02/17/2025    Rod Tomczak, DPM, MD, EdD

The Wonder Bread Solution

There seem to be two recurring and interconnected
questions on PM News lately. First, why is
enrollment in colleges of podiatric medicine
declining and secondly, why is there a push to
increase the scope of practice to include the
prescribing of systemic medications that do not
directly affect the foot? Surprising as it may
sound, the two may be closely associated.

When pre-med major students, not pre-podiatry
majors came to Des Moines to interview for the
podiatry program, we stressed the fact that if
they came to Des Moines they would be completely
integrated with DO students for their classes.
Same lectures, same teachers, same time, same
room, same exams. They could team up with DO
students for study groups and had identical
printed class notes approved by the lecturer and
supplied to both DO and DPM students by the note
service before 6:00 pm the same day as the
lectures.

DPM students soon saw that sometimes they
performed better on the exams than the DO students
during the first two years of didactic education,
and quite correctly reflected that they could be
just as successful if they had been enrolled in
the DO program and could have had more choices
about their future. These DPM students talked to
undergraduate students they knew from home and
maybe told them they liked the program they were
in but certainly told the college students they
were not outperformed by the DO students and with
the increase in DO schools which offer a
opportunity for an unlimited medical license, they
should consider those schools also. There are no
pre-podiatry advisors at universities I know of.

There are pre-dentistry and pre-vet advisors in
some places. Since competition is intense,
especially for a seat in a veterinary college,
advisors have to be sage and experienced, but at
least exposed to all the professional programs.
So, we can see how the equality seed could have
been implanted and DPM students performed just as
well as DO students. But after the second year,
the medical education experience diverged. The
third year DO students go through an intense
medical core of general medical, hospital based,
clinical and didactic experiences. The core
rotations are internal medicine, general surgery,
psychiatry, OB/GYN, family medicine, pediatrics,
and in some places emergency medicine. Podiatry
students spend the third year at the colleges with
podiatric medicine and surgery courses combined
with podiatric clinical exposure.

Podiatry students are now taught the proper use of
an ophthalmoscope, but that’s very different than
using one every day. You can read about palpating
the thrill of an abdominal aneurysm, but until you
actually palpate one, it remains a mystery.
Podiatry students learn the proper way to measure
blood pressure, but DO students take 15 pressures
a day in their rotations. You can see how our DPM
students can start to suffer from the Dunning-
Kruger effect, and we the faculty are partially to
blame. Please, do not think I am against our
students becoming familiar with the use of any
diagnostic tool or procedure, but I am against the
idea of our students being taught they are as
expert reading an occasional ECG as someone who
reads 15 ECGs a day.

Fourth year DO students rotate through sub-
internships in medicine and the ICU where they
gain more experience with sick patients while our
DPM students spend some time in medicine rotations
but more in podiatry externships. Perhaps the
biggest difference is the exposure to sick
patients, ICU patients and dying patients. Even
the future urologist still rotates through the ED
and ICU, and is involved in full codes and
comforts hospice patients as they pass. The
clinical education is vastly different between the
DO and DPM students.

In podiatry’s three-year residency there is a
medical catch up. There is exposure to non-
surgical patients. Our young DPMs are involved
with more general medicine and they become more
comfortable in a teaching environment where they
can diagnose and treat general medicine problems.
This custom is outside the laws these residents
will eventually practice under, but since it is in
a teaching environment it is allowed. I can see
where this must be frustrating. They spend time
scrubbing abdominal aneurysm cases then are never
involved in another abdominal vascular surgery
case again because the law forbids it. These young
podiatrists have profound knowledge and experience
concerning general medicine and surgery.

Unfortunately, these skills become extinct. Those
of us who did multi-year residencies in the 70s
and 80s experienced the same disappointment when
we left our residency and started practice. I
graduated in 1977 to a PSR 24+ across the street
from PCPM. After completing the two years I was in
a state of disequilibrium, convinced I was a
medical polymaths but forbidden to demonstrate it.
I fear the demise of podiatry. As DO seats
increase across the country and MD seats escalate
in the Caribbean, DPM enrollment decreases.

Podiatry as we know it, could eventually burn out.
What could occur is students truly interested in
the diagnosis and treatment of foot, ankle and
lower extremity along with the lure of general
medicine would one day attend a DO school, receive
a DO degree then possibly match into one of the
three-year residencies we know as current podiatry
residencies. This is not a given but a speculation
right now. Who will facilitate the acceptance
criteria so these positions are still federally
funded for DO graduates? These students will take
the same national boards as MD and DO students and
eventually be licensed as DOs.

The challenge will be converting today’s three-
year DPM residencies into three year DO foot and
ankle residencies that are approved by osteopathic
graduate medical education authorities and fall
into a new class of foot and ankle residencies.
Should today’s DPM trainers be allowed to oversee
the portion of the new residency programs that are
concerned with what has historically been
podiatric in nature until there are enough
graduates to eventually become the trainers? Or
would there initially be co-residency directors,
one DO or MD and one DPM?

DPM residency directors might become obsolete if
these new DO graduates replace DPM graduates. The
finished product would be a foot and ankle
specialist different from an orthopedic surgeon
with a one-year foot and ankle fellowship, but
still able to perform all surgeries like the
orthopedic surgeons with a one year fellowship.

The DO graduate of a three-year residency program
previously restricted to DPMs will be able to
legally prescribe tolmetin, tamsulosin, or
Tamiflu. Somehow this will allow the podiatrist DO
or DO podiatrist to fully utilize their training
and not feel the frustration felt now. What to
call the new graduate is another problem, but a
minor one at most.

The DPM degree might go the way of the bowling
alley pinsetter, the elevator operator, and
switchboard operator. The name podiatry will
become obsolete like the term chiropody in the
United States. There will be no DPMs unless there
are enough individuals to keep a podiatry school
open and defray the administrative costs now
shared by 11 schools. Tuition would rise to the
point of being impossible to pay. However, young
podiatrists who now complain about the APMA will
be pleased because there will be no APMA after
attrition of the living DPMs. I can see the ABFAS
might still be in the mix but would be required to
change their modus operandi to include non-DPMs
and address current residency restrictions. ABPM
will be gone, at least in name.

Those hybrid foot specialists who do not want to
perform surgery will have to come up with a new
name. Since there may not be colleges of podiatric
medicine, CPME will become a historical footnote
unless they agree to review and accredit residency
programs for non-DPMs, but that is not in their
mission statement and highly unlikely. The
undergraduate DO curriculum would not have to be
tampered with since there is no guarantee when a
student enters a DO medical school they will
actually opt to enter the match in this three year
foot and ankle residency.

I imagine the residency programs will address
lower extremity anatomy and basic motor skills
taught in podiatry schools. I may not be real
popular right now, but this will be an opportunity
to take a stand about a DO degree for podiatrists.
Unfortunately, folks who complete the total
curriculum will not be podiatrists. Today’s
podiatrist would have to go back to school and
complete a residency to get licensed. Highly
unlikely.

This will be a difficult program to implement.
There are a lot of hidden bumps and curves, but an
unrestricted license is the goal. This idea does
not benefit any individuals currently in practice
or matched to a three-year DPM residency. Once the
plan comes to fruition, it will take years before
it is inclusive and everyone is satisfied.
Ironically, there are two distinct problems. One
is that current DPMs clamoring for change will
never experience the benefits and they will not be
able to prescribe as they wish.

Secondly, and a more serious problem is a
potential end-game; what if no one signs up for
the new DO foot specialty residency? We will
certainly find out if being a fully licensed foot
care provider is as desired and desirable as we
have been telling ourselves for years. Have
podiatrists and students attended podiatry school
because they did not get accepted into medical
school? If that is true, then the landscape is
going to change dramatically as the number of DO
and Caribbean seats increase. The whole idea of a
DO foot care giver becomes ludicrous. Nurse
practitioners will provide the care chiropodists
in Canada offer now as the nurse’s scope of
practice increases.

This idea will test the altruism of Gen Y and Z.
Do they want to encourage this program for the
next generation of foot specialists knowing they
will never reap the benefit from the concept or
the program? The province of Ontario has deemed
podiatry, as we know it, unnecessary. The
government feels the 600 chiropodists, who perform
nail and soft tissue surgery, along with
orthopedic surgeons, can handle all foot pathology
for the almost 15,000,000 citizens of Ontario. If
a US trained podiatrist wants to return to
Ontario, he or she will be licensed as a
chiropodist. The 60 podiatrists now practicing
podiatry may continue, but there will be no new
Ontario podiatrists.

There is complaining about the status quo. The
younger generation of podiatrists must jump into
leadership positions in teaching, research,
policy, and mentoring to continue growing the
podiatry profession you should enjoy for the next
40 years. Podiatry has been very good for us and
it should be for you. I repeatedly told students
that my goal was to help each and everyone of them
become a better podiatrist than I am. My advice is
to be careful what you wish for, you may just get
it. Choose wisely! As I have proposed before, “Be
who you are, and be that well.”

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

Other messages in this thread:

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02/24/2025    Irv Luftig, BSc, DPMI

The Wonder Bread Solution (Stephen Peslar, Bsc, DCH)

Stephen Peslar is correct that many of the
chiropodist graduates have left the profession,
and the actual DPM Podiatrist population is
dwindling because of the idiotic 1993 legislation
stopping any DPM podiatrists coming into Ontario
from practicing their full scope. This was a power
grab by the medical establishment and an extremely
poorly thought-out attempt by the government of
the day to bring in chiropody practitioners to
work in nursing homes and hospital clinics on a
salary. The right to establish themselves as
private practitioners and make positive progress
in Ontario was through a charter of rights
challenge brought by the chiropodists in the late
1980s which was successful. The governing college
for the profession has been fighting tooth and
nail for many years to establish podiatry as a
properly recognized profession and unify us and
increase our scope of practice to a full scope.

I personally had a wonderful and fulfilling career
as a DPM podiatrist in Ontario until my
retirement. There are many excellent, hardworking
chiropodists and many excellent, well trained,
skilled podiatrists in Ontario who have been
pioneers in surgical procedures and put in the
work tirelessly and often thanklessly to advance
our profession in Ontario , such as Drs. Hartley
Miltchin, Sheldon Nadal, Peter Stavropoulos, Bruce
Ramsden, and others.

I spent 7 years volunteering my time, while still
running an extremely busy practice, on the
Discipline committee and the Investigation
Complaints committee (as well as other committees)
of our governing college. I felt I should give
back to my profession. Stephen intimates that over
30% of chiropodists and multiple chiropody
association presidents are no longer practicing
because they couldn’t earn a living wage. In my
time working on college committees, I concluded
that many of the younger generation of
chiropodists were not willing to put in the work,
learn from others and establish their own
practices.

Many took shortcuts with rich quick schemes that
contravened best practices (and I am being
generous), and ran afoul of the college, losing
their license or being suspended for extended
periods of time resulting in practice closures
with insurmountable loss of patients and income.
This generation simply was not willing to put in
the time that we did as podiatrists back in the
1970s, 1980s, and forward. That is why they left
the profession, willingly or not

Irv Luftig, BSc, DPM, Hamilton, Ontario

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02/21/2025    From: Stephen Peslar, BSc, DCh

The Wonder Bread Solution (Dr. Rod Tomczak, DPM, EdD)

Dr Tomczak was correct when he wrote there are
about 600 chiropodists for about 15 million people
in Ontario, Canada. Decades ago, Ontario Ministry
of Health decided to shut down podiatry based on
some unfortunate foot surgery outcomes performed
by podiatrists. In 1991, the Chiropody Act was
passed with the clause, “No person shall be added
to the class of members called podiatrists after
the 31st day of July 1993.”

Then in 2015, the Health Professions Regulatory
Advisory Council completed an extensive study of
over 350 pages, that included a jurisprudence
review and a consultation with stakeholders, the
concluding recommendation to the Minister of
Health was, “no changes should be made at this
time to the current legislation on the
registration of podiatrists in Ontario.”

Since 1983, there have been about 900 graduands
from the Ontario chiropody program. Around 300
have abandoned the chiropody profession mainly due
to low professional income, e.g., less than
$25,000 (pre-income tax and after overhead
expenses).

The competition for foot care in Ontario includes
chiropractors, physiotherapists, foot care nurses
and health care aids. This writer, with 15 years
experience as a chiropodist, started to work at a
nursing home that had 200 residents. The chiropody
service was discontinued 2 months later. Employees
who were healthcare aides, had taken a weekend
foot care course and were called the Foot Care
Team. They would provide foot care for the
residents. The Director of Resident Care said, “if
the Foot Care Team doesn’t work out, we’ll have
you come back.” That was 10 years ago and I
haven’t been recalled.

Since 1985, there have been 22 Presidents of the
Ontario Society of Chiropodists. Six of them have
quit the chiropody profession. It was probably due
to the lack of a good, after overhead professional
income.

Stephen Peslar, BSc, DCh, Toronto, Ontario