Information Statement

Surgical Care of the Lower Extremities

This Position Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.

The American Association of Orthopaedic Surgeons (AAOS) believes that all patients should have access to high quality, comprehensive musculoskeletal care by providers who have met appropriate and uniform standards for education, licensure, training, and certification.

The AAOS supports efficient delivery of healthcare services by teams comprised of individuals performing patient care consistent with their various levels of education, training, certification, and credentialing.

The AAOS believes there should be one uniform standard for patient care to which all providers are held.

Patients will be best served if all providers of surgical care of the lower extremities meet the uniform education, training, and certification standards established by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties.

Medical Education and Licensure

The medical profession has established standards for education, training, and certification in an attempt to ensure appropriate and safe patient care. Medical school educational standards are determined by the Liaison Committee for Medical Education (LCME), and medical school graduates affirm their mastery of the curriculum by passing the United States Medical Licensing Examination (USMLE). This multi-part professional exam is sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). Physicians with the Doctor of Medicine (MD) degree are required to pass this examination before being permitted to practice medicine in the United States. The USMLE assesses a physician's ability to apply knowledge, concepts, and principles, and to determine fundamental patient-centered skills that are important in health and disease and that constitute the basis of safe and effective patient care.

Residency Training and Board Certification

The next step for licensed physicians is graduate medical education called residency training. This training is in a specialty area of medicine or surgery and standards for residency are determined by the Accreditation Council for Graduate Medical Education (ACGME).

During the five years of orthopaedic surgery residency training, medical school graduates develop diagnostic and technical surgical skills in all areas of musculoskeletal care, including knowledge of the body’s endocrine and circulatory systems that affect the musculoskeletal system. Some orthopaedic surgeons develop specialized skills in the care and treatment of the foot and ankle.

Orthopaedic Surgery Board Certification

Upon completion of residency training, medical doctors affirm mastery in their specialty area by taking and passing an examination developed and administered by one of the twenty-four member boards of the American Board of Medical Specialties (ABMS). The American Board of Orthopaedic Surgery (ABOS) is the only certifying board recognized by the American Board of Medical Specialties (ABMS) to certify medical doctors as orthopaedic surgeons. Since 1960 the ABOS has required five years of post-graduate residency education. Doctors of Osteopathic Medicine (DOs) have an equivalent track of nationally recognized uniform residency training standards and board certification exams. The American Osteopathic Board of Orthopedic Surgery (AOBOS) is the only board that certifies DOs as orthopaedic surgeons.

Doctors of Podiatric Medicine (DPMs) and Podiatric Education

Podiatrists (DPMs) provide medical and surgical care of the foot and ankle and have long been considered limited licensed practitioners of foot care. While colleges of podiatric medicine have taken steps to develop educational curriculums that parallel medical schools and suggest equivalency, podiatric education does not yet meet the nationally recognized uniform standards for medical (MD and DO) education and podiatric graduates are not eligible to take the USMLE to attain an unlimited license to practice medicine.

Expansion of Podiatric Scope of Practice

In recent years in the United States the podiatric community has pushed for expansion of the podiatric scope of practice through state legislative, regulatory and judiciary channels. The stated goal of the American Podiatric Medical Association is by 2015 to have “podiatrists being defined as physicians who treat patients in the physician’s specialty without restrictions.” This will require that “state laws need to be changed to include podiatric physicians in the physician scope of practice within a uniform scope of practice. This process will require significant legislative and regulatory change.”¹

In many but not all states, the practice of podiatry has been expanded to include more complex operative treatment of the ankle and lower leg. Unfortunately, in most of the states with expanded podiatric scope, all DPMs are legally allowed to surgically treat ankle and lower leg pathology, including DPMs without post-graduate residency training, those with non-surgical post-graduate residency training, and those with no or limited training in ankle surgery.

Podiatric education and training today is variable, and a number of boards certify in specific areas of podiatry with standards that continue to evolve. The varying requirements have resulted in a range of limited licensed practitioners with varied training and skills. This, coupled with the continued push to legally expand podiatric scope of practice outside of accepted medical education and training standards, creates confusion for patients and the public, including state government officials responsible for oversight for scope of practice and hospitals with responsibility for credentialing and privileging medical providers.

It is the position of the American Academy of Orthopaedic Surgeons that:

1. Nationally recognized, uniform educational standards widely accepted by the medical profession are an essential means of educating and certifying medical practitioners to provide safe and effective patient care and are essential to maintain the public trust.
2. Patients will be best served if all providers of surgical care of the lower extremities meet the uniform education, training, and certification standards established by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties.

The AAOS calls on all interested parties to work toward this single, uniform standard.

Reference

1. Vision 2015: A Plan to Obtain National Recognition of the Podiatric Physician. American Podiatric Medical Association, New Member Resource Letter. 1-2, August 2007, http://www.podiatry.com/images/eZines/PracticePerfect/192/Vision2015.pdf

March 2000 American Association of Orthopaedic Surgeons.
Revised September 2000, June 2009 and June 2012.

This material may not be modified without the express written permission of the American Association of Orthopaedic Surgeons.

Position Statement 1148

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