CHAPTER 22 Podiatry in Australia: past, present and future
Podiatry is concerned with maintaining and promoting the health of the foot and related structures. It is, by anatomical definition, at the bottom of the body. In many ways, this humble position has been a metaphor for the development of the podiatry profession. Starting as tradesmen, ‘corn cutters’ who would ply their trade in the streets of London by singing ribald ditties (Kippen 2004), podiatry in Australia today is an integral part of the health care system across the public and private sectors, working in isolation or as part of a multidisciplinary team.
Podiatrists are primary contact health care professionals who diagnose and treat disorders of the foot and lower leg that may have arisen from disease, injury, developmental disorders or lifestyle factors. Diagnostic assessment techniques include non-invasive vascular, neurological, dermatological and biomechanical evaluations, and referral to radiologists for specific investigations. Treatment methods may be preventative, palliative or corrective, embracing a complex array of medical, surgical and biomechanical approaches. Podiatrists have particular expertise in treating disorders of the skin and integuments, foot orthoses, and in some states of Australia, limited Schedule Four prescription rights (such as antibiotics).
More recently the podiatrist has become a valued member of inter-professional teams working with high-risk patients who present with peripheral vascular disease, neuropathy, structural and functional anomalies of the foot and leg, and the consequences of conditions such as diabetes mellitus, which can include all of these pathologies.
Podiatrists work in a range of settings, including the private and public sectors. In private practice podiatrists may work alone or in a discipline-specific or mixed discipline practice. Opportunities also exist to work in commercial and industrial settings, including consultation to organisations such as athletic shoe manufacturers. In the public sector podiatrists are found in hospitals, community health services, domiciliary care services and specialist services such as providing care to Indigenous Australians and remote and rural communities. The case studies in this chapter give you some insight into the work of podiatrists. Currently under the various state and territory Podiatry Registration Acts, podiatrists may also be recognised as general or specialist practitioners. Specific registration is available to those podiatrists who have gained Fellowship of the Australasian College of Podiatric Surgeons (ACPS). These arrangements may change with a move towards a national registration model in 2008.
James is 45 years old, has been a podiatrist for 23 of those years, and has spent a great deal of time and effort developing his practice as a specialist podiatrist. James is registered in his home state of Victoria under the Podiatry Practice Act 2005 as a podiatric surgeon, his specialist registration being dependent on his Fellowship of the Australasian College of Podiatric Surgeons (ACPS). It has taken James a masters degree, a long residency, numerous overseas study trips and continuous professional development to earn his Fellowship. James’ working hours are long, and his wife is perpetually annoyed.
James started the day early, visiting his post-operative patients who have stayed overnight in the private hospital where he operates. Many of the procedures James performs are done as day procedures, however, more complex surgery often calls for a brief period of hospitalisation to ensure the patient is comfortable and well upon discharge. Under the Health Insurance Amendment Act 2004, patients are able to claim private insurance rebate on the hospital stay, as well as the procedure, but at this stage it is not covered under Medicare.
Having ascertained that all is going well, James commences his surgical list, working closely with an anaesthetist to ensure all medications for post-operative pain relief and prevention of infection are appropriately prescribed. Today he undertakes a plantar fasciectomy (removal of the plantar fascia), a Hallux Valgus (bunion) correction and a tendon repair and transfer procedure. He is currently training a number of ACPS surgical registrars, one of whom works with him in theatre as an assistant.
James arrives at his private practice in rooms he shares with two podiatrists, a physiotherapist, and three general practitioners (GPs). James works closely with the physiotherapist to organise weight-bearing immobilisation of one patient through the use of a specialist splint, and with several other patients who need to have strengthening and stretching programs devised and monitored. One patient presents with an acute infection of the toe associated with an ingrown toenail. James prescribes antibiotics for this patient, and will review the case for possible minor surgery in his office at a later date. The day ends for James at 7 p.m., until a call from the hospital indicates that one of his patients is requesting further post-operative pain management. James visits the hospital on the way home, writes up the notes, and remembers he is due at a meeting, so heads there without dinner. His wife is still annoyed.
Pause for reflection
Podiatrists diagnose and treat disorders of the foot and lower leg’. This is allowed through legislation in each of the states and territories. Why is it so important for the term ‘diagnosis’ to be included? Are all professions able to diagnose conditions? Of what benefit is this to the podiatry profession in their role as primary contact professionals?
If you are old enough you will have memories of ‘chiropodists’ working in the back of the chemist shop. A single, subtly marked door announced that this was the way to relief from corns and calluses. In Australia, chiropody was an unregulated profession usually practised by those who had gained qualifications from the UK, or had completed an apprenticeship under an experienced chiropodist. The nature of the work was principally palliative, offering pain relief from dermal lesions such as corns, calluses or nail deformities. The use of felt pads and insoles offered more extended symptomatic control, but the overall emphasis was on care rather than cure.
During World War Two the army put justifiable focus on the importance of foot health of its members. Army medics were given additional training to become ‘Corporal Chiropodists’, and developed considerable expertise in the care of feet under greater stress than would normally be experienced. When demobbed (discharged from military service), these skilled practitioners often continued to work in the area, and the numbers in the profession grew. In addition, there were pressures associated with the need to provide rehabilitative care to injured veterans, thus introducing elements of more functional and mechanically based treatments. The influx of women into the workforce, as a result of society changing due to forces of war, brought about more sore feet crammed into the fashionable but foot-unfriendly high heeled court shoes of the day.
Private training institutions for podiatry were established in Victoria and New South Wales as early as the 1930s. These existed in various forms, providing baseline levels of education across the country. In South Australia, the South Australia Institute of Technology offered a government funded course by 1959, in New South Wales a course was formally established in the Technical and Further Education (TAFE) sector. To reflect the increased complexity of teaching required to meet the growing education needs of the evolving profession, the Lincoln Institute of Health Sciences in Victoria offered the first undergraduate degree qualification in 1983.
Since that time podiatry has become a degree program with courses offered in Queensland, New South Wales, Victoria, South Australia and Western Australia. The baseline is a 4-year program, with opportunities for higher degrees by coursework or research.
In most instances a podiatrist must be currently registered with the Podiatry Registration Board in the state or territory in which they are working. The registration boards, responsible for administering the relevant state or territory
Jane is a relatively new graduate from the degree program in New Zealand. Trans-Tasman mutual recognition enables her to become registered in any Australian state or territory without having to undertake any further studies or assessments. Jane worked as a locum in New Zealand before moving to Melbourne to take up a Grade One podiatry position in a community health centre. She was attracted by the idea of working in an inter-professional team, and becoming involved in health promotion activities as well as direct client care. Coming from a rural area, she was also interested in seeing how community oriented and client-centred health care could be implemented.
Jane’s day is varied, with a mixture of team meetings, health promotion activities, client care and a never-ending mountain of paperwork. The paperwork has been the biggest shock, everything seems target or outcome driven, and there is so much evidence to collect and collate. The statistical collection for each client is also new.
Jane is the only podiatrist for miles. There is a great deal of pressure by the public to receive podiatry services, however, like most community health services, admission to this service is restricted to clients from the surrounding area with high-risk problems. Most of the clients have musculoskeletal conditions, diabetes mellitus, or peripheral vascular or neurological disease. The emphasis of her work is on taking all possible actions for each client to maintain foot health status, thus preventing potential tissue loss.
Jane’s greatest delight has come in the health promotion activities. She is involved in a walking group, a shoe shopping group, a chronic disease self-management group and an Indigenous health group. For each of these groups she works with a number of staff from other disciplines, volunteers from the community and clients. The activities of these groups are designed to foster healthy lifestyles and empower people to seek help when they need it. For the shoe shopping group, she visits many shoe stores with whom she has a good working relationship. At these stores she can assist clients with the best choices in style and fit to promote foot health. Such a simple and enjoyable task, yet many of the problems of pain, potential wounds and deformity are addressed by ensuring clients understand the need for, and can access, reasonable footwear.