August 2000 Bulletin

Foot, ankle care key to expanded practice

Meeting two hurdles with training, referrals

By Carolyn Rogers

Tens of millions of Americans have trouble with their feet each year. So where do they go for relief? Or more specifically, to whom? It’s not always clear. Given the fact that increasing numbers of orthopaedic surgeons are interested in expanding their office practice, the Academy is encouraging more of its members to rediscover foot and ankle care.

"Twenty percent of orthopaedic problems relate to the foot and ankle," says Glenn B. Pfeffer, MD, secretary of the American Orthopaedic Foot and Ankle Society, (AOFAS). "As orthopaedic surgeons, we want to be the premiere providers of all musculoskeletal care—not just bits and pieces. So it’s essential that we continue with a high quality of education and patient care when it comes to the foot and ankle."

There are great benefits to an orthopaedist for providing comprehensive, seamless musculoskeletal care, Dr. Pfeffer says, not the least of which is patient satisfaction.

"I think you have happier patients if they can have all their musculsokeletal complaints taken care of in one place," he says. "After a total hip, it’s very gratifying for the patient to stay in the same practice to have a bunion taken care of or to receive something as simple as advice on what type of running shoes to wear.

"Secondly, it increases the volume of patients in the office. Next to back pain, foot and ankle complaints are the most common complaint that causes a person to present to a doctor’s office. The more receptive an orthopaedist is to the foot and ankle, therefore, the more patients that will come to his office—both for foot care and comprehensive musculoskeletal care. The patients’ feet may be what gets them through the door, so to speak, but they’ll be back when other musculoskeletal problems arise."

Thomas O. Clanton, MD, AOFAS president, has a theory on why some orthopaedists may not have placed a lot of emphasis on foot and ankle care in recent years.

"Over the past 25 to 30 years of training in orthopaedics, there’s been a real explosion in technology, particularly in the development of joint replacement and arthroscopic surgery," he says. "I think the enthusiasm in those areas is communicated to residents during their education, and areas where technology has improved more steadily—such as the foot and ankle—haven’t received as much attention."

Clearly, there has been encroachment on the area of musculoskeletal care by nonphysicians, Dr. Clanton adds. "When they were limiting their work to nonoperative care, it didn’t seem to be much of a problem, because there was no way orthopaedic surgeons could provide the volume of care needed by the entire U.S. population. Now, with nonphysicians expanding their scope of practice into surgical areas that include not only the foot, but also other areas, there has been concern in quality of care issues and adequacy of training.

"It’s important that the physician evaluating the patient be able to recognize that the patient’s general medical condition may be producing symptoms such as seronegative arthritis that is showing up for the first time as heel pain. The broad education provided to physicians in medical school enables orthopaedic surgeons to understand the differential diagnosis for patients with musculoskeletal conditions as well as the reasons to operate, or more importantly, not to operate."

Dr. Pfeffer believes that orthopaedic surgeons have a moral obligation to provide the highest quality comprehensive care to their patients.

"To summarily eliminate a part of the body isn’t fair to the patients," Dr. Pfeffer say. "They don’t benefit from the expertise of orthopaedic surgeons, given the high quality training and academic rigor of the field of orthopaedics."

Of course, Dr. Clanton points out, some orthopaedists specialize in a very specific area and may not be able to offer comprehensive musculoskeletal care themselves at their individual practice. However, he says they should work with other orthopaedic surgeons in their community in order to provide general orthopaedic care that covers the entire musculoskeletal system.

A "seamless" musculoskeletal practice can be achieved after clearing two hurdles, Pfeffer says. The first hurdle is simply being prepared to provide foot and ankle services. The other is letting patients and referring doctors know that the services are available.

"The first goal can easily be met by taking advantage of courses put on by the Academy and the AOFAS," he says. "Based on a foundation from residency, one or perhaps two comprehensive courses can get somebody up and running for comprehensive foot care and ankle care."

Dr. Clanton points out that some types of basic foot care often can be handled by personnel who are already available in the office, such as a nurse, a physician’s assistant or a physical therapist. "Certain nonoperative techniques of foot care can be performed by non-physicians. But the more complex aspects of foot and ankle care are best performed by orthopaedic surgeons who have the education and training to deal with complicated problems, such as ankle replacement, complicated foot and ankle trauma and reconstruction procedures for diabetic foot complications."

The second hurdle to providing foot and ankle care is overcome by making patients and the medical doctors in the community aware of your interest.

"A letter to the primary care doctors in one’s community expressing interest in providing comprehensive foot and ankle care is one means," Dr. Pfeffer says. "A talk or lecture to the medical staff perhaps at grand rounds on basic foot and ankle care is another means. The AOFAS has a prepared talk on basic foot care that’s avai1able to general orthopaedists who might not have such a talk already."

As soon as primary care doctors find out that an orthopaedic surgeon is interested in providing foot care, Dr. Pfeffer says, the patients are referred.

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