Can We Achieve The ‘Equality’ In Surgery That We Have Achieved In Wound Care And Diabetic Limb Salvage?

Allen Jacobs DPM FACFAS

In the last several months, I have had the opportunity to attend four major wound care conferences. Standing in the back of the room at the Diabetic Limb Salvage conference, world famous researchers and academicians Peter Sheehan, MD, and Andrew Boulton, MD, commented to me how wonderful this meeting and others such as the American Professional Wound Care Association (APWCA) meeting had become in educating medical professionals on limb salvage.

“Look at this,” noted Dr. Sheehan. “You have got MDs next to podiatrists next to nurses, sitting there exchanging ideas between them. This is wonderful.”

In my opinion, there is nowhere in medicine wherein podiatry has gained greater equality than in wound care and diabetic limb salvage. If you attend major national or international wound care or diabetic limb salvage meetings such as the APWCA, the steering and educational committees include podiatric physicians and the scientific programs are replete with podiatric presenters. Attend the usual dinner meetings and the rooms are filled with as many podiatrists as other physicians enjoying the free food and other amenities.

The panel interactions at these meetings always include podiatric physicians alongside of physicians and nurses. Wound care certification, like that available through the APWCA, is equally available to MDs, DOs and podiatrists. The level of respect for podiatrists as equal academic and clinical medical care providers is palpable at these meetings.

In case you have been asleep lately, podiatric physicians have risen to positions of great esteem with the American Diabetes Association. The last time I looked, I failed to see an asterisk next to a DPM’s name qualifying “By the way, this is just a podiatrist.” National vascular surgical associations have now “partnered” with the American Podiatric Medical Association.

Recent studies have demonstrated that the addition of podiatric services to existing clinics reduced the incidence of leg amputation.1,2 I would suggest that saving a leg from amputation, reducing the pain of neuropathy, the early detection of peripheral arterial disease (PAD) and prevention of ulceration are greater services to society than fixing a bunion.

Conversely, we now have podiatrists being incorporated into orthopedic groups in increasing numbers. I graduated in 1973 and never did I believe I would see the day that podiatric physicians would be fully engaged in deformity reconstruction, major trauma management or have a practice fully surgical in nature. The annual scientific meeting of the American College of Foot and Ankle Surgeons is just that, a meeting of foot and ankle surgeons of the highest academic levels. Our profession can boast of accomplished surgeons second to none. The Journal of Foot and Ankle Surgery is the premier publication in the world for foot and ankle surgery.

Although there are certainly personalized and isolated exceptions, the same “equality” of our surgeons does not exist in the medical profession as has been accomplished in wound care and diabetic limb salvage. Podiatric participation in the American Academy of Orthopaedic Surgeons (AAOS) and the American Orthopedic Foot and Ankle Society (AOFAS) meeting is rare, essentially non-existent.

Many orthopedic surgeons, motivated by either greed or stupidity, continue to impede our well trained young graduates from progressing with their professional lives. They interdict practice privileges at every level, from hospital bylaws to state legislation. They steal our literature but seldom cite a “podiatry” reference (not all orthopedic surgeons but many). For every podiatrist initiated into a symbiotic relationship within an orthopedic group, there are 50 more harassed by the orthopedic profession.

I have always believed that podiatry is analogous to dentistry, not medicine. We are a regionalized specialty like dentistry. Dentistry, by defining itself, does not suffer from variations in practice law from state to state. Everyone knows what a dentist is and knows what dentists do. Nobody fails to go to dentists because they are not MDs. Nobody doubts their capabilities. Nobody questions their education. Dental practitioners run the gamut from general care to maxillofacial surgery.

Podiatry is an analogous profession. We do not require a MD degree any more than a dentist does in my humble opinion. We need to stand firm on uniform, high quality education. We must graduate highly skilled individuals at every level, be it “general podiatry,” wound care or surgery. We should stand alone as it were. The desire to be integrated into medicine allows allopathic medicine to “make the rules” for us. The full integration of podiatry into the arena of wound care and diabetic limb salvage came about because we demonstrated our accomplishment to people of an open mind, who are capable of non-discriminatory critical thinking and whose only purpose is the betterment of people’s lives. Our profession has the same surgical capabilities.

What is podiatry? It is the treatment of foot and ankle disorders. In my opinion, we must continue to give equal weight to both the non-surgical and surgical branches of our profession. What do you think?

References

1. Gibson T, Bagalman E, Wang S, et al. Podiatrist care and likelihood of amputation or hospitalization for patients with diabetes and foot ulcer. Late breaking abstract poster presentation. American Diabetes Association’s Scientific Sessions, June 2010, Orlando, FL. Diabetes 2010:59(suppl1).

2. Driver VR, Goodman RA, Fabbi M, et al. The impact of a podiatric lead limb preservation team on disease outcomes and risk prediction in the diabetic lower extremity: a retrospective cohort study. J Am Podiatr Med Assoc 2010; 100(4):235-41.

Comments

Agreed! Podiatry is the medical AND surgical care of the foot, ankle, and leg. I commend all 50 states of the United States to give podiatrists the legal authority to provide medical treatment of the entire foot, ankle joint, and leg. But I find it disturbing that when it comes to SURGERY, some states only allow podiatrists to touch the forefoot. Other states allow podiatrists to treat the entire foot, ankle, and leg.

Why can't podiatrists perform surgery on the entire foot, ankle and leg in ALL 50 states? Blame the orthopedic surgeons, who use their money-power bribery and jealousy to lobby politicians to limit podiatrists to only the forefoot. In states where podiatrists can perform surgery on the entire foot, ankle, and leg, there are orthopedic surgeons who are upset. TOO BAD.

Podiatrists are here to stay and will fight the MD orthopod surgeons who try to hinder podiatrists from performing surgery on the foot, ankle, and leg! Podiatrists have the right to treat medically and surgically the entire foot, ankle, and leg in ALL 50 states. That should be the biggest goal of the APMA, PPAC, ACFAS, NBPME, CPME and all podiatry school faculty members in the next 15 years.

I agree fully with Dr. Jacobs that the scope of podiatry should be the complete medical and surgical treatment of the foot and ankle. Unfortunately, the leaders of the profession seem to be driving in another direction. Project 2015 appears to require all graduating podiatrists to complete a 3-year surgical residency in order to be licensed anywhere in the country. This is an admirable goal but one that begs several questions.

What about those graduates who do not secure a 3-year program? Since there are far fewer such programs than graduates, are they destined for Burger King? What about the non-surgeons, those who choose a more conservative path? Must they also flip burgers?

This is not the way to parity. This is the way to self destruction, the micro-specialization of an already small profession. Before we define podiatry, let's consider the fate of the new podiatrists who must actually try to make a living after graduation. We can't all be "equal" in surgery if we're not allowed to sit at the table with some of our self-exalted peers. Up the revolution!

Jeffrey M. Kittay, DPM
twindragons2@verizon.net
NYCPM 1979, No residency.

Dr. Kittay,

Vision 2015 revolves around making sure all our graduates complete a 3-year residency. I think you are putting the cart before the horse by assuming that legislation will change before this actually happens. The APMA wants all graduating podiatrists to be able to secure three years of training. That is the short-term goal. Once everyone has the "same" training (time wise), then it will be easier to fight for parity amongst our medical peers. This will diminish the confusion as far as what our training is, what our scope of practice issues are, and how we are privileged in the hospitals.

There are already certain communities that require 3 years of training for full surgical privileging at certain hospitals. The APMA is hard at work making sure everyone gets a piece of the pie. The point is that the APMA is not doing this just because. They have understood what the trends are across the nation and are working to make sure everyone can comply to make a good living down the road.

Some of our peers deserve the exaltation they received based on the hard work they've put into the profession on a volunteer basis. We would not have what we have without them.

Best Regards,

Ron Raducanu, DPM, FASPS, FACFAS, FACFAP

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