08/17/2024    Rod Tomczak, DPM, MD, EdD

Who Decides Who is a Physician?

So, are we or are we not physicians and who
decides the answer? Does someone in an ivory tower
get to ratify our decisionsand are the legal
repercussions if we answer in the affirmative, but
another group asserts we made the wrong choice? Is
there some knight in the background counselling us
to, “Choose wisely!”

Chiropractors call themselves chiropractic
physicians in several states, perhaps over 30. It
seems ludicrous to think there are chiropractic
physicians and not podiatric physicians, but yet
here we are, and it is happening. How can this be?
I think the problem begins with which medical
board holds sway over a certain discipline. Every
state has a chiropractic board that more or less
governs chiropractors within the framework of the
state law. Where ambiguities exist, the state
legislature and attorney general turn to the
governing board to interpret and advise on these
questions.

In many states, optometrists and chiropractors can
call themselves physicians without controversy.
The state seems to have the final say over whether
members of a profession call themselves
physicians. Every state has its own optometric and
chiropractic board, and most can call themselves
physicians. Now it would be nice if every podiatry
graduate accepted the challenge to take MD boards
and passed which would put an end to the
podiatrist physician controversy. Knowing NBME and
USMLE won’t allow podiatrists to take the test,
foot and ankle MDs clamor for podiatrists to take
the test knowing they are safe from us picking up
the USMLE gauntlet and succeeding.

I seriously wonder why podiatry, in some states,
is under the aegis of the state medical board when
every other health care profession seems to be
governed by its own board. I ponder what the
advantage is to having podiatry governed by the
medical board. The first response is that we are
medical and maybe chiropractic or optometric
isn’t. It’s not a question of diagnostic and
treatment philosophies, but professional
overwatch. In at least twelve states osteopathy
retains its own board meaning full licensure can
be granted through USMLE or COMLEX and DOs and MDs
have the same unrestricted license regardless of
which test is passed depending on degree granted
by an accredited school.

No one ever suggested podiatry come under the
watchful eye of osteopathy. Is it possible that in
some states podiatrists once looked through rose-
colored glasses and thought if podiatry was under
the same board as MDs, we would have parity with
MDs? Is it possible for podiatry to return to
self-governing and decide we want to be called
physicians because we know we are? Is it that
simple or do others want to control us and have
final say over our existential choices? Is it just
to have ten MD board members for every one
podiatrist deciding our name?

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

Other messages in this thread:

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08/30/2024    Brian Wm. Zale, DPM

Who Decides Who is a Physician? (Rod Tomczak, DPM, MD, EdD)

I was sued some 25 years ago by an attorney who I
believe just hated podiatrists. PICA was my medical
liability company at that time. The patient had
bilateral bunionectomies by another podiatrist
previous to seeing me. She also had some plastic
surgery on her right ankle for a brown recluse
spider bite that looked horrible. Needless to say,
she was unhappy with the bunionectomies I performed
and I was sued along with my assistant surgeon and
the resident on the case. She sued me for all the
normal things of lack of informed consent, chronic
pain, inability to have sex, unable to work, loss
of future income, etc.

They had an economics guru expert from University
of Houston to figure out her future loss of income.
Their expert witness was a "Board certified foot
and ankle orthopedic surgeon" from San Antonio who
hated podiatrists. My expert was a Board certified
podiatrist from Houston.

During the voir dire (the process of picking the
jurors and summation of the case by both
attorneys), the plaintiff’s attorney tells the
potential jury that us podiatrists aren't doctors
and we don't even go to medical school. Then he
asks the jurors if anyone ever had any foot or
ankle surgery by a podiatrist. A lot of hands went
up. Then he asks each one if they knew that we were
not Medical Doctors if they would have had their
surgery. Some said no, others said yes and one
nurse said that she had to have a Podiatrist
correct the failed procedure that an Orthopedic
Surgeon did on her so she could walk again. One
little Spanish lady in the front row raises her
hand and says that her Doctor was so smart he was
chief of staff at the hospital and had so many
plaques on his wall there wasn't any room for more
and "HE SCREWED UP MY SON"!

Another person asked my attorney, "How much are
these non-doctors getting paid to have to go
through this?" His answer was nothing, they are
here to prove their innocence. That juror ended up
being the foreman.

As the case goes on for 4 days, the plaintiff's
attorney asks his board certified foot and ankle
orthopedic expert how much he is getting paid to
come here to Houston and leave his booming practice
and come here to do the right thing to testify
against these non-doctors who screwed up his
client. He responds with $15,000. There were some
whispers among the jurors.

The plaintiff’s attorney then starts showing
pictures of her brown recluse spider bite plastic
surgery trying to somehow convince the jury that I
had something to do with that.

Finally it goes to deliberations the next morning.
I'm not feeling good about anything since I see the
jurors are bringing their sack lunches with them
into the deliberations room at 9AM..

About 45 minutes later, 12-0 acquittal. Defense
verdict! So, here is my take on if we are a
physician. First off, there is only one God, and he
is the only one who could heal people. He is the
greatest physician who ever lived. There are no
other Gods who could actually heal people.
Secondly, if I can get sued for the same amount as
a medical doctor, then we are equal, no matter what
the degree is after our name. I am blessed to be a
podiatrist!

Brian Wm. Zale, DPM, Rosenberg, TX

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08/28/2024    Paul Kesselman, DPM

Who Decides Who is a Physician? (Rod Tomczak, DPM, MD, EdD) EdD,

This is a very interesting topic considering that
on this very day 47 years ago, I attended my first
classes at what was then referred to as the
Illinois College of Podiatric Medicine (ICPM) and
which is now part of the Rosalind Franklin
University (RFU). Almost fifty years later, ICPM
has been incorporated into the "mainstream" medical
educational system. For those who are unaware, RFU
hosts the Chicago Medical School, Scholl College of
Podiatric Medicine, School of Nursing, Pharmacy,
and several other programs in the medical field.

During my undergraduate podiatry rotations whether
at the VA, Naval Hospitals, there was no
distinction for medical (MD) vs. podiatry (DPM) vs.
DO students. We both were treated in the same
tough manner. Not once during those rotations did I
ever hear, "Oh you are a podiatry student we don't
expect you to ...... by any vascular or orthopedic
surgeon. For the most part, these attendings had no
idea who was an MD or DPM student. And if anything,
I made sure I was better prepared for my rotations
and grand rounds than others in order to avoid any
potential finger pointing.

At the University of Chicago, the podiatry
residents and podiatry students participating in
clerkships had the same rigorous schedules and
worked together. My colleagues at other schools
were not so lucky, nor were some of my own
classmates who were constantly reminded that they
had no business training in hospitals and were not
going to be doctors.

Office based surgical training and eventually board
certification in surgery and taking many, many
courses enabled me to compete with the fellowship
trained orthos at the time.

And so when I became an attending, I took ER calls
as often as I could. Nights, holidays and weekends
were filled with the same interruptions as my
colleagues in other specialties and sometimes more
so.. Performing an emergency TMA on a 22 y/o IDDM
patient w/gas gangrene in the middle of the night
because she was brought to the hospital in septic
shock was among the many train wrecks the podiatry
service and I confronted at one hospital. Missing
family events, holiday celebrations was routine due
to an on-call emergencies for many
attendings/residents of the podiatry department as
well.

Many ortho departments were happy to give the
foot/ankle surgeries which come into the ED because
these patients either have MCD, no insurance, no
fault or worker's compensation, all of which are
headaches of one form or another depending on your
state. But these same real doctors, while not
wanting to do these cases and handing them off to
me or others in the podiatry dept. would often
remind us we were not equal when it came to private
pay or private insurance.

I would often answer, if we weren't equal or
equivalent and in their minds, could in fact
endanger patients and the reputation of the
hospital, then why on earth would you refer these
patients and sometimes your own patients and
relatives to us for other non-emergency matters you
didn't want to handle? The answer was plainly
obvious, but they could not or would not admit it.

And yes there were some orthopedists, especially
the older ones who were extremely prejudiced
against DPMs. It took time especially at the
private hospitals for the orthos and general
surgeons to back down, especially after the other
partners in other specialties saw how much money we
were generating to the hospital. Interestingly
enough our best allies were a board certified
vascular surgeon, the radiology and anesthesia
partners. So as one of the original commentators on
this thread mentioned, money does talk! Especially
to hospital administrators!

Another outstanding issue is when insurance
companies pay us a different fee schedule due to us
having 3 letters rather than 2 (RD=Real Doctor)
after our name.

APMA and state associations should be fighting for
equal pay for equal work provisions on every level.
If the work is done equally well by both degreed
professionals, the pay should be the same, just as
it is under Medicare. And admirably while some
states have been successful in passing these
regulations, most have not.

In some cases, third-party payers are paying the
same or higher RVU for employed podiatrists who
work for large multidisciplinary groups and equal
or equivalent to the MD/DO. So they have found a
way to circumvent that bias but again, it should be
the same for all.

The title physician or doctor needs to be earned
through showing you can jump over the hurdles
(passing the licensing exams, etc.) . Additionally,
you must be able to prove you have the training and
can do the work. There are no shortcuts to any of
this nor should there be!

The DOs for the most part have proved they are
separate yet equivalent. DPMs may be able to prove
we can do the same work in our specialty as the
MD/DO colleagues, but
the MD/DO point to several critical course areas
which must be addressed by the podiatry schools
including comprehensive physical diagnosis (not an
issue at ICPM in the late 70's) and course and/or
rotations in psychiatry and OBGYN (again the latter
an elective at ICPM in the late ‘70s and definitely
not my favorite rotation).

As for who is defined as a "physician", that is
often left to the state in which they practice. In
many states podiatrists are not considered
physicians
In searching the NYS Higher Education database,
Podiatrists in NYS are not considered physicians,
yet under Federal and Medicare statutes,
podiatrists are considered physicians. This leads
to the potential for accusations of false
advertising and considerable confusion by the
public.

The solution: Is to prepare our students to take
the same or similar boards during their
undergraduate education as those of the MD/DO
profession. There is nothing wrong with separate
but equivalent. The DO profession for the most part
has solved this situation and it's high time we do
the same.

Lastly, there is a way for Medicare and others to
know what specialty you are. When you enroll in
Medicare, it is not your certification as a medical
provider or office location (PTAN) in Medicare that
distinguishes a podiatrist from a
gastroenterologist, psychiatrist, etc. It is your
taxonomy code which is way more than six digits.
That taxonomy code (and there are several for DPMs)
which you link to your Medicare enrollment tags you
to your specialty and your state's licensing
database is what provides you with the ability to
be reimbursed or not for a given procedure.

Paul Kesselman, DPM, Oceanside, NY

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08/26/2024    Jack Reingold, DPM

Who Decides Who is a Physician? (Rod Tomczak, DPM, MD, EdD)

I graduated from CCPM in 1979 and retired in 2023,
practicing in San Diego, CA the whole time.
Luckily, there were hospitals in the area that let
me have surgical privileges when I started. Within
15 years, all the hospitals in my area granted
podiatrists virtually full surgical privileges
(including ankle) and admitting privileges. Managed
care arrived and discovered that podiatrists
delivered excellent, cost-effective care and began
hiring them in great numbers. Kaiser Permanente
Medical Group went from none to currently 21!

Hospitalists started calling us and begging us to
take patients. Nobody seemed to care about our
degrees, caring only if we could take care of their
patients (and perhaps off their hands). The
hospitals wanted us to take positions on many
committees (of course they were none paid). I am
not even sure if all the physicians in my community
realized we had a different degree. Many of them
became patients and never even mentioned it.

In my 41 years of practice, I do not even recall a
patient asking me what degree I had or if I was a
real doctor! The biggest problem with the DPM
degree is that we are often overlooked by our
legislators regarding new laws and regulations,
which takes a lot of energy to correct.

Medicare and private insurance cannot always
identify a MD or DOs specialty and their use of
billing codes as easily as they can with a DPM
after their name. This sometimes results in unfair,
over scrutinizing of our claim. We are as
knowledgeable in our area of expertise as any other
specialty! Sure, in certain moments it would be
easier to be an MD but, I would not lose any sleep
over it.

What a great time to be a podiatrist. As I use to
tell my son, "have fun, learn something and do some
good."

Jack Reingold, DPM, Encinitas, CA

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08/24/2024    Name Withheld

Who Decides Who is a Physician? (Rod Tomczak, DPM, MD, EdD)

Early this morning I had just finished my coffee
and reading the latest PM News forum. Once again,
we, as podiatrists, were discussing the DPM vs.
MD/DO parity issue and whether or not we are
physicians. As usual, many in our profession
believe we are on par with the MD/DO group and
should be treated as such by all and the other side
believes we should remain as we are, our own
profession.

I have to admit that there had been many times in
my now 35 plus year career as a podiatrist that I
have wished that I had gone the MD or DO route so I
could be a “real doctor, a physician” but that had
not been my path. I was daydreaming about what it
would be like to be that “real doctor” and
contemplating a second cup of coffee but my cell
phone rang. It was a hospitalist standing in the ED
at the local community hospital asking me to stop
and see a diabetic with a foot infection that she
was admitting. I agreed to do so, particularly
knowing that I was headed to the hospital for
surgery anyway so a consult would be easily
accomplished between cases.

I was tired. I had been up a good part of the
night, in surgery. The ED had called about 11 PM
and asked me to come in to see a 15 year old who
was visiting from out of town and had fallen at a
local hotel and had cut the top of her foot on a
metal door. A tendon was severed and readily
visible through the wound. They had already called
ortho, which they typically do for trauma, but
there was no bone involvement so ortho deferred to
me (probably they didn’t want to go in at that time
of night). I had gone in and as an on call team
for the OR had just finished an appendectomy they
were available to set up to repair this injury. I
got home about 3:30 AM.

My day was already busy, over busy really. First to
surgery, then the consult, then a stop to see the
patient I had done and I & D on earlier in the week
that was being discharged. Then to the office where
I had two peer to peer calls to do to get MRIs
approved, a call with the vascular surgeon I worked
with regularly and I knew that there would
obviously be calls that come in of some variety or
another that would have to be dealt with, this on
my afternoon “off” as no clinic patients were
scheduled. Not having seen the new consult yet I
had no idea if it would be a call to the OR to get
some time that afternoon or evening or if it would
be a “ follow” the patient with the hospitalist,
non-surgically.

As usual, we had some family plans on the weekend
with grandkids involved but my children knew well
what I did for a living, having grown up with it
and so they understood that plans sometimes were
bumped or delayed, usually only by a few hours but
none the less, sometimes were altered by a patient
need or the hospital.

While at the hospital one of the internists stopped
me in the hall and asked me to see his wife the
following week for heel pain he could not resolve.
Surgery went well and fortunately, the I&D from
earlier in the week was going home, the patient was
very gracious in praising me, “thank you doctor,
for saving my leg” (those always embarrass me for
some reason). The consult would be treated
medically as agreed with infectious disease and the
afternoon ended calmly.

Name Withheld