04/01/2026    Bret M. Ribotsky, DPM

Podiatry and the Perception Paradox (Allen M. Jacobs, DPM)

Dr. Jacobs has written a thoughtful and honest
analysis of the perception problem confronting
podiatric medicine. I write to add a dimension
that deserves equal weight: the economic reality
practitioners face — and that prospective students
are quietly calculating before they ever submit an
application. Put plainly, when adjusted for the
cost of living, many of us were working for 17
cents on the dollar compared to a generation ago.
That is an 83% effective decline in professional
compensation. Perception may be a problem. But
that number is not a perception.

Dr. Jacobs correctly notes that AI/Google cites
high student debt and poor return on investment
among the factors driving declining applications,
and he counters that many podiatrists do very well
financially. That is true in aggregate. But it
obscures a more granular truth every practicing
podiatrist knows: reimbursement has been in steady
decline for decades while the cost of running a
practice — and living a life — has not.

My own experience illustrates the point. The first
ankle fracture repair I performed in the early
1990s generated close to $4,000 in reimbursement.
By 2015, a comparable procedure paid approximately
$700. The surgeon in 2015 carried the same
training, the same risk, and the same
responsibility as the one in 1993 — for a fraction
of the return. Malpractice premiums, staff
salaries, equipment costs, and basic living
expenses moved in the opposite direction the
entire time.

I have been out of active practice for eleven
years. In that time, the overhead burden on
physician practices has continued to worsen —
driven by inflation, staffing costs, electronic
health record mandates, and relentless
administrative expansion. The 83% effective
compensation decline I experienced by 2015 was
painful. What that number looks like today for
colleagues still in practice, I can only imagine —
but I am confident it is worse. The math that
prospective students are doing is not
hypothetical. It is grounded in a trend that shows
no sign of reversing.

This reality points toward an uncomfortable but
necessary conclusion: survival may depend on
deliberately building practice vectors that exist
entirely outside of insurance reimbursement. Non-
covered services — aesthetic procedures, concierge
care, cash-pay wellness offerings — are no longer
a luxury add-on for the ambitious practitioner.
For many, they are becoming the financial
foundation that makes the rest of the practice
viable. I began teaching the use of aesthetic
fillers within podiatric medicine years ago, at a
time when only a handful of practitioners were
exploring that space. The interest has grown
steadily since, and for good reason. Those who
diversified early understood something the broader
profession is only now beginning to reckon with:
when the insurance-dependent side of the practice
can no longer carry the overhead, something else
must. The DPM who builds competency in non-covered
care today is not abandoning the mission of
podiatric medicine — they are protecting their
ability to continue practicing it.

The profession must be willing to make this case
loudly: every practitioner is entitled to a
reasonable and sustainable return on investment
for their time, training, risk, and opportunity
cost. This is not a mercenary argument — it is an
argument for the long-term survival of the
profession.

Dr. Jacobs is right that perception is a
correctable problem. Economic reality is
correctable as well — but only if we name it,
advocate for it, and refuse to accept the slow
erosion of professional value as simply the cost
of doing business.

Bret Ribotsky, DPM, Fort Lauderdale, FL

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