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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,

Other messages in this thread:



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,



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,



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,



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,



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,



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,



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,



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." 

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,



RE: Special Needs Rotation (Ashley Mychak)

From: Patrick J. Nunan, DPM


I am not sure where there is someone who specializes in disability medicine within podiatry. The AAPSM has partnered for many years with Special Olympics to provide screenings for those with intellectual (and many of them have physical disabilities as well) disabilities.  DMU, like many of the podiatric colleges, participates in Special Olympics events which gives some exposure to students over a weekend.

I recommend that you contact the American Academy of Developmental Medicine and Dentistry. Many of their members specialize in disability medicine. Now if you wanted a fun and educational month, I could connect you with a podiatrist in Northern Ireland who specializes in disability medicine.


Patrick J. Nunan, DPM, Huntington, WV,



RE: Insurance Company Controls

From: Robert Kornfeld, DPM

Today, I received an e-mail from the NY State Podiatric Medical Association regarding the new Blue Cross/Blue Shield policy change for 2012 regarding orthotics. To quote - "Starting in March of 2012, claims for orthotics submitted under your Empire insurance policy will be denied. The only exception is if a claim for orthotics is associated with a disease affecting the lower limbs, such as severe diabetes, which requires the care of a podiatrist or a physician. In those cases, medically necessary foot orthotics will be covered."  So it seems in one swipe of the pen, BC/BS has decided that orthotics are never medically necessary, except in this particular situation. So much for the extensive research on lower extremity biomechanics!! So much for the positive outcomes associated with foot orthotics.


BC/BS, like many insurance companies, is out of control. They are motivated by nothing other than profit. They are NOT in the healthcare business. They do not care about outcome as much as they care about "cheap" medicine. So they raise premiums, pay doctors less, cut out essential coverage, and laugh all the way to the bank. 


I cannot understand why anyone would want to continue participating (cooperating) with these companies. They are not your colleagues. They are not in business to support your medical-decision making. They are in business for themselves to continue to rake in windfall profits while practitioners continue to struggle to pay their bills. Are you mad as hell yet?


Robert Kornfeld, DPM, Manhasset, NY,



RE: SuperGroup Formation In Maryland (Ira Baum, DPM)

From: Robert Kuvent, DPM

With all due respect to Dr. Baum and his comments on Supergroups, he may not be looking at the big picture. Negotiating today's insurance reimbursement is only one small part of what we hope to achieve with our AZ Supergroup. We plan to create an entity with superior care and excellent wealth generation for its owners. We will achieve this through various economies of scale and the ownership of revenue producing ancillary services. We will also be well positioned for whatever changes are coming - specifically ACOs.


Robert Kuvent, DPM, Chandler, AZ,



RE: Keryflex Toenail Restoration (Susan Papp-Mlodzienski, DPM)

From: Cindy Pezza, PMAC

We currently use Keryflex in our office and have for over a year. It definitely goes in cycles according to seasons. Begin introducing the product right away as you will want to start the patients on Formula 3 before treatment. That is how we do it. After the patient has used it for a few weeks twice daily, we perform the procedure. The doctor debrides the nail down until there is 20 percent left, and then I come in and build the new nail.

Introduce this as not only a cosmetic fix for the problem nail, but when you remove the keratin after two months or so, the nail underneath appears healthier as it has been protected, and the patient will continue to treat it with Formula 3. We also suggest using Dr.s' Remedy nail polish after the procedure, as it will not harm the new nail with chemicals. Please feel free to contact me with any further questions.

Cindy Pezza, PMAC, Stoughton, MA,



RE: Cryoprobe (Mark Aldrich, DPM)

From: Harold Koehler, DPM, Mohammad Sharif, DPM

I had the original version for about $2,000 and have since abandoned using it. I had nothing but problems with it constantly malfunctioning. The cartridges are expensive and are basically the same ones used in dispensers making whipped cream that cost 50 cents apiece at Bed Bath and Beyond. The only reason I couldn't use the cheap cartridges was that you need a filter with it that you can only get from the Cryoprobe supplier. I was told that upgrading to the newer version for $3,000 more would eliminate all my problems. Once burned, twice shy. I would consider alternatives like the Cryopen.

Harold Koehler, DPM, Auburn Hills, MI,

I have been using the Cryoprobe for about one year and I must say that I'm not too impressed. Most importantly, it has NOT worked well for plantar verrucae which is the reason why I purchased it. It works well on raised lesions on the dorsal foot, but this constitutes the minority of cases. I've had some success with small poros on the plantar aspect of thinned skin individuals. In addition to the starting cost, the cartridges are also expensive. I find myself returning to cantharidine for its ease of use, predictability, and cost-effectiveness.

Mohammad Sharif, DPM, Atlanta, GA,



RE: Evaluating All-Purpose Lasers (John Moglia, DPM)

From: Joel Morse, DPM

At the 2011 Cherry Blossom Dermatology Seminar, we have three lectures on the topic of lasers for skin and nail problems. These will be in-depth and varied. There will also be exhibitors from top laser companies including: Cutera, Clearly Beautiful Nails/Lightage (Q-Switch), Cooltouch, and Fotona. If you have laser questions - this is the venue to come and learn. This seminar will have the most number of laser exhibitors at a podiatric seminar to date.

Joel Morse, DPM, Washington, DC,



RE: Evaluating All-Purpose Lasers (John Moglia, DPM)

From: John Strisower

If you are interested in a tool that is legally-marketed for the most different possible uses, it is a regulatory question that can be answered by looking at the FDA clearance letters for each device. These laundry lists say nothing about how they can be used for these applications and certainly don't state whether or not they work in practice. If you are interested in treating specific indications or performing certain procedures, ask your colleagues what works and examine the body of clinical experience available for each device.

Generally, multi-purpose tools excel at nothing. Consider asking for the best multi-use automobile. Wouldn't your first question in answering that be since all cars can be used for almost any purpose, what is most important? If you are interested in carrying sheets of plywood or lumber, a pickup truck may be the best tool while a sports car might be poor. If you are trying to comfortably carry a large group on a long trip, that is best performed by a large SUV. For a sunny summer cruise on the coast with just your spouse, an exoticar works best.

If you want something that you "can" use on anything, almost any laser can be acquired. Results will likely be poor for most applications, and patient experience will be unacceptable. A better question is: What are your primary intended uses? Then select from the devices that are best in class with proven track records for those procedures.

John Strisower, CEO, Pinpointe, Inc.,



RE: CPeds and Our Turf

From: Dale Feinberg, DPM

I had the pleasure of attending the 2010 North American Pedorthic Congress in Orlando, Florida this past weekend to pick up some required CPed CME credits. This seminar was well-attended, the break-out sessions were standing room only, and there were two completely filled vendor exhibit halls. The range of the lectures was quite impressive and included the following topics:

1) Plantar fasciitis and treatment options

2) The diabetic foot, complications and modern treatment options

3) Custom foot orthotics, casting, fabrication and clinical use

4) Posterior tibial tendon dysfunction, diagnosis, treatments, AFO casting, coding and billing

5) Video gait analysis

6) Surgical repair of PTTD

7) Modern casting techniques for functional orthotics and AFOs

The head of the Canadian Pedorthic Association got up on stage and announced that C-Peds were the experts on biomechanics and prescription foot orthotics and that they should...

Editor's note: Dr. Feinberg's extended-length letter can be read here.



RE: The Future of Podiatry (Michael Forman, DPM)

From: Kathy Satterfield, DPM

I agree with the majority of what Dr. Forman says in his letter - the wisdom of smaller classes at schools affiliated with medical schools (such as we have now with Western University College of Podiatric Medicine in Pomona, CA, and in Des Moines, IA, and as he reports, at the College of Podiatric Medicine & Surgery). These students have to keep up with the osteopathic and allopathic students to make the grade.


Where we part company, though, is with his statement, "Dr. Jex reiterates what we all know - that there is no shortage of podiatrists in the United States." Many of my colleagues don't know this. In fact, we would argue this as false, and we come bearing facts to prove it. I believe, though, that I know what Dr. Forman is speaking about. He and his friends and colleagues practice in areas that are super-saturated with podiatrists, and it seems as though there are way too many podiatrists graduating right now. I understand that perception.


I would counter with this statement: "There is no shortage of podiatrists in the United States practicing in population-dense, practice-dense areas and that there are shortages in low-income and rural areas as well as other areas where new populations are being redistributed." I would like to ask Dr. Forman and others to consider that statement as a possibility. 


Kathy Satterfield, DPM, Boerne, TX,



RE: Obama and Amputation Rates

From: Ron Renzi, DPM

He may not have said it well, but President Obama’s wish to place more emphasis on preventive and primary care would result in lower amputation rates. Consistent primary care and meticulous foot care decrease amputations. In wealthy areas, where there is access to both, rates  of amputation are low. In poor neighborhoods, there are fewer providers and access is limited by lack of insurance coverage. Under-insured and uninsured suffer five times the amputations of wealthy insured patients. Increasing access to primary care and increasing the importance of primary care may be the only hope the U.S. has of further reducing the amputation rate.

Ron Renzi, DPM, Abington, PA,




RE: Time to Act

From: Robert Bijak, DPM

Week after week, PM News publishes podiatric woes of insurance discrimination, hospital discrimination, confusion of scope of practice, and medicine vs. surgery. It's time to stop this unending cycle of despair and do something! It is incumbent for the schools to not mislead students that they are going to be physicians. The students should sign an informed consent that they accept their limitations. It has become obvious to me after 30 years, that podiatrists for the most part, don't want to put in the effort to change. The schools certainly won't give up the sinecure they enjoy.

Let's say what we all know. Podiatrists are a small step above nurse practitioners and a mile away from MD's and will stay that way without a degree and attitude change by the majority of the profession. If you disagree, just read the next few months of PM News and see the complaints associated with our limited degree and training continue. Do something. Complain to the APMA, hold back your dues, speak loudly at seminars, and meetings. Go up to, and dare I say, even above the ankle. We claim to be THE specialists. Prove it.

Robert Bijak, DPM, Clarence Center, NY,



RE: Physician Executive MBA Programs (Sloan Gordon, DPM)

From: David Helfman, DPM

As CEO of Village Podiatry Centers, PC in Atlanta, I was enrolled in Emory University's EMBA program many years ago. This was at a time when getting an MBA was in vogue. In month six of the program, I found that the material I was learning was not relevant or had any direct correlation to running a successful practice. Many of the classes were theoretically based, and I couldn't seem to apply the material to building a successful and thriving podiatry practice. I decided to drop out of the program and invest my time elsewhere, and ended up focusing on my business and hiring MBA's within the company.

I think that an MBA degree is great if you have time, but can also be a big distraction if you are trying to build a successful practice. MBA programs require an immense amount of time and commitment, and if you think that having an MBA will give you a competitive advantage in the marketplace, as is marketed by many programs, I would urge you to do your homework and reconsider. Okay, some would say, “well, now they have MBA programs designed for physicians which will be more focused and applicable.” I think MBA programs are a big business and physicians are a great target since they are looking for answers.

My experience tells me that most successful entrepreneurs DO NOT have MBA degrees; however, they have many MBA staff members on their team. My focus has always been on developing unique abilities and delegating everything else. Podiatry is a great profession, and you would be better off perfecting your skills, leveraging your podiatric education, and recruiting the appropriate talent to manage your practice.


David Helfman, DPM, Atlanta, GA,



RE: Vibram Five Fingers (Neil Scheffler, DPM)

From: Jenny Sanders, DPM

Vibram Five Fingers were first introduced in 2005. They are currently the shoe of choice for barefoot runners. Vibram originally designed this footwear to be worn while yachting and was surprised initially that anyone would want to run in them. Once they discovered this, however, this shoe with individual toes and Vibram soles became mainstream. I have posted more information about barefoot running shoes on my blog

Jenny Sanders, DPM, San Francisco, CA,



RE: Physician Executive MBA Programs (Sloan Gordon, DPM)

From: Nicholas Sol, DPM, MBA, Ivar Roth, DPM

I completed my MBA degree in Health Administration at the University of Colorado - Denver. My class in the Executive MBA program included physicians (MD, DO, DPM, DDS), nurses, insurance executives, pharmaceutical executives, hospital administrators, etc. This link will take you to their site for more information:

While the curriculum was challenging, the volume of work was less than I remember from OCPM. The knowledge and paradigm shift in thinking is definitely worthwhile. I'm running my practice with greater efficiency and efficacy. The increased income has eclipsed the cost of tuition....therefore, it was both educational and profitable.

Nicholas Sol, DPM, MBA, Colorado Springs, CO,

The University of Irvine in California has such a program, and I am aware of at least one podiatrist who graduated from there.

Ivar Roth, DPM, MPH, Newport Beach, CA,



RE: Insurance Audits

From: Larry Kobak, DPM, JD

As a healthcare attorney, frequently called upon to negotiate settlements with health insurance companies, I can tell you that I agree that you should not cave in and write a check at the insurance company’s first demand. Your demand might come from a location in another state. They might be unaware of your state’s rules that govern an insurance audit.

For example, in NY, unless the issue is fraud or abuse, the insurance company (not a union) may only go back 2 years, not 6 years, in claims they feel were improperly paid. How the amounts are determined vary as your fee schedules change, sometimes several times a year. Are you participating or non-par? What are the terms of your contract as to your rights in an audit? What rules govern?

Larry Kobak, DPM, JD, Brooklyn, NY,



RE: Practice Websites (Mark K. Johnson DPM)

From: Multiple Respondents

Our practice has had our own website since 2005. The benefits are numerous. Our patients can get door-to-door directions, download new patient forms, read information about common podiatric problems, and we have many links to diabetic information. Having patient forms available online is a tremendous time-saver when cycling new patients though the office for an initial visit.

Prior to 2005, we did have a site that was maintained by our local phone/Internet provider. When we decided to expand our site, we found it much more cost-effective to buy the software program and do it ourselves. If you have anyone in your office that is computer savvy, it is much better to build and maintain your own site. I used Dreamweaver to create ours and the cost at the time was $400 or there about. I do use a stat counter to track who is searching and how they are searching for us. This information is very valuable and by changing your key words, you can come up very high in the most popular search engines. I would never pay for any click services that promise to put you “on top.” With a little research you can do this for free.

All we pay is $30 or so monthly to maintain our domain and service. It is by no means a flashy site but it is effective and a good source for new patients. If you would like to check it out, here is our link:

Marcia Ellis, Southern Ohio Foot & Ankle Associates,

My brother, Mitchell Tracy, designed my website. He has 30 years of experience in the computer industry. Check out my website, and see what you think. I am #1 or #2 when people search for a podiatrist in my geographic area.

Mark Tracy, DPM, Port Charlotte, FL,

Today a website is a necessity. It is the best investment in your practice. The website provides a wealth of information about who you are, what you do, where you are located, (you can have directions and a map) and you can design it to have your intake forms available for a patient to download and fill out prior to the first visit. Even requesting an appointment can be done from the website. There are too many things to list here, but my recommendation is to contact a web designer. We have used Officite for many years, they are located in Illinois. Their phone number is 800-908-2483.

One great feature of their web design is you have the flexibility, if you want, to make changes on your own  after the website is up and running. The cost is fair, and as far as the search engines, we are on top consistently. You will be able to blog and even be on Facebook. We are living and working in a highly technologic world. Our website has been great for our practice.

Disclosure: I have no financial interest in this company.

Fay Mushlin, Newtown Square, PA,



RE: Limitation of Privileges (James Breedlove, DPM)

From: Multiple Respondents

Ask your medical staff liaison for a copy of the credentialing requirements for the ortho department.  You may be shocked if it doesn't have 3 (or fewer) boxes for equivalent surgical credentialing: ankle surgery, foot surgery and digital surgery (which may be included in foot), whereas it is not uncommon for podiatrists' credentialing forms to have multiple pages of procedures to check off.  This adds up to having to do more procedures to remain competent if you have to show competence in EVERY category on your delineation request. I would ask to be credentialed in a similar manner that all foot and ankle surgeons at your facility are credentialed.    


Jeffrey M. Dull, DPM Bay Minette, AL,

I had the same problem in CA. Apparently, with JCAHO now, board certification means nothing. If you haven't operated on the appropriate number of neuromas (or whatever) in the last few years, you become neuroma incompetent. Is this new rule based on JCAHO research proving surgeons brains go blank after a few years, or is this just a new make work project for JCAHO? If not based on research to prove physician incompetence, JCAHO needs to be sued for capricious trade restriction. I had to perform a number of surgeries in the office to prove competence to the hospital to get privileges, which proves I don't need a hospital for many of the procedures I perform.


Paul Kruper DPM, Kingsburg, CA, 

It is standard protocol for a hospital to ask how many of a particular procedure you performed, when granting privileges. I am sure it originated from some type of lawsuit, but is, in my opinion, a very reasonable request. If you haven't done a case in over 8 years, they probably wouldn't deny you privileges, but may require someone to scrub in or observe you.


If you haven't done a case in over 8 years, I wonder how often it will even be a factor. After 8 years, it seems like a good idea to have someone more familiar with the procedure be with you anyway. Just playing devil's advocate, I wouldn't want someone operating on me who hasn't done my procedure for 8 years either!  As everyone else is, in today's times, your hospital is just covering itself. I have never heard of someone being denied hospital privileges because of one particular procedure not being done frequently.


Brian Kashan, DPM, Baltimore, MD,