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Joint Podiatry Orthopedics Taskforce
An Interview with Bryan Markinson, DPM
Joint Podiatry Orthopedics Taskforce
An Interview with Bryan Markinson, DPM
In our continuing series exploring the controversial issue about the Joint Orthopaedics and Podiatry Taskforce and the upcoming American Medical Association resolution, now pending a vote in November 2021, I interviewed Dr Bryan Markinson, a well-known and well-respected podiatrist who takes a dissenting view to that of the Taskforce members. It is important to examine both sides of an issue and to have intelligent people like Dr Markinson help us to understand as many facets of a complex issue as possible. I hope you’ll find, like me, whether you agree or disagree, that Dr Markinson’s views are more nuanced than simply “don’t do it” and that it is possible for podiatrists to approach this important issue with mutual respect. In next week’s issue we will (temporarily) close out this topic with some overall thoughts about the Taskforce, incorporating all of the recent interviews and suggestions moving forward. I hope you enjoy this interview.
View the entire interview transcript below or a PDF version Here
Jarrod Shapiro, DPM's Interview of Bryan Markinson, DPM
Jarrod Shapiro: Hi, everyone. My name is Jarrod Shapiro and the editor of the Practice Perfect blog. As part of our continuing series regarding the Joint Task Force of Orthopedic and Pediatric Surgeons, and AMA Resolution J21-303, I'm talking today with Dr Bryan Markinson. Dr Markinson is the chief of podiatric medicine and surgery at the Leni and Peter W. May Department of Orthopedic Surgery of the Mount Sinai School of Medicine in New York City. He is a very well-known national speaker and educator and a person whose opinion I deeply respect. As such, I have asked Dr Markinson to be interviewed today regarding his opinion about the Joint Task Force and the issues surrounding this topic. Thank you for joining me today, Dr Markinson.
Bryan Markinson: Good morning. Thank you for having me.
Jarrod Shapiro: So, we'll get right into this. The AMA J21-303 proposes to investigate if the accreditation education and certification processes for podiatry are comparable to those of DOs and MDs. And this has obviously created a lot of controversy. So, Dr Markinson, can you summarize your views on the initiative so far?
Bryan Markinson: So, independent of the California experience, where there apparently has been some detailed review about the educational process and the residency experience, I believe that globally across the United States, I believe that the portrayal of what we have as being close to the allopathic or MD/DO experience is very much deficient.
Bryan Markinson: I believe that, unlike what they're saying in California about the medical board saying we're almost there, or insinuating that, I believe from my own observation that we are very far away from being almost there when we compare the educational experience from several points. And, first one is application to podiatry school in the first place. The next part is most concerning to me, is the educational experience in the third-year of medical school, DO school versus podiatric medical school. I believe that the deficiency there is way wider than anybody is discussing, okay? And I know for a fact that in the residency experience that we're all proud of, and touting, and that I support completely, is significantly varied across the country, as far as the surgical experience and capabilities of our graduates.
Jarrod Shapiro: So, can you maybe give me a little bit more detail about the deficiencies or maybe the different experience that you see during that third-year student timeframe?
Bryan Markinson: Okay. So, I want to be clear that I am not full-time in any podiatry school. I only give adjunct lectures at the New York College of Podiatric Medicine. So, I am not hands-on with podiatry students in the third-year, but I am with medical students in the third-year.
Bryan Markinson: And I feel that third-year hospital rotations that the medical students have, as compared to the ones that the podiatry students have, are very different in the expected performance of the third-year students, in the work requirement expected of the third-year student in their demonstration requirements about what they're learning. And I believe their work hours in those rotations are much greater than those in the podiatry school experience. Now, talking about when a podiatry student is running or participating in a clinic that may be affiliated with the podiatry school, and when clinic is over 4:00 p.m., it's the end of their day, okay? That just doesn't seem to happen with the third-year medical student experience, where of course they're not running clinics. They're doing patient care on the floors with inpatients to a much greater extent. And their days are rarely over at 4:00 p.m. Now, if I'm misspeaking about the podiatry students who are on rotations other than podiatry clinic, I apologize for that. But I think across the board, that they do not have the same requirements as the medical counterparts. And I might add, that the people in those rotations that are monitoring them, probably do not have the same expectations of them.
Jarrod Shapiro: That's an interesting point. I agree that there seems to be a variety of experiences from the students' experiences during the nine colleges and even the rotations specific to medicine or surgical subspecialties. I'm wondering if do you feel that it would be a good idea for podiatry as a profession to maybe review these differences across our education in a way that the task force is… their suggestion or what they have offered is to look at the accreditation process? It seems at least I hear a lot less controversy about whether or not the accreditation itself is different. It's really more the experience of the trainees themselves that seems to be what is more controversial. I'm wondering, would it be a good idea for podiatry to look at that and maybe do its own survey of the schools?
Bryan Markinson: So, if podiatry does do that, it's almost impossible not to come to the conclusion that I am espousing right now. So, now, I want to remind you, okay, when I use terms like deficient, okay, I'm only talking about as compared to the medical student experience. I don't feel podiatry experience is inferior in any way when it comes to being a podiatrist. I think it's different. And I want to highlight different versus inferior, okay? Now, we have decided, or we seem to have decided as a profession, that our current identity as a podiatrist is somehow unacceptable because of all the external complications that that causes with legislation, with insurance regulations with insurance recognition. I get all that. I understand all that. But the MD world is telling us just do what we did. And we're okay with it, okay? I don't know how we get to that without destroying our identity as DPM podiatry foot specialists. And I don't know how we're going to fit it in to the educational model at what sacrifice of that which makes us special right now. Any of our podiatry graduates goes into a hospital. They know far more than any medical intern about dermatology, radiology, when, of course. When it comes to the foot, they know far more about peripheral vascular disease, okay? This is an absolute certainty. But the task force draft seems to indicate that we don't care about that. We want you to be what we are, and we want you to go through what we went through, okay? So, I don't see that as achievable in the current set of circumstances. Now, when you say we should review that, okay, I would love for all my podiatry graduates to be able to palpate a liver and do rapid interpretation of EKGs. I would love that. But why would any smart, educated motivated third-year undergraduate college student sign on to that and not make themselves open to all the various specialties of medicine that are available to them by completing that type of education? Who would elect before they know anything about all the specialties to commit to podiatry and then going through the same thing that a potential neurosurgeon is going to go through. I don't see us filling 10 schools with students who have made that choice. I don't see us filling 10 schools with students who have made that choice.
Jarrod Shapiro: Yeah, that seems like a very complicated situation. I know of individuals who chose podiatry while they were in college, and then probably a very large number of people who you mentioned maybe they had wanted to go along the allopathic or osteopathic route couldn't get into school and then went into podiatry. But I'm wondering, so at places like Western or Arizona, or I believe Des Moines where they have a very heavy medicine component to their education. I'm not sure that they're really lacking in the number of applicants because the programs are highly medicine-based. I think the thing that I'm wondering about, which maybe gets a little bit of outside of our conversation, is that the overall numbers of applicants to podiatry are pretty low. I think that's pretty fair thing to say that applicant numbers to podiatry schools is much lower than maybe it should be.
Bryan Markinson: Totally inadequate.
Jarrod Shapiro: Yeah. But I'm wondering why that would be if the current situation is that the podiatry, that the schools and residencies make us podiatrists by the time the process has finished. And that's been what's been going on for since it started. I'm wondering, we don't know what the effect is of changing that situation. So, that maybe instead of looking at it, as foot doctors, per se, we're looking at it as medical professionals who specialize in the lower extremity. That philosophical difference may potentially bring more people to the table or bring to the colleges. Do you feel like…
Bryan Markinson: I think that's very pollyannish. If I have 10 students right now committed to being podiatrists and we'll go through the process and become podiatrists, if I now take the same 10 students, three years from now, 10 years from now, whenever it will be and say, hey, do all these things and you will have access and you will not have access to any of the other specialties of medicine, I don't think all 10 will stay in that commitment.
Jarrod Shapiro: Oh, I agree that there has to be… presumably there'll be a percentage. Who would or wouldn't? I mean, I agree, you're definitely not going to get 100% changing.
Bryan Markinson: Right. So, if we have a deficit now in a number of applicants, we're going to dilute it even further. Now, one of the prior interviews you did, and I believe the doctor's name was Cornelison.
Jarrod Shapiro: Yeah, Dr Cornelison is one of the task force members.
Bryan Markinson: Right. So, he made a comment that nobody chooses their profession based on what exams they might have to take. Okay. Well, that's true. But a third-year undergraduate college student, okay, correct, does not choose on the basis of the exam they have to take but finding out that if they commit to podiatry, that they have to do the same thing as the colleague who wants to be a heart surgeon, but will not have access to being a heart surgeon. You are going to lose that interest in podiatry.
Bryan Markinson: That's my feeling.
Jarrod Shapiro: Yeah.
Bryan Markinson: Now, there are people out there, I may have a niece or a nephew, David Armstrong has a daughter and I say this with all due respect, all these people, Jonathan Steinberg mentioned about his own children, okay? Now, I have no problem with legacy issues. I have no problem in children following in the footsteps of their fathers and mothers and relatives. But this is not enough to fill 10 podiatry schools. So, I do accept that there are people, young people out there, brilliant, competent people who may choose podiatry first track based on legacy or family experience, but not enough, not enough to fill 10 podiatry schools.
Jarrod Shapiro: Yeah. It's such a complicated issue. I think if you were to add in things the fact that podiatry doesn't do a terribly good job advertising itself, those types of things, I think make that a difficult question to really pin down to say, would this really affect the profession as a whole? I'm not sure. I know that, like just from my own personal experience, when I started looking at this as a potential career back in the late '90s, for me when I was in college, I didn't know about podiatry. And it wasn't until I found out about it that I liked it. And now as a professor at one of the universities, and I have students who are DOs, who rotate through our clinic, I've actually heard several occasions more than I would say, simply anecdote that they've… when they are rotating with podiatry, they find out what it is about. And some of them has, is impossible for me to become that. And when I hear things like that, it makes me wonder if maybe there might be more to it. It's just that we, as a profession, have failed to advertise the profession and how good it is. And maybe it's more than just simply, we would fail by comparison to medicine or DOs.
Bryan Markinson: So, it's very interesting if these college students visit podiatrist and neuro offices, they will find 99% of them gloriously happy with their chosen profession. I have experienced that. And I know that to be true, okay? But if you go now, right into the freshmen class at your institution, and ask them, by show of hands, how many of you actually visited or observed a podiatrist before applying to podiatry school? You're going to be shocked at the number of people who have not, okay?
Jarrod Shapiro: Well, yeah, that's a good one. So, I had heard a statistic and I do not know where it was published. And maybe somebody just said it. I'd heard a statistic that was one of the primary reasons people choose podiatry to apply to podiatry school is that they had an interaction with a podiatrist prior to college.
Bryan Markinson: Right.
Jarrod Shapiro: Yeah.
Bryan Markinson: Right.
Jarrod Shapiro: I couldn't answer that question from a Western University standpoint, because we have a requirement that students shadow a podiatrist. So, I think that might skew the results a little bit, but I definitely get the point.
Bryan Markinson: Okay. And now, podiatrists also are going to be hesitant to tell a college student all the problems in the profession. It's not going to be that type of in-depth conversation. But to the question at hand, all right, let's just discuss the components of the task force, okay? The American Orthopedic Foot and Ankle Society may be sitting down with members of our profession, okay? But in my hospital right now, the foot and ankle orthopedic surgeon refuses to allow podiatry residents in her operating room. And the one that preceded her refused to allow my podiatry residents into their operating room. Now, when I questioned them on it, now, these are people in my department. I have to sit in faculty meetings with these people, okay? And when I challenge them on it, they tell me right out front. This is what the American Orthopedic Foot and Ankle Society wants me to do, okay? Now, I don't believe that, okay? And they also intimate but they won't confirm that they can actually be sanctioned if it's found out that they are allowing podiatrists in their operating rooms. Now, I don't see how we can be proud of the fact that they're sitting down with us in this task force when under the radar, and actually not under the radar, they are informing their members that it is not a good idea, and in fact, against the mission of our organization for you to train podiatrists. Now, nobody's talking about it. Everybody knows that that's out there. And I don't trust that they will take our education all of a sudden, and say you guys are very close, just past the USMLE. I believe they're setting us up until proven otherwise to expose what they are telling the medical community that we just shouldn't be recognized.
Jarrod Shapiro: Do you know why they would do that? It's actually this is news to me. I have not heard that they had like specific policy about shunning podiatrists. Is there something…
Bryan Markinson: Well, this is out of the mouths of my colleague attendings here, who are foot and ankle orthopedic surgeons. They tell me straight to my face. “This is what my society wants,” when the original foot and ankle surgeon stopped allowing our podiatry residents in the operating room and I asked him about it, he said, “my society found out about it.” So, I have no problem saying that this is a policy of the American Orthopedic Foot and Ankle Society. It may not be written on paper, but okay. I also heard that their annual meeting, they have an agenda item called the Problem of Podiatry.
Jarrod Shapiro: So, in the California experience, as you alluded to earlier, I think California had somewhat a similar relationship somewhat more head-to-head with orthopedics. And, as I understand it, the interaction that the physician and surgeon task force in California had ended up in a much more positive relationship with more support. Do you think that there might be the potential for this current task force maybe help improve that relationship?
Bryan Markinson: Well, make no mistake. All over the country, there are foot and ankle orthopedic surgeons who understand that the American Orthopedic Foot and Ankle Society does not benefit them in any way whatsoever. And they are hiring surgically trained podiatrists to join their practices. They are allowing podiatry residents in their operating rooms and do so. But as long as there is a posture where a orthopedic foot and ankle surgeon feels comfortable and legitimized by forbidding a podiatrist in their operating room, the AOFAS has to acknowledge this and bring it out to open view in the task force and say, hey, we are against that posture. Otherwise, I don't think I can trust them. Now, even in New York City, okay, there are hospitals and orthopedic attendings who wonderfully cooperate with the podiatrist. They're writing research papers together with the residents, no question about it. But that's an individual orthopedic surgeon saying, my society doesn't run me. My society doesn't tell me what to do. And it's to my overwhelming benefit to have all interested parties cooperate, and it makes it better for everybody. So, not all of the orthopedic foot surgeons are following the choices that the ones have made in my institution. So, I want to be clear, I don't indict everybody. But the orthopedic foot and ankle society as a society sitting down with us has to acknowledge that members amongst them are saying that they condone exclusion of podiatrists. So, at that level, where they can't all of a sudden say, “just go take the USMLE, and we'll be on board.” So, there's a dichotomy there that I feel must be addressed and should be challenged by APMA and ACFAS.
Jarrod Shapiro: Yeah, it's obviously as for me, I'm not a person who's privy to their back conversations that they had at the beginning of the task force process, but from what the members told us, there were some discussions that were a series of in nature, again, we don't really know the content specifically. But it sounds like when they found common ground, things seemed to improve or, at least, it gave them a footing for a way to go forward to have this discussion. It seems to me that the talking with them more as opposed to you're just saying, well, they don't like us. We're not going to talk to them again. It seems that has the potential to be beneficial. Would you advocate that they just not have this conversation? Or, would you suggest that different road to have this discussion?
Bryan Markinson: No, no, no, we need to progress the way we're doing. This is a very large, excellent step. But just make both sides aware that a young person going through a medical education, which is what everybody wants, who then is found to be cut off from all the residency choices that are available to someone going to MD or DO school is going to be the next hurdle. It's going to be the next thing where they say, well, right now, we don't get paid as much as orthopedic surgeons. What's going to happen at the educational level is going to be, “I didn't realize that going through the same thing my buddy is going through, who's going to be able to do a residency in cardiology, I did not realize that that would not be open to me.” And that's going to be a very bad thing.
Jarrod Shapiro: Yeah, I agree with you that you definitely… in order to preserve the actual profession of podiatry as a profession, I don't see how making us go through school that would then open you up to every type of residency program available. That just basically makes you an MD or DO student. I think you have to maintain that somewhat separation in the residency process. I agree with you that I think you re-run the risk of damaging the profession. But I'm wondering about with the specific statements that the task force has made, and what the resolution is, for the AMA is really asking for. Do you have issues with the particular things? I mean basically it's looking at… it is our accreditation system for schools, residences, and then certification, are they similar enough to the LCME method that it would then give them the AMA comfort to allow podiatry students to potentially take the USMLE exams? Do you have concerns about that particular review?
Bryan Markinson: Yes, I think if they went in right now and reviewed the experience across the country of third-year podiatry students, and not just a written syllabus, and not just the written curriculum, if they observed what these are actually doing, like I was told they did in California, but I still feel that they need to observe it across the board. For podiatry standards, I feel that we are equivalent. We definitely have the same dimensions of expertise and experience to become a fully qualified podiatrist, but certainly not fully educated MD/DO equivalence, certainly not. And can we teach ultimately to the USMLE exam, part one? Of course, we can. No question about, okay? But that brings me back now, again, to the differences in the application process, okay? We cannot be dishonest about the fact that podiatry schools take and accept people with MCAT scores that would never be even looked at, in most medical schools. What are we going to do when they look at that? They're going to be pretty critical, right from the get-go of the application process. So, I have concerns about that. I don't for one minute feel that the MCAT score is any good indicator of how great someone would be as a physician, okay? But we do accept a lower level of beginning students. So, that could be the deal-breaker right away when they're looking for equivalence, okay? So, again, I feel that this discussion should go forward, but we need to be honest, and we need to be forthright in saying that the DPM identity will have to change dramatically and we're going to lose people going into the specialty. If we can make primary podiatric medicine a resident choice for MD or DO students, that might be a way to go. And some might actually choose that. But that is something that no one is talking about yet. But I will tell you this, as a person who loves what I do. For the federal government to produce documents that says we need to triple the amount of podiatrists in the next 10 to 20 years with the diabetic onslaught and everything that they determined manpower on and to still have such a low level of applicants, in terms of numbers. We definitely are doing a marketing campaign that is not adequate.
Jarrod Shapiro: Yeah, absolutely agreed. But the one thing, I guess, maybe to clarify, I guess, is that the task force and the AMA resolution doesn't state that they're looking specifically at the experience of the trainees. Rather, they're looking at the process that our accreditors use for the accreditation of the schools, the residencies and the certification, as opposed to, yeah, they're going to examine all the schools. At least, when you read it at face value, I would say that there's no plan to look at the schools themselves or the residences themselves specifically.
Bryan Markinson: So, for that reason, I don't think podiatry schools… I think podiatry school should be very concerned about how ever a podiatry student is going to pass the USMLE parts two and three, which that's what I'm talking about, okay? If you're able to leave clinic at 4:00 p.m. and go home, I don't think that's going to work. I don't think it's going to work. The medical students are not doing that by and large. And they're on the wards late at night. And they were examining patients and they're giving presentations in the morning. And their chief residents are expecting them to show up prepared. And I don't know that our third-years are getting that anywhere.
Jarrod Shapiro: Yeah, that's hard to say. It seems like it would be helpful for the profession. If we did have some kind of review of the schools, I think, what at least what I hear is that there are some schools that maybe somehow feel like they're going to suffer by comparison to other schools. I'm not really sure. I haven't spoken to anybody at any schools other than Dr. Kathy Satterfield at Western University. At Western, they have a very medicine-centric educational process. And they have been reviewed, actually by the California Physician Surgeon Task Force. And they're the only school that is taking the CBSE test, the test that prepares the students for the USMLE. In order to know if we really would suffer by comparison, it seems like the only way to do it is to actually have them take the test. But I would echo others comments that if we have to make it mandatory for the students who are taking it, or else they just won't take it seriously. I think it's obvious if it doesn't matter, who cares, right? Why would you spend the time to study for it?
Bryan Markinson: Absolutely. And I know that may have been involved in prior experiments with that.
Jarrod Shapiro: Yeah. And they did, as I understand it, they did they did well, at least up to this point that that process seems to still be ongoing. I am always a little concerned that the podiatry thinks that somehow if everybody looks at us in-depth, that we're going to suffer. Maybe we will to some extent, but I maybe that's healthy for us to see where our deficiencies are. I would say them as true deficiencies like you suggest the entry-level requirements are different for podiatric schools from many of the MD and DO schools. So, maybe there are issues that we need to address. I personally like the idea of looking at us and seeing. I don't love the idea of giving the orthopedic surgeon somehow fodder to damage us as a profession. Though, I don't see this white paper as being something that would do that.
Bryan Markinson: Again, if everybody's sincere and leaving out what I said about what some orthopedic foot and ankle surgeon say is the policy of their society, I think this is a healthy step to go forward. But I don't know how we can do a modified USMLE that would be acceptable to the non-podiatry members of the task force, and that's where I feel our Achilles heel, pardon the pun, actually is. It's just so open to just say, hey, look, you guys, you're just not there. And when we are there, we're going to have people saying I don't want podiatry, I want to be an ophthalmologist. So, our side of the task force is not fully, in my opinion, getting these questions out into the open. Hopefully, this interview and the others that you're doing will stimulate some more conversation. And, but again, again, the opposite side of the coin that I'm talking about is if we have to do USMLE and there are people that stick to the single-track podiatry choice, and they pass all the USMLE we're going to have some pretty great lower extremity practitioners out there who will be indisputable, the most competent for lower extremity medicine, but not enough Jarrod to fill 10 podiatry schools.
Jarrod Shapiro: Yeah, I guess what we'll know when we see this as it goes on. So, this process, obviously, is moving forward. Regardless of everyone's conversations and the controversy, it's clearly… well I would say is the AMA resolution is moving forward, I understand they've moved the resolution, hearing it in their house of delegates to November. So, we won't know what the outcome of the AMA resolution will be until then. But it does seem things are going forward, at least, up until the point where if they've just voted it down. So, given that it's going to go forward for the time being, what suggestions would you give the joint task force and our podiatric leadership on the process, knowing that it's currently moving forward?
Bryan Markinson: So, again, since I've been concentrating mostly on the fact that I am a little bit hesitant to trust the AOFAS portion of this, I believe that they should be forced to reconcile this dichotomy between some of their members who are wonderfully cooperative and the other part of their members who are blatantly toxic to podiatry. And, we don't even know what the membership of the AOFAS feels about this task force or do we?
Jarrod Shapiro: I have not personally heard of any survey of the AOFAS.
Bryan Markinson: Right, right. So, we don't even know if it's dead-on arrival. They have to be more forthcoming about what their own members are telling podiatrist that it's the policy not to teach or be cooperative with podiatrists in the residency level or any other level. So, but I encourage the discussion, and I'm hopeful that in the end, when the orthopedic surgeons realize that the last thing they have to worry about is what is about podiatrists infringing on their turf because they have been seen to prosper very well. Remember, they graduate medical school and residency with all the people that are going to feed them patients. We graduate with all the people that are going to be competing with us. So, that they don't really have to worry about us encroaching on what they do. And even if you look at industry, all the implant companies, they treat podiatrists and orthopedic surgeons equally. There have been some stumbling blocks in the past that orthopedic surgeons have said that if you include podiatrists on these panels of innovation, we won't participate. But that's far and few between, okay? I think there's certainly room as younger orthopedic surgeons train side by side with podiatrists. That's always been a positive as far as I could see. I just feel that these vulnerabilities are strong. Again, I think we train people to be the foot specialists par excellence. But I don't want podiatry portraying itself wrongly as almost equal. We're different. I don't like the pressure of being equal the same because it's not. But that's the way we're portraying it, just a few steps and we are equal. I'm very hesitant to be found out that that is not the case.
Jarrod Shapiro: Yeah, I think that you're right that having a discussion, as you suggested, is a very healthy way to go. I have found in my experience that when somebody doesn't know who we are as a profession, what our training is, what our knowledge and skills are that really does create a very difficult situation. I've had that experience in hospitals and insurance plans. And when I have reached out to educate them, it improves the environment. I can see at the very least that one strong outcome of this would be that the rest of the medical community has a better feel for what podiatrists can do. If no other outcome occurs. At least they'll understand us a little bit better.
Bryan Markinson: Absolutely.
Jarrod Shapiro: Yeah.
Bryan Markinson: I agree with that.
Jarrod Shapiro: So, I like to close out today's conversation by giving you the last word. Is there anything you would feel like you want to mention or maybe something we didn't discuss so far?
Bryan Markinson: So, the last thing that I'll say is that I have been basically a primary care podiatrist for my entire career. I have a clinical interest, I don't consider myself an expert, I have a clinical focus in skin and nail diseases. And I never got the type of surgical training that would enable me to get into a large degree of podiatric surgery, okay? I would like to see more emphasis not less on primary care podiatry. I feel that that is our true identity and calling. And I honestly feel that we need 20% of our graduates becoming foot and ankle surgeons. And I think the rest of us totally supported by the federal manpower study should be soaking up and basking in the sunlight of a known deficiency that we need triple the amount of podiatrists going forward. And you can't be all things to all people, okay? If you're going to be an ankle replacement surgeon and you're going to do… sorry about that, if you're going to be an ankle replacement surgeon, and you're going to do three of those a year, you are not an ankle replacement surgeon, okay? We need 20% of us becoming these high-powered foot and ankle surgeons to have the primary care podiatrists could have confidence in referring patients to and I need to feel that podiatry and the identity of podiatry is much stronger on the primary care side. And I think if that happens, we could potentially show primary lower extremity care and primary low extremity medicine as a legitimate subspecialty of what a USMLE competently trained student can aspire to practice.
Jarrod Shapiro: Beautifully said, I think that is such an important topic and I think we could probably have another hour's worth of conversation just on that exact topic. Dr Bryan Markinson, thank you so much for taking your time and your honest responses to this as well as your national leadership. Really, thank you very much for all of that.
Bryan Markinson: Thank you, Jarrod, and thanks for your good work. I really appreciate it.
Jarrod Shapiro, DPM
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