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

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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