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PARITY

The Path to Parity

71 Here are some thoughts on clarifying the confusion of degree vs. license vs. scope of practice.

BY JON A. HULTMAN, DPM, MBA IN COLLABORATION WITH THE CALIFORNIA PODIATRIC MEDICAL ASSOCIATION BOARD OF DIRECTORS AND THE CALIFORNIA APMA DELEGATION

n 1966, as a prospective stu- . Both medical and surgical was predicted forty years ago! dent, I visited several podiatric care were covered by third-party In 1966, after learning about the medical schools, asking many payers. At that time, it was manda- that DPMs were receiving questions throughout my tour. tory that an MD complete a one-year at the podiatric medical schools, in My first question at each was, program in order to re- residency programs, and in the “real I“What is the difference between the ceive a , while to re- world” practice of podiatric medi- education and training of a medical ceive a podiatric license, a one-year cine and surgery, the thought never and that of a ?” The residency program was optional in occurred to me that DPMs would response was that they were almost the same, with the first two years of basic education being identi- cal. I was told that the primary differ- “A society grows great when old men plant trees whose ence lay in the clinical years during shade they know they shall never sit in.” which the podiatrist would begin training sooner than a med- —Greek Proverb (sometimes attributed to Aristotle) ical doctor. My second question was, “Upon completion of education and training, what are the differences in most states. It was not many years not be considered or that clinical practice between a podiatrist before a one—or even two-year— they did not already have “parity.” and a medical doctor?” Again, the residency program was required for It turns out that, as a student, I had response was that they were quite podiatric . With this expan- little understanding of the difference similar. sion of training, many podiatric phy- between a limited and a universal The schools’ “tour guides” in- sicians in practice and in leadership license, between a doctor and a phy- formed me that, similar to an MD, were predicting that the education sician, or of being a and ankle a podiatrist was able to diagnose and training between DPMs and specialist as contrasted to practic- and treat, held pharmaceutical and MDs was becoming so similar that ing a specialty of (such as X-ray licenses, could admit it would not be long before DPMs ). to , and could perform foot would be “given” MD degrees. This Illustration by © Skypixel | Dreamstime.com with lettering stylized Christopher Donoghue Continued on page 72

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Path to Parity (from page 71) and would never want a DPM’s authority to write a prescrip- an MD degree. The end result is dis- tion for clearly within Limited License agreement and inaction as to how his/her scope and DEA licensure. If one were to ask an objective this goal of parity should be accom- A UCLA once said to lay person to guess the plished, and this is because the pri- me that he felt podiatrists were over- of an individual who independently mary focus and debate has been on trained. I commented back that we diagnoses and treats patients, has a degrees rather than on licensure. were either over-trained or under-li- full pharmaceutical license, admits censed. A limited license limits a patients to hospitals, performs H&Ps Grasping the Distinction DPM’s ability to practice to the level and , works A stumbling block on the path of his/her education, training, and as a member of a medical team, and to achieving our goal is that many experience. At the same time, his/ has full responsibility for the post-op- DPMs do not fully grasp the distinc- her education and training are not erative care of patients, I think most tion between holding a limited li- “limited.” A plenary license enables would say that that person was a cense and holding an unlimited one. a doctor to practice within the level physician practicing a specialty of medicine. Unfortunately, this person guess- Today, DPMs are held to the same standards as any ing may be mistaken because the one who might actually be being other medical or surgical specialist, but they are not described may be a non-physician, allied practitioner who is an accorded all the rights and privileges of one. optional provider under Medicaid—a podiatric physician. It turns out that 72 this classification of practitioner does Many comment, “Why would a po- of his/her education, training, and not have a medical license and is not diatrist need a universal license? Are experience. Because education, train- considered to be practicing a spe- they going to be delivering babies or ing, and experience are life-long pro- cialty of medicine; instead, s/he has doing brain ?” This confu- cesses for physicians, scope should a limited license, his/her specialty sion and lack of consensus regarding not be limited by one’s license, but is not recognized by the American “degree” and “licensure” is where rather, by one’s training, education, Board of Medical Specialties, and the discussion and progress towards and experience. Currently, a DPM his/her scope of practice is not deter- parity has stalled for over forty years. cannot write a physical pre- mined by training and education, but At the same time, we actually have scription to rehab a hamstring strain rather, by statutes written by legis- reached consensus on several im- for a even though that pa- lators—most of whom are not in the portant issues that can lead to par- thology may have a direct effect on healthcare field. ity. I think every DPM would agree the patient’s gait (a condition that Today, DPMs are held to the that we are physicians and that we is within a DPM’s license to treat); same standards as any other med- have earned the right for parity based however, if this same treatment re- ical or surgical specialist, but they on our training, education, and pa- quest were signed by a dermatolo- are not accorded all the rights and tient responsibilities in the practice of gist, it would be recognized. privileges of one. We have been say- medicine and surgery. The difference between DPMs ing for forty years that because our All physicians hold plenary (un- and MDs and DOs is not knowledge training and education are so similar restricted) licenses, regardless of de- or lack thereof; it is that DPMs have to that of MDs and DOs, “It won’t be gree or specialty. Whether we choose a limited license and the others have long before we would achieve pari- to recognize it or not, the way that a plenary, or unrestricted, license. ty.” While many leaders in medicine today’s graduates practice podiatric A DPM discussing diet and walking now recognize that the coursework, medicine and surgery is indistinguish- programs with patients for the pur- clinical training, and competencies able from that of any other medical pose of improving their overall car- of the DPM “end product” are almost specialist, and they have the same dio-vascular health, reducing their indistinguishable from those of MDs patient responsibilities; however, risk of stroke, improving their blood and DOs, one of the things that has they do not have the same rights and pressure, or impacting their weight actually slowed our process towards privileges because they hold limit- loss (which will help the national parity is confusion and disagreement ed licenses and are considered to be obesity epidemic and reduce the pa- among podiatric practitioners them- non-physicians. Not only does this rameters for developing ) selves regarding just what parity is designation keep DPMs as “optionals” would not be reimbursed for that and how to achieve it. Some think in Medicaid, it is the basis for pay dis- consultation, whereas an ophthal- that being referred to as a physician crimination, a lower rank than MDs mologist can be reimbursed for such is the same as being a physician. and DOs in the military, lower pay at consultation. Again, the difference is Some believe the only way to achieve the VA, and a host of other discrim- that the DPM does not hold a plenary parity is through the MD degree; yet, inatory practices—including the fact license and is, therefore, not judged others say that they are proud to be that some still question Continued on page 76

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Path to Parity (from page 72) tion or by the American Academy surgical care; however, they choose of Orthopedic . Interesting- to limit their medical and surgical by his/her knowledge or expertise ly, the following year, the Ameri- scope of practice to their training, ed- but, instead, by the type of license s/ can Medical Association created the ucation, and experience, and hospi- he holds. Scope of Practice Partnership to help tals limit their privileges in the same Even MDs and DOs who refer pa- its state medical associations fight way. Opthalmologists are licensed tients to DPMs are confused about scope battles, and this was followed to deliver babies and perform foot their education, training, and licen- by the AMA “Truth in Advertising surgery, but for good reason, they sure because they often have received Initiative”—put forth as a “patient do not. An example through which biased and incorrect information re- safety measure” to “clear up” public to view this “choice to limit scope” garding the actual training, education, confusion regarding just who was a when holding a universal license is to and experience of DPMs. One reality physician and who was not. consider that I am a licensed DPM in that medical doctors are not confused Fortunately, this initiative empha- California and also hold an ankle cer- about is that they find podiatric physi- sized the training, education, and ex- tificate. I am licensed to perform any cians to be indistinguishable from MD and DO residents during their train- ing years. Medical practitioners also find that their experience working CPMA’s definition of parity is not focused on degree with practicing podiatric physicians because parity does not require a degree change; is no different from that when dealing with any other medical or surgical rather, it requires a licensing change. specialist. It is difficult for our nay- sayers to support the argument that 76 we are a profession “separate” from perience of physicians—comparing it type of ankle surgery, but I did not medicine—such as , acu- to that of non-physicians. There was receive the training and education to puncture, or —as opposed a flaw in the execution of this initia- perform ankle surgery in my residen- to the reality that we practice allo- tive: the hours of clinical training re- cy; therefore, I do not perform ankle pathic medicine in the same way as quired of DPMs depicted in the initia- surgery, and no would give other specialties of medicine such as tive were not accurate. This opened me those privileges if I applied for ophthalmology or otolaryngology. In the door for us to discuss with orga- them—even though I could legally order to achieve true parity, we need nized medicine the actual education, perform them. to define and come to agreement as to training, and experience of podiatric Still, at a later time, I could re- what parity is. The entire profession physicians which, as we were able ceive the relevant training and edu- then needs to get behind achieving to confirm, were not identical, but cation and could then perform ankle this one goal of parity. We need to were quite similar to those of MDs surgery without needing to change progress from talking to taking the and DOs. The original Vision 2015 the law. Another example: many relevant action that can actually ac- has now transformed into the Path of today’s DPMs are well trained complish this goal. If we continue to to Parity. To achieve true parity in in wound care; however, a DPM argue degrees, or believe that those the near future, there can no longer in California can treat an ulcer at who are seeking parity are not proud be confusion or disagreement among the ankle—but not on the leg, even to be DPMs, then we will continue to DPMs as to whether the issue is de- though s/he is probably more ca- “bicker” and never achieve parity. gree, licensure, or scope of practice. pable and better trained than most Ten years ago, the profession de- MDs to treat that ulcer. To gain this Resolution 2-15 fined parity as being designated as one privilege, a DPM would need to In 2005, the APMA House of Del- physicians, and having unrestricted change the law because s/he does egates passed Resolution 2-15 which licensure. Unlike seeking an MD de- not have a plenary license, and this contained the following language: gree—which would require podiatric would involve convincing attorneys “Resolved that the American Podi- medical schools to “convert” to med- and other non-physician members of atric Medical Association (APMA) ical schools—this goal is achievable the legislature, instead of simply doc- commit itself to achieving the goal through a unified strategy with our umenting his/her training and educa- by 2015 of podiatrists being defined existing schools. What is critical to tion as is the process through which as physicians who treat patients in understand is the difference between all other physician specialties gain the physician’s specialty without re- degree and licensure. MDs and DOs new privileges. strictions.” The overall mission of have different degrees but they are this resolution was that podiatrists be both recognized as physicians in all CPMA’s Definition of Parity universally accepted and recognized relevant statutes because they both CPMA’s definition of parity is not as physicians, consistent with their hold the same license—a plenary, or focused on degree because parity does education, training, and experience. unrestricted one. Because they have not require a degree change; rather, This resolution did not go unnoticed a plenary license, they can “legal- it requires a licensing change. Being by the American Medical Associa- ly” provide any type of medical or Continued on page 78

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Path to Parity (from page 76) ity because it is usually in name at a number of California residency only and not in licensure. The only programs. Our goal is the attainment a physician and holding a plenary, or way to get true parity is to cross the of a Physicians and Surgeons Certifi- universal, license is based on training, goal line and reach the point where cate, which is the same unrestricted education, and experience. The edu- MD=DO=DPM, with these three de- license that MDs and DOs hold in cation and training of MDs and DOs is grees all holding the same univer- California. This is the natural exten- not the same, but the common sal license, regardless of specialty or sion at the state level of the national work that makes their training and ed- focus of practice. goal of Vision 2015 and the Path to ucation comparable, or equivalent, is Parity—that goal being that “Podia- what makes them physicians and qual- Three Degrees, Same License trists be defined as physicians who ifies them both for plenary licensure. The concept of three degrees treat patients in the physician’s spe- In every statute, both state and federal, that all receive the same license is cialty without restrictions.” MD = DO, and each is considered to one that is gaining traction and mo- We have been fighting scope be a physician with the same rights mentum in the medical communi- and discrimination battles forever. and privileges. DPMs are, instead, lumped with allied health, which in- cludes all limited licensed practitioners. At the same time, only one of this A successful outcome is achievable group of limited licensed practitioners in the near future through use of this collaborative has comparable training and education to that of MDs and DOs—the DPM. process that involves all stakeholders agreeing to, and Today, DPMs have four years of podiatric and three working towards, the same goal. 78 years of residency, including all med- ical and surgical rotations, side-by- side with MDs and DOs—and with ty because today’s podiatric medical We have won many of them, but we the same level of responsibility and education and surgical training are never win the war because we have the same expectations. Throughout observable and objectively measur- been focused on symptoms rather training, DPMs, MDs, and DOs all able, and are something that can be than on the underlying cause—which have a plenary license. Imagine, a supported by organized medicine as is that we are not considered to be DPM in training has a universal li- being equivalent. This was made par- physicians and do not have the same cense, but upon completion of train- ticularly evident at the recent APMA license as MDs and DOs. Reaching ing, his/her license is “down-graded” House of Delegates at which Paul this goal will not require another forty to a limited one because s/he is not Phinney, MD, the immediate past years of fruitless effort with no end in “actually” a physician. In spite of the president of the California Medical sight. A successful outcome is achiev- curricular changes and the expanding Association (CMA), spoke about the able in the near future through use of residency training programs from Physician and Surgeons Joint Task of this collaborative process that in- “optional” to required three-year, Force in California. It is through this volves all stakeholders agreeing to, comprehensive programs (perhaps, collaborative process that CPMA is and working towards, the same goal. even followed by a ), to- working towards our goal. Instead If this outcome is achieved in just one day’s DPM graduates still receive the of “going to war” over what could state, it is something that could sub- same limited license that I received be viewed as a major “scope expan- sequently be duplicated in any state. 45 years ago. sion,” CMA is supporting—even ex- Ultimately, parity is not dependent on While considers us phy- pediting—the process, based on clear a degree change; it is achieved at the sicians for purposes of reimburse- demonstration from us that podiat- moment when DPM=MD=DO—the ment, we are in a “lesser” category ric physicians have comparable ed- moment we all hold the same un- than MDs and DOs, and we are still ucation and training to that of MDs restricted (plenary) license with the fighting to be physicians in - and DOs. This “demonstration” is the same rights and privileges associated aid. In fact, no matter where you path to parity that California is taking with that license. PM look, no matter how much progress through the efforts of our Physicians has been made—even under the and Surgeons Joint Task Force. Dr. Hultman is Exec- best of circumstances—DPMs are al- This group is made up of repre- utive Director of the ways slightly “less than physicians.” sentatives from the California Med- California Podiatric Moving towards parity is like Zeno’s ical Association, The California Or- Medical Association, practice management paradox. If we keep getting halfway thopedic Association, the Osteopath- and valuation consul- to the goal, we get closer and clos- ic Physicians and Surgeons of Cali- tant for Vitera Health- er—but never cross that goal line. fornia, and the California Podiatric care Solutions, and Even in those states in which DPMs Medical Association. Site visits have author of The Medical are listed in statutes as physicians, been conducted at the two California Practitioner’s Survival in most cases, this is not true par- podiatric medical schools as well as Handbook (available at www.mbagurus.com).

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