The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

April 01, 2010 #3,820 Publisher-Barry Block, DPM, JD

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CA Podiatrist Disputes Claim That Flip-Flops Help Osteoarthritis of Knees  

Rush University researchers followed 31 people with osteoarthritis of the knees. They studied their gaits as they wore clogs, stability shoes, flip-flops, and even in their bare feet. They found people who wore the flip-flops had the least pressure on their knees. Dr. Joseph Ferrante, Huntington Hospital podiatrist, says this finding goes against everything he knows about foot mechanics. "Why would something that doesn't give you support and cushioning be good for the knees?" said Dr. Ferrante. "It allows more motion in the foot. It allows more motion on the tibia which is translated right up to the knee," said Dr. Ferrante.

Dr. Joseph Ferrante

"If you're walking barefoot on a hard surface and you do that for a prolonged period of time, you would think that would be more painful for the knee." But foot experts believe future research will change what is being said today. They say that thong slippers should only be worn for short periods of time. "Just wear it when you don't have a lot of walking to do," said Dr. Ferrante.

Source: Denise Dador, KABC [3/29/10]

Barefoot Trend Now Extends Well Beyond Running: DC Podiatrist

The barefoot trend has taken foothold throughout the nation. But before you set out on a barefoot marathon or even a walk, says podiatrist,  Dr. Stephen Pribut, be sure that your feet can handle it. There are a lot of different foot types.  Barefoot running is not recommended for low arch, medium arch, and high arch foot types.  Other barefoot activities are becoming popular. Barefoot bicycling allows one to “feel the road” much like the feel of a stick shift in your automobile. In bicycling, one does not have to worry about being cut by glass, rocks or other unpleasant items, and barefoot bicycling really exercises the muscles in the feet. “And think about all the time it saves tri-athalon participants not having to put on their shoes after swimming,” says Pribut.

Dr. Stephen Pribut

Going through the airport security sans footwear has its benefits, as well. This fashion statement has a history since the Hari Krishna started it at airports in the 1960’s. “And how wonderful is it to sit barefoot on a long flight?” says Dr. Pribut. 

Barefoot Cycling - The Latest Rage?

Women, in particular, are pleased with going barefoot, because a pedicure is all that is needed for a stylish look.  Many brides, in fact, are footing it down the aisle in shoeless comfort. “Standing in heels for a long wedding ceremony can be very irritating,” says Pribut. Al Gore has taken credit for this phenomenon, claiming that it cuts down on the global footprint. He is in the process of writing a new book about going barefoot entitled An Uncomfortable Truth.

Source:  April Fool’s News [4/1/10]

NAP Awards Fellowship to FL Podiatrist

The National Academies of Practice has announced the selection of Chet  Evans, MS, DPM for its first class of NAP Fellows. Dr. Evans was given this award as a way of publicly recognizing and demonstrating that a Distinguished NAP Practitioner or Scholar has provided loyal, consistent, and unusually energetic service and support to the organization.

Dr. Chet Evans and Mary Costanza, MD, President of the NAP.

The award was presented to Dr. Evans at the annual NAP Membership Recognition Banquet held in Arlington, Virginia. Currently Vice President for Medical Education and Program Development at Lake Erie College of Osteopathic Medicine in Bradenton, Florida, Dr. Evans is the first podiatric physician and surgeon to receive this prestigious fellowship.

Query: Possible Nerve Entrapment After Resection of an Os Trigonum

Last week, I removed a symptomatic os trigonum from a healthy, active young woman. I made an incision midway between the Achilles and the lateral malleolus. I encountered the sural nerve, which I retracted with a Penrose drain. I dissected further to the ossicle, resected it carefully, and noted the flexor tendon to be functional, post-resection. The procedure was performed under general anesthesia with a lateral block placed by the anesthesiologist. A pain pump was placed after the surgery in the area of surgery (2ml/hr of Marcaine 0.25% plain x 100 ml pump).

18 hours later, the patient was in agony. The ER doctor gave her two 4 mg doses of morphine IV, along with 4 mg Versed. Her pain was only on the MEDIAL side behind the medial malleolus. I did a complete work-up with a D-dimer, lab work, Stryker manometer test, and a venous Doppler. When these were all negative, I administered a PT block and gave 100 mg Solu Cortef IV. Her pain went down to 4/10.

I felt she had a neuropraxia related to the posterior tibial nerve. 2-3 days later, she is much better, and can flex and extend her great toe, but cannot flex or extend the lesser toes. There is absolutely no pain over or adjacent to the surgical site. Has anyone else encountered this? Is this type of nerve injury permanent and what further steps would anyone take to resolve the problem? 

Sloan Gordon, DPM, Houston, TX

Query: Hospice Care Rejection

I saw a patient at home, and was rejected because the patient is in hospice care. There is a modifier to identify that my services have nothing to do with the reason for hospice care, but I don't remember what it is. Any help?

Ron Werter, DPM, New York, NY

Response: From the Medicare Claims Processing Manual: "Any covered Medicare services not related to the treatment of the terminal condition for which hospice care was elected, and which are furnished during a hospice election period, may be billed by the rendering provider to the FI (fiscal intermediary) or carrier for non-hospice Medicare payment.

These services are coded with the 'GW' modifier (service not related to the hospice patient’s terminal condition) when submitted to a carrier or with condition code 07 'Treatment of Non-terminal Condition for Hospice' when submitted to an FI. Contractors process services coded with the 'GW' modifier and '07' condition code in the normal manner for coverage and payment determinations."

Harry Goldsmith, DPM, Cerritos, CA

Codingline subscription information can be found at:
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RE: Metatarsal Neck Fractures (Robert A. Dale, DPM)
From: Todd Lamster, DPM, Robert Thiele, DPM

With respect to Dr. Dale, I do not believe that this patient would benefit from the proposed surgery, percutaneous or otherwise. Her co-morbities, lack of palpable pulses (although this could be due to edema) and presence of "stage 3 ulcer" with infection should preclude her from any left foot surgery at this time. The question I have is this: would fixing these fractures ultimately improve this patient's ability to walk, given her rheumatoid arthritis, hip issues, etc, even if she did not have any one of numerous complications?

As far as the technical component is concerned, you would probably have to make small incisions in the interspaces to reduce each met head (with a freer elevator perhaps) and then place your K-wire(s) as you described.  Perhaps a better idea would be to resolve the infection, heal the submet 1 ulcer, and then perform a pan met head resection or a lesser met head resection with 1st MTPJ arthrodesis.

Todd Lamster, DPM, Phoenix, AZ, tlamster@gmail.com

It sounds like you have a pretty good infection submet 1. My advice is to admit this patient, order IV antibiotics, labs, a vascular surgical consult ASAP, and work-up for osteo 1st met. With regard to the met fractures, yeah, they are in bad position, but the infection takes priority. You don’t want to be drilling wires around something as infected as you are describing.

Infection aside, even with vascular clearance with this patient, closed reduction and percutaneous pinning of the mets would be my course of action. You would drill them plantarly with the toes dorsiflexed, so you can go through the met head and into the shaft and fixate like an IM rod. Cap the pins and have the patient non-weight-bearing. It sounds like you have a bigger problem to address than the met fractures.

Robert Thiele, DPM, Denville, NJ, drthiele@comcast.net

RE: Scanning vs. Casting for Orthoses (Robert  Bijak, DPM)
From: Multiple Respondents

Do you think that those residents who are going to be required to do 3 years of post-graduate training are going to want to grind the rhoadur and heat it after walking the hallowed hospital halls? The old ways are dying out and a new profession is emerging.
 
Dr. Bijak, are you implying that since these young doctors have three years of post-graduate training that they are "too good" to grind rohadur or adjust an orthotic?  From the recent graduates that I have seen, many of them do, in fact, have this attitude, and I feel that is a shame. While it's all nice and great to think that they are "too good" to do that, the reality is, if that is what their patients need, why not? Last time I looked, there aren’t a whole lot of triple arthrodesis procedures being performed, but in comparison, many, many orthotics are being dispensed and when need be, modified.  My advice to the new 3 year residency graduates: Don’t be too good to do ANYTHING that your patient needs.
 
Robert Boudreau, DPM, Tyler, TX, rbftdoc@aol.com

Dr. Bijak states: “With millions of non-DPM orthotics out there, you would think there would be failure rates in the 90th percentile, but that's not the case. Many patients do very well with non-DPM orthotics, so the claim that we do it better is not substantiated in real life.”

In this, the age of evidence-based medicine, what study or other evidence can Dr. Bijack provide us to support his claim that the orthotic failure rate of DPM’s is no better than that of non-DPM’s?  I don’t believe that the podiatry schools will stop teaching foot orthotic therapy based on this unsubstantiated claim.

Many patients who received foot orthoses from podiatrists have previously failed to find satisfactory results with self-treatment or by using the services of non-medical providers. Those of us who work within a prescription foot orthotic laboratory see that some podiatrists struggle to achieve acceptable outcomes while others achieve outstanding results. That’s why the Prescription Foot Orthotic Laboratory Association (pfola.org) and some other organizations are dedicated to providing post-graduate education in foot orthotic therapy. Unlike Dr. Bijack, I am not satisfied with the average orthotic failure rate of some DPM’s, and I believe that research and better education is the path to more successful treatment outcomes.

Jeff Root, jroot@root-lab.com

Editor’s Note: Dr. Marc Garfield’s extended-length letter can be read here.

RE: VOIP Phone Service (Michael Loshigian, DPM)
From: Multiple Respondents

VoIP service has come a long way as far as transmission quality. However, many services, including the popular plans have trouble handling data so faxes can be lost or garbled. Loss of an important fax may not be worth the few bucks you save.
 
Robert Kuvent, DPM, Chandler, AZ, ftfixr@gmail.com

I have been using VOIP for many years now provided by Cablevision. The phone service has been quite reliable. There have been a few issues over the years, but no more in my estimation than with standard phone lines. There is also the advantage of no NYS surcharges and taxes.

The downside is that it may have an impact upon your Yellow Page listing if you do not have an ad in the book. I learned this the first year I switched. The listings in the books are purchased from the local telco provider, and if you are not in their database, and you do not have an ad, you may simply disappear from the book.

I personally don’t believe in Yellow Page advertising, but the next year, I purchased a bold listing. Depending upon the number of lines you have and your current status with Yellow Page advertising, you need to decide which is more cost-effective for you.

Michael Brody, DPM, Commack, NY, mbrody@tldsystems.com

We initially went to VOIP when we moved to our new office one year ago and it was a TOTAL NIGHTMARE. Evidently for our needs, it would not work. Although supposedly they are improving the systems. There was difficulty integrating with our server, and who knows what else. It was a Shoretel Phone System with VOIP from Simple Signal, which I would NOT recommend as a business partner. And believe me, when you go this route, they ARE a partner with you.

Vince Marino, DPM, San Francisco, CA, drmarino@marinofootandankle.com

RE: Digital X-Ray System (Michael J Marcus, DPM)
From: Kenneth Meisler, DPM

20/20 Imaging, (formerly Reina Imaging) was the first company to introduce digital imaging to podiatry (2002), and was the first to introduce dedicated DR (direct digital radiography) to podiatry. They support over 700 podiatry installations, including several of the podiatric colleges.
 
The service is excellent as is the quality of the image.  In my experience speaking with many hundreds of podiatrists at various conferences, it is the unit that most podiatrists want to get.

Disclosure: I am a digital imaging consultant for 20/20 Imaging.

Kenneth Meisler, DPM, NY, NY,kenmeisler@aol.com

RE: Changing to Billing Service (Peter Smith, DPM)
From: Marc Klein, DPM, Richard Gosnay, DPM

We changed to a billing service with a one-year contract, and after nine months bought our way out and went back to in-house billing. We know how to bill for what we do and have a true vested interest in getting all we should for those services. Dedicated employees fight best for our money.   

Marc Klein, DPM, Methuen, MA, MAILKlein@aol.com

I am a solo practitioner, and I can't see the feasibility of bringing billing in-house unless there were 5 or 6 podiatrists in the practice. Maybe more.

I pay a flat 6% of collections. My billing service rents the software, posts the payments, balances bills, and provides reports if I ask for them. She isn't in India. She lives two towns over from me. I get prompt payments. (I was swamped on Friday, so I came in on Sunday to catch up on billing. I got one payment today, Wednesday!)

I have seen billing services that charge between 4% and 9%. Depending on their reliability, they all seem reasonable to me. I pay my biller 6%. I pay $600 for every $10,000 that I collect. What would it cost me in salary and quarterly withholding taxes to pay an employee to do that? And I would need to buy the software, computer, and pay postage, provide office space, and parking...

Call me cynical, but I believe that the start-up fee is mostly a mind game. My billing person doesn't charge one because starting to bill for somebody is simple for her. But if you pay a huge fee to work with a billing company, you might be reluctant to leave it because you will feel like you are wasting the start-up fee investment. The higher the start-up fee, the more likely the billing company will take liberties with your good will.

Richard Gosnay, DPM, Danbury, CT, glabroushead@gmail.com

RE: Attracting New Podiatric Students (Michael Trepal, DPM)
From: Michael M. Rosenblatt, DPM, John H. Susz, DPM

It’s no secret that any advanced degree is exceedingly expensive, and students seriously considering any long-term education must balance potential income with cost. But the recent economic crash has brought this profession back into the limelight. Few younger practitioners are aware of our history.  Almost all chiropodists fared very well during the great depression of 1929-36. Virtually all easily supported their families, owned homes, and experienced comfort and security that was very rare then. 

We’re seeing history repeat. While there are some pockets of podiatrists who (perhaps due to their own error) practice far too much RFC, and so are doing poorly, this is not the norm. Practice brokers have assured me that podiatrists continue to do very well, have no concern about losing their jobs, are not faced with serious income loss, age discrimination, or under-employment. Just ask your own patients: They covet you.

And, there are many opportunities for podiatrists, with lots of excellent practices and ASC’s for sale, as well as institutional jobs with HMOs and large group practices unheard of in the past. We face challenges that continue, but the financial collapse has again favored podiatrists in welcoming sunshine. You made the right choice. Many of your neighbors did not. You can share this with prospective students.

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

I had an 11 year old boy in the office today who assists his diabetic father with his ulcer care because "nobody else in the house can look at his father’s wounds." He has expressed interest in wound care on several of his father’s visits. His guidance counselor at school recently suggested shadowing to this young individual. 
 
Several weeks ago, Dr. Gary Smith asked that a 16 year old high school student leave the OR for HIPAA reasons. I made multiple trips to my podiatrist at 11 and 12 years old, but never considered podiatry or any medical specialty until my early 20's, when I returned to my podiatrist to discuss the profession. At the time, he suggested I look at becoming a chiropractor because this was the up and coming profession. Fortunately, I didn't listen.
 
So, at what age should you allow students to begin shadowing you in the office to encourage and nurture their interests without violating HIPAA? 

John H. Susz, DPM, Warren, PA, drsusz@hotmail.com

Editor’s comment: PM News does not provide legal advice. HIPAA regulations don’t specify an age, so this judgment should be made on a case-by-case basis. College students make ideal candidates for this shadowing experience. 

RE: Alleged Improper Treatment of Foot Fracture  (Douglas Pacaccio, DPM)
From: Barry Mullen, DPM, Michael M. Rosenblatt, DPM

Dr. Pacaccio has every right to feel outraged. His comments speak volumes towards the need for meaningful malpractice tort reform. Simple proposals include but shouldn't be limited to: 1) creation of a loser pay system 2) establishment of a small physician panel to review potential malpractice complaints to determine if a given case has any merit that warrants a jury trial and 3) creation of a peer review system of accountability relative to expert witness testimony.
 
Are mechanisms already in place that act as effective deterrents towards false, embellished or misleading expert witness testimony? If so, do these exist on a state-wide or federal level? What is the process for filing a formal medical ethics complaint against an expert witness who falsifies his/her testimony? Who must file it? Does a discovery time line exist? What are the penalties/ramifications for an expert witness who falsifies his/her testimony? I'm sure all of my colleagues join Dr. Pacaccio's frustrations and concerns with respect to these nuisance case examples that utilize incredulous testimony. They simply need to be eliminated from our legal system, and the attorneys and expert witnesses involved must be held accountable for their actions.
 
Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com

Anyone who has treated lower extremity injury cases or been involved with extremity surgery can point to “shortening” of in-line muscle and tendon groups because of non- or restricted-use. This can occur no matter what the cast-positioning is. Atrophy is a very well known result of lack of exercise, and immobilization. This is a key concern for NASA. Atrophy and shortening is a normal product of aging. (The patient who sued was middle-aged, and there is no indication in the report if she was physically active.) This gradual reduction of muscle mass and shortening is called sarcopenia.

I am 67. I can see it happening to me. Statins also contribute to this. This kind of lawsuit represents the worst example of frivolous malpractice lawsuit. The podiatrist (Dr. Touchton) who represented plaintiff did her no favors. She went through an extended period of time hoping for a settlement or judgment that should not occur. Instead, she should have “gotten-on” with her life and extended physical therapy.

I have an article to be printed in Podiatry Management Magazine in the future that deals with “legal obsessions.”  Anyone who contributes to this should recognize the damage it causes.

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

CANADIAN PODIATRISTS COME BACK HOME!

An Edmonton, Alberta group of DPM’s requires an additional Podiatrist. Interest in biomechanics essential. Given Canadian visa restrictions, this position is open only to Canadian Citizens or permanent residents. Very attractive compensation package. Fax C.V. or letter of interest to: (780) 483-5796.

PART-TIME ASSOCIATE POSITION - NEW YORK

Lower Hudson Valley (Carmel area) Tuesday & Friday mornings 9-1. Surgical privileges at hospital available for any cases booked. Compensation dependent on experience. 25 year old practice. Podiatric references will be needed. Reply to: PodiatryAssociate@aol.com

ASSOCIATE POSITION FULL-TIME - SUBURBS OF CHICAGO

PSR 36 - month-trained podiatrist needed for busy suburban Chicago practice. Full benefit package included. If interested, please email your curriculum vitae to foot1st@yahoo.com

ADVANCED RESEARCH AND SURGICAL FELLOWSHIP

Boston University Medical Center has two unique fellowship positions Become an expert in Limb Preservation, Tissue Repair and Regeneration. Be part of this unique Fellowship at a major teaching facility. During this time, he/she would be expected to become a knowledge expert who will contribute significantly to research, surgical procedures, teaching, and innovations in limb preservation and tissue repair. Requirements: Completion of a two or three year surgical residency; Candidate must possess a commitment to an academic career in podiatric medicine and surgery. Annual Salary: Year 1 $61,000, Year 2 $66,000. Submit a CV and letter of interest to: erin.springhetti@bmc.org

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-BERKELEY, CALIFORNIA

We are seeking an energetic individual to join our multi-office practice in Northern California. PSR 24+ with a California license is required. Partnership position is possible with an excellent long term business opportunity for an enthusiastic and motivated individual. Please send resume to Mwolpafootdoc@yahoo.com

ASSOCIATE POSITION - SOUTHWESTERN PA

Suburban Pittsburgh. To work in an established practice and also a new office scheduled to open in  August 2010. Future partnership buy-in possibilities. Rearfoot credentials needed to expand the established practice, and to maximize the potential in the new practice. Competitive salary, benefits. 724-337-4433.

ASSOCIATE POSITION – CALIFORNIA

Looking for a motivated podiatrist to join a rapidly growing practice in Los Angeles. Will hire immediately. Excellent compensation. Please fax CV to: 310-652-3669.

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

ASSOCIATE POSITION - SW FLORIDA, BEACHES

Well-established podiatry practice with excellent mix office/surgery seeking full-time associate PSR 12-36. Excellent salary & benefits for the right hardworking, personable candidate. Email resume to capecoralpodiatry@live.com or fax to 239-573-9201

ASSOCIATE POSITION – CALIFORNIA

Looking for a motivated Podiatrist to join a rapidly growing practice in Los Angeles. Excellent compensation. Please reply to coasttocoastpodiatry@yahoo.com

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.

PRACTICE FOR SALE - MIDDLE TENNESSEE

Turn-key operation ideal for new practitioner. Two locations each with 3 exam rooms, x-ray room, large waiting room, and ample parking.  Excellent locations and growth potential. All equipment and furniture included. Seller happy to discuss extensive financial and professional information. Priced to sell with good reputation, website, and assistance with transition if needed. Call 931-446-5724 for additional information.

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