After 30 Years, Has Podiatry Changed For The Better?

Pages: 82 - 82
Kevin A. Kirby, DPM

It has now been 30 years since I first opened my podiatric practice, joining a group of orthopedic surgeons in a multispecialty practice. It has been a great experience for me as many changes have occurred within podiatry and the rest of the medical profession during this time. Some of the changes within podiatry have been good but I believe other changes have not been so good for our profession.  

One of the positives that has occurred is that podiatrists have become a more integral part of the medical community than three decades ago. When I first started practice, the orthopedic surgeons I worked with were skeptical of my abilities and the abilities of other podiatristsToday, however, these same orthopedic physicians consider me and many of my podiatric colleagues to be an important part of the medical community, showing little evidence of the skepticism that I first noticed three decades ago. Their views also seem to reflect the improved perception of podiatrists in the rest of the medical community.

I believe the change in status of the podiatric profession over the past 30 years is directly due to two factors. First of all, there were, and still are, many dedicated, high-quality podiatrists who worked hard for years before I entered practice, laying the groundwork for podiatrists to gain access to hospital and surgical privileges. This generation of podiatrists selflessly devoted themselves to the promotion of podiatry within all our medical communities and advanced the podiatric profession long before many of us started our own practices.  

The second factor that has elevated the podiatric profession is the improved medical and surgical training of the podiatry students and podiatric residents who have eventually become members of our medical community over the past three decades. The more recently graduated podiatrists, with their increased medical knowledge and surgical skills, set an excellent example for the podiatric profession within our medical community. These young podiatric physicians, with their energy, skills and knowledge, have increasingly become the leaders of our podiatric medical community and will guide us into the future.

Unfortunately, during that same timeframe, I see problems possibly brewing for the future of the podiatric profession. Over the past 30 years, I have taught biomechanics, sports medicine, foot orthosis therapy and shoe biomechanics concepts to podiatry students at the California School of Podiatric Medicine at Samuel Merritt University (formerly the California College of Podiatric Medicine). In addition, over the past 26 years, I have helped train podiatric surgical residents on non-surgical and surgical biomechanics theory and techniques, foot orthosis therapy and sports medicine concepts.  

What concerns me now about podiatry is that even though the third-year surgical residents all possess excellent clinical skills in medicine as well as forefoot, rearfoot and ankle surgery and trauma, many of the practical clinical skills in foot orthosis therapy and sports medicine that were once common among the podiatrists who graduated in my era have become sorely lacking. Even though I train these very intelligent podiatric surgeons on casting, prescribing and modification of foot orthoses along with sports medicine and shoe biomechanics concepts, these young podiatric physicians seem to come to me with relatively little skill and knowledge of non-surgical treatment methods.

Clearly, podiatrists need to be knowledgeable of foot and lower extremity biomechanics, and proficient in their non-surgical skills so they can provide excellent conservative care to their patients. It is important to keep in mind that many patients do not want to or cannot take time away from their work and family to have surgery.

Is this lack of training in non-surgical podiatric skills the fault of these third-year podiatric surgery residents? No. Rather, it is likely due to the podiatric surgery residency hierarchy emphasizing improved surgical skills at the expense of non-surgical skills. It is apparent that important conservative skills have been relegated to a minority status within the current mandatory three-year podiatric surgery residency model while all priorities are devoted toward molding podiatry residents into expert foot and ankle surgeons.  

So has podiatry improved over the last 30 years? In some ways, we seem to be stepping forward but in other ways, we seem to be stepping backwards. Let us hope that we can continue to strive together to correct these deficiencies in non-surgical podiatric education and skills within our current post-graduate podiatric residency programs. It will be essential for us to do so if we want to remain the experts in both the surgical and the non-surgical treatment of foot and ankle pathologies for the good of our patients and for the good of the podiatric profession as a whole.

Dr. Kirby is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is in private practice in Sacramento, Calif.



Dr. Kirby is correct in his lamentations. The questions remain as to how to remedy the situation.

The American Board of Podiatric Medicine is increasing in strength as to the number of diplomates, and it is this arm of the profession that is responsible for setting the non-surgical standards of the residency training. With the adoption of the new CPME 320, the number of biomechanical cases needed for successful completion of a 36-month PMSR has been increased, and the complexity of the evaluations mandated has increased. I believe it is a step forward to improving the training. All PMSR now have to have at least one ABPM diplomate on its faculty. While I realize that not all ABPM diplomates have the expertise of Dr. Kirby, again it is very much a step forward.

Some other things to consider in the training process:

1) Since the profession feels that a separate degree is essential and schools of podiatric medicine should exist that are not allopathic or osteopathic schools, should we then consider that a different set of skills should be required of those who attend podiatric schools?

In 1975, I took a special podiatric school admission test, that had as one of its components a section on 3D visualization. Should we look back and review whether this was of value or whether we are attracting higher quality of students by only having them take MCAT, which has no 3D visualization testing?

2) Should schools put biomechanics into the basic science part of the curriculum, taught by PhDs in biomechanics? Biomechanics is not a concept of studying whether the subtalar joint is in neutral or whether you can make a better arch support. Biomechanics is one of the basic sciences that should be an integral part of our thinking, just as physiology should be an integral part of our thinking. We need to teach basic concepts rather than just kinetics. Biomechanics should be the basis upon which every musculoskeletal surgery is based. The reason that we are the foot experts should not be just that we have superior intraoperative skills, but that we have superior pre-operative and post-operative evaluation skills.

3) Should the actual making of orthotics, braces, be part of the pre- or post-graduate training? I am convinced after 36 years of practice, that if you want to learn the art of orthotic prescription, make your own and fix the problems.

Unfortunately, I agree completely with Dr. Kirby. I've had the opportunity to educate residents for 37 years through the Baja Project for Crippled Children, at various national and regional meetings and at residency consortia around the country. Along with obvious gains in resident knowledge and skill in managing patients with significant medical comorbidities, as well as increased exposure to acute trauma and ankle surgery, a significant loss has occurred in fundamental understanding of foot and ankle function. Furthermore, at this point, the issue has extended several generations with the result that those lacking in this knowledge "do not know that they do not know." Ironically, this has occurred at a time when more is known about foot and ankle function than ever before.

We face a paradox within our profession where newer practitioners are capable of performing a broad range of surgical procedures with less application of the fundamental biomechanical parameters that underlie the very function that the intended surgery was performed to improve. The end result, unfortunately, is a progressive loss of the comprehensive specialist of the foot and ankle (i.e. of being true regional specialists). In its place, we have created structure-oriented, musculoskeletal practitioners who have concurrent skills in wound care. A good but incomplete skill set in this practitioner's opinion. Rather than taking real ownership of foot function, we let it slip away as a profession. It's retrievable, of course, but I see no collective will to do so.

Marc Bernard, DPM
Executive Director, American Board of Podiatric Medicine
Co-Director, Baja Project for Crippled Children

Thank you to Drs. Phillips and Bernard in putting forward their own observations and opinions regarding the teaching of biomechanics to our podiatry students and residents. Unfortunately, the problem only gets worse every year as more biomechanically-trained podiatrists retire and newer podiatrists, who have little biomechanics and foot orthosis training, take their place.  

I jJust had two patients this week who had seen younger podiatrists for the treatment of plantar fasciitis and these podiatrists recommended foot surgery before even mentioning foot orthoses for the treatment of their plantar fasciitis. Patients aren't stupid and will go to the health care provider who is good at providing the service needed when podiatrists only know how to do surgery, and little else. I will likely be training more pedorthists and physical therapists in the future on how to do good custom foot orthosis therapy since most podiatrists don't want to be bothered by such "unimportant" information.

This is bad for podiatry ... and their patients.

Kevin A. Kirby, DPM

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