Bunion surgery without conservative trial, OK for board cert. review?

[Creflo]

I am going to do a bunionectomy on a patient without an extended course of conservative care. It's not going to go away without surgery. I am just out of residency, so am logging cases for ABFAS certification. Will I get dinged for not documenting conservative care before the surgery?

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[NatCh]

Dinged by ABFAS? Back when I submitted my cases to ABPS I don't recall them asking about conservative care. Are they doing so?

Your patient has likely tried conservative measures on his or her own prior to seeing you. They will have bought multiple shoes in the past, and many people will have used otc inserts at one point or another, but lo and behold the bunion is still there. When you take the history make sure to ask them about their shoe history. You can document, "Previous conservative measures have included multiple footwear changes and otc inserts without resolution of the bunion deformity."

 

[dpmgrad]

As NatCh alluded to, you should make an attempt to document (if appropriate) in medical record that patient has failed previous conservative measures (and listed the failed conservative measures) before proceeding with ELECTIVE surgery. If your elective surgery does go wrong and leads to malpractice lawsuit or peer review by hospital or state board, at least there is an indication for the elective surgery by documenting that patient had already failed conservative treatment options. This is a good practice for anyone that you plan on taking to OR for elective surgery.

As for ABFAS case analysis, they are doing a new process starting with 2015 cycle. Since there are no more oral exams, ABFAS will be doing a "deeper" case analysis of all submitted cases for the credentialling portion of the Board Certification process. As with the past, you are require to submit all of the progress notes for the patient. Since ABFAS is a surgical board, they will most likely focus more on proper indication of the surgical procedure than whether or not patient has exhausted conservative treatments before proceeding with surgery. However, you never know with this new "deeper" case analysis.

 

[dpmgrad]

Here is an example of why documentation of previously failed conservative treatments prior to any elective surgery is important:


Failure to Employ Conservative Methods (NY)
Facts: The plaintiff, who was 16 at the time of the 2008 treatment, contended that the defendant podiatrist acted negligently in performing surgery without first attempting a course of conservative measures and that the surgery was unnecessary and excessive. The plaintiff contended that she presented with a moderate bunion on the great toe of the left foot, a mild hammertoe condition on the other four toes of this foot and some signs of a mild ” tailor's” bunion on the other side of this foot.
The plaintiff contended that recommending surgery before conservative measures, ...
Editor's note: The complete jury verdict reporter can be read here.
Result: $775,000 verdict
Plaintiff's expert: Jack Gorman, DPM, Warminster, PA.
Defendant's expert: Paul M. Greenberg, DPM, NY, NY