Scope of practice for podiatrists

[dpmPOD]

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An oral surgeon has to have an MD, if you get my drift.
Podiatry is the only exclusion that I can think of that allows for a residency to replace medical school plus a specialty residency after medical school... If a podiatrist wants to prescribe systemically, then they should have gone to M-e-d-i-c-a-l S-c-h-o-o-l. I think its time for me to stop posting in this thread, because I no longer value podiatrists' training. What a sad outcome. 🙁

Repeat, for the tenth time tonight, no one thinks podiatrists should manage systemic diseases and everyone agrees we should practice within our scope.

 

[confettiflyer]

An oral surgeon has to have an MD, if you get my drift.
Podiatry is the only exclusion that I can think of that allows for a residency to replace medical school plus a specialty residency after medical school... If a podiatrist wants to prescribe systemically, then they should have gone to M-e-d-i-c-a-l S-c-h-o-o-l. I think its time for me to stop posting in this thread, because I no longer value podiatrists' training. What a sad outcome. 🙁

lol, be nice to dpmPOD, he agrees with us. Actually, I think everyone agrees with us except that douche who wants to start prescribing oral contraceptives in the other thread.

 

[RxWildcat]

Wow this thread blew up over night. Look what you did meister

 

[meister]

Wow this thread blew up over night. Look what you did meister

lol, be nice to dpmPOD, he agrees with us. Actually, I think everyone agrees with us except that douche who wants to start prescribing oral contraceptives in the other thread.

This is correct.

 

[girllein]

The lights went off in my head about podiatry. It doesn't matter who's saying what. It was one of them epiphany-thinger-majigers.

 

[bananaface]

Yes, and meister, you made a good point about the pelvic exam. I believe it is the standard of care to administer a pelvic exam/pap smear before oral contraceptives are prescribed. I don't think a DPM could provide that care and therefore, should not be RXing OCP. Under any circumstances. Until, of course, we learn that Plan B cures foot odor. Then, IT'S ON!!!!! 😛

It's actually not necessary. That's why the Direct Access Project was allowed to have pharmacists provide OCPs on protocol after a medical history and a BP check. Also allows Plan B to be OTC.

/digression

 

[All4MyDaughter]

It's actually not necessary. That's why the Direct Access Project was allowed to have pharmacists provide OCPs on protocol after a medical history and a BP check. Also allows Plan B to be OTC.

/digression

Seems to be something that was just in Washington State? The website for the project (www.directaccessstudy.info) is dead.

Women who are sexually active need pelvic exams to screen for cervical dysplasia. Since a DPM isn't going to do that, the DPM shouldn't be writing for OCP.

 

[RxWildcat]

Women who are sexually active need pelvic exams to screen for cervical dysplasia. Since a DPM isn't going to do that, the DPM shouldn't be writing for OCP.

Pelvic exam or not, a DPM shouldn't be prescribing OCs.

 

[meister]

It's actually not necessary. That's why the Direct Access Project was allowed to have pharmacists provide OCPs on protocol after a medical history and a BP check. Also allows Plan B to be OTC.

/digression

What is the direct access project? This is clearly not in widespread use, and the standard of care is to have a pelvic exam done once a woman is sexually active or reaches 21 years of age, and especially before oral contraceptives are prescribed.

 

[All4MyDaughter]

Pelvic exam or not, a DPM shouldn't be prescribing OCs.

Truth. I was looking for a reason outside of the obvious "it isn't in their scope." That they can't meet the standard of care for RXing that med is another reason to support no oral contraceptives from DPMs.

I would like you to quiz Drs. Fink, Cohron and Bouvette about this ethical/legal question and report back. After you finish finals!!!!

 

[All4MyDaughter]

What is the direct access project? This is clearly not in widespread use, and the standard of care is to have a pelvic exam done once a woman is sexually active or reaches 21 years of age, and especially before oral contraceptives are prescribed.

meister, my understanding of the standard of care is about the same as what you've written. I was taught that if a young teenager who is not sexually active is started on oral contraceptives for dysmenorrhea or another reason, a pelvic exam is not always required. Does this match your understanding?

 

[Old Timer]

meister, my understanding of the standard of care is about the same as what you've written. I was taught that if a young teenager who is not sexually active is started on oral contraceptives for dysmenorrhea or another reason, a pelvic exam is not always required. Does this match your understanding?

Define younger. Anyone old enough to be on O'C's should have an examination by a gynecologist.

 

[confettiflyer]

I had a friend who got started on OCs at age 14 for dysmenorrhea and wasn't sexually active 'til 19, don't know if that's the example you want to go with.

 

[All4MyDaughter]

Define younger. Anyone old enough to be on O'C's should have an examination by a gynecologist.

I had a friend who got started on OCs at age 14 for dysmenorrhea and wasn't sexually active 'til 19, don't know if that's the example you want to go with.

confetti's example is about what I had in mind when I asked the question.

 

[Old Timer]

confetti's example is about what I had in mind when I asked the question.

If it was my daughter and I needed to start hormonal therapy at 14, I would make sure there was a baseline pap smear and and a pelvic exam. The uterus and ovaries need to be palpated to make sure you don't have any anatomical problem or a pathology like endometriosis.

OCP, are not innocuous compounds. They have a profound effect on human's physiology. They effect behavior as well. I would want a full work up by an OB/GYN if the cramps were that severe.

 

[All4MyDaughter]

Old Timer, I agree with you. That's what I'd do with my own child as well. But I know I have read that it is not necessarily required when initiating therapy in someone not sexually active. That doesn't mean it shouldn't be done, or that it isn't done most of the time.

 

[Old Timer]

Old Timer, I agree with you. That's what I'd do with my own child as well. But I know I have read that it is not necessarily required when initiating therapy in someone not sexually active. That doesn't mean it shouldn't be done, or that it isn't done most of the time.

You would have to show me the study. If a 14 y/o female has such severe dysmenorrhea you would consider prescribing hormonal therapy, I would suggest that anything less than full history and physical exam would be negligence.

As for the main thought of this thread, everybody is right and everybody is wrong. Let's all take a deep breath and give some perspective. If a pharmacist is uncomfortable with any prescription it is his or her duty to call the prescriber and have an intelligent discussion about the need for the medication and the reasons for the order. Once you have all of the information, you are still free to refuse the prescription and you are obligated to explain to the patient and the prescriber whay you are taking this action.

I have refused to fill many prescriptions over the years because it was not appropriate in my professional opinion. If another pharmacist wants to fill it, that's their prerogative. I don't assume that a DPM prescribing Ambien is automatically out of the scope of practice. I pick up the phone and have a professional conversation. If, after hearing the rationale, I choose not to fill it, I explain why to the prescriber.

I have refused narcotics I thought were shady. I am direct, I don't go with the weasel "we're out of it". I have resused to fill prescriptions from Podiatrists and Dentists for prescribing out of the scope of their practice. I have refused to fill prescriptions for diet pills for a person who could pass for anorexic. If I get an rx for a drug interaction or an over dose and the prescriber says go ahead anyway, I may refuse. I have the professional right and responsibility to protect my patients.

It's wrong for an RpH to assume Ambien by a DPM is automatically out of scope and it's wrong for a prescriber to say "Fill what I wrote".

 

[SpirivaSunrise]

You would have to show me the study. If a 14 y/o female has such severe dysmenorrhea you would consider prescribing hormonal therapy, I would suggest that anything less than full history and physical exam would be negligence.

As for the main thought of this thread, everybody is right and everybody is wrong. Let's all take a deep breath and give some perspective. If a pharmacist is uncomfortable with any prescription it is his or her duty to call the prescriber and have an intelligent discussion about the need for the medication and the reasons for the order. Once you have all of the information, you are still free to refuse the prescription and you are obligated to explain to the patient and the prescriber whay you are taking this action.

I have refused to fill many prescriptions over the years because it was not appropriate in my professional opinion. If another pharmacist wants to fill it, that's their prerogative. I don't assume that a DPM prescribing Ambien is automatically out of the scope of practice. I pick up the phone and have a professional conversation. If, after hearing the rationale, I choose not to fill it, I explain why to the prescriber.

I have refused narcotics I thought were shady. I am direct, I don't go with the weasel "we're out of it". I have resused to fill prescriptions from Podiatrists and Dentists for prescribing out of the scope of their practice. I have refused to fill prescriptions for diet pills for a person who could pass for anorexic. If I get an rx for a drug interaction or an over dose and the prescriber says go ahead anyway, I may refuse. I have the professional right and responsibility to protect my patients.

It's wrong for an RpH to assume Ambien by a DPM is automatically out of scope and it's wrong for a prescriber to say "Fill what I wrote".

Fantastic post OldTimer!!!

I contributed my opinion in the DPM thread too and provided some samples so that they could at least see where pharmacists were coming from in terms of why we can and should question the appropriateness of each prescription we are asked to fill.

But I agree with you 100%...we can't always make a decision by looking at the order alone, and a professional discussion with the prescriber is the way to go.

 

[girllein]

I already said that podiatrists are allowed to use phones... Even if the patient's pharmacy is really busy, what's wrong with leaving a voicemail about the script?

There is no way that a pharmacist can call on every single script that gets denied. Sorry folks but we all know what retail is like these days. And it's likely that the patient was filling the script late because it's a sleeping pill, so the podiatrist probably wasn't even available for consultation that night.

It was a messed up situation backwards and forwards, so right vs wrong doesn't really apply here.


We just got a pain script from a DPM this week. It was written for 7 days and filled without so much as a flinch.
The podiatrist knew better than to write 30 Ambien (without at least calling the pharmacy first), and if he didn't, then that was his own shortsightedness. He knows now though. 😀

 

[All4MyDaughter]

You would have to show me the study. If a 14 y/o female has such severe dysmenorrhea you would consider prescribing hormonal therapy, I would suggest that anything less than full history and physical exam would be negligence.

Here is one source (American Academy of Family Physicians) that says a pelvic examination is not necessary for diagnosis of dysmenorrhea in "young adolescents with a typical history who have never been sexually active." Source: http://www.aafp.org/afp/20050115/285.html. The article is consistent with what I learned in Women's Health Therapeutics last year. I would say that the choice to do the exam or not is a matter of practitioner discretion/preference.

The article goes on to state that "a pelvic examination should be performed in females who have been sexually active to screen for sexually transmitted diseases such as chlamydial infection." I think this reasonable. Maybe this is the reason that "Direct Access" programs allowing women to get oral contraceptives directly from pharmacists (as described upthread by bananaface) have not taken off? I personally have never encountered such a program.

 

[Old Timer]

I tend to be very conservative and a minimalist when it comes to drug therapy. I read the article and remain unconvinced of the advisability of giving hormones to a 14 year old at all, let alone without a pelvic exam. The articles states you can determine normal normal pelvic anatomy with an abdominal exam. Just count me as a skeptic.

 

[diabeticfootdr]

I think A4MD's issue was the use of the word "think". The idea that if he "thinks" it's in his scope of practice he can do as he pleases. I would certainly disagree with that. If he all of a sudden decides to "think" that he's qualified to prescribe LMWH for DVT prophylaxis, I'm not going to accept his script for Lovenox...

But, again, WE are saying that if there is a legitimate medical purpose, we are fine with it. However, using the original example, prescribing 30 Ambien falls out of common practice and is thus not a legal script. I guess we agree to appear to disagree when we actually agree..but semantics or something confuse the hell out of everyone?

F' it, I'm going to sleep.

Basically, I don't think you know what a podiatrist does. I write for Lovenox for DVT prophylaxis at least 2 x weekly, it's standard of care post op in our hospital.

Again, you really come off as a "know it all" with your ... "there's no way in hell I'd fill this or that." Relax. I practice in my SOP and according to current SOC.

 

[WVUPharm2007]

Basically, I don't think you know what a podiatrist does. I write for Lovenox for DVT prophylaxis at least 2 x weekly, it's standard of care post op in our hospital.

Again, you really come off as a "know it all" with your ... "there's no way in hell I'd fill this or that." Relax. I practice in my SOP and according to current SOC.

Jesus H Christ on a freakin' pogo stick destroying an acre of an impoverished dust bowl farmer's wheat field. Ok...and in such a situation you could do as such. Lovenox in this is fine because it's a standard post operative medication...if you perform foot surgery on a person, I hope to God you give them something for DVT prophylaxis, Jesus. As an arbitrary drug example, obviously I was envisioning a situation where a podiatrist deciding whether or not some random inpatient is a candidate for DVT prophylaxis was inappropriate. My thought process on that particular example wouldn't be that consuming. "Hmm...Lovenox...oh, the guy had invasive surgery. That's clearly within reason. I shall process this order." I'm sorry I didn't take the damned time to think of every potential situation in which Lovenox may be prescribed. God ****ing help me for my lack of omniscience. I apologize for not being able to consider the entire realm of podiatry when making a clearly arbitrary and off the cuff comment. Clearly, I don't care too much about your profession, so that would put me at such a disadvantage, I suppose. But do you actually think any of us would have a problem with that specific situation? Is this like your big "gotcha" moment? Guess what, slappy, it doesn't change the fact that 30 Ambien PRN is out of scope of practice.

I'll say it again.

It just seems like the pedos don't seem to understand what *our* legal obligations are, either. I'm obligated to act as a gatekeeper for practitioners that practice outside of their scope of practice. It's actually written into the state regs. And any time a podiatrist is trying to treat a disease in which its etiology stems from outside of the foot/ankle, I am legally obligated to refuse to accept a prescription that would treat said disease.

Now...MOST of the time, I would fill any script without any hassle because I don't really care as it doesn't affect me. However, if something bizarre came around that is primarily used to treat maladies stemming from above the waist, then I am legally obligated to question it if there are no commonly accepted uses for such a drug in podiatry. I'm not talking about off-label uses, that's fine, too...I'm talking about podiatrists writing scripts for Xenical or the ubiquitous birth control. This isn't "oh look at this guy, he's being a dick because he can." This is "this guy is legally obligated to do this and isn't going to break the law because people call me Dr. such-and-such."

If I am presented a script for 30 Ambien PRN, then, yes, dammit, I am going to refuse to fill the thing and call as to why the hell you are prescribing it. I legally have to. After you aren't able to give me a reasonable explanation for such (you wouldn't)...I would refuse to fill it (the aforementioned "there is no way in hell I would fill this" proposition). And don't give me that "it might be for RLS" crap either. First off, it wouldn't be PRN. And if you write for Ambien for RLS, you are damned idiot. That's like prescribing Benadryl for Parkinson's. Like 8th line therapy...if that. If I'm chatty that day, I'd try to get you to switch to common first line therapy like maybe a selective dopamine agonist...but if you refused for no apparent reason..sorry, that ish is getting canned. If there actually is a rational explanation for drug therapy I wouldn't associate with podiatry (i.e. the Lovenox example), I'd fill it and move on, no problems.

But, really, you don't need to be concerned about my opinion, anyway. I don't work in retail for reasons such as this. In retail, every day we see practitioners prescribing drug therapy irrationally and with overbearing God complexes (do as I say, druggist!!!) It's one thing to have physicians dealing with us as if they all have IQs of 190 and we are mental midgets...oh no...now apparently the podiatrists think they are better than everyone and should get privileges as such, too. Nah...F' that. I'm in a cozy hospital. Physicians call me with drug therapy questions sporting a nice, thankful attitude and I don't have to deal with non-physicians that think they have physician prescribing privileges. I don't have to deal with the possibility of a podiatrist rolling up to TCU and checking a patient's ECG because they are worried about their legs getting proper circulatory perfusion. Everyone does what they are allowed to do and certainly nothing more. If an order comes to me, it's not from someone prescribing out of practice or in any conceivable sort of shady way. It's beautiful.

Look on the bright side. Thankfully for you, all of the pharmacists that don't care typically wind up in retail (though not all retail pharmacist are worthless.) Which is probably why if you've written such illegal scripts before, they may have not called you on it. Let's be honest, I'm sure you'll be able to find some guy that will fill birth control for your wife or whatever the illegal prescription may be. It's just like back when you were in high school...everyone knew that corner store that sold 10th graders beer. Find that dude and it will be juuuust fine.

See, the thing is - nobody really appears to disagree about anything as far as I can tell. Podiatrists can't write out of scope of practice. But yet when presented with a few situations in which we would refuse to fill such prescriptions, the podiatry people are up in arms for some damned reason. Seriously, wtf? You folks are going to have to learn to deal with the fact that if you write a script that is questionable, a by the book pharmacist will question you. I don't think it's an unreasonable thing to have to deal with, personally.

 

[diabeticfootdr]

But, really, you don't need to be concerned about my opinion, anyway. I don't work in retail for reasons such as this. In retail, every day we see practitioners prescribing drug therapy irrationally and with overbearing God complexes (do as I say, druggist!!!) It's one thing to have physicians dealing with us as if they all have IQs of 190 and we are mental midgets...oh no...now apparently the podiatrists think they are better than everyone and should get privileges as such, too. Nah...F' that. I'm in a cozy hospital. Physicians call me with drug therapy questions sporting a nice, thankful attitude and I don't have to deal with non-physicians that think they have physician prescribing privileges. I don't have to deal with the possibility of a podiatrist rolling up to TCU and checking a patient's ECG because they are worried about their legs getting proper circulatory perfusion.

I laugh every time I read you put down "retail pharmacy" or doctors that use retail pharmacy, as if your hospital practice is more important.

I mainly laugh because I am a podiatric hospitalist. I am employed by a hospital. I direct a wound healing center inside a hospital. I admit my own patients and continue all their home medications. I write for Lantus and sliding scale insulin. I use beta-blockers in perioperative situations. I use LMWH postoperatively. I use Ambien to help the patients sleep in the hospital.

I get along great with our pharmacists. The always catch any mistakes and call me and we have a polite conversation. The other day we had a nice conversation about what to use for PONV since Zofran was not working.

All of these are considered in my scope as they are needed for me to be an independent foot and ankle surgeon and they are standard surgical practice. We co-admit with I-med if someone has ESRD, CAD, uncontrolled T2DM. We are not afraid to consult FP, I-med, renal, cardio, and psych, which we do frequently.

More than anything, I'm trying to education you on what a podiatrist does. Yes, most clinic podiatrists do not admit their own patients and prefer to be consultants. But academic podiatrists, especially those associated with residency programs are as active as I am. Residency training has changed greatly for DPMs. Residency training is focused on foot/ankle surgery and how to be an independent surgeon.

Podiatrists are not idiots, just because they don't have an MD - as you insinuate. I don't think PharmD's are idiots. I value their opinions. I just don't appreciate your (WVU's) online attitude. I'm sure not under the vail of internet anonymity you act differently, if you've continued to be employed.

So when you comment that you won't have to deal with someone like me, you are probably wrong - since as I stated, I am a hospitalist too.

 

[WVUPharm2007]

Yeah, ok, let me remind you that YOU are the one that started this mess with your condescending attitude about pharmacists in the other thread that infuriated me to begin with. With such gems as "You are not the prescribing doctor. Your job is to fill prescriptions", I'm not really sure you have room to talk. I freely admit that I am a borderline nutjob, as anyone on the pharmacy forum will profess. But, playa, you're the one that started it. Don't start none, they won't be none. So don't come over here with that bull**** holier than thou attitude.

I laugh every time I read you put down "retail pharmacy" or doctors that use retail pharmacy, as if your hospital practice is more important.

See, you have absolutely no concept of how pathetic retail pharmacy has become. You sit there and talk down to me like I have no concept of what podiatry is like, yet you honestly think that a pharmacists job is simply to "fill prescriptions" and that retail and hospital pharmacy are both great professions. To take you're rhetorical style, allow me to "educate" you.

With the exception of the occasional independent that truly practices community pharmacy, RETAIL pharmacy has become a money-first, pathetic excuse for a practice area. It's all about the numbers and quality of work is very, very low and dwindling by the day. Just the other day, some pharmacy in California started promising prescriptions to be filled in under 20 minutes or else the consumer would get a gift card and a DVD rental. Imagine if there was some douchebag with a timer behind you while you are cutting open Mr. Johnson's foot demanding it be done in a hour or less. That is retail pharmacy. I only see the types that entered pharmacy for the money go into retail. The ones that genuinely like the idea of community pharmacy either go into independent pharmacy, or start out at retail pharmacy and quit REALLY fast.

So - yes - my hospital practice is more important than retail practice. Retail is barely even pharmacy practice nowadays. It used to be meaningful...but those days are coming quickly to and end. Someday in the not-so-distant future, there won't even be a pharmacist at each physical location doling out the drugs. Currently, the chains are pulling for a bachelor-holder that could replace pharmacists at the retail level...leaving us to do real pharmacist work. This will actually be a great day for the profession...because then we will all be forced into doing what we are taught and potantially able to do at our finest...but right now...no...it's laughable.

I mainly laugh because I am a podiatric hospitalist. I am employed by a hospital. I direct a wound healing center inside a hospital. I admit my own patients and continue all their home medications. I write for Lantus and sliding scale insulin. I use beta-blockers in perioperative situations. I use LMWH postoperatively. I use Ambien to help the patients sleep in the hospital.

..o...k..? And this would make you laugh at the assertion that hospital pharmacy is better than retail pharmacy because...? Yeah, whatever. Look, AGAIN for the 5 BILLIONTH TIME, if treatment is within the course of typical acute podiatry care, I would have no problem filling a script for someone. But, AGAIN for the 5 BILLIONTH TIME, if a podiatrist tries to write a script to treat a medical problem that doesn't stem from the etiology below the waste, I am legally obligated to refuse to fill it. And, again, this would include 30 Ambien PRN. I'm not sure where we disagree. Yes, podiatrists perform surgery, good for them, I get it. But you don't treat insomnia.

Podiatrists are not idiots, just because they don't have an MD - as you insinuate. I don't think PharmD's are idiots. I value their opinions. I just don't appreciate your (WVU's) online attitude. I'm sure not under the vail of internet anonymity you act differently, if you've continued to be employed.

Again, don't go there, two-face. You were singing a different tune over yonder. But to be fair, you do have to admit that some of your brethren aren't helping. Ambien for RLS before treatments considered gold-standard care? Podiatrists writing scripts for contraceptives without proper physical examinations? Come on...

So when you comment that you won't have to deal with someone like me, you are probably wrong - since as I stated, I am a hospitalist too.

Wow. What I was trying to say was that when in a hospital, I can be assured that whoever sends me an order isn't going to be practicing out of scope because there are protocols in place to keep that from happening. If a fella is a podiatrist and has done surgery, I wouldn't have any problem processing his routine orders. It's all very controlled and I know he is supposed to be allowed to do that. Now what my point was is to CONTRAST that with retail whereas I have no idea if a podiatrist is giving a fellow Ambien for RLS or if he's just giving a buddy a script for Ambien for chronic insomnia. One script can be debated as borderline legal while the other is patently illegal. It's the freakin' Wild West and God knows what's supposed to be what. There are so many shades of gray with legal liability that it is truly frightening the possibilities. That will not happen in a hospital.

And you know what, I wouldn't say I've really "learned" what podiatrists do, per se. I always knew WHAT they did, but I've never really CONSIDERED what, during the course of something like surgery, they would have to prescribe as adjuvent therapy. I.e., the use of Lovenox. And I do see the need for the use of such in typical care and I have no problem with that at all. And for that, I appreciate your enlightenment. Now I'd love for you to tell us how you appreciate what you've learned from us about what our legal responsibilities are in regards to filling prescriptions...that, perhaps, the entire legal scope our job isn't simply to just "fill prescriptions".....but for some reason, I don't see that happening. I have a feeling that behind your little computer screen you think that pharmacists are beneath you...little pill counters that should do as told. This is evident by your posts in the podiatry forum. While I appreciate your attempt of a show of how much you like your pharmacists at your hospital, I honestly can't believe you after your previous display. But, hey, it is what it is. Haters got to hate. There are *******s everywhere. I'm one of them, you're one of them. At least I'm honest about it though.

And, again, if I worked retail and this situation occurred, you are damned straight I'd refuse to fill it. I don't think you understand the legal liability we chose to undertake with such a questionable prescription. If something were to go wrong with the patient, any medical lawyer worth anything would instantly notice that a podiatrist wrote a script for long-term Ambien therapy. They would then claim this is practicing out of scope of practice...and guess who's behind is hanging out the window with a huge kick me sign on it? Me...because I didn't refuse to fill the thing as I'm legally obligated to do. It ain't worth it. I'd hand it back to the patient and tell them I won't fill it. Maybe they could go down the street and Joe Blow, RPh will assume the liability. And that's fine with me. You can look down upon me for not simply doing my job, which is apparently to "fill prescriptions", but you'll just have to agree to disagree with me on that one.