Hospital privileges - is there still discrimination against DPMs?

[janV88]

Hello all,

I have been trying to read up on this topic and I keep hearing the same thing that less and less hospitals are denying DPMs hospital privileges. How widespread is the discrimination against DPMs? Is there a trend? Are there specific states or regions that are typically not DPM friendly? or is it more of a case by case basis?

I also came across this thread in the osteopathic forum http://forums.studentdoctor.net/showthread.php?p=9138067#post9138067

Basically it says that some hospitals only give hospital and surgical privileges to individuals who have trained under ACGME residencies. It also says that this policy is usually with surgical privileges. Do DPMs face the same discrimination as AOA residency trained DOs face?

So to all the Podiatric Physicians and Residents, what are your thoughts on this topic?

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[Podfather]

There will always be either open or behind closed door discrimination. I sometimes compare (and this is not meant to imply equal suffering) our treatment to the civil rights movement. We have come a long way but anyone other than an MD will always be seen differently. With that said today it is mostly a place by place situation. 25 years ago as one of the few 2 year trained podiatric surgeons I spent 1000s of hours fighting for hospital access then forefoot and eventually rearfoot and ankle privileges. At staff meetings no one would sit with me and the orthopedists wouldn't talk to me. However, just this week I was elected vice-chairman of the department of surgery and will be the chairman in a year. Who nominated me? An orthopedist.

Having said that if I applied just 2 miles away at another hospital I couldn't do an ankle fusion (even though I have done 200). It is something all applicants need to know. If you can not deal with the second class citizen status (it still causes me to have GERD sometimes) do not become a DPM,DO, OD, or a DC. If you can handle it and realize your as good and often better than your MD counterparts you can excel in podiatry.

 

[jonwill]

I think it definitely exists but it is minimal. For those who know and understand the profession, there are no issues. Don't let it dissuade you though. Like Podfather's example, there are many great opportunities out there.

I actually enjoy talking to some of the more "seasoned" podiatrists in the profession. They have great stories about what things were like when they first came out. Things such as no hospital privileges, contracts that included not being able to "break the skin", having to co-board cases, etc. We've come a long way.

 

[janV88]

Very good info. It's good to hear that Podiatry has come very far from what it was like ~20+ years ago. The professions owes a lot to the podiatrists, like Podfather and PADPM, that fought for privileges.

From what I have read and heard, I think this discrimination stems from fear of competition. Correct me if I'm wrong, but it seems like specialties that Podiatry does not compete with, like EM for example, are actually very happy when they have podiatry to consult.

Thanks Podfather and jonwill for contributing. And don't worry, this will not discourage me at all.

 

[215353]

From what I have read and heard, I think this discrimination stems from fear of competition.

I agree, from what I have read as well it seems like are biggest critics are the orthopaedic surgeons.

Even though Pods are joining Ortho groups it seems like this is occuring because there are less F & A orthos available and we are essentially a cheaper option. Another reason I think Pods are able to join Ortho groups is because not only can we perform F & A surgeries but we also can treat a wide variety of people who need non-surgical care...thus more $$$$ for the group practice.

But does this all mean we are earning respect?

I guess once, we pre-pods, finally get into our residency programs and the "real world" we will get a better understanding of this issue.

 

[Feli]

...From what I have read and heard, I think this discrimination stems from fear of competition. Correct me if I'm wrong, but it seems like specialties that Podiatry does not compete with, like EM for example, are actually very happy when they have podiatry to consult...

You guys have pretty much hit the nail on the head. It's a matter of dollars. Ortho, esp F&A ortho, has turf wars with pod since the scope overlaps. The same goes for vasc surg and interventional cards, interv rads and interv cards, anesth and neurosurg, neurosurg and ortho spine, plastics and ortho hand, etc.

For the most part, my experience has been mostly what jan described: the primary care or other specialties (IM, FP, ER, ID, vasc, etc etc) are glad to have well trained pod as an available consult and referral to help their patients. Ortho will generally show resistance, or at least a high index of suspicion, for pods since a well trained DPM could do a lot of trauma/recon cases in which they have an interest (scientific or financial, usually the latter).

I agree, from what I have read as well it seems like are biggest critics are the orthopaedic surgeons.

Even though Pods are joining Ortho groups it seems like this is occuring because there are less F & A orthos available and we are essentially a cheaper option. Another reason I think Pods are able to join Ortho groups is because not only can we perform F & A surgeries but we also can treat a wide variety of people who need non-surgical care...thus more $$$$ for the group practice.

But does this all mean we are earning respect? ....

Working with ortho is great, but studywith makes an important observation. I'd bet dollars to doughnuts that few, if any, ortho groups would select a DPM over F&A ortho if the contractual askings were the same. Likewise, few orthos would choose to train a pod resident or let them be the primary assistant if an ortho resident was also wanting to scrub in. That's just the way it is... and why, IMO, you have to be a bit wary of any DPM residency that depends largely on ortho for reaching their RF numbers.

In the end, you have to realize that our training, in and of itself, is very high level for the pathologies in our scope. DPMs being the "cheaper option" for ortho groups, hospitals, multispec, etc employers is only because some of our colleagues have accepted and will accept those contracts, sometimes underbidding one another. However, it's a complicated issue since DPMs can't reasonably demand equal pay as a F&A ortho since they can take gen ortho call while we cannot, and depending on training, they might have more/less many F&A services to offer.

 

[PADPM]

Feli makes excellent points as usual. Feli, I must compliment you for your wisdom and observations for someone so early on in your training.

You are 100% correct. Although I firmly believe that many of today's surgically trained DPM's are on par with most F&A orthopods, the fact remains that in my opinion, the orthopedic groups are necessarily hiring DPM's because they have suddenly found a new respect for us or have fallen in love with our profession.

It's all about the mighty $$$$. I don't know of any orthopod that's going to sign a contract for under $250,000 to $300,000 and even that is considered "low". And naturally, they are not going to start out a DPM at that number. And as Feli stated, the DPM will also treat a lot of non surgical foot/ankle pathology that may be sent out by the F&A orthopod. F&A orthopods don't do wound care (usually) and almost always send out orthoses.

Our profession is well respected by most GP's, IM docs, infectious disease docs, vascular surgeons, radiologists, etc. I'm not sure that the orthopods truly respect us, or simply see us as a commodity that can make them money.

 

[lojick]

... and why, IMO, you have to be a bit wary of any DPM residency that depends largely on ortho for reaching their RF numbers.

are there any programs in the southeast region that depend largely on orthos for there RF numbers?

 

[Podfather]

Feli makes excellent points as usual. Feli, I must compliment you for your wisdom and observations for someone so early on in your training.

You are 100% correct. Although I firmly believe that many of today's surgically trained DPM's are on par with most F&A orthopods, the fact remains that in my opinion, the orthopedic groups are necessarily hiring DPM's because they have suddenly found a new respect for us or have fallen in love with our profession.

It's all about the mighty $$$$. I don't know of any orthopod that's going to sign a contract for under $250,000 to $300,000 and even that is considered "low". And naturally, they are not going to start out a DPM at that number. And as Feli stated, the DPM will also treat a lot of non surgical foot/ankle pathology that may be sent out by the F&A orthopod. F&A orthopods don't do wound care (usually) and almost always send out orthoses.

Our profession is well respected by most GP's, IM docs, infectious disease docs, vascular surgeons, radiologists, etc. I'm not sure that the orthopods truly respect us, or simply see us as a commodity that can make them money.

I agree money talks even within our profession. As to being cheaper I would agree for the first year or two. I have now 7 residents who are in ortho groups. Many are in the top of the group for salary. One is the managing partner. I believe their ability to make non-operative income, an inherit business sense that can be picked up in residency, and the fact that they only have to take non-insured foot and ankle rather than the whole body from the ER makes them succeed. As for as being cheaper than a foot orthopod in the early years perhaps they should be. First they can only take foot and ankle call whereas a foot orthopod can take ortho call. Second orthopedists have a difficult time understanding who they are hiring. The diversity among grads (although changing) can be a risk for an ortho group. I would say an ortho group who hires a DPM for whatever reasons should be applauded. When I came out they wouldn't even talk to me. It took time and patience but we continue to open doors.

 

[janV88]

You guys make some very good points. It seems like Ortho Groups are MUCH better off, financially, by hiring a Podiatrist instead of a F&A Orthopod. Assuming that the Podiatrist and the F&A Orthopod both went to great residencies/fellowships and have equal 'abilities', it seems like the only thing going against the Podiatrist is the inability to take general ortho call. The group will save money, initially at least, by hiring the Podiatrist at a lower starting salary. And, after doing a quick search, it seems like the group would also save on malpractice insurance fees. Correct me if I'm wrong, but it seems like the "average" malpractice for Podiatrists is around $20k whereas the "average" for Orthopods is around $80k.

 

[krabmas]

1. Whenever this topic of DPM vs F&A is discussed it all goes back to the general call issue. I think this is the easy excuse that group practices give for why the salary gap. There are plenty of F&A specialty offices that do not take primary ER call and make similar if not more money that Gen Orthos.
I understand that the gen orthos would want to split call. And, if the practice is getting paid to take ER call even that salary would not explain the gap of >$150,000 per year.

2. I have worked with several ortho attendings that prefer the pod residents to the ortho residents and let them scrub and do cases over the orthos and list the pod as 1st assist.

3. I agree that students must be suspicious or aware of how each residency achieves its numbers. Just because the program is dependent on ortho does not make it bad. Some programs depend on ortho and watch all the recon cases, but then that is the same at some of the non-ortho dependent programs as well. Students should just be suspicious, and closely evaluate all residency options.

 

[PADPM]

I'm not sure where podfather practices geographically, but it's great to hear that some of his former residents have achieved success in orthopedic practices and even "parity" in some of these offices.

In my area, although a few orthopedic practices are slowly hiring well trained DPM's, it's been an uphill battle, because there are some very well known/powerful F&A orthopods in the area that have created quite a monopoly. They receive referrals from orthopods from all over the region, since all they do it F&A surgery and are dedicated F&A orthopedic practices that do not compete with other orthopedic practices. Therefore, they are in the same "fraternity".

It is really the perception of the orthopedic group. Many, many years ago, when I was early in practice, an ortho group actually approached me to join them. However, my role was mostly to handle ankle sprains, plantar fasciitis, and "simple surgery". I opted to stay independent.

Years later I met with a large group and almost merged, but they couldn't decide where they "drew the line" regarding my role. Fortunately, my practice grew and fortunately they also "woke up" and now have a well trained (better trained than me) DPM performing ALL their foot/ankle surgery. This kid is crazy busy.

podfather did hit the nail on the head. The biggest problem in the past has been the diversity of training among DPM grads. The general medical community simply didn't understand the fact that some had no residency, some had one year, two years, three years, four years, "rotating" residencies (the old days), surgical, non-surgical, etc. Add more confusion by having APMA recognized boards such as the ABPS and the orthopedic/primary care/medicine board and the non-recognized boards that are always popping up.

The hospitals and medical doctors were confused since there wasn't really a standard that they could figure out. Fortunately, many used the ABPS as a standard. Now, with the PM&S 24/36 month programs eventually leaning to 36 months as a standard, hopefully this problem will resolve.

Once there really is a "standard", hopefully parity will be in the near future. In the interim, we have certainly made great progress.

 

[215353]

The general medical community simply didn't understand the fact that some had no residency, some had one year, two years, three years, four years, "rotating" residencies (the old days), surgical, non-surgical, etc. Add more confusion by having APMA recognized boards such as the ABPS and the orthopedic/primary care/medicine board and the non-recognized boards that are always popping up.

The hospitals and medical doctors were confused since there wasn't really a standard that they could figure out. Fortunately, many used the ABPS as a standard.

Once there really is a "standard", hopefully parity will be in the near future.

I am only a pre-pod, so forgive me if I am making an erroneous assumption, but it appears that podiatric medicine has made great strides due to the actions of past DPMs who fought for the privileges we have today. Where was the APMA when this was happening?

PADPM stated that the APMA recognized a wide variety of boards and there was no standard. Why did the APMA allow this?

Why has the APMA allowed there to be a residency shortage?

All these questions with no certain answers. It doesn't give me much confidence in the APMA.

Please someone correct if I am wrong to assume this.

 

[PADPM]

I believe you misunderstood. I stated that those outside our profession had a hardtime understanding. There are only two boards recognized by the APMA. The American Board of Podiatric Surgery and the American Board of Podiatric Orthopedics/Primary Podiatric Medicine.

Those OUTSIDE our profession that were attempting to credential DPM's for hospitals, etc., became confused when "bogus" boards NOT recognized by the APMA started popping up. There were many doctors that could not pass the "real" boards so created their own. Those outside our profession had no idea which was "real" and which was not.

The APMA did step in and let the hospitals, insurance companies, etc., know which boards were the only officially "recognized" boards and not fly-by-night boards.

I'm not sure the APMA is "allowing" things to happen. Sometimes things simply happen. Hospitals discontinue residency programs due to lack of numbers, finances, etc., or the ABPS may d/c the program if the program isn't up to par. Not everything falls onto the lap of the APMA, nor can it control everything.

I believe that the APMA has dropped the ball at times, but overall I sincerely believe that the APMA, ABPS and ACFAS are all working hard to better our profession and advance our profession. But sometimes there are obstacles that are out of their control.

 

[Podfather]

The orthopods often try to imply that we have all of "these boards". The MDs far surpass us. Althought they have boards approved by the ABMS ( I believe somewhere in the mid 20s), MDs have scores of "other boards". The typical double standard.