The Voice of Podiatrists

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March 05, 2008 #3,185 Editor-Barry Block, DPM, JD

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Most Runners Require Supportive Shoes: CA Podiatrist

Running without a properly supportive shoe may lead to problems with tendinitis, according to Dr. Bob Baravarian, a podiatrist at the Foot & Ankle Institute of Santa Monica. In addition, landing on rocks, pebbles or rough material can cause wounds that may be difficult to heal. Not every runner needs supportive shoes, Baravarian adds, but most require some level of support for long runs in order to avoid problems, particularly if they have low arches.

Dr. Bob Baravarian

Baravarian has misgivings about the increasing popular practice of barefoot running. Yes, he says, it's done in some African tribes, but most of these practitioners have run barefoot since childhood and their feet have adapted to the running surface.

Source: Janet Cromley, Los Angeles Times [3/3/08]

Beth Jarrett, DPM Elected President of ACFAOM

Beth D. Jarrett, DPM, CPed, FACFAOM, of Vernon Hills, IL, has assumed the presidency of the American College of Foot & Ankle Orthopedics & Medicine (ACFAOM) . Dr. Jarrett took over from Dr. Craig Garfolo of Stockton, CA, who served two one-year terms as president.

Dr. Beth D. Jarrett

Dr. Jarrett received her DPM degree from the Dr. William M. Scholl College of Podiatric Medicine. She is a Diplomate of the American Board of Podiatric Orthopedics& Primary Podiatric Medicine (ABPOPPM). Dr. Jarrett was also certified in Pedorthics by the Board for Certification in Pedorthics, May 2000. She joined the ACFAOM Board of Directors in 2002 and served as President-Elect for the past two years. Dr. Jarrett is an Associate Professor in the Department of Biomechanics and Orthopedic Disease at the Dr. Wm. M. Scholl College of Podiatric Medicine at Rosalind Franklin University of the Medicine and Science.

The ACFAOM executive officers for 2008 are Drs. Kirk Geter (President-Elect) (DC), Denise Freeman (Treasurer) (AZ), and Kathleen Satterfield (Secretary) (TX). Dr. Stephen Albert (CO), elected to his first term, joins the directors: Drs. Bart Gastwirth (IL), Robert Marcus (NJ), and Francine Schiraldi-Deck (PA). The ACFAOM executive director is Dr. Norman Wallis.

Podiatrist Brings Taste of Philly to FL

Philadelphia native Dr. Stephen Kushner grew up on the uniquely-shaped soft pretzels that are a staple of his hometown. When he moved to Florida many years ago, dreams of crisp, golden crusts on top of warm, chewy centers followed. Unfortunately, at the time there was nothing down here that could compare. The only available pretzels were the chainstore sugar-and-cinnamon kind, which are worlds away from what “real” pretzels should be.

Dr. Stephen Kushner

So after several years in practice, Stephen decided to follow his passion and go into the pretzel business. He says, “The transition from providing medical care to developing a recipe for a healthy, delicious, inexpensive, and filling snack food was easy. I developed a recipe where our pretzels are 0% fat/lard, 0% cholesterol and 100% Pretzelicious!” He continued, “Hearing from then-patients of mine who were in the school system, and always hearing on the news how schools and parents need to help make food choices healthy and easier for kids, I thought the timing of my products was perfect.” “Wherever we bring the pretzels, everyone loves them,” Stephen says.

Source: Dave and the Ranches Mar 08

Query: Graft Jacket for Hallux Limitus

There was a recent article in Foot and Ankle regarding using the graft jacket matrix as a joint spacer for hallux limitus after performing a cheilectomy. Has anyone had experience performing this type of procedure?

Syed Ahmed, DPM, Louisville, KY

Query: Storing Old Files

Our office is not totally paperless and we are reaching a point where we are running out of space for old files. An old file will contain a copy of the patient's records, x-rays, and copies of insurance forms submitted. Do actual x-rays need to be kept for a length of time or is a report sufficient? What have some of you done with old files when you find yourselves running out space to store them?

Elliot Udell, DPM, Hicksville, NY

Editor's comment: PM News does not provide legal advice. X-rays are considered part of the medical record and must be maintained for the same period as other materials. Most experts recommend seven (7) years. X-rays and other materials can be scanned and digitized to save space.

RE: Ankle Bursitis in Hockey Player (Carroll Kratzer, DPM)
From: Multiple Respondents

I had a similar type of case and the only thing that worked was excising the bursal sac.

Ira Meyers, DPM, Huntingdon Valley, PA, idmrun@aol.com

I had a problem similar to this myself. After playing hockey for 35 years, I suddenly developed painful bursitis over my medial and lateral malleolus on my right ankle. I applied 1/4" felt donut pads on each side of the boot, thereby protecting the malleolus. It worked perfectly and immediately.

Terry Pedersen, DPM, Yankton, SD, tpedersen@shhservices.com

You may want to look into a product called a Malleotrain made by Bauerfiend USA in Kennesaw, GA. This is an elastic ankle support made out of a high grade surgical stocking type material however it has silicone gel pads sewn into it over the malleoli. If this does not work your can purchase silicone gels sheets from Silipos which you could stuff inside the sock to cover the lateral malleolus. Another thought is to have a shoemaker liner the inside of the skate with something along the lines of PPT.

Steven H. Goldstein, DPM, Royal Palm Beach, FL, stevefootdr1@cs.com

Are you sure it's bursitis and not an ankle capsule tear? Consider an MRI.

Simon Young DPM, NYC, simonyoung@juno.com

RE: Alleged Failure To Properly Perform Removal of Neuroma on Foot (NY)
From: Multiple Respondents

I suspect that a large factor in the jury's thinking is why the podiatrist didn't get an MRI? Well, I had a case of suspected neuroma 2 weeks ago. I ordered an MRI, which was denied by Oxford, stating the patient needed an ultrasound. The ultrasound report was inconclusive, and the radiologist recommended an MRI with contrast. Oxford denied it again. I appealed, and the physician review that upheld the denial said "Neuroma is a clinical diagnosis, and need not be confirmed by MRI."

I told the patient that I would not operate without the MRI (please assume all non surgical treatments have been attempted), and that she should be angry with Oxford, not me. What exactly are we supposed to do?

Peter Smith, DPM, Stony Brook, NY, ps84@bc.edu

I read with interest the plaintiff’s verdict regarding the incomplete removal of a neuroma. I am troubled that it seems as if MRI now becomes the imaging test as standard of care for diagnosing a neuroma prior to surgery.

Those of us in practice prior to this wonderful technology were very successful at clinically diagnosing this common condition. I have seen instances of negative MRI tests with the presence of a neuroma clearly visible at surgery. Does this mean we now have to order a $1,200 test prior to scheduling neuroma surgery? What do we do if the MRI is negative and the patient is still suffering (and other treatments, e.g. injections, cryotherapy) have failed? Is sufficient documentation adequate to protect us from losing a similar case?

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

When did it become standard of care to get an MRI on an intermetatarsal neuroma? This is a classic example of how our legal system pushes up the cost of medical care! The plaintiff’s expert should be ashamed. The nurse—who should know better—should be ashamed.

Just as a note regarding “standard of care.” Here in Mississippi the podiatrists at the VA do not have any surgical privileges and they occasionally send patients out of their system for second opinions. Four weeks ago I was sent a patient from them. They had sent the patient originally to their VA orthopedics department for a suspected neuroma. There he was sent for an MRI for his typical Morton’s neuroma like pain. The MRI was read as negative for any mass therefore the ortho department refused to surgically explore this guys foot. Despite repeated requests and according to the patient a general agreement among his physicians that his problem was typical for a neuroma no one would help him.

On my surgical exploration, I found a very small thickening of the common digital nerve and a very tight transmetatarsal ligament. The patient’s pain was relieved and he is happy as a clam. Now because there was a negative preoperative MRI should I be worried that he would sue me if he developed a recurrence?

Maybe MRIs are now a pre-operative standard of practice in typical neuroma cases. I doubt that the insurance companies would like that. How many people out there get a pre-operative MRI for a typical neuoma? Are MRIs standard of practice for you? Do they, in typical cases, give you any help in determining the extent of dissection needed? I thought the standard was to remove all abnormal appearing nerve tissue and I do that during surgery.

B. Tipton Sullivan, DPM, Jackson, MS, tsdefeet@msfootcenter.net

RE: Podiatric Assistants Performing Routine Foot Care (Michael Forman, DPM)
From: Multiple Respondents

In California, the podiatric medical assistant can only clips nails on a healthy patient. On the high-risk patient this must be done by a medical professional. In fact, podiatry at my HMO, did this for a while and were hit with a cease and desist order from our own legal department.

Presently the high risk nail care is done by RNP's. This helped us as our population pool consisted of over 250,000 patients. These RNP's worked with the pt's primary care doctors at many of the outlying clinics since we are spread out over a large area in Los Angeles. They also help regulate the HTN, DM and other medical factors that could place the pt at even higher risk for foot problems, while they are seeing the patient. We decided to go this route about 8 years ago as we noticed that patients were coming in for their foot care but hadn't seen anyone for their medical issues for 3-4 years. We felt that it was worthless to provide "foot at-risk foot care" when the patient was not having anyone treat the problems that put them at risk in the first place.

This worked out well until recently where our HMO decided not to replace the RNP's who left. They are replacing them with more MD's and DO's. So we recently had to create an non-surgical podiatry criteria, and are now hoping our HMO realizes that we now need more podiatrists to provide this service since no one else wants to do this. Everyone is terrified of hurting the high-risk patient and getting sued for limb loss.

Diane D. Branks, DPM, Baldwin Park, CA, Drbarry999@aol.com

About 20 years ago this was suggested in the Akron area in conjunction with a medical assistant program at a local school for medical and dental assistants. Everyone in our academy thought it to be a good idea until one of our senior members questioned what would prevent these “certified assistants” from hiring out to local family doctors to provide podiatric routine care services through their offices? Once this was considered the idea was rejected.

If practitioners do not want to provide routine care services, they should refer those patients to other podiatrists that do, or teach your staff to do it. Certifying this activity is, in my opinion, not in the best interest of our profession.

David K. Elliott, DPM, Tallmadge, OH, m.b.elliott@earthlink.net

I would say it depends on who is paying for this service to be performed. If you are dealing with a cash paying patient your limitation would depend on your State's laws and rules. If you dealing with a private insurer, then you would have to understand the insurer's guidelines. If you are billing Medicare it appears the Federal Guidelines have been written.

In Florida for Medicare, it appears that 'covered care' (e.g., 11055) is reimbursable only when performed by a physician because of the wording :" The presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease may require scrupulous foot care by a podiatrist or other physician."

For mycotic toenail debridement, however, the wording appears more lenient: "The provider of the service(s) must document the affected nail..." "Provider" could be almost anyone. One caveat: since physician assistants and nurse practitioners cannot bill Medicare at the full rate of their MD or DO, it would be reasonable to assume that the fee billed for a service performed by a podiatric assistant should not be billed to Medicare at the same fee level as a Doctor of Podiatric Medicine.

Richard A. Simmons, DPM, Viera, FL, RASDPM32822@aol.com

RE: CME and Scope of Practice (Remember the Knee) (Stephen M. Meritt, DPM)
From: Beth S Pearce, DPM

I would like to lend further support to the many points of Dr. Stephen Meritt's letter 3/04/08 in the defense of Dr. Bret Ribotsky and his "Remember the Knee" seminar. I have personal knowledge about this issue as I have served on the Board of Podiatric Medicine of Florida since 1999, and was present throughout the circumstances regarding the definition of the human leg as it relates to our scope of practice in podiatric medicine. The following is my personal opinion on the matter (for clarity, not necessarily the view of the Board).

The FMA vs FPMA battle lines were drawn in response to the loss of the appeal challenging the court's interpretation of the definition of the human leg and not due to Dr. Ribotsky's seminar. Dr. Ribotsky therein highlighted the importance of treating the foot in RELATIONSHIP to the knee; non-surgical interventions such as bracing techniques,orthotic device posting etc., as well as a refresher as to the function and anatomy of the knee, not to be forgotten territory, with respect to the reactive forces of the ground and the effects of our biomechanical efforts.

The cascade of mis-information and need to 'blame' Dr. Ribotsky is both disappointing to watch, and really quite mis-informed! Dr. Bret Ribotsky has long provided our profession with entertaining and exceptional educational experiences, and with a consistently unwavering commitment to bettering podiatric medicine. He should be praised and supported, not criticized for his valuable work. This is an opportunity for us to stand together in support of each other, not to buy into the propaganda of those who intend to divide us.

Beth S Pearce, DPM, St. Augustine, FL, drfootmagic@aol.com

RE: Ethical Dilemma (Richard Gosnay, DPM)
From: Michael M. Rosenblatt, DPM

Dr. Gosnay states that the doctor will be forced to testify anyway, and therefore there is no “real difference” between being subpoenaed vs. testifying as a paid witness. I respectfully disagree. It is extremely unusual for a doctor who shared in the actual treatment process to be considered a “professional witness.” A true professional witness is called from the “outside” to offer testimony on whether or not the doctor fulfilled requirements of “standard of care.”

Either side may subpoena those who participated in actual patient care, depending on specific circumstances and their point of view. Since the standard of care was apparently egregiously violated in this case, I agree with the Editor that plaintiff should have no real difficulty in obtaining an outside standard of care expert.

When local orthopedists, furious that the podiatrist is testifying against one of them for a fee starts fomenting patients to sue the podiatrist and submit claims to the Podiatry Board, the expert testimony fee will soon be consumed by lawyers defending the podiatrist.

In a worst case scenario, as the podiatrist learns that patients are being fomented against him, he/she can politely call a local orthopedist and “respectfully remind one of them” that he was compelled to testify. A single call might be enough to stop the nightmare as word gets around. This is the “small-town syndrome” in practice in the real world.

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

PRACTICE FOR SALE - AUSTIN, TEXAS

15 year established practice with good mix of surgery and clinical patients. Nice office condo for sale with practice or lease. Current female Podiatrist will transition the practice. 300-400K yearly gross. Currently keeping two part-ime podiatrists very busy, Turn-key for one full-time physician. MRobsonDPM@aol.com

EQUIPMENT FOR SALE

Tab type legal size records shelving (5 units) $50 each, MinXray P202 works OK, $1000 2 Wolf xray viewboxes (24x12) $50 each, Walker $15, Star x-ray copier $100, 3 xray Paper safe boxes $20 each, Fisher x-ray processor -will do 10x12 $500, 1.5mm moveable x-ray shield on casters $250 Contact Beth @ 919-850-9111 or btl1963@aol.com

FULL-TIME ASSOCIATE WANTED - CHATTANOOGA,TN

Well established, well-respected surgical/medical practice seeking full time associate. Send CV/ inquiries to: chattfootdoc@yahoo.com

CASE CONSULTING

Dennis Shavelson, DPM is now accepting referrals of difficult cases involving biomechanics, surgical complications, diagnostic and treatment dilemma’s and subtalar stenting from DPM’S. Full reporting with second opinion only, rapid return after care and assumption of care options. Medicare and Out-of-Network Only. (212) 288-3668 or drsha@lifestylepodiatry.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.

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