Posted by: notdeaddinosaur | October 19, 2010

Foot Notes

Regular readers have heard me rant about the fragmentation of medical care in this country. Each body part not only has its own medical specialist, but in some cases its own allied health profession. Such is the case with the feet.

Doctors of Podiatric Medicine have to complete a four year course of study after college, followed by a three-year podiatry residency. At the end of all that, I grant, they are expert in the care and management of complex disorders and conditions of the foot, ankle, and lower leg. I refer to them regularly, especially for stubborn ingrown toenails. (I did indeed learn how to remove offending portions of nail bed, but over the years I’ve gotten away from it.) They fail, though, when they try to extend their reach beyond their grasp, which in the case of the Podiatrist ends at the knees.

I’ve had a slew of calls from panicked patients whose podiatrists have either scared the crap out of them, or have screwed up their diagnosis or treatment.

There was the woman with a non-healing wound on the side of one of her toes which the podiatrist had been treating for months. All he did each month was “clean it out” and tell her to soak it. It continued to hurt so she came to me. The first thing I did was order a bone scan, and low and behold, she had osteomyelitis; a nasty bone infection that ended up requiring surgical debridement and weeks of IV antibiotics.

Then there was the patient whose podiatrist noted that I ought to check for nerve damage in the elbow, because of muscle wasting in the hands. I already knew about the problem, but my first thought was, “Why was he looking at the patient’s upper extremities? Does this patient walk on his hands?”

But the one that really ticked me off was the frantic weekend phone call:

My feet are swollen and my podiatrist says I have chronic kidney failure. I have to see a nephrologist right away!

Hey, Foot Guys: even if you happen to work with physicians (orthopedists, actually; it’s not like they’re really doctors either), you’re still not qualified to diagnose anything above the knees. There are plenty of reasons for swollen feet besides CKD, and shooting the patient straight off to nephrology is a truly ridiculous waste of time, effort, and money. Send my patients back to me, please, and let me take care of their medical needs. But thanks for offering to fix her bunion.

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Responses

  1. What I also hate is that many docs, including FP’s, just throw diuretics (water pills) at the problem.

    Yes, there is more to swelling than CHF, renal failure. Venous disease is easily treatable now with non-invasive procedures AND DOES NOT RESPOND TO LASIX! You also don’t always see or feel the varicose veins.

  2. What the hell do they study for four years on feet?

  3. my podiatrist limits himself to below the ankle. i wonder if he only went to two years of school?

    was the ad for family foot care in this post intentional?

  4. The muscle wasting story, as you tell it, sounds like this: Podiatrist sees patient for some foot problem. Podiatrist happens to notice sign that something else may be amiss: the muscle wasting. Podiatrist, instead of thinking ‘none of my business’, checks back with you to make sure you know about it.

    Is that indeed what happened? Because in that case, I’d be more inclined to commend the podiatrist than to disapprove of her or his behaviour. On the other hand, if that’s not all that happened then forget I said anything. My opinion is conditional on me being well-informed. 😉

  5. Oh God, this reminds me of a certain hospital where the DPM was a regular co-surgeon with the GYNs for C-sections. Seriously.

  6. […] Foot Notes […]

  7. The DPM was a co-surgeon for C-sections? Really?

  8. Reminds me of the difference between good and bad chiropractors…good ones claim they can adjust bones that may be out of alignment. Quacks claim to cure strep throat, ADD, and infertitlity with spinal manipulation.

  9. Sounds like foot-mouth disease.

  10. Sorry, I know that this is likely a silly question but what do you expect from an old Mechanical Designer. Does someone actually spend all those years in school just to treat feet? Did they slack off a couple of semesters and this is all a low GPA entitles them to? If that’s the case, proctologists must have really screwed up. Glad I didn’t have to explain something like that to my parents.

  11. Your stories are probably why podiatrists have to spend so many years learning to treat feet- a bad podiatrist can really, really screw things up (friends of mine went to untrained chiropodists for simple problems like corns, and spent weeks healing from the damage). Conversely, a good one can provide a lot of relief, especially for elderly people who need to be able to walk freely in order to keep some independence.

    As for the hands, they use the hands to demonstrate some of the tests and instruments where the patient can see them, before they go poking around at the feet and the poor patient hasn’t a clue what they’re doing.

    Sorry for the necropost btw, it’s just the question had been asked a few times.

  12. Most common cause of swelling in my practice lately has been generic amlodipine … certainly not CKD 🙂


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