Ryan Fitzgerald, DPM PRESENT RI Associate Editor Hess Orthopedics & Sports Medicine Harrisonburg, Virginia

Classification Systems:
Esoteric or Essential?

In the context of studying for the upcoming American Board of Podiatric Surgery (ABPS) oral boards, I have been reviewing a variety of different topics - among them the many classification systems that exist in the management of foot and ankle conditions.  I will freely admit that historically speaking I was not a strong believer in classification systems, although as I have progressed throughout my training and into clinical practice I have come to see a certain value in classification systems – or at least in certain classification systems. 

In the process of reviewing these many and varied classification systems, I have found myself critiquing the essential pros and cons, if you will, of each system. This, of course, got me thinking – in a procrastinating sort of way – about the value of classification systems and about what, indeed, makes them good or bad.  Have you ever considered the purpose of a classification system at such a basic level? Generally speaking, classification systems:

• Make it easier to detect duplicate objects.
• Convey semantics (meaning) of an object from the definition of its kind, in which the meaning is not conveyed by the name of the individual object or its way of spelling.
• Allow users to impart knowledge and requirements about a certain kind of thing so that this knowledge can be applied to the members of the kind, allowing for rapid identification and translation.

So what does this mean?  Simply put, classification systems allow users to quantify like-objects/scenarios/clinical-presentations and to then correlate generalized information regarding these individual objects/scenarios/clinical-presentations to extrapolate certain further information from new scenarios that fit the appropriate system.  Or viewed another way, classification systems allow us to establish truth in the unknown by comparing to that which is known and well understood. 

To be valuable, a classification should provide information to the user beyond esoteric description.  Classifications should MEAN something to the user. They should provide the clinician with information that helps to provide guidance in regard to what to do next in a clinical encounter.   While there are many classification systems from which to choose, Breslow's system for staging malignant melanoma serves as an excellent archetype for "good" classification systems because it does just that.  Breslow's system correlates the depth, in millimeters, of neoplastic invasion, with potential 5-year survival rates, while at the same time providing the clinician with recommended margins for excision of the lesion.

While Breslow's level has recently been replaced with the American Joint Commission on Cancer (AJCC) Depth staging system for malignant melanoma – a significantly more complicated system – many clinicians still routinely implement Breslow's level because it is simple to understand, translates well across language and training barriers, is reproducible, and provides prognostic data as well as clinical information regarding the appropriate treatment options moving forward.

And isn't that the point - isn't that the value of a classification system, really? To be easily applied across training and language barriers while providing appropriate prognostic indicators and suggested treatment algorithms?  Consider this, when you're calling your attending at 3am to describe the radiographic finding for an significant ankle fracture – isn't it valuable to be able to describe at PER 4 and have the attending know what you mean, and therefore what will be required?

As clinicians involved in the management of conditions of the foot and ankle, we have the opportunity to utilize many classification systems.  Frankly, some are more valuable than others, but there are those classification systems that provide each of us with significant value if we will choose to utilize them – and we SHOULD use them.  I encourage each of you to critically evaluate the myriad of classification systems available to you, separate out those that seem to provide the greatest value to you, and then use them.  Use them daily; make it a habit to try to classify the clinical findings that you're experiencing.  It will make you better – and isn't that the point?

When considering "good" or "useful" classification systems, there are far too many to list them all here. Toward that end I have established an eTalk thread on this subject, where I encourage each of you to share your "favorite" or most commonly utilized classification systems, as well as the reasoning's behind your usage. I'm curious - I would imagine that there are some regional differences as well as training background differences.  It is your continued participation that makes our online community great. I look forward to hearing from you.

See you next time.

We at PRESENT love hearing from you. I would encourage you to share your experience, pearls, and wisdom on this topic, or on any other that you would like to share with our online community via eTalk. 

Get a steady stream of all the NEW PRESENT Podiatry eLearning by becoming our Facebook Fan. Effective eLearning and a Colleague Network await you.

Grand Sponsor
Diamond Sponsor
Major Sponsors