Ontario Injustice: Podiatry & Chiropody - How it all went down in the Legislative Assembly

Here is how it all went down in the Legislative Assembly of Ontario on Monday 12 August 1991. The original document can be viewed at: http://www.ontla.on.ca/hansard/committee_debates/35_parl/session1/socdev/s012.htm#P387_110285

(Presentations by Board of Regents of Chiropody; Ontario Society of Chiropodists; Ontario Podiatry Association)

The Chair: Good afternoon. The standing committee on social development is now in session. We have agreement from the Progressive Conservative caucus to begin promptly at 2 o'clock. The parliamentary assistant is here.

I understand there is going to be a joint presentation, or one following the other. The Board of Regents of Chiropody will be followed by the Ontario Society of Chiropodists. I understand you have a video presentation. Would you introduce yourselves for Hansard. I understand there is an agreement with the Ontario Society of Chiropodists that you will have a total of 25 minutes in your presentation and it will have 15 following. In total, there will be a 40-minute presentation with questions and answers at the end of the two presentations. Is that agreed?

Mr Springer: Actually, after my verbal presentation we would prefer to separate the questioning. We will show the video in our part of the session, I will make a verbal presentation and we can respond to questions.

The Chair: In that case, as the agenda shows, there will be 20 minutes for each association and we ask you to leave time during your 20 minutes for questions.

Mr Springer: The society has agreed to give up five minutes of its presentation because of the length of the video.

The Chair: In that case, you will have 25 minutes and they will have 15 minutes.

BOARD OF REGENTS OF CHIROPODY

Mr Springer: My name is Andrew Springer. I am here to make a submission to the committee on behalf of the Board of Regents of Chiropody, the regulatory body of chiropody and podiatry. Accompanying me are Neil Naftolin, a member of the board, and Peter Wilson, who is the chief of the Ontario chiropody program. Unfortunately, our chairman, Dr Diana Schatz, is unable to attend due to the unfortunate passing of her father, Roland Michener, last week.

During the preparation for this presentation, and very commonly in years past, I have continually encountered misconceptions regarding the function and the role of chiropodists in the health care system. It has become increasingly evident that there is a lack of understanding about what it is that chiropodists do. This state of affairs is not surprising. Most people will not have encountered a chiropodist and many have never heard of the profession.

In 1984 the board registered 150 practitioners, 34 of whom were chiropodists. In 1991 there are 319 practitioners registered with the board, 218 of whom are chiropodists. Compared to other professions which will be making submissions here, this represents a very small group. Many of you will not have had any direct contact or experience with chiropodists. To that end, our presentation is designed not only to allow for suggestions that we have to make regarding the Chiropody Act, but also to elevate chiropody from the conceptual level closer to a concrete reality, therefore providing you with another frame of reference for discussion.

With your indulgence, I will display a brief video which the Ontario Society of Chiropodists has agreed to include as part of its presentation. They are sacrificing, as you know, some of their time to allow for the showing of the video. The primary function of the video actually is for the recruitment of potential students, but I believe it will provide you with a broader understanding of what the profession of chiropody has evolved into.

Following the brief video, I will make my comments about our position on the act.

[Video presentation]

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Mr Springer: Thank you very much for your indulgence. I hope that was informative for you. The board is very pleased that the Regulated Health Professions Act and its companion acts have reached this point in the legislative process. Certainly, in many ways, Bill 43 and Bill 45, the Chiropody Act, represent a significant improvement over the existing Chiropody Act, which, except for regulations, remains unchanged from its original form in 1944.

We strongly endorse Bill 45 with one single suggestion for change. We believe the communication of a conclusion identifying a disease, dysfunction or disorder of the foot is an essential authorized act for chiropodists. We believe the nature of the authorized acts that chiropodists will perform -- that is, cutting into the subcutaneous tissues of the foot, administering substances by injection into feet and prescribing drugs -- requires such communication.

Every patient is entitled to informed consent to understand the nature and cause of their condition, the treatment of choice and the alternatives. Without the right to communicate this information, the patients will not be fully informed. There has been some question as to the ability of chiropodists to actually provide this information. The education and training of chiropodists is designed to develop their powers of deductive reasoning, to allow them to come as close as possible to the cause of a problem and then to provide the appropriate care.

This training, of necessity, has developed partially in response to public need and also in response to existing legislation and regulations which require presently that chiropodists furnish a diagnosis as part of each patient record. Included in our written submission is a list of chiropody-specific diseases and general systemic diseases which manifest themselves in the lower limbs. These are commonly seen in the practice of chiropody and are taught as part of the chiropody educational program.

Chiropodists now provide approximately 250,000 patient visits per year in publicly funded clinical settings. This represents a very real saving in tax dollars because of the number of seniors particularly who are kept ambulatory as a result of their treatments. There is an impact on their physical and emotional wellbeing. Their ability to move around freely allows many to maintain a measure of independence and self-esteem that most of us do not value until it is threatened.

Being unable to diagnose will change the nature of the practice of chiropody. Recognizing the right of patients to full disclosure of information regarding their condition and treatment, chiropodists would have to refer patients back to their physicians to have the doctor relay information already discerned by the chiropodists and then send the patient back to the chiropodists for treatment. If this procedure is projected over 250,000 visits, with allowances for the continual growth of chiropody in Ontario, this translates into millions of dollars spent at no increased benefit to the consumer.

You may ask why chiropodists, above other professions who are seeking the same change in their acts, should be allowed to diagnose. Chiropodists are primary care practitioners. This means they commonly see patients without a physician's referral. It is reasonable to assume that when a physician refers a patient to another health practitioner who is not primary care, a communication has already been made regarding the nature of the patient's condition. This permits the patient to make an informed decision about his or her treatment. This assumption cannot be made about a patient who attends a chiropodist.

By including this controlled act in the Chiropody Act, you will be ensuring that patients are fully and accurately informed by trained personnel, thus facilitating informed consent.

In summary, the Board of Regents of Chiropody strongly urges you to seriously consider augmenting the list of authorized acts accorded to chiropodists in Bill 45 to include the communication of a conclusion identifying a disease, dysfunction or disorder of the foot. We feel that this is justified because the public has a right to informed consent; because this is not an expansion of the scope of chiropody practice but accurately reflects the training and practice of chiropody as it has existed in Ontario for quite some time; because there is a foreseeable increase in the cost of what is now a very cost-effective service to the province's population; and because there is a legislative precedent in existence -- specifically, the regulations of the present Chiropody Act, 1944.

I thank the committee for its attention and hope that you will give our arguments every consideration. We will be glad to answer any questions you may have.

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Mr Owens: That was an excellent presentation, Mr Springer. I have a question around your requested amendment, in that the video we saw was basically Toronto centred. Have any morbidity and mortality studies been done in areas where chiropodists are available versus areas where they are not, with patients who have have circulatory problems as a result of diabetes or any of the other illnesses that would affect the feet?

Mr Springer: I believe there have been some preliminary studies. Mr Wilson might be able to respond to that.

Mr P. Wilson: To my knowledge, there have been no such studies specific to chiropody. However, I understand there have been studies conducted which would lead one to the conclusion that if chiropody were introduced to that particular geographical region, there would certainly be an impact and a need for that type of service and it would in fact enhance the health of the local community.

Mr Owens: What happens now in some of the more remote areas where a chiropodist may be available but a physician is not available? Is the assessment and diagnosis made and passed on to the patient? Would this legislation be a change to current practice?

Mr P. Wilson: First of all, with regard to current practice, since the introduction of chiropodists into the province in 1982, physicians have not been involved in the referral of patients to chiropodists, nor have they been involved in the diagnosis of conditions of patients received by the chiropodists. The role of the physician has been that wherever there has been a designated physician in a particular hospital who would take an interest in chiropody, his or her responsibility has been to represent the chiropody department at the medical affairs level of the institution. It has been purely administrative.

Also, to help smooth the introduction of this essentially new profession or health discipline into the hospital, a physician has usually been identified but not in all cases. The relationship is not one where the chiropodist cannot operate independently.

Mr Cordiano: My question is probably directed at the ministry, but I would also like to direct my question to our presenters with respect to the point they make on the degree of sophistication of service they provide in the controlled act. Your suggestion is that because you provide that sophisticated treatment, that you are authorized to perform those acts, you would be able to evolve into a profession which would be probably able to fill the gap which will be created when a cap comes into play in 1993 as suggested by this legislation for podiatrists. Correct?

Mr Springer: I think that like any other profession, there is room for evolution. The original ministry position, I believe, felt that there was not really a gap in existence -- above the level of scope of chiropody, that is -- but that there was a lack of practitioners present.

Our presentation is not based on the contention that we want to evolve into that scope, but simply that to provide the present scope as listed in authorized acts we would have to be able to communicate this information to the patients.

Mr Cordiano: I understand that. Perhaps I could direct my question to the ministry.

The Chair: I have a question from Mr Wilson first and there will be some time with the second presenter who will be discussing this.

Mr J. Wilson: I appreciate the answer to Mr Cordiano's question, because it is a good one. As I understand it, you are currently communicating your assessment to your patients.

Mr Springer: We are.

Mr J. Wilson: Do you know why you are being asked to restrict that function now?

Mr Springer: I would have difficulty giving a full answer to that. My understanding is that there is an impact on other professions, and that has been a concern. Our response to that is that many of the professions that have been presenting or will be presenting on this issue may not be primary care. We can assume, if they are referred by a physician to that particular profession, that communication of that information has been passed on.

I think it is an issue of professional pride as well for many people. Here we feel there is a very practical and real problem in restricting our present practice.

Mr Cordiano: To the ministry, then, I would simply put this: Will there, in your opinion, be a gap created between the two professions at the time we are phasing out podiatrists? There is not really anyone who is going to be filling that void other than physicians. Is that what is envisaged by the ministry to take place?

Mr Wessenger: I will have ministry staff reply to that one.

Ms Bohnen: Specifically in terms of bone surgery?

Mr Cordiano: That is what podiatrists are essentially practising in Ontario. That is the scope of their practice, if I understood correctly.

Ms Bohnen: Podiatrists are not currently permitted by law to perform bone surgery. However, the review recognized that there would be demand for that service and evidence that podiatrists could competently perform limited bone surgery, surgery that is in the bones of the toes and the forefoot, and so concluded that they should be permitted by law to do so.

However, coupled with that was the decision that since Ontario in 1980 had decided to opt for a chiropody model, the number of podiatrists would be capped. As to whether there will be a gap in the accessibility of service, it was anticipated that those patients who require surgery and nothing but surgery will be able to obtain that service from the existing group of podiatrists when they are not available from orthopaedic surgeons. Other patients will be managed more conservatively, using non-surgical techniques.

Mr Cordiano: I am to understand, then, that orthopaedic surgeons would perform the exact same function, or do that now, as a matter of course. What we are allowing in this legislation is for podiatrists to perform a minimal type surgery?

Ms Bohnen: "Minimal" in the sense that it is only certain parts of the foot and certain kinds of surgery.

Mr Cordiano: That is what I mean.

Ms Bohnen: Yes, that is correct. Orthopaedic surgeons, of course, also do surgery on the foot.

Mr Cordiano: What impact would that have on orthopaedic surgeons with respect to their practice at the present time? Podiatrists are not providing that service now, so orthopaedic surgeons are currently doing what is required with respect to surgery on the foot.

Ms Bohnen: You may wish to ask this of the podiatrists whom you will be hearing from shortly, but it is my understanding that in a sense they have been functioning in a kind of limbo. A number of them were performing this kind of surgery. One particular podiatrist was taken to court by the College of Physicians and Surgeons of Ontario. This highlighted the fact that the kind of bone surgery being done was not lawfully provided by podiatrists at this time and put the board of regents in the position of having to police a prohibition which perhaps previously had not been well enforced. I think you should ask the podiatrists to what extent, prior to announcement of this new legislation, their members had nevertheless been doing surgery which under current Ontario law is restricted to physicians.

The Chair: We are going to have an opportunity this afternoon. We will be hearing from two more groups, the Ontario Society of Chiropody and also the Ontario Podiatrists Association. That should afford you an opportunity to pursue the line of questioning further.

Thank you for your presentation.

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ONTARIO SOCIETY OF CHIROPODISTS

The Chair: I will call now on the Ontario Society of Chiropodists. Welcome to the standing committee on social development. You have 15 minutes for your presentation. We would ask that you please leave some time for questioning from members of the committee. Please begin your presentation by introducing yourself.

Mr Kerbl: My name is David Kerbl. I am a practising chiropodist. I am also the president of the Ontario Society of Chiropodists. Our society represents 107 practising chiropodists throughout Ontario. In addition, our position on the proposed Chiropody Act, the position I am about to present, is supported by 78 chiropodists who are not members of the society, which represents about 88% of practising chiropodists. They have shown their support through letters written to the executive, copies of which I will be happy to share with you.

With me are Peter Guy, who has worked in institutional and private practice and is now clinical instructor at the Ontario chiropody program, and Olga Laland, who practises now at Victoria Hospital in London but previously practised in clinics in northern Ontario in underserviced areas.

Chiropodists are foot care specialists, and the development of chiropody in Ontario is a function of government policy. I thought it would be useful if I explain for a moment how that came about.

In 1970 an Ontario government task force forecast that the foot care needs of Ontarians, particularly seniors, would increase beyond the capacity of the established medical profession and other existing health care professions, including podiatry, to meet them. The task force recommended a model oriented specifically to foot care. This thrust is consistent with trends in other jurisdictions -- the US, the UK and Australia -- where chiropody or podiatry flourish by filling a gap in the health care spectrum.

In 1981 a decision was made by the government in power that Ontario would accommodate the accelerating demand for foot care through the so-called UK chiropody model. This meant that a chiropody school was set up in Ontario, with the clinical parts of the curriculum being delivered at Toronto General Hospital and the didactic portions being delivered at George Brown College and increasingly at what is now called the Michener Institute. While awaiting graduation of Ontario-trained chiropodists to meet the demand, UK-trained chiropodists were imported to fill the gap.

Chiropody care is delivered through institutions such as hospitals and clinics. I should emphasize, because it is important background for what I am going to say later on, that an increasing number of chiropodists practise in community-based clinics and provide chiropody services to nursing homes where there is little or no medical supervision over the treatment the chiropodist provides. I, for example, practise in Ottawa in a group practice with two podiatrists.

What distinguishes chiropody -- and podiatry, by the way -- from other modes of foot care delivery is that our treatment modalities focus on the foot, and the approach to foot care revolves around the presumption that improper foot function, or "mechanics," is the root of many foot problems. When confronted with a foot ailment, we address function as well as the actual symptoms. We believe this is what makes chiropody as a discipline a highly successful model.

An unfortunate side-effect of the way in which chiropody has been developed in Ontario is that the interests of chiropody and podiatry have been placed in conflict. Many in our profession, the Ministry of Health and our regulatory board see the continued existence of podiatry as a threat to our profession.

We in the OSC know that chiropody alone, at least in its current configuration, cannot meet the demand for quality foot care in Ontario. With current demographic and other trends, in particular what is known as the greying of Ontario, this situation will only get worse. However, we also know that as long as US-trained podiatrists are allowed to enter and practise in Ontario, chiropody will be stultified. It will never be able to grow and develop, as chiropody has elsewhere, in response to the legitimate and actual health care demands.

It is unfortunate that the interests of one health care profession have been juxtaposed against another, especially when today, demand for quality, professional, full-scope foot care far outstrips supply. But this is a function of a public policy decision made by a government over 10 years ago and confirmed by every subsequent government.

What those professionals whom I represent want, therefore, is a recognition by policymakers that chiropody must be allowed to evolve and grow in order to satisfy the foot care requirements of Ontarians. This was what the Health Professions Legislation Review process was all about: establishing, on one hand, an effective regulatory framework, while on the other hand making the framework flexible enough to respond and adapt to the legitimate and natural evolution of each profession. That evolution occurs because of constant developments in training and procedures and in response to patient demand.

Chiropody has benefited greatly in Ontario by being a creature of government. In crude terms, were it not for a government decision made a decade ago, the chiropody model would not exist in Ontario. The burden of foot care would be delivered by podiatry -- the profession chiropody has been designed to supplant -- and by other health care professionals.

Being a creature of government also has its disadvantages, the major one being the extent to which government fiscal and policy objectives, rather than patient demand, dictate the evolution of our profession. We recognize that fiscal constraints impact to some degree on every health care professional group. In our case, fiscal constraints have meant that insufficient resources are available to many hospitals and institutions for chiropodists to practise full-scope chiropody. While our training has generally evolved to keep pace with chiropody elsewhere, particularly in the UK, public policy constraints have kept us from practising full-scope chiropody as practised in most other jurisdictions. In practical terms, our scope of practice for chiropody -- and I am talking about what most of us do in institutions, as opposed to what we are trained or legally qualified to do -- now lags behind the UK model we were supposed to emulate.

I must convey to you the deep sense of frustration many chiropodists feel in being unable, because of policy constraints, to deliver the type of foot care we have been trained to provide. We have in our profession a revolution of rising expectations that are not being met. This unmet revolution of rising expectations has caused a significant decline in the number of chiropody students enrolling in, or graduating from, the chiropody program. It has caused a small number of chiropodists to move into private clinics on a full- or part-time basis. A few chiropodists have left the profession; a few have gone to the US to train as podiatrists and hope to return to practise as podiatrists in the "podiatric scope" defined by the proposed legislation.

We would like, however, to thank the government and previous governments for bringing forward the Regulated Health Professions Act and the proposed Chiropody Act. Madam Chairman, if I might, I would like to acknowledge in particular the role you played as Minister of Health and the role you continue to play. The proposed legislation will remove many anomalies and some uncertainties relating to our profession and will begin to bring our scope of practice up to speed with our training, existing technology, and patient and practitioner expectations. This brings me to two specific issues I would like to address.

First, while our podiatry colleagues have the right to diagnose under the proposed Chiropody Act, chiropodists do not. We feel this is an unwarranted anomaly for four reasons:

1. Under the existing Chiropody Act, we have to date exercised the right to diagnose. To the best of my knowledge, there have been no issues or problems raised as a consequence of chiropodists exercising that statutory power, and I see no reason for it to be removed. Our regulatory board is of the same view, as are our podiatric colleagues.

2. In our clinical and didactic training, we are trained to diagnose. We can document and explain this further if you wish. Perhaps this is something Peter Guy, who teaches at the school, can respond to.

3. Without the power to diagnose, chiropodists cannot be primary contact practitioners. The practice of chiropody will be restricted to institutions, under the supervision of a medical practitioner. Such a restriction means that chiropody can never become a decentralized, community-based system in response either to patient demand or to the legitimate aspirations of chiropodists.

It also means that practitioners such as Olga, who practised for a time in an outlying area and spent most of her time outside the hospital setting, will not be able to deliver the service they now provide. Without the ability to diagnose, chiropody will be restricted, as a practical matter, to large institutions in the larger urban centres.

4. Without the ability to diagnose, our patients cannot make an informed consent to the treatment being offered by a chiropodist.

The other issue I would like to raise relates to the so-called podiatric cap, the provision whereby no podiatrist may be licensed in Ontario after July 1993. For the reasons I have set out in my introductory remarks, I want to make it clear that the Ontario Society of Chiropodists does not support the podiatric cap. It will impose a glass ceiling on our profession, an arbitrary restriction on the natural evolution of chiropody.

The professionals I represent expect that some day Ontario-trained chiropodists will be able to perform the licensed acts now limited to podiatrists under the proposed Chiropody Act. Without that potential, our profession will stultify and grow stagnant. I have already mentioned that chiropody in other countries is surpassing the Ontario model. In the UK, for example, on which our program is supposed to be modelled, chiropodists are being trained in post-graduate courses to perform bone surgery, and chiropodists routinely perform bone surgery in some National Health Service areas. In Ontario, bone surgery is reserved for podiatrists in the proposed act. As written, Ontario chiropodists will never be allowed to perform bone surgery.

I emphasize the point that the podiatry cap not only limits podiatrists; it also limits chiropodists. For that reason we oppose the cap and would support any amendment that allows chiropodists, some day and with the requisite training and in response to a demonstrated need, to perform the licensed acts now reserved for podiatrists.

Our solution is simple. The wording of subsection 3(2) need only be amended to apply to US or any other foreign-trained graduates of podiatric medicine, leaving it open to qualified Ontario- or Canadian-trained chiropodists to practise in the so-called podiatric scope. This will accommodate the revolution of rising expectations that I mentioned earlier and will, ultimately, be in the best interests of the public.

That concludes my remarks, and I will be happy to respond to questions.

Mr Owens: Thank you for your presentation, Mr Kerbl. Looking at the act under section 4, which to us is the chiropodists, and then looking at the section that addresses podiatrists, can you tell me why you are allowed to do an assessment and then treatment but not to tell me why you are doing what you are doing to me? Is there a rationale? Am I missing something in this language?

Mr Kerbl: This is our concern as well, in that we are currently communicating these conclusions to our patients. The current "assessment" versus "diagnosis" wording is very confusing. To our understanding, we require the ability to communicate this conclusion to our patients in order to continue to treat patients the way we have over the last eight or so years since the program was developed.

Mr Owens: Madam Chair, can I put this question on the list of supplementary questions that we will speak to the ministry about?

The Chair: Yes.

Mr Cordiano: I asked the question in the previous set of presentations, and I think you have answered most of it for me in your brief, with respect to where you would like to see chiropodists evolve into a practice that would include, some day, the act of surgery being performed by your profession, I suppose. I think the question that I asked of the ministry earlier was, would the set of circumstances we are going to be imposing with the new act not create something of a gap down the road when, at some point, all of the podiatrists, by natural forces or otherwise, are no longer with us? What would happen to that niche in the health care market? If it is not going to be served by you, it would be served by, presumably, orthopaedic surgeons. How would you respond to that?

Mr Kerbl: I totally agree, because there is a difference currently between -- in the new act -- what chiropodists and podiatrists would be willing to do. In fact, podiatry is phased out; there will be a segment that will no longer be delivered. Presumably that could be delivered by orthopaedic surgeons, and my response is that there is no reason they could not be providing that at the moment.

Mr Cordiano: And they do not? I do not know; I am asking. Anybody can answer that.

Mr Kerbl: I cannot speak on behalf of orthopaedic surgeons, but if those services were being provided, then there would be no reason for podiatrists at the moment to be providing them. We know that chiropody and podiatry exist because there is a lack in other professions and we do fill a niche.

The Chair: Thank you very much for your presentation.

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ONTARIO PODIATRY ASSOCIATION

The Chair: I call now on the Ontario Podiatry Association. Welcome to the standing committee on social development. Would you begin by introducing yourselves. You have 20 minutes for your presentation, and we would ask that you leave some time at the end for questions from committee members.

Mr Zamojc: Thank you. My name is Tony Zamojc. I am a doctor of podiatric medicine and I am the president of the Ontario Podiatry Association. With me is Neil Koven, the vice-president of the association. Neil is a doctor of podiatric medicine as well; he practises in Mississauga.

The Ontario Podiatry Association represents the majority of podiatrists in Ontario and is part of the Canadian Podiatry Association. In Ontario, podiatrists are licensed and regulated by the Board of Regents of Chiropody under the Chiropody Act of 1944.

Since there is no podiatry school in Canada, podiatrists earn their doctorate in podiatric medicine after a four-year program in one of the seven US colleges of podiatric medicine. Entry to any of these colleges requires an undergraduate science degree. All applicants must also take the Medical College Admissions Test, also known as MCAT, and competition for entry is very intense. After graduation and before being licensed, many podiatrists serve a hospital internship or residency, and this can range between one and four years.

Before moving to the specifics of the proposed legislation, I want to preface my remarks by stating that the proposed Chiropody Act is supported by my membership. Although both podiatry and chiropody are dedicated to foot care, the bill recognizes the distinctions between the two professions, which spring essentially from the differences in our current levels of training.

The Ontario Podiatry Association views chiropody and podiatry as complementary professions, sharing the same health care sector but focusing on different parts of the spectrum by virtue of our respective training, scopes of practice and delivery modes. For example, the unique and enhanced training associated with podiatry -- generally, four years of post-graduate education for podiatry as opposed to three years of post-secondary training for chiropody -- means that certain procedures are more appropriately attended to by one of the professions as opposed to the other. I point to section 5 of the proposed act, which draws a clear distinction between podiatric and chiropody scopes of practice. Under section 5, podiatrists are granted the authority to, first, diagnose, and second, to perform bone surgery.

I can tell the committee that the podiatric profession is pleased that the proposed act provides the legislative confirmation of a podiatric scope of practice commensurate with our training, abilities and patient demand. For that reason alone podiatrists support this bill, and we acknowledge, with thanks, the role that the current and previous ministers of health -- in particular you, Madam Chair -- have played.

Unfortunately, I cannot restrict myself to simply highlighting the benefits of the proposed legislation. I must also address, in the time allotted, our outstanding concerns relating to two issues.

The first relates to a mistaken perception that the interests of chiropody and podiatry are at odds or in conflict with each other; that somehow the development of foot care in Ontario has been a zero-sum game: a gain by one profession was a loss to the other. As a result, one might conclude that podiatrists would be opposed to chiropodists having the diagnosis function. I would like to state unequivocally that the podiatry profession has no objection to the diagnosis function being accorded to chiropodists. By the diagnosis function, I mean the power to communicate a conclusion. In fact, it would be logical in our view that since chiropodists are to perform surgical procedures, they must be allowed to diagnose. Since we are not involved in any way in the chiropody training program, we have no basis on which to judge whether chiropodists are, indeed, trained to diagnose. The board of regents, however, is, and we note that the board supports authorizing chiropodists to diagnose.

In short, if the legislation is amended to allow chiropodists to diagnose as one of their licensed acts, you will get no argument from podiatry.

Our second and only other concern deals exclusively with podiatry. The Ontario Podiatry Association regrets that the proposed act would legislatively implement a plan on behalf of the ministry to eventually consolidate foot care in this province under one profession: chiropody. The ministry's intention is accomplished by establishing July 1993 as the cutoff point, after which no new podiatrists can be licensed to practise in Ontario.

We find this regrettable and inconsistent. On the one hand, the ministry and act have recognized the unique training and role that podiatry plays in foot care. On the other, however, it is prohibiting the entire foot care profession from evolving and growing in response to patient demand and natural professional evolution.

There are two subsidiary issues here. First, the understanding we had with the Schwartz committee and the ministry was that the effective date of the cap would be three years after the date on which the legislation was tabled. That, then, is July 1994. By moving the date to 1994, all Ontario residents currently in podiatry programs in the United States would have the opportunity to return to practise in Ontario. We strongly urge the committee to make this very simple and valid amendment in the spirit of our original agreement with those responsible for the Health Professions Legislation Review.

The second concern is more substantive. Although frankly we do not agree with the rationale, we understand the public policy reasons for putting a cap on US-trained podiatrists practising in Ontario. What we do not understand is why any government would want to prohibit Ontario-trained or even Canadian-trained podiatrists from practising in Ontario at some date in the future.

The podiatry scope represents the natural evolution of the chiropody profession. We can document a persistent and growing demand for podiatric services. With the greying of Ontario, that demand will increase. As the number of podiatrists declines, who will fill that need? Experience shows that orthopaedic surgeons and general medical practitioners cannot.

The logical and natural successors to podiatrists in Ontario are chiropodists, trained to perform what is now called the podiatric scope of practice. The Schwartz committee recognized this, we recognize it and our colleagues in the Ontario Society of Chiropodists look forward to it.

The podiatric cap militates against the natural evolution of the chiropody profession and will leave Ontario, some day, without enough qualified practitioners to respond to patient demand. We propose keeping to the podiatric cap -- extended, of course, to 1994 -- but applying only to foreign-trained doctors of podiatric medicine. This proposal is in harmony with the intent of the legislation, that being to create a flexible framework that accommodates the natural and legitimate evolution of the regulated health care professions. To retain the cap is to place an arbitrary and artificial cap on chiropody and engage in an exercise of swimming against the tide.

That concludes my remarks. I think you will agree that our proposals are in the public interest, and we would be happy to entertain questions at this time.

Mr J. Wilson: I am trying to get a better understanding of the cap on podiatrists in 1993. Is it your understanding that it is the ministry's intention to expand the scope of practice of chiropodists at that time? We are not just putting podiatrists out of business; we are, I understand, putting them into one profession called chiropody.

Mr Zamojc: Yes, the legislation for the act is in basically a two-tiered system. One will include the additional portion as bone surgery for podiatrists in the province, and then the soft-tissue surgical procedures, ingrown toenails, warts and things like that, as well as injections and prescriptions, are extended to everybody. So there is that additional section that makes the podiatric portion of the act slightly different.

Mr J. Wilson: I understand that, but what about after July 1993?

Mr Zamojc: In July 1993 -- or, what we are hoping for, 1994 -- basically any podiatrists who graduate in the United States, regardless of whether they are Canadian -- for example, practising out in British Columbia -- if they wish to come back to Ontario after that date, would be allowed to practise under only the chiropody side of the profession. They would not come in under the podiatric scope after 1993 or 1994. That is the end of that podiatric scope for anybody coming in at that time.

Mr J. Wilson: So after July 1993 or 1994, chiropodists are limited to the scope of practice that we are being asked to pass. If this passes, podiatrists would then be limited to the same scope and neither will be doing bone surgery, which podiatrists are still doing.

Mr Zamojc: But American-trained podiatrists would not be allowed into Ontario to practise under the podiatric scope. Actually, there is one error in that.

Mr J. Wilson: I am just trying to get a feel for the state of affairs after July 1993.

Mr Zamojc: There is one error in that. The practising podiatrists in British Columbia, if they are licensed before the 1994 date, can enter Ontario and practise at the full podiatric scope.

The Chair: For clarification, I have had a request from the parliamentary assistant to clarify. Is that acceptable? It will probably use up your remaining time.

Mr Wessenger: I would like the ministry to clarify this point.

Ms Bohnen: The scope of practice of podiatry will not narrow on that date in 1993. What will happen is that no further additional podiatric registrants will become registered with the college, so that there will be a limitation on the group of practitioners entitled to practise the expanded scope. That is the significance of that date.

Mr J. Wilson: What happens eventually when your podiatrists die off? Who does bone surgery?

Ms Bohnen: There are two answers to that. One answer is that orthopaedic surgeons do the bone surgery, which is what they do today. The second answer is that, should there be a need in the future identified for further practitioners of bone surgery and, second, should the educational program for chiropodists in this country be expanded to teach bone surgery, then at that point I think we would expect to see a proposal for an amendment to the act which would be circulated and placed before the advisory council.

Mr Waters: What kind of cost difference are you talking on these types of things? It is to serve the public. You are saying that as podiatrists die out, I guess, it will all be picked up by someone else. Is that an increased cost?

Mr Burrows: I would like to suggest that question be best directed to the members of the profession in terms of comparative incomes and so forth. However, I would like to point out that the chiropody model, as a matter of ministry policy, has existed since the early 1980s and has not changed under three successive governments. The need, in the ministry's opinion, has been for a much broader access but limited scope of practice because the need in such groups as senior citizens for some sort of low-risk but preventive and supplementary care is what has led to the formation of that policy.

But, as Linda pointed out, should circumstances change in the future, the notion under this legislation is that it is living legislation and should that need be there and the need for additional practitioners present itself, there is a fairly ready way of amending things so that could occur. But that would require a policy change and a decision at that time.

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Mr Cordiano: So in that sense, the ministry has virtually identified a lack of need for this type of specialized foot care. At some point in the future when podiatrists are no longer with us, that void would naturally be filled by orthopaedic surgeons who are currently providing the same surgical treatment.

Ms Bohnen: Yes. In respect of surgical treatment in the forefoot, yes, what you said is quite correct.

Mr Cordiano: So orthopaedic surgeons are, as a matter of course, doing this regularly at the present time?

Ms Bohnen: I believe so.

Mr Cordiano: I should ask the former minister.

Mr Hope: Just for clarity, you are saying "foreign-trained" and they are saying "US- or foreign-trained." I would like to know what the difference is.

Mr Zamojc: We are basically stating that if there is a podiatrist produced in this country and working in British Columbia, because British Columbia also has a podiatry group, and Quebec is in the process of producing a podiatrist model with additional training out of New York colleges of podiatric medicine -- the eventual evolution of a school of podiatric medicine in this country, which is conceivable either in Quebec or in British Columbia in the future -- we want to make sure there is still an opening for those trained people to enter Ontario, rather than limiting it to just the American-trained. We can see the point of the Americans, but when it is our own citizens of anywhere in the country who do not have that free movement to practise, we basically say "foreign-trained." That would be anybody outside of Canada.

Mr Jackson: I am trying to get a sense of the concepts of deinstitutionalization and access here. I am getting nervous about the phase-out of podiatrists coupled with the loss of diagnostic abilities for chiropodists. Essentially, the outcome of that would be the need for more physicians to examine foot ailments and do referrals to orthopaedic surgeons. I have had bad experiences with orthopaedic surgeons and really good ones with podiatrists and chiropodists; it has probably saved OHIP thousands of dollars. I am now nervous that both groups have referenced institutional settings and yet the model for care for the elderly in this province will be in a deinstitutionalized vein. I am really nervous about this because it will be more costly. It might be a Rolls-Royce health care system that we can fast-track them all to orthopaedic surgeons, but by the same token, there is a whole lot of preventive areas involved with foot care that might be limited here. Would you like to comment on my concern?

Mr Zamojc: One problem in the legislation, especially with the cutoff date being so finite, is that there is no room for the evolution chiropodists have mentioned, as well as us, into what Ontario can have as a full scope of chiropody. There is one, then we die off and then there is something else with this space in between. There is no evolving process going on with an interrelationship between the two. That is a weakness I see in the thing as well. That is possibly one of the reasons for the attempt at making the 1994 date, which is still a finite date, but allows all the Canadians down in American schools to come back, as well as providing the other side of it to provide Canadian-trained podiatrists. There will be more of bridging that gap between the two, and the free movement of that level country-wide will provide that. In that respect, I feel this is going to help that gap we referred to earlier as well. That is really my only comment.

The one thing I would like to note is with regard to the orthopaedic surgeons and us doing surgery or foot care as well, there are differences and similarities between the two, versus ambulatory foot surgery and the use of orthopaedic supports and devices and that kind of thing. There is a sort of continuum with the orthopaedic surgeons as well, so I feel we are all going towards the same goal providing a service at a multistaged sort of level.

The Chair: Mr Owens, I have a note that you had a question on this matter of the ministry. Did you want to ask the parliamentary assistant at this time to get it on the record, or has it been answered in the discussions?

Mr Owens: I think it has been answered.

The Chair: A question from Mr Jackson to the parliamentary assistant to be answered at a later time?

Mr Jackson: Yes, that has to do with long-term care reform. I would like to know to what extent foot care matters are being considered in that discussion paper as it relates to the issues I am concerned about with respect to access and deinstitutionalization. I would like to know to what extent there is a dialogue or thinking going on between this piece of legislation and the long-term care agenda.

The Chair: Thank you very much for your presentation. We appreciate hearing from you.