Jarrod Shapiro, DPM
Practice Perfect Editor
Mountain View
Medical &
Surgical Associates,
Madras, Oregon
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Our Schizophrenic Profession
Within medicine, various specialties exist and each specialty has its own quality, its own image. Internal medicine is different from pathology, which is different from neurology. In many ways, podiatry is all of the specialties and none of them. Because we cover so many systems in the treatment of foot and ankle pathology, our own profession can sometimes be schizophrenic. We’re often called on to be biomechanists, dermatologists, vascular specialists, neurologists, and surgeons, among others. This provides us a somewhat unique perspective that few other specialties enjoy. It is also the cause for a lot of unnecessary rancor between podiatrists.
There are two situations which seem to breed the most interpodiatric arguments: surgeon vs. nonsurgical podiatrists and differing biomechanics philosophies. I’ll leave out the dual MD/DPM degree argument for later issues.
Let’s take a look at the first situation: podiatric surgeon vs. nonsurgical podiatrist. As I see it, we seem to have a split in opinion when it comes to this situation. In some cases, we hear about a presumed superiority of the surgeons over the nonsurgeons. Anyone reading the PRESENT Podiatry eTalk can appreciate the various comments about this idea. I’d like to suggest a few reasons why this opinion might exist. Let me first start by saying that this is an unrealistic opinion. For most of us, we spend more of our professional time treating patients nonsurgically to the great benefit of our patients. Additionally, for most of us, treating the foot and ankle consists of a combination of nonsurgical and surgical methods. However, unrealistic this view may be, the opinion does exist.
Having said this I can point to a few factors that might lead one to the opinion that surgeons are at the top of our professional ladder. First, others have said it before, and I agree - podiatry is a surgical specialty. At least some of the pathology of the foot and ankle require procedural-based treatment. Take wound care, for example. One of the tenants of treating a neuropathic ulcer is debridement. Surgery’s increasingly becoming a mainstay of treatment (consider the increasing role of the TAL). Second, unless you attend the PFOLA conference, many of our national conferences focus on surgery, and we often see many of the same national lecturers who are surgeons. Granted, there’s an occasional discussion about nonsurgical treatments, but our “rockstars” of podiatry tend to be surgeons. Third, the nature of surgery often leads to remarkable postoperative physical changes. The postoperative appearance of a severe hallux valgus, for example, can be markedly different from the preoperative shape. The same may be true for flatfoot reconstruction, rheumatoid reconstructions, and amputations. Put all these factors together and one can understand the prominence of surgery in the minds' of most podiatrists, especially those new to the profession.
The other issue is in regard to biomechanical philosophies. We’re all aware of the arguments — often vicious — that occur between our biomechanics experts. This unfortunate situation seems to exist for a variety of reasons. Contrary to the surgical part of our profession, there is the potential for a lot of direct monetary income for the parties involved, especially when they own a biomechanics lab. If, for example, I subscribe to biomechanical theory X, and I make a certain orthotic based on that theory, I might stand to lose money if someone subscribing to biomechanical theory Y more successfully markets their different orthotic. This ingrained competition may create discord in the community. The other issue that may affect this is the level of research. Because it’s nearly impossible to control for all the variables with an orthotic, it’s quite difficult to obtain Level 1 research. As a result, biomechanics — like surgery in many instances — is an art as much as it is a science. My sympathies and respect go out to those involved in this part of podiatry, because although it’s difficult to obtain an unquestionable level of research strength, biomechanics remains the cornerstone of podiatry — both surgical and nonsurgical. Smarter minds than mine will be necessary to solve this dilemma.
So, is there a solution to podiatry’s schizophrenic nature? I doubt it. Here’s my suggestion. Treat your patients’ diseases with every means you have available, including nonsurgical and surgical methods. Consider these as various options to pull from the toolbox when you need them. Practice your medicine as you know best and forget about those who want to compare how many surgeries they do per week or month. If you like surgery, good for you. If you enjoy biomechanics, congratulations. The bottom line: do what you love and do it well. All else will fall into place.
What are your thoughts about this? After reading the eZine, we encourage you to follow up with any additional comments in the PRESENT Podiatry eTalk. Best wishes.
Keep writing in with your thoughts and comments, or better yet, post them in the eTalk forum on PRESENT Podiatry where you can get in on the discussion or start one of your own. Best wishes.
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
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