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RE: Allowing Podiatrists to Administer Flu Vaccinations

From: Elliot Udell, DPM


This year's flu epidemic is considered the worst in ten years. In NY State, Governor Cuomo has issued a directive to allow pharmacists to give vaccinations to kids as well as adults. If a pharmacist can give a flu shot, even though they do not give injections regularly, why shouldn't podiatrists be allowed to give flu shots? Are there any other professionals who give as many injections as podiatrists do?


Not only are we trained to give injections but because we deal with the elderly population, we would reach people who might not go their pharmacy or primary care doctor and get an injection when necessary. I call on the respective state societies to push their local legislatures to allow podiatrists to administer flu vaccinations.


Elliot Udel. DPM, Hicksville, NY

Other messages in this thread:



From: Brian W.  Zale, DPM


I would like to tell you how the opioid crisis has affected me, my wife, son, family, relatives, and friends. Exactly 11 months ago today, my 31 year old son died in the bathroom sitting on the toilet two weeks before his younger brother got married. At 10:00 am, he asked me if he could use that bathroom as we had had some plumbing issues and I said no problem, we had it repaired. At 11:15 am, he was pronounced dead at St. Luke’s hospital here in Sugar Land, Texas. As per the autopsy report, cause of death, opioid toxicity.  


This is a real crisis. Addiction is a terrible thing, a nightmare for everyone involved. It's like being on a electrical fence, you want to get off but you can't. He knew more about the drugs that I prescribe than I did. It has made me a better doctor. I have no problems telling a patient that I won't give them any more Rxs. I have no problem telling these patients I lost my son to addiction. It’s funny how after I tell them that that, they no longer ask for it.  


My son would have been 32 this Wednesday on Valentine’s Day. It's going to be a tough day for my family and myself. God bless you all.


Brian W.  Zale, DPM, Sugar Land, TX



From: Bret M. Ribotsky, DPM


I have been consulting and advising for the past 18 months in the buying and acquisition market for medical dermatology practices. While I have not specifically worked with the DPM market, the foundations and principals from the hedge funds and private equity people are similar. It’s all a function of EBITA (Earnings before interest, taxes, and amortization. EBITA refers to a company's earnings before the deduction of interest, taxes, and amortization expenses). 


In simple terms, it’s the PROFIT left over after you have removed your ownership from the practice and paid someone (or you) to do the work you have done. For example, if you're a single practitioner and your practice gross is...


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



From: John V. Guiliana, DPM, MS


I wholeheartedly agree with Dr. Kashan and Dr. Ressler. It saddens me when I hear physicians state that "their practice has no value and they will someday just close the doors". Surprisingly, I hear this quite a bit.


A practice is a living and breathing entity. It needs to be continuously nourished and maintained. Marketing, continuous quality control, investment in technologies, optimizing processes, etc. all create inherent value throughout the years. In the end, the fair market value can be computed through various techniques which often revolve around net earnings and an applicable capitalization rate. Leave that to the experts. But there are buyers out there, so please take good care of your practice and it will certainly provide you with post-retirement income. 


John V. Guiliana, DPM, MS, Little Egg Harbor, NJ



From: Jack Ressler, DPM


I am very interested to find out the amount of time that passed between when the podiatrist passed away and when the practice was put on the market. I'm sure the deceased podiatrist had an excellent relationship with his patients that probably could not be duplicated by the revolving door of podiatrists who pitched in to help in this unfortunate situation. It led to a perfect storm for that other podiatrist. Although grief and shock by the family of the sudden death of their loved one probably prevented the practice from being put up for sale earlier, that delay cost them a very marketable practice. 


The other podiatrist who opened was very fortunate/underhanded to be able to take advantage of a unique and sad scenario that rarely occurs. I do not believe Dr. Name Withheld’s conclusion about a practice not having inherent value. A thriving modern up-to-date practice should have a good marketable value, especially if the seller takes the time and markets it properly. I worked very hard in my practice for many years and was able to sell it. I took the time to market it properly and got a nice return for my hard work.


Jack Ressler, DPM, Delray Beach, FL



From: Brian Kashan, DPM


I just read the posting by Name Withheld, about how he would choose to open an office next to an older practice instead of purchasing an existing practice. Although the circumstances he describes, with the sudden passing of a doctor is different than the more common scenario of a retirement, there are several similarities. If the practice has been a successful practice and is valued correctly, it should be an attractive opportunity for someone to acquire. 


There are several factors that I feel are being overlooked in the mindset of Name Withheld. Firstly, it is much easier to get a bank loan when...


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



RE: Noridian Medicare's Portal for Checking Patient Eligibility or Deductible

From: David L. Kahan, DPM


Just a head’s up to those that utilize the Noridian Medicare portal for checking patient eligibility or deductible status. The site will NO LONGER show you the deductible status of those patients who are considered “special needs”, i.e. Medicare and Medicaid (SNP). In the past, you may have held claims until deductibles had been met so you did not have to eat the deductibles. Now you will have to just guess or ask the patients when they come in whether they have been to the doctor and estimate the deductible remaining. 


David L. Kahan, DPM, Sacramento, CA



From: Brian Kiel, DPM, Paul Busman DPM, RN


There is a national shortage. I was told that much of this was made in Puerto Rico and because of the hurricane damage there is none being made. I can't be absolutely sure of this as the reason but I do know it is a national problem.


Brian Kiel, DPM, Memphis, TN


I have a somewhat cynical theory about that. The drug companies make up a "shortage" of common but essential items (I once saw a shortage of 3L bags of saline!), let providers stew a while without it, then manage to meet the "shortage" and return the product to the market. Providers are so happy to get it back that they don't gripe about the fact that the manufacturers have raised the price significantly. This probably isn't true, but these days nothing surprises me. 


Paul Busman DPM, RN, Frederick MD



RE: The Passing of Ivan Abrahamson, DPM

I had the pleasure and privilege, back in the mid to late '70s and beyond, to participate and work with Ivan and the Queens County Podiatry Society. We even co-authored a published article on minimal incison removal of a dorsal talar exostosis. Dr. Abrahamson was always a gentleman. He was a kind and caring man who was a credit to the profession of podiatry. He will be missed.

Larry Kobak, DPM, JD



RE: The HIPAA Audit

From: Richard B. Willner, DPM


One of the by-products of the passage of the HITECH ACT as part of The American Recovery and Reinvestment Act (ARRA) was the mandatory HIPAA Audit with mandatory fines. The passage of these laws were delayed to give time to understand the Regs and to come into compliance. It was not until April 2010 that the Office of Civil Rights (OCR) at the U.S. Dept. of HHS awarded two contracts to Booz Allen Hamilton, Inc. The first contract was for audit consulting support to OCR to help train the auditors. The second contract was to help OCR develop training seminars for state atty generals on HIPAA rules and regs. 


The HITECH Act is a subsection of the HIPAA of '96. HITECH Security Act part 2 strengthens many of the rules and regs of HIPAA and can be thought of making it stronger, especially for...


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



RE: Medical Symbol Misunderstanding 

From: Rick Harris III, DPM


Why do we still see the caduceus linked with medical associations instead of the Rod of Asclepius? The confusion seems to stem from the appearance of the caduceus on the chevrons of Army hospital stewards as early as 1856. A misinterpretation led to the caduceus being adopted by the United States Army Medical Department in 1902. It would gain such popularity that it even briefly served as the symbol for the AMA, but would subsequently be replaced by the Rod of Asclepius. 


Many believe the caduceus to be inappropriate as it is associated with the Greek god Hermes, who was patron of commerce as well as thieves, liars, and gamblers. Being as that, it is interesting to see its continued usage. There have been a number of recent articles in the medical literature that have highlighted the inappropriateness of the caduceus as a symbol of medicine and have sought to restore the Rod of Asclepius to its rightful place. For historical context, look no further than the first paragraph of the original Hippocratic Oath, “I swear by Apollo the physician, and Asclepius, and Hygieia and Panacea, and by all the gods and goddesses as my witness, that, according to my ability and judgment, I will keep this Oath and this contract."


It will be interesting to see if there is a continued shift by academic and health institutions to the single serpent entwined rod wielded by the Greek god of healing and medicine, Asclepius.


Rick Harris III, DPM, Jacksonville, FL



From: Jack Ressler, DPM


We've been using Square in a satellite office for several years. The rates are very competitive and they email you a confirmation of payment within a few minutes of the transaction. You can access reports quickly on-line with relatively easy navigation.


Jack Ressler, DPM, Delray Beach, FL



RE: Due Process Rights and Peer Review

From: Richard B. Willner, DPM


Medical peer review is the process by which a committee of physicians investigates the medical care rendered by a colleague in order to determine whether accepted standards of care have been met. The professional or personal conduct of a physician may also be investigated. If the  committee finds that the physician departed from accepted standards, it may recommend limiting or terminating the physician’s privileges at that institution. If the physician’s privileges are restricted for more than 30 days, federal law requires the peer review committee to report that fact to the National Practitioner Data Bank. 


There is no federal statute that requires peer review committees to observe due process, which the Supreme Court has defined as...


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



From: Steven Kravitz, DPM


Dr. Markinson makes some very salient points that podiatrists should consider. There is no turning back the clock; physician extenders are here to stay. But the good news is that there has been a change in podiatry recognition of this aspect of delivery care over the past 3 to 4 years. Assessment of the membership of a well-established physician (MD and DPM) only wound healing association provides interesting data on a dramatic shift with podiatric perspective on NPs and PAs. 


Four to five years ago, there was much more concern about competition with these practitioners and therefore a conflict of interest. But over the past two to three years, more and more podiatrists are working with...


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



From: Janet McCormick, MS


As per dental hygienists practicing without supervision, I would truly like to know where that is? I'm thinking that somewhere in the background there is a "dental supervision" requirement, possibly similar to aesthetic spas level peels etc. as long as they are "supervised by a physician." Many of these medical supervisors are not on site, but there is a responsibility there, and they must be within a set distance. And they are financially involved in some way. 


I find it doubtful that dental hygienists would escape the supervision of dentists fully. The dental associations are very active in the legislative processes and...


Editor's note: Ms. McCormick's extended-length letter can be read here.



From: Lorraine Loretz, DPM 


I have been employed in an academic vascular surgery group for the past 10 years. Vascular surgeons do a lot of work with peripheral vascular disease, and depending on where you practice, do most of the amputations for non-reconstructable PAD. I was hired as an NP (I am dually credentialed), but they quickly realized the potential for having a podiatric surgeon in the group, so added me on to the staff with surgical privileges. You will end up doing a lot of limb salvage. If your state permits, they will have you do all the amputations up to the ankle.


I found it to be very interesting work and introduced all of the 'toe' aspects of 'toe and flow' to the team. I did the reconstructions, grafts, etc., and did all the follow-up in clinic. I introduced advanced wound care products, TCC, orthotics, etc. to the group and assisted in training their resident team in limb salvage principles. You will learn a lot about the value of vascular reconstruction, non-invasive vascular testing, etc. 


Make sure your vascular surgeon does distal bypasses and distal angio work. Like I said, it was very rewarding work, but you need to be sure to negotiate your role in the practice.  A podiatrist will never be replaced by an NP/PA. We have 11 of them, but they can't do the surgeries and don't have the podiatric training to manage post-op salvage to ambulation. Podiatric care is essential to a full scope vascular surgical practice.


Lorraine Loretz, NP, DPM, Worcester, MA



RE: Joint Venture with Vascular Surgeon

From: Steven J. Kaniadakis, DPM


From my practical experience, vascular surgeons, as with the rest of the MD community, will typically employ a physician assistant (PA) . Therefore, I suspect that you will be taking your time training a PA about what we know until the vascular surgeon replaces you with the PA. The solution may be to have a five (5) year contract with some clause on what money you will receive if there is termination for any reason at all (or for no reason at all) short of the time contracted. 


Steven J. Kaniadakis, DPM, Saint Petersburg, FL



From: Eddie Davis, DPM


Dr. Borreggine has concerns about the implication for podiatry caused by expansion of ARNP scope. Dr. Herbert, in his response, related an interesting story about a podiatrist who later became a family practice physician, but his hospital did not offer him privileges for foot surgery. We should not view the efforts of other health professions to expand scope as a threat to podiatry. We should, instead, attempt to better define our scope of practice. 


Podiatrists, relative to training hours, have the narrowest scope of practice of any health profession. APMA believes that we need to emulate the allopathic model and increase residency training time. How do you tell a prospective podiatry student that he/she will be offered training equivalent to an orthopedic surgeon but that the scope of practice can only be less than 15 percent of that of an orthopedic surgeon and then tell that person that he/she may not be able to call themselves a physician?


The dental profession has figured out how to maintain a degree as a “limited licensed practitioner” and make it work. We either emulate the model of dentistry or move toward providing the MD degree. Standing in the middle of the door is not advisable because the door will keep hitting and bruising us.


Eddie Davis, DPM, San Antonio, TX



RE: Sham Peer Review, The Disease

From: Richard Willner, DPM


Description of disease: The scientific method generally involves collecting data, making observations, developing theories on the basis of those observations, performing tests of those theories under controlled circumstances, and finally, taking a course of action if those tests prove the theories. Sham peer review is a backward malignant bastardization of the scientific method. It involves making a decision to take the action, then asking minions to collect the data to support the arbitrary decision. It happens in the corporate world every day, i.e., an executive wants to fire an employee, so he asks his lackeys to "get the documentation". This is exactly what happens to physicians in sham peer review as well. 


Peer review is a healthy, scientific, positive process by which physicians review what their peers are doing, looking at variances, and...


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



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.


Greg Sands, Owner, Ortho-Rite



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



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


Andrew I. Levy, DPM, Jupiter, FL 



From: Lee C. Rogers, DPM


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



From: Name Withheld (TX)


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



From: Neil H Hecht, DPM


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.


Neil H Hecht, DPM, Tarzana, CA



RE: ABFAS Board Exam Pass Rate is Disparaging (Joseph Borreggine, DPM)

From: Name Withheld


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.  

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