Diabetes and Nail care

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Here in the US it seems that a percentage of diabetics with healthy feet believe that they should not cut their own nails. These are patients that have normal circulation, no neuropathy, normal nails, and no impairments making self-care difficult or dangerous. Many GPs hold this notion as well and send off these patients to me. Most patients are happy to learn that they don't need to see a DPM for nail care, but some border on paranoia over the thought of self-care. They are angry and confused that insurance will not cover the service, especially since the GP referred them. Do other's on this forum deal with this situation???

I think we as DPMs have over-emphasized diabetic foot care in general, and paradoxically undertreat the high risk or ulcerated patients. That's just my experience in my region.

 

They are obviously trying to scam the insurance and should not get the service. In Australia and UK they would not be able to access state funded care for their nails unless they have the usual array of risk factors.

 

Scorpio 622

>They are angry and confused that insurance will not cover the service, especially since the GP referred them.

I think for good reason. I believe all diabetics who agree to a care plan with their GP should have access to a podiatrist for risk assessment, education and routine pedicure (if required). I see no problem with promoting better understanding and preventative approaches through empowerment. Assessment and education should be free to the client and pedicure by negociation and or health insurance.

I also uphold the need for improved public podiatry services which operate in tandem with acute services to provide a seemless care approach to those coping with feet at risk (both now and in the future).

Wgat say you?
Cameron

 

Just found this article which again highlights the complications of managing career diabetics.

http://www.o-wm.com/article/6121

Carl C. Van Gils, DPM, MS, CWS; and Lee Ann Stark, APRN, CWS, CWOCN Diabetes Mellitus and the Elderly: Special Considerations for Foot Ulcer Prevention and Care Ostomy/Wound Management - ISSN: 0889-5899 - Volume 52 - Issue 9 - September 2006 - Pages: 50 - 56



Cameron

 

In the UK whether patients (or people if you are politically correct) with diabetes receive nail care depends on where they live. Postcode Health Care.

In some areas ALL patients diagnoses with Type II diabetes are entitled to receive basic nail care even for normal healthy nails. (as did all pensioners a few years ago). The removal of this care has caused newpaper headlines and questions in the House of Commons!

Other areas do not provide this basic care to all pts with diabetes, just those with specific risk factors, such as ischaemia, neuropathy retinopathy etc.

Things are changing and with PCTs having commissioning rights now choices will be made about whether certain pt groups receive care for some conditions.

 

I agree with you.Many,if not all my diabetics have at least some impairment of circulation,sensation,et al.So nail cutting can be high risk.At the least,we should evaluate the people with diminished circulation/sensation a few times a year(3 to 5 is OK)

 

.. not sure if i'm with you on this one cameron ... the "all diabetics" .. "routine pedicure" .. unnecessary overservicing .. time/ money better spent with "high risk" pts ..

 

markjohconley

Yep we will need to beg to differ. This has always been a grey area and I am most certainly commited to self empowerment and encouraging self management (not self care), the evidence does suggest with diabetes there is a career of disease and when complicated with co-moribund complications there is a higher incidence of complications. Easier (and arguably cheaper) then to employ a preventative approach.

I do wish peripheral neuropathy was recognised as a disease this would at least make the highest group of "at risk" people better caried for. It has been very interesting to note the strong association medical colleagues and allied staff have for podiatry and people diagnosed with diabetes yet at the same time the way many practitoners seem to resist becoming involved with routine diabetic screening. I realise in a profession which is mainly private practice (Australia) the cost benefits are less attractive than services to clients with disposable income and or health insurance, but at the same time this function is without doubt appreciated (understood) by the health care community. I would think there is a potential lever here for a political lobby to further engraciate podiatry into secondary care.

I accept some States are different but in the West a major gap exists between the hospital and community with few public podiatry services able or willing to maintain medium risk diabetic clients (often that require pedicure). As a result acute hospital services (out patient podiatry departments) become bottlenecked with servicing clients which could and arguably should be met within the available community services, both public and private.

Short of introducing a publically funded podatry system similar to the UK I am not sure what else can be done.

What say you?

Cameron
Hey what do I know

 

cameron, again not sure if we're disagreeing .. i've worked fulltime public for the last 6 years in a health system which conducts diabetes reviews (educator, nutritionist and podiatrist; assessment and education) for all diabetic pts (regardless of financial status) who are newly diagnosed or recently arrived; from thence periodic diabetes reviews are offered (letters dispatched with invitation), for all bar the very "fit", at 12/12 intervals .. if assessed as "high risk" (neurological/vascular/medical Hx criteria) pts are offered an ongoing regular treatment regime .. i gather something similar would be standard practice in most of aus, regards mark c

 

>i gather something similar would be standard practice in most of aus,

Not so, Marc. It should be, I agree.

I work in Chronic Disease Management and there is a distinct gap where access to podiatry services for the diabetic population is a problem. That does not reflect on the excellent care that does exist within the podiatry community but it is not enough.

Cameron

 

I believe that we have a great opportunity with these diabetic patients.As Dr.Kenneth Malkin has said,we dO NOT have to pick up a nail clipper every time we see a patient-especially diabetics.Many of these people can benefit from periodic foot check ups.Does not a cardiologist check up his or her high risk patients?And the endocrinologists?My mother(may she rest in peace) went to see her nephrologist for nothing more-at times-than to review her blood results and plan action.And how about the GPs/PCPs?They also "screen" patients and check up on what is what.The GPs I work with are great about making sure I see almost all the diabetic patients.The office managers,as well,gently ask(and in the case of one,firmly insist!) that they see me as well.In the one office manager I mentioned she pretty much tells them "You will see Dr.Spina now as well...you need your circulation checked since you are diabetic.."That is beneficial to all parties concerned-MAINLY THE PATIENTS!A little editorial here:if you pods out there can go into a multidisciplinary setting,do so.You will enjoy it.you get to see the PCP's patients and see,as i do,A LOT of diabetics...and I am talking about the ones with glucose readings of 200,300 or higher and Hb1acs that will knock your socks off!

 

John

>As Dr.Kenneth Malkin has said,we dO NOT have to pick up a nail clipper every time we see a patient-especially diabetics.

I wrote up a research project on preventative health based in East Sussex where I introduced a Foot Health Advisory Service (1979/80), published in the Chriropodist circa 1981. What started as a drop-in foot care advice service was later extended to the Endocrinology Dept and the main hospitla where all recently diagnosed diabetics, registered with the endocrinologist came for foot care advice. Bare in mind this was before foot screening and diabetes educators. In any event there is a quote in the original paper from the chiropodist involved, from memoryhe said "I was amazed how helpful I could be to my patients and not even pick up a scalpel."

That was twenty years ago, when "Sgt Pepper taught the band to play."

What say you?

Cameron

 

In Australia there are about 2000 podiatrists and out of a population of 20,000,000 about 1,400,000 will have diabetes. So that is 700 people with diabetes per podiatrist. If we provide nail care to all of these people every 8 weeks, that is 4,200 ocassions of service per year for this care per podiatrist. So that is 80 per week, or 16 a day, not allowing for time off. This wouldn't leave much time for treating the complications of diabetes or foot problems in the non diabetic population.
Even if we just did an annual comprehensive diabetes assessment on everyone with diabetes (at an hour each) this would take 3 hours of every working day.

 

I agree that the ideal situation would be to offer all persons with a potential risk the service which would minimise that risk (as per Cameron), but I agree with Stephen that the resources just are not there. This problem extends beyond the patient with diabetes to all patients who would benefit from routine primary care.

We have the problem in our University Clinic that many of our patients are what we lovingly refer to as 'frequent flyers'. For a number of reasons (from arthritis to vision problems) they cannot attend to their own foot care - and if we do not offer a service, then no-one in our community can. Our Public Health Services (Community Health Centres, Hospital Outpatients) are pushed to the limit and generally restrict admission to patients with proven problems. The Private Sector is financially beyond reach for many of these patients.

Our students and clinicians offer wonderful care to these patients, but our books are full, and we are having trouble finding room to admit new patients who might offer more of a challenge (educationally speaking) to our students.

What do we do? How do we balance the need to provide a service and the need to attract patients of educational value? Our patients are very valued, they are very co-operative and patient, and we are loathe to discharge those who just require 'a pedicure'.

Any thoughts?

Sorry Craig, I've wandered off the thread topic here - but I suspect the underlying problem is common to treating the 'healthy' patient with diabetes.

 

Cameron:As usual you said it best.I was unaware of your role in this school of thought.Sorry about that.
I believe 100% that our services are not limited to nail cutting but it is amazing how many patients think that all we do is cut nails.Most of my house call referrals,for example are for circulation impaired folks who need,you guessed it,nail and or callus/corn debridement.

 

Stephen

>In Australia there are about 2000 podiatrists and out of a population of 20,000,000 about 1,400,000 will have diabetes. So that is 700 people with diabetes per podiatrist. If we provide nail care to all of these people every 8 weeks, that is 4,200 ocassions of service per year for this care per podiatrist. So that is 80 per week, or 16 a day, not allowing for time off. This wouldn't leave much time for treating the complications of diabetes or foot problems in the non diabetic population. Even if we just did an annual comprehensive diabetes assessment on everyone with diabetes (at an hour each) this would take 3 hours of every working day.

I think you have genuinely outlined a very strong srgument for more podiatrists and podiatry assistants.

What say you?

Cameron

 

As long as there is a corresponding increase in governemnt funding for public sector for foot health services. With only 10-20% of pods working in public sector positions (depending on state) the state governements are only providing podiatry to 1% of the population.

 

Stephen

These are interesting figures...but do you really think that podiatrists should take an hour to do a 'comprehensive' diabetic foot assessment?

Endocrinologists I work with take about 15mins to do a full diabetes physical, opthamologists take about the same for retinopathy screening, and I personally devote no more than 20mins to an annual assessment (and I think any experienced pods could do this in half the time).

eg. History/review = 5mins
Physical inspection = 1min
Doppler/ABI/TBI etc = 6min
Neurological = 3min
Orthopaedic = 3min

(naturally this does not include treating any particular problem)

If there truly becomes a 'crisis' in diabetic foot complications, I think governments would wonder why it takes an hour to check a pair of feet for diabetes complications etc.

Any thoughts?

LL

 

>As long as there is a corresponding increase in governemnt funding for public sector for foot health services. With only 10-20% of pods working in public sector positions (depending on state) the state governements are only providing podiatry to 1% of the population.

Me thinks this is long overdue. Neded to form a lobby group I think?

Cheers
Cameron

 

I work in Community Health.

My first thought is that most of my clients have English as their second language (if I'm lucky.) which lengthens the time it takes to do the review and neuro tests. Lets pretend that's 5 minutes extra.

To the suggested 20minutes + the language 5 minutes add:
10 minutes to get in to the room into the chair. (I usually start asking the review questions while this goes on.)
15 minutes for treating their presenting complaint and educating re prevention & self-care.
5 to issue their next appointment(or explain their return period), obtain consent to write to their GP about the results and get them out again.
5 to write notes, clean clinic bench, chair & floor and enter stats on the computer.

Then 10 - 15 minutes later on in the day to write the letter reporting the results to their GP.

So again, it comes down to funding. If the Govt will fund two clinic rooms, and someone to prepare each one and get clients in & out while I just "work" then 20 minute assessments might just be feasible.

Short of pigs growing wings, this is never going to happen in Community Health.



Someone who is healthy, regardless of having diabetes does not need another person to cut their nails. If they have peripheral neuropathy, PVD, mobility or vision issues then that does increase their risk and require Podiatrist assistance. Should this automatically be every 8 weeks?

No. It should be case dependant - reviewed and adjusted annually..


edited to add:

If I had a dollar for every one of my clients who has complained about being kicked out of the specialist's office after 15 minutes and before they get to ask any questions I'd have retired already! They ask me the questions because the specialist is "too busy". Not really economical even if it saves time.

 

dear luckylisfranc, i take it that the "The Restaurant at the End of the Universe" is staffed with an assistant / receptionist; do you wait for the pt to answer your questions before you're asking the next, and how the hell do you do a neuro assess in 3 minutes!, apart from that i'm with you bro

 

I am very much in favour of the notion of Podiatry Assistants to work alongside Pods to do the tasks that patients need (such as routine nail care) but we don't have the time to do. I appreciate there is some concern that Governments would see this as a cheap funding option - ie employ Pod Assistants rather than Pods, and have the system running economically but poorly, but if implemented correctly it would be a boon to the profession and the people who need us.

 

Guess I am fortunate to work with translators in the hospital. The number of languages experts available is quite considerable with the exception of aborigenese ( and its various versions).

I hear what is being stated and share the problem but surely the time has come to do something about it. As individsuals we may be powerless but as a action group we must be able to start convincing the powers that be now is the time to think podiatry. The health of a nation has never been more in focus and the idea that most of the aging population will grow into poverty cannot be ignored by public funded services.

Time to kick ass, I think.

What say you?

Cameron
Hey, what do I know

 

Mark

Yes I have a receptionist in my practice - please tell me that's not unusual (I would think it be unprofessional not to!)? No I don't have a podiatry assistant, but I wish I did - down the track I will look at that.

For example:
Testing 3-4 sites with a 10g monofilament each foot = 1min
Deep tendon reflexes (ankle/knee) = 1min
Vibration perception (1 site each foot) = 1min

I have literally done this many thousands of times, I feel I am sleepwalking my way through it most of the time. In all honesty and seriousness, I think I have reached the stage seeing so many people with diabetes, that it's easily possible to diagnose sensory-motor neuropathy and PAD on sight/history alone (with reasonable confidence) without even touching the patient, so usually the clinical assessment is a formality...

At the tertiary hospital diabetes centre that I have spent many years at, the Director of Endocrinology expected me to do an assessment + treat an active lesion (if necessray) in 20mins - which is a stretch, but I would usually run on time. Lots of practice though...

Patient history may take more or less time, but once you have positioned the patient for their 20mins worth of assessment, that leaves a hell of a lot of time to keep asking more peritent questions, and provide meaningful information to the patient.

Maybe this is out of the ordinary. In my state, we have about 50 endocrinologists to serve a population of several million - so time really is of the essence, hence the increasing role of diabetes educators to fill in the knowledge gaps for patients and assist with insulin dosing.

LL

 

luckylisfranc, fair enough, except i'm public and definitely no receptionist /assistant .. i go fetch and escort in and out .. still i wouldn't like my chances in a neuro assessment showdown against you (timed myself yesterday > just under 7 minutes) .. i wonder if they hold neuro assess "one-on-one" competitions ... certainly get top ratings .. beat the hell out of SURVIVOR, all the best, mark c