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.
After serving a year as an enlisted man at Walter Reed Hospital, I became the 18th commissioned podiatrist (as a 2nd Lieutenant). I agree with W. David Herbert, DPM. A military podiatrist is now serving in the U.S. House of Representatives. I suggest Col. Michael Thomas Neary, DPM as a reference for any article on podiatrists in the military. Col. Neary is the podiatry consultant to the Army Surgeon General and is very active in the APMA Military group.
Dr. Richard Macdonald Being Commissioned
I served as the podiatrist at West Point over 50 years ago. I went back in 2015 on my 50 year anniversary. Col Neary escorted me for 2 days at the Point per the direction of the Superintendent of U.S. Military Academy. The attached picture with the Maj. General, the commanding officer of Walter Reed Army Hospital, also contains the first podiatrist commissioned by the Army (standing next to my wife).
Richard G. Macdonald, DPM, Tremont, IL
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: Podiatrists Serving in the Military
I believe that most of our profession are not knowledgeable about the history of podiatrists who served in the military as podiatrists who were commissioned officers. Osteopathic physicians did not serve as officers until 1967. Some podiatrists served as commissioned officers in the Navy in World War II. In 1957, podiatrists were routinely commissioned in the armed services as podiatrists, but were not actually in the medical corps.
I believe that when podiatrists began serving as officers in the military and began working alongside physicians as fellow healthcare professionals that the image of our profession was improved considerably. I would like to see an article about some of these pioneers in our profession whom I believe have been overlooked. I had three of my four years of podiatric medical school subsidized by the military. I have always been grateful for the military podiatrists who came before me and played a part in making this possible.
W. David Herbert, DPM JD, Billings, MT
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Fire Disaster Relief in Sonoma County, CA and Adjacent Areas
From: Jesus C. Vazquez, PMAC
Sonoma County is very grateful for the support from first responders during the fire disaster affecting our community. Dr. John D. Hollander is going to be providing foot and ankle care at no cost to police, firefighters, utility responders, and paramedics helping our community through this crisis. The office will be providing walk-in and evening appointments to accommodate different working shifts of first responders.
I bought a simple pay as you go (10c per minute) phone with a different phone number from my cell. I log in all my surgery patients on that phone with phone number, procedure abbreviation (ex.HV), and date of procedure, so I'll know who they are and what I did when they call..
I only call patients from that number so they don't have my personal cell. I keep it on on weekends (I do the majority of my larger surgeries on Fridays), and call them Saturday from that number. Monday through office hours Friday, I call forward that number to my personal cell so I don't miss calls, but they still don't have my personal cell
I always tell the patients they have my cell number, and if they call on the weekend, thanks to caller ID, I say "Hello Mrs. ____. They absolutely love it! They think they have my cell, don't have to go through an answering service, and they get me right away. Total cost - $50-$75 per year.
Burton Katzen, DPM, Temple Hills, MD
RE: Alternative to Answering Service (John Scholl, DPM)
From: Donald J. Adamov, DPM,
I have used many different answering services, both automated and an actual live service, throughout my career at different practices. I have been mostly satisfied with the way I have it set up right now. I use my phone provider Brighthouse/Spectrum virtual assistant for dealing with after hour phone calls. We have it set up to ring during the day to the office and go to voicemail in the rare instance we are not able to answer. After hours, we have a schedule set up with Spectrum to forward calls to my personal cell phone or voice mail based on urgent hospital or patient matters. That way, I can screen the call and send it to my cell voicemail for immediate playback. If I then need to call the patient back, I simply dial *67 on my cell phone.
For non-urgent matters and routine consults, another prompt sends to the receptionist phone for voicemail and also my email to allow me to playback (in case of a routine weekend consult). This way I am not bothered at all with appointment changes and other non-urgent matters after hours. Admittedly, we have had some problems with switching to our night/weekend system as we have Spectrum do this for us, but when we call them, they are usually able to remedy this. Usually, this happens for holiday greetings and we just make sure we check the system is set up properly by simply dialing in.
Donald J. Adamov, DPM, Spring Hill, FL
RE: Invest in Time, Not Money to Sell Your Practice
From: Jack Ressler, DPM
It has been a year since the sale of my podiatric practice. I am semi-retired, keeping a satellite office where I work one day a week along with two retirement facilities. The reason I am writing this letter based on a lecture I attended at the last SAM convention in Orlando this past January. The lecture was given by a person representing a company which brokers the sale of physicians’ offices.
Simply put, they take your numbers and use a formula to value your practice. I found it very interesting looking around the room where the lecture was given. There were about 50 attendees and there was quite a change in mood at the end of the lecture and Q & A session. What started as an upbeat audience turned into a lot of deflated podiatrists fueled by a...
Editor's note: Dr. Ressler's extended-length letter can be read here.
The Academy of Physicians in Wound Healing continues supporting VA Podiatric Parity. On July 27, 2017, the APWH sent a letter of support to the Chairman of the House Committee on Veterans Affairs, Subcommittee on Health supporting his amendment, HR 1058, known as the VA Provider Equity Act. The bill provides provisions to raise salaries of podiatrists to be equivalent with that of other physicians.
Last year, on May 31, 2016, APWH submitted a letter in support of Bill S. 2175 which also proposed parity for podiatric and allopathic physicians. At that time, it had passed in the House and was waiting for....
Editor's note: Dr. Kravitz's extended-length letter can be read here.
RE: WHMC Podiatric Residency Program Featured on HCA Healthcare Brochure
From: Hope Jacoby, DPM
Recently, HCAhealthcare.com (one of the United States' largest healthcare companies) made an addition to their graduate medical education program and community tab with West Houston Medical Center (WHMC) podiatric residents as the face of their programs.
WHMC Residents on Cover of GME Brochure
We are delighted and flattered that HCA chose our program that houses 12 residents, a full medical library and cadaver lab to be the highlight of their GME community.
Does anyone have any news regarding PAL Orthotics? Their software won't log in and their website and voicemail simply state, "We are no longer accepting new processing orders." We can't get in touch with a person to talk with, so we have no updates. I suppose I need to find a new lab. Has anyone heard anything?
Joe Gonzalez, DPM, East Lansing, MI
PAL Health Technologies has apparently gone out of business. They are no longer allowing access to their scanning software, and a call to tech support gets a message stating PAL is open. We are not accepting or processing orders. It was very difficult to get a human on the phone, but after finally doing so, they refused to acknowledge or deny that they were going out of business. They simply said that none of the orders we had sent them that had not yet been shipped were going to be processed.
They were able to give me a verbal list of the orders I sent them so that I could contact these patients and make arrangements to have them re-casted/scanned with another laboratory. I recommend any podiatrists in the situation with outstanding orthotic orders to PAL call them as soon as possible to get a list of orders that will not be filled while there is still someone there to answer the phones.
My friend Dr. Robert Hatcher is absolutely dead on about "working smarter, not harder." There is no question that we should all strive for life balance and more efficiency in our practices. But "working smarter, not harder" is predominantly an empty sentiment....but only us old timers get it. I teach students, residents, and young colleagues on a regular basis. One of my most common points is "the days of 9-5 are long gone." If you want to coach little league and catch every ballet recital, and go to "mommy and me", you may need to settle for a three bedroom house instead of a 5 bedroom house. If you don't get what I am saying, advice on office efficiency and life balance is wasted on you.
A comment in Dr. Koon's 9/18/2017 post brings to mind an aphorism I've been hearing for many years which is promoted as the solution for the problems of today's medical practices. That is to "work smarter, not harder". It certainly sounds wise but what does it actually mean? It doesn't seem to offer much in a pragmatic way to our young, or even some of our seasoned yet struggling doctors. Platitudes are a dime a dozen.
There is likely a kernel of truth here but shouldn't we flesh it out to make it actually useful to those who really need help? What do you doctors who have successfully worked smarter rather than harder think?
CMET has the only physician-specific organization certifying all prescribing MDs, DOs, and DPMs. CMET is different from the other certifying bodies in that they do not certify physical therapists, CNPs, or nurses in wound care. CMET certification is well accepted and respected, and an important certification for hospital and wound center privileges. If you want, you can go to the website for the Academy of Physicians in Wound Healing and sign up for their review course before sitting for the exam.
I took both CMET and American Board of Wound Healing exams. Even though both exams are for physicians, CMET questions are generated and beta tested by physicians - MDs/DOs/DPMs. Additionally, since CMET does not offer exams for mid-levels, nurses or allied professionals, you can wholeheartedly trust that this certificate is for physicians. It is not carved out from a pool of questions for all levels of professionals. It gives me the confidence when I present the certificates to other providers and patients.
Even though ABWH seems to be endorsed by the American Professional Wound Care Association and American College of Hyperbaric Medicine, those are two sister organizations. CMET is recognized by the Academy of Physicians in Wound Healing (the only wound care organization exclusively for physicians - MDs/DOs/DPMs), American College of Lower Extremity Surgeons, and the Israel Wound Care Society.
I don't think it would hurt to have more certificates. But if you plan to take only one exam in wound care, CMET should be the choice.
Jengyu Lai, DPM, Rochester, MN
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Millennial Expectations
From: James E. Koon, DPM
For some time now, patients have been researching their doctors on the Internet. I am consistently told by new patients that they chose me based on my Internet reviews. Word of mouth referrals are still a mainstay of my practice. I have never advertised.
My experience has been that all patients’ expectations are rising. Everyone wants everything given to them and they all want their insurance to pay for it. Many come in with pre-conceived ideas of what they have because “Dr. Internet” has seeded their minds. Many come in wanting...
Editor's note: Dr. Koon's extended-length letter can be read here.
RE: Peak Performance (Sterling Management)
From: Name Withheld
I received Peak Performance in the mail yesterday, a publication of Sterling Management and would assume most of my colleagues did as well. Sterling is a direct affiliate of The Church of Scientology, considered by most to be a cult. Back in the early '90s, I worked closely with a podiatry publication to expose their deceptive practices. At that time, dentistry, chiropractic, and other professional publications did articles on Sterling that were less than positive. But the one for podiatry was by far the most hard hitting and well done!
Back then, I had been duped but did...
Editor's note: To read this extended-letter, click here.
RE: Combatting the Opiod Crisis
From: Robert S Steinberg, DPM
Years ago, I woke up to the fact that when I give a patient a script for 30 T3s, they took 20-25, even though I explained to them to take them only when they had pain that would keep them awake. At some point, I started writing for 10. I have been doing this for at least 15 years. Guess what? On average, after an Austin and even a Lapidus, plate and 5 screws, patients only take 4-6. I am guessing they don't want to run out, "when it really starts to hurt," but then it never does. I write for 20 for an ORIF Fib Fx with 7 hole plate. On average, patients take 10.
Five weeks ago, I had a knee scoped. After recovery, my surgeon gave me a script for FIFTY Norco. I did not fill it. Day 1 post-op, I took 2 extra strength Tylenols. After that, none. I question the PA about the script at my post-op visit. He said they write for 50 Norco so I don't have to bother them for refills! I mentioned to my surgeon about my prescribing practices for bunions. I have a friend in Vail who got a knee implant. She stopped all narcotics on day 4.
Why does NBPME/APMLE charge so much money? Because they can.
Nicholas A. Ciotola, DPM, Methuen, MA
Query: Excessive NBPME Exam and Reporting Fees
As students, we are required to take three NBPME examinations, each exam costing $900 a piece. As a third year resident, I’m in the process of applying for my state license and I need to submit board score reports to the state. Prometric/NBPME charges $35 for part I/II scores as well as an additional $45 for part III, just for a literal piece of paper.
ALL students/graduates are required to go through this service. We have no option to opt out or to chose other services. It seems to be an unfair monopoly on board scoring and reporting. Let's say there are about 500 podiatry residents a year requesting/paying for scores. That’s $40,000 a year just on scores alone, nearly a million dollars once we factor in the price of taking the exam. Does anyone have any insight as to why these charges are so costly? It quickly adds up. Why are there separate fees/services for parts I/II versus III? Where is the money going?
I agree with Dr. Caringi. I routinely use gabapentin or Lyrica in my pre-operative and post-operative protocols. This includes patients who do not have neuropathy. Likewise, I have found these medications beneficial for patients who have chronic pain and do not necessarily have neuropathy. It has certainly diminished the need for post-operative pain medications in my surgical patients. When I joined the AENS, I was re-affirmed in my position when I learned their pre-operative protocol included the use of these medications.
We should be good stewards of all medications including gabapentin and Lyrica. The biggest concern I have with these medications has to do with a laboratory study that showed blockage in the formation of new brain synapses in an animal study. I use these medications cautiously in patients with organic brain disease or Alzheimers. There is a great need for us as podiatrists to routinely prescribe these medications with the appropriate precautions.
Several years ago, my wife had joint replacement surgery. As part of her post-op pain management protocol, she was given the combination of Celebrex and Lyrica. She never needed a narcotic pain med. I have used an NSAID (ibuprofen or naproxen) in conjunction with gabapentin many times with great success for both post-op pain management and for those patients where I suspect a nerve component to their pain. It works well for patients with fibromyalgia syndrome. I have also read about the over-prescribing and abuse associated with gabapentin/pregabalin. I find these medications very effective when used properly both as monotherapy and also when used in conjunction with NSAIDs.
Greg Caringi, DPM, Lansdale, PA
RE: Are We Inappropriately Prescribing Gabapentin and Pregabalin?
From: Elliot Udell, DPM
In the August 3, 2017 edition of The New England Journal of Medicine, there was an article titled Gabapentin and Pegabalin for Pain - Is Increased prescribing a Cause for Concern?by Goodman and Brett. The authors cite data and posit that because of the opioid epidemic, physicians are looking for other medications to control pain, and many patients are not candidates for NSAIDs either. Gabapentin and pregabalin are indicated for neuropathic pain such as diabetic neuropathy, herpes zoster caused pain, or fibromyalgia. Many physicians are prescribing them off label for arthritic pain, with mixed results.
Today, I had a new patient in my office whose primary care physician placed him on gabapentin for osteoarthritis and chronic gout. He has not had any benefit from this drug. Have any of us had any success in prescribing these drugs for non-neuropathic caused pain?
The city hospital in my town did this to a group of DPMs a few years back. We were on call there for years taking all kinds of pro bono and indigent cases. The burden became so large that all specialties finally demanded pay for call. The hospital decided to pay all specialties for call except for podiatry, and would not let us out of the call responsibility. Talk about discrimination! A lawsuit ensued which went for over a year, costing both sides a lot of money, and ended in a draw. We resigned our hospital privileges the next day and never looked back.
A year later, the hospital had to hire on two podiatrists to take care of their patients. I can provide no advice on negotiating as even our attorney got no where with them. You would think there would be some laws against discriminating like that, but apparently not. You should be prepared to find another hospital to work at and resign from that one if need be. Feel free to contact me if you want more info.
Judd Davis, DPM, Colorado Springs, CO
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Time Wasted
From: Larry Schuster, DPM
An insurance company just requested we fill out and attest to demographic information on our practice. We have done this many times for many insurance companies. We usually look at a page of pre-filled info, and if no changes, click approve. It takes 5 minutes maximum. If you need passwords, etc. to get on the site, it takes a little longer. .
We are seeing more complex forms every day to the point of craziness. Today, I received a request to fill out such a form with the recommendation that I attend a 30-minute webinar on how to fill out the form. I will have to do this after finding my sign-on credentials.
Larry Schuster, DPM, Parsippany, NJ
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