Podiatric MDs of the Next Generation
by Anonymous
Forum Owner

Scope:
Podiatric MDs of the Next Generation
By Howard Zlotoff, DPM

Predicting the scope of practice for podiatric medicine one generation into the next century, I see extraordinary change. Some of it is already underway. Much of it is inevitable. All of it will change everything about the practice and even the identity of podiatry just a few decades from now. Perhaps no one wants to envision it, but envisioning the future is half of one's ability to cope with it.

I predict there will be no podiatrists as we know them today. Yes, there will be foot and ankle specialists, but they will be MD's, not DPM's. They will graduate not from podiatry colleges, which will all disappear, but from foot and ankle training facilities attached to major allopathic institutions. They will not be antagonistic to orthopaedic surgeons; rather they will be colleagues sharing the same professional and academic associations. Indeed our sons and daughters will not practice in isolation or separation from the rest of medicine, but side-by-side with other medical specialists. My vision will not arrive during my years of practice, but certainly within two decades, maybe within one.

Think of where our profession was a generation ago, or two generations ago, and look forward. Our path has been toward treating the whole body. Our continuing evolution along that path must and will be part and parcel of all of healthcare as it lurches forward in constant redefinition.

The evolution of medical care here in the United States was rather benign and predicable until the Civil War. The only revolution in medicine revolved around new pharmaceuticals until the concept of safe general anesthesia allowed invasive surgeries to proceed and life saving procedures to occur.

Amputations of gangrenous or infected limbs became critical life-saving techniques in wartime. Excising tumors became possible. The advent of penicillin and other antimicrobial drugs further enhanced medical care by eliminating common infections following surgery or traumatic wounds and thus improving survival rates dramatically.

As we look back over the past 50 years, we can see that medical care took a new direction with a sophistication of technology that allowed better diagnostic study of pathological conditions. Clearly, the discovery of therapeutic x-ray was the first milestone on which higher levels of patient care were built. These tools allowed physicians to identify diseased organs, assess wounds more accurately, and develop treatment plans - surgical and conservative - with higher prognostic accuracy and success rates.

How does this relate to the scope of practice in podiatry? The knowledge base for medicine became so complex that specialization of human physiology led to various disciplines of organ systems and anatomic regions of the human body. One person could no longer be capable and competent in the diagnostic and therapeutic procedures related to all medical challenges and effectively render quality care. Podiatry was born to care for lower extremity disorders. Today, podiatric medicine and surgery incorporate the most advanced and very latest technological advances needed to diagnose and treat with successful, safe, and predictable outcomes.

Now modern medicine is being challenged not in the type of treatment rendered, but rather in the way it is delivered to the patient population. Managed care systems have established the gatekeeper and other restrictive concepts, allowing the primary care provider to use a generalized knowledge base to triage patient complaints and render primary care. The care may not be based on the use of sophisticated diagnostic processes or employ state of the art equipment. Rather, it provides a very basic treatment program to relieve pain and return function to the affected system or anatomic structure - even if there is compromised care. In consequence, the patient is no longer in the decision making loop. The patient often cannot select the type of specialist unless the primary care provider makes the options known to the patient and allows access to specialists such as the pediatric physician.

It doesn't take a rocket scientist to look down the road, even just a decade from now, and predict what the scope of practice for podiatry will be. Simply, there no longer will be podiatric specialists treating basic foot and ankle disorders. These conditions will be handled by primary care doctors or their designated nurse practitioners under supervision. Only those patients beyond conservative therapy will be passed along to the specialist for further investigation. That next step will indeed use high cost technologies and procedures to reach a successful outcome. Podiatric surgeons will have a place in patient care at this level and their expertise in making the correct diagnosis and rendering appropriate care will justify their presence. This reality is already in place today with certain medical care models and seems to be highly efficient and successful.

Can podiatry survive once the process of managed care captures the entire marketplace? In my opinion, we will see a gradual absorption of the podiatric profession to allopathic medicine - more precisely orthopaedics with a fellowship in foot and ankle. What will be the decisive factor? The podiatric colleges.

Prohibitive tuition at some point will make standalone podiatric education out of reach. This will be the final pressure on podiatric educational institutions to seek creative solutions. One by one they will blend into osteopathic and medical schools. Already, the Iowa college is associated with an osteopathic university. The California College of Podiatric Medicine is even now merging into an osteopathic institution. And what choice do they have? Podiatric colleges are almost completely dependent upon tuition for support. But they are producing too many students for too few residencies and too few jobs in too few locations.

Joint-venturing with medical schools to share basic science resources and clinical training facilities is step one. Take one obvious step further: why maintain a separate degree of podiatry from that of a medical degree? Students from these institutions will in fact share common basic science education and then branch out into specialty disciplines of their own interest, or based upon community need. Each will take his or her place in the healthcare delivery system. Just after the turn of the century, we will see a growing cadre of double-degree graduates, such as Joe Jones, DO, DPM. Osteopathy, however, will be a waystation. A few years later it will be Joe Jones, MD, DPM and then simple Joe Jones, MD. Indeed, Dr. Jones probably will be a member of the American Orthopaedic Foot and Ankle Society, the American Academy of Orthopaedic Surgeons, and the American Medical Association.

Basic diagnostic responsibilities will fall on primary care providers and their staff. Simple therapeutic measures will be attempted and if successful, the patient will be cured. Conditions or pathologies unresponsive to primary care will be referred to a specialist such as D. Jones who is trained to order appropriate diagnostic tests, incorporate diagnostic skills learned in advanced training programs of that specialty, and then provide appropriate surgical, medical, or conservative care to achieve a successful outcome. Don't expect a leap of scope north of the ankle. the foot and ankle specialist will be just that - a foot and ankle specialist. There will be no need to address the knee once the specialist is but a foot and ankle specialist with the allopathic family.

So, what will the scope of podiatry be a century from now? We will no longer see the profession as an isolated branch of allied healthcare but rather as a branch of allopathic medicine with a specialization of lower extremity expertise rendering care in a managed care delivery system. This will promote financial efficiency both in educating specialists and also in rendering cost-effective and high quality medical care to patients in the future. And the podiatric community will have proven by its own educational, diagnostic, and treatment record that it has earned the long-delayed right to function shoulder to shoulder with all other doctors in all delivery modes. Did it have to wait until the next century?

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Howard Zlotoff, DPM, is the President of the American College of Foot and Ankle Surgeons. His Predictions are personal and do not represent the organization.

The above article appeared in the December 1996 issue of BIOMECHANICS