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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: 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



From: Name Withheld (TX)


To echo Dr. Borreggine’s concern, I am currently sitting for my boards in both foot and rearfoot/ankle case reviews. I have the most recent training with the PMSR with the RRA certification. I had my share of failures with the CBPS portion of the exam and I found after speaking with the board that it was not due to my intellectual abilities to reason or make good decisions; it was how I was taking the test which was not explained at the time that I took that portion of the exam. After speaking with them, a video was posted regarding my specific issues that I experienced, which leads me to believe that this was a common problem among candidates. 


Once I passed my CBPS portions, I sat for my case review. This was the most frustrating aspect of the process. I was failed based on...


Editor's Note: This extended-length letter can be read here



RE: ABFAS Board Exam Pass Rate is Disparaging (Joseph Borreggine, DPM)

From: Name Withheld


I graduated from a 3-year residency program in 2013. I passed all my NBPME exams the first time and I passed the ABFAS qualifying exams the first time. Then I bought a non-surgical practice in a small town and set to work. I have spent 4 years building up my case volume and then was able to sit for the exam. I failed both the case studies and the computer-based examination. My hospital says I have to be board certified in a 5 year window. I have one more shot at it in 2018. 


During residency, ABFAS lets you take yearly practice tests to be prepared for the qualifying exam, but not after residency. So, I went 4 years not taking a practice test and then finally being able to sit for it and failing it (They used to make you wait until your case volume was built up prior to taking the computer-based exam). Just this year, I heard that ABFAS is allowing candidates to...


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



From: Kenneth T. Goldstein, DPM


I totally agree with Dr. Udell. Years ago, when a patient didn't want to pay a bill, they threatened to sue. Now-a-days they threaten to post a "nasty review"(because it will cost them money to hire an attorney). The fact that this patient not only wanted the fees removed, but also a DISCOUNT! is absolutely ridiculous. Should you give in, this person sounds like they will write the negative review anyway and say to themselves - "Gotcha".


You have done all of the correct manners and given more than enough time for this patient to pay. At this point my answer would be - It is out of my hands and the collection company has control of your account.


Kenneth T. Goldstein, DPM, Williamsville, NY



From: Jarrod Shapiro, DPM


I'm writing in response to Dr. Sherman's comments about online CME. I agree with his comments and support the opinion that online CME should be unlimited in all states. Simply put, the content and delivery is the same, the requirements for proof of viewing is higher than at live conferences, and this delivery method is appropriate for adult learners. The various online CME available allows a physicians to receive rapid answers to topical clinical problems using on-demand education services. This format is innovative and able to change with developing technologies. Allowing online CME to flourish is equivalent in the medical community to the progress of the Internet itself. This system must be allowed to develop.


Disclaimer: Dr. Shapiro writes the column Practice Perfect for PRESENT e-Learning Systems.


Jarrod Shapiro, DPM, Pomona, CA



From: Bret Ribotsky, DPM


I’ll take the counterpoint to my friend and Boca Raton neighbor, Dr. Sherman. Live CME events are best. Not only have I had the opportunity to have lectured in 49 of the 50 states and many 15 different countries, but I have also been the patient for multiple foot operations. For the months after my accident, I spent many months in rehab, unable to walk, and did many online classes. I collected online training certifications in real-estate, insurance, financial planning, securities series 7, 63, and a bunch more. But... there is nothing as good as live learning. And as a physician, there is so much more to learn at a seminar than what is learned in the lecture hall. I have learned so much in the hallways, and at the bar from my colleagues. Meet the Masters was started 8 years before my injuries, with the idea that learning outside of the lecture hall was priceless.  


I do enjoy online events, but I would hate to miss the yearly get togethers to learn from and with others. As a patient, I know the difference between great and outstanding care; that it comes from those with exposure to many viewpoints which only a live event can deliver.  


Bret M. Ribotsky, DPM, Boca Raton, FL



From: Dennis Shavelson, DPM


I am a 71 year old practitioner and find myself more and more successful attracting millennial patients by marketing how I practice.

  •  I offer holistic cures, not just tunnel vision Band-Aid care.

  •  I offer care of treatable underpinning pathology (medical, biomechanical and   kinesiological).

  •  I practice Prevention, Performance Enhancement and Quality of Life Upgrading.

  •  I offer more seamless office visits and availability in the cloud.

  •  Rather than state that I treat everything for every foot, I market niche compartments of diagnosis and care (biomedical engineering and ugly toenail cures).

  •  I have hardship and sliding scale fees available.  

Dennis Shavelson, DPM, NY, NY



From: George Jacobson, DPM


Since this topic has come up again, I would like to remind everyone of a posting that I wrote on 03/05/2016. You can search it in the PM News archives. In a nutshell, here is the main excerpt, "We received a letter from Palmetto GBA stating that they have received information from the National Supplier Clearinghouse (NSC) indicating  that we have not billed the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) within the last four consecutive quarters."   


George Jacobson, DPM, Hollywood, FL 



RE: Enough Already with Time-Consuming Chart Requests (David P. Luongo, DPM)

From:  Cynthia Ferrelli, DPM


I have experienced the same problem, so I came up with a solution several months ago that has been working fine. When my office is called for a chart review, we say we will comply but that their reps come to my office, will have to pull all the charts themselves, and find what they need in the chart. We tell them that this is how we do it and we set the guidelines. Set your boundaries. You are paying your staff to do work for you, not for the insurance companies. We seem to do enough of that already.


Cynthia Ferrelli, DPM, Buffalo, NY



From: David Gurvis, DPM


I also have a missed appointment fee. I find the “threat” alone reduces missed appointments. Do I apply the fee uniformly? No. Actually, I hardly ever use the fee unless a patient has been egregious in repetitive missing of appointments. What I find then is that if I apply the fee, the patient goes away. The desired result. They fire me and I don’t have to discharge them!


I don’t have the fee on new patients as it is too difficult to make sure that they understand my policy, but if they miss two appointments, I refuse to take them back. As always, there is common sense. Missing an appointment without a call later is frowned upon more than missing with a call later that indicates the patient is sorry and had a lapse in memory or perhaps a real reason.


David Gurvis, DPM, Avon, IN
Orthotics CadCam

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