In this issue of STRIDE, podiatric surgeon Andrew van Essen prepares to launch ‘Podiatrists & Prescribing’; a six-part series to run across 2024. It will cover a range of topics related to podiatrists when it comes to the issue of prescribing medications. Topics will include the history of non-medical prescribing, the effect this has had on other professions, the shape of healthcare reform regarding policy changes, and its impact on our role and scope of practice; along with future reflections.
Framing this conversation is Andrew’s lived experience as a podiatrist and a podiatric surgeon who, for nearly 30 years, has had endorsement to prescribe a range of Schedule 4 and Schedule 8 medications.
My goal for this series is to stimulate our collective thinking. I want to seek feedback from fellow podiatrists on the role of endorsement to prescribe scheduled medicines as a contributing factor in influencing professionalism in podiatry practice; potentially even moving the needle on podiatry workforce recruitment and retention.
Over the course of 2024, I am keen to make the concept of prescribing Schedule 2 and 3 medications a little less mysterious, through these articles. Ultimately, to encourage you to embrace prescribing medicines as an integral part of your practice. Perhaps this will be the next step on your journey toward becoming an endorsed prescriber.
Non-medical prescribing is a component of the government’s health reform agenda that has the potential for greater efficiency in health care delivery, with timelier access to scheduled medicines.
As it currently stands nurses, midwives, optometrists, and podiatrists with appropriate training can prescribe scheduled medicines; with expansion being considered into pharmacy and physiotherapy.
After a slow start, there is a significant increase in the number of podiatrists seeking endorsement. Undergraduate courses are embedding scheduled medicines within their curriculums, and we are now beginning to see podiatrists graduating as prescribers.
There appears to be reluctance by some podiatrists in response to these changes. Reasons given include no perceived need to prescribe while working within their current scope of practice, their stage of life and career being unconducive to additional time commitments, and the cost it takes to undertake the pathways for endorsement. Whilst external resistance comes in the form of pushback from the Australian Medical Association.
Health care reform that ultimately benefits patient outcomes also challenges preconceived professional silos, and we are all defensive about our patch. Podiatry is no exception when I see how unhappy we are about the increasing uptake of orthotic therapy by other professions, while at the same time experiencing reluctance to step outside our patch by using Schedule 4 medicines. It can understandably be intimidating for a practitioner who is not trained or familiar with prescribing medicines, but it should not be as daunting as some podiatrists may perceive.
All podiatrists are trained in the use of at least one Schedule 4 medication and are very familiar with its use: that being, local anaesthesia. We also have a range of Schedule 2 and 3 medications which include analgesics, anti-inflammatory, antihistamines, topical anti-fungal, and corticosteroids that we are all trained to provide advice on and recommend to patients.
Professor Ian Maddocks elaborates on how silo mentality is bad for patients in the following excerpt from the Medical Journal of Australia, and the 2016 Journal of the Consumer Health Forum of Australia.
“We work in silos, increasingly focused on a discrete area of knowledge, expertise, and activity. It grows inexorably, encompassed only by allocating more time and attention to its detail.
We know that thoughtful engagement with colleagues or science outside of our personal patch feeds intellectual excitement, spawns new ideas and promotes wisdom, but confined by ‘keeping up’, we become less open to the broader reaches of medical need and knowledge.
In the face of their (health institutions) apparent dominance, we retreat from organisational involvement into our own small towers of expertise.”
Podiatrists are also used to ‘prescribing’. We prescribe footwear, orthoses, and exercises, but typically we tell our patients to go and buy some medication from a pharmacy or supermarket. This is a bit like a doctor saying to a patient, ‘Go and buy an arch support’, which would cause no end of frustration to any podiatrist.
If we apply this same perspective to a podiatrist who recommends Schedule 2 and 3 medications, it makes sense to manage this process more closely to benefit the patient outcome.
Rather than say to a patient, “Go get some Ibuprofen”, or whatever it is you want them to take, start thinking like a prescriber. Recommend the appropriate formulation and dose, after having considered your patient’s existing medications and their health status. Also provide consumer information on side effects and monitor their symptoms.
Do all these things even if you think it is an innocuous drug like paracetamol. Bear in mind that one of the most common causes of drug-related hospital admissions is owing to paracetamol overdose.
Now is the time to step outside of that professional silo and revisit your undergraduate training in pharmacodynamics and pharmacokinetics. Consider formulation, dosages, and drug interactions. Then apply this knowledge to the medications you can already recommend to your patient.
This shift in thinking can help to reduce the sense of a hurdle when it comes to the next step of undertaking your endorsement for scheduled medicines.
While all this is based on opinion and personal experience, it is also rooted in the context of Australian health care system and the global experience of the podiatry profession; particularly within the United Kingdom and the USA.
I look forward to exploring the issue of prescribing by podiatrists in more detail across 2024.
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