My Scope of Practice: Treating the Absence of Pain

    Podiatry is in David Armstrong's genes. His father was a podiatrist and little David would enjoy going to his office, proud of the fact that people would come in hurting and leave feeling better.

But it wasn't only that sense of instant gratification that set young David on his career path-it was also an experience that occurred not long into his residency. Dr. Armstrong had participated in a surgery on a high-performance athlete. The six-foot, nine basketball star was writhing in pain during a postop visit to clinic, while another clinic patient, a four-foot, eight Indian woman with a diabetic foot ulcer, sat serenely with her family, waiting for debridement. She was completely peaceful despite the hole in her foot, while the strapping athlete was in agony, just one door away. The literal and figurative juxtaposition provided an epiphany. "That's where it's at," Dr. Armstrong thought. "Treating the absence of pain."

    When Dr. Armstrong went to his Residency Chief Bill Todd and shared that enlightening moment, he was directed to the writings of Paul Brand, a surgeon and missionary who authored Pain: The Gift that No One Wants. Brand, who Dr. Armstrong calls, "the Mother Teresa and St. Francis of Assisi of medicine," described the critical nature of loss of sensation (neuropathy) in both diabetes and leprosy. This further piqued Dr. Armstrong's interest. "To be frank, I always thought I'd work in the family business," Dr. Armstrong says. "Ironically, the day before graduating from podiatry school, I received an offer of a Diabetic Foot Fellowship at University of Texas Health Science Center in San Antonio, Tex., under the leadership of my friend and then section chief Lawrence B. Harkless. While I was there, I was fortunate to meet Lawrence Lavery, then a junior faculty member and emerging star at the institution. In the course of my fellowship, we had an enormous productivity spurt, writing approximately 30 peer-reviewed papers on the diabetic foot in a single academic year. The research and writing was part of my learning experience, as well as a revelation: The reaction to our submissions was almost, 'What's a podiatrist?' This was news - that a podiatrist could research and write about the diabetic foot. Before then, few peer-reviewed journals had podiatrists listed as primary authors. That has changed dramatically. Larry Lavery and I now have, combined, perhaps 300 peer-reviewed manuscripts - most of them published in non-podiatry-specific journals."

    After his fellowship, Dr. Armstrong decided to stay on as attending physician and educator where he sought to make academic podiatry a goal for young foot practitioners. His years as clinician, teacher, and author focused his interest in raising the status of podiatrists. "Unlike other fields in medicine, podiatry lacks an institutionalized system of role models and mentorship," says Dr. Armstrong. "Podiatry had been mostly a private practice-centric profession. Yet few specialties are as well suited to be the central manager for all the issues involved in a wounded foot. Because the infected diabetic foot brings the patient to the hospital, it also brings in the podiatrist. The foot is the podiatrist's organ; as such, the podiatrist can serve as the triage agent, the central member of the multidisciplinary diabetic foot care team. Or to use a basketball analogy, the podiatrist is the point guard, serving up assists to the vascular surgeon, the enterostomal nurse, the endocrinologist, and other members of the team.

    "Over the past 5 to 7 years, knowledge in the foot wound arena has increased for specialists and is beginning to increase for generalists," he continues. "Clinicians have to know, for example, how to respond to absence of pain and when and how to refer. In doing so, they have to learn how to work within a team. Orthopedists, nurses, infectious disease specialists, and podiatrists all need to work together, bucking the trend toward a parochial, specialty-specific approach to providing medical care for certain conditions. I would like to see multidisciplinary training and experience expand by an order of magnitude. The greatest technology doesn't just involve cytokines, antibiotics, vacuums, and lasers. It involves the telephone - concerned colleagues playing well together. With that kind of cooperation and knowledge employed, amputation rates have dropped and will continue to drop."

    Dr. Armstrong says that to provide good care, clinicians also must have perspective. This means constantly questioning why you do what you do, from the most mundane to the most complex care. "If I can't explain why or what I am doing, I'm probably not doing it as well as I should," Dr. Armstrong says. Perspective also involves thinking outside the box. He finds it gratifying that he is good at putting disparate concepts together and seeing how they fit. He also advises clinicians to avoid standing on pretense - that is, "Never say ‘always' and never say ‘never'." He says incorporating such philosophy into his work has allowed him to grow.

    Elevating the worth of education is extraordinarily valuable. "It's a form of interdisciplinary treatment," Dr. Armstrong says. "The best thing we can do is to share experiences. The clinic is where all the thinking happens - you can't treat the wound from the keyboard. But you can't keep what you know to yourself." Because he feels so strongly about integrating practice with education, he recently accepted an offer to serve as Professor of Surgery, Chair of Research, and Assistant Dean at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin School of Medicine and Science (the merger of a podiatry school with a medical university), working with his mentor Bill Todd. "The position that I have just started affords me an enormous amount of latitude to work toward several goals," Dr. Armstrong says. "The most important of these goals is inspiring the young students and residents in medicine in general and podiatric medicine specifically. I see the program rapidly becoming a major international center for education and research in the lower extremity. I envision this program becoming the equivalent of what my great friend and mentor, Andrew Boulton (with whom I performed my PhD) produced in Manchester, UK. This facility will essentially be a magnet for patients and providers interested in amputation prevention." Dr. Armstrong founded his institution's Center for Lower Extremity Ambulatory Research (CLEAR). This interdisciplinary group will be dedicated to collaborative clinical and translational research in the lower extremity.

    Additional institutional goals include enhancing dual degree programs, building up a diabetic foot center of excellence from an already robust foundation, and helping to develop young talent in the profession. "We are also in the process of exploring the development of an endowed academic post to honor Paul Brand and the influence he had on my career," Dr. Armstrong says.

    Despite his new and growing responsibilities (or perhaps because of them), Dr. Armstrong hasn't lost sight of the reason he chose to focus on the diabetic foot - that is, the challenge of providing treatment in the absence of pain. He offers words of wisdom, learned from providing years of care (see "Dr. Armstrong's Pearls"). Not merely enamored with following in his father's footsteps, Dr. Armstrong turned respect for and ability to heal into opportunities for "meetings of the minds" among renowned clinicians, teaching, and professional growth, opportunities all podiatrists should seek in their scope of practice. 

My Scope of Practice is made possible through the support of ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ