As a teacher at one of the podiatry colleges, one of the hardest aspects of teaching is trying to make the podiatric content accessible to students while also remaining true to real life. When I was a student, the various aspects of podiatry were presented to me in a black and white fashion.

For example, when evaluating hallux valgus deformities on radiographs, we were taught to measure specific angles and then use those angles to choose a certain surgical procedure. We were also taught concepts such as the total adductus (TAA) and intermetatarsal angles (IMA). We were supposed to use these angles to pick a surgical procedure based on specific parameters. If the IMA was less than 10°, then a soft tissue procedure would be appropriate, while 10° to 15° made a head procedure the surgery of choice. Information such as this presented in a very black and white fashion makes one think that the subject is set in stone.

Then came the real world.

When I became a resident and started actually doing these procedures, the world all of a sudden became grey. Some attending surgeons, for instance, would perform a particular bunionectomy on a patient who radiographically would have been a better candidate for a different procedure… at least according to the textbook.

The rub was that these procedures were being performed on actual human beings. Some people would not be able to remain non-weightbearing postop, which is desirable for optimum healing of certain procedures. Others had medical conditions such as Down syndrome that changed the procedure choice. The surgeons, who lived in the real world, understood that they could not always pick the best textbook procedure.

Our professional experiences clearly have a significant effect on how we view our profession as either black and white or grey. For example, early in practice I read an article on the Lapidus bunionectomy in one of the magazines. I was interested that the author had not mentioned anything about addressing deviations of the proximal articular set angle (PASA). When I contacted him and asked my PASA question, his response was a terse, “There’s no such thing as PASA.”

Over my 10 years of clinical practice, I have grown to see the world as grey rather than black-and-white. I live in a world in which compromise is often necessary to achieve the best results for my patients.

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“I live in a world in which compromise is often necessary to achieve the best results for my patients”

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Examples of this abound. Here’s one: the rare situation in which I have a very elderly and unhealthy patient with a painful crossover second toe due to untreated hallux valgus deformity. Often the best procedure is to simply amputate the toe. When I was in school, this procedure would have been anathema. However, in real life, this is often the fastest way for these patients to return to pain-free walking.

Fast forward to 2016, and here I am, the “Realest”, teaching students who are often uncomfortable with the “Grey”. My biggest personal conundrum is teaching biomechanics. We teach Root biomechanics, since that is primarily what is tested on the boards. However, over my years of practice, I have moved increasingly away from this paradigm. I tend toward other theories such as tissue stress and the Kirby rotational equilibrium model. In the past, I have attempted to teach several theories in a sort of general survey of biomechanics, but invariably, my students became confused. They simply did not have the background to look at foot function in variable ways. Currently, I stick to the standard curriculum and tell the students there are other theories that they can discuss with me outside of class.

Imagine the looks on their faces when I say things like, “The joints in the foot don’t move like hinges” or most classification systems are worthless or down right wrong (such as the Lauge-Hansen classification of ankle fractures) or “many bunions don’t need to undergo any soft tissue release.” The list of what we thought we knew but is actually wrong is long .

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“The list of what we thought we knew but is actually wrong is long”

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For those who are open to it, this is the fun part of podiatry. But for others, this can be a very uncomfortable world, living in the grey.

For those of you still in training (student or resident), one of your goals should be to eventually think outside of these black and white terms. I suggest two thought activities to focus on. First, always consider all aspects of your patients when making decisions. Does your treatment fit as many of your patient’s situational attributes as possible? Second, be open to the reality that nothing is either-or. Medicine is complex and requires creative thinking. Free yourself from the chains of “what is known” and enjoy the thrill of discovery when something you thought was true turns out to be explained in a new way. Enjoy exploring the grey.