After much internal debate, I’ve chosen to step down as CEO of Bako Integrated Physician Solutions (Bako) and resign from its Board of Directors as the result of principled differences with the company. I will no longer be involved in their educational initiatives or laboratory services. Bako represents the embodiment of my life’s work to this point, and coming to the decision to begin a new chapter in my professional life has been extremely difficult.
That being said, I have not completely excluded the possibility of a future return to Bako should our differences be hashed out. On the heels of the prior somber news, let me relate a silver lining that is giving me a more altruistic sense of...
Editor's note: Dr. Bakotic's extended-length letter can be read here.
I have two identical digital x-ray systems and dropped the support about a year ago. I have had no issues with the x-ray hardware or software. I have had an occasional communication problem between the acquisition computer and server when Windows installs automatic updates, but this has been rectified every time by simply restarting the server which I run full time.
Walter Roth, DPM, Lake Mary, FL
I have had software issues associated with my imaging software. The unit and server are only a year old. Magically, at around the one year mark (when the warranty for the software expires), there is an issue with the server that requires occasional phone calls to support. Unfortunately, only by calling them will the issue be fixed and they have been unable to explain the reason the issue continues to re-appear. I find it unusual and coincidental that there is a software glitch that only they can fix. For a device that costs that much money, the support should be included, or at least bug-free.
Adam Siegel, DPM, Chicago, IL
RE: Podiatrists Now Defined as Physicians in VA
From: Jeffrey M. Robbins, DPM
Podiatrists in the VA will now be defined as physicians and surgeons in the Department of Veterans Affairs. This has been a 12-year journey, beginning with initiatives from the Office of the Director of Podiatry Services VACO and the Federal Services Podiatric Medical Association, and ultimately the American Podiatric Medical Association. The APMA did the heavy lifting on the legislative side. Introduced by Congressman Brad Wenstrup (R-Oh) and shepherded by Ben Wallner, Director of Legislative Affairs of APMA, the bill took two years to get through Congress once it was introduced.
As with all major efforts, no one does this alone. We offer our thanks to the rank and file podiatrists for their contributions to APMAPAC and the individuals who contacted their representative to encourage support of the bill. This will allow the Department of Veterans Affairs to recruit and retain our most experienced providers and provide America’s veterans with the best in podiatric medical and surgical care.
Jeffrey M. Robbins, DPM, Director Podiatry Services, VACO
Great MIS recap and points. I am “the younger DPM”, finishing a 3-year residency in 2013. To answer some of your questions, I have noticed about fifty older generation doctors who have never given up MIS - and have been doing so for 30+ years. They are anxious to teach and happy that MIS has a growing acceptance, despite being more so internationally as opposed to locally. I believe the appearance of a resurgence is more due to the industry “getting in the game” (nominally Wright and Trilliant; maybe more companies making screws specifically for MIS style bunion correction).
This is interesting because the originators of the MIS bunion-style surgeries rarely use any hardware, if any, in their procedures! But now that industry is involved, it instantly becomes interesting, and a more acceptable, viable option or technique. Show me the percentages of established lecturers or board members in any medical organization who consult for at least one company, likely more. Money talks.
When I graduated from PCPM in 1976, I was then fortunate to do a residency and join a local hospital. We were trained to do everything open and follow orthopedic thinking. I bought a small practice from an older practitioner. It was obvious that he was doing in-office MIS after taking a weekend course. The x-ray results were uniformly poor and I found a lot of letters from angry patients and investigations from insurance companies. It was clear to me he had little understanding of basic operative procedures, blood chemistry, and standard operative protocol. I steered clear of all of this and used the hospital only. Now years later, with new techniques, changes in insurance, and the blessing of orthopedists doing essentially the same procedures, MIS has found a place in the podiatry world.
Having witnessed the origins of MIS and the political squabbles within the profession, I now have a broader perspective on it. Yes, there were two schools back then. There were the "open" surgeons and there were those who took the late Dr. Ed Probber’s one-week course on how to do MIS (in the back of his Long Island office). The training was often supplemented by learning at other doctors’ offices and at MIS conventions.
There were conflicts and a lot of name calling. Some of the criticisms of MIS were valid and some were purely political. At that time, podiatry was striving to be part of the medical/surgical establishment and MD surgeons did not know from MIS. Today, things are different. MD surgeons are gravitating toward minimal incisional techniques. They do spine surgery, knee operations, gall bladder removals, and hernia repairs using very small incisions. The healing time is reduced. Hence, there should no longer be a need for two schools of thought in 2018. It’s time for foot surgeons to learn open and minimal incisional techniques and choose the best one for each and every patient who needs foot surgery. Let’s leave the politics of it back in the 1970s.
The answers to Dr. Borreggine's questions are long and complicated ones dating back approximately 60 years. Minimally invasive surgery is now the standard of care in many countries throughout the world. However, I can say that resurgence of MIS in the United States can be traced, in no small part, to the exceptional outcomes our surgeons are seeing. This includes less patient downtime and the maximum use of the surgeon’s time and the ability to perform many of our procedures in an office setting or an outpatient ambulatory surgical center.
I believe that the future of MIS lies in the ability to teach the procedures in the schools and the residency programs. I am happy to note that the next Academy Of Minimally Invasive Foot and Ankle Surgery LSU lecture cadaver seminar to be held in New Orleans on May 31, June 1, and June 2 will include several residents from programs throughout the United States.
Burton Jay Katzen, DPM, Temple Hills, MD
RE: MIS Returns to Podiatry
From: Joseph Borreggine, DPM
With the recent article that appeared in PM News, I began to wonder why this type of foot surgery has had an unbelievable resurgence in light of the years that have passed that caused podiatry to distant itself from this type of surgery in lieu of the more traditional techniques taught in the APMA and CPME mandated three-year, post-graduate DPM surgical residency?
I graduated in 1988 and received my DPM from Scholl College. One of the reasons that I decided to become a podiatrist was because I found an interest in minimal incision surgery or “MIS” as it was...
Editor's note: Dr. Borreggine's extended-length letter can be read here.
Dr. Boylan asks a great question regarding cyber insurance when he asks “how much is enough?” The answer depends on several factors:
1. How large is your practice? How many patients could you potentially need to offer credit monitoring to as the result of a breach?
2. Is your practice fully electronic? If so are you using the ‘cloud’ to store your patient records? Are you using a third-party vendor for your EHR or medical billing and if so, have you read what the limits to their responsibility are in case of a breach on their end that affects your data? All of these scenarios potentially increase your...
Editor's note: James Spitsen's extended-length letter can be read here.
Newsday, our local paper carried a two-page article this weekend on this topic. It said that gabapentin is the eighth most prescribed medication in the country and for good reason. It is safe, non-addictive and is used either alone or in combination with certain antidepressants to manage millions of people suffering with neuropathic pain.
I have never had a case of a patient abusing gabapentin nor becoming addictive to this medication. To the contrary, this medication has been a "lifesaver" for so many of my patients. By no means does it have the potential for abuse associated with opioids.
If gabapentin is now in the crosshairs of the government, will Lyrica and Cymbalta be next? What will millions of patients suffering with neuropathic pain do if gabapentin and similar medications are restricted?
Elliot Udell, DPM, Hicksville, NY
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: NJ to Monitor Gabapentin Prescriptions
From: Allen Jacobs, DPM
I know a lot of docs who decreased scripts for narcotics and began using gabapentin. Now this:
Effective May 7, 2018, the New Jersey Division of Consumer Affairs adopted amendments to the New Jersey Prescription Monitoring Program (NJPMP) rules at N.J.A.C. 13:45A to require New Jersey licensed pharmacies and registered out-of-State pharmacies to electronically transmit information to the Division about prescriptions dispensed for gabapentin. The recognition of gabapentin as a “drug of concern” stems from national prescription and overdose data. New Jersey is joining a growing list of states who have already begun to monitor gabapentin use, including those that have scheduled the medication at the state level.
Studies have shown that gabapentin prescribing in the United States has increased...
Editor's note: Dr. Jacobs' extended-length letter can be read here
It had been years since I've seen MBT shoes until a new patient came in the other day wearing them. I can't speak for other MBT styles, but the pair he was wearing were ridiculously heavy (as much or more than a steel-toe boot). It's a rocker bottom with a ton of cushion in the soles, especially in the heels; kind of like wide Sketcher Shape-Ups with cement inlays!
Tom Silver, DPM, Minneapolis, MN
These may work well for patients with a painful hallux limitus, dorsal first MPJ exostosis, or hallux rigidus where they don't have adequate hallux dorsiflexion at the first MP joint during the propulsive phase of the gait cycle. The rocker bottom sole allows for facilitated propulsion when the hallux doesn't dorsiflex.
MBT shoes are basically a rocker bottom shaped shoe. See their website:
Donald R Blum, DPM, JD, Dallas, TX
Massai Barefoot Technology (MBT) shoes are high-priced rocker bottom soled shoes alleged to be fashioned after the feet of this African tribe. Your patient can get rocker bottom soled shoes at a better price from other brands.
Sigma Digital X-Ray having sold numerous Alara systems through the years, have all Windows drivers and CrystalView software available to re-install remotely at a minimal charge. As one of the original digital x-ray pioneers having introduced DR digital x-ray into the US in 1997, Sigma has survived the test of time, serving the dental/medical/veterinary community nationwide for over 25 years, with an A+ Better Business rating.
Lawyers do not bill Medicare for billions of dollars. Lawyers aren't the ones ripping off Medicare. And Florida is the epicenter for Medicare fraud. Don't take it so personally.
Robert Scott Steinberg, DPM. Schaumburg, IL
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Absurd Repeat Fingerprinting Requirement
From: George Jacobson, DPM
I got fingerprinted five years ago as a requirement for Medicaid participation. I don't know if this is just in Florida or a federal requirement. We have a renewal application and were told I have to get fingerprinted again. Did my fingerprints change? This is an absurd waste of my time. There aren't many places that do this that can directly send the fingerprints electronically. I think I spent around $150 last time. I hate stupid government requirements like this. Do government employees, congressmen, senators, and their staffs have to get fingerprinted every five years? I doubt it. When they start fingerprinting lawyers every five years perhaps it won't bother me as much.
I disagree that decreasing undergraduate education would somehow increase the applicant pools at podiatry schools. Even if this was correct, it would be a bad idea for other reasons. In California, we have been working on the idea of “parity” between DPMs and MDs. In other words, we take a separate pathway to achieve the same goal, a competent physician. After many years of having an independent board take a look at the curriculum of our schools and our residencies, we are almost there!
The presidents of the California Medical Association and Osteopathic Medical Association have, on several occasions, addressed our state delegates at our annual meeting and have told us that they consider us to be...
Editor's note: Dr. Reingold's extended-length can be read here.
I agree with Dr. Gudeon. There is a difference between “trained” and “educated”. Let me be clear. I am a big fan of Mike Rowe. Not everyone needs a college education. There are many occupations that are noble and do not need a college education. And we, in the U.S., need to go back to stressing that concept (Heck, my plumber makes more than me!). But when we talk about college education, I am a big believer in liberal arts.
I respect those in our profession who only believe in science majors. But I went to a highly acclaimed liberal arts school that enabled me to major in English, participate as a violinist in its orchestra while still being pre-med. I am better for it. I credit Hamilton College for my education much more before I credit Scholl College of Podiatric Medicine. While I love my profession, we should look to enlist young people from all backgrounds to our profession.
Although I agree that Dr. Herbert’s letter has some merit financially, and possibly speeds up the route to a doctorate, I’m not sure I totally agree with his concept. A well rounded four year pre-med course, which includes the humanities, the study of how people process and document the human experience, including courses such as philosophy, literature, religion, art, music, history, and language gives one a better understanding of the world we live in. There’ll be enough concentration and focus on science and medicine in their next four years, and in their residency programs. On a personal basis, I’m very glad to have graduated NYU with a major in English literature, minor in history, and playing clarinet in the (then) football band, before entering NYCPM. I think you end up a more well-rounded and interesting person.
Arthur Gudeon, DPM, Rego Park, NY
RE: Suggestion for Recruiting Podiatric Students
From: W. David Herbert, DPM, JD
I have two cousins who became dentists in the 1970s. My younger cousin was admitted to dental school with only two years of college. I believe podiatric medical schools should recruit very well qualified high school students and guarantee them a place in class if they complete the appropriate science courses, even if they do so before completing a 4 year (college) degree. I believe some students could do this in just two years. It would be possible for a well-qualified student to become a fully trained podiatric surgeon in 9 years after high school. This student would be actually only paying for 6 years of school as the last 3 years of training would be accomplished as a resident.
Podiatric medical students are now virtually guaranteed a residency position when they receive their DPM degree. This cannot be said for dental students or even medical students who are trying to go into a residency that they truly want.
Greg Sands, OP, & Ortho-Rite have been the sole fabrication subcontractor for FootHelpers Lab for decades. He accepts the cost and high maintenance standards needed to produce foot centering orthotics. That enables me to offer an alternative to subtalar joint neutral cast devices where needed. During the recent shutdown, I made the mistake of sending casts to two other labs that assured me they could produce RestorThotics to my standards. The 75%+ return rate that ensued proved more destructive than if I had shut down and waited for Greg to rebuild.
My devices dispense by conforming to two tests. They must “integrate” to optimal casting position and they must activate the 1st ray rockers when underfoot. The replacement devices were too wide, too long, under-vaulted, and poorly posted. LLD lifts were not applied professionally and many made 1st ray activation worse, not better.
Although some patients and clients accepted the makeshift devices without complaint, I have re-dispensed more than half of the back-up devices with an Ortho-Rite product in order to re-establish my reputation. I have stated many times that Greg is the best production administrator of a custom foot orthotic lab. This was a pricey way to find out. I'm so glad to have you back.
We apologize for what your friend experienced. However, it is unfair to turn this misinformation into an accusation that Georgetown is somehow discriminatory towards podiatric surgery. I am the co-director of the Center for Wound Healing at MedStar Georgetown University Hospital. Our team is composed of podiatric surgeons, plastic surgeons, vascular surgeons, nurse practitioners, and numerous other specialists.
MedStar Health is a system of over 36,000 employees with 10 hospitals, so I cannot speak for every circumstance, but I can tell you that podiatric surgery is well established here and is not in a discriminatory status. I believe it would be best for you and me to speak directly about what happened rather than have this debate on PM News. Please contact me at 202.444.3059 and I would be happy to reach out to your friend to provide assistance.
John S. Steinberg, DPM, Washington, DC
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
RE: The Importance of Examining Legs
From: Robert D. Phillips, DPM
I would like to commend the thoughtful letters written by Dr. Forman (4/14/18), Dr. Silver (4/18/18), and Dr. Jacobs (4/16/18). All bring to the fore the important facts that diabetes not only has a negative effect on all the systems in the foot, but that decrease in the utilization of the foot also accelerates the impact of the disease on the other body systems.
Certainly, the main goal of any podiatrist treating the diabetic patient is to increase the activity level of the patient. Many years ago, I heard Dr. Root talk about no longer thinking of geriatric foot care as trimming calluses and nails and moisturizing the skin. Instead he stated that...
Editor's note: Dr Phillips' extended-length letter can be read here.
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
RE: Podiatrists Disparaged by Georgetown Staff
From: Lloyd Eisenberg, DPM
Recently, a close friend fell and was sent by ambulance to the hospital. After having her leg wounds dressed by the ED staff, she was told to make an appointment with the hospital's wound staff. She was given a list of names. She selected a name from the list and called to schedule an appointment for evaluation and treatment. She was told by the receptionist that the doctors on the wound management staff were all podiatrists and she should seek treatment at another hospital in the Washington metro area where the wound management docs were physicians. This type of discrimination is not tolerable and should be queried by the podiatry department at this large teaching hospital.
Lloyd Eisenberg, DPM, Chevy Chase, MD
Podiatry Management • 10 E. Athens Avenue, Suite 208 • Ardmore, PA 19003 • 610-645-6940