News Story on 10 - Podiatric Surgery

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Did anybody see the news article on Channel 10 about <name removed by Admin for now>? The lead was that a podiatrist pretending to be a surgeon operated on patients. However they didnt mention that he was a qualified podiatric surgeon.

 

I did not see anything on 10 in Melbourne.

 

Saw it. Sounded harsh.

Every practitioner has failures and disgruntled patients, so I'm still working out what the allegations are.


I guess to the lay population, the pathway of going from nail cutter (podiatrist) to podiatric surgeon is unclear. Whether it is right or wrong, my perception, and the perception of the lay person is that the orthopod would have a more thorough, indepth and detailed education/training/experience on matters surgical. Although I wouldn't expect the orthopaedic training to focus solely on foot/ankle.


From a podiatric surgery perspective, I would assume that an extended clinical experience with the foot/ankle could be seen as an advantage. My concern is going further proximal from the toes. For instance the ankle. As a physiotherapist and a podiatrist, I don't think many podiatrists (or physios for that matter) have a complete grip of the ankle joint in relation to conservative management. If we don't clincially, how can proclaim to have complete grip of the ankle in relation to surgery, once we have gone from pod to pod surgeon?


On the flip side, other than surgery techniques and reading the odd scan, I have not come across too many orthopaedic surgeons with any decent understanding of conservative care. And sports physicians for that matter. Unfortunately to them, post-ankle surgery is all about "peroneal strength, proprioception and wobble board". This is simplistic icing. Little idea about the cake.



Ron

 

Re: News Story

Definitely on channel 10 late news in Melbourne.



Admin, if 10 are going virtually national with it, why not on cyberspace?:dizzy:

 

I'd like to say that for anyone who has worked with or spoken with a podiatric surgeon such as the one mentioned in the story, it would be unclear why he started out cutting toenails in the first place. Sure, plenty of pods don't understand the concepts required, but the rigorous training that pod surgeons have is very different from the training us mere pods do (and i did the 4 year degree!).

I was constantly amazed by the amount of knowledge and the grasp of difficult concepts that the pod surgeons and surgeon interns (if thats what they are called) had. They discussed the benefits of various osteotomy techniques like they were choosing between vegemite or honey sandwiches.

It's my humble belief that we should stand by all podiatric surgeons, as one of them put it, if the establishment stops them doing their job, it won't be long before nail cutting is really all we do.

 

This was a case of bad Journalism. I feel sorry for the guy and it did nothing for the college of Podiatric Surgeons.

For a college that is constantly battling against the orthopods, this news story was not a pretty sight for any Pod surgeon or Pod.:boxing:

 

Ron, I can assure you that surgical correction of toe deformities can be equally or even more challenging that a big fat joint like the ankle or the subtalar joint. In fact, the bigger the joint, usually the easier the job. Easier access, larger surfaces, greater tolerances.

Multiplanar digital correction with several potential points of instability requires much greater finesse that scraping back a large surface like an ankle joint and placing in large gauge internal fixation (eg for ankle fusion).

In fact the most difficult/tricky procedures I have seen and been trained in relate to multiple digital corrections (eg in a pan metatarsal head excision). By contast a pan-talar fusion looks big and impressive, and takes a long time, but is mostly grunt work compared to the delicate touch of digital surgery.

The question then is not where to draw the anatomical line, because surgical risks and adverse outcomes (even death) can occur from something as 'trivial' as an ingrown toenail procedure, or a simple digital arthroplasty. It is not so much the specific procedure risks (eg non-union, stump neuroma), but the global surgical risks that are arguable the most important and pertinent in patient care (DVT, PE, infection). Hence it is not 'where' the cut is made that is important, it is a sound knowledge of general surgical risks and complications that are critical for public health and safety.

Once surgical skills in musculoskeletal pathology have been attained, they can virtually be practically applied to any structures where the practitioner has sound anatomical knowledge. This is why general orthopaedic surgeons (and even some general surgeons) are willing to take on most foot procedures, even if they might have only undertaken a few bunions as the extent of their foot experiences during training. Some podiatric surgeons might argue that this is what keeps them in business (ie fixing orthopaedic failures).

The bottom line is that adverse outcomes will always occur in surgery, regardless of the professional group in question. Where the volume and nature of these adverse events is above the accepted norms in the literature - then there is a risk to public health and safety.

In this situation, I am confident of the profession and the public being reassured about the quality of podiatric surgery activities in this country, regardless of the predictable misrepresentation of the facts by the media.

LL

 

I have seen the vice-versa as well LL.


Orthopod's might have the luxury of trying to fix their own failures because medicare/p.insurance is behind them. One example I have seen, orthopod stuffs up a bunion which turns out to become hallux-adducto-valgus (big toe pointing toward other foot). Orthopod tries again....and then tries again. I assume the patient would have paid big dollars the first time. I then assume that the orthopod may have done the 2nd and 3rd operations closer to or at the medicare rebate.

The pod surgeon on the other hand would be forced to charge again or do it for nothing.

Just my hunch from outside the loop.

 

I agree. And this doesn't just apply to surgery.

Quite regularly, everyone in health care has the opportunity to scrutinise the adverse outcomes of complications and failed treatments by other practitioners. An example from this week alone was a patient whom I saw with osteomyelitis from a failed bunion procedure. The fact that she had end-stage peripheral arterial disease and should never had surgery to begin with seemed to be lost on all others involved in her care. But I digress...

Dissatisfied patients will seek alternative opinions when they 'lose faith' in the original service provider. I am sure that others see my 'failures' as often as I see theirs, since we all have been educated to a similar paradigm.

We see this in orthotics, physical therapies, prescribing, surgery and alternative and complementary therapies almost daily.

Unfortunately, professional boundaries, money, politics and ego can sometimes lead to situations where patients are pawns in a bigger game that they may not even be aware is being played around them...

LL

 

:good:

 

Those who live in glass houses should not throw stones!

Show me an orthopod who has no disgruntled patients and I will eat my words.

On a DAILY basis in my practice I see what I would term "stuff ups" from orthopaedic and general surgeons. I have numerous patients who are in the process of litigation against their orthopaedic surgeon or othewise. Does that get splashed over the nightly news? (In Sydney it was the 2nd lead story at 5pm).

The reports was obviously biased and in my personal opinion rather unfair.

Whilst I do not agree or condone the way in which the report was handled, I do feel that until legislation can be settled on a state and national basis, reports like this will continue to be sensationalised in the media.

I believe more could be done by our national body, state bodies and the ACPS to facilitate this.

The first thing that needs to be done is formalisation of a Podiatric Surgery specialty at a federal level when amalgamation of the Boards takes place in 2010/2011. I know the NSW Podiatrists Registration Board recently sent out a document for discussion regarding protection of title and changes to pave the way forward. Possibly if this had been done previously in said state there would not have been as much ammunition to fire at the Podiatrist in question? Then again - it may have made absolutely no difference. Where are the ACPS guidelines in terms of use of title for its members?

The second thing is formal university based training of said Podiatric Surgical speciality. Even the current ACPS website states the training document is "UNDER REVIEW"? When things like that are hidden from plain sight and are not transparent to both the public and the profession is it no wonder people get concerned?

I was extremely saddened by the report for the person involved and for the profession in general. Is this the start of the great downward spiral for Podiatry? Or will this spur us on to bigger and better things?

Only time will tell.

 

Here: http://www.acps.edu.au/PDF's/Use%20of%20the%20Title%20Dr%20and%20Surgeon%20Policy.pdf


LL

 

Thanks Tony,

I think you would agree this document was drafted after the events in question and most likely as a response to them? As per the date September 2007.

The document clearly states its up to STATE/TERRITORY law as per use of title, hence the document itself is nothing more than an in-house ACPS protocol.

Also there is no mention of the term "Surgical Registrar" or guidelines on how the use of this title is addressed from a trainee perspective?

There are massive gaps in the Legislative Podiatry world at present, and its time to start plugging the gaps as quickly and effectively as possible.

If there is one good thing that can possibly come out of this, its that we can learn from our mistakes. In NSW we have been working for over 18 months on plugging holes such as this one, trying to protect Podiatrists who perfrom surgery (I can't use their correct title because I am writing this whilst currently sitting in NSW.):wacko:

I am just sad that one of our own (and a damn good one at that) has had to have been media bashed to have us realise something needs to change, and that we need to do it extremely fast.

Lets hope no one else has to go through it.

 

Everything we do is a reflection of juridictional law. All that guidelines and policies can do is reflect the most appropriate way to conduct ones-self under these conditions.

A similar policy is here: http://www.acps.edu.au/PDF's/Use%20of%20the%20Title%20Registrar.pdf

There are gaps, and then there are deliberate 'exclusions'. To overturn laws and policies that exclude podiatrists from competitive service delivery models is called politics. We are generally small and weak when it comes to the politics, but we hit hard for our weight. It will be a never ending battle, just look at the US. We are competing in an uneven playing field and we just need to accept that we wont ever be treated as 'fairly' as our esteemed medical colleagues.

Mistakes, naiiviety...call it what you will. In the educational system, which is relatively benign and non-punitive, this is called reflective learning. In the big bad world of health care, we just get stomped on until we learn a different approach or a political saviour comes along (??? Roxon???).

I think that it is only a matter of time...

LL

 

Why not an RCT (or other type of solid research (retrospective)) on bunion surgery done by pod-surgeons versus foot-ankle orthopods. Also ankle surgery?
We need "evidence" to recommend and implement an intervention, yet when we are about to refer a patient to have surgery, we go on hunch or what one lecturer recommended?


It might mean less subjectivity and more objectivity. I welcome the support for pod-surgeons, but I don't know about the cheerleading. To use a political/industrial analogy, reducing tariffs provided short-term pain for industry, but in the long-term was the impetus for productivity gains and worlds-best-practice attainment. It raised the bar.

I always thought, "closer to the toe, pod surgeon" and "closer to the ankle, orthopod". But on what basis was my thinking?.

For those that don't send to orthopod's in VIC, how do you know how good/bad the Beischers, the Schneider's, the Edwards', the Rice's, the Blackney's are?

Likewise, the fact that I have not referred to the pod-surgeons more than a couple of occasions means that I might be equally in the dark about them.





Who knows, the results might favour podiatrists/pod-surgeons, which then could be sent to channel 10 to be used on a slow-news-day.



Ron

 

Ron,

an RCT in surgery of this kind would be very difficult, seeing that the Orthopods and Pod Surgeons would have to work together.

There has already been a number of outcome studies indicating that the outcomes from Pod Surgery are no worse than than of Orth Surg, but that doesn't make the orthopods take any notice, and currently MG is undertaking his doctoral thesis on Pod surg outcomes.

The RACS has been attempting to limit any increase in podiatry scope of practice for the last 25 years, creating "policies" on what a completely seperatley regulated profession should be able to do. The AMA has provided no constructive input into any advacement in podiatry, eg Prescribing. Just wait for the headlines when a patient needs hospital admission following a mistake in podiatry prescribing, despite the multitude of medication errors that happen daily with medical prescribing see National Prescribing Service

I wouldn't be suprised to see the AMA as the source of the Ch10 story, and it is probably in response to Nicola Roxon's plan to open up health.