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
