Who are we?
I could be wrong but it seems to me that, at last, podiatry is gaining a modicum of respect.
Although it may just be limited pockets of success, witness any diabetic conference to realise the value placed on podiatric input. Just as well thought of is podiatry in rheumatology. Nail surgery is ours, and podiatric surgery continues to blaze the trail for day case surgery under local anaesthetic while significantly enhancing the standard of foot surgery in the UK.1 I believe we are on the threshold of further gains. But at this very point, it is vital that we are discerning with whom we form alliances and what direction we allow our leaders to take us. Our full potential is never going to be realised if we align ourselves with the other AHPs or nursing.2 We are different; we have diagnostic privilege and clinical autonomy, and we have medicines and surgery, and it is these that should push us closer to the medical and surgical professions.
Podiatry is a resourceful profession; how else could we have survived the massed opposition to podiatric surgery, degree courses or even our use of local anaesthesia? We never fail to use the opportunity to encroach on other professions and expand our practice.3 Patient group directives and greatly enhanced access to diagnostic imaging are examples of such opportunities that will allow our further development; and while podiatric diabetic care is now relatively common and podiatric rheumatology is growing, they are not nearly as vast as the area of practice that we should now be dominating: foot pain in the general population.
Foot pain is our future
Podiatrists in musculoskeletal posts or specialist biomechanical services will be only too aware of the overwhelming epidemic of foot pain that, when not referred to podiatry, is treated somewhat haphazardly by a range of services. Heel pain, metatarsalgia, Achilles tendinopathy and painful flat feet are common enough and difficult enough to treat to engage the whole profession. Yet we remain poor at diagnosis and as a profession are only occasionally and haphazardly involved in this vast and barely tapped market place. Morton’s neuroma is massively overdiagnosed while capsulitis of the metatarsophalangeal joint is massively underdiagnosed. Flat foot is treated with in-shoe orthotics only, heel pain with heel cups, lateral border pain is poorly understood and Achilles tendinopathy is referred to physiotherapy.
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Podiatric training should be based on the medical model
The solution, as well as our future professional alliances, lies in redesigning our undergraduate education. From the beginning our undergraduate courses should focus on the investigation, diagnosis and comprehensive management of foot pain. Investigation should be based upon the clinical clerking and system review model taught to every medical student.
To achieve this, our undergraduates should be sharing the pre-clinical foundation training of medicine and dentistry. Treatment should combine the options of injectable steroids, oral medication, acupuncture, homeopathy, orthotic and exercise therapy. The role of podiatric surgery as the next inevitable part of the management plan when conservative measures fail should become very much part of how a podiatrist thinks.
But it should not finish there. Once through preclinical training, podiatry students should have a formal programme of rotation through relevant medical specialties where they can use their clerking skills in the initial work up of the patient. Our most powerful ally, medicine, remains largely unaware of what we can offer patients. Would that remain the case if we trained alongside them? Medicine is a great international profession. While we have some international alliances, American podiatry will never recognise our qualification as commensurate with theirs until the medical profession does so.
The future for continuing professional development
But what of those currently in practice? I am deeply impressed by the way the entire profession has grasped continuing professional development (CPD). But while attendance levels at CPD conferences are excellent, the CPD that is delivered is often quite pedestrian. This tremendous opportunity should not be wasted on revision of what we already know, but should be pushing the profession forward, and where better to start than with the immense opportunities that technology provides for us. Podiatrists must learn how to use diagnostic ultrasound (Figure 1) and have access to the relatively cheap and portable ultrasound scanners. 4 Diagnosis, grading and outcome measurement of a whole range of conditions is possible with this equipment.
While dermatology has risen and risen in importance in the profession, our diagnostic abilities could be greatly enhanced by wider access to the hand-held dermatoscope.5 No CPD session should fall short of expanding the clinician’s practice, and to facilitate this, digital video recordings of everything from skin biopsy to local anaesthetic techniques should be available via the website for that is all the revision that is needed once the techniques have been taught. Such digital images should also be available to our patients and other professional colleagues. CPD should now focus and develop the profession’s understanding and use of diagnostic imaging techniques, blood tests for diagnosis, disease staging and management and gait analysis and fluoroscopy for dynamic evaluation of the foot.
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