Unlocking The Door To A National Scope Of Practice
Is it time for a national scope of practice in podiatry? Individual state laws prevail for now, but disparities between them raise eyebrows, not to mention the legal challenges. Are politics getting in the way of DPMs being able to provide complete podiatric care for patients or is the lack of universal training a far greater obstacle?
Let’s get to the wish list first. Some advocate broad parameters of what constitutes lower extremity care for a national scope of practice. One podiatrist says it should be the widest currently defined state law that encompasses care in the lower extremity. Another DPM says the national scope of practice should be diagnosis and treatment of foot and ankle disorders by whatever method or treatment is necessary to effectively manage or heal the patient.
Specifically, there seems to be an emerging consensus that an ideal national scope of practice for podiatrists should include "tibial tuberosity and all structures distal to it with specific exclusion of the knee." This specific language would allow DPMs to treat the conditions they currently do as well as the bony structures of the lower leg.
Podiatrists should also be clearly defined as "physicians" in any national scope of practice act. While most states and Medicare do define DPMs as physicians, some states do not. In Pennsylvania for example, podiatrists are defined as "practitioners." Having a clear definition in a national scope of practice act is important to obtaining parity within hospitals and health systems.
There are obstacles that restrain the pursuit of this goal for the profession. Political opposition from the orthopedic community is one significant hurdle. Those in the know say the orthopedic community has traditionally been resistant to podiatrists requesting privileges and a scope of practice for treatment of the ankle and lower leg. Texas was the most recent battleground as there was plenty of legal jostling over whether podiatrists should be treating ankles (see "Texas DPMs Win Legal Battle Over The Ankle," News And Trends, September 2002 issue).
Those who have resisted defining DPMs as physicians usually cite inadequate training, more focused training in medical school and fears that podiatrists will want to manage conditions outside those of the lower extremity. While these fears have routinely been proven to be unfounded, podiatrists say the lack of standardized training is a major problem.
Citing the variability and inconsistency of training, one experienced podiatric surgeon and educator notes that currently, few DPMs can treat ankle fractures and few can perform procedures such as triple arthrodesis and ankle fusions. He maintains that the common denominator of highest clinical skill level among podiatrists is not where it should be. Those in the know say it’s fine to specialize, but when podiatric students have completed their education and training, they should be able to do it all when it comes to treating the functional foot.
It’s clear that standardizing podiatric education and training is vital to unlocking the door to a national scope of practice for podiatry. The recent move by the Council on Podiatric Medical Education to CMS-24 and CMS-36 residency programs with three-year programs being the gold standard has been hailed as a great first step. (See "Raising Expectations By Reforming Residency Programs" in this month’s "Forum" on page 84.)
Indeed, universal podiatric training is a worthy goal that should go a long way toward defusing the notion of podiatrists being "forefoot specialists" and reinforcing the stature of DPMs as true experts on the foot and ankle.