So what is a podiatrist, what is podiatry? I’ll start this article off with a question, and if you are diabetic you should already know the answer. So? Do you know the answer?
A podiatrist is a physician and surgeon of the foot, ankle and lower leg. That’s a pretty broad area, and many things can go wrong in the areas that a podiatrist treats.
Podiatry Academic Training
A podiatrist is a physician, and our course of training follows the allopathic model. We are trained very similar to medical doctor (MD) or osteopathic doctor’s (DO). A podiatrist needs to complete a four year degree (a few students per year are admitted with 3 years of undergraduate training, and receive their four year degree while in podiatry school) before admission to podiatry school.
Podiatry school is four years in duration, first two years of academics followed by two years of rotations in different hospitals and clinics. For the MD/DO physicians, they usually choose a surgical or medical specialty. I like to refer to podiatry as a hybrid, as we have both surgical and medical training. More on podiatry training here.
Upon completion of podiatry school, you apply for residency. What is residency? It is a period of advanced medical and surgical training. It is called residency because way back when, the residents used to live at the hospital. Due to living at the hospital they were available 24 hours per day and 7 days per week. Even residents who were married or had families were expected to live at the hospital, and the residency was often of an undetermined duration, meaning it lasted as long as it lasted. Not great for planning, but the model offered good training.
Residency is the time where you start pairing all of your fancy academic (book) knowledge with clinical and surgical experience. Only when the two are combined will you be a physician and surgeon. Theory without experience is dangerous, just as experiment without theory is reckless. Residency now is 3 years in duration, and you are expected to perform a certain number of examinations in various different rotations. There are also several different types and categories of surgeries that you must perform and show proficiency in. You cannot graduate until you hit all of your numbers. Once you do hit your numbers, you are expected to assist with training those who are junior to you.
I should also mention that I am a podiatrist in the United States of America. We have an international audience here at Diabetic Survivor, and I have never noted diabetes to particularly care where you are from. Where you are seeking care may have a large impact on the role that podiatry plays. A podiatrist in the US is a physician and surgeon, that will coordinate with MD’s, DO’s and allied health. In other countries this may not be the case. In the western world podiatry is common, but the surgical privileges vary depending on the country. The duties of podiatry as relates to diabetic foot infections in other countries are often performed by vascular surgery, orthopedic surgery, or general surgery. In countries where podiatry is not present or surgically trained, there may not be much effort expended at attempting limb salvage (meaning that a patient with a foot infection may go directly to amputation).
Podiatry in Practice
Upon completion of residency you begin practice. What is practice? It’s where you go out and get a real job, the training is largely over (but the learning never ends). Some podiatrists will go into solo-practice, this is where they open an office, or buy out a retiring podiatrist. It’s becoming more common today for podiatrists to be employed by hospitals or multi-specialty groups. I think over the next 10-15 years the demographics will shift, and more and more podiatrists will be employed by hospitals and large groups.
Podiatrists can treat any condition in the areas that they are allowed to treat. This sounds complicated, and it sometimes is. Every state has a slightly different ‘scope of practice’ which will determine how far up the leg the podiatrist can treat. In some states podiatrists are allowed to do bone surgery of the ankle, and in some states they are not. As we move out of the US to the international sphere, scope of practice muddies further. Podiatrists also cover all the different subspecialties as it pertains to the patient. For example a podiatrist can treat the skin (dermatology), joints (rheumatology), vessels (vascular), nerves (neurology) and so on. But we don’t directly treat the heart or brain as these areas are out of our scope of practice. In reality every podiatrist is a little different, not every podiatrist is interested in everything.
You will often see this reflected in the practice environment that a given physician chooses. I practice with a group, and I focus on high-risk patients. High risk refers to people who often have multiple medical problems (also called co-morbidities). Many of my patients have diabetes (DMI, DMII, etc), peripheral vascular disease (PVD), peripheral arterial disease (PAD), peripheral neuropathy, non-healing surgical wounds, and on and on. This practice is not for everyone, some podiatrists are more interested in sports medicine, some are involved in residency programs training future podiatrists, some work for the government, and some are researchers. One of the great things about podiatry is how varied it is, whatever your interests you will be able to find challenging and diverse problems to solve.
I also want to mention that a podiatrist works with MD/DO’s. We may treat joints, vessels, muscles, nerves and etc, but sometimes we will refer to a specialist in this area. Conversely, other medical specialties often refer to podiatry, as we are specialists in the foot, ankle and lower leg. We work together.
All podiatrists have training in diabetes, specifically in diabetic foot complications. One of the dreaded complications of diabetes is amputation, but nobody starts out needing an amputation. You are reading this article right now, and you don’t need an amputation right? One of my goals as a podiatrist is to prevent amputations. The key to amputation prevention is early detection and education.
Amputations Are Preventable
An amputation will happen in a sequence. The problem usually begins with too much pressure, either due to improper fitting shoegear or neuropathy, or both. Peripheral neuropathy means that the patient either cannot feel their feet appropriately, or they have lost some of the feeling. So the patient has lost some feeling, and they have too much pressure, usually near a bony prominence (where a bone stretches against the skin). This will cause a callus; a callus is a thickening of the skin in response to pressure.
Usually the callus would create pain once it gets thick enough, but this patient has some neuropathy. As the callus continues to build, it puts more pressure on the tissue between the callus and the bone. Eventually this pulverizes the soft tissue, and creates an ulcer (an ulcer is like a non-healing sore). The ulcer is often covered by the callus, kind of like a hat.
Hopefully the problem is realized at this point and you are referred to a podiatrist. At some point the callus may break open and bacteria may enter the ulcer. This will cause infection, or if still covered, it may cause an abscess. If the infection gets into the bloodstream it is called bacteremia (which leads to sepsis); if the infection gets into the bone, it will cause bone infection (osteomyelitis). Once the bacteria is established in the bone they are very difficult to eradicate. This may lead to amputation, or removal of the infected bone and surrounding soft tissue.
Why Should You Care?
I hope it’s obvious why you should care at this point. If you have diabetes, you want to avoid amputation, and you can do this by involving podiatry early. If you do not have diabetes, presumably you are here because you know somebody who does have diabetes, and you can help them to avoid amputation. Again, get a podiatrist involved early. I talked earlier about our surgical training, I should mention that not all podiatrists perform surgery, some don’t really like surgery. Not all podiatrists like high-risk patients, or diabetic ulcers. Ask your podiatrist if they are a specialist in wounds or limb-salvage, they can refer you to one in your area if they don’t specialize in diabetes.
Patients with diabetes should have an annual diabetic foot exam by a podiatrist
Patients with prediabetes may need an annual foot exam, especially if they have any neuropathy
Begin checking your feet daily (every day, yes both feet)
Sign up for our newsletter so that you’ll know when new articles are available, knowledge is power!