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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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