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02/02/2021 Samuel Cox, DPM
It's Time for Parity with MDs and DOs
This article is about nurse practitioners and you
could add in there PAs, these physician extenders
have better and broader licensing and scope of
practice then we is podiatric physician and
surgeons do. I really find this offensive, I
completed a 3-year PM&S residency in which I was
required to be the physician covering literally
thousands of patients through my course of those
3 years, I was not just the podiatrist I was the
doctor for these patients granted I did have
coverage and oversight, but it was a learning
environment.
The focus was on podiatry, however I still was
responsible for managing the rest of the patient
co-morbidities. Yet depending on the state, the
practice and I am drastically limited to what I
can and cannot do when the lower extremity.
Honestly I am fed up, I think this needs to be
addressed on a national level and I know APMA has
tried over the past years but it just does not
seem to be materializing. I think now is the time
for podiatry to change the parameters.
I am a third generation podiatrist and I am tired
of being a stepchild. I currently employ a nurse
practitioner as a physician extender in my
practice, because I have had difficulty finding
an associate podiatrist, she has a broader
license than I do in Arizona. In Arizona, an NP
can go out on her own and hang up her own
shingle. This does make it easier in my office
because, she can treat not only just podiatry
stuff, but anything else she feels comfortable
with, however we have not done that as yet, but
this is still offensive.
My training is so far superior in all aspects of
the human body to hers, it is really just not
right. It is time that we have parity with MDs
and DOs. In today's litigious society, physicians
understand what they know and do not know and
generally do not go outside of that. As an
example, an orthopedist who may do a lot of
scopes and surgery for shoulders and knees really
does not do anything to hands, feet or other body
parts. They are not going to all of a sudden
start doing spine or hands cases even though with
their license, if they could find a facility to
do that, they could legally.
Samuel Cox, DPM, Goodyear, AZ
Other messages in this thread:
02/10/2021 Michael M. Rosenblatt, DPM
RE: It's Time for Parity with MDs and DOs (Samuel Cox, DPM)
There was a time when I expected “a degree of
consistency” for American medicine and licensing
(pun intended). I was extraordinarily naïve. It
took the irregularities of the pandemic to prove
that to me. I actually EXPECTED the U.S.
healthcare system to even-handedly handle Covid
and allow allopathic physicians to prescribe and
follow their own internal scientific guidance.
Well known medications were politicized and
forbidden, no matter your license.
I just wrote three sentences and deleted them
because the Editor can’t print them. That tells
you everything you need to know. Consistency and
loss of freedom of speech were the first
casualties of the pandemic. Consistency in
licensure no longer applies to MDs and DOs. Why
would we expect it to exist for us? Now to
podiatry. Because of my age, I witnessed the
transformation of DPM from the earliest meetings
to “beg” my local hospital to let me on, to the
fact that DPM’s are now welcome at hospitals and
large group practices all over the US.
Podiatry itself was a shock to me. After my
training at a VA hospital and Army hospital, I
expected to be prescribing orthotics and doing
routine foot and ankle procedures. THAT was
before the HIV AID’s crisis hit. I found myself
actively treating patients with HIV.
I had the medical and prescribing freedom to make
some spectacular mistakes. I worked in
partnership with MDs and DOs to actively treat
infections that the founders of podiatry would
never imagine. When I got my Medicare Certified
Surgical Center licensed, a local anesthesia
group had a bloodbath of firing. Soon I got calls
from (previously employed) physicians asking to
“take me to lunch” in search of a new job with me
and my ASC.
I agree with the value of a plenary license. I
just did not personally find the lack of it to be
a problem. An argument can be made that I had TOO
much freedom for my training and experience. I am
just trying to be completely honest about it.
There were days I was prescribing openly for
diseases and medications not actually within my
licensure. I never got into trouble. Perhaps I
should have.
I believe I am the only DPM who actively
publishes on Medscape, using my real name and
degree. I publish on data that is not involved in
my degree or training. I am sure that some
readers think ill of me because of that. But I
know they read me. It is time that they
understand that some podiatrists write really
well.
I don’t expect anything of value from Government,
with the exception that I got a REAL license to
do medicine and surgery from several states. It
was an amazing and deeply appreciated “ride.” The
more I think about it, the more I realize how
deeply I was honored to become a DPM.
Michael M. Rosenblatt, DPM, Henderson, NV
02/09/2021 James DiResta, DPM, MPH
It's Time for Parity with MDs and DOs (Samuel Cox, DPM)
I always find the comments related to parity for
podiatrists on PM News to be so interesting but
unfortunately of such little value. I can't help
but equate this to the "cowboy" activity of my
early years in practice when EBM equated to "in
my hands". Probably the lowest level of evidence
yet we listened to this as dogma, and yes we
truly knew no better. Yet, today some of our most
esteem colleagues and I might add some of the
brightest in our profession reflect on their own
experiences alone when commenting on this topic
and we need to be mindful of this before arriving
at any conclusion.
The bias in their comments and the diversity of
opinions on this topic are largely influenced by
one’s age, previous and present level of
training, provider practice experiences,
socioeconomic status and a host of other biases.
What we ought to be doing is looking directly at
our present cohort of podiatric medical students
and ask ourselves are we making their careers
less valuable because we have determined what was
good for us should be equally as good enough for
them? Shouldn't we want to see how our students
measure up to present day allopathic and
osteopathic medical students?
In doing so we also need to be mindful that all
medical students are not created equal. Yes there
are levels of minimal competency but it wouldn't
take a rocket scientist to discover that a
student at a less demanding program may not meet
even the lowest level of competency at a highly
competitive medical school. Finding the
appropriate place to get ones medical education
is not necessarily at the school with the most
competitive admission stats. It's finding the
right fit and the right environment at which you
can learn and thrive. Ultimately you will need to
pass the licensing exam whether that be the USMLE
or the COMLEX to reach parity.
As you know, the USMLE step 2 CS exam has been
dropped and come next January 2022 the USMLE Step
1 will be pass/fail (similarly COMLEX level 1
goes pass fail as of May 2022). I think myself
that the majority of our podiatric medical
students given the appropriate level of
preparation can be successful in passing USMLE
step 1 and if provided the additional training
can pass the USMLE step 2 CK exam.
The pathway to parity is needed for a number of
reasons. I am not advocating to do away with our
profession or with the DPM degree. My hope is
that all of our students will remain as
podiatrists with a plenary license which will
allow real change in practice scope for the
future of our profession and not based on
anatomical level except perhaps for our surgery
practice. We all want to achieve equal pay for
equal work. Our students deserve this future.
As a group, podiatrists can be quite aggressive
when they need to and will prepare themselves
with the education and experience needed to
achieve this goal. Those of us who are
approaching retirement broke so many barriers to
get where our profession is today. It's mind
boggling to even fathom what we achieved. This
last piece, achieving parity by exam, is a no
brainer. I get it i.e. the political hurdles in
gaining access to these exams but it's very
doable. We can do this. We should do this. Please
let's get this done before many of us "kick the
bucket".
James DiResta, DPM, MPH, Newburyport, MA
02/09/2021 Ronald Sage, DPM
It's Time for Parity with MDs and DOs (Bryan C. Markinson, DPM)
I’m writing to add to the astute comments made by
Drs. Jacobs and Markinson. When I entered
podiatry school in1973 a pep talk to some of our
class from Dr. Chuck Gudas promised that we were
joining the “greatest profession in the world”!
After 40 years of practicing and teaching
podiatric medicine and surgery, I have not been
disappointed. The evolution of this profession
during my career was nothing short of remarkable.
When I graduated, only a fortunate few filled the
limited number of one, or rarely two, year
residency training positions available. Hospital
privileges were largely limited to small
community institutions, in some cases struggling
to fill their beds and operating rooms. We
encountered all kinds of restrictions that would
shock todays graduates of three year residencies.
Eventually, my DPM degree, and certification from
what was then The American Board of Podiatric
Surgery, were sufficient credentials to allow me
medical and surgical privileges at an academic
health science center. I treated everything from
mycotic nails to ankle arthritis in the clinics,
in-patient services, operating room and emergency
room. I received support and encouragement from
the medical school to start and maintain a three
year podiatric medicine and surgery residency. I
retired as a full professor in the Department of
Orthopaedic Surgery and Rehabilitation. By the
way, my old ID and lab coats always proudly
displayed my name and DPM suffix.
None of this happened without some challenges
along the way. Those hurdles were overcome by
practicing high quality traditional and advanced
podiatric medicine and surgery, eventually
earning referrals and consultations from my
medical colleagues. Equally important, was
demonstrating respect for their expertise by
referring and consulting when my patient’s
conditions required skill or experience beyond my
ability. Legislating an MD or DO degree not
earned by graduating from an allopathic or
osteopathic program would not have made a
difference.
To those who believe we need an MD or DO degree
to practice the “specialty" of podiatry, I
suggest the following. Close the podiatric
medical schools. Open the podiatric medical and
surgical residencies to graduates of allopathic
or osteopathic programs, and seek ACGME approval.
Anything short of that would simply be a pseudo
credential, lacking the prestige or parity that
is being sought.
I encourage the next generation of podiatric
physicians to learn the history of our
profession, and take pride in where we’ve come
from to where we are. Young practitioners need to
produce and publish validated outcome studies
that demonstrate the importance and success of
our care. Legislation may be necessary in some
cases to practice the full range of services we
are trained to provide. However, advancement of
our profession should be motivated not by a
desire for “parity”, but for a desire to provide
the best possible foot and ankle care for our
patients.
Ronald Sage, DPM, Beloit, WI
02/08/2021 Steven Kravitz, DPM
RE: It's Time for Parity with MDs and DOs (Samuel Cox, DPM)
I find it interesting that for the past many
years, the question of “parity” keeps arising. In
the meantime, it also appears to me that the vast
majority podiatrists are satisfied with their
practices. It probably is a quiet majority ----
those who do not participate in writing articles
or commentary these kinds of publications are
busy practices and are earning what they feel is
a satisfactory income with a healthy family
lifestyle. I understand the concerns many of my
colleagues presented. I also think that their
frustration is not related just to podiatry, but
is in fact with all medicine.
Limitations of practice is generic and part of
how we treat medicine today. Ophthalmologists
refer cardiac questions to cardiologists and do
not think about trying to treat these problems. A
dermatologist I worked with did not do extensive
wound care, but referred to me and my colleagues.
As I see it, podiatry provides full scope license
allows us to do anything we need to do in our
anatomical area of practice. The limitation in
anatomical areas well defined before when chooses
the field. If one wants a broader anatomical area
treat and choose another medical field.
Additionally, nurse practitioners, physician
assistants have become an increasing partner with
many podiatrists across the country. This is
especially true in wound healing. As president of
wound healing Association, I can attest that many
members have requested that nurse practitioners
and physician assistants who work with them
become part of the organization. They work with
these colleagues on a regular basis and share
patient care. This is a trend go through medicine
and podiatry alone cannot stop the process.
Podiatrists are best trying to work with it, work
with your colleagues, get to know a few nurse
practitioners and physician assistants who are
open to working with you and move forward. I am
not very familiar with other fields of practice
anymore because of past 20 to 30 years, I have
been limited to wound healing. But in that area
of practice, I can tell you without a doubt the
partnerships between our advanced practice
providers and podiatrists keeps on growing and
will continue to do so.
Steven Kravitz, DPM, Winston-Salem, NC
02/05/2021 Allen Jacobs, DPM
It's Time for Parity with MDs and DOs (Bryan C. Markinson, DPM)
In my opinion, the expressions of doctors
Markinson and Agostinelli regarding the issue of
“parity“ are spot on. Yes there are frustrations
inherent to the limited podiatry degree. It seems
illogical that I can prescribe opioid analgesics
and other potentially dangerous medications, yet
I am not permitted to prescribe medical
marijuana. It is intriguing that I can perform a
Syme amputation or utilize an IM nail to
stabilize a Charcot’s ankle but require an MD
signature to prescribe therapeutic footwear for a
diabetic patient. It defies logic (to me) that a
podiatrist is paid less than on orthopedic
surgeon for the same service when, in fact, a 3
year residency and fellowship trained podiatrist
is better trained in foot surgery.
The parity argument is, to my thinking, a straw
man argument. As a podiatrist, you are a limited
licensed health care provider. You are not a
“specialist”. You did not graduate medical
school. Your training is not that same as an
allopathic physician, nor should it be. Podiatry
education and residency and fellowship is to
prepare you for the practice of podiatry. Not
cardiology. Not gynecology. Not dermatology.
Whenever I hear a podiatry student or resident
tell me they attended medical school it rattles
what’s left of my bones. Similarly, the lack of
respect for the primary care podiatrist, and all
the good they do for the public, is disturbing. I
suppose calling yourself a “ foot and ankle
surgeon “ brings you greater internal peace in
wrestling with what you probably are, a
podiatrist who performs foot and ankle surgery.
What you really desire is PARITY OF RESPECT for
your degree.
When your jacket says “Dr.” rather than DPM, you
do not advance your profession. When you state
you attended “medical school” you do not advance
the profession. When you refer to yourself as a
“foot and ankle surgeon” you do not advance the
profession. You simply attempt to hide your
education and degree for self-serving ends.
If you do not respect your own degree, why would
you expect others to respect that degree?
Yes there are frustrations. However, every time
an MD or DO or NP or RN is in your office as a
patient, that is parity. Every time you are
referred a patient with a significant infection,
ulceration, or Charcot’s foot, that is parity.
When you receive an ED call to care for a
fractured ankle, that is parity. Every time a
patient appears in your office for treatment on
neuropathy, plantar fasciitis, or a
dermatological condition, that is parity.
As an old guy, I remember the days when a
podiatrist could only see a Medicare patient with
MD authorization. I recall the days when a
physical therapist would not honor the requests
of a podiatrist. The days of severely restricted
pharmaceutical prescribing for a podiatrist. The
days of little or very restricted hospital
privileging for a podiatrist.
I also remember the many dedicated educators who
devoted their lives to advancing the competency
of the podiatry profession.
Parity of respect is something that is earned,
not legislated. It has been said that all
politics are local. So too is respect for you and
your degree. Remain educated and continue your
education. Provide excellent and thoughtful and
compassionate care. Do so and you will obtain the
“parity” you seem to do desperately seek.
Allen Jacobs, DPM, St. Louis, MO
02/04/2021 Randall Brower, DPM
It's Time for Parity with MDs and DOs (Samuel Cox, DPM)
I have to push back a bit regarding the whole
parity argument. This argument is frankly old and
tired. We are podiatrists. I did a 3-year
residency in Detroit at DMC from 2001-2004. Yes,
the first year, we did a 4-8 week course of
internal medicine, ICU, ER, trauma, general,
vascular and plastic surgery rotations. Yes, we
have a very small overview knowledge of these
general medicine and surgical specialties. But,
Dr. Cox, what do you want to do with a parity
degree?
We are both somewhere between 15-20 years in
practice. Medications, disease management and
surgical approaches have changed significantly in
the past 2 decades for all specialties. I think
you might be overstating that you, or I, have
vastly more knowledge in medical treatment of the
whole body. That is simply not a correct
statement. Tell that to an internist, or an NP,
and they will laugh you out of the physician
lounge.
Orthopedic, general and ENT surgeons, for
example, don't even draw labs or write for
medications or do surgery outside their specialty
scopes. You may say that they could if they
wanted. I push back that, from a medical legal
perspective, they would have just as much
liability treating patients outside their
specialty scopes as podiatrists would. I recently
asked a general surgeon friend of mine the last
time he did a venipuncture. He replied it had
been 30 years. I see a huge boon for malpractice
attorneys if grandfathered podiatrists start
treating heart disease, and doing surgery on
other parts of the body. We just are not
adequately trained in the increasingly
specialized medical/surgical world we live in.
We need to come to terms, as a profession, that
we are podiatrists and always will be
podiatrists. Specialists. I am not so sure where
the anger comes from. We all knew what the
limitations were when going into this profession.
My suggestion is to focus on being the best
podiatrist you can be, and enjoy this great
profession that has largely been recession proof
and for many of us, covid-proof. We are a blessed
group of specialists.
Randall Brower, DPM, Avondale, AZ
02/03/2021 Bryan C. Markinson, DPM
It's Time for Parity with MDs and DOs (Samuel Cox, DPM)
The usual flurry of parity-related posts are once
again upon us. Clearly, the frustrations of any
DPM when it comes to the limitations (both
anatomical and procedural) of varied Podiatry
practice acts is totally understandable. Not at
all intending to place anyone’s veracity in
question, unfortunately, this frustration also
leads to statements that strain credibility,
which are not helpful, but detrimental in any
quest for parity. For example, Dr. Cox states, "I
completed a 3-year PM&S residency in which I was
required to be the physician covering literally
thousands of patients through my course of those
3 years, I was not just the podiatrist, I was the
doctor for these patients granted I did have
coverage and oversight, but it was a learning
environment." Thousands?
Let’s assume conservatively that "thousands"
means 2,000. That means in a 5-day work week over
three years he was the "required physician" for
over 10 patients daily. Although certainly
believable if he is talking about daily inpatient
rounds as part of a team, but "covering
physician" is what he states. What about state
work hour limitations for residents? What about
those MAVs? I’ll leave that there. Dr. Cox
clearly states that if he were to have parity, he
would not all of a sudden be doing surgery out of
his specialty, just as orthopedic spine surgeons
do not do bunion surgery. But although we seek a
license that does not restrict us, the kind that
the MDs have, and now as he outlines, the nurse
practitioners increasingly have, we have to be
careful how we justify it in public.
Dr. Cox supports the argument with the statement
that "My training is so far superior in all
aspects of the human body to hers (referring to a
NP who he employs in Arizona)." Although I have
no idea where his NP was trained, any DPM who is
hospital based as I am knows that this is
patently untrue, especially the part about "all
aspects of the human body." Nurse practitioner
training, at all levels, including 2-3,000
supervised hours under an MD or DO to become
independent is totally different than that of a
DPM, as is their daily experience in total
patient care. I did not say superior, I said
different. If Dr. Cox’s training is truly
superior, he is in a distinct tiny minority of
one.
One thing will never change, and that is that if
you desire the practice life and license of an MD
or DO, or Nurse practitioner, don’t go to a
school of podiatric medicine. But for me, and I
would say the majority of my colleagues, the
attaining of the DPM degree, with all its
limitations and frustrations, was the best
decision of our lives. The key is not parity,
unless you think that draining a paronychia on a
finger is practice Nirvana. Yes, a plenary
license would solve a lot of issues, but I
suggest taking a new picture with a different
lens, as life below the ankle for me has been
intellectually as rich as I could have ever
dreamed. How about it colleagues? Is all practice
dissatisfaction due to external factors? Or
better yet, isn't the great fulfilling practice
more in your control than you realize? Or am I in
the minority of one? Chime in please.
Bryan C. Markinson, DPM, NY, NY
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