One Podiatrist’s Insights On Prescribing In Australia

“All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.” - Arthur Schopenhauer¹

The story of how Australian podiatrists accessed our first prescription medication (lidocaine) is folkloric. For decades, we lobbied for access to local anesthetic, consistently being blocked by larger stakeholders. The story goes that it took a high-profile politician having nail surgery without anesthetic (yes, you read that right) in the 1970s to turn the tide. More than twenty years of fruitless lobbying, and by this parliamentarian’s one-week postoperative review, we all had access to lidocaine. Fast forward to 2010, we achieved access to a list of 53 prescription medications for those of us who completed an additional, rigorous, 12-month post-graduate prescribing internship. In one press of a button, we went from one drug (lidocaine) to 53. That’s a big day at the office.

Unsurprisingly, the Australian Medical Association (AMA) was irate.Their then-president, Harry Henley, published in the Sydney Morning Herald in 2009 a statement opining that podiatrists’ training was not adequate for prescribing.²

In Australia, podiatrists are independent practitioners with the right to perform minor foot surgery, refer patients for relevant investigative tests and to administer drugs necessary for the treatment of podiatric conditions. Podiatric surgeons are podiatrists who have completed extensive post-graduate medical and surgical training and perform reconstructive surgery of the foot and ankle. The qualifications of podiatric surgeons are recognized by Australian State and Federal Governments. It is an approved specialty by the Australian Health Practitioners Regulation Agency. Podiatric surgeons are included within both the Health Insurance Act and the National Health Act.³

Most podiatry programs in Australia are four-year undergraduate degrees, in contrast to the course one takes in the United States. To obtain prescription rights in Australia, one must meet multiple criteria before embarking on a 12-month prescribing internship.⁴ For those wishing to progress to specialist surgical practice, the road is much longer, requiring an additional Master’s degree and multiple other prerequisites, followed by a six-to-eight year surgical training fellowship,⁵ equaling an additional 10 years on top of the undergraduate degree, in most cases.

I completed my 12-month prescribing internship under the guidance of my good friend and excellent doctor, Katrina Philip, achieving my prescribing qualification in 2015. My prescribing portfolio, submitted to our board, was 130,000 words long. That’s a lot of words - and I lost inch or two of my hairline in the process. This internship involved over forty exhaustive case-studies on prescribing episodes, along with a plethora of other requirements. Interestingly, my six years of prescribing (during which I have written over 2,500 prescriptions) has been almost entirely uneventful. I had anticipated regular angry phone calls from doctors up-in-arms at me daring to prescribe. This hasn’t happened, and many doctors in my area are supportive of my prescribing and compliment my prescribing choices.

Australian pharmacists, however, hadn’t seen a podiatrist prescription before, and often didn’t dispense my prescriptions. I found out later this wasn’t due to bias, but because Australian pharmacy software was not updated to allow for podiatric prescriptions. A pharmacist friend talked me through a loophole to staple onto the back of my scripts with instructions to the pharmacist if they did use one of these software packages. Thankfully, this is very much the exception and rather than the rule now.

My most unfavorable incident occurred when a patient presented with the classical signs of gout; a red, hot, swollen great toe joint, sudden onset of exquisite pain, et cetera. After completing the appropriate evaluation, I discussed the condition with him and completed the requisite paperwork. I wrote him a prescription for indomethacin and sent him on his way. The next morning, I was in the operating theatre when I received a panicked phone call from my reception staff. This man had stormed into the clinic and berated my team. He had met with his general practitioner friend later that day, who told him I was a ‘cowboy’ and couldn’t be trusted. His friend felt high-dose prednisolone was the proper choice. This patient then telephoned my association and complained about my cowboy antics. In Australian medicine, being called a “cowboy” is a significant insult; it indicates carelessness, brashness, and non-evidence-based practice. Thankfully, I was supported by my association and my colleagues. Nonetheless, I was still licking my wounds.

Those on the front lines take the bullets, and hopefully by taking some of this heat, those who come after me won’t have to. As part of my everyday practice, I now supervise a dozen podiatrists undertaking their prescribing training, which I enjoy. In my estimation, Australian podiatrists have proven themselves to be impeccable prescribers; safe, honest, and reliable. What is the end goal for us here “down under?” Access to the full formulary of medicines, just like our colleagues on the other side of the Pacific. Full formulary, I hope, will be achieved during my career.

Dr. Edwards is undergoing his podiatric surgical training in Melbourne, Australia. He has completed a Master’s degree in podiatric medicine from Queen Margaret University, Edinburgh and a Master’s degree in evidence-based health care from the University of Oxford. He lectures in podiatric medicine and pharmacology within the La Trobe University podiatry school. He has published over 20 articles in peer-reviewed journals and is a reviewer for several foot medicine and surgery journals.

References

1. Phillips A. The three stages of truth. Medium. Available at: https://medium.com/@alan_46156/the-three-stages-of-truth-eddd98151f0a . Accessed December 8, 2021.

2. Miller N. Podiatrists should not prescribe. Sydney Morning Herald. Available at: https://www.smh.com.au/national/podiatrists-should-not-prescribe-20090913-fm76.html. Published September 14, 2009. Accessed December 8, 2021.

3. Podiatry Board Ahpra website. Available at: https://www.podiatryboard.gov.au . Accessed December 8, 2021.

4. Endorsement for scheduled medicines. Podiatry Board Ahpra websites. Available at: https://www.podiatryboard.gov.au/Registration-Endorsement/Endorsement-Scheduled-Medicines.aspx . Accessed December 8, 2021.

5. Australasian College of Podiatric Surgeons website. Available at: https://www.acps.edu.au. Accessed December 8, 2021.