Does The APMA Advocate DPMs Hiring Pedorthists?

I just reviewed the agenda for the pedorthic section of the upcoming American Podiatric Medical Association (APMA) National. Some may be surprised that the Pedorthic Footcare Association (PFA) has combined its national meeting with the APMA National. If you are, please see some debate on this subject at Podiatry Today.¹

Previously, I have voiced my dismay that a commercial company was promoting a program in which it provided a “leased” pedorthist to a podiatric practice to carry out essential biomechanical treatments.² There are ads from the same commercial company running on a podiatry website showing video testimonials from podiatry customers of this service touting the “improved” profitability of this service allegedly because the pedorthists could sell more shoes, foot orthotics and ankle foot orthotic (AFO) devices. The assumption and message are that the podiatrist is either too busy doing more important functions in the office or may be inept at carrying out biomechanical treatments.

This same commercial company has now gained two podium spots at the APMA National meeting promoting the hiring of pedorthists in podiatry practices.

An area of pedorthic training that is superior to podiatric training is shoe fitting and shoe modifications. Few podiatric physicians would argue that a certified pedorthist is more qualified and experienced in shoe fitting than the average podiatrist. However, the scope of the pedorthist has expanded over the past 20 years and many are asking for employment in podiatry offices to virtually take over the entire biomechanics side of the practice. The “Central Casting Program” advocates a leased pedorthist doing patient evaluation, casting, dispensing, fitting and adjustment of foot orthotics and AFOs.

Is a pedorthist really better qualified to perform these vital functions than a podiatric physician? Is a pedorthist better qualified to treat dropfoot, Charcot-Marie-Tooth deformity and adult-acquired flatfoot deformity?

To those unfamiliar, a certified pedorthist only needs three weeks of formal training and requires no college degree. Yes, pedorthists must complete 1,000 “clinical hours” but simply working in a pedorthic shoe store can satisfy this requirement.³

Since this training exceeds that of the orthopedic surgeon and primary care medical doctor in the area of shoe fitting, AFO and foot orthotic therapy, pedorthists have traditionally relied upon referrals from MDs and physical therapists to practice their craft. Historically, the orthopedic community has used pedorthists to provide conservative treatment of foot pathologies in an effort to make the need for podiatry obsolete. While the PFA grew from its inception with a strong alliance with the orthopedic community, podiatric medicine was never a part of the referral formula.

There has never been and never will be a “win-win” or “two-way” referral climate between podiatrists and pedorthists for several reasons.

Over the past 15 years, the podiatric physician would occasionally refer to the pedorthist for diabetic therapeutic footwear service, often to avoid the hassle of Medicare regulations to fulfill this treatment. If one made a referral for foot orthotics or AFO braces to the pedorthist, the podiatric physician would be obligated to do so from an HMO contract. These contracts existed between HMOs and a large chain of orthotic and prosthetic facilities that hired pedorthists and never referred patients to a podiatrist. Begrudgingly, the podiatrist had to surrender this service, only because a national chain had won a contract with the insurance carrier.

Surrendering diabetic shoes and inserts was not difficult for most podiatric physicians who lacked expertise and interest in this area. However, other than contractual restrictions, why would any well-trained podiatric physician turn over his or her most challenging biomechanics cases to a pedorthist? Would this be for the hope that a reciprocal surgical referral would happen from the pedorthist to the podiatrist? How many of my colleagues get surgical referrals from pedorthists? Please weigh in.

The only other reason for referral from a podiatric physician to any specialty, other than commercial contract obligation, would be a recognition on the part of the podiatric physician that another specialist would be better qualified to treat the patient. When treating adult-acquired flatfoot patients, dropfoot patients and Charcot-Marie-Tooth patients, is a referral to the pedorthist an admission of inferiority in expertise and training?

Never would anyone assume that a pedorthist was better qualified to carry out biomechanical examination, casting and fitting of orthotic devices than a podiatric physician. Until now.

Apparently, the APMA is jumping on a bandwagon called “Central Casting,” which was started and promoted by Orthotic Holdings, Inc., and will be showcased in two lectures at the upcoming APMA National:⁴
·    Central Casting: A New Pedorthic Partnership through Podiatry
·    Podiatry and Pedorthics: A Win–Win for Everyone

Neither of these two lectures focuses on shoes or shoe fitting. The syllabus only describes the role of the pedorthist to fulfill casting, fabrication and fitting of orthotic devices for the podiatrist. The emphasis is on increasing profits to the practice.

This is not meant to be a condemnation of the pedorthic profession. It is a condemnation of my profession or at least our elected officials who have apparently endorsed a commercial interest, and also disenfranchised the vast majority of practicing podiatric physicians who take pride in our superior education and expertise in biomechanics and orthotic therapy.

I applaud the role that pedorthists play in providing vital service to our orthopedic colleagues who lack any training in orthotic therapy. I am shocked and disappointed that the leadership of the podiatric profession thinks that we have now achieved “parity” and cannot provide these services anymore in our own practices.

References

1. McCurdy B. APMA to partner with Pedorthic Footcare Association at 2015 annual meeting. Podiatry Today. 2014; 27(11):14-18. Available at www.podiatrytoday.com/apma-partner-pedorthic-footcare-association-2015-annual-meeting .

2. Richie D. Should podiatric physicians surrender orthotic therapy to pedorthists? Podiatry Today DPM Blog. Available at www.podiatrytoday.com/blogged/should-podiatric-physicians-surrender-afo-therapy-pedorthists .

3. Available at www.bocusa.org/certification-boc-pedorthist
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4. Available at www.pedorthics.org/resource/resmgr/2015_National_Con/Nat2015_Prog_Desc_Synopsis.pdf .