Scope Of Practice Update: Where Things Stand

Rachel L. MacAulay, Contributing Editor

   “Many orthopedists and MDs do not view us as ‘real doctors,’” notes Michelle Butterworth, DPM, FACFAS, who practices in South Carolina. “They go through four years of medical school and so do we. With evaluation of our schooling, I think they would see that our education is very similar to theirs. Unfortunately, they do not understand the depth of our education and training, nor do they really want to. We are not considered ‘equal’ to them because we have a different degree. This is a primary issue in our state scope of practice battle. Since we have a DPM (degree) and not a MD (degree), our scope battle has become very ego driven and turned into a turf war.”

   Most podiatrists undergo 11 years of schooling, just like MDs and DOs. Those who pursue a Fellowship with the American College of Foot and Ankle Surgeons (ACFAS) have an extra, year-long advanced training in specializations such as advanced rearfoot reconstruction and diabetic limb salvage. This puts them on equal footing, experience-wise, with orthopedists.

   “Our profession has had their problems because not everybody has had the same training. Some had one-year residencies and some had three-year residencies,” says Dr. Butterworth. She adds that recently, “all (podiatric) residencies have converted to three years, resulting in three years of surgical training at the very least. A lot of people are doing fellowships after their residency.”

   Licensing boards are leading the change. Currently, the State Board of Podiatry in Kentucky only approves licensing for podiatrists who have attended one of seven colleges of podiatric medicine. Applicants who have graduated from the more newly established podiatry colleges — the Arizona School of Podiatric Medicine at Midwestern University in Glendale, Ariz., and the College of Podiatric Medicine at the Western University of Health Sciences in Pomona, Calif. — currently have to wait for a license while the Kentucky board evaluates their college for academic standards and requirements.

   As part of the APMA’s Vision 2015 goal, a single three year training program — the Podiatric Medicine and Surgery Residency (PMSR) for all podiatric medical school graduates — began in 2011. This will help ensure that all new podiatrists have similar skills and knowledge before they go into practice, and it is just one of several steps the APMA is taking to standardize podiatrist’s education. The burden now is to ensure that an evolution in education leads to an evolution in scope.

   While a standard of education is a necessary step toward undermining any argument against enlarging the podiatry scope of practice laws, it appears that those who currently have the necessary education and training, even in some states with narrow scope of practice definitions, are able to practice what they were trained to do anyway.

   With a nod to the inter-professional relations touted by the APMA, most podiatrists I talked to were quick to point out that most allopathic and osteopathic physicians are not their opponents. Many work in the same practice and in collaboration with orthopedists, or treat patients with the help of “friendly” doctors, such as DOs. As with anything, knowledge and familiarity can lead to a better understanding.

Why There Is Looming Uncertainty In Many States With Reforms

As Dr. Pollak explains, while podiatrists were doing ankle work at small surgical centers and smaller hospitals in Texas, when courts first upheld the law expanding the scope of practice, larger hospitals that had been conservative in what they let podiatrists do had to then give them ankle privileges. Now that the decision may have been overturned, he says these same hospitals are not sure what to do.

   In the year since the state Supreme Court decision, the Texas Podiatric Medical Association has received requests for more information regarding the podiatric scope of practice from 80 hospitals and surgical centers. The bulk of these facilities decided that podiatrists were still legally allowed to perform ankle procedures, according to the Texas Podiatric Medical Association. However, the association notes that four facilities have terminated or at least put a hold on ankle privileges for podiatrists, pending further research.


Look at all the effort, expense and animus with the MDs we expend by trying to legislate our license instead of earn it. We would have the support of the MDs, increase our scope and, once and for all, end ALL podiatry's problems by changing our schools to have exactly the same 4-year curriculum and rotations, and announce our desire to offer the MD instead of keeping us apart with the disdained DPM.

It is time to drop the sentimentality of our chiropodal past and return to allopathy where we originated from. Even if the MDs acquiesce to "giving us the ankle," there's still the rest of the body and a majority of diseases we will be considered too inferior to treat. For the next 100 years, podiatrists will sue to creep up the leg. It IS possible to change pod schools to MD offering institutions but there are still too many frightened and lazy podiatrists who don't want the increased responsibility.

Podiatric politicians must be bold and brave at this stage, and scuttle the incrementalism associated with project 2015, which does not guarantee any increase in scope in and of itself. It will only provide grounds for another series of suits.

Dear colleague Dr. Bijak,

We are a specialist medical profession full of hardworking, intelligent, well educated professionals who need to explore and expand our limits. Yes, we need to prepare better. We all do.

Nevertheless, we as a profession specialized in an anatomical area need to do as other specialties do, allow the alpha dogs to cause that change and, as always, the time is now.

José A Mattei, MD, DPM
Chief of Medical Staff
Hosp Metropolitano Dr. Susoni
Arecibo, PR

According to the proposed law, the ankle means the skin. You mean since I did not complete a residency back in 1985, I cannot even cut the skin around the ankle to obtain a wound culture? And someone who completed a non-surgical podiatric approved residency in 1985 can be licensed to cut the ankle bones? How does this relate to current competence? Shouldn't proposed laws relate to current competence? Why not open it up equally for all podiatrists?

Furthermore, board certification by a nonsurgical podiatric board is not written as accepted in the law and the health commissioner may turn around and decide not to accept
a non-surgical board regarding cutting skin around the ankle to be able to get a culture and sensitivity of ankle ulcers. I should send my patients to another podiatrist who performed
a non-surgical podiatric residency program for treating and culturing ankle ulcers. How does this make me look in the eyes of my patients? Why should this law even be passed as written? There are other podiatrists in the same situation as me.

Disclaimer: The above comments are only my opinions.

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