07/17/2024    Rod Tomczak, DPM, MD, EdD

Podiatric Physician Gatekeepers

RE: Podiatric Physician Gatekeepers

For years Leonard Levy, DPM advocated the roll of
podiatrists as gatekeepers. Afterall, the Iowa
college spent the first two years of school seated
next to DO students in lectures and took the same
exams. The third year of school was spent in
podiatric clinics and learning diagnostic skills
and formulating treatment plans with a Problem-
based Learning Curriculum. The fourth year was
spent in clinical rotations away from Des Moines
but with a strong emphasis on both general medicine
and podiatric medicine. Now, all graduates spend
three years in residency and many add an additional
year in a fellowship. So, the APMA has declared
what they think we, as podiatrists, ought to be,
but not necessarily what we are. The state
podiatric societies can opine about what they think
we should be, but only the state legislatures can
decide what we are at any moment. The podiatric
colleges can decide what should be taught but this
may not correspond to what is learned.

Our podiatric graduates are certainly equipped to
be healthcare gatekeepers, opening the gates for
patients into a healthcare system. Truth be told,
I’m not sure why we want to order lab tests and
diagnostic procedures. We open the gate, but are
we opening a can of worms? It seems logical that if
we can open the gates, we must also be equipped,
positioned, and willing to close those gates when
required. It may sound initially ludicrous but if
we are so well educated that we are able to care
for these patients, we should also be prepared to
sign the patient’s death certificate if that
patient passes away while under our care.

We perform a history and physical on a patient,
admit the patient to our service, operate, and
follow them post operatively because our curriculum
has been engineered for us to do that. God forbid,
if that patient passes away while we are caring for
them, perhaps from a PE or a STEMI. We should be
responsible gate closers and sign the death
certificate. We lobby to be real physicians,
accountable for the care of our patients proving we
have been trained to do so exactly like MD and DO
students and residents. We continually tell each
other that we have the same training as the DOs and
MDs. It all sounds good up until the unspeakable
happens. We must accept the most undesirable
outcome along with the best outcome and sign the
death certificate.

Suppose we perform a complicated rearfoot or ankle
procedure, maybe keeping the patient overnight,
maybe sending the patient home only to be called at
4:00 am and told the patient has expired. What
now, Gatekeeper? Someone must close that gate by
signing the death certificate. The deceased
patient’s real gatekeeper and primary care provider
hasn’t seen the patient in a few months. After
all, there is no need to see the patient every six
weeks when they receive a 90 day prescription for
medications. It may just be me, but if I were the
primary care physician for this patient and a
podiatrist called and said, “Dr. Jones I performed
an ankle replacement on your patient Horace
Everyman yesterday and he passed away during the
night, would you be able to sign the death
certificate?” I don’t think I would be willing to
comply with the request. As a podiatric physician,
or a podiatrist or whatever we are this week, do I
really want to put my signature on what I think may
be cause of death?

It did happen to one of my patients, a diabetic
smoker who had an extensive ulcer debrided and he
had an MI during the night. It was in the hospital
and well documented and the hospitalist who over
saw the code signed the certificate. I can see
podiatric physicians opening a brand-new Pandora’s
Box of questions I don’t want to be required to
answer. The real primary care doctor is not going
to jump in and volunteer to clean up a mess when
they haven’t seen the patient preoperatively. Even
though we have supposedly learned all the same
material MDs and DO learn, was there something I
should have done, something I should have done
differently, or something I shouldn’t have done
that contributed to the patient’s demise? I think
the primary care doctor doesn’t want to perform
foot surgery on my patients and I know I don’t want
to do their job.

Someday podiatrists may take and pass all three
parts of USMLE. Then we will call ourselves
physicians with no asterisks attached or winks
aside. Today, the phrase, “Stay in your own lane.”
makes a lot of sense to me. The risk/reward ratio
for venturing outside my lane doesn’t seem to be
worth it. This question doesn’t depend on how many
boards there are or whether there are certificates
of added qualifications. Why are we never satisfied
with what we do? What we do, we do better than
anyone else. Let’s not dilute our expertise and
let’s not place unnecessary burdens on ourselves so
we can tell each other we are real doctors. We
already are real doctors.

Rod Tomczak, DPM, MD, EdD, Columbus, OH

Other messages in this thread:

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07/19/2024    Steven Kravitz, DPM

Podiatric Physician Gatekeepers (Rod Tomczak, DPM, MD, EdD)

I fail to understand why there is so much attention
to podiatrists or at least some podiatrists trying
to expand scope of practice beyond that of our
specialty area - the foot and ankle. The concept of
the serving as gatekeeper brings many questions and
I agree with Dr. Rodney Tomczak. The DPM degree has
served me well and the podiatrists I know, my
colleagues (many in wound care) have benefitted
from their education and ability to practice
medicine within the scope of DPM degree they
earned. That degree points to the general public
and more importantly to other medical providers
that we are indeed specialists in the foot and
ankle pathology. We have developed very good
reputations generally; we as a group provide
excellent service to patients. At the end of the
day it is the patient that matters.

Becoming gatekeepers necessitates overseeing
treatment of medical conditions out of our scope of
defined practice. There's no reason to do this. .We
do not need to treat the entire body. Other
professionals do that. That's not to say we should
not have very good knowledge of systemic disease
affecting our treatment area, however, we should be
able to refer on a regular basis as I pointed out
in my recent post last week. Good practice is
dependent upon cross referral to specialists in
other fields of medicine on a regular basis to
maximize patient care. Secondarily, it provides
opportunity to demonstrate to your colleagues and
the medical community your knowledge and expertise
in treating the lower extremity. They will
reciprocate and refer back to you because they are
aware doing so provides best practice for their
patients as well.

There are approximately 15,000 practicing
podiatrists in the U.S. Based on that demographic,
all podiatrists should be extremely busy. If you
practice good medicine you will be busy. It is time
that we as a profession and our leadership move on
and accept who we are, very best providers of foot
and ankle medicine generally in the world. Be proud
of your DPM degree. Provide a very best medicine
you can to your patients. Spend time in diagnosis,
look at etiology not easily identified for patients
with more complex problems.

Demonstrate knowledge to other prescribing
physicians so they can refer back to you.
Correspond with these physicians on a regular basis
to keep them updated on pertinent patient care.
Build a reputation in your area.

Steven Kravitz, DPM, Winston Salem area, NC

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07/18/2024    Allen Jacobs, DPM

Podiatric Physician Gatekeepers (Rod Tomczak, DPM, MD, EdD)

The recent “gatekeeper“ discussion in PM News, is
in my opinion, reflective of the Dunning-Kruger
effect in reasoning: there appears to be a failure
to recognize one’s own incompetence. As noted by
Dr. Tomzack and me in previous postings, the
question is how far out of your lane do you wish to
drive? Are you unconsciously incompetent?

The DPM degree is a restricted medical degree with
restrictions on practice determined at the state
level and locally by institutional delineation of
privileges. A podiatrist today is exceptionally
well trained for the evaluation and management of
foot and ankle pathology. This is what you do. This
is what you have been educated to do. This is what
society, through its regulatory legislation has
determined, based on education and clinical
training, has granted you permission and trust to
do. You are entrusted to perform surgery, and to
determine when surgery is or is not
appropriate. You are entrusted to perform
amputations. You are entrusted to prescribe all
manner of medications in the treatment of foot and
ankle disorders, some of which medications could
result in serious sequela and complications. You
are entrusted to set standards for board
certification, residency and fellowship training in
podiatry. You are trusted to set the educational
standards in the colleges of podiatry for the
training of a podiatrist.

When people do not stay in their lane, accidents
and injuries can occur. Perhaps my perspective is
different. Having graduated in 1973. I go back to
days when a podiatrist could not see a Medicare
patient without a permission slip from a physician.
I remember the days that most decent hospitals
would not allow podiatrist on staff let alone to
perform surgery. I remember the days when we were
limited to forefoot surgery only. I remember the
days when we had limited prescribing abilities. I
look at the growth of this profession to its
current status, and while I understand that there
were still some political issues which arise,
overall I believe this profession is exactly where
it needs to be in a general sense. For the most
part, you are able to practice that for which you
have been trained. I do not understand this
continued pretense that a DPM degree is somehow
analogous to an MD degree. It is not.

If you took the time to evaluate the regarding the
refusal to allow a DPM to sit for the USMLE
examination, you saw that the authors stated you
were not being trained to be a general physician.
The authors of the rejection letter were very
complementary regarding the growth in education of
our profession. I’m not certain as to why you want
to leave this lane. Those who practice general
medicine with an MD or degree enough to know what
they don’t know. They know when to refer to others
who know more because they are aware that others
know more. They are consciously ignorant. They
know what they do not know.

Sadly, I feel those advocating driving out of our
lane. Do not understand this. For example, it is
one thing to treat an acute gout, arthritic attack
or two evaluate a patient for hyperuricemia make a
diagnosis of arthritis treat the acute attack, and
then refer the patient for evaluation and treatment
of the hyperuricemia. I hear those who say they
would start the therapy with urate lowering agents.
Let me ask this question. Are you prepared to
monitor renal function and other adverse effects of
the urine therapy and deal with that? What about
the causes of elevated acid? Are you prepared to
evaluate Patient for occult malignancy? For a
hematologic disorder or renal disorder or in fact
any disorder which may result in elevated uric
acids? Why would you even think that you were
capable of doing this.

This is not what you were trying to do nor licensed
to do or should be doing. If you suspect a patient
has a neuropathy, it is one thing to perform,
epidermal, nerve, fiber, density, testing, order,
nerve, conduction, studies, perform an appropriate
neurologic evaluation. But that is where it ends.
Once you have established the presence of a
neuropathy, while you might assist in treatment of
the symptoms, further evaluation is outside the
scope of our profession. Again, what if that
neuropathy is a manifestation of multiple myeloma,
or multiple sclerosis, or an occult malignancy, or
other systemic disorder. The good doctor knows when
to refer. That is the true gatekeeper an individual
who understands when a foot problem is not
intrinsic to the foot and makes an appropriate
referral. This is what everyone else in medicine
does.

I do not understand why, as Dr. Tomczak pointed
out, you are not satisfied with your degree. It is
a wonderful degree which allows you to practice
podiatry. That is what you went to school for. That
is what you trained for. That is what you are
licensed to do. I simply do not understand this
suggestion that you are a specialist in the lower
extremity because you are not. You are good at what
you’re good at. Keep it that way. Stay in your
lane. By doing so you will avoid accidents and
injuries.

Allen Jacobs, DPM, St. Louis, MO