Professional Development within Podiatry - Essay Example

Professional Development within Podiatry in the Context of Health Policy Reform: How National Health Service (NHS) Reform Has Influenced the Development of Podiatric Surgery The role of podiatry within the health care profession concerns the diagnosis and of disorders of the foot. Podiatrists who are registered with the Health Professions Council (HPC) are considered to be autonomous practitioners who are fully accountable for their independent professional practice. This medical discipline has become a focus of controversy within the medical profession ever since the National Health Service (NHS) established a surgical specialty in podiatry that allows podiatric surgeons to perform operations on the foot that were previously the province of medical doctors trained as orthopaedic surgeons. The focus of this essay is a discussion the changes and reforms in NHS which led to the creation of this surgical specialty within the realm of podiatry and assessment of the general qualifications of surgical podiatrists as compared to orthopaedic surgeons. The NHS Improvement Plan and Priorities Related to the Establishment of the Podiatric Surgical Specialty The NHS Improvement plan has had a dramatic impact on the field of podiatry as it has recognised a new surgical specialty within the field that allows a podiatrist who has not attended traditional medical school to specialize in a surgical field pertaining to the primary discipline involving disorders of the foot. The NHS has acted within its capacity as a regulatory body to mandate such changes; it has also a supervisory role in the establishment of a curriculum and training regimen with uniform standards that are uniformly enforced to ensure that the surgical discipline is enhanced by professionals that are highly trained specialists within the field of podiatry. . The integration of podiatric surgery as a new specialty was afforded early support in 1985 by the SCP and the State Board. In 1987 a surgical interest group was formed within the SCP that included members of the PA. The internal market providing funding opportunities in 1990 and a growing sentiment discouraging monopolies within the medical profession created a climate favouring the development of this new surgical specialty. The PA campaigned effectively to bring about the surgical specialty in podiatric medicine by emphasizing the potential benefits to standard of care and cost effectiveness afforded by the podiatric surgical specialty. The PA argued that a highly focused surgical specialty within podiatry would contribute to a high standard of patient care, greater accessibility to care and greater cost effectiveness overall. These arguments were compelling as the NHS was embarked on a strategic plan to minimize hospitalization costs and increase accessibility and uniform high standards of care in the medical profession. This “best value” approach was effective in promoting the implementation of this new surgical specialty and was enhanced by data suggesting that shorter waiting lists and greater patient satisfaction could be achieved with the emergence of this surgical specialty in podiatry. Further positive developments regarding the establishment of a podiatric surgical specialty by the NHS included a GP report published in 1995 that indicated that the podiatric surgery service was cost-effective and highly accessible, producing excellent patient outcomes. The DoH employed a “feet first” campaign in a promotional effort to support the new surgical specialty in 1994. Challenges to NHS Implementation of Podiatric Surgical Specialty The RCS was ambivalent in its support however, first publishing a supportive statement on the effectiveness of the podiatric surgical service in 1995 that was later withdrawn. This was followed by an effort by the RCS to control the service which was repudiated as monopolistic by the DoA. Moreover, the JCC in 1996 issued a statement comparing the podiatric surgical specialty as an example of surgery by “technicians”, implying that the absence of the MD degree rendered the specialists inferior and improperly trained. Perhaps the greatest challenge to the development of this new surgical specialty came from the medical profession itself as there were many, particularly orthopaedic surgeons, who felt that the new plan was an invasion of their surgical “territory” since traditionally foot surgeries were performed by orthopaedic surgeons. Their primary argument was that podiatrists should not be permitted to study a surgical specialty since they do not attend a traditional medical school and only receive training on a very limited specialized area, consisting entirely of disorders of the foot. The fact that the waiting lists for orthopaedic surgery failed the Patients Charter in 1991 made the NHS less favourable to this viewpoint as one of the stated goals is to provide accessible patient care. Moreover, the NHS has established a rigorous training program for podiatrists who wish to specialize in surgeries of the foot. Overall, these training requirements have established a very high standard of patient care in this specialty. Nevertheless, some in the medical specialty of orthopaedic surgery are unhappy with the new specialty and are unwilling to accept podiatric surgery service as a legitimate medical specialty. .Development of Podiatric Surgical Specialty Podiatric Surgeons are Fellows of the Surgical Faculty of the College of Podiatrists, which is registered under the Health Professions Council. The high standard for fellowship, structured by the Surgical Faculty of the College of Podiatrists, is reflected by the many thousands of patients who have been helped by podiatric surgery provided within the NHS. Over the last 20 years Podiatric Surgeons have pioneered the growth of day case surgery under local anaesthesia. The swift improvement of this new specialty is evidence of the superiority and cost effectiveness of the service. Results of a number of current patient satisfaction surveys in different practices all demonstrate that more than 80% of patients fell in highest bracket on a 1-10 Visual Analogue Scale of satisfaction in reply to the services rendered by podiatric surgeons.. The majority of the respondents stated that they would advocate the podiatry surgical service to others and would return for additional surgical care, should the occasion arise. Podiatric Surgery Training Programme Following a three year BSc Honors degree course in podiatric medicine, graduate podiatrists are required to complete a minimum one year post registration year prior to commencing a Masters Degree course in the Theory of Podiatric Surgery. This course is jointly authorised by the Royal College of Surgeons, Edinburgh. The post graduate certificate section of this course involves Masters Degree modules in anatomy, physiology, medicine, pathology, podiatric biomechanics and diagnostic imaging. Further professional development involves completion of an Objective Assessment of Professional Skills Test at one of the five designated UK centres. This is frequently referred to as the “passport” to surgical training and permits the candidates to apply for a surgical training post in one of the three ‘Schools’ of podiatric surgery. The three schools are the West Midlands, East Midlands and the South East. The surgical training post requires a minimum of two years, during which the candidates rotate throughout a number of NHS departments of podiatric surgery in their selected school. The students engage in a comprehensive experience in foot surgery under the direct supervision of an NHS Consultant Podiatric Surgeons. Throughout this phase of training, the surgical trainees are evaluated regularly in regard to their knowledge and practical skills. The surgical candidates maintain a detailed log of their experience. Candidates also continue with the Masters Degree university course, accomplishing modules in clinical pharmacology and research methods, culminating in a research project in a surgically associated field. This project must be of sufficiently high standard to merit publication in a peer-reviewed journal. Additional practical exams in clinical diagnosis and surgical treatment planning are also accomplished throughout this period which culminates in a fellowship exam when the candidates’ surgical capability and clinical experience are appraised by two senior fellows of the Faculty of Podiatric Surgery. During this exam candidates must perform a comprehensive range of foot surgery on a number of patients. Once awarded Fellowship of the Faculty of Podiatric Surgery and the Royal College of Surgeons Edinburgh, Diploma of Podiatric Surgery and the Masters Degree in the Theory of Podiatric Surgery, the podiatric surgeon is permitted to apply for Specialist Registrar in Podiatric Surgery posts in the National Health Service. These are generally three year posts during which the podiatric surgeon focuses on improving their podiatric surgical skills and experience. Again their experiences are documented in a log book to afford the opportunity for reflective development. At the end of the three year Specialist Registrar post, the podiatric surgeon must present their log book to the Faculty of Podiatric Surgery for the award of the Certificate of Completion in Podiatric Surgical Training (CCPST). The CCPST permits the podiatric surgeon to apply for Consultant Podiatric surgeon posts in the NHS. All such posts are given as awards by a panel dedicated to maintaining the high standards of clinical authority demanded by the National Health Service. The minimum training period for UK podiatric surgeons is 10 years and at least two post registration years in clinical practice. The whole process is extremely competitive as there are many more candidates than there are surgical training places; moreover, it is well recognised that this element of competition ensures the highest standards of clinical practice. Comparison of Orthopaedic and Podiatric Surgical Training Podiatric surgeons are not the equivalent of orthopaedic surgeons as their training pertains solely to the surgical and non-surgical management of the foot. Orthopaedic surgeons are required to complete a degree in medicine before specialising further by receiving additional training in the management of bone and joint conditions which encompass the entire body. Podiatric surgery training starts with the non-surgical administration of foot problems prior to completing a three year degree and at least one post registration year in clinical practice, prior to the commencement of surgical training. Although their specialty is limited to disorders of the foot, podiatrists are trained to recognize problems with the foot that may be symptomatic of other conditions in the body. Podiatric surgeons are part of the healthcare team and frequently refer patients to medically trained physicians or surgeons when a problem is outside their scope of practice. The benefit of such a focused training and scope of practice is that a podiatric surgeon has the opportunity to develop intensive experience in managing foot problems. A number of podiatric surgeons employed full time in the NHS typically perform up to 1000 foot operations a year. This extensive experience facilitates the development of very high levels of expertise within this focused practice Common Surgical Procedures Undertaken by the Surgical Podiatry Team: Hallux Valgus (bunion) corrective osteotomies Neuroma Excisions Lesser toe arthroplasties/arthrodeses for correction of hammer toes,claw toes and mallet toes Soft tissue lesion excisions e.g. ganglions, lipomas, bursas, fibromas, epidermoid cysts, mucoid cysts Tendon procedures- repairs and transfers Skin plasties Lesser toe amputations Lesser metatarsal osteotomies Intractable plantar keratoses excisions Patients may be referred directly by their GP to the podiatric surgery unit. Otherwise, patients who have been referred or who have self-referred to the podiatry service may be further directed internally if community or hospital podiatrists believe a surgical opinion is appropriate. It should be noted that referral does not automatically designate that a patient will receive surgery. At preliminary consultation and after proper history, assessment and diagnostic tests, a treatment plan is devised which may include non-surgical treatments such as biomechanical, physical and injection therapy. Normally, a surgical intervention would not be proposed unless or until conservative options are exhausted or deemed unsuitable. In addition to any discussion and counseling about treatment options, a range of informative leaflets is used to indicate the treatment options and the risks, benefits and aftercare requirements of surgical interventions and to help patients make informed decisions about their treatment. At all levels of care the podiatric service thus works as part of a larger health care team to ensure appropriate clinical management. Before the development of the podiatric surgery specialty, orthopaedic surgeons undertook almost all foot surgery and very few people were referred for foot surgery because the waiting lists for foot surgery were so long. The development of this specialized field within podiatry has greatly increased patient access to surgical procedures for foot disorders. The vast majority of podiatric surgery: is performed using local anaesthetic is undertaken on a day case basis (with the patient going home on the day of the operation). Current Status of the Podiatric Surgery Specialty The New Labour Party policy has embraced a philosophy that is in keeping with the development of the podiatric surgery service. Its agenda stresses collaboration between diverse specialties in medicine and surgery and is dedicated to providing accessible high-quality health care throughout the nation. The podiatric surgery service has made significant progress in achieving a high standard of practice which is consistent with current government goals. The idea that better healthcare may result from non-traditional approaches to healthcare delivery is a viewpoint supported by the current government policy and well-represented by the outcomes documented for the podiatric surgery service thus far. A highly rigorous, highly specialized competitive training programme with ongoing feedback and supervision by the NHS has produced a successful outcome. Podiatric surgery training continues to expand in the UK. The RCSE and RSC (Glasgow) in conjunction with the SCP have initiated a joint diploma in podiatric surgery. In addition Glasgow Caledonian/ Queen Margaret University College have implemented an MSc in Theory of Podiatric Surgery. Nevertheless, the controversy continues. The British Orthopaedic Association (BOA) continues to insist that podiatric surgeons are “untrained” and should not be called surgeons. Is this a territorial war or are their concerns legitimate? The podiatric surgery service continues to produce excellent outcomes consistent with a high standard of practice. Professional relationships are essential to effective practice; policymakers might do well to encourage a greater collaborative emphasis between these related medical specialties. References: Professions and Politics: The Case of Podiatric Surgery Borthwick AM, Occupational imperialism at work: the case of podiatric surgery, British Journal of Podiatry, 2001; 4(3): 70-79. * Borthwick AM, Challenging Medicine: The Case of Podiatric Surgery, Work Employment and Society, 2000; 14(2):369-383. * Borthwick AM, Challenging Medical Dominance: Podiatric Surgery in the National Health Service, British Journal of Podiatry, 2(3), 75-83. * Carter J, Farrell C and Torgerson, The Cost-Effectiveness of Podiatric Surgery Services, London, King’s Fund, 1997. Gilheany M, Health Policy – can the organisational change literature provide assistance to the podiatry profession?, Australasian Journal of Podiatric Medicine, 2003, 37(1): 7-12. Editorial, Podiatric Surgery in Scotland: a historic agreement, Podiatry Now, 2002, 5(10): 526. Editorial, Chiropody, Podiatry and Orthopaedics, Foot and Ankle Surgery, 2002, 8:83. * Klenerman L, Development of Foot and Ankle Surgery, in Klenerman L (Ed), The Evolution of Orthopaedic Surgery, London, Royal Society of Medicine Press, 2002, 167-173. British Orthopaedic Foot Surgery Society, Are you the same as chiropodists?, www.bofss.org.uk/html/are_you_the_same_as_chiropodists.shtml (2003). Borthwick AM, Medical Dominance or Collaborative Partnership? Orthopaedic Views on Podiatric Surgery, British Journal of Podiatry, 2004, 7(2): 36-42. * Read More