The Voice of Podiatrists

Serving Over 9,000 Podiatrists Daily

March 05, 2007 #2,825 Editor-Barry Block, DPM, JD

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Canadian Podiatrist Collects Shoes For Central American Needy

Dartmouth podiatrist and pedorthist Frank Keogh has a room full of used sneakers and sandals that will certainly benefit people in Third World countries.

Dr. Frank Keogh

One room of his Atlantic Foot Care & Orthotics office at the Dartmouth Professional Centre is piled high with bags of shoes. He keeps collecting and, by March 7, hopes to have them delivered to the Guelph, Ont., headquarters of Missionary Ventures Canada from where they will be taken by volunteers to Nicaragua, Guatemala or Honduras. Frank says he feels "warm and fuzzy inside. There’s a joy and a sense of something unexplainable. I get goose bumps thinking about it, realizing the happiness I’ll bring others."

"I started Footwear for Friends a couple of months ago," says the Toronto-born man who moved to Dartmouth 13 years ago. He says he wanted to "enjoy the laid-back life of Nova Scotia, and be near the coast, where, at the time, there were few podiatrists."

Source: Joel Jacobson, Halifax Chronicle Herald [3/2/07]

WV Podiatrist to Serve up to 10 Years for Running Pill Mill

A West Virginia doctor who was arrested last spring and charged with running a pill mill entered a guilty plea this week in Logan Circuit Court before Circuit Judge Roger Perry. Prosecuting Attorney Brian Abraham said that Dr. Dan Johnson, 58, of Boone County, will face up to 10 years in prison and a possible fine when he is sentenced later this year.

"He pled guilty on Tuesday," Abraham said Wednesday morning. "As part of his agreement he has forfeited his medical license. The investigation determined that over the past three years he wrote over 50,000 prescriptions for schedule II and schedule III drugs which made him one of the highest prescribers in the state. What you have to remember is that he is a podiatrist. We believe that the vast majority of his prescriptions deviated from standard practice. He let some people stay on prescriptions for a number of years with no effective treatment."

Source: J.D. Charles, Logan Banner (WV) [3/2/07]

MedPAC Releases Recommendations for MD Reimbursements

The Medicare Payment Advisory Commission on Thursday released a report on the Medicare physician reimbursement formula that proposed alternatives to the current system, CongressDaily reports. For the past 10 years, Medicare has used the Sustainable Growth Rate formula to calculate physician reimbursements. Under the SGR formula, Medicare physician reimbursements decrease when prior year payments exceed a target level based on the growth of the economy.

The SGR formula would reduce Medicare physician reimbursements by 10% next year and by 40% during the next eight years, according to the report. One alternative recommended in the report would "drop the SGR approach" and "create new incentives for practitioners to provide better preventive care to head off more expensive ailments," and a second alternative would "apportion physician payments on a regional basis tied to the varying costs of treating patients from one place to another" and "reward physicians who clearly improved their efficiency of care," CongressDaily reports (Hess, CongressDaily, 3/2).

According to the report, Medicare should:
* Provide physicians with more guidance on whether they overuse medical services and more accurately calculate prices to eliminate incentives for physicians to use unnecessary services;
* Encourage physicians and hospitals to organize into groups that are
measurable on quality of care and efficiency;
* Establish incentives for physicians and hospitals to work together to improve the efficiency of treatment;
* Establish incentives for primary care physicians to provide more
preventive and coordinated care;
* Conduct research to compare the effectiveness of different treatments for specific conditions (Reichard, CQ HealthBeat, 3/1); and
* Encourage younger physicians to establish geriatric practices
(CongressDaily, 3/2).

MedPAC remained divided on whether Medicare should continue to use a target level to calculate physician reimbursements. However, the report said that any target level should apply to all health care providers in Medicare, not only physicians.

Source: American Health Line [3/2/07]

Query: X-Ray Processor Recommendation

I’m interested in purchasing a new x-ray processor. Can anyone provide recommendations on current new models?

Andrew I. Levy, DPM, Palm Beach Gardens, FL

Editor's Note: Additional topics appear after this section of the newsletter.

RE: APMA Resolution 13-07 Single Certifying Board
From: Kathleen Toepp Neuhoff, DPM,

I favor this resolution. I believe the purpose of board certification is to encourage professionals to move to achieve excellence AND to help the public select those who have achieved a higher level of education and/or expertise. If we believe both boards promote excellence (which I do), the first objective is equally well accomplished by either board. The second objective is NOT well accomplished by having two boards because the public does not understand the difference between the two boards. Of course, it would be possible to spend millions of dollars educating the public about the difference in the boards, but I would prefer we spend those dollars educating the public to "Go to your podiatrist for ALL your foot and ankle needs".

An additional argument for combining the boards is the basic business concept of economy of scale. We are already a very small profession. Many medical specialties contain more members than our entire profession. It is wasteful to have the redundancies of time and expenses required to manage two boards.

Finally, because our profession is so small, it is more effective on a political level for us to speak with one voice. Multiple boards divide that voice and weaken us all. In addition, I frequently read literature from both boards which is phrased in "we" vs "they" language. Unfortunately, the "we" refers to those who hold the certification of that particular board and the "they" are other podiatrists who do not hold this certification. Again, I would prefer we spend our efforts differentiating our entire profession form others who are not as well qualified as podiatrists to handle foot and ankle patients, rather than from each
other.

I am board certified in both of these boards so it is clear that I am not speaking from a position of desiring to increase any personal advantage.

Kathleen Toepp Neuhoff, DPM, South Bend, IN, VETPOD@aol.com

RE: AFO S/P Amputation (Daniel Alan Chaskin, DPM)
From: Multiple Respondents

With a Chopart amputation, all of the dorsiflexors are gone. This leaves the powerful Achilles complex unopposed and you will likely get an equines, resulting in new distal foot/stump wounds. If the patient is going to be ambulatory, consider an ankle fusion of some type.

Art Hatfield, DPM, Long Beach, CA, afootjob@juno.com

A plantar stop can be applied to the brace hinge to limit plantar-flexion (to neutral or 5 degrees plantar-flexion) but allow for full dorsi-flexion. Be sure that there is not already an equinus contracture present. Due to the loss of the normal attachments of the dorsi-flexors, the Achilles tendon can frequently contract by overpowering the residual dorsi-flexion strength. When I do a Chopart's amputation (which is rare), I try to reattach the dorsi-flexors to either the interosseous talo-calcaneal ligament and/or the remnants of the midtarsal joint capsule. This should be at physiologic tension. A tenotomy or lengthening, of the Achilles tendon is also perfomed to prevent this type of contracture. I do not believe you mentioned if there is already any equinus present, if so, it may need to be addressed before the AFO is made. There were several articles in JAPMA and JFAS about 2-3 years ago on Chaopart's amputations that may mention other bracing options.

Palmer Branch, DPM, Chattanooga, TN, drcuboid@aol.com

Any amputation that prevents STJ transverse plane motion in the foot/ankle complex, will force Z-axis motion to occur at the heel instead. Although I've read some new opinions from the orthopods on the success of the Symes amp, I was taught and routinely saw patients with Symes amps ulcerate at the distal stump because there was no sub-talar joint range of motion to prevent friction in the prosthesis. The same applies with a Chopart's amp (no forefoot to contact the ground and so no motion at the STJ) and besides being difficult to keep in anything but custom fitted and usually not normal-looking footgear, is a tough amp to keep from re-ulcerating.

If an Achilles release was done, it may help the forefoot from re-ulceration, but what help a spring dorsi-flexion assist MAFO would render is questionable. There may be a place for the Boyd and Pirogoff procedures and the Symes may work in some patients, but as long as there is no forefoot purchase and no active STJ ROM to absorb Z-axis motion, reulceration is going to be tough to avoid. He would probably do better with a BKA.

David Secord, DPM, Corpus Christi, TX, David5603@pol.net

In the case of this type of amputation where there really is no foot left other than the talus and calcaneus, the tibialis anterior that fires up at heel strike in order to decelerate the force and speed of the foot going into plantar-flexion and creating a foot slap on the ground no longer has that function. The same is true for the posterior muscle group that acts as accelerators in the propulsion phase of the gait cycle, no longer have the ability to function in propulsion due to the fact that the lever arm has been shortened.

What is used many times in such cases is a PTB (patella weight-bearing brace) AFO either solid ankle or semi-solid that would 1. transfer the pressure away from the amputation site, and 2. restore the deceleration of heel strike and acceleration of propulsion in the gait cycle as much as possible. Another important consideration for this condition is the type of footwear used in conjunction with these types of braces. The shoe should have a beveled heel or a S.A.C.H. heel (solid ankle cushion heel) depending on the type of brace used, and a firm rocker sole to assist in reducing ground reaction forces to the foot while going into propulsion.

Filler made using the SAFIO (shoe and foot interfacing orthoses) process invented by Carl Reiken which is made of PQ gel, a viscoelasic polymer, and Plastazote or EVA, is also very functional and appropriate in such a case. To answer your question directly, I think that a flexible hinge AFO by itself would not only allow dorsi-flexion at the wrong time, it would also allow plantar flexion inappropriately resulting in friction, shear and pressure at the distal end which would ultimately cause further breakdown.

Itamar Rosenbaum, C.Ped., Brooklyn, NY, nycped@verizon.net

Editor's note: These topics are now closed.

RE: Consumers Can Now Use Web-based Firm to Negotiate Fees Barry Mullen, DPM)
From: Shay Fish, DPM

This piqued my interest as well, particularly since the web-based service (as referenced in the article) doesn't understand the relationship between fee schedules and insurance contracts. The "best price" in medicine is a fee theoretically agreed to in return for something - like patient volume - and varies from contract to contract. The web-based claims adjuster only attempts a variation of the price matching scheme utilized by big box retailers. What is their reference point?

On occasion I've received such a request to a "bundled fee" or "re-priced fee" (so insulting) on behalf of an insurer that I already contract with at discounted fees. So I refuse the offer. It's too late by that time to be seduced by "prompt payment" and I don't know how this information is shared in the industry. But, I always offer discounts (steep discounts) to cash paying patients at the time of service. Any discount offers after the patient leaves only comes after further expense.

To me the problem is created by those who yearn to get on "all the plans" and by those who accept contracts and the terms as dictated by the payers. More of us need to say "no."

Shay Fish, DPM, San Antonio, TX, fishdpm@aol.com

RE: Plica Syndrome of the Achilles Tendon? (Gary Dockery, DPM)
From: Ray McClanahan, DPM

I proudly carry the degree of DPM, but owe much of my success to the chiropractic profession. My first office was a small space that I shared with a chiropractor, who welcomed me in every way, including using his x-ray machine until I could get my own. He referred patients to me. His colleagues referred patients to me. My clinic gradually grew and eventually found a larger space, but to this day he is a referral source, and a friend.

Most of the referrals that I receive for the specialized care that I provide to runners and walkers, are from chiropractors who are not willing to throw out a term or a diagnosis, and perhaps most importantly, are not throwing treatments at the foot problems they are encountering in their athletic patients.

Chiropractic medicine is our ally, if we can get beyond the generalizations. We probably all know a chiropractor who misdiagnoses, treats inappropriately, or practice manages their patients. But as Dr. Gluck pointed out, many of our podiatric colleagues’ exhibit questionable professional behavior as well, which causes other medical professions to lump us all together.

I would like to see podiatry and chiropractic work together and learn from each other. To that end, I would like to see podiatric leaders temper their professional bigotry, particularly in print, or when speaking.

Ray McClanahan, DPM, Longview, WA , footdr@nwfootankle.com

RE: Diflucan for Onychomycosis (Cynthia S. Ferrelli, DPM)
From: Bruce Smit, DPM

If my memory serves me correctly, many years ago when the oral anti-fungals first came on the market, all were off label for mycotic nail infections. I attended a seminar in Chicago at which two prominent dermatologists were guest lecturers. After the lectures, an open question session ensued and my question was "What liability do we as physicians sustain if we prescribe these meds off-label?" The response was that as physicians, we are to take into account the best approach to aid the patient’s recovery. If we must rely on clinical results and experience in these cases, to hell with the clinical trials that did not declare nail infections to be studied at that time! Again, if my memory serves me correctly, the positive nail responses in the clinical trials were an incidental finding and since nail studies were not declared part of the study, "on-label" was prohibited.

I used Diflucan regularly after that meeting with excellent results.

Bruce Smit, DPM, Frankfort, IL footbiz@sbcglobal.net

ASSOCIATE POSITION: MONTGOMERY COUNTY, MARYLAND

Three doctor practice has one associate relocating, creating immediate patient flow for new associate. Certified surgery center, up-to-date-diagnostic electronics (US, digital x-ray, voice recognition charting, etc), administrator, and in-house billing. Tremendous opportunity to join busy practice with need for the right podiatrist. Please respond to: associatedpm@comcast.net

LEASE SPACE MANHATTAN/ LONG ISLAND

Are you sending your MRs out? Now you can lease space and run your own MRIs, bill global, and have them read by a board certified radiologist. Two locations to lease, Manhattan East 60th street (near all public transportation) and Plainview, Long Island. Call for details, lease arrangements and reimbursements Email podo2345@aol.com or Call 516 476-1815

PRACTICE FOR SALE -NORTHERN CALIFORNIA

Great opportunity to own a well-established turn-key podiatry practice located in modern medical office building in East Bay; Electronic billing, good payor base, no HMO contracts; biomechanics, general podiatry with great potential for surgery. Please send CV and letter of interest to: norcalpod@hotmail.com

WELL ESTABLISHED PODIATRY PRACTICE IN MT. AIRY, NC

Dr. John H. Hodges had a well established practice in Mt. Airy, NC that is either for sale or in need of an associate/partner to take over patient care. Dr. Hodges unexpectedly passed away, leaving approximately 3,500 patients. This is a unique opportunity to be able to begin work in a busy podiatric practice. If interested, contact Carolyn McMackin at (336)577-2886 or cmcmackin@triad.rr.com

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 WANTED - MICHIGAN-DETROIT AREA

Great opportunity-must be hard-working, reliable, responsible and good with patients & staff-surgical training a plus-partnership after 1 yr. Michigan license required fax resume to 248-478-1370

ASSOCIATE POSITION - NORTHERN VIRGINIA

Well-established, busy, diversified, multioffice/multidoctor practice seeking associate with opportunity for partnership. Must be highly motivated and ethical with strong interpersonal and patient skills. Excellent opportunity for PSR 24 or higher trained DPM to complement a full-scope podiatric medical and surgical practice. Competitive salary and benefits package. Please send CV and references to saglag2@aol.com or fax to (703) 368-5103.

ASSOCIATE POSITION – PORTLAND, OREGON

Immediate opening in beautiful Portland, OR. Busy, well-established private practice is seeking a dynamic, motivated, surgically-trained podiatrist. High volume of primary care referrals. Work with a well-trained support staff in one of the most efficient offices in the area. Surgically-oriented practice. Competitive compensation package including malpractice and benefits. Call (503) 652-1121. Ask for Dr. John Mozena or email jlmozena@aol.com

SEEKING RESIDENT FOR PSR-24 POSITION: BALTIMORE, MD

Mercy Medical Center -Position for a highly motivated individual with completed non-surgical residency or one desiring additional surgical training in well-established Podiatric Residency Program. Busy metropolitan hospital with high surgical numbers and inpatient care. Resident is integral member of multidisciplinary team. Begins mid June 2007. Includes competitive salary/benefits. Send inquiries to rsher18@yahoo.com

ASSOCIATE POSITION - EAST/CENTRAL TEXAS

Practice in East Central Texas has an opportunity for an associate to join as an associate leading to partnership. Hospital supported practice which has two doctors seeking a third for new office. Practice is leading provider in market and offers an outstanding compensation and benefit package. This position is targeted to be an equity partner within two to three years. easttxdpm@comcast.net

ASSOCIATE POSITION - SANTA FE, NM

Established, 30 year practice with multiple office locations looking for a PSR 24/36 trained, hardworking, personable, ethical, highly motivated individual for associate position with immediate partnership available. E-mail CV and reference letters to sfpodiatry@aol.com

SOUTH CENTRAL PENNSYLVANIA-PM&S 36 ASSOCIATE WANTED

Large, busy podiatry group looking for associate interested in future partnership. Practice facilities and technologies include: Surgical Center, Physical Therapy Department, six appointment locations, EMR, MRI and Digital X-ray. Full compensation and benefit package offered. Mail CV to Martin Foot and Ankle, 1203 S. Queen St. York, PA 17403 or email business administrator, johnreitzel@comcast.net

POSITION AVAILABLE - SOUTHEAST TENNESSEE/ NORTH GEORGIA

Immediate position available or will wait for the right individual. Unique practice opportunity in growing multi-physician/multi-office practice. Well established/cutting edge within the medical community. Close proximity to hospitals as well as opportunity to become involved with a free standing podiatric surgical center. Must be BQ/BC. Minimum PSR/24. Competitive salary, bonus structure and benefits. E-mail CV to afcjen@hotmail.com

ASSOCIATE PODIATRIC SURGEON POSITION - TEXAS

We are looking for an exceptionally trained podiatric surgeon to work in the Houston, Texas area. Candidates seeking this opportunity need to be dynamic, people friendly, and have current licensure in Texas. Future licensure in Arizona will be required. Exceptional opportunity, with attractive benefits, and excellent starting salary. The successful candidate will find a rare opportunity to integrate into a specialized lower extremity practice with emphasis on peripheral nerve surgery, endoscopic and arthroscopic surgery, and other special surgery of the foot and ankle. Please submit a cover letter with current curriculum vitae via email to: Slb99@pdq.net Stephen L. Barrett, D.P.M., MBA

ASSOCIATE WANTED FOR SOUTH MIAMI AREA

Large group, busy, multi-office, partner potential. Motivated applicants only. Mail resumes and letters of intent to 999 N. Krome Avenue, Homestead , FL 33030. July start time OK, sooner preferable. E-mail lianadpm2@aol.com

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