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The Age of “Reason” Part II: Podiatrists Training Orthopaedic Surgeons?

2006; Elsevier BV; Volume: 45; Issue: 1 Linguagem: Inglês

10.1053/j.jfas.2005.10.013

1542-2224

James Thomas,

Orthopedic Surgery and Rehabilitation

Should podiatrists train orthopaedic surgeons in foot and ankle surgery? Quite an interesting question indeed. As an individual who has done just that for almost a decade now, I have received many opinions (both solicited and unsolicited) on just this topic, from both podiatric and orthopedic colleagues through the years. Although the majority of these comments have been positive, there have been quite a few ideas opined on the negative side of the equation also. Secondary to the dichotomy of the responses I have received on this topic through the years, I embarked on an introspective look at what benefits and/or ill effects I produce as a podiatrist functioning as a full-time attending faculty member at a major university orthopaedic surgery training program. Am I a detriment to podiatrists by training future ankle surgeons with a different degree, who could potentially decrease the surgical caseload of a podiatrist? Or am I a benefit producing an improved working relationship between the two groups of physicians providing foot and ankle surgical care to the American public? Certainly I am not alone in this situation, as there are many other areas in this country where podiatrists, in one form or another, are also engaged in training orthopaedic surgeons. Historically speaking, the opposite has been true for decades, with orthopaedists providing surgical training to podiatrists. The setting for this training has ranged from private practice, to the military, to the group practice setting, and this continues today. Although many of these training scenarios were not formal in nature, they existed nonetheless, and were a major influence in bringing podiatrists to the level that we have achieved regarding foot and ankle surgery. So if we owe, at least in some part, a portion of our surgical training to orthopaedists, why can’t the reverse be true? In my practice I interact with 23 (soon to be 30) orthopaedic surgery residents on a daily basis. They scrub all of my cases, they see clinic patients with me, and I provide the bulk of their didactic lectures on foot and ankle surgery. It is from this setting that most of the negative comments have been generated from my podiatric colleagues. Their thoughts are that by training these young orthopaedic surgeons I (and others like me) are in essence, slowly dooming the future of the surgical podiatrist. Well, I truly don’t think anything could be further from the truth, and there are a host of reasons that I discovered that have cemented this belief for me. The first is the simple fact that many orthopaedic surgeons elect not to do a high volume of elective (or even traumatic for that reason), foot and ankle surgery. However, there is no doubt they will see these patients in their practice at some time or another. Now, doesn’t it stand to “reason” that if these individuals were trained by a podiatrist that the chances for referral of these patients to a podiatrist for surgery would increase? Certainly, it does not guarantee this, but at least a podiatrist would be considered when that referral is made to a foot and ankle surgeon. Another interesting scenario is often repeated in our outpatient clinic setting. Because I practice in a university setting, a large part of my caseload consists of revision surgery referred from outside podiatrists and orthopaedists alike, and patients seeking second opinions regarding their surgical care. Many patients, not realizing that my resident is an orthopaedist in training, often complain about that “orthopaedic doctor who did my original surgery,” and that they should have seen a podiatrist in the first place. On the flip side, because my examination rooms and reception area are located in the orthopaedic surgery clinic, many patients at first mistake me for an orthopaedic surgeon. Now my resident will hear that the patient is sure that if an orthopaedist had done their original operation and not a podiatrist, that revision surgery would not be necessary. As you would expect, these complaints are basically split right down the middle between the two groups. The important thing gained by the resident is that they quickly realize both groups of surgeons at times may gain less than optimal results and that these revision operations and second opinions are not skewed to either group. From this, the resident gains a “reasonable” perspective right from the very beginning and is not biased toward either side. They also see all the excellent care that both groups can provide. And the list of reasons really goes on and on. Although I have no tangible data, I certainly have an intangible feeling that the medical legal climate in my practice area is better off having a podiatrist in the mix with the other orthopaedic specialists at our university practice than without. It would stand to “reason” that, hopefully, frivolous actions would be decreased or eliminated when communication and the ability to confer is readily available between the two groups. Also, just as the orthopaedic resident in training does, the attending orthopedic surgeon gains a realization of the competency and skill of a podiatrist in performing foot and ankle surgery, and many of the old biases and taboos are washed away. Podiatric surgical residents have rotated on the orthopaedic service for 7 years now, and are treated as full participants in the care of orthopaedic trauma cases. Both attending and resident staff routinely comment to me how much the podiatry resident is missed after their rotation is completed. I think it is fairly reasonable to say that without an attending podiatrist on staff the podiatric surgical rotation simply would not exist. I could go on, but the space of this editorial limits me. The fact of the matter is that podiatrists training orthopaedists (and visa versa) is a vital part of the educational process, which creates a ripple effect, positively impacting multiple different areas. For instance, as a result of having podiatric attending staff and rotating podiatric surgical residents, the orthopedic residents at our facility have gained a working knowledge of what the American College of Foot and Ankle Surgeons (ACFAS) is all about and the quality of our members. Also, on the national scale, the ACFAS has continued to see a steady increase in orthopedic registration at our annual scientific conference and our skills courses. Two years ago in this journal, past ACFAS president Dr Gary Jolly brought us up to date on “The Age of Reason,” referring back to an inaugural address by a past president of the American Orthopedic Foot and Ankle Society (1Jolly G. Whither podiatry?.J Foot Ankle Surg. 2003; 42: 317-318Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 2Samilson R. President’s address: whither podiatry? The age of reason.Orthop Clin North Am. 1974; 5: 3-6PubMed Google Scholar). He expertly summarized the great advantages of improved postoperative training of podiatrists, and the publications of authors from both groups’ foot and ankle surgeons in each other’s journals. The comingling of educators is just another of these stepping-stones to eliminate the “historical and political differences” and “the mutual suspicions” that Dr Jolly addressed, allowing the age of reason to begin (1Jolly G. Whither podiatry?.J Foot Ankle Surg. 2003; 42: 317-318Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar). Or maybe it is a new age of integration. Whatever you would like to call it, it can only benefit all foot and ankle surgeons whether already in practice or still in training programs, be they podiatric or orthopaedic. But, most importantly, the welfare and safety of the public, our patients, will also continue to be improved. And isn’t that what it is really all about anyway?