Thanks For Playing Orthopedics

Allen Jacobs DPM FACFAS

Increasingly, podiatric physicians are being employed by orthopedic surgery groups to provide varying levels of care for foot and ankle surgery. The degree of acceptance for podiatric physician care by such groups is somewhat variable. However, it would seem that overall the competency of podiatrists as physicians and surgeons has been increasingly accepted.

The trend toward acceptance of podiatrists as competent or equal healthcare providers is not however universal. As an individual who has the occasion to review charts for medical-legal issues, I still see numerous charts in which a patient, dissatisfied with the care rendered by a podiatric physician, receives subsequent care from a “real doctor,” typically an orthopedic surgeon, who informs the patient that his or her prior care was substandard as it was rendered by a podiatrist and not an orthopedic surgeon. In fact, I would say that this continues to be a very common occurrence, which results in litigation against the podiatrist. This presumes, of course, that an orthopedic surgeon by definition possesses greater diagnostic and therapeutic skills than a podiatric physician. After all, they have the MD to prove it!

Although in many instances relationships between podiatry and orthopedics have improved, particularly in situations of institutional care (e.g., Kaiser Permanente system, Veterans Affairs system, medical schools, public welfare clinics), this improvement is in no way universal, particularly in the private practice setting. As a drug lord advised Tony Montana in the movie Scarface: “Never underestimate the greed of others.” An orthopedic surgeon in private practice may be social enough but remember, “just because the lion is smiling does not mean that it is friendly.”

Not infrequently, I review charts in which the subsequent treating orthopedic surgeons refer to the prior care of podiatric physicians as “a podiatry misadventure,” a “podiatric misadventure” or “failed podiatry surgery.” Suddenly, a non-union of an Austin bunionectomy is a non-union of a podiatry surgery, a recurrent hammertoe a “podiatric misadventure,” persistent pain following a neuroma excision becomes a “failed surgery by a podiatrist.”

Memorialized in the medical records, these self serving attacks on our profession are reviewed by referring primary care or other physicians, insurance carriers and juries in cases of litigation. The implication of such statements is obvious.

There is also an obvious tendency to say that “she underwent surgery by a podiatrist.” It is always interesting to me how “the podiatrist” never has a name -- a member of some cult of quackery undoubtedly -- whereas orthopedic surgeons seem to always record, in respectful manner, the name of prior treating orthopedic doctors (who, after all, are members of a learned profession).

As an aside, I frequently have the occasion to evaluate and treat patients with “failed orthopedic foot surgery” or “failed foot surgery by an orthopedic doctor.” That is exactly how I document my observations to be read by the referring physician.

Typically, the subsequent treating physician proceeds to perform surgery after surgery to correct the podiatric misdeed, resulting in an unhappy foot, unhappy patient and litigation. When the patient remains less than improved following his or her trip down orthopedic foot surgery land, the victim ... er ... patient is informed that, “We have done all that we can do.” As a former resident of mine used to say, they take the money, could care less about the outcome, get the podiatrist blamed and sued, and essentially say: “Thanks for playing orthopedics.”

What A Few Recent Malpractice Lawsuits Reveal

Several recent cases in which I participated as a defense expert illustrate the point. In one case, a patient sustained a Weber B fracture of the lateral malleolus. Following four months of care by an orthopedist, she had a painful delayed union and sought the care of a podiatric physician. After two months of casting, bone stimulation failed to heal the fracture. The podiatrist revised the fracture and fixated it in proper order with a tension band. Although she healed the fracture, some months later when she was called to serve in the middle East with her reserve unit, the ankle suddenly became painful.

An orthopedic doctor, without the benefit of anything but his examination and standard X-rays, could see that the peroneal tendons were inflamed by the misapplied fixation in “an unfortunate podiatric misadventure.” The hardware was removed and the tendons were debrided of scar tissue from the misapplied fixation.

Following the orthopedic foot surgery, the patient rapidly developed a varus foot deformity and increasing pain. The orthopedic doctor then performed a second surgery and “discovered” a rupture of the peroneal retinaculum and PERONEAL TENDONS. Obviously, this was due to the surgery by the podiatrist, even though neither the varus foot nor the ruptured tendons were present prior to his first surgery.

In another case, a patient claimed she was unable dorsiflex her foot following an uncomplicated tarsal tunnel release. She consulted an orthopedic surgeon who declared that “the podiatrist placed her in a plantarflexed splint for 10 days,” which resulted in permanent contracture of the Achilles tendon. (I suppose he never conservatively treats Achilles tendon ruptures.) She was treated one month following her tarsal tunnel surgery with a tendo-Achilles lengthening (TAL) and repeat tarsal tunnel release. She developed an infection, required multiple debridements, another tarsal tunnel release, Botox injections and, surprise, was diagnosed with possible chronic regional pain syndrome (CRPS). All of this was the fault of “the podiatrist,” who did a “failed podiatry surgery.”

In another case, a patient underwent subtalar joint arthroereisis by a podiatrist for a flatfoot, which, in retrospect, was secondary to an occult talocalcaneal coalition with no foot rigidity, no spasm and no secondary coalition signs. When the true cause of the flatfoot was eventually detected, the patient left the care of the podiatrist and sought the care of a “real doctor.”

The real doctor noted “the failure of the podiatrist to recognize the actual cause of the problem and (the patient) was subjected therefore to a failed podiatry surgery.” Actually, it was the podiatrist who eventually diagnosed the problem. The orthopedic doctor then resected the coalition. Following that surgery, the patient developed a tarsal tunnel compression requiring surgery. She then developed peroneal tendonitis and was treated with a peroneal tendon debridement. She then developed a peroneal tendon rupture and sural nerve entrapment, each of which necessitated surgery. Then the patient developed subtalar joint arthritis and ultimately required a triple arthrodesis. All of this was the fault of the “podiatry surgery.”

Final Notes

My advice is simple. Document well preoperative findings. Document well preoperative disability, limited range of motion and so forth. Take the time to document range of motion and quality of motion. Document well your rationale for operative intervention. I fear that the EMR will create lazy documenters, relying on preset notes which lack individuality, not because of the system, but because of inattention and lack of input by the doctor.

Oh and one more thing. Thanks for playing orthopedics.

As always, I look forward to your comments.

Comments

Entertaining. I am tired of the blame game. Isn't the patients' best interest what needs to be served?

R. Dirksen, DPM

The blame game will exist forever. It occurs in every aspect of medicine when something goes wrong. There is always someone who thinks the initial doctor who addressed the issue could have done X, Y or Z.

My issue with all this and the first thing I bring up when this ugly situation comes up is a matter of expertise. I take comfort in the AMA article that points out that 80% of foot and ankle fellowship trained orthopedists didn't have a foot and ankle trained orthopedist on staff where they did their fellowship training. Some of them were even trained alongside their podiatric colleagues at these institutions. I need to find that article online to link it.

I loved "Batman Begins" and the gangster, Carmine Falcone, brilliantly comments that "people fear what they don't understand." This applies to some of our medical colleagues. Especially those who think they are better at what we do then we are. We are the experts. We just have to be better experts and rise above the challenge over and over again. I say, bring it on.

The funny part is that F&A orthos aren't usually to blame. Typically, they have enough of their own dirty outcomes floating around town that they won't throw the DPMs under the bus since they know it could easily be done to them in return.

Typically, it seems to me that it's the older generation orthos who like to "enlighten" patients that DPMs are incompetent with trauma surgery, etc. Their old fashioned mentalities persist and we pay the price. The most upsetting part is that most of those guys who love to bash pods do essentially noting but THRs and TKRs, and wouldn't know what to do with most of the F&A cases they're laying critique on. Many haven't touched anything distal to an ankle fracture or fusion since residency, yet they're happy to help plant any seeds that will make a patient litigious against a DPM.

Excellent blog by one of the most brilliant podiatrists in our profession. The best defense attorney too.

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