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

Should Podiatrists Treat Metabolic Diseases?

We in podiatry have reached a point in our education, residency training, and capabilities that it becomes important to ask if we should be treating the metabolic diseases that have local manifestations in the foot. I thought of this concern while reading an interesting roundtable discussion in the May 2010 issue of Podiatry Today regarding treatment of wound-related pain and peripheral neuropathy. The article was quite informative and clinically applicable, but at no point did any of the participants mention whether we should be treating these diseases at all. Should podiatrists be permitted to treat the diseases that originate proximal to the lower extremity?

Podiatrists are permitted by law in most states to diagnose and treat disorders of the foot and ankle (sorry New York, Massachusetts, etc. no ankles for you — keep fighting to change that!).  When it comes to metabolic diseases with manifestations in the foot and ankle, we are allowed in many states to treat the local manifestation, but not the metabolic condition itself.  Here’s the definition of podiatrist according to the Oregon Medical Board (where I currently practice):

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After reviewing the Oregon Revised Statutes, I have been unable to find any specific limitation that prevents us from treating the systemic disease itself, rather than its manifestation in the lower extremity. I have to admit that I actually thought there was a statute prohibiting this in Oregon. Here’s a contrary state law example, this one from Alabama. According to the APMA’s Scope of Practice and Regulations Chart, medical treatment consists of the following:

These two differing examples show the contrast between what is allowed in different states.  Obviously the law differs by state and region, but should we actually be allowed to treat that systemic disease that manifests itself in the foot and ankle?

Each of us has our own opinion on this issue I’m sure, and I’d love to hear yours on the PRESENT eTalk.  Here’s my opinion: within our level of training OF COURSE WE SHOULD!

For those who might disagree with this, let me explain it simply: we’re doctors.  Simple. You’re the expert of the foot and ankle.  That includes treating certain diseases that affect the lower extremity.  Being the expert of the foot and ankle doesn’t stop at the ankle as if this were some line in the sand we can’t cross.  We treat disease AS IT AFFECTS THE LOWER EXTREMITY.  If an orthopedist prescribed Uloric for gout of the knee, would anyone question them?  Of course not.  When a PCP prescribes treatment for plantar fasciitis, do we podiatrists go bananas? No. There’s no discussion about scope of practice for them.  Why are we any different? 

Does that mean I should treat the diabetes that leads to neuropathy?  Of course not.  Appropriate glycemic control and management of its concomitant diseases is the purview of our medical colleagues.  However, on the flip side of this coin, if I admit a diabetic patient to the hospital for a podiatric issue, I am going to order their in-house medications, including their insulin regimen.  The MD or DO I consult will modify my orders as they would with any other doctor. 

At the same time, I have no qualms about ordering blood work on my patients to evaluate their disease.  If, for example, I’m treating a diabetic with a neuropathic ulcer, I might order a CBC (infection), comprehensive metabolic panel (renal function, nutrition, etc.), and HBA1c (glycemic status) among others.  Am I going to modify their insulin regimen as a result of these labs?  No.  But this will become further data to help me treat their wound, provide education, and assist their medical doctor in managing their disease.  It will also help with obtaining a nutrition consult and adjusting antibiotics for those with renal disease.  This is one part of a greater comprehensive limb preservation program.

I’ve heard other podiatrists say in reference to gout, “I don’t want to worry about having to order a 24 hour urine uric acid and keep the bottles in my office.”  Or “I don’t want to worry about the complications associated with allopurinol.”  Yes, I’ve truly heard these complaints.

Again, we’re the experts of the lower extremity.  This means being physician enough to know how to treat gout and deal with the side effects, even if that means referral to a nephrologist if the patient’s renal insufficiency is leading them to be an underexcreter.  Afraid of the complications?  Don’t be a doctor.  Ever thought of the potential complications with anti-inflammatories?  How does a bleeding duodenal ulcer sound?  Or an MI?  Of course, we don’t want these complications to happen, but that doesn’t mean we’re not going to prescribe anti-inflammatories, does it?  Afraid your patient’s going to have anaphylaxis after prescribing Keflex?  Better not prescribe that antibiotic (or any antibiotic for that matter).   Concerned about DVT/PE?  Better stop doing surgery.  If you disagree with this, stop treating that knee arthritis you’ve been referred with an orthotic.  Better refer that to the orthopedist.  Sounds ridiculous?  You bet it is. 

Why did those doctors involved in the round table discussion not mention whether or not we should be treating neuropathy?  Because we should!  They’re not advocating treating patients’ diabetes.  They are advocating treating that manifestation, that symptom, which we as podiatrists see more often than any other doctor.  We keep mentioning repeatedly that our residents are the best trained in history, and this includes medical treatment of various diseases.  If you have the training, then do the doctoring.  Simple.

Keep writing in with your thoughts and comments, or better yet, post them in the eTalk forum on PRESENT Podiatry where you can get in on the discussion or start one of your own. Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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