Jarrod Shapiro, DPM PRESENT Practice Perfect Editor Mountain View Medical & Surgical Associates, Madras, Oregon

One of the controversial national issues between podiatry and other medical practitioners, is whether or not we should be able to perform our own history and physicals. I don’t see this as controversial within the podiatric community; the problem seems to be with the other members of the medical/legal community. I generally hear a unanimous agreement for our privileges.

Should podiatrists be allowed to perform their own preoperative history and physical?

Of course we should.  First, our residency training is on par with our MD and DO counterparts.  If this is true, why shouldn’t we do our own H&P’s?  I was recently told by one of our CRNAs that my preoperative H&Ps are better than some of the local family physicians.  I recently received word from my local family practice group that if I send a patient for a preoperative H&P, I need to indicate what labs/tests I want ordered.  How ridiculous is that?  The preop evaluation dictates what tests should be ordered.  If they are doing the evaluation, shouldn’t they determine what tests are to be performed?  Why should I send the patient back to the primary care provider if I’m already doing the evaluation?  

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Second, our national organizations, as well as the online community like PRESENT Podiatry, provide continuing education to keep us current.  With all the educational opportunities available, our chances of loosing clinical acumen is greatly reduced.

Third, I’m the captain of the surgical ship.  If the patient is hypokalemic on the morning of surgery, is the PCP going to run in and take care of it?  I don’t think so.  If handling the complications are in my hands, then I want to do the evaluation preoperatively and be ready if something untoward occurs.

Here’s the caveat to our privilege:  we’re liable for the results.  If you fail to obtain the appropriate preoperative cardiac workup in a patient with known cardiac disease, for example, and the patient has an MI, you may be on the legal hook.  If the PCP did the preoperative evaluation, they are now liable.  Of course, if this happens, you may simply be one of several entities to be sued.  Either way, your medicolegal risk still remains high. Here are some suggestions for those of us who want to perform our own H&Ps:

1. If you send your patient back to the PCP for the preop exam (which you may, depending on state laws or your community) make sure you do one yourself.  Remember, your patients’ health is on the line.
2. Always keep the PCP involved.  Remember, they’re an important referral source.
3. Keep yourself educated and current.  Take advantage of the CME opportunities available to us.
4. To that end, here are the ACC/AHA 2007 guidelines for perioperative cardiac evaluation and care.
5. For those patients with complex or severe medical conditions, consider referral for medical clearance.  For example, a diabetic, CHF patient should have cardiology clearance.
6. Be aware of your local hospital/medical community bylaws and guidelines.
7. If you are being discriminated against, call the APMA’s advocacy department.  It’s nice to have “friends” if you have to fight for your privileges.

For my part, I’m going to keep doing my own H&Ps on all healthy patients and those with controlled illness. When appropriate, I will involve the PCP and other specialists. For patients with more advanced illness, I’ll continue to send to the PCP for preoperative medical clearance. I think we are going to increasingly see issues like this, as podiatry becomes increasingly incorporated into the general medical community. Hopefully, we will all continue to advocate for our patients and our privileges. Best wishes.

Keep writing in with your thoughts and comments or visit eTalk on PRESENT Podiatry and start or get in on the discussion. We'll see you next week. Best wishes!

Jarrod Shapiro, DPM
PRESENT New Docs Editor
[email protected]

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