ACPS

Part 2: The history of podiatric surgery in Australia

In the first part of this series which we ran in April 2021, we provided a brief outline of how the Australasian College of Podiatric Surgeons (ACPSV ), aided by our American colleagues, fostered the beginnings of podiatric surgery in Australia. This process of genesis occurred over 15 years, from 1975 to 1990. In this instalment we describe how podiatric surgery developed over the next 20 years. It was a period of great change!

Fellows instruct the next generation of ACPS registrars in foot surgery at a fresh frozen cadaver workshop in Sydney in 2005.

The use of medicines in the peri-operative setting is fundamental. Until the 1980s, podiatry in Australia was not broadly accepted as a profession with the training, expertise and need to access such medicines.

Surgical practice needs pharmaceuticals!

The most significant reform was driven by South Australia. A meeting with the Minister for Health Dr John Cornwell in 1988 resulted in a sub-committee to examine a submission from the then-called ‘APodA South Australia’ for scheduled medicines for podiatrists. The sub-committee included Dr Malcolm Collings, Dr Max Dunstone, Lloyd Davies (pharmacist), Professor Lloyd Sansom, and podiatric surgeons, Drs John Pickering, Hans Jordan and Bill Kutcher.

Prof Sansom pragmatically supported the view that podiatrists should be allowed to prescribe medicines as part of peri-operative management. From this point onwards, podiatric surgeons in South Australia could prescribe oral preparations of medicines, including antimicrobials, non-steroidal anti-inflammatories and codeine.

Incidentally, this was a landmark event that formed the foundation to build the medical and pharmacologic training basis that ultimately resulted in national scheduled medicines access for the podiatry profession from 2009 onwards across Australia.

Overseas comparisons as the catalyst

Like in medicine and dentistry, the use of prescription medicine within the scope of general and surgical podiatric practice is core and it is reflected in the podiatry profession globally, as evidenced in the United States (USA), England, Canada and Spain. The next important step back in the late 1980s and early 90s was to align podiatric prescribing in Australia with these countries would be regulatory inertia to facilitate scope appropriate and broad prescribing. That is to say, access to an open formulary.

The new wave

Around the start of the 1990s, a group of young podiatrists from Western Australia, South Australia and Victoria began the process of training and examination under structured training programs. The desire to be at the cutting edge of foot and ankle surgery meant ongoing trips to the USA for this new wave of podiatric surgeons.

At the time, the Podiatry Institute (PI) in Atlanta was one of the leading education programs for podiatric surgery in the USA. This next wave of podiatric surgeons was supported in their education by the generosity of podiatric foot and ankle surgeons at PI, such as Drs Dalton McGlamry, John Ruch and Alan Banks. This initiative was driven by a young ACPS member Dr Rob Hermann, who was seeking more advanced surgical training, particularly in reconstructive rearfoot and ankle surgery.

International bonds are forged

An informal dialogue was established between the PI and ACPS. Dr Hermann flew to Atlanta to complete the first mini residency alongside residents of PI. He was warmly welcomed by residents Drs Dave Calderella, Tom Chang, Luke Cicchenelli and Craig Camasta. Such rotations became a compulsory component of the ACPS training program.

An invaluable fraternal relationship between the PI faculty and ACPS fellows was forged during these years, and still exists today. This relationship also included rotations for PI graduates in Australia. The PI graduates conducted extended surgical tutelage in Australia, which resulted in improving surgical practice of Australian podiatric surgeons to PI standards. The selfless efforts of Drs Luke Cicchinelli and Craig Camasta were particularly significant.

Rearfoot surgery is practiced in the Podiatry Institute cadaver lab during the first USA mini residency by an Australian podiatric surgeon, Dr Robert Hermann in 1990. From left to right: Dr Craig Camasta DPM, Dr Robert Hermann and Dr Luke Cicchinelli DPM.

Collaborative outreach

During the 1990s Australian podiatric surgeons were also invited to join medical missions in the Philippines via collaboration with a USA based podiatric surgical mission facilitated by Dr Rob Hermann.

Following a trip to Vietnam in 1995, Dr Mark Gilheany, together with podiatric surgeon Dr Paul Wade and Australian podiatrist Sinead O’Donovan developed an Australian led podiatric medical/surgical mission to Vietnam in 1996. ACPS members continued to be involved in – and lead – such aid missions for over 20 years. In the process, these missions welcomed a range of health care practitioners from around the world and raised significant financial and local resource capacity. Dr Paul Wade continues in this role to this day.

The birth of the ‘Fellowship’ & curriculum development

During the early 1990s the training program had also evolved and in December 1992 the qualification of ‘Fellowship’ was awarded to successful trainees. This new group included Drs Mark Gilheany, Andrew Kingsford, Andrew van Essen, Robert Hermann, Mario Horta and Nick Marino.

The remainder of the 1990s was characterised by curriculum development, modelled on the PI three-year full time residency program and linked to post graduate university education. Dr Alan Banks, as PI residency director at the time, shared the educational framework, teaching and assessment protocols with Dr Mark Gilheany who was leading the drive to facilitate Australian training posts.

A change in nomenclature

By the late 1990s, the Australasian College of Surgical Podiatrists (ACSP) had evolved the education, training, and scope of practice of surgical podiatrists, that a change in nomenclature was required.

In 1998 re-incorporation under Corporations Law in Victoria as the Australasian College of Podiatric Surgeons was undertaken. The terms ‘podiatric surgery’ and ‘podiatric surgeon’ became the norm.

From this point forward, trainee surgeons were titled ‘Registrars’.

The 21st Century

After serving as a council member and driving a broad reform agenda. Dr Mark Gilheany was elected as ACPS president in 2002. He gave the ACPS 10 years of continuous leadership (and remains active on subcommittees and in his role as Education Chair).

Dr Gilheany also led the ACPS push to achieve the first federal government recognition of podiatric surgeons. The process was initiated by Dr Gilheany in 1996 and successfully achieved in 2004. This achievement meant podiatric surgeons were recognized under Federal legislation, joining medical practitioners, dental practitioners and midwives as recognised providers of hospital care under the Health Insurance and Health Acts.

During this period, many initiatives to improve the professionalism of the ACPS and education of podiatric surgeons were likewise conceived, designed and implemented.

Dr Gilheany also oversaw the building blocks required for independent accreditation, specialist registration and ongoing development of the training curriculum. He fought to have the legislation in NSW upgraded to enable podiatric surgeons to operate in hospitals. Throughout this period Dr Gilheany steadfastly endured significant opposition and public rebuff from various sectors.

ACPS Fellows during early surgical mission to Philippines in 1995. From left to right: Dr Andrew van Essen, Dr Paul Wade, Margaret Carty (background), Sinead O’Donovan (Foreground), Dr Mark Gilheany, Dr Robert Hermann and Dr Andrew Kingsford. Son of the local Mayor (foreground), province of Laguna.

Stronger global connections

This timeframe also saw the beginning of international education rotations within the United Kingdom (UK) in the NHS. Formalised rotations for ACPS registrars in the USA were developed and these remain embedded in the ACPS training program requirements.

Dr Gilheany was tireless in his efforts to forge a relationship with the American College of Foot and Ankle Surgeons (ACFAS). The quality of the relationship between the ACPS and ACFAS resulted in the forming of an international affiliation status within ACFAS. These professional links and training rotations provided a platform for ongoing collaboration and recognition between the ACPS and our international peers in podiatry.

The quality of graduates of the ACPS program is recognised internationally. ACPS Fellow, Dr Matthew Cichero has been practicing podiatric surgery, including lower limb salvage and reconstruction, within Great Western Hospitals NHS Foundation Trust over the past 10 years.

A current update

Back home the ACPS is now involved in stakeholder consultations along with providers from other surgical specialties. There is national recognition of podiatric surgeons as accredited surgical specialists under National Law 2010.

As with all evolutionary processes, the gains of today are a culmination of the years of vision and nurturing demonstrated by a group of committed individuals.

National specialist recognition and ongoing reform relies heavily on a national training program and a professional body such as the ACPS. The strategies put in place during the 20 years from 1990 to 2010 resulted in large strides in recognition of podiatric surgery and the successful development and evolution of the ACPS education and training program.

ACPS Fellowship training requires diverse medical and surgical rotations, interstate foot and ankle surgical rotations and rotations in the NHS in the UK, and within residency programs in the USA. The logbook of a registrar at completion of ACPS Fellowship training is extensive. ACPS graduates log direct involvement in the peri-operative and operative management of greater than 2500 hospital-based procedures across all subspecialties of foot and ankle surgery. The training includes reconstructive, trauma and limb salvage. Research and publication are a requisite for all aspiring podiatric surgeons.

Dual recognised UK and Australian podiatric surgeon and ACPS Fellow, Dr. Matthew Cichero, performs limb salvage surgery at the Great Western Hospital, in Swindon and Marlborough NHS Trust.

The future

Of the many challenges facing podiatric surgery in Australia, perhaps the most pressing is normalisation. This term refers to the integration of podiatric surgery within the Australian public health system. Normalisation of podiatric surgery includes access to Medicare rebates for services provided by accredited podiatric surgeons and provision of services to the public healthcare system.

One of the main justifications for normalisation of podiatric surgery is the publicly available audit data demonstrating safe and effective practice (https://www.acps.edu.au/publications). Annual and national peer review of ACPS member surgical outcomes have repeatedly demonstrated that podiatric surgeons provide highly efficient, cost effective and safe surgical care to the Australian public. This work is largely due to the work of Drs Rob Hermann, Valeri Dobie and Andrew Shox in the establishment of the ACPS National Audit and Peer Review program.

A shared challenge

The efforts of the ACPS have been world-leading in many domains. Yet unlike our international peers, podiatric surgeons are not fully integrated into Australian healthcare. Comprehensive integration into healthcare to match the level of integration of our international colleagues is an important policy direction for the ACPS.

Additionally, the accreditation standards for podiatric surgery represent a globally unique process and the ACPS is constantly reviewing its education and training program to ensure success in this endeavour, including ongoing engagement with universities, with the aim to deliver a truly collaborative podiatric surgery training program. We look forward with much interest and excitement to see how the future of podiatric surgery will continue to unfold.