The University of Utah is limiting the practice of podiatrists in its medical facilities, severely restricting their ability to perform surgeries and ending their existing adjunct faculty appointments.
University Health Care officials say the changes and transfer of oversight from the department of surgery to the department of orthopaedics are important for the U.'s educational and treatment mission.
Podiatrists, including one who has practiced and performed surgery at the U. for a quarter-century, describe the move as a poorly executed turf battle over surgery patients. The motive is not money, they say, but feet on which to train future orthopaedic surgeons.
In February, the podiatrists were notified that their specialty would be moved from surgery oversight to orthopaedics. Signed by the chairmen of surgery, Dr. Sean J. Mulvihill, and orthopaedics, Dr. Charles Saltzman, the letters said each podiatrist could apply for adjunct faculty appointments through orthopaedics, but their scope of practice would be limited to soft tissue, nail and skin surgery and non-surgical foot care.
They would have to agree not to operate on U. patients at non-U. facilities, too.
"Basically, that means that podiatrists will be able to come up and clip toenails for them and take care of painful callouses the kind of thing they refuse to do anyway," says Dr. Terry Smith, who has practiced podiatry at the U. part time since 1980.
A typical podiatry practice, he said, might include treatment of a painful corn or a viral wart, diabetic foot and limb salvage, ulcer care, hammer toe repair and cases where sprained ankles have become chronic problems. Podiatrists deal with medical problems from gout to sports injuries, including a fair amount of surgery, he said.
Dr. David Bjorkman, dean of the U. School of Medicine, said the move does not reflect shortcomings on the part of the podiatrists. The school, he said, "is indebted to them for the years of service they provided when we did not have dedicated foot and ankle surgeons."
But the expanded department of orthopaedics now has three foot and ankle surgeons who "can and should" provide high-quality surgical care.
"That they do so is crucial for the training of our students. We're not a school of podiatry, but a school of medicine," he said. "We have an obligation to our students that they be involved in these cases.... We thought hard about this what's the best way to deal with this that's most fair for the podiatrists involved, but will meet our obligation to patients and trainees?"
Bjorkman and Saltzman said letters gave the podiatrists several months notice, and they were invited to apply for new adjunct faculty appointments through orthopaedics and to continue to provide skin, nail and ulcer care. "We recognize there's a financial impact on them. There's more money in doing a surgery, rather than minor procedures. So we gave lots of lead time," Bjorkman said.
What was not provided, according to Utah Podiatric Medical Association President Dave Edwards, was an appeals process.
Smith said the move caught the podiatrists by surprise, although they had heard generalized rumblings that "something was coming." When they received their letters, they were looking for a division chief to oversee the podiatry residency program at the U. That three-year training program has now been taken on by Intermountain Healthcare instead, he said.
They were not invited to meet with U. officials until after they got their letters, he said. When they asked for "a trial run" to work with the residents and surgeons through orthopaedics for a year, he said they were told it would not be of value to the residents or fellows "basically, that podiatrists have nothing to teach about foot or ankle surgery," Smith said.
This is an example of one specialty that simply does not recognize the contributions of another specialty, according to podiatrist Scott Soulier, a UPMA board member who does not treat patients at the U., but took part in the discussion after the announcement. He said Bjorkman told them, "'This is going to hurt you people.' Well, hurt is not the word."
The bottom line, Bjorkman said, is "our core competency is foot and ankle care by physicians. We really don't have a place within the academic structure for podiatrists."
For years, several podiatrists practiced a day or two a week at the U. without oversight, unusual in typical academic structure. A few years ago, they were "artificially put into the Department of Surgery," which Bjorkman said was "never a good academic fit."
"Our view is they have provided excellent care for our patients. But I think orthopedic surgeons can provide the highest possible quality care. I'd be dishonest if I said I thought (podiatrists) could provide the same qualify of foot and ankle surgery as a physician board-certified" in that care, Bjorkman said.
Smith disagrees. "There are many types of patients that have foot and ankle complaints that orthopedists simply will not touch," he said. "They're going to send you to a nurse practitioner, who may be very competent but hasn't had four years of podiatric medicine and three years residence afterwards, dealing just with foot and ankle problems."Bjorkman said there's still a place for podiatry at the U. Besides working in the hospital, there are two full-time podiatry positions in UHC community clinics. One is filled by a podiatrist who was already there and is willing to accept the new terms. The other vacancy is being filled. That podiatrist left for reasons unrelated to the change.