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I'm thinking verrucae?

Discussion in 'General Issues and Discussion Forum' started by Footcheck, Nov 3, 2010.

  1. Footcheck

    Footcheck Member


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    Hi all i saw a client today and she has this growth i just assumed that it was a some form of wart however she said she shes had it for a long time and no podiatrist has known what it is...... maybe Im missing something.....just wanted to check with you guys what you think this is. Its not painful. ive attached some pictures.
     

    Attached Files:

  2. Re: Im thinking verrucae

    I'm wondering cutaneous papilloma.
     
  3. blinda

    blinda MVP

    Re: Im thinking verrucae

    It`s certainly an `oma`, but you really, really need histology for definative dx.

    Is this the first time you have seen this pt? How long is a long time? Has it changed shape, size? What is the pts med history? Any systemic disorders?

    Remember your ABCDE;

    Assymetry
    Border
    Colour
    Diameter
    Evolution (change)

    First impressions; possible dermatofibroma. The clinical test is performed by lateral squeezing pressure on the lesion. A dermatofibroma will indent or dimple in the centre, whereas other lesions will protrude above the plane of the adjacent skin. This may be difficult as there appears to be a `cluster` of omas there.

    I would be keen to rule out nodular basal cell carcinoma. This is the most common form of BCC. Starting as a white, small, domeshaped nodule it can extend peripherally while remaining flattish. As the lesion becomes more elevated it forms an oval mass and may become multilobular Although Nodular BCC is a slow growing tumour, it is liable to ulcerate and can extend into deeper tissue.

    Then again it could be a common garden variety of HPV....only a biopsy will reveal the result you absolutely need.

    Cheers,
    Bel
     
  4. W J Liggins

    W J Liggins Well-Known Member

    Re: Im thinking verrucae

    Hello Jspiel

    I completely agree with Bel. It could be a squamous cell carcinoma (Bowen's disease) or even an amelanotic melanoma. On the other hand it could be an unusual presentation of a VP. Whatever the guesses, it is sufficiently unusual in appearance to merit histological analysis. Take a punch biopsy, or ellipse it out if sufficiently small and send to your local lab. You might be doing this patient a huge favour.

    Just a thought, is the patient taking any immunosupressive drugs?

    Bill Liggins
     
  5. cornmerchant

    cornmerchant Well-Known Member

    Re: Im thinking verrucae

    With respect Bill

    Us common or garden pods cannot do punch biopsies - it is a case of referring back to GP and requesting further investigations, which is absolutely indicated in this case.

    CM
     
  6. W J Liggins

    W J Liggins Well-Known Member

    Re: Im thinking verrucae

    Hi Cornmerchant

    Well, that's a shame. I know that there are a number of skin surgery courses - there's one at the University of Hertfordshire that a colleague has undergone, which are quite high level. Certainly the Institute would insure a pod who had taken such a course and I imagine that the Society would do so also. Are they not teaching this sort of material at the schools now? (It's a few years since I trained).

    Bill
     
  7. cornmerchant

    cornmerchant Well-Known Member

    Re: Im thinking verrucae

    Hi Bill

    As far as I know it is not taught by the schools, it certainly was not in my training 16 years ago. To be honest, I would not want to invest the time and money to do it now- I have so little call to use it on a regular basis, and it would not be cost effective. If it comes back with a worrying result the patient would end up going back to GP/consultant dermatologist anyway.

    Regards
    CM
     
  8. blinda

    blinda MVP

    Re: Im thinking verrucae

    Tis true that punch biopsies, etc are not taught at undergrad level, which is a shame, but I can understand why some would prefer not to do this. However, in light of the expectations that GP commissioning may bring about, I would suggest that it is a worthwhile postgrad skill to embark upon. The more skills that we can demonstrate as AHPs who can improve pt outcomes, reduce costs, admissions, etc then we have a better case to present to the GP consortia.

    It`s always a good idea to have a direct relationship with your local path lab and dermatology consultants anyway. The GP`s don`t always appreciate being bothered as a go between. In my experience, and if the GP`s know you and trust your clinical decisions then, more often than not, they are happy to just receive notification of any histology results that you receive.

    Cheers,
    Bel
     
  9. W J Liggins

    W J Liggins Well-Known Member

    Re: Im thinking verrucae

    Fair comment

    It would be nice to send such a patient to a colleague anyway and keep it 'in house' as it were. The GP/Dermatologist could then be informed of the result and this would elevate the profession in the medics eyes, as a result.

    All the best

    Bill
     
  10. blinda

    blinda MVP

    Re: Im thinking verrucae

    Oops....posted at the same time as you Bill! Think we`re singing from the same sheet here.
     
  11. W J Liggins

    W J Liggins Well-Known Member

    " I'd like to teach the world to sing in perfect harmony......" as we are Bel!

    Cheers

    Bill
     
  12. Re: Im thinking verrucae

    http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=56681
     
  13. cornmerchant

    cornmerchant Well-Known Member

    Mark

    I take it that is your attempt at sarcasm??

    There is absolutely no point in most PP pods undertaking skin surgery in the hope that once in a while a patient may need a biopsy. I am sorry but I do not belong to the 'old boys' network and tend to pass patients to GP/NHS rather than keep it 'in house' as Bill suggests, when the patient deserves to have treatment from an expert in that field. It is enough for me to have the underpinning knowledge to know when to refer on. There are many things out of our remit and just because I say that it does not make me a pedicurist. Our training is different to the states yet many here aspire to be like that. Fine, pod surgeons have made great leaps forward, but it is not for all of us. I dont have a problem with further training,but by the same token I do not wish to be derided if I choose not to do it!

    Off to polish some more nails
    CM
     
    Last edited: Nov 5, 2010
  14. blinda

    blinda MVP

    Hi CM,

    I get you, you dont want to do post grad training for skin surgery. That’s fine, no one is deriding you for that. However, I would disagree that it is “out of our remit”. We have a privileged position in that we posses in-depth anatomical and physiological knowledge of the lower limb along with license to use local anaesthetic and, as you rightly pointed out, the underpinning expertise to know when something is amiss. Put it all together and we are in an ideal position to build on our clinical skills, in this case with simple skin surgery, and we can formulate direct referral pathways to the experts that you speak of.

    Have a great weekend.

    Cheers,
    Bel
     
  15. cornmerchant

    cornmerchant Well-Known Member

    Bel

    You make very good points and in an ideal world that would be very nice. However, many patients would not want to pay for something they can get free. GPs will do this simple skin surgery themselves, after all we are not talking huge numbers in any one area.They dont even want to refer nail ops to us ,wanting to have a go themselves! Maybe in the NHS environment it could be something pods will end up doing anyway?

    I wonder what the dermatologists response to this idea would be?

    CM
     
  16. W J Liggins

    W J Liggins Well-Known Member

    Hi CM.

    Mark will speak for himself, but I don't think that he was necessarily being sarcastic against an individual, but rather against a certain negative mindset. You don't have to become a full blown pod surgeon to undertake skin surgery. There is an excellent practitioner locally who carries out all sorts of skin surgery, (he has taken the course I referred to) in his surgery located in a large GP practice. He receives referrals from pod colleagues, from GPs in his own practice and, intriguingly, from GPs elsewhere. The pod colleagues he accepts referrals from are not anxious about referring their patients because he treats what he has to treat and then sends the patient back. This, in my view, is how we should work as a profession and until we can get it into our heads that we are the profession that treats feet, ALL foot problems, then we cannot get it into the heads of others, such as GPs. Dentists/Maxillo-Fascial surgeons did it with the jaw, we should be doing it with the feet.

    This is my view only, and you may have your view, to which you are entitled.

    All the best

    Bill
     
  17. blinda

    blinda MVP

    Maybe, but it`s good to give them the option. If a patient requires histology, or culture of skin samples, I will always point out that their GP can do it for `free`. Whilst some opt for this, many choose to pay for the service privately.

    Tell me about it!!:bang:

    I`m not trying to be argumentative, but I dont see why it would be any different in PP? Maybe I am not `most PP pods` but I did not find it difficult to create a professional relationship with the dermatological team here. In answer to your question; they are delightful to work with and fully appreciate our input and referrals.

    Yep, I agree.

    Amen.

    Hope you both have a great weekend...i`m off to eat my omlette!

    Cheers,
    Bel
     
  18. You're never slow to criticise other practitioners such as FHPs who may aspire to greater understanding of foot problems, so I guess I just find it rather curious that you adopt a fairly inhibited mindset when it comes to your own practice. Horses for courses - so do whatever you're comfortable with and refer on when you think it's indicated - just as the majority of FHPs do and other clinicians do when faced with something out of their own scope of practice.

    Kind regards
     
  19. George Brandy

    George Brandy Active Member

    Why is CM's attitude negative? It is business like, rational and appropriate. I am not acting in his/her defence.

    I would love the beautiful area I inhabit, out of choice, to be affluent then it would make good business sense to have a practice which engages patients in paying for simple skin surgery including biopsy. I am not and therefore it would be foolish and inappropriate to believe that paying for such a course would turn me into an expert in skin surgery. I simply would be a bumbling, inexperienced fool - unfit for this scope of practice.

    The situation Bill Liggins describes is indeed an ideal situation for his pal to be in but this is not ideal for everyone. It makes commercial sense to know, understand and be appreciative of the demographics of the locality one works in. It then makes good business to know the limitations of ones practice based on the income of ones client base ie what they can afford to buy from you.

    I would love to arm myself with the skills to carry out simple skin surgery, to be able to independently prescribe (if and when the time comes) and to produce the most up to date orthotics. But I would be bankrupt before I knew it. Is this a negative attitude? In my opinion it is a responsible attitude to your business, your patients and your profession.

    I have an excellent relationship with my local GP's - certainly with the practices that do not function on locums alone and a fantastic relationship with my local podiatrists. I have had discussions in the past regarding patients who were struggling to afford private care in the belief that the NHS podiatry service was rubbish. Between GP, NHS Podiatrist and myself we have team worked them successfully into NHS care. This is the opposite of the skills you are talking about I realise but it highlights the need for different marketable skills based on regional variations within the UK.

    I am certain that with a turnaround of the recession I will once again increase the use of my more specialised skills and it may be a sound business proposition to some day take on the skills of simple skin surgery but I am doubtful. I do not hold the same hopes that commissioning will make a massive change to the private practitioner within this region. This does not worry me.

    I pride myself on being able to deal with every condition that walks through the front door of my practice and I also pride myself on knowing who is the best to treat that condition dependent upon need and affordability - whether that be myself, a specialist podiatrist, another AHP or medical practitioner/consultant.

    I understand that I am held in disregard by some of my profession, I have been accused of holding back professional development and demoted to the lower echelons. I also realise that this debate is on a personal level and aimed at attacking one persons viewpoint. Sad.

    "until we can get it into our heads that we are the profession that treats feet, ALL foot problems, then we cannot get it into the heads of others, such as GPs. Dentists/Maxillo-Fascial surgeons did it with the jaw, we should be doing it with the feet."

    Until we can stop concentrating so much on status, and finger pointing at those who you believe to be affecting status, we will never grow our market share. I long for the real benefits of commissioning but I have been around long enough to realise this will be a long stream of urine directed into that southwesterly and when the wind changes direction along comes another set of conditions.

    All you have to do is witness such a debate and realise the attitude within the regulated profession is not conducive to business. And how the commissioners so know this.

    As a fragmented profession we could not organise a p*** up in a brewery. So lets find someone to blame...CM perhaps?

    GB
     
  20. W J Liggins

    W J Liggins Well-Known Member

    Hello George

    I am certainly not finger pointing at CM or anyone else. I am simply stating my belief that this profession should be the one that treats feet, not one that hands that responsibility to others.

    I fully accept your point about demographics, but I started in a relatively poor area of Birmingham and interestingly found that when I started using techniques such as nail phenolisations, people did find the fee quite readily. These same 'working class' people would go on holiday abroad and their wives would pay goodness knows how much for hairdressing, so when they were in pain, they found the fee relatively easily.

    I really do feel that a positive attitude towards our practice and responsibility is a necessary precursor to obtaining NHS work in pp. If there is a skill which you do not possess, then refer on to a colleague. They may be able to explore different methods of payment with the patient. Crucially, always remember that the commissioners to whom you refer will also be the GPs with whom you state you enjoy an excellent relationship.

    All the best

    Bill Liggins
     
  21. blinda

    blinda MVP

    Hi George,

    I agree with much of what you say, except the above. None of my remarks have been either personal or attacking. I have a lot of respect for CM.

    Our scope of practice or `status` has nothing to do with finger pointing or blaming, I was purely highlighting the positive position that we are in. I agree with Bill; A positive attitude towards our practice is absolutely necessary to survive in PP and, who knows, we may even benefit from the commissioning.

    Gotta stay optimistic.


    Cheers,
    Bel
     
  22. As is your response, as always! But there are two ways of looking at this. The first, as you allude, is from the individual standpoint - consider your practice area, demographics, competition and cost benefit and other local factors. Fully agree with that - and perfectly understand CMs argument. But the other view is that from the profession's perspective - or where we would like to see the podiatric profession placed in terms of clinical delivery and professional integration in the medical marketplace. I'm sure you understand brand placement and marketing and what the public perceive what a profession delivers. A large part of this should be done nationally, through the professional bodies - but we all play a part of that too, each and every day - through the services we provide for our patients. Going back to the original poster's complaint on the thread about podiatry/pedicure - the patients perception of him/her in their practice setting. If the perception was that they are a pedicurist - who's fault (if that is the correct term) is that? The patient's? The clinician? The profession's? If there is a concern that other groups such as FHPs or assistant practitioners are encroaching into "our" scope of practice - and you can extrapolate that concern across almost every country where podiatry is organised into professional groups - then we should really ask ourselves why this might be so before we start complaining about it.

    I really fail to see why some clinicians complain about having to undertake basic aspects of footcare as demeaning or beneath them whilst at the same time refusing to advance their own scope of practice and then bemoaning about encroachment!

    There's a whole different conversation to be had about how you solve the problem and how you elevate the profession in the public's eye and to do that you need to look at how podiatric training is delivered and structured and where the attendant supporting groups fit into that model, but that's for another day I suspect.

    Best wishes


    PS can one of the mods change the orientation of the photograps to make it more browser friendly please?
     
  23. George Brandy

    George Brandy Active Member

    Bel, Statements such as "I get you, you dont want to do post grad training for skin surgery. That’s fine, no one is deriding you for that." CM has not even intimated this, so depending upon how one inflects when reading this it could come across as heavily sarcastic especially when the person this is directed at is standing accused of not having a positive professional outlook rather than using a responsible decision making process.

    "I really do feel that a positive attitude towards our practice and responsibility is a necessary precursor to obtaining NHS work in pp."

    I could not agree more with a positive attitude. In my opinion though, seeking what is traditionally NHS work is not good business and is likely to create instability as policy makers change. But for those who wish to go down this route, first and foremost our profession has to unite and step out from the shadow of the DoH. We must stop conceding to their demands. Until we can do this, I do believe that the commissioners will largely overlook the profession.

    " If there is a skill which you do not possess, then refer on to a colleague.
    They may be able to explore different methods of payment with the patient."


    Indeed one does, as do many of my regional colleagues but if a patient simply cannot afford a private payment we must take it at face value. To try and keep patients within the profession via NHS referral it can often involve a round trip of 50 or so miles and understandably many patients cannot commit the time/cost/travel to achieve this especially when the service can be obtained locally outside of our profession. To highlight I have two Pod Surgeons who function approximately 20 miles away. One will take both NHS and PP, the other NHS referrals only. Pre- recession I was referring 2/3 times a month. I have had the pleasure of being able to send one referral to the PP Pod Surgeon this year, the others preferring the local NHS Foot and Ankle Surgeon (orthopaedic). No it doesn't sit well with me either.

    "Crucially, always remember that the commissioners to whom you refer will also be the GPs with whom you state you enjoy an excellent relationship."

    Indeed I am poised to expand the practice should this materialise but I am not expecting it given my reasons above. I am more likely to see practice expansion via "usual methods" rather than commissioning particularly as manufacturing and industry locally is increasing. As in the past, this increased turnover will fund the training of the skill base. We have had to contract slightly due to recession from where we were in 2008 but Bill, we are talking "individual" here rather than in multiples of professionals and as Mark has now taken the debate down a completely different pathway, out of respect for the original poster I feel we should ask the moderator to perhaps separate the latter half of this thread if we wish to continue the debate?

    GB
     
  24. Ah you know me, never stay on the straight and narrow for very long. Life would be too dull anyway.... :empathy:
     
  25. blinda

    blinda MVP

    :confused: So what did CM mean here;




    That is the problem with forum speak; inflection is in the eyes of the beholder. As I stated before, I respect CM but that does not mean that I cant disagree occasionally. I have not accused her of `not having a positive professional outlook`, nor made personal attacks. In fact I think CM has raised some good points. This is such one;

    Ok, this is going completely off thread, but this worries me as a PP. GPs ARE doing nail ops, soft tissue surgery and using their practice nurses to undertake the annual diabetic foot health reviews and treat diabetic foot ulcers. Which is why I agree with Bill when he stated;

    Cheers,
    Bel
     
  26. cornmerchant

    cornmerchant Well-Known Member

    Bel
    Perhaps I should make myself a little clearer since there is a problem with the interpretation of my statement, and I personally cannot see how you came to the conclusion that it was sarcastic- I assure you it was not meant to be !

    My reasoning for not doing post grad training on skin surgery would be that it would not be cost effective, as I do not see the need croppping up other than on rare occasions in my practise. Nor would it serve the best interests of the patient if I did not become proficient in the technique through lack of experience . I would prefer to refer on to someone with far more expertise . I would not be against undertaking training if it was viable.

    With the best will in the world I would like to think that the GPs would consider using us pods more, however even working within 2 GP practises I cannot see this happening. We do not have the same profile as pods in the States, nor the extent of skills regarding surgery, although our Pod surgeons do. How many GPs still do not understand the scope of practise regarding pods? And this is after GP packs were sent out by SCP I believe in an effort to educate them. I am also very aware that the majority of my patients would go to their GP for a proceedure rather than pay me - lets face it doing a biopsy would not come cheap.

    In pp one has to make a living and to do that the area dynamics play a big part of what your scope entails and after 16 years I think I know my area pretty well. I am fully in favour of enhancing the publics perception of podiatry but while the overall image could be raised, within the pp sector there are all of us beavering away in isolation dealing with what comes through the door. The fragmentation of the foot health sector adds to the diverse standards of treatment hence parity is going to be very hard to achieve if ever.

    Regards
    CM
     
  27. blinda

    blinda MVP

    Hi CM,

    I have a feeling that we are playing chinese whispers here....I never thought/said your comments were sarcastic :confused: It was GB who suggested that MY comments were "heavily sarcastic" But they were not intended to be and I apologise if that is how you read them.

    I genuinely understand why you don't want to do skin surgery, any more than I don`t want to do podiatric surgery. No problem with that. The ONLY minor point that I disagreed with you on was your comment that skin surgery was “out of our remit” for the reasons I outlined in my postings.

    As you work closely with GPs I guess you are probably in a better position than most to ascertain their views on us as AHPs. It is depressing, especially as you say even after the SCP sent information packs to GPs, that our scope of practice is not understood.

    Personally, I found it helpful to introduce myself and perform a ten minute presentation to the GP practices, outlining what I can offer them and their patients. I have received many referrals as a result and continue to enjoy a good professional relationship with most GPs.

    With regard to obtaining parity within the profession...let`s not go there on this thread, eh? We`ll end up going in the usual circles.

    Cheers,
    Bel
     
  28. cornmerchant

    cornmerchant Well-Known Member

    Bel

    Sorry-my mistake, I am up to speed now!

    GPs are a law unto themselves. We can certainly 'educate' our local ones but you cannot reach them all and even the new ones ( my next door neighbour) seem to have a great lack of understanding what exactly we do! I dont know what the answer is! The problem is , if they dont understand the basics of what we do , what chance would you have of persuading them to the extra skills you may acquire post grad? Which is why I think training in skin surgery may well be far more appropriate for NHS pods who are moving away from basic skills towards more and more specialisation.

    Regards
    CM
     
  29. blinda

    blinda MVP

    Fair comment....We can`t win them all.

    I think we`ll have to agree to disagree on this one. I think all Pods (and their patients), PP or NHS, would benefit from building on their skills in whatever area they choose, should they wish to, whether that be skin surgery, independent prescribing, use of ultrasound, laser, etc, etc.

    Even if we miss the boat with GP commissioning, we can build pathways and refer directly to the appropriate expert, saving the pt time and reduce some of the burden on the GP`s. Just my opinion of course.
     
  30. footsiegirl

    footsiegirl Active Member

    I have been reading this thread with great interest. Just to get it back on track though, I would like to know what the OP decided to do with this patient.
     
  31. George Brandy

    George Brandy Active Member

    "I think we`ll have to agree to disagree on this one. I think all Pods (and their patients), PP or NHS, would benefit from building on their skills in whatever area they choose, should they wish to, whether that be skin surgery, independent prescribing, use of ultrasound, laser, etc, etc."

    I doubt anyone disagrees with your sentiments its how you present reality that is cause for concern.

    Come on Bel admit it, your practice is just like the majority....85% routine/ palliative/care/educational/preventative and 15% more specialised work. Even the SCP survey into private practice provides the evidence to support this statement. There is nothing wrong with ambition to be specialised in PP and to change these statistics providing you don't run the risk of making oneself a Jack of all Trades and master of none.

    Surprisingly you haven't classed business and practice management as skill building, only clinical study. I find that intriguing in today's commercial climate. In my opinion it is much more of a sound proposition to aim to expand clinical practice by employing podiatrists who each present with a specialised skill rather than trying to do it all yourself. One to lead the business and marketing side of the practice, to research opportunities in practice growth and development and others who can combine their clinical skills.

    Even with this kind of practice model it is doubtful that the 85:15 statistics would alter much but it is a more positive approach rather than the single handed professional who can offer little in the way of continuity of care for the commissioner. What would happen if you were ill for 2 weeks as a single handed practitioner? There is so much more to being a provider of NHS services than upskilling.

    Even if we miss the boat with GP commissioning, we can build pathways and refer directly to the appropriate expert, saving the pt time and reduce some of the burden on the GP`s. Just my opinion of course.

    Do you really think GP's are burdened? Go back to the last time we saw GPs as budget holders. How many built beautiful new premises and employed business managers? Under the Labour Government we have seen spacious and modern poly clinics being developed. GP practices have become small businesses with GPs and nurses financially enabled to expand their skills. How many GPs carry out their own out of hours service? In my opinion they simply are no longer burdened. Harsh I know but most have time off midweek and weekends free of practice commitment.

    I would also urge caution with your inclusion of independent prescribing as a specialised skill. This is very much in its developmental infancy. At the moment we can train to become supplementary prescribers but quite how this benefits the independent PP I have failed to grasp. Independent prescribing, if it comes to fruition, is going to be controlled by some authority/quango who will decide if it is necessary for you to become an independent prescriber. How and who will audit the suitability of the private practitioner is not clear but I urge you to become familiar with DoH engagement exercise. There will certainly be benefits for some within the private sector but not all. Obviously for CPD purposes carrying out the required training is beneficial to your portfolio and you will gain the credit of being annotated with POM next to your name on the HPC register. But for a substantial investment, I expect a monetary return and as yet this is not guaranteed.

    GB
     
  32. blinda

    blinda MVP

    Why the concern? I just expressed my opinion that any Pod, regardless of where they work, should feel free to build on any skill they deem would benefit their practice. I was not endeavouring to portray the political/commercial climate in any way, just expressing an opinion. I may not have mentioned that business and practice management are also important skills to build upon, of course they are. As are many other skills, but that is not what we were discussing. Interesting thoughts on employing pods, maybe in the future. First, I have to pay back my student loans...

    Yes, my practice is like the majority. I am fortunate to work in a relatively affluent area, but the statistics you quote still remain an approximate reflection of my practice. The only difference is that I have an interest in dermatology and this is evident in my practice.

    OK, maybe `burden` was not the word I was groping for...but I feel, and this is only my opinion, that referring work that is within our remit to GP`s does not benefit us individually nor as a whole. You`re right about POMs...this was part of my undergrad training and it does not benefit my practice....yet ;)

    Cheers,
    Bel
     
  33. Mr C.W.Kerans

    Mr C.W.Kerans Active Member

    Agree with previous post. I would like to find out the final Dx on the skin lesion illustrated.
     
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