I have been doing LOTS of talks on onychomycosis over the past few months. The vast majority of these have been CME lectures where I spend significantly more time reviewing the background information of onycho than talking about new drug therapies. What has amazed me since I first started speaking on this topic over 25 years ago is the lack of understanding of the science behind this INFECTION. Yes, you read that correctly…onychomycosis is an INFECTION and should be treated with anti-INFECTIVES. We don’t think twice about treating a bacterial infection with an antibiotic, why don’t we feel as strongly about treating a fungal infection with an antifungal? This has been my introductory statement in every lecture I give about this disease since I first became interested in this topic and my feeling has not waivered about it.
Perhaps I will expand upon that concept in a future post but for this entry, I want to talk about the total lack of understanding/interest in learning about onycho exhibited by our next generation of this profession; our students and residents. Many students and residents have been attending some of these CME lectures. I don’t know that they are necessarily there to hear my talk or rather it is just a diversion between the “more interesting” surgical topics that are being presented at the same meetings. Their lack of knowledge about onychomycosis, however, was driven home to me recently while I was speaking at the PRESENT Residency Summit in Teaneck, NJ.
At this well attended seminar I was in front of close to 200 podiatric residents. I started my talk by polling the audience asking how many of them could recite for me the Lauge Hansen Classification of ankle fractures. As you could imagine, every single resident raised their hand. I then asked how many could recite the Zaias Classification of onychomycosis**…NOT A SINGLE HAND was raised! My comment to them was: “Let me get this straight. Everyone one of you can recite a classification system for a condition that 1/3 of you may see twice a year but NONE of you can recite the classification system used in every scientific paper written about a condition you will see 20-30 times a day!”
I believe that this is an indictment of our educational system. This lack of knowledge is not necessarily the fault of the residents/students. They are just learning what has been preached to them as being “important” by their school faculty residency directors and attendings. Onychomycosis is something to be palliated (debrided, trimmed, ground, etc) and then discharged and reappointed for 60+ days, not treated as the potentially important infection that it is. I am afraid that more is being taught about how to properly code onychomycosis than any science behind it. (There are, of course, notable faculty members who really believe in teaching this information as something critically important) We need to start concentrating on the cognitive, medical aspects of podiatric medicine as well as, if not even more than surgical technique. Being as common a condition as it is, I see no better place to start that new paradigm of podiatric education than in teaching about onychomycosis.
**In 1972, Nardo Zaias, MD, one of the “Godfathers” of onychomycosis in the dermatology world, developed the classification system that is still used today (with some minor modifications) identifying 4 types: Distal Subungual (DSO), White Superficial (WSO), Proximal Subungual (PSO) and Candidal onychomycosis