The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

July 03, 2009 #3,587 Publisher-Barry Block, DPM, JD

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AZ, DC Podiatrists Discuss Footcare for Diabetics

If you've just learned you have diabetes, you should arrange to meet with a podiatrist and talk about the importance of foot care, say experts Erika M. Schwartz, DPM, a spokesperson for the American Podiatric Medical Association (APMA) and Dr. David G. Armstrong, a podiatric surgeon and professor at the University of Arizona's Department of Surgery. Here is help for sidestepping the foot pain complications of diabetes.

Dr. Erika M. Schwartz

If you have neuropathy or symptoms of vascular disease you should leave toenail clipping to your podiatrist. If you are cutting your own toenails, cut straight across the top of the toenail, leaving part of the whiter nail plate, advises Dr. Schwartz who adds, "If you are unable to feel a cut, or don't have the blood supply required to heal a cut, you likely shouldn't be cutting your own toenails."

Dr. David G. Armstrong

Keeping blood sugar levels low is the best protection against nerve damage in a diabetic person. "There is some compelling emerging evidence that controlling high lipid levels may reduce the progression of neuropathy, too," says Dr. Armstrong.

Source: Amy Zerello, Reader's Digest [7/1/09]

CMS Proposes 21.5% Cut in Medicare Doc Payments

Physicians would receive a 21.5% cut to their Medicare payments starting Jan. 1, 2010, under a proposed rule issued by the CMS. In a major step to revise the way it pays physicians, the agency is also proposing to remove physician-administered drugs from the formula used to calculate Medicare's physician fee schedule. The proposal to take drugs out of the formula won't prevent the anticipated cut in 2010; however, physicians will experience fewer years of negative updates if it is implemented.

The American Medical Association, which has been pushing for this measure for years, applauded the proposal. “The removal of physician-administered drugs from the broken Medicare physician payment formula is a major victory for America's seniors and their physicians,” J. James Rohack, president of the AMA, said in a written statement. “The AMA has been calling for this action since 2002 so that Congress can afford to repeal the flawed Medicare physician payment formula.”

The sustainable growth rate formula ties Medicare physician payments to several factors, including changes in the economy. Physicians would experience the 21.5% cut in 2010 unless Congress intervenes, as it has in the past.

Source: Jennifer Lubell, Modern Healthcare [7/1/09]

Recover When Your Mind Goes Blank

Take the following measures if you forget what to say next during a presentation:

•  Stop speaking. Resist the urge to “umm” and “ah”; nervous verbal tics like those can damage your credibility. Move a couple of steps backward and take a deep breath while you collect your thoughts. Then smile, step forward and proceed with your prepared remarks.
•  Repeat to remember. When you are not sure what to say next, repeat your last sentence. Often that will trigger your memory and your next words will come to you. 
•  Involve your listeners. If you still have no clue what to say next, ask an audience member to repeat the last thing you said. If you have given your listeners a written outline of your speech, ask someone to tell you the next topic you planned to discuss.

Remember: Usually your listeners want you to succeed, and many among your audience will offer to assist you. You will gain the help you need as well as time to collect your thoughts, and your audience will be more energized and involved.

Source: — Adapted from “Ten Quick Presentation Skills Tips for Outstanding Presentations,” by Ed Sykes via Communication Briefings

Query: Surgical Closure of First Metatarsal Growth Plate to Correct For a High IM Angle

I have an 11 year old female patient who has a 14 degree IM angle and a painful bunion deformity. I have heard that I can prematurely close the lateral one half of the growth plate to cause the metatarsal to drift back into a more rectus position.

Painful Bunion in 11 Year Old with 14 Degree IM Angle.

Who is doing this or where can I go to find out how this can be successfully accomplished? 

Nick Tanner, DPM, Spokane, WA

Query: Switching From DSL to Cable

Has anyone made the switch in their office to a cable access connection? There seem to be substantial savings, but is the service reliable? My land-lined traditional phones almost never go out, but my Internet services often have difficulties, and when the electricity goes out, my computer also goes out, but my phone still works. Should I "modernize?"

Steve Bennett, DPM, NYC, NY

RE: Forefoot Striker With LLD (Chris Seuferling, DPM)
From: Multiple Respondents

Check for partially uncompensated equinus. People with such an LLD usually compensate with walking on their forefoot. Can the patient get to 90 degrees? If he can, check that the knee is not hyperextended. If possible, slowly correct for LLD (parallel ASIS). TAL might be needed.

Simon Young, DPM, NYC, simonyong@juno.com

It may prove more effective to put the lift on the outside of the shoe, sandwiched between the midsole and outsole. The ratio of elevation is two to one from heel to ball, and two to one from ball to toe. If you are adding 1cm to the heel, add 5mm to the ball and 2.5 mm. to the toe. You may find it more effective to elevate his heel more than 1cm and more than 5mm to the sole.

Robert S. Schwartz, C. Ped., NY, NY,  rss@eneslow.com

I have always felt that a heel lift is more of a static adjustment, than a functional adjustment. Once the heel begins to unload, you no longer have your lift. I always try to utilize a full-length lift. In athletes, what I like to try to do is give them a series of 2 mm. full-length liner cut-outs to add to the shoe. The instruction is to add one, use for several days to a couple of weeks, then add another. You may get close to 1 cm. in a running shoe before you run out of space.

If the individual still wants more lift, I glue high durometer EVA to the outsole of the shoe, starting with 1cm, and having the individual remove the lifts that have been added to the inside of the shoe, with the exception of one unit. From that point on, they add 2 mm. to the interior of the shoe until you find the height that the athlete finds most comfortable. After that, they will need to utilize shoes that a shoe repair place can alter with the correct lift height. Keep in mind, that with adding the lift to the shoe, you will end up with a heavier shoe on that side.
 
Philip McKinney, DPM, Eugene, OR, opodiatry@oregonpodiatry.net

RE: Chronic Ulcer with Plantar Fibromatosis Lesion (Dang H. Do, DPM)
From: Art Hatfield, DPM

It is stated that the fibrous mass is "beneath" the plantar fascia. Does this mean it is deep to the plantar fascia or between the skin and the fascia? If it is just below the skin, it is likely to be a cicatrix as a result of the chronic wound. While a cicatrix is technically a "soft tissue" mass, they can be very indurated and as much of a cause of an ulcer as an exostosis.

When removing an exostosis as the cause of an ulcer or pressure point, the possibility of a cicatrix should always be considered, and if found, excised. If removed, and the skin circulation is not compromised, partial closure (due to debulking) may be possible after excising the ulcer. I doubt that this lesion is a true plantar fibramatosis.

Art Hatfield, DPM, Long Beach, CA, Afootjob@juno.com

RE: Discontinuing Services at an Assisted Care Facility (Barry Block, DPM, JD)
From: Richard W. Boone, Sr.

On extremely rare occasions, your Learned Editor and I disagree.  This is one of them.
 
I think those patients are BOTH the podiatric physician's patients AND the nursing home's patients. I think the physician has a duty to ensure that the patients continue to receive adequate care until the nursing home, or the patient's caretakers, have found a suitable replacement physician. And I think the physician has a duty to ensure an appropriate transition to the new doctor.
 
If all of that has been taken care of, then a simple letter of resignation to the facility will certainly suffice.  But until the departing physician is sure that the facility has arranged for satisfactory ongoing care for those patients, I think their care is the departing physician's continuing responsibility. Failure to provide that continuing care might very well be considered abandonment, if the patients suffer harm from lack of care during the transition.
 
Richard W. Boone, Sr., Fairfax, VA, RWBoone@aol.com

RE: DC Podiatrist Supports Public Healthcare Option (Douglas Pacaccio, DPM)
From: (Elliot Udell, DPM , Marc Garfield, DPM, DPM)

A great deal has changed since the Clinton administration's failed attempt at national healthcare. One of the table-turning changes is the cost of private health insurance which has skyrocketed. When Hillary proposed her version of national healthcare sixteen years ago, I was paying a little over 300 dollars a month for my own coverage. I was weary of her plan. Today, this premium is equal to my med-mal monthly premium and the coverage is not as great as it was back then. I'm one person, but such exorbitant premiums for private health insurance is putting a strangle-hold on big corporations that cannot afford to remain competitive and offer healthcare to their employees. These companies which fought against government intervention now want it to step in and do something.

Years ago, physicians were, by and large, doing well financially because most patients paid out-of-pocket and were reimbursed by their carriers. Insurance companies paid doctors well for the services provided but managed care soon took over. Today, as we all know, they pay physicians so poorly that many doctors cannot meet their overhead expenses and provide quality healthcare at the same time. Hospitals and local governments are suffering because of the millions who have no insurance at all and wind up in ER's for primary care, causing financial hardship to taxpayers and potential bankruptcy to hospitals. So, you see, as the songwriter wrote: "the times they are a-changin." Government will have to step to the plate as other industrialized nations have done and make sure that all patients have health coverage and we as physicians are properly paid for the services we provide.  
 
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

Editor’s note: Dr. Garfield’s extended-length note can be read at: http://www.podiatrym.com/letters2.cfm?id=27192&start=1

ASSOCIATE POSITION - CHICAGO AREA

PRACTICE FOR SALE - FLORIDA—CENTRAL/SOUTH

Turn-key operation grossing $570,000 annually based on one full-time doctor. Great opportunity for growing the top-line. Surgery is only 14% of the professional man-hours; it can significantly increase income. Medicare makes up 64% of revenues. Seller will assist with transition. Call 863-688-1725, ask for Chas.

ASSOCIATE POSITION – SOUTHERN CALIFORNIA 
 
Flexible, Part-Time or Full-Time opportunity with growing podiatric medical group in busy offices in Southern California. CURRENT DME supplier number a plus. NO nursing homes. Most days are available with flexible hours available. If interested, e-mail scpods@yahoo.com

ASSOCIATE POSITION – MARYLAND

Maryland Eastern Shore Practice has opening for associate with ownership interest. MCR approved ASC, EMR, Ultrasound, Flouro, with Hospital Privileges available. E-mail CV to: patimmons@comcast.net 

ASSOCIATE POSITION AVAILABLE-MIDTOWN MANHATTAN 
 
Looking for Full-time associate to work in well established practices in midtown Manhattan and Forest Hills. Immediate opening for PSR 24-36 surgically trained Podiatrist. Great opportunity with competitive salary along with malpractice benefits. Position includes Saturday office hours. Please send CV to slurie@papapc.net

NEEDED CHICAGO -- NW IND & BALTIMORE/WASHINGTON, DC PODIATRISTS 

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists in Chicago, Northwest Indiana, and Baltimore, MD. Full and part-time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-342-4201 FAX 773-486-3548-E-Mail sschneider@homephysicians.com Visit our website

INTERESTED IN JOINING A DYNAMIC GROUP PRACTICE?

That treats all patients ethically · That offers an academic environment with an exceptional residency program· That will improve your clinical and surgical skills· That offers a strong case load to get you Board Certified fast· That provides a guarantee for growth and advancement. Does this sound unusual and refreshing? IT IS! Do NOT miss this incredible and exciting opportunity- apply now to: Hudson Valley Foot Associates, PO Box 3300, Kingston, NY 12402-3300; or email CV and cover letter to: jobs@hvfa.com

PRACTICE FOR SALE – NEW YORK CITY

NY Manhattan, prime location. Upper East Side, 23. Y.O. practice, high visibility-traffic area next to post office, street level, All phases of Podiatry, NO surgery, retiring due to disability. call 516-759-4062 or Paulfxfeet@aol.com

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