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02/13/2015
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Copyright Trolling
From: George Jacobson, DPM
When I built my website, I copied an image of an ingrown toenail from the Internet and put it on the site as an example. There was no watermark, name across the photo, or any claim that the image was protected. I received a letter demanding $720 for the use of the image. The exact same image is still on the Internet and on several other medical sites including WebMD, with and without ownership information.
Be aware of using anything from the Internet as you may become a victim of "copyright trolling." I filed consumer complaints to the Florida and Washington State AG, and the U.S. Postal Inspectors office. I learned about trolling from Florida's AG office today. It's not just pictures. It is a legal scheme, if they actually own the patent or copyright. It is deceptive. It is federal Law and the states can't do much, but they are aware of it in all 50 states. I was advised that even if you pay the money, they may come back at you, knowing you paid once and that you are worried about it. This may be via another company claiming you infringed on their licensing too.
George Jacobson, DPM, Hollywood, FL
Other messages in this thread:
01/02/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Over-Training and Under-Thinking
From: Rod Tomczak, DPM, MD, EdD
I remember quite vividly completing my residency which jammed a lot of learning and doing into two years, then starting practice in Monroe, MI. For the first few months, my patients were being admitted under my name alone, something not usually done in Philadelphia or Cherry Hill, New Jersey in the 1970s. I said nothing, did my own H&Ps, wrote all admitting orders, and continued writing the systemic medications patients were taking. It was a matter of ego once the policy started. I thought I could manage patients’ co-morbidities up to a point. This small town had no anesthesiologists, and the anesthetists were comfortable with my assessments, orders, and management of slightly ill patients.
Then I was informed Michigan state law mandated an MD or DO co-admit. I guess I felt humiliated that my abilities were being questioned by a diabetic, obese, smoking RN administrator. I was angry and had no right to be. I went so far as to claim my physical examination skills were on par with...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
01/01/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Rod Tomczak, DPM, MD, EdD
Ten or twelve years ago, the television was inundated with commercials for Laser Spine Surgery Institutes or similar organizations. One of the entrepreneurs wanted to establish a program in Belize as a medical tourist destination center. It was short lived. Malpractice claims in the U.S. skyrocketed. The surgery was performed endoscopically and any doctor who wanted to be trained and work for the company could. Patients showed up with $30,000 or so in hand to turn over to the company because no insurance was accepted. Since radiculopathies and painful feet along with foot drop affect patients, we can assume California podiatrists could have been trained to perform the procedure. Unfortunately, non-spinal surgeons were not trained to address the surgical complications resulting in deaths and paralysis. They make intra-operative neurophysiologic monitors to alert board certified neurosurgeons of impending disaster. But a weekend course should obviate the need for that. There is at least a day’s worth of reading concerning the topic on the Internet.
Dr. Roth, I would not feel very comfortable performing a stent placement in the Fem-Pop area of the leg because you and your podiatry friends think it’s OK. You cannot possibly believe that you folks define and interpret the law. The opinion of the CPMA attorney makes it legal? It is an opinion. You know that old saying, “opinions are like mouths; everyone has one.” If the California Supreme Court felt stent placement was within the legislated definition of podiatry in California, that may be another thing. Stent placements have been known to go wrong and the vessel ruptured. Are you and your DPM friends prepared to perform a Fem-Pop arterial repair, anastomosis, or insert a new surgical graft? I realize you have not had to address many complications, but there are surgeons who have.
Rod Tomczak, DPM, MD, EdD, Columbus, OH
12/31/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Rationale for Podiatrists Ordering Urine Dipstick Tests
From: Daniel Chaskin, DPM
If a pedal condition of PVD warrants Doppler studies or an evaluation of the circulatory status of the entire lower extremity, then perhaps in the case of bilateral edema, a podiatrist could order a urine dipstick. Diagnosing the systemic cause of conditions such as bilateral edema enables us to be able to refer to the proper specialist such as a nephrologist.
Daniel Chaskin, DPM, Ridgewood, NY
12/19/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Read the Fine Print
From: Gary S Smith, DPM
We were approached by a Rep from Samaritan Biologics, a company that supplies various biologic grafts. They presented us with a video and emails/text messages detailing that we would keep 40% of whatever Medicare approves for the material. We did order and apply a graft in the office. We were presented with a bill from Samaritan for 100% of what Medicare approves.
When we questioned this, the CEO called us and told us we missed the fine print where it says we pay 100% of what Medicare approves for the first 3 grafts in a month, THEN you get to keep 40% of the fourth! Obviously, nobody would order a second material from this company. I suggest anybody being approached by them to not purchase, or at least, read the fine print.
Gary S Smith, DPM, Bradford, PA
12/18/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Definition of Podiatry
From: Allen M. Jacobs, DPM
What is the definition of podiatry? A podiatrist is educated at the didactic and clinical level to diagnose and treat disorders of the foot, and in some states, the ankle and lower leg. The willful misinterpretation of the limited scope of practice of a podiatrist by some DPMs does not justify the practice of general medicine by a podiatrist. Example: a patient presents to you with tingling and burning paresthesia. You rule out local nerve entrapment. You order electrodiagnostic studies. The studies demonstrate a peripheral sensory neuropathy. Or you perform an epidermal nerve fiber density study. The test is consistent with small fiber neuropathy.
Now what? This is not pathology intrinsic to the foot. Whatever the etiology, as a podiatrist, you are not educated to proceed with further...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
11/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Who Determines the Standard of Care?
From: Rod Tomczak, DPM, MD, EdD
The term "standard of care" has been bandied about recently in a few postings in PM News. One author seemed to impugn whether the standard of care had been breeched because a patient had sought treatment from another podiatrist rather than from the author because the author of the letter was in his humble opinion, the standard of care, and if you read between the lines, also the gold standard. That is an absurd assertion.
The standard of care, not the gold standard, is the level at which an ordinary, prudent professional with the same training and experience in good standing in a same or similar community under the same circumstances would perform. This is not the “average podiatrist since that would mean half the foot and ankle physicians would not qualify. The plaintiff must prove that the...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
11/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1D
From: Robert Maccabee, DPM
In Ivar Roth’s recent post, he claims "the medical billing (in his mind) is a rip off”... One of his 411 posts to PM News. Not exactly the guy I would expect to do forensic reviews regarding toxic billing. He claims to be out-of-network and his Concierge Podiatry and “SPA” giving mani and pedi treatments. This just doesn’t seem like the practitioner to be reviewing billings. So if a patient comes in, as he mentions in his post, don't use shockwave as it’s not covered via insurance - but you’re out-of-network and charging them even if they might not want an injection initially. I gather he’d nail them for orthotics even before attempting what he calls a worthless therapy program.
After, if I read correctly, an injection that didn’t work, prescribe an orthotic that for this guy didn’t work, but when all else fails, don’t attempt surgery but go to you (as you’re the be all and end all), but charge him out-of-network and call all this toxic. Really? Come on - sounds like a little B.S. to me from the guy who's promoting mani, pedis, facials, or what you call hydro facials and inject some wacky “Paincur” that he seems to have invented as the website has him as the inventor. I know of no real pain management “physician” who has ever heard of it, but I gather he's charging multiple visits for that. Really? and he claims other podiatrists are charging “Toxically”.
Robert Maccabee, DPM, NY, NY
11/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Allen M. Jacobs, DPM
Dr. Roth expresses his "disgust" at the treatment of plantar fasciitis by a colleague. He opines that the "younger podiatrists" are motivated by money rather than patient well-being. He states that the patient consulted with an insurance covered podiatrist rather than "me", (that is) Dr. Roth. What was most disconcerting to me was the statement that Dr. Roth reviews anything for the purpose of making a judgment on the necessity of care and, hopefully not, standard of care.
Dr. Roth is critical of the utilization of ECSWT for the treatment of plantar fasciitis. In point of fact, while I personally do not employ ECSWT due to the general difficulty in obtaining insurance coverage for this modality, it is an acceptable and not-infrequently utilized modality for the management of plantar fasciitis. There is reasonable literature support for this modality in the management of...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
11/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: Adam M Budny, DPM
I read this post earlier today and quite honestly I was perplexed, as I am one of the "insurance podiatrists" who I believe represent the majority of the profession, as opposed to a boutique/direct pay" podiatrist (which seems to be Dr. Roth's implied practice model?). I see nothing wrong with billing a new patient visit or x-ray as a diagnostic study. How else would a practice run if you did not bill new/established visits of one sort or another?
Specifically, in my experience and clinical practice, stretching exercises are actually the mainstay of management for plantar fasciitis, and all of my patients are given literature and a home exercise program (HEP) for performing this at their initial visit. Regarding shockwave therapy, this is also a well accepted treatment option per the American College of Foot and Ankle Surgeons Clinical Consensus...
Editor's note: Dr. Budny's extended-length letter can be read here.
11/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Charles Morelli, DPM
I'd like to echo Dr. Roth's sentiment and experience when it comes to the fact that "the medical billing rip-off is rampant in medicine and podiatry." Yes, every profession has their bad actors, but sometimes you come across with a story that makes you shake your head. I'll try to be brief.
A patient was seeing the same podiatrist every 6 weeks, for over 22 years. He was treating her for a chronically ingrown nail, was cutting the corner of her nail, charging her the $25.00 co-pay and I imagine also billing her insurance carrier. She called one day for an appointment and asked to be seen as she was in pain, and felt it was an emergency. According to the patient, no matter how hard she pleaded, she could not be seen and...
Editor's note: Dr. Morelli's extended-length letter can be read here.
11/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: Jon Purdy, DPM
I had a similar frustrating experience when I sent myself for my first routine colonoscopy. I was told an exam was necessary and received one from their PA. A little palpation here and there and an order for stool examination. To my protest, I was told the doctor will not do the procedure without it. I complied and received my first bill for a CPT 99204. I questioned the validity of that exam level with the office manager to no avail.
On the day of the procedure, the doctor asked if I was ready and said they would be taking me back. I said what about my results? He looked confused. I told him I was told he would not do the procedure without the stool path and he said “that is not true.” So I underwent my procedure irritated about the entire process thus far. In recover the doctor said, “everything looks great, but there was one spot of inflammation I needed to biopsy.” It was a “Where’s Waldo” game to discern anything in the photo, but I know that extra $350 comes in handy.
So they made some good money on me while I was stuck with unnecessary bills, frustration, and inconvenience. This just verified to me of what is out there, and what I do not do to my patients.
Jon Purdy, DPM, New Iberia, LA
11/18/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: My Surgical Experience as a Patient
From: Joel Lang, DPM
I recently had an outpatient surgical procedure under general anesthesia. While the procedure itself went well and I have largely recovered, I feel there are lessons I can share regarding this experience. I was told to show up early for the procedure to complete about eight pages of medical information forms and releases. So, at a time when I was most anxious about the procedure itself, I had lots of forms to complete.
Between the time I was told in the office that the procedure was necessary and the actual arrival at the surgi-center for the procedure, I accumulated several additional questions for the surgeon and the anesthesiologist. Both were very busy with their schedule at that time and had only limited...
Editor's note: Dr. Lang's extended-length letter can be read here.
10/30/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: Paul Kesselman, DPM
I have to partially disagree with Dr. Tomczak. There is no question that the MD degree may get doors open that another doctorate degree may not. I also know at least 2 MDs who either decided not to pursue residency programs or who quit their surgical residency in midstream to pursue other areas of interest, such as medical IT, etc. This area is growing by the day as physicians with clinical experience and those in medical school see how difficult clinical practice is.
However I know many DPMs who, for one reason or another, pursued work outside the clinical arena in the pharmaceutical industry, orthopedic equipment or orthotics and prosthetics industries, and some even the teaching profession, at one level or another. Other DPMs are working for insurance companies as investigators, others as...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
10/30/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Howard Bonenberger, DPM
Everything is related to the perceived value brought to the table. In their minds, a degree which is universally recognized by the public, VC firms, or other businesses, the MD (DO) can author research on the entire body. The DPM has limited scope which can be covered by orthopedic research, at least in their minds.
Perhaps submit research that is blind as to the authors' names and degrees. It would not be for actual publication but to have it read by someone who is curious. If of high enough quality and the publication inquired, then it would be revealed that the author(s) were DPMs. I may be way off base, I'd appreciate thoughts on this idea.
Howard Bonenberger, DPM (Retired), Nashua, NH
10/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: Kathleen Neuhoff, DPM
When I was in veterinary school, I remember my instructors telling us that the difference between a trade and a profession was research, I believe this to be true. We have some amazing researchers in podiatry but they are rare. The value of contributing research should be part of the mindset of us all and as Dr. Secord pointed out, it is not.
Kathleen Neuhoff, DPM, South Bend, IN
10/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Paul Kesselman, DPM
I stand by my partner Alan Bass, DPM, whose opinion is absolutely correct. Each patient encounter should have at a minimum an appropriate history and physical with components of lower extremity systems including but not limited to dermatology and must also include neurovascular and a MSK examination. Any changes in patient history or PE should be well documented and incorporated into the note.
But the change in history is not what will get you paid for a separate E/M nor is documenting a change in the physical examination. It is that last part, the management, what exactly did you do? If all you did was document a change in history, nope. If all you did was document a change in the PE, again, no dice. You must document all 3 issues, ...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
10/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Lawrence Rubin, DPM
A recent post in PM News pertaining to insurance reimbursement compliance said, "Any abnormal findings on the LEAP Vitals Exam, i.e. dry and xerotic skin (L85.3) caused by sudomotor dysfunction, is a significant risk to a patient with diabetes. It therefore warrants a care plan." To prevent confusion of business names, this is not a stated opinion of the 501(c)3 not-for-profit LEAP Alliance.
Lawrence Rubin, DPM, Las Vegas, NV
10/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: David Secord, DPM
Although it pains me to say so, I agree with Dr. Tomczak on the issue of research. In 2013, I practiced in Riyadh, Saudi Arabia, at the King Abdulaziz Medical City, Central Region hospital. At that time, the Chief of the Section, Dr. Abdulaziz al Gannass, was doing Charcot reconstructions (as indicated) as ankle fusions, either with or without talectomy. Instead of using an intermedullary rod, he repurposed the Synthes VA-LCP Condylar Plate (normally used to fixate femoral fractures) to connect the tibia to the calcaneus. The butterfly shape of the condylar plate worked amazingly well at the calcaneus and after removing the distal fibula, laying the plate at the lateral aspect of the tibia to the calcaneus made for a robust structure, as it is a locking screw and plate system with variable angle abilities. The majority of the patients walked on it post-op (although informed that they were to be non-weight-bearing) and none of these patient failed to fuse.
In the case of a talectomy, allograft bone stock was used to...
Editor's note: Dr. Secord's extended-length letter can be read here.
10/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Physician or Allied Healthcare Provider?
From: Rod Tomczak, DPM, MD, EdD
We are convinced that we are physicians. Unfortunately, the rest of the world has not universally been persuaded to classify us as such. It’s not so much what the 40,000 or so of us call ourselves, but what does the rest of the world call us? Why is there a reluctance to move us from the allied healthcare provider column into the big boys’ physician column? I always look at economics as a reason for most social problems, then move to self-esteem issues before considering what may be the truth. One horrible truth is that there is nothing we do that other physicians or healthcare providers can’t do.
I was on the admissions committees at both Des Moines University College of Podiatry and the Ohio State University College of Medicine. Yes, there are vast differences. That is not to say that students at the podiatry colleges could not...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
10/14/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: APMA Should Promote Annual Comprehensive Diabetes Prevention Foot Examination for At-risk Patients
From: Lawrence Rubin, DPM
The American Medical Association (AMA) states its policy position on aspects of medical care it believes should be promoted to the public. An example is the information it provides about having regularly scheduled female mammography examinations (see link).
As one of the most senior APMA life members, I suggest APMA develop and promote a policy statement that is posted on the Internet that advocates for an annual comprehensive diabetes amputation prevention foot examination for at-risk patients. When the policy statement is published online, the concerned public could easily promote this information to family, friends, and others through group and individual sharing in LinkedIn and other social media, as well as through APMA-generated national news releases.
Lawrence Rubin, DPM, Las Vegas, NV
10/05/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Robert Kornfeld, DPM
I think it is an absolute travesty that as the years went on, podiatrists have been paid less and less. I agree with Dr. Kass that something must be done. However, it is my opinion that a union will have only limited success because insurance companies will still retain the power of payment. After all, they collect the premium dollars. They don't want to share that money with doctors. You can go on strike, but you will be limited to the power of negotiation and the amount of money that insurance will be willing to let go of.
There is a movement (finally) in medicine back to private practice/direct-pay models. I am friendly with many MDs and DOs who are leading the charge away from...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
10/05/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Irv Luftig, DPM
Although it may be a good thought to unionize physicians, podiatrists, dentists, etc., it's a really bad idea. It was a tactic used by various medical groups a few times up in Canada and each time ended quickly as a miserable failure. There was absolutely zero support from the general public. There was palpable outrage from the public. Simply put, doctors (MDs, DOs, DPMs, DDS’) are perceived as wealthy because "we all make hundreds of thousands of dollars."
The public doesn't care about overhead, salaries, etc. Most people make $50,000 or less, maybe a bit more. You will be viewed as greedy, wealthy, uncaring, and if you withhold services in a strike, then watch out for the swift reaction from politicians and the public. Politicians will make mince meat out of you and the public will hate you. It won't be pretty and you will potentially be losing your patients' trust for years.
Irv Luftig, DPM (retired), Toronto, Ontario, Canada
09/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Robert Kornfeld, DPM
I thoroughly enjoyed reading Dr. Tomczak's post about how exciting it is to have a new APMA administration that finally understands what is happening and is going to do something about it. Well, I am a 1980 graduate of NYCPM. If you do the math, I graduated 44 years ago. And during all 4 1/2 decades that I have been a podiatrist, APMA has been "working" on making things better for us. Sometimes, they work "hard" at making things better. Yet, in all these years, not only has it not gotten better, it has gotten so much worse.
I won't go into details about my personal issue with my own NYSPMA which I quit many years ago, but what I will say is if anyone out there wants to make things better, you need to stop counting on APMA and do it yourself. When I realized that nothing was changing for the better, I decided to do it myself. And to be honest, my efforts to improve my professional experience all paid off without dues to an organization that is always working hard for us but never seems to accomplish what they promise.
I'm sure I'll catch some backlash for this, but my career is nearly over and I don't care what they have to say about me and my opinions. Of course, what I have already heard is if I'm not a dues-paying member, then I'm part of the problem. Nah. My career was amazing in spite of, not thanks to, APMA.
Robert Kornfeld, DPM, NY, NY
09/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Jon Purdy, DPM
Regarding the post from Dr. Tomczak, I did find that very amusing. I don’t intend to do a back and forth on this, but suffice it to say, I never put someone’s name in print without their permission. I’m sure that person would have been fine with it had I asked.
All associations post-covid have struggled, which necessitated change. As treasurer of the American Academy of Podiatric Practice Management, there has been change required of our own organization. We welcome constructive criticism, as it helps us improve and grow. It’s no different for the APMA. Time will tell, but I like the vibe they are currently putting out, and its leaders seem to be in tune with positive change.
Jon Purdy, DPM, New Iberia, LA
09/26/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Rod Tomczak, DPM, MD, EdD
I wonder if Jon’s letter was written tongue in cheek. If accurate, Jon’s report about a recent encounter with a secret agent from APMA who assured Jon there are changes a comin’ at APMA headquarters gives cause for celebration. That’s tongue in cheek. If what Jon was told is indeed true, and why should we doubt anything out of the mouth of an unnamed secret APMA leader, then I am grateful that the spirit of Deep Throat is alive and well in Washington, DC. One difference between the original Deep Throat and the APMA Deep Throat is that the current mole is wearing old Rohadur orthotics posted to the casts to throw off younger potential trackers.
But there is a disparity between these new APMA promises and those made in the waning moments of the Nixon administration. Deep Throat’s assertions proved to be true. Both the current APMA Deep Throat and the Watergate Deep Throat were accurate when they presently advised Purdy and in...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
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