Two Roads, and the Cost of Walking Down Neither
For more than thirty years — from podiums across
this country, in the pages of these publications,
and in every room where this profession’s future
was being discussed — I have argued a simple,
unfashionable truth: unless you can keep the doors
open to your practice, you cannot help anybody.
Economics is not a peripheral concern for the
practicing physician. It is the precondition for
everything else. So when the anonymous
correspondent frames our enrollment crisis as a
pure economics problem, I do not disagree with the
diagnosis. I have been making a version of that
argument since before many of our current
applicants were born.
The debt-to-income calculus is brutal. The
downstream comparisons to NPs and CRNAs are
damning. The profession’s identity confusion
between “surgeon” and “specialist” has left a
generation of graduates holding credentials that
the credentialing world does not know quite what
to do with. These are facts, not provocations —
and they are thirty years overdue for a direct
response from leadership.
Where I part ways with the previous letter is
here: the economics are the symptom. The disease
is that this profession has been standing at a
strategic fork in the road for two decades without
choosing a direction. The enrollment numbers are
simply the market’s verdict on our indecision.
Two Roads, and the Cost of Walking Down Neither
The first road leads into allopathic medicine. If
podiatry’s future is genuinely surgical — ankle
reconstruction, limb salvage, complex diabetic
wound management — then the honest path is an MD
degree with podiatric surgery as its own ACGME-
recognized residency track, no different from how
hand surgery emerged as a subspecialty claimed by
both orthopedics and plastic surgery. This would
end the credentialing ambiguity overnight. It
would place podiatric surgeons on identical
footing with their orthopedic colleagues in every
hospital privileging committee in the country. The
price is steep: complete dissolution of the
independent college system, absorption into
allopathic medical education, and the surrender of
a separate professional identity that many in this
profession have spent careers defending. But at
least it is a coherent destination.
The second road accepts, rather than resists, a
non-doctoral scope. Not a diminishment — a
redefinition. A highly skilled, nationally
licensed practitioner focused on palliative and
preventive foot care, operating within a
collaborative model not unlike the optometrist-to-
ophthalmologist or the dental hygienist-to-dentist
relationship. This practitioner does not aspire to
ankle replacement parity with orthopedics.
Instead, this practitioner owns the chronic
disease interface: the diabetic patient with
sensory neuropathy who needs regular debridement
and ulcer surveillance, the aging athlete whose
Achilles pathology will be managed conservatively
for years before anyone considers a knife, the
patient whose quality of life depends on someone
who genuinely understands the biomechanics of
gait. This is not a lesser profession. It is a
different one — and it is one that a rational 22-
year-old might actually choose if the training
timeline, the debt load, and the scope were
honestly presented.
The Middle Path Has Already Failed
What the profession has actually done is attempt
to occupy both roads simultaneously — to be
surgical enough to compete with orthopedics while
remaining accessible enough to attract students
who cannot get into allopathic schools. The result
is the exact position the anonymous letter
describes: graduates who are surgeons in name,
specialists in practice, and neither in the
credentialing matrix. Tweaking the curriculum from
four years to three, or restructuring the
admissions pipeline to mirror accelerated MD
programs, does not resolve this. It decorates the
middle path with new signage while the destination
remains undefined.
I served as national president of what was then
the American College of Podiatric Medicine and
Orthopedics — known today as the American Board of
Podiatric Medicine . I have delivered over 750
professional lectures on five continents. I have
written and spoken repeatedly, in these pages and
others, about the financial literacy this
profession demands of its practitioners and has
historically failed to teach. I am not writing
this as an adversary of the profession’s
ambitions. I am writing it as someone who has
watched this fork approach for a long time and
believes we can no longer afford to pretend it
does not exist.
What an Honest Conversation Requires
The profession needs a structured, transparent
strategic planning process — not another task
force that produces a white paper and dissolves —
but a genuine reckoning with these questions. What
is the realistic credentialing ceiling for a DPM
in American hospital systems over the next twenty
years? If the answer is “not comparable to an MD
orthopedic surgeon,” then the profession owes
applicants that honesty before they sign loan
documents. What is the economic floor for a
practitioner operating in the non-surgical,
collaborative care model? If that number is
competitive with NPs and CRNAs without requiring
surgical fellowship training, then that model
deserves real investment and real advocacy, not
quiet dismissal as a downgrade.
I would add one specific observation for those
focused on the curriculum debate. The anonymous
letter is correct that shortening training while
claiming parity with allopathic medicine is
incoherent. But the inverse also applies:
lengthening or intensifying training while the
destination remains ambiguous will not attract
better applicants. It will repel the last ones.
What attracts applicants is clarity — a clear
answer to the question every prospective student
is actually asking: “If I do this, what will I be,
and will my life be better for it?”
The enrollment crisis is real and the economics
are as brutal as described. But enrollment will
not recover through curriculum adjustment alone.
It will recover when this profession chooses a
road, communicates that choice with the confidence
of an institution that knows its own value, and
builds its training pipeline to deliver exactly
what it promises. We are not there yet. The first
step is admitting we are at the fork.
Bret M. Ribotsky, DPM, Fort Lauderdale, FL
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