Podiatry Management Online


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From: Robert Scott Steinberg, DPM


Dr. Musser asked for advantages and disadvantages. I'll give you one big disadvantage. If you do not do plaster slipper casts, then there is really nothing that separates you from chiropractors, physical therapists, pedorthists, or the shoe store salesman who does a scan. It does not matter which scanner you use. They all make you run-of-the-mill and..... beige. Let the slings and arrows fly, especially from those of you who don't want to get your hands dirty, or those of you who have "trained" your office staff to handle the mundane stuff, or those of you who failed to master the art of casting.


Robert Scott Steinberg, DPM, Schaumburg, IL,

Other messages in this thread:



From: Ed Cohen, DPM


If this patient came into my office, I would discuss her insurance and ask her if she would like information on where to get better coverage at a more affordable rate. If the patient was interested, I would tell her about our experiences and how we got a 39 year old employee a policy with a $5 co-pay for PCPs, a $10 co-pay for a specialist, a $250 deductible with a maximum out-of-pocket of $500 for $176 a month after the employee tax credit. This person also was a smoker and had cancer several years ago. Another employee, a 45 year old, found a policy for  $218 which also included dental and vision coverage with no deductible and a 30% co-pay on all medical and hospital bills. This policy has a $1,000,000 coverage limit.


We also ask our patients if they are interested in saving money on our prescriptions and if they are, we tell them about the GoodRx website. Every doctor should be familiar with this site because it can save the patient a lot of money. On expensive prescriptions, such as Zyvox, there is a number 855-239-9869 to call where the patient can get the antibiotic for free, based on income. 


Ed Cohen, DPM, Gulfport, MS



RE: Setting the Record Straight

From: Bradley Bakotic, DPM, DO


I'd like to set a rumor that has been circulating recently straight. Years ago, due the threat of Obamacare, and changes in reimbursement, Bako partnered with a private equity firm, thereby giving us a nest egg, in case the worst came to fruition. As it turned out, had we not done so, we likely would have been put out of business by the various adverse changes. It was one of the best, and luckiest, business decisions I've ever been fortunate enough to make. Recently, as that fund matured and their stock became available, another firm purchased that stock (recapitalized). I have never given up control of my company, and have retained ownership. 


At Bako, we're going to continue to support the podiatric profession; in fact, during 2017, we'll do so at the highest level ever. This profession is by in large awesome, and we're incredibly fortunate to have had its support through the years. Thank you!


Bradley Bakotic, DPM, DO, Alpharetta, GA



From: David E. Samuel, DPM


Several years ago, better vitamin therapy was introduced by a few companies that started showing better efficacy for diminishing neuropathic pain. You purchase the vitamins and resell them to your patients. You make a little on the vitamins and many times, patients feel better and are happy. 


Good clinical studies on it and biopsy, I'm sure, played a roll in determining what the vitamins ultimately did to warrant a trial with them. We have used these vitamins and some have seemed to give some moderate improvement and some have also not been helpful. It just depends on...


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



From: Bradley Bakotic, DPM, DO


I'm a bit confused by the post related to ENFD by John Hurchik, DPM and some of the subsequent responses, particularly that offered by Elliot Udell, DPM, who seemed to imply that clinical doctors, and their labs, are doing ENFD testing strictly for "massive" financial gain rather than optimal patient care. 


First, let me say that I have been informed that Dr. Hurchik did intend for his note to take the negative tone that it seemed to. Secondly, those that believe that a punch biopsy pays a "massive" amount of money, probably have never done a punch biopsy. The "massive" reimbursement for a punch biopsy is about $85.00. It might buy you...


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



RE: $105 Office Visit Co-Pay

From: Keith L. Gurnick, DPM


Yesterday, a 25 year old female patient returned to my office for a follow-up visit, but with a new insurance plan beginning calendar year 2017. Her health insurance is an Anthem/Blue Cross PPO 60 EPO individual policy with a $105 office visit co-pay, and a $6,300 calendar year deducible. Should this really be called "Health Insurance" or just a major medical policy?


Keith L. Gurnick, DPM, Los Angeles, CA



From: Ed Cohen, DPM


I think if the patient has a good hgba1c, the procedure is safe. The nerve biopsy is slightly more accurate than a Sudoscan. The Sudoscan is a three-minute test where patients step on plates while placing their hands on other plates. I  think the Sudoscan is accurate enough to give you a good diagnosis and has the advantage of not having to treat a biopsy wound. Another great advantage the Sudoscan has is that you can safely run the test on any diabetic patient no matter how high their blood sugar, and the equipment can never cause an infection.


The  patient is usually more receptive to a non-invasive test and the Sudoscan is a good practice builder. The downside is insurance reimbursement, which used to be very good, but has now become a problem in the last few months. In some states, podiatrists are not authorized to use the machine. I have found the Sudoscan a great objective tool to evaluate the effectiveness of my treatments and selling the various nerve food products to the patients can also be a nice revenue generator. Patients also don't mind paying for the test when it is not covered by insurance.


Disclosure: I have no financial relationship to Sudoscan.


Ed Cohen, DPM, Gulfport, MS



From: Connie Lee Bills, DPM


I have been using simple Facebook ads for 2 years. I have a maximum of $5/day based on website clickthroughs. I love it and it reaches existing and new patients and they even have conversations about foot issues as a result. This is an awesome tool. I have not used Google yet, but be sure you have a Google place page (free) no matter what. It will make it easier for patients to search for you.


Connie Lee Bills, DPM, Mt Pleasant, MI



From: Jeff Kittay, DPM


Hooray! Finally the Boards will be accountable to SOMEONE. The high-handed attitude that many state boards have exhibited against the members of our profession may at last be at an end. More than twenty years ago, I was the victim of such board abuse which cost me two years of aggravation and nearly $5,000 in legal expenses before the board rescinded their accusations of professional misconduct (I had had the nerve to suggest in a malpractice case against another DPM that he had indeed violated the standard of care, an opinion with which I stand).  


I was advised at the time by my attorneys that the board members had “governmental immunity” and could say or do whatever they pleased without fear of retribution and that I could not pursue them to recover my costs. Perhaps the removal of such immunity by the SCOTUS will put the Boards on notice that their actions can indeed have consequences and that they must be more careful when making accusations or levying punishments. Those board members that feel that they must resign in protest to being held responsible for their decisions should feel free to do so and will not be missed by the profession.


Jeff Kittay, DPM (retired), San Rafael Norte, Costa Rica



From: Michael Forman, DPM,  Joseph Borreggine, DPM


Thank you Dr. Evans for warning us about the North Carolina Dental Board v. Federal Trade Commission decision. I was under the impression, obviously false, that you could not be sued for stating your opinion. Perhaps this decision can be used to punish "hired gun" experts who testify whichever way they get paid.


Michael Forman, DPM, Cleveland, OH


This has been an issue for many years. Click here.


Joseph Borreggine, DPM, Charleston, IL 



From: Steven N. Solomon, DPM, JD, Raymond F Posa, MBA


With the latest Yahoo breach, encrypting your email is a great idea. As a medical practitioner though, you need to make sure that the people you're communicating with are using the same email system as you are. You also need to make sure that you have a BAA signed with the email provider so as to be HIPAA-compliant. You may find it easier to use a patient portal for your communications as it forces the people communicating with you to do so securely. 


Steven N. Solomon, DPM, JD, NY, NY 


I recommend Zix Corp ( to all of my HIPAA clients. It is fairly inexpensive and works seamlessly through Outlook. Also, along similar lines, if you need to encrypt your text messages, check out Tiger Text (


Disclosure: I have no financial relationship to either company. I just have years of experience with them and they are solid reputable companies that offer outstanding service.


Raymond F Posa, MBA, Farmingdale, NJ 



From: David Cutler, DPM


For those of you who prefer evaluating newer surgical procedures with a bit more published research behind them, look at the European orthopedic literature on MIS bunionectomy. Most of these procedures are variations on the same technique, namely a through-and-through metatarsal neck osteotomy with aggressive lateral translation of the capital fragment along with a unique stabilization of the capital fragment using a 2mm K-wire as shown here. 


Post-op X-ray of SERI Bunionectomy


There are several of these published studies dating back to the early 1990s, but the most expansive is by Giannini, et al. in International Orthopedics, September 2013 entitled "A Minimally Invasive Technique for the Surgical Treatment of Hallux Valgus; Simple, Effective, Rapid, Inexpensive (SERI)" (PMID 23820757) with 1,000 cases. At first glance, this technique seems prone to non-union, though in this study, none were reported. Dorsal malunion was observed though only in 8 cases.


I’ve been doing open bunionectomy techniques since I started practice in 1988, though with robust studies on MIS such as these, I’ve started doing the SERI technique over the past several months. It is trickier to perform than you might expect, though patients do experience very little post-op pain and minimal swelling compared to open techniques, and they do appreciate the smaller scar.


David Cutler, DPM, Bellingham, WA



From: Martin S. Lynn, DPM, Jay Seidel, DPM is an excellent resource, providing options such as email destruction after a pre-determined time.


Martin S. Lynn, DPM, Oil City, WA


I use G Suite. It's the paid version of Gmail, Calendar, and Drive. You can sign a BAA with them and they are HIPPA- compliant. Also, it looks more professional, as you'll have Pricing starts at $5/month per user for 30gb of storage, and for another $5/month, storage is unlimited.


Disclosure: I have no financial interest in Google's products.


Jay Seidel, DPM, Baltimore, MD



From: Andrew Levy, DPM


I commend Dr. Loshigian for his letter and stance with Castle Connolly. It is important for each of us to speak up for the profession where we can.  For several years, their representative tried to sell me advertising space in the Top Doc issue in this area. Each year, I wrote a similar letter, essentially telling them I would consider an ad if and when they included podiatry as a classification. Now they have given up soliciting me, and unfortunately still haven't moved to a more enlightened inclusive focus. Keep up the good work Dr. Loshigian.


Andrew Levy, DPM, Jupiter, FL 


Editor's note: Write to William Liss-Levinson, PhD, VP, Chief Strategy & Operations Officer. His email address is:



RE: Time for Podiatrists to be listed as Castle Connolly Top Doctors 

From: Michael Loshigian, DPM


Well It's that time of the year again when Castle Connolly is open for nominations for its published lists of Top Doctors across the country. Every year, I nominate doctors that I have worked with closely and know to be among the best in their area of their specialty. Every year, it is a bittersweet experience as I cannot nominate deserving doctors of my own specialty. For as long as I can remember, podiatry has been excluded from this publication. 


This year, I have written to William Liss-Levinson, PhD, VP, Chief Strategy & Operations Officer. His email address is:


I have included my letter below as an example...


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



RE: Nutraceuticals and Diabetes

From: Paul Kesselman, DPM


I recently reviewed the following article available to Medscape subscribers regarding the use of nutraceuticals for the treatment of diabetic neuropathy. No matter the side of the fence you want to be on, this will be interesting reading and no doubt create some controversy. I wonder what others think.


Paul Kesselman, DPM, Woodside, NY



RE: Kudos  for New Residency Director

From: Stacey Baptiste, DPM


I would like to congratulate Jason E. Feinberg, DPM on establishing the first podiatry residency training program at Huntington Hospital at Northwell Health, Huntington, NY. Dr. Feinberg has been the Chief of Podiatry at Huntington Hospital for the past four years and worked diligently during this time to have a residency program established and approved by the CPME. This was an even greater task to accomplish as this would be the first residency training program of any medical specialty established at Huntington Hospital at Northwell Health.


Approval for three PM&S-36 residents was received earlier this year, and the first round of residents started their training September 1, 2016. Dr. Feinberg's program has been met with great success and he looks forward to future growth of the program as the hospital expands to meet a growing, challenging and diverse population.


Stacey Baptiste, DPM, Huntington, NY



From: Eric Edelman, DPM


If Chase/JP Morgan Chase is available in your area, they are likely to be the lowest cost option for credit cards processing. Chase Paymentech is one of the 5 direct processors in the U.S., so there is no third-party involvement. Almost everyone else you talk to is going to be a third party which will add another layer of service fees. Also, if you move your operating account to Chase, you will have your daily settlements in under 24 hours (Monday's transactions have funds available Tuesday, etc.). Their equipment cost is reasonable too; we just got new chip- compliant terminals for $350 that can go to CAT-5 cable and your Internet router for fast processing times. 


Eric Edelman, DPM, Syracuse, NY



From: Dane J. Myers, DPM, JD, Mark A. Hardy, DPM


I attended the Global Foot and Ankle Conference in Cleveland this year. As advertised, it included foot specialists from around the world. The lectures were timely and well presented by podiatrists, orthopedists, and others involved in foot care. Insights from specialists from around the world showed different perspectives on treatments. I highly recommend the conference.   


Dane J. Myers, DPM, JD. Springdale, AR


This is a legitimate meeting unlike some predatory conferences and spam emailings that we all receive from time to time. Current and past presidents and leaders from foot and ankle societies throughout the USA, UK, Europe, and the Asia-Pacific rim, founded this organization in 2015. The inaugural event was held in Cleveland, OH this past June. As a global organization, GFAC will rotate the annual meeting to a different host country each year. Much like the Olympics, each host country will bring its own flare and cultural contributions to the annual congress. 2017 will be in Chongqing, China; 2018 will be in Milan, Italy; 2019 will be in Delhi, India. Faculty and council members are comprised of ACFAS, AOFAS, EFAS, APSFAS in addition to many other national/international organizations. GFAC is an organization designed to be inclusive (MD, DPM, DO, PhD, PT, RN, etc.), not exclusive. Thus, the organization’s name: Global Foot and Ankle Community. 


Mark A. Hardy, DPM, Cleveland, OH



RE: Podiatrists and Diabetes

From: Robert Creighton, DPM


According to the CDC, more than 1 in 3 adults have pre-diabetes and 9 out of 10 do not even know they have it. The foot complications associated with diabetes are well-known, but I would venture to guess there is also a higher prevalence of foot problems presenting to our offices who are either directly or indirectly associated with metabolic syndrome/pre-diabetes. A just released study in JAMA Neurology found an association between metabolic syndrome components and polyneuropathy. 


I believe our training programs should create podiatrists who can confidently counsel their patients who present with the metabolic dysfunction that places that patient on a path towards diabetes and its life-altering complications that we know all too well.


Robert Creighton, DPM, St. Petersburg, FL



RE: Dermatoscopes and Amelanotic Melanomas (Daniel Chaskin, DPM)

From: Elliot Udell, DPM


Kudos to Dr. Chaskin for advising all of us to use dermascopes in our practices. I have been using one for several years and picked up two melanoma cases as a result. In one case, the patient's primary care doctor looked at the lesion and felt it was benign. The patient went to a dermatologist who also visually examined it and made the same misdiagnosis. As a result of my examination with a rudimentary dermascope I bought on Amazon for less than 150 dollars, the patient was properly referred, and to this day thanks me for saving his life.


There is a learning curve in dermoscopy and one pathway is a website called You can access dozens of case studies where they show you pigmented lesions viewed by the naked eye and then how they appear under a dermascope. They further show you slides of the lesions after a biopsy was done. There are also many textbooks available on the subject.


Elliot Udell, DPM, Hickville, NY



RE: Dermatoscopes and Amelanotic Melanomas

From: Daniel Chaskin, DPM


There may be dermatologists, podiatrists, and other healthcare practitioners who are surprised when the results of a pathology report come back as amelanotic melanoma. Here are some useful ideas: 


1. Read the section "Amelanotic and Hypomelanotic Melanoma" in the second edition of the Atlas of Dermoscopy.

2. Attend medical seminars which include dermoscopy as a topic.

3. Request that future podiatry seminars include learning about dermatoscopic images that could be sent along with biopsy specimens to a pathology lab. Dermoscopy provides additional horizontal information often missed by the naked eye. This additional information is helpful to the pathologist in best sectioning the specimens to ultimately arrive at a more accurate diagnosis. Without this information a dermatopathologist might miss a lesion's surrounding pattern of pseudopods. 


Daniel Chaskin, DPM, Ridgewood, NY 



From: David M Davidson, DPM



David M Davidson, DPM, Buffalo, NY



From: Gary S Smith, DPM, Tip Sullivan, DPM


Unilateral edema in the absence of obvious pathologies is almost always caused by a DVT or a bulging disc in the lower back.


Gary S Smith, DPM, Bradford, PA


This sounds typical for early RSD -- now known as CRPS. The first line treatment is aggressive PT. You may want to get a second opinion if you have not seen much of this.


Tip Sullivan, DPM, Jackson, MS



From: Hal Ornstein, DPM


Every physician has experienced the situation where they need something from their back office assistant and they are not available. This situation happens numerous times each day in most practices and leads to us walking to finding the assistant or the infamous call down the hall to find them. Now there is a low-cost, low-tech way to solve this problem and ultimately enhance the efficiency of your practice. 


The concept makes use of inexpensive walkie talkies which are worn by the doctor and various members of your staff. The walkie talkies are worn on the belt or scrub suit with an ear bud and a microphone hanging at the level of the collar for the assistants and a microphone for the doctor. When you need anything from a staff member or have something you want heard in the back office, you simply...


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



From: Jon Purdy, DPM

There are a number of ways to achieve better patient flow in an office. Some are more expensive with installed lights or computerized options within EMR systems. There are less expensive manual colored flags that hang outside patient rooms and used as indicators for what is to occur in that room. I feel tthat the system I have always used in my practice is even more simple and effective. 

I have designed a “task sheet” which is a categorical list of our most common diagnostic and therapeutic procedures, dispensed items, medications, and other “tasks” that I perform. This sits in the chart holder outside the patient room. If it is vertical and backward, I know this is the next patient to be seen. I take it in the room and fill out what I need performed for that patient. My assistants then know to orient the task sheet of the next patient to be seen, from horizontal to vertical.

When I walk out of the patient room, I place the task sheet vertical and forward. The assistants perform and prepare what I have checked off, such as x-rays, injections, medications, and bracing, as I walk into the next room, which has a vertical task sheet. By the time I am done with that patient, the tasks I have marked for the previous patient will have been performed and initialed. I can finish up with that patient and mark any additional tasks needed - and the process continues. Of course all HIPAA compliance is followed, so no patient identifiers are visible. Theoretically, one could see and treat patients without ever having to verbally communicate with the well-trained assistant.

Jon Purdy, DPM, New Iberia, LA