The suggestion that podiatry consider a six year
combined DPM/bachelors degree program was offered
as a potential solution to the declining
matriculation pool at our colleges. It has been
suggested that, although this is a model followed
by much of the world, it is not the model followed
in the United States or Canada, and therefore is
not appropriate for our society. I would like you
to consider the following however, this concern is
based on a presumption that the current standards
will continue to prevail. I’m not certain that is
true as medical care has been rapidly changing in
the United States and will continue to evolve and
change.
I believe the proposal for a six year combined
DPM/bachelors degree represents needed change,
consistent with the changing environment of
medical care in our country. In fact, if I had my
way, I would even eliminate the mandatory
bachelors degree and simply go as a direct
admission from high school to the four-year
podiatry program.
Increasingly, medical care in the United States is
provided by individuals who have not graduated
medical college and completed a residency or
fellowship. We see patients daily whose primary
care is administered by nurse practitioners and
physician assistants. Increasingly nurse
practitioners and physician assistants have been
gaining independent diagnosis, and treatment
privileges. I recently admitted a patient to the
hospital with bilateral early exertional
compartment syndrome. He began by telephoning his
primary care physician and spoke to the nurse
practitioner. He was diagnosed over the phone is
having cellulitis and started on an antibiotic.
When he failed to improve, he went to an urgent
care center where he was evaluated by a nurse
practitioner.
He was told he may have a serious problem and
directed to the emergency department. At the
emergency department, who is evaluated by a nurse
practitioner and given a prescription for an
alternate antibiotic. He failed to improve and was
referred by the nurse practitioner to physical
therapy. The physical therapist initiated therapy,
and when he failed to improve, told him that he
should seek the care of his podiatrist to happen
to be me. He was very clear that he never saw any
doctor. This is in fact, not unique, but is the
way of the world today. That is not a standard
that existed 10 years ago or 20 years ago. Times
have changed and standards have changed and
acceptable medical care has changed. Why should we
not be part of the leadership in that change. Non-
physicians administer a great deal of the medical
care in our society today. You know that and I
know that. All of us experience this ourselves
personally.
There are six year combined MD/bachelors degree
programs already in place. My closest friend
through elementary school and junior high school
and high school was accepted to a six year MD/
bachelors degree program. This was in 1965.
Obviously a very bright guy. We were fellow
science nerds throughout our lives. You may be
interested to know that not only did he decline
the opportunity to do so, we continued to our
friendship through college and then he entered
PCPM and we went through podiatry college
together. So much for the theory that podiatry
colleges are filled with medical school rejects.
There is a reality. Much of what is provided as
primary care podiatry care in the office setting
does not require 11 years of post graduate
education. Several generations have fought very
hard to bring podiatry to its current status. Yes
there are some minor problems and to suggest that
we are recognized as total equals in medicine is
incorrect. Look at the recent Covid crisis in
which the majority of Podiatric physicians were
not allowed to administer a vaccination that
pharmacist or nurse practitioners were allowed to
administer. That is hardly a vote of equality.
Some would argue that we are not a trade, but
rather a profession, and present the definitions
of each. I would argue that to some extent
podiatry is a trade as is most of medicine. When I
admit a serious diabetic foot infection to the
hospital, a hospitalist or internist careers for
the diabetes. Infectious disease manages the
infectious disease component such as antibiotics.
Vascular surgery or interventional cardiology
cares for the vascular complaint. I am called upon
for incision and drainage, amputation, or the
wound care. My role is specifically defined.
Before you get your dander up and start speaking
about a plenary degree again consider reality.
The infectious disease doctor addresses the
antibiotics and potential side effects and does
nothing about the vascular disease nor the care of
the diabetes or any concurrent, renal disease and
so on. In fact, if you take the time to read the
notes, they do not even comment on these other
comorbidities other than list them at the
completion of the note under assessment. The
nephrologist makes no comment on the antibiotics
or the management of the diabetes or the care of
the foot. Each of them in their own way is
practicing a trade staying in their own lane of
expertise. With that said, they consult podiatry
for evaluation and care of the foot and ankle and
distal leg pathology and trust us to do so.
They trust us to do so the same way they trust the
nephrologist to care for the kidney disease, the
infectious disease specialist to properly manage
the antibiotics, the radiologist to properly
interpret the MRI studies and so forth. In that
regard, we are a total equal. This is what we have
been trained to do. I do not understand why a
podiatrist would want responsibility for
evaluation of cardiac disease or a pulmonary
disease or anything outside of lower extremity
pathology. You are an equal and you are trusted to
do what you have been trained to do just as other
medical specialist are trusted to do what they
have been trained to do. They all stay in their
own lane. I do not understand what is wrong with
that.
Your degree is respected. If it was not, you would
not be receiving the consultations that you do
from the remainder of medicine. You are there. You
have arrived. The DPM is respected for what is
represents itself to be.
I do not require equality in the form of an MD
degree to practice podiatry. I remember the days
when we required a referral from an MD to see a
Medicare patient. I remember the days that
pharmaceutical companies would not sample the
offices of a podiatrist. I remember the days when
hospital privileges were restricted to the mid
foot forward if privileges were available at all.
I remember the days that a physical therapist
would not carry out any orders written by a
podiatrist.
I remember the days when the thought of a
podiatrist, having surgical privileges, let alone
full privileges, at an institution, such as
Harvard, Yale, any legitimate hospital here in St.
Louis, was a laughable proposition. We have made
tremendous strides, and I believe have recognition
for what we actually are trained to do. This is
one of the reasons that I feel strongly we do not
require an MD degree. I can do everything I want
to do, need to do, and quite frankly should be
allowed to do.
I am respectful for those who do not agree with
the proposal for a six year combined DPM bachelors
degree. I can understand all the good reasons why
it is proposed that we cannot do it. Change is
always difficult. There will be financial losers
no question. I could think of 1 million excuses
not to go forward because of this that or the
other thing. However there is not a single problem
that cannot be overcome if we decide this is the
path we wish to follow, or in fact, any alternate
path to the current lack of interest in the
podiatry profession.
In my opinion, self-interest, self-serving,
motivations, and egocentricity have played a role
in our current state of affairs. it is time to
look at the current model and recognize the
changes occurring in the provision of medical care
in the United States. Which is my hope that
podiatry will be included and not left behind.
I hate to say it, but I will. Maybe if APMA
would’ve spent more time prospectively worrying
about the future of this profession instead of
worrying about getting themselves appointments as
speakers and consultants for corporations, and
starting businesses for which they are
stockholders we would not be “in this pickle“.
Looking backwards does not matter at this point.
However, we require true insightful effective
leadership at this point and going forward or we
will lose everything that we have gained. Maybe
not in the short term, but in the long-term as
medicine continues to evolve.
We can also make the decision not to change.
However, the decision not to change is just that,
it is a decision for the status quo.Perhaps the
lack of applications to our colleges is a
temporary glitch which will self correct over
time. We have no way of knowing other than waiting
for the future and retrospectively looking back
and seeing what happened. The question is, can we
afford to do this?
Allen M. Jacobs, DPM, Saint Louis, MO
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