Dr. Gordon rationalizes his opinion that
podiatrists have an obligation to diagnose and
primarily manage osteoporosis citing reliance upon
a flawed study (multiple parameters) whose own
conclusion suggests additional studies need
undertaking before the test is validated. He
laments colleagues who question his decision,
implies his treatments are successful
supplementing some of his surgical
reconstructions, and lastly, among other comments,
opines clinicians should be compensated for the
test's performance.
Dr. Udell's response alone, is probably enough to
validate why patients with suspected osteoporosis
be tested utilizing the existing gold standard
bone densometry study, followed by appropriate
referral to their PCP for systemic osteoporosis
therapy. While I applaud Dr. Gordon's "outside the
box thinking" via extrapolating this EBM to
anecdotally assist his patient's pedal care, there
are multiple inherent flaws in the study which
could lead to inaccurate results and affect
patient outcomes. Dr. Udell's reply needs
expansion.
First, the study Dr. Gordon cites utilized a very
small patient sample. Second, the patient sample
was both uni- sex and ethnic; its authors
correctly imply variations may exist in the test's
accuracy from one ethnic group to another, and
from one sex to another. Third, the authors
correctly imply that variability may exist in
therapeutic responses to systemic calcium
supplement therapy from one skeletal part to
another. Fourth, they conclude that utilizing
calcaneal measurements to track therapy efficacy
could be misleading, all of which lead them to the
ultimate conclusion that while utilizing calcaneal
bone densometry appears promising, additional
studies need to be undertaken before it can be
validated.
Now, while I don't possess Dr. Turlick's EBM
manuscript dissecting acumen, it is CLEAR that
this is hardly the type of study one should
primarily rely upon to rationalize assessing, then
formulating clinical decisions diagnosing and
managing a potentially very serious systemic
disorder, like osteoporosis. Dr. Gordon, that's
exactly why a clinician cannot expect to be
compensated for performing the test because it
fails to conclusively validate its accuracy along
multiple parameters. You state "I know we use them
successfully pre-and post-operatively in Charcot
reconstructions".
While I agree that anecdotally, it might make
sense in certain clinical scenarios to employ
calcium supplement therapy, how do you know it
worked? How can you prove that? How can you be
assured your pre op assessment was accurate when
the authors themselves cannot conclusively prove
such? AND, most importantly, how can you possibly
rationalize relying on such an ambiguous study to
primarily manage osteoporosis?!
At any rate, the anecdotal utilization of a given
systemic therapy to enhance a pedal outcome in
certain clinical settings is one parameter;
primarily undertaking systemic management is quite
another and falls outside one's practice scope.
Relying upon inconclusive, flawed EBM through
utilization of FDA unapproved testing is both
reckless and foolish. Suppose you miss an
osteoporosis case, perhaps several cases, and your
patient sustains a vertebral fracture and becomes
paralyzed, or some other heinous adverse sequellae
results from a misdiagnosis formulated from
reliance upon an unproven, non-FDA approved
diagnostic modality? A) I don't know how you can
rationalize that; B) I don't know how you could
live with that; C) I don't know how you can defend
it; D) Why would anyone want to place themselves
in that position? and, E) Do you hold any regard
how those realistic adverse sequalle would
negatively impact your profession's reputation and
its global medical community standing?
Lastly, the obligation podiatrists have with
respect to systemic disease management is not to
primarily TREAT the disease itself...it's to
manage its podiatric manifestation(s), RECOGNIZE
the disease process
and REFER its primary management to an appropriate
specialist; AND, within a TIMELY fashion! Failure
to do so IS what constitutes grounds for
malpractice and likely one, if not THE most common
cause for claim generation. This applies whether
it is with respect to primary management of
osteoporosis, diabetes mellitus, hyperurecemia,
CRPS, and ANY other systemic disease process one
wants to concoct.
While Dr. Gordon may be sick and tired of
negativity and infighting, those who have
developed impeccable professional reputations
built over prolonged careers of performing primary
podiatric medicine ARE the ones who are sick and
tired of the hits our profession continually takes
when inadequately trained podiatrists practice
beyond their scope and knowledge base, then land
in the courtroom. Primary care medicine belongs in
the hands of our distinguished medical
colleagues...period. Managing the pedal
manifestations of systemic disease, i.e. primary
podiatric medicine, is our expertise. Want to
practice the former, then respectfully, return to
medical school and earn your medical degree.
Practice scope, which varies from state to state,
defines what is treatable and what is not. Gray
areas always exist.
When a podiatric colleague decides to step well
outside the box into grayest shaded areas of
practice scope, one better be armed with EBM much
more conclusive and germane to the disease process
one elects to primarily manage than the study you
just cited. You know what pisses me and my other
distinguished colleagues off? It's when our
collective malpractice rates rise when someone
gets taken down, including the enormous hit our
entire profession's reputation takes when an
egregious mistake is made, purely to satisfy one's
ego! And...therein lies one of the main components
in our profession's dichotomy...and please, please
spare me the diatribe about the improvements in
podiatric medical education or the course one
took, etc. That topic has been dissected ad
infinitum on PM News.
The conclusion remains the same- we may and should
know more about the pedal manifestations of every
single systemic disease known to mankind, but the
bottom line is, if we truly desire to practice
primary care medicine, our podiatric curriculum
needs to parallel our medical colleague's at every
level, including the standardized testing that
validates proficiency.
Barry Mullen, DPM, Hackettstown, NJ,
yazy630@aol.com
