The Voice of Podiatrists

Serving Over 12,500 Podiatrists Daily

January 10, 2011 #4,059 Publisher-Barry Block, DPM, JD

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NY Podiatrist Doubts Claim That Wearing UGGs Leads to Athlete's Foot

Not all podiatrists are in agreement about whether UGGs put their wearers at increased risk for foot fungus. “Foot fungus likes a dark moist environment–so any sock and shoe could provide that, especially during the winter,” says Dr. Howard Shapiro, of Manhattan Podiatry.

Dr. Howard Shapiro

“UGGs have a wool lining, so if anything, I would think that they would absorb the sweat [that leads to foot fungus].” Shapiro also notes that he’s never seen an UGG-related case of foot fungus. “Foot fungus affects about 40% of the population,” says Shapiro, “prior to UGGs, it was still affecting 40% of the population.”

Source: Leah Chernoff, Fashionista [1/5/11]

Lack of Medicaid Coverage Causing Diabetic to Lose Limbs: AZ Podiatrist

It's not only Medicaid enrollees waiting for organ transplants who are suffering as a result of state budget slashing. Benefit cuts that took effect Oct. 1 also prevent Arizonans on Medicaid from going to a podiatrist. That service elimination is hitting the diabetic community hard, local podiatric surgeon Dr. David G. Armstrong says. Armstrong runs a local podiatric clinic at University Medical Center. "These are not patients who will die immediately. They won't make headlines. They won't make noise. Rather, they will wither away--limb by limb," says Armstrong.

Dr. David G. Armstrong

"Literally every day we are seeing patients call and show up whom we literally can't treat," he said. "They're ending up in the ER. One young fellow we just saw has been in the emergency room twice and admitted once for a simple problem that would have been a $20 office visit." Armstrong said the Arizona Health Care Cost Containment System (AHCCCS, the state's Medicaid program) could solve the problem by  allowing foot doctors to see diabetics.

Source: Stephanie Innes, Arizona Star [1/6/11]

CMS Issues First EHR Payments

Just days after the CMS opened registration for the Medicare and Medicaid electronic health-record incentive programs, the first provider payments have been issued. Oklahoma issued payments to two physicians at the Gastorf Family Clinic of Durant, OK for $21,250 each, for having adopted certified EHR systems under the Medicaid incentive program.

Funding for the incentive payments programs was made available through the Health Information Technology for Economic and Clinical Health Act provisions of the American Recovery and Reinvestment Act of 2009. Registration for the program opened Jan. 3. 

Source: Rebecca Vesely, Health IT Strategist [1/7/11]

Doc-Fix Amendment in Repeal Resolution

When the U.S. House of Representatives votes on whether to repeal the Patient Protection and Affordable Care Act next week, it will also vote on a resolution to replace the landmark 2010 law—which includes an amendment to permanently fix the Medicare physician payment formula. House Rules Committee Chairman David Dreier (R-CA) this week introduced a resolution that directs the House Ways and Means Committee as well as the Energy and Commerce, Education, Workforce, and Judiciary committees to begin the work of drafting replacement provisions to the Affordable Care Act.

These provisions would foster economic growth and job creation; lower healthcare premiums through greater competition and choice; expand incentives to encourage personal responsibility for healthcare costs; and eliminate duplicative government programs and wasteful spending. Included in Dreier's resolution was an amendment from Rep. Jim Matheson (D-UT) that instructs the committees to find a permanent fix to the sustainable growth-rate formula. That could mean good news for physicians, except for the fact that it's attached to a bill that the AMA does not support.

Source: Jessica Zigmond, ModernPhysician.com [1/7/11]

Query: Bunion in RA Patient

My patient is a 53 y/o RA patient with a incongruent/subluxed hallux valgus deformity of the right foot (IM 14.8 degrees, hallux valgus angle 36.6 degrees, tibial sesamoid position 6, pronated hallux and foot type; ROM WNL w/no crepitus).

Hallux Valgus in RA Patient

I have a procedure in mind but wanted other colleagues' opinions.
 
Mario Dickens, DPM, Chattanooga, TN

Query: Volunteering Abroad in the Summer

We are students at Scholl (SCPM) and some of us were interested in volunteering abroad in the summer. Are there any programs that you recommend for us podiatry students?
 
Rashad Sayeed, Scholl '14

RE: Chronic  Verrucae (Michael J. Ryan, DPM)
From: Multiple Respondents

Consider excision with possible grafting (consult plastics if uncomfortable with options).  
 
Roody Samimi, DPM Cincinnati, OH, roody.samimi@gmail.com

This sounds like the perfect case for the Panacos graft.

David Secord, DPM, Corpus Christi, TX, secord@medscape.com

Dr. William Fischo gave a good summary of various treatment options for plantar warts in the Dec. 2010 article Podiatry Today. 

Autoimmunization has been mentioned as a treatment, in which a small piece of a wart is placed into the abductor hallucis muscle belly to provoke an autoimmune response. This was recommended for severe cases of warts that cover a large surface area. It appears that this patient fits that description.

Robert Colligan, DPM, Norfolk, NE, rcolligan@cableone.net

You might consider intralesional injections of bleomycin. These can be painful, and the medication has to be mixed fresh. I work at a VA Medical Center, so it is easy for my hospital pharmacy to mix it up as needed (1.5 IU bleomycin sulfate reconstituted with 0.5% marcaine, per dose). This treatment causes a blistering reaction with eventual resolution of the verruca over about two months. With such a large lesion, you may have to treat with serial injections depending upon your patient’s response and his tolerance to treatment.

Evan F. Meltzer, DPM, Jackson, MS, Evan.Meltzer@va.gov

RE: Chronic Verrucae (Michael J. Ryan, DPM)
From: Robert Kornfeld, DPM, Elliot Udell, DPM

This is a good example of a case where addressing symptoms only leads to clinical failure. My offering here is that instead of trying to figure out better treatment approaches, it would be best to look at causes (mechanisms) as to why this patient has a high viral load and why his immune system is not efficiently managing it. Functional medicine analysis is where you are going to find your answers. Once you obtain all the needed epigenetic information, you can order the appropriate tests. We look at any issues physiologically which may be impeding or mis-directing normal immune system function. There are many things to look at that burden the human immune system. A thorough understanding of cause is the first step in getting this patient well.

Unburden the immune system and you are well on your way to successful outcome. Once you address the mechanisms, you can use safe, natural medicines (oral and topical) to resolve the skin lesions. I have done this with many patients who failed conventional therapy. Even patients whose feet were covered with large areas of mosaic infection responded. The other plus to this is that you are creating a health-promoting protocol which addresses future pathology very pro-actively.
 
Robert Kornfeld, DPM, Manhasset, NY, Holfoot153@aol.com

Kudos to Dr. Ryan for doing a biopsy and confirming that the lesions are verrucae, and not a rare malignancy mimicking verrucae. Verrucas are virally-induced benign neoplasms. The literature says that 75% of verrucae will respond to  debridemont and sal acid therapy. The late Dr. Carl Abrams used to refer to this process as "autoinnoculation", even though the treatment may appear as being a chemical and physical destruction of the neoplasms. So, how do we deal with the remaining 25%? There is no magic bullet, and the sky is the limit to the amount of different treatments.
 
I polled colleagues at a series of lectures delivered on this topic, and found that many were having success in treating recalcitrant verrucae using: 1. intralesional injections of bleomycin, or 2. immunotherapy using intralesional injections of candida. The former is aimed at the neoplastic element and the latter is aimed at stimulating the immune response. Antiviral therapy was not high on anyone's list. Both treatments have a learning curve, along with risks. A colleague with experience should be consulted prior to initiating either therapy.  
 
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

RE: Undiagnosed Diffuse Skin Lesions (Simon Young, DPM)
From: Michael M. Rosenblatt, DPM

Dr. Young states: "The premise for a biopsy is obvious suspicion of pathology, but fortunately most biopsies reveal benign lesions." While it is certainly true that the "premise of a biopsy is obvious suspicion of pathology, there are other reasons to order and take a biopsy. One of the chief reasons is medico-legal, because a pathology report, whether positive or negative, confirms that you actually DID a particular procedure, because you have a sample to prove it...reported by a "disinterested" third party.
 
A negative biopsy could be highly protective if a patient alleged that a tumor she/he had was primary to the lesion you removed, but did "not" biopsy.
 
A few year's ago, there a case in Indiana involving a podiatrist who was moving offices. While in the process of moving, the biopsy sample was "allegedly lost." The case resulted in a $8.1 million dollar verdict.

Michael M. Rosenblatt, DPM, San Jose, CA, Rosey1@prodigy.net

RE: In-office Fluoroscopy (Gino Scartozzi, DPM)
From: Mak Yousefpour, DPM, Robert Kornfeld, DPM

I have been using fluoroscopy in my office for five years now. For the most part, for small, acute pathologies it works great. I also use it when I need to triagulate a foreign body and for sinus tarsi injections. Several downfalls is that, due to the limited pre-set collimination on most fluoros, the image is focused on one location. So you may have to do multiple shots. Another thing is for pre-op evaluation, it will not provide you weight-bearing and full view of the foot to evaluate the angles. What I have to do is send my patients out for x-rays.

Mak Yousefpour, DPM, Los Angeles, CA, makdpm@yahoo.com

I must respectfully disagree with Dr. Scartozzi's assessment that fluoroscopy cannot be used for weight-bearing evaluation. It can be. You just need to be creative enough to do it. Suspending a clear plexiglass plate between two solid bases with an eight inch separation provides the space to position the C-arm head underneath. In this way, you can capture full weight-bearing dynamics with no stress on the C-arm at all.
 
I have been using in-office fluoroscopy for over 12 years. While I admit that there are rare cases where the visualization is inadequate, the greater majority of pathology are easily seen. You can't beat it for intra-articular injections and minimally invasive procedures. I have also picked up numerous cases of early osteomyelitis. As far as the reimbursement goes, I have had my two machines paid for many, many times over. The difference is that I have not let insurance companies dictate my standard for using the machine.

Let's be honest. The only reason insurance companies do not want to pay for fluoroscopy is not because it is without merit. It is because their "standard of care" is the least expensive one. My point here is that you should not be disappointed with insurance denials. You should be disappointed if you have allowed yourself, like most other DPMs, to be exploited by insurance companies. Your "participation" (i.e. cooperation) just gives them the right and power to set the standard of care in medicine. 
 
Robert Kornfeld, DPM, Manhasset, NY, Holfoot153@aol.com

RE: Practice Fusion (Steven Frydman, DPM)
From:  Joshua Kaye, DPM, Elliot Udell, DPM

The greatest attraction to Practice Fusion is the free software that they provide. They make their income on banner ads similar to the method that Google uses. They provide excellent customer service, YouTube tutorials, and the software is easy to use.  Some problems with the software include blending their program with your current billing software, the relative slow speed in which uploaded scanned copies are available on their website, lack of ability to draw a diagram or sketch of a foot or other structure, inability to create a non-proprietary backup system, and their relative lack of willingness to modify their software based upon user comments. The lack of an effective backup is a "deal breaker" for me. My thinking is to equate lack of medical malpractice insurance to lack of an independent backup system.
 
We are also looking at that $44K from the federal government based upon the establishment of useful purpose. Although many software vendors will help with that requirement, I have not yet found a vendor who will guarantee that their software will comply. One should also carefully determine what needs to be clinically accomplished and documented in the software patient notes in order to qualify for that federal government tax credit.  It is also important to evaluate the implications of the tax credit based upon a sole proprietorship compared to a professional corporation.
 
Joshua Kaye, DPM, Los Angeles, CA,jk@joshuakaye.com

Dr. Kaye makes a very good point when he asks what would happen if the company managing the EHR software goes out of business or is taken over by another company. What will happen to the notes? This already happened to the thousands of doctors who bought and used Medinotes. With the case of web-based programs, the notes are housed in cyberspace so as Dr. Kaye asks, "what happens if the company goes bust? At a state-sponsored symposium for doctors considering EHR programs, I spoke with the director of the program and he was certain that many of the new companies selling EHR programs will go out of business. The market cannot support all of the companies that have jumped the bandwagon selling EHR programs.

Not only will clients lose their patients' notes but if you've leased the program for 15 or 20 thousand dollars, you will still have to pay out that lease even if the program ceases to exist. If the government changes and decides that they can't afford this part of the stimulus package and finds a way to defund it, the majority of these companies will go bust. This is why I am gravitating toward Practice Fusion which is free. I will print a hard copy of every note I take. If practice Fusion goes out of business, at least I won't sustain a financial loss. 
 
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

RE: The Passing of John Carson
From: Simon Young, DPM

I personally did not know John Carson and I am disappointed that I never had the pleasure of meeting him. Based on all the postings at PM News, he must have been a great positive force in our profession and to many of our colleagues. It was nice to read that he was told how much he was appreciated and loved by our profession while he was alive.

Too often, we eulogize people once they have passed on. We should all show our appreciation to our colleagues whenever possible while they are alive. Life is so fleeting.

Simon Young, DPM, NYC, NY

ASSOCIATE POSITION - WISCONSIN

Seeking a surgical podiatrist in Central Wisconsin. Great salary and benefits. Potential for partnership. Busy, well-balanced practice in a rapidly growing area. Email interest to ftsurg@yahoo.com or fax resume and cover letter to 715-241-8102.

ASSOCIATE POSITION - PHILADELPHIA, SOUTHERN NEW JERSEY 

  Seeking motivated, independent foot & ankle surgeon to join large practice. Our multi-office practice covers all aspects of foot and ankle pathology, including heavy hospital volume. Offering competitive salary and benefit package. Send CV and two references to bleich5252@yahoo.com

ASSOCIATE POSITION - NEW YORK CITY

One of the fastest growing podiatry practices in New York City and Queens seeks a podiatrist who participates with HealthFirst, Fidelis, and other Medicaid plans. Preferably a Spanish speaking podiatrist. Contact me at Podocare@aol.com

PART-TIME / FULL-TIME PODIATRIST NEEDED ASAP - CHICAGO

Part-time podiatrist needed for 2 offices in Chicago with an average of 20 hours/week. Must have Illinois license. Must have completed 2 years of surgical residency. If qualified, email to: A-Storjohann@footexperts.com

ASSOCIATE POSITION - TAMPA BAY AREA

Excellent opportunity to join a well established multi-office group practice in the Tampa Bay area starting July 1, 2011. We are seeking a hard working, ethical and outgoing physician with Florida license.  Salary commensurate with training plus benefits. Please email or fax CV. podiatryfl@yahoo.com 813-254-8262.

TEXAS- WONDERFUL OPPORTUNITY! 

Successful multi-office, multi-professional practice seeks well-trained new and established Podiatric Physicians with expertise in one of these areas: 1. Sports Medicine/Biomechanics/Gait Analysis, 2. Podopediatrics, 3. Diabetic Specialist, 4. Ankle & Rearfoot Surgery/Ankle Arthroscopy. A must to be really good in this niche, be outgoing, motivated, and personable with a dedicated hard working ethical desire to become successful. Send resume and letter of intent to sierrajip@gmail.com

ASSOCIATE POSITIONS – TEXAS

Looking for podiatrists to join group to work in nursing facilities in Texas (Ft. Worth, Dallas, and Houston) Please respond to: doconcall02@aol.com

ASSOCIATE POSITION - FLORIDA

Three physicians providing comprehensive podiatry services to Jacksonville, FL. Senior partner retiring after 37 years is seeking associate with 3-year residency trained in reconstructive foot and ankle surgery. Salaried position leading to buy-in. Send letter of interest and CV to padler@adlerpodiaty.com

ASSOCIATE POSITION - SOUTHERN CALIFORNIA

Douglas Richie, DPM is seeking a well-trained, motivated podiatric physician to join his two office practice located in North Orange County, California. Applicants must have completed a 3-year residency program and must have exceptional skills in reconstructive foot and ankle surgery, sports medicine and podiatric biomechanics. This is a salaried position with a goal of long-term buy-in for equity ownership. Send letter of interest and CV to drichiejr@aol.com

IMMEDIATELY AVAILABLE- ASSOCIATE POSITION - DAYTON, OHIO

Join a well-established modern practice with an excellent reputation and referral base. Base salary $100,000 and benefits with a bonus structure. EMR, diagnostic ultrasound, all aspects of DME, Padnet vascular studies, and CO2 lasers. We seek a surgeon that is well trained, personable and motivated to join our group of 3 Podiatric Surgeons. Would like this individual to buy in the practice eventually. Please send resume to ohiodoctors@aol.com
 
ASSOCIATE POSITION - SOUTHWEST FLORIDA

Immediate opening. Well-established podiatric group in Southwest Florida. Multi-office practice with EMR, Digital x-ray, Ultrasound and more. Seeking full-time associate that is PM and S-36 trained, personable, independent and highly motivated. Must be BC/BS in rearfoot and ankle with confidence in complex reconstructive cases. Full benefits package, competitive salary, excellent lifestyle. Email CV to: JLH459@aol.com

PART-TIME/FULL-TIME PODIATRIST NEEDED - INDIANA

Part-time full-time Podiatrist needed for our Indiana offices. Must have Indiana license. Must have completed two years of surgical residency. If qualified email to f-massuda@footexperts.com

ASSOCIATE  POSITION - SOUTHEAST FLORIDA

Southeast Florida practice seeks PMS-36 graduate for associate position. Candidate should posses strong work ethic, motivation and excellent interpersonal skills. He/She should be comfortable in multiple clinical settings and all aspects of foot and ankle surgery. Competitive salary, benefits, incentive structure. Reply to petaldaisy@gmail.com

ASSOCIATE POSITION - CT - (FAIRFIELD AND NORTH HAVEN)

Join one of the largest podiatric groups in Connecticut. Well-established and progressive offices, including EMR, digital x-ray, vascular and NCV studies, Pinpointe and CO2 lasers, diagnostic ultrasound and electrical stimulation therapy. You can expect a full schedule of patients the day you start, and a very competitive salary. For more info, www.GreatFootCare.com. Send resume to Dr.Kassaris@yahoo.com. Applications due by Jan 31st.

ASSOCIATE POSITION - BOSTON

CPME Board certified podiatrist wanted to join Orthopedic & Arthritis Center at Brigham & Women’s Hospital, Boston, MA. The position is per diem, 2 days/ week. Interested candidates should send their CV to: Brenda Surowiec, Orthopedic & Arthritis Center, 75 Francis Street, Boston, MA 02115. Or email to bsurowiec@partners.org

PRACTICE FOR SALE- MARYLAND, DC SUBURBS

Be an owner not a worker. Well established and equipped practice for sale. Office includes state licensed Ambulatory Surgical Center. Present owner is retiring but will stay on as needed for smooth transition. Average gross over past 3 years is $575 K. dpmpracticeforsale@yahoo.com

PODIATRY PRACTICE FOR SALE - DENVER, COLORADO 

Turn-key operation with very low overhead in a multi-disciplinary office. Young patient population. Physician’s office building affiliated with a prestigious hospital. Very low buy-in/buyout. Expected transition of about two years. Perfect for family. Contact podpracsale@hotmail.com

PRACTICE FOR SALE- SOUTHERN CALIFORNIA

An extremely well-run, paperless  office on sale.  Owner moving out of state due to family reasons. State-of-art EMR system, trained staff. Office across from main hospital. From 2005-2009, average gross was ~500 K with potential of grossing a lot higher. For more details contact: podiatry-practice4sale@hotmail.com

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