I ran into the following article which caught my attention:

Nurse Pract Forum. 1996 Sep;7(3):120-4.

The ankle joint: the evaluation and treatment of sprains.

Abstract

Nurse practitioners in a variety of settings may frequently be called upon to examine a patient with an ankle sprain. These sprains are extremely common and are easily and successfully treated conservatively. However, a chronically unstable ankle may result if certain treatments are not instituted almost immediately after the injury. For the purpose of this article, the anatomy of the ankle and its examination are reviewed, including the ligaments injured with inversion, eversion, dorsiflexion, and plantar flexion injuries. Key studies and laxity tests are described. Principles of treatment are explained with mention of various treatments and products that can be easily used in any setting. Finally, preventive suggestions are made so that nurse practitioners can educate patients on how to avoid these annoying injuries.

 

We are living in an era where other specialties are increasingly stepping on "our turf". While I understand some area are underrepresented by Podiatry, I have been seeing a pattern of decreased referrals to specialists and more General Medicine / Internal Medicine / Family Practice physicians attempting to treat conditions they normally would have referred out.  I have seen this in my visits to doctors offices in various parts of the country and several of my Podiatrist friends have also noted this alarming pattern. Could this be a sing of the financial times? I'll guess yes.

When I was in practice, I had a few General practitionerswho'd send me their heel pain, nail care, ankle sprain patients routinely. My last year in practice saw an increasing trend for these MD's / DO's to try a heel spur injection or two before sending the patients over. I even had a General Practitioners try to treat a venus stasis ulcer once per week for 6 weeks before he finally "gave up" or didn't want to deal with it before he referred the patient over. Usually these cases are mismanaged to a degree (for example - 6 weeks of bactroban the MD's 'cure all' for wounds with no compression in the setting of a venus stasis ulcer). I think it may be a case (one MD actuallyadmitted to be once that my suspicions were correct) of the MD's / DO's trying to squeeze in one or tw more visits or injections before sending the patient out. Yes, they mean well for the patient in that they actually think they are going to help - but they very well could actually be doing better for the patient BY sending them out to an appropriate specialist.

What are your thoughts on this?

 

  • Comments (10)
  • I am not sure why the discussion was limited to ankle sprains. Alex - I find the same holds true for any pedal complaint and is not limited to the nurse practioner.More and more if one presents with heel pain to a PCP - I find a few who used to refer now attempt one or 2 steroid injections before even referring the patient out.And as you already alluded to - I think money has alot to do with it. 50 - 70 bucks an injection - well heck yeah, they'll try jabbing the heel once or twice. That's life.In most cases its not even up to the patients either as the PCP, Nurse practioner or whomever are the gate keepers of some plans. A patient might think to go to the foot doc only to be stopped and treated by the gate keeper.
  • I think it is a matter of triage.  We can all agree that all primary care providers function in a triage capacity for essentially all specialties --consider their referrals to cardiology, nephrology, podiatric surgery, orthopedics.  The opportunity for us is to educate members of the NP community to the value of early referrals to podiatric/ orthopedic specialists when considering ankle sprains...  Every day we have the opportunity to develop these referral patterns....

  • Dan, a Podiatrist since we (for the most part) can treat ankles.

    The ankle is defined in NYS under the new law.

    "

    THE PRACTICE OF PODIATRY MAY ALSO INCLUDE DIAGNOSING, TREATING, OPERATING AND PRESCRIBING FOR ANY DISEASE, INJURY, DEFORMITY OR OTHER CONDITION OF THE ANKLE AND SOFT TISSUE OF THE LEG BELOW THE TIBIAL TUBEROSITY IF THE PODIATRIST HAS OBTAINED AN ISSUANCE OF A PRIVILEGE TO PERFORM PODIATRIC STANDARD ANKLE SURGERY OR ADVANCED ANKLE SURGERY IN ACCORDANCE WITH SECTION SEVEN THOU SAND NINE OF THIS ARTICLE. "

    In order to even medically treat the ankle or ankle sprains one must meet the criteria above if they are a
    podiatrist in NYS. If the criteria above is not met one is not licensed to medically treat ankle sprains and
    if they are not licensed to treat ankle sprains how can they advertise they do this? However they
    can treat foot sprains. And the foot contains skin and ligaments at the level of the ankle. Furthermore
    the treatment of the foot can be done which affects other body parts so long as the other body parts are
    not being "treated". The whole concept is to make the public aware we only treat the foot and not the
    ankle and if the ankle is affected by a foot treatment the ankle is not being treated. Therefore in
    no way whatsoever in NY should a podiatrist without an issuance of a privilege to perform
    podiatric standard ankle surgery or advanced ankle surgery advertise or represent themselves licensed in NYS
    to perform or treat ankle sprains but they can represent to the general public that they treat foot sprains.
    The above is just my personal opinions regarding when the above NYS law takes effect. The whole key is that
    the "ankle is defined in NYS law as "
    FOR THE PURPOSES OF THIS ARTICLE, THE TERM "ANKLE" SHALL BE DEFINED AS THE DISTAL METAPHYSIS AND EPIPHYSIS OF THE TIBIA AND FIBULA, THE ARTICULAR CARTILAGE OF THE DISTAL TIBIA AND DISTAL FIBULA, THE LIGAMENTS THAT CONNECT THE DISTAL METAPHYSIS AND EPIPHYSIS OF THE TIBIA AND FIBULA AND TALUS, AND THE PORTIONS OF SKIN, SUBCUTANEOUS TISSUE, FACIA, MUSCLES, TENDONS, LIGAMENTS AND NERVES AT OR BELOW THE LEVEL OF THE MYOTENDINOUS JUNCTION OF THE TRICEPS SURAE. "

    and "
    2. The practice of podiatry shall not include treating any part of the human body other than the foot, "
    and so the ankle is a part of the human body other than the foot.

    Am I correct in my opinions?

     

    My opinion of the wording of the NYS law that passed and will become effective is that a sprain of the ankle as defined under the NYS law would be illegal for a podiatrist to treat unless the podiatrstist meets the criteria under the NYS law for a privilefe to perform podiatric standard ankle surgery or advanced ankle surgery.

    Two possible ideas I came up with to possibly advocate for:

    One technique that can be used is to have NYS pass a law that says any podiatrist in a sister state licensed to treat the ankle can do so in NYS. This I believe is a wonderful and easy approach to attempt to get every currently licensed podiatrist with at least 10 years experience a chance to get licensed in a sister state and to advocate for a NYS law allowing reciprocity regarding "ankle surgery privileges".

    One approach that can be advocated for is to have NYS pass a law that says any podiatrist in a sister state licensed to treat the ankle can do so in NYS. This I believe is a wonderful and easy approach to attempt to get every currently licensed podiatrist with at least 10 years experience a chance to get licensed in a sister state and to advocate for a NYS law allowing reciprocity regarding "ankle surgery privileges".

     

    Do you think the NYS legislature needs a reason to offer "ankle soft tissue medical and surgical care "   to all podiatrists? A compelling argument is if in New Jersey a podiatrist is licensed to treat ankle fractures there is no reason that same podiatrist cannot invite that New Jersey patient to go to their NY office to treat the ankle fracture. It encourages outside residents to visit our state and increase their tourist economy. Therefore a financial impact in a positive fashion. Why should a state turn away tourists who come to NYS for podiatric care?

     

     

    Another possible approach for podiatrists who may not have 10 years experience or a license in a sister state: under the wording of the NYS law there is no specific mention of any specific board or any particular podiatry organization  or any particular podiatric accrediting agency.  This opens up the door for other podiatric organizations to form and to have additional accrediting organizations with perhaps less stringent criteria so as to form additional "podiatric medical and surgical residencies that may not be perhaps recognized by any current podiatric accrediting agency that we currently know about but by an additional accreditating agency outside the scope of any current podiatric society with less stringent criteria but enough to meet the legal requirements to meet the criteria as proposed in the NYS law. In doing so it it quite possible to legally get all graduating podiatrists licensed without any future residency shortge in the future and to enable all currently licensed podiatrists in NYS to become licensed to treat "ankle sprains as per the definition of ankle as defined in NYS law. Such an accomplishment does not necessarily need any current podiatric organization but could perhaps be done by having podiatric schools set up additional podiatric accreditated residency programs not that will perhaps not meet the standards of any current accredidating agency but the future agencies that perhaps schools can form. Look at the law. To treat an ankle sprain a 2 year residency in podaiatry medicine and surgery and certification in rearfoot surgery by an accreditation agency acceptable to the dept ALL JUST TO BECOME ABLE TO TREAT AN ANKLE SPRAIN AS PER THE DEFINITION OF THE ANKLE UNDER THE NYS law. If the law is "crazy" but legal why not set up a "crazy" but legal system so evey podiatrist can be enabled to meet the legal definition of the current law passed in NYS so as to be enabled to become licensed to treat "ankle sprains" as per the definition of the ankle under the NYS passed law.

    As per the question above: a nurse practitioner should not be referring ankle sprains to any practitioner not licensed to treat the ankle as per any state law. They should only be referring ankle sprains to licensed practitioners or treating such conditions themselves.

    The above represents my personal opinions and possible solutions:

    Daniel

  • Quote:

    First of all, an "appropriate specialist" would be an orthopedic surgeon, or yes Dan, a Podiatrist since we (for the most part) can treat ankles.

    That being said, I am of the opinion that podiatry should be treated as any other specialty by the referring MD/DO (or their nurse practitioner / PA). If a patient has a renal issue they get referred to a nephrologist, if a patient has a heart issue they get sent to a cardiologist, etc. For example, can the general practitioner treat / manage hypertension, diabetes or some cardiac condiitons themselves? Why yes of course - but there has to be a certain point where that patient would be better managed by the specialist and it is up to that individual physician to know when to refer. I find it curious though that with a faltering economy, many general practitioners are choosing to try to "keep things in house"' longer than they may have in the past. may this be occurring more with just podiatry vs other specialties, I'm not sure.

    Alex,

    First of all, I agree with David, NPs now function in the role of PCPs in many facilities, we had a blog regarding this growing trend a while back.  Therefore I believe the function in the capacity of treating initial injuries and refer when they believe is appropriate.

    Some scenarios surrounding what we may consider delayed referral include:

    1. They really believe they are initiating a course of treatment that is appropriate in regards to standard of care.  Many can implement a conservative management course and refer appropriately if there is no response. 

    2. Faltering economy, yes, but not necessarily a sole decision of the primary whether MD, DO or NP.  Many times it is the patient who does not want to pay a higher co-pay to see a specialist.  And if there is treatment their primary can initiate, they tend to be receptive to going this route first as well

    3. I also believe many doctors or NPs who function as the PCP have been asked to initiate a level of treatment before referring to a specialty service and in essence, exhaust the basic conservative steps to certain ailments/pathology.  For example, ortho at our facility likes if the primaries will do a knee or hip injection and if no response they can refer to ortho for further management options.  I believe something like an ankle sprain sees initial management such as this.  Keeping in mind that family practitioners and medicine graduates will at times do a sports medicine fellowship as well and gear their practices towards this.

    4. Finally, whether we like to admit it or not, Many NPs are still not aware of the role podiatrists can play in addressing problems of the ankle.  So I do not believe it is that they don't want to, but more a case of lack of knowledge and knowing they can.  This is where we can continue to make an educational impact given the growing number of NPs in the PCP role....and even now in the Emergency Rooms where many of these patients may go first.

    The VA we are at is full of NPs in the role of primary provider.  Copying them on consults and keeping them in the loop through educational conferences and open communication has been key in regards to increasing their knowledge on approriate referral.

    I personally do not feel I have seen less of a referral base given the role of the NP.

  • Alex,

    That's an argument doctors lost a long time ago. Statistically it's less expensive for a small percent of patients to get less than optimum treatment and have a poor result as a consequence.

    I don't think it's the PCP's trying to keep more money, though I'm sure that plays a part. I think it's a move on the part of insurers to maximize their profits.

  • Dan:

    I'd agree with you to some degree. If one CAN - yes, get the MD degree and hopefully one can match to a residency of their liking. An MD degree certainly gives you the versatility in one's practice which a DPM degree certainly does not provide. That said, Yes, Podiatrists certainly provide the best comprehensive foot care and Podiatrists referring to other DPM's is certainly a good thing.

    David:

    I completely understand the role of Nurse Practitioners in today's day and age with the economic climate taken into account. I understand and respect other medical providers handling the "simple / routine" stuff. What I have a potential issue with is other providers trying to treat something they may not have the expertise to handle & problems they would have normally referred out in the past; it's especially worrisome if this practice is occurring simply as an attempt to increase revenue in the name of patient care taking secondary role.

  • Alex,

    Nurse Practitioners function as PCP's now. It would be expected that they take care of simple ankle sprains and refer out the more complicated and/or non-responding ones. The same as any PCP MD would do.

  • "That said, with all due respect Dan, most of us on here know very well your plight & the unfair treatment you feel you ave been subjected to."

    DEAR Alexander, how can this be about me it the subject matter I am bringing up is the inability to get licensed as a podiatrists for unlucky podiatrists who did not get a match? THIS IS NOT ABOUT ME BECAUSE I ALREADY GOT MY LICENSE TO PRACTICE in New York, New Jersey and PA. I am trying to be compassionate about the plight of all those podiatrists that cannot get licensed in New York and other states that already require residencies. Just because I was "grandfathered in" I am still aware of the position of others less fortunate and to me this is the highest priority so as to get licensed first and then to worry about an increase in scope. Then again there may be podiatrists new to this that are not aware of these opinions. Basic licensure rights for all podiatrists that graduate an accredited school of podiatric medicine. My comment is that just because a podiatrist is lucky to get licensed general MD's also may be licensed to treat the foot who may be interested in treating the foot.

    In podiatry what preference is given to any podiatrists who already have been denied once from a residency match and if none is given wow won't even more undue hardship occur for those who are denied and if states still have such minimal screening criteria regarding licensure. Why not forget about podiatry school and get an MD degree and perhaps won't your chances of getting licensed with a license to treat the foot increased by more programs available to get an MD license? ANYWHERE IN THE COUNTRY WAS A GRADUATE FROM A MEDICAL SCHOOL DENIED A MATCH FOR RESIDENCIES FOR 2 YEARS IN A ROW WITH MEDICAL DOCTORS? Why did this happen in podiatry to some?

    Back to the topic of "turf and appropriate care which I have some questions about"

    "By the way did you ever hear of a hospital requiring a 2 year PSR and certification in rearfoot surgery for the ability to initially apply for the privilege of draining an onychia?" How can most podiatrist support the current system  when there are hospitals out there and states out there making all these regulations preventing podiatry graduates from draining onychias? This is why I belive it is better to get an MD degree so as to be enabled to be credentialed to drain an onychia because with that MD degree it is much easier to achieve the legal ability to do so. By easier I mean greater chances of becoming licensed or credentialed to do so. Once licensed this opens up the door to aquire experience which leads to current competence.

    As per a direct answer to your question:

     

    MD's are referring to podiatrists and this is to better enable their patients to be treated by specialists who are familiar with foot care. I too refer my patients to other podiatrists for second opinions. Bottom line is it is not only the MD that refers to podiatrists but others do as well. I believe that generally podiatrists are excellent providers of foot care. The more licensed podiatrists the better because the public needs us. We provide a valuable service.

     

    Daniel

    class 84

  • First of all, an "appropriate specialist" would be an orthopedic surgeon, or yes Dan, a Podiatrist since we (for the most part) can treat ankles.

    That being said, I am of the opinion that podiatry should be treated as any other specialty by the referring MD/DO (or their nurse practitioner / PA). If a patient has a renal issue they get referred to a nephrologist, if a patient has a heart issue they get sent to a cardiologist, etc. For example, can the general practitioner treat / manage hypertension, diabetes or some cardiac conditions themselves? Why yes of course - but there has to be a certain point where that patient would be better managed by the specialist and it is up to that individual physician to know when to refer. I find it curious though that with a faltering economy, many general practitioners are choosing to try to "keep things in house"' longer than they may have in the past. may this be occurring more with just podiatry vs other specialties, I'm not sure.

    That said, with all due respect Dan, most of us on here know very well your plight & the unfair treatment you feel you ave been subjected to. In my opinion, not EVERY point of discussion here on this forum relates to the residency shortage when you graduated. I understand how you may feel as you were cheated by the system and how an unfair advantage may exist.

    So, keeping on my original topic; Dan, do you feel MD's/DO's are referring less to podiatrists, is it about the same, or have you noticed a difference?

    Do you feel that MD's/DO's should refer out more than they do to podiatrists (in your experience) or is it "about right"?

  • In NYS the ankle is defined as a different anatomic structure than the foot. If a podiatrist is not licensed to treat the ankle they are not licensed to treat any condition of the ankle including ankle sprains. Thus it would be inappropriate for any nurse practitioner to refer an ankle sprain to any individual not licensed to treat the ankle as per under NYS law. Please familiarize yourself with the wording of the NYS law as per recently passed and also as per the definition of the ankle as per under NYS law. Then again when I travel to New Jersey I find that an appropriate specialist would include a podiatrist who is licensed and practicing in New Jersey.

    Let me say that I am proud to be a podiatrist under the system in which I was able to get licensed and I feel that for me it is a profession in which I can help others.  The problem is the system has changed so that others who become podiatrists may suffer financially due to an inability to have podiatric residency programs give preference to them if they already were rejected once from a match process. No podiatrist should have to go through 2 years in a row of not being matched. There is no such process to protect against this and podiatrists graduating find it difficult to get licensed to earn a living.

     

    What is 'OUR TURF" AND WHY SHOULD WE EVEN address this issue without first addressing and advocating for other podiatrists who are less fortunate than ourselves who cannot get licensed.  Only after every podiatrist can get licensed should this be brought up because isn't the MD degree path the way to go?

    My last year in practice saw an increasing trend for these MD's / DO's to try a heel spur injection or two before sending the patients over. I even had a General Practitioners try to treat a venus stasis ulcer once per week for 6 weeks before he finally "gave up" or didn't want to deal with it before he referred the patient over.

    What are my thoughts. It is the intelligent thing to do for a student who wants to treat the foot and maximize their chances of getting a license to do so why not enter a profession that does not have any residency shortage and a very limited history of having graduates get denied a match 2 years in a row in order to qualify to get that license. If someone wants to treat the foot the isn't best way to get licensed to do so is to get that MD degree so as to maximize the possiblitiy of getting matched to get a residency program so as to get the license to practice treating the entire body including the foot?. ISN'T THIS THE FUTURE AND IT IS AN INTELLIGENT CHOICE TO MAXIMIZE THE ABILITY TO BECOME LICENSED TO TREAT THE FOOT AND ENTIRE BODY WITHOUT HAVING TO WORRY ABOUT GETTING LICENSED FOR FAILURE TO GET A PODIATRIC RESIDENCY 2 YEARS IN A ROW OR EVEN GREATER PERIOD OF TIME. Onced licensed the training and continuing education programs are out there.

    If a student goes to school 4 years or more gets debt can't get a residency in podiatry wow applies again can't get licnesed. Well what's wrong with helping educate others who were smart enough not to take such a great risk of not getting matched with a podiatric residency yet getting licensed in treating the foot. They understand the importance of getting licensed to treat the foot and entire body and then going for training and or experience treating the foot. In the future there is nothing wrong with MD's or DO's treating the foot. They may have been students who wanted to treat the foot but heard about the residency shortage in podiatry and decided to get that MD degree to have the highest probability of getting licensed and that license includes treating the foot and learning how to treat the foot.

    (THIS WORDING OF APPROPRIATE SPECIALIST MEANS A LICENSED PODIATRIST? Or is is a podiatrist lucky enough to get matched to a podiatric residency program so they can become licensed? What about the MD trying to increase their experience and letting their patient know how much experience they had treating the problem. An appropriated specialist is a licensed professional who informed patients of any lack of experience performing the procedure obtaining a consent and performing the care at an adequate standard as per their peers. This is my own definition. )

    In podiatry what preference is given to any podiatrists who already have been denied once from a residency match and if none is given wow won't even more undue hardship occur for those who are denied and if states still have such minimal screening criteria. Why not forget about podiatry school and get an MD degree and perhaps won't your chances of getting licensed with a license to treat the foot increased by more programs available to get an MD license? ANYWHERE IN THE COUNTRY WAS A GRADUATE FROM A MEDICAL SCHOOL DENIED A MATCH FOR RESIDENCIES FOR 2 YEARS IN A ROW WITH MEDICAL DOCTORS? Why did this happen in podiatry to some?

    Back to the topic of "turf and appropriate care which I have some questions about"

    "By the way did you ever hear of a hospital requiring a 2 year PSR and certification in rearfoot surgery for the ability to initially apply for the privilege of draining an onychia?" How can most podiatrist support the current system  when there are hospitals out there and states out there making all these regulations preventing podiatry graduates from draining onychias? This is why I belive it is better to get an MD degree so as to be enabled to be credentialed to drain an onychia because with that MD degree it is much easier to achieve the legal ability to do so. By easier I mean greater chances of becoming licensed or credentialed to do so. Once licensed this opens up the door to aquire experience which leads to current competence. 

    just my personal opinions until states stop this discrimination against non residency trained podiatrists not being able to become licensed even after being denied a match for 2 years.


    Daniel

    class of 84