Why Complete H&Ps Should Be More Common In Podiatry
In recent years, there has been more of an emphasis upon podiatrists performing their own history and physical examinations (H&Ps) for the purposes of hospital admission. This was spurred on to a large degree by the pivotal ruling by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 2000 and the new residency models required by the Council on Podiatric Medical Education (CPME), which now require a minimum number of history and physical examinations during the residency training period.1,2 Most training programs will certainly exceed this number. In December 2000, JCAHO clarified that permitting DPMs to conduct medical history and physical examinations independently was consistent with its standards and is in keeping with the delivery of safe, high-quality healthcare.1 While the JCAHO interpretation was instrumental in the push for DPMs to become more involved in performing their own preoperative H&Ps, this did not resolve the issue completely. The JCAHO interpretation was subject to applicable state laws and podiatric physicians being granted such privileges by their hospital. In some hospitals, medical staff bylaws may still present a formidable hurdle. More recently, the Centers for Medicare and Medicaid Services (CMS) has also clarified its position regarding DPMs performing admission H&Ps.3 Up until this year, section 1861 (r) of the Social Security Act ruled that a medical history and physical examination must be performed by a physician. A physician was defined as a doctor of medicine or osteopathy, and included oral surgeons. In March, CMS proposed a revised rule on Conditions of Participation of services (CoPs) for hospitals that would allow a “medical history and physical examination ... by a physician (as defined in section 1861 (r) of the Social Security Act), or other qualified individuals who have been granted these privileges by the medical staff in accordance with state law” on admitted patients covered by Medicare. This is an area that the American Podiatric Medical Association (APMA), the American College of Foot and Ankle Surgeons (ACFAS) and other organizations have been in contact with CMS and JCAHO over a long period of time.4 It is likely that the proposed new ruling will come into effect after a 60-day comment period from the date of the proposed revision and followed by a final policy change that may take another eight to 10 months to implement. This proposed ruling again adds weight to the case for it being more common for DPMs to perform their own admission and preoperative H&Ps. The key issue with regard to the proposed CoPs revision is that it should now resolve a potential non-payment issue for a hospital if a DPM has performed the admission H&P. For frequent, independent podiatric admitters, this will remove an enormous financial obstacle.
How The Scope Of Practice Issue Figures Into The Equation
One of the main problems affecting this issue is the lack of a clearly defined national scope of practice for podiatric medicine. Currently, there are no two states with an identical scope of practice for DPMs and very few that clearly define the issue of admission and preoperative H&Ps. Most states have a hospital administrative code that delineates who can admit patients. Some states have recently revised these codes to include podiatric physicians. 5 Many state laws on podiatry allow DPMs to function as licensed, independent medical providers. In these states, performing a H&P is a right that every DPM has within his or her licensure. Unfortunately, the specifics of the physical examination are rarely delineated. However, I believe the interpretation should be left up to the independent, licensed practitioner. The issue of “Should I be doing a more comprehensive type of examination?” or “Am I allowed to perform this type of examination?” should not really present a problem. More often, it is the individual’s practice philosophy that is the source of any discomfort when it comes to performing more comprehensive examinations. However, unless the profession embraces the concept of independent admission and preoperative H&Ps performed by all podiatric physicians, we are not fulfilling our full potential.
Developing A Greater Comfort Level Beyond The Podiatric History And Physical Exam
The reality is the podiatric examination is a very limited body part examination. Until recently, many podiatric educators have overemphasized this limited examination at the expense of other areas of physical examination. Granted, there are other limited types of physical examination such as the orthopedic examination (upon which the podiatric examination is loosely based) and the ophthalmologic examination, etc. However, these other limited body examinations are well understood and recognized throughout medicine. The problem with the “podiatric examination” is it is relatively unknown outside of the specialty and there is little reference to it in the more popular physical examination texts. 6-8 The introduction of the Evaluation and Management Guidelines in 1997 did help expand the nature of the podiatric exam. 9 While students may have been exposed to the podiatric examination as early as the PM1 or 2 year, there may have been no introduction to the complete H&P until as late as the PM3 year. In the past, while some may have had exposure to it during an internal medicine rotation during an externship or residency training, the majority of students may not have the opportunity to reinforce their skills in performing complete H&Ps during podiatry-specific rotations. This is troubling as students or residents may not develop a comfort level in looking beyond the foot and ankle in terms of the physical examination of a podiatric patient. 10 This is changing gradually as more U.S. podiatric medical schools are introducing physical diagnosis as early as the PM1 year and certainly by the PM2 year. Casual observation of our current PM3 students at the Scholl College suggests a greater comfort level than we saw with PM3 students at the same stage of training five years ago. There is at least one limited study that would reinforce the notion of more recent podiatry school, pre-residency graduates having a stronger comfort level in performing a complete H&P than graduates from 15 and 20 years ago. 11 There could be several reasons for this beyond the earlier introduction of physical diagnosis courses. There is a greater emphasis today upon general medicine, general surgery and emergency medicine being part of the core rotations in the four-year program. Each of those rotations allows current students much greater exposure than previous students in honing the complete H&P skills. Along with the introduction of the new residency models, namely Podiatric Medicine and Surgery 24 (PM&S-24) and 36 (PM&S-36), there is also a greater emphasis for residents on perioperative involvement as well as preoperative management including preoperative H&P skills. 2 Getting comfortable beyond the podiatric physical examination at the student/resident level probably requires more than just practicing these skills in a non-podiatric setting. Students and residents need to see this being reinforced in the podiatric setting as well. There are no studies available regarding the number of podiatric physicians who routinely perform their own admission and/or preoperative H&Ps. While this number will surely increase in the future, casual observation again suggests a reluctance on the part of many podiatrists at the present time. When it comes to our graduating residents, I tell them the first privilege they should apply for once they are members of a hospital medical staff is not necessarily surgical privileges but the privilege to perform their own admission and preoperative H&P. It may seem rather obvious but this is actually the number one privilege to square away in front of a hospital’s privileges committee. This is particularly the case if one is applying to a hospital in a state where the law allows for the privilege but no one in the podiatry department/section has yet obtained the privilege. Too often, there is reference in the medical staff bylaws to podiatric physicians being allowed to perform the “podiatric examination.” This type of terminology is becoming outdated and needs to be replaced with more generic terminology regarding H&Ps.
Addressing Other Potential Issues
In regard to other potential stumbling blocks, the lack of practice or training at the H&P process is easy to overcome. For practitioners fresh out of residency training, there should be no issue. Podiatric physicians are already well versed in taking patient histories as part of their daily practice. Also keep in mind that more and more institutions are offering CME update courses in performing H&Ps. 12 Once one has acquired these skills, it is simply a matter of honing them on a regular basis. For example, listening to heart sounds or lung sounds on a regular basis should enable one to identify an abnormality and make an appropriate referral. There are very few, if any, podiatry practice acts that prohibit the examination of the human body as part of the diagnosis and treatment of a foot or ankle problem. In fact, one could very well argue that examining other body areas via a physical examination is indeed necessary to arrive at a diagnosis. 13 Almost every podiatric practitioner has patients who have asthma or have an atrial fibrillation or flutter. The more one listens, the more one becomes comfortable. It is simply a matter of practice. Podiatrists may detect something that has been missed by another treating physician. Documenting the findings of a more comprehensive type of physical examination will also help reinforce what one observes and also aids DPMs in becoming more comfortable with the terminology. That said, there is a concern about missing a physical examination finding outside of the foot and ankle and being held responsible for it. Another popular notion is that if we don’t perform the complete preoperative H&P, we can avoid a portion of the liability in a malpractice case. This has been disproven on several occasions when there have been postoperative complications in a podiatric surgical case. This brings us to the question: What is the purpose of a preoperative H&P? In short, it is a screening and risk assessment type of examination and podiatrists should apply this to their patients irrespective of the simplicity or complexity of their problems. In other words, after assessing the results of the physical examination and history taking, the podiatric surgeon should be comfortable making the call that a patient is medically stable and can undergo a planned procedure. Podiatric surgeons should also feel comfortable making the decision to take patients to surgery based upon the results of the physical examination. This should be particularly true for patients in the ASA I and II categories. If one detects an abnormal finding or complicating medical problem during the preoperative examination, then he or she should pursue an appropriate consult with a medical colleague. This general concept already applies across the board in allopathic medicine. Although the orthopedist possesses an unrestricted license to practice medicine, very few are going to attempt to manage a medical comorbidity on their own. Similarly, podiatrists need to recognize their role within the multidisciplinary team.
Understanding The Benefits Of Performing Complete H&Ps
There are essentially two and they both benefit the patient. First, there is the concept of “one-stop shopping” for the patient, particularly in the case of an ASA I or stable ASA II patient. There is nothing more frustrating for the patient than needing to see two separate physicians in order to have an elective (or non-elective) surgical procedure done. More involvement adds to the overall cost of doing business and, in many cases, it is an unnecessary burden on the patient and the system. It is frustrating for the involved physicians as well. There is at least one insurance company that now has a fixed amount for a surgery package regardless of how many providers are involved in providing the services. This can be as little as 10 percent of the global fee for the preoperative management. 14 It is already difficult at times to find a primary care provider (PCP) willing to take on ASA I type patients simply for “medical clearance” for surgery. Moves such as this by insurance companies will not improve matters. In fact, for continuity of care issues, it makes perfect sense for the surgeon to be the one who provides clearance for such patients. There is another and perhaps hidden benefit for the provider in this set of circumstances. In the patient’s eyes, the surgeon is now his or her doctor. He or she is responsible for getting the patient through the operative experience. This should add an overall sense of satisfaction for the provider as he or she can fully live up to the role of podiatric physician as opposed to the notion of being a “foot doctor,” which may have different implications. Yes, it does force us to look at ourselves in a different light and that is not a bad thing. Additionally, those who admit their own patients have more control over what happens to them. This is particularly true when it comes to admissions for diabetic foot infections. Depending upon the practice climate (insurance, etc.), one can control the choice of consultants, choice of medications, etc. There are countless anecdotal stories of how no one listened to the advice of the podiatric consultant on a case and how the podiatrist’s role was relegated to that of a passive follower as opposed to being an active manager.
In regard to the aforementioned fear or concern about the increased responsibility for the patient due to performing the complete H&P, consider the following question. Is there any less responsibility in performing complicated reconstructive foot or ankle surgery than there is in performing a physical examination on a healthy or medically stable patient? Podiatrists are the premier providers of foot and ankle care. We are doing our patients a disservice if we strive for less at this stage of our professional development. We have developed from chiropodists to physicians. It is incumbent upon every resident graduating from a program today to obtain these basic medical privileges when they apply to hospital medical staffs. Some practitioners will rightly claim that they have developed good referral bases from primary care providers over the years by having them perform the exact process that we are advocating that they perform themselves. Why should they rock the boat now and jeopardize their practice base? This is the price of progress and it not going to change the way we practice overnight in any case. Clearly, there are still patients who we will need to refer to another specialist or generalist for further work-up before surgery. We will not lose those relationships. Clearly, this a charged issue and like many issues that have factored into the development of podiatric medicine in the United States, the idea of podiatrists performing their own H&Ps will have its supporters and detractors. Not every practitioner is going to want to do this and that is fine. Not every orthopedist (a close parallel) wants to do this but at least the mechanism exists should orthopedists choose to do so. With recent changes in JCAHO, CoPs, CPME residency requirements and state hospital administrative codes, the stage is set for complete H&Ps to become a widely and commonly accepted practice for podiatric physicians. To those already involved in this aspect of podiatric practice, share this knowledge with others. To those who are reluctant to perform complete H&Ps, aspire to new heights of practice. Dr. Yorath is the Chairman of the Department of Surgery of the Dr. William A. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine and Science in Chicago. He is the Director of the Podiatric Medicine and Surgery-36 Residency Program at the Advocate Illinois Masonic Medical Center in Chicago. Dr. Yorath is a Fellow of the American College of Foot and Ankle Surgery, and the American College of Foot and Ankle Orthopedics and Medicine.
1. Manual/Standards, 6.2.2, JCAHO. December 22, 2000.
2. Standards and Requirements for Approval of Residencies in Podiatric Medicine and Surgery, CPME, January 2003.
3. Conditions of Participation of Services for hospitals, Federal Register, 3/25/2005.
4. ACFAS, Bulletin, Vol. 7, Issue 1, January/February 2001.
5. Illinois Hospital Administrative Code, Section 250.320, January 31, 2003
6. Bickley S, Hoekelman R. Bates’ Guide to Physical Examination and History Taking, 7th Edition, Lippincott, 1999
7. Novey, D. Rapid Access Guide To the Physical Examination, Year Book Medical Publishers, Inc., 1988.
8. Expert 10-Minute Physical Examinations, 2nd Edition, Elsevier, Mosby, 2005.
9. Evaluation and Management Guidelines, 1997.
10. Syllabi in General Surgery (PSUR 804), Internal Medicine (CPM 403), Emergency Medicine(CPM 404), Essential Skills Podiatric Medicine (PMED 701), Essential Skills Surgery (PSUR 701), Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science.
11. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine And Science Post-Graduate Satisfaction Survey, 5, 10, 15 and 20 year Follow-Up, May 2005.
12. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine And Science, State-of-the Art History Taking and Physical Examination Review: Improve Your Clinical Efficiency, March 2005
13. Personal communication, Legal Counsel, Advocate Illinois Masonic Medical Center, January 1993.
14. Aetna, Inc. Global Fee Rule, January 1, 2005.