Podiatry

Podiatry

Podiatry or Podiatric Medicine is a branch of medicine devoted to the study of, diagnosis, and treatment of disorders of the foot, ankle, and lower leg. The term podiatry came into use in the early 20th century in the United States. 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 related structures of the leg. Within the field of podiatry, podiatric physicians can focus and specialize on different areas, including surgery, sports medicine, biomechanics, geriatrics, pediatrics, internal medicine, diabetes, orthopedics, or primary care.

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. In many non-English-speaking countries of Europe, the title used may be "podologist" " or "Podólogo". 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.

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. 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."

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.

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.

The first society of chiropodists, now known as podiatrists, was established in—and still operates in—New York in 1895 as NYSPMA, with the first school opening 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.

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 and sports podiatry. Australian podiatrists are able to practise abroad with their qualifications recognised in some Commonwealth countries.

Registration and regulation

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

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

  1. Fellowship of the Australasian College of Podiatric Surgeons
  2. Doctor of Clinical Podiatry, University of Western Australia
  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 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 techniques such as partial and total nail avulsions, wound debridement, and other cutaneous and electrosurgical 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. 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.

Prescribing and referral rights

There is considerable variation between state laws regarding the prescribing rights of Australian podiatrists. 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, which are expected to come into effect soon, will allow registered podiatrists and podiatric surgeons in Victoria and New South Wales to prescribe relevant schedule 4 poisons. In other states, such as Western Australia and South Australia, podiatrists with Masters Degree's 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.

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. 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.

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 either medical doctors or osteopathic doctors 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 and/or complete a bachelor's degree. 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.

The four-year podiatric medical school is followed by a 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. Podiatric residents rotate through core areas of medicine such as emergency medicine, internal medicine, infectious disease, behavioral medicine, physical medicine & rehabilitation, vascular surgery, general surgery, orthopedic surgery, plastic surgery, dermatology and of course podiatry — both clinic and surgical. During these rotations, surgeons and physicians train the resident podiatrists in medicine and surgery of the foot and ankle. Fellowships are available for further training and experience after residency.

Podiatric Surgical Training

Upon completion of their residency, podiatrists can become board certified by either the 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. 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.

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. 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.

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.

Colleges and education

There are nine colleges of podiatric medicine in the United States. These are governed by the American Association of Colleges of Podiatric Medicine (AACPM). The AACPM describes its mission as to enhance academic podiatric medicine. All podiatric medical schools in the United States are accredited by the Council on Podiatric Medical Education.

  • Arizona School of Podiatric Medicine (AZPod) at Midwestern University
  • Barry University School of Podiatric Medicine
  • California School of Podiatric Medicine
  • Des Moines University College of Podiatric Medicine and Surgery
  • New York College of Podiatric Medicine
  • Ohio College of Podiatric Medicine
  • Scholl College of Podiatric Medicine
  • Temple University School of Podiatric Medicine
  • College of Podiatric Medicine at Western University of Health Sciences

Podiatric Specialities

Podiatrists treat a wide variety of foot and lower extremity conditions, through nonsurgical and surgical approaches. There are those podiatric physicians who also specialize (ie. specialists) in such fields of practice of podiatric specialties as:

  • Reconstructive Rearfoot and Ankle Surgery (Consultant Podiatric Surgeon)
  • Sports Medicine (Podiatric Sports Physicians)
  • High Risk Wound Care
  • Podiatric Rheumatology
  • Neuro-podiatrist
  • Onco-podiatrist (Skin Cancers) or Podiatric Oncologist
  • Podiatric Vascular Specialist
  • Dermatological Podiatrist
  • Diagnostic Podoradiologist
  • Gerentological Podiatrist
  • Diabetic limb salvage and wound care
  • Podopaediatrics (the study of children's foot and ankle conditions)
  • Forensic Podiatry (the study of footprints, footwear, shoeprints and feet associated with crime scene investigations)
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