02/18/2025    Chris Seuferling, DPM

American Foot Care Nurses

I cannot speak for the rest of the country (though
I imagine most states have similar concerns), but
I am well-versed in Portland, Oregon's podiatry
and foot nurse dynamics. I am also familiar with
Portland Foot Care Clinic and its CEO Amarachi,
RN. In fact, we have had multiple conversations at
the state level and national APMA level to address
this issue… even introducing Proposition language
at the 2024 HOD (see my proposed language below ).
It did not gain the traction I had hoped for, but
I’m told it’s on APMA’s radar.

With that said, I ultimately feel it’s an “us”
issue, not a “them” issue….ie; it is a “Podiatry
Identity” crisis and not a “Foot Nurse
competition” one. Many times during the course of
the year, I have the following conversation with a
new patient…”Mrs. Jones, I noticed podiatrist Dr.
X performed your ankle fracture surgery. Why are
you not seeing him/her now?”

“Oh, Dr. X said they don’t do routine foot care or
diabetic foot care, so I needed to find another
podiatrist.” These are nearly always
younger/newer 3-year residency-trained DPMs. They
are coming out of training more “orthopedic”
minded than classic podiatry-minded. I’m an older
dying breed now and the pendulum is only going to
continue swinging in that direction. No judgment
from me. This is just the new paradigm shift
reality of podiatry training.

These newer DPMs provide a critical service by
doing complex surgeries and saving limbs everyday.
We have a great back-and-forth referral
relationship and my schedule is full of routine &
diabetic foot care patients for the next 4-6
months. Great “problem” for me to have! However,
it is a problem for the general public. We have
more and more toes (growing elderly and diabetic
populations), but less and less DPMs willing to
see these patients for nail/foot care.

Simple supply and demand economics at play.
What’s an at-risk patient supposed to do for foot
care, particularly when I can only see them every
6 months? There’s no other podiatrist option for
them, so where should they go? Nail salon?
Family member? Certainly, these are not safe or
ideal options for at-risk patients. Solution?
Enter the Foot Nurses. At least this is what’s
been working in my practice for the last several
years. I refer patients to foot nurses all the
time and they refer back to me.

In fact, I have trained several of these nurses
(no $$$ cost) and even had them shadow me to learn
techniques; and so I can observe their skills. I
want to make sure my patients are safe and being
treated by skilled nurses. Who better to train
them than us? It’s the right thing to do for our
patients and I will continue this model until a
better solution arises. As Dr. Allen Jacobs said
in his post, “serving the public well-being in
priority to our own self-interest.”

I know this is a sensitive and complex topic and
I’m certainly open to suggestions, but for now
this is the reality on the ground here in Oregon.
Hoping we can get this conversation to the
national table to discuss. This shouldn’t be
punted for states to solve individually, as it
affects all of us.

At the end of the day, I view the “foot nurse”
issue as an opportunity and not a threat, but only
if we are pro-active and not reactive.

=======================

-Whereas, we have a national public health crisis
with a growing number of elderly and diabetic
population requiring regular foot care (ie; nails
and calluses).

-Whereas, due to a number of reasons (Changes in
younger podiatrist’s training, insurance issues,
etc) there is a shortage of DPMs willing and able
to perform these duties.

-Whereas, there is void and gap in the need for
foot care and qualified medical personnel to
provide this care.

-Whereas, an increasing number of “Foot nurses”
are appearing nationally to fill this gap or void.
They are providing this care independent of
DPM/Physician supervision and without any
standardization of training or certification.
Concern for public safety of patients has emerged.

-Whereas, DPMs disagree on the role of these “Foot
nurses”. Some accept and embrace their role,
while others view them as competition and oppose
their practice. In fact, here in Oregon some
providers have been torn whether to train these
“Foot nurses” to protect the public….or to reject
them altogether.

Proposed Position:

-APMA lead the charge of this public health crisis
and be pro-active by creating a national team to
discuss this multi-faceted issue. (There are many
layers to this topic that need to be addressed
including, are “Foot nurses” the solution to
fulfill this gap in care? Should we suppress
these “Foot nurses” from practicing? Is there a
restriction of trade issue? Who should train
these “Foot nurses”? How do we standardize their
training and certification in order to protect our
patients/public? Is this an opportunity for us as
a profession to benefit financially by creating a
new “foot nurse” curriculum and certification
process? …etc.)

-APMA not leave this issue to be resolved at the
state level. We need to come together nationally
to formulate a solution.

-APMA realize that we are aware a single
Proposition will not resolve this complicated
issue, but rather our “ASK” is to get this topic
to the table for further discussion, regardless of
whether we call the entity a “task force”, team,
committee, or other entity.

Chris Seuferling, DPM, Portland, OR

Other messages in this thread:

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02/21/2025    Allen M. Jacobs, DPM

American Foot Care Nurses Association (Ivar E. Roth, DPM, MPH)

Dr. Roth has made the observation that some of the
young residents and practitioners lack the drive
and intensity to work longer hours and harder than
his generation. Many of today’s younger doctors
are smart and seek a much better work life balance
than did my generation. This is in my opinion a
good thing not a bad thing. This generation wishes
to reduce the stress and burnout that has
afflicted so many healthcare providers in today’s
world. The newer generation is not as motivated to
generate maximum income, but rather maintain a
good work balance while providing good care for
their patients. They do not wish to engage in the
long hours and sacrifices that our generation was
taught to be part of being a doctor.

Work life balance integration is important to many
of our younger doctors. Older healthcare providers
may not relate to this manner of thinking.
However, younger doctors are anxious to limit
commitment to being a podiatrist and set
boundaries for their work hours versus their
personal time. They participate in physical
fitness activities, which is helpful for stress
reduction, and overall health. They are more adept
at utilizing technology to make them more
efficient than our generation was.

In addition, studies have shown that only 9% of
medical graduates wish to enter private practice
with the remainder looking for some type of group
or institutional employment. In summary, work life
balance is a greater priority for many of today’s
graduates. The need for such work life balance was
discussed by the great medical educator, Sir
William Osler, MD over 100 years ago. This remains
true today.

Of course, remuneration for medical services
remains important given the fact that our young
graduates have several hundred thousand dollars in
debt when completing their education. However, it
is admirable that they want to be full-time people
and part-time doctors rather than full-time
doctors and part-time people. There there is
nothing wrong with this. Perhaps the major problem
is the inability of the older generation to accept
this perception of what a doctor should be.

Hopefully the young generation of new podiatrists
will not make the same poor choices with regard to
lifestyle that many in my generation have made. I
warned the residents with whom I work that life
goes quickly. In the end your family and friends
are with you. Podiatry will not be.

Allen M. Jacobs, DPM, St. Louis, MO

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02/19/2025    Ross B. Feinman, DPM

American Foot Care Nurses (James DiResta, DPM, MPH)

I have been practicing for over 22 years; I have
seen the ups and downs of the profession as well
as the residency programs. I have been fortunate
enough to be involved with podiatric students
through the various programs at multiple
hospitals, I have worked with some very talented
residents through the years as well as students!
In previous years, students were hungry for
knowledge, enjoyed the banter of being “pimped”,
they knew it was for educational purposes, not a
personal vendetta against them. They also came
prepared for the case, knew the basics and seemed
interested.

Unfortunately, many students now want to be done
by 5 PM, not show up, or have to take their dog to
the vet. The idea of this as a lifelong profession
seems to have become lost in the fog as many
students today seem to be more interested in
dinner time than actual learning. It seems
inexcusable for a student to come into a bunion
procedure and not be prepared for the case, to not
know the anatomy of the foot or toxic doses of
anesthetic is a commonality that I have run into
all the time!

Hence, no one is saying they won’t be good
practitioners, but maybe surgery is not for
everyone, and we need to look at a 2 tier type of
residencies like in the past, one for basic
forefoot, office-based podiatry and the others for
surgery. Many of the candidates have been told you
can’t get certified, make a living etc. without a
3-year surgical residency and for whatever reasons
they have been scared off by the 3-year standard.
Is it possible that the governing board needs to
review this and change for the future of the
profession.

Ross B. Feinman, DPM, Walled Lake, MI

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02/17/2025    Allen M. Jacobs, DPM

American Foot Care Nurses Association (James DiResta, DPM, MPH)

Dr. DiResta appears to be somewhat concerned that
a podiatrist is serving as an instructor in foot
care for nurses. I wonder if orthopedic surgeons
express the same concern to their colleagues who
participate in podiatric medical and surgical
education. After all, by doing so you are aiding
and abetting the competition (enemy), are you not?
At the NYSPMA association meeting this year, there
were interactive panels with orthopedic surgeons,
and a program in which dermatologists were
instructing in the evaluation and treatment of
foot and ankle dermatologic disorders. Should they
have refused to do so over concern for decreased
patient revenue?

Some years ago, Dr. James Ganley asked me if I
would be comfortable teaching family medicine
residents how to manage ingrown toenails and
common foot problems. He told me that he regularly
instructed non-podiatrists in the evaluation and
treatment of common foot disorders. His reasoning
made sense to me. First of all, he told me that by
education of "the competition", he found that
whatever decreased patient load he might
experience was replaced by referrals for much more
complex pathology. Secondly, he found that by
educating others, they realized that many
seemingly simple problems were more complex and
required greater knowledge and experience than
they had perceived, again resulting in more
referrals. Finally, Dr. Ganley reminded me that if
alternative health care providers were going to
evaluate and treat foot pathology, we have an
obligation to instruct them in proper evaluation
and technique, serving the public well-being in
priority to our own self-interest.

I have always willingly and enthusiastically
participated in the education of MDs, DOs, DCs,
NPs, whomever. It affords me the opportunity to
highlight the podiatry profession, to show them
how we evaluate and treat foot and ankle
pathology. In my experience, non-podiatrists are
appreciative of the discussions, and consistently
rate these presentations as amongthe best at their
seminars. What I sell is not podiatry per se, but
the knowledge and experience that you have,
providing them with education and insight. What
follows is respect for the DPM degree, and not
infrequently new referral sources. The more they
learn, the more they realize that which they did
not know. And with that is an appreciation of our
profession. As Mark Twain so aptly stated; " It
ain't what you don't know that gets you into
trouble. It's what you know for sure that just
ain't so".

Allen M. Jacobs, DPM, St. Louis, MO

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02/15/2025    Joseph Borreggine, DPM

American Foot Care Nurses Association

The APMA, I would opine, is totally fine with
this? And, I assume so is the profession? We are
the first line of defense when it comes to routine
foot care? That’s nice. I would consider this to
be an insult to the legacy of our profession. We
are the primary foot care provider period end of
story! So, if we cannot get paid for “routine foot
care”, then we just do not see the patient?
Really?

So, just send them to a registered nurse? Really?
That makes no sense. I guarantee that if a
podiatrist were to truly do a foot examination on
a patient that qualifies for routine care that
other pathology would be identified with respect
to any all the bodily systems that we are so duly
trained.

We are not and have never been “toenail
technicians”. If a podiatrist opines that they are
beneath the ability to provide routine foot care,
then just go an become an MD/DO with a 1 year
internship, 4 year surgical residency, and 3 year
fellowship in orthopedics so that you can shine as
a board certified orthopedic foot and ankle
surgeon.

Be proud of being a podiatrist. There is more to
podiatry than foot/ankle surgery folks. “Routine
foot care” should be dropped from the Medicare/CPT
verbiage and replace it with the new and improved
evaluation and management CPT codes that allow us
to utilize and bill our exemplary skills as
podiatric physician to diagnose and treat the
foot/ankle conditions that most patients do not
even know they have.

Our podiatric specialist services that our
profession is known for over the last century will
always be needed, however or professional
association need to rebut organizations like this
that downgrade what we do.

Take a look at this and see what I am talking
about. https://www.afcna.org/.

Joseph Borreggine, DPM, Fort Myers, FL