BILL ANALYSIS
AB 932
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Date of Hearing: January 13, 2004
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Lou Correa, Chair
AB 932 (Koretz) - As Amended: January 8, 2004
SUBJECT : Podiatric medicine: scope of practice.
SUMMARY : Makes substantive changes to existing law regulating
the practice of podiatric medicine. Specifically, this bill :
1)Deletes the prohibition against a podiatrist doing any
amputation.
2)Permits a doctor of podiatric medicine who is ankle certified
by the California Board of Podiatric Medicine (Board) on or
after January 1, 1984 to do the following:
a) Perform surgical treatment of the ankle and tendons at
the level of the ankle pursuant to statutorily authorized
locations where the doctor of podiatric medicine has
surgical privileges.
b) Perform services under the direct supervision of a
physician and surgeon, as an assistant at surgery, in
surgical procedures that are otherwise beyond the scope of
practice of a doctor of podiatric medicine.
c) Perform a partial amputation of the foot no further
proximal than the Chopart's joint.
3)Prohibits a doctor of podiatric medicine from functioning as a
primary surgeon for any procedure beyond his or her scope of
practice.
4)Updates the statutory reference of "podiatrists" to "doctor of
podiatric medicine."
5)Prohibits a doctor of podiatric medicine from performing an
admitting history and physical examination of a patient in an
acute care hospital where doing so would violate the
regulations governing the Medicare program.
6)Increases the requirement for satisfactory completion of
postgraduate podiatric medical and podiatric surgical training
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from one year to two years. These requirements include:
a) Evidence of successful completion of training that must
be submitted directly to the Board by the sponsoring
institution.
b) Postgraduate podiatric medical and podiatric surgical
training that must be done in a general acute care hospital
and be approved by the Council of Podiatric Medical
Education.
7)Requires an applicant for a certificate to practice podiatric
medicine to pass an examination in the subject areas required
by statute, including:
a) Requiring a passing score on the National Board of
Podiatric Medical Examiners Part III examination.
b) Requiring, as of July 1, 2005, a passing score one
standard error of measurement higher than the national
score until such time that the National Board of Podiatric
Medical Examiners recommends a higher passing score.
8)Directs the board, in consultation with the Office of
Examination Resources of the Department of Consumer Affairs,
to ensure that the Part III examination fully evaluates the
entire scope of practice established in statute, including
amputation and ankle procedures.
9)Makes other technical, clarifying changes.
EXISTING LAW :
1)Defines "podiatric medicine" to mean the diagnosis, medical,
surgical, mechanical, manipulative, and electrical treatment
of the human foot, including the ankle and tendons that insert
into the foot and the nonsurgical treatment of the muscles and
tendons of the leg governing the functions of the foot.
2)Specifies that no podiatrist shall do any amputations or
administer an anesthetic other than a local anesthetic.
3)Permits surgical treatment of the ankle and tendons at the
level of the ankle by a doctor of podiatric medicine that was
certified by the Board on and after January 1, 1984.
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4)Specifies that surgical treatments administered by a
podiatrist concerning the ankle and tendons governing the
functions of the foot shall be performed only in the following
locations:
a) A licensed general acute care hospital as defined by
existing law.
b) A licensed surgical clinic, as defined by existing law,
if the podiatrist is granted surgical privileges by the
surgical clinic, including privileges to perform surgery on
the ankle.
c) An ambulatory surgical center that is certified to
participate in the Medicare program of the federal Social
Security Act, if the podiatrist is granted surgical
privileges by the surgical clinic, including the privilege
to perform surgery on the ankle.
d) A freestanding physical plant housing an outpatient
surgical clinic of a licensed general acute care hospital,
if the podiatrist is granted surgical privileges by the
surgical clinic, including the privilege to perform surgery
on the ankle.
5)Defines "freestanding physical plant" to mean any building
that is not physically attached to another building where
inpatient services are provided.
FISCAL EFFECT : Unknown
COMMENTS :
Purpose of this bill . According to the author, the Podiatric
Practice Act (Act) has not been significantly amended with
respect to scope of practice since 1983, when the Legislature
recognized that podiatrists should be specifically authorized to
treat the ankle as well as the foot. It has been over 50 years
since any other significant change. While there have been some
minor changes to various provisions of the Act, nothing has been
done to modernize the Act's provisions to reflect contemporary
podiatric medicine, training and practice. The author states
that the provisions of this bill would modify ambiguous and
outdated statutes in existing law regulating the scope of
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practice of podiatry. This bill would authorize podiatrists to
continue to practice in areas of podiatric medicine where they
have consistently demonstrated competence in providing effective
and quality healthcare to their patients. The author maintains
that the provisions of this bill modify existing statutory
language regulating the practice of podiatry that are unclear or
limit the ability of podiatrists to provide effective, quality
healthcare to their patients.
Partial foot amputations . Existing law provides that "No
podiatrist shall do any amputation?." Since 1983, however, the
Board of Podiatric Medicine (which supports this bill) has
interpreted this language to prohibit amputations of the entire
foot, and has explicitly authorized licensed podiatrists to
perform lesser surgical procedures other healthcare
practitioners might interpret to mean "amputation." These
surgical procedures are typically administered to remove dead or
diseased tissue from a patient's foot that would otherwise
threaten a more serious amputation. A podiatrist's goal when
performing necessary surgical procedures on patients is to save
the patient's foot or lower limb, thus allowing the patient to
remain independent of any prosthetic or artificial device.
The Board believes that debridement (surgical excision of dead,
devitalized, or contaminated tissue from a wound) with plastic
repairs has been and continues to be the treatment for these
disease processes. This position has never been challenged in
the courts. Also, staff counsel for the California Medical
Board and the Board both concurred, in 1993, that the term
"amputation" is not a legal term but a medical term referring to
many different types of surgical procedures.
According to the Board, podiatrists are recognized in many
facilities throughout the state as the experts in the care and
preservation of the diabetic foot. Podiatrists prevent and
minimize necrosis through conservative care. They perform
amputation procedures as necessary to preserve healthy portions
of the foot and leg, mobility, and quality of life. Literal
interpretation of current law, reflecting language written in
1921 to regulate chiropodists, would disrupt diabetic foot care.
Medical staffs refer this work to podiatrists because it is one
of the things podiatrists do exceedingly well.
Doctors of podiatric medicine are recognized as foot and ankle
specialists. According to supporters of this bill, when a
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podiatrist has trained as a surgeon and meets the training and
competence standards sufficient to obtain surgical credentials
at hospitals, there is no reason to preclude a podiatrist from
performing surgical procedures on the foot and ankle. According
to the board, it has recognized to a significant extent that
many procedures that some people would categorize as
"amputation" are not what the statute was aimed at, and are well
within the scope of practice and expertise of trained licensed
podiatrists.
Assisting in non-podiatric procedures under supervision of a
physician . The California Podiatric Medical Association
indicates that it is common practice for a surgeon to ask
another licensed doctor to participate in a surgical procedure
that is clearly outside of the physician's scope of practice.
Even non-surgeon physicians engage in this type of activity,
particularly when one of their patients is undergoing a surgical
procedure.
Existing law specifically authorizes graduates of podiatric
medical schools, while completing their residency, to
participate in non-podiatric procedures under the direct
supervision of a licensed physician and surgeon. However,
existing law is silent when podiatric medical residents complete
their residency. Nevertheless, many physicians and surgeons ask
licensed podiatrists to assist them, and as trained surgeons,
podiatrists provide highly skilled services that may not
otherwise be available to the primary physician and surgeon.
This bill would expressly authorize podiatrists to engage in
surgical procedures as an assistant at surgery, in surgical
procedures that are otherwise outside the scope of practice of a
doctor of podiatric medicine. Podiatrists would only be able to
perform these services in licensed or accredited facilities, and
only under the direct supervision of a physician and surgeon
requesting the assistance.
The Board is frequently asked if podiatrists may assist MDs in
surgery. Podiatrists may practice as authorized by their
license and provide any service for which a license is not
required. Because podiatrists generally have greater surgical
training than unlicensed surgical assistants, physician
assistants, and nurses, health facilities may wish to utilize
their services. The Board encourages inter-professional
teamwork for the benefit of the patient.
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With respect to surgical assistance on procedures above the
ankle, supporters of this bill state that this is a practice
that is specifically authorized (where supervised by a qualified
physician) for podiatric residents. (See B&P Code Section 2475,
subdivision (a).) In addition, the federal government
acknowledges that this practice is an acceptable and valuable
treatment in the Medicare program. The Board recognizes that it
is acceptable. Furthermore, malpractice insurance companies
provide to California-licensed podiatrists a specific policy
rider to cover this activity for those podiatrists who choose to
engage in the practice. Also, according to podiatrists, many
hospitals and peer reviewed surgical facilities do not have
concerns with physician-surgeons requesting podiatrists to
provide surgical assistance. The problem, similar to the
"amputation" issue, is that the current statute is vague on this
issue as well. A hospital or peer reviewed surgical facility
cannot simply look to the statute and obtain an easy answer to
the question: "Is this lawful?" Instead, these facilities are
forced to engage in the nebulous debate about whether or not a
practice common in many peer reviewed healthcare facilities
should be allowed.
Support . Additionally, proponents state that the provisions of
this bill will enable licensed podiatrists to better practice
their abilities in light of their rigorous and extensive medical
and scientific education and training. This bill will enable
podiatrists to continue their critical role in providing safe,
high quality and cost-effective care to their podiatric
patients. This bill codifies existing practices and, in some
respects, expands a podiatrist's scope of practice authority to
areas that podiatrists are educated and trained to provide safe
and effective treatments for many patients.
Opposition . The January 6, 2004 amendments to this bill make
substantial changes to the bill's scope and are the product of
extensive negotiations between proponents and opponents. These
amendments have removed almost all opposition to this bill. The
California Medical Association, the California Orthopeadic
Association, and the California Society of Dermatology and
Dermatologic Surgery have removed their opposition to this bill.
The only remaining opposition to the latest version of this
bill is the California Association of Physician Organizations,
and it is unclear if they are aware of the negotiated settlement
on the current amendments.
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Previous legislation . AB 2728 (Washington), introduced in 2002,
would have added outpatient settings, meeting certain criteria,
to the list of locations where surgery of the ankle and tendons
may be performed. AB 2728 also would have deleted the existing
statute prohibiting podiatrists from performing amputations. AB
2728 authorized podiatrists to perform trans-metatarsal or
mid-foot amputations as an assistant surgeon, and would have
allowed podiatrists to treat superficial conditions of the lower
leg that are related to or part of a condition of the foot or
ankle, in specified facilities and if certain conditions were
met. AB 2728 was referred to the Assembly Business and
Professions Committee but was never heard.
REGISTERED SUPPORT / OPPOSITION :
Support
California Podiatric Medical Association (sponsor)
Board of Podiatric Medicine
Burbank Podiatry Associates Group
California Association of Nurse Anesthetists
California Labor Federation, AFL-CIO
California Latino Medical Association
California Federation of Teachers
Central Labor Council of Contra Costa County, AFL-CIO
Congress of California Seniors
Foot Health Center of Northridge
International Alliance of Theatrical Stage Employees, Moving
Picture Technicians, Artists, and Allied Crafts of the United
States
Kaiser Permanente
Orange County Musician's Association, Local 7 of the American
Federation of Musicians
Orinda Podiatry Group
Palo Alto Medical Foundation
Paper, Allied-Industrial, Chemical and Energy Workers
international Union, AFL-CIO
Tower Nephrology Medical Group
University of Miami School of Medicine
Utility Workers Union of America, AFL-CIO, Local 132
West Torrance Podiatrists Group, Inc.
Individual Podiatrists
Opposition
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See "Opposition" discussion in above Comments.
California Association of Physician Organizations
Analysis Prepared by : David Pacheco / B. & P. / (916)
319-3301