Why Podiatric Medicine Must Embrace Pain Management
Approximately 14,000 doctors of podiatric medicine (DPMs) are actively practicing in the United States.1 When compared to the 700,000 or so physicians practicing other specialties (either MDs or DOs), DPMs account for only a tiny fraction of providers. But despite our small numbers, podiatrists play a major role in managing painful foot conditions. In fact, the majority of foot surgeries are performed by podiatric surgeons. Thomson Reuters collected data in 2010 showing that podiatric surgeons performed 316,000 of the most common foot surgeries; this compared to 97,659 foot surgeries performed by orthopedic surgeons.2 The majority of patients who present for foot care are motivated by a desire to eliminate or reduce a painful condition. In essence, we are pain management specialists, albeit in a very different way.
Because DPMs encompass so few providers, many in the medical profession do not know what a podiatrist does, nor do they understand the extensive amount of training a DPM has undergone.
What type of training have we undergone? For example, at Midwestern University College of Health Sciences, at which I am an adjunct professor, the Arizona Podiatric Medicine Program students take all of the first 2 years of basic medical sciences with the Doctor of Osteopathy students. In addition, the DPM students have to take about five additional course-work hours each semester. Frankly, it is a more demanding track for the DPM than the DO at Midwestern.
Podiatric surgeons are extensively trained to provide a diverse range of very sophisticated surgical procedures ranging from the complex—Charcot foot reconstructions, total ankle joint replacements, and treatment of complex trauma, including microsurgical and complex peripheral nerve surgery—to very simple, yet vitally needed, procedures such as surgical removal of an ingrown toenail.
Recently, the Association of Extremity Nerve Surgeons, an interdisciplinary group that includes podiatric, orthopedic, hand, and plastic surgeons, has recently been accepted as a recognized affiliate organization of the American Podiatric Medical Association.3 There also is collaboration between the Society for Vascular Surgery and the American Podiatric Medical Association.4,5 In just the last 30 years, podiatric medicine and surgery have undergone a rapid transformation in the extent of training and the level of expertise of the current specialist, resulting with many DPMs becoming rapidly integrated into large orthopedic and other multispecialty groups.
The Podiatric Surgeon
The modern podiatric surgeon has undergone 4 years of podiatric medical school, with the same first two years of basic medical sciences as allopathic medical students. In the third and fourth years, the podiatric surgeon begins specialized clinic rotations in disciplines that are more aligned with what the final training objective is for the lower extremity specialist, such as internal medicine/endocrinology, dermatology, neurology, orthopedics and podiatric surgery, general surgery, plastic surgery, and even hand surgery. This is usually followed by 3 years of residency training. Today’s podiatric surgeon is simply the most comprehensively trained specialist for diagnosing and treating pathology of the lower extremities, which was emphasized in a recent commentary in the Journal of Bone and Joint Surgery by Augusto Sarmiento, MD, in which he stated: “…[podiatrists] 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 wide territory.”6 He was referring to the scope of work routinely and currently done by podiatric surgeons.
Most patients who seek podiatric treatment do so for the relief of pain—usually acute pain and fortunately non-centralized. Pain is the motivating factor for almost all of the patients who seek us out whether it is for a reconstruction of a hallux valgus (bunion) deformity, or due to some type of previous or current trauma or failed surgery. Additionally, with the number of surgeries that are being performed by our profession, we must be ever vigilant to prevent the normally expected postoperative pain from becoming chronic and centralized pain. As has been shown in a number of studies, a small percentage of surgical patients will develop chronic pain from their acute postoperative pain, and it has been estimated that the cost of treating chronic pain in a 30-year-old patient over their lifetime can reach more than $1 million.7
Chronic Pain: A New Area
Despite the extensive training already described, the podiatric profession, in my opinion, is not trained extensively enough in the management and prevention of chronic pain, as well as the benefit of becoming more adept in the perioperative delivery of optimal analgesia to prevent the development of chronic pain. And frankly, our patients are pushing us for this, with their demand for more comprehensive care from their primary surgeon. It also is my opinion that this holds true for almost every other surgical specialty.
A huge percentage of the patients treated and resources expended by podiatrists is related to diabetes with lower extremity sequelae. However, the primary focus of managing these patients has been the very targeted paradigm of the prevention of skin ulceration and subsequent amputation prevention, or limb salvage, in extreme cases. Interestingly, it has been demonstrated that when podiatric surgeons are included in the team management of those patients, there is a lower cost and better outcome compared to when they are not involved in the care. In one study, patients who visited a podiatric physician had costs that were $13,474 lower in commercial plans and $3,624 lower in Medicare plans during 2-year follow up (P<.01 for both). 8
To this point we have not talked about the devastating and life-changing pain of diabetic peripheral neuropathy. In type I diabetes, 54% of patients will develop peripheral neuropathy; in type II diabetes, 45% will develop peripheral neuropathy.9 Many of these patients have unremitting pain that causes desperation, ideation, and even suicide in some. The professional “soup de jour” is a prescription for duloxetine (Cymbalta) or gabapentin, with the usual advice that there “is nothing more I can do.” In an upcoming article I am authoring, the reader will learn that this is definitely not the case, and there is great hope for restoration of sensation and cessation of pain for these patients.
My call is for the integration of more pain management learning and experience into the podiatric profession—which will greatly help our patients. To a lesser extent, there will be exchange in the other direction, where with our expertise, we can help the practicing pain management specialist augment their knowledge and subsequent treatment, leading to improved patient outcomes.