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From: John Parmelee. DPM


Here is what I used while in practice. 



95% of patients had no problem with it. 5% did and they would probably be the ones that you would have had a hard time collecting a deductible balance from.


John Parmelee. DPM, Seattle, WA

Other messages in this thread:



From: Gary Docks, DPM


Being a cancer survivor myself, I was diagnosed with Stage 4 non-Hodgkin lymphoma in 2006. Four years of intermittent chemotherapy and a successful bone marrow transplant in 2011 spared me from oblivion. Two cases of kidney CA, two other cases of lymphoma, two throat cancers, two liver CAs, are just a small sample of diseases suffered by other podiatrists, I have personally known who have died.


X-rays, fluoroscan, phenol, fungal nail dust, adhesives, are just some examples of the causative agents. Let’s help future podiatric physicians stay healthy and cancer free. Time to call in epidemiology. 


Gary Docks, DPM, Beverly Hills, MI



RE: Reported Increase in Non-traumatic Amputations in People with Diabetes will Challenge Podiatric Medicine

From: Leonard A. Levy, DPM, MPH


An increasing challenge to podiatric medicine is occurring. Health News (December 12, 2018) reported that there are a growing number of people with diabetes in the U.S. losing toes and feet to the disease by middle age. A study suggests a reversal after years of progress against diabetes. From 2000 to 2009, the rate of non-traumatic lower extremity amputations fell by 43 percent, from 5.4 cases to 3.1 cases for every 1,000 adults in the U.S with diabetes.


But then amputations increased by 50 percent between 2009 and 2015, to 4.6 cases for every 1,000 adults with diabetes and was most pronounced in younger adults, ages 18 to 44, and in middle-aged adults, 45 to 64, researchers report in Diabetes Care. The senior author Edward Gregg of the Centers for Disease Control and Prevention (CDC) in Atlanta, stated, “This is the first time we have observed an increase in amputations.” 


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL



From: Jeffrey Kass, DPM


I would like to thank Linda McSmith from PICA for contributing to this forum regarding the Sports Medicine Licensure Clarity Act of 2018. We don’t only need clarity regarding medical professionals traveling to other states. As podiatrists, we need clarity on telemedicine, and scope issues.


In reality, if all states had the same scope, no clarity would be needed. If all podiatrists are graduating from the same schools, we are taught the same stuff and we should all have the same scope of practice - that my friends is clarity. 


Jeffrey Kass, DPM, Forest Hills, NY 



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 



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



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. 



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



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



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: 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



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



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



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



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



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



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



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



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



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 



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