08/25/2025    Rod Tomczak, DPM, MD, EdD

Physician Extenders Friends or Foes? (James Hatfield, DPM)

I have two daughters who are physician extenders,
but I can’t simply define what a physician
extender really is. Ludwig Wittgenstein an
analytical philosopher said in 1953, “The meaning
of a word is its use in the language.” That
certainly clears it up.

It seems an extender is now able to perform a task
or interpret some evidence and act on it in a
realm that previously was limited to a physician.
A CRNA provides anesthesia for our patients. They
act independently except during induction and
emergence when the anesthesiologist is required to
be present in the operating room according to most
state laws. You and I know that is not always the
case. State laws limit the number of anesthetists
an anesthesiologist should be supervising so the
anesthesiologist is not caught in one OR when a
patient is ready to be induced or woken up. It’s
not always possible for the anesthesiologist to be
physically present in the same OR when one of
these more crucial moments is happening. The
anesthesiologist may be 15 feet away, but there is
a wall separating the two rooms. So the
anesthesiologist is not circumscriptively present
but the patient is ready, the surgeon is ready, so
what the hell, let’s wake the patient up and break
the law.

There used to be anesthesiology nurse assistants
whose job it was to monitor the patient while the
patient was “safely” asleep and may or may not
have administered some medications. This evolved
into the present day nurse anesthetist with now a
doctorate in nursing, the ability to start
arterial lines, intubate and extubate, along with
other duties. Today, most patients think the nurse
anesthetist does everything from preop holding to
the PACU. The meaning of the word anesthetist in
common parlance to the usual patient is the same
as an anesthesiologist.

Not too, too long ago in small hospitals the
anesthetist was supposedly supervised by the MD or
DO who was operating. No one gave much thought to
the fact that the surgeon who was responsible for
and supervised the anesthetist would be very busy
in the operative field if the anesthetist was
gravitating toward a crisis mode. Was the
anesthetist an extender of the surgeon?
We have long debated the words podiatrist and
physician being used as a couplet. The term
“physician of the foot and ankle” limits the term
physician to a certain body part. Soon podiatrists
who train west of the Mississippi on the left
coast will be physician of the left foot and
ankle.

Are podiatrists evolved physician extenders? Dr.
Hatfield in his recent posting wrote that because
Dale Austin put an X-ray machine in his office,
orthopedists who referred patients to chiropodists
for palliative care would no longer do so. This
meant that chiropodists who had been seeing
palliative care patients referred by orthopedists
would no longer have this referral source and lose
patients they were previously thankful to take.
Before crosses are burned in my front yard or
there are 20 different “for sale” signs in my lawn
or the trees have been tepeed, hear me out.

Some of us who are old enough remember when our
patients were admitted to the hospital we needed a
real physician MD or DO on the plastic card used
to imprint every piece of paper pertaining to our
patient? The physician may or may not have seen
the patient, but they adhered to the letter of the
law. We couldn’t operate early cases unless there
was an MD or DO in the hospital. You and a nurse
anesthetist weren’t able to properly care for that
patient, we needed a real physician who could be
in the cafeteria eating breakfast and reading the
paper, but they were responsible for the patient.
That set of circumstances put us into a physician
extender category. It didn’t matter that the
physician probably had no idea what we were doing.
Sometimes the GP who referred the patient stopped
by the pre-op area to say hello to his or her
patient and reassure the patient they would be
there for the surgery. I enjoyed it more if the GP
did scrub in and I got to teach them what I was
doing.

We go back to Dr. Hatfield’s letter and read on to
see Dr. Austin was frustrated with the course of
events and became a DO, then by legislation an MD
with I assume an X-ray machine in his office to X-
ray the foot and ankle. Was he the first true
physician who was a podiatrist or podiatrist who
was a physician. What mattered most is he helped
podiatry evolve to the point we are today. We saw
from the PM News poll many of the profession are
frustrated like Dr. Austin because we are not MDs
or DOs.

Instead of podiatric physician extender, I think
we are in the midst of podiatric gamesmanship. I
wrote to each of the schools being curious about
the size of the class of 2029. School has already
started, White Coat ceremonies in the books, oaths
sworn, tuition in the bank.. No school answered my
question, but I received advertisements about the
schools and one school answered that the size of
the class was, “…in flux.”

We are the mushrooms of physician extenders. AACPM
keeps us in the dark and feeds us manure so we
will jump on board of the Foundation for Podiatric
Education without question but ready to give a
pint of blood. Podiatry continues to make its own
rules but wants to be considered in the same
breath as MD and DO medical schools. Our schools
tried to emulate the MD/DO schools, not wait to
see if they could pluck up a few stragglers who
never heard of podiatry before July. That’s called
extending the school year, extending recruitment
and extending an acceptable GPA. That’s not
extending, it’s restricting the profession.

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

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