A Journey Towards Change: One Surgeon’s Story

A recently released book, ReFounder, by Patrick Colletti, highlighted eight changemaking individuals across a broad range of business and social areas. I’m honored that he chose my work as part of his project.

I remember Patrick calling me about a year and a half ago about this. I love this specialty. I can think of two great gifts when one is looking after someone’s feet. One is that, in this era of chest thumping and hubris, taking care of the feet is truly an expression of humility. My father was a podiatrist and I would watch him take care of patients. I always saw him being so humble. Another great gift is that of perspective. Besides your love, one of the greatest gifts you can give another is perspective. Working at the end of this sort of anatomic peninsula, you can either be out there on your own, marooned, or you can collaborate with the mainland, so to speak. This has really guided what has become this specialty of limb preservation. I saw this as a kid growing up, a student and as a resident.

It was when I was a resident that I really remember it. I love operating, and remember a particularly complex reconstructive case back then at Kern Hospital that we had just finished with Guy Pupp, DPM, one of my mentors. The patient was a college athlete, and on postop day one, I was getting ready to change his dressing. In the treatment room next door, I thought I’d help out. It was a tiny, older woman with her family. Her son was interpreting, and she had a tiny ulcer on her plantar foot. While I’m talking with her through her son, I notice her hands are almost gangrenous. It turns out she had leprosy in remission as well. She said she was a baker, and burned her fingers because of lack of sensation and her neuropathy.

I had a sort of epiphany at that point. I could see both of these patient rooms from one spot in the hallway. The high-performance athlete was (understandably) in a lot of pain after a complicated surgery. I was invested in taking care of him, sure. But what about treating the absence of symptoms, as in the woman with her family just next door? I thought to myself, “wow, that’s what I really want to do.” This was probably my 2^nd or 3^rd day in residency. I continued to learn and study those reconstructive surgeries, but I thought a lot about applying those reconstructive techniques to those without the gift of pain, to try to help them move throughout the world a little better. What an avenue to effect change.

I learned it’s important to take a step back and look at the bigger picture. We look at our own individual practice, month-to-month, or day-to-day, and that is important. But it’s also important to take a step back and look at the fact that we are in the midst of creating a new specialty within a specialty. A significant part of podiatric surgery can be limb preservation. You see this unmet need in the U.S. and around the world. The concept of podiatric surgery is used to refer to what we call “limb preservation surgery” in other countries, including Asia and India.

No clinician is unto himself or herself an island. Any worthwhile effort here is a team effort. When it comes to our patients, so many are clinically depressed if we measure this. Yet, as a field we haven’t quite addressed this yet. On our team, we’ve tried to do this, and in our flagship clinic, while we have not had psychology and psychiatry on our team (due to them being urgently and importantly needed throughout the health system), we do have, interestingly, occupational therapy. These OTs are uniquely trained as specialists in areas of behavioral health. They can help steer patients in the right direction on this, behaviorally and as far as seeking therapy when needed. Between physical therapy, dieticians and others, we are able to help shepherd these patients into better behavioral health, although there is a long way still to go. Not everything can be fixed with a scalpel, an antibiotic or a spatial frame.

Patrick’s definition of a ReFounder is someone who identifies what’s broken and makes it better. For podiatric surgeons, the “toe and flow” model of care is a good example of this. In building limb preservation teams, we’ve found the irreducible minimum members of the team includes that “toe” specialist (podiatric surgery) and “flow” specialist (vascular surgery). That’s really where the magic happens. Especially with my “flow-migo prime,” Joseph Mills, MD, we really worked to cultivate this approach, building on the great work begun by colleagues at Beth Israel Deaconess and others around the world. That has led to the American Limb Preservation Society (ALPS), which brings clinicians together that care about these problems.

For future generations of podiatric surgeons and limb preservation specialists, it’s such a humble and rich specialty. There’s so much to learn and do and you can make such a difference for patients. Medically, surgically, mechanically; there’s so much in limb preservation. I think it’s an exciting time.

Dr. Armstrong is Professor of Surgery at the Keck School of Medicine at the University of Southern California. He is the Director of the Southwestern Academic Limb Salvage Alliance (SALSA). 

Editor’s Note: For a more in-depth discussion, listen to our podcast with Dr. Armstrong at https://www.hmpgloballearningnetwork.com/site/podiatry/podcasts/evolution-specialty-limb-preservation-one-surgeons-journey .