Foot Doctor / Podiatrist / Podiatry

The term “podiatry” came into use first in the early 20th century United States  where it now denotes a Doctor of Podiatric Medicine (DPM), a specialist who is qualified by their education and training to diagnose and treat conditions affecting the foot, ankle and related structures of the leg.  Within the field of podiatry, practitioners can focus on many different specialty areas, including surgery, sports medicine, biomechanics, geriatrics, pediatrics, orthopedics or primary care.

Podiatry is practiced as a specialty in many countries including Australia, Brunei, Canada, Cyprus, Ireland, Malta, New Zealand, Singapore, South Africa, the United Kingdom, and the United States. In many English-speaking countries, the older title of “chiropodist” may still be used by some clinicians but is gradually falling out of use.  In many non-English-speaking countries of Europe, the title used instead of podiatrist may be “podologist” or “Podólogo”. The level and scope of the practice of podiatry varies among countries. Podiatry is a very high paying job and was listed by Forbes magazines as the 15th best paid profession 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 originalscalpels. 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, ankles 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 as NYSPMA, 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 exist 2 levels of professional accreditation and professional privilege: Podiatrist and Podiatric Surgeon. Australian podiatrists are able to practise abroad with their qualifications recognised in some Commonwealth countries.

Registration and regulation

Australian Podiatrists must register with the Podiatry Board of Australia.  The Podiatry Board of Australia is responsible for regulation and recognition of Podiatrists and Podiatric Surgeons, and assessing foreign trained registrants.

The Podiatry Board of Australia recognizes 3 pathways to attain specialist registration as a Podiatric Surgeon:
1. Fellowship of the Australasian College of Podiatric Surgeons

2. Doctor of Clinical Podiatry, University of Western Australia

3. Eligibility for Fellowship of the Australasian College of Podiatric Surgeons

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, wound debridement, and other cutaneous and electrosurgical procedures.

Australian podiatric surgeons are specialist podiatrists with further training in advanced medicine, advanced pharmacology, and training in foot surgery. Podiatrists wishing to pursue specialisation in podiatric surgery must meet the requirements for Fellowship with the Australasian College of Podiatric Surgeons. They first complete a degree of 4 years, which includes 2 years of didactic study and 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), rotations within other medical and surgeons’ disciplines, overseas clinical rotations, and passing oral and written exams, Registrars may qualify for Fellowship status.  Fellows are then given Commonwealth accreditation under the Health Insurance Act to be recognised as providers of professional attention, for the purposes of health insurance rebates.

Prescribing and referral rights

There is considerable variation between state laws regarding the prescribing rights of Australian podiatrists.  While all registered podiatrists in each state or territory are able to utilize local anaesthesia for minor surgical techniques, some states allow suitably qualified podiatrists further privileges.

Recent legislative changes, which are expected to come into effect soon, will allow registered podiatrists and podiatric surgeons in Victoria and New South Wales 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. In Queensland, Fellows of the Australasian College of Podiatric Surgeons are authorised to prescribe a range of Schedule 4 and one Schedule 8 drug for the treatment of podiatric conditions.

All podiatrists may refer patients for Medicare rebatable plain x-rays of the foot, leg, knee and femur, as well as ultrasound examination of soft tissue conditions of the foot. Podiatrists may refer patients for other radiology investigations such as CT, MRI or bone scans, however Medicare rebates do not currently exist for these examinations. Similarly, podiatrists may refer patients when needed to specialist medical practitioners, or for pathology testing, however similar exclusions in the Medicare Benefits Schedule prevent rebates being available to patients for these referrals.

Canada

In Canada the definition and scope of practice of podiatry can mean very different things. For instance, in some provinces like British Columbia and Alberta, the standards are the same as in the United States where the Doctor of Podiatric Medicine (DPM)is the accepted qualification. Quebec, too, has recently changed to the DPM level of training although other academic designations may also register. Also in Quebec, in 2004, Université du Québec à Trois-Rivières started the first program of Podiatric Medicine in Canada based on the American definition of podiatry. In the prairie and atlantic provinces, the standard was originally based on the British model now called podiatry (chiropody). That model of podiatry is now the accepted model for most of the world including the United Kingdom, Australia and South Africa. The province ofOntario, now only registers Chiropodists since July 1993 where the Ontario Government imposed a cap on new podiatrists. Even if an American, British or other countries registered podiatrist were to emigrate to Ontario they would have to registar and practice as a chiropodist. The podiatrists who were practicing in Ontario previous to this cap were grandfathered and kept the title of podiatrist as a subclass of chiropody. The scope of these grandfathered (mostly American trained) podiatrists includes boney procedures of the forefoot and the ordering of x-rays in addition to the scope of the chiropodist.

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. Auckland University of Technology is now the only provider of podiatry training in New Zealand.

United Kingdom

A podiatrist is 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 and health professionals to treat the foot and ankle based on their education, training and experience. The scope of practice of UK podiatrists on registration after their degree in podiatric medicine includes the use and supply of some prescription only medicines, injection therapy and non-invasive surgery e.g. performing partial or total nail resection and removal, with chemical destruction of the tissues.  Podiatrists complete some 1,200 supervised clinical hours in the course of their training which enables then to recognise systemic disease as it manifests in the foot and will refer on to the appropriate health care professional. Those in the NHS interface between the patients and multidisciplinary teams. The Scope of Practice of a Podiatrist is varied.

In a similar way to podiatrists in Australasia, UK podiatrists may continue their studies and qualify as podiatric surgeons. This training programme has developed over the last 30 years including development of standards in co-operation with the Scottish Royal Surgical Colleges. The training requires a number of years study at postgraduate level including a Masters degree in the Principles of Podiatric Surgery, then a year as a pre-surgical trainee working within a podiatric surgical team, at least 2 years as a surgical trainee working to complete parts C and D of the surgical training and complete pre-Fellowship surgical training. Following this, and having successfully passed a practical surgical assessment, a Podiatric surgeon will work at a specialist registrar (SpR) level for a minimum of three years under a Consultant Podiatric Surgeon. This SpR period must be satisfactorily completed before being eligible to apply for a Consultant National Health Service (NHS) post. These posts are subject to an appointments panel including an assessor from the Faculty of Surgery of the College of Podiatrists (an existing consultant podiatric surgeon). Only if successfully appointed to such an NHS post may he/she then be able to use the title Consultant Podiatric Surgeon.

Podiatric surgery in the UK is not a recent development. The First UK training in podiatric surgery developed over 30 years ago in North London. The original podiatric surgery faculty invited over by UK podiatric surgeons who had trained with them in the USA were leading US podiatric surgeons including; E Dalton McGlamry, Tildern Sockaloff, Guido LaPorta and later Lowell Scott Weil. The First specific podiatric surgery in the NHS was provided via Shropshire Health Authority in 1983 and shortly after in the adjacent English county of Herefordshire. The first specific podiatric surgery service was approved by Herefordshire Health Authority in 1986. Subsequently these NHS services developed with Consultant Podiatric Surgeons being appointed to lead these growing services. The First dedicated NHS Podiatric Daysurgery Unit was officially opened in Hereford in 1993. There are now a number of NHS dedicated NHS Podiatric Daysurgery Units and many NHS Trusts providing podiatric surgery.

A podiatric resident performs surgery on a patient who sustained trauma to the foot.

Podiatric surgeons specialise in invasive foot surgery. The scope of practice is defined as “surgery of the foot and associated structures”. The majority of work reflects the frequency of foot pathology presenting in the UK, most commonly digital and forefoot surgery, as well as mid foot and rearfoot surgery including triple arthrodeses, ankle stabilisations and Achilles tendon lengthenings/repairs. At present these surgeries are not carried out by all Podiatric Surgeons.

In the UK, individuals may not use the title “chiropodist” or “podiatrist” unless they are registrants of the Health Professions Council (HPC).  They are protected titles and their use by non-registrants is unlawful.  This protection extends to titles including the adjectival forms e.g. “podiatric surgeon” or “chiropody practitioner”. Such registration is normally only granted to those holding a specialized Bachelors degree or Diploma in podiatry from one of the 13 recognized schools of podiatry in the UK.

The nomenclature surrounding the job titles of podiatric surgeons has been the source of some criticism from some constituencies within the medical community (in particular orthopaedics). The stated concern underlying the criticism is that podiatric surgeons are not medically qualified or regulated by the Royal Surgical Colleges and may be misleading lay-people into believing that their title ‘podiatric surgeon’ implies that they are medically qualified and regulated by the Royal Surgical Colleges.  This issue has been debated several times over the last 30 years despite the fact that all podiatric surgeons provide clear information to their patients regarding their training and qualifications as part of the process of informed consent. Despite this much co-operation exists and in many areas podiatric surgeons and orthopaedic surgeons work closely together for the greatest benefit of patients, in multidisciplinary teams while respecting each others’ professional independence. Appropriately qualified podiatrists are licensed to access and supply a limited range of POMs including antibiotics, analgesics, and steroids for injection.

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. Foot Health Practitioners: Since the recent statutory regulation/registration of the Chiropody/podiatry sector by the Health Professions Council there has been an increase in the number of former practitioners (of private sector routine chiropody) not being allowed to use their former title – (Chiropodist/Podiatrist) – as a higher degree (or the alternative diploma) in podiatric medicine etc became the required standard for statutory registration. Former practitioners of Chiropody in the UK who did not meet the requirements to be admitted to the HPC register now use the title of Foot Health Practitioner which came in being in 2005. These practitioners provide basic footcare and may refer clients who require more advanced treatments to a Chiropodist/Podiatrist. Clients who have a condition not directly related to the health of the foot, but which is recognised by the Foot Health Practitioner may be referred to a medical doctor for examination (this can be the case especially with elderly clients). It should be noted that it is not only former private sector chiropodists/podiatrists who use the title of Foot Health Practitioner – There are now courses available from well established private training colleges throughout the UK The longest established being The Smae Institute – Founded in 1919) allowing individuals with little or no health care experience to train to become an FHP. Appropriately trained Foot Health Practitioners can become associate members of the following Podiatry/Chiropody bodies: The Institute of Chiropodists and Podiatrists & The Alliance of Private Sector Chiropody and Podiatry Practitioners as well as other professional organizations that are not recognized by the HPC. There is currently no statutory registration/ regulation for practitioners in the private foot health sector – much like the lack of regulation of private sector Chiropody/Podiatry prior to 2003–2005. The title “Foot Health Practitioner” is a title not regulated by statute and can be used by anyone regardless of training levels. The HPC has no plans at present to regulate FHPs despite representations being made by those professional organisation who have FHPs as members.

United States

In the United States, medical and surgical care of the foot and ankle is mainly provided by two groups of physicians: podiatrists (Doctor of Podiatric Medicine or DPM) and orthopedists (MDs or DOs).

The first year of podiatric medical school is somewhat similar to training that physicians (either medical doctors or osteopathic doctors) receive, but with a limited scope on foot, ankle, and lower extremity problems. 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.

A podiatry student examines the adductionangle of the hallux.

The four-year podiatric medical school is followed by a residency, which is 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, and general surgery and of course podiatry — both clinic and surgical. During these rotations, attending podiatrists train the resident physicians in medicine and surgery.

Upon completion of their residency, podiatrists can become board certified by either the American Board of Podiatric Orthopedics and Primary Podiatric Medicine or the American Board of Podiatric Surgery.

Podiatrists certified by the 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 passing a written examination.

In the United States, the previous titles used for the Doctor of Podiatric Medicine (DPM) degree were Doctor of Surgical Chiropody (DSC) and Doctor of Podiatry (PodD). Podiatry in the US currently encompasses a broader spectrum of practice than it used to. Podiatrists can now perform medical and surgical procedures in all 50 states, though the specific scope of practice varies slightly in each state.

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 US 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.

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. Surgical podiatric principles rest on a base of orthopedic and kinesthetic knowledge.

Invasive surgery can be avoided in some limited foot problems, including certain bunion related problems.

Colleges and education

There are nine colleges of podiatric medicine in the United States. 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.

• Western University School of Health Sciences
• Arizona Podiatric Medicine Program (AZPod) at Midwestern University
• Barry University School of Podiatric Medicine
• California School of Podiatric Medicine
• Des Moines University College of Podiatric Medicine and Surgery
• New York College of Podiatric Medicine
• Ohio College of Podiatric Medicine
• Scholl College of Podiatric Medicine
• Temple University School of Podiatric Medicine

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)