Time to discuss a clinical topic Section

Feature UK Podiatric Surgeons. What’s in a name? The Difference between healthcare professionals.

Foot health Month. Expanding skills amongst health professionals

 

It is difficult to know who is who in a hospital. When is a doctor a doctor and when is a surgeon called a surgeon. All females are not nurses and some males are nurses. Not all those carrying stethoscopes are doctors. CONFUSED?

As a podiatrist I am not a doctor but I am a specialist because I have added to my training substantially and am registered to perform treatment at a higher level. All podiatrists hold a basic three-year qualification. All podiatric surgeons in England hold a fellowship; those recently qualified will have a second degree within a post graduate training of a further 10 years. As with many clinicians some have a PhD and so are entitled to use doctor of philosophy even though it may be in science. British podiatrists who practise in foot surgery will explain this to patients if they hold a PhD to avoid confusion with the term ‘medical doctor’.

Many of the websites are very helpful in providing such information. Broadly there are three groups of people in medicine: medically qualified and trained doctors, nurses and allied health professionals (AHPs). Dentists fit somewhere between doctors and AHPs. Some dentists go onto specialise in surgery and medicine i.e reconstruction to the face (maxilla-facial or max-fax surgeons). There has been much consternation about dentists using the term doctor. The Max-fax surgeons became double qualified i.e too medical degree but use the older historical title Mr that the barber surgeon used. Throughout the world you will find most countries use doctor for surgeon, but not in Britain! We do like to be different…

AHPs include psychologists, physiotherapists, radiographers, occupational therapists and operating department practitioners as well as podiatrists. There are over 20 professionals which make up a very large group of clinicians who provide a variety of treatment, keeping the nation fitter. Here again some will use the prefix doctor but this will be taken to mean doctor of philosophy, not associated with medicine. As the natural educational standards rise and more responsibility is assumed by many professionals, overlap inevitably arises. Many regulated professionals other then doctors and dentists can provide medicines related to the conditions that they treat. In 2014 Independent Prescribing licenses gave podiatrists an extension to their role in helping to treat appropriate conditions.

All podiatrists study medicine as part of their qualification so that by the time we qualify we know the function at cellular level to macro-level, anatomy of muscles and diseases of the heart for example. To learn more about podiatry please link to www.feetforlife.org

All podiatrists have to be registered in British law to practise podiatry. Unqualified people who use the term ‘podiatry’ are breaking the law. The register is held by the Health Care Professions Council (HCPC) charged with similar powers to the General Medical Council in that they protect the public where clinical staff fall below the expected standards of care. Please note that Foot Health Practitioners may be registered but not under the HCPC but have a narrower scope of practice.

Regulators in healthcare

In the UK only podiatric surgeons and some orthopaedic surgeons are ‘wholly’ dedicated to elective foot and ankle surgery although orthopaedic surgeons may not practise on the foot and ankle surgery exclusively. Please note that the orthopaedic profession’s opinions are not necessarily shared by the podiatric profession although members of both professions do try to work closely over a wide range of health concerns. Podiatric surgery is recognised by the Department of Health as providing a valuable contribution to health care in the UK although curiously is not separately annotated presently. However to reassure the public this is coming within the next 2 years.

The podiatric surgeon works on the foot and associated structures which can include the tendon achilles. We deal with skin trauma due to pressure and fixed deformities as well as diagnose and manage pain.

If confused always ask your consultant what his qualification is and who his regulator is.

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Why is podiatry sliding toward the Independent sector?

Why is podiatry sliding toward the Independent sector?

Podiatry is a profession that cares for foot health. With a profession of 10,000 dedicated men and women according to The College of Podiatry sources we can only deliver limited care within the NHS and so that leaves the independent sector to provide the rest. Forty-one percent of podiatrists work in the independent sector, 23% share between NHS and their own practice leaving 35% for the NHS (Farndon 2016).

What is a podiatrist and why should you use this group of specialists? Read on to pick up the true meaning of podiatry.

With GPs ever more under pressure, podiatrists offer a number of dedicated services, not just dealing with those age old complaints often ascribed jokes about corns, ingrown toe nails and bunions. Of course these complaints are no joke. However, despite being a profession dedicated to the foot evidence from 2010-13 from the Clinical Practice Research Datalink, of over 1/2 million episodes of foot pain attending GPs only 21% went to podiatrists with 30% going to orthopaedics. The health service is failing to recruit podiatrists and the independent sector is creeping under the strain.

I have taught podiatrists at undergraduate and postgraduate level and know the efforts the profession has travelled over the last 40-years to offer a quality service directed at improving mobility. We go to the GP because the service is the ‘go to guy’. Listening to the radio or TV news or the newspaper we are now out of synch with many world leading healthcare services. The idea of ‘free’ is distorted as we don’t pay enough for British healthcare at face value.

When it comes to Foothealth there are many who can offer advice but as a podiatrist myself I cannot square that circle for want of an awful cliché and say well you don’t go to your GP for your teeth. Why would you go to your GP for your feet? The answer is simply that the doctor is the first line of call, especially if you do not know what the problem is. When I joined the NHS in 1978 the main direction of podiatry (called chiropody then) considered those over 60 ‘the elderly’. Now that term grates as I find I am now a pensioner!

Children attended mainly for warts and a fledgling service offered inlays we call orthoses. This was previously the domain of the orthotist, supported by generous consultant sourced budgets 30 years after the NHS was formed. The rheumatoid and diabetic patients were targeted as having greater need and as far as working with other groups, such as physiotherapists and other specialty consultants, this was rare.

So much has changed since those times and budget trimming as with much of the health service has eroded care delivery. As a tax paying user of the health service I now have higher expectations of my speed of delivery of health care but this is where the NHS has failed for less intrusive conditions. Foot health being one. A referral for a NHS podiatry consultation for orthoses has descended into ridiculous delays, so, as a specialist desiring one of my colleagues to help a patient, a long period opens up where little help is being offered to redirect their problem. This delay is critical and limits the benefit of many treatment programmes. While I believe in the NHS, until there is common agreement from all the political drivers toward non-life threatening conditions, the independent sector will become ever more important.

The independent sector is where many healthcare providers (podiatrists, physiotherapists, doctors and surgeon) are moving to avoid the stressors of the NHS’s unreasonable demands. The healthcare professional is asked to become more of an administrator in the NHS than a clinician and this offends those that care so much about patients. More time, access to more treatment, unconstrained processes that cripple delivery attract those of us more. Toward the end of my days in the NHS I attended useless meetings that caused me to cancel clinics. As a foot surgeon any significant meeting could affect my surgery lists, or the dreaded winter effects filled up surgical beds affecting operation cancellations. Arguing the case with my Chief Executive bore little fruit and another list was cancelled. My podiatry colleagues were no better off and any criticism of management was rejected forcing colleagues into those shadows of despair.

More than ever I see the NHS unable to deliver best podiatric care, not because of poor podiatrists but because of a systematic failure to recognise the importance of less sensitive areas of medicine. Put bluntly this means areas that carry less political gravitas.

Today podiatrists can screen for blood pressure, assess weight distribution, check for diabetic risk and other health diseases, undertake neurological and vascular assessment of the limb, and contribute to smoking cessation support. Podiatrists study medicine as well as their own field and can offer first line advice related to Foothealth and allied medical disease. The profession is split into musculoskeletal podiatric specialists dealing with muscles, tendons and joints, higher risk conditions affecting skin and other tissue damage including rare skin conditions such as congenital epidermolysis bullosa. Some podiatrists have a special interest in dermatology while others work closely with orthopaedics and podiatric surgeons to advise on the appropriate time for foot surgery.

Times have changes. A new focus for the NHS – definitely. For podiatry, well we have been adapting for years to meet patient’s needs, the only problem is patients do not know who we are and what we do. Hopefully another foot Health Month might improve that misunderstanding or not? Anyway to the go to person for feet MUST BE A PODIATRIST.

David R Tollafield is a former podiatric surgeon, member of the College of Podiatry (London) and registered podiatrist, and now author and journalist for podiatry. He writes regularly in ‘Footlocker’ his personal monthly blog. His website is consultingfootpain.co.uk and you can write to him at busypencilcase_rcb@yahoo.com. He also publishes Reflective Podiatric Practice for colleagues signed up to his newsfeed.

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June is Foot Health Month

Why should we look after our feet?

The profession of podiatry launches their annual foot health awareness this month. More about Foot Health and the College of Podiatry later. As a podiatrist and independent author, I believe our work is vital to maintaining the Nation’s health. Foot health matters to all people, not the elderly or young but everyone. But surely every health profession, covering teeth to toes makes the same promise or uses a similar strap line? ‘Tooth pain,’ ‘back pain,’ ‘foot pain,’ is the worst type of pain!

Of course, we are all passionate about health. Why take up a career in health if you are not passionate. So, to kick start why feet?

Basic Principles

We need them to walk on? Yes, of course, but they are more than just wheels/tyres driving the body forward. They are shock absorbers and they change into levers. Anything that affects those two principle functions will impede the body’s progress. The forces that act against the ground when moving require absorbing. Muscles, tendons, fat, skin and correct foot adaptation help with this contact, but also bear the brunt of impact. The kangaroo has a significant bounce when hitting the ground with some 90kg weight and avoids harmful reaction forces. Tendons have built in elastic properties to harness lost energy so it is not wasted and can be used in the next leap. Humans do not leap but joints work together with tendons to achieve a similar aim; absorb and harness that energy to be used again.

As the body moves forward, leverage occurs making the foot  a rigid stable platform for our 50-100+kg bodies. Chimps, with similar foot anatomy cannot form levers around the middle part of the foot and adopt a curious walking pattern that is less efficient and harder to sustain for any distance. Movement involves walking, running or sprinting. Feet should not hurt while standing still or moving about, but they do suffer injuries. Podiatrists as foot health specialists have now established a greater focus on sports and recreational foot health adding their first degree with extended qualifications at Master’s degree and now doctoral levels. This means podiatry provides a wider service than considered traditionally.

Car analogies

Don’t you just hate having to pay out for new tyres on the car. The treads have worn or you have a crack in the wall. Foot skin is thickest under foot. It is the soul of contact (pun intended). If the skin weakens, breaks down, this becomes a big deal. Unlike tyres there is is no ‘Kwick-fix’. Infection, pain, ulcers… not nice; but what of their impact?

The body no longer wants to move as it did. Mobility crisis means giving rise to plenty of concerns for the podiatrist. Your foot health is letting you down and we need to find the source of the pain. Is it infection, skin quality problems, fixed deformity, or are those muscles and tendons not working? Has an old injury come back to haunt you? Arthrosis (a better term than arthritis) affects shock absorption. This is where joint surfaces are damaged; often through wear and tear. In some cases, we can replace joints, but it is best to deal with the problem before that is necessary. Muscles imbalanced with tendon strain are bad news for walking free from pain.

The go-to profession

Can we fix your foot? Yes, mostly.

Some 95% of foot problems can be helped, many cured with timely intervention. Lost days from work, impact on social life and family life, side effects from medication, weight gain, are all matters podiatrists have concern for working with patient’s GPs and other health professionals. Our aim: TO KEEP YOU MOBILE.

So, is Foot Health Month just another fad? No, it is an attempt by a caring profession to reach out to people to take a greater interest in their foot health. The College of Podiatry, the driving force behind Podiatry in the UK, hope to make 2018 a notable campaign. They have said,

‘We want more people to understand the importance of foot health as part of their overall health, and for people to visit a podiatrist when they need to – and to know when they need to!’

The campaign started around 1983 by The Society of Chiropodists and shortly after incorporated the modern name Podiatry. Foot Health Month focuses on health education. The College of Podiatry (educational and academic wing) hopes to deliver information in an appealing and engaging way.

Look out for information during June from independent podiatrists and the professional body, promoting itself now under the banner. Steve Jamieson, the Chief Executive Officer for The Society (the formal body and trade union) and College of Podiatry has been concerned about mixed messages from the various titles, one of which still retains the 19thcentury title, chiropodist. Lewis Durlacher Surgeon Chiropodist to royalty wrote extensively on the foot as far back as 1845. In 2011 the profession tried to change the name of its’ Society, dropping the term chiropody, but this was rejected. June should see another attempt to solve this anomaly. ‘Footlocker’ will be publishing more on confusing titles.

If in doubt about your foot health consult a podiatrist early. The profession has not changed to podiatry from chiropody overnight, but now offers wider scope and expertise, developing over the last 40 years in both the NHS and Independent sector. Foot Health Month was established by the Society of Chiropodists after an initiative around 1983-4 led to the first promotion but has no sponsorship as the largest body dedicated to Foothealth training. Today it has many sub-specialties from sports podiatrists to podiatric surgeons. There is no designated age group that has special attention alone, but of course patients with impairment of circulation ever remain an important focus as we strive to improve lives and prevent unnecessary limb amputation.

To find a podiatrist in your area you can go to https://www.scpod.org/ but do stay in touch with me at Footlocker. Thanks for reading – look out for the next article.

 

David Tollafield is an author and former Consultant Podiatric Surgeon

 

 

 

 

 

 

 

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When was Local Anaesthetic First Taught in Schools of Podiatry?

Local anaesthetic makes life more comfortable for patients

Most podiatrists would agree that the advent of local anaesthetic, that is the ability to produce numbness in and around a painful part of the foot, impacted on the profession of podiatry significantly. Today all podiatrists can offer essential care with this pain relieving medication legally. However it was not something that just happened overnight. The profession of podiatry actually fought against itself at one point which seems bizarre by today’s attitudes of doing the right thing for the patient. This historical fact was uncovered in a PhD thesis by Dr Alan Borthwick.

In 1978 schools of chiropody (as they were called before the term podiatry) introduced the local anaesthetic certificate as part of the three year diploma course (DPodM). This has now been replaced by the BSc (Podiatry) degree, but ’78 was a momentous occasion, not that we as students quite realised we were the first cohort at London Foot Hospital to acquire this skill formally. The year before, I recall, a good friend (and best man at my wedding) had to come back after qualifying to take the course as an add-on… and pay for it out of his own pocket. How lucky we were. Soon after, Part A (theory), then Part B practical local anaesthetic courses were run to allow previously qualified podiatrists to upgrade. It may seem strange that we started with the toe block as shown.

This picture came from a u-tube film of a patient taking his own video footage so no copyright needed as the event is in the public domain! Thankfully, today, podiatrists can offer patients a range of different methods of treating without pain.

This month I am proud to publish Mr Ralph Graham’s, FCPodS, account of the hidden workings behind acquiring local anaesthetic for podiatrists which reveals some interesting historical facts. Ralph Graham was one of the founder members of the leading groups at the time that facilitated these changes.

The article is only available to registered podiatrists and students signed up to my Busypencilcase Communications articles.

 

 

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Medicine and health is more about sharing healthcare with the client.

A publication from the new journal: Advanced Research on Foot and Ankle

Advanced notice of my latest academic publication is accessible to all by free download. Do experienced students do better than novices? Do nurses do as well as podiatrists when looking at lesions? Can classification be used as part of teaching OSCE’s?

In this paper I have explored an old classification system and asked experts to make a comparison with unskilled and semi-skilled students.

The key to this new original research questions the use of classification methods without considering reliability and the value of narrative called the ‘Descriptor.’ The sensitivity of the descriptor in the hands of experienced clinicians can make a difference to the most appropriate decision making.

The revised system from the same author came from a number of pilot studies in 2013 and 2014 and was then to put forward through an ethics committee. Fifty-five podiatry students and 20 nurses volunteered to test the system. Contrasting the old paper (above-click the link) maybe useful for educationalists as there has been a gap of 33-years. Much has changed include podiatry and methods. The 1985 demonstrates how far the profession of podiatry has travelled as it is more a historic reference to the old journal style from the Society of Chiropodists.

Podiatry is about foot health and what was seen as  cosmetic approach to hard skin management can harbour greater sinister influence in affecting patient mobility, pain and walking comfort.

Although it is only part of the conclusion, consider the value behind classification of skin lesions applied to tele-medicine. The need to speed diagnosis. Obtaining access to the correct clinician is vital for expedient treatment, especially where approval is blocked by a healthcare provider based on lack of evidence or cost effective benefit. This classification can aid assessment and hopefully support clinical triage – and at its bassist, who gets treated first!

When we cry out for more educational models in podiatry or even dermatology, this new system might be worth looking at. Patients who might wish to read the different grades might even attend clinic or ring up and say,

‘I have a grade 2 callus and I think I need an ultrasound?’

Medicine and health is more about sharing healthcare with the client. We are the resource they are our customers.

This paper  support my previous paper which considered observation with photography published in October 2017. A further paper is planned on the effects of debridement. Sign up to receive my regular news feed. ‘Subscribe me. I am a podiatrist’ to busypencilcase_rcb@yahoo.com.

 

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In the Shadow of Hippocrates

Forty years on this July I first embarked on a career in Podiatry, so this year is special to me.

No-one makes a successful career without benevolence from other sources. We owe much to those who gave their time freely for little recompense. This was in part due to a medical profession who transferred their confidence to a disparate group of men and women back in the seventies. The part that USA podiatry played cannot be ignored, and today we see  our US cousins still making the same journey to the UK to lecture, only now to see a stronger profession.

Following the successful podiatric surgery conference in March in the West Midlands, I am pleased to pass my second article on for those signed up – In the Shadow of Hippocrates. A book in draft that gathers dust and charts my past, but too effervescent to publish in its original form. Not least it runs to 300,000 words! Maybe one day it will come out, but, in the meantime I pay tribute to colleagues sadly passed and those still working who made a difference to our profession, and not just in foot surgery.

Wishing you all a Happy Easter holiday…

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Upgrading my website

 

One of the most difficult actions to take is how much to put in and how much to remove when changing from one professional occupation to another. I sat down with my website designer yesterday as Spring heralded a fresh season ahead and discussed the needs of the website consultingfootpain. I am very pro-patient focus for podiatry but also feel it is essential to meet the modern needs of colleagues delivering information. My view takes the angle do a little well than a lot badly.

There is so much development in podiatry and there are pressures to stay ahead of the game, but we must build on what we do well and know works. So, anyone with a view should let me know, write to me as Busypencilcase_rcb@yahoo.com so I can take on board new ideas and areas that podiatrists or patients feel should be represented. You can fill in the box below as well. Patients are more empowered than ever before and the idea of providing edited information is anachronistic.

 

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Podiatric Surgery and database PASCOM-10 hits 100,000 patients this week!

Podiatry –  a profession to be proud of

 

The College of Podiatry (London) represents the largest group of podiatrists in the U.K. Their database known as PASCOM-10, an audit system originally developed in 1997 (PASCOM-2000), has gathered on-line data for the last 8 years (mainly for podiatric surgeons) but reached an impressive 100,000 patients this week. The database is possibly the largest database held anywhere covering the specialty of podiatric surgeons and is used to capture the benefits of treatment amongst patients with foot health problems. While surgery has been an important component, the high risk foot has equally developed a significant contribution to preventing limb amputations and early loss of life, especially from chronic arthritic vascular conditions and diabetes. The latest Government working party paper on focusing on healthcare manpower recognises that podiatrists within the National Health Service have fallen amongst recruit numbers, and yet their contribution to foot-care in the UK is paramount to maintaining  mobility amongst the population for all age groups.

Dealing with pain, skin damage (tissue viability) and deformity rank as the key contributions to the foot health of the UK nation.  British podiatry is probably able to provide a wider service than any other podiatry service in Europe. The growth of muscle-skeletal services within the NHS has combined with other groups such as physiotherapy and orthopaedics. Working together with other groups in multi-disciplinary teams has become an important development for British podiatry in the last 10 years.

The top ranking podiatric conditions seen by those centres audited by PASCOM-10 includes hallux valgus (bunion) at 32%, followed by hammer toes (23%) and then arthritic stiff toe joints (11%). Ingrowing toe nail only ranks no.5 at 4% providing a strong suggestion that other conditions are considered more significant and referred to podiatrists by GP practices in the UK. In 1989 majority of surgical management by podiatrists involved ingrowing toe nails and simple skin conditions. The College formed in 1987-8 after an amalgamation took place of the different groups of podiatry professional bodies now has some 10,000 members within the professional body known as The Society of Chiropodists & Podiatrists. The profession continues to develop more treatment programmes for a wide range of groups. The organisation’s website feetforlife.org provides more information about UK Podiatry.

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Belated Homage to a Great Teacher

Fascination with typed words

At 9 years-old the fact that my words could be typed up by my Dad’s secretary was a pure delight. The script was a play based on ‘Green Acres’, a new 1965 U.S. sitcom about a farm.

My play was silly, as was ‘Green Acres’, and short, but then it was written as a class project for our drama session with my influential speech and drama teacher, as unlikely as her name was – Paddy Field. She was my inspiration into adulthood. I loved her for boosting my confidence when speaking in public something I was to need in adulthood.

Six pages of neatly spaced script looked impressive on A4 paper. I waved them proudly at the friends I had selected to be in MY play. The only other play that day had been hand written, so mine looked more professional in the eyes of a child.

Today I am still mesmerised by the appearance of my own typed script. Today, typewriters seem destined for museums rather than the slick word processors we all have. Set on pristine 80g white paper, I waste time ogling my words as they appear spurred on by the intermittent drone of my HP printer.

The subject matter is more serious these days. My affection for the sight of printed words has not diminished, but my memories of that wonderful lady never fade. Share thoughts of someone who influenced your early life.

www.consultingfootpain.co.uk

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Footwear can be tricky

As a child of the late fifties I had my feet measured with loving care. It was an independent shoe outlet called Pomfret’s. As the years went by the father moved on and left it to his son, a smart forty something with tight but neatly creases trousers, and sharp pointed slip on shoes. By the time I finished my education as a podiatrist the grandson has taken over and John, like his father spent more time in the small box office with glass window.

Originally x-rays had been installed for measurement but concerns over radiation exposures were rectified and the standard slide measuring scale was used instead. One recalls the simple actions of the fitter. The foot tickled as the heel hit the back plate. Then a further sensation was noted as the yellow tape enwrapped the foot to achieve the width measurement. The smells of the shop, new leather and busy activities as my mother and I watched John Pomfret climb wooden steps, 12-foot high, to reach a green box imprinted with Clark’s name on the top. Invited to walk around the shop or take home on ‘approval’ was how the final decision was made.

Returning as an adult and now having to pay for my own shoes, plus tax, I selected a pair I thought were ‘podiatrically’ sound. Overconfidence and not a little arrogance allowed me to buy a pair that were too long. I never returned the shoes but decided I was clever enough to adapt these with an insock and tinkering in the orthotics lab at college. That was a big mistake and a serious learning curve.

Podiatrists should have a love affair with shoes and take a broad attitude to their patient’s attitudes toward style and suitability. In reality footwear can and does cause many foot health problems, and like my self-styled fool of an expert, patients and the public will settle on footwear because passion overrides common sense and impetuous decisions ignore practicality.  My shoe fitting knowledge came from our trip to Clark’s in Somerset where we were instructed in the practicalities of shoe fitting. This led to a greater understanding about manufacture, while the adaptations needed for shoes came from a senior lecturer with a wealth of knowledge called Mr England.

Wandering into a Clark’s shoe shop in Taunton this year I recalled my love affair with Clark’s shoes over a span of 50 something-years. Ironically Taunton was in Somerset, home county of Clark’s. I have tried many shoe designs during my life and reliability is a hallmark I am prepared to pay for. The anatomy of a shoe is best learned by dissection and our students were given this exercise when I was tasked to teach about footwear as a lecturer in podiatry in the eighties. My post-graduate education at the California College of Podiatric Medicine, San Francisco expanded my knowledge, not least in the market of sports footwear at a time when running had taken off big time.

As I surveyed the shop’s offers during the post winter sales, I found a shoe I liked enormously. The tall shop assistant was very pleasant but gone were the days of the family business and personal touch. Modern shoe shops, and I include most brands, no longer exude the passion I would so much like to see today. Shoes, like glasses are vital pieces of apparel and like tyres on a car bestow comfort, warmth, safety as well as practical style to match daily clothing needs. The skill in fitting has largely disappeared for adults who are expected to say if the shoe is suitable or not. My assistant disappeared to find the right shoe partner. As she returned I looked at her and said,

‘I am sorry to have wasted your efforts. The foot is my larger foot and does not fit comfortably so the left shoe is not required.

There was no doubt I was taken with the shoe, the colour and sensible design which would become a work horse. Common sense prevailed and I would have to scout around some more. As an experienced foot specialist my expectations are high in a market when shoes are so expensive. That said the cost of work-horse shoes are worth ever penny if they last and do the job.

 

David writes regularly as a podiatry author. You can read his Footlocker posts by clicking on the link below. Share ideas on foot related subjects and send a message to his e-mail address – myfootjourneys@mail.com

 

 

 

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