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From: Robert Scott Steinberg, DPM


I have to call Dr. Fullem, on the appearance of bias, when it comes to him recommending Hoka shoes. I have found them very unstable. They do have the unwanted tendency of excessively straining the calf and the Achilles. Because they are unstable, there is unnecessary overuse of certain muscles. Is there anything worse than getting or treating Achilles tendinitis if you are a runner? His use of the word "old", in an attempt to cast doubt on the proven protective properties of the classic 10-12mm drop, stability running shoe, further exposes his bias. Once runners get past the gimmicky nature of fad running shoes, they see the foolishness of some trends.


Robert S. Steinberg, DPM, Schaumburg, IL

Other messages in this thread:



From: Warren Joseph, DPM


I feel your pain! We were getting our insurance through my wife’s teaching job at a University. After she left the position, we have been on COBRA, which ran out September 30!  We have been looking for decent coverage for months. We found a reasonable “Short Term” catastrophic plan, which will only cover us for 3 months which started today. In the “Marketplace”, the best we could do was a BC/BS PPO Bronze plan at $1,900/mo and a $15,000 out-of-pocket deductible! Of course, there is only one provider, Independence Blue Shield. We hear that come Nov. 1 when Open Enrollment begins, 2 more insurers will enter the fray so maybe, just maybe, there will be some competition. 


So, I can’t help you with any suggestions; but I can commiserate. I too would love to hear from anyone who may have some thoughts on obtaining coverage.


Warren Joseph, DPM, Hatboro, PA



From: Richard D Wolff, DPM


I have not used a virtual scribe, so I cannot offer an opinion about that. Pretty sure Dragon Naturally Speaking, which I have used, is not the same. For years, I have used a scribe and have found it helpful in many ways. Patients have commented about how their other doctors are buried in their computer during the encounter, whereas my patient has my undivided attention the entire time. I ramble off my physical exam quietly to my scribe, who checks it off on "Quicksoap". I speak to the patient about their condition and treatment plan as the scribe writes it down.


My scribe will also note if the patient expresses pain with a facial expression, as they don't always tell me as instructed. As I begin my treatment, my scribe is dismissed, and she goes to start the note in the computer at another location. This situation has worked well for me. My scribe has learned to pick up on the subjective part of the note and she relays the follow-up plan to the scheduler.


There are additional benefits. Patients have also developed a rapport with my scribe and will ask about her if she is not present on a given day. She has also developed the habit of reviewing the patient's chart. She will let me know if there are any insurance coverage issues and she will let me know if the patient is due for new diabetic shoes, should they desire it. I have found this system to be invaluable.


Richard D Wolff, DPM, Oregon, OH



From: Vito Rizzo, DPM


As a healthcare professional and now having the distinct advantage of serving in the U.S Congress, Brad Wenstrup should be leading the charge in reforming healthcare and advocating to put medical professionals back in charge. He should take no contributions from insurance companies that have a record of putting profits before patients and should be focused on eliminating the channeling of healthcare dollars into any other purpose than patient care. He should never stand behind or support policies that undermine the protection of the sick and less fortunate. Being a representative can be easy if certain principled actions are followed.


Vito Rizzo, DPM, Bay Shore, NY



From: Jon Purdy, DPM


I couldn’t sit idle after reading Dr. Kass’ comment promoting universal healthcare with salaried positions. There are reasons monopolism in a free market society is not tolerated in the private sector; the reasons being stifling of ingenuity, lack of price competition, and the elimination of free choice to name a few. To promote it in the public sector is the antithesis of what drives this country’s greatness.


Imagine for a minute, a doctor who has no incentive to keep a patient a satisfied returning customer, or to direct staff to provide a welcoming environment. There may be minimum outcomes to obtain, but anything difficult or time-consuming could be written off as a loss. Certainly, one could “hope” all doctors practice to their fullest ability, but that is not reality and an unfortunate consequence of human nature in the absence of incentive.


When the government controls the livelihood of individuals and their freedom of pursuit, especially after going through training 99% of humanity is unable or unwilling to do, it will no doubt create a catastrophic physician shortage. If a singular controlling entity wishes to eliminate podiatry, it could do so next week. Take a moment and imagine yourself as a patient in that environment with a serious condition. I certainly can’t. There is corruption in all walks of life including the government or any other controlling body. I am not willing to sell my freedom of individual pursuit because of the actions of others.


Jon Purdy, DPM, New Iberia, LA



From: David E Gurvis, DPM


I respectfully disagree with Dr. Al Musella. My most frequent code for a new patient is CPT 99203. I also frequently use 99201 and 99203. On occasion, if the time has been spent in counseling - 99204. I have a similar distribution on established patient visits... 99212 and 99213, for the most part.


When appropriate, I do a complete LE neurological, muscle strength and testing, ROM, integument and nails, along with musculoskeletal. I read and document that I have read and gone over with the patient the family history, social history, and ROS. At times, a patient who has waited too long to come in presents with 4 or 5 complaints, and each requires an...


Editor's Note: Dr. Gurvis' extended-length letter can be read here.



From: Al Musella, DPM


Take a look at the proposed rules before making comments. They specifically ask about something that is not addressed in the APMA letter. They specifically say on page 345: "We are soliciting public comment on what that total time would be for payment of the proposed new podiatry G-codes. The typical times for these proposed codes are 22 minutes for an established patient and 28 minutes for a new patient, and we could use these times."


I think that is reasonable. They predict that the changes will result in a net loss of 2% of our...


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



From: Jeffrey C Kass, DPM


I would like to applaud Dr. Frisch and the APMA for allowing not only members, but non-members and anyone who wants to be part of the letter writing campaign to say "no" to the proposed CMS changes to their reimbursement policy.


I know that on a divisional level here in NY, I used to complain that only members of the association were able to partake in letter campaigns to state senators and assembly persons.


So, I thank APMA for recognizing the importance of everyone fighting for the cause. I sent in my letter tonight through APMA.ORG and I invite all members or non-members, all active or retired podiatrists, all students and residents to do the same. It literally takes no more than one minute to fill in your info, click send, and might just be the most important minute of the year.


Jeffrey C Kass, DPM, Forest Hills, NY



From: David S. Wolf, DPM


"The times, they are a changin." The old mantra was "if you did it and didn't document it, you didn't do it; and if you documented it and didn't do it, you did it."


Now with the new CMS proposition, the mantra is the converse... you don't have to document it (copy and pasting bullets to satisfy the coders) and you get paid. Go figure.


David S. Wolf, DPM, Retired, Houston, TX



From: Steve Tager, DPM


It sounds like the WAR continues with CMS using the “Divide & Conquer” approach to isolate podiatry from the next battle. Are we not still struggling to gain parity with main stream medicine? Nice fragmentation tactic CMS! Maybe APMA needs to increase the offense instead of continuing to beef up the defense.


Steve Tager, DPM, Cupertino, CA



From: Don Peacock, DPM


With ABFAS board certification discussions, we sometimes miss a very important point. The boards give credence to our surgical achievements and that’s all. Our greatest achievements will be in helping people, not in ABFAS certification. Lacking certification will not prevent a good podiatrist from making a great living. The huge effort to obtain and remain board-certified for the purpose of hospital privileges is becoming less important as well. I perform most of my surgeries in the office setting where hospital privileges or board certification is optional. 


Whether we're board-certified or not, our surgical income means little with respect to our financial health. The bulk of reimbursement for a successful foot surgeon remains non-surgical. With current cuts in procedure-based and fee-for-service models, it would behoove all of us to move more surgeries to the office setting where reimbursement is better and turnover quicker.


In the overall scheme of things, board certification is not as important as being a good doctor, having patients that like you, and doing a good job at treating those patients. That is how you will be successful. The board certification is the icing on the cake. It is not the cake.


Don Peacock, DPM, Whiteville, NC



From: Name Withheld 2


Much like Name Withheld, I also wish to remain anonymous for fear of incurring the wrath of ABFAS, which carries far too much power over our career progression. I failed the case review for RRA this year and the justification provided was ridiculous, arbitrary, and in just about every case, flat out wrong. This suggests to me that my cases weren't actually reviewed with any degree of scrutiny. Unfortunately, we have no recourse other than "you still have 2 more years of eligibility so try again next year." 


It's well known among my colleagues that it's a scam and you'll pass in your 6th or 7th year. If ABFAS was concerned about quality of its diplomates, the case review would be...


Editor's note: Name Withheld 2's extended-length letter can be read here.



From: Steven Finer, DPM


When I graduated from PCPM in 1976, I was then fortunate to do a residency and join a local hospital. We were trained to do everything open and follow orthopedic thinking. I bought a small practice from an older practitioner. It was obvious that he was doing in-office MIS after taking a weekend course. The x-ray results were uniformly poor and I found a lot of letters from angry patients and investigations from insurance companies. It was clear to me he had little understanding of basic operative procedures, blood chemistry, and standard operative protocol. I steered clear of all of this and used the hospital only. Now years later, with new techniques, changes in insurance, and the blessing of orthopedists doing essentially the same procedures, MIS has found a place in the podiatry world.  


Steven Finer, DPM, Philadelphia, PA



From: Elliot Udell, DPM


Having witnessed the origins of MIS and the political squabbles within the profession, I now have a broader perspective on it. Yes, there were two schools back then. There were the "open" surgeons and there were those who took the late Dr.  Ed Probber’s one-week course on how to do MIS (in the back of his Long Island office). The training was often supplemented by learning at other doctors offices and at MIS conventions.


There were conflicts and a lot of name calling. Some of the criticisms of MIS were valid and some were purely political. At that time, podiatry was striving to be part of the medical/surgical establishment and MD surgeons did not know from MIS. Today, things are different. MD surgeons are gravitating toward minimal incisional techniques. They do spine surgery, knee operations, gall bladder removals, and hernia repairs using very small incisions. The healing time is reduced. Hence, there should no longer be a need for two schools of thought in 2018. It’s time for foot surgeons to learn open and minimal incisional techniques and choose the best one for each and every patient who needs foot surgery. Let’s leave the politics of it back in the 1970s.


Elliot Udell, DPM, Hicksville, NY



RE: The Importance of Examining Legs 

From: Robert D. Phillips, DPM


I would like to commend the thoughtful letters written by Dr. Forman (4/14/18), Dr. Silver (4/18/18), and Dr. Jacobs (4/16/18). All bring to the fore the important facts that diabetes not only has a negative effect on all the systems in the foot, but that decrease in the utilization of the foot also accelerates the impact of the disease on the other body systems. 


Certainly, the main goal of any podiatrist treating the diabetic patient is to increase the activity level of the patient. Many years ago, I heard Dr. Root talk about no longer thinking of geriatric foot care as trimming calluses and nails and moisturizing the skin. Instead he stated that...


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



From: Thomas Silver, DPM


I have tons of patients sent to me for "routine care" from large managed care clinics in my area. I often hear from these patients that they were seen by the podiatrists in their clinic and told by them, "I'm a surgeon. I don't trim toenails or calluses!" and that they often don't even look at their feet. They refer them out to the few clinics in my area (population >1 million) that do "routine care". 


In most all cases, I do a full lower extremity exam for these "routine care" patients. Many of the elderly have had knee or hip replacements, so I routinely measure for leg-length discrepancies, excessive pronation, collapsing or collapsed medial column, and I have them stand and walk. As a result, we fit...


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



From: Dennis Shavelson, DPM


I reviewed the RESA website. They have a homogeneous proprietary plan using software, an algorithm, a technician, and a scanning method developed by a cyclist + engineers to create what they value as a $199 product. Remember the Soles 3-D printed orthotics that DPMs were dispensing that is now out of business having lost $30 million. 


I welcome the competition from Costco that will help educate the foot and postural suffering public towards the need for customized orthotic props. My insult comes from Costco stating that the DPM product is worth $300 when mine are...


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



From:  Steven E. Tager, DPMShashank Srivastava, DPM


I too saw the ad. This sort of thing is malignant in this country. All who think they can capitalize on the benefits of orthotics try to do so. It suggests to me that we as a profession lack the necessary influence over this type of misrepresentation. This is possibly because there are insufficient concrete guidelines for orthotics prescriptions?


Steven E Tager, DPM, Scottsdale, AZ


I also saw this in my Costco mailer. My feeling is that this is largely an automated process that is not under the oversight of a physician. This has been an increased trend in the DC, Maryland area with various shoe stores that offer a similar service. This was quite frankly very predictable. One of the downsides to easy digital scanning is that it opens the floodgates to this type of automation and scaling that eventually devalues the product. My feeling is that with 3D printing, this will probably be more prevalent in years to come.


Shashank Srivastava, DPM, Rockville, MD



From: Elliot Udell, DPM


The story as referenced by Dr. Williams is not about a compounded drug, but is about  Kerydin, which is a brand name drug widely available for the treatment of onychomycosis. It is applied topically and it became available at roughly the same time as Jublia, another topical antifungal. These medications are not only expensive but if used properly, only last a month. What is even worse is that the clinical success data provided by these companies does not rate them as panaceas for the treatment of  fungal nails. They are by no means gold standards. 


In our practice, after fungal testing, we might prescribe these medications, but only if the patient's insurance company combined with company incentives make them affordable. If the patients are going to have to pay over a thousand dollars for a month's supply, we will offer them a choice of several new antifungals which not only can be dispensed from the office but have been shown to be clinically effective. 


Elliot Udell, DPM, Hicksville, NY



RE: The Importance of Challenging Medicare

From: Amy Schunemeyer, DPM


So, I noticed that my Medicare allowable was less than the Novitas website posted allowables for my claims coming back for 2018. There is a Novitas mistake that they were following the WRONG fee schedule up to 2/23/18, and they are working on resubmitting corrected claims. This is one problem fixed. 


And, I notice that the increased payment adjustment is in the form of a positive ($xx.xx) adjustment on our EMRs. This is quite a software accounting nightmare. How are others handling this? These are a few of my questions because I am NOT receiving increased payment from the many, many....


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



From: Simon Young, DPM


With 3-year residencies programs, a publishable, even collaborative, paper should be a requirement for graduation.  So much research can be done over their tenure as residents and they should recruit their podiatric director, administration, and other specialties in neurology, orthopaedics, ER, medicine, endocrinology, dermatology, podiatry, rheumatology, infectious diseases, biomechanics, physical therapy, etc. What a plethora of topics available to be researched and put us on the map. We need to show the other professions that foot pathology is more than nails and callosities.


When I was a residency director, it was difficult to impossible to get my residents to publish or offer research ideas. I did have the cooperation of administration and some specialties but not all. The ER was willing so I was able to get one research paper published.


NYCPM has a relationship with Ireland Podiatry School and they present more research than our graduating 3-year residents. What are they doing right?


Simon Young, DPM, NY, NY



RE: Lack of Podiatric Authors in Our Journals (Joseph Borreggine, DPM)

From: Amol Saxena, DPM


There are many reasons for the lack of DPM-produced research and more non-DPMs publishing in our journals. 


Most podiatric students and residents are not required to actually complete written and publishable research during their training. There may be less "perceived value or need". As I interview fellowship candidates, I am able to see how much research they are actually required to complete. Most are case studies. There was a time where podiatrists were trying to document their cases and show the pathology they were capable of seeing. Publishing was the only way to...


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



From: Bret M. Ribotsky, DPM


I have been consulting and advising for the past 18 months in the buying and acquisition market for medical dermatology practices. While I have not specifically worked with the DPM market, the foundations and principals from the hedge funds and private equity people are similar. It’s all a function of EBITA (Earnings before interest, taxes, and amortization. EBITA refers to a company's earnings before the deduction of interest, taxes, and amortization expenses). 


In simple terms, it’s the PROFIT left over after you have removed your ownership from the practice and paid someone (or you) to do the work you have done. For example, if you're a single practitioner and your practice gross is...


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



From: Brian Kashan, DPM


I just read the posting by Name Withheld, about how he would choose to open an office next to an older practice instead of purchasing an existing practice. Although the circumstances he describes, with the sudden passing of a doctor is different than the more common scenario of a retirement, there are several similarities. If the practice has been a successful practice and is valued correctly, it should be an attractive opportunity for someone to acquire. 


There are several factors that I feel are being overlooked in the mindset of Name Withheld. Firstly, it is much easier to get a bank loan when...


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



From: Janet McCormick, MS


As per dental hygienists practicing without supervision, I would truly like to know where that is? I'm thinking that somewhere in the background there is a "dental supervision" requirement, possibly similar to aesthetic spas level peels etc. as long as they are "supervised by a physician." Many of these medical supervisors are not on site, but there is a responsibility there, and they must be within a set distance. And they are financially involved in some way. 


I find it doubtful that dental hygienists would escape the supervision of dentists fully. The dental associations are very active in the legislative processes and...


Editor's note: Ms. McCormick's extended-length letter can be read here.



From: Eddie Davis, DPM


Dr. Borreggine has concerns about the implication for podiatry caused by expansion of ARNP scope. Dr. Herbert, in his response, related an interesting story about a podiatrist who later became a family practice physician, but his hospital did not offer him privileges for foot surgery. We should not view the efforts of other health professions to expand scope as a threat to podiatry. We should, instead, attempt to better define our scope of practice. 


Podiatrists, relative to training hours, have the narrowest scope of practice of any health profession. APMA believes that we need to emulate the allopathic model and increase residency training time. How do you tell a prospective podiatry student that he/she will be offered training equivalent to an orthopedic surgeon but that the scope of practice can only be less than 15 percent of that of an orthopedic surgeon and then tell that person that he/she may not be able to call themselves a physician?


The dental profession has figured out how to maintain a degree as a “limited licensed practitioner” and make it work. We either emulate the model of dentistry or move toward providing the MD degree. Standing in the middle of the door is not advisable because the door will keep hitting and bruising us.


Eddie Davis, DPM, San Antonio, TX