Celebrating 50 Years of Podiatric Education, Research, and Innovation at UT Health San Antonio

Editors’ Note: In September 1991, Podiatry Today highlighted the thoughts of Louis T. Bogy, DPM, and others surrounding UTHSCSA’s podiatric residency program, the first supported by an allopathic university system. Now over 3 decades after that article, the program has yielded many landmark leaders in podiatric education and research. In celebration of 50 years blazing these trails, Podiatry Today had the chance to mark this milestone by hearing from many key individuals who either trained or taught within the program. They share pivotal lessons, what concepts they still apply in their practices today, and what fellow DPMs can learn as well.

Q: What was the most impactful thing you learned while part of the UTHSCSA program?

A: Lawrence B. Harkless, DPM, FACFAS, MAPWCA, cites the uniqueness of the program, saying it was one of the few programs that was fully integrated in a major academic health science center and had state support to train residents in podiatric medicine and surgery from 1975–2017. Dr. Harkless was a resident in the early days of the UT program in 1975–76, and joined the faculty in 1977.

“I had two goals—to earn the respect of every discipline at the Health Science Center and be treated similarly as a discipline,” says Dr. Harkless.

To accomplish this, Dr. Harkless and his colleagues created what he emphasizes was a culture of learning in venues where undergraduate medical education (UME), graduate medical education (GME), and continuing medical education (CME) transpired weekly with research questions emanating from discussion, creating the foundation for evidence-based learning and scientific discovery.

Lee C. Rogers, DPM, says few programs in podiatric medicine have had the same impact on the profession as UTHSCSA, noting former residents/faculty have been presidents of the American Podiatric Medical Association, Texas Podiatric Medical Association and American College of Foot and Ankle Surgeons. He adds that many residency directors have come out of UT and 3 deans of podiatric medical schools have emerged from the program. Seminal research has stemmed from the program, says Dr. Rogers, on subjects like the diabetic foot infections, negative pressure wound therapy, foot temperature monitoring, and offloading total contact casts.

Lawrence Lavery, DPM, calls the program “transformational,” and says it was driven by evidence-based medicine from an early stage. “That was the foundation for me to examine questions and then try to get answers that are better and based on evidence,” he says.

Davd G. Armstrong, DPM, MD, PhD, says in the program, Dr. Harkless and his mentees were able to make “an Olympian difference in the lives of a lot of patients … if that’s not paying it forward, I don’t know what is,” praising Dr. Harkless’s impact.

Jerry Patterson, DPM, was the first resident to go through the UTHSCSA program and remembers the challenges he faced related to parity, access and obtaining staff privileges. Even then, he says he was limited by the hospital in what surgeries he could perform.

“And I argued … and said, ‘No, you’re not going to do that to my profession. If someone’s qualified to do these procedures as much as you are, then they should be able to do those things,’” says Dr. Patterson. “If I hadn’t been persistent, this thing would not have turned out as well.”

“The most important thing I learned stemmed from the chip on my shoulder that I brought with me when I moved home to Texas,” says V. Kathleen Satterfield, DPM, FACPM, MAPWCA.

Dr. Satterfield recalls she had just come from a practice environment in the Midwest where the podiatry profession was not well respected. She was joining the UTHSCSA Orthopaedic Department as a DPM and wondered about the professional climate there. She expressed her concern to Dr. Harkless and she says he looked confused.

“After asking for me to explain myself, he said something that surprised me,” Dr. Satterfield remembers. “He said, ‘But Kathy, they need us. Nobody does what we do as well as we do. We have a seat at the table.’”

After that, Dr. Satterfield says she received immediate respect at Grand Rounds and Vascular Rounds. “These were MDs asking for our opinion and listening,” she says. “It was a new paradigm, and that informed how I presented myself and my skills from that day on.”

John Steinberg, DPM, FACFAS, cites the importance of working with Dr. Harkless and realizing what the program has to offer the health care system. He notes that there was mutual respect between disciplines, and “DPMs were truly shoulder to shoulder with their peers in other specialties.”

For Suhad Hadi, DPM, the most impactful thing she learned at the program was not to be afraid to approach others and other specialties. She cites the importance of fostering communication among multidisciplinary groups, saying it has enhanced her practice today. “It was second nature because we were so used to doing it as trainees that it didn’t intimidate,” she says.

Khurram Khan, DPM, refers to his appointment as chief resident and his experience as the final resident in the pyramid program as “the hardest thing I’ve ever done in my entire life.

“I imagine it like climbing Mount Everest,” he says. “Knowing I got through, battle hardened after going to hell and back, has given me the confidence to take on any challenges that have come forth ever since.”

During her years as a fellow and then faculty member at UTHSCSA, Rosemay Michel, DPM, FACPM, FFPM RCPS(Glasg.), learned the importance of forming relationships. “Connecting with patients, students, residents, my fellow faculty members and visitors to our program was the most impactful skill I gained—one I actively use daily,” she says.  

Javier La Fontaine, DPM, MS, MEd, says his time in the program expanded his capacity and ability, helping him transcend his limitations. He also cited the camaraderie he found there.

“Most of my career has been dedicated to the diabetic foot and obviously the comprehensiveness of evaluating patients who have diabetes,” says Dr. La Fontaine. “Each patient is an individual and not a number. I learned that from here and I always will be gracious about the fact that I came through here and learned that aspect of managing patients that way.”

Q: What one clinical technique or concept do you use as a result of being part of this program in everyday practice that other DPMs can incorporate?

A: Dr. La Fontaine emphasizes that to be an excellent physician, you need to talk to the patient. When it comes to research, Dr. La Fontaine says UTHSCSA really broke through many things, saying the program was a pioneer in areas such as negative pressure wound therapy, tissue substitutes, percutaneous tendon lengthening, and transmetatarsal amputation.

“I have to say that’s something that I’ve carried with me—parking at the bedside … in medicine,” says Dr. Hadi. “Today we’re so rushed, we’re trying to push patients out every 15 minutes or 20 minutes, and sometimes we forget to really sit and chat with them, and learn, maybe, what other external factors affect their care, especially with the diabetic population.”

Likewise, Dr. Khan asks his students, after parking at the bedside and after a thorough exam, what’s your thought process? He will still repeat to students to remember the etiology, epidemiology, natural history, and treatment options, both conservative and surgical, using evidenced-based medicine. “Think along those lines and a diagnosis will always be present,” he says.

Dr. Steinberg cites learning the “intricacies of the diabetic foot,” a subspecialty of podiatry that he learned he could make a difference in while at the program.

“You’re going to do everything you can to help improve this patient’s quality of life and their function, hopefully by performing limb salvage care and surgery,” says Dr. Steinberg. “The passion of the health care providers towards their patients at UT was inspiring to me. It really helped change my dynamic and my outlook on what our role is during this difficult time for these patients and their families.”

Dr. Patterson emphasizes the program’s care for patients with diabetes, saying a number of patients also had lower incomes. “If you really cared about people, you did the right thing to try to help them,” he says.

More than a single technique, Dr. Harkless says he drew from UTHSCSA the fundamentals in information gathering, presentation skills, and knowledge. He explains that one should be sure each resident or student obtained the information and performed the examination appropriately with checks and balances. These were the principles embedded throughout the program, notes Dr. Harkless.

At each venue at UTHSCSA, Dr. Harkless says there was an opportunity to test a resident’s knowledge. He says was all about two words—learning and growing—thus becoming.  

The venues for learning at the UTHSCSA program included:

• Clinic. “Charity starts at home and home was the clinic,” says Dr. Harkless.
• Orthopedic grand rounds weekly.
• Pre-op conference weekly. Every case that had to go to surgery had to come to conference for presentation and discussion, he notes. This was for the county hospital as well as the VA hospital.
• Problem-focused grand rounds weekly. He would cover most clinical topics on the foot and ankle within approximately 1 to 1 ½ years. This usually started with 2 cases where residents answered questions and discussed the case in detail from an evidence-based medicine perspective. He notes this culminated in a 10–12-minute lecture by a resident, fellow or faculty summarizing the best evidence on the topic. This conference provided the mechanism for knowing the 3 best evidence-based articles on the topic. This was always discussed in detail. “Having a conference weekly always provided unanswered questions—clearly a reservoir for research,” says Dr. Harkless. “Since we were in an academic environment, we were required to publish for promotion and to be accepted and integrated within UTHSCSA.”
• Anatomy lab monthly
• Journal club monthly
• Scrub sink
• Operating room

The UT program has covered a lot of bases on the diabetic foot, notes Dr. Lavery. He cites the ulcer classification as being used around the world,¹ saying the classification has enough variables that drive outcomes but not so many variables that one can’t incorporate the classification into practice. “It helps facilitate communication with other medical providers and it helps drive your decision for medical care,” says Dr. Lavery.

Dr. Rogers also cites the diabetic foot risk classification first generated at UT, saying it can determine when to see the patient, level of risk, the need for diabetic footwear, and necessary resources to optimize outcomes.

Although Dr. Michel gained many clinical skills/techniques, she says the most useful is performing gait analyses on all patients with biomechanical complaints. Gait analysis doesn’t take much time, and when she discusses her observations, she fully involves patients. The value of a gait analysis is undeniable, stresses Dr. Michel.

Dr. Satterfield learned not to take anything for granted. She learned not all positive magnetic resonance imaging studies (MRIs) were osteomyelitis and most were not, instead indicating marrow edema—but still, biopsy was vital to be sure. Along the same lines, she says not all “air” on a radiograph is gas. A pocket caused by debrided tissue often reads the same, cautions Dr. Satterfield.

It was an adjustment for Dr. Armstrong to learn different techniques at the UTHSCSA program and he cites the guidance of Lawrence Lavery, DPM.

“You have to ask the questions and challenge everything that you’re doing, and that’s really what we did,” says Dr. Armstrong. “We challenged a lot of the techniques and data that we had.”

Q: Based on your experience, what do you feel programs like UTHSCSA and others across the nation should do to continue to innovate and pioneer in podiatry 50 years from now?
 
A: The culture of UT, notes Dr. Rogers, is teamwork and leadership. When the program looks to bring residents on, he looks for future leaders. “I feel like that really is the legacy of the UT program—developing the profession’s leaders,” says Dr. Rogers.

Dr. Satterfield advocates for uniformity in licensing and practice among DPMs, MDs, and DOs, sharing that she feels this would remove misconceptions about podiatry in the medical world. More specifically, Dr. Satterfield says programs need to look at their patient population and serve that specific population, noting people like Dr. Armstrong and Dr. Lavery did so with Dr. Harkless’s encouragement.

“They took the patient population of patients with diabetes and concentrated on that group with research, innovation and care,” says Dr. Satterfield. “Harkless was right. He always said ‘the patient is the truth,’ and this was an example of that.”

Dr. La Fontaine emphasizes the importance of honing the concept of the multidisciplinary approach to patients, particularly the role of nurses, social workers, physicians, and physical therapists.

“We were doing that 20, 30 years ago for the diabetic foot in this program. So, I think that’s the way to go 50 years from now,” says Dr. La Fontaine. “We are the expert on the foot and ankle, but other specialties help you taking care of your patients. We need to teach that, and we need to embrace that.”

Dr. Hadi says it’s important for the podiatry profession to branch out into the larger medical arena as a whole. Dr. Steinberg stresses the importance of podiatrists taking “a seat at the table.”

“We should be part of this big tent of medicine and surgery,” he says. “Don’t underestimate what we bring to that setting for the patients and for the hospital system. It’s inspiring to see where we can take this profession and don’t be afraid to look beyond that horizon.”

“We’re a specialty,” asserts Dr. Armstrong, “and the reason we’re a specialty is because of programs like this that have integrated it … and made it equal. It’s folks like Louis T. Bogy, and Lawrence B. Harkless that have gone through, done the work and effected change.”

One should always go back to evidence-based medicine, says Dr. Khan, stressing that he feels this is the only way to innovate moving forward.

During her time at UT Health San Antonio, Dr. Michel always felt that the podiatry program was ahead of its time. “The contributions we made in education, clinical care, research, and in the community were valuable and long lasting, just with our day-to-day operations,” she says. “Trainees understood the importance of actively interacting with other medical and surgical colleagues, and as a result of these interactions, innovative research ideas were developed. Continuing such interactions will inevitably lead to such valuable contributions.”

Dr. Lavery cites the importance of residency programs meeting the changing opportunities for education, as well as integrating what you see in clinic into practice. He notes you have to see patients, interact with faculty, and seek knowledge yourself.
 
Q: Please share an interesting or informative anecdote from your program experience that other DPMs might enjoy or benefit from.

A: Dr. Harkless recalls when one of his former residents interviewed for a surgical job at a podiatric college and had to give a lecture. After the lecture the leaders at the school asked the former resident where he learned to provide such an informative and well-presented lecture. “His answer was it was the culture of his residency program,” says Dr. Harkless. “Educational resources filmed the lectures and gave feedback facilitating for residents, fellows, and faculty.”

Dr. Satterfield remembers working “ridiculously hard, sometimes soul-crushingly hard” but says the work “created some purpose in us that I did not experience elsewhere.

“Our UTHSCSA grads are star researchers, educators, trailblazers, here and around the world,” says Dr. Satterfield. “That reputation came at a price, whether it was with families or even health. But it all centered around one thing—the patient.”

Dr. Michel quotes Dr. Harkless’s saying: “You see what you look for; you recognize what you know.” As she notes, anyone training at UT under Dr. Harkless would never get that quote right until after graduation, but says it all does make sense.

Dr. Steinberg recalls attending the morning conferences, calling them “in some ways the most intimidating academic setting that I’ve ever been thrust into.

“Everyone has brought their top game to that conference, and everyone’s read up on the topic, and you are going to be pelted with great questions that are going to make you think beyond what you prepared for,” remembers Dr. Steinberg. So, it challenged me to do better and be more prepared.”

“I think deep inside, all these people remember the program and I think we played a big value in their career and for that, I’m really proud to be part of it and influence people that came to here,” says Dr. La Fontaine. “But without predecessors, we couldn’t do it. And those people, Dr. Harkless, Dr. Bogy—it’s just an honor to be part of a program that he created.”

In 1998, Dr. Harkless won the Presidential Excellence in Teaching Award and received a congratulatory note in writing from a Professor and Dean of Research in the Nursing School, who was a former patient and award winner. He says the note stated, “I knew you were a master teacher; your students knew you were a master teacher; now everybody knows. Congratulations.”

For a slideshow of related photos, click here.

To learn more about the Great Debates and Updates in Diabetic Foot Meeting this December in Texas, click here.

David G. Armstrong, DPM, MD, PhD, is a Professor of Surgery at the Keck School of Medicine at the University of Southern California. He is the Director of the Southwestern Academic Limb Salvage Alliance (SALSA).
 

Suhad Hadi, DPM, is the former Chief Resident and Director of Residency Education at UTHSCSA. She is currently a full-time faculty member at the Louis Stokes Veterans Administration Medical Center in Cleveland and at the Akron Community-Based Outpatient Clinic. She served as a Past PAVE Program Director at the Veterans Administration in Puget Sound, Wash.

Lawrence B. Harkless, DPM, FACFAS, MAPWCA, was Interim Dean of the University of Texas Rio Grande Valley (UTRGV) School of Podiatric Medicine, Professor Emeritus, SOPM Founding Dean Emeritus and Professor Emeritus of Western University of Health Sciences College of Podiatric Medicine in Pomona, CA. He is a retired Professor in the Department of Orthopaedics and former Louis T. Bogy Professor of Podiatric Medicine and Surgery at the University of Texas Health Science Center at San Antonio (UTHSCSA).

Khurram H. Khan completed a three-year surgical residency specializing in high-risk diabetic foot and limb salvage and reconstructive foot surgery at the University of Texas Health Science Center in San Antonio, and was named Chief Resident in his final year. He is a Clinical Associate Professor and Chairman in the Department of Podiatric Medicine at the Temple University School of Podiatric Medicine in Philadelphia.

Javier La Fontaine, DPM, MS, MEd, is a former Associate Professor, Chief and Director of Podiatry Residency Training at University of Texas Health Science Center at San Antonio. He is a Dean and Professor of UT Health Rio Grande Valley (UTRGV) School of Podiatric Medicine.

Lawrence A. Lavery, DPM, MPH, is a Professor in the Department of Plastic Surgery at UT Southwestern Medical Center. He is also the Medical Director of the Diabetic Limb Salvage (DLS) program at Parkland Memorial Hospital and works as part of the DLS team at William P. Clements Jr. University Hospital. He is board certified by the American Board of Podiatric Surgery and a Fellow of the American College of Foot and Ankle Surgeons and the Royal College of Surgeons (Glasgow).

Rosemay Michel, DPM, FACPM, FFPM RCPS(Glasg.) completed a diabetic foot/limb salvage fellowship at the University of Texas Health San Antonio and served as Assistant Professor in the Department of Orthopaedics. She is board certified by ABPM and ABFAS and currently practices in North Carolina at the VA Fayetteville Coastal Health Care System.
 
Jerry W. Patterson, DPM, FACFAS, is an Associate Professor in the UTHSCSA Residency Program. He practices at Patterson Foot and Ankle Associates in San Antonio.

Lee C. Rogers, DPM, FFPM RCPS, is the Chief of Podiatry and Associate Professor/Clinical in the Department of Orthopaedics at UT Health San Antonio. He is the President of the American Board of Podiatric Medicine and a Fellow Faculty in Podiatric Medicine at the Royal College of Physicians and Surgeons of Glasgow.

V. Kathleen Satterfield, DPM, was an Assistant Professor in the Orthopaedic Department of the University of Texas Health Science Center at San Antonio. She has served as the Dean of Western University of Health Sciences College of Podiatric Medicine and is now a consultant there.

John Steinberg, DPM, FACFAS, is a Fellow and Past President of the American College of Foot and Ankle Surgeons. He is the Co-Director of the Center for Wound Healing at MedStar Georgetown University Hospital and the Director of the Podiatric Residency Program at MedStar Washington Hospital Center in Washington, D.C.

Reference

1.     Armstrong D, Lavery LA, Harkless LB. Treatment-based classification system for assessment and care of diabetic feet. J Am Podiatr Med Assoc. 1996;86(7):311-316.