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A visit over to the UK forum and recent threads on Foot Health Practitioners and Pedorthists in the UK, reminded me of an editorial in JAPMA a while back (CL Jones: Who treats feet? J Am Podiatr Med Assoc 1995 85: 293-294. ).

Just who does treat the foot?

Podiatrists (still 'Chiropody' in some pockets of the world)
Podiatry assistants
Foot Health Practitioners (in the UK)
Nurses (generalists, specialist, practitioners & 'foot care' nurses)
Pedorthists
Footwear technicians
Prosthetists & Orthotists (or 'Orthotists & Prosthetists', depending on which part of the world you are from)
Physiotherapists (Physical therapists in the USA)
Orthopaedic surgeons ('orthopedic' in the USA)
Pediatricians (paediatricians' in the rest of the world )
Osteopaths (Osteopathic physicians in the USA)
Chiropractors
Athletic Trainers
General medical practitioners/family physicians (GP's)
Dermatologists
Diabetes physicians/diabetologists
Footwear retailers
Orthopedic Shoe makers/technicians
Rheumatologists
Myotherapists
Wound care 'technicians'
Massage therapists
Alternative health practitioners/Naturopaths/Chinese medicine/etc
Pharmacists/chemists
Accupuncturists
Neurologists
Physiatrists (do a Google search if you are unsure about this one )
Reflexologist
Quacks
Receptionists (I have heard of the doing orthoses issues in some practices )

Have I covered them all? A lot of these disciplinses are welcome members here at Podiatry Arena.
We do not own the foot. Is it not time we got over the teritorial boundaries and just got on with the job?
What say you?

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

You have just missed a very important inclusion:

the owner of the feet.

We all encourage self help where it is appropriate.

GB

duh .... they should have been at the top of the list! When you look at all the advertisments for self care products, they are an important source of 'treating the foot'

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

Craig
An impressive list and very true, you conclude with 'lets get on with the job', so 'what is the Job' I know what I do but keep seeing other people wanting to do bits of it, always cheaper than me. I just wander what 'bits' I will be left with or will it be clearing up the mess the 'dabblers' made.

Bob

To avoid having parallel discussions ... in this thread on FHP's in the UK, George posted: to which I replied: and Reg replied George replied Lets pursue this on here...

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

That is an issue - what defines "podiatry" as "podiatry" so that it is different from other professions --- in the USA, podiatry is clearly part of the medical model - in the rest of the world it is not, where it is a discipline similar to physiotherapy etc (that is despite limited numbers with surgical qualifications in places like the UK and Australia). While it is one thing to aspire to the medical model, but is that feasible outside the USA where historical development and educational models are different?

One train of thought I have been considering for a while, is just what is it that underpins the 'podiatric model'?

Take nursing as an eg....they used to be the doctors 'hand maidens' - the textbooks of >20 or so years ago reflected that. BUT, now there is no doubt about the very high levels of independance, professionalism and status of nurses as not being the doctors 'hand maidens'. What changed? What gave them this independance as a profession ..... take a look at the current and recent nursing (up to 10 or so years ago) textbooks - the change is obvious....its the concept of a 'nursing diagnosis' that has got nursing to where it is.

For example - the medical diagnosis might be 'chronic obstructive pulmonary disease'. The nursing diagnosis "is a clinical judgment about an individual, family or community response to actual and potential health problems/life processes" - is it will focus on restrictions in ADL's and how they can be facilitated etc

Look at attempts in the physiotherapy literature to define and develop a theoretical model/framework to define the "physiotherpy model'. Look at the plethora of recent textbooks from occupational therapy defining the occupational therpy model with models and frameworks --- they are very well developed and rapidly catching up to nursing in their ability to define their profession in such a way (no wonder they are no longer perceived as basket makers ).

Maybe its time we need to consider the concept of a 'podiatric diagnosis' that needs to be addressed in each patient to better define podiatry as a profession. Those who want to pursue the medical model will disagree with me here...

For eg that corn on the fifth toe has a medical diagnosis of hyperkeratosis due to an adductovarus deformity of the fifth digit.... a podiatric diagnosis could be pain due to a pyschosocial problem that prevents them wearing appropriate footwear .... for which problem did the patient really come to us for? Which definition of this problem should we be directing our treatment at? (Thanks to Felicity who gave us this eg at our recent Departmental planning session).

The concept of a nursing diagnosis has defined 'nursing' and directs nursing interventions --- Do we need something similar?

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

Craig - sorry I can't contribute much to this thread, except to say that it is what is written here is what makes Podiatry Arena as good as what it is. Somehow we have to make it compulsory reading for everyone. Its not a matter of agreeing or disagreeing. Its a matter of being informed of all the issues. Your insights contribute significantly to that. Do you ever sleep?

Craig,

I endorse Dr Pods comments. A very refreshing 'different' approach to the subject, and one I wholly agree with.

Just some, I think, interesting numbers from the UK HPC register

' 1967 2001 2005

Pods 4530 8673 12357

OTs 2627 22197 24630

PHYs 9171 31235 39602

Growth for pods to 2001 191% to 2005 272% (some grand patenting effect.

Growth for Phys to 2001 341% to 2005 4.31%

Growth for OTs to 2001 844% to 2005 937%.

I find this amazing, is your explanation the answer and have they just grabbed everything on offer, unlike us pods who decided nail cutting was below us and allowed the NHS to invent the concept of 'social nail cutting', thus 'giving it' away together with our 'general caring role'.

"Maybe it is time that we as Pods stopped viewing the world through tunnel vision and expand our role, our definition"
Definitely.
In Oz ,the way that sports medince is approached in podiatry exemplifies this narrow attitude. Surely focussing on "injury mamagement" which covers all and sundry is a more appropriate line to adopt. Not all of our patients suffer their injury whilst participating in sport. The injury mechanisms are the same whether they are on the field of off. Rather than moan about whether other groups may "encroach " on the foot, let's expand our range of treatment options to make podiatry more inclusive not exclusive.

Netizens

Craig wrote>

Maybe its time we need to consider the concept of a 'podiatric diagnosis' that needs to be addressed in each patient to better define podiatry as a profession. Those who want to pursue the medical model will disagree with me here...

I feel there are two issues here.

The medical model usually refers to the superstructure of a passive recipient of care (patient) interacting with the physician (of whatever order), who acts as the gate keeper to health. The medical model is product driven and fails to describe the process. Podiatry and medicine operate in significantly different ways and many pods wrongly assume the mantle of the medical model as a process and not a product.

What Craig refers to as "podiatric diagnosis" , I would call podiatric process.
I wholeheartedly agree an absence of process in the manner of podiatric practice has sadly been detrimental to profession and a weakness which has already adversely impacted on the profession's future in many countries. For decades undergraduate programs have consistently omitted to develop podology (the study of the foot in health and disease) in preference to prepare the practitioners to practice podiatry. Much of this comes from the profession itself, eager to assure themselves the new starts will be employable without need for in-service (expensive) training. The absence of the very 'ology ' which underpins the principles and practice of podiatry within the realm of academia has been a dreadful omission which not only has severely stifled research and development of the podiatric process, but made the podiatry vulnerable as an autonomous entity. Unable to articulate clearly the podiatric process and the value podiatric intervention can bring, has made podiatry oddly at risk. If podiatry is in trouble, then through collective responsibility, we have all made it that way.

Despite being part of higher education for three decades there still remains glaringly obvious overstrong emphasis on apprentiship almost to the exclusion of liberal thought within the podiatry curriculum. This harps back to the good old days when a 1000 hours in front of the patient was a prerequisite to master the basic technique skills necessary to earn a living. Many reading this would have come through that very system and justifiably feel it was good enough for them, so why not the new generation too? The difference is the old technical training has gone and can no longer be sustained within the higher education sector. Syllabi full of technique combined with prescriptive number of hours dedicated to supervised podiatry in a higher education degree is an athema and an indulgence which may not always be there. Note the closures of schools of podiatry, all of which have cited funding problems. Organisers of new programs would be well advised to think beyond the initial seeding and honeymoon period when long term sustainability will become totally dependent upon an ever reducing pool of funding.


Footnote
The attraction to full fee paying students and a proverbial ocean of professions out there all eager to extend their clinical range to foot care as CPD, could become incredibly attractive to cash strapped podiatry education centres. Emphasis on skills competence as a base line to the practice of podiatry makes it appear very easy to cross over skills to other disciplines. The absence of a podiatry process makes this all the more so. Blair's Government in the UK currently are exploiting this and other countries are likely to follow the pattern. The thing we must all remeber is this is not anti-podiatry or podiatry specific but "foot care" offers a good starting block for a new order of health professionals. Lamentably from the perspective of evolution and to paraphrase Alfred Hitchcock, "Podiatry no longer exists." In terms of the last of the Dodo species, we probably have a lucrative and positive life span ahead. So I would take Laurie's advice and get in there.

What say you?

Cameron

__________________

Cameron Kippen, Podologist and Shoe Historian




Cameron Kippen

A really interesting thread. As a former nurse, I experienced in a small way the advent of professionalisation within nursing as a discipline. The formalisation and teaching of "The nursing process" during the early 1980s was (IMHO) the turning point -- it did not introduce something new or revolutionary, it merely formalised and documented much of what good, experienced nurses were doing anyway. Over time this provided a springboard for the development of "extended practice" roles and the possibilty of developing specialisms which were then formalised through accepted educational pathways and development of career structures and routes of progression.

Just a few reflections,
Poll

__________________
If you are on the rollercoaster, open your eyes and enjoy the ride.

Dears Craig and Cameron,

Believe or not there is podiatric life outside English speaking countries :) . In Spain http://medicina.umh.es/10P/Pod.htm and other Spanish speaking countries http://www.podologia.fmed.uba.ar/inicio.htm podiatry is called podologia (podology). In Spain for example our scope of practice is like in UK and our scope is protected by law (no foot health practitioners or other fancy names can be found here).

Regards,

Javier

Javier

>In Spain for example our scope of practice is like in UK and our scope is protected by law (no foot health practitioners or other fancy names can be found here).

I know a little about podiatry in Spain and other EC counties. Well I am old enough to have lived through its evolution. How old does that make me?

As they say in Scotland, "Long may your lum, reek." (translation - I hope your fire burns brightly, forever."

Feliz Navidad

Cameron





Javier

__________________

Cameron Kippen, Podologist and Shoe Historian




Cameron Kippen

Craig,
Clarify for me how you see Podiatry and Physiotherapy as similar professions?

Ann, PT

Ann

Outside the USA -- Podiatry, Physiotherapy, Nursing, Occupational Therapy, etc are all generally 3/4 yr undergraduate degrees. In most cases for podiatry, the surgical component is a additional postgraduate qualification, but licensure/registration is obtained at the end of the 3/4 years - its a different model ... what I was refering to above waas the similar educational structure between these disciplines .... outside the USA.

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

I have been working within public health for some time, and have found a glaring problem facing podiatrists, and the patients who use our skills.
Diabetes is on the rise - with our aging population, and certain lifestyle factors being prevalent, therefore our knowledge and skills are becoming very sought after. Not just diabetics, but the plethora of conditions which prevent people being able to even reach their own feet, or maintain their own toenails is vast.
Think:
obesity - especially central adiposity (big tummies)
hip/knee replacements
rheumatoid/osteoarthritis
spinal problems
poor eyesight
abdominal hernias
there are lots more, but those are example enough.
Now many individuals whose toenails are relatively healthy (no onychomycosis, or onychokryptosis etc) simply need someone to cut their toenails. Public health doesn't cater to these individuals, so it is up to them to seek private podiatry care. Unfortunately, many pensioners and beneficiaries survive on a fixed income and can't afford a podiatry fee every 2 months ((or however often they would visit), so - quite naturally - they seek a cheaper alternative, and find it in nurses, carers, European-trained podiatrists who arn't registered in the area etc....(this seems to happen a lot)
Should I - who can accurately diagnose peripheral musculoskeletal injury, and perform a derotational arthroplasty when needed - be threatened when my patient just wants their toenails cut for $20 by someone rather than $40 for a podiatist's fee?
The cheapies are performing 'Podiatry' too, but only where podiatry means cutting healthy toenails.
There is a huge group of people on low and fixed incomes (you tend not to be aware of them if you work only in private practice) and they all have toenails, which - unfailingly - need to be cut. But would you or I insist they need to pay a podiatrist what they cannot afford?
And isn't 'Podiatry' so much more than this anyway?

Barbara

Should I - who can accurately diagnose peripheral musculoskeletal injury, and perform a derotational arthroplasty when needed - be threatened when my patient just wants their toenails cut for $20 by someone rather than $40 for a podiatist's fee?

You describe yourself and your skills as a specialist podiatrist. I feel that a more generalist practitioner, unlike yourself who cannot perform derotational arthroplasty, may feel threatened by the rate at which our skills are being given away particularly in the UK. Nail care, once upon a day, was fundamental to a generalists skills.

Rather than becoming specialists and narrowing our capabilities in order to survive we should be expanding our role and definition to include remedial therapys-exercise, massage, manipulation, acupuncture; utilising our diagnostic and preventitive skills; promoting our abilities to assess and maintain those at risk and yes continuing to cut non-pathological toe-nails. A well managed and private Podiatry practice could offer affordable nail care to those that cannot pay a high premium for podiatry, if nail care is their only need. How long does it take to provide a non pathological nail cut and a brief over view of the patients foot health status? 10 minutes? I could have factored a half day of such patients into my schedule had nail care not been passed over to the untrained and voluntary sector here in the UK. I fear these patients whose health status could change from one day to the next are missing out on Podiatric diagnoses as some of us insist on promoting podiatry as a highly specialised service.

What are we actually gaining from promoting specialisation and that Podiatry is much more than nail care? Often within my clinic a routine nail cut expands into a musculoskeletal consult when a patient attends with an awkward, involuted nail.

I feel that in 2006 we should ground ourselves, bring ourselves back down to earth look at what we as a profession want to achieve and resume our status as generalist practitioners acknowledging our specialist sector. We must expand upon our role and definition by utilising CPD but 1st and foremost we must stop the professional erosion and provide our patients with a service they deserve.

GB