Steps of Progress: 25 Years of Innovation in Podiatry and Podiatry Today
As Podiatry Today marks 25 years as part of HMP Global, we asked several thought leaders in podiatry: Is the profession better off today than it was in 2000?
“The profession is much better off than it was 25 years ago because of greater acceptance and advances in technology and refinement in surgical procedures,” asserts Lawrence Fallat, DPM, FACFAS. “Not only do primary care physicians refer to podiatry but many of the specialists do the same. Twenty-five years ago, these referrals were very rare. But podiatry is now accepted as part of the team.”
Windy Cole, DPM, CWSP, agrees that the profession is better off, and since she completed residency in 2001, she has experienced a lot of those changes firsthand. She recalls that in those early years, she had to fight to get privileges at a hospital system just to be able to perform a new patient history and physical (H&P) in a wound care clinic, as at the time, an MD or DO had to see all new patients to perform the H&P at the initial visit. Then, if the MD or DO felt it was appropriate, the patient got a referral to Dr. Cole at a subsequent visit. She successfully petitioned the medical staff office and had the bylaws changed to allow podiatrists to see new patients and perform H&Ps.
Early in her career Dr. Cole also was denied privileges to debride a venous leg ulcer in the OR even though her Ohio podiatry license permitted DPMs to perform soft tissue procedures below the knee. She again petitioned the medical staff for those privileges and was supervised for several cases by the chief of surgery.
“Now I hold many international leadership positions and sit shoulder-to-shoulder with renowned multidisciplinary experts on the world stage educating healthcare providers in the best practices in wound management,” says Dr. Cole. “If that’s not progress, I don’t know what is.”
Javier La Fontaine, DPM, MS, MEd, says the profession is a lot better than it was in 2000 in the surgical arena. However, he feels other points of progress are vital to bring into focus.
“I do not think we are training the full scope of podiatry at the highest level,” he notes. “This is a key to having a higher applicant pool.”
Dr. La Fontaine advocates that residency programs’ requirements should be detailed not only in surgery but also in medicine. He says the profession should decide which are the best electives for surgery and medicine instead of each program deciding what is best for residents.
How Residencies Have Evolved
Residency training has evolved greatly since 2000, with Dr. La Fontaine noting that the standardization of residency training
to 3 years has been one of the most impactful changes, saying this has “raised the bar to train very well-trained podiatrists to serve the community.”
Dr. Cole says the evolution of residency training into a structured surgical 36-month program creates a uniform residency training experience for all graduates. She adds that podiatrists are encouraged to pursue advanced training by way of fellowships in areas such as sports medicine, research, diabetic foot care, or advanced surgery. Over the last 25 years, she says clinical practice settings have shifted from single office solo practices to larger multispecialty clinics, hospital groups, or acquisition by private equity firms.
Twenty-five years ago, Dr. Fallat notes most podiatry residency programs were 12 months, although some were 24 months. He says training was primarily in the forefoot and consisted of bunions, hammertoes, and possibly heel spur resections.
“Most podiatrists (in 2000) didn’t treat trauma other than broken toes,” says Dr. Fallat. “There were virtually no emergency room referrals to podiatry. When podiatrists treated trauma, it was pretty much what walked into their office. Now many residents rotate through the emergency room, and there are a lot of podiatrists who receive trauma patients from the emergency room.”
In 2000, Dr. Fallat remembers there weren’t that many referrals from primary care physicians, and the referrals that did occur were primarily for nail debridement and occasionally for a painful hammertoe. “That is completely different now, and many primary care physicians refer to podiatry for any type of foot and ankle problem,” he notes.
Dr. Fallat cites “a tremendous increase in the scope of practice in the last 25 years.” Now, he notes all residencies are 3-year programs with many residents going on to do a fourth-year fellowship. He adds that many programs also get routine referrals from the emergency department. Medical rotations are required with a minimum of 3 months of medicine, usually including time in internal medicine or family practice, infectious disease, and the emergency department.
Dr. Fallat notes rotations also include general surgery, orthopedic surgery, vascular surgery, endocrinology, plastic surgery, pain management, and physical medicine and rehabilitation to list just a few. As he says, most programs teach new innovations in foot and ankle surgery, including refined techniques in first tarsometatarsal surgery (Lapidus), minimally invasive surgery, and reconstructive surgery.
Residency programs now receive comprehensive evaluation, notes Dr. La Fontaine, saying the Council on Podiatric Medical Education (CPME) has implemented a number of requirements over the last quarter century that make programs meet specific objectives to obtain and retain approval.
Dr. La Fontaine believes fellowships will take training to a different level and advises the profession to think about the broader areas to expand. These include a need for podiatric radiology fellowships and biomechanics fellowships, rather than just patient care–directed fellowships.
How Podiatry Research and Education Have Evolved
Podiatry education has evolved dramatically in the last 25 years, asserts Dr. La Fontaine. He points to the schools of podiatric medicine adapting innovative ways of teaching in the classrooms. Dr. La Fontaine is trying to expose students to important connections by bringing basic science into clinical context in the first and second years of podiatry school. The accreditation process is rigorous, so he adds that schools and residency programs have to continuously raise their effort to provide top education.
Noting that podiatry has “changed a great deal” in the last 25 years, Dr. Cole says the curriculum at the colleges has expanded to include course work that is identical to that of students in MD and DO schools. She says most of the podiatry student rotations take place in clinical and hospital settings alongside podiatrists’ allopathic and osteopathic counterparts.
Research in the fields of podiatry and wound care has significantly evolved due to advances in technology, according to Dr. Cole. As she notes, digital tools for data collection are now the norm, which allows for better capture of information.
“The use of these technological advances also supports better patient recruitment, engagement, and clinical trial management and oversight,” says Dr. Cole.
Dr. Cole cites a trend towards decentralization of clinical trials (DCT). She advocates it is crucial for researchers to recruit participants who represent the individuals most affected by a particular disease, condition, or behavior.
“Certain populations such as women, certain ethnic and racial groups, and other marginalized people are notably underrepresented in many clinical trials,” says Dr. Cole.
By leveraging these new and innovative platforms to support remote patient monitoring and telehealth, Dr. Cole says DCT design is making it easier to collect, transfer, and store electronic data on study subjects who are located outside of typical study locations. As she notes, such alternate locations can include the participant’s home, a local health care facility, or a nearby laboratory. “It can be easier to recruit trial subjects and keep them enrolled if they don’t have the restriction of one particular geographic location or the burden of extended travel,” she says.
Additionally, Dr. Cole notes AI has been increasingly in use to collect data such as wound measurement and other information, analyze datasets, identify patterns, generate predications, and overall enhance the capabilities of research studies.
Multiple podiatry schools have opened since 2000, and Dr. La Fontaine calls that “good for the profession. As he notes, there are many areas within podiatry that providers can go into. As the profession expands, adds options for fellowships, and educates the prospective students all the areas that podiatry could be part of, he says podiatry will have a larger pool application.
“There are plenty of patients and feet to take care of,” says Dr. La Fontaine.
