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Podiatry
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Podiatry is a branch of medicine devoted to the study, diagnosis and treatment of disorders of the foot, ankle and lower leg.
Within the United Kingdom, the titles “podiatrist” and “chiropodist” are to some extent interchangeable. Although the UK government-appointed regulator acknowledges both titles and makes no distinction between them, they are used differently within the occupation. 'Podiatrist' is a reserved title in the UK, meaning that it can only be used by those registered with the Health Professions Council.
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Encyclopedia
Podiatry is a branch of medicine devoted to the study, diagnosis and treatment of disorders of the foot, ankle and lower leg.
Within the United Kingdom, the titles “podiatrist” and “chiropodist” are to some extent interchangeable. Although the UK government-appointed regulator acknowledges both titles and makes no distinction between them, they are used differently within the occupation. 'Podiatrist' is a reserved title in the UK, meaning that it can only be used by those registered with the Health Professions Council. Inside the profession, chiropody is used to suggest the routine processes of foot care, whilst podiatry is indicative of the higher skills and academic levels.
In the USA, a podiatrist is a Doctor of Podiatric Medicine (DPM), also known as a podiatric physician or surgeon, qualified by their education and training to diagnose and treat conditions affecting the foot, ankle and related structures of the leg. Podiatrists are uniquely qualified among medical professionals to treat the foot and ankle based on their education, training and experience.
Podiatry is also practised in other countries such as Australia, Canada, New Zealand and the UK. The level and scope of practice may vary in these countries as compared in the US.
History
The professional care of feet was in existence in ancient Egypt as evidenced by bas-relief carvings at the entrance to Ankmahor's tomb dating from about 2400 BC where work on hands and feet is depicted.
Corns and calluses were described by Hippocrates who recognised the need to physically reduce hard skin, followed by removal of the cause. He invented skin scrapers for this purpose and these were the original scalpels. Aulus Cornelius Celsus, a Roman scientist and philosopher, was probably responsible for giving corns their name. Later Paul of Aegina (AD 615-690) defined a corn as "a white circular body like the head of a nail, forming in all parts of the body, but more especially on the soles of the feet and the toes. It may be removed in the course of some time by paring away the prominent part of it constantly with a scalpel or rubbing it down with pumice. The same thing can be done with a callus."
Until the turn of the 20th century, chiropodists - now known as podiatrists - were separate from organized medicine. They were independently licensed physicians who treated the feet, ankle and related leg structures. Lewis Durlacher was one of the first people to recognize the need for a protected profession. He tried to establish the first association of practitioners in 1854, although it would take another century to come to pass.
There are records of the King of France employing a personal podiatrist, as did Napoleon. In the United States, President Abraham Lincoln suffered greatly with his feet and chose a chiropodist named Isachar Zacharie, who not only cared for the president’s feet, but also was sent by President Lincoln on confidential missions to confer with leaders of the Confederacy during the U.S. Civil War.
The first society of chiropodists, now known as podiatrists, was established in- and still operates in- New York in 1895, with the first school opening in 1911. One year later the British established a society at the London Foot Hospital and a school was added in 1919. In Australia professional associations appeared from 1924 onwards. The first American journal appeared in 1907, followed in 1912 by a UK journal. In 1939, the Australians introduced a training centre as well as a professional journal. The number of chiropodists increased markedly after the Great War then again after World War II.
Increased numbers of ex-soldiers needing to be gainfully employed gave chiropody a boost and led to the need for registration in all English speaking countries. The study of the foot (i.e. podology), brought greater knowledge to the practice of foot care or podiatry.
Specific country practices
Australia
In Australia, podiatry is classified as an allied health profession, and is practised by individuals licensed by their representative State Boards of Podiatry. There are seven registration boards and six teaching centres, with two levels of awards — unclassified bachelors degree and honours level. In Australia there exists 2 levels of professional accreditation and professional privilege; Podiatrist and Podiatric Surgeon (Surgical Podiatrist in the state of Queensland). Australian podiatrists are able to practice abroad with their qualifications recognised in some Commonwealth countries.
Education and training
Australian podiatrists complete an undergraduate degree ranging from 3 to 4 years of education. The first 2 years of this program are generally focused on various biomedical science subjects including anatomy, medical chemistry, biochemistry, physiology and patient psychology, similar to the medical curriculum. The following two years will then be spent focusing on podiatry specific areas such as podiatric biomechanics and human gait, podiatric orthopaedics or the non-surgical management of foot abnormalities, pharmacology, general medicine, general pathology, local and general anaesthesia, and surgical techniques such as Partial and Total Nail Avulsions, and electrosurgical procedures.
Australian podiatric surgeons are specialist podiatrists with further training in basic medicine, basic pharmacology, and training in foot surgery. They first complete a degree of 4 years, 2 years of clinical experience. Following this, a masters degree must be completed with focus on biomechanics, medicine, surgery, general surgery, advanced pharmacology, advanced medical imaging and clinical pathology. They then qualify for the status of Registrar with the Australasian College of Podiatric Surgeons. Following surgical training with a podiatric surgeon (3-5 years), and passing oral and written exams, Registrars may qualify for Fellowship status.
Prescribing rights
There is considerable variation between state laws regarding the prescribing rights of Australian podiatrists. While all are able to utilize local anaesthesia for minor surgical techniques, some states allow suitable qualified podiatrists further privileges. Recent legislative changes, which are expected to come into effect soon, will allow Victorian graduates to prescribe relevant schedule 4 poisons. In other states such as Western Australia and South Australia, podiatrists with Masters Degree's in Podiatry, and extensive training in pharmacology are authorised to prescribe S4 poisons. States such as Queensland and New South Wales only grant prescribing privilege to those who are fellows of the Australasian College of Podiatric Surgeons, and thus are Podiatric Surgeons.
Canada
In some parts of Canada the situation is legislatively stratified between the U.S. and British systems. For instance, in some provinces like British Columbia and Alberta, the standards is the same Doctor of Podiatric Medicine (D.P.M.) level as in the United States. Quebec, too, has recently changed to the D.P.M. level of training. Also in Quebec, in 2004, Université du Québec à Trois-Rivières started the first program of Podiatric Medicine in Canada. In the prairie provinces, the standard has been based on the British model of chiropody. Recognising this fact, in the province of Ontario, chiropodists and podiatrists are legislatively distinct occupational designations. Ontario chiropodists have a narrower scope of permitted practice than Ontario podiatrists (i.e., limitations on surgical practice).
New Zealand
Chiropody became a registered profession in New Zealand in 1969 with the requirement that all applicants take a recognized three-year course of training. Soon after the professional title was changed from Chiropody to Podiatry and The New Zealand School of Podiatry was established in 1970 at Petone under the direction of John Gallocher. Later the school moved to the Central Institute of Technology, Upper Hutt, Wellington. In 1976 the profession gained the legal right to use a local anaesthetic and began to introduce minor surgical ingrown toenail procedures as part of the scope of practice.
New Zealand podiatrists were granted the right of direct referral to radiologists for X-rays in 1984. Acknowledgement of podiatric expertise marked improved services to patients and eventually in 1989 suitably trained podiatrists were able to become licensed to take X-rays within their own practice. Diagnostic radiographic training is incorporated into the degree syllabus and on successful completion of the course, graduates register with the New Zealand National Radiation Laboratory.
In 1986, the profession undertook a needs analysis in conjunction with the Central Institute of Technology to identify competencies for podiatry in 2000. A Bachelor of Health Science was introduced in 1993.
United Kingdom
A podiatrist is a specialist professional who studies leg and foot pathology from a structural and functional standpoint and treats conditions of the leg and foot.
In the UK their scope of practice covers:
- Minor foot ailments
- High risk patient management
- Sports injuries and biomechanics
- Foot and nail surgery
- Foot health education
In the UK, podiatrists may continue their studies and qualify as podiatric surgeons. Podiatric surgeons practice more invasive surgery to that of podiatrists.
In the UK, individuals may not use the title “podiatrist” or “chiropodist” unless they are registrants of the Health Professions Council (HPC). They are protected titles and their use by non-registrants is unlawful. Such registration is normally only granted to those holding a specialised Bachelors degree or Diploma in Podiatry from one of the 13 recognised schools of podiatry in the UK.
Professional bodies recognised by the Health Professions Council are : The Society of Chiropodists and Podiatrists, The Institute of Chiropodists and Podiatrists, The British Chiropody and Podiatry Association and The Alliance of Private Sector Chiropody and Podiatry Practitioners.
Appropriately qualified podiatrists are licensed to access and supply a limited range of POMs including antibiotics and steroids for injection.
United States
In the United States, podiatric medicine and surgery is practiced by a licensed Doctor of Podiatric Medicine (DPM). Education consists of a second entry degree which is a four-year program followed by a two- or three-year residency. Similar to Medical School, this training follows their four-year undergraduate college degree. The first year of podiatric medical school is similar to training that traditional physicians (either medical doctors or osteopathic doctors) receive, but with more emphasis on foot, ankle and lower extremity problems and less emphasis on other topics such as embryology, pediatrics and psychiatry. Some of the podiatric medical schools are integrating into MD and DO schools for the first year or two. Being classified as a second entry degree, in order to be considered for admission an applicant must first complete a minimum of 90 semester hours at the university level and/or complete a bachelor's degree. In addition, potential students are required to take the Medical College Admission Test (MCAT). The DPM degree itself takes a minimum of four years to complete. Thus there are four medical professions in the United States that allow for independent diagnosis and treatment: conventional and osteopathic medicine (MD and DO); podiatric medicine, (DPM); dental medicine (DDS and DMD); and, optometry (OD). (In some states, optometrists are permitted to perform chemical dilation to diagnose macular degeneration and other common diseases of the eye; however, only practitioners of the first three professions may perform surgery.)
The four-year podiatric medical school is followed by a residency, which is the hands-on post-doctoral training. There are two standard residencies named Podiatric Medicine and Surgery 24 or 36 (PM&S 24 or PM&S 36). These represent the two- or three-year residency training. Podiatric residents rotate through all main areas of medicine such as: emergency, pediatric, internal medicine, orthopedic and general surgery and of course podiatry — both clinic and surgical. During these rotations, attending physicians train the resident physicians in medicine and surgery. The surgical training varies from forefoot surgery to more complex foot, ankle, and leg reconstruction and salvage as well as trauma.
Podiatric Foot and Ankle Surgeons certified by the American Board of Podiatric Surgery (ABPS) have successfully completed an intense board certification process comparable to that undertaken by individual MD and DO specialties. Certification by the ABPS involves written, oral, and computer-based patient simulation questions, in addition to submission of surgical case logs. Prerequisites for board qualification in Foot and Reconstructive Rearfoot/Ankle Surgery require successful completion of a three-year podiatric surgical program and passage of the written examination. ABPS board certification in Foot Surgery is a prerequisite for board certification in Reconstructive Rearfoot/Ankle Surgery. A candidate must pass both the written, oral, and computer-based patient simulation questions in Foot Surgery as well as the written, oral, and computer-based patient simulation questions in Reconstructive Rearfoot/Ankle Surgery. In addition, ABPS requires submission of 65 cases for certification in Foot Surgery and an additional 30 cases for certification in Reconstructive Rearfoot/Ankle Surgery, for a total of 95 cases. ABPS requires four years of post-DPM degree clinical experience before taking the certification examination. Additionally, diplomates must re-certify every 10 years to maintain their board-certified status.
In the United States, the previous titles used for the Doctor of Podiatric Medicine (D.P.M.) degree were Doctor of Surgical Chiropody (DSC) and Doctor of Podiatry (PodD) Podiatry in the US currently encompasses a broader spectrum of medical practice than it used to. Podiatrists can now perform medical and surgical procedures in all 50 states, though the specific scope of practice does vary slightly in each state.
Early educational developments
William Scholl founded the Illinois College of Chiropody and Orthopaedics in 1912. Scholl was a Medical Doctor (MD) who felt the need to focus more on footcare. Just prior to Scholl founding a Chiropody College in Illinois, other innovators and individuals around the United States were founding other institutions of learning for foot care. Among these was M.J. Lewi, MD, who founded what is now the oldest and largest college of podiatric medicine located in New York City. His institution later became the M.J. Lewi School of Podiatric Medicine and ultimately became the New York College of Podiatric Medicine.
The New York College of Podiatric Medicine notes that by 1911 the New York School of Chiropody had been created, dedicated to educating and training chiropodists. Maurice J. Lewi, a physician and educator, then serving as Secretary to the New York State Board of Examiners, was named the first president of the school.
Lewi assisted in developing the first legislation governing the practice of chiropody. He also developed the curricula and training programs for the first course of study at the school.
Lewi was the first to suggest that the term "chiropody" be changed to "podiatry", since the term "chiropody" was considered by some to be etymologically incorrect. Some years later, the term "podiatry" was adopted by all other colleges of podiatric medicine and by the National Association of Chiropodists (NAC), now known as the American Podiatric Medical Association.
Practice characteristics
While the majority of podiatric physicians are in solo practice, there has been a movement toward larger group practices as well as the use of podiatrists in multi-specialty groups including orthopedic groups, treating diabetes or in multi-specialty orthopedic surgical groups. Some podiatrists work within clinic practices such as the Indian Health System (IHS), the Rural Health Centers (RHC) and Community Health Center (FQHC) systems established by the Federal government to provide services to under insured and non-insured patients as well as within the United States Department of Veterans Affairs providing care to veterans of military service.
Scope of practice
The differences in podiatric medical and surgical practice are determined by state law. Podiatrists are often defined as podiatric physicians in many States. Each state allows or limits the practice of podiatric medicine to the foot, ankle, and in many States, portions of the leg or related leg structures.
This may include surgery above the ankle and leg in 44 states. Most states require completion of a residency or a post-graduate training to practice. Most podiatric surgeons work in surgery centers or hospitals performing both medical and surgical treatments for patients. As in many other specialties, some podiatrists work in nursing homes and some perform house calls for patients. Podiatric patients range from newborns and infants to the geriatric.
Surgical practice
Within the scope of practice, podiatrists are one of two types of experts at foot and ankle (the other type are orthopedic surgeons, a type of medical doctor). Some podiatrists have primarily surgical practices. Some specialists complete additional fellowship training in reconstruction of the foot and ankle. Many podiatric surgeons specialize in minimally invasive percutaneous surgery. Most podiatrists utilize medical, orthopedic, biomechanical and surgical practices. Indeed, surgical podiatric principles rest on a base of orthopedic and kinesthetic knowledge.
United States
Within the United States medical and surgical care of the foot and ankle is mainly provided by two groups of physicans: Podiatrists (DPM) and Orthopedists (MDs or DOs).
Podiatric Foot and Ankle Surgeons who are Certified in Foot and Ankle Surgery or Certified in Foot Surgery and Certified in Reconstructive Rearfoot/Ankle Surgery by the ABPS are podiatrists specifically trained to diagnose and perform complex surgical treatments of the foot and ankle. They are an integral part of the health care team, and combined with all other podiatric physicians, currently treat the majority of foot related medical issues in the U.S. Orthopedists are the second largest providers of foot related medical issues.
Each ABPS Board Certified Podiatric Foot and Ankle Surgeon has:
• Completed four years of Podiatric Medical School. The Podiatric Medical School curriculum covers basic and clinical sciences, including, but not limited to: general anatomy; pathology; biochemistry; pharmacology; general medicine; surgery; pediatrics; behavioral sciences; and ethics. Unlike MD and DO Medical Schools, the Podiatric Medical School curriculum also provides intensive foot and ankle “specialty” specific education beginning in the first year.
• Completed post-graduate Podiatric Medicine and Surgery (PM&S) Residency (PM&S-24 or PM&S-36). While current Podiatric Residency models range from two to three years, the majority of graduates complete three years of podiatric surgical training and some continue on to do fellowships.
Job opportunities and salary
The US Department of Labor, Bureau of Labor Statistics expects the need for podiatrists to rise, but slowly because podiatrists tend to have long careers before retirement. The 2008 APMA survey on podiatric physician salaries revealed an average income of $176,000.
Colleges and education
There are eight colleges of podiatric medicine in the United States with a ninth school being added in 2009 at Western University of Health Sciences. These are governed by the American Association of Colleges of Podiatric Medicine (AACPM). The AACPM describes its mission as to enhance academic podiatric medicine. All podiatric medical schools in the United States are accredited by the Council on Podiatric Medical Education.
Speciality branches
Podiatrists treat a wide variety of foot and lower extremity conditions, through nonsurgical and surgical approaches. There are those podiatric physicians who also subspecialize in such fields of practice as:
- Reconstructive Rearfoot and Ankle Surgery
- Sports Medicine
- Diabetic limb salvage and wound care
- Podopaediatrics (the study of children's foot and ankle conditions)
- Forensic Podiatry (the study of footprints, footwear, shoeprints and feet associated with crime scene investigations)
Professional societies and organizations
- (APMA)
- (ACFAS)
- (ABPS)
- American College of Foot & Ankle Orthopedics & Medicine (ACFAOM)
- American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM)
- American Academy of Podiatric Sports Medicine (AAPSM)
- American Society of Podiatric Dermatology (ASPD)
- Federation Internationale des Podologues (FIP)
- Student National Podiatric Medical Association (SNPMA)
- (APMSA)
See also
External links
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