06/30/2025 Joseph Borreggine, DPM
Becoming a Podiatrist
Considering the recent and mostly recurrent news
about the low enrollment numbers in all the
podiatry schools in the U.S.for the incoming
class of 2029, the profession is still thriving
especially for those in practice for the last
four decades and beyond. Why is that? Why is this
profession still a successful medical occupation?
There must be a reason. Every one of my colleagues
that I graduated with in 1988 along with others
that graduated before and after me are still
working and making a wonderful living and have a
great career. Yes, there are those that have left
the profession to excel in other things for other
reasons, but graduates with a DPM degree are doing
quite well financially. They have continued to
practice, considering the changes with insurance
reimbursement fees that have waned, competition
with corporate and hospital employment, the
historical battles with scope or practice
limitations, and/or garnering respect from our
allopathic/osteopathic colleagues.
The profession has certainly evolved through the
years from the years of just providing foot care
back over 75 years ago to now being the leading
foot and ankle healthcare providers in the nation.
The profession of podiatry has always weathered
the storms of adversity and has found its way by
navigating or forging a path to allow not only for
the profession to prosper, but to allow the
individual practitioner to be successful in the
day-to-day operation of running a practice.
Unfortunately, the public is still woefully
unaware of who we are and what we do as well as
being confused that we are just "foot doctors" who
did not go to medical school and just clip nail
nails and trim calluses. Yes, due to social media,
the internet, cable TV shows and other advertising
avenues, the public has become a little more
educated about what we do. You would think by now,
the patient population at large would know to seek
the care of a podiatrist any time they have a foot
problem, but alas that is not the case.
Frequently, patients are referred by their primary
care provider to other specialties such as
orthopedic surgeons, dermatologists, physical
therapists, wound care specialists, and so on.
This may not have happen all the time especially
in multi-specialty corporate or hospital settings
where the employed physicians work as a group and
refer to one another, but in the smaller group or
individual practices, the podiatrist must make the
primary care provider knowledgeable of who they
are and what they can do for referring provider's
patients. This is why it is important to
constantly be in communication and network with
the medical community in the locale that a
podiatric physician is practicing.
The big push about 15 years ago in podiatry was to
require every graduating DPM to have a 3-year
surgical residency. Whether this was a good or
wrong decision is unimportant because this was a
request by the APMA membership to create a
resolution to mandate postgraduate surgical
residencies. The APMA House of Delegates voted and
approved this requirement and henceforth all DPMs
since that time are residency trained in foot and
ankle surgery and then have the option to pursue a
fellowship after that in a podiatric surgical or
medical subspecialty.
This change certainly helped unify and standardize
the profession when it came to what was expected
of every podiatrist after they graduated and
aligned all the state licensing boards to
incorporate this requirement to obtain a state
license for podiatry across the country. This was
the good thing, but the bad thing that may have
occurred as a result of this requirement is that
all the residency trained podiatrist may have not
wanted to become a foot and ankle surgeon or after
they obtained the surgical training may never
perform surgery after going into practice. That is
a discussion for another day.
Regardless, with the advent of more surgical
trained podiatrists who all eventually become
board certified by the American Board of Foot and
Ankle Surgery (ABFAS) which allows a podiatrist to
never be prejudiced by a hospital staff which was
a big problem many years ago.
This leads to a topic on how things go full
circle, but in this case for the benefit of
podiatry. Years ago, most podiatrists could not
obtain or had a challenging time obtaining
hospital privileges. This was because of lack of
completing a postgraduate residency because they
were either rare or the only coveted 3-year
surgical programs were only available in a couple
of places in the country. As a result, most
podiatrists just graduated from podiatry school,
received their state license, and opened their
practice. Most obtained a scant amount of surgical
training in school and externship programs if they
were lucky, but most that wanted to do surgery did
so in their offices. At that time, the minimal
invasive foot surgery (MIS) was performed in place
of the traditional procedures especially when
performed in the office.
These practitioners who did MIS procedures in the
office promoted these novel surgical techniques as
a small incision, less disabling, faster recovery,
and walking the same day. These podiatrists who
were performing MIS were criticized by their peers
because they were not practicing the traditional
surgical methods taught in school. The certifying
surgical board in podiatry at that time along with
other professional organizations representing
podiatry did not associate or support the MIS
technique as a surgical alternative in podiatry.
In response, a separate certifying ambulatory
surgical board was established to allow these
pioneering podiatrists from all over the country
and from Canada to join in meetings and
conferences learning about advances in MIS.
Over the years, MIS fell out of favor in podiatry
as increasingly DPMs were able to obtain hospital
surgical privileges because surgical 1–2-year
surgical residencies became readily available
allowing for board eligibility and eventual
certification in podiatry. Over the last 10-15
years there has been a resurgence of MIS in
podiatry with its procedures evolving now into a
5th and 6th generation which includes not only new
more advanced techniques, but with fixation
hardware particularly for bunionectomies that
again promote faster healing times, less
disability and an ability to walk sooner. The
ABFAS and the American Academy of Orthopedic
Surgery have both adopted MIS as an accepted
standard of care for foot surgery.
There have been multiple surgeons in the podiatry
arena that have authored articles in podiatry and
orthopedic literature, given lectures at
conventions, and continue to promote MIS as the
leading surgical alternative to most elective and
reconstructive foot and ankle procedures
available. This is a fine example of how the
podiatrist has been and continues to play a role
in advancements in foot and ankle surgery along
with the tried-and-true methods that have been the
mainstay of the profession for years.
Outside of MIS and traditional foot and ankle
surgery, podiatrists are also involved in healing
wounds not just through the skin substitute graft
applications that have been available, but also
they are participating in muscle belly relocation
with their associated perforating angiosomes and
split thickness skin grafting to help cover
chronic non healing wounds due to vascular
compromise. These procedures have proven to be an
excellent method to help in the field of limb
salvage. Not to mention how podiatrists are an
essential component in the realm of wound care
particularly in the diabetic that are affiliated
with many corporate or hospital owned wound care
centers throughout the nation. Podiatrists at the
University of Texas and the Southern Arizona Limb
Salvage Alliance (SALSA)have been the epicenter
for years in wound care research, diabetic
neuropathy, and developing the science behind skin
substitute grafts and technologies that have been
created to improve wound healing.
Podiatry has also played a key role in several
other subspecialties that include dermatology. The
podiatry profession is very diligent in
identifying skin lesions and performing biopsies
to reduce the morbidity and mortality associated
with dermatopathology. Through early pathological
identification of suspicious skin lesions podiatry
has become the first line of defense against
combating skin cancer.
Podiatry also plays a pivotal role in identifying
peripheral vascular disease (PAD) through in-
office vascular testing on the patient population
who are at risk for vascular compromise such as
diabetics, smokers, and patients with
hypertension. Podiatrists have partnered with
vascular surgeons to work together to help detect
PAD early and be able to provide a referral for
vascular intervention to help reduce the risk of
wound formation, gangrene, or amputation. The
Society of Vascular Surgery has their Annual
Conference in New Orleans that is widely attended
by the podiatric profession because of how
essential the foot care provider is to the
vascular field in general. Again, podiatrists are
the first line of defense informing a patient the
"silent killer" AKA PAD.
The venous system has also been a mainstay of the
podiatry practice for years especially when it
comes to managing lymphedema and venous
insufficiency. Podiatrist gained a big win in Jan
2024 when Congress passed the Lymphedema Act of
2024 signed into law by then President Joe Biden.
This now allows for the coverage of lymphedema
garments that are essential to controlling and
quelling and eventually reducing the chronic lower
extremity swelling that is present with
lymphedema. If left uncontrolled or not
effectively managed with compression therapy, then
the patient is prone to venous ulcers that can be
slow to heal and require wound care and/or
grafting. The risk of amputation in non-healing
venous ulcers can lead to eventual lower extremity
amputation as well.
Podiatrists also can also be trained and to
practice in certain states that allow for
resolving varicose veins through venous ablation
procedures. So, podiatrists are advancing the
profession in the vascular fields identifying,
treating, and preventing the complication of
chronic arterial and venous disease.
Sports medicine is also a part of the podiatric
profession that has evolved dramatically
throughout the years with newly advanced
technologies along with scientifically backed
research to help the athlete improve their
performance to the highest level attainable.
Whether it is through the longstanding field of
biomechanics, orthotic therapy, and other
treatment modalities the podiatrist is the key
provider to assist any patient with a sports
related injury, diagnosing abnormal foot and leg
biomechanics, and provide the best treatment
available the latest modalities.
The podiatrist also plays an essential role in
pediatric foot care from correcting clubfoot with
serial casting or surgery and other childhood foot
deformities along with making the early diagnosis
of congenital or delayed developmental issues
affecting the feet and lower extremity. There is a
wide variety of available treatment options to be
utilized on this type of patient population to
arrest and/or reduce early childhood pediatric
foot problems. The podiatrist is not only a doctor
when it comes to diagnosis and treatment of
pediatric foot deformities, but they are also an
educator and counselor for the child's parents to
assure them of the probable outcome of the
observed issue. Therefore, allowing the parent to
have reduced anxiety about their child's foot
problem that may not be permanent and what the
podiatrist can do to resolve the foot problem(s)
that will prevent future issues arising as they
become and develop into an adult.
Let me not forget to mention the need for the
podiatrist in the geriatric population, especially
when it comes to the need for routine foot care.
Podiatry historically has been known for the
ability to provide the needed foot care for the
elderly. When Medicare was created by Congress in
1965, it was President Lyndon Johnson who rallied
to include podiatry. He said that if Medicare
could not pay his podiatrist, then he would never
sign it in law (or so the story goes).
Podiatry is allowed to see Medicare patients every
61 days for foot care whether it be nail and/or
callus care as long as the qualifying diagnosis
approved by Medicare is present in the history or
physical exam along with appropriate "Class
Findings" mandated in the Local Coverage
Determination (LCD) policy set the Medicare
contractor. This treatment makes up most of the
care provided to Medicare patients in podiatry
practices that are either in office-based settings
and/or may include nursing homes (NHs), assisted
living centers (ALFs), or Independent or
Behavioral Health Care Living Facilities. The foot
care provided by podiatrists is a necessity not
only because of the complications that may ensue
if the patient is left unattended or would be at
risk if left to self-care or care provided by the
non-professional.
Podiatrists play an important and vital role
because of the number of diabetics, PAD, and
anticoagulant therapy, et al. Medicare patients
that a podiatrist sees daily. Routine foot care is
not just "routine", should never be considered a
"lesser than" service, and it should never be
relegated elsewhere because what the podiatrist
sees, diagnoses and treats when providing routine
care on a patient's feet will never be seen by any
other provider whether it be an Advanced Nurse
Practitioner (ANP) or anyone else certified to
provide palliative foot care. The propriety that
the podiatry profession has attained with routine
foot care should not be ignored.
This article is just a tiny slice of what the
podiatric profession is all about. There are so
many nuances when it comes to everything in
podiatry. The recent issue of a podiatry
periodical indicated that there is a low
application pool of prospective podiatry students
which could lead to the demise of the profession.
I sorely disagree. The podiatry profession is
never going away. It will be here in perpetuity no
matter what happens in the future. The continual
discussion of DPMs needing to become MDs will
always be up for debate.
The constant drumbeat of promoting the profession
through mentoring podiatric students or
advertising that there is a faster way to becoming
a "surgeon" is a necessity to try and harbor
interest in podiatry. The fact remains: that
podiatry has a long history, been able to survive,
and has succeeded even with all the adversity that
the profession has faced throughout its tenure.
So, with all that said the next step for anyone
entering the medical profession is to decide
whether it is worth it becoming a podiatrist. The
choice is up to that person. I say choose wisely.
Joseph S. Borreggine, DPM, Fort Meyers, FL
