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Canadian Medical Alliance for the Preservation of the Lower Extremity

Podiatric Medicine and Surgery

Podiatric Medicine is the medical discipline devoted to the

foot and lower extremity.   ("Pod-" is Greek for 'foot,' and

'iatros' is Greek for 'physician.')  

To provide context to the status of podiatric medicine and

surgery in Canada, let's start with some background of the

profession in the United States, where the profession in its

current and modern form originates. 

As is the case with any physician, podiatric training in the United States begins with four years of undergraduate university training, where the student receives a bachelor degree.  Students then take the same medical college application tests as any physician, and if the scores are acceptable, they then enter four years of medical and surgical training.  Upon completion, the student earns a doctorate degree.  The doctorate degree is followed by three years of hospital-based surgical residency training.  Some then go on to additional fellowship training in specialized fields such as pediatrics, sports medicine,

specialized surgery and the diabetic foot.

Once in practice, board certification is an additional process one may pursue to demonstrate competence and expertise in a specialty field.  The American Board of Foot and Ankle Surgery (ABFAS) and the American Board of Podiatric Medicine (ABPM) are the two major boards in the profession.  Sub-specialty certification exists.  For instance, physician-level wound healing

certification exists as one such subspecialty discipline.

Podiatrists in the US work in offices and hospitals, and have positions in top-quality academic institutions like Harvard and Yale, the University of Chicago, Penn, Columbia and Stanford.  They serve on the staff of ballet companies, the Olympics and professional sports teams. 

There are approximately 13,500 podiatrists practicing in the United States, and each year there are approximately 60 million visits to a podiatrist.  So podiatric medicine is relatively well understood and well established in the US.  

In Canada, the podiatric profession has a more complicated story. 

Podiatrists in British Columbia and Alberta have the same

standard of training as the US.  In fact, as there are no US-

level schools in Canada, all podiatrists in these provinces

were trained in the United States, and did the same post-

graduate training.  The scope of practice is similar, too. 

Podiatrists prescribe medicines, and perform all manner

of surgical procedures.  

Quebec has a similar, but not identical standard to the US, BC and Alberta.  However, the province does not require a residency to practice.  The majority of practitioners in Quebec were trained at a school in Quebec, with the instruction in French.  Unfortunately, the school is not accredited in many parts of English-speaking Canada, with the result that there are few Quebec-trained podiatrists in much of Canada. 

For the most part, practitioners in the Prairies have a British-level of training.  The training is different from the US model, as is the scope of practice.  

Ontario has some US-trained podiatrists, but there are fewer since the province has moved to a lesser-trained chiropody model based on a level of instruction somewhat unique to Ontario, different both from the US, UK and Quebec models. 

In the Maritime provinces, the title of 'podiatrist' is largely unregulated.  The people using the title 'podiatrist' there have varying degrees of education and training.

This inconsistency in education, training and scope of practice has made

things difficult for the podiatric profession in Canada.  Sometimes

physicians trained in Canada haven't encountered a podiatrist
and are not familiar with the profession.  Sometimes they
know the term, but have a misunderstanding as to the
level of medical training podiatrists receive and are
unaware of their scope of practice, particularly
when the physician was trained in a place
where the word 'podiatrist' has one
meaning, then they practice in a
place where the term means
something rather different.   

 

Government officials are often
similarly uneducated with regards
to the podiatric profession.  This has
led to the unfortunate situation that we
see today where most podiatric services are
not covered by provincial health, even in BC and
Alberta, where the training is greatest. 

This is unfortunate for the Canadian public, because the                       

efficacy and value of podiatric medicine and surgery has been
demonstrated repeatedly in the medical literature. 

As this is a website devoted to wound care, let's look at some recent       
studies on the value of podiatric medicine specifically in the wound care setting.

Recent Studies on the Value of Podiatric Medicine in Wound Care in Canada and the US

A 2018 Canadian study from Quebec compared the effect of podiatric medical care on diabetic foot ulcer patients (N=67).   Before podiatric care was implemented, 27.3% of ulcers resolved in an average of 44.6 weeks.  After podiatrists were integrated into patient care, 73.2% of DFUs healed in an average of 19.8 weeks.

Blanchette V, Hains S, Cloutier L.  Establishing a multidisciplinary partnership integrating podiatric care into the Quebec public health-care system to improve diabetic foot outcomes: A retrospective cohort.  Foot (Edinb). 2019 Mar;38:54-60. doi: 10.1016/j.foot.2018.10.001. Epub 2018 Oct 9.  PMID: 30639800 

A 2018 data-mining study from the University of Michigan examined the impact of establishing a fully-integrated and specialized podiatric serve in a tertiary academic health system on preventative foot care on limb salvage rates.  They examined all encounters for diabetes and any foot complications between 2000-2005 and 2010-2015, preceding and after full implementation of podiatry service, respectively.  100 million patient encounters were compared.  Podiatric services cut the amputation rate in half and the number of major amputations by a third.  Podiatric services also resulted in a shift of care to the less-expensive outpatient setting.  

Schmidt BM, Holmes CM, Ye W, Pop-Busui R. A Tale of Two Eras: Mining Big Datafrom Electronic Health Records to Determine Limb Salvage Rates with Podiatry.Curr Diabetes Rev. 2018 Oct 16. doi: 10.2174/1573399814666181017104818. [Epubahead of print] PubMed PMID: 30332970; PubMed Central PMCID: PMC6531350.

A 2010 Duke University study of 656,590 Medicare patients with diabetes, those who were treated by podiatrists experienced 23-69% fewer lower extremity amputations than if treated by other health professionals.

Sloan, F. A., Feinglos, M. N. and Grossman, D. S. , RESEARCH ARTICLE: Receipt of Care and Reduction of Lower Extremity Amputations in a Nationally Representative Sample of U.S. Elderly. Health Services Research, no. doi: 10.1111/j.1475- 6773.2010.01157.x   2010 Aug 16

A 2010 study out of Brown University found that patients treated by podiatrists had half the rate of significant amputations and a significantly higher survival rate of patients with diabetes at high risk for ulceration and limb loss.

   

Driver VR, Goodman RA, Fabbi M, French MA, Anderson CA “The Impact of a Podiatric Lead Limb Preservation Team on Disease Outcomes and Risk Prediction in the Diabetic Lower Extremity:  A Retrospective Cohort Study” J Am Podiatr Med Association 2010 Jul-Aug; 100(4): 235-41

A 2013 University of Tennessee study of 47,753 patients, care by podiatrists in the year prior to a diabetic foot ulcer was associated with fewer re-ulcerations, fewer hospitalizations, and 65-80% fewer major amputations.  

Gibson TB, Driver VR, Wrobel JS, Christina JR, Bagalman E, DeFrancis R, Garoufalis MG, Carls GS, Gatwood J. Podiatrist care and outcomes for patients with diabetes and foot ulcer. Int Wound J. 2014 Dec;11(6):641-8. doi:10.1111/iwj.12021. Epub 2013 Feb 4. PubMed PMID: 23374540.

 

 

A 2011 healthcare study of 474,000 patients by the Toronto research group Thomson Reuters found that US diabetic patients treated by podiatrists had a cost savings of $19,686 per patient, and for each dollar invested in care by a podiatrist results in $27 to $51 of savings for the health-care delivery system.

They found that non-Medicare patients with diabetes had a 20% lower amputation rate and a  26% lower hospitalization rate if they had seen a podiatrist.

Carls GS, Gibson TB, Driver VR, Wrobel JS, Garoufalis MG, Defrancis RR, Wang S, Bagalman JE, Christina JR 
“The economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers” J Am Podiatr Med Assoc. 2011 Mar-Apr;101(2):93-115, accessible at:  www.tinyurl.com/trstudy.

 

A 2014 study by (British Columbia-born) Grant Skrepnek and David Armstrong examined the repercussions following Arizona Medicaid’s 2009 announcement that they would cancel coverage to podiatric physicians for their 1.5 million enrollees, with the goal to save $351,000. 

The result was that inpatient hospitalizations went up 36.7%, hospitalized stays went up 22.5%, inpatient charges went up 37.5%, severe outcomes (death, amputation, sepsis, etc.) went up 49%.

Overall costs went up $16.7 million. This means that for every dollar saved in cutting podiatry, $44 more was spent on the complications.  This is very much in keeping with the 2011 study quoted above.  

(Based on the results of this study, podiatric medicine has since been re-included by Medicaid in Arizona.)

Grant H. Skrepnek, PhD, University of Oklahoma Health Sciences Centre Statistics from a presentation at Georgetown University Hospital Diabetic Limb Salvage conference, October 11, 2014, Washington, DC, accessible at    http://www.apma.org/files/FileDownloads/AZMedicaidStudy.pdf

 

A 2016 study examining the implementation of the Affordable Care Act examined three years of inpatient discharge files in the state of California, and found that even limited podiatric services cut hospital admissions and amputations by 10% and saved 4.1% in costs.  The authors indicate that these numbers can be improved with better access to podiatric care, and they recommend the inclusion of podiatric medical services in chronic care to realize the greatest cost savings.

 

Labovitz JM, Kominski GF  "Forecasting the Value of Podiatric Medical Care in Newly Insured Diabetic Patients During Implementation of the Affordable Care Act in California" J Am Podiatr Med Assoc. 2016 May;106(3):163-71. doi: 10.7547/15-026.

 

These are very recent studies with large numbers of patients to draw robust conclusions, and they yield significant results.  The value podiatrists bring in dealing with wounds, both in their general medical background, their surgical training and their understanding of biomechanics--skills vital for healing wounds--is not replicated in mainstream medicine.  

 

 

Studies done in other parts of the world show similar success with podiatrists treating wounds.  

A Danish study from 2000 found that the implementation of a multidisciplinary team including podiatrists resulted in a 75% reduction in the incidence of major amputations.  

Holstein P1, Ellitsgaard N, Olsen BB, Ellitsgaard V.  Decreasing incidence of major amputations in people with diabetes. Diabetologia. 2000 Jul;43(7):844-7.

 

A 2013 follow-up Danish study to the one cited above examined amputations from diabetes between 2000 to 2011 when treated by a multidisciplinary diabetes specialist centre with podiatrists.  They found  the incidence of all lower‐extremity amputations decreased by 87.5% among men and 47.4% among women with Type 1 diabetes and by 83.3% among men and 79.1% among women with Type 2 diabetes.  

 

M. E. Jørgensen, T. P. Almdal, K. Færch Reduced incidence of lower‐extremity amputations in a Danish diabetes population from 2000 to 2011  First published: 25 September 2013 https://doi.org/10.1111/dme.12320

 

An 11-year English study published in 2008 found an 82% drop in major amputations with the implementation of a multidisciplinary team including podiatrists. 

 

 

Krishnan S, Nash F, Baker N, Fowler D, Rayman G. Reduction in diabetic amputations over 11 years in a defined U.K. population: benefits of multidisciplinary team work and continuous prospective audit. Diabetes Care 2008;31:99–101.

 

 

A 2014 study from Madrid, Spain analyzed the incidence of lower extremity amputations (LEAs) after introducing a foot care team coordinated by an endocrinologist and a podiatrist. The incidence of LEAs dropped by over a third, from 6.1 per 100,000 to 4.0 per 100,000.

Rubio JA, Aragón-Sánchez J, Jiménez S, Guadalix G, Albarracín A, Salido C, Sanz-Moreno J, Ruiz-Grande F, Gil-Fournier N, Álvarez J. Reducing major lower extremity amputations after the introduction of a multidisciplinary team for the diabetic foot.  Int J Low Extrem Wounds. 2014 Mar;13(1):22-6. doi: 10.1177/1534734614521234.

 

A 2016 study from Guanzhou, China found that when endocrinologists teamed with podiatrists to coordinate a multidisciplinary team to treat diabetic wounds, the overall amputation rate dropped by up to two-thirds, and the above-ankle amputation rate of Grade 3 and 4 ulcers declined from 35.7% to 4.4% in three years.

Wang C, Mai L, Yang C, Liu D, Sun K, Song W, Luo B, Li Y, Xu M, Zhang S, Li F, Ren M, Yan LReducing major lower extremity
Amputations after the introduction of a multidisciplinary team in patient with diabetes foot ulcer.
BMC Endocr Disord. 2016 Jul 7;16(1):38. doi: 10.1186/s12902-016-0111-0.


A 2018 British study found that the major diabetes-related lower limb amputation rate "is significantly inversely correlated with foot care services provision," and more effective foot health delivery, including better screening, more clinics with podiatric care resulted in significant reductions in major amputation incidence within 2 years. Failure to provide foot care service resulted in a continued high amputation incidence.

Paisey RB, Abbott A, Levenson R, Harrington A, Browne D, Moore J, Bamford M, Roe M; South-West Cardiovascular Strategic Clinical Network peer diabetic foot service review team.  Diabetes-related major lower limb amputation incidence is strongly related to diabetic foot service provision and improves with enhancement of services: peer review of the South-West of England.  Diabet Med. 2018 Jan;35(1):53-62. doi: 10.1111/dme.13512. Epub 2017 Oct 11.

 



A 2018 study out of Kuwait found that the introduction of a podiatry provision in a multidisciplinary team led to a diminished healing rate (52 days) for diabetic foot ulcers--similar to British and US rates, locations with access to podiatric care, and much lower than rates reported in 2010 in India (241 days to heal) where podiatric care is lacking.  

Messenger G, Masoetsa R, Hussain I, Devarajan S, Jahromi M.  Diabetic foot ulcer outcomes from a podiatry led tertiary service in Kuwait.  Diabet Foot Ankle. 2018 May 28;9(1):1471927. doi: 10.1080/2000625X.2018.1471927. eCollection 2018.

 

 

A 2018 study out of Australia found that the economic benefits of having  podiatrists treat diabetic and high-risk patients to prevent severe infections and lower the rate of lower extremity amputations more than covered the cost to cost to educate and train them.  

Couch AG, Foo J, James AM Maloney S, Williams CM.  Implementing a podiatry prescribing mentoring program in a public health service: a cost-description study.  J Foot Ankle Res. 2018 Jul 13;11:40. doi: 10.1186/s13047-018-0282-1. eCollection 2018.

 

 

 

Study after study, in countries around the world, the story

is the same.  Podiatric medical care saves limbs, saves lives,

and saves money.  

Yet Canada still doesn't insure podiatric services for this care.

Part of what the Canadian Medical Alliance for the Preservation of the Lower Extremity (Canadian MAPLE) does is advocacy--promoting access to good quality foot care for Canadians.  Part of this is that we believe Canada should join the rest of the world and make certain podiatric medicine and surgery is an insured service by provincial health plans for the treatment of diabetic and other high-risk, lower-extremity wounds.

To return to the top of the page, click on the maple leaf below.

 

 

  • Each foot has 26 bones.  They combine to contain nearly one quarter of all the bones (206) of the body.

  • Each foot is made up of a complex and intricate network of over 100 tendons, ligaments, and muscles.

  • Every step places 1.5 times your body weight of pressure on your foot. (So a 150-pound person places 225 pounds of pressure on the foot with every step).

  • The average person walks 5,000 to 7,000 steps a day. The American Podiatric Medical Association (APMA) estimates that the average person will walk nearly 100,000 miles in a lifetime, between three to four times the earth’s circumferences.

 

--American Podiatric Medical Association

Autumn maple leaves. Background of maple

This page written by Dr. S A Schumacher
Podiatric Surgeon
Surrey, British Columbia  Canada

"The human foot is a masterpiece of engineering and a work of art"

                            --Leonardo da Vinci

Podiatry (/poʊˈdaɪ.ətri/) or podiatric medicine (/poʊdiˈætrɪk, -ˈdaɪ.ətrɪk/) is a branch of medicine devoted to the study, diagnosis, and medical and surgical treatment of disorders of the foot, ankle and lower extremity.  

--Wikipedia

"I marvel that society would pay a surgeon a large sum of money to remove a persons leg, but nothing to save it."

                                --George Bernard Shaw

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