Over many years the advancement of the podiatry and podiatric surgery professions has been subjected to resistance from a select number of sectors of the broader medical profession. A most recent example of this is seen in recent public statements (Statements) released by the Australian Medical Association (AMA), Australian Orthopaedic Association (AOA) and the Australian Orthopaedic Foot and Ankle Society (AOFAS) 1 regarding podiatry, podiatric surgery and the Australasian College of Podiatric Surgeons (ACPS). In this article, I respond to those Statements in the interest of protecting the interests of our profession and on the basis that you, as our readers, have a proper interest in reading what is conveyed in this message.
The Australian public and the Australian Healthcare System deserve a better understanding from parts of the medical profession who, in our opinion, and judging by their statements, seek to advance their own interests.
The Statements I refer to above call for the elimination of the title “podiatric surgeon” and the removal of the endorsement for scheduled medicines (ESM) from podiatrists and podiatric surgeons. To distil their public statements down – these organisations are, in our view, seeking to unduly influence the way the Podiatry Board of Australia (PBA) accredits podiatric surgical training and remove non-medical prescribing privileges.
It is also our view that the effect of their Statements can be characterised as a classic example of culturally embedded medical dominance under the guise of public safety rhetoric. The history of medicine is littered with examples of such activities. These include similar arguments against non-medical prescribing, nurse practitioners and the joint replacement register, as well as against the accreditation of podiatric surgeons. The assertions made in these Statements are highly disputable when considered against the proven quality of outcomes and leadership in provision of collaborative patient centred care by the podiatry profession.
We must recognise that the sentiments of these organisations are not necessarily supported by individual medical practitioners, of which many understand and appreciate the importance of the full scope of the podiatry profession. However, the Statements serve nothing more than to unduly attempt to undermine public confidence in a profession that has consistently and professionally served its patients, and the health system it is governed by.
Throughout its 43-year history, the ACPS has been dedicated to providing support and best care for the Australian community. This commitment to fulfilling the college’s values of service, integrity, respect, compassion and collaboration for foot and ankle surgical care is met with what we characterise as continual public misinformation and negative criticism by influential sectors within the medical profession.
Members of the ACPS are committed to sharing our longitudinal experience and insights with all health care practitioners. The purpose of such sharing by the ACPS has always been for the collaborative and pragmatic delivery of best foot and ankle care for the Australian public. However, some groups who perceive themselves as competitors in the foot and ankle surgical space, appear to be reluctant to collaborate with the ACPS in podiatric surgical training and patient care – despite several invitations from the ACPS to collaborate in the past. In contrast, the international collaboration of vascular and podiatric surgeons is leading the world in diabetic foot disease outcomes.
Recently, the AOA, AMA and AOFAS have collaboratively politicised a public consultation process related to the development of updated competency standards and capabilities for the podiatry profession. This is a process linked to regulatory requirements for all registered health professionals in Australia. Our assessment of their responses is that they were opportunistic and failed to address the scope and intent of the consultation. Additionally, these organisations responded in a manner which was factually incorrect.
For example, in their response, these organisations cited the number of procedures logged by registrars within the ACPS training program as being significantly lower than the minimum 2,400 procedures required within the accredited ACPS training program. Secondly, the AOA makes claims that surgical procedures are unbundled to create an artificial increase in logged procedures. Both of these claims are incorrect, inaccurate and completely false. As evidenced in the ACPS Audit, there are on average 2,200 cases logged per year. In this, many cases will have more than one procedure – such as a hallux valgus correction and hammer toe correction, this being two cases. The registrars can only log two cases and this is supervised by the attending podiatric surgeon and overseen by the ACPS Training Committee. Registrars take between 5-6 years on average to complete their ACPS training program and have to log a minimum of 2,400 logged procedures prior to undertaking their final exam. In most instances the registrars will have logged in excess of 3,000 surgical cases.
Also not mentioned is that virtually all of the ACPS registrars spend a minimum of 3-6 months training in the United Kingdom’s National Health Service within an orthopaedic foot and ankle surgery team, working with both podiatric and orthopaedic surgeons. In our opinion, the unfounded claims and inaccuracies made by these organisations run the risk of undermining the integrity of the entire process of national regulation and accreditation of health practitioners in Australia.
It is extremely disappointing that these organisations are disseminating such information which has the real potential of misleading the Australian public. In our assessment of them, the responses by those organisations to the consultation process in their statements lack insight, are manifestly inaccurate, fail to respect the processes of the national health regulation scheme, and ignore historical timelines which reflect evolution in curricula for training, registration, and accreditation of health professions.
There is a well-documented and public history of major concerns with how some of these organisations have functioned in the recent past and these concerns have been strong drivers for reforms in the governance of these organisations..2 Reforms designed to address issues such as systemic bullying and discrimination within their own ranks.
Additionally, such behaviour and performance issues are examples of drivers beginning in 2004 for reform in accreditation within the medical specialities – a process that is still evolving. Improving performance, equity and patient centred outcomes is at the core of why organisations such as AHPRA, the professional Health Boards and independent accreditation processes exist: to ensure that standards and capabilities are met. A process that was implemented by the Podiatry Board of Australia (PBA) and APRHA in 2010 for podiatry and podiatric surgery, a few short years after medical specialities were initially accredited via a similar process.
The Statements by these organisations to podiatry standards and capabilities contain broad based multi profession and organisation attack. However, this Message and my commentary will focus on clarification of some of the key policy and education issues that are relevant to podiatric surgery.
Accreditation
The ACPS training program is accredited under the same regulatory framework as for all registered health practitioners in Australia. As the Medical Board of Australia does for medical practitioner specialities, the PBA executes its statutory obligations for the podiatric speciality of podiatric surgery. This process has been in place since 2010 when the national scheme commenced. Prior to this, the podiatry profession was accredited through processes of the national podiatry association and subject to State law. The same type of professional accreditation existed for orthopaedic and other medical specialities until the mid-2000’s. The title podiatric surgeon is appropriate and recognised under the Health Practitioner Regulation National Law (National Law). The process for ministerial approval to use the protected title “podiatric surgeon” was extensive and transparent.
It is our position that there are no grounds, or any form of evidence to support the position taken by these organisations in relation to title and accreditation. The facts about accreditation for podiatric surgery include the reality that the ACPS training program is the only hospital based surgical training in Australia that has been accredited specifically for foot and ankle surgery. In addition, the ACPS has met all its accreditation obligations under the National Law since 2010 and continues to do so to the satisfaction of AHPRA and the PBA.
Training
The ACPS believes in and has developed a model of training which involves a minimum of 2 years vocational experience, including practice in general podiatry prior to entering specialist training. Admission to the training program is open to podiatrists and medical practitioners who also have a podiatry degree and experience. Admission is competitive and based on an evidence-based multi model approach to selection. Surgical training should be hospital based with university collaboration as the ACPS curriculum reflects. ACPS surgical training meets best practice in surgical education. Registrars are required to log more than 2,400 procedures in a range of capacities from perioperative medical management to intraoperative experience in addition to a range of simulation activities and rotations. During training, registrars have medical and surgical rotations with physicians and surgeons from other specialities, including orthopaedic surgery.
In fact, there are several UK and US training programs where both podiatric and orthopaedic surgeons work collaboratively within the same department. The latter development is an outcome that the ACPS has been open to for many years and remains open to today. Unfortunately, any efforts to explore such collaboration has been blocked by the AOA.
Training and access for scheduled medicines
ACPS trained podiatric surgeons have been prescribing scheduled medicines including Schedule 8 medication for over 30 years in the Australian healthcare setting with no reported adverse events. That is, zero reported adverse events. Since the broader podiatry profession has been granted access to prescribing scheduled medicines in 2010 (an extension of access to local anaesthesia which has been in place for over 40 years) there has also been no reported adverse outcomes. This means there is no evidence, despite decades of prescribing, to support the concerns raised by the AMA and the AOA. In addition, various expert and regulatory groups continue to publicly support non-medical prescribers in the interest of patient access to best practice in prescribing medicines.
Outcomes
Podiatric surgeons work within a medical model of training and practice. All Fellows of the ACPS have comprehensive exposure and training to practice the diagnosis, surgical and adjunctive treatment of disease, injuries and defects of the human foot and ankle and associated structures.
The ACPS also provides certification that podiatric surgeons have complied with continuing professional development (CPD) activities. Such CPD activities are in addition to those required to maintain speciality registration with the PBA. Certification by the ACPS ensures that podiatric surgeons meet CPD requirements for ongoing hospital accreditation.
A key element of ACPS CPD requirements is mandatory participation in national peer review of clinical audit. ACPS accredited surgeons are required to capture all perioperative data including 30 days after surgery using the ACPS National Online Audit. Every single surgical case performed in the hospital, day surgery centre or office setting is captured. Both data capture and reporting occur in real-time. Surgeons can compare their outcomes with the national outcomes of all ACPS members thereby supporting individual continuous quality improvement. This data is published annually and openly available to the public via this link.
Yearly national peer review of surgical outcomes also supports continuous quality improvement of the entire ACPS surgical workforce. In contrast to the high level of evidence publicly available for the outcomes of ACPS members, no such data exists for our orthopaedic colleagues. This very fact was cited by the Medicare Services Advisory Committee in its conclusion for assessing MBS item numbers for podiatric surgery, when it stated “there remains a lack of directly comparable evidence for safety and effectiveness, albeit primarily because of the paucity of high-quality contemporary evidence for the safety and effectiveness of the same services delivered by orthopaedic surgeons.”
ACPS training and post-training CPD certification means that ACPS surgeons have the educational and clinical skills to provide safe, effective, and cost-efficient surgical care. All ACPS surgeons are committed to lifelong learning, continual quality improvement and patient centred care. The evidence that ACPS surgeons provide safe, effective, and cost-efficient surgical care is publicly available in clinical audit reports.
The past 43 years has seen all ACPS members dedicated to delivering foot and ankle surgery at the highest possible standards, via a patient centred and medical model of care. The ACPS will continue to advocate and provide accredited training, ensuring the public has access to expert specialist foot and ankle surgery.
References:
1 Australian Doctor (23/3/2021). AOA SUBMISSION Consultation paper: Draft proposed professional capabilities and accreditation standards for podiatry and podiatric surgery.
2 RACS (2015): RACS apologises for discrimination, bullying and sexual harassment.
MSAC 1344.2 Public Summary Document, 2020: Assessment of foot and ankle services by podiatric surgeons (Resubmission)
