Is podiatry a profession?
Is there a need for a Podiatrist and Chiropodist in Worcester and Droitwich Spa?
Podiatry as a health related profession has experienced an evolutionary journey from its humble origins, to the current scientific and knowledge based approach. Expansion into a variety of clinical avenues in recent years has taken place, both in public and private sectors, which has demonstrated the versatility of the discipline. In order to discuss whether podiatry is a profession, we must define both the terms ‘podiatry’ and ‘profession’. Key events will be delineated which have steered the course of professional development, with a historic chronology of the pivotal bodies that have directed and governed the podiatry profession over the decades in the UK, and the subsequent changes that have ensued. Confinement of the podiatry profession by the medical profession will also be discussed and underpinned utilising the Weberian concept of social closure. Podiatry will be shown as that of a legitimised, educated and clinically diversely professional group, as it responds to the needs of the population. As proficient and independent practitioners in their own right, podiatrists will be shown to experience limitation, manipulation and on occasion, exclusion by the medical profession. More positively, a contemporary view of podiatry will be demonstrated, especially in relation to the management and treatment of the diabetic patient through inclusion in multidisciplinary teams and the extended benefits/privileges of interprofessional learning, with the specific aim of improving patient outcomes.
The definition of Podiatry has disappointingly been simplified in the Oxford English dictionary, as the ‘treatment of the feet and their ailments’ (Oxford English Dictionary, 2015). The American publication Encyclopaedia Britannica (2015) sees podiatry more robustly as the ‘medical specialty dealing with the diagnosis and treatment of diseases and disorders of the foot’. Differences in definitions however reflect the level of status, categorisation and acceptance Podiatry has in Britain and worldwide, relative to the exclusion or assimilation by the medical field.
Professionalism may be considered as a philosophy or a standard by which a person can be judged or aspire to be perceived in their behaviour or ‘ethical code’ during clinical professional practice (Burford et al., 2014:366). By definition, a profession is a group of individuals who ‘engage in political activity to gain State recognition and to develop a legal monopoly of certain activities’ (Mandy et al., 2003:13). This can be seen as an extension of social group identity, where shared knowledge, skills or attributes sets these people apart and distinguishes them from others (Hogg, 2006:111). Lester (2009:226) cites that such a collective most often are governed by a body or an association that has the right to action disciplinary procedure in the event of deviance from the rules or laws of practice. In addition, the demand for higher skill, educational attainment and continued professional development (Haywood et al. 2013), as well as the interaction between ‘competition, regulation and accountability’ (Lester, 2009:227) are seen as critical, when considering these elements that dictate a profession.
The origins of podiatry were founded in its predecessor, Chiropody. From as far back as the ancient Greeks, the word ‘kheiropodes’, was thought to have been an adaptation of a few words to mean ‘chapped feet’ (Dagnall, 1983:137). Historically, the chiropodist in the UK was qualified to treat aliments of the skin and nails of the feet but this role was to be officially extended when the Podiatry Association was founded in 1972 which saw the legitimation and adoption of local anaesthetic techniques (Brothwick, 2005:87). In 1975 the Society of Chiropodists accepted that specialists interests were developing within the profession and as a consequence, a Postgraduate Board was established which included representative from the Faculty of Anaesthesia, Podiatry Association and Royal College of Physicians to appraisal and commend educational attainments so that excellence, protection and indemnity would be maintained (Bristow and Borthwick, 2013: 2). From the end of the 1980’s the development of specialities in podiatry was thought motivated by the inception of the new degree status (Marsh, 1989: 109). Monumental change was not only in title, but also advanced the profession through the adoption of biomechanical and surgical techniques, and the use of local anaesthetics, this expanded role was though due to insufficient interest by general orthopaedic surgeons in foot surgery (Klenerman, 1991).
In 1942, the original body representing the podiatry profession was established with the title of Board of Registration of Medical Auxiliaries (BRMA) and in 1960, an act of parliament saw the Council for Professions Supplementary to Medicine (CPSM) brought into being; to provide a regulatory board for each profession they supported (Mandy et al., 2003:10). The CPSM in 2002 was subsequently replaced by the Health Professions Council (HPC), then under the pivotal Health and Social care Act of 2012, the HPC became the current Health and Care Professions Council (HCPC, 2012) which governs and regulates a variety of similar status health and care professions under its jurisdiction.
A strict code of conduct is stipulated for Podiatrists under the standards of proficiency by the HCPC (Health and Care Professions Council) to ensure ‘knowledge, skills and experience to practice lawfully, safely, ethically and effectively ….by professions...to protect the public’. (HCPC, 2015: 3-4). Podiatric professionals in the UK are expected to have a degree qualification recognised by a professional organisation, the Society of Chiropodists and Podiatrists (which also acts as a trade union) in addition to being registered with the afore mentioned Health Care Professions Council. Furthermore, under the Human Medicines Regulation of 2012, Podiatrists in the UK have claimed prescription rights to enhance their practice and provide the full complement of care to address their patients’ podiatric requirements (DoH, 2013). This is in line with neoliberal theory that patient centred care dictates the type, style and quality of the service provision (Nancarrow and Borthwick, 2005).
Historically, struggles and conflicts within and between professions have occurred in order to achieve definable parameters, and develop collective autonomous professional titles. The ‘maintenance of occupational cohesiveness’ such as in the medical profession was thought to be a primary strategy to limit access, through strict procedures and qualifying strategies, to become accepted into the specific profession that had universally elevated social standing (Mandy et al., 2003:13). Podiatry has its origins in an occupational structure that has had to adapt within and to the confinements exerted by the medical profession. Larkin (1983) discusses the limitations that the social and cultural authority of the medical profession exerts, and forwards that the podiatry profession has been regarded uniquely in terms it complementary value to medicine.
In the case of medicine, the Webarian concept of ‘social closure’ has been applied, which considers strategies of social collectives such as professions, and how they obtain and underline their status through strict criteria to the exclusion of others (Weber, 1987). Specifically, podiatry has been the recipient of such rivalry between professions, ‘largely … aimed primarily at monopolisation and the legal exclusion of competitors’ (Borthwick, 2000:13). Medical hegemony has resulted in a healthcare monopoly which subjects limitations (Dentists), exclusions (osteopathy and homeopathy) and subordination (podiatry, radiography and nursing) to a variety of professions (Borthwick, 2000:14). Fournier (2000:69) asserts that by establishing and preserving boundaries in the professional sense, provides the protection of an ‘independent, autonomous and self-contained area of knowledge’ upheld in isolation from other professionals, consumers and markets. Podiatry finally attained such status and has protected its boundary or professional title since 2010 as forwarded by the Council for Healthcare Regulatory Excellence (CHRE, 2010), with notable and significant success to the profession to include, the advent of university degree education (Borthwick, 2000:17). The hitherto failure to close the profession invited unregistered practitioners to provide services to the misperception of the general public, where quality and accountability of service provision could not be guaranteed (Farndon et al.,2002).
The medical model is considered to have an overarching influence over critical elements of education and practice within podiatry, and demands that a mechanistic approach be utilized in the consideration of illness (Mandy et al, 2003:2). Ellis (2009:16) argues that Podiatry has transitioned beyond the medical model to biopsychosocial model which is thought to empower the patient to engage patient and podiatrist to work together to ameliorate the condition that is of concern. The needs of service users as Nancarrow and Borthwick (2005:898) assert require adaptability in working activities and in service provision, therefore challenging professional hegemony.
Modernization has seen a change in policy focus, the redesign of the health service, and the extension of roles and transfer of skills in allied health professionals which were previously under the jurisdiction of the medical profession (Department of Health 2008; Boyce, 2008). With increased need for accountability, choice for patients and directives from the State through health policy, the podiatrists’ professional capacity continues to adapt and expand its parameters, whilst also reclaiming previous roles (Green et al., 2011; Nancarrow and Borthwick, 2005).
Podiatrists work within a variety of environments form the NHS, private practice, in business settings, research and education. Specialisms in Podiatry include surgery, diabetic care, rheumatology, dermatology, podopaediatrics and biomechanics and those who engage with such specialisms are considered as higher in the professional hierarchy (Mandy et al., 2003:9). It is argued however, that allied health professionals have had in some instance, informal methods of identifying professional specialisation (Larkin, 1983). Such is the case for ‘the charismatic authority’of specialist podiatrists in diabetic Multi-Disciplinary Team where ‘podiatry post specialising in diabetes care is not linked to any educational or experiential prerequisites’ (Bacon and Borthwick, 2013: 1085). This adapted role is evidence of the coexistence that can develop between medical authority and podiatry but with limited jurisdiction. The dominance of the medical profession in relation to the allied health professional persists when boundary encroachment arises is attested, as in the case of accepting prescription rights, the podiatrist was seen as a distinct challenge to medical supremacy and control (Borthwick et al., 2010).
For those podiatrists who decide to pursue training to become a podiatric surgeon, requires an undergraduate BSC (hons) degree in Podiatric Medicine; one year of clinical practice; following by a three year MSC on the Theory of Podiatric Surgery. A further three years of surgical training is required to complete the nine year podiatric surgical program. This specific academic attainment and further clinical experience, is required in order to fulfil the conditions of the Faculty of Podiatric Surgery, which parallels academically with those who are trained by the Royal College of Surgeons and The Society of Chiropodists and Podiatrists (SoCaP, 2015). However, the British Orthopaedic Foot and Ankle Society insist ‘that operative podiatrists should be titled ‘podiatric surgical practitioner’ as opposed to ‘podiatric surgeons’ (Laing, 2007: 5), reigniting the medical dominance perspective and possibly cultivating a notion of podiatry as a limited profession in the absence of medical authority.
The medical hegemony perspective is further advanced by the alignment of the podiatric and medical professions to produce an MSc in the Theory of Podiatric Surgery. This course of study is jointly validated by Society of Chiropodists and Podiatrists, the Royal College of Physicians and Surgeons of Glasgow and the Royal College of Surgeons of Edinburg (Isaac et al., 2008). Kuhlmann (2006: 221) suggests that under the modernist approach traditional forms of profession tenaciously utilise the strategies of ‘exclusion, hierarchy and demarcation’ whilst coexisting with more contemporary views of the ‘new professionalism’ with notions of transparency, collaboration and group interactions.
Chandratilake (2014: 346) discusses the benefits of a more collaborative multidisciplinary team approach in delivering health care, which provides educational opportunity by increasing interaction and exchange of information and experience, creating a ‘professionalism of health care teams’, over the professionalization of specific groups. This concept has particularly gained ground in recent times, thorough the adaption of the ‘interprofessional learning’ concept, where there is a focus on mutual learning, and a unified ‘collective identity and shared responsibility’ demonstrated, for those under the groups care. In Canada, the benefits of such an approach have been proven to help to reduce pain, improve wound management and rates of healing in those with chronic wounds (White-Chu and Conner-Kerr, 2014: 111).
The evolutionary journey for Podiatry from the outset has been demonstrated to be that of struggle, compliance and perseverance. Having defined what it is to be a profession, this has revealed the need for adaptability of knowledge, skills and behaviour by those who ascribe themselves to the role, with the additional need for support from the State, to preserve the critical features of accountability and regulation of the profession, so that the skills of the contemporary professional podiatrist may be upheld and protected. The need for interactions between groups has also been disclosed as an imperative feature of adjustment in the jostling for boundary identification and their maintenance. Elements of constraints from organisational influences, demands and limitations made by the medical profession, societal demands and the State all have been shown contribute to what defines a profession.
In conclusion, Podiatry as a profession has been shown to possess many of the numerous and critical traits of what is thought to be a professional group. Firstly, the profession has been shown to be upheld at an individual level: through a sense of ethical or moral code; possession of educational requirements of access; maintaining a legal monopoly over certain activities; continued professional development to maintain membership, as well as being accountable for professional actions. At group level, it has been shown that those of the profession engage with political activities and contribute to shared knowledge, as well as possessing the specific skills and attributes that envelop the profession. Furthermore, State recognition and protocol guided by health policy dictate professional activities, to which the professional governing body (HCPC) representing the profession is answerable. Finally, the adaptability of the profession in response to the needs of the patients has been shown to mirror the neoliberal perspective and market forces, where efficiency, responsiveness to demand and quality of service provision are thought key.
It has been shown that Podiatry has experienced continuous metamorphosis through adjustment to the demands for competition, regulation and accountability. This journey has been portrayed through to the present time, where there is a more inclusive and unified focus on multidisciplinary engagement. Such interprofessional learning is considered to promote the sharing of responsibilities, knowledge and joint learning, with the collective aim of enhancing patient care, whilst also contributing to the expanding knowledge base of the podiatry profession.
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