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Could Enhancing and Embracing Conservative Foot and Ankle Care Decrease Malpractice Claims?
A new study underscores the importance of training and competency in conservative care of foot and ankle disorders.1 Kadakia and coworkers reviewed the Westlaw legal database for medical malpractice lawsuits pertaining to foot and ankle surgery for the years 2008 thru 2018. The reasons for litigation, among the forty-nine cases reviewed included:
o Negligent operative treatment (33 percent)
o Negligent nonoperative treatment (27 percent)
o Unnecessary operation (8 percent)
o Delayed diagnosis (4 percent)
o Lack of informed consent (2 percent)
Kadakia, et al found that most of the malpractice claims in this study involved nonoperative treatment either by itself or as a precursor to surgical intervention.1 They found that the impetus for these lawsuits did not revolve around failure to provide nonoperative treatment. Instead, the quality of nonoperative treatment was lacking or the patients were not properly informed about the possibility of failure of the nonoperative treatment, which could lead to a need for surgery. Lawsuits filed alleging negligent operative treatment often included claims about improper nonoperative care prior to the surgery.1
Of interest, the number of malpractice cases filed during this ten-year period equally divided between orthopedic and podiatric physicians. Podiatric physicians were the defendant in 22 (44.9 percent) cases), orthopedic surgeons were defendants in 21 (42.9 percent) cases, and other providers comprised 6 (12.2 percent) cases.
It is not clear whether podiatrists had the same numbers of malpractice cases related to nonoperative treatment compared to orthopedic surgeons, as this statistic was not reported in the study. However, my expectation and experience supports that podiatric physicians would have training equal to or better than orthopedic surgeons in the nonoperative treatment of foot and ankle disorders and therefore might have fewer claims related to this type of treatment.
In podiatric medicine, one of the mainstays of nonoperative treatment is foot orthotic therapy and ankle-foot orthotic therapy.2-4 I have personally witnessed a trend towards the elimination of teaching of biomechanics and orthotic therapy in the schools of podiatric medicine as well as continuing education symposia for licensed podiatric physicians.5-9 With the reduction of education and training in a vital non-operative treatment option for many foot and ankle pathologies, I have observed both young and older podiatric physicians referring their patients to other specialties for implementation of foot orthotic therapy and ankle-foot orthotic therapy.10-12
I am baffled by this trend where my colleagues may literally pass off the critical nonoperative treatment of their patients to other health care providers. At the same time, the study by Kadakia, et al raises new questions:
1. When does dissatisfaction with the quality and outcome of nonoperative treatment contribute to a malpractice suit after a poor surgical outcome?
2. What impression might a patient get when the treating podiatrist says “I am going to refer you to somebody else for further treatment, but come back here if you need surgery.”
3. How confident is that referring podiatrist in the skills of the orthotic provider who gets the referral and now must maintain patient confidence?
4. How effective is the communication between the referred patient and the orthotic provider if conservative treatment fails? Who might the patient blame for the treatment failure?
The lesson learned from the study conducted by Kadakia, et al is that poor surgical outcomes are not the primary reason malpractice suits are filed against foot and ankle providers. Nonoperative treatment can trigger distrust and retaliatory action by patients just as often as surgical treatment. The best protection, I feel, for the podiatric physician is to continually sharpen their skills and take charge of the nonoperative treatment while maintaining contact with the patient during throughout the entire treatment program.
Dr. Richie is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. Dr. Richie is a Fellow of the American College of Foot and Ankle Surgeons, and the American Academy of Podiatric Sports Medicine. Dr. Richie is the author of a new book titled "Pathomechanics of Common Foot Disorders," which is available from Springer at https://www.springer.com/us/book/9783030542009 . He discloses that he is Founder and President of Richie Technologies.
REFERENCES
1. Kadakia RJ, Orland KJ, Sharma A, Akoh CC, Chen J, Parekh. Medical malpractice trends in foot and ankle surgery. J Foot Ankle Surg. 2022;61:104−108.
2. Piraino JA, Theodoulou MH, Ortiz J, et al. American College of Foot and Ankle Surgeons Clinical Consensus Statement: Appropriate Clinical Management of Adult-Acquired Flatfoot Deformity. J Foot Ankle Surg. 2020;59(2);347-355.
3. Schneider HP, Baca JM, Carpenter BB, Dayton PD, Fleischer AE, Sachs BD. American College of Foot and Ankle Surgeons Clinical Consensus Statement: Diagnosis and Treatment of Adult Acquired Infracalcaneal Heel Pain. J Foot Ankle Surg. 2018;57(2):370-381.
4. Shibuya N, McAlister JE, Prissel MA, et al. Consensus Statement of the American College of Foot and Ankle Surgeons: Diagnosis and Treatment of Ankle Arthritis. J Foot Ankle Surg. 2020;59(5):1019-1031.
5. Richie D. What happened to continuing education for biomechanics? Podiatry Today. Available at: https://www.hmpgloballearningnetwork.com/site/podiatry/blogged/what-happened-continuing-education-podiatric-biomechanics . Published November 18, 2011. Accessed April 12, 2022.
6. Richie D. Is there a gap between biomechanics knowledge and new trends in bunion surgery? Podiatry Today. Available at: https://www.hmpgloballearningnetwork.com/site/podiatry/blog/there-gap-between-biomechanics-knowledge-and-new-trends-bunion-surgery . Published September 14, 2021. Accessed April 12, 2022.
7. Richie D. Proposed CPME 320 changes may dramatically reduce required biomechanics cases in residency training. Podiatry Today. Available at: https://www.hmpgloballearningnetwork.com/site/podiatry/blogged/proposed-cpme-320-changes-may-dramatically-reduce-required-biomechanics-cases-residency . Published December 1, 2020. Accessed April 12, 2022.
8. Richie D. How can we make biomechanics relevant to podiatric residency training? Podiatry Today. Available at: https://www.hmpgloballearningnetwork.com/site/podiatry/blogged/how-can-we-make-biomechanics-relevant-podiatric-residency-training . Published December 31, 2020. Accessed April 12, 2022.
9. Richie D. What I learned at the best biomechanics conference that hardly any DPMs attended. Podiatry Today. Available at: https://www.hmpgloballearningnetwork.com/site/podiatry/blogged/what-i-learned-best-biomechanics-conference-hardly-any-dpms-attended . Published April 19, 2018. Accessed April 12, 2022.
10. McCurdy B. APMA to partner with pedorthic footcare association at 2015 annual meeting. Podiatry Today. Available at: https://www.hmpgloballearningnetwork.com/site/podiatry/apma-partner-pedorthic-footcare-association-2015-annual-meeting . Published November 2014. Accessed April 12, 2022.
11. Richie D. Does the APMA advocate DPMs hiring pedorthists? Podiatry Today. Available at: https://www.hmpgloballearningnetwork.com/site/podiatry/blogged/does-apma-advocate-dpms-hiring-pedorthists . Published June 25, 2015. Accessed April 12 ,2022.
12. Richie D. Should podiatric physicians surrender AFO therapy to pedorthists? Podiatry Today. Available at: https://www.hmpgloballearningnetwork.com/site/podiatry/blogged/should-podiatric-physicians-surrender-afo-therapy-pedorthists . Published June 23, 2014. Accessed April 12, 2022.
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