Since my letter on the podiatric enrollment crisis
appeared in these pages, I have received a
meaningful volume of private correspondence from
colleagues across the profession — practitioners,
educators, and organizational leaders. I am
grateful for the engagement. The responses were
thoughtful, and several came from individuals
whose standing in this profession I genuinely
respect. Because they were shared privately, I
will not attribute them by name, but I believe the
arguments they raised deserve a public answer,
because they reflect exactly the kind of
institutional thinking that I believe is
preventing this profession from moving forward.
The responses I received shared a common
architecture. Each acknowledged, to varying
degrees, that the economics are real, that student
recruitment is suffering, and that the profession
has struggled with unclear messaging about its
identity. And each, having made those
acknowledgments, arrived at the same conclusion:
the answer is a better, more unified articulation
of the comprehensive vision of podiatric medicine
— one that holds together surgery, biomechanics,
wound care, diabetic limb preservation, sports
medicine, geriatric care, and palliative foot care
under a single banner. I was told that the
challenge is not the vision itself, but getting
the profession’s different constituencies to align
behind it.
I want to respond to that argument directly,
because I think it is both sincere and
insufficient.
A Menu Is Not a Mission
I do not dispute that podiatry does all of those
things. What I dispute is that describing
everything we do is the same as having a strategy.
A menu is not a mission. After two decades of
attempting to hold this comprehensive vision
together, the market — in the form of applicants
who will not enroll, payers who will not pay
fairly, and hospitals that will not credential
equitably — has rendered a verdict that a better
brochure will not reverse. The correspondence I
received asked me to have more patience with the
process of building consensus. I would ask my
colleagues to consider whether patience has been
the problem or whether patience has been the
excuse.
I have spent more than thirty years arguing one
truth that organized medicine consistently
resists: unless you can keep the doors open to
your practice, you cannot help anybody. That
principle applies to individual practices and it
applies to professions. A profession that cannot
recruit students, cannot achieve reimbursement
parity, and cannot resolve its own credentialing
identity is not executing a comprehensive vision.
It is executing a slow exit. And the decision to
continue doing what has not worked for twenty
years is itself a decision — one with consequences
that compound annually. Failure to make a decision
is a decision. And in this case, it is a decision
that leads to failure.
The Blind Men, the Elephant, and the Question
Nobody Is Answering
One of my correspondents invoked, with genuine
affection for the profession, the parable of the
blind men and the elephant — each man touching a
different part of the animal and describing it
accurately, but none describing the whole. It was
offered as an explanation for why unifying the
profession’s constituencies is so difficult. I
found the analogy more instructive than perhaps
intended.
In the parable, the failure is not that each man
is wrong. Each is describing something real. The
failure is that no one steps back to describe the
whole animal in terms that are useful to someone
deciding whether to feed it, care for it, or
invest in it. That is precisely podiatry’s
problem. The surgeon, the wound-care physician,
the biomechanics specialist, the diabetic limb
salvage expert — each is describing something real
and valuable. But the college student weighing
enrollment, the insurer setting fee schedules, and
the hospital administrator making privileging
decisions are all asking one question: what does
this profession do that no one else does as well?
Until that answer is specific enough to be
actionable, the parable is not a charming
illustration of our diversity. It is a diagnosis
of our paralysis.
And here is the part of the elephant that I
believe the profession has been most reluctant to
name: the business model is broken. Not the
clinical model. Not the educational model. The
financial architecture that is supposed to sustain
the practicing podiatrist is structurally
disadvantaged, and no amount of vision-
clarification changes that until the reimbursement
gap is closed.
What the Lobbying Investment Has and Has Not
Produced
Organized podiatry spends hundreds of thousands of
dollars annually on lobbying efforts through APMA
and its state affiliates. I do not question the
sincerity of that work. I question the return.
Third-party insurers systematically reimburse
podiatrists at lower rates than they pay other
specialties performing identical procedures. That
gap has persisted through multiple lobbying
cycles, multiple administrations, and multiple
strategic plans. If the investment were producing
reimbursement parity, I would say nothing. It is
not. My private correspondents did not challenge
this point. They acknowledged it and returned to
the importance of the long game. I would ask: how
long is long enough? At what point does repeating
the same strategy while the gap persists become
the definition of institutional denial?
Consider what a fraction of those resources,
redirected toward a focused parity campaign with
measurable benchmarks, might accomplish. Not a
campaign to preserve the comprehensive vision in
statute, but a campaign with a single, auditable
goal: equal reimbursement for equal procedures,
regardless of the degree held by the physician
performing them. That is a winnable argument —
grounded in outcomes data that already exists.
Particularly in diabetic limb salvage, where
podiatry’s track record is superior to
alternatives at demonstrably lower cost to the
health care system. Every major insurer knows
this. The argument has not been made with
sufficient focus and discipline. It should be.
The One Claim That Can Win
Podiatry’s single most defensible and
differentiated claim is diabetic limb
preservation. Not ankle replacement. Not sports
medicine. Not general palliative foot care. The
outcomes data are the strongest argument this
profession has — economically, clinically, and
politically. Every dollar spent on amputation
prevention returns multiples to the health care
system. If organized podiatry directed its
advocacy resources toward enshrining itself as the
designated specialty for diabetic foot care — with
reimbursement parity as the legislated standard —
the enrollment problem would begin to resolve
itself. Students who can see a clear, well-
compensated clinical identity will enroll. They
are not enrolling now because they cannot see one.
This does not mean abandoning the comprehensive
vision. It means leading with the strongest hand.
Every specialty in medicine has a flagship claim —
a reason to exist that is beyond dispute. Podiatry
has one. It is not using it.
The Difference Between a Vision and a Strategy
My correspondents are united in their belief that
the comprehensive vision is correct and that the
task is to communicate it more effectively. I do
not disagree that the vision is worthy. I disagree
that communication is the primary deficit. The
primary deficit is strategic. A vision describes
where you want to be. A strategy describes how you
will get there, what you will prioritize, what you
will explicitly accept will not be prioritized,
and what success looks like in a defined number of
years. I have not seen that document from
organized podiatric leadership. Until it exists —
with specific commitments, measurable outcomes,
and an honest accounting of what has not worked —
the comprehensive vision is an aspiration, not a
plan.
Institutions that cannot say “what we have been
doing is not working” are institutions that cannot
change. And institutions that cannot change in a
market that is changing around them do not
survive. I say this not as an adversary of the
profession I spent decades serving, but as someone
who believes it is capable of more than it is
currently demanding of itself.
The doors have to stay open. That is not a
metaphor. It is the operating condition for
everything else this profession aspires to
accomplish. I am grateful to everyone who wrote. I
hope this response advances the conversation — and
I hope that conversation finds its way,
eventually, into a room where the decisions that
need to be made are actually made.
Bret Ribotsky, DPM, Fort Lauderdale, FL
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