The Voice of Podiatrists

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March 01, 2008 #3,182 Editor-Barry Block, DPM, JD

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High Heel Shoes Present Frostbite Risk: IL Podiatrist

Foot fashion comes with a price tag. “We’ve seen a higher percentage of shoe-related incidents among women this winter,” said Dr. Neal Frankel, a podiatrist at A Foot and Ankle Centre in the Loop. Frankel said he has seen more twists, fractures and frost bite of the feet—all caused by wearing high heels.

Dr. Neal Frankel

“Last week we had a few patients with significant frostbite,” Frankel said. “It’s because they were wearing nylons and the high heeled shoes themselves are really thin and their toes are cramped, so there’s a lack of circulation that led to frostbite.”

Frankel said it takes just five minutes for a woman in high-heeled shoes to get frostbite if she’s standing outside in weather below zero. Add damp conditions to the mix and it could happen even faster.

Source: Ali Reed, Medill Reports, [2/26/08]

MO Podiatrist Receives Man of Year Award and Bravos

Dr. Gerald Cohen, a local podiatrist long active as a volunteer at Congregation Shaare Emeth, was honored as the first local recipient of the "Man of the Year" Awards, by the Midwest Region of the Federation of Jewish Men's Clubs. Over 150 people filled the auditorium of Congregation of Shaare Emeth, where Dr. Cohen was honored for his many years of service to his synagogues and to the entire community.

Dr. Gerald Cohen Photo: Dennis Caldwell

Jerry continues to maintain his podiatry practice on a part-time basis, having maintained a full-time commitment for more than 40 years. He has been recognized as a past president of the St. Louis Podiatry Society and was selected as the 2004 Podiatry Man of the Year for the State of Missouri. Jerry's interest and love of children continued through his professional career as he performed magic show's for school children throughout the area as 'Footso the Clown.' In summary, Jerry displays a love of family, synagogue and profession that is hard to match."

Source: Robert A. Cohn, The Jewish Light [2/28/08]

RAC Program Finds $371.5 M in Improper Medicare Payments in 3 States

The Centers for Medicare & Medicaid Services (CMS) today announced that $371.5 million in improper Medicare payments has been collected from or repaid to healthcare providers and suppliers as part of a demonstration program using recovery audit contractors (RACs) in California , Florida and New York in 2007. Nearly $440 million has been collected since the program began in 2005.

Approximately 96 percent of the improper payments identified by the RACs in 2007 were overpayments collected from healthcare providers; the remaining 4 percent were underpayments repaid to healthcare providers. The demonstration program began in California , Florida and New York in 2005 and expanded into Massachusetts, South Carolina , and Arizona in 2007. CMS will enter into new contracts as the national program is implemented before January 1, 2010.

Source: CMS

Query: Post-Op Care For Matrixectomy

I have to perform a chemical matrixectomy on a blind, mentally-challenged patient who eats anything applied to his feet or toes. For fear that he will eat the post-operative dressings I ask if anyone has a suggestion to post-operative care.

Frank DiPalma, DPM, Athens, GA

Query: Patient Bankruptcy

One of our patients has had a lot of surgery performed, as well as medical treatment. Even after her insurance plan paid, she owes the practice over $500. I have called her, without success, to set her up on payments. Today, we received a notice of bankruptcy (Chapter 7) on the balance. There is a meeting for the creditors.

Our question is, if it were you, would you go after the balance through the bankruptcy court?

Vicki Hicks, Office of Daniel Brown, DPM, Herrin, IL

Response: I am not a bankrupcty expert, but I know that it is not particularly difficult for a creditor to file with the court a notice of a claim against the bankruptcy estate. Filing the notice of claim will then put you on the mailing list for the bankruptcy, and allow you to follow developments in the case.

One of the first things I would want to see is the debtor's schedule of assets to evaluate what assets are available to pay you.

J.Kevin West, Esq, Boise, ID

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RE: Non-painful Click after Sclerosing Alcohol Injections (Bob Sage, DPM)
From: Multiple Respondents

I have seen this a few times in the past 30 years following a series of injections of dilute 4% alcohol solution for intermetatarsal neuromas. The patients have all been asymptomatic but the palpable or audible click is still present. In all cases I have had, the patients eventually report that they no longer feel or hear the click. This is still such a nice alternative to the original neuroma pain.

G Dock Dockery, DPM, Seattle, WA, gdockdockery@aol.com

The lack of pain upon percussion of the intermetatarsal space is a good indication the alcohol was successful in sclerosing the nerve, thus preventing the conduction of pain sensorium from the mass itself. The click remains because the injections don't address the mass' presence. Just observe the patient over time to ensure symptoms don't return, as on occasion, the chemical pain pathway blockade with lower concentrations of injected alcohol may not create true permanent "sclerosis".

Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com

If it is not broke do not fix it. Plenty of anatomic machinery will click. If it is really an issue with the patient, then do an endoscopic decompression or external neurolysis which should resolve the click. The MRI is not going to change what you do unless there is a tumor. Ultrasound can be helpful with proper Mhz machine and user familiarity.

Peter Bregman, DPM, Tewksbury, MA, footguru@comcast.net

The click is the neuroma. The reason is does not hurt is that the sclerosing injections “turned the nerve off” so the patient does not feel the neural related pain anymore. The 4% solution most of us use is too low to truly sclerose the nerve. My experience is that 25% of the patients will return for “touch up” injections due to low grade, lingering pain. The “touch up” injections usually work very quickly to resolve the remaining pain.

Howard Stone, DPM, Glenview, IL, drstone@nspodiatry.com

RE: Diagnose This lesion (Philip E. Larkins, DPM)
From: Bryan C. Markinson, DPM

Dr. Larkins presents a case which clearly represents a severe inflammatory eruption which he states was non-responsive to "strong topical steroids" but does not say which and/or how they were applied. The vesicles and hyperkeratotic skin are highly clinically suggestive of an intense dermatitis. One responder suggested "biopsy of the dome" of a vesicle in search of herpes. This is not correct. The quickest test for viral infection is actually a scrape of the base of a vesicle for preparation of a Tzanck smear.

The base of the blister is scraped with a scalpel, and as much cellular material as possible is gathered and applied to a glass slide. Wright's stain is then applied and the slide is examined under the microscope for multi-nucleated giant cells and inclusion bodies. Since this is out of most podiatry office capabilities, a simple punch biopsy will also help diagnose an inflammatory dermatitis or viral infection. My personal opinion without much history is that this case represents a severe form of dyshidrosis which requires oral steroids. I would have started that empirically and done a biopsy if I did not get results.

Bryan C. Markinson, DPM, NY, NY, bryan.markinson@mountsinai.org

RE: Ethical Dilemma (Name Withheld)
From: Multiple Respondents

With all due respect, the Inquirer's ethical problem is entirely self-created and I believe the Inquirer must continue to serve as the patient's expert. In my opinion, it is always improper for a subsequent treating physician to serve as a standard of care expert against the prior treating doctor.

Ethically, the subsequent treating physician should refrain from giving expert testimony because he will invariably also be called as a fact witness in the case. As a fact witness he will inevitably be required to defend his own care. Also, the witness may well find himself as an additional defendant in the case when the defendant blames all of the patient's subsequent problems on him. These are standard defense tactics. When they occur, they put the witness's interests at odds with those of the patient. This creates an irreconcilable conflict of interest.

So I generally agree with the Learned Editor that the Inquirer should not be an expert in this case. Unfortunately, the Inquirer is already committed to be one. I also believe it is unethical for the Inquirer to withdraw at this late date. Doing so will unquestionably work a serious hardship on the patient/plaintiff. So even though the Inquirer may have created an ethically uncomfortable situation for himself, two wrongs never make a right. The Inquirer needs to remain in the case.

I also think the Inquirer is ethically obligated to report his conversation with the defense attorney to the patient's lawyer immediately. The defense attorney is guilty, in my opinion, of gross misconduct and is subject to being removed from the case by the Court on account of that misconduct.

Richard W. Boone, Sr., Health Care Attorney, Fairfax, VA, rwboone@aol.com

My advice is to testify as a "factual witness". As a treating physician, you are not the best "expert" witness anyway because the jury may consider you to be biased, but you are the best factual witness since you were actually there. No one knows the case better than you. No one! I would not wait to be subpoenaed, but offer your "factual testimony" and expect to be paid for the time and effort to prepare your research for deposition and testimony (which can be very time consuming). This way, you say the truth, the whole truth and no opinions. Your moral integrity is never in question. Truth is better than opinion. Let the "experts" make opinions. When their opinions totally disagree (one will say "north" and the other "south"), the jury will use your factual testimony in the end. As a factual witness, you will be more believable than the typical money hungry "experts". You are MORE important to the case than the experts, and will serve your patient and the system well.

Pat Caputo, DPM, Holmdel, NJ, pat_caputo@alumni.rutgers.edu

I hope that there is more to the case then that what was described. My recommendation is NEVER get involved with a case where the plaintiff is a diabetic. I have been involved with many diabetics that I thought should respond well after a minor injury or surgery and find myself with a nightmare that goes from bad to worse, for no apparent reason. It is sometimes (when least expected) to be the nature of the beast.

I would not advise you to testify against the orthopedist because his/her clinical judgment did not follow-up the drainage of an abscess with the placement of a drain. There must be a lot more to this story then what was published.

Barry A. Wertheimer, DPM, Redondo Beach, CA , bwertheimer@cox.net

RE: No Plumbing Needed Automatic Processor (Jerome Leff, DPM)
From: Multiple Respondents

Veterinarians have typically used the Fischer AutoTank, but that no longer exists. It has been replaced, check:

http://www.classicxray.com/autotankx-rayprocessor.html

Stephen H. Zimmerman, DPM, Memphis, TN, drzimmerman@poplarpodiatry.com

I currently use the Agfa CP 1000 which is completely self-contained. It is a low volume processor and it takes about 2 1/2 minutes for the film to exit the machine. It is totally self-contained and drains into jugs which my x-ray company removes monthly.

I had two of them at one time and recently sold one of them. They work beautifully. Check with a local supplier in your area, you might be able to pick one up at a discount

Ira Weiner, DPM, Las Vegas, NV, vegasfootdoc2005@yahoo.com

All-pro makes developers which do not require plumbing-

Mark Gresser, DPM, Center Moriches, NY, doctorblues@optonline.net

RE: Are Those Orthotics Really Custom-Made? (Susan L. Boren)
From: Multiple Respondents

Ms. Boren relays a dilemma faced by all the labs. There are very few that pour plaster into negative plaster impressions. Those that do construct a true custom-made orthotic have to charge a higher fee than those using mass produced "shells." They are making a "custom tailored" orthotic rather than forming an orthotic form raw materials. Maybe it is time for a demand for truth in advertising and time for the orthotic dispensers to realize that buying cheap and selling high can lead to problems. It also would help the economy if the orthotic dispensers purchased them locally, if possible, and/or made sure the orthotics were made in the USA.

Jack Glick, DPM, MHA, Beaumont, TX, afolab@att.net

Kudos to Susan. $100.00 barrels of oil and 5% unemployment, custom foot orthotic fees like everything else are creeping up. It is sheer folly to think that a company can produce a truly custom, one of a kind product from your patient model, in the $50.00 price range. The days of vacuum forming a piece of poly over a plaster cast in your garage are gone. Some companies (read “enterprising individuals”) have decided there are ways of getting around time tested, costly, production methods and have begun pulling foot plates from bins of neatly packaged injection-molded or pre-formed “pieces.”

Talk to your lab and ask them if they build your devices from flat stock or if they use pre-formed footplates. Labs like ours have worked hard and spent a great deal of money to be able to keep our costs down while maintaining the standards of the industry. Pre-formed foot beds are an ideal option when your patients do not have a need for or cannot afford custom devices. These products can be purchased from labs or material suppliers and most times will cost you no more than $25.00 per pair. Don’t get caught up in the shell game. And as with most things, if it sounds too good to be true… it is. Your patients have real foot problems, they deserve real orthotics!

Howard Hillman, President, Rocky Mountain Orthotics Lab. Inc., Howard@rmolink.com

Dr. Kesselman has some excellent words of advice for his colleagues on this subject. Since the advent of managed healthcare there has been increasing pressure on podiatrists to keep their fees down. As a direct result, those same doctors have placed enormous pressure on orthotic labs to do the same. This creates a strong incentive for labs to reduce their manufacturing costs and labor is their main expense. Many labs have turned to automation, library systems, and other means of reducing their manufacturing costs. While this is generally good for consumers, it has created some ethical dilemmas and the potential for some manufactures to intentionally or unintentionally mislead their customers as to how their orthoses are made. This could result in improper billing and potential liability for the practitioner.

Jeff Root, President, Root Lab, jroot@root-lab.com

ASSOCIATION POSITION - MONTANA

Two Doctor group seeks individual with three years of surgical training with emphasis on the forefoot. Diabetic foot fellowship desirable. Practice includes two physical therapists that work on site. Rural setting with excellent outdoor activities. Competitive salary and benefit packages with opportunity for partnership. Respond to: jclough@sofast.net or Fax to: 406-761-7219

PRACTICE FOR SALE - DALLAS TX

10 year old general podiatry practice, including, geriatric care, diabetic care, surgery, biomechanics, etc. Grossing approximately $185,000 part-time, can be made full-time. Hospital privileges available. Will stay for transition. Please reply to: footdoc8390@yahoo.com

P/T ASSOCIATE POSITION - QUEENS, NY

10 yr old practice seeks motivated, surgically-trained individual. Fax CV with hours available to (718) 458-0053.

ASSOCIATE WANTED – NEW YORK IMMEDIATE OPENING

Busy multi-dimensional practice; 70 miles north of New York City . Currently four (4)-doctor practice. looking to expand – all phases of podiatric medicine. contact: (845) 454-8308 EXT: 106

ASSOCIATE WANTED -BOCA RATON-DELRAY BEACH AREA

Great opportunity-must be hard-working, reliable, Responsible and good with patients & staff-surgical Training a plus-partnership after 1yr. Florida License required fax resume to 561-865-2225.

ASSOCIATE POSITION - NEW YORK CITY

Excellent opportunity for foot/ankle surgeon, Manhattan and Brooklyn Associate position leading to possible partnership. Requirements: Two years enrollment in a surgical residency program Qualities of self-motivation and impeccable skills in forefoot and rear-foot surgery. Package Includes: Malpractice insurance, Health Insurance plus salary, Incentives. Terms negotiable Email CV to Manfootcare@aol.com 212-349-7676

ASSOCIATE POSITION- KANSAS CITY, MO

Excellent opportunity for a hard working, ethical podiatrist to join a vibrant, successful and growing podiatric medical and surgical practice. Dedicated, supportive staff with strong marketing and medical knowledge. Must be board eligible/certified. PSR/24. Partnership opportunity. Competitive salary, bonus structure, benefits. Wonderful place to raise a family. Fax CV to 816-455-8901.

ASSOCIATE POSITION - NEW YORK STATE

ASSOCIATE Wanted To Be fast tracked into PARTNERSHIP. 6 doctor group with one partner anxious to retire. DON'T MISS THIS OPPORTUNITY. Check out our website www.footcaregroup.com then e-mail me to arrange a visit mhudes@footcaregroup.com

PRACTICE FOR SALE - PORT ST LUCIE, FLORIDA

The office is 0.2 miles away from the hospital. Good mix of Medicine, Surgery, Wound care, and general podiatric care. Wound care center privileges available. No HMO's. Please call 1-772-475-7920 or derrico@pol.net for details

Connecticut- Part time or Full time position available for a PSR 24 trained Podiatrist in the New Haven Area. We are seeking a hard working, ethical, charismatic practitioner for a well rounded established office Please email resumes to Surgeonseven@aol.com. Position available ASAP or July.

15 year established practice with good mix of surgery and clinical patients. Nice office condo for sale with practice or lease. Current podiatrist will transition the practice. 300-400K yearly gross. Flexible payment options MRobsonDPM@aol.com

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