Raising Questions On Training And Double Standards For Hospital Privileges

Ron Raducanu DPM FACFAS

The controversy rages on. Patrick DeHeer, DPM, reminded us of this in his recent blog, “An Open Letter To Foot And Ankle Orthopedic Surgeons,” in which he discusses how we need to take charge of the constant uphill battle we are faced with when dealing with our orthopedic colleagues (see http://bit.ly/eaTMrN ). Even though we have made great strides in our exposure and training, there are still questions as to our expertise.
 
The most recent glaring example of this is in the most recent issue of Foot and Ankle Specialist, which has a roundtable discussion on pediatric flatfoot and the various diagnoses and treatments pertaining to this complex issue.1 There were four participants in this roundtable, two podiatrists and two orthopedists. One of the two podiatrists is Harold Schoenhaus, DPM, one of the true pioneers in our profession as a whole but also in the realm of podopediatrics. I have been lucky enough to share the podium with him at various conferences and always enjoy hearing him speak.
 
If you happen to read this exchange presented, I am hoping you will quickly realize that our orthopedic colleagues are not as versed as we are in the biomechanics of the foot, the various ways to properly identify pathology and the various treatment modalities available for these small feet.
 
One of the most striking things in the roundtable article is that one of the orthopedists, when asked if surgery was warranted on seemingly asymptomatic flat feet, responded, “Never!”1 However, later in the discussion, one of the orthopedists on the panel recommends fusing the subtalar joint in a young patient with a certain level of arthritis noted on the magnetic resonance image (MRI) and a rigid flatfoot secondary to a tarsal coalition.
 
Really? So rather than evaluate this patient clinically, we check MRI and recommend fusion? I am always at a loss when faced with these scenarios and constantly wonder where exactly I was when our colleagues presented the lecture about that topic when I was a student.
 
I am now facing another issue, which many of us do when trying to secure hospital privileges at new facilities. I know for a fact that when an orthopedist applies for privileges, the medical executive committee does not ask the orthopedist for proficiency reports. I am trying to get privileges at a new hospital and the hospital is asking me for proficiency reports, even though I am board certified by the American Board of Podiatric Surgery and have been out of residency almost 10 years now. The hospital is asking for Quality Improvement(QI) data on my performance based on peer review by hospital administration.
 
I was shocked. I have never been sued (knock on wood) and have no disciplinary action in my record. I promise I am a good boy. Strange that some get a free ride and others have to continually prove their mettle to get what they need — not what they want, but what they need.
 
Is this double standard self perpetuated? I just do not know. I hope not. If it is self perpetuated, we need to stamp it out and make things smoother for the next generation. If it is not, the fight continues.
 
Reference
 
1. Kelikian A, Mosca V, Schoenhaus HD, Winson I, Weil Jr. L. When to operate on pediatric flatfoot. Foot Ankle Spec. 2011; 4(2):112-119.

Comments

I am alarmed to hear of the arduous bureaucratic process our colleagues face when recertifying residency programs while residency palcement declines. I am also concerned about the recent emphasis on Level 1 EBM. As presented, one would assume without such studies, our sevices have a weighted value near zero. We all know from our own patient successes this is a false dichotomy.

At the same time, we seem to be discouraging podiatric case and small cohort studies. I think too often we seek only binary problems and are confounded by multivariate solutions.

Curiously, the American Society of Anesthsiologists has for several years called for case studies to be presented in an online database as valuable in improving patient care and generating studies in anesthesiology.

In addition, I see a divergence in the studies indicating the need for more primary care and podiatric physicians while income trajectories trend downward.

I am also reminded of a recent excellent lecture presentation on surgical management of pediatric cerebral palsy patients in which cerebral palsy was defined as spastic cerebral palsy only. The absence of discussion of ataxic, athetoid, mixed and hypotonia occurred because the surgeon's universe captured the spastic child for intervention. Phenomenologically, the others did not exist for his practical purpose.

As a profession, we must be forward thinking and simultaneously develop metrics for promoting podiatric success. The recognition of our podiatric "utility" is obvious to vascular surgeons, diabetic specialists, radiology, sports medicine and wound care colleagues in general and to each of our patients who are treated in a satisfactory manner.

The acceptance of podiatry specialties into major hospital and university settings have been hard won successes to be built upon. And the process continues...

Let's get real here. The fact is that podiatry, as it climbs the stairs toward recognition, reveals itself to all of its almost universal lower standards with respect to education training and experience. As podiatrists become more vociferous regarding demands for increased privileges, they come under greater scrutiny by the general medical community. This is what is widely known: podiatry school is not medical school.

The scope of practice varies on a state-by-state basis forcing hospital chains reeling as to just what podiatrists can and cannot do in the U.S. This is time consuming and not an effective way to populate hospital staffs, especially with questionable practitioners. Too often, podiatrists extoll the virtues of so-called residency programs which are at best a reflection of the lowest tiered MD or DO training. Podiatrists actually do not fit in with the ever changing models for advancing the changes happening in healthcare. Until DPMs undertake the recommendations of the AAOS and institute the USMLE examinations parts I II and perhaps III, their education as well as core clinical clerkships in school, not in so-called resdiencies with no uniform standards, will not be considered remotely near that of an MD.

As long as podiatrists refuse to integrate their so-called specialty boards into the ACGME, they will remain an island onto themselves. There won't be an easy solution for podiatrists coming up the ranks as the more demands made by podiatrists, the more scrutiny will focus on just what the letters DPM stand for? Unity… hardly. Petty tyranism? Absolutely. Any DPM who thinks that things are rough for podiatry now need only watch and wait until the next crop of highly trained foot mechanics go job searching. Podiatry schools must get in line with the rest of medical education and training, or it will become no more than an interesting footnote in history.

Caddypod,

Interesting spin. You clearly have never dealt with the politics and administrative bodies within the AMA. Interesting how you also mention the D.O. in your comments as they are also having identity crises within their profession as well. I would be interested to know who you would prefer to have foot surgery by.

As an anecdote, the busiest foot and ankle orthopod in my area has been in practice for over 30 years. I did more bunion surgery in my first year in residency than this chap did in his whole CAREER. "Universal low standards"? I think you would be interested to know that the AMA released an article which basically said that 80 percent of the facilities that have Foot and Ankle Fellowships for orthopods DON'T have a foot and ankle fellowship trained ortho on staff to teach these fellows. Guess who is teaching them? Podiatrists are. Maybe podiatrists should stop teaching their art to those who criticize them so vehemently.

Hmmm ...

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