Like many seniors, my cousin, aged 77, needs help cutting her toenails, so she went to a foot care clinic north of Toronto. The clinician noticed a blister on her baby toe and, without any discussion, promptly cut it open, causing much pain and bleeding. Then she remarked that there was the beginning of an ingrown toenail on the big toe and, again with no discussion, plunged a sharp instrument deep into the toe, causing severe pain and heavy bleeding. After a few days at home, barely able to walk and unable even to put shoes on, my cousin went to her family doctor. The baby toe was infected and would require bathing in warm water and Epsom salts five times a day. Blisters should not be cut open. The injury to the big toe would take about six weeks to heal. My cousin was stuck at home for weeks. How can someone with apparently no understanding of foot care, wound care or even basic first aid have the authority to slice up people’s feet?
Aging is pretty hard on our feet. They support the weight of our bodies and undergo a lot of wear and tear. Some of the most common foot problems in seniors include bunions, corns, calluses, hammertoes, ingrown, thickened or discolored nails, diabetic foot conditions, poor circulation, flat feet and heel pain. Restricted mobility often means we can’t cut our own toenails. So many of us need foot care services. And those services are everywhere: community health centres, family health teams, foot care clinics, long term care, home care, hospitals. How do you choose the care that’s right for you?
Here's where things get murky. This field is just teeming with people with vastly different levels of skill and training, all offering foot care. And they all want our business, so as far as I could tell, none of them wants to help you figure out who can do what. But it matters who you see; anything beyond toenail cutting is a form of health care. You’d think that for the sake of patient protection, somebody would have laid all this out for us, but since I couldn’t find anything, I’ve tried to pull it together myself. Look at all these players:
- Podiatrists. To practice as a podiatrist in Ontario, one must hold a Doctor of Podiatric Medicine degree from one of the nine Colleges of Podiatric Medicine in the United States, or from the podiatry program offered by the Université du Québec à Trois-Rivières. They’re trained in an accredited program and licensed. They can diagnose and treat all manner of foot disorders, order radiographs, prescribe medications, and perform surgery on the bones of the foot. Of all the foot care providers, they are the only group whose services get covered by OHIP, but it’s only partial coverage. You can’t train to be a podiatrist in Ontario, so there aren’t very many of them in the province. You can look for one here.
- Chiropodists can do almost everything podiatrists can do, minus bone surgery and some kinds of prescribing. In Ontario, they’re trained in a comprehensive three-year full-time program at Toronto’s Michener Institute of Education. They’re trained in an accredited program and licensed. You can find a chiropodist here.
- Pedorthists can prepare custom-made orthotics and modify footwear. Pedorthists are not regulated by any college and are not part of the Regulated Health Professions Act. Chiropodists and podiatrists are the only regulated health professionals in Ontario whose legislated scope of practice includes the provision of orthotics. However, pedorthists may join the Pedorthic Association of Canada and voluntarily follow a code of conduct as a requirement of membership. Pedorthists train by taking Western University’s Diploma Course in Pedorthics, with eight online courses and two practicums. You can find a pedorthist here.
- Diabetes educators. Specially trained diabetes educators provide foot care services for individuals living with diabetes. They aim to reduce foot complications associated with diabetes through early intervention, regular monitoring and proper treatment of foot related concerns. To become certified, they must already be registered, licensed health professionals – for example, nurses or chiropodists – whose scope of practice permits them to provide diabetes education, and must have a minimum of 800 hours of practice in diabetes within three years, in order to qualify to write the certification exam. You can find a certified diabetes educator here.
- Foot care nurses. These are professional RNs or RPNs who have taken additional training in foot care. But, as the Canadian Association of Foot Care Nurses cautions on their website, at this time there is no certification process for nursing foot care in Canada that is recognized by provincial regulatory bodies. So the training is all over the map. There are courses available at some of Ontario’s public colleges. Others are offered through private career colleges. Some are run by private businesses. Sometimes foot care nurses running their own clinics create and offer training as part of their business. The clinician who butchered my cousin’s foot got her training in one of those nurse-designed private courses. The programs range in duration from a couple of days to a few months. In other words, it’s the wild west: a bonanza for nurse entrepreneurs and a minefield for foot care patients.
- Personal support workers. Various continuing education courses are available to them, from both public and private programs. The courses vary greatly in scope and depth. The Ontario Personal Support Workers Association has issued a foot care standard of practice document.
So what sort of foot care should you choose? If you’re living in long term care, or are housebound and dependent on home care, then you have to take what’s on offer. But if you live in the community and are mobile, then you can make some choices. Seniors often have more than one foot problem, and the problems are often complicated by systemic disorders like arthritis or diabetes. If all you need is nail-cutting, it doesn’t really matter who you see. But as my cousin learned, a simple cosmetic procedure can quickly cross the line into health care, and then who you see matters very much. If you choose a nurse, you might get a professional registered nurse who has taken several months of training at an accredited college. Or you might get someone who trained in a private facility, spent a few hours in a classroom, watched some videos, and thinks that the best way to treat blisters is to cut them open. So I think the safest bet is to choose a chiropodist. In Toronto, community health centres with foot care clinics staff them with chiropodists. OHIP doesn’t cover most foot care services, but if you have private insurance, you might get reimbursed. Foot care clinics in some community health centres are covered by OHIP. So take your time choosing. Finding good quality foot care should not be a matter of luck.