June 07, 2006 #2, 599 Editor-Barry Block, DPM, JD

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George W. Koster, DPM, 82, of Manchester, died Saturday, June 3, 2006, after a lengthy illness.

George W. Koster, DPM

Dr. Koster was a podiatrist from 1954 until his retirement in 1985. He served as president of the New Hampshire Podiatry Association for three years and was a member of its board an additional four years. He served on the board of directors for Magdalen College and was a member of the Knights of Columbus, Christ the King Council, Nashua, and served as its president in 1967. He had a lifelong love of World War II aircraft and a lifelong devotion to his religion. His biggest accomplishment was raising his six children.

PM News policy is to recommend that memorial contributions be made to the APMA Educational Foundation Student Scholarship Fund, 9312 Old Georgetown Rd., Bethesda, MD 20814.

Source: Nashua Telegraph [6/5/06]

MS DPM Offers More Summer Foot Health Tips

Want to cut down on foot odor and prevent blisters on your feet? "When your feet sweat, you can get blisters pretty easily," podiatrist Dr. Joel S. Craig said. He recommends reaching for a deodorant such as Arrid Extra Dry, and spraying your whole foot. Also, people can get sunburn on their feet, too. So Craig reminds people to be sure to apply sunscreen to their exposed feet.

Parents also need to protect their children's feet and discourage them from running barefoot in the grass. During the summer months, children end up with bee or other insect stings when their feet are not protected. "Children are not little adults," Craig said. And children might not always express when their feet hurt, he said. So if you're at the playground and your son or daughter is sitting at the sandbox while other children are taking off running, parents need to ask if the child is experiencing foot pain or see if he has possible sunburn on his exposed feet.

As for women wearing high heels, this may actually do more harm than good. "Some women have actually fallen and had fractures, and they blame it on the shoes," Craig said. For that reason, he is convinced that "high-heeled shoes were probably invented by a man who was angry at his wife."

Source: Wendy Isom, The Jackson Sun, [6/5/06]

Query: Rupture of FHL Tendon

I am treating a 24 y/o healthy female who is unable to move her hallux IPJ. She has a history of pain about a year ago behind ankle and under 1st MTPJ. MRI scan read by radiologist –intact FHL. Clinically it was not. In Mississippi, we cannot go proximal to the talus. Despite radiology reports, we decided to surgically explore. Intra-op findings: rupture of FHL with the proximal end posterior to the talus and the sheath distal to the IPJ was completely scarred down. Proximal sheath was identifiable and intact. The remaining tendon was not viable and left about a 10cm length to be grafted. Options and things to think about:

Fuse IPJ – concerns: What long -term (20+ years) effects has anyone seen with loss of FHL? Effect on mechanics (mid foot, rearfoot and first ray)?

Graft—no standard graft from the “foot” long enough. I cannot get plantaris or a long enough p. tertius due to legal limits. Option: place tendon rod in sheath and repair at later time by ortho or plastics—this commits the patient to another surgery even if she decides not to do anything and accept the problem.

Anastamose stump of FHL to FDL and fuse IPJ- What are the long-term effects of increasing the strength of FDL on lesser digital function?

I placed a small vascular clip at the tendon stump (no tendon rod) and did not fuse the IPJ. I explained to the patient and family that now the options were: 1-live with it and watch for changes which could be corrected as they become problematic. 2- fuse the IPJ 3- Go to plastic or ortho and get a graft from above her ankle.

B. T. (Tip) Sullivan, DPM , Jackson, MS

tsdefeet@MSfootcenter.net

RE: Valuing a Practice (Name Withheld)
From: L. Polizzi, DPM, Hope Rachel Hetico; RN, MHA

A method I use to decide if a seller is asking a fair price is to look at the cash flow that can be generated and determine if it covers the debt service (what some brokers refer to as the "income method"). What will it cost you per month to buy the practice (loan payment, payments to the seller, etc.)? Does the practice generate enough excess cash to cover that?

As an example, I once looked at a very established practice that generated almost zero net on paper. It sounded like a bad deal until I reviewed the financials and noticed that the owner spent a lot on "variable" expenses, meals and entertainment, CME courses in Europe, vehicles, etc. After looking at what expenses could be trimmed there was a few thousand dollars available per month after the loan payment; therefore, what seemed to be a high asking price compared to the net was in reality reasonable.

To me cash flow is king, just like real estate income property. If the income of the property covers the expenses (including debt service at the seller's asking price) it is a fair price, if you have a positive cash flow, it is a good price, if it is a negative cash flow, the price is too high. Potential, location, possible growth, appreciation, etc. are factors, but are not predictable. Cash flow is what makes you survive. You pay for your food with cash, not the fact that your home value increased by 100% since you bought it! Trump said it best, "Location, location, PRICE".

L. Polizzi, DPM, Haines City, FL, lpolizzi@tampabay.rr.com

For podiatrists, buying or selling a practice may be the biggest financial transaction of their lives. Some reasons for appraising practice worth include: succession, retirement and estate planning; partnership disputes and divorce; or as an important tool for organic growth and strategic planning. However, the transaction is fraught with many pitfalls to avoid.

For example, we recall the DPM who asked her accountant for the “value” of her practice and was correctly given its lower “book value”, rather than its higher “fair-market-value” as a profitable ongoing-concern. The doctor lost tens-of-thousands-of-dollars in a subsequent sales transaction. Although her CPA produced correct figures for exactly what was requested, the doctor did not differentiate between the two terms-of-art. Later legal mediation determined that neither was responsible for the linguistic error, as both parties acted in good-faith. Of course, it was the DPM who paid dearly for her mistake in linguistic communication and business acumen.

And so, in the stable distant past, doctors occasionally used “rules of thumb” to value their medical practices. “Rules” typically were expressed as multipliers (e.g. "one times revenues" or "five times cash flow"). But today, because of the financial volatility in the healthcare industrial complex, “rules of thumb” should not be used to value any medical practice (other than as a general sanity check). Moreover, they are fraught with legal liability should the deal, sour.

And so, we believe that IRS and USPAP (Uniform Standards of Professional Appraisal Practice) styled valuations should be done in most cases for buyer/seller protection.

Editor’s note: The full version of this response can be read at:
http://www.podiatrym.com/letters2.cfm?id=9698&start=1

Hope Rachel Hetico; RN, MHA, Norcross, GA,

marcinkoadvisors@msn.com

ASSOCIATE POSITION - OHIO

Associate needed for high volume practice with eventual buy-in. Requires highly motivated individual with immediate high volume patient load. Competitive salary with bonus, malpractice, and health insurance. Send resume to rubwalk@hotmail.com or fax to 419-473-1230

ASSOCIATE POSITION- NEW ENGLAND

Terrific Opportunity Now Available in growing New England practice. Well established and respected practice with new, large office space, latest technology, very helpful staff, loyal patients and solid referral base. Close proximity to hospitals with modern surgical suites. Opportunity for shared ownership. Prefer 24 month PSR with clinical practice experience or an experienced doctor looking to improve their situation. E-mail CV and particulars to NEAFC3@aol.com

ASSOCIATE POSITION - PALM BEACH COUNTY, FLORIDA

Excellent for upcoming residency grad. Well rounded practice- 2 podiatrists. Fax resume: 561-637-9596.

EQUIPMENT FOR SALE - ESWT

If you are using or thinking of using ESWT, I have a new machine that has only been used twice. There is no Orbasone in the country priced like this one. Will provide training and installation. Take a look at http://www.orbasone.com Call 1-856-229-2939.

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