The Voice of Podiatrists

Serving Over 10,900 Podiatrists Daily

July 01, 2008 #3,286 Editor-Barry Block, DPM, JD

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Cushioned Insoles Not Likely to Relieve Back Pain: NY Podiatrist

In a current TV ad for Dr. Scholl's Back Pain Relief insoles, a grimacing man hobbles into his bathroom and reaches for pills in his medicine cabinet. The voice-over says, "Back pain? You don't just have to rely on pain relievers. Now you can take two of these." On cue, a pair of insoles pop out of his medicine bottle. The ad goes on to say the insoles are "clinically proven" and will "absorb jarring shocks with every step you take."

Dr. Andrew Shapiro

A 2007 report in the influential Cochrane Database of Systematic Reviews, however, was a blow to anyone pinning their hopes on insoles. After pooling results of six published trials of insoles and back pain, the review authors concluded that there was "strong evidence that insoles are not effective for the prevention of back pain." They also said there aren't enough data to say if insoles help relieve back pain once it starts.

Andrew Shapiro, a podiatrist in Valley Stream, N.Y., and a spokesman for the American Podiatric Medical Assn., agrees that extra cushioning in the feet isn't likely to relieve back pain. "These things don't do anything biomechanically for the body," he says. High arches and flat feet can sometimes set off a reaction that puts stress on knees and back, but you'd need custom-fit orthotics to address such conditions, he says.

Source: Chris Woolston, Los Angeles Times [6/30/08]

Spike in Diabetic Cases Met with Prevention at Temple Podiatry

A surge in diabetic cases is evident at Temple University’s School of Podiatric Medicine, where podiatrists have seen a spike in recently diagnosed diabetic patients who have been referred by their primary-care physician as part of a heightened awareness of the disease.“Diabetes has reached epidemic proportions, and healthcare providers are becoming more proactive in their approach to care,” said Temple podiatrist Kathya Zinszer, who specializes in diabetic wound care. “In years past, patients would come to their doctor with chronic foot wounds, and would be so far gone that the only option would be to amputate. Now, that’s not the case, thanks to the push for preventive care.”

Dr. Kathya Zinszer (Photo by Jeanne Lockner)

Temple’s approach to preventive care is two-fold. At the Foot and Ankle Institute, newly diagnosed diabetics undergo a number of baseline tests, including shoe fittings and gait analysis, to determine and correct any problem areas before they develop into chronic ulcers or wounds.

In addition, Zinszer and her colleagues stress the need for patients to make foot care a part of their everyday lives. She suggests wearing good, supportive slippers in the house, never going barefoot outdoors and checking inside the shoes to make sure there are no foreign objects that could rub or cut the foot. “Our goal is to do everything we can to salvage limbs and help our diabetic patients maintain a good quality of life,” she said.

Alleged Negligent Severance of EHL During Bunion Surgery (Michigan)

Facts: Plaintiff claimed a severed tendon in his toe occurred during podiatric surgery, which defendant denied. The jury returned a verdict in favor of defendant podiatrist.

Plaintiff Geoffrey Gale presented to defendant podiatrist for the implantation of a ‘Bio-Pro‘ implant in his big toe. He claimed that, during the procedure, defendant severed his extensor hallucis longus (EHL) flexor tendon. As a result, he had difficulty walking because his big toe stuck up vertically and he was unable to find shoes to fit.

Plaintiff alleged defendant violated the standard of care when he severed the tendon in his big toe and he sustained a permanent injury as a result.

Defendant contended that he complied with the standard of care and did not sever plaintiff's tendon. Rather, defendant argued that plaintiff's complaints were likely related to scar tissue in the area and nothing he did caused this condition. However, defendant maintained that, if the tendon was severed, it was a risk of the surgery.

Alleged Injury: Severed extensor hallucis longus (EHL) flexor tendon in plaintiff's foot which resulted in difficulty walking and finding shoes to fit. Plaintiff's toe stuck up vertically as a result of the injury.

Result: Defense verdict

Plaintiff's expert witness : David E. Beneson, D.P.M., Royal Oak, MI
Defendant's expert witness: Charles G. Kissel, D.P.M., Warren, MI

Source: JAS Publications, Inc.

Three Steps to a Happy Staff

Motivation isn’t always about pats on the back or pay hikes. Here are a few inexpensive but effective ways to keep your staff happy and motivated:

1. Walk in their shoes. Take on an employee’s job from time to time. Staff the phones for 30 minutes. Call an insurance company to appeal a rejection. Your employees will love it, and you’ll find out what’s really happening in the trenches.
2. Train continuously. People forget much of what they hear within 60 minutes, but we remember what we see. And we learn even more of what we experience, so use training techniques that demonstrate the desired activity and involve employees.
3. Practice judicious termination. One of the toughest assignments a podiatrist can have is cutting deadwood. If an employee is not doing his or her job it drains your energy and discourages co-workers. Show the door to an under-performing employee.

Source: Adapted from ”How to Treat Your Employees with TLC” by Jum Collison

Query: Alternate Device for Limb Compression

I am treating a 89 yr old female who needs to wear 30-40mm/Hg class BK stockings. The problem here is that she can't get them on and off. She has the cotton undergarment and has used the Donner device. She sufferers from chronic ulcerations and stasis dermatitis and without compression, ulcerates. Can someone offer another approach to the application of these stockings or an alternative device for lower limb compression?

Frank DiPalma, DPM, Athens, GA

Query: Abandonment Issues and Dropping Medicare

I am seriously considering stopping seeing all Medicare patients as soon as possible. I cannot stand idly by and watch as congress cuts our pay by 10%. I don't think congress and the president will act based on fear of our tiny voting block. Next week, I would like to start passing out leaflets telling all my patients, Medicare and all others, that I will no longer be seeing Medicare patients in 30 days unless congress acts to reverse this huge pay cut. I will say that I simply cannot and will not take a 10% pay cut. I feel sorry for my Medicare patients who may have a very hard time finding another doctor to take them, but I have to make this pay cut their problem, and not just mine. I feel particularly bad for my patients at my satellite office where the next closest podiatrist is over 50 miles away, but again, this can't be just my problem. Is this legal and is anyone else out there considering doing something like this? Any suggestions as to how to avoid abandonment issues?

Michael Cohn, DPM, Albuquerque, NM

Editor’s comment: PM News does not provide legal advice. With the exception of situations such as post-operative, infection, or ulcer care, it is not abandonment to inform patients that you are no longer accepting Medicare. In fact, thanks to the efforts of the APMA, podiatrists have the same opt-out privileges granted to allopathic physicians. This process, however, is complicated and requires diligent adherence to the Medicare rules and regulations. We recommend that you use an attorney to assist you in the process. Opting out allows you to continue to treat Medicare patients and charge whatever you wish. The catch is that neither you nor the patient can bill Medicare.

RE: Protocol for NAOH (Elliot Udell, DPM)
From: Multiple Respondents

I use a sequence of mini-applicator stick applications: sodium hydroxide for 15 -20 seconds, followed by acetic acid 20 seconds, followed by a dry swab; I repeat the same cycle, curette the area and repeat one last time with visual inspection of the nail bed. I utilize AmeriGel + gauze cover routinely post-operatively, which diminishes inflammation. I do not have patients soak. With partial nail ablation procedures, generally the nail bed is no longer inflamed or draining after 10-12 days and contraction of the nail fold is well underway. I have no financial affiliation with Amerx.

Mark K. Johnson, DPM, West Plains, MO, DDR004@centurytel.net

The procedure for NaOH is the same with exception of the solutions that are used and the exposure time. I use 10% NaOH applied to the matrix twice for about 10-15 seconds. I look for a darkened type color change as a guide. If the area darkens quickly, I may only do 5 seconds. This chemical is very strong so don't get carried away or the site will blister.

The site is then flushed with vinegar/acetic acid to neutralize the chemical reaction. NaOH is a base so vinegar application is a true chemical reaction that stops the chemical burn, unlike alcohol which just dilutes phenol. I then apply Silvadene and bandage. Expect serous drainage. I encourage patients to let the area stay open at home after the first week.

My patients do not soak. They clean the area with soap daily, dry, apply Silvadene and a Band-Aid. No fancy dressings are needed, although PolyMem is good to remove drainage and prevent maceration.

Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com

My protocol is (3) five-second applications with micro-tips and then flush with acetic acid for 5 to 10 seconds, post-op per your preference. Results are comparable to phenol technique @95% success rate on partials, with less drainage from my experience. I use approximately 4 to 5 applications with full Q-tips for a total nail, depending on severity of matrix hypertrophy.

Angelo J Bigelli, DPM, N. Providence, RI, toedocri@aol.com

RE: Senate Rejects Medicare Increase
From: Philip E. Larkins, DPM, Dennis Shavelson, DPM

Eventually the eleventh hour "pay increases," which are really decreases every year when compared to COLA and other mainstream professions, will cease entirely, and in a few more years, as remarkable as it may seem, we will be paying patients to treat them. The absolute best thing that could happen to podiatry at this point would be for all insurance companies to turn our "luxury ingrown toe nail avulsions", "not medically necessary incisions and drainages", "and it could wait until next week amputations" into a pure cash business ala the dentists. Boy were they smart!

Philip E. Larkins, DPM, San Marcos, CA, larko33139@yahoo.com

Perhaps our profession has a better grasp of what our position is in power politics both now and in the future. If the 10% cuts were eliminated, the insurance industry stood to lose $16 Billion (with a B) over five years. I guess calls from healthcare professionals do not compete with the #1 lobby in Washington, the insurance industry.

Another dose of reality is that if you have a 50% overhead (average) and you get a 10% cut in collections, you take a 20% cut in net profit. So if you did $200,000 in Medicare last year, you will see a $20,000 cut in your draw. Even worse, the insurance company in network panels base their fees on Medicare, so its time to buy cheaper gas, corn, milk and potatoes in order to cut corners. The argument from those in favor of removing the doctor pay cut was that there was going to be a large drop in access to healthcare for patients. Now is the time to prove them right. To paraphrase one of the Mantra's of the Woodstock Generation. Turn Off the Downward Spiral, Tune In to Reality, Drop Out of Insurance and Medicare.

Dennis Shavelson, DPM, New York, NY, drsha@lifestylepodiatry.com

ASSOCIATE POSITION - QUEENS, NY

Associate position leading to partnership. Seeking highly motivated and personable individual, for busy, well-established practice in western Queens. Prefer PSR-36 trained. Must be willing to address all phases of a busy podiatric practice. Please provide references w/ CV. Fax# 516-829-2537, or e-mail to lpbbdw@aol.com

ASSOCIATE WANTED IMMEDIATELY – NEW YORK

Part-time or Full-time for group practice Fast track to partnership. Located in Orange & Sullivan County, NY. Commute from adjoining counties to see how it fits. Monroe, NY office is only 1 hour from Manhattan. All phases of podiatric care. Call Dr Marc Hudes 845-807-8864. Check out our practice website

ASSOCIATE POSITION WITH OPPORTUNITY FOR PARTNERSHIP NY/PA

Group practice located on NY-PA border with excellent growth in the area’s industrial, retail, and college campuses. Surgical privileges in medical centers in NY and PA. This position will involve rotating through multiple office locations, and wound care centers. Local insurance reimbursement involves mostly private pay PPO models. We are looking for an ABPS Board Qualified podiatrist to join our team. Candidates would need to obtain licenses in NY and PA, and become ABPS certified to maintain hospital privileges. Base salary starting at 85,000.00 with bonus plan incentive, vacation, and health/mp insurances. Forward CV to prefprovider@hotmail.com

ASSOCIATE POSITIONS – CALIFORNIA

Coast to Coast Mobile Podiatry Group, California's premier provider of mobile on-site health-care services is seeking hardworking, caring Associates to provide excellent health-care to the greater Los Angeles areas, Organge County, San Bernadino County, Riverside, San Diego, and Santa Barbara. Salary and benefits available. Please email you CV and salary request to coasttocoastpodiatry@yahoo.com

ASSOCIATE POSITION - BALTIMORE, MARYLAND

Seeking surgically trained individual competent in all phases of podiatric care. Outstanding salary and benefits. F/Tor P/T contact email rsher18@yahoo.com

ASSOCIATE POSITION - BOSTON, MA

Associate wanted, Full-time or part-time, for busy long time, well established, and well rounded practice. Good mix of general podiatry and surgery. Office will generate approximately 100+ surgical cases per year. Must have surgical background for this practice, ABPS Qualified minimum needed to obtain hospital privileges. Associate position is open for partnership or purchase. Contact robert.nunberg@comcast.net

PRACTICE AND EQUIPMENT FOR SALE: RIVERTON, WY

Solo practice of 8 years left without doctor due to illness. Clinic name is still in the phone book with active phone number. Over 4,000 patients on the books. Various supplies and equipment available (ultrasound, xray, processor, Osada drill, mayo stands). Will consider all offers. Contact Sylvia at jefsyl@windstream.net

IMMEDIATE OPENING - MINNEAPOLIS, MN

Associate leading to partner in well-established practice. Seeking personable, skillful, and attentive podiatrist. No nursing homes, evenings or weekends. Competitive compensation package including health insurance, malpractice, short term disability, 401(k), generous vacation, paid holidays, and excellent salary plus bonus! E-mail cover letter and CV to jbremer@associatedpodiatrists.com or fax to (612) 866-5875 attn: Jennifer Bremer

BIOMECHANICS FELLOWSHIP – NEW YORK

Neoteric Biomechanics (patent pending) Nine-Month Fellowship: At The Foot Typing Center® in New York City. Practice, Research, Publish and Credentialize Yourself In This New Paradigm. $36,000 Stipend. New York License Required.Fax Interest to: 212 288 3034 or apply to Dr. Shavelson @ drsha@lifestylepodiatry.com.

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