G.P.s performing nail avulsions

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I was just wondering what colleagues think about GPs performing nail avulsions. The reason I ask is that at least three of my clients have had total avulsions performed by a local GP and the procedure has been done in each case without phenolisation. Needless to say, the nails have regrown and two of the three have had the procedure done twice. I'm not sure what the doctor thinks he is achieving and (cynically) wonder whether it is one these things that the GPs get paid extra for performing.

 

The article in this link is interesting...

www.taxresearch.org.uk/.../gps-cant-do-this-and-shouldnt-do-this-and-we-should-not-tolerate-it/ - Cached

 

Hi Kyrret, this has also been a frequent experience of mine. I often see patients who have had a PNA performed by their local GP without phenolisation and I too am baffled as to what their expected outcomes were :wacko:. Over the last year working in a Community Health situation we have been able to "gently" make our presence known to the local GPs outlining the extent of the services we provide. This in turn has lead to a greater number of referrals for surgical treatment which also leads (hopefully ) to better surgical outcomes, Cheers,
Paul.

 

All,
This seems to be a common experience among pods just lately and there was a thread about just this topic on another site (Thatfootsite) a little while back. Unfortunately, many patients go for the GP option as it is free, depite advice to the contary.
I agree with quirky that we need to raise our profile here and explain to GPs just what we can, do in order to save patients having to have repeated unecessary surgery.

CF

 

Nail surgery is also free when performed by the NHS Podiatry teams.

I always advise patients in my private clinic of the alternatives.

Informed choice.

Kind regards,

Mandy.

 

Education is the key, but also is Evidence- Whick will make your side of the discussion more stable.

This is from a cochrane review.

 

Mandy,
I am aware that NHS nail surgery is also free and my patients are made aware of that fact. However, most choose the local GP as it is not far to travel. NHS Nail Surgery in rural areas is usually performed at central locations, which can involve, in some areas, a hour hour bus ride.

CF

 

I do too Twirly. If fact I always fax a referral to the GP requesting NHS Podiatry for this, though to be honest, I hadn't realised until now just how important doing that is

 

Thanks for these replies. When I refer to GPs I always tell the patient to request NHS podiatry but haven't been backing this up with a letter to the GP. I'm going to have to start doing this.

Michael, thank you for that Cochrane review. Whilst there may be an increased risk of post -operative infection with phenol I would have thought that the risk was worth it to prevent the reoccurance of the agony most people suffer from ingrowing nails.

 

Hi once again CF,

I disagree with 'most'. In my experience the NHS Podiatry team perform the majority of nail surgery locally in this area. Doncaster NHS have a dedicated nail surgery team which runs every week. However, I appreciate that you indicated in your post 'rural' areas may differ.

Regards,

Mandy.

 

Mandy,
When I said "most", I was alluding to my own experience in a particular rural area. When I worked in Manchester there was a School of Chiropody that was only too willing to take referrals !
Frustrating as it may be, at the end of the day I'm sure we agree that it is the patient's Right of Self determination that must be respected.

Footsie,
Whilst faxing may be speedy there are Data Protection implications,

http://www.medicalprotection.org/uk/uk-factsheets/communicating-with-patients-by-fax-and-email


CF

 

I actually don't really have a problem with it. They are allowed to do it, so will continue. We shouldn't be discussing whether or not they should be doing it, as they legally can full stop. My guess is that they don't perform a chemical matrixectomy for two reasons;

1) they treat the acute problem, as they would if in the ED. That being removing the nail and eliminating the immediate problem. In their eyes long term outcoime isn't an issue at that point.

2) They probably don't know how to do it.

I actually have lectured at a couple of GP training days teaching them how to do nail surgery, this has increased my referral rate for nail surgery as they understand that i can do it better.

So i don't mind as the patients that get a regrowth are very happy with the outcome after coming to me for a revision surgery.

 

I go along with George here. My experience is that GPs will have a go and then refer when their technique fails to be effective. There are some who enjoy in house surgery, and that's fine, many do not and actually prefer to refer. Getting your name known is the crucial step.

ll the best

Bill

 

My experience in the U.S. has been quite different. I'm part of an extremely busy practice, and most G.P.'s don't want to go near an ingrown nail. We probably see 3-4 of these referred daily as "urgencies" by GP's who don't want to touch these patients.

They know that the patient can be seen in our office and treated in a matter of minutes with much less discomfort, and much more efficiently than in their offices.

However, in the instance when we do treat a patient that had been treated previously in the emergency department or by his/her G.P., it simply makes us look that much better. The majority of the time the ED or the GP does a horrible and traumatic job due to inexperience, lack of proper instruments, poor technique, inability to adequately anesthetize the area, etc.

No one does it better that we do. Period.

 

I am not surprised that more and more patients are seeing MDs for things that we should be experts in. Within the VA scenero alone, almost no podiatrisst are performing nail procedures because they have nurse practitioners and even poorly trained (if trained at all) nail technicians doing nail procedures! These young podiatrists now and days think it is beneath them to even look at toenails. I saw one diabteic patient who first went to a colleague of mine just up the street and all he did for this patient was look at the foot the patient had no complaint about and started talking about surgery on his asymptomatci HAV/bunion. He NEVER even looked at his other foot which had two digital mal perforans and thick mycotic toenails! I was too embarassed for our profession to even be happy I've gained a new patient thanks to his utter disregard for this patient as a human with a body and another foot attached to him. And as more programs go toward high volume surgeries (PSR 36 with phasing out of RPRs and even primary podiatric medicne) it will only get worse and podiatry will cease to be a profession emcompassing all aspects of feet ailments; not just those corrected with surgeries. I don't blame a GP for doing something that we should do the best and if he/she is getting paid more than more power to h__. We are too busy udermining ourselves; comparing one another with those who did big surgical programs and looking down on others who just were not fortunate enough or even as myself did not want to be stressed down with a high power surgical practice and therefore was satisifed with a mere RPR. I am still Dr. soandso with the same DPMs behind my name along with everyone else. And this is what's wrong...that we should respect one another as cohesive colleagues and fight others who underpay us for same procedure that an MD would get paid more for and just plain treat us as allied professionals rather physicians with emphasis on the foot!

 

It is interesting even with the few UK participants within this debate how the supply of nail surgery varies.

Locally we have seen 2 new build polyclinics over the last 5 years with a 3rd planned. I have no idea if this 3rd one is still happening due to the change in Government. An operating theatre for minor surgery has been incorporated at both new builds and the larger GP practices are taking more responsibility for minor surgical procedures. This has included nail surgery using phenolisation. Some GPs are more successful than others with this technique.

The recession has seen a drop off in the usual numbers of patients attending with minor O/Cs within my private practice and this has been reflected within other practices locally, including the NHS Podiatry sevice. Understandably patients look for the cheapest/no cost route if they are struggling financially and as we know the GP, more often than not, is the 1st point of contact with an "ingrown toenail".

Like Twirly, if patient's do make their way into my practice and a simple removal of the offending spike of nail is not an option or the OG/OX nail has gone beyond conservative and self care then the patients are offered a choice of where to seek treatment to resolve the problem. Thankfully I can refer directly into the NHS Podiatry team and with service reprofiling they can usually see urgent PNA cases within a matter of days.

Where my ramblings are leading, is locally we do have a good Podiatry service for acute cases both in the NHS and Private Practice but what I find unethical is that many GP services do not offer their patients with O/Cs or gryphotic nails any alternative other than Partial or Total Nail avulsions. I would bet 75% of the GP nail surgery waiting lists could be resolved with appropriate Podiatric intervention which does not involve surgery.

Is there an evidence base anywhere that shows how many O/Cs or OG/OX nails are resolved or managed with conservative/self care alone? In other words a short course of treatment with the Podiatrist and then discharge to self care.

Should we be pressurising for such evidence, especially with commissioning just over the horizon?

Why don't the professional bodies take up the case?

GB

 

Hello George

The Institute is indeed taking up the case with the DoH. However, the proposals are, at the moment, only in the form of a 'White Paper' ie. a series of broad proposals setting out where the government wishes to go and to consult. The paper is well worth reading though and may offer an opportunity for the private practitioner.

All the best

Bill

 

"what I find unethical is that many GP services do not offer their patients with O/Cs or gryphotic nails any alternative other than Partial or Total Nail avulsions. I would bet 75% of the GP nail surgery waiting lists could be resolved with appropriate Podiatric intervention which does not involve surgery."

George,

Having heard a talk from a top solicitor and expert witness, a health professional is medico-legally obliged to inform patients of ALL the options which they have available, the pros and cons. It is then upto the patient to decide which option is best for them, but we cannot make that decision for them. Only they can. Also, if a consent form has made no mention of alternative forms of treatment to nail surgery, then the consent is simply not valid in law and could be viewed (I seem to recall) as an assault.

 

DP,
You said

Now that's interesting.
If I read it it correctly, that means our consent forms for nail surgery should also mention conservative treatment - even if that would not give a good treatment outcome ?

Could you clarify this? I think you are referrig to the SCP course by Andrew Andrews on "Consent" and I didn't attend that one.

Thanks.

CF

 

Catfoot,

This is the line I use on my consent form to cover other forms of treatment...

"I have also discussed the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns the patient had."

How well it would stand up in court I have not a clue.

Bill,

I am sure that all the professional bodies will be attempting to influence the white paper you mention.

Do I read from your post that the Institute has evidence to back up the case that I suggested regarding the need for cost effective and timely conservative treatment of O/C , O/G and OX rather than immediate surgery?

Without it and with the GPs potentially being fund holders we stand little chance of influencing the DOH in this case.

GB

 

George,

That's pretty similar to the wording on the consent forms I've used. I just wondered if DP was throwing up something new.

CF

 

"If I read it it correctly, that means our consent forms for nail surgery should also mention conservative treatment - even if that would not give a good treatment outcome ?"

Yes, you should mention conservative treatment. Mention, for example, by it's appearance that conversative treatment would be out of the question as it would be too painful for the patient, or, the nail is growing in too far, proximally.

Mention, for example, that for a severely OM nail, that medication is available but the patient has been informed that the nail will never ever look the same again.

For a severely OX nail (caused by trauma) that treatment wise, they could have regular reduction with a burr, or have it removed by nail surgery.

Mention the pros/cons of each form of treatment on the consent form, and you are covered. If it is not on the consent form in detail, you may want to have a patient information sheet detailing, with reasons for nail surgery (incl. pros/cons)and the pros/cons of alternative treatments. You may want to have this on a patient info leaflet, BUT this must be dated with day on creation on it. If they have been shown this leaflet, this MUST be documented on the consent form together with the date the info leaflet was written.

That way medico-legally, you are practically bullet proof.

What makes me laugh is that a lot of GPs apparently don't even get a consent form signed for this, let alone go into as much detail. And we worry about being sued!

SCP has courses on this run by Bond Solon. I've only been on the consent one! Excellent!