The Voice of Podiatrists

Serving Over 10,800 Podiatrists Daily

April 30, 2008 #3,233 Editor-Barry Block, DPM, JD

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Hiking in Under-Sized Boots a Common Problem: CA Podiatrist

Many hikers insist on wearing shoes that are 1½ sizes too small. "It's really common," said Dr. Kathryne Rupley of the All Valley Podiatric Group in Fresno. "People are in denial about their shoe size. I don't know what it is. It's just a number, but both men and women don't want to admit their feet are getting bigger."

Dr. Kathryne Rupley

Rupley explained that as people get older and heavier, the increased pressure (i.e., weight) causes their arches to collapse while ligaments become permanently stretched. So not only do feet grow larger, they also grow wider.

There are other factors to consider as well. When one of her patients seeks advice on hiking boots, Rupley suggests they always try them on while wearing the same socks they intend to hike in. She also recommends shopping in the afternoon. "Everyone's feet are a little larger in the afternoon than they are in the morning," Rupley said. "They're more swollen and spread out from walking."

Source: Marek Warszawski McClatchy, Reno Gazette Journal [4/26/08]

PA Podiatrist Named New Head of Foot & Ankle Center

Benjamin Overley, Jr., DPM, was recently appointed medical director of the Foot & Ankle Center at Limerick. A 1997 graduate of Pennsylvania College of Podiatric Medicine, Overley completed his residency in Germantown Hospital.

Dr. Benjamin Overley, Jr.

“I learned quite a bit during my time there,” said Overley. “It made me work hard and realize what my future goals were to be.” Overley said he got into podiatry due to his interest in surgery. “The orthopedic aspect of podiatry interested me,” he said. “I have bad ankles from playing basketball. I noticed how the doctor was treating me, and felt like it was something that I wanted to get involved in.”

Overley came on staff at the Phoenixville Hospital in January 2007, and was appointed medical director of the Foot & Ankle Center earlier this month.

Source: Dennis J. Wright, Phoenixville News (PA) [4/27/08]

Medical School Group Pushes Curbs on Industry Gifts

Academic medical centers should accelerate their adoption of policies to better manage and, if necessary, prohibit industry gifts, free drug samples and sponsored educational programs that could create conflicts of interest or undermine standards of professionalism, according to a report issued by an Association of American Medical Colleges task force.

The report has been posted on the AAMC Website and members have been encouraged to submit comments. Comments will be weighed by the AAMC Executive Council when it meets June 18-19 and considers making the report’s recommendations official policy.

The Pharmaceutical Research and Manufacturers of America industry trade association said it will also pass on its comments. “Effective, responsible marketing by pharmaceutical research companies plays a critical role in fostering the appropriate use of medicines,” said PhRMA Senior Vice President Ken Johnson in a written statement.

Source: Andis Robeznieks, Modern Healthcare [4/28/08]

Query: Replacements Parts for Hill Podiatry Chair

I am in search of a replacement "lift extension" for one of the sides of the foot rest in my office chair. To my understanding, Hill Podiatry is no longer in business and trying to obtain a replacement part for my podiatry model chair has been a task. Any suggestions for a contact for replacement parts?

Mike Bluhm, DPM, San Antonio, TX

Query: Global Follow-Up for Surgery

A diabetic patient is being seen by the doctor for an ulcer on the foot. The ulcer is present because of a plantar-flexed metatarsal. The doctor surgical elevates the bone (osteotomy) through a dorsal approach.

Can the doctor charge for follow-up debridement of the ulcer every 10 days? Can he bill for office visits (CPT 99213) for the ulcer follow-up within the 90-day global of the surgery?

DJ Campbell, Pierre, SD

Response: If the debridements are planned, staged or subsequent, then, yes, you can bill for the debridements every 11 days using a "-58" modifier appended to the procedure codes.

As for the follow-up E/Ms, no, you can't bill for those UNLESS an unplanned complication or other reason necessitates a reason for an evaluation. If you're doing follow-ups for or with the debridement, that's considered part of the surgery package for the debridement.

Leslie Johnson, CPC, Fort Wayne, IN

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RE: Standard of Care – MRSA (Jeffrey Kass, DPM)
From: Narmo L. Ortiz, Jr., DPM, Philip Wrotslavsky, DPM

Anytime you take a culture from a wound, you should be prepared to treat that wound properly depending on the quantitative and qualitative amount of the organisms found. While most wounds are already colonized by microorganisms, when the presence of MRSA is detected, the standard of care has been to place the patient on IV antibiotics for 6 to 8 weeks (usually Vancomycin) and monitor the patient’s renal function and antibiotic levels. Nevertheless, there are some strains of MRSA that are sensitive to oral Clindamycin, and in cases where there is just colonization of MRSA on the wound, topical Clindamycin has been effective as well.

Narmo L. Ortiz, Jr., DPM, Cape Coral, FL, nlortizdpm@embarqmail.com

MRSA is split into 2 catagories- Community-Associated Methicillin Resistant Staphylococcus aureus (CA- MRSA)and Healthcare-associated MRSA(HA- MRSA). MRSA infections that occur in otherwise healthy people who have not been recently (within the past year hospitalized or had a medical procedure (such as dialysis, surgery, catheters) are known as community-associated (CA)- MRSA infections. At least five types of genetic material (SCCmec genes I-V) have been identified. Hospital-acquired MRSA (HA-MRSA) usually have genes I-III while community-acquired MRSA (CA-MRSA) have genes IV-V. HA-MRSA is resistant to more antibiotics than CA-MRSA.

An important difference between HA-MRSA and CA-MRSA relates to mechanisms of resistance that antibiotics displayed toward these pathogens. The methicillin resistance cassette gene found in CA- MRSA differs from that found in most HA- MRSA isolates. ß-lactam resistance is conferred in CA-MRSA by the mecA gene. This gene encodes for a penicillin- binding protein that has reduced affinity for ß-lactam antibiotics. As a result, ß-lactam antibiotics cannot interfere with bacterial cell wall synthesis. With regard to the standard of care, It would be a good start to know what kind of MRSA you are treating, the treatment for each is different. for a good review of CA-MRSA click here.

Philip Wrotslavsky, DPM, La Jolla, CA, drphilipw@msn.com

RE: Office Assistant Paging System (Will Parker, DPM)
FROM: Multiple Respondents

I have had great success with the Cobra Brand micro talk 2-way radios in my office. When I need my assistant I press a call button. A pleasant, audible sound alerts her to come to the room. I also have the option of directly speaking to her 'on the run'. It is cost efficient and has saved us time and energy.

Howard Gale, DPM, Rincon, GA, howie@dr-gale.com

The system I have in place works very well for me. I purchased a relatively inexpensive wireless doorbell with two buttons. Each button has a distinctive tone, so that my assistant knows which of my two exam rooms I am in. I put tape over the chime box to muffle the sound so that it is not too loud. My patients are often amazed when my assistant appears in the doorway, seemingly without being prompted. It was installed in minutes.

Richard D Wolff, DPM Oregon, OH, wolffie@sbcglobal.net

I have used wireless door bells for years. It is not specific, but for about $12 you have a quick way to "ring" your assistant. We have also toyed with walkie talkies but then the patient knows and sometimes I am just trying to get out of the room, so I push the button with out the patient knowing and magically the nurse shows up.

Greg Mowen, DPM, Ventnor, NJ, gregmowen@comcast.net

RE: ACFAS Members Vote to Reject APMA Membership Requirement
From: Multiple Respondents

We live in a democracy and the vote is what it is. We have to accept the vote of the membership. I do have a few comments that may need clarification. The time line on this issue was that the ACFAS Board of Directors made a "policy change" NOT a by-laws change. A policy change is a board decision not a membership decision. A bylaws change requires a two-thirds majority vote. The vote that ACFAS members voted on was for a by laws change to reject the policy change. That two thirds majority did not occur,so the board of directors vote on the policy change was affirmed. If the recent vote was for a by laws change -there was not a two-thirds majority.

My issue is not with the vote of the members but with the convoluted way that the board presented this change. The proper way for the board would have been to have a bylaws change vote on a membership issue --but I think that the ACFAS board knew they could not receive a two-thirds majority -as the recent vote illustrated. That aside, the old saying "be careful what you wish for, it might happen" is appropriate in this case.

Joe Agostinelli, DPM, Niceville, FL, jmpa21@cox.net

Why is it that APMA is the only organization requiring membership in the national organization if we want to be members of the state or local organization? Membership in the state medical and county medical societies does not require membership in the AMA. When will APMA grow up and stand on its merit? It’s time for all of us to have a choice of which professional organizations we want to have membership in. This will force these organizations to be efficient and more effective, and they will be more accountable to the membership.

Amram Dahukey, DPM,Tuscon, AZ, drd@premiersurgeons.com

RE: Medical Nail Technicians (Bryan C. Markinson, DPM)
From: Jack A. Reingold, DPM

I read Dr. Bryan C. Markinson's letter on "medical nail technicians" with interest. I believe I had one of Dr. Robert Spalding graduates show up at an assisted facility I provide podiatric care for. They already have a full-service cosmology service that does manicures and pedicures. On the day I was there, she was providing "medical level nail care" at no charge to introduce herself to the facilities. I believe she was listed as a medical nail technician. The fact she was there on the same day I was, was a coincidence. However, it did create a lot of confusion. I was not sure where these technicians fit in. I do not know the state laws for cutting nails with that certification. I pointed out to the administrator that I carry 1mil/3mil of malpractice insurance in case I make a mistake and should there be a problem with a patient having their nails cut by her, they might be “the deep pocket.” After that day, I never saw here there.

I am always in favor of more training and certification, but it does create some confusion as to who is the foot specialist. I have read articles written by C. Peds. on how to provide conservative care for plantar fasciitis and ingrown nails. Perhaps it is time for us to leave basic chiropody behind and become full-fledged foot and ankle orthopedists. Many of us certainly have the training for that. I really don't know.

Jack A. Reingold, DPM, Solana Beach, CA, footdoc@san.rr.com

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