Further Discussion on Whether Podiatry is a Surgical Specialty, and Whether We Should go to a Dual-Track Third Year in Podiatric Residency Programs

In Dr Shapiro’s Practice Perfect 644, “Is Podiatry a Surgical Specialty – A Response”, he agrees with many of the premises of the original article, but then identifies four important challenges regarding the implementation of the dual-track third year of podiatric residency programs. I’d like to address them one at a time.

1. Creation of a confusing identity to the medical profession

It is true that consolidating our residency program structure to a single three-year track has made it simpler for the public and the medical hierarchy to understand our training. However, the simple explanation that we’ve left them with is that all podiatrists are advanced foot and ankle surgeons, and that is simply not the case. Not only is that not honest and not accurate, it is not desirable. We are no more all advanced foot and ankle surgeons than all orthopedic surgeons are advanced foot and ankle surgeons.  It’s also like the famous fable, the Emperor’s New Clothes. We shouldn’t be promoting ourselves as anything other than what we truly are, for the simple reasons that it is dishonest but also because what we really are is terrific. Most of us are general practice podiatrists that have some foot and ankle surgical skills. Some of us are highly skilled advanced foot and ankle surgeons. Yes, that requires a more complex explanation. Orthopedic surgeons and many other medical and surgical specialists have their basic training programs, and then go on for fellowships if they desire to be considered “advanced”. Maybe we should follow their lead?

We really need to define the “divide”, the menu of surgical skills that general practice podiatrists must have vs those that advanced foot and ankle surgeons must have.  That alone will be the most important set of decisions to be made if we are to pursue the dual-track third year of podiatric residency education.

2. Residency conversion difficulties and unanticipated consequences

I acknowledge that changing the resources made available to residents in over 200 programs across the country will be challenging. I contend, however, that the improved outcomes of those doing the advanced foot and ankle surgery track getting more surgical cases, and those doing the general practice podiatry track focusing on those aspects of practice, will produce better-trained residents in both tracks, and will be ultimately worth the effort.

3. The surgery versus clinical hierarchy

In today’s surgery centric podiatry schools and residency programs, students and residents are conditioned to aspire to be surgeons. The atmosphere and attitude towards surgery is so gung-ho, that I believe that the majority of podiatrists who are not going to be advanced foot and ankle surgeons are reluctant, even afraid to openly express their goals of being general practice podiatrists. They think they are letting their peers down by not aspiring to be advanced surgeons. Most poignantly, many of them feel a sense of failure that they are not becoming advanced foot and ankle surgeons, and are “only” becoming general practice podiatrists. This is nonsense. Our goal should be to encourage them and assist them in becoming the absolute best general practice podiatrists that they can be. Leadership at the schools and residency programs needs to stop promoting surgery as the pinnacle of podiatry. It is, in fact, only one pinnacle where there are many.

4. Incorporating the general practice podiatrist into the current job market

This was a very interesting comment by Dr Shapiro that caught me by surprise. He states his belief, and I believe he is quite knowledgeable in this regard, that the residency graduates with the best surgical skills are getting the highest paying jobs today. He cites the Kaiser Foundation that pays their surgical podiatrist more than their nonsurgical ones. He thinks this is less true in private practice. So, the adage that quoted Jon Hultman’s analysis that non-surgical treatment generates more income than surgical treatment may be out of sync with the hiring practices of big institutions. Hiring salaries are set after considering a lot of factors, and I’m sure there are good reasons that Kaiser pays top dollar for surgeons. One factor is that I believe that they are self-insured, meaning that they don’t depend on being reimbursed by an outside insurance company like BS/ BS or Anthem which sets fees. They are only concerned with managing costs and utilization, and perhaps they are better at that than other institutions.

In conclusion, the consideration of whether podiatry is a surgical specialty per se vs surgery being a sub-specialty of podiatry, and whether to pursue changing the third year of residency to a choice of two tracks, one for advance foot and ankle surgery and the other being general practice podiatry, is quite complex and does have ramifications on the public image of podiatry, the allocation of resources in podiatric residency programs, the self-image of podiatrists, and the job market for podiatrists. It’s a case of weighing the current good vs bad against the good vs bad were we to make the transition. Many of the good vs bad points have been outlined in what has now become an extensive online discussion. I’d like to see more podiatrists participate in the discussion, as I believe the more diversity of opinion that we hear, the better job we can all due in predicting what would truly be best for the profession in the years ahead.