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Podiatry

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Not to be confused with Pediatrics.
This article is about Podiatric Medicine. For the profession see Podiatrist.
Podiatric Physician
Occupation
Activity sectors
Medicine, Orthopedics, Endocrinology
Description
Competenciescritical thinking, analytical skills, professionalism, management skills, communication and interpersonal skills
Education required
Doctor of Podiatric Medicine
Fields of
employment
Hospitals, private practices
File:Podiatric medicine symbol.jpeg
A foot and winged rod, a symbol for podiatric medicine

Podiatry or podiatric medicine is a branch of medicine devoted to the study of, diagnosis, and medical treatment of disorders of the foot, ankle, and lower extremity. The term podiatry came into use in the early 20th century in the United States and is now used worldwide with countries such as the United Kingdom and Australia.[1] A Doctor of Podiatric Medicine (DPM), is a specialist qualified by their education and training to diagnose and treat conditions affecting the foot, ankle, and structures of the leg.[2] Podiatric physicians have extensive background knowledge in human anatomy, physiology, pathophysiology, sociological and psychological perspectives, general medicine, surgery and pharmacology. Specialist podiatric physicians are podiatrists who are qualified by additional postgraduate training or fellowship training and experience in the specialised field.

Within the field of podiatry, US trained podiatric physicians rotate through major areas of medicine gaining exposure and practice to areas including but not limited to: surgery, sports medicine, biomechanics, geriatrics, internal medicine,[3] diabetes, vascular, neurological, pediatrics, dermatological, orthopedics, or primary care.[4]

Podiatry is practiced as a specialty in many countries including Australia, Brunei, Canada, Cyprus, Ireland, Malta, New Zealand, Singapore, South Africa, the United Kingdom, and the United States. In many English-speaking countries, the older title of "chiropodist" may be used by some clinicians.[5] In Australia the title is podiatrist or podiatric physician and the specialist is the podiatric surgeon. In many non-English-speaking countries of Europe, the title used may be "podologist"[6] " or "Podólogo".[7] The level and scope of the practice of podiatry varies among countries. Podiatry is a high paying specialty and was listed by Forbes in 2007 as the 15th best paid profession in the United States.[8]

History

The professional care of feet was in existence in ancient Egypt as evidenced by bas-relief carvings at the entrance to Ankmahor's tomb dating from about 2400 BC where work on hands and feet is depicted.

Corns and calluses were described by Hippocrates who recognised the need to physically reduce hard skin, followed by removal of the cause. He invented skin scrapers for this purpose and these were the original scalpels. Aulus Cornelius Celsus, a Roman scientist and philosopher, was probably responsible for giving corns their name.[citation needed] Later Paul of Aegina (AD 615–690) defined a corn as "a white circular body like the head of a nail, forming in all parts of the body, but more especially on the soles of the feet and the toes. It may be removed in the course of some time by paring away the prominent part of it constantly with a scalpel or rubbing it down with pumice. The same thing can be done with a callus."[citation needed]

Until the turn of the 20th century, chiropodists—now known as podiatrists—were separate from organized medicine. They were independently licensed physicians who treated the feet, ankles and related leg structures. Lewis Durlacher was one of the first people to call for a protected profession. He held the appointment of Surgeon-Chiropodist to King George IV, King William IV and Queen Victoria. He tried to establish the first association of practitioners in 1854, although it would take another century to come to pass.[citation needed]

There are records of the King of France employing a personal podiatrist, as did Napoleon. In the United States, President Abraham Lincoln suffered greatly with his feet and chose a chiropodist named Isachar Zacharie, who not only cared for the president’s feet, but also was sent by President Lincoln on confidential missions to confer with leaders of the Confederacy during the U.S. Civil War.[citation needed]

The first society of chiropodists, now known as podiatrists, was established in New York in 1895—and still operates there today as NYSPMA,[1]. The first school opened in 1911. One year later the British established a society at the London Foot Hospital and a school was added in 1919. In Australia professional associations appeared from 1924 onwards. The first American journal appeared in 1907, followed in 1912 by a UK journal. In 1939, the Australians introduced a training centre as well as a professional journal. The number of chiropodists increased markedly after the Great War then again after World War II.[citation needed]

Scope of practice

United States

Scope of practice varies from different demographic and geographic areas. In the United states there is varied scope on where reconstructive surgery is done. According to the California Board of Podiatric Medicine, Doctors of Podiatric Medicine (DPMs) are licensed under Section 2472 of the State Medical Practice Act.[9] They diagnose and treat medical conditions affecting the foot, ankle and related structures (including the tendons that insert into the foot and the nonsurgical treatment of the muscles and tendons of the leg). Any procedure and modality is within the DPM scope if utilized to diagnose and treat foot, ankle or other podiatric conditions.[9] In addition to performing foot and ankle surgeries, DPMs are also licensed to assist physicians (MD or DO) in any surgery - podiatric or non-podiatric. DPMs are trained and fully licensed to independently perform full-body history and physical (H&P) examinations in any setting for any patient. DPMs, many of whom develop expertise in the care and preservation of the diabetic foot, perform partial amputations of the foot as far as proximal with the Chopart's joint, to prevent greater loss of limb, ambulation, or life. While podiatrists may order and administer anesthesia and sedatives, the administration of general anesthesia may only be performed by an anesthesiologist or certified registered nurse anesthetist (CRNA). DPMs commonly administer intravenous (IV) sedation.[9]

Podiatrists are uniquely qualified among medical professionals to treat the foot and ankle. Given its specialization, podiatry is to the foot and ankle what ophthalmology is to the eye or cardiology is to the heart. Whether it’s sports medicine, pediatrics, dermatology or diabetes, today’s podiatrist can tackle the many diverse facets of foot care. Podiatrists are often the first to identify systemic diseases in patients, such as diabetes and associated complications, high blood pressure and heart disease. [10] Today’s podiatrists:

  • perform surgery
  • perform complete medical histories and physical examinations
  • prescribe medications
  • set fractures and treat sports-related injuries
  • prescribe and fit orthotics, insoles, and custom-made shoes
  • order and perform physical therapy
  • take and interpret X-rays and other imaging studies
  • work as valued members of a community’s health care team

Doctors of podiatric medicine receive medical education and training comparable to medical doctors, including four years of undergraduate education, four years of graduate education at one of nine podiatric medical colleges and two or three years of hospital-based residency training. All podiatrists receive a DPM degree.[11]

Australia

The Australian Podiatry Council has defined the scope of podiatry in Australia as: Podiatry deals with the prevention, diagnosis, treatment and rehabilitation of medical and surgical conditions of the feet and lower limbs. The conditions podiatrists treat include those resulting from bone and joint disorders such as arthritis and soft-tissue and muscular pathologies, as well as neurological and circulatory disease. Podiatrists are also able to diagnose and treat any complications of the above which affect the lower limb, including skin and nail disorders, corns, calluses and ingrown toenails. Foot injuries and infections gained through sport or other activities are also diagnosed and treated by podiatrists.A range of skills are employed by podiatrists.[12] Direct consultations include a clinical history composition, physical examination, diagnosis, preparation of a treatment plan and provision of a range of therapies. Clinical assessment techniques aim to secure a diagnosis and prognosis and take into account clinical, medical and surgical history, footwear, occupational and lifestyle factors, and may incorporate the use of diagnostic equipment such as vascularscopes or radiology. Gait analysis will often be undertaken through visual or computerised means and might include range of motion studies, postural alignment evaluation or dynamic force and pressure studies. Clinical services require skilled use of sterilised instruments and appropriate infection control procedures, along with appropriate application of pharmacological agents, specialist wound dressings and a variety of physical therapies. Prescription foot orthoses (in-shoe devices) offer permanent solutions in the treatment and prevention of corns, callous and necrotic ulceration in their capacity to provide pressure redistribution. As a technique for providing consistent weightbearing realignment they are utilised in the treatment of acute and chronic foot conditions such as tendonitis, recurrent ankle sprain, chronic knee pain and stress fractures, to supplement and enhance clinical care. Foot health education regarding self care techniques and prevention of foot pathology is an important component of individual care but is also frequently implemented on a greater scale, either to specific target groups or as community projects. In order to facilitate enhanced clinical care, podiatrists establish and maintain collaborative relationships with other health care providers, often working within a site-based, multi-disciplinary team.[12]

Podiatric Surgery

Podiatric surgery is a specialist field in the podiatry profession. Podiatric surgery is the surgical treatment of conditions affecting the foot, ankle and related lower extremity structures by accredited and qualified specialist podiatrists.[13] Podiatric surgery is designed to ensure continued functionality of the foot and ankle areas. Patients who complain of joint and ligament problems, as well as those with congenital deformities, are offered a plethora of surgical solutions that fix bones, muscles, and joints. Certain podiatric surgeons specialize in minimally invasive surgery, while others perform full reconstructions.[14]

Specific country practices

Australia

In Australia, podiatry is considered as an allied health profession, and is practised by individuals licensed by their representative State Boards of Podiatry. The current issue is however though with the Podiatry associations in Australia believing that it is a profession distinct from allied health because it shares little in common with the 'allied health' group, the evidence points to the fact that in the HEALTH INSURANCE ACT 1973, podiatry is one of 3 including dentistry and medicine as the providers of 'professional attention' as well as the only 3 professions that are able to operate surgically on patients. There are seven registration boards and six teaching centres, with three levels of awards — unclassified bachelors degree, honours level and the post graduate Doctor of Podiatric Medicine offered by the University of Western Australia. In Australia there currently exist 2 levels of professional accreditation and professional privilege: General Podiatrist and the specialist - Podiatric Surgeon. There is current lobbying for other specialties to be recognised in Australia such as podopediatrics, diabetes, high risk and sports podiatry. Australian podiatrists are able to practise abroad with their qualifications recognised in some Commonwealth countries. General podiatrists in Australia have the rights to the use of the 'Dr' title as per regualtion through AHPRA, this is legal as a part of federal law, however in Queensland there is state legislation prohibiting health professionals other than medical practioners and dentists using the title.

Registration and regulation

Australian Podiatrists must register with the Podiatry Board of Australia.[3] The Podiatry Board of Australia is responsible for regulation and recognition of Podiatrists and Podiatric Surgeons,[15] and assessing foreign trained registrants.

The Podiatry Board of Australia recognizes 3 pathways to attain specialist registration as a Podiatric Surgeon:[16]

1. Fellowship of the Australasian College of Podiatric Surgeons[17]

2. Doctor of Clinical Podiatry, University of Western Australia[18]

3. Eligibility for Fellowship of the Australasian College of Podiatric Surgeons

Education and training

Australian podiatrists complete an undergraduate degree ranging from 3 to 4 years of education. The first 2 years of this program are generally focused on various biomedical science subjects including anatomy, medical chemistry, biochemistry, physiology, pathophysiology, scociology and patient psychology, similar to the medical curriculum. The following two years will then be spent focusing on podiatry specific areas such as podiatric biomechanics and human gait, podiatric orthopaedics or the non-surgical management of foot abnormalities, pharmacology, general medicine, general pathology, local and general anaesthesia, and surgical procedural techniques such as partial and total nail avulsions, matricectomy, cryotherapy, wound debridement, enucleation, and other cutaneous and electro-surgical procedures.

Australian podiatric surgeons are specialist podiatrists with further training in advanced medicine, advanced pharmacology, and training in foot surgery. Podiatrists wishing to pursue specialisation in podiatric surgery must meet the requirements for Fellowship with the Australasian College of Podiatric Surgeons. They first complete a degree of 4 years, which includes 2 years of didactic study and 2 years of clinical experience. Following this, a masters degree must be completed with focus on biomechanics, medicine, surgery, general surgery, advanced pharmacology, advanced medical imaging and clinical pathology. They then qualify for the status of Registrar with the Australasian College of Podiatric Surgeons. Following surgical training with a podiatric surgeon (3–5 years), rotations within other medical and surgeons' disciplines, overseas clinical rotations, and passing oral and written exams, Registrars may qualify for Fellowship status.[19] Fellows are then given Commonwealth accreditation under the Health Insurance Act to be recognised as providers of professional attention, for the purposes of health insurance rebates.

Australian Podiatric Medical Schools

There are currently 7 universities offering varying degrees of podiatric medicine from a Bachelor of Podiatry/Podiatric Medicine (BPod), a Masters of Podiatric Medicine (MPod) to the Doctor of Podiatric Medicine (DPM). All podiatry schools are accredited by the Australian and New Zealand Podiatry Accreditation Council (ANZPAC). ANZPAC is an independent body comprising members consisting of the Podiatry Registration Boards in Australia and New Zealand. The Board of Management comprises registered podiatrists (nominated by the Registration Boards), nominees from the professional associations (Australasian Podiatry Council and Podiatry New Zealand), nominees from the educational institutions offering podiatry programs and community representation. ANZPAC has been assigned the accreditation functions for the Podiatry Board of Australia under the National Registration and Accreditation Scheme for Health Professions. There are also two more podiatry schools currently being developed at the Australian Catholic University and the University of Ballarat. The following universities offering podiatry are:

Prescribing and referral rights

There is considerable variation between state laws regarding the prescribing rights of Australian podiatrists.[20] While all registered podiatrists in each state or territory are able to utilize local anaesthesia for minor surgical techniques, some states allow suitably qualified podiatrists further privileges.

Recent legislative changes, allow registered podiatrists and podiatric surgeons with an endorsement of scheduled medicines in Victoria, Western Australia, Queensland, South Australia and New South Wales to prescribe relevant schedule 4 poisons.[21] In states such as Western Australia and South Australia, podiatrists with Masters Degrees in Podiatry, and extensive training in pharmacology are authorised to prescribe S4 poisons. In Queensland, Fellows of the Australasian College of Podiatric Surgeons are authorised to prescribe a range of Schedule 4 and one Schedule 8 drug for the treatment of podiatric conditions. Currently endorsed podiatrists who have the ability to write prescriptions do not have those prescriptions qualify for the Pharmaceutical Benefits Scheme. There is also political lobbying for more Enhanced Primary Care places from 5 to 12 visits a year to a podiatrist for chronic diseases such as diabetes and for PBS rights.[22]

All podiatrists may refer patients for Medicare rebatable plain x-rays of the foot, leg, knee and femur, as well as ultrasound examination of soft tissue conditions of the foot. Podiatrists may refer patients for other radiology investigations such as CT, MRI or bone scans, however Medicare rebates do not currently exist for these examinations. Similarly, podiatrists may refer patients when needed to specialist medical practitioners, or for pathology testing, however similar exclusions in the Medicare Benefits Schedule prevent rebates being available to patients for these referrals.

Canada

In Canada, the definition and scope of the practice of podiatry varies provincially. For instance, in some provinces like British Columbia and Alberta, the standards are the same as in the United States where the Doctor of Podiatric Medicine (DPM)is the accepted qualification. Quebec, too, has recently changed to the DPM level of training although other academic designations may also register. Also in Quebec, in 2004, Université du Québec à Trois-Rivières started the first program of Podiatric Medicine in Canada based on the American definition of podiatry. In the prairie and Atlantic provinces, the standard was originally based on the British model now called podiatry (chiropody). That model of podiatry is currently the accepted model for most of the world including the United Kingdom, Australia and South Africa. The province of Ontario has been registering Chiropodists since July 1993 (when the Ontario Government imposed a cap on new podiatrists). If a registered podiatrist from outside of Ontario relocates to Ontario they are required to register with the province and practice as a chiropodist. Podiatrists who were practicing in Ontario previous to the imposed provincial cap were 'grandfathered' and allowed to keep the title of podiatrist as a subclass of chiropody. The scope of these 'grandfathered' (mostly American trained) podiatrists includes boney procedures of the forefoot and the ordering of x-rays in addition to the scope of the chiropodist.

New Zealand

Chiropody became a registered profession in New Zealand in 1969 with the requirement that all applicants take a recognized three-year course of training. Soon after the professional title was changed from Chiropody to Podiatry and The New Zealand School of Podiatry was established in 1970 at Petone under the direction of John Gallocher. Later the school moved to the Central Institute of Technology, Upper Hutt, Wellington. In 1976 the profession gained the legal right to use a local anaesthetic and began to introduce minor surgical ingrown toenail procedures as part of the scope of practice.

New Zealand podiatrists were granted the right of direct referral to radiologists for X-rays in 1984. Acknowledgement of podiatric expertise marked improved services to patients and eventually in 1989 suitably trained podiatrists were able to become licensed to take X-rays within their own practice. Diagnostic radiographic training is incorporated into the degree syllabus and on successful completion of the course, graduates register with the New Zealand National Radiation Laboratory.

In 1986, the profession undertook a needs analysis in conjunction with the Central Institute of Technology to identify competencies for podiatry in 2000. A Bachelor of Health Science was introduced in 1993. Auckland University of Technology is now the only provider of podiatry training in New Zealand.

United Kingdom

The scope of practice of UK podiatrists on registration after obtaining a degree in podiatry includes the use and supply of some prescription only medicines, injection therapy and non-invasive surgery e.g. performing partial or total nail resection and removal, with chemical destruction of the tissues.[23] Podiatrists complete about 1,000 supervised clinical hours in the course of training which enables then to recognise systemic disease as it manifests in the foot and will refer on to the appropriate health care professional. Those in the NHS interface between the patients and multidisciplinary teams. The scope of practice of a podiatrist is varied.[24]

In a similar way to podiatrists in Australasia, UK podiatrists may continue their studies and qualify as podiatric surgeons. Due to recent changes in legislation, the professional titles ‘chiropodist’ and ‘podiatrist’ are now protected by law. Those using protected titles must be registered with the Health Professions Council (HPC). Registration is normally only granted to those holding a Bachelors degree from one of 13 recognized schools of podiatry in the UK. Professional bodies recognised by the Health Professions Council are : The Society of Chiropodists and Podiatrists, The Alliance of Private Sector Practitioners, The Institute of Chiropodists and Podiatrists and The British Chiropody and Podiatry Association.

United States

In the United States, medical and surgical care of the foot and ankle is mainly provided by two groups of physicians: podiatrists (Doctor of Podiatric Medicine or DPM) and orthopedists (MDs or DOs).

The first year of podiatric medical school is similar to training that M.D. and D.O. students receive, but with an emphasized scope on foot, ankle, and lower extremity. Being classified as a second entry degree, in order to be considered for admission an applicant must first complete a minimum of 90 semester hours at the university level or more commonly, complete a bachelor's degree with emphasis on general/organic chemistry, biochemistry, biology, etc. In addition, potential students are required to take the Medical College Admission Test (MCAT). The DPM degree itself takes a minimum of four years to complete.

A podiatry student examines the adduction angle of the hallux.

The four-year podiatric medical school is followed by a surgical based residency, which is hands-on post-doctoral training. There are two standard residencies: Podiatric Medicine & Surgery 24 and Podiatric Medicine & Surgery 36 (PM&S 24 or PM&S 36). These represent the two- or three-year residency training. By July 2013, all residency programs in podiatry will be required to transition to a minimum three-years of post-doctoral training.[25] Podiatric residents rotate through core areas of medicine and surgery. They work along side their MD and DO counterparts in such rotations as emergency medicine, internal medicine, infectious disease, behavioral medicine, physical medicine & rehabilitation, vascular surgery, general surgery, orthopedic surgery, plastic surgery, dermatology and of course podiatric surgery and medicine. Fellowship training is available after residency in such fields such as geriatrics, foot and ankle traumatology, infectious disease etc. In reality though, the residency training of most podiatry residencies today are already highly inclusive of these medical areas.

Podiatric Surgical Training
A 40 watt CO2 laser used for podiatry

Upon completion of their residency, podiatrists can decide to become board certified by a number of specialty boards including the more common American Board of Podiatric Orthopedics and Primary Podiatric Medicine and/or the American Board of Podiatric Surgery. The ABPMS or The American Board of Podiatric Medical Specialties has been certifying podiatrists since 1998. [26] Within the American Board of Podiatric Surgery, PM&S 24 graduates can sit for Board Certification in Foot Surgery and those that complete PM&S 36 can sit for Board Certification in Foot Surgery and Board Certification in Reconstructive Rearfoot & Ankle Surgery. Both boards in ABPS are examined as separate tracks. Though the ABPS and ABPOPPM are more common, other boards are equally challenging and confer board qualified/certified status. Many hospitals and insurance plans do not require board eligibility or certification to participate. [26]


Podiatrists certified by the ABPS have successfully completed an intense board certification process comparable to that undertaken by individual MD and DO specialties. There are two surgical certifications under ABPS. [26] They are Foot Surgery and Reconstructive Rearfoot/Ankle (RRA) Surgery. In order to be Board Certified in RRA, the sitting candidate has to have already achieved board certification in Foot Surgery. Certification by ABPS requires initial successful passing of the written examination. Then the candidate is required to submit surgical logs indicating experience and variety. Once accepted, the candidate has to successfully pass oral examination and computer questions of clinical simulation. [26]

Practice characteristics

While the majority of podiatric physicians are in solo practice, there has been a movement toward larger group practices as well as the use of podiatrists in multi-specialty groups including orthopedic groups, treating diabetes, or in multi-specialty orthopedic surgical groups. Some podiatrists work within clinic practices such as the Indian Health System (IHS), the Rural Health Centers (RHC) and Community Health Center (FQHC) systems established by the US government to provide services to under-insured and non-insured patients as well as within the United States Department of Veterans Affairs providing care to veterans of military service.

Some podiatrists have primarily surgical practices. Some specialists complete additional fellowship training in reconstruction of the foot and ankle from the effect of diabetes or physical trauma. Other surgeons practice minimally invasive percutaneous surgery for cosmetic correction of hammer toes and bunions. Podiatrists utilize medical, orthopedic, biomechanical and surgical principles to maintain and correct foot deformities.

See also

References

  1. ^ a b New York State Podiatric Medical Association. NYSPMA. Retrieved on 2010-11-27.
  2. ^ "American Association of Colleges of Podiatric Medicine".
  3. ^ About Residencies. gundluth.org. Retrieved on 2012-06-27.
  4. ^ About Podiatry. Apma.org. Retrieved on 2010-11-27.
  5. ^ "What is Chiropody?". Ontario Society of Chiropodists. Retrieved 28 June 2011. those who are registered by the Ontario College Of Chiropodist are licensed to practice as Chiropodists or Podiatrists
  6. ^ "The Association of Podiatrists of Malta". Malta-podiatry.com. 1982-12-20. Retrieved 2012-08-25.
  7. ^ Col·legi Oficial de Podòlegs de Catalunya > El Col·legi – Events i Articles. Podocat.com (2010-10-19). Retrieved on 2010-11-27.
  8. ^ "America's Best- And Worst-Paying Jobs". Forbes. 2007-06-04.
  9. ^ a b c Information on Scope of Practice. bpm.ca.gov. Retrieved on 2012-06-27.
  10. ^ Today’s Podiatrist Does it All . opma.org. Retrieved on 2012-06-27.
  11. ^ Uniquely Qualified . opma.org. Retrieved on 2012-06-27.
  12. ^ a b Scope of Practice. apodc.com.au. Retrieved on 2012-06-27.
  13. ^ [1]. Podiatric Surgery phio.org.au. Retrieved on 2012-06-27.
  14. ^ [2]. Podiatric Surgery surgery.com. Retrieved on 2012-06-27.
  15. ^ "Overseas Trained Podiatrists". AHPRA Podiatric Board. Retrieved 28 August 2012.
  16. ^ AHPRA – Overseas Trained Podiatrists. Podiatryboard.gov.au (2010-09-21). Retrieved on 2010-11-27.
  17. ^ ACPS. ACPS. Retrieved on 2010-11-27.
  18. ^ Doctor of Clinical Podiatry: School of Surgery : The University of Western Australia. Surgery.uwa.edu.au. Retrieved on 2010-11-27.
  19. ^ Fellowship Training Program, Australasic College of Podiatric Surgeons
  20. ^ Drugs and Poisons legislation in the States and Territories of Australia – How does it apply to Podiatry?, Podiatry Board of Australia.
  21. ^ Ahpra – Ahpra Home. Podboardvic.vic.gov.au. Retrieved on 2010-11-27.
  22. ^ APODC – APODC News Room. Podboardvic.vic.gov.au. Retrieved on 2012-04-14.
  23. ^ "Conditions of practise". Health Professions Council (UK). Retrieved 2010-01-30. ...must not perform any type of Podiatric Surgery. For the avoidance of doubt this prohibition does not prevent Mr ... from performing partial or total nail resection and removal, with chemical destruction of the tissues.
  24. ^ Chiropodists/podiatrists
  25. ^ "Approval Information for Residencies | CPME". Apma.org. 2012-08-06. Retrieved 2012-08-25.
  26. ^ a b c d US Podiatry. K12 Academics Retrieved on 2012-08-24.
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