Podiatric Medical Research

This issue’s article by Michael A. Turlik, DPM, and Donald Kushner, DPM, entitled “Levels of Evidence of Articles in Podiatric Medical Journals” takes a much-needed critical look at the types of papers published in our profession. In their study, the authors found that, of all of the articles published in two podiatric medical journals during two arbitrarily selected years, only 1% met “level 1” criteria for strong evidence to guide therapeutic decision making, a category comprising randomized controlled trials and metaanalyses. By far the most common type of article was the case series or individual case report. This has been a refrain of critics of the podiatric medical literature for as long as anyone can remember. It is a frequent topic of discussion on Internet listserves and at continuing medical education conferences. Anyone who has ever served on an editorial board of one of the profession’s journals has heard derogatory comments about the abundance of case reports. The blame for the dearth of controlled studies is generally placed on the podiatric medical colleges but is also variably laid on residency directors, residency training programs, and private practitioners. In fact, no one group can be held responsible. The problem rests more in the overall structure of the profession than in any particular component.

In other medical and scientific disciplines, most of the large controlled studies originate with faculty members at colleges and universities. I remember reading an interesting article published roughly 10 years ago in a medical journal (unfortunately, I do not recall the exact reference) that looked at the highest academic degrees obtained by first authors in the published medical literature. The largest number of articles were authored by MD/PhD recipients. This was followed by researchers who had obtained the PhD alone. The “practicing” doctor of medicine published the least number of scientific papers. The conclusion of the study was that the amount of research training obtained by an individual is directly correlated with number of scientific publications.

In podiatric medicine we lack a “critical mass” of trained researcher-authors. If one were to combine all of the faculties (full and part time) of all of the colleges of podiatric medicine, the result would be fewer people than in an internal-medicine department at a single medical school. Furthermore, the faculty members who are at the podiatric medical colleges are generally given clinical assignments 5 days per week, 52 weeks per year, except for the time they are on vacation. Other medical schools may have faculty members “on service” only 3 to 4 months out of the year, with the balance of the time given to research and writing. Also, we lack significant numbers of DPM/PhD researchers. Throughout the profession there are barely a handful of people with both degrees, and many of them are busy trying to make a living in private practice.

As noted in the study I referred to above, the practicing physician is generally the least likely to write a scientific paper. Podiatric medicine is a profession of practitioners. Residency directors are usually private physicians who volunteer their time to run a program. They are not full-time educators, authors, or researchers. At many residency programs, the requirement to produce a publishable manuscript prior to successful completion has been dropped. Those that do require a paper will accept an interesting case report in lieu of original research. This is not unreasonable: With the typical resident spending just 2 years of training in all aspects of medicine and surgery, there is rarely going to be time to design and write a research protocol, send it through an institutional review board, and execute the study while trying to keep up with the Council on Podiatric Medical Education requirements for training rotations. Finally, the typical practicing podiatric physician may bemoan the dearth of clinical trials but does not have the training, interest, or funding to perform them. Given the hardships of private practice and the difficulty in getting appropriately reimbursed for one’s services, making a living is a full-time occupation.

So, what is the answer? There is no easy solution, and I see no significant change coming. If anything, instead of expanding faculties to allow support to perform prospective, controlled research, the colleges are cutting back their staffs. Faculty members at both podiatric medical colleges and medical schools are learning a new buzzword: productivity. This is not the academic productivity of only a few years ago, however, but financial productivity. Salaries must be covered by clinical service. Unless a faculty member has a major outside funding source, such as the National Institutes of Health, forget about performing unfunded research—get thee to the clinic! Obtaining reimbursement is becoming increasingly difficult, so even those practicing podiatrists who were interested in running a residency program and in the generation and collection of data are being forced to forgo these activities in order to pay their overhead.

In order not to close on a “down” note, here are some “pie in the sky” suggestions to increase the number of good, controlled, prospective therapeutic trials published in the podiatric medical literature.

1) The podiatric medical colleges need to lead the way and understand the need to actually increase the volume of original research, not just pay lip service to it. This would include providing the means for interested faculty members to obtain training and possibly advanced degrees in research methodology. Provide support, most importantly time, for those faculty members to perform research. Hire, value, and retain faculty members with research training and dual degrees. Obtain outside funding from grant agencies and industry to supplement faculty salaries.

2) Hospitals are still able to receive government Medicare funding for podiatric residency training. This funding usually includes payment for the salaries of residency directors. Develop the position of Director of Residency Education as a hospitalbased, full-time occupation. Staff these positions with podiatric physicians dedicated to the advancement of knowledge. Develop residencies in academic health-science centers. Only there will we find the expertise, collaboration, and support to perform world-class research.

3) Expand residency-training length to allow time to become trained in and perform original research for those interested, or develop sources of funding for research fellowships in various subspecialties of podiatric medicine.

4) Finally, court the pharmaceutical industry. Almost every major prospective therapeutic trial is underwritten by industry. Although some purists may feel that this does not constitute “real research,” it can yield important data that provide the underpinnings of evidence-based medicine. Up until just 5 to 8 years ago, podiatric prescriptions were not tracked and entered into databases, so the pharmaceutical industry was virtually unaware of our existence. It is now known that podiatric physicians in the United States write more than 5 million prescriptions per year. We are major prescribers of anti-inflammatories, antifungals, and antibiotics. Use our market power to promote the need for DPM-performed clinical trials of medications important to our profession.

Hopefully, with a concerted effort of all involved parties, the number of “level 1” studies in the podiatric medical community will increase. I agree with Drs. Turlik and Kushner that, if we wish to participate in the world of evidence-based medicine, our profession must become more active in the performance and publication of significant original research.