The Voice of Podiatrists

Serving Over 10,800 Podiatrists Daily

March 25, 2008 #3,202 Editor-Barry Block, DPM, JD

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ESWT Introduced in Air Force Podiatric Surgery

Medical specialists in the 59th Orthopedic and Rehabilitation Squadron at Wilford Hall Medical Center here are introducing a new procedure in the podiatric surgery department. The procedure, Extracorporeal Shock Wave Therapy, or ESWT, is a form of treatment for chronic plantar fasciitis.

Dr. Hjalmar Contreras

According to Capt. Hjalmar Contreras, chief of podiatric surgery at Wilford Hall, severe heel pain is the number one complaint in podiatry. The new non-invasive procedure cuts recovery time by 70 percent and replaces the previous surgical method, which required an incision to be made in the heel and a portion of the fascia to be removed or cut. The previous procedure involved a recovery time of approximately three months, and the surgery involved a risk of a non-healing wound, nerve injury, infection, bleeding and the destabilization of the foot.

Captain Contreras, who was certified to perform the procedure in the civilian sector in 2001, emphasizes the convenience of the new method, because of the rapid healing time. "As the Air Force continues to stress the importance of physical fitness, it is vital to implement the latest procedures with minimal healing time requirements," said Captain Contreras. "Keeping airmen mission-ready is our main concern."

Source: Erin M. Peterson, Air Force Link [3/21/08]

Barry Students Continue Holy Week Tradition of Treating Homeless

Students from Barry University's School of Podiatric Medicine were on hand -- or feet -- to honor the spirit of Holy Week Friday during an event called "Thanksgiving in March" at the Miami Rescue Mission. Congregation members from Granada Presbyterian Church washed the feet of those who came in -- some homeless, some low-income, some just neighborhood residents -- with dish soap and sponges.

Barry Students Attend the Homeless

The podiatry students took over, tending to their feet, sanding down nails, buffering off calluses, and treating foot fungi with iodine. The event provides an opportunity for those who couldn't ordinarily receive podiatric medical care. "A lot of the people we see have undiagnosed diseases like hypertension and diabetes," said Diana Rogers, a fourth-year student. "What we see the most of are toenails that are not cut and the nails curve under the skin and bacteria and fungus cut into the skin." Some of the patients had toenails up to five inches long.

The 15 students get experience and they also get volunteer hours they can use toward externships. Five licensed podiatrists were also there. Those who had their feet washed and treated got free socks and sneakers. The sneakers were donated by local shoe businesses.

Source: Erika Beras, Miami Herald [3/21/08]

April Deadline Looms For Tamper-Proof Rx Pads

Most physicians are prepared to meet the April 1 federal deadline for writing many Medicaid prescriptions on tamper-resistant pads, according to medical, pharmacist and other organizations. But these groups continue to reach out to doctors who may be unaware of, or confused about, the law.

By April, written Medicaid prescriptions must have at least one feature to prevent unauthorized copying, erasure or modification, or counterfeiting. Written prescriptions must have a feature from all three categories by Oct. 1. The law, adopted by Congress as part of a military spending act in May 2007, does not apply to electronic, faxed or phoned prescriptions, or those paid for by Medicaid managed care organizations, according to the Centers for Medicare & Medicaid Services.

Physicians looking for information about the law, such as where to purchase prescription pads, are encouraged to contact their state Medicaid agencies or their medical societies. They also can visit a National Assn. of State Medicaid Directors Webpage dedicated to the issue (www.nasmd.org/issues/trpp.asp).

Source: Doug Trapp, AMNews [3/24/08]

Query: Chronic Severe Pain Left Hallux

My patient has intermittent, random firing pain to the left great toe. The pain occurs proximal to the interphalangeal joint and lateral to EHL tendon and occasionally at the end of the toe. Physical exam findings are normal. The pain began in 1991 after hiking with boots that were rigid and tight to the toes. X-rays and EMG’s are normal. MRI suggested a small mass of tissue which was removed in 1994 and was found to be fat deposit.

Pain increased after surgery and the patient was thought to have RSDS for which the patient saw pain control specialists and received sympathetic nerve blocks (Bier blocks) and physical therapy. Neurontin and Effexor XR were tried and helped decrease the firing pain but the patient couldn’t tolerate the side-effects. Nerve blocks to the toe help. Clonidine helped slightly. Lidocaine patch wasn’t effective. The patient now asks if chemical neurolysis or surgery to remove the nerve would help.

Bruce Krell, DPM, Chandler, AZ

RE: Squamous Cell Carcinoma (Austin Reeves, DPM)
From: Bryan Markinson, DPM

Dr. Reeves reports that he performed an "excisional" biopsy on a lesion of a nail bed on a 32 year old male which was signed out by the pathologist as squamous carcinoma, recommending complete excision. Either the procedure was NOT an excision, or the clinically visible lesion that Dr. Reeves thought he was excising extended beyond the margins of resection. Both are possible, but the distinction is important.

In most cases like this, an incisional biopsy is done and definitive treatment is dictated by the results. Perhaps Dr. Reeves meant to say "incisional." In any case, the definitive surgery for the lesion ranges from Moh's microsurgery to amputation. An MRI should be done to further elucidate the extent of the tumor. A dermatopathologist should review the tissue and give a statement as to the aggressiveness or grade of the malignancy.

Although I am partial to amputation, Moh's surgery may be a great option for this young patient. This technique spares tissue while excising with very reliable margins. It is performed by a dermatologic surgeon who is also a certified dermatopathologist. The lesion is removed in small increments with histology done on the spot until resected sections are free of tumor. I have seen very cosmetically acceptable results on nail unit lesions of SCC. This technique has been highlighted for the past two years at the annual scientific meeting of the Council for Nail Disorders.

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

RE: ACFAS / APMA Membership Vote
From: Multiple Respondents

Dr. Kanat is right on point. The ACFAS sends ballots out on every unimportant issue imaginable and then makes an “executive” decision to drop continuing membership in the APMA as a requirement for membership in the ACFAS. It was only after a large number of ACFAS members criticized the ACFAS “leadership” on this issue that a decision was made to hold a vote. Everyone concerned about the future of podiatric medicine should protest this nonsense. The ACFAS “leadership” even had the gall to state the decision was partially driven by financial hardship on the part of board-certified foot and ankle surgeons. This is monumental B.S.

David Mullens, DPM, Palo Alto, CA, dmullens@mullenslawoffice.com

I found it interesting to note that it only took a few members of the ACFAS Board to initiate and pass the rules change to disenfranchise ACFAS from APMA, but it will now take a 2/3 majority vote of the membership to alter that change.

Charles F. Ross, DPM, Pittsfield, MA,cross12@nycap.rr.com

For many of us, the reason for supporting the divestiture of ACFAS and APMA is purely financial. No hidden agenda of "self-anointed superiority." I also have no time for "internal squabbling, political positioning, inflated egos and hurt feelings." I just have to figure out who gets a check at the end of the month and who does not. Podiatry has been good to me and my family for almost 27 years. Dr. Kanat and my education at Kern have been an integral & important part, and I remain thankful. I have a sense of history and understand the importance of a single, unified representation of our profession. But, I also see a steady decline in my income each year thanks to capitated podiatry programs in Southeastern PA, despite the fact that I am busier than ever seeing patients.

Managed care has created a horrific state of affairs for our profession in many areas of this country. Many of us are having a hard time making ends meet with crushing overhead expenses and ever-diminishing payments. Something has to give. Although I respect the work of the APMA, it is an expense that I cannot afford for myself and the other doctors in my practice at this time. My membership in ACFAS and my ABPS certification must be maintained for my insurance panel participation. Given the financial constraints, the choice is obvious.

If ACFAS chooses not to require APMA membership, they are not preventing their members from remaining APMA members. In fact, they should encourage them to do so if it is financially feasible. It should be a choice, however, not a mandate. I have no blinders about the history of podiatry, but Dr. Kanat and others should also have no blinders about the financial crisis that exists in many parts of this country for otherwise successful members of our profession.

Greg Caringi, DPM, Lansdale, PA, DrGregC@msn.com

RE: Outside Payroll Services (Bob Levoy)
From: Multiple Respondents

We have been using ASC payroll (212-684-0800) for over 10 years and they have been great. They are efficient and cost-effective. They take care of all payroll taxes and tax filings so you never have a compliance problem.

Steven Abramow, NY, NY, ManhatPod@aol.com

I have used Quickbooks for my bookkeeping software program for years. Just started using their payroll service and I have been very happy. It will save me money in the long run on accounting fees.

Bill Lockner DPM, Minneapolis, MN, billlockner@yahoo.com

We have used Paycycle.com for years. They walk you through the initial set-up process step by step, send email reminders for various payments as needed, send everything electronically and have had terrific, fast, response, courteous (live or via e-mail) help when it was needed. Reporting is complete and the price is very reasonable.

Alan Kalker, DPM, Middleton, WI, ajkalker@facstaff.wisc.edu

RE: PM Hall of Fame Honorable Mention List
From: Bob Levoy

My thanks to those who nominated me for the Annual Podiatry Management Lifetime Achievement Award. I am highly flattered to be included with so many of my heroes. . . and those who done so much for the profession.

Bob Levoy, Great Neck, NY, b.levoy@att.net

RE: Value of APMA Membership (Bruce N. Block, DPM, Michael A. Conway, DPM)
From: Bryan C. Markinson, DPM

The benefits of and need for APMA membership are abundantly clear. Almost all arguments for NOT being a member are anemic, except one, and that is affordability. There are probably more practitioners embarrassed to say they can't afford almost $2,000 per year than there are who won't be members just out of principle. In proportion, those who are staunch critics of non-members are largely oblivious to this as a reason, stating that they are struggling as well. It is a matter of priorities, one would argue. However, the cold, hard facts are that some cannot afford it, period.

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

ASSOCIATE POSITION - CHANDLER/GILBERT/PHOENIX, AZ

Multi-location office and soon to start a wound care office in a local hospital. Seeking a well-trained graduate of a PSR 24+/36 Residency. This is a practice with a nice mix of 35% surgery/trauma, 20% diabetic/wounds, 25% biomechanics, 20% pediatric. ER Call for 2 hospitals. Opportunity for partnership at 2 surgery centers. Very modern office with EMR, U/S, Digital X-Ray, Vascular Testing /Nerve Testing Machines and our own ESWT. Excellent referral base, and a well-trained certified staff. Board eligible/certified a plus. Competitive salary, bonus structure, benefits. Please e-mail CV and references to main@footanklespecialtycenters.com

ASSOCIATE POSITION – CONNECTICUT

Connecticut Surgical Group, one of the largest multi-specialty surgical group practices in New England, is seeking a Podiatrist to add to our three-physician Podiatry division based in Hartford. Provide all aspects of Podiatric care with a focus on wound and surgical care to a well-established patient base. PSR-36 training and board certification or eligibility and excellent surgical and wound care skills required. We offer competitive salary and productivity bonus, partnership opportunities, excellent benefits, and reasonable overhead. Apply online at https://home.eease.com/recruit/?id=21426 or via our website or fax your CV to 860-524-2653. No phone calls. EOE

ASSOCIATE POSITION NYC AND STATEN ISLAND

Associate needed for NYC and Staten Island. Spanish speaking a plus. Must have 2 years training . Growing practice with possibility of partnership. Please Send CV to Staff@nynjfoot.com

PRACTICE FOR SALE - BUFFALO'S KENSINGTON SECTION

Established satellite practice. In urban metropolitan area on a busy commercial street corner - commercial building with an attached retail store that allows easy advertising of the podiatric medical practice. Gross $170K+ at 2 ½ day per week. Great potential for growth. 260 402-7490

PRACTICE FOR SALE - EASTERN WASHINGTON

Established practice located in the fastest-growing city in the state of Washington. Enjoy the lifestyle available in the area. Practice is directly across the street from the hospital - surgery center located within the hospital, and podiatric surgical privileges are not restricted. Gross $200K+ at 4 days per week. Can easily grow. 260 402-7490

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

PART TIME PRACTICE W/ PROPERTY FOR SALE, BLOOMFIELD, NJ

Very busy 3 days/week. All modern equipment including digital x-ray and recently remodeled office suite. Office over 1300sf with 3 treatment rooms, large consultation room and second private office suite with full bathroom. Located in a professional building with plenty of parking on a main road. Bus stop in front. 2 blocks off Garden State Parkway. Please contact doccapo@yahoo.com

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