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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
Other messages in this thread:
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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