Ep.28 Surgical Podiatry and Podiatric Challenges: Mark Gilheany

Embark on an insightful journey with Podiatric Surgeon Mark Gilheany and myself, Jason Agosta, as we peel back the layers of what it takes to make it in the high-stakes world of professional tennis, as well as the intricate field of podiatry. Mark, whose dual roles as a medical expert and the parent of an up-and-coming tennis star offer a rare dual perspective, provides an in-depth look into the solitary battles and mental fortitude required of athletes at the pinnacle of the sport. Together, we navigate the evolution of podiatric surgery, underscoring the significance of ongoing education, the rigors of specialization, and the hurdles of funding and advocacy that shape the profession.

Feel the pulse of a profession as we dissect the challenges and triumphs within podiatry, from the diversity of cases in country practice to the complex pathway of becoming a podiatric surgeon. We tackle the controversies and necessity for unity within the field, emphasizing how collective efforts are crucial in overcoming policy barriers for the sake of patient care. Our dialogue extends into the practicalities of career progression, both on the tennis court and in the healthcare arena, highlighting the adaptability and mentorship essential for success and the professional responsibilities that come with high-pressure roles.

Concluding with a strategic approach, Mark and I address the need for collaboration to navigate the hurdles podiatry faces. By examining the relationship between podiatric and orthopedic surgery, we shed light on the potential for synergistic patient care and the importance of a regulated approach to surgical practice. We also consider the broader implications of media misrepresentation and public policy on the profession. Join us for a conversation that promises to enrich your understanding of what it means to strive for excellence, whether that's by serving a tennis ball or saving a patient's mobility.

Transcript

Speaker 1: 0:07

Welcome back to Simply the Best Paddier Tree, where we want to pass on simple tips to enhance your best paddier tree practice.

Speaker 1: 0:15

I'm Jason Agosta and I hope you've all had a great break and enjoying a sort of summer so far. I had a lengthy chat with podiatric surgeon Mark Gilhaney recently, which encompassed talking about pro tennis due to having his daughter being an up and coming player, his background as a podiatrist and the training and accreditation of podiatric surgeons, which, as we all know, following the recent incredibly poor and lightweight media regarding podiatric surgery, is super important to pass on and clarify. We also discussed the development and lack of, or loss of, certain skills within podiatry, in that Mark, being an educator, has a depth of understanding of what it takes to be a good podiatrist and a good surgical podiatrist. Mark has been one of those people who has done so much for podiatry behind the scenes and I hope you enjoy listening to Mark Gilhaney starting with the development of pro tennis players. Thanks for tuning in. That's a good way to lead into it talking about the tennis, so go on. You're talking about being at college in the States as a tennis player.

Speaker 2: 1:34

Yeah, so a lot of the parents, or a lot of families, if you put an athlete onto the pro tour in a sport that requires so much travel and it's a gladiatorial, individual sport. It's not a team-based sport. It's actually worse than boxing, because boxing is probably the closest. At least. With boxing you get to the corner every couple of minutes and somebody gives you a cuddle or a slap around the cheeks. And I never played tennis so I didn't know anything about it. But I'm quite amazed by it. I'm quite amazed by how gladiatorial it is and how you have to be a really well-tuned athlete and you have to be psychologically just on ball, and if you're not right on ball you're gone. And so if you're all trying to transition and go on to a pro tour, that's a pretty big ask, exactly. So a lot of tennis players spend a lot of time sleeping on park benches and airports and wherever else they can, just to save a few dollars.

Speaker 1: 2:48

It's a common thing with the sports. I talk about this a lot on my other show, the Champion Within, about how you handle yourself, and one of the things we always talk about is composure and then being able to turn on that competitive animal as soon as you step on the white line. And one thing about tennis is the people who have been really, really good, and I've spent a lot of time with some amazing people over. You probably know that I was helping Australia, and for 17 years, but some of the people who were the best at it, they were amazing with being so composed. Then, as soon as they turn around on the white line, I'm going to knock your block off, yeah, yeah. And when you met these people and hung out with them a little bit, they were just so beautifully together and calm, saving energy, but at the same time, just the competitive animal was extraordinary.

Speaker 2: 3:45

The engine room. In behind the head there's an outward calm, but the engine room's already going yeah.

Speaker 2: 3:52

You know, once they get to, once they get to tournament day, you know the routines, the rituals. They start really the night before a match and at any point you see them. That's why they say things like particularly the young ones. You know, you see the young ones and they'll lose a match and you don't even bother trying to talk to them for six or eight hours. Yeah, yeah, yeah, you've got to learn that. You know they have to deal with the things they have to do in their own head to be able to move forward, and if they don't have space to do that, there's trouble.

Speaker 1: 4:22

Yeah.

Speaker 2: 4:23

But you've also got. You know. I mean you've seen this. I mean you've read all the psych books. I'm sure the problem that you have is that the real champions have got that psych under control, total, Total and you can be technically as good as any of them. But if you haven't got that psych ready to roll and if you haven't got that desire for absolute perfection and to push and, push and push just, you won't get there saying anything that you wouldn't know. But you know, if you get to be decent on an international stage, that's 150% more accolade. If you get to that kind of real top 10 type of lead stuff, that's, that's, that's, that's rare, as you know. Ex athlete, you know this stuff.

Speaker 2: 5:22

But there's somebody who never played these sort of sport. The congratulation I used to give was I am so proud that you can walk into onto a court, stand across the net from one other person and start hitting balls back and forward on your own. And you can do that as an eight year old, a 10 year old, 12 year old, and be competitive. And you haven't got mum and dad, you know around you. You haven't got a team around you, you know you're, you're prepared to go out there back yourself. Win, lose, draw doesn't matter. The very fact that you've walked out means to me you're a winner.

Speaker 1: 6:06

Yeah, it's just having a good crack, isn't it? Yeah? Yeah, I should say we got onto this chat talking about your daughter, who is on the tennis circuit, but also going to college in the States, and one thing about going to the college in the States, as we were just talking about, was there's incredible support, but the depth of competition is extraordinary as well, and that is an unbelievable breeding ground. We see it with the athletics.

Speaker 2: 6:35

You'll see it with the athletics, but you see it with basketball, you'll see it with this. Yeah, I'm not. I'm not an athlete or tennis player. I've just been invested in that because of kids for a long time. So you know, I can. You know, my anecdotal experience is that 10 years ago people were saying why would you go to college? Yeah, exactly, why would you do that? Yeah, you know, tennis.

Speaker 2: 6:59

Australia was not interested in those sort of pathways. The pathway was you know, I know you, you, you, as a 13 year old, you have to be the best in the country and then we'll support you and you won't be going to college. You're just going to. You know, we're just going to look after you here and we're going to throw a lot of time and money and effort at you and you know you might break, you might, you know, when you're 17 or 18, or you might walk away from it because you found other distractions in life. You're still going to back you into that. That's it, and I think that's been across the board. Whereas in the US they've taken this view that people develop at different times physically, mentally. People have different family structures, they have different financial structures. So you can't, I don't think and again, you're the ex athlete, you know I don't think you can create a one size fits all.

Speaker 1: 7:52

No, exactly, but it's exactly the same history with the track and field and, as you know, I've been involved athletics Australia a long time and I can tell you I've sat in many meetings where people have been, oh my God, you know you've got over 140 athletes in the States at colleges and there was a sense that we were losing them. But now there's like all these years later and over a decade later, as you mentioned, there is this acceptance that this is a great thing for these up and comers to be part of over there because of the support and the depth of competition.

Speaker 2: 8:27

You create more successful people. For sure, we know that Great, great kids that have worked their hearts out through the 12s, the 16s, the 18s. They get all this kind of support from various groups, told they're the best in the world, they're going to be fantastic. They dropped their education because they put everything into their sport. Then they enter the big bad world of 18, 19 year olds when you've got all the distractions. But then you kind of what am I going to do? I'm going to become a pro.

Speaker 2: 9:04

So then you get on a plane and you go to Europe or somewhere and you get belted because you suddenly realize it is as important and successful as you were in this little island of ours. I know it's a big island, but there's bugger all people on this island. As soon as you get somewhere like Europe or the US, you kind of look oh right, I'm not as good as I thought, I was Number one. I've got a couple of choices here. I work harder. How do I work harder with no money? I'm 19. Now I'm 20.

Speaker 2: 9:34

My parents have run out of money. They put all their money into me when I was a 14 year old, 15 year old, 16 year old. My parents are now saying well, what do we do Then? They haven't done enough academically so they can't go into a university program. I've seen some of them do various things and they kind of float. They float, they tease into the sport, they go back and they play the odd tournament. They float around until they're in the mid to late 20s. Then they walk away with frustration. Then the sport loses them because they end up disgruntled.

Speaker 1: 10:09

That's one of the things we've been talking about a lot, as I said on Mother Show the champion, about so many people going into activities unskilled and coming out unskilled, the best ones are the ones who are well rounded. Yes, got a family, you know Link still going to college, educated, trained, the house down. They're the best.

Speaker 2: 10:30

I think so. I don't for one moment take anything away from the exceptions. You're Cocoa Goffs, and there's various people that come along and they're once in a generational kind of you know. They can walk onto a court when they're 16 and kill anybody in everybody in the country and in the world. That's fantastic. But the majority, but the dreams of the majority, are not satisfied by the success of one. Yeah, exactly.

Speaker 1: 11:00

And that's one of the things I think is very poorly coached is that if you look at success, there is so much to learn and in the you know, in the tennis circles, if you look at some of the best people, they are so grounded and so well rounded and people are not smart enough to look at that and think, okay, I need to, I need to sort of model myself on, you know, a river keener or a Charapova or someone. I need to model themselves on that successful person and pick apart the traits that have got them there.

Speaker 2: 11:33

Over the journey and this is because you know, my oldest has also gone through this and has gone through American College system. So so we've been doing this for quite a long time and over that journey we've got to know quite a few professional players and they've during the Australian Open. They've stable fuss and you know our house is a bit of an open house to people. We meet up with some of these people around the world and different events and one of the guys that is most grounded that we know is it really fits what you were just saying because he happened to just go and play a tournament that got him noticed by a coach and ended up at a college in the US, Did his college degree so then went on to the pro tour, started playing minor events with under the pro tour. I first met him when he was playing qualifying for singles at the Australian Open. He was staying with us at the time to save money. He is now a double specialist. He's been in top 10 doubles in the world for a long time Now, married with a couple of kids.

Speaker 2: 12:42

Where he can, he travels with his kids. He plays all the grand slams. He's the most balanced, reasonable person you could come across. He loves what he does, but he basically just let talk, sits down. He's now become one of these people, I think, where a lot of the younger players go to for advice what to do with their finances, what to do with this, what to do with that. You've got to understand early on that this is just a job for us. Every six months, you have to sit down and you've got to do your spreadsheet. What sort of money have we made in the business? Yeah, yeah, yeah, In the last six months or so? Yeah, Do I have enough money to justify continuing to do what I'm going to do? How am I going to balance this with my family life? How am I going to continue to manage my injuries? And it's not about for people like him. It's not about he knows he's not going to win Grand Slam singles or anything like that. He just loves the life.

Speaker 1: 13:38

Yeah.

Speaker 2: 13:39

But for him it's about. My occupation is as a professional sports person, and I treat it like a job. Sure, it's just that simple and a lot of. When you're 17, 18, 19, you see the glory lights. You don't think of it as an occupation or a job.

Speaker 1: 13:56

There's a lot of players on tour. They will openly tell you that it's nowhere near as glamorous as it's made out to be.

Speaker 2: 14:04

Because they're living out of a suitcase, living in shitty hotels. They get to the Grand Slams and it's all a lot nicer.

Speaker 1: 14:12

But I can't remember when. But I know you taught me at some stage which we did briefly chat about.

Speaker 2: 14:17

I'd only graduated a relatively short period before I was teaching you from. I was working in a practice in the country that I'd set up, which was a great place to be great practice.

Speaker 1: 14:28

That was your Turalgan workplace, wasn't it? It was.

Speaker 2: 14:31

Yeah, okay, but that was I worked when I first graduated there. It wasn't really any work or jobs per se, it was basically a new profession in this country. I actually thought, oh, I wouldn't mind trying this out to see where I can go with it. I didn't know if I'd stay in the profession or not.

Speaker 1: 14:49

Why do you say that? I mean, was there some fascination at the start of it that got you into it, or was just more?

Speaker 2: 14:55

I was more just not 100% sure what I wanted to do with my life.

Speaker 2: 14:59

Like everybody who's young, I mean you've got lots of options, I guess, ahead of you. But I just was, I was just experimenting, I was looking at it. I worked in a couple of hospitals part-time. I worked at the Alfred in what was the first sort of setting up a diabetic unit. I worked in diabetic unit in another hospital which is now no longer there. It was at Queen Victoria Hospital which was knocked down. I worked in community health. I worked in an Aboriginal health center which was pretty interesting. I just felt that it was a country kid and I knew that there was an opportunity to work in the country. So I set up a practice in the country.

Speaker 1: 15:41

But did you develop some fascination then after a short period of time, either through study or through the early years of work?

Speaker 2: 15:49

No, the early years of work, I think, in the country, because what I discovered was that this was an anatomic area that nobody was interested in. There were no physiotherapists working in Fort Nangall. It didn't exist. There was no such thing as an exercise physiologist, there was no such thing as a sports physician. There were orthopedists, of course, but there was one orthopedist in Victoria who worked on feet. What I discovered pretty quickly, and particularly in a country practice, was that I had a massive diversity of pathology age coming through the door. So I was being faced with pediatric cases of mild clubfoot, through to metaductis, through to calcaneovalgus and all milder problems. I was being faced with fractures. I was being faced with chronic, chronic, chronic pain syndromes that there was nobody offering any solutions for, so ulcerating lesions on a little toe, and all they needed was a minor procedure to fix the toe, but there was nobody doing it. Our profession was in its complete infancy and it was just this big box of clinical goodies.

Speaker 1: 17:13

Yeah yeah, yeah, I know exactly what you mean, exactly.

Speaker 2: 17:17

Which was actually really quite fascinating. And so then I started to do things like even biomechanics. Oddly enough, the whole concept of prescribing orthotics from a biomechanical perspective was completely new, completely new. So when I sat in Terelogan I'd done some work with some American guys and I started to look at all this biomechanic stuff and full orthoses and making these. So there was hands-on skills which I really liked. There was lots, lots going on, lots and lots going on, and then there were. So then I just dug deeper. I thought well, this is really fascinating. I've got all these people that want help. There's no one else offering them help.

Speaker 2: 18:00

Now, perversely, despite all the health care practitioners we have available now in the regions, the same thing exists. So the only difference is that we're becoming a little bit more siloed. We're supposed to be more into collaborative care and helping one another in management of patients, but I think what's actually happening is that we're getting confused as to who they should be seeing where. There is no confusion. When I was young, if you had a foot or ankle problem, the podiatrist looked after it, end of story. It didn't matter whether it was rehab, it didn't matter whether it was serial casting. It didn't matter whether it was splint therapy, it didn't matter whether it was surgery, it didn't matter whether whatever it was, it didn't matter. That was your domain. I don't think that's really the case now.

Speaker 1: 18:48

Yeah, no, I think you're right too. You've just reminded me. Actually, one of the things that got me into it, as I've said on the show before, is my running background, and I knew that there was nobody focusing on being a podiatrist and focusing on athletics. I knew there was no one around, so I went to the States and spent time with Steve Sabotnick, who you remember that name, classic textbooks and that. And then I must go back and have a look at the textbooks, because at the time that was cutting edge though Absolutely cutting edge.

Speaker 2: 19:21

Well, they were, and that's where the running foot doctor and all the stuff out of California, the profession in the States, was gangbusters. That's also evolved and changed because I go back to the States quite a bit Completely hasn't it.

Speaker 2: 19:35

It's really changed a lot as well. But this was a really fascinating area of the body. There were no limitations on what I could do. It had great potential to provide clinical benefit to people and the only sad thing I had back then was that there was seem to be limited opportunities in the public health system but people with our skill sets, so you were forced into going into a private practice setting.

Speaker 1: 19:59

So if we go back to like having a fascination, obviously surgery came along your pathway at some stage. So how long have you been in practicing surgery for?

Speaker 2: 20:10

This year will be 30 years, yeah okay, well, I can say it's qualified.

Speaker 1: 20:14

Well, in my time both yourself and Andrew Kingsford were at the cutting edge of it and really quite groundbreaking. Obviously, that passion and that development of the sort of podiatric surgery aspect of things has been a massive fascination for you and a driver as to why you're still going now, yep. So what fascinated you with?

Speaker 2: 20:38

surgery.

Speaker 2: 20:38

At its core there were probably two or three things.

Speaker 2: 20:43

One was I'd been looking after people conservatively, so that the classic example is that fifth digit where terrible pain, no one can fix it, and you were able, through a surgical procedure, to provide relief reliably, safely, with the right conditions in mind.

Speaker 2: 21:11

And it's also the manual skills that I found fascinating. Yeah, and I think that pods because of the way that they were taught back then. So you were taught to use scalpels, you were taught to use hand instrumentation like a dentist as soon as you walked in the door. You were taught to manufacture orthotics, all the way from taking a plaster cast through to the intricate grinding process where you were having to use fine motor skills and clinical judgment and bring together the clinical judgment and the fine motor skills. So, by its very very nature, I therefore think podiatrists with a good clinical set naturally will make a good surgeon for the thing, because there's a few preconditions. One is that you have to be well-trained. Two is you have to be, you have to really develop your medicine. You've got to develop a whole range of other intellectual elements as well, and so therefore, surgery sort of just gradually grew and there was no one doing it.

Speaker 2: 22:19

There was just no one doing it. So I know that now, where there's a lot of people interested in foot and ankle surgery, that's evolved. I don't think that it takes away from the reality that a pod who's worked in a general care environment with a continuum of quality, quality, conservative care, who then has the training and the skill set to apply a surgical procedure and then also has that intimate knowledge of the patient to be able to provide appropriate directed follow up, I don't think he can beat it. Yeah, sure, I really don't. And surgery, so I just got fascinated by it. I'll be fascinated by it. I'll be fascinated by education as well.

Speaker 2: 23:00

So for me, I started teaching, as you know, very soon after I graduated and I still teach. I did a masters in education, I still teach. I try to innovate with procedural work. I love to see people excel after they've been exposed to new knowledge. I love to see people you know explore and take things further. It doesn't have to be surgery, you know. I'd say things like I designed for the college. I designed a basic surgical introductory type course a few years ago and one of the reasons I did that was that if we can introduce people to what would have brought a diversity of skill sets. It can give them an insight into a career path that maybe they may be interested in. It doesn't mean they have to do it. You're always going to be picking up new skill sets that you can bring back to your general practice.

Speaker 1: 23:54

So what does that involve then, If I wanted to go into that introductory course? What's that involve?

Speaker 2: 23:59

Oh, you just contact the college and there's some online modules and then some workshops within an office and a bit of operating theatre observation. Nowadays it probably also. I think the other thing is schedule medicines. It's to me after I was trained in surgery and this was something I didn't realise prior, but I realised that at a disadvantage, our patients were at a disadvantage because regulation in Australia didn't really hadn't really caught up with whom, what we were, and funding hadn't recognised whom what we are Funding. For what exactly? Funding for clinical services and for either the private health insurance model or public health or call it Medicare, whatever you want to call it. There wasn't support for the funding else. That's a significant barrier. It's still a significant barrier.

Speaker 2: 24:58

I'll diverge. I was going to say it's still. That's how it is now, isn't it? It's crazy. So even now, the private health insurance rebates for a consultation with yourself are probably the same as they were 20 years ago. No, it's terrible. That's largely or the health insurance industry will tell you that's because you're not big enough fish. People aren't looking for your services. Okay, now, that's based on the consumer survey stuff. So when you talk to them they say well, you know, people are really interested in podiatric services, you know, okay, so we can't justify it, maybe? Well, if that's the case, the profession is at fault, because the profession needs to be collecting the right sort of data and putting together the right sort of proposals to convince the health insurance industry that you are worth much more than they think. You are the podiatric surgery.

Speaker 1: 25:54

Has there been much lobbying? Has this been a consistent sort of challenge? Like well, it has any acceptance from the health insurers or Medicare.

Speaker 2: 26:04

It has. Andrew and I hit the wall in the mid 90s where we were building up a reputation we're doing some great work. Then the health insurance companies turned around and said oh no, we're not going to pay for any of the hospital admissions or anything you're doing at all. Yeah, we're like. Well, hang on why? Yeah, we're licensed to do this. You know, surely that doesn't make sense.

Speaker 2: 26:26

So I then spent the next 10 years working with lobbying, generating data, writing articles, talking to the Department of Health in Canberra, talking to politicians, and the first part of that journey was discovering what we needed to do. So I ended up with a meeting with the, who is, at that time, the highest level of the Department of Health in Canberra, looked at me and said well, you know who are you, what are you? Who regulates you? How are you accredited? Bang, bang, bang, bang bang. Now we had answers for those questions, but I knew deep down that they weren't necessarily the best answers in the world. So I went away from that meeting and I wrote out a bit of a personal plan, and that personal plan was okay.

Speaker 2: 27:18

We do need to be more regulated. We do need more legislative recognition. We do need to work on improving our training programs. Sure, and we do need to be getting training programs accredited. Now, remember, back in the 1990s, the first Medical Council accreditation of Specialist Medical Colleges didn't occur until the around about 2002. So not so. Podiatry and podiatric surgery was not unique in that.

Speaker 1: 27:48

Yeah.

Speaker 2: 27:49

The only issue was that medicine had. Medicare was created essentially for medicine, at a time and era in Australian policy history where other professions weren't really doing terribly much, which is a key understanding. Okay, and then Medicare has just kind of evolved over the 20 or 30 years. And right now the government's now saying, yeah, we do realize that Medicare is actually a very old car that probably needs to be completely reinvented. And you know, we need an electric version of the healthcare system. Yeah, the problem is it is so, so entrenched into what it was back then it's pretty hard to change it. Sure, yeah, so so I went away. I went to the states. We talked to some of the best programs in the states. They generously provided the whole of their curriculum. We rebuilt our training program. We based it on the world's best. You know, I wrote the one of the we're training programs. I went through a training program but after I basically said, look, that's a good base, what do we need now to do to make it better? Yeah, sure, so.

Speaker 1: 28:55

I this is to implement back here in Australia. Yeah, yeah, yeah.

Speaker 2: 28:58

Yeah, yeah, yeah, this was. This was back in the late 1990s, yeah, early 2000. Reinvented, or the whole program included more specific rotations to places like America. It did a whole bunch of curriculum design, essentially to bring the training program up to a point where we could be proud of it, that we knew that it would stand up to external accreditation. That was step one. Step two was getting is the best form of accreditation we could get at that point.

Speaker 1: 29:35

Yeah.

Speaker 2: 29:36

You know and remember we're not dealing. People forget this sort of stuff and make grand comments. But in, say, 2000,. Specialty colleges in medicine, as I've just said, they weren't accredited. Yeah, there was no national accreditation of any podiatry program. That didn't occur until 2000 and 2010 or 11, with national registration. I was on the national board when that, when that all went through. So that was a decade later again, so back around 2000,. The only way you could get accredited was through mechanisms like a pod C, so professional accreditation, which is essentially where most accreditation started for physio, for all sorts of different groups. So it was via professional accreditation. So we did that. Then we went back and went back into government and lobbied very hard and and was successful in convincing the federal legislature that that we should be changing the health act and the private health insurance act to include podiatric surgery right, which we did, and that was 2004. Big, big change.

Speaker 1: 30:43

So what happened with that? What was? What was what? That the outcome, in simple terms, like in simple terms.

Speaker 2: 30:49

In simple terms, it opened, it removed the barriers for private insurance companies paying rebates for our services and for paying hospital costs for our services.

Speaker 1: 31:01

Right, so there was some health insurer support. Yes, so what it?

Speaker 2: 31:05

did, yeah. So what it did was it put us on the same level as medical and dental practitioners Okay, for the purposes of private insurance, right in a hospital environment. Yeah, yeah. So it was a pretty major change, absolutely. Other changes you know through time with national registration.

Speaker 2: 31:26

I was involved with scheduled medicines, where there were bits of scheduled medicines authority around the country. We, when I was on the board that was part one of the projects was to combine all of that and became the skin indoor scheduled medicines program we have now, which is now 14 years old, which is crazy and that needs to be changed. It needs to be brought forward a new form of accreditation through ANSPAC at that time and then ultimately a second form of accreditation in the last few years run by opera. So so there's been all these steps that started in about 1995 and took till about a year or so ago, so that right now, for instance, the College of Pod Surgeons, its training program, just in the last six months, has gone through successfully a full accreditation, independent accreditation of the training program through opera and the pod podiatry board of Australia, and that is currently the highest level of independent accreditation you can get.

Speaker 1: 32:33

Okay and this is really important for people to know this about how the, the involvement of training and medical training and accreditation has taken such a long time, but it's. It's there though.

Speaker 2: 32:45

It is there. Yeah, it is. It is all there and there's different views on on going forward, because the biggest issue for pod surgery but I actually don't like that's always to talk about pod surgery I think the biggest issue more broadly is for podiatry. Yeah, is I go back to my roots in the country when I talked about having the whole scope of practice sorts of things. The podiatry is especially already Now every podiatrist within the next, you know, probably five years, I would virtually every podiatrist coming out of school in this country will be endorsed to prescribe medicines. That that will be the situation. So, go forward 10, 15 years. There won't be a podiatrist here that doesn't prescribe. The sophistication in terms of medicine, pharmacology that you require to be able to step up to that plate is high. Yeah, so there's no reason, depending upon your interest, if Jason and Costa says, well, look, I'm going to basically concentrate now on injection therapies for sports injuries, off you go, there's, there's no limitation really in what you may be able to do. So then the question comes in Well, what are the barriers to that? Well, the barriers to that are probably getting enough immersive training in different areas, because one of the problems you have at the moment is that podiatrists are sort of getting to work, sometimes in fairly narrow scope, for a couple of reasons. One, because they're working in corporate environments where there's large practices employing them and they want them to be working to keep KPIs and doing certain things, and the corporate environment doesn't want to take any risks and doesn't want to let people work outside of blah blah blah, whereas you and I grew up in an environment where you were in your own little business doing your own thing and you didn't have a watchdog like that, you know, around the head. If you, if you, if you decided to prescribe a slightly different type of orthotic, you've got corporatization of medicine in general and or podiatry, which I think is profit driven and not necessarily about clinical care.

Speaker 2: 34:54

I guess the point I'm trying to make is that then the next barrier is funding. Funding on two levels. I'm saying this for the whole of the pod profession, not just pod surgery. Funding for delivery of services is pretty hard to deliver your full scope of service when you've got a private insurance company only prepared to give a patient $16 for an intervention. You've got Medicare providing you an EPC arrangement, which is also financially very constraining and quite difficult and not really, I think, fit for purpose.

Speaker 2: 35:32

So how do you expand and deliver services in that type of environment? It's pretty hard Now, if you're the only person doing it, maybe, but when you've got better rebates now for people doing getting exercise physiology rebates higher than pod, you've got sports physicians, you've got all these other sorts of healthcare and I'm not wanting to be, it's not a competitive statement. It's almost like we've turned from being the people that had this whole kind of anatomic area that you could work with. It's almost like it's been stripped away, not because of our skill set, but because we're not getting funded adequately to deal with it.

Speaker 1: 36:10

Sure, so that's for all of us as practitioners. What's happened with the surgery side of things, then, and the private health insurance? They vary.

Speaker 2: 36:20

Private health insurance is still something you have to negotiate with individual funds to a large degree. In the West, the largest health fund in Western Australia that has something like 70 or 80% of the market share provides incredibly positive rebates for podiatric surgery and it's done so based on an actuarial review. They can see that there's positive outcomes and positive financial savings, so they support it very, very well. Some of the health funds on this side of the country choose not to support us at all, but by law they have to provide some basic hospital funding, but they're not supporting our services and they're not supporting anesthetic services etc. I'll come to that in a sec.

Speaker 1: 37:12

This is still a huge challenge, then. Although there's a lot of work policy-wise and with the heads in Canberra and stuff, this is still like a massive sort of barrier.

Speaker 2: 37:23

There are two issues from a funding perspective, and funding does affect capacity for clinical care. The two issues are one a thing called valid referral. So if you're a dentist, a graduate dentist or a graduate medico without any specialty training, you can refer to a physician, to a surgeon, to a broad range of diagnostic tests, blood tests and the like. Pathology is a Medicare rebate for that, but I actually doesn't have that. So if you're in a world where you're endorsed to prescribe the antibiotic to deal with the pus dripping out of the foot, if you take a swab of that pus to excuse the word pus but if you take a swab of this and you send it off to pathology, which is what the clinical guidelines say you should do, You're not going to get a rebate.

Speaker 2: 38:28

The patient's not going to get a rebate. Therefore, your decision making in the pathways of care will develop a bias that is not necessarily clinically appropriate and it makes no sense on any planetary scheme. Yeah, I get it.

Speaker 2: 38:48

You're giving people the right to prescribe medicines and we're dealing in surgery constantly. But even in general pod you're dealing with wounds, with ulcers, with spectosis, with things that require pathology, things that require more advanced imaging, and you're licensed as a physician. It's a physician, you're a physician prescribing medicines, yet the government's saying, oh well, we don't realize or don't think it's necessary to give you a valid for referral.

Speaker 1: 39:19

That's rubbish yeah.

Speaker 2: 39:21

It's rubbish. Now the whole profession should be hammering, hammering the government on this. Now the next, and we have the pod surgeons have been trying to do this, but we're a small subset of a larger profession, but our larger profession is actually still quite small. Yeah, so we've affected a lot of change, but we need the whole profession to be singing the same tune, Sure, and pushing, because there is opposition to change like this.

Speaker 1: 39:51

Well, that makes complete sense. What is that? 2,000 podiatrists in the country.

Speaker 2: 39:54

I know it's about four and a half now.

Speaker 1: 39:56

Four and a half. Sorry, yeah. How many podiatric surgeons are there? About 40. Yeah, okay, so it's a small group, though, where's small.

Speaker 2: 40:06

We need the you know no, no, 100 times yeah. But small doesn't mean.

Speaker 1: 40:11

We need the body.

Speaker 2: 40:14

You need the groundswell, you need persistence, you need people to have a strategic view and fight for it over a period of time, collectively, and.

Speaker 2: 40:23

But you have to appreciate that there are things that will work against you, things like lack of data, because governments now wanna see data that will support any changes. So, unless you can go into them with solid data as to, like you know, how many ingrown toenail operations to podiatrists in this country do every year, do we know? No, we've got no idea, no clue. So how many prescriptions to podiatrists right every year? We don't know. Yeah, okay, so you know. Until you gather that sort of data, you're behind the eight ball.

Speaker 1: 40:59

Yeah that's not the entire profession, though, as to what you're saying, Well, the entire profession.

Speaker 2: 41:04

You can't leave it up to the surgeons alone. Now, if you leave it up to the surgeons alone, there's a threat that the surgeons will disappear, and I think if you lose podiatric surgery, that would be a real shame. Yeah, absolutely. The other one is that you will hit barriers because governments don't wanna spend money. They'll avoid spending money where they can. So you have to be pretty persistent and pretty persuasive. And then the other thing is that there are always vested interests that come into this, and vested interests in our health area are not always what you might think. If you collectively say, that's probably gonna add up to I don't know 100,000 practitioners potentially yeah, so if you give podiatry direct referral rights, that's only a small group, just give it to us.

Speaker 2: 41:56

One of the concerns of government is that, well, the next thing is gonna happen is a chiro those in the physios and the already else is gonna bang on our door and they're gonna want it and we're gonna see an explosion in costs. So you have to be able to argue that, as a profession, you are a true specialist group with a true clinical need and that this is about helping the public, which is what it is about.

Speaker 2: 42:17

And then you've got other elements within musculoskeletal medicine where there are, frankly, people that don't want you to progress because you become a competitive force to them, and that we see, and we all know about that that happens.

Speaker 1: 42:29

This is the stuff that's been obviously a huge barrier, as you said, from the 90s, as far as insurances, and the funding and the involvement of training and accreditation has been a massive job for you, obviously. And is that still evolving now or is it 100%? Yeah, okay, because people will obviously more recently had questioned that, but without actually knowing the details too. So, and you have to speak to me because I'm completely ignorant as to what it takes to become a surgeon Okay, that's what I asked about the introductory course, but like, how long does it take? If I said to you today okay, I want to do surgery, what's my pathway? And, and, well, you're, what do I do?

Speaker 2: 43:13

Your pathway apply go through an application process. Do you know? I'm still currently chair of education at the Australasian College of Podiatric Surgeons, so our pathway is this you can also go through another pathway, through a university pathway in the West, but our pathway is essentially you make an application, where it's a bit like applying to any specialty college. So you would have to submit a portfolio of your academic background, your GPAs, anything you can contribute, like what's GPA Grade point averages for different programs you would have to submit for an interview. There's a whole range. We have a ranking system so we can look at anybody.

Speaker 2: 44:01

You have to have been a podiatrist. You have to have been a podiatrist for two years. That's a regulatory issue and I don't see it as an issue. It's appropriate Because if you've been working as a podiatrist for two years, you are more likely to understand how to manage foot and ankle pathology non-surgically Sure, you know, and that, as I said earlier, that helps you develop your fine motor skills for some of the fine reconstructive procedures we do. It also means that you're more connected with people on their foot health for want of a better term.

Speaker 2: 44:34

Yeah, yeah, so you have already developed some expertise in clinical management, so that's a prerequisite. That is now a board regulation that you have to have. That we call it. We say to people coming out of university now that you want to spend the first couple of years, if you're interested in specialty training, doing pre-vocation or work, if you will, where you are trying to get experience of the health sector in different aspects of an eye tree, if you like, but other parts of healthcare, and that's also important because it helps you decide whether you want to stay in healthcare.

Speaker 1: 45:14

Well, it's also important for that time to work out whether you want to do surgery too Exactly.

Speaker 2: 45:19

Which is crucial, Exactly so. Then the next bit you go through an admission process where we say, okay, look, we've got training positions available and we run a five-year cycle. So if we have, it varies. Some years we have two or three positions available, Some years we might have four or five, and that does vary a little bit. But we post that and let people know what's available and where it's available.

Speaker 1: 45:42

What does that mean, though? Like you have four or five positions available, positions Scatter, what?

Speaker 2: 45:49

To go into a training program where we've got adequate supervision, adequate locations to train, adequate resource.

Speaker 2: 45:56

Adequate resource is the important point. The other point, though, which is equally important, is that we look at workforce implications. So we look at a range of things in deciding where and when and how we can train people. Let me put it to you another way, and the reason for this is that the brutal reality is that if you do any specialty training in any field, it's going to cost you several years and it's going to cost you quite a lot of money in lost income and or cost. So a specialty training program might cost you $100,000 to $150,000 expenditure. You want to be pretty sure that, if you're going to be spending that sort of money, that there's work for you when you finish and that it's something you really want to do. Ours is run on a six-year process, okay, so once you get admitted, the curriculum design is based around a six-year timeframe. Okay, you know there's academic work, there's research work and you'll be working immersed in hospital environments, with pod surgeons also doing rotations with other physicians and the like.

Speaker 2: 47:07

Yeah, Any overseas training that's required, but up till now, we have required that you spend time in the UK and you spend time in the US. Right, and one of the reasons? There's two reasons for that. I'm a policy type person. I think that it's good for you to experience other healthcare systems around the world. You mentioned earlier that you went to see Stephen Sabotnik. Until you get out of your own comfort zone and see what other people do and how they do it, it's pretty hard for you to do your job well. Yeah, so there's value in sort of experiencing your own profession in different countries, and the other component to it is that it also provides us an opportunity to get you exposed to some of the areas of surgical practice which you may not get readily exposed to here in Australia Because we're not through the public system. For instance, at the moment it's pretty hard for you to be trained in diabetic reconstructive surgery in Australia. However, we can place you in institutions where you can get that exposure and you can understand how it works and how to do it. So there's advantages in terms of maintaining the international links, and that's built into the training program.

Speaker 2: 48:21

It's part of the credit training program is that you need to do that. Yeah, you also have to do a whole bunch of additional courses. So we have to know, for instance, you have to have your scheduled medicines done. You need to be authorized for that. You need to be authorized for using radiation a radiation license because we need you to be able to operate mini C arms and operate your theater equipment. We need you to be across advanced life support. So we require that you complete advanced life support courses, cannulation courses, general perioperative medicine yeah, Is very, very strong, and in our program you have to complete all of these courses during that journey At different stages.

Speaker 2: 49:11

So it's divided into three stages. In the first stage it's mostly about perioperative medicine, mostly about getting those courses under your belt, and those courses are often they're the same courses that medical interns are running or doing, or medical specialty training or nurse specialist training courses. We plug into what's available, Sure, so you have this broad-based kind of perioperative medicine and medical training, then specific surgical training, yeah, and then you plug your way through and, yes, it's gonna take a few years and at the end of it you have to sit in examination. And that examination for instance, we have three guys about to sit in examination in February- Okay.

Speaker 2: 49:52

Yeah, who will be examined by a mixture of people, including medical physicians, podiatric surgeons, consumer representatives. So it's what we call an exit examination and that's one of those exams where, if the physician sort of quizzes you about management of infection and DVT and blah, blah, blah, and you're not providing the right answers, automatic fail. Sorry, sure, okay, can't come back another time.

Speaker 2: 50:20

So it's quite robust oh yeah, now you know, guys, they're very, very, very, very well trained and prepared in perioperative medicine surgery. I'm really, to be honest, I'm proud of it. It's constantly up for improvement. It's constantly up for international benchmarking. I'm part of an international committee out of America, out of the American boards, and in March I'm off to some conferences in a group of worldwide surgical educators and podiatry educators. We're talking more about international benchmarking and how we can improve this. So when people start to say things like, oh no, they're not well trained, or there's all these weird commentaries made, it's generally made by people that have no knowledge of the system we're working in, or the other thing that happens, which is like journalists.

Speaker 2: 51:17

You can keep going on this, because you know I'm gonna ask you and say it, but yeah, or the other thing that happens is that they'll quote a commentary from somebody who wrote something 25 years ago Surgery looked different in 1995. Yeah, what it looks like in 2025.

Speaker 1: 51:35

But people will always cherry pick what suits them. Oh, 100% Information.

Speaker 2: 51:40

This is no different to what I do day to day.

Speaker 1: 51:41

I mean 100%. You can't help everybody. There's probably, you know, people walking around going holy shit, that was a disaster and all this stuff, and they've gone off to see another podiatrist or physio, you know, and they others turn up to your rooms or whatever. People can always point the finger, Always.

Speaker 2: 51:59

Jason I talk about. I try to be collaborative, reasonable, honest, pragmatic. I know exactly what you're talking about and you would be surprised, just just as a fun exercise, I've always kept a little note of different cases that I've seen come through my door that I'd look at and go. Jesus, this is not a good outcome and there's about 200 cases on it.

Speaker 1: 52:21

Yeah, but it's gonna be the same for all of us.

Speaker 2: 52:24

But I have the same I have. I know that we all I work day to day in a high risk activity. What surgery is recognized as a high risk activity? It just is in terms of clinical outcome. It's a very, very intricate part of the body. It's a difficult area of the body to work on. You make minor, you have a minor misjudgment and people are suffering with discomfort going forward. So what we teach is don't operate.

Speaker 2: 52:58

The first thing I talk to all of my registrars about and the thing I'm constantly saying to my patients is they'll come in for an opinion and they think that they've got some idea. I've heard about this guy. He operates. He's gonna tell me I need surgery. I think I need surgery. 98% of the time they walk out of their office the office oh no, I don't need surgery. Mark was able to tell me what I can do to avoid surgery and the next thing I'm gonna say is, unless you've got a fractured bone poking out your leg, you don't need urgent surgery. Yeah, yeah, it doesn't exist. So it's like what can we do to avoid surgery? One of the great things about my background is that I started in podiatry, spent years in conservative management, I made orthotics.

Speaker 1: 53:42

You learned what it takes to have assistance with a conservative. That's right, yeah.

Speaker 2: 53:48

And so I bring that into surgery and that's why I don't want to see, personally, I would never want to see podiatric surgery lose that grounding in podiatry. Yeah, because we're different.

Speaker 1: 54:02

I'm not an orthopedist, sure, I don't want to be an orthopedist, Tell me is the two years out of college enough before you apply, based on what we're talking about? Learning conservative measures you can take.

Speaker 2: 54:16

I think it would depend. I think it is depending upon the type of work you are doing. Yeah, sure, if you went and you were working in a GP office doing EPC clients with little academic stimulation, I suspect not. Sure, yeah, if you were working with Jason Agosta for two years, I think you'd be probably okay. Yeah, and then the next bit of it is also because, although it's a six-year program, like training in any specialty, you're spending a lot of time doing other things. So we're wanting our guys are also working in general practices and they're continuing to build their bank of experience.

Speaker 2: 54:59

Yeah, so when people have come to me and I've trained them, for instance, in scheduled medicines, and they've gone out and they've obtained their rights to prescribe various medications, they will say, oh Jesus, this is too hard, I don't want to do it. Oh, no, I do want to do it. Okay, I'll do it. Why are you so hard on me? Well, because I look for excellence. Yeah, you want to get that ticket. You got to do it well. You want to get your surgical ticket? You got to do it well. There shouldn't be shortcuts. We're playing with people's lives here.

Speaker 2: 55:28

It's not something you have a right to just get.

Speaker 2: 55:31

Now if you get a license to do this stuff fantastic, but make sure you deserve it. And what I've always found is that the people I've taught then that have ended up endorsed for, say, scheduled medicines is the example will come to me six months later and say that has completely changed my practice life. Yeah Well, that was hard. That has changed who I am as a person, who I am as a practitioner, and I'm really enjoying what I'm doing in my general practice in, but I actually know yeah, massive addition to their practice.

Speaker 1: 56:00

But what you're also talking about is doing things with integrity, yes, and the best you can like. You mentioned the word excellence, and that has to be upheld but doing everything at the most integral way you can, because this isn't easy. Well, that goes back to what I was saying at the start of this it's learning what you want to do and what your fascinations are about.

Speaker 2: 56:21

And understanding that we're at the pointy end here. Yeah, and sometimes you're having to have very difficult conversations with people where things have not gone well. Some people think that they might be made for it, but they don't know. And the only way you know and this is why I like our program is because we put people in there and it's like and at the end of the concert we'll sit down and we'll talk about what my options were, where I think I may have been able to do better, what I might have to do going forward, what we might have to do to manage it. Some people revel in that and some people go. Do you know what? I'm not sure I want that level of responsibility and I thought I did, went through all of the admission processes, went through all of the hard work, got in there and when, when you're really in there and I'm not talking about playing on the edges, I'm talking really in there- Is this person beyond that is now looking, leaving the professional together.

Speaker 2: 57:18

right, it has got a job in medical devices or something.

Speaker 1: 57:21

Yeah, well we have about it, about how there's like 50% attrition rate within five years, but what you're setting off is Learning whether someone really wants to do it, whether it's really them, which is a good thing, and that's been talking about this a lot on the show as well about especially with the following students and you grads Suss out a mentor or someone who's going to take you on for a period of time. It's so important.

Speaker 2: 57:47

I think, look with new grads intensely important and I think, if I could, if I could suggest what would be the ideal and I've said this time and time again the ideal, particularly in an environment when you grads are prescribing, I think that probably the public health system. Yeah, now, when I say that medicos do their degree and then they work in the public health system and that's where they learn to prescribe, they get watched. I think we need in term positions for podiatry graduates in this country, but they need to be in term type positions where they're you know they're. They've been rotated, rotated through different departments in the hospital. They need to be in the emergency department, they need to be in the rheumatology area, they need to be in different sections of the hospital, and that all should be used to consolidate their prescribing skills, should be used to consolidate their medical skills because they're well trained pharmacologically, medically.

Speaker 2: 58:43

Don't forget this. Accreditation authorities are not going to allow the government doesn't allow podiatrists to prescribe meditations unless they're pretty god damn comfortable. That you're underlying medicine and pharmacology is up to it I've described. Yeah, okay, I don't buy the notion that you have to have a medical degree per se to be a valid kind of practitioner in surgery and prescribing. I just don't buy it. That's not what happens in America, it's not what happens in the UK and we've got in Australia nurse practitioners and a whole range of other practitioners. It really just comes down to what does your training say? You can do the regulators happy with that. If the regulators are happy with that in, your training says you're okay, the barriers should be removed right.

Speaker 1: 59:33

so the barriers are put up by other professions? Well, they are, and that's, that's fine. That's not a classic, so the new ones to delivering babies, but the physicians say, hey, you can't do this, we need to take this on board. But they haven't done any of it and they stopped the midwives doing their job. But then they're learning from them along the way.

Speaker 2: 59:59

This is in the early 1900s, yeah, and that has occurred in Scotland and it was also replicated in the US. Yeah, it's well documented. And it was delivering babies was not in medical curriculum as a lot of things weren't, but the medicos felt that they kind of wanted it, I guess. Yeah, you know, from a policy perspective. Remember when I started there was one orthopod doing foot surgery in the whole of Victoria, yeah, yeah.

Speaker 2: 1:00:38

Midwives. They started to in an organized manner. They started to claim that they weren't safe and they weren't trained well enough, and they put this out into the media of the time, which was the newspapers they went to. This is well documented. They went to the regulators and said midwives aren't trained. But this is terrible. You know, you can't let them do this. This is a medical thing. Yeah, midwives have been doing it for probably a thousand years, I'm more. How long have we been having babies? Yeah, so, so, so they went through this process and discrediting pretend or telling people that they were not doing it, pretend or telling people that they were unsafe and then they were making sure the regulators started to not provide funding for them and back them off. And then what they did was wrote into their curriculum that you know, we're training medicos to do midwitery type, delivery type stuff. Now, that was. We're now 2020. That was basically 100 years ago. Now I read that stuff and I think you know I'm a podiatric surgeon in Australia.

Speaker 1: 1:01:49

Not much has changed. Talking about the surgery side of things, which we'll go into in a sec. In regards to not much has changed from 100 years ago, is it? You know you were saying getting the podiatrist on board who have a few years experience so they learn what conservative measures can do and, like yourself, your background, running your practice, country. So you've done, you've had to do it all so you've learnt what it takes. I have to say, as you know this I get a lot of referrals from orthopedic surgeons, foot and ankle. There's three or four I work quite closely with and I think it probably took that as many years as that three or four years for them to really understand what I had to offer. Yeah, and it's great, it's a great collaboration with this group, small group but then also my experience is there's a whole lot of others who don't understand what we can do conservatively.

Speaker 2: 1:02:46

I'd be happy to work for an orthopedist and train them with some of my skill sets, be more than happy to work with any orthopod and collaborate with legal staff to patients.

Speaker 2: 1:02:54

So I don't mean it that way. Yeah, what I'm trying to do is I, I I distinguish the concept of a podiatric surgeon from an orthopedist. We know we're not really quite the same. I don't know how you could ever ever become the one, because the paradigm of orthopedics is around training and trauma, hip, upper body, all the way through, and then foot, foot, ankle is a kind of a fellowship at the end, if you want. Yes, so, so you're talking about. It's a completely different paradigm to our paradigm, which I see has been more a bit like the, the, the dental paradigm in a sense, where we have an area of anatomic expertise and then we have the medicine and the pharmacology and everything else in behind that to enable what we do. But what we do need is is more open collaboration with orthopedic colleagues and there is a competition type thing there and unfortunately, unfortunately it is complete bullshit.

Speaker 1: 1:03:59

Yeah, and squeeze the language people. But what was recently put up on that program and I can tell you now I've presented for that television station and I've presented medical, hosted medical episodes for that TV station and television is so contrived so this profession is taking a beating from one report a month ago than the one a couple of weeks ago with having a crack at the surgical podiatrists. But I can tell you now from that experience of being in television, it is so contrived and I looked at that article that was presented a couple of weeks back. It was, and you know they pull a couple of patients out and, as you and I just discussed, I've got patients walking around who would probably extremely dissatisfied with my service.

Speaker 1: 1:04:53

But you know I thought it was a really lightweight article and I don't think anyone really should. It's almost like the best defense is, oh yeah, whatever bit like Nike and you know, community a to broaden Oxfam. You know, 15 years ago what was their defense when they were at, you know, had all these allegations. We don't care, we're not doing the wrong thing. Did you get your back up about that article?

Speaker 2: 1:05:22

No, I knew it was coming.

Speaker 1: 1:05:24

Yeah.

Speaker 2: 1:05:24

And I've known it was coming for a long time. It wasn't surprising for a couple of reasons. Yeah. One is that there's been a simmering disquiet among orthopedists in this country around pod surgery for for a while. There's lots of reasons for that. I suspect that I don't need to go into in great detail, other than I think it's an unreasonable stance to take.

Speaker 2: 1:05:55

I think in terms of modern medicine and collaborative care, I think that it would be much smarter for them as a collective to say hey, listen, you know, people like Mark have probably got some really interesting skill sets that we could learn from. Why don't we get him in here and let's, let's work together. And if we were in the public sector, I believe that would happen. And that's what's happened in the UK, that's what's happened in the US, that's what's happened in different countries. Here we're in the private sector and, unfortunately, what? An ankle surgery is mostly elective and it's mostly in the private sector. So guess what that means? There's a money imperative and there's a business imperative and there's a corporate imperative. So I'm not suggesting that that's the only reason that there's concern here, but we have, over the last couple of years, been trying to get funding through MBS through Medicare with the federal government, and it's a very tough, tough thing to do.

Speaker 2: 1:06:58

Sure, we got knocked back by the Medicare Services Committee a couple of years ago and one of the primary reasons in their paperwork was that we'd come up with a lot of data on outcomes. But when you've got an existing group that are being funded under the Medicare system and this is the difficulty and we would like to see change going forward, this is what I was referring to earlier Sure, the incumbents are sitting there. Now. The incumbents don't have to be challenged in the same way that newcomers will be challenged. So at that point and I'm sure that you know, as we all know there's more for pods doing some great work and there's some that are not doing the best work. There's a lot of variation.

Speaker 2: 1:07:42

But the truth is that they don't have any publicly available data. At that time and I'm not sure that they still do. Because there was no data available, the government couldn't do any comparison between us and them, right? So the government said look, your data is great, your training is great, everything looks fine. But we can't fund you under this sort of approach to funding unless we've got comparative data to look at. And that's how I understand that. Yeah, then the next thing is what the ball lies in the other side of the court, though.

Speaker 1: 1:08:15

Yes, you can do all the hard work you want.

Speaker 2: 1:08:18

Yes, yes, and the encounter so that other body would say, unless you can get governments with enough intestinal strength to see the ridiculous circumstance that you've got yeah, got a group of providers who are regulated, well trained, providing a surgical service, where the only surgical providers in this country with this imposter against us yeah, it would make more sense from a policy perspective to bring us in under something like MBS, because then they could keep a closer eye on us. So if the government and the authors really cared about patients, what they do is that encourage the government to put us on Medicare, because Medicare by default actually is a way of recording what you're doing and how you're doing. It Submitters to all sorts, whatever, whatever analysis you want, submitters to it. If you really cared about patient safety, that's what you do. Yeah, excellent point.

Speaker 2: 1:09:21

That's the challenge. If that's not what you care about, what is it you care about? Is it because you've got a big mortgage you want to pay off, or because you've got an ego problem, because you think this guy's just an I trust? Yeah, you're my, I'm a medical yeah.

Speaker 2: 1:09:34

I just I just wanted to be able to provide some appropriate clinical services to my patients and I want to be able to do it safely, effectively, and I want to know that I can pick up the phone to one of you guys. If I need to through hand, you should be able to pick up the phone and give me a call, yeah. Work together All of this media stuff's been building and it's been on the cards.

Speaker 1: 1:09:54

I think that body is behind the media. Push. I can't. I would.

Speaker 2: 1:09:59

I can't love to find out. I really want to find out. I know more than I'm prepared to say.

Speaker 1: 1:10:05

Well, as I said, it was so lightweight I could see straight through it. Yeah, I know I know.

Speaker 2: 1:10:10

I know more than I'm prepared to say yeah, yeah, the the. The other thing about it, though and this is an in fairness and in fairness what it does do, and I'll pull this back in a sec but what it does do is it does at the core of it. If there are patients who have been harmed or not happy, that's not good and it needs to be dealt with, and if we have practitioners that are repeatedly causing problems, we need to do something about it.

Speaker 1: 1:10:37

Whether that's not different to the article that was you know, proceed, proceeded. The recent one a month ago.

Speaker 2: 1:10:43

So that. So I have no problem with that at all, and there are some issues that have been brought to light there that you know kind of should be dealt with. For instance, all pod surgeons should be endorsed for scheduled medicines. Currently they're not. They should be it might. As a personal view, there's no place for a pod surgeon to not be endorsed for that.

Speaker 2: 1:11:02

In my personal view, that was brought out in the program.

Speaker 2: 1:11:06

One of the things that was not fair in the program was, though you know they brought out issues in some subsequent in the programs and all the press release stuff commentary around some events that were about 14 years ago, hmm, ok, and that individual was not found to have done anything wrong, and at that time that individual was targeted by a group of other health care providers, right, and that individual served time. And then there was another individual that was about 10 years ago who is deregistered and went through all the pain and suffering that this you know, I'm not not disputing that the reality of patient care, if you ever had a complaint raised against you, and you know, and I'll be honest and say, yeah, I've had complaints raised against me at different levels by different people I'm fortunate that I've survived as long as I have, but but it's the most devastating thing in the world for a health care practitioner. So if you've gone through and this program brought up somebody who has had previously gone through, all of that and then put it out there again, so this individual is then going to talk to their children again about, well, why are they still attacking you? Yeah, ok, 10 years later. Why are they attacking this person 10 years later?

Speaker 1: 1:12:33

You know, the first thing I think of this goes back to the other episode that was put up a month ago and I said, hey, everyone out there, just remember the positives to take out of this and even if they've cherry picked the information, which is all shit for us practicing now just uphold doing the you know, uphold your excellence and your integrity, the whole thing 100 percent 100 percent is what they have done in the media is actually cherry picked, that you know that little bit of history and those names.

Speaker 1: 1:13:05

Hold it out and just blown it up.

Speaker 2: 1:13:08

And then there are a couple of contemporary circumstances now. Those contemporary circumstances, they need to be dealt with, but but, yeah, it's not necessarily the right forum to be taking that stuff out there. You know, I mean, if it's if anything. And look in pod surgery, there's now a regulatory review underway through opera. One of the things that I think could positively come from that is that if there are practitioners or trends in behavior that are identified by complaints to opera as an educator, somebody like myself, we need a feedback loop so that we can we understand that that's going on. See the current circumstances.

Speaker 2: 1:13:52

There is no current regulation that says you have to have indoor scheduled medicines to be a pod surgeon. To me, that's an error. Yeah, and now we don't. We don't, we won't graduate anybody, we don't even. We want the people to have endorsement before they live and come into the program, because there's a possibility that you won't pass endorsement processes. Yeah, it's not that easy. So you could. You could end up qualifying as a surgeon never having the prospect of being able to prescribe an antibiotic. That's an absurdity. So you should not be going into a surgical training program without endorsement medicine in your back pocket already.

Speaker 2: 1:14:27

In my view Strong view and the board and the regulators should be looking at saying well, in the pod surgical group, are there any of these historical hangovers who haven't got this? Oh yeah, here's a few. Well, we need to give them a year or two to sort themselves out, otherwise we're going to take some action. Now I don't know whether they can do that or not, but they're the sort of things that come out of the regulatory review. The other things are that you know, if you've got a particular person who has multiple complaints or issues and there's real themes around that Professionalism, skill set, knowledge base, whatever it is feed that back the educators, feedback that back to the college process so that the college peer review can sort of say to this person they listen, you need to back off and do a little bit more work on your skill set or your professionalism or your knowledge base, because here you're creating problems for the community here.

Speaker 2: 1:15:29

Recognizing that I don't think it was high quality journalism, it's terrible. The problem you have is, if you're a small group, you've got a couple of choices. One is you just say let's try and ride the storm and ignore it, which is okay, because most of these storms will pass over the top of you, and you just then got to pick yourself up and dust yourself off and keep going. If you can learn something from it, though if you can learn something from it you move on, but where there are factual error and misrepresentation in some forum and potentially forums like yourself is offering those need to be rebutted.

Speaker 2: 1:16:14

And it's not appropriate to be saying that people are not well trained. There's a whole lot of claims within that reporting period were just not correct, just not correct.

Speaker 1: 1:16:31

I should also say that you're not speaking on behalf of the college here.

Speaker 2: 1:16:34

This is you and I.

Speaker 1: 1:16:35

This is two old boys having a chat in the couch.

Speaker 2: 1:16:40

And I've been very careful with my words.

Speaker 1: 1:16:42

You've been extremely diplomatic. It's good, but also straight to the point. I love it, but it's important to mention that, though You're not representing anyone.

Speaker 2: 1:16:50

Yes, I'm not representing anybody.

Speaker 1: 1:16:51

It's our opinions really.

Speaker 2: 1:16:53

The problem is this is a delicate issue at the moment.

Speaker 1: 1:16:59

For the profession.

Speaker 2: 1:17:01

This is two articles. Yes, well, this is my point and this is my point about, I think, the professions at a crossroads station. I think that, and if I go back and I just give you that little timeline, you'll be. But if you go back and you see that timeline and say, here's Mark, who started mucking around with this anatomic area back in the 1990s, wherever it was, the scope of practice was fascinating. So you've got this profession where you can do immense good for a very broad range of people, but it's getting eroded. Pod programs are having trouble attracting people into the programs and you're seeing pods leave the profession. Why?

Speaker 1: 1:17:47

Massive numbers, okay, so let's go back to just give me the quick rundown. Why do you think people are leaving the profession? Remember the stats? I'm quite sure around about 50% for podiatry within five years. Physiotherapies is about 53% within five years. My take on it is I think people get into it because they either didn't get a score for something and they thought, okay, I'll go and do that. That sounds okay, which is quite vague. What's the dropout rate for?

Speaker 2: 1:18:15

med. I've got no idea. There's a question for you.

Speaker 1: 1:18:19

The second thing is I think people find it harder than what they thought it would be. I think some people expect they're going to earn tons of money early up and realise it's much harder than it actually is. And then there's the dealing with the people side of things. Is this for me or not? Do I have a fascination and a passion for people? I think people, if they don't have that, that is probably the number one reason why, very early on, they realise, either during the course or not long after, this is much harder, and I don't think I really have the passion for people. I think you pretty well nailed it. What's your take on that, though? Anything else, brad?

Speaker 2: 1:19:03

I think that the only thing you haven't mentioned appropriate support and breadth of education in the first year or two after graduation, and that's what I mentioned earlier the need for internship type roles, Because internship type roles actually would give people the opportunity to understand what they can do. You're never going to remove the fact that a lot of people are attracted to healthcare because there's an image of healthcare somehow sexy. Then when they get into it they realise it's not. You're just dealing with people that are in pain. So in your meeting 20 to 25 people who are looking to you to solve their clinical problem, and you go home and you're worn out you said about you need to be a certain type of person to be in healthcare. A lot of people just aren't suited to be clinicians, that's it.

Speaker 1: 1:20:00

And it's the passion for people thing getting off and helping people.

Speaker 1: 1:20:03

I've got to tell you, if you tune into the show, I just recently spoke to a young guy who's one year out of college, very articulate and really switched on one year out of college, and I have absolutely no doubt that he in his final year, spent six months, six hours a week, sitting in with another practitioner. And this person has clearly, even after one year, he's got a maturity beyond his years. When he talks about his you know podiatry life and what he's doing professionally, it was very, very impressive. I think you're spot on as far as that internship program or having something in place where it needs to be formal, joe, you must.

Speaker 1: 1:20:51

I agree with you, I think there's got to be a certain amount of hours there where someone has to go and spend time with someone. I'm not sure what's happening with the universities, whether they actually place people, you know with them.

Speaker 2: 1:21:04

They place people, but clinical placements are difficult. That's why I'm the advocate of saying like a proper intern position. Remember, podiatry is a prescribing profession and, yes, there's pod surgeons and we should be in the public hospitals as well. We should be there. That's a big statement from me. I would quit my private practice tomorrow if any public hospital was to give me an opportunity to help them out in working in that environment. We should be in that environment and that's how we'll break down barriers fastest.

Speaker 1: 1:21:38

You've just reminded me again, talking about the 2025 people a day and whether the profession is for you or not. We did an episode with Fiona Rowland as a podiatrist in Launceston, talking about practitioner management. Get into a stage where, as you just mentioned, there's people or colleagues of yours who at the stage of retirement and they've stayed with the whole profession all of this time. One of the things we've spoken a lot of is pacing yourself and not drilling yourself like day in, day out and maxing out your patient numbers and just getting to a point where you'd be like, come on, you're gone within five years or not long after. Well, I pissed off with your work and people and whatever else comes with it. I think the pace of yourself is crucial.

Speaker 2: 1:22:26

It was work to live or live for work.

Speaker 1: 1:22:29

Have you backed?

Speaker 2: 1:22:29

off at all.

Speaker 1: 1:22:31

No, you see I think the clinical side things.

Speaker 2: 1:22:33

Yeah, look, what I say is that I've kept in because I've been involved in teaching for the whole of my career. I did some research, I did publication work, I did further study and I branched off into a different specialty. I've continued to study. My most recent degree was only a couple of years ago. That's how I've stopped burnout the diversity. It's the diversity. I've kept moving. I've moved sideways, I've moved forward, back. I've changed what I do. That's how I've kept in there. Now what I do is I work three days a week clinically. At the moment, I have, for a year or two, same but there's a balance there.

Speaker 1: 1:23:16

There is balance. You're facing yourself and having clarity because you've got a bit of time, it's balance and not chasing.

Speaker 2: 1:23:22

The other thing that I will say and this is something that I'm a bit sad for at the moment is when I talk to some younger people, a lot of people are getting into the corporatisation stuff. I've never, ever, thought about money ever. It might surprise people. He's a materialistic. Exactly the same.

Speaker 1: 1:23:43

I've let it go over the top of me.

Speaker 2: 1:23:46

I was never for any of my career. Sure, I don't know exactly who you are. I was never conscious of how many people I saw or how much revenue I made in a week or a day or a month. I just did what I wanted to do and help people where I could. That's it. Sometimes I was financially really quite well rewarded by that, and sometimes I'm not. Sometimes you look at the thing and go, oh geez, I've just done an awful lot of work for nothing. That's okay.

Speaker 1: 1:24:13

Yeah, I know exactly who you mean.

Speaker 2: 1:24:17

Because I'm in surgery. Surgery is not something you want to go into to make an awful lot of money. It just isn't.

Speaker 1: 1:24:27

You'll make more money in general, but I treat it in surgery if you're smart, I think it's a generational thing, though Like you're a little bit ahead of me, and I've been what been going for 35 years.

Speaker 1: 1:24:38

But now I'm the same like you, as you just touched on the commercialization of being a healthcare practitioner Good use of term but basically the commercialization of is a completely different playing field now than when we went through or were practicing like back in the day decades ago, and I think we've got to have a. You know there's a level of acceptance with that that it is just a new world. So what's interesting and you touched on this earlier about you know the precision, grinding and making things up in your rooms and the practical skill set that we developed from university to now my thing and it pieces me off and maybe I'm just past it for the new age. But the new age crew come in and it's like what the fuck are you stuffing around with this stuff for? Why are you getting your hands dirty? For? Why don't you just send it off to someone? They just don't get it. They just don't get their hands on stuff that you can, what you want and get it as best you can for the patient.

Speaker 2: 1:25:41

I think that's a lost skill. There's a lot of value in that still.

Speaker 1: 1:25:45

And one of the places is that.

Speaker 2: 1:25:48

That leaves you in the position where you're really losing your identity, because if that's what you're at, the same thing could be done by a sports physician. I've got sports physicians dispensing orthotics, now physios. There's no craft specialty anymore about it.

Speaker 1: 1:26:10

And if there is the podiatrist, don't speak about it. Well, they don't know. In the next month there's going to be four or five episodes just on orthosis.

Speaker 2: 1:26:20

I'm happy to contribute One of the things that I, weirdly enough, I do still and you talked about my daughter earlier. That's weirdly enough. I was in the office grinding a prefab device with specific spots because of my mechanics background and my skill set in manufacturing orthotics, and I will still, with patience, make little funny adjustments to their devices, or I'll communicate with the podiatrist about what will benefit for different conditions, and what's happening is often people just haven't clicked because they're not playing with the things themselves, they're not looking at things from a mechanical perspective, but there is still a place for various forms of ortho-mechanical devices Exactly, and you need to understand how to work with them.

Speaker 1: 1:27:10

Well, I love for you to tune in next few weeks because there's going to be like a fair bit sort of exposed and spoken of from lots of different people on board as well. You are someone who has paved the way for so many people and we've discussed a few things on the show with people who have done similar things behind the scenes. But your work behind the scenes there's a lot of time and a lot of effort goes into all the policy making, like you were talking about going to Canberra and talking to people of different departments in whether it's Medicare or health insurers or whatever but all that time and effort behind the scenes no one sees that and you are one of the guys who has paved the way and done so much for the profession and, in particular, just create a reputation as the podiatric surgeon goes without saying. So it is a great privilege to have you on the show on Simply the Best Pediatry. Great to catch up with you again too, after so many years. Thanks, Jason, Been a very long time.

Speaker 2: 1:28:13

It's been a very long chat.

Speaker 1: 1:28:14

But I really appreciate your time and loved having you on, so thanks a million for coming on.

Speaker 2: 1:28:20

Not a problem.

Speaker 1: 1:28:22

Anytime. More details regarding Mark Gilhaney can be found on the FASAnetau website. That's FASAnetau. More details regarding podiatric surgery can be found on the Australasian College of Podiatric Surgeons website, acpseduau. Media statements from the CEO of the Australian Pediatrics Association and Australasian College of Podiatric Surgeons can be read on the ACPS website. That's ACPSeduau. More details in the show notes, where you can also follow and support the show. Stay tuned as we now move on to a series discussing the use of orthoses in clinical practice. Tell your colleagues, as we're going to discuss different approaches and philosophies to using orthoses, what people are using, the evidence of the use of orthoses and preformed and casted or scanned custom orthoses. Thanks for listening to Simply the Best Penitentiary and Speak to you Soon.