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11/30/2017    

RESPONSES/COMMENTS (NON-CLINICAL)


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.

Other messages in this thread:


12/06/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Marc A. Benard, DPM


 



Kudos to Dr. Belli. I’m happy to read that he, as well as others, have been motivated to provide international humanitarian foot and ankle care. For those of you who have not yet had the opportunity or motivation, I urge you consider it. Indeed, it can be life-altering for both the patient, the patient’s family, and for you. 


 


I’ve been co-director for the Baja Project for Crippled Children for many years (aka Operation Footprint) and my enthusiasm has never waned. I literally had an epiphany in 1977 when,...


 


Editor's note: Dr. Benard's extended-length letter can be read here


12/06/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Vladimir Gertsik, DPM


 


SCFE does not occur in infants. It is a disease of older kids and adolescents. Perhaps there is a hip dislocation? 


 


Vladimir Gertsik, DPM, Brooklyn, NY 

12/05/2018    

RESPONSES/COMMENTS (NON-CLINICAL)


RE: Medical Mission to Peru


From: Richard Belli, DPM


 


I recently returned from a 10-day medical mission to Peru. It was hosted by Soul of the Peruvian Andes (SOPA). Thirty professionals from around the world attended to 4,000 people in four days at five different sites. I was posted to two towns, Castroverryna and Chiris, both at 12,000 feet in the Andes. Hot running water was scarce and electricity was spotty at best. There was no cell service in Chiris, which was a refreshing break from the hectic modern world.  


 


I attended to 140 people in the 4 days, working under difficult conditions. What made it all worthwhile was a diagnosis I made of a slipped capital femoral epiphysis (SCFE) on an eleven month old. The child is scheduled for corrective surgery in Lima, Peru. SOPA is a very worthwhile endeavor. I am glad I got involved. It has humbled me and made me more tolerant in my daily life. I highly recommend a mission of some sort to all my colleagues at some point in their career. It will change your life for the better.  


 


Richard Belli, DPM, Woodside, NY

12/04/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: David S. Wolf, DPM


 


Patients don’t care if you wear a tie or a starched white lab coat. Patients want to know that you care.


 


David S. Wolf, DPM, Retired


 


Editor's note: This topic is now closed. 

12/04/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Robert Scott Steinberg, DPM


 


Dr. Shavelson talks about a more patient-friendly, evidenced-based paradigm. As for the patient-friendly part, I have been doing that for all the years I have been in practice, by sparing my patients an ego-based showing-off of my biomechanical knowledge, choosing instead to have the devices I dispense speak for themselves. And... FYI, I am closely following everything Dr. Kevin Kirby publishes about biomechanics. I don't agree with everything, but he is consistent, and presents all his reasoning behind his newer theories.  


 


Robert Scott Steinberg, DPM, Schaumburg, IL

12/03/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Arden Smith, DPM


 


I think that many of you are missing my point. It's not about your sleeves and ties picking up "little feckies". It's not about your patients loving you even if you come to the office in your underwear. It's not about the pragmatic issue of your laundry bill.


 


The question was simply, "Is one more productive with a tie?" I am not a big fan of wearing a tie either, as my neck has gotten larger over the years, but it seems to work in our large 4 office, 10 doctor practice, covering 3 counties.


 


Arden Smith, DPM, Manhasset, NY

12/03/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Time to Develop Consensus Biomechanical Protocols


From: Dennis Shavelson DPM


 


I published a short white paper years ago entitled “The Tower of Biomechanics” where I imagined a forum that put together many different lower extremity biomechanical theories to show that biomechanically-oriented DPMs agree 90% of the time. For example, Dr. Phillips and I agree 90% of the time when debating biomechanics. I replaced his time-consuming measurements and pedobariograph technology with a simple, quick, and effective open and closed chain evaluation.


 


Biomechanics would flourish if we developed consensus terminology, examination, treatment, and presentation protocols. This would allow interested professionals to offer patients foundation stability, support, strength, symmetry, and balance with a promise for a more comfortable, injury free, upgraded quality of life.


 


As Drs. Schuster, Root, and Dananberg did for biomechanics years ago, we need to unite behind a new common vocabulary that replaces the poorly evidenced subtalar neutral, rearfoot varus, pronated, acquired flatfoot with a more patient-friendly, clinically relevant, presentable, evidence-based paradigm. 


 


Dennis Shavelson DPM, NY, NY

12/01/2018    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Ivar E. Roth DPM, MPH


 


I have read all the personal comments on why the tie may not be important to wear. Most comments about NOT wearing a tie are about personal comfort. The real question is what would be the most professional situation. There is no doubt in my mind that if you did a survey of your patients and you gave them a choice of how they would prefer to see their doctor dressed, the majority would prefer professional attire.


 


Let’s face it...appearance is important. Do you like to drive a dirty car or a clean one? Both get you from a to b. No one really complains if your car is dirty. It is a hell of a lot cheaper and easier to have a dirty car vs. a clean one.


 


Lets stop making excuses. If you do not want to dress professionally, then you are really doing a disservice to yourself, your patients, and the profession. Take pride in yourself and your appearance. Would you go to a wedding or to a special event wearing casual clothes or scrubs? Of course it is a hassle and may be not as comfortable, but that is life, and you accepted the responsibility of being a professional, so you should dress like one. This is not about the lowest common denominator.


 


Ivar E. Roth DPM, MPH, Newport Beach, CA

11/30/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Keith L. Gurnick, DPM


 


For my first 20-25 years in private practice, I always wore a full-length lab coat, nice slacks and nice dress shirt, and a nice tie in the office on days when patients were scheduled. I often got compliments on my ties, but mostly when I would wear the flashy silk ones, like the Zegna or Hermes ties. I always felt confined and hot wearing the tie and somewhat restricted wearing the lab coat, but it seemed like the proper thing to do, especially since I was younger and this was at a time when our profession was not as generally understood and respected as it has become today by patients and... 


 


Editor's note: Dr. Gurnick's extended-length letter can be read here

11/30/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From:  Charles Morelli, DPM


 


When I first got into practice 28 years ago, I wore slacks, a dress shirt, tie, a new lab coat and $200 shoes. After the first year seeing my dry-cleaning bill soar into the thousands of dollars, I quickly changed how I dressed. If I was a primary care physician who did nothing more than check my blood pressure, listen to my lungs, look in my ears, etc., and then call in his nurse to do everything else, I too might dress in a shirt, tie, and a lab coat. In my practice as with many of us, I am continually exposed to not only wounds and bodily fluids, but also things like.. 


 


Editor's note: Dr. Morelli's extended-length letter can be read here.

11/28/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Elliot Udell, DPM


 


Look at some of the panels on CNN, Fox News, and MSNBC. Some of the men wear ties and others do not. That's enough for me. I take the most comfortable way out and do not wear ties at all anymore. I just hope that they never do a survey showing that doctors with tuxedos make more money because that will never happen in my office in my lifetime.


 


Elliot Udell, DPM, Hicksville, NY

11/28/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Neil H Hecht, DPM


 



I thought “BBE”, i.e. “bare below the elbow” had been adopted as appropriate infectious disease prevention protocol in many places, especially in the UK. Wouldn’t that apply to our offices as well?


 


From MDLinx November 14, 2018: Neckties: Yet another reason to forego the necktie: Studies have shown that neckties and other items of clothing quickly become contaminated with bugs such as MRSA and C. difficile.


 


Worries about clothing contamination have fueled a new policy in the UK National Health Service hospitals banning neckties and jackets. Healthcare workers engaged in direct patient care are, instead, required to wear re-processable garments.


 


Neil H Hecht, DPM, Tarzana, CA


11/28/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C



From: Spencer F. Dubov, DPM


 



In response to Dr. Smith’s article concerning proper attire in the office, it has always been my view and experience of 55 years in practice, especially running courses in “Practice Administration”, that proper business attire sends a positive message to your patients of respect for them, yourself, and your profession. Wearing a white lab coat requires a business shirt and tie, or surgical scrubs. Nothing short of that is acceptable. When you visit a lawyer, his dress code is a suit and tie. Why would anyone want to present with a lesser appearance as a podiatric physician? The key is to “Dress for Success!” 


 


Spencer F. Dubov, DPM (Retired), Naples, FL


11/27/2018    

RESPONSES/COMMENTS (NON-CLINICAL)


RE: Revisiting the Tie


From: Arden Smith, DPM


 


Whenever we’ve discussed this issue in the past, we usually look at it through the patients' perspective. Most of the analytics that have been discussed seem to state that what the doctor wears really doesn’t matter to the patient. It’s the doctor's personality and demeanor that’s important. That being said, I would like to open discussion addressing this issue from the doctor's perspective.


 


I recently spoke with one of my practice management gurus and heroes. Over the last few years, he had been generally coming into his office in business casual and donning a white lab coat. He said that the spirit moved him to see what would happen if he returned to wearing a tie. He stated that in general terms, from the day that he started wearing a tie in the office again, he scheduled more surgery, prescribed more orthotics, and sold more products than prior.


 


Productivity has been up in an already productive and well managed practice. He has continued to wear a tie. I have been in private practice almost 40 years and have returned to wearing a tie [returned from the land of I couldn't give a "hoot" and at this point I'm "entitled" and it doesn't matter what I wear]. It seems to work. There has been increased productivity and patient compliance ... at least for now. What say my colleagues?


 


Arden Smith, DPM, Great Neck, NY

11/26/2018    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Jeffrey Kass, DPM


 


"At board meetings of the American Society of Podiatric Medicine, we have often lamented that there are no good studies to support the use of PT blocks, when clinically indicated." - Dr. Udell


 


Perhaps, this is the reason the CPT code 64450 disappeared? 


 


Jeffrey Kass, DPM, Forest Hills, NY

11/23/2018    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Elliot Udell, DPM


 


Dr. Musella is correct when he asserts that we often rely too heavily on evidence-based medicine and ignore clinical judgment based on common sense combined with years of clinical experience.


 


Part of the problem is that we still live in an era where research into new medications and subsequent papers need to be funded by corporate entities. Unfortunately, if a procedure or medication cannot earn a company a 'pot of gold', they won't fund the research. At board meetings of the American Society of Podiatric Medicine, we have often lamented that there are no good studies to the support the use of PT blocks, when clinically indicated, because there are no corporations willing to fund the research.


 


The great thing about EBM, however, is that it prevents 'bullies' in many medical fields, including ours, from promoting non-effective treatments based solely on their personal opinions and political status in their respective professions.


 


Elliot Udell, DPM, Hicksville, NY

11/21/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Has Evidence-Based Medicine Gone Too Far?


From: Al Musella, DPM


 


I was at a cancer conference recently and there was a discussion on how we moved too far to the "evidence-based medicine" camp and lost all common sense. A doctor at the meeting (Brian Alexander. MD) presented this funny abstract: Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized controlled trials


 


Objectives: To determine whether parachutes are effective in preventing major trauma related to gravitational challenge.


Design: Systematic review of randomized controlled trials.


Data sources: Medline, Web of Science, Embase, and the Cochrane Library databases; appropriate Internet sites and citation lists.


Study selection: Studies showing the effects of using a parachute during free fall.


Main outcome measure: Death or major trauma, defined as an injury severity score > 15.


Results: We were unable to identify any randomized controlled trials of parachute intervention.


Conclusions: As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomized controlled trials. Advocates of evidence-based medicine have criticized the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence-based medicine organized and participated in a double-blind, randomized, placebo-controlled, cross-over trial of the parachute.


 


Al Musella, DPM, Hewlett, NY

11/17/2018    

RESPONSES/COMMENTS (NON-CLINICAL)



From: James Koon, DPM


 


I can easily suggest the SIUI CTS-550 from Fisher Biomedical. Great unit. Great price. Great company. Buy a used Sony printer off Ebay and you will be good to go. 


 


James Koon, DPM, Winter Haven, FL

11/15/2018    

RESPONSES/COMMENTS (NON-CLINICAL)


RE: Marcaine/Bupivacaine Strategies  


From:  Robert D. Teitelbaum, DPM


 


We are all having difficulty getting these drugs in our offices. A rep at Moore Medical stated in a decisive way that Marcaine will not be available until nearly 2020. Henry Schein currently does not have it either, but they are selling a package of ten 1ml ampules of epinephrine, 1:1000, for $138. That's about $7 per half an ampule, which is all you need to add to a 0.25% bupivacaine multi-dose 50ml bottle. It turns out to be 10 micrograms of epinephrine per ml of bupivacaine. 


 


Where can you get that? Clint Pharmaceuticals. They sell a rack of 25, 50ml bottles for a good price with a limit of one rack per doctor. Now, I'd rather use 0.5% bupivacaine, so I am using 0.25% which is something new. I will listen closely for patient feedback on duration and effectiveness. But I also have personal experience with dermatologists who think nothing of using 1% lidocaine--and it works just fine--so that tempers my anxiety about the lesser strength.


 


Robert D. Teitelbaum, DPM,  Naples, FL

11/13/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Ed Davis, DPM


 


The lack of studies on this subject may be due, in part, to it being classified as a “rare” disease.  I am not sure if it is really that rare. Diagnosis codes may be used to track disease entities and there is no unique code for Ledderhose disease.


 


I have been using serial ultrasound-guided injections of hyaluronidase mixed with triamcinolone acetonide for about 20 years with very good results. I would be happy to share my protocol with any interested podiatrist.


 


Ed Davis, DPM, San Antonio, TX 

11/13/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: Dealing with Pay Reductions for Multiple Procedures


From: Allen Jacobs, DPM


 


There is actually a CMS rule that addresses performing procedures on multiple days to increase reimbursement. It is in Chapter I (Page 8) General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. “Physicians shall not inconvenience beneficiaries nor increase risks to beneficiaries by performing services on different dates of service to avoid MUE or NCCI PTP edits”. 


 


Even though this is CMS/Medicare policy, many insurance companies utilize these guidelines.  


 


Allen Jacobs, DPM, St. Louis, MO

11/12/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Allen Jacobs, DPM


 


Injectable collagenase may be helpful for plantar fibromatosis, although neither robust nor long-term studies are available for reference. My personal approach is as follows:


 


1. Confirm the diagnosis with MRI, ultrasound, or percutaneous needle biopsy prior to treatment;


2. Daily BID application of a compounded mixture of 5% lidocaine, 5% diclofenac, and 15% verapamil (EBM);


3. Stretching of the plantar fascia (night splint and/or active stretch);


4. Avoidance of hard insoles or rigid orthotics. 


 


My experience (for many years) with the utilization of this technique for non-aggressive type fibromatosis has been nothing short of excellent.


 


Allen Jacobs, DPM, St. Louis, MO

11/12/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Ira Baum, DPM


 


I’m taking an opposing position than most of the previous posts. I think there is a place for altruism, but I believe podiatrists must be pragmatic. I don’t think that the decision to perform multiple procedures in one session based on one variable is appropriate. Podiatrists and healthcare providers dependent on third-party payors have been financially battered with no real potential recourse. So, if patients depend on a third-party paying for their care, then by implication, they should also expect the care their payors are willing to pay.


 


Podiatrists have overhead responsibilities. If those obligations can’t be met, then I don’t see how this benefits anyone. I am not a proponent of putting patients at increased risk, but I am also sensitive to the financial predicament put on our providers.  


 


Ira Baum, DPM, Naples, FL

11/09/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Hal Ornstein, DPM, Tip Sullivan, DPM


 


I agree with Dr. Jacobs to always tell the patient the truth when it comes to performing all services. In teaching practice management most of my career, I have always professed what we call “The Mother Test”, doing what one would simply do if the patient were their mother. What many successful practices have in common is that they are always driven by what is best for the patient. Our podiatric oath should be out guiding light to do what is best and safest for the patient and not driven by what one gets paid. Whether one believes in this or not, our actions come full circle and karma can be quite rewarding.


 


Hal Ornstein, DPM, Howell, NJ 


 


I agree with Dr. Jacobs. The truth will set you free, but if you are not doing multiple procedures (if they are needed) just because you don't want your payment diminished, then your heart is not in the right place. To make a patient go through multiple surgeries and the associated surgical risks of each surgical intervention is wrong. Your financial gain does not come before the patient’s well-being. I can remember when I would see patients who would tell me that their previous hammertoe surgery was done one toe at a time at different times. I am certainly not against staging procedures when the decision is based on the patient’s welfare and not financial compensation of the physician.


 


Tip Sullivan, DPM, Jackson, MS

11/09/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 3



From: Jeffrey Kass, DPM


 


I echo the sentiments of Drs. Fellner and McCormick. I also had issues with my computer malfunctioning during my exam. An error message popped open telling me the computer disconnected. This occurred with little time left and my diagnosis sitting in the queue. I called the proctor over, informing him of my concern that my answer be recorded. The proctor decided to take control of my mouse and burnt my time out.


 


When contacting the Board, I was told my answer was...


 


Editor's note: Dr. Kass' extended-length letter can be read here.
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