With the upcoming CPME 320 rewrite, the changes to the document that relates to the rules and regulations of running a residency (ah, alliteration!), there has been quite a bit of discussion about the way podiatric residencies are structured. As we all know, some years back the 3-year podiatric residency became more standardized, eliminating the alphabet soup of past residency options. Gone are the days of the PPMR, PSR-12, PSR-24, PSR-36, POR, and RPR. If you don’t know what those are then don’t worry about it. You’re the beneficiary of a hard-earned change.

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Whether a budding podiatrist likes it or not, in today’s system of podiatric education, he or she is going to be trained in foot and ankle surgery.

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One of the possibly unfortunate and unanticipated results of this change has been a move toward a more heavy focus on surgery with loss of the nonsurgical side of training. Whether a student likes it or not, he or she is going to be trained in foot and ankle surgery. However, as many distinguished leaders in our field have stated, there is a nonsurgical side to practice, which, for most podiatrists, covers the majority of their practices. Very few podiatric practices come anywhere close to even 50% surgical volume. The reality for most is actually much, much less.

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What’s wrong with being a general practice podiatrist?

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As a side note, for those of you currently in training, remember it is possible to create a fine and successful practice without a major surgical component. If having a nonsurgical practice is what you want, I strongly suggest making sure your residency has a clinic or you can work in one of your attending’s practices. I understand that training is likely to remain heavily surgical, but that doesn’t mean a podiatric residency graduate must do surgery. Complete your minimum activity volume to satisfy the basic graduation requirements. Remember, it’s also important to know which of your patients will need surgery, whether you do that surgery or not.

As many you also know, podiatry has a recruitment problem. Having such few applicants to podiatric colleges is very bad for the profession. Dr Alan Sherman once brought up the excellent point that some number of potential applicants to podiatric colleges may be dissuaded from applying because all of our marketing is toward the surgical side (personal communication). Consider this important point for a moment. There must be some percentage of potential applicants to podiatry school that don’t want to become surgeons. Look at allopathic and osteopathic physicians. Most of them are not surgeons. Bear in mind all of the medical fields that are not surgical. Maybe some of them wanted to be surgeons but didn’t make the cut, but most of them wanted to enter nonsurgical professions.

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How many potential applicants to podiatry schools are we missing because they don’t want to be primarily surgeons?

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With this thought in mind, why aren’t podiatrists advertising both the surgical and nonsurgical aspects of practice to potential applicants. Why not advertise to all of our strengths? How many people are we missing by avoiding this aspect of our practices?

This long-winded discussion brings me to the point of today’s commentary: maybe it would be better if we created a practice structure in which nonsurgical podiatrists teamed up with surgical podiatrists. This type of combined dichotomy has the potential to be highly successful.

Let’s take an example: Me. I consider myself a surgical podiatrist. My professional interests veer toward the surgical (my true passion is surgical biomechanics). I enjoy being in the operating room. I find joy in seeing my patients with successful surgical outcomes. I also love the nonsurgical side as well, but my real intellectual interest is in surgery. As much as I enjoy the clinic I’d rather be in the OR. However, most of my clinical practice is just that: clinical. I don’t spend nearly as much time in the OR as I’d like.

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We need many more clinical podiatrists than surgical podiatrists.

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But what if there was a different model?

What if I were partnered with a high-quality nonsurgical podiatrist – let’s call that person a clinical podiatrist. We should not define anyone by what they don’t do, but instead by a more positive measure. The clinical podiatrist would see a certain number of patients and “specialize” in treating patients without surgery. Eventually, some of those patients will end up needing surgery, and they would be funneled to the surgical podiatrist.

Imagine how good each of those podiatrists would be if they were able to focus on the aspects of patient care about which they were truly passionate? The clinical pod would gain huge experience treating foot and ankle pathology in novel nonsurgical ways, while the surgical podiatrist would have thousands of surgical experiences under their belt.

To some extent this model exists in large-scale organizations such as Kaiser Permanente, who employs clinical podiatrists. These doctors provide very important treatment to the large number of patients that don’t need surgery. The surgical podiatrists benefit from the large numbers of patients screened by the clinical podiatrists, of whom only a small percentage need surgery, but all end up being referred to them, creating the large surgical volume they long for.

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In private practice, clinical podiatrists can and often do earn more than their surgical podiatrist colleagues. Surgical podiatrists’ earnings rise to match those of their clinical podiatrist colleagues when they achieve high volumes of surgery.

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Of course, what is yet to exist in this organization is an equal pay structure between the surgical and clinical podiatrists. Kaiser offers a lower compensation package to clinical podiatrists than it does to the surgical ones. I’m sure Kaiser has done some kind of analysis to determine pay ranges, but I have a hard time believing the surgical ones are really worth that much more money than the nonsurgical ones. It’s well known that in private practice the clinical side can bring in much more income than the surgical.

That brings us to the advantages of this type of team practice. Besides improved patient care resulting from docs who emphasize their skills and passions, they stand to make greater incomes. Clinical practice can bring in more money than the surgical except when the surgical side has very high volume. Increasing the volume brings with it economies of scale in which efficiency is maximized and less time is lost.

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Imagine what our applicant pool would look like if we let everyone know just how varied and open to opportunity the podiatric profession really is?

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Another advantage brings us back to the beginning of today’s discussion about podiatric college applicants. If our podiatry schools learned to equally emphasize clinical podiatry and surgical podiatry in their marketing messages, and in the way they advocate for students once they enter the schools, the schools would begin attracting all possible types of applicants, including both those looking be primarily surgical and those looking to be primarily general practice, clinical podiatrists. Imagine what our applicant pool would look like if we let everyone know just how varied and open to opportunity the podiatric profession really is? One of the ways to do this would be to open the pathways of practice to all directions by having clinical and surgical podiatrists team up. The future will be bright for podiatric medicine – as long as we continue to innovate technologically but also socially.

Best wishes.