Podiatry’s Pathway Towards Parity
"What is the objective? Whose hearts and minds must be won to get there? Then, identify those people and work backward from there."
- Erika Jagger DeHeer 11-8-2021
Erika is my wife, and the quote is from a discussion we had immediately after an intense conversation I had regarding the pathway to equivalency for podiatric physicians. The conversation frustrated me, and I needed to vent. Erika's quote was brilliant in its directness and structuring of the issue. Providing clarity on those questions is essential to achieving what all the key stakeholders are currently debating regarding the best pathway towards parity for the podiatric profession.
What Is The Objective?
The profession’s objective has remained unchanged since Vision 2015 in 2005 and was reaffirmed on the consent agenda at APMA 2019 HOD as Resolution 4-19 (Directive); podiatric physicians practicing to the full extent of their education, training, and experience.1-5
Changing podiatric physician classification in Medicare from R3 (DPM) to R1 (MD/DO) is the most direct method to achieve this goal. Additionally, other federal health care programs that do not classify podiatric physicians as physicians include Medicaid, the Children's Health Insurance Program, Indian Health Services, and the Department of Defense. Changing status of podiatric physicians in Medicare theoretically assists in the change for the other federal health care programs. Of note, the Veteran's Health Administration (VHA) program moved podiatric physicians into the physician category with the passage of the VA Mission Act of 2018.6 The passage of this law, in my opinion, was podiatric medicine's most significant legislative victory to date. Changing Medicare classification most assuredly would require the American Medical Association’s (AMA) and the American Osteopathic Association’s (AOA) support.
Conversely, APMA's efforts to change podiatric physicians' classification in Medicaid for the past seventeen years, while spending a tremendous amount of money and time and effort from the APMA staff and members, is without success to date. In my experience, federal legislative victories are rare, requiring perfect timing and circumstances. State legislative victories have a slightly better track record, but only slightly so.
Whose Hearts And Minds Must Be Won To Get There? Then, Identify Those People And Work Backward From There.
The AMA and AOA define what it means to be called a physician. Those are the hearts and minds that we need to change. To help accomplish this goal, a National Task Force convened, consisting of representatives from the American College of Foot Ankle Surgeons (ACFAS), the American Association of Orthopaedic Surgeons (AAOS), the American Orthopaedic Foot and Ankle Surgeons (AOFAS), and the APMA. The members and association Boards from all four organizations agreed upon a proposed methodology to move podiatry towards equivalency. No other agreed-upon suggested pathway exists. In my observation, no matter how great the idea is to accomplish our goals, if it is not agreed upon by AMA and AOA, most likely via a recommendation by the AAOS and AOFAS, the idea is doomed to fail.
Another possible option is a bottom-up (state law change) or top-down (federal law change) legislative approach, but history demonstrates both processes are arduous at best. For example, three states and Puerto Rico still do not have ankle privileges. Some states with ankle privileges are almost as restricted as those without ankle privileges. In addition, podiatric physicians in New York cannot perform a Baumann or Strayer gastrocnemius recession due to the narrowness of their practice scope. The variation in scope of practices between states demonstrates the inherent challenges of the bottom-up legislative approach. Despite the success of the VA Missions Act, the profession's struggle with Medicaid reveals the difficulty in passing a federal law (top-down legislative approach).7
The recent letter from the National Board of Medical Examiners (NBME) declined the request of the National Task Force members for podiatric medical students to take the United States Medical Licensing Examination (USMLE®).8 APMA is reviewing the response from NBME and will discuss how to move forward with input from our stakeholders and the National Task Force. In addition, APMA will consider the work underway led by Lynn Curry, Ph.D., in her interviews with stakeholders under the auspice of APMA's Pathway to Parity Committee.9 While APMA believes that NBME is not fully aware of podiatric physicians' level of education and training, APMA is examining the best options for moving forward to achieve equality.
Despite the angst within the profession, everyone involved wants to do what is best for the future of podiatry. However, the singular, collective focus must remain moving our profession forward, allowing podiatric physicians to practice to the full extent of their training, education, and experience. Debate is healthy and warranted. But ultimately, it comes back to my wife's brilliant quote. Answer those questions, formulate a strategy that aligns with those answers, galvanize the entire profession to get behind the plan, then single-mindedly work to make the goal a reality. If together we can achieve equivalency for the profession where MD=DO=DPM, we will have paid it forward and left the profession better than we found it.
Dr. DeHeer is the Residency Director of the St. Vincent Hospital Podiatry Program in Indianapolis. He is a Fellow of the American College of Foot and Ankle Surgeons, a Fellow of the American Society of Podiatric Surgeons, a Fellow of the American College of Foot and Ankle Pediatrics, a Fellow of the Royal College of Physicians and Surgeons of Glasgow, and a Diplomate of the American Board of Podiatric Surgery.
References
1. Taubman RE. Reflections on Vision 2015 and our journey to parity. J Am Podiatr Med Assoc. 2009;99(2):181-182.
2. Robertozzi CA. Vision 2015: blueprint for parity. J Am Podiatr Med Assoc. 2007;97(4):349.
3. Glickman HB. Address to APMAs House of Delegates. J Am Podiatr Med Assoc. 2006;96(3):278-279.
4. Levrio J. Podiatric medicine: a current assessment. J Am Podiatr Med Assoc. 2009;99(1):65-72.
5. American Podiatric Medical Association House of Delegates: Ninety-Ninth Regular Sessions. Available at: https://www.apma.org/applications/secure/index.aspx?FileID=104572& . Accessed November 18, 2021.
6. S.2372 – VA MISSION Act of 2018. Congress.gov website. Available at: https://www.congress.gov/bill/115th-congress/senate-bill/2372/text . Accessed November 18, 2021.
7. American College of Foot and Ankle Surgeons. State scope of practice provisions for podiatric foot and ankle surgeons. Available at: https://www.acfas.org/uploadedFiles/Physicians/Health_Policy_and_Advocacy/Scope_of_Practice/Content/State%20Scope%20of%20Practice.pdf . Accessed November 18, 2021.
8. Letter from USMLE. Federation of Podiatric Medical Boards website. Available at: https://www.fpmb.org/fpmb/documents/Joint%20Task%20Force/USMLE%20-%20Response%20to%20Request%20for%20DPM%20Eligibility%20-%202021-10-19.pdf . Accessed November 18, 2021.
9. American Podiatric Medical Association. Announcement from the committee on physician parity. Available at: https://www.apma.org/News/NewsDetail.cfm?ItemNumber=47402 . Published October 16, 2021. Accessed November 18, 2021.
Additional References
10. American Podiatric Medical Association. Substitute Resolution 4-19 Available at: https://www.apma.org/applications/secure/?FileID=133290 . Accessed November 18, 2021.
11. American Podiatric Medical Association. Update to the 2015 HOD. Available at: https://www.apma.org/applications/secure/?FileID=133292 . Accessed November 18, 2021.
12. American Podiatric Medical Association. Vision 2015 Task Force Report. Available at: https://www.apma.org/applications/secure/?FileID=133293 . Accessed November 18, 2021.
13. American Podiatric Medical Association. Resolution 2-05: Vision 2015. Available at: https://www.apma.org/applications/secure/?FileID=133291 . Accessed November 18, 2021.
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Comments
Dr. DeHeer, Do you believe that the current education and training of podiatric medical students is adequate to assure their successful passage of all steps of the USMLE?
Hi Dr. Richie. Thank you for the question. It is part of the overall process to determine if the education and training are adequate. That would be one of the initial steps of a plan that I outlined in a prior blog on this topic. If changes need to be made at the schools, adequate time and preparation would be required to implement those changes. The key is to remember this process over an extended period of time like 7-10 years at best guess.