges of
podiatric medicine and surgery for all the
problems affecting podiatry for the next fifty
years following a student’s graduation. Podiatric
problems exist right now and forever if you listen
to the word on the street that is disseminated by
graduates of podiatry schools. Educators live by
something called a mission statement. Everything
that happens at every podiatry school should
synchronize with the mission statement. Some
schools have lofty mission statements about
finding and curing all foot pain, onychomycosis,
bromhidrosis, sheltering the homeless, and
creating new knowledge to benefit mankind. Pretty
lofty plans.
Realistically, all the podiatry schools today
should have an identical, singular and
straightforward mission, “We will prepare students
for the next level of training.” If students can
pass their boards and are ready to learn at the
PGY I level, the schools will have done their job.
Then it’s up to the next group of podiatrists, the
trainers and residency directors, to continue the
task of preparing these young minds and hands to
begin practice. The residencies have a more
intense three years teaching than the schools have
in four. Seven years, maybe eight to prepare an
individual for a life of service and healing,
maybe to discover new knowledge, but that’s at the
end of training.
OCPM was an 8 month program when it started in
1916, eight years before the first orthopedic
residency. In 1932 OCPM became a 36 month program.
That’s an awfully big jump. Was there suddenly
that much more to learn? There wasn’t much science
involved with orthopedics or podiatry back then.
In fact, pre-med requirements weren’t established
until much later, and ironically the one hard
science most applicable to podiatry wasn’t
enforced as a prerequisite. Physics was listed as
a must have, but there was a lot of “wink-wink”
about physics when it came to evaluating a
transcript. The same can be said for state
podiatry boards where physics is listed as a
prerequisite but not always enforced.
The first orthopedic residency didn’t start until
1924. It was common knowledge that MD graduates
who didn’t sign contracts in other specialties
went into orthopedics. The most important
yardstick for acceptance into orthopedics was
rumored to be the size of the applicant’s biceps.
But do we have evidence of that statement? There
was no emphasis on physics. Bone setters in
Appalachia knew that if there was restoration of
length, a minimal amount of angulation and
rotation, they had an adequate reduction and a
good chance of healing. Around 1900 doctors
started using Xray to evaluate fractures.
Podiatrists didn’t need Xray during those early
years since the profession debrided lesions and
applied padding. There wasn’t much science
involved, just a lot of intuitive thinking and
experience.
In 1877 W.K. Clifford wrote a famous essay (
famous to philosophers anyway) titled, ”The Ethics
of Belief.” The substance is that it is always
wrong to believe anything based upon insufficient
evidence. This is way before the onset of evidence
based medicine, but you can certainly trace
evidence based medicine’s origin to the 1877
essay. We all used the concept in deciding there
is no Santa Claus. Evidence doesn’t support it.
There was no science to back up dear old Santa.
What we must distinguish is the difference between
truth and belief. When something is believed, even
by everyone, it could be false. Ask Copernicus.
Belief does not exist in reality. Truth exists in
reality. History offers numerous examples of this
in the form of rhetoric proposed by dictators
speaking from a bully pulpit. We learned things
they said were not true.
The bully pulpit as such doesn’t exist in podiatry
today. It is much more subtle but just as
effective, if not more. We run into terms such as
fake news, conspiracy theories, social media,
pundits, talking heads, concierge, and fee for
service The big questions are at what age can one
be responsible for forming their own conscience or
belief ethic and secondly, how does one come to
know the truth?
We all began to doubt Santa Claus at different
ages, and although it may sound counter-intuitive
to say it, our parents and family were responsible
for instilling and sustaining this false belief.
It’s called lying from good intentions. The three
words …from good intentions… are paramount. Our
elders wanted to preserve our innocence and simple
belief systems as long as possible to shield and
protect us from the ugly realities that lie ahead.
Then came that period of doubt when our peers, who
didn’t believe, told us there was no Santa Claus
or mocked us for still believing. By the time we
get to podiatry school we should be able to intuit
truth, but when in doubt, we have respected
professors to ask for guidance. Physics tells us
Santa cannot perform the tasks he supposedly does
on Christmas Eve.
This past year made us wonder if anybody tells the
truth. The fact that we need fact checkers is
abhorrent. The same thing happened concerning
social media, talking heads, and pundits. Walter
Cronkite is deceased, and Dan Rather is in his
90’s. Promises are fiction. I’m not talking just
politics, I’m talking medicine and podiatry in
particular. Two journal articles directly
contradict one another. A speaker at a seminar
tells you the opposite of the speaker before them.
One speaker is paid handsomely by the company he
speaks for, but the other is a huckster pitching a
drug he eventually hopes to monetarily endorse. Do
we know the real criteria a product is subject to
before it is approved or given some sort of seal
by APMA? Why is the process right out of the
Secret Squirrel TV show? There is no debate over
the fact that these companies pay APMA for their
approval sticker. Is the Seal of Approval
targeting the public or podiatrists to recommend
the product?
We’ve come to learn, painfully I might add that
people in authority are not always to be trusted,
especially if on a payroll. Ohio State University
recently took away a person’s PhD for falsifying
dissertation results. The results were not
reproducible on multiple attempts from other
sectors. That fallacious dissertation led directly
to employment.
Plato’s cave is an extended metaphor or analogy
that tells us what we see is not reality but a
shadow cast upon the wall of a cave by a fire. We
can only ascertain an image of what is casting the
shadow so truth is not what we see on the cave
wall. Newscasters and networks have been
characterized by political leanings so why not
podiatrists? The biomechanics guru preaches from
that podium while the surgical podiatrist preaches
from the operating room. Is there a true
biomechanical surgeon or is it just the term
biomechanical surgeon that is a shadow on the wall
of the cave we live in?
Podiatrists have begun to publish meta-analyses.
This is a very powerful form in establishing an
ethical belief…if done correctly. The process
takes multiple journal articles on the same topic
with identical inclusion and exclusion criteria
and uses a statistical function to produce a
result. It often requires a true statistician to
enter the data into the formula and program the
computer. Before computers, investigators used
something called a Delphi technique to find the
ethics of belief or establish true evidence-based
medicine grounded on experience. The mathematical
analysis has replaced a so-called expert with
inherent biases
Mathematicians claim there is only one true
science, mathematics. Numbers cannot lie, cannot
be loosely interpreted, or judged to be anything
but what they are. Someone making measurements may
be biased but the numbers themselves cannot be
anything but numbers. Five plus five will always
be ten, but someone measuring an angle may mistake
six degrees for five. When we look at numbers when
forming our own ethics of belief, we need to judge
the person measuring the angle and determine if
the calculations are correct.
Scientific articles are not meant to be
interpreted. They are meant to convey the truth.
Scientific articles are not written to be like
Moby Dick where one reader thinks the book is
about whales. The conclusion of a scientific
article should be a foregone conclusion. The
conclusion cannot be an interpretation. There can
only be one final statement based on the data
presented.
Blind faith and value judgements have no place in
medicine. If you can preface another person’s
statement with, “I think…,” and it is
grammatically correct, the statement may not exist
in anyone else’s reality. “The moon is made of
blue cheese.” And “I think the moon is made of
blue cheese.” is an example. The person may be a
good friend or someone widely respected, but a
controversial statement lacking objective proof is
a value judgement. When a statement seems too good
to be true…. That’s why we are morally bound to
form our ethics of belief.
