Once again, podiarists are tripping over their DPM and asking how to get trained in a general medical field they weren't taught in podiatry school. The answer to Dr. Roseblatt is: learn it in a medical school. Podiatry continues to teach limited medicine. You can't teach all the broader subjects surrounding a disease in a one-day seminar.
Obesity requires knowledge of endocrinology, biochemistry, cardiac and other major systems. Don't tell me we learned some of this in school or rotating through as a resident. If we were competently taught, we should be allowed to take the USMLEs, but podiatry education is not recognized to do this.
Despite the majority of the profession clamoring for a general degree, the schools and the APMA want to keep the power and control for themselves. Despite their self-aggrandizement, they are frightened that getting MD control of our education will put them back in the toenail cutting end of the profession instead of the glorified position given them by frightened students.
Here is how I currently handle this situation. On any patient where I order imaging done outside my office, I inform patients that they must phone their insurance company before scheduling the test to find out if a pre-authorization or pre-certification is required.
Also, they are instructed to get the name of the person whom they spoke with. If pre-authorization is not required, they are to schedule the test. If, however, a pre-authorization is required, the patient is then required to...
Editor's note: Dr. Gurnick's extended-length letter can be read here.
When I have to get on the phone with some “doctor” to explain the medical necessity of needed imaging, I feel sorry for that doctor, the patient, and myself. Something has had to go wrong in that physician’s world to have to, or want to, work for an insurance company denying medical treatments to insured patients.
As physicians, we have been through extensive training and testing, and are required to perform continuous training and testing in our specialties. After all this, we find ourselves being questioned as to the necessity of the treatments and tests we want to perform on our patients. This has absolutely NOTHING to do with...
Editor's note: Dr. Purdy's extended-length letter can be read here.
RESPONSES / COMMENTS (NON -CLINICAL) - PART 2
RE: Be Prepared for Healthcare Changes - Part 3
From: Joseph Borreggine, DPM
To move forward on this topic, I would like to disclaim that I am not "expert" on this subject, but rather one who is a "forward thinker." I have not begun to change how I practice podiatry, or even implemented the suggestions that I have made in the last two posts. But, we are and will be progressing in the next few years to a modified “cash-based practice” and become very selective on whom we see and treat. Our participation in Medicare, Medicaid, and other managed care entities will continue, but over time, these types of patients will be few and far between.
We are looking for a more "select" patient population that has a more healthy and progressive outlook on foot care. The "entitled" patient mentality and expectation for healthcare delivery make us enslaved to an insurance company. We cannot continue to...
Editor's note: Dr. Borreggine's extended-length letter can be read here.
Dr. Robert Kornfeld is mistaken when he states that if you do not participate in an insurance company, you cannot be asked for any money back. Insurance companies DO audit non-participating providers. Additionally, they can and do ask for money back if they ascertain that the provider inappropriately billed patients. They can recoup this money on a theory of unjust enrichment and fraud among other legal theories. This is not uncommon. I encourage all practitioners to be knowledgeable and accurate in their billings whether or not they are a participating provider. Additionally, inaccurate billing can have repercussions on a practitioner's license. Forewarned is forearmed!
Dr. Shipley makes an excellent point with regard to DR vs CR, and that was one of the major reasons I went with a CR unit, as did many of my colleagues who were shopping at the same time. One of us got the ICRCO unit and some the ALL-PRO unit. We are all happy with our systems and glad we moved towards digital.
I have been using this device for approximately 2 years on my patients, with marginal results. I recently had surgery on my thumb and tried the VAD during the 1st injection and then let the doctor finish the other injections without the device. I found out first-hand (so to speak), that I didn't notice any difference!
Having given thousands of injections in my career, I'm not sure what I am doing different, as I have never needed to use ethyl chloride. My patients report that my injections are better than others they have received. I do not need any vibratory item, cold spray, etc. I just use as small of a needle as I can. I use a 27 gauge for blocks, and a 25 gauge for injections with solid steroids in a 3cc syringe.
The dermatology practice I'm involvement with uses a lot of 30 gauge 1/2" needles on the face and fingers. I have tried them on the foot and did not notice a difference. With kids, I have used Emla Cream to treat the patients, or an ice cube if thay are really anxious. I often play a game with the patients where I ask them on a scale of 1 to 10 how much do they think the shot will hurt. I almost always get an answer of 8-10, but after the shot, they almost all (99.9%) say it's about a 3 or 4. My suggestion is to be calm, direct, and don't move the needle once a lot (use a second puncture if needed). I use a two-stick injection to block a hallux for a nail procedure.
I started using this device in December of 2010. Previously, I was using ethyl chloride spray. The company claims that the device offers the abilty to perform "ouchless injections." In practice, very few patients report complete pain elimination upon needle stick. I believe that the device does provide an extraneous stimulus that perhaps does overload some of the cutaneous nerves. Patient response is variable. Most do report a level of painful stimuli reduction. A few patients who have had ethyl choride prefer it, and vice versa.
I certainly believe that needle stick pain is reduced with the device on most patients. Generally, it does not completely eliminate the pain of a needle stick. In my hands, it appears to be as effective to slightly less effective than ethyl chloride spray. Sometimes, it appeared that the spray caused as much discomfort as the needle stick. The device itself does not cause any pain or discomfort. You simply warn the patient that there will be a vibratory sensation just prior to the injection. The use of the device is well-tolerated. I continue to use this device exclusively. It has saved me hundreds of dollars as I no longer purchase ethyl chloride spray.
After looking through the responses to the VAD inquiry, we were surprised to see a post by Dr. James Ricketti because he invented two competing products. Dr. Ricketti invented two cotton swabs that, when combined with ethyl chloride, make a topical skin anesthetic, the exact same purpose as the Vibrating Anesthesia Device. We feel it is a HIGHLY unprofessional move by him to post a negative comment without disclosing his obvious conflict of interest. We wish to inform PM News readers of Dr. Ricketti's bias.
I have had the Sigma system for about 4 years now, and I am very happy with the product. I have their original scanner and plates, but I know there is a new system now. Their customer service is top notch and can fix most issues through remote connection. The unit is very fast and efficient and easy to use. They installed it in our office at noon, and we were using it by the first 1:00 pm patient. The images are great, and patients seem impressed with what we are able to do with it and love the convenience. Once you start with digital x-rays, you will wonder why you did not do it sooner.
A little more detail about On Line Provider Services, at least for CA: Go to palmettogba.com/Medicare/palmetto.NSF/docscat/home. Click on J1 PartB MAC-CA, HI, NV. Under Self-Service Tools, click on Beneficiary Eligibility & Claim Status and follow the instructions.
You do need to have an EDI Enrollment Agreement on file. The instructions for the Interactive Voice Response is also available on the same page.
Having recently graduated from podiatry school, I can relate to this. Bullying in podiatry school continues to be a problem. Kudos to UCLA for setting up a department and then publishing the results. If you report abuse from an attending faculty, resident, or even co-students in the class, many podiatry schools will hush you up and won't take things seriously to avoid a bad reputation. But looking at the bigger picture, bullying, verbal, and sometimes physical abuse becomes a much bigger issue during residency. Again kudos to UCLA and hopefully APMA/CPME will follow with a similar department for podiatry students and residents.
In contrast to Dr. Bijack's opinion that we are not competent to talk to patients on weight loss, I feel that we are; at least as competent as most family docs, internal medicine docs, surgeons of any specialty. When my wife had colon problems, the GI doc told her to eat more fiber, and if she needed more help, he would refer her to a nutritionist. When I hovered around the pre-diabetic state, my internal medicine physician told me to lose about 10% of my body weight and be retested. He offered to send me to a dietitian if I wanted. I dare say I can do that as well. What does counseling entail? Telling patients that they need to lose weight or stop smoking? Offering a referral to a nutritionist or to a "stop smoking" clinic?
If it entails a full discussion of weight loss methods, talk of strategies to stop eating, a psychological evaluation of causes of over-eating, and caloric counting vs. fat counting and so on...then very few docs, DPM or MD/DO, are competent. Yes, Dr. Bijack, we are competent to talk with a patient about weight loss - not to discuss all the ins and outs of it, but to "discuss" it.
I spoke with the owner of Mowbray Company 2 weeks ago. He is trying to sell the company and ceased production of 3-WEA a few months ago. If he can sell the business, perhaps the new owner will again produce it. If he cannot, perhaps the patent will be sold to another manufacturer. He has no 3-WEA in reserve. It has all been sold to suppliers.
Yesterday, Chicago Medical Supply allowed me to order 2 bottles of 3-WEA, and I received it today. I don't know if they have more in stock or not, but you should call them. They are the only supplier that still has any.
A great alternative to 3-WEA is Dreft, the laundry product. We mix water with it at about a 10:1 ratio. Softeners are useful for corns, calluses, warts, painful mycotic toenails, psoriasis, etc. to make the shaving of these lesions easier/faster for the podiatrist, and more comfortable for the patient. I never knew 3-WEA to be useful for anything but softening lesions prior to debridement or shaving down.
The query was how to find out if a patient is deceased without using the IVR. Personally, for the expense, time, hassle and other aggravations, I would simply mail the announcement to the information that my office has on file. That said, the most current free site is the Death Master File edition of November 30, 2011. This site can be found at ssdmf.info/. Paid sites include ancestry.com, genealogy.com, etc.
One can also use the paid site CheckMedicare.com (the parent company is strongly supportive of podiatry) that provides information directly from CMS. From this site, you also get the current address of your patient, plus the patient’s zipcode+4. The CheckMedicare.com site can be copy/pasted into other computer programs (e.g., Microsoft Word). My office prints the CheckMedicare.com into a readable pdf file for future easy access. I am not aware of any site that provides this information for free anymore, so the November 30, 2011 is the most current free information. Though tedious and not always accurate, you can perform a search using the terms: obituary death “patient name” which will give you paid obituary information. The advantage of CheckMedicare.com is that the site is HIPAA compliant.
We fully agree with Dr. Katz that a protocol is needed for treating onychomycosis. Regardless of what laser is used (or other treatment options), your patients are at greater risk of exposure to the microorganisms that cause onychomycosis when they are stepping into a contaminated shoe. The in-shoe environment must be dealt with for the most effective treatment possible.
A study discussing shoes as part of the infection cycle and proving the efficacy of the SteriShoe ultraviolet shoe sanitizer is publishing in the 2012 July/August issue of JAPMA. The SteriShoe sanitizer provides a controlled, clinically proven treatment with each use and doesn’t fill the shoe up with toxic chemicals.
Why not have residents become 'Board Certified Podiatrists' upon completion of residency, a short period of practice [3 or 6 months], and successfully passing some test at the end of residency [either the ABPS, ABPOPPM or some other certification exam]?
This creates a level playing field and still allows for individual specialization later on. All podiatrists with CPME-approved certification would also be included in this, and individuals who met these specifications at some time in the past should be eligible. Podiatrists who want to go on and be board certified by ABPOPPM or ABPS would contintue on the path they are on now. One can debate the hypotheticals of how to help those who don't have a residency so that a mechanism to allow them access to board certified status exists.
Board certified podiatrist would have meaning...
Editor's note: Dr. Gottlieb's extended-length letter can be read here.
From: Rob Lagman, DPM, Robert Scott Steinberg, DPM
I have had some dealings with Ovation Medical. They were quite pushy when calling to try to sell us on CAM walkers, night splints, and post-op shoes. In the end, I got a sample of one of each and was actually quite pleased with the CAM walker. They are reasonably priced and seem to be decent quality. I ordered a few of them for now. I was not as pleased with the night splint or the post-op shoe. They are fine, but I feel that I get better quality for roughly the same price from my current vendor.
I have been using Ovation Medical's pneumatic walkers for over 2 years. They are well made and have a very low bottom profile. When they first contacted me, they offered to send me a sample. They did not bill me for that sample. In Dr. Hatfield's case, my first guess is that it was just an innocent mistake. Ovation Medical is the only supplier I use for walkers.
From: Ivar E. Roth DPM, MPH, Michael Lawrence, DPM
I agree with Dr. Kittay. There are no studies to support the board and they should have at most given him a warning letter. I suggest that anybody who has a similar problem consult their malpractice carrier, which usually covers board complaints, and fight back vigorously. Chances are that, with a competent attorney, the board will back off or reduce the punishment to a letter. In my opinion, the boards in many aspects are over-reaching and playing judge and jury, and that is wrong.
When Dr. Joseph speaks, I listen. And on this particular topic, I am in complete agreement and have been so for well over a decade. If there are any arguable points, and it still comes down to the jury being out, WHAT WOULD YOU WANT DONE IF IT WERE YOU OR YOUR LOVED ONE? This makes the decision pretty clear for most of us, I'd say. Properly cleaning and sterilizing the instruments we use is not at all difficult, and why should it not be an expected standard of care?
I am not agreeing or disagreeing with Dr. Kittay's office procedures. I would like to point out his willingness to describe a possible deficiency and his request for validation from colleagues. Is it really necessary to post Dr. Albright's demeaning criticism? Dr. Michaels, Medical Director of the Reconstructive Foot & Ankle Institute Surgery Center, uses a laser to treat mycotic nails. He warns about numerous OSHA regulations against grinding. I checked as best I could, and could only find one reference (04/30/1993) - that toenail particles do not qualify as regulated (OSHA online).
Dr. Elliot Udell proclaims, "I have not burred any nails in my practice." I went on to Pub Med and typed in "nail dust" as he suggested and could not find NUMEROUS articles on infectious aerosol. Is anyone aware of a statistically significant number of our colleagues who are suffering from pulmonary disease related to grinding nails?
Why the hysteria? More importantly, why not stand by another podiatrist? There are companies that sell devices to reduce nail dust. There are disposable sanding discs that can be used only once for each patient. It sounds to me that Dr. Kittay may have been criticized excessively, and the very people who should close ranks gleefully join in condemnation. It's amusing how we are still our own worst enemies.
Dr. Ribotsky made a reference in his recent letter about Jeffrey Toobin, (a writer for The New Yorker Magazine), who was interviewing a New York City attorney. In that rather nasty article was the discussion of various illegal shenanigans some podiatrists were being charged with. It is sad that we have podiatrists who get into trouble. But even that attorney may someday have a parent in a nursing home who needs a podiatrist and instead ends up with a third-world aide (who speaks no English) who snips his Mom’s toe in half while trying to trim her nails.
That article stands in my mind as the most vicious one I have ever read about us. That said, I would ask the simple question: “Who is calling the kettle black?”
In response to Dr. Charles Morelli's question regarding patient satisfaction surveys, Eneslow uses the following 4-question survey as follow-up for all customers. Customers are asked to reply on a scale of 1-5, with 5 being strongly agree and 1 being strongly disagree.
1. I was treated professionally and with courtesy.
2. I was given complete instructions on the proper use, care, and maintenance of my device(s), including any wearing schedules and pamphlets that may be appropriate.
3. My devices, shoes, and/or modifications meet my expectations.
4. I was told to re-contact Eneslow if there is a problem with the fit or function of my device.
We also allow space for customers to write comments.
A good source of education which discusses the nuances on the various AFOs which can be used to treat complex rearfoot and midfoot disorders, is Hersco Orthotics.
I strongly urge you not to dispense these items unless you have a good working relationship with a local laboratory. These are very complex devices and often require several adjustments prior to being ready to dispense. This is especially true for those who do not have significant experience with these devices.
I have always treated the acute phase of gout, but it has taken me many years to make the decision to treat gout as a chronic condition. My early protocol was to treat the acute phase and refer the patient back to the PCP for chronic management. But after being told by countless PCPs that they don't treat first attacks, (and usually not second or third attacks), I thought how ridiculous!
Although the attack happens suddenly, the hyperuricemia that produced the attack has been brewing for years, perhaps as long as 20 years. I learned in first year pathology that gout affects 3 organs, joints, kidneys, and heart! Rheumatologists are now saying that first attacks should definitely be treated. I think that any time a basic metabolic profile is done, a serum uruc acid should be included. I have seen gout attacks in males as early as their 20s. This is a very common and complex medical issue, but I just wanted to start the ball rolling and hear from my colleagues about this matter.