Why I No Longer Remove Ingrown Toenails in Primary Care

A former colleague once told me that there are few primary care procedures more satisfying for the patient and physician than removing part of an ingrown toenail. I disagree, but I performed this procedure quite a few times during my residency and first few years in practice. The patient would usually have been in pain for days to weeks and have tried soaking their foot or putting wisps of cotton under the ingrown nail edge, without relief. I would draw up a syringe of lidocaine with epinephrine and perform a digital block on the affected toe. After waiting 5-10 minutes for the toe to become numb, I would clean the area, use a nail elevator to push the cuticle off the nail plate, and lift up the lateral edge of the plate. I would then cut the lateral edge with a nail splitter and remove the cut nail fragment with a hemostat. Finally, after an inspection to make sure that I hadn›t left any pieces behind, I or my nurse would apply petrolatum gauze and a bandage.

I don’t do toenails anymore. Because this procedure was requested every several weeks at most, the offices where I worked weren’t organized to make it easy to do; sometimes my medical assistants didn’t know what supplies were needed or where to find them. Adding up the time it took to obtain consent, wait for the local anesthetic to take effect, and do the procedure, it was more efficient for me to see two or three patients for medication checkups and refer toenail problems to a podiatrist instead. The same thing happened with circumcisions on infants who, for whatever reason, hadn›t had them done in the hospital. After a few years of doing these, I decided it would be easier to send these patients to pediatric urologists.

My choice to reduce my scope of practice during the early part of my career mirrored a national trend among graduating family medicine residents. I value the joint injections, laceration repairs, biopsies, and other skin procedures that remain in my repertoire for the change of pace and saving my patients more costly visits to specialists with long waiting lists. In fact, a previous study showed that family physicians who provide more comprehensive care generate lower healthcare spending and fewer hospitalizations than those with a narrower scope of practice.

A recent evaluation of Comprehensive Primary Care Plus, one of several alternative payment models that the Centers for Medicare & Medicaid Services has piloted over the past decade, found that it modestly reduced emergency department visits and inpatient costs but didn’t save money after accounting for additional dollars going to primary care. However, when researchers looked at six specific services — immunizations, behavioral counseling, laceration management, skin lesion removal, joint or tendon injections, and point-of-care ultrasound — they found that patients who saw physicians who provided more of these had lower care costs and sought less acute care outside of the office. On average, independent-practice physicians provided more services than physicians who practiced at sites affiliated with hospitals or health systems. That makes sense: While health systems bring in more income for procedures performed in their operating rooms and subspecialists› offices, private practices do better by keeping services in-house.

Supporting physicians in maintaining the broadest possible scope of practice is, in my opinion, the missing piece in the federal government’s initiatives to strengthen primary care. Investing in primary care training programs and paying practices for care coordination are necessary but insufficient steps if family physicians are expected to improve population health and bend the cost curve.

Dr. Lin is Associate Director, Family Medicine Residency Program, Lancaster General Hospital, Lancaster, Pennsylvania. He has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

A former colleague once told me that there are few primary care procedures more satisfying for the patient and physician than removing part of an ingrown toenail. I disagree, but I performed this procedure quite a few times during my residency and first few years in practice. The patient would usually have been in pain for days to weeks and have tried soaking their foot or putting wisps of cotton under the ingrown nail edge, without relief. I would draw up a syringe of lidocaine with epinephrine and perform a digital block on the affected toe. After waiting 5-10 minutes for the toe to become numb, I would clean the area, use a nail elevator to push the cuticle off the nail plate, and lift up the lateral edge of the plate. I would then cut the lateral edge with a nail splitter and remove the cut nail fragment with a hemostat. Finally, after an inspection to make sure that I hadn›t left any pieces behind, I or my nurse would apply petrolatum gauze and a bandage.

I don’t do toenails anymore. Because this procedure was requested every several weeks at most, the offices where I worked weren’t organized to make it easy to do; sometimes my medical assistants didn’t know what supplies were needed or where to find them. Adding up the time it took to obtain consent, wait for the local anesthetic to take effect, and do the procedure, it was more efficient for me to see two or three patients for medication checkups and refer toenail problems to a podiatrist instead. The same thing happened with circumcisions on infants who, for whatever reason, hadn›t had them done in the hospital. After a few years of doing these, I decided it would be easier to send these patients to pediatric urologists.

My choice to reduce my scope of practice during the early part of my career mirrored a national trend among graduating family medicine residents. I value the joint injections, laceration repairs, biopsies, and other skin procedures that remain in my repertoire for the change of pace and saving my patients more costly visits to specialists with long waiting lists. In fact, a previous study showed that family physicians who provide more comprehensive care generate lower healthcare spending and fewer hospitalizations than those with a narrower scope of practice.

A recent evaluation of Comprehensive Primary Care Plus, one of several alternative payment models that the Centers for Medicare & Medicaid Services has piloted over the past decade, found that it modestly reduced emergency department visits and inpatient costs but didn’t save money after accounting for additional dollars going to primary care. However, when researchers looked at six specific services — immunizations, behavioral counseling, laceration management, skin lesion removal, joint or tendon injections, and point-of-care ultrasound — they found that patients who saw physicians who provided more of these had lower care costs and sought less acute care outside of the office. On average, independent-practice physicians provided more services than physicians who practiced at sites affiliated with hospitals or health systems. That makes sense: While health systems bring in more income for procedures performed in their operating rooms and subspecialists› offices, private practices do better by keeping services in-house.

Supporting physicians in maintaining the broadest possible scope of practice is, in my opinion, the missing piece in the federal government’s initiatives to strengthen primary care. Investing in primary care training programs and paying practices for care coordination are necessary but insufficient steps if family physicians are expected to improve population health and bend the cost curve.

Dr. Lin is Associate Director, Family Medicine Residency Program, Lancaster General Hospital, Lancaster, Pennsylvania. He has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

A former colleague once told me that there are few primary care procedures more satisfying for the patient and physician than removing part of an ingrown toenail. I disagree, but I performed this procedure quite a few times during my residency and first few years in practice. The patient would usually have been in pain for days to weeks and have tried soaking their foot or putting wisps of cotton under the ingrown nail edge, without relief. I would draw up a syringe of lidocaine with epinephrine and perform a digital block on the affected toe. After waiting 5-10 minutes for the toe to become numb, I would clean the area, use a nail elevator to push the cuticle off the nail plate, and lift up the lateral edge of the plate. I would then cut the lateral edge with a nail splitter and remove the cut nail fragment with a hemostat. Finally, after an inspection to make sure that I hadn›t left any pieces behind, I or my nurse would apply petrolatum gauze and a bandage.

I don’t do toenails anymore. Because this procedure was requested every several weeks at most, the offices where I worked weren’t organized to make it easy to do; sometimes my medical assistants didn’t know what supplies were needed or where to find them. Adding up the time it took to obtain consent, wait for the local anesthetic to take effect, and do the procedure, it was more efficient for me to see two or three patients for medication checkups and refer toenail problems to a podiatrist instead. The same thing happened with circumcisions on infants who, for whatever reason, hadn›t had them done in the hospital. After a few years of doing these, I decided it would be easier to send these patients to pediatric urologists.

My choice to reduce my scope of practice during the early part of my career mirrored a national trend among graduating family medicine residents. I value the joint injections, laceration repairs, biopsies, and other skin procedures that remain in my repertoire for the change of pace and saving my patients more costly visits to specialists with long waiting lists. In fact, a previous study showed that family physicians who provide more comprehensive care generate lower healthcare spending and fewer hospitalizations than those with a narrower scope of practice.

A recent evaluation of Comprehensive Primary Care Plus, one of several alternative payment models that the Centers for Medicare & Medicaid Services has piloted over the past decade, found that it modestly reduced emergency department visits and inpatient costs but didn’t save money after accounting for additional dollars going to primary care. However, when researchers looked at six specific services — immunizations, behavioral counseling, laceration management, skin lesion removal, joint or tendon injections, and point-of-care ultrasound — they found that patients who saw physicians who provided more of these had lower care costs and sought less acute care outside of the office. On average, independent-practice physicians provided more services than physicians who practiced at sites affiliated with hospitals or health systems. That makes sense: While health systems bring in more income for procedures performed in their operating rooms and subspecialists› offices, private practices do better by keeping services in-house.

Supporting physicians in maintaining the broadest possible scope of practice is, in my opinion, the missing piece in the federal government’s initiatives to strengthen primary care. Investing in primary care training programs and paying practices for care coordination are necessary but insufficient steps if family physicians are expected to improve population health and bend the cost curve.

Dr. Lin is Associate Director, Family Medicine Residency Program, Lancaster General Hospital, Lancaster, Pennsylvania. He has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.