Guest Editorial: This week I am pleased to continue our series of 'Future of Podiatric Medicine' editorials with a great piece from Dr. Andrew Boulton. Many of you have seen Prof Boulton speak at CME events and likely already know of his key position in the international diabetes scene. Dr. Boulton is an MD diabetologist who is among the world's leaders in the treatment of diabetic foot complications, but comes at the topic from the perspective that only a medical doctor can. His advocacy of the team approach to treating diabetic foot disease pre-dates almost everyone in the field. He is no novice to international travel given his many active roles including Professor of Medicine at University of Miami and Professor of Medicine at University of Manchester. Please see below and learn even more about how our profession is viewed by the international community and how we can continue to better our ability to contribute to patient care.

     —John Steinberg, DPM, PRESENT Editor

Andrew JM Boulton, MD, DSc (Hon), FRCP Professor of Medicine, Miami, FL, USA Professor of Medicine, University of Manchester, UK Consultant Physician, Manchester Royal Infirmary. Vice-President and Director of Postgraduate Education for the European Association for the Study of Diabetes.

Future of Podiatric Medicine:
An International Perspective

Podiatry is not a new profession:  as in most areas of medicine, podiatry has a long history.  There is evidence from Egypt, for example, that some form of professional foot care existed > 2000 BC.  Modern podiatry, of course, developed over the last 120 years or so, with the first professional podiatry association, the New York State Podiatric Medical Association, having been founded in 1895.  However, even as we enter the year 2010, only a small minority of countries worldwide have podiatry as a recognized profession, and these include the USA, Canada, UK, Scandinavian and Benelux countries, Australia and New Zealand.  Even amongst these countries, the duration of training and the degree of surgical involvement vary tremendously.  In North America, podiatrists qualify after four years of podiatry school, which they enter with a Bachelor’s degree:  this is followed by the awarding of a doctoral degree and a period of postgraduate training.  In Europe and elsewhere the level of training is not so high.  In the UK, for example, students can enter podiatry school straight from high school, and obtain a Degree of Podiatric Medicine (DPodM) after three to four years.  Increasingly, however, after qualification and some clinical experience, practitioners are taking training courses in podiatric surgery and can then practice almost as our American colleagues in podiatry.

A key question relates to the future of podiatry — or even, will podiatry survive as an independent profession?  Encouraging news comes from Ireland in 2008 with the opening of the first podiatry school in that country as part of the National University of Ireland in Galway.  However, to return to the question “will podiatry survive” I am optimistic that it will, although its success will depend on two factors:

1. A change of the philosophy of podiatry schools
   Most successful departments in any subject in universities across   the world are active in both teaching and research.  Unfortunately,  as I look at our podiatry departments, with few exceptions, these are research inactive, and focus only on teaching.  This is unfortunate, and I hope to see in the next decade, a change in this approach to employ research-active faculty, which would stimulate podiatry students to question dogma and to engage in clinical or even basic research.  This change can only be achieved gradually but I feel that this is a critical challenge to the survival and hopefully expansion of podiatry training to other countries.  Residents should be encouraged not only to rotate through university hospitals but also  to participate in research projects which might even become a compulsory part of postgraduate teaching.
   
   
2. Working together with other health care professionals
   The need for a team approach to include podiatry is best demonstrated in my area, that is, the diabetic foot.  In no other area is the need better illustrated.  The podiatrist is a key member of the diabetic foot team, which should also include as a minimum and as well as the patient, diabetes physicians and surgeons (typically orthopedic and vascular), diabetes nurses/educators and an orthotist.  There is supportive evidence that this team approach might be beneficial:  in 2004 Van Houtum and colleagues (1)   reported a significant reduction in the number of major amputations in diabetic patients in the Netherlands (36% reduction in males, 38% in females). This was preceded by an increase of podiatry input into the diabetic foot, and an also an increase in the number of      hospitals providing podiatry services.  More recently, Krishnan and colleagues in the UK (2) reported a 70% reduction in major amputations after the establishment of a multidisciplinary diabetic foot team.

Thus I believe in a healthy future for the podiatry profession providing that these two major points are addressed in the future:  but with one further caveat.  It is stated in the book of Matthew in the bible that “A house divided against itself cannot stand”.

If we take that household to be the “foot-care family” then it is imperative that we all work together with a team-spirit.  It is therefore unfortunate that in some areas of North America and the UK, there is often squabbling and even fighting between two important members of the team – orthopedic surgeons and podiatrists.  I sincerely hope that this stops because as my good friend Larry Harkless, now Dean of a new podiatry school in California said, “There are enough feet to go round us all!”  It behooves us all to remember these important words.

REFERENCES

1. Van Houtum WH, Rauwerda JA, Ruwaard D, Schaper NC, Bakker K.  Reduction in diabetes – related lower extremity amputations in the Netherlands, 1991-2000.  Diabetes Care 2004; 27: 1042-1046.
   
   
2. Krishnan S, Nash F, Baker N, Fowler D, Rayman G.  Reduction in diabetic amputations over 11 years in a defined UK population: benefits of multi-disciplinary team work and continuous prospective audit.  Diabetes Care 2008; 31: 99-101.

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