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04/18/2012
RESPONSES / COMMENTS (NON-CLINICAL) -
RE: Urgent Care Clinics (Elliot Udell, DPM)
From: Bret Ribotsky, DPM
After reading Dr. Udell's post on PM News, I think he said that he liked "doc in the box" medicine. While I'll agree that for a cold, etc. while out of town, you can be helped from a "doc in the box". I worry about the masses of patients who are getting treated at these places by a nurse practitioner who has received a PhD, and is being called DOCTOR.
I am sure you would love to see the foot doctor in the back of the drug store (Boot's pharmacies in London has these). Personally, I want only the best care for me and my family, not Wal-Mart medicine. I am not inferring that Wal-Mart medicine is not just fine, but, I am sure we can all agree that today, when you think of a great medical centers and great physicians, the names, Wal-Mart, Target, K-mart, Sears, and JC Penny's are not on the top of your tongue.
The great strides in America have come from the capitalistic system. Work hard and you can command a good fee for what you produce. If medical care gets relegated to a shift job, quality can only go down.
Bret Ribotsky, DPM, Boca Raton, FL, ribotsky@yahoo.com
Other messages in this thread:
06/17/2013
RESPONSES / COMMENTS (NON-CLINICAL) - PART 1
RE: Time for EBM Study on Custom Orthotics
From: Carl Solomon, DPM
I appreciate the ongoing discourse about biomechanics theory and who’s right/who’s wrong. But I’m still waiting to see ANY decent controlled study in our literature.
When will one of our “experts” please take a couple hundred patients, and divide them into two groups? Have one group use “custom” orthotics and the other use OTC inserts for some condition (heel pain, metatarsalgia, whatever). After some period of time, maybe a year, look back and see whether there’s a statistical difference in outcomes. How about the same study (but longer than a year) with custom orthotics vs. no orthotics on patients with early hallux valgus to see if there's REALLY any effect upon progression of the deformity.
Until that’s done, we are at the mercy of insurance companies who (rightfully) say our “custom” orthotics are unsubstantiated. Worse yet, we are denied the ability to refute the ads that are now popping up for commercial orthotic stores who claim that theirs are “300% better” than podiatrists’ custom orthotics!
Carl Solomon, DPM, Dallas, TX, cdsol@swbell.net
01/16/2013
RESPONSES / COMMENTS (NON-CLINICAL) - PART 1
RE: Podiatrists and Flu Shots
From: Elliot Udell, DPM
The governor of the State of New York just declared a "flu emergency" and will ease vaccine restrictions. What this means is that pharmacies which are giving most flu vaccinations these days will be able to give them to children and there will be more promoting of the need to get vaccinated. Wouldn't it make sense for our state podiatric medical societies to petition to allow podiatric physicians, who give far more complicated injections, all day long, to administer flu vaccinations? So many of our patients are elderly people who are at risk of developing serious complications from influenza. By offering this service to our patients, we could really be making another needed contribution to the health and well-being of our community.
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com
12/17/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 2B
RE: Efficacy of "Pain" Creams (Tip Sullivan, DPM)
From: Howard Dananberg, DPM, John F. Swaim, DPM)
I never used “pain creams” in practice. That was until I was introduced to Motion Medicine™ while lecturing in Canada over two years ago. I was so impressed as to how effective this was that I became the U.S. importer.
Motion Medicine™ uses an array of ingredients which act for pain relief as well as a significant anti-inflammatory effect. It contains glucosamine and chondroitin to help restore joint cartilage. It contains thymol, which in small amounts, acts as a local anesthetic. MSM and sea cucumber works to reduce inflammation and support healing.
Disclaimer: I am the owner of Motion Medicine, LLC in the U.S.
Howard Danneberg, DPM, Stowe, Vt, hdananberg@gmail.com
I too became frustrated early in my career over the lack of a reasonable alternative for my patients with painful neuropathy who did not gain benefit from Neurontin and its sister medications. If you read the labels, most all of these rely mostly on the effects of menthol. The only alternative at the time was to have the local compounding pharmacy make and dispense a 2 oz jar containing a mixture of clonidine, lidocaine, and ketamine; and it cost $70 out-of-pocket and worked about 33% of the time.
My frustration with this void in treatment options for symptomatic neuropathy led me into extensive research and the development of...
Editor's note: Dr. Swaim's extended-length letter can be read here.
12/05/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 1A
RE: CMS to Now Cover Obesity Counseling (Robert Bijak, DPM)
From: Elliot Udell, DPM
Dr. Bijak is correct when he implies that prior to starting an aggressive exercise program, cardiac pathology should be ruled out by the patient's internist or cardiologist. Walking, however, can be part of a "medical solution" to obesity. Weight Watchers International has just invested millions of dollars into a new program and participants are asked to wear a monitor all day long which will record the amount of walking each participant does over a week-long span. If it is low, the person can then increase his or her movement by increasing daily walks. In addition to scheduled exercise workouts, the medical experts at Weight Watchers who developed this program feel that increasing walking throughout the day, along with diet control, comes a long way at reducing obesity.
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com
10/09/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 1b
RE: Combination Billing/Collection Service (Ron Werter, DPM)
From: Dennis Shavelson, DPM
I have great suggestions for Dr. Werter that (if we all followed) would change the panorama of podiatry as I feel that many DPMs are too forgiving when it comes to co-pays and especially deductibles because our neighboring DPMs are.
1. Collect your co-pays before patients enter your treatment area or otherwise, don’t let them in.
2. If a patient has not met his/her deductible(s) from a previous visit, don’t let him/her into your treatment area.
3. If you are forced to deny a patient treatment, consider lowering your fees or having them give a written explanation of why they cannot pay.
4. As you deny a patient access to your care, if they are non-compliant to their insurance contracts, ask politely, “Where do you want me to forward your records?” That’ll persuade them.
Dennis Shavelson, DPM, NY, NY, DrSha@foothelpers.com
10/08/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 3B
RE: Vibration Anesthesia Device
From: Charles Morelli, DPM
I am surprised at the interest this device and topic have evoked. We all know that the pain associated with an injection is from the medication filling the space in which it is being injected into. The pain is almost never associated with the initial stick of the needle. I've always found a quick blast of cold spray works perfectly. I don't use ethyl chloride because it's just too expensive. Why waste your money?
For the benefit of the young practitioners reading this, if you simply insert the needle quickly, the pain that may be sensed is minimal at best (with the exception of the heel). Then, inject slowly to minimize the discomfort. My understanding is that the vibration device does little to minimize pain around the fat pad of the heel or any deep injections (sinus, ankle, neuroma, etc.). For digital or nail anesthesia, try to avoid injecting directly at the level of the joint. Instead, insert the needle point directly associated with the middle of a phalanx. There is much more soft tissue between joints for fluid to fill into, as opposed to directly around the joint itself.
Charles Morelli, DPM, Mamaroneck, NY, podiodoc@gmail.com
08/03/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 1B
RE: Affordable Care Act (Obamacare) Perk (Jon Purdy, DPM)
From: Bryan C. Markinson, DPM
Dr. Lang clearly supports the notion of universal coverage (so do I) and clearly supports it to be run by the government. My personal preference is cradle to grave Medicare for everyone, financed by premiums through payroll deduction. This way, younger people who will use it less can finance the costs of the traditional Medicare we have now for the elderly and disabled. However, I would also like to see an "in" or "out" option for both doctor and patient.
Dr. Lang is also well versed in the provisions of the ACA. However, in present form, the ACA is dependent on the "exchange" to provide healthcare insurance to those now forced to purchase it. I find it incredulous to believe that 10 to 30 million people (no one knows how many for sure) are going to find the exchange premiums affordable, especially when they are used to having it painlessly withdrawn from their paychecks. Employers also have incentives to NOT provide coverage under ACA.
I foresee a groundswell of people, maybe millions, who will find themselves protected by ACA provisions, but unable to afford to participate. I am not talking about poor people here; I am talking about working middle class whose employers will take advantage of paying a fine rather than providing coverage.
Bryan C. Markinson, DPM, NY, NY, Bryan.Markinson@mountsinai.org
07/26/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 1
RE: Articles In Podiatric Journals by Non-DPMs
From: Stephen Doms, DPM
I just received the July/August 2012 issue of JAPMA. As an observation, I noted that there were 13 articles, not including the president's message. Of those 13, only 4 were authored by DPMs. And also, 5 of those 13 articles were from outside the United States: England, Wales, China, and two from Germany.
In contrast, when my fellow residents and I published an article in JAPA in February 1982, there were 10 articles. All 10 articles were authored by DPMs and all originated in the United States. It was my understanding at that time that all approved residency programs had to produce a research project that was "acceptable" for publication (not necessarily accepted for publication). Has this changed over the past 30 years?
Stephen Doms, DPM, Hopkins, MN, sdoms@aol.com
07/25/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 1A
RE: Artificial Toenail Innovation/Successes (Eric Hart, DPM)
From: Mark L Bauman, DPM
I have been working on a permanent artificial nail implant, with pilot pre-clinical trials completed by a local colleague having been successful, and hope to begin clinical trials by next year.
Mark L Bauman, DPM, Voorhees, NJ, nailsone@comcast.net
06/22/2012
RESPONSES / COMMENTS (NON-CLINICAL) -
RE: My Retirement from Pedinol Pharmacal
From: Richard Strauss, RPh
After 43 years of being associated with Pedinol Pharmacal Inc. as its Chief Executive Officer, President and consultant, I will be retiring in July. As some of you may know, in April, Pedinol was sold to Valeant Pharmaceuticals. While this was a difficult decision to make, I am confident, that it will allow Pedinol to continue to thrive as a leader in podiatric pharmaceuticals. Valeant Pharmaceuticals is committed to the podiatric profession and will continue in Pedinol’s tradition of supporting podiatry and bringing useful products to podiatrists and their patients.
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Richard Strauss |
I wanted to take this opportunity to thank the podiatric profession. During my 43 years at Pedinol, I have had...
Editor's note: Richard Strauss' extended-length letter can be read here.
06/08/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 4
RE: Vision 2015, Vision 20/20 (Ed Davis, DPM)
From: Jeff Kittay, DPM
I'm not sure, but I think that Dr. Davis' tongue was completely inside his cheek with most of his "suggestions" (Really? a Congressional ban on flip-flops?). Judging by the responses, though, it seems that some people took him seriously. Asking any prospective podiatry student to incur debt of 100K to 200K for both schooling and underpaid residency training is a non-starter. And I think he missed the boat on naming the 4-5 year residency grads. They must be called "Superpods", for they shall lead those of us with blinders into the light, with truth, justice, and the American (APMA) way. Kind of gives you goosebumps, doesn't it?
Jeff Kittay, DPM, Boston, MA, twindragons2@verizon.net
05/31/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 1B
RE: Unethical Behavior By Foot Solutions (Peter Mason, DPM)
From: Geroge Jacobson, DPM
I have kept an advertisement from them for plantar fasciitis and heel pain. It boasts that for $549 you'll get a package which includes "Custom Accomodative Shoe Inserts That Support Your Arch", "A pair of MBTs or Chung Shi Lifestyle Shoes Designed to Gently Caress the Plantar Facia and Relieve Pressure and Discomfort at the Heel", and "An Over The Counter Orthotic For Your Dress Shoes."
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Foot Solutions Ad |
Imagine all three for $549. Wow what a deal! I keep the advertisement in my office with my heading of "Why Waste Your Money?"
Geroge Jacobson, DPM, Hollywood, FL, fl1sun@msn.com
05/31/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 1A
RE: Unethical Behavior by Foot Solutions (Lawrence Rubin, DPM)
From: Jack A. Reingold, DPM
I agree that each store must be judged individually, as they are franchises and are individually owned. However, my experiences with Foot Solutions, the Good Foot Store, and several running specialty stores have been similar. We may be to blame for this. As our training has increased and we are now part of the department of surgery at every hospital, many of us no longer have the desire or the knowledge to be the expert in “orthotic therapy.”
In addition to this, our institutions, which were graduating 700 plus students a year during the 1980s, have only been graduating 400-500 this past decade. These factors, along with population increases and epidemic obesity, have resulted in an increased need for foot care that we have been unable to meet. In my area, where it is very economically competitive in healthcare, I have seen many chiropractors in the paper claim that they are foot experts. As I tell my residents, “everyone wants a piece of the foot.” The only thing we can do is to be the best at foot/ankle care every day.
Jack A. Reingold, DPM, Solana Beach, CA, footdoc@san.rr.com
05/17/2012
RESPONSES / COMMENTS (NON-CLINICAL) -
RE: Sterilizing Bits Between Debridements (Warren Joseph, DPM)
From: Robert Spalding, DPM
Dr. Warren Joseph's note confirmed the importance of the sterilization of burrs and any instrument used to treat fungal nails or provide routine foot care. Podiatrists who have not been following this sterilization approach could be as big of a factor as nail salons in contaminating the general public. First, tossing "dirty burrs" back into a liquid disinfectant to be re-used 5 or 10 minutes later on another patient is also a guarantee to infect your next patient. The heavy layer of bioburden trapped in the cutting recesses of a burr will not be sterilized even by gluteraldehyde in...
Editor's note: Dr. Spalding's extended-length letter can be read here.
05/10/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 2
RE: Is it Time to Bring Back Chiropody?
From: H. David Gottlieb, DPM
An ongoing thread on sterilization shows the split personality of podiatry. The skill with which we have historically eased the pains of humanity's feet is the foundation upon which all our advances have come. Many practitioners still provide valuable services to those who are otherwise unwilling or unable to have surgery using time-tested methods often passed down one to one. These skillful hands can ease discomfort and restore the ability to walk without cutting skin, just by using felt.
Residency training now is surgically geared with a secondary emphasis on biomechanics, but none to little on the old 'c and c' ['corns and calluses' or 'chipping and clipping']. I am actually fine with this. Personally, I found the old practice style to be...
Editor's note: Dr. Gottlieb's extended-length letter can be read here.
04/09/2012
RESPONSES / COMMENTS (NON-CLINICAL) -
RE: Pyrocarbon and Foot Surgery (Vincent J. Hetherington, DPM and Jill S. Kawalec-Carroll, PhD)
From: Tip Sullivan, DPM
If one uses a hemi-implant for degenerative changes in either the base of the proximal phalanx or the first met head, pyrocarbon with some modification looks great - theoretically. In my practice, I rarely see one or the other involved, but I usually see degenerative changes in both surfaces of the joint. I believe that the basic problem with joint replacement of the 1st MTPJ is not the materials we use, but is the anatomical fact that there are actually 3 joints involved functionally and anatomically.
I have yet to see an implant that is designed to take into account the sesmoid articulation. Over the years, I have drifted away from implants and more toward fusions. In my hands, fusions are more predictable in the long run. I would love to see someone come up with a pyrocarbon “total“ joint implant that was both functionally and structurally sound.
Tip Sullivan, DPM, Jackson, MS, Jackson, MS, tsdefeet@MSfootcenter.net
04/07/2012
RESPONSES / COMMENTS (NON-CLINICAL) -
RE: Digital X-Ray Sizing (Jeffrey Kass, DPM)
From: Michael L. Brody, DPM, Alan Berman, DPM
The best thing to do in order to test the magnification factor of your x-ray is to take an x-ray of a metal ruler. Then view the x-ray and use the same ruler against your screen. You will be able to determine if your system magnifies the image and by what percentage it is magnified.
Michael L. Brody, DPM, Commack, NY, mbrody@tldsystems.com
In our practice, we use a standard size ball bearing taped on the plate to ascertain that the image size is correct. Just measure the size of the ball bearing, and you will be assured that the foot image is sized correctly.
Alan Berman, DPM, Carmel, NY, anbdpm@aol.com
03/27/2012
RESPONSES / COMMENTS (NON-CLINICAL) -
RE: ICD-10 Preparation (Edmond F. Mertzenich, DPM, MBA)
From: Marc Garfield, DPM
ICD-10 is delayed. ICD-11 will probably be released before or close to when a conversion to ICD-10 occurs, but we are not expected to implement ICD-11 until around 2020.
The biggest costs are in retraining courses for staff and doctors and productivity losses, a readiness analysis, and code conversion tools. Another cited cost is “increased documentation.” The expectation is that the doctor will have to learn how to document in such a way that a coder can translate a few statements and turn those into a specific and appropriate ICD-10 code, as ICD-10 is being referred to as the “new language of medicine.” This is not just adding another digit to an ICD-9. It is a new system and the documentation in your software will have to be standardized to produce an ICD-10 code rather than converting your coding capture tied to a diagnosis in your chart now. At least that is what is supposed to happen.
Here is a link to one of several ICD-10 cost breakdowns. They are all similar, from what I have seen.
Marc Garfield, DPM, Williamsburg, VA, mgarfield1@cox.net
03/26/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 3
RE: Appoint an Inspectress (Hal Ornstein, DPM)
From: Charles Morelli, DPM
It sounds like Dr. Ornstein needs a better cleaning service? After reading his employees' very long list of over 60 individual items (all of which I agree with) that need to be addressed, I compliment him on his ability to get all of this done for $10 a week. Does your employee have a sister? If so, have her contact me. She's hired!
Charles Morelli DPM, Mamaroneck, NY, podiodoc@gmail.com
03/22/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 3
RE: ICD-10 Preparation (Joseph S. Borreggine, DPM)
From: Marc Garfield, DPM
If you think ICD-10 is more accurate, look up ICD-10 for plantar fasciitis, M72.2. Note that it is still the same code as plantar fibromatosis. M72.2. No laterality is used for plantar fasciitis, but you will need laterality for bunions and hammertoes. Both fingers and toes share the same L60.0 code in ICD-10. Do you still think that the “accuracy” will make your claims process more effectively?
We are the last county to convert to ICD-10. Most did so 10 years ago. There are no crosswalks planned. There have never been crosswalks. Only 26% of claims could be crosswalked, if there was a crosswalk. Does anyone out there think that $80,000 per 1-3 doc practice could be put to better use than a new diagnosis classification system.
By the way ICD 11 is scheduled to be released in 2015. At the very least, we should encourage our associations to support the AMA in killing or postponing the ICD-10 implementation.
Marc Garfield, DPM, Williamsburg, VA, mgarfield1@cox.net
03/17/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 2
RE: ABPS Name Change (M. W. Aiken, DPM)
From: David McKenzie, DPM, PGY-2
As new foot and ankle surgeons nearing completion of our training and entering our specialty, we have been observing the changes in our profession and specialty. Much has occurred and continues to occur which gives us cause for optimism. We are enthusiastic about the possible name change of our surgical certification organization.
We believe this is a major step forward in our identification and recognition, which allows us a clear statement of what we are training for and what we hope to...
Editor's note: Dr. McKenzie's extended-length letter can be read here.
03/07/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 2
RE: Podiatry Chairs (Robert Lagman, DPM)
From: Richard Rettig, DPM
I have had a Hill chair for about 15 years and it has held up nicely. I had a boatload of little aggravations with it, based on poor design choices, and I had to work with the company to get the chair to be serviceable. I wrote a letter to the company at the time, stating that all these changes should be made permanent, as they would be needed to meet the needs of a typical podiatrist. Sadly, I believe they ignored all my suggestions.
When another DPM recommended the chair to me, he said he bought an 'oversized' foot cushion. I didn't see any need for 'oversize', so I got the regular size. I found out in a matter of days that it was perfectly suited if your typical patient is 5 foot tall, and your tallest patient is 5'8". I had to have them remake it "oversized" to be useable. All the hand switches were poorly placed, and I had them move or change all of them. I was disappointed that the company had so little regard for getting it right the first time.
Richard Rettig, DPM, Philadelphia, PA, rettigdpm@gmail.com
02/21/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 2
RE: Podiatric Physicians Practice Podiatric Medicine: RIP Podiatry (Eric Roberts, DPM)
From: Daniel. J. Tucker, DPM, Leonard A. Levy, DPM
I completely agree with Dr. Roberts. His commentary summarizes exactly the attitude that we as podiatric physicians and foot and ankle surgeons need to perpetuate in order to remain an integral part of the healthcare community. The nomenclature attached to our medical degrees and post-graduate training programs reflects the progression that we as a profession have made in past decades. It's time for our professional titles to catch up as well.
Daniel. J. Tucker, DPM, Atlanta, GA, reekat@aol.com
For most of the history of medicine, the term “physician” referred to someone who treated the whole body. According to practice acts in every state, MDs and DOs are licensed as physicians and surgeons. But that is an overstatement, certainly far from being true, not in the best interest of the public, and an anachronism. For example, psychiatrists and radiologists are licensed physicians and surgeons. But if these highly qualified physicians did any surgery, they would be targets of massive malpractice actions. DPMs independently diagnose, prescribe drugs, order laboratory tests, perform invasive surgery, and treat fractures.
That is certainly the practice of medicine regardless of what the law may state. Laws in some states prohibit us from saying we are physicians, but because of what we do, we are physicians. Such laws will continue and remain a dinosaur until and unless we engage with vigor in changing them. No one will do that for us.
Leonard A. Levy, DPM, Ft. Lauderdale, FL, levyleon@nova.edu
02/17/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 3
RE: Source for Medical Nail Technicians (Tracy Edwards)
From: Robert Spalding, DPM
Information on medical nail technicians can be found at Medinail Learning Center, medinails.com. The course is 14 modules online, 7 in a pre-requisite course called the "Advanced Nail Technician," and 7 more in the medical nail technician program that trains technicians specifically to work in a podiatry office. There are three exams during the courses and a 40 hour internship is required in a podiatry office or podiatry clinic following the passing of all the exams.
To find the current graduates, go to the home page and click on graduates.mln, which helps podiatrists find a nail technician who will fit well in their offices. They provide three hours of free consulting for any podiatrist who 1) hires an MNT and 2) wishes to set up a pedicure area in the offices.
The MNT can be one of three workers in your office. 1) performing cosmetic pedicures on your patients and bringing in new patients, 2) performing routine foot care and assisting the podiatrist and 3) doing both. These nail technicians are usually the top technicians in the field who wish to work aseptically and in a podiatry office. If you have questions, email me.
Robert Spalding, DPM, Signal Mountain, GA, rts9999999@aol.com
01/10/2012
RESPONSES / COMMENTS (NON-CLINICAL) - PART 2
RE: Bone Mineral Density Testing (Elliot Udell, DPM)
From: Sloan Gordon, DPM
My point was that, as specialists, we have the education, ability, and obligation to treat those disorders for which we were trained. It is also my opinion that DPMs should be reimbursed for the procedures we perform. I was not suggesting that one test vs. another was more accurate. It's unfortunate that Dr. Udell refers everything out. So what is left for him to treat?
I simply stated there are other tests which previous writers did not acknowledge, and which DPMs can perform. Is there a problem doing non-invasive vascular testing in the office when others read the results? If there is, many internists in my town must not be following Dr. Udell's dogma. There are always those narrow-minded professionals who are in self-denial vis-a-vis their own abilities. That's unfortunate, and again highlights my suggestion that we are often our own worst enemies. It's the "if I can't do it, neither should you" mentality. Don't we have enough people making us look bad? Do our own colleagues feel the need to encourage them?
Sloan Gordon, DPM, Houston, TX, sgordondoc@sbcglobal.net
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