March 20, 2008

Do we have nothing else to argue about?

Legal battle rages over whether ankles exist

10:53 PM CDT on Wednesday, March 19, 2008

Associated Press

AUSTIN - For every foot, there's an ankle. Or not.

In Texas, that all depends on a legal battle between medical doctors and podiatrists, who both claim the ankle as their turf. The debate has raged to the point that the two sides disagree in court on whether the ankle actually exists.

A state appeals court recently sided with medical doctors when it determined that the state board that licenses podiatrists exceeded its authority in defining the ankle as part of the foot.

"You don't have an ankle," said Mark Hanna, a lawyer for the Texas Podiatric Medical Association. "The foot actually includes the ankle. If you took the foot off the leg, there is nothing lying there that's the ankle."

Not so, said Dr. David Teuscher, an orthopedic surgeon in Beaumont who said treating the ankle is complicated enough to require medical school training.

"If they say the ankle doesn't exist, why do they want to operate on it?" asked Teuscher, immediate past president of the Texas Orthopaedic Association. "Everyone knows what an ankle is."

The Texas State Board of Podiatric Medical Examiners bypassed the Legislature to create its ankle-is-part-of-the-foot definition in 2001. Podiatrists say they've been treating ankles for decades and accuse medical doctors of trying to limit competition. The Texas Medical Association argues podiatrists should stick to corns, calluses and diabetic foot care.

The physicians group interprets last Friday's ruling as saying the ankle and foot are separate. The podiatrists group says the ruling doesn't go that far and plans to appeal. About 900 podiatrists await the outcome.

"If people wish to practice medicine, they should attend and complete medical school," said the Texas Medical Association's president, Dr. William Hinchey. The ruling "protects Texas patients," he said.

Orthopedists must complete four years of medical school, plus a one-year internship and a four-year residency. Podiatrists must complete four years of podiatry school and an internship of at least one year, though some have more extensive training.

San Antonio podiatrist Thomas Zgonis completed four years of training after podiatry school and specializes in reconstructive foot and ankle surgery.

"I have saved all these diabetic patients' feet" from being amputated, he said. "All of a sudden you wake up one day and you question this?"

Zgonis said he will have to quit his practice if he has to cut off his practice at the ankle.

"It would be a disaster. These people are crazy," he said.

The debate is a traditional medical turf war, said state Sen. Bob Deuell, R-Greenville, a physician and vice chairman of the Senate Committee on Health and Human Services. He sides with the orthopedists.

"There are some (podiatrists) out there who are very good above the foot," he said, "but they've never convinced me that it was possible to have the entire profession be taught to do that."

The podiatry board decided to define the foot in 2001 because the state law that defines podiatry does not define what a foot is. The board said that caused confusion among podiatrists, insurance companies and hospitals. The board's definition included the tibia (shin bone) and fibula (calf bone) "in their articulation with the talus and all bones to the toes."

But then-Texas Attorney General John Cornyn rejected that, writing in a formal opinion that it "unreasonably extends the practice of podiatry to include treatment of the tibia and fibula, parts of the body that are not located in the foot."

A judge in Travis County disagreed, siding with the podiatrists. Last week's ruling by the Texas 3rd Court of Appeals overturned that decision.

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