RE: Maximalist Running Shoes are In, Minimalist Running Shoes are Out
From: Kevin A. Kirby, DPM
Over the last five years, there was a rise in interest in barefoot and "minimalist" running, along with an increase in runners getting injured by trying to transition into barefoot and/or minimalist shoe running. Two years ago, here on PM News, I mentioned a new shoe that I had run in, the Hoka One One, which I had thought represented a new design breakthrough and a new shoe category, the "maximalist shoe". Hoka One One running shoes have much thicker and more cushioned midsoles and have become increasingly popular, especially in the ultra-marathon and trail running community.
Recently, other running shoe manufacturers have taken notice of the popularity and success of the Hoka shoe and are now jumping on the "maximalist shoe bandwagon" with their own form of thick-soled, highly cushioned midsole running shoes. Most notable in this category is the newly released Brooks Transcend shoe, which has a much thicker, cushioned midsole, like the Hoka.
At the same time, minimalist shoes, such as the Vibram FiveFinger shoe, are on closeout specials throughout the country as runners are increasingly voting with their feet and wallets to move away from the much-hyped, questionable benefits of barefoot and minimalist shoe running. I suggest all podiatrists who do treat runners to go to their local specialty running shoe stores and inspect and test-wear both the Hoka and Brooks Transcend running shoes that will likely represent the latest trend in running shoe design: the maximalist running shoe.
It is no wonder that Dr. Markinson wonders about the fluid injected in a plantar fascial treatment. I wonder as well. However, the first scenario deals with someone who injected a dorsal ganglion ten times. Now come on Bryan, that is not the fault of an ultrasound machine. The doctor was obviously a goof ball.
Regardless of the utilization of ultrasound or not, 10 injections of a steroid into a ganglion cyst seems to fall beneath the standard of care. I think that is the issue here, rather than the use of ultrasound, which is peripheral. As to Dr. Markinson's musings about how much steroid would remain in the body of the plantar fascia, I “guess” that it is mostly due to the nature of the structure, but I cannot, of course, prove it. Your study would be most interesting if indeed it could be accomplished morally in a manner where it could be measured.
If a new technology comes along, and...
Editor's note: Dr Gurvis' extended-length letter can be read here.
Generally speaking, getting a 90% success rate with an injection, as Dr. Forman writes, would be considered excellent, however to ultrasound everyone and bill for it under these circumstances is an example of overuse. If you feel that you need to get 100% accuracy with every injection and use ultrasound, why make 90% of your patients (and thus the insurance companies) pay for unnecessary services?
If you feel you need to use an ultrasound to give an injection, do so but do not charge the patient or the insurance company, or bill for those where it actually helped, i.e., the 10%. In summary, if you choose to give a shot and need assistance, that is your choice in providing better care, not a requirement, and so ultrasound should be included in the shot charge. As podiatrists, we cannot think, "Oh, I saved the insurance company $2,000 for an MRI" to justify using ultrasound on every patient who requires an injection."
Three years ago, I started my own practice after spending one year out of residency with another group. To secure my start-up business loan, I went to multiple local banks to get interest rate quotes and the requirements necessary for their bank/credit union. For a start-up loan, I needed 1:1 collateral to secure the loan, and since I had recently just finished residency and had a large amount of school loans, I did not have the 1:1 collateral necessary. My parents had to co-sign on the loan with me in order to secure the loan.
I also had a very detailed business plan to show them how I planned on repaying the loan and what I projected the practice to bring in for the next 3 years. I did figure in a salary for myself (very modest and just enough to live on) and $50,000 of working capital. I was surprised how long it actually took for the money to actually start coming in, and all of the little expenses that I did not expect when I started the practice.
I would be happy to talk to anyone who is looking at starting/buying a practice and to give any tips/advice that I can. Although it was a lot of hard work, it was very much worth it!
The First Aid Bandage Company has stopped making Fabco. I asked them why, and the response was that only podiatrists were using it, and not enough of them, so it did not pay for them to continue manufacturing it.
The replacement is made by General Bandage, Inc. known as Gauzetex - it is NOT exactly the same. The main difference which I hear from podiatrists is that FABCO was softer. Otherwise, it is basically the same. We sell it in 1/2", 1", and 1-1/2" - packed the same way as Fabco.
While I understand and appreciate your concern about the cost of medical tools:
1. The multi-tool is that price because they make millions of them for wood workers and home repair users. Their manufacture is completely unregulated. They have no need to comply with any FDA regulation, clinical validation, safety testing.
2. In the event that you ever injure a patient with that tool and wind up in court, neither the manufacturer OR YOUR MALPRACTICE PROVIDER has any obligation to stand behind you.
If I walked into a doctor's office and he used a tool he had gotten at Home Depot to perform a medical procedure on me, I would never go back, and I would tell all of my friends about the experience. And yes, I have a dog in this fight.
The post from Mark S. Davids, DPM is right on point. It is a great analogy, only if it were "Ma Bell." My practice experience discovered that there are bundles and packages of supplies and services -like your T.V., Internet, phone. The price keeps going down for the bigger bundle or package, so-called "global bundle" or "global package" in podiatric coding of supplies and services rendered. Yet, the expectation is that providers of healthcare must provide the maintenance while the bundle of "what's included" gets bigger.
Healthcare licensees need an "unbundling rule" like that of licensees of FCC. Meanwhile, pay the toll for extra marshmallows in your Starbucks coffee, since it is not part of the bundle or package.
Like Dr. Davids, I am from the early '80s graduating classes of podiatrists, which means we have seen quite a few changes over thirty years. I also have the same sense of frustration he expressed; however, I am acutely aware that the doctors and philosophies of practice preached in the '80s will not survive in this current environment. Today’s graduates have an innate ability to use a computer, smart-phone, and a myriad of other modern technologies that more than perplex my generation. The early adapters of technology seem to be faring much better in today’s world than those who scoffed and waited.
When I started practice is when doctors were beginning to use diagnosis codes rather than simply scribbling a diagnosis at the bottom of a super-bill that the patient would then submit to the insurance company for reimbursement. I remember looking at the “old-timers” gathered at state meetings discussing the right numbers to use.
Today, I am that “old timer” of thirty years ago. My generation sees doom and gloom, but the new graduates see opportunity. My generation is faced with the same daunting choice as those who have preceded us: adapt quickly or get out of the way.
For far too long, the U.S. has allowed in far too many FMGs. Where do you think they are coming from? From countries that are having their brightest doctors, engineers, programmers, etc., "stolen". Is it any wonder so many countries cannot improve the conditions in their countries?
RE: Educational Commission of Foreign Medical Graduates (ECFMG)
From: Robert Bijak, DPM
I recently read in the ECFMG Reporter about the development of GEMx (global education in medicine exchange). ECFMG is the authority for recognizing medical training as equivalent enough to take medical licensing exams. Successfully meeting the requirements allows you to qualify for residencies and take the exams to be licensed to practice medicine in the U.S.
I suggest that our APMA and/or CPME liaison with the ECFMG to see if a "third pathway" can be developed for U.S. DPMs to be considered at least as equivalent as foreign medical students. Podiatry needs to think about merging with medicine instead of running a parallel, but substandard course. It's time to drop the blind loyalty to podiatry as an independent field. As chiropodists, we were unique and could be independent, but to evolve, the lines of the two professions must intersect. We should try every path to make this happen. The APMA needs to change its focus and get serious.
As of the last report, there are still 92 of the 2013 (and before) graduates, who did not match because there are more graduates than there are residency slots. This is blatantly unfair. The APMA and the CPME have failed to assure that there are enough residency slots. CPME knows exactly the number of students we have, in the too many colleges of podiatric medicine. This is akin to the practice of selling more seats on a flight than there are seats available. But unlike the airlines which have to pay for their greed, it seems that the APMA and CPME think they can skate free. CPME needs to be overhauled. They won't do it themselves, so I expect the APMA to show them the door.
Dr. Katz's letter expressing his concern over the present costs of compounded topical pharmaceuticals is reflective of medicine in general, and his concerns are not unique to the compounding industry. How much does Dr. Katz charge for orthotics? Probably more than he gets for a digital arthroplasty. How about CAM walkers? Probably more than he gets for a level-2 office visit. And how many orthotic labs bid for our business?
The assertion that these pharmacies add components to drive up the cost is ridiculous. The pharmacies may only dispense what...
Disclosure: I have lectured for TPS and Bellevue pharmacies on these subjects.
Editor's note: Dr. Jacobs' extended-length letter can be read here.
I have always been willing to do my part. I will immediately open my NYC practice for one year to one of the unplaced DPMs. Grow, learn, and practice - we commit to preparing you for a residency next year.
In addition, I am available to work with any DPM nationwide willing to do the same. Let’s show these young men and women that we are on their side.
Concerning Dr. Kornfeld’s observations, here is what happened recently with some highly qualified 2013 graduates who did not match, and the preceptorship program that I offer. These graduates initially said they wanted my program, so I accepted them. Shortly afterwards, they said they needed some more time to make one last effort to get a residency program and asked if they could put my program on hold. I said yes. After their drop dead acceptance date passed, they again asked for more time. Again, they were not matched.
They were scheduled to start on June first. They then notified me that they wanted to take a month-long vacation, so I said okay. Just before going on vacation, they said that they could not now promise to take the program unless I agreed that they would have the full ability to apply to programs as they came up during the year, and that if they were accepted, they would leave my program. I said "no" at that point.
I was prepared to pay them very well for a year and give them excellent training. It seems like they want to have their cake and eat it too. I bent over backwards to help them out, and they seem so unappreciative of the opportunity made available to them. So now, they will probably do nothing in podiatric medicine for the next year. What a shame.
Dr. Ribotsky's article concerning the situation doctors face with respect to medical billing is expounded on in this article:
Ed Davis, DPM, San Antonio, TX
This is a great article that SHOULD be in every physician's office. Given the present climate in Washington, might this scenario ever apply to the other necessities ("entitlements") such as groceries, shelter, and clothing?
Not withstanding Dr. Markinson's practice management expertise, and the efficiencies he achieves by depending heavily on his staff, there are the realities of private practice that most of us still have to face on a day-to-day basis. First, let's go back to reality and the post that started this discussion. "Name withheld" was quite upset to hear what his/her staff was pulling, and had a secret shopper confirm his/her suspicions. Except for Dr. Markinson's off-topic scenario, it is very clear that staff can hurt a doctor's practice if they are not carefully monitored. Things are simple in my office. My staff asks. Novel, huh?
I completely see the potential for office sabotage that is being discussed. However, there are two sides or more to a lot of things, and this may be one. Maybe some of your staff are looking at the book, at you, and listening to callers and trying to protect you. How many "black toes" have you rushed in for a little dried blood on a thick hallux nail? We don't know how to say no, or not today. If we were our own receptionists, we would never go home.
The only suggestion I would make is that if questionable in any way, they put the patient on hold, give you their chart or fill you in on the new patient, show you the book, and ask you how to fit them in. That should be a rare instance. Part of a good receptionist's job is to protect you, while availing patients to care as can be done reasonably.
When I have encountered this problem in the past, I have established a bonus payment system for "filling the appointment book." Establish what constitutes a full schedule i.e., 90% of all available appointments full, establish a bonus such as $50 per filled day. Be sure to establish the fact that the patients must also SHOW UP for the appointments! Have a staff meeting dedicated towards brainstorming for filling the appointment book.
Ideas such as trying to fill the least desirable appointments first, moving patients forward from later dates to earlier ones if they are open, reviewing old files (by hand or EHR) to find overdue patients and calling them to come in, reminding patients of their upcoming appointments, making sure that all patients have their next appointment scheduled before leaving, etc. This had been most effective for me with one person in charge of filling the schedule, but it can probably be used for the entire team also.
Dia-Foot is a podiatry-owned, full-service diabetic shoe company. Dia-Foot features high quality footwear from New Balance, Aravon, Dunham, Rockport, Hush Puppies, Pure Stride and Orthofeet. Dia-Foot manufactures pre-fab diabetic inserts (A5512), custom diabetic inserts (A5513) and custom orthotics (L3020). In addition Dia-Foot manufactures the Pure Stride line of pre-fab orthotics, comfort insoles, diabetic socks and diabetic shoes. Dia-Foot carries the Ossur line of soft goods and features custom AFOs from Pine Tree Orthopedics.
Dia-Foot offers their customers all the proper Medicare documentation needed to pass a Medicare pre-audit. In addition Dia-Foot will assist in helping your practice get the needed documentation from the patient's PCP so your patient can receive their diabetic shoes. We invoice once a month.
Amen! To Dr. Moskowitz. We have all been faced with the "new" patient to our office who just needs nails trimmed, has no class findings, etc. When you explain to the patient that this is not covered by Medicare or a secondary insurance, the usual reply is "well, my last podiatrist billed Medicare and they paid." They usually leave the office in search of that "other" podiatrist who will bill Medicare fraudulently.
Folks, we're talking about $43 for being stupid. Is it worth it? Remember, it is because of "you" that Medicare and many other insurance companies flag podiatry or require prior authorizations from the UM departments for every little procedure we do. On the flip side of that coin, why can't we turn patients in for fraud also?
I recently wrote a letter on this forum excoriating the APMA for its incompetence and irresponsibility in the development of the Pinterest site Beat-Bunion-Blues. A response to my post was published on this site several days ago and it is even more ridiculous and irresponsible than the site itself.
Crystal Holmes DPM, the chairperson of the APMA communications committee stated, "images (not the source of the images) are the content users are interested in)." So, according to this web wizard, people looking for advice about bunion treatment are only looking for pictures, not...
Editor's note: Dr. Kiel's extended-length letter can be read here.
I agree that as an APMA member, I am not thrilled with the APMA Pinterest page. But I want to be clear, I do not have any complaints with the APMA having a Pinterest page. Dr. Holmes accurately pointed out that Pinterest is a very popular social media site, and it is being used effectively by organizations such as the AMA. They have created a very professional site that promotes their members to the public.
I believe the style of the Pinterest site that our organization has does not present a professional image. Just as there needs to be a level of peer review and quality for an item to be published in a professional journal, there needs to be a vetting process on the APMA site to avoid an unprofessional presentation to the Pinterest community that visits the APMA Pinterest page.
I applaud the APMA on the forward looking approach, and utilizing social media to educate the public about our profession, and urge them to reconsider the current content of the site. It should be a site that makes each and every member proud to be a podiatrist and helps to encourage the best and brightest to join our ranks.
I am glad Dr. Udell brought this to light, pun intended. Smokers, or more properly nicotine addicts, will do or say anything to justify something that is clearly bad for them, just like a heroin addict. We all know patients who are so addicted and troubled that they continue to smoke after being diagnosed with lung cancer, emphysema, or a heart attack. Now, this is a free country, but I do not want to pay for their health problems or the second-hand smoke problems, but those of us who pay taxes do just that. Furthermore, cigarette smell is off-putting to most people, and sometimes downright offensive. Again, these addicts don't care what you clean air breathing people think.
So, I have never hired a smoker and never will. Even if I could get sued, I would make the arguments above in court. I can very easily detect a smoker by sense of smell. So, set up any interviews either right after lunch or in the evening and you will surely smell it on them.
I don't operate on smokers unless I have no other choice. I am still surprised when they ask "why do I have to stop?" As long as we don't mind the billions of cigarette butts scattered across the land of our nation as people just flick them in the ground, then nothing will change. So, until the tobacco lobby goes away, we all suffer because others are too weak and too addicted to change.
I would like to publicly thank Drs. Markinson, Bakotic, and Lemont for consistently reminding us to keep our 2mm punches in the top drawer and to use them with the swipe of an alcohol swab, a cc of lidocaine, and a little Monsel's solution. So often we look but do not see!
Malignant lesion on sole of foot
This new patient had this lesion for years...seen by many, but never biopsied. She is now managed by the Yale surgical oncology service.
Did Dr. Scholl's really save ICPM (I'm an alumnus), or BUY an advertising billboard on every graduate's diploma to hang in their office for thousands of "customers" to see? I wonder if there is a corporate tax write-off each year for advertising their name. Is our impecunious podiatry school a (un?) willing partner in this scheme? Will the MDs ever have a "Depends" college of urology?
I have tried the Dr. Scholl's, "custom foot orthotic fitter" machine at Walgreen's. The funny thing is, it all depends on how you stand on the foot plates. When you stand on the outsides of your feet, it reads, "high arches" and "prescribes" an, "orthotic" for high arched feet. Stand with knees bent, and you have "flat feet", and it "prescribes" an, "orthotic" for flat feet. And so on...That's the problem.
I have many disappointed patients who have spent the $40 or so on these, and gotten no relief. Then, they are reluctant to try the appropriate orthotics I wish to prescribe, because they've "already tried orthotics" and failed. hmmm...frustrating.
Also, I wish the FDA would force Scholl's to stop selling/making the corn/callus "medicated" acid plasters. These have eaten holes in people's feet. Acid does not have a brain; it just keeps eating away. Although the fine, tiny print states not to use if you are diabetic, have circulatory problems, etc., many lay people don't know that they have (undiagnosed) diabetes or PVD.