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From: Elliot Udell, DPM


Many doctors and dentists penalize patients for missing appointments irrespective of whether it is the first or a subsequent visit. One rheumatologist in my area is even bolder. If a patient misses a single visit, he sends them a letter letting him or her know that he or she is persona non grata in his practice and should find another rheumatologist. I know he does this because two patients recently were upset at me for referring them to this doctor. Because of his behavior, I am now reluctant to refer any more patients to him.


Several years go, I missed a dental appointment and his office manager called me and told me they are charging me a hundred dollars. I let the dentist know that I would pay him what he asks, but would no longer use his services. He retracted the fee and since that time he has done a number of crowns for me as well as other dental work. Had he gotten the hundred dollars out of me, he would have lost thousands.


The bottom line is that if you are prepared to penalize a patient for missing a visit, you should also be prepared to suffer the consequences of angering a patient. In my practice, when this happens, I bury my ego, give up being right, and continue rendering podiatric care to my patients.


Elliot Udell, DPM, HIcksville, NY 

Other messages in this thread:



RE: Smart Patient With Smart Phone (Bret Ribotsky, DPM)

From: Jeffrey Kass, DPM

I had the exact situation occur in my office that Dr. Ribotsky describes.

Jeffrey Kass, DPM, Forest Hills, NY,



RE: Affordable Care Act (Obamacare) Perk (Jon Purdy, DPM)

From: Jason Kraus

Dr. Purdy hit the nail on the head in identifying why there is such a deep ideological divide in our country today. Dr. Purdy's hope that he still lived in a world that was founded in 1776 and his narrow view of capitalism, juxtaposed with those who believe that we don't really live in that world any longer, and that unbridled capitalism cannot solve all of today's very real challenges, has created an ever-widening abyss.

While I think most Americans still place their faith in the foundational pillars established by our founding fathers, many have come to realize that the unimaginable changes that have taken place in the past 230 years require us to reflect on the needs of our modern world and adapt in ways that preserve our democracy and advance society. Those who insist on harkening back to the days of yore will always be at odds with those who believe that our nation is best served by constantly evolving in a changing world in a manner that preserves our core beliefs as a nation.


Jason Kraus, Deer Park, NY,



RE: Sterilizing Bits Between Debridements (Warren Joseph, DPM)

From: Gary S Smith, DPM


I agree with everything Dr. Joseph has said about what is cultured from un-sterilized bits. I did, however, attend a lecture by Dr. Joseph about 20 years ago where he told us that research had been done where people had been purposely exposed to fungus spores and there was no increase incidence in onychomycosis. In other words, it was like with warts. Many people are exposed to the pathogen, but only those already pre-disposed become infected. The likelihood of giving somebody onychomycosis by using a bit that has been wiped or soaked as opposed to autoclaved is pretty much nil.


Gary S Smith, DPM, Bradford, PA,



RE: ABPS Name Change (M. W. Aiken, DPM)

From: Craig Breslauer, DPM

I respectfully disagree with Dr. Aiken. The proposed ABPS name change is of paramount importance and is long overdue. It is not about where we have been or where we came from as a profession. It is not about you and me today as much as it is about our future practitioners and the challenges they will face.

We need much wider public awareness as to the skills and services modern podiatric surgeons offer. For example, I walked into a treatment recently to see an established patient of mine for an ingrown nail. I asked her about the Swedo brace on her ankle, only to learn that she recently suffered an inversion sprain. When I advised her that I would have been happy to help her with that problem as well, she stated, "Oh, I thought podiatrists only treated toenails." Then, after being thoroughly insulted, I learned that she saw one of my orthopaedic partners the day before for treatment of her ankle.

To the average person, ABPS might indicate that we are certified in toenail surgery. The American Board of Foot & Ankle Surgery leaves zero room for ambiguity. We do not need surgical board certification for the valuable services we provide day-to-day in our offices. However, we do need this certification to communicate to the public and insurance carriers that we are the most qualified physicians to address foot and ankle pathology in the OR as well as the hospital.

Craig Breslauer, DPM, Palm City, FL,



RE: Starting A Practice (Nicole Rubackin-Hayward, DPM)

From: Edmond F. Mertzenich, DPM

I'm glad to hear you are starting out in practice and that you are curious on how to make it work. I have been in practice, both private and clinical, for over 20 years. My wife and I work with practitioners who are interested in beginning or expanding their practice. When speaking with practitioners, some of the information we require to assist in their endeavors is the same information you need to make your decisions.

"What is your business plan?" This should be where you want to be in 1, 3, 5, and 10 years. "What steps do you need to take to reach these goals?" Part of this would be how to brand yourself. Most times, this is enough to get them thinking in the correct direction. There are many other steps practitioners need to take to achieve success. You can’t build a house without blueprints. Building a business without a plan is a bad route to take. Using the suggestions in the other posts could be included in the steps to reach your 1, 3, 5, and 10 year goals.

Edmond F. Mertzenich, DPM, MBA, Rockford, IL



RE: Medical Missions (Andrea Mills)

From: Krista Richter

Two of the societies I work with offer mission trip options:


1) Assn of Extremity Nerve Surgeons - Ecuador - leprosy patients and extremity nerve surgeries only.

* Space very limited and students would be allowed upon approval of experience .

* Costs would be covered by volunteer, unless grants are given for the trip for residents/ staff/ students.

* Since this is advanced surgery and MDs also provided hand sx, it is rare students go, unless they have done externships.

2) Texas Podiatric Medical Foundation -

San Miguel de Allenda, MX Mission - July annually. 2012 pending travel safety issues. Travel grants provided for students and residents and based upon availability. Submit request via e-mail with professor referral. Spanish a plus. Provide clinic, surgery to adults and children for lower extremity care. Also provides shoes to three orphanages.

Santo Domingo, Dominican Republic - NEW mission this year - Aug 17-21, and will return Feb 2012 dates TBA. August mission is full .  Volunteers have to be approved by government 3 weeks prior. We will provide clinic and sx for adults and children through the government hospital there. Travel grants will be available for 2012 trips for students/residents, Spanish a plus.


3)  Honduras Mission - Dr. David Cavallaro, Oklahoma.

The TPMF is affiliated with this mission and helps provide supplies  The missioon to San Pedro Sula, Honduras provides predominantly surgery for adults for lower extremity care. Volunteers pay their own way unless travel grants are given. Dr. Cavallaro runs the mission, and it goes twice a year: Jan. & July. His phone is 405-631-2333.

Krista Richter, Director, Texas Podiatric Medical Foundation,



RE: Rem Jackson's Top Practices (Stephen Pirotta, DPM)

From: Peter Wishnie, DPM, Jennifer Feeny, DPM

The summit meeting given by Rem Jackson of Top Practices is the best seminar on marketing your podiatry practice, hands down. I guarantee you will at LEAST increase your profits by 20 percent. Rem is an amazing speaker and gives you a complete cookbook on how to run your practice efficiently while increasing your patients. I have learned so much from Rem and I am very thankful that I have met him. I have been to the summit meeting for five years now and I plan on taking my associate doctor this year. 

This will be the best thing you can do for your practice this year.

Peter Wishnie, DPM, Piscataway, NJ,

I joined Top Practices three years ago and it has been a game changer for me. At the ripe age of 37, I was already burned out on podiatry and contemplating searching for a different career. With Rem's help, I have gotten my weekends and evenings back! I changed my practice and now see the types of patients I want to see, when I want to see them. I enjoy podiatry again. Rem and Top Practices members have given me the tools and resources to accomplish my goals.

Jennifer Feeny, DPM, Roanoke, VA,



RE: 1st Providers Choice (Len Sanchez, DPM)

From: Adnan Shariff, DPM

I am using IMS from 1st Providers Choice. 1st Providers Choice is a third-party reseller of IMS by Meditab. You get support from Meditab directly and from 1st Providers Choice. The billing software is really good. The software handles both my tax IDs well. The EMR involves a lot of work. There are no good podiatry templates; you have to make your own or use Dragon Pro.  Training is not very good. They are a new company and sometimes can't handle all the training, etc.

Their support doesn't respond to e-mails in a timely fashion. You have to call, then wait for someone to call you back. Support is okay. Many times we go directly to Meditab-support because either we can't reach 1st Providers Choice or they can't get back to us soon enough. I'm still waiting for two months to get eRx through 1st Providers Choice. They have recently hired more staff to handle all their new clients. I think the price is good though.

Adnan Shariff, DPM, Fort Pierce, FL,



RE: Difficulty Passing National Boards Section (Name Withheld)

From: Dwight L. Bates, DPM

Spend one hour with me on Skype to learn how to pass the exam. Every podiatry student by the third year knows the facts, but podiatric terminology is so awkward, it is confusing on paper exams. I will not charge a fee for this.

Dwight L. Bates, DPM, Dallas, TX,



RE: Answering Service (Bela Pandit, DPM)

From: Jack Sasiene, DPM

I quit using an answering service three years ago as the cost kept going up, and their service was part human response and part "the patient left a message we retrieved later." I figure, why pay them for what I could do. I bought a cordless system from Panasonic that has a base unit and can expand w/cordless units. It can handle numerous voice mail boxes and multiple messages, and auto-answer to leave a message if your staff is busy .

We record a message that tells patients: "If you have an emergency and have just had surgery, or you are a current patient seen in the office in the last two weeks, please call #... Otherwise, please go to the emergency room as we can't help you over the phone, if we have not recently seen you in the office." This is followed by the usual "leave a message for..., etc." 

I have had less than five calls in three years that I would consider unnecessary. It can also depend on your community, but it cost $500 for the base unit and $100 for each cordless. It paid for itself in half a year or less.

Jack Sasiene, DPM, Texas City, TX,



RE: Fraud and Abuse (David Gurvis, DPM)

From: Multiple Respondents

I would like to thank Dr. Gurvis for bring up this vital topic of providing nail care as a covered service when you know it is not. I have a practice in the Midwest and frequently have patients without qualifying conditions mad that they cannot get their podiatric services for “FREE.” It is time-consuming to explain that there are specific rules and that they do not qualify. The mass majority are not even remotely close to qualifying.

I tell them that I would not like to go to jail, and that I will not lie to get their desired services covered. Some will decline the services if not covered, but most request care as an out-of-pocket expense.

I have a podiatry friend who told me that he was billing for services when he knew that they were not covered. His excuse was that the patient deserved the care. I think that this is true, but are you willing to go to jail so that the patient does not get the bill? I am not. We should clean our own house.

Scott Shields, DPM, Enid, OK,

With all due respect to Dr. Gurvis' frustration, the input staff of the office should be trained to screen out patients such as these.  Questions should be asked when the patient first calls the office (if the potential patient states they need toenails trimmed, the phone-screener should ask questions that will certify routine foot care).  The input questionnaire should be very clear as to what constitutes routine foot care. When the staff reviews the questionnaire and does not see routine foot care qualifiers, the patient should be informed of that. In my opinion, those not eligible for Medicare's covered foot care can be screened out during the initial phone call. There is no sense having the doctor go on a hunting expedition trying to find a reason to qualify a patient for routine foot care.


Richard A. Simmons, DPM  Rockledge, FL,

If what you say is true, the previous podiatrists are stealing money from you. Document the good health of the patients, and encourage them to file qui tam lawsuits against the podiatrist thief.   

Dwight L. Bates, DPM, Dallas, TX,



RE: APMSA Urges Profession’s Intervention to Avert Residency Crisis

From: Multiple Respondents

We are writing this letter in response to the Urgent Request published yesterday by Zackary B. Gangwer, APMSA President. First, we want to assure all of the students in each of the nine schools that the profession is aware of this residency crisis and that the profession is moving in a coordinated manner on the immediate and the long-term fronts to eliminate the shortage that the ASPMA President described.

The message that we want to convey to the APMSA is that the Goldfarb Foundation, the APMA, the AACPM, COTH, CPME, ACFAOM, PMAP and each and every state podiatric medical association have an acute understanding of the shortfall and its impact on the students. All of the stakeholders know that you are our collective future in that you are the continuation of our profession.

The final tally of residency shortage was...

Editor's Note: The extended-length letter written by Drs. Thomas Ortenzio and John Marty can be read here.

I am the Chief of Podiatry and Director of Podiatric Medical Education at St. Barnabas Hospital, Bronx, New York. Currently, we have 16 residents in our PM&S-24 and 36 Programs. I blame CPME, its rules, and ridiculous regulations for the shortage. Several program directors feel the same way as I do.

I am planning on cutting the number of residents that I will take in July 2011 solely as a result of the policies that CPME implements which have made my job as a residency director more and more difficult each year, only creating more paperwork, and actually decreasing the time that I can spend teaching. 

Now they have implemented a new CPME 320 with more and more of the same rules and regulations. After reading it, the only conclusion I can make is that I need to decrease the number of positions, to make sure that  I have enough time to implement them, even though the hospital's resources could easily allow for more, not less, residents.

Emilio Goez, DPM, Bronx, NY,



RE: Help for Class of '10 Without Residencies (Hal Ornstein, DPM)

From: Kathy Satterfield, DPM

While the pain of not having a residency stings now, AAPPM's offer of this preceptorship is going to pay off in huge ways when these young doctors are in practice a few years from now. They will have what we never did - business acumen.


As a graduate of a surgical residency program 20 years ago, no one taught me how to do billing or coding, or how to offer patients more than my medical and surgical services. These graduates will have the best of both worlds. But, of course, it is delayed gratification. Although it hurts now that you did not get a program, be smart and take Dr. Ornstein up on this valuable offer. In terms of the bottom dollar, you will fare better than those who got the best programs right out of school. Thanks, Hal. You continue to give to the profession more than you get. Thank you, friend, for your generosity and collegiality. 


Kathy Satterfield, DPM, Upland, CA,



RE: Doctor (DPM) Doctor? (Bryan C. Markinson, DPM)

From: Robert Bijak, DPM, Narmo L. Ortiz, Jr., DPM

A structure or profession is only as strong as its foundation. Dr. Markinson is correct in saying that to increase OUR scope we have to emulate the training (foundation) of nurse practitioners and physicians assistants, and real medical schools. As it stands now, we have seen that the highest the podiatric skyscraper can climb with its limited license is a 3-year residency, and then things begin to topple. (viz a viz Name Withheld's parity problem).


Where does the architectural planning begin for the podiatric skyscraper? The schools and the APMA. Without a change in their educational resolve, podiatry will continue to rest on the shifting sands of insurance companies, MDs, and hospital boards. The podiatric community needs to introspect and decide on what methods can be used to nudge the inertia of our schools and the APMA. If they felt as strongly as we do for a degree change, we would have seen a proposal. As of yet, nothing.

Robert Bijak, DPM, Clarence Center, NY, rbijak@

After reading all of the posts concerning parity and scopes of practice and comparisons to nurses, physician assistants, and MDs, it's obvious that our profession will not progress to anything else unless the first step is taken once and for all: achieving equal scope of practice and reciprocity of licensing of podiatry among ALL of the United States. Dear APMA, please help us with this issue NOW!

Narmo L. Ortiz, Jr., DPM, Cape Coral, FL,



RE: Loss of Privileges (Ivar E. Roth DPM, MPH)

From: Craig Breslauer, DPM

I suggest a careful review of your hospital’s bylaws. There should be clear language as to how credentialing for advanced surgical privileges needs to be documented. For instance, if a certain number of a given procedure are not performed within the reappointment period, you may be able to document proficiency via an advanced training course/CME.

Since you have not performed an ankle fusion recently, you should be able to document proficiency by taking a cadaver course or perhaps assisting in a couple of cases with another surgeon.

I recently had my privileges for total ankle replacement removed due to financial constraints. Essentially, the hospital decided that the cost of the ankle implants was too high compared to the reimbursement. I have not decided on my next step, if any.

Craig Breslauer, DPM, Palm City, FL,



RE: Loss of Privileges (Ivar E. Roth DPM,MPH)

From: Timothy James Henne, DPM, Ira Deming, DPM

I am having a similar issue. This is how I handle it. 1) Make a list of orthopedic procedures and how to revise them. 2) Have all the surgeons show all their cases for the RARE revision rates. Ask for knee fusions, shoulder fusions, hip fusions, etc.  3) Then be prepared to meet with everyone in the room with administration and "talk about it." By the end of my meeting, my orthopedic referrals actually increased.

Now whether you should be fusing, replacing, etc., it is up to you to show that you are qualified. Not having done ANY in the last two years does raise concern, so you to should be reasonable as well.   


Timothy James Henne, DPM, Clermont, FL,

In order for the hospital to do this, it would have to apply the same standards to anyone performing this type of surgery, such as orthopedic surgeons. The basis for their decision - if something went wrong, you would need to perform a fusion, and according to them, you are not qualified to do this - is nonsensical. Even if you were not competent to perform a fusion, you could refer the patient to someone else who could. This happens all the time in all specialties. The reason that your hospital is doing this is a recent change in JCAHO rules for hospitals in which continued competency to perform a procedure must be demonstrated somehow. I suggest that you have a discussion with either the chair of the credentials committee or the VP in charge of medical affairs of the hospital. You may have a problem if you are unable to demonstrate continued competency, but this same standard  needs to be applied to all who perform such procedures.

Ira Deming, DPM, Bethesda, MD,



RE: The Residency Shortage (Gregg Young, DPM)

From: Lawrence Oloff, DPM

I read with dismay Dr. Young’s post that we have more graduates than residency slots this year. More disturbing is that this is anticipated to get worse in subsequent years. There clearly needs to be better planning to create a scenario where the number of graduates closely parallels the number of residency positions. When I read statements like, “ we actually need an additional 100 graduates per year to replace the graduates from the ‘70s and 80’’s”, I feel that the parties responsible for overseeing such issues as class size and residency genesis are not steering our ship in the right direction.

I think the alarms should go off right now and that a meeting of the minds should occur to correct this imbalance, not only by residency genesis but also by capping the number of graduates until such time that all graduates have a residency position. The success of podiatry as a profession is not determined by the number of practicing podiatrists, but rather by the quality of the practicing podiatrists. In my opinion, that quality is as much a product of the post-graduate training experience as it is the undergraduate training experience.

I am not sure who is at blame here, and I certainly have no intention of casting stones. I am just uncomfortable with what I read. There has been so much emphasis on absorption of podiatric medical education into allopathic health science centers in recent years. That education will be meaningless without a residency to complete the educational product.

Lawrence Oloff, DPM, Menlo Park, CA,



RE: Discharging a Neo-Nazi (Narmo L. Ortiz, Jr., DPM)

From: Joseph J. Weisenfeld, DPM, Ivan Cooper, DPM

I must disagree with Dr. Ortiz. This is the correct forum to discuss professionalism. We are doctors, not automatons. We are emotionally affected by our environment. We have an obligation to treat patients in a courteous and professional manner to the best of our ability. However, if something in the patient's behavior and/or demeanor leads you to question that it may affect your ability to care for the patient impartially, you actually have a duty to inform the patient of your concern. 


Joseph J. Weisenfeld, DPM, Staten Island, NY,

Dr. Ortiz does not get a lot of things.  PM News is not being used for a political publication. "Dr. Name Withheld" had a dilemma in his office. He needed advice. More than ever, podiatrists are faced with situations like this. It is a REAL problem in Dr. Name Withheld's medical practice and obviously in others. Look at the responses.  Obviously, it needs addressing. There is a real concern. It seems that Dr. Ortiz wants to turn his back on a serious problem called doctor-patient relationship.

Ivan Cooper, DPM, Knoxville, TN,



RE: Physician Status in Title XIX (John Chisholm, DPM)

From: Randy Brower, DPM


Dr. Chisholm, did you proof-read your response? You talk out of both sides of your mouth which actually highlights frustration felt by many of us. I have been a paying member of the APMA for the past 5 years of my post-residency career. I have made contributions to PPAC over the years, although admittedly small due to my giant student loan burden.

I am choosing this year to remove myself from the APMA. I don't feel the dues match the changes and benefits I had hoped for. I am not saying our efforts have been timid, but have honestly fallen flat on the national stage. Dr. Chisholm is frustrated over lack of progress nationally over the years with title XIX but encourages us to continue to invest?  Is money really the answer?  Texas can't get ankle scope of practice fixed.  As Kathleen Stone from Arizona knows well, Arizona can't change its scope so that we can amputate a toe. If states can't fix their issues, it explains why nationally, not much gets changed. Hence the thought by many of us....the definition of insanity is doing the same thing over and over while expecting a different result. Until a real world long-term plan to accomplish title XIX is presented and implemented with incremental results achieved, don't berate those of us who withhold our money in skepticism.

My advice, instead of focusing on title XIX, go state by state,, standardize scope of practice in each state, and the APMA will see a large increase in membership and future ability to tackle national issues. Let's form an equal and empowered United States of APMA that can tackle national issues on equal footing.

Randy Brower, DPM, Prescott Valley, AZ,


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