11/06/2019 Alan Sherman, DPM
The Need to Provide a Separate Medically Intensive Podiatric Medicine Residency (Charles M Lombardi, DPM )
In Charles Lombardi’s comments on the discussion
regarding the need for a separate medically
intensive podiatric medical residency, he
criticizes certain unnamed people for being
schizophrenic, for changing their minds as to
whether such a program is needed between 2000
and 2019. To be clear, I am not for such a
program. But I would point out that we are all
scientists, trained to collect data and draw the
best possible conclusions from that data, and
that data has changed as podiatric practice and
training has evolved in the past 19 years.
The situation is now quite different than it was
in 2000. That “certain people” have changed
their opinions during those 19 years is not only
reasonable, but it is admirable. In fact, those
who cling to obsolete opinions in the face of
new and changed data are not only unscientific,
but they risk becoming obsolete.
Let’s examine the facts. In 2000, the
predominant board in podiatry was the “surgical”
board, the American Board of Podiatric Surgery
(ABPS) which is now known as the American Board
of Foot and Ankle Surgery (ABFAS). As a
practical matter, certification by the
“surgical” board was required to get on a
hospital staff, which was required to get on
insurance panels, which was required to get paid
by patients’ health insurance policies. So all
podiatrists had to seek certification in surgery
in order to get paid. During these years, the
ABPS/ABFAS was doing their job, which was to
maintain high standards, while the profession
was complaining that ABPS/ABFAS was keeping too
many podiatrists from achieving that board
certification.
I’m going to be honest here and admit that
though I did achieve that certification, I
thought this board was getting in the way of
many podiatrists’ ability to earn a living.
Today, the data has changed and I have changed
my mind, for two reasons. First, we have
witnessed the rise of the American Board of
Podiatric Medicine into a well-run board that
certifies in podiatric medicine (i.e. podiatry)
and whose certification is generally accepted at
hospitals across the country for staff
privileges and insurance panels to get paid.
So the rise of ABPM has eliminated the need for
every podiatrist to get training in and to do
advanced foot and ankle surgery. General
practice podiatrists can and are getting boarded
by ABPM, getting on hospital staffs, and getting
paid by insurance companies. And secondly, I
have come the believe that ABFAS SHOULD have
very high standards and should be granting
certification to only those podiatrists who are
truly advanced foot and ankle surgeons, and can
demonstrate such to their peers.
The reality is that most podiatrists are not
that. Not only are most podiatrists not
advanced foot and ankle surgeons, we or the
public DO NOT NEED them to be advanced foot and
ankle surgeons. The trend of ALL podiatrists
getting trained as advanced foot and ankle
surgeons was DRIVEN by the NEED to be boarded in
surgery, and with the rise of ABPM, that need is
now obsolete….it is no longer needed.
Advanced foot and ankle surgery should be a sub-
specialty of podiatry, and only a subset of
podiatrists are needed to populate that sub-
specialty. Of course, ALL podiatrists needs to
do some surgery, ie. nail surgery, ID abscess,
excision soft tissue lesions, arthroeresis. But
advanced foot and ankle surgery, ie. ORIF ankle
fractures and major trauma, calcaneal
osteotomies, rear foot fusions…we just don’t
need ALL podiatrists to do these procedures.
With this new set of facts, I believe it’s time
to re-assess our needs as a profession as far as
post-graduate training and board certification,
and to make some adjustments as a profession, as
Leonard Levy suggests in his last message on
this topic. Follow the growth of any profession
and you’ll find that seldom is there long term
planning by its institutions and voluntary
cooperation among them. Most often, the
institutions are separate silos, each with their
own goals, personalities, and esprit d corps.
When they need to change for the overall needs
of the profession, oversight BY THE PROFESSION
is needed.
I believe we are at a point in history for our
profession when we need oversight of the boards
and CPME to assess our needs and plan changes in
those institutions to best meet those needs. As
a profession, we need to determine not what is
best for ABFAS and ABPM and CPME, but what is
best for podiatry and how those institutions can
best meet the needs of our profession and the
foot health needs of America.
There has been a lot of discussion over the past
year surrounding these issues, which seems to be
rightly focused on: (1) The current model for
podiatric residency education and (2) the
structure of our boards and the certifications
that they issue. There is justifiable confusion
in the medical hierarchy as to what a podiatrist
is and what certification they should use to
ascertain that a podiatrist is certified as a
podiatrist. They ask, reasonably, what
constitutes THE board certification in podiatry?
During the first 19 years of this century, we
have created what I call an “emperor’s new
clothes” situation where we are telling the
medical hierarchy and the public that we are all
advanced foot and ankle surgeons, supported by
the fact that we are all completing this
standardized 3 year surgically focused residency
program.
But we know that we are not all advanced foot
and ankle surgeons, nor do we need us to all be
that thing. Most of us are general practice
podiatrists, or focused on one or another sub-
specialty of podiatry as their predilections and
talents dictate and the fact that all recent
grads are completing 3 year surgically focused
residency programs doesn’t make them advanced
foot and ankle surgeons. Of course, most are
not, by choice or circumstances.
In effect, I think our drive to advance the
profession and achieve respect, status and all
that comes with it, has driven the progress
pendulum way past the midline as far as the
balance between surgery and podiatry, and what
we need now is for it to swing back. The only
way that is achievable is by an assessment of
our situation and a reconsideration of the
structure of our colleges, residency programs
and our boards. We need the 21st century
equivalent of the Selden Report…an examination
of how well the institutions of podiatry are
currently serving our needs, where the pain
points are, what our needs are predicted to be
in the decades ahead, and how best to mold our
institutions to best meet those needs.
It is my opinion that our residency programs
will need to allow options for some diversity in
training, and that we need a merger of ABPM and
ABFAS, to the end that we have a single board
that offers a single essential certification in
podiatry, with sub-specialty certifications in
advanced foot and ankle surgery, sports
medicine, podiatric dermatology, and any of subs
that the profession wishes to offer.
Alan Sherman, DPM, Boca Raton, FL
