In December 2023, The Age, the Sydney Morning Herald, and 60 Minutes ran stories condemning podiatric surgeons “Sole destroying: How surgeons wield scalpels without medical degrees“. The charge: they could “pick up a knife with only a podiatry or science degree” at institutions “not accredited by the Australian Medical Council.”
The timing was not coincidental. The Australasian College of Podiatric Surgeons had just applied for Medicare reimbursement.
The public response was swift and largely hostile. Only doctors should use the title “doctor.” Only the Australasian College of Surgeons should accredit surgery. The foot is too complex for anyone without a full medical degree to operate on.
I have spent thirty years studying health professional boundaries. My purpose here is not to defend or attack podiatric surgeons. It is to ask a more interesting question: why did the Medicare application — not the surgery itself — trigger such a visceral response about safety and legitimacy?
The answer tells us something important about how healthcare work gets owned, and how that ownership is maintained.
The outrage arrived late
Podiatric surgeons have been operating in Australia for decades. They operate in hospitals and private rooms, under clinical governance frameworks. A 2024 Independent Review, commissioned by the Podiatry Board of Australia and AHPRA, found that concerns about the quality of their education and training were not supported by the evidence.
The controversy did not erupt when podiatric surgeons began operating. It erupted when they sought Medicare recognition.
In the United Kingdom, podiatric surgeons were introduced in 1983, received general NHS funding in 1993, and have been appointed to consultant grade since the 1990s (see Borthwick, 2000). In the United States, they operate as recognised members of the healthcare team. Neither country requires a medical degree. In neither country is the basic existence of the role treated as the same kind of public anomaly. What differs is the institutional history — and crucially, the funding architecture.
In Australia, podiatric surgery existed, was regulated, was taught at degree level, and was practised. But its surgical procedures did not have routine Medicare recognition. The Medicare application was not a request to begin doing something new. It was a request for the federal funding system to recognise work that education, regulation and established practice already recognised.
And that is what activated the response.
How work comes to be owned
Healthcare work does not naturally belong to any profession. It comes to be owned — through history, through legislation, through the accumulation of institutional decisions made over long periods of time.
Medical ownership of surgery and prescribing can be traced to the mid-nineteenth century. The 1858 Medical Act in Britain, and analogous laws in Australian colonies, gave the medical profession not a simple monopoly but a set of mechanisms through which the roles of other emerging groups could be shaped and restricted. Medical practitioners sat on the registration boards of other health professions. Access to some allied health services was made conditional on medical referral. Funding arrangements recognised medical work and, for a long time, largely nothing else.
That history is encoded in the structures we now take for granted. A physiotherapist who can assess and treat without a referral was not always permitted to do so. A pharmacist who can vaccinate acquired that authority through specific regulatory change at a specific moment. The scope a profession currently holds reflects what it was able to claim or defend historically — not simply what it is now capable of doing.
What makes professional ownership durable is not any single rule. I call the process professional boundary instantiation: the way a profession’s authority becomes embedded across the institutions that educate, regulate, classify and fund work. A boundary that feels natural is usually a boundary that has been encoded often enough, in enough places, for long enough, that the encoding has become invisible.
The podiatric case is almost textbook
By the time of the Medicare application, substantial institutional recognition already existed. Podiatric surgeons in Australia had formal university education, statutory professional regulation, an established scope of practice, and decades of documented clinical activity. What they did not have was fiscal recognition — public funding that would acknowledge their work as a legitimate, reimbursable service within the healthcare system.
The UK comparison makes the significance of this visible (see Kannegieter et al, 2025). UK podiatric surgeons complete approximately eleven years of training and are required to perform 850 foot procedures before qualification. Trauma and orthopaedic surgical trainees, by contrast, complete a combined minimum of twenty elective osteotomy procedures drawn from nine different anatomical sites — foot, hip, spine, humerus, wrist, hand and others — before sub-specialising. The difference in training length almost certainly reflects what the Health and Care Professions Council observed when establishing UK annotation standards: orthopaedic surgeons gain broad experience before sub-specialising in the foot; podiatric surgeons focus exclusively on the foot and its associated structures from the beginning.
This is not an argument that one training is better. It is an observation that “how long did they train?” is not the same question as “are they trained for this work?” The conflation of those two questions is one of the ways that historical ownership is defended in clinical language.
The Independent Review’s conclusion was clear: concerns about the quality of podiatric surgical training and education are not supported by the evidence.
What the Medicare application newly put at stake was not whether podiatric surgeons could operate — they already did — but whether the funding system would formally recognise their work. Safety became the language through which that institutional contest was fought. That does not require assuming that every safety concern was insincere. Institutions shape what people genuinely perceive as legitimate, natural and safe. The clinical concern can be real and the contest can still be jurisdictional. Those are not mutually exclusive — which is precisely what makes the pattern so persistent.
The question worth asking
The standard debate about contested professional boundaries asks: who does it better?
This is almost always the wrong question. Studies comparing podiatric and orthopaedic outcomes in foot and ankle surgery show strong confirmation bias according to the professional affiliation of the authors. There is no published evidence that either profession does the other’s work better. Both produce literature defending their position. Neither produces the disinterested comparison the question seems to demand.
The question is framed as clinical. The contest underneath it is jurisdictional.
The more useful question is: what work is being done, at what level of complexity, by whom, and under what governance?
That question does not ask whether a podiatric surgeon or an orthopaedic surgeon is generically superior. It asks what capability is required for this work, in this context, and whether it exists — under appropriate governance — in this practitioner.
This matters beyond podiatric surgery. The same pattern recurs across professional boundaries throughout the healthcare system: nurse practitioners seeking prescribing rights, allied health professionals seeking direct referral access, pharmacists seeking expanded clinical roles. In each case, the debate is conducted in clinical language while the underlying contest is about which institutional mechanisms will extend their recognition to which work.
The profession is not the work
None of this is an argument for dismantling professional structures or removing the governance frameworks that make clinical practice safe. Training, regulation, supervision, and accountability matter. The argument is more specific.
The current allocation of tasks between health professions is not a natural or inevitable arrangement. It reflects historical power as much as clinical necessity. Professional identity and professional ownership are not the same thing. And the question “whose work is this?” — asked as though the answer were obvious — is almost always a question about history, not about capability.
The harder conversation is about what we are actually trying to achieve. If the goal is healthcare systems that allocate work according to what practitioners can safely do, at what complexity, under appropriate governance — then the profession of the person doing the work is one relevant consideration among several. It is not a sufficient answer on its own.
The outrage that greeted the podiatric surgery Medicare application was entirely predictable. It followed the same logic that greets every fiscal challenge to existing professional ownership: safety concerns, training concerns, title concerns — all of them real, none of them new, all of them arriving precisely when the economic architecture of the arrangement is threatened.
Understanding why that pattern recurs is more useful than adjudicating any individual case. The work does not change because the institution changes its mind about it. What changes is whether the system has learned to see it.
Susan Nancarrow is a health workforce sociologist and Principal of HealthWorX Futures. She is co-author of The Allied Health Professions: A Sociological Perspective (Policy Press, 2021)
