Jarrod Shapiro, DPM Practice Perfect Editor Mountain View Medical & Surgical Associates, Madras, Oregon

Conference Time!

It’s that time of the year again – conferences. As I’m writing this, I’m on my way home from the ACFAS Scientific Conference in Las Vegas. This has been an unusual year for me, in that I normally attend one national conference and something local, but this year, I’ve also managed to attend the International External Fixation Symposium in San Antonio and the Western Podiatry Conference in Anaheim.

From a general standpoint, I thoroughly enjoyed them. This year’s conference was well moderated by Sean Grambart, DPM and was remarkably well attended, with about 1400 podiatrists and over 200 exhibits. So much for the recession !  I've learned that our colleagues continue to put a high value on attending high quality live clinical conferences.   As always, the ACFAS put on a professional and entertaining conference that provided new alternatives to current treatment and good ideas to take back to practice.  Dr Sigvard Hansen presented a strong keynote address, reviewing both the evolution of his practice, as well as the interactions between the orthopedic and podiatric communities.  It was also fun to meet up with fellow podiatrists that I haven’t seen in years.  I love hearing about the successes of my prior fellow students and residents.  I send out my best wishes to all of you young podiatrists.  You’re the future of our profession!

Now, it’s been a few years since I’ve been to an ACFAS conference – I try to rotate my conferences to avoid hearing similar lectures year after year – but this year I noticed certain trends.

Pride and Maturity

In years past, I’d heard various speakers make comments about the orthopedic community and what they would think of what we do.  There always seemed to be a self consciousness behind this, as if we were the weak little brother looking up to our bigger sibling for acceptance.  This year, the almost complete absence of the “orthopod” comments displayed that podiatry has come into its own – we don’t care what the orthopedists think.  At no point did I feel that Dr Hansen’s keynote address had a sense of coddling podiatrists.  He spoke to us as fellow foot and ankle surgeons, which was appropriate.  I’m not saying that the orthopedic community accepts us – Dr Hansen is well known to be at odds with orthopedists – but rather that podiatrists decreasingly care what orthopedists think.  As one lecturer argued, we need now to refer to ourselves as podiatric foot and ankle surgeons rather than “podiatrists.”  I wholeheartedly agree. 

I also found a level of maturity and wisdom from many of the speakers.  “Technique trumps technology” was heard more than once.  The speakers were much less guided by what shiny new screw or machine was in vogue, but rather, returned to fundamental concepts and techniques.   Our sponsors are important and help to advance our profession, but our lecturers returned to a discussion of a rational approach to their use, which I personally found refreshing.

	Tonight's Premier Lecture is Nail Pathologies by Myron Bodman, DPM.

EBM Is Here

Almost every lecture contained references to the current literature, and in many cases, I found the strongest arguments for various practice techniques from those referring to the research literature.  There was even a lecture series devoted to the appropriate use of evidence based medicine in podiatric practice.  Clearly, EBM is here to stay.  It’s time for us to all learn the levels of evidence classification.  This year I heard “this is based on Level 4 or 5 studies.”  I fully expect to hear declining statements like this and more level 1 or 2 research by our leaders.  I was also comforted to hear that experience and clinical judgment still reign as the final arbiters of our patient care (as much as the insurance companies would like it otherwise). 

Changing Practice Patterns

What we do with our patients often changes as the years go by (as it should), and this year, I saw more changes.  I heard various speakers relate their reticence to attack the Charcot deformity as aggressively as previously done.  Several speakers discussed their “humbling experiences” when dealing with these patients.  Increasingly, I heard a call to return to exostectomies and aggressive bracing, as well as giving patients very low expectations for long term success.  Even the dreaded BKA was advocated as a first line recommendation to certain patients.  This is not to say limb salvage has been abandoned, but our national leaders advocated for a more mature approach to these difficult patients, rather than trying to fix it because we can.  We should all follow their lead.

Increasingly, I saw a questioning of podo-dogmas.  External fixation, for example, was decreasingly emphasized.  If anything, locking plate technology seemed to be the star of the fixation show.  Paul Kim, DPM provided a strong argument about the significance – even the existence of – ankle equinus.  More work needs to be done!  Similarly, Glenn Weinraub, DPM argued convincingly for a change from the classic triple arthrodesis, to a medial approach fusion, leaving the calcaneocuboid joint alone.  Food for thought!

More Questions than Answers

I’ve never left an ACFAS conference with all my questions answered.  In fact, this year’s conference seemed to bring up more questions than answers.  Various lecture tracts emphasized rather than downplayed the lack of our knowledge of most foot and ankle disorders.  Whether it was the Surgical Evolution lectures, 2nd MPJ Controversies, or the Mythbusters lecture, it was clear that there are many ways to skin the cat (or maybe the cat’s foot).  More questions.  Maybe they’ll answer them next year, though I doubt it!

On a final note, I applaud the conference organizers for creating an environment of honesty and questioning.  I found it appropriate – and very entertaining – that the conference ended with a debate about adult acquired flatfoot.  No, it didn’t convince me to change my practice methods, but it was quite enlightening.  I also have to express my gratitude to those physicians who lectured on their worst cases.  It takes guts to put your failures on display in front of your peers, but it teaches the rest of us how to be better doctors.  I’ll try to apply your level of honesty to my own practice.  Perhaps that’s the most important message of the conference. 

Keep writing in with your thoughts and comments or our eTalk discussion forum on PRESENT Podiatry and start or get in on the discussion. Best wishes, and I’ll see you at the ACFAS in Fort Lauderdale next year.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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