Texas Scope Issue

[G0dFather]

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Hey Everyone , How do you guys feel about the scope of practice in Texas issue and the way the supreme court responded to it ? Im just afraid that this becomes systemic ... what are your takes on it?

 

[jonwill]

Hey Everyone , How do you guys feel about the scope of practice in Texas issue and the way the supreme court responded to it ? Im just afraid that this becomes systemic ... what are your takes on it?

I don't think it will mean much. This has been going on for a couple of years now (at least) and will probably go on for a while. In the end, I don't really see anything changing. Pods are still fully practicing down there and will continue to do so.

 

[Podfather]

Hey Everyone , How do you guys feel about the scope of practice in Texas issue and the way the supreme court responded to it ? Im just afraid that this becomes systemic ... what are your takes on it?

DPMs still have full privileges for now. I believe all residencies are PM&S-36 and a few are nationally known. DPMs can do all procedures but continually are being challenged by the orthopedists. It seems to be a few orthopedists who have made this a personal issue. Eventually this will have to be codified in the legislature.

 

[crusader123]

what is happening in texas and the scope?

 

[Marry2Pod]

Can someone please give me some background on this issue of Orthopedists challenging Podiatrists current scope of practice in Texas? I am unfamiliar with the issue but wantt o learn more. My husband (who is in Pod school) and I are looking to move to Texas after residency. Is it a good state to practice podiatry? Is it possible for the state to "take away" what podiatrists are already doing? I thought with Vision 2015, scope of practice would increase, not decrease...

Thanks!

 

[165007]

what school does your husband go to?

 

[Marry2Pod]

Nycpm

 

[Marry2Pod]

Someone plz clarify my questions above... and what is this loss in texas?

 

[Marry2Pod]

High Court Gives Podiatry the Boot

Keywords: Patient_Safety Scope_of_Practice

Physicians prevailed in the courts once again in mid–June when the Texas Supreme Court sided with TMA and the Texas Orthopaedic Association (TOA) in their 10-year battle with podiatrists over the definition of the foot. The court declined to review an appellate court's previous decision rejecting a Texas State Board of Podiatric Medical Examiners' rule that would have allowed podiatrists to treat ankle injuries.
The podiatric board has the right to ask the Supreme Court to reconsider its decision. However, it has withdrawn the rule in light of the litigation and ongoing negotiations to reach some agreement with TMA and TOA on an expanded scope of practice for podiatrists.
In 2008, the appeals court said the podiatric board was wrong when it adopted a rule that expanded the definition of the foot to include the bones in the ankle. "We conclude that the board exceeded its authority when it promulgated the rule and that the rule is invalid," the appeals judges wrote at the time.
The legal battle began in 2000 when the podiatry board defined the foot as "the tibia and fibula in their articulation with the talus, and all bones to the toes, inclusive of all soft tissues (muscles, nerves, vascular structures, tendons, ligaments and any other anatomical structures) that insert into the tibia and fibula in their articulation with the talus and all bones to the toes."
TMA and the orthopedic association objected. Even the then-Attorney General John Cornyn issued an opinion stating that the podiatry board acted outside its authority. He added that only the Texas Legislature, not an unelected administrative board, can establish or change the scope of practice for podiatrists, physicians, or any other health care practitioner. Nevertheless, the podiatry board refused to withdraw the rule.

Last Published: 6/28/2010

http://www.texmed.org/Template.aspx?id=8807

 

[sorham]

I know I am only going into my first year and a lot can change, but I was really hoping to get into a residency in Texas like West Houston when I am done due to family reasons. Is it not a good place now to do residency because of this or do I just need to keep a close eye on this situation over the next four years? I guess I am just wondering how much this will affect residencies there?

 

[Podfather]

I know I am only going into my first year and a lot can change, but I was really hoping to get into a residency in Texas like West Houston when I am done due to family reasons. Is it not a good place now to do residency because of this or do I just need to keep a close eye on this situation over the next four years? I guess I am just wondering how much this will affect residencies there?

The scope remains the same for now. A motion for rehearing has been filed and DPMs still have full privileges in TX. West Houston remains the same and is full scope performing over 4,000 cases per year. The TPMA is working to either negotiate or pass a bill which will finally end this. There is some uncertainty but for now everything remains unchanged

 

[Marry2Pod]

That's good to hear. Does this mean that NY (due to the new bill) would have a greater scope of practice than Texas if all remains the same?

 

[jeffersonswall]

That's good to hear. Does this mean that NY (due to the new bill) would have a greater scope of practice than Texas if all remains the same?

No. There will be no hospitals that will actually allow the ankle procedures in NY, the orthopedic surgeons have too much sway to have that. It will be legal but very hard to actually do for quite a few years. Still... a step in the right direction! yaay

 

[Marry2Pod]

Thanks for the info! I think in a few years Orthos wont have much to back up their claims with the direction Podiatry is going and Vision 2015. I read that most (44?) states let Podiatrists treat diseases related the foot - Does that mean a podiatrist can treat diabetes for example? (plz correct me if I understood this wrong). Which states don't allow this?

 

[jeffersonswall]

Thanks for the info! I think in a few years Orthos wont have much to back up their claims with the direction Podiatry is going and Vision 2015. I read that most (44?) states let Podiatrists treat diseases related the foot - Does that mean a podiatrist can treat diabetes for example? (plz correct me if I understood this wrong). Which states don't allow this?

DPMs need to be able to recognize systemic disease through a thorough physical exam and history, refer to the proper specialist or back to their primary care doc, and then treat (or prevent!) the results and manifestations of systemic disease in the lower extremity- much like any other specialist.

 

[krabmas]

Thanks for the info! I think in a few years Orthos wont have much to back up their claims with the direction Podiatry is going and Vision 2015. I read that most (44?) states let Podiatrists treat diseases related the foot - Does that mean a podiatrist can treat diabetes for example? (plz correct me if I understood this wrong). Which states don't allow this?

by disease related to the foot it means ailments that are systemic but manifesting in the foot. So diabetes is systemic, the neuropathy effects the foot 1st so the nueropathy can be treated by the podiatrist as well as ulcers, infections, charcot... typically the PAD associated will be treated by the vascular surgeon.

Also, podiatrists can treat a flair of gout in the foot. Some may treat the systemic gout as well, but most of these are in rural areas where PMDs may be hard to find, or just to start the patient on the medication.

there are many more examples of this.

While in school you think you want to do it all, treat it all. When you get out you will not want the risk nor will you keep up with all the latest greatest research and recommendations for every disease. That is why there are people that specialize in primary care, infectious disease... let them do their job and you stick to yours.

It is nice to learn about all the diseases and how to treat them while a resident so you are not afraid of your patients and so you can intellegently discuss your patients with other specialists, but it is also nice to know that you will not have to treat them once out and practicing.

 

[Brodiatrist]

I don't understand why, if we have unlimited prescribing rights, if a diabetic patient is under my care for ulcers and is on Metformin, Humalog, etc., why I can't refill (not alter dose or change) these prescriptions. Most, if not all of our patients are diabetics and already on these meds.

 

[janV88]

I don't understand why, if we have unlimited prescribing rights, if a diabetic patient is under my care for ulcers and is on Metformin, Humalog, etc., why I can't refill (not alter dose or change) these prescriptions. Most, if not all of our patients are diabetics and already on these meds.

Why don't you just have the patient call their other doc and get a refill sent to their pharmacy?

 

[Marry2Pod]

Thanks to all for answering my questions.

I am curious - Why is the Texas Podiatric Medical Association/Texas State Board of Medical Examiners negotiating with the Texas Medical Association and Texas Orthopaedic Association on Podiatrists scope of practice? Certaintly the TMA and the TOA do NOT have the best of interest for Podiatrists. They want to limit Podiatrists scope of practice as much as possible. Why even bother negotiating with them?

 

[Brodiatrist]

Why don't you just have the patient call their other doc and get a refill sent to their pharmacy?

Sure, why not? I'm only paying $250,000 and 7+ years of training to learn how to treat a condition 99% of my patients have, yet when I graduate as a physician I can't even refill a prescription.

Well, 99% of my patients also have unsightly toenails, so while I'm reminding them to call their real Dr. for a big boy prescription, why don't I tell them to put their shoes back on and head down the street to Wong's Nails in Chinatown for the same pedicure without the hastle of a physical exam, medical history, white coat or copay?

Our education is evolving, but our scope is not. So, I ask, why should the sliding scale I write for my diabetic patient as a 3 year resident be any different from the day I graduate? Oh yeh, I can't because there's no MD over my shoulder. Damn, time to get on the phone..

/rant (not against you)

 

[janV88]

I'm only paying $250,000 and 7+ years of training

How much would a lawsuit cost?

when I graduate as a physician I can't even refill a prescription.

Copying another doctor's prescription is not the job of a physician.

why should the sliding scale I write for my diabetic patient as a 3 year resident be any different from the day I graduate? Oh yeh, I can't because there's no MD over my shoulder. Damn, time to get on the phone..

Well first off you said you would re-fill the prescription without doing the necessary examinations. Doesn't sound like a smart idea to me. You're going to rely on someone elses examination? And maybe there's a reason the patient's prescription has no more refills...maybe the patient needs to see his/her endocrinologist again. And without examining the patient and just refilling...how do you know the current dosage is effective?

You will train for 7+ years in order to make sound medical decision for your patient...not to pad your ego. Everyone specializes these days. It's not a matter of sending the patient to the "real" doctor...it's about sending the patient to the best doctor for the job.

How would you feel if the endocrinologist said..."oh while your here let me treat all of your foot complaints...I do have an unlimited license."?

 

[Brodiatrist]

It's hard enough to have this conversation with someone outside our profession who doesn't understand our training...but I'll entertain nonetheless.

How much would a lawsuit cost?

For refilling a prescription? I'm not sure what lawsuit you're talking about, but let's say it's for liability should the patient (lets take an extreme case) die as a result of your negligence. Well, you assume that risk every time you prescribe any medication.

Now, since you're not actually a student and haven't taken law and medicine I won't go into scope or standard of care issues regarding malpractice. My point was that you'll eventually be prescribing these drugs, by yourself, for 3 years, every day, for the same patients and that will stop the day you graduate. Are you all of a sudden not competent to handle those issues once you're actually practicing? Perhaps for those who never refilled an insulin script for a diabetic in the first place, but that's not how we're trained today (incase you've never spent a day with a resident).

Copying another doctor's prescription is not the job of a physician.

Who's copying a prescription?

Well first off you said you would re-fill the prescription without doing the necessary examinations.

I never said that, but lets say I did...for someone who's been on sliding scale, like say a type 1 diabetic who's been on the same medication their whole life, what would you perform?

how do you know the current dosage is effective?

You've taken pharmacology, spent endless hours with these patients in clinic, spend no less than 3 years prescribing these medications to these patients, etc..you tell me? Oh, wait...

You will train for 7+ years in order to make sound medical decision for your patient...not to pad your ego.

So not only am I not a sound decision maker by refilling my patient's script, but I'm padding my ego by stating that my training is adequate to manage my patient? Pad on..

..it's about sending the patient to the best doctor for the job.

How would you feel if the endocrinologist said..."oh while your here let me treat all of your foot complaints...I do have an unlimited license."?

That's the patient's decision. The difference is, he wouldn't prescribe a medication he's never prescribed before for a condition he's never seen. Currently, we can't prescribe a medication we've prescribed every day of our training for a disease that nearly all of our patients have.

 

[jeffersonswall]

My point was that you'll eventually be prescribing these drugs, by yourself, for 3 years, every day, for the same patients and that will stop the day you graduate. Are you all of a sudden not competent to handle those issues once you're actually practicing?

True, however lets look at a different example. Diabetics need to 'see' (i kill me) an ophthalmologist. Ophthalmologists don't manage their diabetes, but technically can.

specialists don't have the time to be dealing with that shiznot... they have to stay up to date on the myriad of treatment modalities they use within their specialty.. not writing for meds that are handled by primary care docs and endocrinologists.

Personally, if I wanted to manage systemic disease as a career... I would have applied to an MD program.

 

[janV88]

Brodiatrist,

I really don't understand your point. In the original post I responded to you said...

I don't understand why, if we have unlimited prescribing rights, if a diabetic patient is under my care for ulcers and is on Metformin, Humalog, etc., why I can't refill (not alter dose or change) these prescriptions. Most, if not all of our patients are diabetics and already on these meds.

So you don't want to alter or change the prescription...you just want to copy it? You don't mention doing anything else but "refill (not alter dose or change) these prescriptions".

I admit I don't know the standard of care but there's gotta be a reason for a prescription correct? I mean you can't just write a prescription based on someone else's work up, right?

Maybe you can elaborate.

 

[Podmeister]

So you don't want to alter or change the prescription...you just want to copy it? You don't mention doing anything else but "refill (not alter dose or change) these prescriptions".

I admit I don't know the standard of care but there's gotta be a reason for a prescription correct? I mean you can't just write a prescription based on someone else's work up, right?

You are correct.

Legally, you can not prescribe meds without a full work up (physical exams, lab studies, etc), diagnosis and treatment plan FULLY documented in the patient's medical chart. "Refilling" is the same as prescribing a medication and I personally know of doctors who got in trouble with the state medical board for refilling meds for family members, friends, in-laws, etc....without any work-up or documentation. Unless you are the primary treating physician for such medical condition, how would you know that all the patient needed was a prescription refill and not a follow up office visit with his doctor for further evaluation, further studies and perhaps an alternative treatment plan.

 

[janV88]

You are correct.

Legally, you can not prescribe meds without a full work up (physical exams, lab studies, etc), diagnosis and treatment plan FULLY documented in the patient's medical chart. "Refilling" is the same as prescribing a medication and I personally know of doctors who got in trouble with the state medical board for refilling meds for family members, friends, in-laws, etc....without any work-up or documentation. Unless you are the primary treating physician for such medical condition, how would you know that all the patient needed was a prescription refill and not a follow up office visit with his doctor for further evaluation, further studies and perhaps an alternative treatment plan.

Thanks for clarifying. 👍

I also just thought of another reason not to treat systematic diseases. Where do Podiatrists get referrals from? I bet the majority come from PCPs and Endocrinologists. We wouldn't want to bite the hand that's feeding us...

 

[Brodiatrist]

The point was lost, forget it.

 

[Dental Jarry]

So let me get this straight. Texas isn't saying that podiatrists shouldn't be treating the ankle because they are improperly trained or because they are practicing based on an improper definition of foot. They are saying podiatrists shouldn't be able to treat it because the Texas State Board of Podiatric Medical Examiners didn't have the authority to alter the definition and expand their scope themselves without going through the legislature. If this is the case and podiatrists lose that privilege in Texas, I'm sure they would be able to go to the Texas Legislature and regain it. They would just need to go the "proper legal route" to increase their scope, which shouldn't be that hard since they have been working on the ankle for the last 10 years.

 

[Marry2Pod]

So let me get this straight. Texas isn't saying that podiatrists shouldn't be treating the ankle because they are improperly trained or because they are practicing based on an improper definition of foot. They are saying podiatrists shouldn't be able to treat it because the Texas State Board of Podiatric Medical Examiners didn't have the authority to alter the definition and expand their scope themselves without going through the legislature. If this is the case and podiatrists lose that privilege in Texas, I'm sure they would be able to go to the Texas Legislature and regain it. They would just need to go the "proper legal route" to increase their scope, which shouldn't be that hard since they have been working on the ankle for the last 10 years.

I do not know - Is that what the court is saying; that the Texas State Board didn't have the authority to change the scope but they are not "questioning" the scope itself? Could it possibly take ANOTHER 10 years this time around? I hope they don't take privileges away...This all seems very backwards to me... Are there any updates on this?

 

[BlueMerlin]

Podiatrists ankle privileges have been revoked in Texas - I can't believe some of the stuff the orthopedic association there said about pods to get this ruling passed. We should "stick to treating corns, calluses, and diabetic feet." And we shouldn't "practice medicine" either, apparently. I was truly surprised at the venom towards us. So here's a little back:

First they wanted nothing to do with ankle or feet until the 80's (it was a waste of their time), until medicaid made it profitable to do surgery there. Now, medicaid got massive cuts from the health care bill, so they need to do more surgeries to keep their half-million dollar salaries (As opposed to our 110,00). So they take over surgery on the ankle. Next will be the forefoot, I'm sure. Unless something is done they will slowly strangle our profession.

But what can we do? Our education is continually getting better, and from individual orthopods I've heard nothing but good about us. So why Texas? What were you thinking?

 

[jonwill]

Podiatrists ankle privileges have been revoked in Texas - I can't believe some of the stuff the orthopedic association there said about pods to get this ruling passed. We should "stick to treating corns, calluses, and diabetic feet." And we shouldn't "practice medicine" either, apparently. I was truly surprised at the venom towards us. So here's a little back:

First they wanted nothing to do with ankle or feet until the 80's (it was a waste of their time), until medicaid made it profitable to do surgery there. Now, medicaid got massive cuts from the health care bill, so they need to do more surgeries to keep their half-million dollar salaries (As opposed to our 110,00). So they take over surgery on the ankle. Next will be the forefoot, I'm sure. Unless something is done they will slowly strangle our profession.

But what can we do? Our education is continually getting better, and from individual orthopods I've heard nothing but good about us. So why Texas? What were you thinking?

No, their ankle privileges have not been revoked. Pods are still doing ankles. The court basically said that the podiatry board exceeded their authority in defining their scope. This is all legal "mumbo-jumbo" that probably won't amount to much in the end and will most likely take years to resolve.

 

[347932]

No, their ankle privileges have not been revoked. Pods are still doing ankles. The court basically said that the podiatry board exceeded their authority in defining their scope. This is all legal "mumbo-jumbo" that probably won't amount to much in the end and will most likely take years to resolve.

This.