Emphasizing Persistence In Expanding Podiatry Privileges

As the field of podiatry continues to advance and graduate residents with a greater well-rounded residency experience and those who also perform a post-graduate fellowship, the training in our profession continues to push the bounds of foot and ankle medicine. I am grateful and appreciative of those before me laying the groundwork both in residency and real life. I continue to champion their efforts in promoting our profession to garner a wider audience of both colleagues and patients who understand what a graduating podiatry resident in 2018 can do.

However, as we graduate and move on to various parts of the country, particular locations or regions of the country may not be ready for us. We may hit roadblocks. We may encounter pushback. We may need to educate. We must not give in. We must push forward.

After recently relocating to Nashville, I learned upon arriving that it may be difficult initially to gain rearfoot and ankle patients into my practice due to the current culture,  and orthopedic foot and ankle offerings right in the vicinity of my particular office. This point was actually the lesser of my problems. I realized when I began filling out hospital privilege forms, they only included procedures for (1) calcaneus, distal with no inclusion of the talus, (2) midfoot/tarsometatarsal joint, distal, (3) and ankle, distal. Three hospitals all in close proximity had three very different scopes of allowable procedures.

Previously, they did not have podiatrists performing surgeries proximal to the hindfoot region. As I was the first podiatrist at these hospitals to ask for surgical privileges for hindfoot and ankle procedures, I knew there was going to be work required to expand these privileges into what I was used to having.          

Thinking this was a regionally isolated problem, I was recently speaking with a friend in another state going through similar issues. At his hospital, he does not have rearfoot and ankle privileges. However, at the same time, the hospital requires American Board of Foot and Ankle Surgery boarding credentials. We can see the problem here as there is no way to get the credentials if you are not allowed to do the cases. He and a group of local podiatrists are appropriately working up the chain of command through their state organization with the potential of legal action.

My personal strategy was to go into these meetings well prepared. Have letters from your residency director and multiple attendings, and a list of your logs (even breaking it down between how many forefoot, rearfoot and ankle procedures you have done), highlighting procedures that may be “out of the norm” such as ankle fusion, pilons, total ankle, etc. Have letters from fellowship directors and if you are a current fellow, continue to keep a log of your procedures (i.e., I did this on Excel since there was no formal logging mechanism).

If you moved from a previous practice as I did (and worked for two years), obtain letters from local colleagues in and out of your practice as well as the chief of podiatry/orthopedics/trauma from your hospital attesting to your skills and referencing a list of procedures you performed while there. Write a well-crafted letter explaining why you think you deserve these privileges. Discuss and cite the state’s rule on scope of practice for a podiatrist (i.e., Tennessee allows podiatrists to perform foot/ankle procedures (with the exception of pilons). At the meetings, bring all of this documentation and have a positive, open dialogue about what you want to achieve, why you think you should be bestowed these privileges, and how it will help the medical community.

Get in touch early with your state organization president/vice president or law team so they are aware of the issue and what you are doing in case you need them to write formal letters to the hospital boards. The last thing you want to do is create a hostile environment before you start and threatening civil lawsuits. Not only are these credentialing board members your judges but also your future peers and referral sources. There is a fine line you must walk during the whole process.

After going through the process and being close to getting my privileges expanded (it took me six months, which I heard was on a “quicker” timeline than normal), all I can say is do not give up. It may take time, meetings (many meetings), and explaining things that may make sense to you but do not to other physicians, especially those on the committee who are not orthopedic. For example, one hospital allowed me to fix calcaneus and ankle fractures but not talus fractures until I got it changed.

You may feel frustrated, infuriated and insulted at times. But again, do not give up. I have worked very hard over the last six months and I am starting to see the fruits of my labor, both in actually having the privileges rewritten (for three hospitals) and also in the local medical community (e.g., primary care physicians, emergency department) with respect to referrals for the types of pathology and patients I want to build my practice around.

Dr. Hood is a fellowship-trained foot and ankle surgeon. Follow him on Twitter at @crhoodjrdpm or check out his website www.footankleresource.com, which contains information on student/resident/new practitioner transitioning, as well as links to academic and educational resources found throughout the Internet.