The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

March 10, 2010 #3,800 Publisher-Barry Block, DPM, JD

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Proper Shoes Can Help Control OA: CA Podiatrist

Though experts don't know how many people have OA of the big toe, they agree it is more common as we pass the half-century mark. Some people also develop an overgrowth of bone, or a bone spur, on top of the joint, which many patients mistake for a bunion.

Dr. Bob Baravarian

See a doctor as soon as you suspect a problem, says Bob Baravarian, DPM, co-director of the University Foot and Ankle Institute in Los Angeles and chief of foot and ankle surgery at Santa Monica/UCLA and Orthopedic Hospital. At this point, he says, you may be able to control the OA with shoes that are long enough and have a deep enough toe box to keep your big toe from rubbing against the side of the shoe. A rigid sole should also help, as it prevents your big toe from bending and twisting.

Source: Catherine Winters, Prevention

IN Podiatrist Works as Primary Care Physician in Haiti

Dr. Randy Kline said he arrived in Haiti a couple of weeks after the earthquake. Kline said his team saw about 250 patients a day, and more than 5,300 people during his two-week stay. "By the time we made it there, most of the major trauma had either made it to the hospital or had (died) from their injuries," Kline said.

Dr. Randy Kline

Even though Kline is a foot doctor, he worked as a primary care physician during his time in Haiti."We spent a lot of time changing dressings and reinforcing casts," he added. Kline dealt with everything from gastrointestinal and respiratory issues to post-traumatic stress. But there were plenty of instances that could be classified as anything but routine, according to Kline. Though the team was based at a site affiliated with Nehemiah Vision Ministries, the medical workers went by bus to tent cities erected throughout the country, Kline said.

Source: Howard Dukes, South Bend Tribune [3/8/10]

FL Podiatrist Creates Scholorship Program for Student Athletes

Seniors student athletes from each of Collier County’s public high schools were awarded certificates and sports medals and have become eligible for one of three $2,500 scholarships awarded in late spring.

Dr. Mickey E. Gordon

Mickey E. Gordon, DPM, a Naples podiatrist with Gulfcoast Foot & Ankle Center, created the program after hearing of the difficult times his patients’ children and grandchildren were having with increased expenses of a college education. During his 31-year career as a podiatric physician and surgeon, Dr. Gordon has treated many athletic and sports injuries and has become well aware that lower extremity injuries are all too common in high school sports.

Gordon recruited his bank, Bank of Florida - Southwest and hospital Physicians Regional Medical Center to jointly pledge three $2,500 scholarships for student athletes. “It is a pleasure to recognize these student athletes for their hard work and accomplishments both in the classroom and on the field, court, pool or track,” said Dr. Gordon.

Source: NaplesNews.com [3/7/10]

VA Podiatrist Runs Medical-Supply Firm

As a practicing podiatrist, Dr. Dodd Marshall Levy found that many of his diabetic patients were unaware of the Medicare benefit providing coverage for shoes designed for diabetics. He also discovered it was difficult to find companies that provided the shoes. In 2004, seven years after retiring from his practice, he started Diamedix Healthcare, now CarePoint Medical, specializing in providing shoes that fit properly to diabetics, who can have issues with their feet, such as poor circulation and numbness.

Dr. Dodd Marshall Levy (Photo: Mark Gormus)

The company's shoe division servicing diabetics uses 3-D scanning technology to build insoles for shoes. "The digital scanning technology is the most sophisticated way to capture the best impression of the foot," Levy said. Since its founding, the company has evolved into a health-care-products provider. CarePoint began expanding its product base in 2006, adding diabetes-testing supplies, arthritis products, orthopedic bracing, home assistive aids and power mobility equipment. Its newest offerings include specialty products, such as bone stimulators and continuing passive-motion devices, for the repair of certain types of fractures that become delayed in healing.

Source: Joan Tupponce, Richmond Times Dispatch [3/8/10]

Editor's Note: PM News is proud to present excerpts from Meet the Masters.

Bret Ribotsky: What’s your take on claims that fitness shoes help you lose weight?

Dr. Kevin Kirby

Kevin Kirby:  I think this is a very deceptive advertisement in that regard. This is the year of advertisement and hype. Companies are making these claims that are not supported by any real research that can be validated. When people pick it up and the newspapers pick it up, and say it over and over again, pretty soon we have something that people believe, even though it is based on company research, though they really have not done good research.

Dr. Frank Kase

Meet the Masters is broadcast each Tuesday Night at 9 PM (EST). This week's show features  Dr. Frank Kase, former president of the California Podiatric Medical Association. You can register for this event by clicking here

Query: Topical Tolnaftate for Onychomycosis

What clinical experiences have PM News readers had with the topical tolnaftate preparation (Formula 3) for treating onychomycosis?

Mark K. Johnson DPM, West Plains, MO

Query: Home Visit: Box 32 CMS 1500 Claim

I am having trouble with Medicare paying for home visits. I am using Place of Service "12." I am curious what I am supposed to have in Box 32 (Service Facility Location Information) at the bottom of the claim form. Previously, I was told to type "HOME," which I have done, but I keep getting denied. When seeing a patient in their home, what needs to be in Box 32?

Kimberlee Colaluce, St. Petersburg, FL

Response: Place of Service "12" is correct, but you need to leave Box 32 of the CMS 1500 claim form blank. If you put in the patient's home address in Box 32 when the instructions specifically say not to, that may kick out the claim, denying the services.

Tony Poggio, DPM, Alameda, CA

Codingline subscription information can be found at:
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RE: Post-op Numbness Status Post EPF (Neal Kramer, DPM)
From: Multiple Respondents

Although we do not use endoscopic plantar fasciotomy (EPF) as a procedure for chronic plantar fasciitis, we have seen over 20 cases of numbness on the plantar surface of the foot following this procedure. Now, allow me to make this clear that these 20 cases are over a period of 15 years and most, at a time when the "learning curve" was still being learned! I believe that the problem is that the incision appears to have been made a little too distal on the medial side of the foot. However, perhaps Stephen Barrett, DPM (the inventor of EPF) will log in and render his expert opinion of over 1,000 cases.

The good news is that although it is a little frightening early in the post-op, our experience has been that the condition becomes tolerable or goes away in about 4-6 months after the procedure. The only real complication was on one patient, 13 years ago, who had an EPF and then numbness and the podiatric surgeon attempted to operate again to repair the nerve. It got worse and I referred it out to a peripheral neurosurgeon who thought it too risky to try again. I am sure that the case was never litigated since I would have been asked for my records. My opinion is: wait it out  as it could just be edema causing the symptoms. Do not treat with injections, etc, since that will just irritate the problem at this juncture.

Lowell Scott Weil, Sr., DPM, Des Plaines, IL, weil4feet@aol.com

It is apparent that the nerve was nicked during the surgery, and while it was trying to repair, developed a neuroma in continuity. Steroids are not what you want to be injecting around nerves, if possible, because while reducing scar and inflammation, they have long-term deleterious effects. The only thing you can do at this point is wait six months and try some palliative treatments such as acupuncture or E-stim or any other therapy to limit pain.

The nerve has to "settle" down and hopefully repair itself. It may not, and Wallerian degeneration may continue. Let the patient know about this complication, and that you need to wait six months to see if it will repair itself to some degree. It is likely the numbness will be permanent so education on this is important. If after six months it is not better, it will likely need to be excised and replanted or grafted. Refer her to a peripheral nerve specialist. 

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

This is a tough problem! Since the problem began only several weeks after the surgery, one must assume that there was minimal to no physical injury to the nerve during the procedure. This could only happen if you performed the surgery somewhat distal to the routinely described location or you missed the original diagnosis. I have had a couple of medial cal nerve entrapments that fooled me. Maybe you had a lateral plantar nerve entrapment or  a tarsal tunnel-like situation before surgery?

If you think, that clinically, this is scar tissue at the surgical site, I would try to use an ultrasound to localize the scar tissue and try a very carefully ultrasound-guided perineural injection. In most cases of neurapraxia  Dr. Time does much more than Dr. Sullivan. I would treat the neurological pain with whatever I was comfortable with from tricyclics to narcotics, and be very upfront with the patient about your thoughts and reasons for your actions. You can always send for a second opinion to another podiatrist who might have been around longer or who is familiar with neurolytic techniques. A neurologist might have some ideas or reassurances, or even a good pain management specialist could offer a different perspective in management.

Tip Sullivan, DPM, Jackson, MS, tsdefeet@msfootcenter.net

RE: Defeat of Podiatry in NJ Diagnostic Ultrasound Case (Henry Slomowitz, DPM)
From: Multiple Respondents

Dr. Slomowitz has quite simply and clearly stated the results of either ignorant or blinded representative(s) negotiating a compromise with an insurance company. To "give up" the ability to be paid for using an acquired skill that is a 100% safe and accurate method of diagnosing soft tissue pathology is a crime! I have personally diagnosed 3 sarcomas (that were then confirmed with MRI). These lesions could have easily been treated as a "ganglion cyst" had I not imaged these swellings. As one that continues to educate podiatric students and podiatric physicians on diagnostic ultrasound for many years. I am appalled.

Remember that Medicare considers podiatrists as "physicians."  Consider that the sonographers training (a 2-year course) includes anatomy, physiology, pathology, physics, and "hands-on" imaging of a number of protocols (abdominal, OB, cardiac, renal, thyroid, vascular, etc). They are deemed qualified to acquire images to be read by a physician.  It should be obvious that we have had those courses and need to learn some ultrasound physics and "buttonology."  For those podiatrists that have studied and have acquired these skills, it is clear that diagnostic ultrasound has provided an invaluable service to our patients along with helping the bottom line.

Many patients have benefited from our ability to image them in real-time. They appreciate that they do not have to be subjected to an MRI, know that ultrasound is safe, and 1/10 the cost (no-brainer for insurance companies). They love seeing in real-time, on the screen that they have a plantar fasciitis instead of a plantar fascia tear. They are comfortable knowing that their Achilles tendon is not torn but just inflamed and that they really have a neuroma and not some other type of tumor. It is TIME for a board certification in diagnostic ultrasound of the foot and ankle. 

Martin E. Wendelken, DPM, RN, Elmwood Park, NJ, drmew@optonline.net

The bigger picture in this case is not that we won back something but that an insurance company has taken a privilege away from us that the New Jersey Board of Medical Examiners has licensed us to perform.  This is a very bad precedent and needs to be appealed. Since when does an insurance company delineate what we can and cannot do? Cigna and Healthnet already do this by not allowing ultrasound.  This is a problem APMA needs to help fight not just NJPMS, because otherwise, we are going to be cut out across the country.
 
Eugene A. Batelli, DPM, Clifton, NJ, eabdpm@gmail.com

Wow! What a dangerous precedent. How is it possible for any insurance company to re-define our licensure? I am having an issue now with Blue Shield. They are telling me that they no longer pay podiatrists for any type of physical therapy; only physical therapists may bill PT codes. Can some lawyer out there please explain the legal ramifications of this practice by insurance companies? Soon they will say that only orthopedists are entitled to bill for foot surgery.

Bob Kornfeld, DPM, Manhasset, NY, Holfoot153@aol.com

RE: The Future of DME in Podiatry (Narmo L. Ortiz, Jr., DPM)
From: Lawrence M. Rubin, DPM

Dr. Ortiz’s fear that there may be a trend for insurance companies to channel patients away from podiatrists to a limited number of contracted DME, orthotic, and prosthetic supply companies is justified. Considering today’s health insurance reform climate, it is reasonable to expect this patient-channeling trend to go beyond DME, orthotics, and prosthetics. In addition to limiting patient access to suppliers, payers are expected to go full-speed-ahead in negotiating exclusive contracts for medical services with physician-organized, multispecialty and single-specialty provider networks. These physician-driven networks are attractive to insurers, because, with one contract, the insurer can acquire an area-wide network of credentialed providers who have developed and offer a complete cost savings and quality assurance program. Entrepreneurial podiatrists can form a foot care specialty network. When the do, they can successfully gain exclusive contracts with insurers. 

Patients are channeled to the foot care network because they are penalized with higher co-pays and/or deductibles, or, in some cases, will have no coverage if they see a non-network provider. Unlike large “open” PPO’s operated by insurers, such as the Blues, these physician-driven “closed” specialty networks include just enough geographically dispersed practice locations necessary to handle the contracted patient volume. This is a great situation if you are in a foot care network that has contracted for a decent payment schedule from a major payer – but, not a good situation if are not in that network and lose patients to a doctor who is. There are presently some successful podiatry networks securing exclusive contracts. I imagine that as the benefits of being part of a foot care network become more apparent, more will form.

Lawrence M. Rubin, DPM, Las Vegas, NV, lrubindoc@aol.com

RE: Laser Holds Hope for Treating Onychomycosis: (Lowell Weil, Sr., DPM)
From: Marc Katz, DPM, Bryan C. Markinson, DPM

I think you will find that lasers are effective at killing fungus; however, the word "cure" will likely not be an outcome. I believe that podiatrists who use the word "cure" in relation to laser onchomycosis treatment are misleading the public. Patients should be told that laser is a treatment that will kill fungus but there can still be infection remaining or recurrence. They will likely need additional treatments in the future and maintenance measures will need to be in place to keep the infection in check. Saying that this is a cure just sets up the patient for failure.

We will look forward to Dr. Weil’s study results.

Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com

I have been working with a new laser technology company for the past four years as an advisor to Nomir medical, makers of the Noveon Laser. Dr. Weil's comment that "there have been NO evidenced-based studies to prove that lasers are effective" is not entirely accurate. The study commissioned by Nomir that has been submitted to the FDA is about to be published. I can tell you that efficacy is not the issue. Whether ablative or not, (Noveon is not ablative), these technologies are efficacious, not only in clinical but also in mycological cure.

The problem, is that for some reason, podiatrists do not accept recurrent onychomycosis similarly to recurrent cellulitis, recurrent paronychia, or recurrent any other kind of infection. We have to be very careful what we mean by "cure." The FDA's definition is set in stone and unmoveable. It includes clinical and mycological cure and there is no sign that they will relent on this. But having a laser accomplish this is a small part of the story. Onychomycosis is an infection. The organism is ubiquitous. Susceptibility is proven to be genetically host-dependent. There are infinite ways that one can get re-infected. So when Dr. Weil states that he is a skeptic, he will remain so if his definition of cure is what all other DPMs' definition seems to be: Clinical and mycological cure FOREVER with no further treatment.

This, in my view, is an unreasonable expectation, which is supported by current science. Just as an aside, dermatologists largely ask for the same thing, "does the laser work and is the patient cured FOREVER?" I have never understood why treatment for onychomycosis demands total and permanent cure, while everyone accepts recurrent ear, nose, throat, and sinus infections, but do not classify the antibiotics used for them as anything but efficacious. Peculiar.

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

RE: $1,475,000 Settlement for MD's Failure to Diagnose Charcot Foot
From: Michael M. Rosenblatt, DPM

There are certainly co-morbidities associated with severe adult-onset insensate diabetes, which range from kidney disease, blindness, and severe generalized arteriosclerosis to of course amputation. For a patient “a diagnosis” is not just a name. It represents a description of what they have to face in the future. The issue of patients getting a correct diagnosis is tied into what can or cannot be done for them, and what they might have to expect.

A certain percentage of patients with Charcot foot and ankle disease will succumb to amputation (and early death), no matter when the diagnosis was made. But patients have a right to hear both good and bad news, and so do their families. A patient and family might decide to plan a wedding, retirement celebration, vacation or other event based upon a diagnosis. We tend to “automatically assume” that such bad news “always” comes in the form of cancer. But important medical information (in the shape of a diagnosis), has real value to us all. Missing a diagnosis of Charcot foot is a significant error.  The patient may or may not lose the leg no matter when the diagnosis was made. But there is a huge qualitative difference between a “swollen” ankle and a weight-bearing bone and joint structure which is literally disintegrating.

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

ASSOCIATE POSITION (PART–TIME) WHITE PLAINS, NY

Part-time associate wanted for busy 22 year old White Plains office. Call 914-325-9198 for further details.

PRACTICE FOR SALE - FLORIDA CENTRAL/SOUTH

Turn-key operation grossing $570,000 annually based on one full-time doctor. Great opportunity for growing the top-line. Surgery is only 14% of the professional man-hours; it can significantly increase income. Medicare makes up 64% of revenues. Seller will assist with transition. Call 863-688-1725, ask for Chas.

PRACTICE FOR SALE – CONNECTICUT

Outstanding practice for sale in northern Fairfield county, CT. Shared space with other medical professionals. Very low overhead. Grossing almost $300K on 30 hours per week. Referrals from three different primary care physician offices. If interested e-mail CTPodiatry@gmail.com

FULL-TIME PODIATRY OPPORTUNITY -  BOSTON, MA

HealthDrive is seeking a caring podiatrist to join our group practice. We currently have a FT non-surgical opportunity available in the Boston, MA area. We offer a competitive salary, Paid malpractice Insurance, health and dental Insurance, long & short term disability, flexible schedule (No weekends), established patient base, equipment, supplies and complete office support provided. If interested in this opportunity, please call Maria Kelleher (toll free) at 877-724-4410 or email caring@healthdrive.com
  
OFFICE SPACE TO SHARE - NYC

Wanted- Licensed podiatrist to share space in a State-Of-The-Art medical office in the midtown area. Please call Dr. Robert Singer (212) 921-5775 or e-mail dr.roberth.singer62@netzero.net

ASSOCIATE POSITION - TAMPA BAY

Associate needed for a dynamic multi-doctor practice in the Tampa Bay area. Preference given to a PSR 24+ training and must have a Florida license. Well-established practice, high-tech with EMR and digital x-rays, with specialties in sports medicine, surgery and wound care. No nursing homes or HMOs. Excellent hospital privileges available. Choose an area of practice concentration that you are passionate about and enjoy a lifestyle for yourself and your family second to none. Kindly forward C.V. to e-mail drcosentino@tampabay.rr.com

ASSOCIATE POSITION - DAYTONA BEACH, FLORIDA

Associate position with buy-in potential. Daytona Beach, Florida Great opportunity for PSR 24-36.trained physician to join state-of-the-art practice. Please forward resume to pfk4@yahoo.com

ASSOCIATE POSITION-INLAND EMPIRE, SOUTHERN CALIFORNIA

Associate needed full or part-time for multi office practice. Must be ABPS BC/BQ. Hard working, ethical individual who is looking to a possible partnership opportunity. Looking for current licensed or resident completing program this spring. Email CV to bkatzman2@earthlink.net or call Martha 909 984-5614.

ASSOCIATE POSITION - TEXAS

Dynamic, growing practice in Dallas/Fort Worth area, seeking surgically trained, Board Certified/Board Qualified Podiatrist. Excellent salary and benefits compensation package, for the right candidate, with partnership/buyout opportunity. Contact/Send resume to: jmh6122@yahoo.com

PRACTICE FOR SALE: TENNESSEE

Established 30-year full-scope podiatry practice. Excellent hospital and surgery center privileges with investment opportunities. Fully equipped 2200 sq.ft. office across from hospital. High volume of new patients, DME, and local referral base. Great community for a family and the outdoorsman. Reply to tnfootdr@gmail.com

ASSOCIATE POSITION - NORTHERN VIRGINIA/DC SUBURB

Excellent associate practice opportunity leading to partnership for PSR 24-36 foot and ankle surgically-trained physician. Currently 4-doctor/2 office practice in fast-growing area, expanding to 5 doctors. Hard working, personable, highly-motivated individuals needed. Great opportunity with excellent salary and benefits. No nursing homes. Top hospitals. Fax CV with references to 703-491-9994

ASSOCIATE POSITION - MICHIGAN - (OAKLAND COUNTY)

outstanding opportunity for associate in well established practice, general & surgical podiatry forefoot, rearfoot & ankle (full or part-time). Well-trained, responsible, motivated with good communication skills, ABPS qualified or better. Send CV & letter of interest to: PodiatristWanted@AOL.COM

PM News Classified Ads Reach over 12,000 DPM's and Students

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