NP doing nail avulsions

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There’s an Instagram podiatry account of a private practice that has two podiatrists and a NP and PA employed. The NP is seen in a video doing a nail avulsion. Is this the future?
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That's not even legal is it? Nail avulsions are considered a surgical procedure.
 
Actually it’s not even the NP. It’s the PA. Maybe that’s worse? No idea
 
They have unlimited scope. They are fine doing it. This is nothing new.
Warts and ingrowns are fast and easy and pay well... why wouldn't they try them? (and botox, knee inject, and whatever else)
Many primary care and Urgent care midlevels and MDs in my area do podiatry stuff (nearly all try warts, tinea Rx, some do onycho Rx, some try ingrowns usually total nail avulsion but sometimes they try partials, some inject heel pain, a few biopsy/ablate foot skin lesions, etc).

My late residency director always said this is a good thing. Let them do it. Teach them F&A skin and nail procedures if you have time; be non-judgemental when you have to save them on bad outcomes. They will do it fairly well sometimes, screw it up other times... and they will remember who taught them or backs them up and and where to send it if it goes sideways. Most will try it a time or two and give up and just send all of it to you. As long as yours come back looking good, what's the issue if they want to try stuff that's "yours" once in awhile?

Basically, don't sweat it.

Everything podiatry can be done elsewhere, there is overlap:
Nail salons do nail cares... derm does a bit.
Orthotist shops do DME, orthotics, pads, shoes, etc.
Ortho can do all of the deformity and injury bone/msk surgery.
Vascular and gen surg can do the wounds and amps.
Derm can do the nail and skin stuff... warts, tinea, whatever.
Rheum and ortho and sports and PCPs can do the injects, gout, arthritis, etc.
PT does much msk stuff.

Just because our job is useful and valued doesn't mean it's special or necessary. It's not.

...All you have to do do is do the work well...
or be a lobster (take stuff nobody wants... wound care, DM/MCA trauma, nursing home or inpt decub and nails, amps, etc)...
or do both good work + lobster.

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Boba Foot said:
That's not even legal is it? Nail avulsions are considered a surgical procedure.
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They have unlimited scope... it's just an office/bedside procedure, like biopsy or warts or inject or whatever.
They can reduce fx or cast or debride wounds or do whatever they want (some just have to be billed under MD/DO).
 
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Adam Smasher said:
Fear not.

While mid-levels may swim onwards and upwards, only to be gobbled up by bigger fish, the noble podiatrist crawls humbly along the ocean floor, feasting on their leavings. It is the way of the lobster.
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Can you please help me with an analogy for the cheddar biscuits?
 
On the trauma service at my residency (which we rotate with) the NPs and PAs are putting in chest tubes, suturing lacs, putting in ART lines, and intubating. The trauma surgeon is usually there overseeing everything but not always. Not sure if this is common.
 
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MicroPod said:
On the trauma service at my residency (which we rotate with) the NPs and PAs are putting in chest tubes, suturing lacs, putting in ART lines, and intubating. The trauma surgeon is usually there overseeing everything but not always. Not sure if this is common.
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Ok but the above are all minor bedside procedures. We are talking about a REAL surgical procedure here.
 
Are we just going to sit back and do nothing????! Do we even know if a PA or NP knows when to spin the phenol stick clockwise or counterclockwise like a fellowship trained quadruple board certified podiometric total toenail replacement physician and SURGEON would?!???
 
I've never seen an ER doctor, PCP, NP or PA do a partial nail avulsion the right way. They are equally terrible at it. I've probably revised several hundred in my young career. I hate throwing them under the bus since they are referral source so I do not. But it is always the case that the partial nail avulsion was executed wrong. On top of that the patient is scared because they didn't anesthetize them the right way either.
 
Why would it be an issue? PAs can do a lot of things especially if they’re practicing under a provider but even without that, their scope is pretty broad. Just saw a PA job posting for a foot and ankle practice paying $150k base….which is more than I’ll likely be offered out of residency 🙃
 
Retrograde_Nail said:
I've never seen an ER doctor, PCP, NP or PA do a partial nail avulsion the right way. They are equally terrible at it. I've probably revised several hundred in my young career. I hate throwing them under the bus since they are referral source so I do not. But it is always the case that the partial nail avulsion was executed wrong. On top of that the patient is scared because they didn't anesthetize them the right way either.
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Bingo. ER docs should stick to doing simple crap in the ER that they can handle like thoracotomies or whatever and leave the REAL surgical stuff to highly trained total toenail replacement surgeons.
 
FutureDPM323 said:
Why would it be an issue? PAs can do a lot of things especially if they’re practicing under a provider but even without that, their scope is pretty broad. Just saw a PA job posting for a foot and ankle practice paying $150k base….which is more than I’ll likely be offered out of residency 🙃
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post link. I don't believe it
 
Pronation said:
Bingo. ER docs should stick to doing simple crap in the ER that they can handle like thoracotomies or whatever and leave the REAL surgical stuff to highly trained total toenail replacement surgeons.
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I know this is sarcasm but it is true. They suck at nail procedures. I also hate how they leave the toenail on after a crush injury and punch a bunch of holes in the nail and suture it back onto the skin thinking that is going to do something. Just take it off.
 
Retrograde_Nail said:
post link. I don't believe it
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I saw it on indeed and it’s $115-150k after I clicked on it so a little misleading from how it was posted but still better than what I may get out of residency but here it is:


This is a DPM looking to hire a PA. So I guess at some point we won’t even have crappy PP associate jobs to be fighting over anymore when all the PP owners start hiring a bunch of PAs and NPs instead 🙂
 
I see a fair number done elsewhere that were botched. The patient's are appreciative, grateful to see it done right, somewhat shocked how easy we make it look, and often pissed at the other doctor for putting them through it instead of just referring. Inevitably as noted above the other provider blocked poorly or not at all. I'm probably told near 100% of the time that my block hurt less / worked better. I don't beat anyone else up. I do make clear to the patient that this is something I view as a point of pride and that our procedural volume is going to be higher than anywhere else. We are the people who should be doing this.

I had a family medicine resident in my clinic awhile back - he told me one of his attendings had attempted a plantar fascial injection recently and walked out of the room saying they'd never do it again. He wanted to know if we do them - yeah, everyday, all day.

People have spoken about it elsewhere, but untrained NPs trying a nail surgery a few times isn't a danger to the practice. The danger is what the hospital people have mentioned - the simple truth is a busy provider would often be better served training a NP/PA than bringing on a new associate. There's always more non-surgical work available.
 
I was a family medicine PA for about 5 years and my supervising MD taught me how to do a nail removals. Did this many times without incident. Maybe I got lucky but I never considered referring out to podiatry for it. If my supervising physician recommended referral, then I wouldn't have hesitated. Honestly, I felt guilty if I didn't do it myself since the patient would have to wait longer for treatment if I referred out.

If I end up practicing as a physician in primary care, I'll try to hook up my local podiatrist with these cases. 👍
 
orthoPA81 said:
I was a family medicine PA for about 5 years and my supervising MD taught me how to do a nail removals. Did this many times without incident. Maybe I got lucky but I never considered referring out to podiatry for it. If my supervising physician recommended referral, then I wouldn't have hesitated. Honestly, I felt guilty if I didn't do it myself since the patient would have to wait longer for treatment if I referred out.

If I end up practicing as a physician in primary care, I'll try to hook up my local podiatrist with these cases. 👍
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How many do you think you did? Did you do avulsions and matrixectomies? Sharp / chemical? Revisions etc?
 
orthoPA81 said:
I was a family medicine PA for about 5 years and my supervising MD taught me how to do a nail removals. Did this many times without incident. Maybe I got lucky but I never considered referring out to podiatry for it. If my supervising physician recommended referral, then I wouldn't have hesitated. Honestly, I felt guilty if I didn't do it myself since the patient would have to wait longer for treatment if I referred out.

If I end up practicing as a physician in primary care, I'll try to hook up my local podiatrist with these cases. 👍
Click to expand...

Did you actually have the patients follow up 1-2 weeks after?
 
We let our Corpsmen do these in the military, we trained them and they did a good job. But there will always be the issues like yesterday when a patient came in, under care of his pcp, on his second 90 day course of terbinafine because the nails weren't clear from the first 90 day course he just finished.
 
This is not new. When I did private practice we had an NP and she did everything that a non surgical podiatrist would do. Heel infections, flexor tenotmies, wound debridements, nail avulsion etc. It was cheaper for the practice to hire an NP than a podiatrist.

Now I am in hospital setting and it is the same story. We employ several PAs now for podiatry clinical and inpatient work.

It isn't the future. It is already happening
 
Creflo said:
We let our Corpsmen do these in the military, we trained them and they did a good job. But there will always be the issues like yesterday when a patient came in, under care of his pcp, on his second 90 day course of terbinafine because the nails weren't clear from the first 90 day course he just finished.
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What's your expectation here? 90 days of terbinafine is not going to clear a nail that is mycotic throughout the entire nail. In that time period it will produce a zone of clearance that extends perhaps to the lunula or a few mm further. There's literature showing 6 months is superior to 3 months and in my anecdotal opinion its superior because until you clear the nail you can still have recurrence. I follow at 3 months and simply refill if the nail is resolving. Terbinafine isn't toxic. It isn't a big deal. People are on it years without complication. If they are on it that long it probably isn't doing anything, but it still happens routinely.
 
heybrother said:
How many do you think you did? Did you do avulsions and matrixectomies? Sharp / chemical? Revisions etc?
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I usually did one a week for several years. I did avulsions with chemical matrixectomies. I didn’t do any revisions…if they had issues with prior procedures from other providers then I would have the MD manage it.
 
Retrograde_Nail said:
Did you actually have the patients follow up 1-2 weeks after?
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Yep, I would see them one week later. No issues.

I was active military at the time so patients couldn’t self refer to specialists. I would have known if it went sideways and they had to see a specialist for complications.
 
orthoPA81 said:
I usually did one a week for several years. I did avulsions with chemical matrixectomies. I didn’t do any revisions…if they had issues with prior procedures from other providers then I would have the MD manage it.
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Always curious to hear others experiences. I enjoy doing them. Most I've done in 1 day is I believe 14. I went home feeling fairly drained.
 
orthoPA81 said:
Yep, I would see them one week later. No issues.

I was active military at the time so patients couldn’t self refer to specialists. I would have known if it went sideways and they had to see a specialist for complications.
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Strong work.
If you ever do private practice, do 2 week follow up (10 day global). 🙂
 
Retrograde_Nail said:
I smell fraud
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What? You've never had a patient come in for flat foot complaints and you were like "hey did you know this toenail is a little bit ingrown? we should go ahead and fix it before it causes you to die"
 
heybrother said:
What's your expectation here? 90 days of terbinafine is not going to clear a nail that is mycotic throughout the entire nail. In that time period it will produce a zone of clearance that extends perhaps to the lunula or a few mm further. There's literature showing 6 months is superior to 3 months and in my anecdotal opinion its superior because until you clear the nail you can still have recurrence. I follow at 3 months and simply refill if the nail is resolving. Terbinafine isn't toxic. It isn't a big deal. People are on it years without complication. If they are on it that long it probably isn't doing anything, but it still happens routinely.
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I don't know if anything you said here is true. It might be. It might be a complete lie. But I promise you and everyone in this forum I don't care and and don't remember and never will learn how nail fungus works. Take these pills for 90 days and wait 6 months to see if it works, let me remove the nail permanently or do nothing. There you go.

Also isn't the lunula the thing in the back of your throat? Or is that one of the lady parts?
 
air bud said:
I don't know if anything you said here is true. It might be. It might be a complete lie. But I promise you and everyone in this forum I don't care and and don't remember and never will learn how nail fungus works. Take these pills for 90 days and wait 6 months to see if it works, let me remove the nail permanently or do nothing. There you go.

Also isn't the lunula the thing in the back of your throat? Or is that one of the lady parts?
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That’s a labia. We already knew you didn’t know female anatomy well.
 
air bud said:
I don't know if anything you said here is true. It might be. It might be a complete lie. But I promise you and everyone in this forum I don't care and and don't remember and never will learn how nail fungus works. Take these pills for 90 days and wait 6 months to see if it works, let me remove the nail permanently or do nothing. There you go.

Also isn't the lunula the thing in the back of your throat? Or is that one of the lady parts?
Click to expand...
1688871223587.png
 
air bud said:
I don't know if anything you said here is true. It might be. It might be a complete lie. But I promise you and everyone in this forum I don't care and and don't remember and never will learn how nail fungus works. Take these pills for 90 days and wait 6 months to see if it works, let me remove the nail permanently or do nothing. There you go.

Also isn't the lunula the thing in the back of your throat? Or is that one of the lady parts?
Click to expand...
I never prescribed terbinafine a single time as a resident. I got tired of telling 20 year old college girls with nail fungus I didn't have an option for them and learned to prescribe terbinafine.

Right now I'm watching Don Peacock's (Rest in Peace) MIS videos on youtube trying to find new options for hammertoes. This seems more fun than terbinafine.
 
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