The Voice of Podiatrists

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July 16, 2007 #2,986 Editor-Barry Block, DPM, JD

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Stinky Feet are Totally Curable: VA Podiatrist

Our feet are made for walking, or running, but they often smell when the shoes come off. "It's just a breakdown of fungus, bacteria, yeast in the foot," explains podiatrist Dr. Debra Aleck. "Typically if a foot’s very wet, you're gonna have more bacteria. If it's very dry, you're gonna have more fungus, but a lot of times it's a combination."

Dr. Debra Aleck

Stinky feet are completely and totally curable Dr. Aleck, who has a practice in Portsmouth, VA has been treating foot problems for 15 years. She says simple hygiene can help. "Change your socks, change your shoes every three days. I always say wash your feet. Many people don't wash their feet." If those solutions don’t help, try soaking your feet in tea. Dr. Aleck says the tannin in tea neutralizes the pH and helps keep bacteria from spreading. Vinegar also helps.

You can even give stinky shoes the cold shoulder. "Throw 'em in a plastic bag, throw 'em in the freezer for 24 hours. It'll kill everything," adds Dr. Aleck. Your choice of socks can add to the problem. "Cotton socks basically retain moisture, so it actually adds to your problem. You want to wear synthetic socks - socks that wick away moisture." In severe cases of foot stench, there is medical help. "If the basics don't work, then you should seek out your podiatrist or doctor of choice to help you with maybe a prescription product for anti-fungals, anti-bacterials." Above all, Dr. Aleck says, listen to your body. If your feet smell really bad and at-home solutions aren’t working, call your doctor.

Source: Vanessa Coria, WVEC-TV ABC 13 Hampton Roads (VA) [7/13/07]

CLEAR's International Visiting Clinician Program

Physicians from around the world have always been frequent visitors to Scholl's Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University of Medicine and Science. However, recently, CLEAR has formalized the program. "It is wonderful to work at such a cosmopolitan facility.", notes Stephanie C. Wu, DPM , MS , Assistant Professor and Director of CLEAR's Education and Outreach efforts. " Chicago really is a hub city -- both for airlines and, in our case, for foot care."

Drs. Aly, Armstrong and Martinez (from left) participate in CLEAR's visiting physician program.

Over the past year, clinicians from five continents have partaken of the program. Recently, Dr. Wu and David G. Armstrong, DPM, PhD, Professor of Surgery and CLEAR's Director, hosted Professor Jose Lazaro Martinez of Madrid's Universidad Compultense and Yousry Aly, MD, chief of the Diabetic Foot Service at Al-Yousif Hospital in Saudi Arabia and Hilwan University Hospital in Cairo. Dr. Armstrong concluded by saying that, "This is one of the real treats in medicine -- exchange of ideas and friendships. In this way, we can commiserate with one another but also share clinical and research tips. It's one way that we can make a difference at home and around the world."

Previously Uninsured Seniors Costlier to Medicare

Older Americans with common chronic diseases who were uninsured before age 65 needed more intensive and costly care after enrolling in Medicare than those who were covered under private health plans in their 50s and early 60s, according to a study by Harvard Medical School researchers.

Analyzing 12 years of medical data on more than 5,000 people, 1,300 of whom were uninsured, the researchers found the previously uninsured had 13% more doctors visits, 20% more hospitalizations and 51% higher total medical expenditures from ages 65 to 72 years than those who previously had private health benefits.

Uninsured seniors with cardiovascular illnesses and diabetes had the most healthcare needs after becoming eligible for Medicare, according to the study, published in the current issue of the New England Journal of Medicine.

Source: Rebecca Vesely, Modern Healthcare [7/12/07]

Query: Chemotherapy as a Possible Cause of Toenail Deformity?

Does anyone know if there are any effects on toenail growth resulting from chemotherapy treatment for breast CA? I have a patient who complains of increased thickening of her toenails after this treatment.

Evan F. Meltzer, DPM, Browning, MT

RE: CMS Audit (Barry H. Block, DPM, JD)
From: Michael King, DPM, Cheri Derochie

Yes, I agree an actual CMS audit of so many requested records is not a good sign. However, the Medicare Advantage Plans seem to be actively engaging in audits of practices asking for large number of records. Some practices here in MA have been asked for 25-50 records and a 6-hour review is carried out in their offices. We are looking into this practice by the carriers and are finding if employed by a Medicare advantage plan, (MAP) it may not be for payment audit purposes as much as it is a diagnosis related review. This appears to be a way for the MAPs to justify their existence and seeking greater payments from CMS for their services.

If this is coming from a Medicare Advantage Plan: First, whether they can do it is relative to two issues (1) what does the DPM's contract with the MAP say (most likely it will provide for a broad audit right) and; (2) Is the broad review consistent with HIPAA? As you might recall, under HIPAA, there's an obligation to use the "minimum necessary" information to achieve the purpose of the use or disclosure.

In the end, it might be that they can do the broad audit. I would find out the purpose for the audit. Based your request to know the purpose on your obligation to only disclose the minimum necessary information. In addition, see if the MAP contract provides any additional protections that might not be met, e.g., limiting audits to convenient times for the office or requiring reasonable notice.

There are a number of reasons they might want to look at the entire record. A lot of physicians are having similar experiences as more payors (like Medicare) move to risk-adjusted payments and plans hire companies to ensure that all possible diagnoses are captured.

Michael King, DPM, Chair, APMA Health Systems Committee, mkftdoc@aol.com

I am not a podiatrist, but I am a former fraud auditor for Medicare and worked for Aetna in Phoenix for 17 years. I performed many audits for both the Fraud/Abuse and Medical Review department. I can guarantee that a request for 36 charts would never be considered routine and should be dealt with very carefully.

An audit can be initiated under several different circumstances, including a complaint filed by either a beneficiary or another physician but the most likely source would be data analysis that identified a provider as an outlier for specific procedure codes. The physician who sent in this letter should not feel that he is not at risk just because only 4 of the 36 charts belonged to his patients. It may be that the selected sample was based on the percentage of total services billed by each physician rather than a random sample of all services billed by the group.

Cheri Derochie, Logic Billing and Consulting, cherirose_85029@yahoo.com

RE: Complex Regional Pain Syndrome (Jim Clark, DPM)
From: Multiple Respondents

In addition to the sympathetic nerve blocks, active intense physiotherapy is highly recommended. I have also use steroids orally, such as multiple Medrol dose packs, and used drugs such as Lyrica, Cymbalta, Neurontin, and sometimes add Ultracet, which works for breakthrough pain, as well as some of the tricyclic antidepressants, like Elavil. If you feel uncomfortable using these meds in combination a pain management consultation would be advisable.

Steven H. Goldstein, DPM, Wayne, NJ, Stevefootdr1@cs.com

If you have even the slightest suspicion of CRPS, you must immediately refer the patient to the best pain specialist (almost always an anesthesiologist) in your area. Do not attempt ankle blocks! This disorder occurs mostly due to abnormalities within the sympathetic nervous system. It is in the patients best interest to be fully evaluated and treated by a pain specialist ASAP. By doing this, you are also significantly protecting yourself if a future malpractice claim is filed.

Howard A. Stone, DPM, Glenview, IL, justus313@comcast.net

I just read an excellent review published on ortho supersite www.orthosupersite.com/view.asp?rID=22311), June 2007. “Early diagnosis in post traumatic complex regional pain syndrome.” This may help you develop a treatment plan. It has excellent references.

Tip Sullivan, DPM, Jackson, MS, tsdefeet@msfootcenter.net

While 5 weeks post op seems extremely early for this diagnostic call, if you are correct, that bodes well for your patient. Best advice: get this patient to a physiatrist/pain management specialist ASAP who has extensive experience treating CRPS. It's called complex for good reason! It's often difficult to correctly diagnose early and even tougher to manage once diagnosed.

How absurd to think this problem can be adequately managed by a series of local chemical sympathectomies, ie. PT blocks. It demonstrates how little the syndrome is understood. If a patient's pain was managed with a PT block, then they likely didn't have CRPS. I don't fully understand the syndrome myself, but I do recognize that most cases require a multidisciplinary approach including but not limited to 1) lumbar sympathectomy, albeit chemical (via injection) first and occasionally surgical with 2) early aggressive PT, 3) extensive pain management medication prescribing and in some cases 4) psychotherapy.

Even in the best hands, some cases, especially those with delayed diagnosis and/or treatment that allows the syndrome to progress to later stages may lead to permanent impairment. On rare occasion, persistent pain may become so intense that patients actually beg for ablation. With all due respect, if you want to do the right thing for your patient, refer them to the appropriate specialist. Failure to timely refer leads to treatment delay which may adversely affect your patient's outcome thereby potentially increasing your medical liability.

Barry Mullen, DPM, Hackettstown, NJ, YAZY630@aol.com

PRACTICE FOR SALE - MAINE, SOUTHERN COAST

Established practice for sale. Practice with well developed infrastructure and location. Current technology in place. Good mix of surgery and office based care. Practice has stable income and consistent patient flow. Office open three full days and two half days per week. dpminmaine@comcast.net

ASSOCIATE WANTED – NEW YORK IMMEDIATE OPENING

Busy multi-dimensional practice; 70 miles north of New York City. Currently five (5)-doctor practice. looking to expand – all phases of podiatric medicine. contact: (845) 454-8308 EXT: 106

PRACTICE FOR SALE - NORTHERN CALIFORNIA

Great opportunity to own a well-established turn-key podiatry practice located in modern medical office building in East Bay; Electronic billing, good payor base, no HMO contracts; Biomechanics, general podiatry with great potential for surgery. Please send CV and letter of interest to: norcalpod@hotmail.com

POSITION AVAILABLE - SOUTHEAST TENNESSEE/ NORTH GEORGIA

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Immediate position available or will wait for the right individual. Unique practice opportunity in growing multi-physician/multi-office practice. Well established/cutting edge within the medical community. Close proximity to hospitals as well as opportunity to become involved with a free standing podiatric surgical center. Must be BQ/BC. Minimum PSR/24. Competitive salary, bonus structure and benefits. E-mail CV to afcjen@hotmail.com

PODIATRISTS NEEDED - CHICAGO --NORTHWEST INDIANA

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists. We are located in Chicago and Northwest Indiana. Full and part time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-292-4800. Fax 773-486-3548 ---------------------E-Mail sschneider@homephysicians.com -- www.homephysicians.com

ASSOCIATE POSITION – BOSTON, MA

20 year old, well established, modern practice with 2 locations just out of Boston, looking for associate, P/T or F/T, motivated 24/36 trained or ABPS-Certified or eligible to start immediately. Strong surgically-based practice. Looking for motivated individual, able to practice all facets of podiatry practiced. Electronic scanning for orthotics and voice activated EMR already in office. Fax CV to (617) 567-0822

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