Podiatry Admissions

[PeaJay]

Instead on derailing another thread with this topic, here is a new thread.

Every time this topic is broached, we have people that make arguments that there are zero situations where a podiatrist should admit. Otherwise pose questions such a what if something happens?

I think this is a great discussion. I know I am in the minority of providers that would admit, but I just think some of the arguments against are ridiculous.

Admission and management is the same as any other skill/service. You should only perform it if you are adequately trained and comfortable managing the patients co morbidities. You should not take on things outside of your training. In podiatry’s case that is a simple patient needing pain control or basic sliding scales in most cases.

The arguments against admission privileges that I have heard here are the same as those used to prevent surgical privileges.

As a surgeon, what if your surgery has a complication…probably shouldn’t do it unless you can manage the complications. That means most pods should not manage ankle fractures as is could be an unrecognized pilon (most pods are not trained to handle). Probably shouldn’t be allowed to do a TTC. What if the tibia cracks while reaming a nail? Most pods can’t fix that. Calcaneal osteotomy? What if there is a complication… most pods are not trained well enough on Calcaneal fracture management techniques.

These are all arguments with the same substance as the ones against admission. If you don’t like the arguments above…then stop bashing admissions.

The point is don’t take on anything you cannot handle.

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[Pronation]

As a surgeon, what if your surgery has a complication…probably shouldn’t do it unless you can manage the complications. That means most pods should not manage ankle fractures as is could be an unrecognized pilon (most pods are not trained to handle). Probably shouldn’t be allowed to do a TTC. What if the tibia cracks while reaming a nail? Most pods can’t fix that. Calcaneal osteotomy? What if there is a complication… most pods are not trained well enough on Calcaneal fracture management techniques.

I’m not really sure how to reply to this other than… dubya tee eff?

My admitting principles are the same as other specialties (except Gen surg, they seem to prefer to medically manage most of their patients as well), whereas I’ll admit generally healthy patients and all elective post ops, everything else goes to the hospitalist because I don’t have the time or interest in medically managing or coordinating complex medical patients.

 

[heybrother]

There are philosophical, practical, legal, and bureacratic arguments that can all be made here.

#1 - The simple truth is most podiatrists with admitting priviledges are still required to have a co-admitter simply based on hospital regulations.

#2 - The act of admissions became substantially more complicated during Covid, but even prior to Covid "Bed Control" was still under the control of hospital medicine. If they already have a say in deciding who gets to be in the hospital they might as well be on the team.

#3 - The hospitalist is already there. This is literally their area of expertise. They are much more familiar with the hospital formulary for medication reconciliation and for let's face it everything associated with the medical management and investigation of patients.

#4 - We aren't going to be joined by hospitalists here - but let's say that instead of making your argument to us you had to make this argument to a hospitalist. They would say - you don't know what you don't know. Read the other forums on here - people with expertise in their field have unkind feelings to people who do something a few times or for a year and decide they are comfortable with it when its someone else's specialty. Example - sliding scale, one of your examples, is bad medicine.

#5 - You are already there, but most of us aren't.

#6 - Scope of practice. My scope of practice essentially says I address foot problems. Diabetes impacts my foot problem but isn't a foot problem.

#7 - During my 1st year of residency a hospital refused to admit a patient and made podiatry the primary because "the patient had no history except diabetes so we'll just follow along with you". The patient had gas gangrene. He had PVD. He got a BKA during the hospitalization. He developed pneumonia. It turned out he needed a heart bypass and ultimately got transferred to another hospital. Cardiology called me asking permission to do something because I was the primary. They kindly took over as primary at that point. My hospital ultimately let go all the hospitalists, hired new one's, and told them there job was be primary on admissions as needed and to help other services.

#8 - However comfortable you feel with this plan - the day it blows up in your face will be the day you never do it again. I hope it doesn't happen. In the majority of instances when a foot problem blows up and I'm unhappy I still can manage it. If a medical problem starts blowing up though you won't be able to.

#9 - Our patients will routinely resolve their foot problem but still find a reason to stay forever in the hospital. Do you want to be listed as the primary on a patient who is there 2 months later? I get it - someone else would take over, but depending on your hospitals bureacracy and culture it would be a lot easier for this never to happen.

 

[PeaJay]

Thank you for you logical and well thought out answer.

 

[CutsWithFury]

Instead on derailing another thread with this topic, here is a new thread.

Every time this topic is broached, we have people that make arguments that there are zero situations where a podiatrist should admit. Otherwise pose questions such a what if something happens?

I think this is a great discussion. I know I am in the minority of providers that would admit, but I just think some of the arguments against are ridiculous.

Admission and management is the same as any other skill/service. You should only perform it if you are adequately trained and comfortable managing the patients co morbidities. You should not take on things outside of your training. In podiatry’s case that is a simple patient needing pain control or basic sliding scales in most cases.

The arguments against admission privileges that I have heard here are the same as those used to prevent surgical privileges.

As a surgeon, what if your surgery has a complication…probably shouldn’t do it unless you can manage the complications. That means most pods should not manage ankle fractures as is could be an unrecognized pilon (most pods are not trained to handle). Probably shouldn’t be allowed to do a TTC. What if the tibia cracks while reaming a nail? Most pods can’t fix that. Calcaneal osteotomy? What if there is a complication… most pods are not trained well enough on Calcaneal fracture management techniques.

These are all arguments with the same substance as the ones against admission. If you don’t like the arguments above…then stop bashing admissions.

The point is don’t take on anything you cannot handle.

The problem with this entire post is that you probably hold a job that's relatively close to where you trained. Therefore you have NEVER been exposed to the rules and regulations podiatrists face in other regional areas. Remember each state scope is different which breeds different interpretations of what podiatrists should and should not be doing in the eyes of MD/DO.

This is just another hypothetical scenario that really has no merit.

The reality is hospitalists are medical doctors who's sole purpose is to manage patent's medical problems in the hospital. That is their only job. They should be used for all admissions. If they refuse you should just escalate it to the director of their service. I promise that would resolve that issue.

99.95% of podiatrists are uncomfortable medically managing anything.

Even if you felt confident enough to medically manage your patients the issue is that this is not a reasonable option in a lot of states where the rules and regulations and/or scope is rather conservative for podiatry. If something happened you wouldn't have one leg to stand on in the eyes of your hospital's review board therefore why even put yourself in this situation? Remember that nurses also manage your patient in the hospital too. Most nurses are hypersensitive to being thrown into a bad patient outcomes or complication. They will contact the hospitalist behind your back or complain to their nursing supervisor if they disagree with your management because you are a podiatrist. Don't underestimate the nurses who can be rather two faced.

We might have been able to make strides in medical management if each state had the SAME scope but that is not the case therefore the definition of podiatry will continue to be vague, misinterpreted, misunderstood, etc.

As for your surgery scenario. I agree. Don't do the case if you can't manage the complications. But in reality that is not the case. Everyone will tackle whatever they can to make a buck. Then when it goes south they will call up their well trained DPM buddy.

 

[Feli]

I just let everyone do what they're good at...

I let Pcp manage gout, let Endo and Rheum do DM or RA meds before/after surgery, let Peds or Pcp clear pts pre op, let Vasc do any major eval & tx, let ER stabilize and send to office or floor if at all possible.

It gets your name out to refer to IM or etc, ppl know you're not a cowboy, C.Y.A. and more per hour sticking mainly to own specialty if PP, etc. Heybrother and Cuts make some good points about risk/reward. I think the main risk is stepping on toes of refer docs or consuming your time that is be$t in the office.

There are really no right and wrong answers... mostly a training and facility and how much time you have thing. Every situ is unique.

 

[msion]

I think it's lack of time.
Most podiatrists practice in a group/supergroup, from time to time get consulted to manage foot/ankle problems in the hospitals. They will need to drive to the hospital before or after clinic, write their consultation notes, do the cases, write an Op note and then maybe a progress note. And then sign off.
Most won't have the time to write the discharge/SNF transfer orders and the DC summary in the mid of their clinic day while the patient still sits in the hospital. Or talking with case managers on what to do as all SNFs declined the transfer request due to poor insurance. Or signing off on a KCI VAC form before discharge. Let alone answering RN calls later in the night about "Patient is hypertensive, do you want me to start the hydralazine..." "Patient is requesting for Percocet again, but it's not due until 2 hours later."

I am comfortable being a consultant because that way I can utilize my time more efficiently.

 

[icebreaker32]

Admitting for ego and added scope and adding medicine as a consultant in years past is different than it is now. You could wait to do stuff until Monday or after clinic most more often than not. With hospitalists at most hospitals, many 24/7 there are expectations for doing things quicker now, that is just the way it is. By giving over control (if control is even an option at your hospital), yes occasionally you will have a patient discharged to home health you were insistent needed LTAC or SNF or wanted to see one more time before being discharge, You can most often make the call on admit and discharge on your own patients with the hospitalist if the patient is otherwise stable. If family practice can live with giving over complete control to the hospitalists, we should be able to give over a little control, which also makes sure you are not adding unneeded liability and paperwork. There are very few settings it makes sense to be the admitting physician as a podiatrists now. Soon patients will be able to log on and read all their hospital progress notes and labs, imaging results etc in real time while in the hospital. Do you really want the added liability and have the time to make sure every consult and test ordered was done in a timely fashion and nothing was missed completely? I found it easier to work with hospitalists than admitting on my own in the past and making sure their PCP put an H&P on the chart in a timely manner before I could go to surgery.

Hospital and surgery center bylaws are all over the place with podiatry and the fine details for admitting patients to the hospital and for outpatient surgery. The only thing that frustrated me was that most facilities required a H&P from their PCP for elective surgery. I had no problems for an ASA class II or III patient, but felt it was unnecessary for a true ASA class I patient. It is a hard thing to enforce though, either you need an H&P from a pcp, or you do not as a podiatrist and bylaws. Most other specialties only bothered for medical clearance on ASA III patients.

 

[diabeticfootdr]

In academic settings it’s more common. And there are other benefits to consider with being an admitting service vs a consulting service.

Consultants make recommendations and the admitting team makes the decision on whether to accept the recommendations. For example, if ID makes some recommendations that aren’t practical (i.e. continued admission for 6 weeks for IV antibiotics on patients with a h/o IVDA) we can override that an D/C on PO antibiotics.

Also, as an admitting service we get “credit” for the admission. Administration knows exactly how busy we are. We have a census that gets to 25-35 sometimes. Because we are a demonstrably busy service with a needy population of patients, it’s why we’re getting our own floor of the hospital in 2023.

Of course, we have family medicine manage medical issues and consult any specialists while inpatient.

 

[de Ribas]

In academic settings it’s more common. And there are other benefits to consider with being an admitting service vs a consulting service.

Consultants make recommendations and the admitting team makes the decision on whether to accept the recommendations. For example, if ID makes some recommendations that aren’t practical (i.e. continued admission for 6 weeks for IV antibiotics on patients with a h/o IVDA) we can override that an D/C on PO antibiotics.

Also, as an admitting service we get “credit” for the admission. Administration knows exactly how busy we are. We have a census that gets to 25-35 sometimes. Because we are a demonstrably busy service with a needy population of patients, it’s why we’re getting our own floor of the hospital in 2023.

Of course, we have family medicine manage medical issues and consult any specialists while inpatient.

Do podiatry docs get paid more when they admit patients and manage them as primary?

 

[icebreaker32]

No we can arguably not bill as high of a visit level as a hospitalist and once we do surgery all this is for free as the global period kicks in.

 

[de Ribas]

No we can arguably not bill as high of a visit level as a hospitalist and once we do surgery all this is for free as the global period kicks in.

Then no, thank you. Let hospitalists do their jobs and us do our jobs.

 

[PTPuser]

Do podiatry docs get paid more when they admit patients and manage them as primary?

No we can arguably not bill as high of a visit level as a hospitalist and once we do surgery all this is for free as the global period kicks in.

Lol, de Ribas you beat me to it. Was literally going to ask this. I hated my house medicine rotation and now hearing we don't get paid for it?! LMAOOOO

 

[de Ribas]

Lol, de Ribas you beat me to it. Was literally going to ask this. I hated my house medicine rotation and now hearing we don't get paid for it?! LMAOOOO

Win win

 

[heybrother]

Lol, de Ribas you beat me to it. Was literally going to ask this. I hated my house medicine rotation and now hearing we don't get paid for it?! LMAOOOO

1. Inpatient documentation rules match outpatient next year.

2. Recent coding changes within the last 2 years do allow billing for rounding / follow-up for some limited codes ie. partial/total toe amputation and deep fascial incision and drainage type procedures. However, once you touch bone you start an eternal global.

Just some food for thought.

 

[diabeticfootdr]

I’m salaried. I just focus on doing the right thing for the patient and teaching the residents and not if, or how much, I might get reimbursed from the insurance.

 

[PeaJay]

In academic settings it’s more common. And there are other benefits to consider with being an admitting service vs a consulting service.

Consultants make recommendations and the admitting team makes the decision on whether to accept the recommendations. For example, if ID makes some recommendations that aren’t practical (i.e. continued admission for 6 weeks for IV antibiotics on patients with a h/o IVDA) we can override that an D/C on PO antibiotics.

Also, as an admitting service we get “credit” for the admission. Administration knows exactly how busy we are. We have a census that gets to 25-35 sometimes. Because we are a demonstrably busy service with a needy population of patients, it’s why we’re getting our own floor of the hospital in 2023.

Of course, we have family medicine manage medical issues and consult any specialists while inpatient.

I was starting to think I am the only one working in this type of set up. Getting recognized for admission “credits” is very important. Podiatry as a service line is highly valued by hospital administrators once they realize the true volume of inpatient work podiatry can offer. Our profession often runs under the radar by undervaluing our work (no admit credit and free call). As dibeticfootdr has demonstrated, admin responds when you start demonstrating worth in their currency “admission credits”.

 

[AttackNME]

@PeaJay
What are the hospital bylaws regarding availability? If you're primary admit on septic patients, what's your setup for the day and night time? Do you have to be in-house? I'm happy to be proven wrong about being a hospitalist podiatrist and I'm curious to learn more about what you're doing and your setup. Do you sign off to someone after your call duty? Are other podiatrists within your practice group doing the same thing?

@diabeticfootdr Not a lot of podiatrists are comfortable managing inpatient stuff, I'm curious how much medical management are you and the podiatry department doing before consulting medicine? Are you adjusting insulin dosage? Changing BP meds? Ordering KUB as part of AKI workups when needed?

 

[PeaJay]

What are the hospital bylaws regarding availability? If you're primary admit on septic patients, what's your setup for the day and night time? Do you have to be in-house? I'm happy to be proven wrong about being a hospitalist podiatrist and I'm curious to learn more about what you're doing and your setup. Do you sign off to someone after your call duty? Are other podiatrists within your practice group doing the same thing?

Must be able to be in the hospital seeing the patient in 30 minutes as a requirement for being on call (all service lines in hospital). Call is 3-4 days straight. Podiatry service line is an admitting service in the hospital system. Medicine takes primary following index procedure for patients that are more complex or hemodynamically unstable or if requested (may get push back).

If patient is admitted following elective surgery podiatry is primary. This is for all podiatry providers.

There is ZERO private practice in the entire system. Rotating call between employed providers. This goes for all service lines.

I never claimed anything about a “hospitalist podiatrist”.

 

[CutsWithFury]

You guys are so gullible.

Both peajay and diabeticfootdr work in hospital programs with a ton of residents available. Give me a break. Seriously.

If we all had 10-15 residents to do our busy work we would be fine admitting more patients because the residents are doing all the consulting.

Can we come back to earth now?

 

[PeaJay]

You guys are so gullible.

Both peajay and diabeticfootdr work in hospital programs with a ton of residents available. Give me a break. Seriously.

If we all had 10-15 residents to do our busy work we would be fine admitting more patients because the residents are doing all the consulting.

Can we come back to earth now?

You just need residents and then you can join the ranks. You are not too far, we can send some to rotate.

I realize that I am in a unique position. It however is important to know what is possible. I believe the community based folks need to understand there is a different world out there. One with joint commission standards (that make crazy volume near impossible), clipboard nurses (that make efficiencies void), accessible medical records (that makes fraud less likely), and admission as a responsibility.

 

[CutsWithFury]

You just need residents and then you can join the ranks. You are not too far, we can send some to rotate.

I realize that I am in a unique position. It however is important to know what is possible. I believe the community based folks need to understand there is a different world out there. One with joint commission standards (that make crazy volume near impossible), clipboard nurses (that make efficiencies void), accessible medical records (that makes fraud less likely), and admission as a responsibility.

Nice arrogant response. Your facility is not an academic institution. It’s a community hospital system with residents. So stop with higher power yammering.

If you are going to come on here and speak like this is accepted or normal sorry I’m going to shoot this down 100000% of the time.

It’s not a reality for 95% of the profession to have residents available to do your bidding 100% of the time. If you didn’t have residents you wouldn’t be primary. Plain and simple so stop lying.

Is it possible? Sure. Is it the normal? No. Let’s talk current accepted standards for podiatry and stop wandering down the road of what ifs.

 

[PeaJay]

More arrogant than your “I trained at level I trauma centers” plastered on numerous posts. It was meant to be cheeky. I’ll lock the thread no good is coming of this.