Clearing Up The Misconceptions Of Orthopedic Surgeons Over The VA Provider Equity Act

Over the last week or so, the podiatric community has been up in arms about the letter that has circulated from David Teuscher, MD, the President of the American Association of Orthopedic Surgeons (AAOS), and Mark Easley, MD, the President of the American Orthopedic Foot and Ankle Society (AOFAS) President, to United States Senators Johnny Isakson (R-GA) and Richard Blumenthal (D-CT). In the letter, both doctors raised their concerns regarding S 2175, the Department of Veterans Affairs (VA) Provider Equity Act. They are reacting and trying to prevent the passage of legislation (HR 3016), which was introduced by Congressman Brad Wenstrup, DPM (R-OH) and passed the House in February.

“The bill essentially will enable podiatrists (DPM) to be placed on the same level as doctors of medicine (MD) and osteopathy (DO) with the Veteran Affairs VA medical system,” note Drs. Teuscher and Easley in the letter (see https://apma.files.cms-plus.com/FileDownloads/AAOSS2175letter.pdf ).

The letter has supporting facts but misrepresents quite a bit about the role of podiatry, and the differences in training for the care of foot and ankle pathology between orthopedic surgeons and podiatric surgeons. I have received many texts and emails from angry colleagues, and read arguments on daily listservs like PM News.

I don’t know why everyone is so surprised by this. For the last 50 years, podiatric medicine has grown to be the major provider of care for all foot and ankle pathology. No medical specialty comes close to performing the comprehensive care of the foot and ankle that podiatrists perform. Podiatrists can deal with every aspect of foot and ankle problems from the most basic care to the most complicated reconstructive foot and ankle surgery.

My MD family members and friends spent very little time on learning the gross anatomy of the foot and ankle, and some say they never even got there in their course. None have taken formalized courses on lower extremity biomechanics. Will our lack of OB/GYN training have a huge impact on the treatment of our treasured veterans in the VA system? I think not. How many fellowship trained foot and ankle orthopedic surgeons are spending their time at the VA, passing up on their hugely lucrative private practices or academic appointments? Are they dealing with the chronic care and daily needs of treating these veterans? 

The letter suggests there are 18,000 board-certified orthopedic surgeons who have more experience in ankle surgery than podiatrists. How many of those 18,000 have done much more than take care of ankle fractures during their training or practice other than on their mandatory trauma call? Few. How many of them want to take care of complicated foot and ankle problems? Few.

The letter also suggests there are 2,200 orthopedic surgeons who specialize in foot and ankle disorders. Less than half of those have participated in a fellowship concentrating on foot and ankle disorders, and many of those have spent only six months in a foot and ankle fellowship. Many of these 2,200 orthopedic surgeons have less than half their practice dedicated to the care of foot and ankle problems.

That is a stark contrast to the education and exposure podiatrists receive. Podiatric medical education gives its students and residents far more foot and ankle basic anatomic and biomechanic exposure as well of exposure to thousands of foot and ankle patients during podiatric medical education and residency. The exposure to patients with foot and ankle problems and corresponding surgeries far exceeds that of the busiest foot and ankle fellowship.

Do not misinterpret this. There are many exceedingly qualified orthopedic surgeons who specialize in foot and ankle surgery, many of whom have revolutionized surgical procedures for the foot and ankle, and provided groundbreaking research and publications to improve the care of patients worldwide. As the fellowship director of the longest running podiatric surgical fellowship, I have worked side by side with many of these orthopedic surgeons.

Do the people writing this letter really care about the treatment of veterans? Hopefully yes but maybe no. This is an effort to stop any governmental consideration that podiatrists provide equal care to that of orthopedic surgeons. I submit that podiatrists do not perform equal care but superior care to the VA community. When it comes to foot and ankle care, we should not be looking for equality when, in fact, we perform superior, comprehensive, foot and ankle care.

How The Podiatry And Orthopedic Communities Have Clashed

The orthopedic community has been trying to deal with the evolution of the podiatric profession for decades. At Specialty Day during the 1969 American Academy of Orthopedic Surgeons Annual Meeting, a member of the American Orthopedic Foot and Ankle Society raised a question to the society: “What are we going to do about the podiatry problem?” with Lowell Weil Sr., DPM, and Steven Smith, DPM, in attendance at the back of the room.

Since that time, total joint replacement and sports medicine/arthroscopy have consumed the attention of the American orthopedic community while the majority of orthopedic surgeons have overwhelmingly neglected the care of the foot and ankle. During that time, podiatry has evolved. Education and training have substantially improved. Patients are appreciating higher level care as a result of the treatments provided by podiatrists.

Now as the market has become saturated with surgeons specializing in total joint replacement and arthroscopy, the foot and ankle have finally become a focus for the orthopedic surgeon.

There is now a concerted effort to reduce educational opportunities for podiatric surgeons. It is well known that the American Orthopedic Foot and Ankle Society (AOFAS) will not allow any of its committee chairs, board of director members, or aspiring leaders to participate in the education of podiatrists, whether it be at the residency level, fellowship level, continuing medical education or industry-sponsored events. There is a systematic effort in place to prevent podiatrists from continuing to improve their skills, thereby reducing the level of care of the American public.

Does this seem like an organization that is looking out for the welfare of people suffering with foot and ankle problems, or one that is just worried about its self-interests?

Interestingly, many of the people who have been presidents, board members or committee chairs of the AOFAS have developed surgical innovations that they are currently marketing to foot and ankle surgeons worldwide. Many of these doctors have intellectual property that provides them with royalties for their inventions when surgeons utilize the products. We live in a capitalist society and there is nothing wrong with people making money on their intellectual and physical contributions to the advancement of patient care. I personally have several intellectual properties and receive royalties for different inventions.

However, I find it incredibly hypocritical that many of the orthopedic surgeons who have publically taken an anti-podiatry stance and have created the AOFAS policy of not allowing education of podiatrists are still collecting royalties and personal financial gain from the products that podiatrists are using. Has any of our leadership required industry to divulge who is getting financial gain from podiatrists’ work? Wouldn’t podiatrists like to know if they are funding their own demise? 

Personally and organizationally, we have welcomed orthopedic surgeons from around the world into our clinic and operating room, and they have valued the experience, knowledge, techniques and outcomes we have become known for. Some are even former presidents, board members and committee chairs of the AOFAS, or leaders of international foot and ankle societies. I have never turned anyone away who is interested in improving patient care.

During Specialty Day at the 2016 American Academy of Orthopedic Surgeons (AAOS) meeting, the AAOS President, addressing the AOFAS, said, “I promise, as a fellow orthopedic surgeon, to be sensitive to and help deal with the podiatry problem.”

One of our associates, who sat on the American Podiatric Medical Association (APMA) Young Members Committee, told a high-ranking APMA member about the speech. He downplayed the comment as something you say to appease your audience and that the APMA has a great relationship with the AAOS president.

Some great relationship, huh? Keep your friends close … and your enemies closer? Should the podiatric political leaders have been more proactive in expecting these kinds of letters? Should it have taken them until last week to be aware of these feelings and three months to react to it? (See https://apma.files.cms-plus.com/FileDownloads/APMAS2175responseletter.pdf) Few, if any of them, were in attendance at the AAOS meeting. Are they sitting in a bubble and don’t have a finger on the pulse of what is happening out there?

For years, podiatrists in our practice have regularly attended the AAOS Annual Meeting, Foot and Ankle Specialty Day and the Annual Summer Meeting of the AOFAS. We have encouraged our fellows and friends to do so as well. We have regularly presented our research at the AAOS meetings, sharing our experiences with the rest of the medical world. The value of attending meetings and conferences from all disciplines is that it provides one with knowledge of different thought processes and emerging techniques and technology to which one might not be exposed. By attending these meetings, not only do we gain clinical and surgical knowledge, we also get a pulse on the political landscape for these disciplines.  

Why doesn’t the leadership of our podiatric organizations find the time to do that? Had they done so over the years, there may have been a better understanding of what is happening outside of the podiatry bubble and they could have been more proactive to address those issues.

The letter that the AAOS and AOFAS sent to the senators should not dishearten the podiatry community. Instead, it should be a clear indication that our profession has made enormous inroads over the years to the point where we are an economic threat to those trying to prevent our financial equality. It should embolden the podiatric community and strengthen our resolve as we continue to provide the most complete, comprehensive and compassionate care of the foot and ankle.

How To Help

You might be wondering what you can do to help. 

1. I suggest holding the political leaders of our profession more accountable for the issues that are important to the growth of the profession. There are many terrific and dedicated people who have and are representing our profession. They need to know the issues that are important to their constituents. 
2. Support your colleagues or institutions that perform evidence-based research. The podiatric community has historically not done a good enough job through evidence-based research to show the world that we provide the best outcomes and care. We owe it to the medical world and ourselves to further the growth of foot and ankle care through publishing research and outcomes.
3. Be strong ambassadors of the profession.
4. Attend strong CME meetings and not just convenient ones. Expand your horizons and attend meeting of other medical disciplines.
5. Forward this to other colleagues so everyone is aware that those working toward our demise are collecting money off our work.