The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

March 11, 2010 #3,801 Publisher-Barry Block, DPM, JD

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We've just mailed the March 2010 issue of Podiatry Management. This month's Cover story is titled "Is it Your Time for Group Practice?  In addition, you'll  find our usual assortment of features, including our columns, and a CPME-approved CME.

March 2010 Podiatry Management

MI Podiatrist Uses Low-Level Laser Therapy

Dr. Aaron Rives wants to stay a step above the rest when it comes to finding new ways to treat his patients. The podiatrist often uses new technology in his practice as a way of improving the lives of his patients without surgery, needles, or analgesics.

Dr. Aaron Rives (Photo: E.L. Conley)

About four months ago, he added low-level laser therapy. The new technology can be used for the treatment of soft tissue and joint pain such as arthritis, plantar fasciitis, heel pain, all levels of wounds and ulcers, and neuropathy.

“The therapy is light energy that penetrates through the skin and affects the mitochondria, which is the engine of each cell, such as a skin cell, nerve cell or muscle cell,” Rives said, adding that the procedure uses selected wavelengths of light and delivers them deep into tissues. The lasers are able to penetrate into tissues, causing no damage to cells.

Source: Lisa Vidaurri-Bowling, Southgate News Herald [3/9/10]

Scholl College’s CLEAR Research Unit Produces “Off-Loading” Video

The Center for Lower Extremity and Ambulatory Research (CLEAR) at the Dr. William M. Scholl College of Podiatric Medicine has produced a DVD presentation that shows viewers the medical reasons and the benefits of using “off-loading” footwear.

CLEAR Off-loading Video

The video is designed to increase patient adherence with off-loading footwear by educating persons about its necessity. Unfortunately, many of these patients have lost the “gift” of pain, and they can’t feel the further damage they are inflicting with unprotected steps. Research has shown that these patients only wear their off-loading footwear 28% of the time. 
 
Dr. James Wrobel, DPM, MS, Acting Director of CLEAR, first devised this educational tool several years ago. He then recruited CLEAR faculty, researchers and staff, including Stephanie Wu, DPM; Bijan Najafi, PhD; Ryan Crews, MS, Nancy Sloane-Rivera, MS, APN, NP-C, CWON; and Sarah Woodward, to produce the DVD project.

APMWA Announces 24th Annual Student Writing Competition

The American Podiatric Medical Writers Association has announced its 23rd Annual Student Writing Competition.

• All papers MUST be non-technical in nature. Appropriate subjects include practice management, ethics,or any topic that would be suitable for a lay publication.
• There is no word limitation. Papers will be graded for content, style, grammar, neatness, and overall impact.
• First prize will be one thousand dollars ($1,000.00) and recognition in the APMA NEWS and the APMWA Newsletter. Honorable Mention Certificates may also be awarded.
• This competition is open to ANY enrolled podiatric student.
• Entries must be received by 4/1/10 via e-mail at bblock@podiatrym.com
• Entries become the property of APMWA, which may arrange publication of the entry.

AZ Podiatrist Hosts PBS Diabetes Event

Diabetes and the amputation epidemic were front and center yesterday during PBS's annual pledge drive. To match a program on "Taking Control of Diabetes" led by Dr. Neal Bernard, KUAT, the Arizona PBS affiliate, invited David G. Armstrong, Professor of Surgery and Director of the Southern Arizona Limb Salvage Alliance (SALSA) at the University of Arizona, to host the evening's event.

Dr. David Armstrong on the set of PBS affiliate KUAT studios

"It was a privilege to participate in this program that supports PBS, which is a jewel to our nation in general, and our community specifically." noted Armstrong. The two-hour program was held Monday at KUAT/PBS studios on the campus of the University of Arizona.

Query: Eclinicalworks EMR

Does anybody have any experience using Eclinicalworks EMR?

Robert Bondi, DPM, Lee’s Summit, MO

RE: Topical Tolnaftate for Onychomycosis (Mark K. Johnson DPM)
From: Multiple Respondents

I have had great luck with this product. My patients seem to be improving, are compliant, and are impressed with the results. Most are willing to try due it due to the relatively low cost, good efficacy, and potential for reimbursement. I like the product a lot. The company has backed its promises and always has product available for distribution.

(Comments made here are in no way reflective of an opinion of APMA or its affiliates but are made solely from a practitioner's point of view. I have no financial or vested interest in the product or the company.)

Michael King, DPM, Fall River, MA, MJKing@apma.org

I have been using topical Formula 3 for about one year now.  I confess that I was probably one of the most skeptical of providers, and was a firm believer that the oral delivery was the only way to be effective. Since we started with Formula 3 in our office, we have taken close-up digital images of the involved nails, for documentation purposes, and to be less subjective. There is no question that we have seen very favorable results. I would estimate a 80–90% success rate.

With all that being said, outside of a few pre-treatment biopsies, this is in no way a formal “clinical, mycological cure” study, but rather just pure clinical observation. The bottom line is that the improvement is visibly significant, and the patient satisfaction rate is very high.

I would note that I am amazed on a daily basis how many patients voice their frustration over nail care not being covered by Medicare, but would gladly pay out of their own pocket for a topical medication that they must use twice a day for 180 days.  Their motivation towards a “cure” is much greater than their motivation for periodic nail debridements.

Robert Colligan, DPM, Norfolk, NE, rcolligan@MidwestHealthPartners.com

I have been using Formula 3 in our office for one year. At our state conference, for years, I have seen companies come and go who promote their product as the best. I practice in a small community and stand by my products. I was hesitant at first, and tried it out on 6 reliable patients who agreed to be guinea pigs.  We took before and after photos. My staff and I were actually shocked at the results. They surpassed our expectations for a topical product. Now, we can't keep it on the shelf. When we sell the product, we tell the patient of the money-back guarantee. During the past year, one patient did call the company and received a check promptly and hassle-free. 

Olga Luepschen, DPM, Sebring, FL, feetdoctor@hotmail.com

RE: Post-op Numbness Status Post EPF (Neal Kramer, DPM)
From: Multiple Respondents

I would advise "Tincture of Time" for this patient. In addition, she needs to be examined for cuboid subluxation syndrome, as plantar fasciotomy can lead to a temporary lateral column instability. Treatment would include manipulation, an elastic foot-ankle support and orthotics. I prefer a custom-molded rubber butter orthosis, along with soft, supportive shoes.

Stanton C. Southward, DPM, Colorado Springs, CO, sbsouthie@comcast.net

The most likely cause of the sudden onset of lateral plantar neuritis after partial plantar fasciotomy is compression on that nerve by the abductor hallucis muscle. Partial plantar fasciotomies involve transection of the medial half of the plantar fascia, which is an important stabilizer of the medial longitudinal arch. Transection of the medial plantar fascia has the potential to cause increased contractile activity of the abductor hallucis muscle which shares many of the same functions as the plantar fascia in maintaining medial column stability (Kirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona, 1997, p. 46). 

Increased contractile activity of the abductor hallucis muscle will increase the volume of the abductor hallucis muscle during weight-bearing activities which may, over time, cause a compression of the lateral plantar nerve within the porta pedis. Even though I have never seen lateral plantar neuritis develop after partial plantar fasciotomy, I have seen a number of patients who complain of abductor hallucis muscle pain after the procedure.
 
Treatment of these patients with custom foot orthoses that prevent significant arch collapse during weight-bearing activities would be the most reasonable therapeutic option for this patient. I co-authored a paper in the American Journal of Sports Medicine 18 years ago which detailed a power lifter who had identical symptoms and nerve conduction study findings as Dr. Kramer’s patient. I treated the athlete with custom foot orthoses, and he had complete resolution of his neuritic symptoms and a normalization of his nerve conduction velocities seven weeks following treatment with orthoses (Johnson ER, Kirby KA, Lieberman JS: Lateral plantar nerve entrapment: Foot pain in a power lifter. Am J Sports Med, 20 (5):619-620, 1992).  
 
Kevin A. Kirby, DPM, Sacramento, CA, kevinakirby@comcast.net

Editor’s note: Douglas Pacaccio’s extended-length letter can be read here.

RE: Unscrupulous Billing of Routine Care
From: Dan Klein, DPM

Today, I had to justify routine foot care treatment, performed on an older patient, to an irate daughter, who stated that other doctors billed Medicare for the same service and they paid. I tried to explain that I could not be held responsible for what other podiatrists billed Medicare. The daughter suggested that I submit a claim with another code that would be approved. I then proceeded to state the integrity code of ethics guidelines.

Why is our profession still dishonest about the "routine foot care" codes and submitting false claims just to bring in money? As long as there are unscrupulous podiatrists out there, we will have to defend against them, and read about their sentences of jail time for insurance fraud. Sad state of affairs!
 
Dan Klein, DPM, Fort Smith, AR, TOEFIXER@aol.com

RE: Defeat of Podiatry in NJ Diagnostic Ultrasound Case (Henry Slomowitz, DPM)
From: Ben Pearl, DPM, Barry Mullen, DPM

I could not agree more with Dr. Slomowitz's well timed and spot on sentiments on the ultrasound situation in New Jersey. I am currently finishing an update article on this issue that will be featured in an upcoming issue of Podiatry Management. We must continue to publish in the literature on this topic and lobby to insurance carriers to demonstrate our capabilities in this emerging field .
 
Ben Pearl, DPM, Arlington, VA,  abenpearl@netscape.net

I echo my esteemed NJ colleague's responses to the recent "partial victory" NJPMS has claimed. How our state society's leadership has the gall to claim a "victory", when additional services podiatrists are licensed to perform are STILL being denied, is beyond OUTRAGEOUS! FYI- A similar scenario occurred some 15 years ago. I was so outraged by the results that I resigned from NJPMS (for 1 year) in protest. NJPM's legal counsel grossly misrepresented...

Editor’s Note: Dr. Barry Mullen’s extended-length letter can be read here.

RE: Laser Holds Hope for Treating Onychomycosis: (Lowell Weil, Sr., DPM)
From: Elliot Udell, DPM, Allen Mark Jacobs, DPM

Dr. Markinson is correct when he points out that doctors treat many conditions that often reoccur but these same physicians demand permanent cures when it comes to onychomycosis. The closest example is dermatophytosis. We all have some patients who develop seasonal attacks of tinea. I always tell my patients with tinea pedis to keep antifungals in the medicine chest so that they won't have to buy a new tube if and when the problem comes back. 

There is a key difference, however, with regard to laser treatment for onychomycosis, and this may be the root of why many practitioners are approaching it with skepticism. These devices are not covered by insurance plans and patients are being asked to shell out anywhere between a thousand dollars to fifteen hundred dollars for a treatment. In my socioeconomic area, patients want to know that by spending that kind of money in this kind of economy, the treatment will stand the test of time. It's not acceptable to most people living in my region to spend over a thousand dollars for a treatment that might not last.

Sure, there are some  people who will not flinch at spending thousands of dollars for a facial procedure knowing that the wrinkles will eventually return. My practice is not blessed with this population. If Nomir gets approved by insurance carriers, the tables would be turned, and I would have no problem offering it to every one of my patients suffering with mycotic nails. Such a  scenario would also allow for re-treatments, should the need arise.
 
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

The recurrence rates of onychomycosis following the utilization of terbinafine itraconazole, griseofulvin, and fluconazole, are all quite substantial, yet all are approved for treatment of onychomycosis. If you would like a real shock, check out the data for the ultimate cure rate of topical 8% ciclopirox, also approved for onychomycosis.
 
As noted by Dr. Markinson, a true authority in dermatologic disorders of the foot, the cause of such re-infection is multifactorial. The combination of debridement, topical therapy, and systemic therapy has been shown to be superior to oral therapy alone.
 
Some have suggested that disinfection of shoes, disgarding of infected socks, disinfection of home showers may be helpful in preventing re-infection. As is the case with certain currently utilized lasers, there is simply no good data to support this otherwise seemingly intuitive approach.
 
Lasers do not currently have FDA approval for treatment of onychomycosis, although the NOMIR laser data appears promising. Until proven otherwise, patients, who are paying out-of-pocket for such therapy, should be told that such therapy is unproven and is at best, investigational.
 
Allen Mark Jacobs, DPM, St. Louis, MO, allenthepod@sbcglobal.net

RE: Bad Toilet Leads to Loss of Leg  

Fix a toilet and you can lose your leg - in a most disgusting manner. That, at least, is the claim made by Houstonian Oscar Batres, who is suing his apartment complex because, he says, they would not fix his clogged toilet. "As plaintiff was in the process of unclogging the toilet, the water in the toilet commenced to overflow," Batres says in his complaint in Harris County Court.

Three days after his toilet overflowed, Batres cut himself while trimming his toenails in the bathroom. He used over-the-counter ointment on it, but his toe and part of his foot turned red, he developed a fever and flu-like symptoms, and went to the emergency room, he says. Tests showed that he had gangrene and his right leg was amputated below the knee. It was a little over 2 weeks since his toilet overflowed.

"The specimen taken at the hospital revealed the plaintiff's infection and eventual leg amputation was caused due to an infection caused by bacteria commonly found in feces," Batres says. The suit -- which asks for unspecified damages -- says that the apartment complex cleaned the rug two weeks after the amputation.

Source: Richard Connelly, Houston Press [3/9/10] via Dr. David Armstrong

RE: $1,475,000 Settlement for MD's Failure to Diagnose Charcot Foot
From: Allen Mark Jacobs, DPM

The commentary on the recent litigation in this matter is interesting, as I suspect almost no PM readers know the actual facts of this particular case, and whether the "missed" diagnosis was understandable.
 
A recent study from Loyola University published in Diabetes Care demonstrated the amputation rate associated with Charcot's joint disease to be only 2%. A previously published study demonstrated a 2.7% amputation rate. Many of us have cared for many patients with clunky, deformed feet from old burnt-out Charcot's foot deformity. Yes they get the intermittent ulcers, have to wear braces and bad looking shoes, but they still have their feet and are community ambulators. The diabetic patient with a Charcot's deformity is at no greater statistical risk for amputation than the diabetic patient without such deformity.
 
The specter of amputation arises when there is ulceration or severe deformity. The majority of Charcot's joint deformities do not result in pedal amputation, and the suggestion that all or most Charcot's joint deformities require surgical intervention is not supported by any good EBM.
 
Allen Mark Jacobs, DPM, St. Louis, MO, allenthepod@sbcglobal.net

ASSOCIATE POSITION - SAN FRANCISCO, CALIFORNIA

We’re seeking an energetic and enthusiastic Associate to help our thriving non-surgical practice grow. We provide state-of-the-art sports medicine, trauma and lower extremity care. Excellent compensation package. Visit  our website to apply.

HOME FOOT CARE PHYSICIAN NEEDED - LOS ANGELES, CALIFORNIA

Honest, caring, hard-working podiatrist needed to make visits to homebound patients, facilities, etc. for Home Foot Care, Inc. Part time position, flexible hours, independence and excellent compensation. If interested email CV to homefootcare@hotmail.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 (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

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

Whether you have used equipment to sell or our offering an associate position, PM News classified ads are the fastest, most-effective way of reaching over 12,000 DPM's. Write to bblock@podiatrym.com or call (718) 897-9700 for details. THIS OFFER DOES NOT APPLY TO BUSINESSES PROVIDING PRODUCTS OR SERVICES. Note: For commercial or display ads contact David Kagan at (800) 284-5451

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