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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 Kiel, DPM


Using tube foam, cut alongside to allow it to fit over the hallux. Let the hallux extend through the end of the tube foam. Cut it so it extends proximally past the MPJ about 2-3 inches. Remove the tube foam and in a small bowl pour liquid latex over the tube foam and work it into the tube foam so it is soaked. Place on the hallux, cover with a plastic bag and then place the sock and shoe on the foot. 


Make your own latex bunion shields.


I tell patients to keep the shield on until bedtime and then gently loosen and suspend it on a pencil so it does not lie flat. The next day, they bring it in and I re-soak it in latex. Once this has dried, you can trim any excess off. If you want a thicker bunion shield, add a third dipping. I have had patients use these for several years. 


Brian Kiel, DPM, Memphis, TN



From: Martin V. Sloan, DPM


Whenever cost of medication becomes an issue with my patient, I pull out my smartphone and go to the “GoodRx” app, click on it, and show the patient the options. Four or more pharmacies will pop up in your area with their coupon prices, usually SIGNIFICANTLY lower than what you’d expect. The app is free and available to everyone. 


Martin V. Sloan, DPM, Rockwall, TX



From: Jill Berkowitz-Berliner, DPM


Are you talking about the brand name drug or including generic terbinafine? The generic used to be on the $4 co-pay list at Target. When CVS bought Target, it went up to $5. As of 1/1/19, it is approximately $64, but with the pharmacist gag rule repealed, the pharmacist can use a coupon, making it approximately $24, according to one of my patients. 


Jill Berkowitz-Berliner, DPM, Mount Kisco, NY



From: Alan Sherman, DPM


I am interested in the issue that Dr. Silhanek raises regarding the limitation that some states impose on earning CME online or in print, and agree with her, that we should all be allowed to earn our CME in the most convenient and effective manner. Whether that be live or online will depend on the person. Although I do own and run PRESENT e-Learning Systems which delivers over 20,000 CECHs annually, as we run both live conferences and offer online CME, I have two dogs in this race and wish that both could win.


Most of all, I believe in freedom of choice and do object to states limiting how much credit is permitted to be earned online. Polling done by Barry Block and us clearly shows that podiatrists want freedom to earn their CME in that way that they feel provides the most convenience and effective learning. Having this data, why are the states still resisting? We should all make our opinions known to our state associations and boards of podiatry to get these regressive regulations changed.


Alan Sherman, DPM, CEO, PRESENT e-Learning Systems



From: Alison Silhanek, DPM


I have been thinking more about this.

1) I realize that the organizations that hold these conferences think they rely on the revenue generated by attendees. But here’s the thing: if they hired videographers to record the lectures and panel discussions, had the lecturers each create a short test that would confirm the viewer actually watched the lecture (like Podiatry Management does with its online CME articles) and charges a reasonable fee to take the test and thereby gain the CME credits, those organizations are gaining a revenue stream from podiatrists that they might not have otherwise reached. It’s a “win-win”. 

2) I don’t know how we would work to change the rules of the various state education departments. I’m just suggesting that, if many people agree with this idea, maybe our state and national organizations should try.

3) Regarding Dr. Steinberg’s reply, I have great respect for his opinion, but I do not see conferences as having much social benefit (for me) anymore. As a solo practitioner, if I have to shutter my office for a week, I would rather spend that week exploring the temples of Cambodia or the coastline of Croatia, but that’s just me. And then I would prefer to get my CME credits at 2 am sitting on my couch in my PJs. But his points are well taken as that might just be my own preference.


Alison Silhanek, DPM, Smithtown, NY



From: Jeffrey Kass, DPM


Dr. Silhanek makes some excellent points regarding “CME in the 21st century”. One possible mistake in the posting was the statement “we, as are all physicians, are regulated to participate in a specific number of CME credits per year.” Once again, podiatrists are not considered physicians in this realm. In NY, podiatrists must log 50 credits per three years to renew their license (maximum of 25 home study). MDs in New York do not require any CMEs in New York.


This, in my humble opinion, should have been used as part of the podiatrists' argument for expanded scope. Podiatrists with their limited anatomy are always staying current, whereas MDs with a broader license don’t have to. Hence, the MD may not actually be up to date on advances in medicine.


I agree with Dr. Silhanek that one should be able to obtain all CME online if they so desire. There is no reason in the 21st century that one should have to pay for flights, hotels, etc. if they don’t want to. I am curious as to who sets the state rules for CME credits? Is this the Board of Podiatry for the particular state? 


Jeffrey Kass, DPM, Forest Hills, NY



From: Robert Scott Steinberg, DPM


At the CME meetings I attend, there are multiple tracks going on at the same time. I do not see how Dr. Silhanek knows who does or does not attend lectures! Getting together with colleagues should not be dismissed. I am not a fan of online CME. Oh sure, it's easy, maybe far too easy. Yes, it is cheaper. What I think is more problematic is the money being taken away from state associations when someone pays to attend non-member organizations' CME - part of what helps to keep our dues down is the money that comes from state association-sponsored conferences.


Robert Scott Steinberg, DPM, Schaumburg, IL



From: Bret Ribotsky, DPM


I believe that Dr. Silhanek brings up an interesting discussion that we all need to entertain. A very common thought is that the purpose of obtaining credits is to maintain licensing and to keep privileges, while the truth is why we all need credits is to continue our knowledge, so that we can practice medicine at the highest level possible. We all have seen many who just show up to get the badges scanned. Whose fault is this? Should we blame the seminar for not having speakers charismatic enough to pack the room, or should we blame the state regulations for requiring so many credits each year?  


Do we really need a sales pitch on an expensive treatment with zero new research on onychomycosis, or a lecture from a politician (with no published research) who secured a position on a speakers bureau. To me, it's crystal clear who is to blame, and it’s the person you see each day in the mirror.  


The 21st century cure is something all should participate in. The seminar should have speakers and information that delivers incredible value. The attendees should be responsible for being in the room learning and this can be monitored via GPS and smartphone technology available. States should not judge CME by hours, but by content needed each year for practitioners to master. I can dream. 


Bret Ribotsky, DPM, Boca Raton, FL



RE:  CME in the 21st Century

From: Alison Silhanek, DPM


As I endeavor to collect my CME for hospital recredentialing, I have begun to re-evaluate the entire experience of CME. Specifically, the cottage industry that promotes “live” CME. I see this question as generational. After being in practice for 20 years, I fully see the value of not only CME but live workshops for certain learning experiences— surgical, biopsy, etc.


But we, as are all physicians, are regulated to participate in a specific number of CME credits per year. In my state of NY, it is required that a hefty percentage of those hours be live. I question this. To be frank, these conferences cost a lot of money; the same lecturers show up every time and those speakers end up benefiting in the long run more than attendees. (If you are a regular speaker and disagree, so be it.)


More importantly, most attendees at these live conferences skip the lecture and show up to have their badges scanned to get credit. At least with online courses (like those offered by Podiatry Management), one actually has to read the article and take an exam to get credit. Can’t physicians enter the 21st century already?


Alison Silhanek, DPM, Smithtown, NY



From: Richard M. Cowin, DPM, JD


I highly recommend the Facial Plastics Camera from The cost is $795. We utilize a label maker to print the patient's first initial, last name, and the date. We attach it to the foot and take the photo(s) which are stored on an SD card. We then remove the SD card from the camera and upload the images to the patient's EHR record. 


Richard M. Cowin, DPM, JD, Orlando, FL



From: Donald R. Blum, DPM  


I think that you will need to visit with your EHR vendor. E clinical Works (ECW) has a mobile app that allows the provider to see the office schedule, dictate, and take pictures with a smart phone. The picture is not stored in the smart phone, nor is it stored in the office computer, but it is directly uploaded to the patient's record for that visit date and stored in the cloud. 


If the photo is stored in the device and the patient and photo are related, there could be a HIPAA issue if there is unauthorized capture of the information.


Donald R. Blum, DPM, JD, Dallas, TX



RE: TayCo External Ankle Brace (Frank DiPalma, DPM)

From: Dennis Shavelson, DPM


I have been working with the inventor and the orthopedic surgeon associated with the TayCo Brace (the first patented AFO that lives outside of the shoe instead of inside the shoe) for about 7 months. It is truly a game changer for many CAM walker, AFO, and custom foot orthotic applications. It was originally developed by Mike Bean, an associate athletic trainer at the University of Notre Dame for inversion ankle sprains (players are back playing football and basketball in days rather than weeks).


Think of this brace as an external, temporary, frontal plane stabilizer plus a subtalar arthroereisis procedure all in one. It is measured and fabricated to the patient's shoe and leg (no casting). Since this brace has no foot plate, it can be used in combination with an OTC or custom foot orthotic, especially when additional rearfoot control, vaulting or forefoot control is necessary as a part of care such as in PTTD, flexible juvenile flatfoot, and fall prevention.


Disclosure: I am a biomechanical consultant to TayCo Brace.


Dennis Shavelson, DPM, NY, NY



From: Jack Ressler, DPM, David Zuckerman, DPM


I'm not sure what your parameters are for disposable nail nippers but the company called TRIM, which provides many manicure and pedicure products, makes curved nail nippers that work great. They are under $9.00 and can be purchased at Target. The spring mechanism is a poor design but should last for several months. If any manufacturer of quality nail nippers reads this query, please buy one of these and replicate it. The size and function is the best I have used!


Jack Ressler. DPM, Delray Beach, FL


I am one of the exclusive distributors of disposable nail clippers.


David Zuckerman, DPM, Cherry Hill, NJ 



From: Ira Baum, DPM


I find the concern regarding payment disparity a sad topic. It’s sad because podiatrists have been fighting this issue since the beginning of managed care and nothing has changed for the better. Reading the post made me think that it’s just another generation of podiatrists learning that our profession, as noble as it is in the minds of third-party payers, has a value that can be deeply discounted. Unfortunately, most patients accept our financial value, even when we perform limb-saving treatments. The courts have not been kind to us and have indirectly enabled insurance companies to continue to discriminate against equal pay for equal service. Maybe the new generation will have success in fighting this obvious inequity.


Ira Baum, DPM, Naples, FL 



From: Richard Rettig. DPM


Dr. Silver has brought up two separate issues. One is up-coding. It seems clear that the MD has up-coded in this instance. There are certain doctors (including podiatrists) who do this routinely. Of course it is fraudulent. They are always in danger of being reported to the insurance company. Did you do that?  Should you do that? The other issue is MDs getting paid more for a procedure than we do. This is multi-factorial. I am not sure it is as prevalent as we sometimes think. First, you need to be comparing their reimbursement to yours for the exact same insurance company and policy.  


Secondly, are they hospital-based? It may not be fair, but hospital outpatient departments, even some located off-campus, get a much higher fee schedule for higher overhead allowances. Finally, are they a large enough group that they have bargaining power to create their own fee schedule with the insurance company? That is just the capitalistic nature of private insurance and private enterprise that many of us consider ideal and encourage. Yes, it's a bummer when we are on the losing end of that kind of system. I think all these factors are more likely than the insurance company discriminating against podiatrists. 


Richard Rettig. DPM, Philadelphia, PA



RE: Payment Disparity Between DPMs and MDs

From: Thomas Silver, DPM


As podiatrists, it appears that we are highly discriminated against (ripped off?) by insurance companies in MDs are being reimbursed at significantly higher rates than us! For example: In my office, we periodically bill 99214 for more complex/more time-consuming patient visits (with more extensive documentation). We submit for $194 to insurance for the visit and the most I have been allowed in the past year is $132, with the average allowed amount of $112!


I was recently seen by an orthopod for a 2 minute check-up to see if an injection helped. It didn't, so he said to give it a couple more weeks and if it is still not better to come back for another injection. He billed a 99214 visit to insurance for $307 and was allowed $249!  


For MD visits for me and my family in this past year, I have not only seen consistent visit up-coding but also much greater disparity in amounts charged by MDs (especially the amounts allowed to them by insurance companies) as opposed to when I submit the same visit codes.  I would like to hear comments from other podiatrists regarding this disparity and how we might deal with this.  


Tom Silver, DPM, Golden Valley, MN



RE: Changes in Sports Medicine Licensure

From:  Linda McSmith


As part of the healthcare and podiatric community, I want to share pertinent information regarding recent changes that could affect your practice. 


The “Sports Medicine Licensure Clarity Act of 2018”, established by H.R. 302, provides clarity for sports medicine physicians, athletic trainers, and other healthcare professionals. This Bill extends the medical professional liability insurance coverage of a state-licensed healthcare professional to a secondary state when the professional provides covered medical services to an athlete, athletic team, or team staff member pursuant to a written agreement. Prior to providing such services, the professional must disclose to their medical professional liability insurer the nature and extent of the services.


This Bill requires the professional to be licensed in their primary practice state but allows the professional’s license to be deemed valid in a secondary state when traveling with sports teams. Licensure requirements of the secondary state must be substantially similar to the licensure requirements of the primary state. We recommend being aware of the scope of practice in the state that the treatment occurs. This law is specific in that it only applies to professionals who are traveling with an athlete or team and rendering sports medicine. Be sure to contact your medical professional liability insurance company before engaging in sports medicine care. 


Linda McSmith, Manager of Risk Management, PICA



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



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 



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



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



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



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.



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



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

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