Sole destroying: How surgeons wield scalpels without medical degrees

It was Christmas day in 2014 when Suzanne Hogan removed her surgical boots for the first time. She could not believe what she saw – her feet were two different sizes.

“I measured and remeasured the foot continuously,” she says. “I was in disbelief.”

The answer came out the same every time, her right foot was three sizes smaller than her left. Her big toe, meanwhile, hovered one centimetre above the ground.

Suzanne Hogan has different sized feet and her toe cannot touch the ground after her operation.Credit: Brook Mitchell

By this point, she had been operated on three times by Paul Bours, who once counted himself among a small but controversial group of practitioners known as podiatric surgeons.

None of these podiatric surgeons has completed a medical degree, so not one of them is a medical doctor, yet they can lawfully call themselves “doctor” and perform complex and invasive surgery.

Each time Bours operated on Hogan, her pain afterwards intensified, but her surgeon could not prescribe medication.

“He comes out in a white coat, he’s called doctor, a surgeon, I thought he was fair dinkum,” she says.

Nor did Hogan know, Bours was found guilty of professional misconduct in October 2014 and was banned from operating for one year. But the suspension did not take effect immediately, allowing him to perform the third procedure that left her with permanent disability. “It’s turned my life upside down,” she says.

Suzanne Hogan ended up with two different sized feet after three operations with Paul Bours.Credit: Suzanne Hogan

This troubling pattern was repeated many times in a joint investigation by The Age, The Sydney Morning Herald and 60 Minutes, where patients around the country have been left deformed, out-of-pocket and feeling misled about the qualifications of the person they allowed to operate on them.

Over interviews with 29 patients, they described being “shocked” or “completely floored” to learn these practitioners can lawfully call themselves doctors or surgeons despite not having medical degrees.

Their complaints were backed by 22 orthopaedic surgeons, who say they often treat patients to correct issues following podiatric surgeon procedures. They make allegations of poor and unnecessary surgeries and inappropriate treatment of complications.

“Podiatric surgeons are the only group of individuals who operate on the Australian public who do not have their training accredited, inspected and audited by the Australian Medical Council [an independent training organisation for medical professionals],” the Australian Orthopaedic Association said in a recent submission to the regulator.

Some patients will not speak publicly on advice from their lawyers as they pursue medical negligence claims following severe complications – such as deformed feet, chronic pain, and dying limbs.

One says she was left to walk on a broken and blackened foot for two years, another described an operation which left her with a dangling toe and crippling pain. Many developed depression when they were left unable to walk, work, drive or live independently.

“This is a big problem,” says lawyer Ian Murray, who has represented a number of patients of podiatric surgeons. “I’m glad someone is exposing this.”

Orthopaedic surgeon Nicole Leeks treats patients who experience problems after surgeries by podiatric surgeons once a fortnight.

“Over my years, I’ve seen three amputations after podiatric surgeons have operated,” she said.

Leeks acknowledges that all surgeries have complications, but she describes cases by podiatric surgeons she has seen as “outrageous” and “experimental”, which she believes indicates a lack of adequate surgical training.

“I’ve had complications. But it’s not because the wrong operation has been performed for the patient, or the screw is not in the bone.”

After receiving questions from this masthead about problems with podiatric surgeons, regulator Australian Health Practitioner Regulation Agency (AHPRA) launched an independent review of the industry, noting that it had a “much higher rate” of complaints about these practitioners compared to podiatrists, including “serious concerns about patient safety”.

AHPRA conducts investigations into alleged misconduct for the Podiatry Board of Australia (PBA), which in turn makes disciplinary decisions. PBA chair Cylie Williams said reform was needed, and everything from tighter rules around titles such as “doctor” and “surgeon” to auditing training standards would be examined.

“That’s heartbreaking,” she says, in response to Hogan’s predicament.

Paul Bours has apologised for a patient’s unhappiness about her outcome but says he acted within the rules.

Hogan’s surgeon, Bours, regards criticisms of the industry and his work as a “hatchet job” driven by orthopaedic surgeons who want to protect their turf.

He was critical of the tribunal finding against him, saying there were “factual errors” and it was “totally biased”. While he accepts his surgery left Hogan with two different-sized feet, he said she presented to him with pain and deformity, all risks were explained and “unforeseen issues” emerged during surgery, which is common for all surgeons.

“I’m so sorry for the outcome. I wish it was better. But with the skill set that I had and the presenting change pathology, I didn’t do anything illegal. I was Commonwealth-accredited, had all the bona fides to perform surgery. It’s not like these are beauticians with a knife,” Bours said.

“I met my statute requirements for practice. I was not obliged to disclose anything. This story isn’t about patient outcomes … It’s about money and control.

“Foot surgery is really complex. You’re dealing with degenerative pathology. It’s never going to be 100 per cent,” Bours said. “I felt my training was of a high standard on foot and ankle. But there was very little trauma surgery,” he said. “Who made them king?”

Former AHPRA investigator turned lawyer David Gardner says the revelations point to systemic failures with the way healthcare is regulated in Australia, from accrediting training courses to investigating complaints and suspending rogue practitioners, not only in podiatry but across all professions.

“The system is broken,” he says.

‘Extremely concerning’

Most podiatric surgeons in Australia are either members of, or have completed training at, the Australasian College of Podiatric Surgeons – unlike the vast majority of surgeons in other fields who must have AMC-accredited training.

The college was established in the 1970s to create an alternate pathway for podiatrists to expand their services beyond physiotherapy and orthotics to surgery. Early entrants joined the college with a diploma in podiatry, and after completing the college’s three-year course, began performing an extensive range of surgical procedures on the foot and ankle.

The college has a dual role, providing training but also lobbying for greater rights of its members. Over the decades, it has launched campaigns with state and federal governments to expand the rights of the profession by promoting greater competition as one way to reduce costs and strain on the public health system.

By far the biggest win for the college came in 2010, when AHPRA agreed to recognise the profession and accredit its training courses – meaning graduates could legally call themselves surgeons in every state. On its website, the college claims this “affirms” surgery performed by its members is “safe, clinically effective and cost-effective”.

“No individual or organisation should imply or suggest that the training and or skills of podiatric surgeons in Australia is in question,” the college’s website states.

However, this investigation has found many of its members have been subject to conditions on their practice after complaints about clinical care were upheld – including senior members of the college.

Many podiatric surgeons have also been the target of medical negligence lawsuits – which frequently result in out-of-court settlements with no admissions of wrongdoing, and are not publicly available.

Perth-based Andrew Knox had conditions placed on his ability to practice earlier this year, but those have since been removed from his profile. There is no requirement for past conditions to be published once they have been completed, and he now has a clear public record.

Through lawyers, Knox said he was unable to comment due to patient confidentiality.

Knox has two lawsuits currently against him in WA where judgments have not yet been made. In one case, a patient has alleged Knox did not have the appropriate training and performed a surgery which left the patient with insomnia caused by pain, psychological distress, and a reduced capacity to walk and stand, according to court documents.

This masthead does not suggest the allegations made against Knox are true, as the cases are yet to be determined.

Two college fellows with past leadership roles – former treasurer Bours and former president Robert Hermann – have each been called before tribunals at various stages of their careers. Bours was found guilty of professional misconduct for one patient, and unsatisfactory conduct for three others.

Hermann was initially subject to conditions on his practice in 2006, after the Podiatrists Board of Queensland found he posed “a serious potential risk to the wellbeing of vulnerable persons” in the wake of complaints from eight patients.

Proceedings against Hermann were dismissed when in 2010 he agreed to “comprehensive” undertakings, including mentoring by a third party. Hermann made no admissions of unprofessional conduct but agreed to comply with mentoring within three years.

Hermann did not respond to requests for comment.

The Australasian College of Podiatric Surgeons declined requests for interviews and did not answer detailed questions but issued a statement, defending the “years of specialist training” completed by its members.

“All surgical colleagues and cohorts must, from time to time, deal with circumstances in which patients are unsatisfied with outcomes,” the college said. “This is part and parcel of the profession.”

What is the relationship between AHPRA and the Australasian College of Podiatric Surgeons?

AHPRA was created in 2010 and was the beginning of a national scheme to regulate healthcare. One of its key duties is approving education courses for health practitioners. For podiatric surgeons, AHPRA accredited training provided by the Australasian College of Podiatric Surgeons (ACPS) which allows graduates to use the term “surgeon”. AHPRA then set up the Podiatry Accreditation Committee to assess standards and monitor training. Former ACPS president Mark Gilheany was appointed as deputy chair of the committee, which the AOA claims creates a conflict of interest by allowing the college to assess its own courses.

A spokesperson for AHPRA says the law does not require medical negligence lawsuits to be reported to the regulator or published on the national register of practitioners.

They say Australian health ministers considered changing the law on this recently, but decided against it.

Concerns ignored

While the college’s training standards will be a focus in the Podiatry Board review, there has been internal division within the college about the quality of its courses for years.

US-trained podiatric surgeon Walter Coffey was a founding member of the college. He contributed to its policy and training documents, but quickly became disillusioned with the leadership’s approach to medical training.

Over the next decade, he claims to have seen invasive surgeries by podiatric surgeons in Australia that turned patients into what he describes as “surgical assault victims”. He provided expert evidence against podiatric surgeons on more than one occasion, and believes this, combined with his advocacy for higher standards, meant he was expelled from the college.

The tipping point for Coffey came when members of the college began participating in trips to Vietnam’s Da Nang Hospital in the late 1990s and early 2000s to perform surgeries on patients with complex problems, such as limb deformities from bomb blasts or children with club foot, without what he considered to be adequate training.

Sue Gibson, a podiatrist who attended one of the Vietnam trips in 2002, says she observed podiatric surgeons performing operations that they would not be allowed to perform in Australia, on young children.

Gibson became so concerned by what she saw that she and another podiatrist, Miriam Clarkson, wrote to the organisation responsible for funding the trip to outline their concerns. “We never got a response from them … And I wasn’t invited on another trip.”

Walter Coffey met Kevin Rudd to discuss dangers of podiatric surgeons. 

Coffey has spent the past decade trying to draw attention to what he sees as the dangers of podiatric surgeons by reaching out to regulators, departments and politicians, including a meeting with former prime minister Kevin Rudd in 2012. All have been ignored, he says. “The Australian public has been hoodwinked,” he says. “Does someone need to die before action is taken?”

It wasn’t only Coffey who challenged college’s training internally. Podiatric surgeon Alan Bryant was a fierce advocate for the college, joining in 1986 and seeking to partner with the University of Western Australia to improve the quality of training.

However, in 2010, he resigned, citing a refusal to allow university graduates to become fellows. In a letter sent to the college, obtained by this investigation, Bryant said his decision to resign had not been reached lightly.

“The ACPS has for many years embellished and exaggerated its practical training program to make it seem more credible than it is in reality,” Bryant wrote.

Bryant described the training program at the time as “professional deception” and “untenable” where trainees experience “scant surgical exposure” that often amounted to only two days per month.

Bryant was critical of the leadership team’s perspective that the ACPS was the “podiatric equivalent” to the Royal Australasian College of Surgeons – the gold standard for surgical training.

“I cannot, in good conscience, remain a member of an organisation that places self-preservation beyond the best interests of the profession,” he wrote.

Bryant did not respond to requests for comment.

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There are around 40 podiatric surgeons registered in Australia, who perform a range of procedures, from removing ingrown toenails to more complex procedures like foot reconstructions.

One podiatric surgeon, who declined to be named, says orthopaedic surgeons have a tendency to over-operate, where podiatric surgeons can blend conservative treatments with surgical options.

“If all you have is a hammer, everything looks like a nail,” the podiatric surgeon says.

AOA Foot and Ankle Society president David Lunz disagrees saying the industry’s objections are motivated by patient safety and a concern over the “vast difference” in training.

Orthopaedic surgeon David Lunz is calling for greater regulation of podiatric surgeons.Credit: Steven Siewert

“If you concentrate on it being a turf war, then you completely ignore the difference in training and education,” Lunz says. “A turf war assumes that the two parties involved are equally trained and equally competent.”

Lunz routinely performs revision procedures on patients who have been operated on by podiatric surgeons, describing cases of irreparable joint damage or amputated toes. He said these outcomes indicate a lack of surgical training, or general medical knowledge.

“You’re not just operating on a foot or toe,” Lunz says. “You’re operating on a person. That person has got medical conditions, they’ve got cardiac conditions, they’ve got vascular conditions. You need to know about everything.”

Following revelations of widespread misconduct in the cosmetic industry, the federal government introduced new laws to ensure all surgeons are medically trained, and complete courses accredited by the Australian Medical Council.

However, these laws excluded podiatric surgeons.

“There’s been this public outcry, ‘How can these people be called cosmetic surgeons?’ ” Lunz said. “Well, it’s exactly the same situation … The training between a podiatric surgeon and orthopaedic surgeon are vastly different.”

Concerns about podiatric surgeons have been repeatedly raised in public forums and private submissions. In one parliamentary hearing this year, AMA WA president Mark Duncan-Smith warned of unintended consequences of the carve-out for podiatric surgeons. He said this would create a “potential loophole” where they can still use the title of surgeon, “even though they are not technically part of the surgical class”.

“Podiatrists do not just shape bunions; they actually do joint replacements in feet and surgery of this type. By leaving it the way it is, it means that potentially the public – and this bill is about the safety of the public – would consider podiatric surgeons to be part of the surgical class.”

In the same hearing, Australian Ethical Health Alliance chief executive Adrian Cosenza said there had been warnings about podiatric surgeons for more than a decade, adding he believed the education, skills and training were substandard to orthopaedic surgeons.

“This is a community health problem that is long overdue to be addressed before more patients are further harmed,” he said.

AHPRA podiatry board’s Cylie Williams defended the training completed by podiatric surgeons and denied knowledge of problems with the industry prior to the triggering of the current review. “We can’t fix things we don’t know about,” she says.

Williams said the review will consider everything from lifting registration standards to introducing rules for who can use the term “doctor” and “surgeon”, despite claiming “really strong guidance” already exists.

Who can call themselves ‘doctor’ and ‘surgeon’?

‘Doctor’ is not a protected title in Australia, meaning a range of health practitioners (podiatrists, dentists, chiropractors) can use “doctor” as a courtesy title without completing a medical degree. People who complete post-doctorate degrees in any field can also use “doctor”. It is an offence for a health practitioner to mislead patients into thinking they are medical doctors. 

“Surgeon” is a protected title in Australia, with recent changes requiring all surgeons to complete a medical degree and training approved by the Australian Medical Council (AMC). Podiatric surgeons are exempt from this requirement. 

‘I want to apologise’

Only three of the patients interviewed for this investigation made complaints to AHPRA or NSW regulator, the Health Care Complaints Commission, (HCCC), after procedures with podiatric surgeons went wrong. Even some who had sued did not make complaints.

Some felt the regulator couldn’t help them, or felt ashamed for not realising podiatric surgeons were not medical doctors.

One who did complain to AHPRA is 67-year-old Norah Manson. She was dissatisfied with the response.

Manson had an operation performed by podiatric surgeon Knox in 2020, but was left hospitalised after a severe infection.

Documents and correspondence seen by this masthead show it took five months for the regulator to decide to launch an investigation, six months to impose interim conditions on his practice, and more than a year before they obtained independent expert opinions.

In October 2022, 17 months after Manson’s initial complaint, AHPRA wrote the investigation was continuing, but the interim conditions had been removed.

“I acknowledge that this investigation has taken longer to complete than we had expected … I want to apologise for that,” AHPRA wrote. “Without trying to make excuses, as an organisation, we have been undergoing significant change to our structure and our ways of working.”

Manson says she was never informed about the final outcome of her complaint. His AHPRA profile is clear.

Gardner says conditions such as mentoring allow the regulator to “look to be taking action” without actually stopping the practitioner. “It’s become the default,” he says. “They don’t want to rock the boat.”

While AHPRA is responsible for investigating patient complaints, disciplinary action is ultimately decided by one of the 15 national boards for each profession.

For podiatric surgeons, this action is determined by the Podiatry Board of Australia – made up of nine people, mostly podiatrists, and no medical doctors.

Gardner queried how these practitioners are qualified to evaluate complex surgeries, a position shared by Lunz. “They are well suited to regulate podiatrists, but they’re not surgically trained,” Lunz said. “So they are not trained to assess surgery.”

There are no set rules around podiatric surgeons’ scope of practice, meaning the decision on whether to perform complex procedures, such as ankle fusions and foot reconstructions, come down to the individual practitioners’ risk appetite.

In one since-deleted video, Sydney podiatric surgeon Ozan Amir was filmed draining fluid from a knee without gloves – treatment the AOA described in a regulatory complaint as “extremely concerning” due to the infection risk and practitioner’s lack of training in this body part.

In a statement, the HCCC agreed the video raised issues of concern and the matter was referred to the Medical Council of NSW.

Amir has conditions on his AHPRA profile and did not respond to questions.

One former board member, who could not be named because they were bound by confidentiality agreements, said they observed a number of podiatric surgeons who were “gung-ho” but the board was powerless to stop them.

“If you say, ‘I can fix this, do that’, and it doesn’t work, people can’t walk … AHPRA needs to be more careful about who they allow into the college,” the former board member said. “They were too anxious to get people through and let people in who should not have been there.”

Transparency

This year, AHPRA reviewed what information should be published on its register of practitioners, including whether historic conditions or medical negligence lawsuits should be published.

Former ACPS president Rob Hermann made a submission to this review, obtained by this masthead through freedom of information laws, in which he advocated against additional information being published.

“The register’s main purpose is to provide a definitive list of registered health practitioners,” Herman states.

Hermann agreed to comprehensive undertakings in 2010 after complaints were made by eight of his patients on the basis he made no admissions of unsatisfactory conduct.

In his submission, he says a surgeon’s history is accessible on request and advocated for the “right balance” between public interest and safety and the rights of an individual practitioner.

Hogan believes the system entirely failed her – from allowing Bours to operate on her while under investigation, to failing to enforce consistent training standards for all surgeons.

She has spent years seeking answers from AHPRA, and other bodies, and says the complex web of regulators and professional bodies makes finding critical information all but impossible.

“I don’t know where else to turn,” she says. “It’s too late for me, but hopefully speaking out can stop other people from going through what I’ve gone through.”

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