Like Ponseti, DPMs Should Show Tenacity In The Pursuit Of Equality

Ignacio Ponseti, MD, is a hero of mine whom I had the honor and privilege of getting to know personally.

One of the many things I admire most about Dr. Ponseti was his steadfastness. He developed the Ponseti method in the 1950s at the University of Iowa and first published on the Ponseti method in 1963.¹ It took decades of research to change the paradigm for the treatment of clubfoot, decades that included being ignored and dismissed while methods such as Kite’s method and early surgical intervention became the standards of care. Today, the Ponseti method is the World Health Organization’s and the Pediatric Orthopaedic Society of North America’s standard of care for clubfoot treatment.^2,3

The podiatric profession can take solace from Dr. Ponseti’s determined fight for acceptance, which in turn positively affected the lives of millions of children born with a clubfoot deformity. Podiatry’s role in healthcare and the advancement of the profession in my 25-year career is remarkable. When I speak with podiatric physicians who preceded me, like my father-in-law Anthony Jagger, DPM, and they tell me of the struggles just to get into hospital operating rooms, the fight for equality takes on an entirely different perspective. It took Dr. Ponseti approximately 40 years to get a non-surgical, safe and efficient method of treatment accepted into mainstream medicine for comparative purposes.

Dr. Ponseti’s success was based on sound science and evidence-based research until his voice resonated and lead to change. What about the podiatric profession? The American Podiatric Medical Association’s (APMA) Vision 2015, Pathway to Parity and Vision 21st Century initiatives have brought about tremendous professional change. The changes in education, training and experience continue to move our profession forward. Research like the Thompson Reuters Study, the Duke Study and the Arizona Medicaid Study prove podiatry’s value and role in the healthcare system.^4-6 The profession is no longer just claiming to be the best providers of lower extremity healthcare but is proving it, much like Dr. Ponseti showed his treatment was the best for clubfeet.

Is progress slower than everyone involved would like? It is frustratingly slow at times but the needle continues to move in the right direction despite the occasional obstacles. The podiatric profession continues to raise the bar to exceed these hurdles. Many factors are at play that will impact the move toward equality. Key podiatric stakeholders realize that our future depends on collaborative efforts on behalf of the profession. We are stronger together than we are divided.

There is a growing shortage of musculoskeletal healthcare providers as described by Day and colleagues in this month’s Journal of Bone and Joint Surgery’s (JBJS) “AOA’s Critical Issues” section.⁷ Granted, the proposed solution was increased use of nurse practitioners and physician assistants without mention of podiatric physicians.

However, a similar article by Sarmiento in JBJS in 2012 stated, “Likewise, podiatrists, who for generations had limited their work to minor surgeries of the toes, managed, over a very short period of time, to become doctors/surgeons who currently care for patients with all types of musculoskeletal conditions below the knee. They treat traumatic injuries as well as degenerative, infectious, and congenital diseases with clinical and surgical means. They perform internal fixation of fractures of the tibia, ankle, os calcis, hindfoot, and forefoot. In addition, they perform total ankle arthroplasties and tendon transfers. In the process, they have become experts in the field to the point that it is ludicrous to argue that their qualifications do not allow them to cover such a wide territory.”⁸

The APMA is undertaking a bold initiative to develop its registry. This registry will provide a wealth of research opportunities similar to those discussed previously to prove podiatry’s value in the healthcare system and to our millions of patients. It is easy to say you are the best but you have to prove it, and the APMA is leading the effort with this project. It will require a team approach with the other aforementioned key stakeholders to ask the important questions and evaluate the ultimate answers.

The number of orthopedic surgeons doing foot and ankle fellowships each year is approximately 50 to 55.⁹ This number of providers leaves a significant gap in care for more than 320 million Americans. The APMA’s primary goal is legislative advocacy according to its strategic plan. The primary objective is federal legislative parity, which would subsequently have a universal effect. Podiatric physicians serve as chiefs of staff in hospitals all over the country. Finally, podiatric physicians are already part of orthopedic groups, multispecialty groups and hospital staffs providing the majority of foot and ankle care in the United States.¹⁰

Although we have yet to summit the peak of the equality mountain, the forward progress in undeniable even by the staunchest of critics. One of my favorite Mahatma Gandhi quotes is, “First they ignore you, then they laugh at you, then they fight you, then you win.” Ignacio V. Ponseti, MD, provided an example of heroic determination and commitment that ultimately led him to win. Heroes who are committed to professional equality fill the podiatric profession. Are you one of those heroes?

References

1. Ponseti IV, Smoley EN. Congenital club foot: the results of treatment. J Bone Joint Surg Am. 1963; 45(2):261-344.
2. World Health Organization. Congenital anomalies. Available at https://www.who.int/surgery/challenges/esc_congenital_nomalies/en/ .
3. Pediatric Orthopaedic Society of North America. Available at https://posna.org/ .
4. Carls GS, Gibson TB, Driver VR, et al. The economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers. J Am Podiatr Med Assoc. 2010; 101(2):93-115.
5. Sloan FA, Feinglos MN, Grossman DS. Receipt of care and reduction of lower extremity amputations in a nationally representative sample of US elderly. Health Serv Res. 2010; 45(6 Pt 1):1740-1762.
6. Skrepnek GH, Mills JL, Armstrong DG. Foot-in-wallet disease: tripped up by “cost-saving” reductions? Diabetes Care. 2014; 37(9):e196-e197.
7. Day CS, Boden SD, Knott PT, et al. Musculoskeletal workforce needs: are physician assistants and nurse practitioners the solution? J Bone Joint Surg Am. 2016; 98(11):e46.
8. Sarmiento A. The projected shortage of orthopaedists may be our fault. J Bone Joint Surg. 2012; 94(14):e105.
9. American Orthopaedic Foot and Ankle Society. Available at https://www.aofas.org/medical-community/resident-fellow-opportunities/Documents/Fellowship_Match--Previous_Stats.pdf
10. American Podiatric Medical Association. The majority of foot/ankle care in the US is performed by podiatric physicians but Medicaid patients may not have access. Available at https://www.apma.org/PMResources/Brief.cfm?ItemNumber=8162 .