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Should all podiatrists know medicine?
Yes.
End of the editorial. Have a nice day…
Just kidding.
In reality, my answer to this question is a simple yes. The reason it’s so simple is because it’s one of the few things that are clearly in our best interest as physicians and also incredibly helpful to our patients.
 Here’s an example. I commonly see patients for bilateral plantar foot pain (sometimes bilateral heel pain) that present with complaints that don’t sound like typical plantar fasciitis. They’ve been treated by several other physicians, often podiatrists, with many treatments, none of which help the patients. After some investigation, it turns out to be lumbosacral radiculopathy. Understanding and finding this diagnosis requires a more global view of the body. Obviously, the treatment for this problem is highly different from plantar fasciitis.
Since we podiatrists like to call ourselves “podiatric physicians”, we need to emphasize a bit more the “physician” part of this. It’s a simple talk the talk, walk the walk argument. We need to be able to speak the same language and function similar to our colleagues in the medical community. This requires training that is similar (not the same, mind you, just similar).
Additionally, it allows us to simply provide better care. How many medications are your diabetic patients currently taking? Do you understand how these various medications might interact with something you prescribe? Do you know what terbinafine will do to a patient’s anticoagulation status if they’re on warfarin? Do you know how to identify and treat a duodenal ulcer that occurs as a result of the anti-inflammatory you’ve prescribed?
A while back, I had a young female patient with a bilateral arch nonblanching purpuric rash. Anyone focusing entirely on her feet would have called this tinea pedis or dermatitis, prescribed a cream, and been done with it. However, upon further questioning, I found that her father had a CVA at 35 years of age. This raised my index of suspicion, so I ordered a battery of autoimmune testing, including a hypercoagulable panel, and lo and behold, she had a factor V Leiden deficiency. I referred her back to the primary care physician after a phone conference. Hopefully, my patient will not have to suffer the same fate as her father. I relate this not to brag about my diagnostic skills (they’re no better than anyone else’s) but to demonstrate the importance of the podiatric visit and the opportunities to help our patients if we keep a more global view.
It’s entirely possible that your gout patient could suffer from gout as a result of cancer. The increased metabolic state and tissue breakdown may lead to hyperuricemia and subsequent gouty arthropathy. Are you aware of this relationship? I never had a hematology class or rotation while in training and learned this while in practice. On a more common basis, podiatrists need to understand the role of antihypertensive medications and renal disease in the etiology of gout. How can a podiatrist recommend a reasonable course of action if they do not understand that thiazide diuretics alter the excretion of uric acid from the kidney?
This list goes on and on. Psychological pathology in many of our patients, cardiac disease, various endocrinological problems. Is your idiopathic neuropathy patient suffering from occult undiagnosed diabetes or cervical myopathy? Does bilateral hand and foot numbness and paresthesias raise your suspicion for another diagnosis? Do you ask about hand numbness or is that too far above the ankle to matter? Are you able to perform a full body neurological examination when necessary, or do you just check protective sensation? There are so many new medications our patients take. Do you stay up to date?
One argument I’ve heard is about orthopedists. Someone once said to me, “Orthopedists don’t know everything; they consult other doctors and focus on the bone and joint diseases, and they are still doctors.” This may be true, but we podiatrists have a different charter from orthopedists. We are not only bone and joint doctors, but also dermatologists, neurologists, rheumatologists and endocrinologists, among others. At least that is what we advertise – that we cover a large number of conditions that manifest themselves in the lower extremities. I agree that we are required to have a certain level of knowledge of these various specialties since we are generalists of a particular body region, but to do this effectively, we need to be better educated in the overall medical aspects.
If we want to be considered equal or equivalent to our MD and DO peers, then we should do the following:
- Increase the amount of medicine training our colleges provide to podiatric students. A few of the schools already do this, especially the ones that are actually integrated into an allopathic or osteopathic medical college.
- Increase the amount of medicine rotations our residents receive while in training. Rotations that have our residents functioning as an integral member of the service should be favored over “observational” types of rotations.
- Podiatrists in practice should be required to maintain and demonstrate a certain level of medical knowledge. This could be documented by designating an amount of yearly CME requirements for medicine the way radiology CME is currently documented.
- Other types of CME should be made available online for general medical knowledge expansion the way PRESENT e-Learning Systems has made many of these topics available.
As a student and resident educator, I spend a good deal of my time teaching my trainees to look above and beyond the foot and ankle when treating their patients. In fact, this is easily the more complex part of podiatric medicine. Understanding why a patient should or should not have a surgical procedure and the medical issues leading up to that surgery are as important as acquiring skill in dissecting the foot or inserting a screw. We all know there is a patient attached to that ankle, but do you know enough medicine to understand what’s happening with that patient? Are we physicians? Or is that just podiatric lip service? I’ll leave the answer up to you.
Best wishes,
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
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