Podiatric Medicine: A Current Assessment

Abstract

Podiatric medicine had its own evolution in the medical field apart from allopathic and osteopathic medicine. Podiatrists are well-respected members of the health-care team and have earned recognition as physicians within their education, training, and credentialing processes. Unlike allopathic medical doctors and doctors of osteopathic medicine, whose scope of practice is based upon their education, training, and credentialing processes, podiatristsʼ scopes of practice are determined by state laws (and are often influenced by politics) with variances across the United States. In contrast to a lack of uniformity in the training and credentialing processes of an allopathic medical doctor, podiatrists complete a streamlined educational process that is competency-based and well-aligned from the undergraduate phase (podiatric medical school) to the postgraduate phase (residency) through the credentialing processes (licensure and certification). Podiatric medical students begin to directly engage in the specialty related to the diagnosis and treatment of the lower extremity much earlier in the educational process than an orthopedist, whose foot and ankle exposure is less extensive by comparison.

Vision 2015 is the name the American Podiatric Medical Association (APMA) has given to the profession-wide effort to further raise awareness that doctors of podiatric medicine (DPMs), just like allopathic medical doctors (MDs) and doctors of osteopathic medicine (DOs), are physicians, but physicians who specialize exclusively in diagnosing and treating ailments affecting the lower extremity. Vision 2015 sets forth the proposition that consistent with their education, training, credentialing, and experience, podiatrists are the best qualified physicians to manage diseases and conditions affecting the foot and ankle. This recognition has been earned through the hard work of educational institutions, credentialing bodies, and individuals, and their collective dedication to advancing the podiatric medical profession. As suggested by the rubric, the Vision 2015 initiative intends to remove any lingering confusion about the definition and scope of podiatric medical practice by the year 2015. By some estimation (at least in 33 states and the federal government) the goals of Vision 2015 have already been met.

Over the past 150 years, podiatric medicine has evolved to its current status as a valued field of medicine and surgery and, as such, is one of only three medical/surgical professions with similar education and training pathways leading to eligibility for practice. In the same manner as MDs and DOs, DPMs become candidates for licensure only after they successfully complete an undergraduate program with an emphasis on the premedical sciences, followed by a 4-year medical professional program and at least 2 years of postgraduate, hospital-based residency training. Podiatrists collaborate with their health-care colleagues in patient diagnosis and treatment, while also working together to effectively educate patients on the importance of healthy lifestyles, diabetes, and other health issues.

A History of Advancement

The US health-care community has long recognized the contributions and expertise offered by podiatrists. With its roots in the 12th Egyptian Dynasty (1991–1786 BCE), the birth of modern podiatric medicine dates back to the 19th century when the first textbooks were written on foot care and formalized instruction began to occur.[1]

As in all organized health professions, the individuals who make up the podiatric medical profession see an ongoing responsibility to raise the bar and be good stewards of public health and safety. Podiatric medicine has a long and extensive track record in evaluating and raising its standards for the education and credentialing of podiatrists. Reforms in the podiatric medical educational process date back to the early 1920s, around the same time allopathic medicine was reacting to the Flexner Report [2] and making changes of its own in what Flexner and the Carnegie Foundation viewed to be substandard and marginal medical education.

The profession’s often cited 1961 report, “Podiatry Education in the 1960’s, Status and Opportunities” [3] was compiled by several prominent individuals in the fields of higher and medical education including a representative of the American Association of Medical Colleges (AAMC). The report of this independent study on podiatric medical education has been viewed to have sparked the significant changes in podiatric medical education that occurred in the 1960s and 1970s.

Another such landmark report is the Project 2000 Commission’s Comprehensive Foot Care: The Report of the National Commission on Podiatric Medicine,[4] which was published in 1986. The Commission was comprised of well known PhD and MD educators, including William Ruhe, retired senior vice president of the American Medical Association (AMA); William Rial, past president of AMA; and John Kenzora, Professor and Chief of Orthopaedic Surgery at the University of Maryland Hospital; among others. The Commission evaluated the role of the podiatrist in the future health-care arena, looking specifically at podiatric medical practice and education and the relationships of podiatric medicine to other health-care professions. In its report, the Commission offered the following assessment of the relationship between podiatrists and other physicians: “Medicine has failed to understand that podiatrists do perform many physician functions; that is, they independently diagnose and treat diseases of the foot, for which they receive adequate training.” [4] (p14) The report generated 19 recommendations that were conscientiously pursued over the following years with most, if not all, completely addressed and resolved.

The Educational Enhancement Project (EEP), an inter-professional collaborative effort, was a direct result of recommendations emanating from the Project 2000 Commission and, by far, has been the most comprehensive effort by the podiatric medical profession to further elevate standards for podiatric medical education. The EEP created a comprehensive plan to organize and enhance podiatric medical education, offering direction to educators, residency directors, and credentialing groups on how to solve recognized problems and improve systems. The Council on Podiatric Medical Education (CPME), American Association of Colleges of Podiatric Medicine, and APMA have implemented many recommendations of the EEP.

Along with these aforementioned formalized studies of podiatric medical education, the CPME conducts regularly scheduled reviews of its accreditation criteria involving many individuals who represent a cross section of the profession. These reviews focus on the current relevance and reliability of the standards and requirements for the accreditation of colleges of podiatric medicine and approval of residency training and continuing medical education programs. These formalized reviews are conducted at least every 5 years.

These studies point to the advancements made in the profession, all of which have had a dramatic influence on the education and training of podiatrists. The clinical skills and knowledge of DPMs continue to expand, yet the legal authority that governs their scope of practice lags behind mostly because of the efforts of MDs whose challenges of all health-care professionals appear to reinforce their desire to maintain exclusive control of the medical field.

The “Limited License” Debate

Some have suggested that DPMs must complete comparable, if not identical, education, training, and credentialing processes to those established for MDs. The “medical model” for education, training, and credentialing often has been criticized, however, because it is established on the outmoded principle that all MDs are capable of dispensing medical care without limitations—the so-called “unlimited licensed practitioner.” Yet, MDs are trained in very specialized areas and are unable (and, wisely unwilling) to provide care in areas for which they were not trained but for which their licenses allow them to legally practice.

In comparison, podiatrists are sometimes categorized as, “limited licensed practitioners.” Their license “limits” them to medical and surgical treatment of the lower extremity. Although variations exist from state to state as to what exactly is included in the definition of the lower extremity, most states agree that this definition minimally includes the foot and ankle. A majority of states include governing structures (ie, soft tissue and bone) above the ankle to be within the scope of podiatric medical and surgical practice.

The fallacy in pointing to limitations on licensure is that MDs, because of what sociologist Eliot Friedson refers to as “the exclusive right to practice,” have been given great latitude to claim that to be licensed as an MD equates to being competent to treat the entire human condition.[5] This “first in time, first in right” perspective, as referred to by Barbara Safriet in her essay on scopes of practice, suggests that the time has come for policy makers to recognize that there “are models that both value public protection more than professional prerogatives and allow clinical ability to guide legal authority … to promote truly effective changes in the scope-of-practice laws.” [6] (p331)

Education and Training of a DPM

“Limited license” does not mean “limited knowledge” or “limited ability.” Doctors of podiatric medicine receive basic and clinical science education and training comparable to that of MDs and DOs. The AMA agrees that “colleges of podiatric medicine offer a core curriculum similar to that in other schools of medicine.” [7] (p351) Following successful completion of an undergraduate education focused on the premedical sciences, students in podiatric medical colleges devote 2 years to classroom instruction in basic sciences (including, but not limited to, anatomy, chemistry, pathology, microbiology, biochemistry, and pharmacology) followed by 2 years of clinical education based in accredited hospitals, clinics, and private-practice settings. During these third- and fourth-year rotations, students not only receive intense medical and surgical training related to the lower extremity, but they also learn how to take general and podiatric histories, perform routine physical examinations, interpret diagnostic tests and findings, and make differential diagnoses.

Specific competencies categorized under six broad objectives have been established for colleges of podiatric medicine. The achievement of the following competencies is evaluated as part of CPME’s accreditation process: 1) demonstrate knowledge of the preclinical sciences that provide the foundations of podiatric clinical training, residency training, and practice; 2) prevent, diagnose, and manage diseases and disorders of the lower extremity in a cost-effective manner; 3) assess medical conditions that affect the lower extremity and refer, as appropriate, those patients with conditions identified during the evaluation; 4) practice with professionalism, compassion, concern, and in an ethical fashion regardless of the patient’s social class, gender, or racial or ethnic background; 5) demonstrate the ability to communicate and work collaboratively with others, and to function in a professional manner in an interprofessional setting; and 6) practice and manage patient care in a variety of communities, health-care settings, and living arrangements.[8] Implementation of these competencies by all of the colleges along with their continued assessment helps to prepare students for residency training and the next steps in the continuum of podiatric medical education. These competencies also ensure some degree of uniformity upon which residency program directors, certifying boards, and state licensing agencies can rely.

The significant difference between the educational model that is followed in the training of MDs and the one used to train podiatrists is that podiatric medical education begins to focus on the specialty area much earlier and in much greater depth and breadth. During the podiatric medical education process, the curriculum integrates basic science education with clinical education specific to lower-extremity anatomy. Specialized training for MDs does not occur in any significant way until one begins residency training, with each phase of the educational process functioning in broken segments and in isolation from each other. Reporting on the transformation of medical education, AMA describes how medical education expanded in the 20th century to add specialty training (graduate medical education) and continuing medical education in “virtual independence from undergraduate medical education (medical school).” [9] (p20) The problems associated with this “compartmentalization,” AMA concludes, should be the stimulus for rethinking the medical education model.[9] With an earlier commitment to the specialty occurring when a student selects podiatric medicine as a career, graduates are well-prepared for the even more intensely focused clinical training provided in the podiatric residency that follows.

During residency, podiatrists receive advanced training in medicine and surgery and participate in clinical rotations in anesthesiology, internal medicine, pathology, radiology, emergency medicine, and orthopedic and general surgery, as well as elective rotations. Emphasis is placed on patient diagnosis and management throughout residency.

The residency in either Podiatric Medicine and Surgery-24 (PM&S-24) or Podiatric Medicine and Surgery-36 (PM&S-36) is a resource-based, competencydriven, assessment-validated program that consists of 2 or 3 years, respectively, of postgraduate training in inpatient and outpatient medical and surgical management.[10] The principal difference between 2- and 3-year programs is that residents in a 3-year program have more training experiences in reconstructive rearfoot and ankle surgery and trauma. Both types of programs provide training resources that facilitate the resident’s sequential and progressive achievement of specific competencies.[10]

Table 1. Average Volume of Podiatric Surgical Procedures and Cases (N = 72).

and

Table 2. Average Volume of Podiatric Nonsurgical Procedures and Cases (N = 72).

provide an analysis of types and numbers of diagnostic, medical, and surgical procedures performed by a podiatric resident at the conclusion of a PM&S-36. The analysis shows the average number of these procedures completed at the end of 35 months of training (through May 2008). Data were taken from the composite clinical logs of 72 residents in 35 programs that were randomly selected from among 160 PM&S-36 programs approved by CPME. Table 1 reveals that the average resident completing 3 years of training has a substantial involvement (more than observation) in more than 1,000 foot and ankle surgical procedures performed on more than 600 patients.

Accreditation

Accreditation of podiatric medical education is based upon the tenet that podiatric medicine is a unique profession of such complexity and benefit to the health of the US population that it requires a defined educational process based on consistently applied national standards.[11] For more than 90 years, the CPME has served as the professional accrediting agency for podiatric medicine, evaluating and promoting the quality of doctoral education, postdoctoral education, certification, and continuing education for DPMs. The control of accreditation within one central body has helped to establish and maintain a strong continuum for the education, training, and credentialing of podiatrists.

The CPME recognizes eight accredited colleges of podiatric medicine, 211 health-care institutions as approved sponsors of podiatric medical residencies, and 61 approved sponsors of continuing education in podiatric medicine.[11]

National Testing and Licensing

The National Board of Podiatric Medical Examiners (NBPME) was established in 1956 as the national testing agency for podiatric medicine. Passing the NBPME examinations has been accepted by most state licensing entities as a requirement for obtaining a license to practice.[12]

The NBPME examinations are designed to measure the important knowledge that is necessary to perform at the level of minimal competence as a newly licensed podiatric medical practitioner. The validity of the NBPME examinations is based on a national job analysis survey of practicing podiatrists. The results of this survey inform the NBPME of the activities podiatrists perform and the knowledge and skills needed to complete those activities at a level that would protect the health, safety, and welfare of the public. Reliability of the examinations is based upon the involvement of experts from the basic science and clinical faculties, residency directors, and podiatric medical practitioners who participate in the writing and review of examination items. Extensive reviews, both by content experts before each administration of the examination and through statistical analyses and content expert review after each examination administration, ensure that the items are appropriate.[13]

Certification

As in allopathic and osteopathic medicine, a voluntary certification process is present in podiatric medicine. Certification in podiatric surgery or podiatric orthopedics and primary care attests to the achievement of individual podiatrists in possessing higher levels of knowledge and skills beyond those needed for minimal competence. Rigorous examination and reexamination processes exist in podiatric specialty areas that help to validate these higher levels of knowledge and skills.

The CPME, through its Joint Committee on the Recognition of Specialty Boards, has been responsible for monitoring specialty certifying boards in podiatric medicine since the early 1960s. The CPME oversight of certifying boards in podiatric medicine is analogous to the role played by the American Board of Medical Specialties (ABMS) in its review and recognition of 24 specialty boards in medicine. The CPME currently recognizes two certifying boards, the American Board of Podiatric Surgery (ABPS) and the American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM).

The ABPS certifies in two areas: foot surgery and reconstructive rearfoot/ankle surgery. One must be certified in foot surgery before being eligible for certification in reconstructive rearfoot/ankle surgery. According to information available on the ABPS Web site, “certification in foot surgery indicates that a podiatrist has demonstrated a cognitive knowledge of podiatric surgery, including the diagnosis of general medical problems and surgical management of foot diseases, deformities, and/or trauma, and those structures which affect the foot and ankle”[14] and, “certification in reconstructive rearfoot/ankle surgery indicates that a podiatrist has demonstrated a cognitive knowledge of podiatric surgery, including the diagnosis of general medical problems and surgical management of foot and ankle diseases, deformities, and/or trauma, and those structures that affect the foot, ankle, and leg.”[15] A recertification examination must be successfully passed every 10 years to maintain certification.

According to the most recent data available, ABPS reports that 6,178 DPMs have been certified, including 3,779 certified in foot surgery and 2,399 certified in foot and ankle surgery (435 of whom are certified at an advanced level in reconstructive rearfoot/ankle surgery). Also ABPS recognizes 2,074 podiatrists who were board qualified in foot surgery and 1,175 who were board qualified in reconstructive rearfoot/ankle surgery.[10]

The ABPOPPM indicates that Podiatric Medicine and Orthopedics is the medical specialty concerned with the comprehensive and continuous foot health care of patients. It integrates the biological, biomechanical, rehabilitative, clinical and behavioral sciences and encompasses first contact care, continuous care, long term care and general medicine. Board certification provides the assurance to both the public and health professionals that the highest level of achievement has been attained in the specialty area.[16]

Certification by ABPOPPM indicates that the podiatrist has been judged by peers to have demonstrated a fund of knowledge and competence in the areas being tested.[16]

According to the most recent data available, ABPOPPM reports that 2,416 DPMs have been certified in podiatric orthopedics and primary podiatric medicine. Also, ABPOPPM recognizes 333 podiatrists who were board qualified in podiatric orthopedics and primary podiatric medicine.[11]

Scope of Podiatric Medical Practice

Doctors of podiatric medicine are physicians and surgeons qualified by their education and training to diagnose and treat conditions affecting the lower extremity, ie, the foot, ankle, and their governing and related structures, including the leg and the local manifestations of systemic conditions. Yet, the recognition of these qualifications appears to be largely ignored as scope of practice is determined solely by what the state laws allow. This distinction contrasts with MDs and DOs whose scopes are determined solely by their education, training, experience, and credentialing.

In 33 states, podiatrists are recognized as physicians in the licensing laws governing the practice of podiatric medicine.[17] The federal government also recognizes podiatrists as physicians. Section 1861 of the Social Security Act, which governs the conditions upon which health-care providers or entities may participate in Medicare, defines the term “physician,” when it is used in connection with the performance of any function or action, to mean (r)(1) doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he performs such function or action … (3) a doctor of podiatric medicine for the purpose of subsections (k), (m), (p)(1), and (s) of this section and sections 1395f(a)(2)(F)(ii), and 1395n of this title but only with respect to functions which he is legally authorized to perform as such by the State in which he performs them ….[18]

Recent legislative efforts occurring in Florida, Texas, and other states prompted by orthopedic surgeons, has rekindled debate as to whether podiatric surgeons are qualified to treat and perform surgery on the ankle and its related governing structures. Several generations of podiatrists have received focused and advanced education and training to treat ailments of the lower extremity including the ankle. Ankle surgery has been fully integrated into podiatric medical education for many years. Podiatric residency programs have incorporated training in the treatment of the ankle since the 1970s. As noted in Table 1, current graduates of 3-year podiatric medical and surgical residency programs are participating in more than 230 reconstructive rearfoot and ankle procedures during the course of their training. With its inception in 1975, the ABPS has included ankle surgery in both the case credentialing and the oral examination for certification. The inclusion of ankle requirements for certification was based upon evidence gathered by ABPS that significant curriculum and training opportunities related to the ankle were available to students and especially residents. Also, laws in 44 states permit surgical treatment of the ankle.[17] The challenges raised by orthopedic surgeons have been couched under the guise of protecting the health and safety of patients, but one easily can see the economic motivation behind these challenges to the qualifications of podiatrists.

Orthopedic Surgery–Podiatric Surgery: A Comparison

Who is the most qualified to perform surgery on the foot and ankle? Because the education, training, and experience of a DPM is more sophisticated and specialized in the care and treatment of the lower extremity than that of the more broadly trained orthopedic surgeon, podiatrists merit recognition as the primary-care givers of such treatment.

Exposure to foot and ankle cases in orthopedic residencies does not appear to measure up to the much more significant exposure residents receive in podiatric residencies. Although orthopedic training programs provide a broad exposure to general musculoskeletal conditions and treatments during their years of residency training, the number of hands-on medical and surgical experiences for orthopedic residents and fellows in orthopedic subspecialties may be far fewer in specific aspects of the human anatomy. The Accreditation Council for Graduate Medical Education (ACGME) reports that the national average for total foot procedures performed by orthopedic residents is 109.5 procedures per resident over the entire course of 5 years of training.[19] Podiatric residents must participate in a minimum of 525 procedures (per resident) over 3 years of training. As shown in Table 1, the actual number of procedures performed by podiatric residents is two times the required minimum.

Pinzur et al [20] state that residency training in the foot and ankle is important in developing a well-rounded orthopedic surgeon but that training guidelines are indistinct and do not mandate specific experience or proficiency in the foot and ankle. The conclusion is that orthopedic residency training does not require a commitment to learning about the foot and ankle shown by the lack of support of such training in terms of the limited number of faculty members committed to foot and ankle education and that no time is specifically allocated to this area of training.[20]

Additionally, podiatric surgeons earn board certification in the specialty field of foot and ankle surgery. This specialty certification benefits the public by attesting to the extensive training and evaluation a practitioner must complete to receive this credential. Orthopedic surgery has no comparable foot and ankle certification.

Podiatric Medicine–Collaboration and Cost Benefits

Many podiatrists are integral members of group medical practices while others have their own solo medical practice. Medical specialists in primary care, endocrinology, rheumatology, and geriatrics routinely refer patients to podiatrists. Podiatrists serve on the staffs of hospitals and other facilities, on the faculties of schools of medicine and teaching hospitals, as commissioned officers in the Armed Forces and the United States Public Health Service, in the Department of Veterans Affairs, and in municipal health departments.

An aging population, in addition to the growing epidemics of diabetes, obesity, and their concurrent complications are among the many reasons why podiatrists are essential members of America’s healthcare team. These foot and ankle physicians not only diagnose and treat medical conditions, but they also play a vital role in preventing many of the untoward consequences of local and systemic diseases such as amputations caused by complications associated with diabetes and peripheral arterial disease.

From current data, the American public has often been reminded that being overweight and the occurrence of obesity are increasing. Estimates show that 65% of US adults are either overweight or obese, an increase of 60% over the previous 10 years.[21] Promoting healthy lifestyles, such as walking, hiking, and maintaining moderate physical activities could reduce leading conditions that drive up health-care costs, such as diabetes.[21]

In a state-by-state analysis of medical expenditures for 1998, 9.1% of the total US medical expenditures were attributable to obesity. Estimated in 2002, the cost of obesity-attributable medical expenses was $92.6 billion.21 The American Diabetes Association (ADA) estimates that there are 23.6 million people with diabetes or 8% of the population.[22] The cost burden of diabetes accounted for 18% of all US health expenditures ($865 billion in 2002).[23]

Recent reports estimate that more than 60% of nontraumatic lower-limb amputations occur in diabetic patients and that comprehensive foot-care regimens may reduce amputation rates by up to 85%.[24] The projected cost savings from amputation-prevention strategies is between $14.9 and $21.8 billion.[23] Podiatrists are recognized as a vital link in the healthcare team responsible for treating diabetic patients and playing a key role in saving feet and lower limbs.[25]

Podiatric medical colleges, residency programs, and other training opportunities continue to prepare DPMs for the increased incidence of diabetes. In classrooms, clinics, and hospitals, podiatrists are trained to detect the early warning signs and prevent and treat diabetic ulcers, infections, and other conditions in the lower extremity.

No doubt exists that the podiatric medical profession has been successful in evaluating the health-care needs of the public against the backdrop of medical advancement, patient safety, and cost and efficiency in the delivery of healthcare.

Policy Implications

The podiatric medical profession expects that individuals who desire to practice podiatric medicine will complete comparable education, training, and credentialing processes as those established for MDs. In view of the significant endorsement in the laws and policies established by 33 states and the federal government recognizing podiatrists as physicians, the remaining states should have no reasonable alternative but to acknowledge the comparability of the education, training, and experience of DPMs as equal to other physician specialists. Any limitations on scope of practice within these remaining states would seem to only impede the opportunities of health-care consumers from reaping the benefits of access to quality healthcare.

The education, training, and credentialing model that has always existed in podiatric medicine now, more than ever before, makes a great deal of sense. The podiatric model successfully and efficiently interweaves the teaching of students in both the premedical and specialty areas early in their professional education and ensures an end-product that enables the development of a practitioner who, by achieving established competencies, is well-prepared to serve the health-care needs of the public. In contrast, medical education is compartmentalized and lacking in a uniform or streamlined approach. One might also question whether its overall length is a result of its lack of uniformity and could be shortened if it were more streamlined. Although orthopedic training provides a broad exposure to general musculoskeletal conditions and treatments during residency, exposure to specific aspects of the human anatomy may be far less than a podiatrist’s significant exposure to foot, ankle, and lower-extremity cases available to residents in podiatric medicine and surgery residencies. And, although orthopedists may focus on subspecialization in foot and ankle surgery, no additional credentialing or verification of qualifications currently exists. Nor is there any ABMS-recognized subspecialization certification for orthopedists related to surgery of the foot and ankle. Certifications in podiatric surgery and podiatric orthopedics and medicine, however, are focused on a specialized area of anatomy while taking into consideration the overall health of the patient. Such certification enables patients to be more confident that podiatrists have the requisite education and training.

Doctors of podiatric medicine are the only specialists who are specifically examined and licensed in all 50 states and the District of Columbia for the practice of podiatric medicine. The state licensing boards are legally responsible for setting the educational and training requirements related to licensure. Allopathic medical doctors have no similar state oversight of their specialty education and training. Policy makers need to look seriously at the question of what is the exclusive domain of MDs and what is not. Additionally, state legislators need to be reminded that they have created licensing boards specifically to oversee health-care professions and to protect the public. They should remain confident in these regulatory systems and the appointees who have the authority to function in an appropriate manner. Similarly, these high-ranking decision makers should not forget that all health-care providers have professional and ethical obligations to conscientiously discern their own clinical limitations and provide care accordingly. Equally capable and well-credentialed professionals, such as podiatrists, should not be precluded from performing the services for which their education, training, and experience have qualified them to provide to the public.