|
|
|
Search
10/17/2018 Daniel Chaskin, DPM
Requests to Trim Fingernails
Trimming or debridement of fingernails might be interpreted as part of good podiatric care concerning a comprehensive podiatric exam in conjunction with podiatric treatment. The purpose of such an exam is to ultimately treat the foot so that its condition remains as healthy as possible.
Look how far we came. In NYS, for example, podiatrists can cut above the malleolus to perform Epidermal nerve fiber density (EFND) testing so long as the purpose of the exam is treat a foot condition. The law says that we cannot cut above the malleolus, but I believe this refers to cutting to treat anatomic structures above the foot. It has already been established that one can cut above the foot if the purpose of such cutting is part of a comprehensive physical examination. If one can cut into the leg to perform EFND testing, then one should be within scope to cut or debride fingernails and send specimens to the lab as a part of the comprehensive podiatric exam.
Page 5-2 of Principles and Practice of podiatric medicine 2nd edition states that he podiatric history and examination can include questions a podiatrist can ask such as " Have the nails become discolored, brittle, deformed, or softened"?. This "history question" opens up the podiatrist to trim or even debride a finger nail FOR THE PURPOSE OF A PHYSICAL EXAM in conjunction with podiatric treatment which will give dermatologic information to a podiatrist regarding a fingernails brittleness, deformity or how soft or hard the fingernail is. Even if a fingernail looks normal when one debrides it one may possibly see pathology, brittleness or softness, that needs to sent to a lab This valuable information may affect the ultimate treatment of conditions of the foot. If symptoms of psoriasis, lichen planus, onychomycosis, etc.. are present then these are findings that provide valuable information to alert the podiatrist to look out for such conditions in the feet.
For example, if a psoriatic nail on the hand is sent by a podiatrist to a lab and it comes back as psoriasis, lichen planus, etc...then hyperkeratotic callus formation on the feet might be caused by the psoriasis in the hand. The whole key is that a podiatrist is not treating the hand condition but using the information gained from such an exam in ultimately being better informed on what is going on in the feet.
State societies should contact every state podiatry board to interpret that trimming fingernails is part of a comprehensive podiatric exam. It’s a win-win situation because dermoscopy, and podiatric exams can yield valuable information for which the pathology in the hand can ultimately be treated by a referral by the podiatrist to a dermatologist once the podiatrists first took a fingernail specimen and sent such a specimen to the lab.
Daniel Chaskin, DPM, Ridgewood, NY
Other messages in this thread:
10/19/2018 Bryce Karulak, DPM
Requests to Trim Fingernails
I truly think we are hyper-focusing with respect to trimming patient's fingernails. I am willing to bet that if anyone of us cut a patients fingernails and went to the majority of the PCPs in our respective areas, they would not care and even say, "Great!"
Where this conversation should really focus on is enhancing our scope. I work in Texas and the law for podiatry basically reads, "A podiatrist may treat the human foot by any system or method." That means that we can literally do anything we want to promote the health of the human foot. Easily, that wound encompass a vascular bypass to increase blood flow to the lower extremity and foot. However, most of us are not trained in vascular bypass surgery. But the law technically allows for it but here we work off of precedence.
But, on a simpler level, why can I not adjust a patient's insulin when it is well documented that a blood sugar below 200 decreases a patient’s risk of complication after foot surgery? I have many limb salvage patients that would benefit from immediate intervention by me rather than waiting for the anesthesia or IM to come around in the acute setting. I have been asked by a nurse practitioner to adjust insulin and had to tell them I couldn't because of scope. She then stated, "You can't, but I can."
We are required to do extra training in residency that many of the well established podiatrists never did because times were different. But why are we going the extra mile? Why are we progressing in education if I can't use half of what I learned in my IM rotation or other rotations. It's rather unfortunate for the patient to have care delayed when I'm more than capable of adjusting medications. This is not to say that when I admit patients that I would not consult IM but it would be nice to do what is necessary when other services are busy.
Beyond all this, many of us do good surgical work and give patients their function back. With many of the similarities observed in the foot and hand, I am not sure why we haven't pushed for hand surgical privileges. It blows my mind that a general orthopedist with very limited foot and hand training can post a foot or hand case at almost any given hospital and perform that surgery while I have to demonstrate case load in residency to perform surgery on the ankle. On top of that, I am asked by many hospitals to send in a proficiency log to demonstrate that I am still doing these surgeries. I know other surgical specialties are rarely asked for this.
I know these ideas seem progressive but I know I'm not the only one who has felt this way. Especially, when I find myself revising a foot and ankle orthos surgery let alone general ortho. So what is the future of our profession? How are we going to evolve or should we? Based on the conversation about fingernails, I believe many of us want the profession to progress beyond its common scope.
Bryce Karulak, DPM, San Antonio, TX
|
|
|
|