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11/08/2018
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: Allen Jacobs, DPM
It is not appropriate to willfully misrepresent facts to a patient. Tell the patient the truth. You are paid less for multiple procedures performed concurrently. You are not willing to accept the reduced payments. The patient should be made to understand that you utilize the same degree of care, time, cost, and expertise for each procedure.
If you are found negligent in the performance of a second or third procedure, I do not believe the jury award or settlement by the carrier is reduced 25 or 50 or 75 percent. Just tell the patient the truth. Misrepresentation is always unethical regardless of any well-intentioned reasons for doing so.
Allen Jacobs, DPM, St. Louis, MO
Other messages in this thread:
02/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 B
From: Lawrence Rubin, DPM
I agree with Dr. Steinberg. From what I have observed and have been told, the curriculum in our schools has not kept up to the standards for today's podiatric physicians and surgeons to become successful in practice. A glaring, practical example applies to information that pertains to a podiatrist's personal financial success. It is my understanding that there is little if any classroom content on practice management and "The Business of Podiatry."
I don't find this surprising. Having been a podiatrist for 66 years, I have observed a long-time reluctance of our schools to include practice management and podiatric medical economics educational curricula. For example, right now, our entire healthcare reimbursement system is dramatically changing from a fee-for-service model to a value-based care model. In fact, in a recent issue of APMA News, there was a very informative article advocating podiatric practices transition from fee-for-service to value-based care.
I doubt whether current podiatry students are being informed that their future insurance reimbursement for spending an hour of preventive services, providing chronic care management (CCM) for a patient who suffers from lower extremity conditions such as diabetic peripheral neuropathy and peripheral artery disease. This already surpasses what they can earn in an hour for providing most surgical procedures that include post-operative care. Knowing this might influence a student to not become financially dependent upon providing major surgical procedures, especially if they are elective. Or, maybe even go, “Direct Care” and not accept anything other than cash payment. Who would deny that, forewarned is forearmed? Our students deserve to be better prepared for the future.
Lawrence Rubin, DPM, Las Vegas, NV
02/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: John Mozena, DPM
Dr. Daniel Jones brings up a great point! Maybe it’s time to revisit the idea of our specialty being absorbed by osteopathy or the allopathic schools. Is there really that much difference in our training these days? With so many medical and osteopathic schools, I’m sure there is room for our students and their money.
John Mozena, DPM, Portland, OR
02/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 C
From: Daniel Jones, DPM
If there is one thing that schools are good at, it's taking money. With the federal government fully subsidizing all education at ANY cost, there is no incentive for schools to consolidate. And if you already have an MD or DO school set up, why not cast a larger net to get more money?
Perhaps the conversation with applicants goes something like this, "Oh, I'm sorry, you didn't have good enough grades to get into our medical program. Why not apply to our DPM program? You can be a foot and ankle surgeon! By the way, that will be 60,000 dollars a year for the next 4 years."
Who wouldn't start a program? 90% of the classes are the same. You only need to hire one or two podiatry professors and use the existing machinery already set up for your med students, and your med school now makes an extra million a year. Until CPME denies new schools from popping up, the number will continue to grow. Would that be a restraint of trade violation? Probably. So we will keep adding more schools as numbers of applicants dwindle to a point it's no longer sustainable, and podiatry gets absorbed by the allopathic and osteopathic professions.
Daniel Jones, DPM, Casper, WY
02/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 B
From: Narmo L. Ortiz, Jr., DPM
According to an article published on March 27, 2023, in collegiategateway.com, "the latest figures put overall medical school enrollment at 96,520, an almost 18% increase over the past decade. This surge has been made possible by increasing class sizes, the opening of more medical schools, and government intervention to add Medicare-supported graduate medical education positions, and is a welcome response to the projected shortage of physicians in the coming years."
While those statistics apply only to MD schools, on the March 21, 2023 informational article on tiberhealth.com, "There are very few podiatry schools. According to the American Association of Colleges of Podiatric Medicine (AACPM), there are only 11 DPM programs in the U.S. as of 2023. As a result, the overall number of applicants is lower than those who apply to MD programs. The AACPM reports that there were just 910 applicants to DPM programs in 2021, a tiny fraction of the 62,443 people who applied to MD programs that year."
So, it still begs the question to ask what is our profession, the APMA, and all of the other podiatric professional organizations doing to increase awareness to the public, colleges, and universities on the career of podiatric medicine and surgery in order to increase the number of applicants?
Narmo L. Ortiz, Jr., DPM, Davenport, FL
02/13/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 D
From: Philip Radovic, DPM
It's unlikely any of our organizations will take action to neutralize misleading practices by establishments like the Good Feet Store. It's not sensible for any legitimate podiatrist to support their methods. We all know that many patients with generic foot issues can benefit from over-the-counter inserts costing less than $100. Over 30 years ago, when I was a new delegate to the CPMA, I proposed a resolution to tackle this issue, which received support from the then-presidents of both CPMA and APMA. Both of them visited a local store to investigate and reported that the staff was essentially practicing medicine without a license, in their opinion.
The store’s marketing at that time included claims disparaging traditional orthotics from podiatrists. They may still. At the Western CPMA conference, where I had proposed the resolution, I was astonished to see a Good Feet booth and a sign-up sheet for potential franchisees, attracting interest from many notable figures. The resolution ultimately did not lead to any action. I suspect quite a few “influential” podiatrists might be investors or franchisees in such stores or have some financial relationship. It is doubtful that our Associations would intervene in this matter, so we need to be vigilant and address such deceptive practices and questionable opinions in our professional and patient interactions as well as platforms like this one.
Philip Radovic, DPM, San Clemente, CA
02/13/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 B
From: Rod Tomczak, DPM, MD, EdD
As much as we all know that The Good Feet Store (TGFS) is practicing podiatry without a license, it is difficult to do anything about TGFS. Complaints to the podiatry board or medical board often fall on deaf ears. The boards have no influence over TGFS since boards only intervene with licensed professionals. One might accuse TGFS with practicing podiatry without a license but the podiatry board is essentially impotent.
Practicing podiatry or medicine without a license comes under the aegis of the law enforcement branch of the government after a board determines the law was broken. Hence, the police or sheriff would have to arrest the owner of the store or the dispenser of the orthotic for practicing medicine, go through a legal process, and issue a fine or short jail term for a first offense. Actually, I defer to the DPM/JDs in the profession to correct me, but this is what I've been told is the process in most states. Pushing readymade orthotics doesn't really endanger the public like practicing plastic surgery without a license and is not worth the legal effort.
Rod Tomczak, DPM, MD, EdD, Columbus, OH
02/13/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: James Koon, DPM
In response to a recent letter reflecting how much the Good Feet Store charges for inserts, it is my experience that they now charge about $1,500 for three different sets of pre-fabricated inserts matched to the patient after performing their manner of examination. Each pair is purported to be for a specific reason/activity/purpose.
On occasion, I will have a patient who has been in my practice for years show up one day complaining of continued heel/foot pain after having gone there and gotten these inserts with no improvement. I quit asking why they didn't come to me first, because what's done is done. Most of the time, the story goes that they developed the foot pain for which they got the inserts and went there because they thought they would help. And they must help an awful lot of people because there are franchise stores...
Editor's note: Dr. Koon's extended-length letter can be read here.
02/12/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Howard Bonenberger, DPM, Ivar E. Roth DPM, MPH
In response to patients who had similar problems with GFS inserts, I would write on an Rx pad "The devices (I never called them anything else) were not appropriate for the person's foot/ankle structure or their diagnosis. Please promptly provide a full refund. It always worked. Patients loved it, and they had me mold true Rx orthotics. Good for them and good for my practice.
Howard Bonenberger, DPM, Hollis, NH
My esteemed colleague asks how does Good Feet get away with charging $2,000 for an over-the-counter insert and some top covers. The answer is that they advertise and have salespeople work for them. Also, in general, the devices they sell work quite well. I am a big believer of supporting the arch maximally with an orthotic and the ones they sell do that. My patients LOVE the orthotics I make them and as I have said before are willing to pay a reasonable price for them... $850 for the first pair. I give a $200 discount on second pairs. I have a unique way I present orthotics to patients with which I have a 25% acceptance rate because they “get it”.
Ivar E. Roth DPM, MPH, Newport Beach, CA
02/08/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 B
From: Allen Jacobs, DPM
Dr. Kravitz is making reference to what is generally termed the technological imperative, a concept first elucidated by Victor Fuchs in his textbook Economics and Policy. The technological imperative generally refers to an inclination to utilize a technology that has the potential for some benefit, however marginal or unsubstantiated that potential is. It is fueled by an abiding fascination with technology, the general expectation that newer is better, and unfortunately, at times, there are financial or other professional incentives driving the use of relatively unproven technologies. It is driven at times by what Sir William Osler, over 100 years ago, referred to as “pseudoscience”.
Podiatry like medicine in general, is an industry-dominated profession. We rely on industry for the medications we utilize to...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
This topic is now temporarily closed.
02/08/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
RE: New PSSD Diagnostic Device
From: James Wilton, DPM
I have to read with some amusement this continuing line of thinking about the PSSD machine. I think a little education of the podiatric profession may be in line here. Two-point discrimination, which is what the PSSD machine does, was originally developed in the plastic surgery world for complex nerve repair, starting with battle wounds in the Second World War. Dr. Lee Dellon of Johns Hopkins University further developed the technology to look at what pressure threshold would be needed to determine two-point discrimination and also moving two-point discrimination, which are both significant diagnostic tools in looking at nerve regeneration. Two-point discrimination looks at nerve density and the innervation density of a particular area of skin that you are testing.
The brilliance of the PSSD technology is especially utilized in complex nerve repair cases where you are looking at re-innervation or in complex re-implantation procedures of arms, fingers, or toes. For basic screening for diabetic peripheral neuropathy, the hands-on clinical neurologic examination is the gold standard, utilizing hot and cold, vibratory thresholds, sharp and dull perception, and monofilament testing. As a screening tool, two-point discrimination is an excellent test using a wheel, and this is much more sensitive than monofilament testing. I hope this information adds some insight into this interesting thread.
James Wilton, DPM, Claremont, NH
02/07/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 C
From: Philip Radovic, DPM
I would like to acknowledge Heather Kaufman, DPM and Richard Manolian, DPM for their professional integrity in addressing concerns related to recent PM News posts. Their decision to voice these concerns demonstrates a commitment to upholding ethical standards within the podiatry community. It has come to my attention that certain podiatrists' representations of themselves as mentors and authorities in the field have raised significant concerns among peers.
Please note that this message is intended to encourage professional dialogue and should not be interpreted as a definitive statement on the conduct or practices of any individual. It is merely an acknowledgment of the ongoing conversations within our community and a call for continued commitment to excellence in our field. The method of loss leader bilking of patients is unseemly, if not fraudulent. A podiatrist's portrayal as a sole gatekeeper for podiatric privileges in local hospitals, based on the claim of being the only podiatrist with a three-year residency, has been a subject of contention. These representations impact the professional advancement of other podiatrists and bring into question the integrity of such actions.
The hyper-promotion of a surgical procedure, advertised extensively in the newspapers as a universal “orthotic solution” for all ages, leads to considerable professional scrutiny. A lack of understanding of adjunct procedures can lead to post-interventions by orthopedists and podiatrists, ultimately resulting in the procedure being excluded from local hospitals. Again, this brings our profession into scrutiny. These situations highlight the importance of professional integrity and evidence-based practice and the ethical responsibility of medical professionals to prioritize patient welfare over personal or professional gain.
Philip Radovic, DPM, San Clemente, CA
02/07/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 B
From: Jack Ressler, DPM
The last response to the query by Heather Kaufman, DPM was quite the character assassination of Ivar Roth, DPM. The thoughts expressed by Dr. Kaufman, "The hypocrisy and arrogance that drips from every word of his posts like slime down a wall is nauseating" was off base and extreme. Although on the surface, Dr. Roth's treatment plan of turning a $125 debridement service into a $3,000 plus visit seems extreme, I'm assuming a detailed treatment plan to address the patients fungal nail condition is incorporating medication and probably the use of a series of laser treatments.
The bottom line is that his patients are paying cash. I'm sure he gives his patients a detailed explanation of the course of treatment along with other options. Seeing that he is practicing in a liberal state like California, he is not holding the proverbial gun to his patients' heads forcing them into their decisions. I am sure Dr. Kaufman is an asset to the podiatric community. Going off on a fellow podiatrist like she did is not helping our profession.
Jack Ressler, DPM, Boca Raton, FL
02/07/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Howard Bonenberger, DPM
I wonder about the remaining 13% of patients with peripheral neurological involvement who ostensibly go undiagnosed or with a delayed diagnosis. What is the cost to them in time, advanced imaging, neurological consults, EMG, and potential degeneration of their health?
Do practitiners fret about recommending orthotics even when the patient must pay out-of-pocket? If not, is it because we believe that we are giving them our best advice? It is unfortunate that the discussion of abuse rises to the top in more than a few podiatry conversations.
Howard Bonenberger, DPM, Hollis, NH
02/06/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 B
From: Heather Kaufman, DPM
I am finding it difficult to hold my tongue any longer as I read the posts submitted by Ivar Roth. The hypocrisy and arrogance that drips from every word of his posts like slime down a wall is nauseating. He bombasts about ethical patient care in the same sentence in which he brags about billing $3K+ to a patient coming in for $125 nail care because he (as a "favor" to the patient) "pointed out" and "educated" that patient about all the things that were wrong with their foot.
He likely convinced them they needed thousands of dollars of additional products/services. Or, when he tries to argue that he is more qualified than a pain specialist to implant spinal cord stimulators for patients with pain not responding to pain medications. Yes, take the Abbott course Dr. Roth and implant such a device. I would love to be the expert witness for the plaintiff on that case!
Heather Kaufman, DPM, Anchorage, AK
02/06/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Ivar E. Roth DPM, MPH
I read Dr. Kravitz's thoughtful response, and I agree with him on several points. The first is that when one purchases or leases a piece of expensive diagnostic equipment, there is a great chance of over-utilization to justify its use and expense. The second is that new technologies should be looked at and incorporated into practices. In the case of the PSSD device, if Dr. Jacobs' 87% success with the standard test is correct, what patients would really want to pay $300 for a test with a free alternative that is that effective?
I see this new device as an excuse to bill patients for non-covered testing that is not necessary. It just gives doctors cover to charge and make money that is NOT in the patient’s best interest. Please ask yourselves if you would want to pay for a test when the free one is 87% effective.
This reminds me of unscrupulous podiatrists who take screening x-rays on all their new patients just to make sure nothing is missed. This includes patients who complain of ingrown nails, etc. While the insurance companies may pay inadvertently for an unjust x-ray CPT code, if the patient had to pay for these out-of-pocket, I think they would question why they needed an x-ray. I hope that some of our more recent graduates read my posts and understand that being ethical is first and foremost what we need to be as professionals and break the cycle of trying to make money at all costs.
Ivar E. Roth DPM, MPH, Newport Beach, CA
01/30/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 B
From: Cynthia Cernak, DPM
I was not responding to the value of the PSSD, the machine which was introduced so many years ago when we had so few examinations except for clinical vibratory, Semmes-Weinstein, and nerve conduction study/EMG. I no longer have the machine or use it. The question was billing and abuse with the Medicare system.
My response was it was never covered by Medicare. That should have been made clear at the time that the machine was used. Unfortunately, that was not the case with the person that I was responding to. I absolutely agree with everything Dr. Jacobs said. Many abuse the system, trying to charge for nerve testing. My response was not the value or lack of value of the PSSD machine, but the billing of what was done.
Cynthia Cernak, DPM, Kenosha, WI
01/30/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Ivar E. Roth, DPM, MPH
I could not agree more with Dr. Jacobs. I smell the rat also when using this new diagnostic test for neuropathy at a great cost to the patient and little extra, if any, diagnostic value. Unfortunately, many DPMS will gravitate to questionable new diagnostics and treatments to make an extra buck at their patients’ expense.
Practicing ethically should be every professional’s goal, not chasing the dollar as so many of our colleagues are doing.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
01/12/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Greg Caringi, DPM
I had an unusual relationship with Dr. Ganley. Since I was an OCPM graduate, I did not know him as a professor. He was a personal friend of Dr. Chauncey Roelofs, my first employer in Lansdale. Like myself, Dr. Ganley's first job out of the Navy was in Dr. Roelofs' original office in Phoenixville. He was introduced as a friend. We worked together training residents at our respective hospitals in Norristown.
His "residency" was the best fellowship a student could have at that time and his former residents have all had great success in our profession by following his lessons in podiatry and in life. As CPME requirements for residencies became stricter, ...
Editor's note: Dr. Caringi's extended-length letter can be read here.
01/12/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 B
From: Steven Kravitz, DPM
Dr. Jacobs’ post to pay tribute to Dr. James Ganley is an absolute pleasure to read. Thank you Dr. Jacobs for taking the time to articulate this and to Dr. Block for publishing and helping it gain some traction and attention, so that many have the ability to read it. There are a lot of lessons in it, and Dr. Jacobs' beautifully touches the surface describing attributes, nuances, and the ability to get to feel who Dr. Ganley was, and why he is recognized as an icon. Humble with humility, brilliant, without exception compassionate for others, a sense of balance in life, and ability to enjoy other aspects outside of his profession... sailing being just one of them.
One important point that comes out as you read the tribute is how much Dr. Ganley appreciated and enjoyed being a podiatrist. There's too much negativity today about our profession and...
Editor's note: Dr. Kravitz's extended-length letter can be read here.
01/11/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 B
From: Joe Agostinelli, DPM
I am writing this after reading Dr. Allen Jacobs’ thoughts on Dr. James Ganley three times. That brought back memories from 1977-1981 during my time at PCPM; during that time, Dr. Ganley lectured mostly on pediatrics to our class. Dr. Jacobs’ comments are “spot on” as to the influence Dr. Ganley had on his students! Personally during my 23 years in the USAF, we had Dr. Ganley speak to our armed forces DPMs several times. We had one particular seminar where Drs. Ganley and E. Dalton McGlamry lectured a full day, each back to back.
I still remember the "pearls of knowledge" from both of these giants of our profession. Dr. Ganley would sit in a chair on stage, reflecting back on his few slides - but was talking to us rather than lecturing about various topics. He always mentioned the medicine/surgery education and training he received as a corpsman in the U.S. Navy, and like all of our armed forces DPMs, his experiences in the military mirrored ours as far as our training with and working with orthopedic...
Editor's note: Dr. Agostinelli's extended-length letter can be read here.
01/11/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Frederic C. Spector, DPM
"Revere your teacher as you would heaven.” - A Hebrew proverb. Kudos to Dr. Jacobs for his tribute to Dr. Ganley. As a student at OCPM, I first became aware of his contributions by Dr. Dalton McGlamry in the mid-70s. All three of these doctors have been giants in our field and contributed to the success of countless podiatrists.
Frederic C. Spector, DPM, Savannah, GA
11/09/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 B
From: Paul Kesselman, DPM
Many of us have been saying this for years and it starts and ends with the absurd laws which prohibit doctors from really unionizing in a manner in which they can collectively bargain and strike. Under the current structure, these powerful tools are kept at a distance and all we can do is gripe and act independently but not with a collective force that a real union can effect. Without the ability to collectively bargain and possibly strike, we are in effect powerless to stop this continuous downward spiral. Nurses, residents, and others in healthcare can unionize and have walked out on the picket line. Physicians must find a way to fight back and get that right back! This downward spiral cannot be allowed to continue.
So yes the UPS driver and others with some seniority can make almost as much as a family practitioner and actually eclipse them with overtime. They additionally have no worries about liability, who may or may not show up for work, and all the other responsibilities a small business owner has to saddle.
Even employed physicians have to work harder, longer hours to keep up with absurd EHR requirements to see more patients in less time and are effectively being paid less per patient as they are on an hourly or RVU cycle. We are now in parallel with our colleagues in the former Soviet Union, where the joke was that bus drivers made more than doctors. Well, that joke is now at our doorsteps and it is no longer funny!
Paul Kesselman, DPM, Oceanside, NY
11/09/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Farshid Nejad, DPM
Bret, I could not agree with you more. The pious faith in our field has been our downfall. Healthcare has pivoted but the physicians have not. Our leaders are failing us. APMA wants our money and wants our voices to help make change, but is it really listening? As I said in my previous post, enough is enough. We as physicians need to make a stand against this bullying. Medicare Advantage plans just received another increase in pay from Medicare. This money does not trickle down to physicians. It lines the pockets of the executives of these plans. When LA Care has huge signage on a skyscraper in Los Angeles, next to US Bank, what does that say to you. How are they spending money that should be earmarked for us?
I challenge our leaders to set up a meeting with all the other medical associations and create a new path for us. The Writers Guild in Los Angeles also received a pay raise in addition to the other industry that Bret mentioned. Let’s get one too. And it better be in the double digits!
Farshid Nejad, DPM, Beverly Hills, CA
10/12/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 C
From: Allen Jacobs, DPM
Sadly, I must respond to the sophomoric comments recently made in PM News regarding my comments on Krystexxa. Krystexxa is utilized to lower serum uric acid and for the treatment of chronic tophaceous gout. The goal of treatment is to lower the uric acid to less than 6. It is not used to manage acute gout. It is a drug which typically requires multiple IV administrations. It is not a drug typically utilized by podiatrists. The comments made were a classic example of not knowing what you do not know.
I did not suggest that podiatrists do not or should not treat acute gout or in fact any acute monoarticular disorder. Rather, if you would read my comment rather than embark on an inaccurate diatribe, my point is that Horizon does and has participated in podiatry education. They do not appear to ignore podiatry. However, they accurately conclude that Krystexxa is a medication appropriately employed by rheumatologists in the majority of...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
10/12/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 B
From: Gary Dorfman, DPM
In no way was I inferring that a podiatrist should take over the responsibility of treating a systemic condition such as gout. I agree with Dr. Jacobs 100%. However, diagnosing, providing appropriate labs, and providing relief for a patient with acute manifestations of the affliction is well within our scope of practice. And so is, obviously, an appropriate referral to an MD or DO physician. A podiatric physician should be familiar with all forms of medication and treatment available to patients; but the pharmaceutical houses should likewise be aware of, and inform the public of, who can provide or refer those services.
I also understand Dr. Gurnick’s consternation. It can be very frustrating when podiatry is left out of the equation entirely. Keep in mind that Krystexxa is an IV medication. The very fact that a podiatrist received information on the medication, will allow the podiatrist to discuss in an intelligent manner the pro’s and con’s of the medication if he or she is asked.
Gary Dorfman, DPM, Dana Point, CA
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