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.