The ACFAS/APMA split was one of the most controversial developments to affect podiatry in years. Accordingly, this author talks to various podiatrists about the aftermath of the controversy, the emergence of the American Society of Podiatric Surgeons and how the proposed CPME 320 changes might affect both surgical training and biomechanical knowledge.
When the American Podiatric Medical Association (APMA) parted ways with the American College of Foot and Ankle Surgeons (ACFAS) in 2008, did it mark a turning point for the podiatric profession? After a decades-long partnership, the ACFAS is no longer the surgical affiliate of the APMA and DPMs are wrestling with the future of podiatric surgery in the form of a new surgical organization and possible changes in surgical residency requirements in the Council on Podiatric Medical Education (CPME) 320 document.
Two years ago, the ACFAS removed the requirement that those renewing college membership must maintain their APMA membership although the ACFAS did leave in place the provision that podiatrists must still belong to the APMA when they join the college. Fifty-three percent of the ACFAS membership supported the board’s decision not to require renewing members to belong to the APMA.
“The split between these organizations is the worst thing to happen to the profession in the past 30 years,” asserts Doug Richie Jr., DPM.
When the ACFAS changed its policy on APMA membership, the APMA said the college was in violation of APMA bylaws. After ending its relationship with ACFAS as the APMA’s surgical affiliate, the association founded the American Society of Podiatric Surgeons (ASPS) as its new surgical affiliate.
Has the establishment of the ASPS affected the ACFAS membership numbers? By the end of 2009, ACFAS membership was at 6,100, a slight increase from 2008, according to Michael Lee, DPM, the President of the American College of Foot and Ankle Surgeons. He notes it was a record membership total despite the economic downturn and decreased membership in other medical organizations. About 80 percent of college members are fellows and 15 percent are associates. More than 98 percent of members renewed their ACFAS membership for 2010, notes Dr. Lee, who says this is consistent with recent years. Dr. Lee says these numbers signify that the membership sees “tremendous value” in ACFAS programs and its Journal of Foot and Ankle Surgery.
In the past two years, he notes “a very small number” of the college’s members did not renew their membership in a dispute over the majority vote on the college’s membership requirements. Dr. Lee suspects the APMA had the same situation, noting that “the sky has not fallen for either organization.”
Officials from the APMA declined comment for this article. However, the association’s Web site notes that its membership is “close to 12,000.”
As Dr. Lee points out, both the ACFAS and APMA now have similar membership policies granting their respective members the right to choose their own professional affiliations as is the case in other organized branches of medicine. He emphasizes the April 2008 decision by the majority of ACFAS members was in favor of the “right to choose.” In addition, he notes the ACFAS has not only maintained the requirement for APMA membership for admission to the college but the ACFAS official policy is to urge its members to maintain their APMA membership throughout their career.
Dr. Lee also notes a difference in the mission of the two organizations. He notes the primary mission of the ACFAS is education and research while the APMA’s primary mission is government relations.
“These missions have and should continue to dovetail nicely,” he says.
The APMA Web site notes a mission statement that it “advances and advocates for the profession of podiatric medicine and surgery for the benefit of its members and the public” and “influence(es) public and private policy affecting the future of podiatric medicine and surgery.”
Dr. Richie, a Fellow of the American College of Foot and Ankle Surgeons, says the APMA should consider binding mediation to resolve continuing differences with the ACFAS. He cites the importance of any effort to get both parties back to the negotiating table.
In four instances between July 2008 and July 2009, the ACFAS offered to discuss a new relationship with the APMA, according to Dr. Lee. “In each instance, the APMA did not respond or declined our invitation,” he says. “Instead, APMA decided to start an in-house surgical organization that may sap its own resources to, in effect, reinvent the wheel.”
Dr. Lee says the ACFAS will continue its interaction with the American Academy of Orthopedic Surgeons (AAOS) and American Orthopedic Foot and Ankle Society (AOFAS). He notes that two ACFAS members served on an AAOS Clinical Practice Guidelines panel last summer and the college conducts most of its surgical skills courses at the Orthopedic Learning Center in Rosemont, Ill. Since the college’s office is less than a mile from the AAOS, he says their staffs have frequent interaction.
Alan Catanzariti, DPM, believes there will be “not much of an issue” with the ACFAS dealing with orthopedic organizations without APMA backing.
“I think the ACFAS is equipped to deal with this better than anybody,” says Dr. Catanzariti, a Fellow of the American College of Foot and Ankle Surgeons. “I think ACFAS will continue to be quite effective.”
In addition, Dr. Lee emphasizes that the members of ACFAS interact with MDs and DOs in hospitals, surgical centers and, in his practice, are partners with AAOS and/or AOFAS members.
“These relationships should never be discounted and this is the future for podiatric surgeons,” says Dr. Lee, who is a partner and in private practice at Capital Orthopaedics & Sports Medicine, P.C. in Des Moines, Iowa.
“Let us remember that AAOS does not require members of AOFAS to also be AAOS members yet they work together harmoniously so our similar membership policies have not surprised or concerned them,” points out Dr. Lee.
In regard to efforts by some organizations to curtail state podiatric scopes of practice, Dr. Lee says these “battles must be fought every day in the hospitals where board-certified surgeons are proving their competency to hospital medical staffs.” Dr. Lee notes the ACFAS frequently receives calls from board-certified surgeons who are facing privileging problems in hospitals. He says the college’s health policy staff works one on one with each member to overcome the roadblocks and the ACFAS Web site has more than 20 documents dedicated to this issue.
Dr. Lee also notes that the ACFAS was the first organization to propose a model state scope of practice act, which is also available on the site.
Dr. Lee maintains that scope of practice battles are also fought in the “halls of state legislatures, where ACFAS spokespeople work side by side with APMA leaders and, to the best of my knowledge, have not lost a battle in many years.”
When it comes to scope of practice legislation, Dr. Lee says the college primarily works with state podiatric medical associations. He notes this is helpful because state leaders know the local players and politics best. As Dr. Lee notes, multiple voices are more effective in politics than lone voices so state leaders call upon the ACFAS, APMA and other groups to help. He says the college provides board-certified spokespeople to address surgical issues, noting that these issues are always the crux of battles over scope of practice.
Dr. Richie believes the APMA and ASPS cannot properly represent the surgical arm of the profession without the involvement of the ACFAS, noting the college’s decades as the profession’s surgical organization. Furthermore, he notes the APMA has evolved to have an identity as a voice for primary foot care and the association did so knowing that “ACFAS was always going to be there as our surgical advocate.”
What about the ACFAS’s relationship with other podiatric organizations such as the American Board of Podiatric Surgery (ABPS)?
Dr. Lee says the college’s relationship with ABPS remains the same and notes the two executive committees recently met in February. As he points out, the formation of the ABPS came from the ACFAS in the 1960s. Dr. Lee says the ABPS is now independent and accountable only to the Joint Committee on the Recognition of Specialty Boards. Therefore, he notes the ABPS is and should remain neutral on issues outside of the board’s own operations.
“We always stand ready to support their efforts since ACFAS is the only surgical organization that requires ABPS status for membership,” asserts Dr. Lee, a Diplomate of the American Board of Podiatric Surgery.
The American Society of Podiatric Surgeons requires its Fellows to be certified by the ABPS while the Associates must be board qualified by the ABPS, according to bylaws posted on the ASPS Web site. The society’s other membership categories do not require an ABPS affiliation.
In addition to the new surgical landscape formed by the establishment of the ASPS, proposed changes to the CPME 320 may affect the surgical requirements of residents. Changes include lengthening residency training requirements from two to three years. The committee was due to vote on the final changes in late April.
Several months ago, the CPME proposed dropping the word “surgery” from PM&S terminology in the residency statements, according to Dr. Lee. He also notes that proposed changes also lowered the requirements for H&Ps during residencies. For the college’s part, he notes it recommended to CPME that the committee retain “surgery” and require a much higher number of H&Ps during residencies.
Dr. Catanzariti agrees that the word surgery should be a part of PM&S terminology and like Dr. Lee, does not agree with the proposal to reduce H&Ps.
“Anything you can do to maintain the numbers and the quality when you are looked at by the public or certifying organizations should remain,” says Dr. Catanzariti, the Director of the Residency Training Program within the Division of Foot and Ankle Surgery at the Western Pennsylvania Hospital in Pittsburgh.
As Bret Ribotsky, DPM, argues, the number of procedures is not a barometer of accomplishment for residents. He says the evaluation should focus more on competency. He adds that if residents perform the procedure wrong a number of times, they will keep performing it wrong.
“The ACFAS has a long track record of pushing for better and more surgical training, and the result has been a transformed profession over the past 30 years,” notes Dr. Lee.
The CPME changes “need to be a conscious evaluation of who we are as a profession,” according to Dr. Ribotsky, a Past President of the American College of Foot and Ankle Orthopedics and Medicine. “Are we a surgical specialty or are we a biomechanical specialty? The last thing you want to do is lose the medical side.”
Dr. Richie feels the proposed CPME 320 changes would place too much emphasis on surgical training at the expense of biomechanics and other areas of podiatric expertise.
“These changes will do nothing to improve the surgical expertise of podiatric residents and will significantly weaken their training compared to our allopathic counterparts,” argues Dr. Richie, an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University.
In addition, Dr. Richie believes the ACFAS “continues to ignore” the vital role that biomechanics plays in foot and ankle surgery. He notes that in the past five years, topics even remotely related to biomechanics have disappeared from the curriculum at ACFAS meetings while biomechanics is growing in importance at orthopedic surgery meetings.
Reducing the biomechanics exposure for training podiatric residents “will doom our efforts to achieve parity in training with allopathic physicians and will certainly ensure that our podiatric surgeons will become inferior to their orthopedic counterparts,” states Dr. Richie.
“Surgery and biomechanics go hand and hand,” notes Michael Graham, DPM. “We must first understand the biomechanics in order to understand the pathomechanics that lead to the need for surgery.”
As Dr. Graham notes, this can be difficult because to prevent recurrence of the deformity, the surgical procedures must address or eliminate the underlying etiology. Given that the major underlying etiology for foot disorders is from the pathomechanical forces, he emphasizes that surgery is usually the required method to stabilize these excessive abnormal forces.
Are the current medical and biomechanical CPME requirements enough? Dr. Lee advocates having more medical and biomechanical training as part of the CPME. As he says, biomechanics is more than custom orthotics and surgical planning and technique require sound biomechanical principles. Dr. Catanzariti concurs with the need for more medical and biomechanical training as part of CPME 320. Dr. Lee says the ACFAS sent comments to CPME in March on the 320 document that urged the current medical requirements be maintained.
Although he says the CPME’s current requirements are adequate in terms of time exposure for medical and biomechanics training, Dr. Richie feels the requirements are inadequate in terms of content. He says the description of the biomechanics requirements is outdated as far as what is happening today in the biomechanics community. He supports giving residents access to a gait lab and biomechanics research, and emphasizes that biomechanics is not just foot orthotic therapy.
Stephen Barrett, DPM, believes there cannot be too much emphasis on podiatric surgical training.
“We largely are a surgical specialty and do extraordinary work, which will continue to be sought out by patients seeking the ultimate in foot surgery,” maintains Dr. Barrett, an Adjunct Associate Professor in the Arizona Podiatric Medical Program at the Midwestern University College of Health Sciences. “Many podiatric surgeries are biomechanical corrections in and of themselves so it is difficult to separate (biomechanics and surgery).”