Learning From The Wisdom Of James Ganley, DPM
As a student at the Pennsylvania College of Podiatry, my classmates and myself had the privilege of studying orthopedics under the direction of James Ganley, DPM. Dr. Ganley was a friend of E. Dalton McGlamry, DPM, and in a manner similar to Dr. McGlamry set a standard of academic and a scientific excellence that far exceeded the podiatry profession in those days. He practiced in a smaller Pennsylvania town and published a good deal in various areas of lower extremity pathology, always maintaining a keen interest in pediatric orthopedics.
There is not a week that passes in which I do not recall some of the philosophy and wisdom that he imparted on students at the college. Each week, Dr. Ganley would present an eclectic variety of lectures. One week, it would be rheumatoid arthritis, the next week metabolic bone disorders, the next week management of pediatric flatfoot deformity, the next week management of tendon disorders, and so forth. I thought it might be appropriate to share some of the insight he shared with us as students.
The job of a great teacher is not to teach you everything about a subject. It is the job of a great teacher to teach you the reason that you should go about learning a subject.
As I mentioned earlier, every week Dr. Ganley presented some topic relevant to the general practice of podiatry. For example, he made clear to us the need to go out and learn about rheumatologic disorders affecting the lower extremity. His several lectures in this area motivated me to read intensively regarding rheumatic disorders affecting the lower extremity. I did so enthusiastically as he had made it clear to me that this knowledge would be necessary for me to properly diagnose and treat rheumatic disorders affecting the lower extremity.
Dr. Ganley never pretended to be a world authority on any subject that he presented to the students. Rather, when he completed his weekly presentation, it was clear to anyone listening that these were areas of knowledge and clinical expertise that we would have to go about mastering to be maximally effective as podiatric physicians and surgeons. He did the same thing for soft tissue and bone tumors, tendon disorders, metabolic bone disorders, common forefoot deformities, common rearfoot deformities, congenital and pediatric deformities, and neuromuscular disorders to name but a few other topics he discussed with us.
Thanks to Dr. Ganley’s influence, I went about making it my business to learn as much as I could about all of these topics and then some. There is not a day in practice when I do not appreciate my understanding of neuromuscular disorders, pediatric deformities and so forth as a result of my studies that his actions motivated.
Today, it seems to me that many students and residents are in a "teach me” mode. They expect to be handed all of the knowledge required for the general practice of podiatry by their teachers or residency directors. I believe there is some lesser degree of motivation among many students and residents to go about and learn, over many years, if things that are required for the diagnosis and treatment of disorders they see in daily practice.
Dermatology is such an example in today's world. I do not expect Bryan Markinson, DPM, or Bradley Bakotic DPM, DO, to teach me everything I need to know for the evaluation and treatment of skin disorders I encounter in the daily practice of podiatry. What I do expect from them and what I do believe they try to impart to this profession is an understanding that evaluation and treatment of dermatologic disorders represents a substantial portion of our daily practice, and that we need to go about gaining greater expertise in the diagnosis and treatment of these disorders that we see in daily practice.
If The Student Does Not Surpass The Teacher, Then The Teacher Has Failed
Many years ago as a residency director, I encountered a patient for whom I had done an implant arthroplasty of the great toe. The patient had developed a Pseudomonas osteomyelitis following his surgery. It was a younger individual who had a symptomatic hallux limitus deformity and the available options at that time were not at all satisfactory.
I was searching for an answer beyond the amputation and a resident of mine, Mark Tuccio, DPM, came up to me in the hallway and said "Dr. Jacobs, I was reading about antibiotic beads. Do you think these might be helpful?" He handed me some articles and I learned about the use of antibiotic-impregnated bone cement, which at that time was new to both orthopedics and podiatry. This therapy of course went on to become standard care under certain clinical circumstances. I learned about this therapy and utilized it because a resident taught me about something that I previously was unaware of.
Some years later, another resident, Vincent Sollecito, DPM, brought in an article entitled "The Fate Of Exposed Bone."1 This taught me that not all exposed bones required radical excision and treatment by amputation.
Over the years, students and residents have taught me a great deal. I am thankful every time I learn from a former resident. I feel that when my residents have exceeded my level of practice, not only do I learn from them, but that somehow I have succeeded as a teacher.
We still tend to have an "old boys network" in podiatry academics. When we look at some of the regional and national meetings, we see the same speakers over and over again. We hear younger practitioners complaining that they are denied the ability to present at such meetings. I believe that to a large extent they are correct and perhaps people such as myself are indeed part of the problem. I believe we need to encourage younger individuals to present at our meetings and not use the fact that they may be inexperienced in public speaking as an excuse. All of us, at one time, were inexperienced in public speaking.
How Many Bad Results Can You Afford To Have Walking About Your Town?
Quite some years ago, the Hershey podiatric conference, held annually in Hershey, Pa., was arguably the premier meeting in podiatry. These were the days of slides, by the way, and speakers were always carrying slide carousels. One particular conference featured a group of very well known, famous thought leaders in our profession lecturing on new techniques in bunion surgery. I can tell you in retrospect that the majority of practitioners have long since abandoned all of the techniques presented as new and exciting at that time.
However, at the time, the same individuals were presenting their newly discovered bunion procedures. The last speaker in this session was Dr. Ganley. While everyone had been spending a good deal of money on fancy, colorful slides, Dr. Ganley began his lecture with slides he made by simply typing his message on a sheet of paper and photographing them for conversion to slides. His first slide stated, "How many bad results can you afford to be walking about your town?"
His point was quite simple. Reputation based on success was paramount to the practice of surgery. Although he had no doubts that some of these techniques were in the short-term likely promising, he took a more conservative view toward the use of established, proven surgical interventions. He pointed out that in a smaller town, it is difficult to maintain referrals and a good practice if too many people suffered from complications were poor outcomes from surgery.
I remember very well chairing the podiatry department at a smaller osteopathic hospital in New Jersey. A new younger "hot shot" joined our staff and made it clear that he was the best trained, most qualified podiatrist to hit the area ever. The first case he scheduled was a rather complex reconstruction, which ended up with major complications, a patient in the intensive care unit and eventually the death of the patient. His reputation was set. He could never obtain referrals from the medical staff following that event and he eventually moved on.
Why You Should Correct That Which Is Deformed
Many years ago, the distal metaphyseal osteotomy increased in popularity in both orthopedics and podiatry. Dr. Ganley was long an advocate of either the Lapidus-type procedure, or cuneiform osteotomy for the correction of bunions. He would show an X-ray and ask us to demonstrate the deformity in the first metatarsal that required a distal or even proximal osteotomy. He would point out that the deformity was at the metatarsocuneiform joint or within the cuneiform itself with an obliquity to the distal articular surface, but that no deformity actually existed within the metatarsal itself.
This was in the early and mid-1970s when very few, if any, practitioners were doing the Lapidus procedure, or any type of a cuneiform osteotomy. We now see that these approaches to the correction of bunion have become popular and that indeed, Dr. Ganley was almost 50 years ahead at this time in his evaluation and treatment of bunion deformities. He pointed out that in treating any deformities, the question to ask is "Where is the actual deformity?" and go about correcting that. If a first metatarsal had excessive shortening following a bunion procedure, when possible and practical, why not restore length to the metatarsal rather than shortening all of the adjacent metatarsals, creating additional deformities to compensate for a defined deformity? I believe he was correct.
Why Morphology Does Not Prove Etiology
In the 1970s, podiatry was overwhelmed by the work coming out of California, primarily defined by the Compendium Of Podiatric Biomechanics by Merton Root, DPM, John Weed, DPM, William Orien, DPM, and Thomas Sgarlato, DPM.2 The profession began to speak about compensated deformities, such as compensated forefoot varus, compensated forefoot valgus and so forth, and that all symptomatic flatfoot deformities were the result of a compensated deformity. As evidence of this, the California "biomechanists" suggested, for example, that the presence of abnormal torsional relationship between the head and neck of the talus, relative to the body of the talus, resulted in a lack of normal frontal plane ontogeny in this bone, creating a forefoot varus deformity.
Dr. Ganley asked a simple question: How then do we explain calcaneovalgus in infancy? The newborn is not ambulating, is not weightbearing and therefore cannot have a compensated deformity. Yet we see flexible (as well as other forms of flatfoot) deformities in non-ambulatory pediatric patients, thereby eliminating the possibility that all flat feet were due to compensation. Dr. Ganley asked the question (which opponents never addressed to the contrary) as to whether variations of foot type associated with a flatfoot, such as a compensated forefoot varus, were in fact just variations in the manner to which the foot was compressed in utero. Therefore, Dr. Ganley questioned whether or not torsional abnormality of the head and neck of the talus relative to the body was secondary to intrauterine pressure, and that the finding of abnormal shapes to bones did not prove an etiology basis for the foot types presented.
Dr. Ganley wrote a classic paper on calcaneovalgus of infancy, which in my opinion should be mandatory reading for all podiatric physicians.3 Many years later, I was lecturing at the North Carolina state podiatry meeting and Dr. Ganley was in the hall with his wife. I must admit I was somewhat nervous with my respected professor in the hall. I was in fact lecturing on flatfoot deformity in a pediatric patient and stated that "morphology does not prove etiology.” I saw Dr. Ganley take out a piece of paper and write something down as I was speaking at that moment. I was thinking to myself that what I had said was wrong or controversial.
After the lecture, Dr. Ganley came up to me and said, "You know I really like that about ‘morphology and etiology.’ Where did you come up with that?”
He was so humble that he did not realize this was a quote from his own work. When I reminded him of that, he tore the paper up and told me "No wonder I liked it so much."
Do You Want That Job?
I had the opportunity to serve as the scientific chairman for the American Podiatric Medical Association (APMA) annual program for several years. At the time, the House of Delegates met concurrently with the scientific section. I was very upset at what I perceived to be priority given to the House of Delegates rather than the scientific program that I had worked to put together. In fact, I was very upset.
Somehow, Dr. Ganley sensed my dissatisfaction and said “Let’s take a walk around the exhibit hall.” As we walked around the exhibit hall, he asked me what I was upset about. I explained to him that I thought it was ridiculous that so much emphasis was on the APMA House of Delegates. He stopped, grabbed my shoulder and explained very simply that neither he nor I, or in fact any of our close friends, were involved in the politics.
However, he pointed out that this was a job that had to be done to protect the interest of and advance the profession. He stated that we needed effective political types to do those jobs that needed to be done and for which neither he nor I nor our immediate friends were qualified or experienced. He asked me, relative to politics, "Do you want that job?" He made me understand the necessity for effective politicians in the profession and not just in academics.
Hopefully, this brief glimpse at my experiences with James Ganley, DPM, will be as helpful to you as he was to me. Although he has been deceased for quite some time now, his wisdom continues to influence my life daily.
1. Brown PW. The fate of exposed bone. Am J Surg. 1979; 137(4):464-9.
2. Root M, Weed J, Orien W, Sgarlato T. A compendium of podiatric biomechanics. California College of Podiatric Medicine, 1971.
3. Ganley JV. Calcaneovalgus deformity in infants. J Am Podiatr Assoc. 1975; 65(5):405-21.