In 1962, Thomas Kuhn, a professor at numerous
highly acclaimed universities such as Princeton,
Harvard, Berkley, and MIT published his seminal
work, The Structure of Scientific Revolutions. It
was extremely influential across multiple
disciplines, but for us it was powerful in change
theory for education and science. Kuhn introduced
the concept of paradigm and paradigm shift in
order to explain how we think about the structure
of ideas and how those ideas change.
We know that over time, paradigms shift and we
have a change in how we think about things. Over
time we evolved from a geocentric to a
heliocentric universe. When the idea of change was
originally set forth, it was not readily accepted
and heliocentricity was the reason Copernicus was
excommunicated by the infallible Catholic Church.
The Church preached a geocentric universe. Such
diametrically opposed ideas were incommensurable,
meaning they were not able to be discussed because
they were absolute concepts with no common ground
upon which to begin a discussion. In reality,
there was common ground and the telescope and
astronomy began to open the idea of a paradigm
shift.
Problem-based Learning in a pure form is not used
in many medical schools. As a theme for my
dissertation, I examined the use of problem-based
learning and student outcomes during their third
year at Des Moines and it proved to be successful.
Most podiatrists objected to the concept including
CPME which threatened to put the Des Moines school
on probation for implementing it. The common
ground to produce the paradigm shift was how well
our students did on national boards, clinical
evaluations, and matching into their top choices
for residency programs. Now, most medical schools,
including podiatric schools use some form in
classes called clinical applications of podiatric
surgery or medicine. I am not aware of any medical
school that does not use some form of problem-
based learning in their curriculum. So, the
paradigm shift was from a complete lecture-based
curriculum where teachers would say, “I have time
for three questions.” to a curriculum where small
groups discuss patient problems and solutions.
In the 1500s, most people still believed the earth
was the center of the universe for various reasons
but we know they were wrong and it took thought
leaders like Baruch Spinoza to teach
heliocentricity to change ideas. People hold on to
old concepts for various reasons.one of the most
important being, “It seems to work for me, and it
keeps organized religion off my back.” Another
reason to continuing to believe an idea is
because, “It’s always been that way.” Or ”That’s
what I was taught by some of the greatest minds
to walk the earth.” In the case of podiatry, MDs
concluded, “Podiatrists, they’re not real
doctors.” “Their education is sub par.” “They
couldn’t get into medical school.” “Their board
certification is weak.” “They teach each other.”
This means podiatry did not have a nephrologist
and renal physiologist teaching the urinary
system.
When MDs say, They teach each other they were
referring to a couple podiatrists driving across
town to watch another podiatrist perform an
osteotomy, go back to their office, perform the
same osteotomy on a patient then he would invite
other podiatrists to watch him perform one. The
paradigm of, “See one, do one. Teach one.” right
or wrong was born.
We can all think of various examples within the
profession. That’s just the way it was and Kuhn
would call this a stable paradigm. You knew this
was the accepted thought paradigm within the
profession and outside the profession. Podiatry
was confused with reflexology. Podiatrists were
welcomed into the hospital as a patient or to
visit a sick friend being tended to bya real
doctor. We were encouraged to visit our mom who
would be NWB for a month with her fractured hip
because science was behind that treatment plan or
paradigm.
Then the medical and evidence based paradigms
began to shift thought. MDs and podiatrists
changed paradigms. People recognized non-weight
bearing hip fractures resulted in pulmonary emboli
and moms died, podiatrists had real pathologists
to teach pathology, and pharmacologists taught
pharmacology. But this didn’t happen overnight.
There was the stubborn podiatric paradigm. Why pay
a nephrologist to teach renal diseases or a PhD in
nephrology to teach renal anatomy? Why should the
schools pay visiting faculty since that’s not
important for a podiatrist to know? There were
conflicting paradigms in podiatry.
In the 1970s, the old paradigm began to shift but
as usual, it was not without resistance. Again,
why pay MDs to teach subjects these students will
never use? Why teach any anesthesia except
lidocaine which they will use in their offices to
“numb” a hammertoe? Why pretend office surgery is
sterile? Let’s just teach how to make the office
setting “very clean.” Podiatrists don’t need all
this, they’ll never be working in a hospital. The
old paradigm was in crisis because future thinkers
and thought shapers had the nerve to demand real
courses, start multi-year residencies, begin a
real board certification process, challenge
hospitals for privileges and gain active staff
status.
Podiatrists were now faculty members at academic
medical centers. They had challenged the old
paradigm because which didn’t work anymore, and
they won. The paradigm had undergone a huge shift
and podiatry now had everything it could ever want
and those of us who worked to get the changes
became comfortable in the new paradigm. There were
developments over the years that were noticed, but
not always in a good way. Why did podiatry
accredit itself? Was it afraid to have outside
professionals come into our sacristies and
sanctuaries? Podiatric politicians became a self-
serving group. They were like our parents telling
us, “We gave you everything you could possibly
want, and this is the way you treat us?” No, they
gave us everything they wanted and it wasn’t what
a new generation wants.
A new generation has arrived on the podiatric
scene and they are not satisfied nor comfortable.
Piaget called it “disequilibrium.” Some were not
satisfied with a mandatory three-year residency
which could prepare everyone to become board
certified. Some wanted more time in training, some
less. Some wanted plenary licenses and not a DPM
degree. Some even asked, “Why don’t the schools
just give us an MD degree,” believing that was
possible. Many did not want to perform
reconstructive ankle surgery or replace ankle
joints. Many felt the financial compensation was
not equal to MDs. Some wanted to dump the
insurance companies the Baby Boomers had worked so
hard to be included in.
A lot of these new podiatrists wanted to use
regenerative medications, pseudo stem cell therapy
and place orthobiologic dressings on diabetic
ulcers as often as the law allowed. There were
even new podiatrists who wanted to accomplish all
this without an office and others preferred a
mega-group management company. Without insurance
companies meddling, they wanted patients to pay
cash. They didn’t like the curricula in the
schools and hated the tuition but had to pay it
anyway only to find out they would not make as
much as an MD for the same work.
This was met by the podiatrist who has been in
practice suggesting they made double or triple the
mean of what podiatrists reported. The new
generation couldn’t understand why some very
qualified podiatrists could not become board
certified and worried they might end up on the
wrong side of the certification Mason-Dison Line.
The new young podiatrists figured there were
better ways to practice but have not been in the
profession long enough to figure out the answers.
The Old Guard replied with incommensurability.
Generation Z learned all this through
transformative learning. This is not a new style
of lecture where speakers presented the same
slides they have used for years and showed cases
95% of podiatrists will never perform.
Gen Z were critical thinkers, much more so then
the Baby Boomers which proceeded them. They were
reflective and open-minded about ideas presented
to them and did not want teachers to tell them
that they were correct 100% of the time and Baby
Boomers had accomplished so much for the Gen Z;
they had the answers. Rather this transformative
theory of thinking permeated the young and taught
students to form a new podiatry weltanschauung
based on their perspectives and an introspection
that is radically different than the Baby Boomers
who had shifted a previous paradigm.
There would be an intellectual dilemma, followed
by reflection and discussion. Much of the process
was emotional and feeling driven. Students tried
to learn empathy in classes like Patient Centered
Treatment, Pain Management with and without
addictive substances. They learned how to say they
were sorry when a procedure went wrong, how to
explain complications. First year students went to
nursing homes to take histories from senior
citizens, some of them terminal.
All of this was aimed at refocusing, and
transforming the beliefs they held when they
started podiatry school. They enjoyed problem-
based learning where the object was to learn basic
science and solve the patients’ problems.. Along
with merely solving the medical problem, they
would have to address peripheral problems; elder
abuse as an undiscussed problem, how best to treat
a painful bunion in a terminally ill patient, and
in-toeing child who would probably self-correct.
Disorienting dilemmas are imperative to discover
in a patient rather than focusing on whether to
perform a proximal or distal osteotomy. Emotional
Intelligence becomes a skill that needs to be
learned in addition to all the skills and
hallmarks podiatry has acquired. Maybe it’s more
important to learn before first year students tell
others they’re going to be foot and ankle surgeons
then later find out the reality is not the
illusion that seduced them, or the rush of
adrenalin that made them think they were the
Greatest Generation who planted the flag on
Suribachi. Along the way things changed.
It’s the imperfect remedy Schopenhauer talked
about, an existential compromise where no one is
completely happy, yet or maybe never. When I
reread postings to PMNews, I wondered to whom they
were written. Are we writing to convince the next
generation they should be thankful to us for all
the fights we fought and how good they have it now
because of us, and God forbid this new generation
wants to change things. The posts are not being
written to me. I was there for every check I
signed for another lawsuit, for every enemy that
began with the MIS movement we disparaged only to
find them now in the catbird seat.
We espoused cell by cell dissection and incisions
that were limited only by the length of the foot.
We inserted more titanium in the foot every year
until metallosis became a viable cause for a post
op fever. We were wrong about those parts of the
paradigm and now the new generation of podiatrists
is questioning we Boomers. You’re not going to
influence them with your high salaries.
Or, more likely, are we writing these PM News
postings to ourselves, to convince ourselves and
others that everything we did was the right thing?
If I can read it, it makes it easier to swallow
and if the next generation reads and agrees with
what we did, and how we did it, we get outside
justification or absolution. If the next
generation of podiatrists wants to do things
differently, does that mean what we did was wrong?
Would the Wright brothers have done anything
different if someone pointed to the moon and told
them man would walk on that thing in 66 years? The
following group of visionaries combined using
transformative thinking took the right steps
without judging Wilbur and Orville. Paradigms
shift whether you or I like it.
Rod Tomczak, DPM, MD, EdD, Columbus, OH
