Podiatry

Podiatry as a separate field of medicine began in the early part of the twentieth century. At that time, the hands and feet were considered some of the most complicated parts of the human body. Each human foot contains 26 bones, and the 52 combined bones in the feet comprise approximately one fourth of the bones in the body. Podiatry was one of medicine's first attempts at specialization. In the 1930s, the AMA Judicial and Ethical council reported that podiatrists provided a needed service that MD's are too busy to attend to with their patients. Modern podiatrists are generally defined as people devoted to the study, diagnosis, and treatment of disorders, diseases and injuries of the foot. Medicare data shows that currently, by far, the single largest paid service for podiatrists is nail debridement.

The ability to provide quality care for disorders of the foot requires the efforts of a multitude of health care professionals such as orthopaedic surgeons and nurses, and can include the services of podiatrists. This does not mean, though, that the services of podiatrists can replace the work done by physicians. A recent AMA report has stated that substitution of physician care by nonphysicians raises questions of patient safety, competence of therapeutic decision, and fragmentation of care. The report concluded that "physician care is based on cognitive and technical skills that are shaped by a unique education and experiences to form a foundation of clinical knowledge that allows physicians to decide what needs to be done across the wide variety of human maladies; that is irreplaceable by anyone with lesser training." Although podiatrists can have a role to play in care of the foot, serious patient safety issues are raised when they act beyond their training, and when podiatry is substituted for physician care. Concern within the physician community regarding the expansion of podiatrist scope of care beyond their training, knowledge and abilities stems not from financial concerns, but rather from concerns with patient safety.

The reason why this has become an issue is that various pro-podiatry groups have been pushing for changes in the law to allow podiatrists to significantly expand their scope of practice. Legislative, and other changes, have been (or are being) considered to expand podiatrists' scope to include lower legs, knees, and even the leg up to the hip. In a small number of states, podiatrists are allowed to treat hands. There is also a push to expand the ability of podiatrists to amputate beyond the toes, up to the whole foot or even the ankle, and to expand podiatrists ability to use anesthesia and give prescriptions. There is even a push to give podiatrists an unlimited scope of practice, the same as physicians have. Although a small number of podiatrists may have training and experience to safely expand their scope beyond the foot, there are serious concerns that the training that the majority of podiatrists receive may be insufficient for the proposed expansions in scope. In addition, serious concerns have been voiced regarding the lack of consistency in podiatric programs between different colleges of podiatry and the lack of consistency between podiatric certification boards, which make an expanded scope of practice for podiatrists look especially problematic.

The concern for patient safety from the physician community has been miscast by some, though. Many mistakenly see this as nothing more than a financial issue. One podiatrist was quoted as saying, "I don't know why the orthopedists are battling to take away our privileges because there are enough patients for everyone." But this misses the real issue, and the real need for concern, which is podiatrists practices expanding beyond what their training and abilities will safely allow.

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