RE: VA Provider Equity Act Introduced in the Senate
From: Jeffrey Robbins, DPM
Senate Bill 1871 “…to clarify the role of podiatrists in the Department of Veterans Affairs” has been introduced in the Senate and has been referred to committee. The is the next step in the long process of bill approval. Once again, this is the result of our combined efforts with the Federal Services Podiatric Medical Association and the American Podiatric Medical Association.
What is most disconcerting is that the ABPM is excluding the majority of our profession from being able to sit for their exam in wound care and limb salvage. I read their requirements that all applicants would have to have gone through a residency in wound care or have worked for a wound care center and document cases. This excludes ABPM-certified members such as myself who have practiced wound care for over thirty years in solo practices.
Dr. Benard and those who created the exam are among my most respected colleagues and friends. But in not allowing most podiatrists to participate in this new level of certification, they are being very unfair to my colleagues as well as to me. I trust that they will reconsider this process and come up with a program that is far more fair and equitable.
Elliot Udell, DPM, Hicksville, NY
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Notice to the Customers of Ortho-Rite
From Greg Sands
Our lab sustained significant damage from a major fire in our building the night of Dec 12th and we currently cannot operate. We are doing everything we can to return to full operation as quickly as possible but at this point we simply don’t know when that will be. We regret any inconvenience this may cause our clients, and we assure you that, as always, we are committed to accommodating your needs to the best of our ability. Our competitor friends are willing to help under our supervision so that we can still operate on a limited basis in the short-term.
Having personally consulted and currently engaged with the VC/Private Equity (PE) world and founder of Extremity Healthcare, I would like to add some very important and direct points to Hal’s comments on podiatry and VC. Podiatry has always been a bit behind other specialties when you look at other healthcare consolidations.
The main reasons that PE firms have not been able to really see value in podiatry as a platform investment is because the successful PE firms saw podiatry groups as too loosely affiliated, were concerned about integration issues, compliance issues, and the ability to...
Editor's Note: Dr. Helfman's extended-length letter can be read here.
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Venture Capitalists Target the Podiatric World
From: Hal Ornstein, DPM
Corporate America is finally recognizing the value of podiatry. Recently, private equity investors/venture capitalists have taken a very close look at specialty physician groups such as podiatric practices. Many podiatry practices have great growth potential and simply need the guidance and financial backing to significantly increase earnings. Investors are attracted by the prudent, routine medicine practiced in a podiatrist’s office combined with the added benefit of being able to perform profitable elective procedures, such as foot, ankle, and sports medicine surgeries.
Further, there is the potential for ownership of ambulatory surgery centers. By owning and controlling the operating environment, practices are able to function outside hospitals, leading to better physician economics, improved cost containment, and better access to care for patients. From an investor’s perspective, a business model of an efficient successful practice thriving in one location so that it can be replicated elsewhere is very attractive. In fact, the practices that are most attractive to investors are ones that have developed strategic plans to compete against regional health facilities and acquiring smaller practices. By owning and controlling the operating environment, practices are able to function outside hospitals, leading to better physician economics, improved cost-containment, and better access to care.
Hal Ornstein, DPM, Howell, NJ
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: ABPM Wound Certification
From: Randolph C Fish, DPM
Parity is here, why take a step backwards? Lately, I have seen several advertisements from the ABPM touting their new examination for certification in wound care. Since the ABPM is a CPME-approved board, I am concerned that someone will perceive that this particular certification is worth more than it is. This is not a board certification. It is, rather, recognition for demonstrating an added skill set called a “Certificate of Added Qualification” (or CAQ for short). There are several exams in the marketplace offering a similar certificate. Whereas the ABPM certificate is for podiatrists only, other groups offer podiatrists the same certification as allopathic and osteopathic physicians, giving parity to DPMs, MDs and DOs in the wound care field.
The certification I prefer is through the Council for Medical Education and Testing (CMET). It is a non-profit, physician-specific examination that has certified DPMs, MDs, and DOs on the same level for the past 10 years. By numbers alone, it is the largest and most widely accepted certification of its kind in the United States. Selecting a certification process is important, and being certified by the same organization that certifies all physicians is a step forward. Anyone who recognizes the need for parity in the wound care arena will look to the APWH and CMET certification.
Disclaimer: I have no financial interest in either the APWH or CMET.
Randolph C Fish, DPM, Tacoma, WA
RE: Nationwide Shortage of Local Anesthetics Mixed with Epinephrine
From: Robert D.Teitelbaum, DPM
For reasons not explained to me nor anyone else, as far as I know, there is a shortage or absence of local anesthetics mixed with epinephrine. I have found an easy and I believe safe solution to this problem. Adrenaline/epinephrine is available from our suppliers (you may have an extra vial in your emergency kit) for less than $10 for a 1mg total in 1 cc, at a 1/1000 ratio. I extract 0.2 cc from this vial and inject it into a 50 ml vial of bupivcaine 0.5% for a 1/250,000 ratio. I repeated this four more times to use up that one vial and now have 250 ml of local anesthetic that should last until the shortage is over---which the suppliers say is close at hand.
I have used this combination twenty times in the last two weeks without any side-effects or sequelae. The blanching effect is the same and is very appreciated when one needs a bloodless field, especially in the short-term.
Robert D.Teitelbaum, DPM, Naples, FL
RE: CRIP Scheduling
From: Charles Lombardi, DPM,
As a residency director for 20 years, my program as well as many other programs from the tristate area have benefitted from a local CRIP facilitated by NYCPM in the week following the national CRIP. I in no way wish to take away from the national CRIP. It serves a valuable purpose. However, having a local opportunity to interview greatly benefits students and programs who for a variety of good and valid reasons cannot travel to Texas.
This year, the local CRIP would conflict with the annual New York State meeting. Plans were in place to hold the local CRIP the weekend of January 27 and 28. A request was made to the AACPM board to push back the closing date by 4 days. Such a move would not negatively hurt anyone, would not cost any money, and would benefit many. Unfortunately, the request was denied because of one single negative vote by a single AACPM board member. Their bylaws require a unanimous vote. Consequently, many will suffer. We do seem to eat our young.
Charles Lombardi, DPM, Bayside, NY
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Holiday Sock Drive
From: Andrew I. Levy, DPM
Here is a picture of our Annual Holiday Sock Tree, in its early stages. This is an idea we got from PM News many years ago and have used in my office ever since. In each of the last 2 years, we collected over 1,000 pairs of adult and children's socks. One of our patients also donated, funding 50 pairs of shoes for children 2 years ago and 200 pairs of shoes last year.
Christmas Sock Tree
The children’s shoes and socks go to a church organization that provides basic supplies and clothes to 50 to 60 children a month, The adult socks go to 2 senior centers. This is just one of the great ideas shared on PM News, I think it deserves to be recognized and the idea spread again
The complaints regarding the ABFAS board certification process are completely unwarranted. I say this not to be elitist but to recognize that we all should strive to remain independent. I feel empathy for anyone going through the board certification process. I remember it well and it was challenging. However, I do not feel sorry for anyone complaining about it. The experience should be difficult and will make you more knowledgeable in the end. Complaining about it is silly and serves no purpose. You should prepare and do your best; and like a boxer, you need to be strong enough to give and take a punch.
I will be taking the recertification exam in 2018 and I plan to study and pass it. If I do not...
Editor's note: Dr. Peacock's extended-length letter can be read here.
I am glad that there is some discussion about the ridiculously poor pass rate of the ABFAS Exam. The objective data posted comparing our pass rates with our orthopedic colleagues absolutely should be taken into consideration. I attended a great residency program where I obtained solid training, both didactically and practically, with surgical requirements more than tripled in all categories. I never had difficulty with any of the board exams taken through podiatry school. I have established myself in my community quickly and built up a practice with good referral sources and the respect of my fellow medical colleagues at the facilities I am an attending at.
I passed 3 of the 4 ABFAS Part 1 exams on my first attempt, but had to retake the forefoot computer-based problem solving exam 5 times. In this period of time, I studied specifically for the format of the CBPS exam, spoke to the staff of ABFAS administering the exam (who to their credit was very responsive and open to helping in any ethical way they could). I am almost to the portion of submitting cases which, after hearing other examples of respectable surgeons who have failed this portion, makes me very nervous.
The system needs an overhaul which would absolutely cost ABFAS money since it did cost me thousands of dollars to even get to this point with the many retakes of CBPS. It's an excellent business strategy for ABFAS to continue to fail that many people, but unfortunately it is at the expense of the next generation of our profession.
Dr. Williams mentions that we must “not be inferior to that of our MD colleagues.” So I suppose the solution is to do what most podiatrists seem to do: overcompensate in an effort to unnecessarily prove something to an audience that does not exist. If orthopods see a suitable pass rate as 90%, podiatrists should aim to set our pass rate at a comparable level. After all, it is completely up to the board to determine what arbitrary score is considered “proficient.”
This certifying board is a bit of a monopoly that every podiatry student has to deal with to progress to the next level of their career. This certification process is exorbitantly expensive and arbitrary. The rules continually change which apply to everyone except those already certified? I passed all the written exams and (first time every exam) and interviewed well at the time the decision was made that new applicants would no longer be allowed to select their cases to submit for certification. It was at that same time the decision was made that applicants would log their cases as is done in residency.
I played the game and paid the small fortune over the years only to be told that my cases that they selected were not up to their standards. I was told that I could pay more money next year and hope they pick better cases. I continually see plenty of cases from providers certified by this board which have resulted in suboptimal outcomes. I will often end up doing the revisions to improve the health and welfare of the public. There are other boards who value your dollar and I recommend that route for those who value their time and money. In closing, I have seen some excellent work from colleagues with many different certifications. I have no hard feelings toward ABFAS and I am happy that I chose a different certifying board.
The ABPM is now offering a Certificate of Added Qualification (CAQ) in Amputation Prevention and Wound Care in response to requests from a growing number of our diplomates who requested a mechanism to demonstrate specific expertise in wound care and limb salvage to hospitals, payers, referral sources, and patients. This is a validated, computer-based exam created by an exam committee of subject matter experts.
While JCRSB doesn’t yet recognize CAQs in podiatric specialties, the CAQ is a common process in allopathic medicine (for sub-specialty recognition). The ABPM notified JCRSB of our intent to offer this CAQ to our diplomates in 2015 and there were no questions or concerns at that time. We are working with JCRSB to help create an approval process for CAQs in podiatry.
We believe the granting of CAQs is necessary since CPME already has approved fellowships in wound care, but there is no examination endpoint to those fellowships. A certification process is required before GME funds will be available to podiatric fellowships. Therefore, we have taken the initiative to help support CPME and fellowship programs by creating this CAQ process.
Lee C. Rogers, DPM, ABPM Board of Directors, Chair; CAQ Exam Committee
To echo Dr. Borreggine’s concern, I am currently sitting for my boards in both foot and rearfoot/ankle case reviews. I have the most recent training with the PMSR with the RRA certification. I had my share of failures with the CBPS portion of the exam and I found after speaking with the board that it was not due to my intellectual abilities to reason or make good decisions; it was how I was taking the test which was not explained at the time that I took that portion of the exam. After speaking with them, a video was posted regarding my specific issues that I experienced, which leads me to believe that this was a common problem among candidates.
Once I passed my CBPS portions, I sat for my case review. This was the most frustrating aspect of the process. I was failed based on...
Editor's Note: This extended-length letter can be read here
I have read the recent posts regarding the ABFAS Board Exam pass/fail rates. I looked up the American Board of Orthopedic Surgery statistics in an attempt to compare. Although the MD/DO residency in orthopedics is 5 years, their scope is the whole body, and therefore it seems to me that 3 years of post-doctoral foot and ankle residency training would be appropriately rigorous and adequate for our DPM graduates.
The American Board of Orthopaedic Surgery posts these statistics on their website:
2013 86% pass 593/689 candidates passed
2014 93% pass 713/770 passed
2015 95% pass 707/747 passed
2016 96% pass 700/729 passed
2017 93% pass 689/743 passed
Statistics can be difficult to interpret, but certainly more than 90% of our 3-year residency-trained post-doctoral DPM candidates should be able to pass “our” certification examination. If not, either we have poor candidates for foot doctors or something is wrong with the test. I would like to believe that the test needs to be closely re-evaluated and rewritten in order to better reflect the trained doctors who seek to become boarded.
I graduated from a 3-year residency program in 2013. I passed all my NBPME exams the first time and I passed the ABFAS qualifying exams the first time. Then I bought a non-surgical practice in a small town and set to work. I have spent 4 years building up my case volume and then was able to sit for the exam. I failed both the case studies and the computer-based examination. My hospital says I have to be board certified in a 5 year window. I have one more shot at it in 2018.
During residency, ABFAS lets you take yearly practice tests to be prepared for the qualifying exam, but not after residency. So, I went 4 years not taking a practice test and then finally being able to sit for it and failing it (They used to make you wait until your case volume was built up prior to taking the computer-based exam). Just this year, I heard that ABFAS is allowing candidates to...
Editor's note: Name Withheld's extended-length letter can be read here.
Being complacent and accepting criticism from this Orthopod is not the answer. My first thought is....is it justified? If not, then I would go meet him and discuss it in person. If you’d rather hide behind your computer, then just inform him that two can play the same game. Obviously, he is an insecure doctor who is trying to boost his own ego by putting you down. This is probably not an isolated incident. Just remember, you encourage what you tolerate.
The American Board of Foot and Ankle Surgery’s (ABFAS) mission is to protect and improve the health and welfare of the public by the advancement of the art and science of podiatric surgery. As surgeons, we want the best outcomes for our patients, and ABFAS will continue to strive to fulfill our mission to certify high quality surgical candidates for the betterment of the profession.
The trending of Part I spring exam results for first time takers shows the impact of the three-year surgical residencies.
ABFAS Part 1 Pass Rates
Although there is a drop in the pass rate for...
Editor's note: Dr. Williams' extended-length letter can be read here.
RE: ABFAS Board Exam Pass Rate is Disparaging
From: Joseph Borreggine, DPM
I have been a member of both the ABFAS and ACFAS for the last 20 years. However, I have concerns about both organizations as it relates to the podiatric profession and the certifying foot and ankle surgical board exam.
If the ACFAS has been touting that we are the "the leading experts in foot and ankle care" based on their recent PR campaign "Take a New Look at Foot and Ankle Surgeons", then they need to tell us how this is a fact if the passing rate is so low for the ABFAS board certifying exams. The ACFAS also goes on to state...
Editor's note: Dr. Borreggine's extended-length letter can be read here.
A segment of an on-topic article from JAPMA has been forwarded to me by a PM News reader. We welcome any insights or comments from our readers.
Cleaning, Disinfection, and Sterilization of Podiatric Medical Instruments
"Given the challenges with cleaning, disinfection, and sterilization of podiatric medical instruments seen in these outbreaks, disposable, single-use instruments and devices should be used whenever possible and disposed of immediately after use in accordance with state and local medical waste regulations. All reusable patient-care instruments and devices used must be first cleaned and then disinfected or, preferably, sterilized before use to prevent patient-to-patient transmission of infectious agents."
I refer you to the OSHA standards for sterilization of burs that state that burs are considered sharps and should be discarded and not sterilized after each patient. For example, VA Podiatry clinics discard nail burs after each podiatry patient. It appears from this research there may be potential OSHA violations if you try to sterilize nail burs twice.
Q: What are the guidelines for sterilizing dental burs, according to OSHA?
A: Since sterilization of instruments is not an employee health issue, OSHA does not provide guidance for sterilization. However, since used burs are a contaminated sharp, employees must wear the appropriate personal protective equipment when handling them after patient care. Like other contaminated disposable sharps, used burs should be discarded into sharps containers.(1) Because dental burs are difficult to clean and are degraded by the sterilization process, dental offices should consider making burs a single use disposable item.
RE: Standard of Care for Electric Debridement of Nails (Norm Wortzman, DPM)
From: Eliiot Udell, DPM
As an allergy sufferer, I had to make the decision many years ago to give up drilling mycotic, dystrophic nails or give up being a podiatrist. Even with expensive specially designed vacuum devices, I would still wheeze after grinding toenails. What lead me to my final decision to junk all of my Dremels and vacuum devices were papers published out of England showing that doctors who breathe in infected nail dust can develop pulmonary problems as a result.
There were also lectures at that time by respected colleagues on the OSHA regulations, where the experts said that if you do grind mycotic nails, the dust remains in the air for over 8 hours, and legally you cannot use that room for the rest of the day. This made sense to me. A more recent paper published out of Australia on March of 2015 in JAPMA by Hainsworth, et al., concluded: "The presence of viable fungal pathogens in the dust could potentially pose a health problem to podiatric physicians."
When I first gave up the odious practice of grinding infected toenails, I did lose some patients to colleagues who continued the practice. Most patients, however, were happy when I explained to them that breathing infected nail dust from other patients could be a detriment to their own well-being. In one case, I compromised and gave the patient an emery board and she was happy.
Elliot Udell, DPM, Hicksville, NY
RE: New Medicare Card Info for Patients
From: Joseph S Borreggine, DPM
CMS is starting to conduct a major education campaign about the new card for people with Medicare. Help alert your patients by displaying a poster in your office and giving your patients tear-off sheets or fliers.
This email is in response to Dr. Udell's inquiry if you can sue a patient or social media site that posts an untrue review. The answer is sometimes. If the review merely expresses an opinion, that is protected constitutionally. In NY, if the patient goes further and states something that reflects on the podiatrist's ability, such as "(s)he is a butcher", or inaccurately, such as (s)he lost his/her license last year, that is actionable. I have successfully sued the patient for libel in such cases. Please be warned that there is a statute of limitations in such cases. In NY, it is only one year from the time the review was first published.
Larry Kobak, DPM, JD, Senior Counsel, Frier Levitt
I totally agree with Dr. Udell. Years ago, when a patient didn't want to pay a bill, they threatened to sue. Now-a-days they threaten to post a "nasty review"(because it will cost them money to hire an attorney). The fact that this patient not only wanted the fees removed, but also a DISCOUNT! is absolutely ridiculous. Should you give in, this person sounds like they will write the negative review anyway and say to themselves - "Gotcha".
You have done all of the correct manners and given more than enough time for this patient to pay. At this point my answer would be - It is out of my hands and the collection company has control of your account.
Kenneth T. Goldstein, DPM, Williamsville, NY
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