Amputate..?

[une]

Do i as i podiatrist have the option of not amputating a foot...i mean seriously how much money would i be losing if not going about it?

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[FootAndAnkle]

Do i as i podiatrist have the option of not amputating a foot...i mean seriously how much money would i be losing if not going about it?

In Arizona, unless you work for a federal entity, amputations are out of our scope of practice, so you could of course avoid amputations by working under the standard scope of practice here. In other states, I'm sure you could have another physician do your amputations for you, as well. Podiatrists here apparently make a living well enough without doing amputations, so assumedly you could, too.

 

[EK18]

Whole foot amputations are out of the scope of practice of a podiatrist in almost all states I believe. Some states allow amputations of toes, some allow partial foot amputations, and some don't allow a podiatrist to perform any amputation at all. You would have to look at the scope of practice in each state to see what is permissible.

 

[heybrother]

Before devoting any significant time or effort to responding to une's posts you should consider viewing his old posts.

 

[une]

Before devoting any significant time or effort to responding to une's posts you should consider viewing his old posts.

Hey pal get a life and get off my d.

 

[Gigantron]

Whole foot amputations are out of the scope of practice of a podiatrist in almost all states I believe. Some states allow amputations of toes, some allow partial foot amputations, and some don't allow a podiatrist to perform any amputation at all. You would have to look at the scope of practice in each state to see what is permissible.

Just curious as to why this is the case? If the patient presents with such a condition where it is necessary to remove the limb in order to preserve life, then why aren't podiatrists allowed to perform the case considering they have the most training in the foot and ankle?

 

[EK18]

Just curious as to why this is the case? If the patient presents with such a condition where it is necessary to remove the limb in order to preserve life, then why aren't podiatrists allowed to perform the case considering they have the most training in the foot and ankle?

The scope of practice of podiatry is legislated on a state-by-state basis. What this means is that basically podiatrists have to fight for expanding practicing rights in each state individually. However, we are a very small profession and one of the consequences of that means change happens very gradually.

The biggest reason however is because podiatry gets lobbied against constantly by the American Medical Association and the American Orthopaedic Association. They are extremely well-funded and extremely well-organized. The lobbying by the AMA and Ortho Association is probably the biggest reason why there are still a handful of states where Pods can't legally treat the ankle yet.

 

[Gigantron]

The scope of practice of podiatry is legislated on a state-by-state basis. What this means is that basically podiatrists have to fight for expanding practicing rights in each state individually. However, we are a very small profession and one of the consequences of that means change happens very gradually.

The biggest reason however is because podiatry gets lobbied against constantly by the American Medical Association and the American Orthopaedic Association. They are extremely well-funded and extremely well-organized. The lobbying by the AMA and Ortho Association is probably the biggest reason why there are still a handful of states where Pods can't legally treat the ankle yet.

That is absolutely ridiculous. You spend 7-8 years learning everything about the foot and ankle, only to be out lobbied by those with only 1 year of fellowship training in the foot and ankle? I thought the amount of states where podiatrists can treat the ankle as well as the foot was much higher. Why bother doing a residency with RRA credentials when the same state you did that residency in potentially bars you from ever taking on those cases? 😕

This clearly is a $$$ game, I can tell. The AMA and ortho associations could probably care less about the patient, which is ultimately why many of us entered the medical profession in the first place. >_>

EDIT: There was also an excel spreadsheet posted not too long ago that compiled the scope of practice for podiatrists in every state, and many of these laws mentioned "ankle" in that scope of practice.

 

[EK18]

Well yeah, during residency you will be doing a lot of things that you normally won't be allowed to do after residency during normal podiatric practice and working under a podiatry license. I was referring to the state-by-state licensure where most laws bar a podiatrist from amputating a whole foot, and how podiatric amputation laws vary significantly from state to state.

 

[ldsrmdude]

Do i as i podiatrist have the option of not amputating a foot...i mean seriously how much money would i be losing if not going about it?

From my limited experience, most podiatrists I've seen that have at least some presence at a hospital will end up doing amputations of some sort at some point. There are some that just have another podiatrist see their inpatients, including the ones the need amputations. Most states allow amputations of some sort for podiatrists whether that is toes, forefoot, etc. I think that most states don't allow whole foot amputations for podiatrists, but then again, I don't think I've ever seen just a foot amputation. At least here if it's not a transmetatarsal amputation or maybe LisFranc or Choparts, it goes to a below knee (or above knee depending on the circumstances). I don't think I've ever seen a Symes, Boyd, or Pirigoff. There are probably placed where podiatrists do them though. Point is if you don't want to do amputations, and are fine with not having a large hospital or inpatient presence, you'll probably be fine.

 

[MaxillofacialMN]

Residency programs function under the same state laws that pods practice in private or group practice. You don't get to do whatever you want because you are in residency. What are you talking about?

If you are skilled enough and practicing under the state scope you should be able to do everything you were trained to do.

Wait... I don't know a lot about what happens during residencies, but I think you're wrong here?

During residency, residents rotate through different medical specialties, right? So if the resident can't actually do anything during his time in internal medicine or plastics, what's the point???

 

[EK18]

I'm only a first-year so I don't know much about residency training or how it works, but basically what I meant was that as a resident you will practice procedures (both podiatric and non-podiatric) that you won't be allowed to perform legally out in the world. For example, you might learn how to amputate a toe, but as a poster above has stated, legally in the state of Arizona, you cannot perform that procedure as it doesn't fall under the scope of podiatry in that particular state. There are also non-podiatric procedures that you will also learn from rotating through those particular specialties that you won't be able to perform because they don't fall under the scope of podiatry anywhere (treating systemic disease, knee surgery, etc).

 

[Zalligan]

There are also non-podiatric procedures that you will also learn from rotating through those particular specialties that you won't be able to perform because they don't fall under the scope of podiatry anywhere (treating systemic disease, knee surgery, etc).

Also, from a fellow first year's understanding, this ^^.

 

[ldsrmdude]

I'm only a first-year so I don't know much about residency training or how it works, but basically what I meant was that as a resident you will practice procedures (both podiatric and non-podiatric) that you won't be allowed to perform legally out in the world. For example, you might learn how to amputate a toe, but as a poster above has stated, legally in the state of Arizona, you cannot perform that procedure as it doesn't fall under the scope of podiatry in that particular state. There are also non-podiatric procedures that you will also learn from rotating through those particular specialties that you won't be able to perform because they don't fall under the scope of podiatry anywhere (treating systemic disease, knee surgery, etc).

Let me just add that beyond whether you can legally perform a surgery, there will probably be cases you don't feel comfortable with or will have no desire to do, getting back to the OPs question. I've got a friend who graduates this year and who is well-trained in "big" cases (Charcot recon, trauma, frames, etc) but he has little desire to do those cases and plans n referring those out. The OP could do the same with amputations, I suppose.

Oh, and just for the record, just because amputations aren't "allowed" in Arizona doesn't ran the don't happen.

 

[Gigantron]

I'm only a first-year so I don't know much about residency training or how it works, but basically what I meant was that as a resident you will practice procedures (both podiatric and non-podiatric) that you won't be allowed to perform legally out in the world. For example, you might learn how to amputate a toe, but as a poster above has stated, legally in the state of Arizona, you cannot perform that procedure as it doesn't fall under the scope of podiatry in that particular state. There are also non-podiatric procedures that you will also learn from rotating through those particular specialties that you won't be able to perform because they don't fall under the scope of podiatry anywhere (treating systemic disease, knee surgery, etc).

I'm still really confused by the reasoning behind this. You could theoretically learn how to amputate parts of the foot in an arizona-based residency program, only to be barred from performing this procedure again when you actually start to practice....even though such a procedure falls well within the scope of podiatry? See, the reasoning makes sense for procedures that fall outside of the scope (as you've mentioned, treating systemic disease, knee surgery, etc.), but not inside. 😕

 

[ldsrmdude]

I'm still really confused by the reasoning behind this. You could theoretically learn how to amputate parts of the foot in an arizona-based residency program, only to be barred from performing this procedure again when you actually start to practice....even though such a procedure falls well within the scope of podiatry? See, the reasoning makes sense for procedures that fall outside of the scope (as you've mentioned, treating systemic disease, knee surgery, etc.), but not inside. 😕

Agreed, doesn't make sense. From what I was told, the scope has been that way for a while and the leadership in the state doesn't want to open up the scope for debate out of fear that they may lose ground. No idea whether that's entirely true or not. In any case, like I mentioned, amputations still happen. They're either called "aggressive debridements" or an MD will pop his head in so he can be listed as a surgeon on the procedure or some other way to get by the rule.

 

[dyk343]

If an amputation needs to be done it should be done. Whether or not you refer that out is up to you.

To my knowledge the only state that does not allow amputations of any kind is Arizona. And as pointed out in a previous post they are done in AZ under the term "aggressive debridement". Correct me if I am wrong but all other states allow up to the level of a TMA.

Research shows that anything proximal to a TMA frequently leads to a BKA, and an argument for a BKA can be made when a TMA fails.

Podiatrists do not do BKA procedures as they are proximal to our scope of foot/ankle. That goes to ortho/vascular/general surgery.

For the pre-pods:
TMA = Trans metatarsal amputation
BKA = Below knee amputation.

 

[Zalligan]

From what I was told, the scope has been that way for a while and the leadership in the state doesn't want to open up the scope for debate out of fear that they may lose ground. .

That's what we learned in one of our pod classes. When the books are opened to change scope, it can go either way. There's no guarantee that the scope will be expanded, and the fear of having scope narrowed keeps the pod lobbying folks from pushing for it. That being said, with a state like AZ where the scope is clearly more narrow than the "norm" for most other states, you'd think expanding the scope wouldn't be too much of an issue. Though AZ may have a strong group involved with ortho or AMA lobbying, discouraging the pods from taking the risk.

 

[Zalligan]

To my knowledge the only state that does not allow amputations of any kind is Arizona.

I believe South Carolina is on that short list as well. Not 100% positive on that though.

 

[Gigantron]

Agreed, doesn't make sense. From what I was told, the scope has been that way for a while and the leadership in the state doesn't want to open up the scope for debate out of fear that they may lose ground. No idea whether that's entirely true or not. In any case, like I mentioned, amputations still happen. They're either called "aggressive debridements" or an MD will pop his head in so he can be listed as a surgeon on the procedure or some other way to get by the rule.

Well, it makes sense that anything from the distal tibia downward falls well within the scope of podiatry. You spend 7-8 years studying and working on that part of the body, after all. And even if the scope was opened up for debate, while I can't see the profession gaining any more scope that isn't related to conditions pertaining to the foot and ankle, I definitely can see them making a good case as to why certain aspects of the foot and ankle should be treated by a DPM and only by a DPM, and certainly not losing any ground over it. After all, is it really economical for an orthopedic surgeon with only 1 year of fellowship training to be encroaching on territory that he/she truly does not have comparable experience in?

EDIT: I'm only a pre-pod, so please forgive me if my ignorance starts to show on this matter.

 

[ldsrmdude]

Well, it makes sense that anything from the distal tibia downward falls well within the scope of podiatry. You spend 7-8 years studying and working on that part of the body, after all. And even if the scope was opened up for debate, while I can't see the profession gaining any more scope that isn't related to conditions pertaining to the foot and ankle, I definitely can see them making a good case as to why certain aspects of the foot and ankle should be treated by a DPM and only by a DPM, and certainly not losing any ground over it. After all, is it really economical for an orthopedic surgeon with only 1 year of fellowship training to be encroaching on territory that he/she truly does not have comparable experience in?

EDIT: I'm only a pre-pod, so please forgive me if my ignorance starts to show on this matter.

I think in most places ortho doesn't do many amputations. Could they? Sure. Do they? Not much from my experience. Most of the time it's vascular or general surgery from my experience.

But in the broader sense of your statement, most of the ortho guys that I've seen are good at what they do, just like most podiatrists are good at what they do. Saying that the foot and ankle is something that should only be treated by a DPM is frankly silly.

 

[Gigantron]

I think in most places ortho doesn't do many amputations. Could they? Sure. Do they? Not much from my experience. Most of the time it's vascular or general surgery from my experience.

But in the broader sense of your statement, most of the ortho guys that I've seen are good at what they do, just like most podiatrists are good at what they do. Saying that the foot and ankle is something that should only be treated by a DPM is frankly silly.

I only said certain aspects, but thanks for the clarification.

 

[NatCh]

I only said certain aspects, but thanks for the clarification.

I can't think of a single foot and ankle problem that is exclusively within the domain of podiatry. I'm curious as to what conditions you were thinking of.