Interesting post. Daniel.  I would take exception to one "red flag" comment that you made.  You said, "Training and experience is not as important if the patient was treated properly and if the documentation is present showing that such proper treatment occurred."  This might be a practical opinion of yours, but it is not shared by most physicians with a general scope of practice and certainly is not shared by attorneys.  Training, not practical experience, is the benchmark for scope of practice. Many podiatric residents ARE getting training in the treatment of the system disease diabetes mellitus today, and limited by scope of practice definitions in the states they are licensed in, do have a strong basis for the argument that they can treat systemic diabetes, just as an ophthalmologist or urologist can do.

I have advocated for all podiatry residencies to add a rotating medical internship as a first year, in order for us to attain true parity with MDs and DOs.  You bring up the precise reason why....  

I have to agree with Alan about the issue of training.  Much of the first year of my 3 year residency was involved with rotating through various medical specialties.  I can as a result of my training manage a hospitalized diabetic patient.  However, the question becomes do I really want to manage my patients medically?  Managing the extremity complications of disease is complex enough without worrying about the patient's diabetic complications.  Do you really want to worry about which insulin method to use or the fact that your diabetic patient needs to be on an ACE inhibitor to protect their kidneys?  How about managing their hyperlipidemia?  Are you really updated on the most recent diabetic studies?  Do you want to be?  It's tough enough to stay current in our own field.

In many states the scope of practice laws are clear on this type of issue.  When a podiatrist diagnoses a foot-related symptom of a systemic disease then that podiatrist needs to refer to the appropriate doctor to treat it.  This isn't always black and white.  Many of us, for example, treat acute gout - a local manifestation of a systemic disease.  Perhaps a smaller number will treat the chronic component, while others will refer to rheumatology of back to the PCP.  The same is true for peripheral neuropathy.  Many of us prescribe meds like Lyrica or Neurontin for the pedal manifestations of this systemic disorder.

Another problematic exampe is lumbosacral radiculopathy.  According to the above statements by Dr Chaskin, I might extrapolate and say if I diagnose spinal stenosis as the etiology of this patient's foot complaint then as long as I read up on the internet I can perform the spinal surgery because I'm treating the foot.  I know - it sounds ridiculous.  My point here is to recognize our logical limits.  There's a reason neurologists, physiatrists, and neurosurgeons exist - to treat those disorders that manifest in their areas.

This is all besides the legal point Alan made above.  Let's say you treat your gout patient with allopurinol and as a consequence he goes into acute renal failure or, say, develops Steven's Johnson syndrome.  You'd better be able to deal with these complications or you won't have a leg to stand on in a court.  I can hear the lawyer for the other side, "Dr X, why were you treating this patient's chronic gout and renal failure instead of referring to internal medicine?"  You're going to have a hard time defending this as scope of practice.  

Our medical system is moving every day to a team approach to health care as evidenced by leaders such as Dr Armstrong's SALSA and Dr Steinberg's limb salvage group in Georgetown, not to mention the University of Texas limb preservation center of excellence and the evolving concept of medical home.  With medicine moving in this direction do you really want to be the doctor who starts insulin on his diabetic patient to treat a foot problem?

My advice is to stick to what you're comfortable and well trained in.  Don't do the internist's job.  Podiatry has plenty to keep us busy!

I read this comment "Let's say you treat your gout patient with allopurinol and as a consequence he goes into acute renal failure or, say, develops Steven's Johnson syndrome.  You'd better be able to deal with these complications or you won't have a leg to stand on in a court.  I can hear the lawyer for the other side, "Dr X, why were you treating this patient's chronic gout and renal failure instead of referring to internal medicine?"

Daniel Chaskin's response:                       

                       1. Please carefully read the wording in my post. No where did I say that a podiatrist is

licensed to deal with the complications of their treatment of "foot gout" if those complications

occur in pats of the body other than the foot. Your defense in a court of law is that you originally told

the patient that you are not licensed to treat other parts of the body and to see a medical doctor if

complications occur in other parts of the body. Also you told the patient that there may be "affects" of your treatment that may occur in other parts of the body. With limited scope of license of the body comes a limited liability.

                       2.  Regarding if training is the basis of scope of practice issues, who cares about this

if such training is out of date or more than 10 years old and has nothing to do with current competence.

This precisely why the whole system involving scope of practice should not be based on training

but current competence demonstrated by current experience or current residency training. Outdated

training more than 10 years old if it does not relate to current competence should in my opinion not

be a reason to grant licensure or scope of practice increases to podiatric applicants. Discrimination

against competent podiatrists who have not completed a podiatric residency program should be

addressed so that such podiatrists can freely qualify to be licensed in all states. Competent podiatrists

should not be forced to give up their practices to complete a certified residency in podiatric medicine.

                          Regarding lawsuits of a competent "nontrained" podiatrist.  A plaintiff lawyer has to prove that

malpractice has occured. So long as adequate care was given and documented if substandard

care is not proved by the plaintiff attorney, any lack of so called residency training is irrelevant. An astute

defense attorney would claim that their client who did not complete a residency if they had completed one

today, it would have been outdated and not related to current competence. Furthermore

an astute defense attorney will point out that if a plaintiff expert witness is present and completed

such residency training more than 10 years ago, they may point out that such training is

probably outdated and not related to current competence. Believe me, I believe more and more

defense and plaintiff attorneys may possibly begin to use such logic. If the care that was

given and not the so called training that may be outdated is the focus of malpractice lawsuits, credentialing decisions, licensing decisions, hopefully this will end discrimination against competent non residency trained podiatrists.

disclaimer: The following are my personal opinions. Do not rely on my personal opinions

but consult with a licensed health care attorney in your state.

podiatrist1@optonline.net

Daniel Chaskin

Regarding this comment: "Another problematic exampe is lumbosacral radiculopathy.  According to the above statements by Dr Chaskin, I might extrapolate and say if I diagnose spinal stenosis as the etiology of this patient's foot complaint then as long as I read up on the internet I can perform the spinal surgery because I'm treating the foot.  I know - it sounds ridiculous. 
Dr. Chaskin Podiatrist responds:
Please carefully read my post. A podiatrist is not licensed to operate and cut through tendons or bones to perform
spinal surgery because the spine is a body part other than the foot. However if the distal aspect of the nerve
is showing pain and an abnormal gait analysis of the left foot vs the right foot when the gait cycle is
timed using video analysis, then propper foot orthotics can treat the abnormal foot gait. But be
perfectly clear to the patient that you are not treating the radiculopathy and that they have to
see their medical doctor to treat all disease and pathology of body structures that are not the
foot.
                   Regarding podiatric residency training programs: before producing any more residency programs,
isn't it  important to address the discrimination that is occuring against competent podiatrists
that did not complete such training programs that would have been outdated if they had completed them?
I believe that a profession that addresses and prevents such discrimination from occuring
would have a compassionate accomplishment to be proud of.
disclaimer: Do not rely on any of the above opinions but please consult with a licensed health care attorney in your state.
podiatrist1@optonline.net
Dr. Chaskin Podiatrist

Quoting Alan Sherman above....As I review podiatric residency programs across the nation, I continue to see that more of them do include an internal medicine rotation.

"Way back when, in the day," I had good rotations that allowed me exposure to medicine. My experience was that the podiatry residents often, actually make that always, outshined the Yale residents (this was in Connecticut). But don't we always? We TRY HARDER.

A resident diagnosed a case of Herpes Zoster moments before a patient was taken to the OR for exploratory surgery for exquisite pain over the liver. EXPLORITORY SURGERY! Can you imagine?? I just happened to be the fresh faced intern who had walked in the door that morning at 4 a.m. for the first day of my reidency....and that was the first day that that patient's Zoster had decided to declare itself with skin lesions. I can't say that I made a friend of the 3rd year Yale surgical resident, nor the chief - 5th year resident. But damn it, I was proud of my accomplishment and the 2nd year Yalie  took me to the side later that day to give me a compliment as well.

But you know what, I was not unique and we all got better that first year for our medicine experiences because we learned what Dr. Levy had taught me back in Iowa....those feet are connected to a body and we have AN OBLIGATION to diagnose anything that happens to that body.  And while I was in my residency I did hernia operations, rectal exams, above knee amputations, femoral sticks, breast exams, straight caths, placed Swan-Ganz catheters, defibrillated patients, prescribed morphine drips for dying cancer patients, was the first on-call doctor in the SICU for four very nervous nights, wrote for cancer drugs, debrided skin from patients who had upper extremity burns and searched endlessly with a 5th year Yalie surgeon for a foreign body in the chest of a healed patient.

Will I ever do these things again or should I? No.     Am I glad I had the opportunity to do them. You bet your britches!

I agree with the above posts.  While during residency training I had the opportunity to manage a number of systemic diseases while part of internal medicine, orthopedic, and trauma, and plastic surgery teams.  I learned to effectively perform a history and physical, which i now continue to do for many (though not all) of my pre-operative patients.

I would caution against any podiatrist (and really ANY physician) who is operating beyond the scope of their training --even if they've had positive outcomes thus far.  The absence of previous bad outcome despite  no focused training will not protect you from litigation.  Especially if in doing so one is practicing beyond the standard of care.

I think it is important to recognize that the ability to do something does not necessarily mean that you SHOULD do something.  The literature demonstrates that outcomes are significant improved with the various medical specialties work together (each within their scope of their own specialty) to provide comprehensive care for the patient.

A perfect example of this would be effectively utilizing Infectious disease consults in the comprehensive management of  diabetic patients with osteomyelitis.  While theoretically i COULD also manage the antibiotic regimen, i feel it is most appropriate to include infectious disease specialists into the case to provide the greatest care for my patients.

In addition to providing better patient care through comprehensive interdisciplinary management, the improved interaction between the podiatric physician and other members of the medical community often results in increased podiatric consultations to the podiatrist, which can be a significant practice builder.  An excellent example of this from my own practice has been my referral of my neuropathic patients to a local neurologist who also does some work in pain management.  I certainly could prescribe the lyrica, Cymbalta, or Metanx, I have found it appropriate to refer these patients away for additional neurological testing (not EVERYONE with diabetes and neuropathy has diabetic neuropathy) and management.  Consequently, i have started receiving numerous new patient consults from this neurologist  (both surgical and nonsurgical) on everything from tarsal tunnel releases, neuromas, and heel pain.

This can be one of those great intersections  between excellent patient care and excellent practice management.....

I have to agree with Alan, Kathleen and Ryan's above (and abridged) postings.

The issue of systemic management of disease is not for us to treat, but to diagnose if there are pedal manifestations, and refer to the appropriate medical specialty.  In no way, should we, even with 12 months of internal medicine training, be managing a patient's insulin, rheumatologics, cardiac or even systemic antibiotics > 14 days.  This just isn't what we do for a living.  

We are specialists of the foot and ankle (and leg in some states).  Our job is to identify, diagnose and treat within our scope of practice and training.  While some states allow X, some others Y, but the issue is not what plaintiff lawyer A has to prove, but it is YOU, as Dr. XYZ, defend your actions relative to the standard of care.

All systemc diseases that I diagnosed in the last week were referred to specialists in my area for further follow-up evaluation and treatment.  I initited treatment modalities after discussing the case with the patient and communicating with the referred-to physician.  I don't want to manage some of these conditions, even as I agree with Ryan, I COULD, but I don't want to.  It's not my job.

I just also want to point out that unless you hold a Juris Doctor, there really should be no discussion regarding WHAT any attoney, plaintiff or defense, would interpret because there are a lot of readers/podiatrists on this forum from various states aound the country and the legal advice may not be appropriately offered.

Eric 

This thread I found particularly interesting. The question seems that if one can treat the systemic disease which may impact on pedal health, should we treat the systemic disease? ....yes or no? My feeling is that this cannot be answered as a straight "yes" or "no" answer. I will further clarify that my answer would be in the acute situation or immediate situation pending further consultations....yes. However, my point is that  further treatment of the underlying etiological state should be referred to the appropriate specialties. There are many reasons one may take this stance..... medical-legal implications of "failure to refer" should complications occur, incorporation of your practice into a "team" approach with other specialties and development of "good will" to further enhance your practice with other specialties. Many times I will discuss with the patient as part of my "canned speech" that "good medicine is where one treats the etiology rather than the symptomatology."  Dan brings up a good point however, in that you should be able to know how to treat systemic conditions that may impact on a patient's pedal health. If you want to impress your patients and their physicians be able to discuss with them their overall healthcare issues with appropriate treatments. In discussions with their medical physicians I have been met with many thanks and gratitude with development of referral sources from them.

A New York Podiatrist is licensed to treat the diabetes or high blood sugar in a patients foot, so long as they explain to their patient that they are not licensed to treat any other part of the body. If a podiatrist prescribes insulin and this has a positive effect on other parts of the patients body, the podiatrist has to clearly explain that they are not treating any other part of the body other than the foot.