Podiatrists, tenders of corns, bunions and other troubles of the humble foot, are classified as second-class citizens in the medical world - a rung below full-fledged M.D.s.
But with the surge in people with diabetes, they're playing a particularly vital role these days in preventing amputations. And there's a move afoot to boost their official status as well.
"We kind of see ourselves as the profession that keeps people walking," said Dr. Jon Hultman, executive director of the California Podiatric Medical Association.
Diabetes diagnoses rose 40 percent statewide between 1999 and 2008. Today, an estimated 3.7 million Californians live with the chronic condition, according to the California Diabetes Program.
Obesity is the primary culprit for the boom in cases of type 2, or adult-onset, diabetes. As the numbers rise, so does the need for early treatment - especially of foot sores or ulcers that can quickly threaten the lower limbs. Sixty percent of all non-traumatic amputations in the United States are due to diabetes, according to the American Diabetes Association.
But here's the thing: Though podiatrists can operate on the foot and ankle, give injections and provide other medical care, they aren't licensed doctors of medicine, or M.D.s. As such, Hultman and others maintain, the state's 1,800 doctors of podiatric medicine (DPMs) are hamstrung by law from treating many of the 7.5 million Californians insured through Medi-Cal (due to a 2009 state budget cut), partnering fully in the hospital care of diabetic patients and gaining access to first-rate residencies in their podiatric training.
"We've evolved over the last 30 or 40 years. What hasn't changed is this limited license," Hultman said. "We're treated differently even though the way we practice is essentially the same."
Indeed, on a given day with the Sutter Medical Group, 30-year podiatrist Dr. Spencer Lockson treats the foot from several angles: dermatological, as in athlete's foot and eczema; bone and joint issues, such as bunions, fractures and "hammer toe" deformities; and nerve conditions, which are often associated with diabetes.
"We avoid amputations the best we can," he said.
Podiatrists have attracted an unlikely ally in the bid to boost their status: the California Medical Association. The powerful doctors' lobbying group is notorious for its turf battles with chiropractors, nurse practitioners and others it defines as "mid-level practitioners and other allied health professionals."
But this time around, the CMA is playing the opposite role. It's teaming up with the California Podiatric Medical Association and the California Orthopaedic Association to consider putting the training of foot specialists on par with M.D. standards, according to CMA Chief Executive Officer Dustin Corcoran.
The three groups are creating a task force to review the curriculum at California's two podiatry schools and, depending on the outcome, appeal jointly to the national Liaison Committee on Medical Education to reclassify the licensing for podiatrists.
Dr. Lawrence Harkless, a podiatrist and dean of the Pomona-based College of Podiatric Medicine at the Western University of Health Sciences, believes the move makes good sense. "I don't have an M.D., but I practice medicine every day. If I'm that close, why not just be it?" he said.
The first two years of podiatric training are similar to those for full-fledged physicians, with the emphasis on anatomy, physiology, pathology and other core subjects. Podiatry students jump into more specialized training the next two years, then generally spend the last two or three years as hospital residents. Training for licensed medical doctors generally takes several years longer, with the length for residencies determined by the specialty.
At his first hospital internship in Texas in the 1970s, Harkless worried he'd be less prepared than his M.D. peers. "After two months, I knew I learned more than anybody about feet," said Harkless, considered a national pioneer in the field of diabetic limb salvage. "But if you have a different degree, they want to make you feel less than."
Corcoran of the California Medical Association agrees the perception is not always favorable. He and Hultman are expecting pushback on the collaboration to bring podiatry into the medical mainstream.
"There will be a freak-out, those naysayers, who say, 'They're just the foot guys and will always just be the foot guys,' " said Corcoran. "But this is really how scope of practice should be decided."
With a physician shortage in California, and the aging baby boomers' growing need for care, podiatry may become a more attractive option if granted M.D. status, he added.
Franklin High School graduate Brittany Rice just completed her first year at the California Podiatric School of Medicine at Samuel Merritt University in Oakland. She is used to frequently explaining that podiatry is a credible medical field. "I know people in society put the M.D. on a higher pedestal. They don't take us seriously," said Rice, who is considering specializing in diabetes care. "Not that (a change in licensing) would affect what I do, just how people perceive the profession."
Sacramento podiatrist Kevin Kirby isn't convinced. He chose podiatry school in the 1980s, in part because of its "efficient" focus on the foot and a postgraduate commitment of six years instead of eight or nine. If new requirements called for additional training, he wonders if students would just choose a different branch of medicine.
"I never had the feeling that I was a lesser doctor because I had a DPM," said Kirby, who is on staff at two Sacramento hospitals and shares his practice with an orthopedic surgeon. "For me, I don't lose any sleep over this. I'm plenty busy. I do a lot of good for people."