2. The Current Role of Podiatry in America
3. American Podiatry and Public Health
4. A Brief History of American Podiatry
7. Sources for Further Information
The following is a brief chapter on
podiatry, that branch of medicine which deals with the care of the human foot.
Although podiatry, or chiropody as it is sometimes known, is quite
international in scope, the following account in focused on podiatry in the
THE CURRENT ROLE OF PODIATRY IN AMERICA
It is interesting to note the inclusion of the hand which recalls the days when the profession was known as chiropody, before its official name change in 1958. The word chiropody derives from two Greek word roots meaning ‘hand’ and ‘foot’. The name chiropody is still in common use internationally along with podiatry. The title of podiatrist derives from Greek words combining ‘foot’ with ‘healer, or physician’, and is considered more etymologically correct, since there is very little treatment of the hand rendered by the profession.2 The State of Ohio in paragraph 4731.56 O.R.C., authorizes a podiatrist to use the title “physician” or the use of the term “surgeon” “...when the title is qualified by letters or words showing that the holder of the certificate is a practitioner of podiatric medicine and surgery.”.
The scope of modern podiatric surgical practice is very broad and includes all the procedures and techniques which are also employed by the specialty of orthopedic surgery, in so far as they are applied to the foot and ankle. For example, such procedures would include: treatment of open and closed fractures of the foot and ankle using both internal and external fixation; similar pediatric trauma surgery; major arthrodesis of the joints of the foot and ankle; the use of implanted bone stimulators; the reconstruction of pediatric and adult congenital deformities; treatment of feet crippled by arthritis; emergency incision and drainage of significant diabetic foot and ankle infections; amputations of the foot; plastic surgical techniques such as rotational skin flaps and skin grafting; surgery on the major nerves of the foot and leg; and excision of many kinds of tumors from the foot or leg. All of the above procedures are ones which this author has performed and also taught to second and third year podiatric surgical residents over his career of 25 years.
Because these services might be rendered by either an orthopedic surgeon or a podiatrist there is a potential for friction not unlike that which exists where many other surgical specialties overlap. Such types of unhealthy competition may exist where economic considerations prevail, but seem less consequential where all practitioners are simply “trying to get the job done”, and are equally salaried from sources such as the military, the Veterans’ Administration, or large HMOs.
In fairness to orthopedic surgeons it must be pointed out that orthopedic surgeons have postgraduate education and training, i.e. surgical residencies in hospitals, which is more extensive than that required for podiatrists. Orthopedic surgeons frequently spend five to seven years in such residencies and may take additional fellowship specialization in foot and ankle surgery for an additional year.3 The orthopedist has an unlimited license which means that he or she may operate on any bone of the human body, not just the foot and ankle. However, in practice most do specialize in certain areas of orthopedic surgery such as shoulder and hand surgery, back surgery, large joint replacement, sports medicine and surgery, or foot and ankle surgery. Podiatrists, on the other hand, are more likely to have two to three years of surgical residency, although some programs do offer an additional fellowship year, sometimes providing an opportunity to study in Europe with famous orthopedic surgeons on the Continent.4 Most states require at least one year of postgraduate education for a podiatrist, and all podiatric residency programs are designed so that the first year is a rotating medical internship, in which the podiatrist performs in exactly the same capacity as other first-year medical residents.5
While podiatric medicine has matured as a sophisticated medical and surgical discipline, it is nevertheless, a tiny profession. The United States Bureau of Labor Statistics reports that “...podiatrists held about 13,000 jobs in 2002.”.6 By comparison, there are 700,000 physicians in the United States.
The following profile of the American podiatrist of today is abstracted from the 2002 Podiatric Practice Survey as reported to the American Podiatric Medical
Association by Al Fisher Associates, Inc.7 There were 9,392 members of APMA , of which 2,955 (31.5%) responded to a two-page, 30-question survey similar to surveys that were conducted in 1995 and again in 1997.(In which this author participated.) Most (56.6%) podiatrists were still in solo private practice, although the trend compared to 1995 and 1997 is toward more group practices of podiatrists and also participation in multi-specialty groups. The average age of the respondents was 44.9 years of age, reporting 16 years of practice experience. Most were male (86.6%), and white (90.2%), although the trend among younger podiatrists did include many more women and minorities. Most podiatrists had completed a residency program (90.2%), generally in surgery (66.3%). Fully 84.5% reported still having some student loan indebtedness despite being in practice for 16 years. The average student loan debt owed by podiatrists with fewer than three years of practice was $119,773. Most podiatrists were board certified by the American Board of Podiatric Surgery, ABPS, (51.6%) or the American Board of Podiatric Orthopedics and Primary Podiatric Medicine, ABPOPPM, (22%), and 10.7% were certified by both boards.
In 2001, the average podiatrist worked 41.8 hours per week, averaging 101.4 patient visits per week. On average, 77% of their working day was devoted to treating patients, and 23% was required for administration. The foot problems that these doctors were treating divided as follows: 44.8% heel pain, 23.9 fungal nails, 8.9% ingrown nails, other nail problems accounted for 9.9%, and 4.4% of their treatments were devoted to diabetic foot care. It is interesting with regard to this last percentage that 4.4% is the exact figure that the Center for Disease Control and Prevention8 reports as the prevalence of diabetes in the United States.
It is gratifying to this author to note that in 2001 nearly 22% of podiatrists were independently performing their own History and Physical exams for patients whom they admitted to the hospital. This capability was certainly not always the case, and represents the beginning of a fundamental change which the author has very strongly advocated.
In terms of earnings, podiatrists reported a gross income of $276,680 with a net income of $134,415. At least ten percent of podiatrists were earning a net income of more than $250,000. Podiatrists employed in multi-specialty groups received an average salary of $148,786. In order to compensate for declining reimbursements from third party payers, podiatrists increased their patient volume. The sources of this income were Medicare (38.6%), HMOs (21.6%), and fee for service (18.8%). Only a small fraction of the reporting members of the American Podiatric Medical Association were in military service or employed in the Veterans Administration (1.2%).
The above statistics would
accurately reflect this author’s practice experience of 20 years in an
AMERICAN PODIATRY AND PUBLIC HEALTH
Every branch of medicine has been blessed by certain far-sighted individuals who possessed both the wisdom and the energy to move their discipline into a positive future. Podiatric Medicine was fortunate to be moved toward public health by Marvin W. Shapiro, D.P.M., who believed that “...podiatric medicine’s greatest contribution could come in the field of public health.”.9 In the 1950s and 1960s, Dr. Shapiro and a select few other podiatrists put together exhibits at the American Public Health Association’s annual meetings. Eventually, Dr. Shapiro became the first podiatrist to be awarded fellowship status in the APHA. Several physician members of APHA took notice of foot health as a separate topic of health concern. Foot health was seen as especially critical for older persons. Eventually, Arthur E. Helfand became the second podiatrist to receive the honor of fellowship in the APHA. In 1962, the APHA funded Dr. Helfand’s project, entitled “Keep Them Walking”. This was aimed at the older population, and this three-year study provided important justification for the inclusion of podiatric medicine as a necessary service under Medicare.Ibid,9 In 1970, the American Podiatric Medical Association established a Council on Public Health, bringing together all APMA-related committees, coordinating a public health policy, and helping to foster a growing relationship with the American Public Health Association. All these years of cultivation bore fruit in 1972, at the 100th annual meeting of the American Public Health Association, the Podiatric Health Section was formally created. The section was granted three seats in the APHA’s Governing Council. Podiatric medicine has been an active, contributing part of APHA
since that date. Within the first year, this Podiatry Section was able to formulate and guide
through the Governing Council of APHA a resolution titled “Foot Health and Public Policy”. The Podiatric Section immediately began developing interdisciplinary scientific programs that infused podiatrists’ expertise into major programs of the APHA.Ibid,9
It must be said that the APHA benefited too, from the dynamic leadership of several podiatrists. Dr. Helfand became the chairman of APHA’s task force on malpractice. It was under his guidance that a resolution was adopted by the Governing Council and submitted as the APHA’a policy statement to the National Academy of Sciences hearings on medical injury compensation.10 Association-wide activity by podiatrists did not end there. Podiatrists also took a lead role in representing the APHA in its efforts with the National League of Nursing to accredit home health agencies and community nursing services.
While podiatrists were eagerly contributing their services to APHA, podiatry as a profession was benefiting by the association. Dr. Helfand has said: “No other external organization has opened so many doors for podiatric medicine and made it an equal partner in the development of health policy than has APHA.”.11
In 1975, APHA adopted a statement on the Functional and Educational Qualifications of Podiatrists in Public Health, but it was not until 1983 that the American Podiatric Medical Association formally approved public health as a special area of podiatric medical practice. Although the Podiatric Medical Section of APHA had made great initial strides during the 1970s, and could boast of a membership of over 700, this involvement declined and membership dropped significantly during the next dozen years.
Jeffery M. Robbins, D.P.M. was moved to write in his “Chair’s Message” for the Podiatric Health Section Newsletter, Winter 1998-1999 that: “The Podiatric Health Section has lacked a dynamic agenda in the past.”. There is some evidence that certain presidents of the American Podiatric Medical Association, and their administrations, did not fully understand the role that should be played by podiatrists in improving the Nation’s foot health, and consequently they did not provide an adequate level of support for activities in APHA.12 Fortunately, the APMA presidencies of Dr.Marc Lenet and later Dr. Terence Albright provided excellent support and the Podiatric Health Section increased its membership by over 100 members. Dr.Jeffery M. Robbins was (and remains) director of the entire department of podiatry services for the Veteran’s Administration, and he brought this considerable administrative skill to his chairmanship of the Podiatric Health Section. He worked hard to ensure that foot health, particularly that of diabetics, was included in the goals advocated and published in Healthy People 2010. As podiatry enters the 21st century it appears that it has rediscovered its mandate to improve the Nation’s foot health. In a telephone interview which this author conducted recently with the incoming Chair-Elect of the Podiatric Health Section of the APHA, Patricia Moore, D.P.M., there are exciting plans being made now to create a textbook of podiatric health directed toward an audience of other health professionals, and greater emphasis will be placed on podiatrists participation in other sections of APHA.
A BRIEF HISTORY OF PODIATRY IN AMERICA
Bates has pointed out that although
podiatry may have a new name (see elsewhere in this chapter), “...and the
recognition of podiatric medicine as a primary care profession is fairly
recent,...podiatry, itself, is as old as any other branch of medicine.”. 13
Humans have undoubtedly always suffered from foot problems since evolving
to bipedal gait. Indeed, there is written documentation in an Egyptian papyrus
of 1500 B.C.A., outlining a treatment for corns. Hippocrates advocated a
sensible approach to corns (thick, hard skin which usually forms on the
knuckles of the toes). He recommended a simple operative technique and getting
rid of the cause (probably tight sandals or boots). There are records of the
King of France employing a personal podiatrist, as did Napoleon. In the
According to Bates history14,
the licensing of podiatrists began in 1895 in
Both traditional allopathic medicine
and podiatric medicine required the wake-up call of a formal report to begin
moving into the modern era. For medicine this came in the form of the Flexner
Report published in 1910 which was initiated by the American Medical
Association. The Flexner Report had major impact. Sub-standard medical schools
closed, and those that remained became affiliated with universities, admission
standards were raised, full-time faculty became the norm, and teaching included
work in laboratories and hospitals instead of lectures only. Podiatric medicine
had to wait until 1961 for an analogous phenomena with publication of the
Selden Commission Report.16 By 1978 all the colleges of podiatric
medicine agreed to adopt the exact same requirements as
These were watershed events in the history of podiatric medicine because in the words of Leonard Levy, D.P.M., M.P.H., “...they began providing the basis for establishing legitimacy to the call by the profession for parity with medicine.”.17 In 1967 two separate national changes in policy had a significant impact on the development of podiatric medicine. In 1967 Congress amended the Medicare Act of 1965 to include podiatry. This permitted podiatrists to qualify for payment as did the other physician categories: M.D., D.O., D.D.S. This same year, “...the then Joint Commission on Acreditation of Hospitals issued a bulletin permitting hospitals accredited by the Joint Commission on Accreditation of Hospitals to allow qualified podiatric physicians to perform surgery without having a scrubbed-in ‘physician-surgeon’ in the operating room who was a member of the active medical staff.”Ibid,17
The growth of post-graduate training programs for podiatrists was slow. The first residency program was opened in 1958 in Philedelphia at St.Luke’s and Children’s Medical Center.Ibid,17 However, it required another thirty years before all graduating podiatric medical students received residencies.18
Given that podiatry began as chiropody with ‘knife-in-hand’ cutting corns and
calluses, it should not be surprising that most board certified podiatrists are, in fact, board
certified in foot surgery.Op.Cit.
The road to a place alongside orthopedic surgery, establishing podiatric
surgery as a legitimate specialty area was a long, slow road. One significant
step along this road took place in 1942 when the American College of Foot
Surgeons was organized. Almost immediately, rigid requirements for membership
included both a written and an oral examination.19 A corps of
competent podiatric surgeons ( still called Doctors of Surgical Chiropody)
lectured throughout the
“The renaissance of podiatric
surgery occurred with the opening on June 4, 1956 of
Fortunately for podiatric medicine and surgery, two podiatrists at the California College of Podiatric Medicine, Drs. Merton L. Root, and Thomas E. Sgarlato, became intrigued with the pioneering research of Verne T. Inman, M.D., who was unraveling the mysteries of human gait. Both Dr. Root and Dr. Sgarlato began to study the biomechanics and kinesiology of the human gait cycle, including pathological conditions that appeared
in the foot. Both began to lecture widely in this country, greatly helping podiatrists to base both their conservative and their surgical treatments on scientific understandings of the complex patterns of human locomotion.
Podiatric surgeons learned early the great importance of intense postoperative
care, and since many of their surgeries were performed in outpatient settings, an early emphasis was placed on ambulatory care. By 1974, Kaplan could claim in his historical review of podiatric surgery that “...the majority of foot surgery is now being performed by podiatrists.”Ibid,19
Most developed counties have
professions of chiropody or podiatry. Many countries have several colleges of
podiatric medicine which have welcomed guest lecturers from
service to their patients. And so, step by step, podiatry grows internationally by a winding path not unlike that followed by American podiatry.
An ancient healing art has evolved in America to become a highly complex surgical subspecialty. The advances that podiatry has made in the 20th century are unquestionable. Modern American podiatrists with advanced postgraduate training are some of the finest foot and ankle surgeons in the world. However, despite these advances there are some questions that remain.
Some skilled podiatric surgeons wonder if it makes any sense to have a separate branch of medicine for the care of the foot. Such a division has worked well for dentistry, but, perhaps, not so well for podiatry. Podiatry does not stand side by side with medicine as dentistry does. Even a cursory look at medical literature, or medical research, or medical schools will confirm this. These podiatrists can often be found advocating that podiatric medicine be subsumed under the allopathic umbrella. They argue that podiatrists should attend standard allopathic medical schools and then specialize in podiatric surgery , podiatric orthopedics, podiatric primary care, or podiatric public health. This would, they believe, eliminate the confusion that sometimes surfaces regarding a podiatrist’s education and training, and podiatrists’ role in the developing healthcare complex.
Other podiatrists counter that such an abdication would wipe out entirely the special affection which so many patients feel for their ‘foot doctor’. They claim that such a change would lose that body of knowledge which excels at treating human foot problems without surgery! These doctors and educators, including surgeons as well as non-surgeons, lament their impression that as young podiatrists gain more and more years of postgraduate education, and master increasing complex surgical skills, they grow farther and farther away from the core techniques (and values?) that created the enduring and beneficial profession of podiatry. Only time will answer this.
John D. Waddell, D.P.M.
Diplomate, American Board of Podiatric Surgery
Board Certified in Foot and Ankle Surgery
Fellow, American College of Foot and Ankle Surgeons
Board Certified, American Board of Quality Assurance
Please contact me at: email@example.com
to offer criticism and corrections which will be incorporated in future chapter revisions. Thank you.
1. Viehe RB, Diabetic Foot Care: podiatric physicians are the experts.
J Am Podiatr Med Assn. 2002 Sep; 92 (8) : 477
2. This author does have a colleague practicing in the same city who routinely removes
warts from patients’ hands by laser surgery, in addition to his foot surgical practice.
3. American Orthopedic Foot and Ankle Society
2517 Eastlake Avenue East, Suite 200
Seattle, WA 98102 www://firstname.lastname@example.org
4. For example, the three year podiatric
surgical residency at the
offers a fellowship year in
modern concepts and techniques of using metal screws and plates to fixate fractures.
5. Viehe RB, How Else Have We Arrived
J Am Podiatr Med Assn. 2002 Oct; 92 (9) : 528-9
6. United States Department of Labor, Bureau of Labor Statistics
Occupational Outlook Handbook www.bls.gov
7. Allan H. Fisher, Jr., Ph.D.
Al Fisher Associates, Inc.
406 New Mark Esplanade
Rockville, MD 20850-2735
8. Centers for Disease Control and Prevention
1600 Clifton Rd.
Atlanta, GA 30333 www.cdc.gov
9. Helfand AE, Hausman AJ, A Conceptual Model for Public Health Education in
Podiatric Medicne, J Am Podiatr Assn. 2001 Oct; 91 (9): 488-95
10. Rowena A. Wilson, R.N., M.P.H. J Am Podiatr Assn. 1977 Jul; 67 (7) 463-4
11. Helfand AE, History of the Podiatric Health Section of APHA as recorded by
the American Podiatric Medical Association on their website: www.apma.org/phshis
12. Personal Correspondence
13. Dagnall JC, The History of Podiatry; J Am Podiatr Assn. 1976 Dec; 66 (12) 944-5
14. Bates JE, Podiatric Medicine: History and Education; J Am Podiatr Assn. 1975 Nov;
65 (11) 1076-7
15. Viehe RB, The Effectiveness of Organized Podiatric Medicine. J Am Podiatr Assn.
2003 Mar-Apr; 93 (2): 165-6
Sources for Further Information
American Podiatric Medical Association Tel: 1 301 571 9200
Bethesda, Maryland 20814 Email: email@example.com
USA Website: www.apma.org
Affiliated and Related Organizations
American Academy of Podiatric Sports Medicine Tel: (301) 845-9887
P.O. Box 723 Fax: (301) 845-9888
Rockville, MD 20848-0723 USA Website: www.aapsm.org
American College of Foot and Ankle Orthopedics and Medicine
3525 Ellicott Mills Drive, Suite N Tel: (206) 682-8741
Ellicott City, MD 21043-4547 USA Website: www.acfaom.org
American College of Foot and Ankle Pediatrics Tel: (410) 772-9245
P.O. Box 33
American College of Foot and Ankle Surgeons Tel: (847) 292-2237
515 Busse Highway Fax: (847) 292-2022
Park Ridge, IL 60068-3262 USA Website: www.acfas.org
Sociedad Científica de Podología de la República Argentina
Libertad 174 2º - 3º Piso Tel: 54 4382 9173
Capital Federal (C.P.: 1012) Fax: 54 4381 7342
Republica Argentina, America Del Sur
Australasian Podiatry Council Tel: 03 9416 3111
41 Derby Street Fax: 03 9416 3188
Collingwood, Victoria 3066 Website: www.apodc.com.au
Associação Brasileira De Podólogos-ABP Tel: 55 22 4422.7500
Av. Prestes Maia, 241 - 21º Conj. 2111 Fax: 55 11 3311.7557
São Paulo – SP – Brazil
Canadian Podiatric Medical Association Tel: 1 416 927 9111
900-45 Sheppard Avenue East Fax: 1 416 733 2491
North York, Ontario
Fédération Nationale des Podologues Tel: 33 1 44 79 90 91
17 rue de l’Echiquier Fax: 33 1 44 79 08 02
Zentralverband Der Medizinischen Fußpfleger Deitschlands E.V. (ZFD)
Johannisstr. 12 Tel: 49 02302 83781
D 58452 Witten, Germany Fax: 49 02302 88537
The Society of Chiropodists and Podiatrists Tel: 44 020 7234 8620
1 Fellmongers Path, Tower Bridge Road Fax: 44 020 7234 8621
London SE1 3 LY, England
Israelic Podiaric Medical Association Tel: 972 2 625 4162
P.O. Box 37166 Fax: 972 2 625 9282
Associazione Italiana Podologi-A.I.P. Tel/Fax: 39 06 228 20 23
Via dei Berio 91
Nederlandse Vereniging van Podotherapeuten Tel: 31 033 465 55 51
P.O. Box 1161 Fax: 31 033 465 05 01
3800 BD Amersfoort
The New Zealand Society of Podiatrists Incorporated Tel: 64 4 9142000
P.O. Box 24-139
Singapore Podiatry Association Fax: 65 6259 3175
Orchard Post Office
P.O. Box 410
The South African Podiatry Association Tel: 27 11 406 2233
P.O. Box 29139 Fax: 27 11 401 0675
Johannesburg 2131, South Africa
Federación Espaňola de Podólogus Tel: 34 1 531 50 44
San Bernardo, 74, bajo dcha Fax: 34 1 523 31 49