The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

September 10, 2008 #3,344 Editor-Barry Block, DPM, JD

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Fewer Than Half of Severe Bone Infections Require Amputation: Study

Fewer than half of people with serious limb and life-threatening infections require an amputation, according to a just-published study by researchers at The University of Arizona College of Medicine and two other institutions. Offering new hope to patients, the study is the first in the medical literature to evaluate a large number of patients (185) with laboratory-confirmed bone infections. Researchers at the Complutense University in Madrid and La Paloma Hospital in the Canary Islands also participated in the study, which was published Aug. 22 online (ahead of print) in the journal Diabetologia.

David G. Armstrong, DPM

"The data from this study are very encouraging," said David G. Armstrong, DPM, PhD, professor of surgery at the UA Department of Surgery and the study's senior author. "It suggests that people who once were thought to be condemned to amputation may be treated with local conservative surgery. “Previous work over the last decade showed that 40 percent of patients with similar infections received high-level (above-the-foot) amputations.”

Dr. Armstrong, who directs the UA’s Southern Arizona Limb Salvage Alliance, added, "We now know that what we term 'aggressive conservative therapy' -- offering targeted surgical intervention to the bone infection coupled with targeted vascular surgery -- may offer significant hope for people who previously had few options.”

Source: Health News Digest [9/5/08]

If Elected, WY Podiatrist Will Overcome AMA Lobby

Although all three candidates for the U.S. House of Representatives say being a Wyoming native does not matter as a credential, the subject came up repeatedly in a forum Friday. Libertarian candidate W. David Herbert, a podiatrist and attorney, said he was born in Salinas, Calif. Although he was first licensed to practice medicine in Wyoming in 1976, he was not born here.

Dr. W. David Herbert

Herbert focused on his experience as a doctor, lawyer and military veteran and his independence as a Libertarian. Libertarians, he said, are like "super Republicans" in their belief in very limited government and market solutions.

Several times he emphasized that he sees the American Medical Association as an impediment to market-driven health-care solutions. He said he can overcome the influential AMA lobby, which he called "the elephant in the room." "I can short-circuit this area because of my background," Herbert said.

Source: Bill McCarthy, Wyoming Tribune-Eagle [9/6/08]

GA Podiatrist Ordered to Jail By Federal Judge

Monroe County Hospital has suspended the hospital privileges of a Macon podiatrist after he was jailed, accused of crippling patients and refusing to pay a $3.9 million civil judgment. Dr. George Vito turned himself in to U.S. Marshals on Aug. 8 after being held in civil contempt. Vito has refused to pay $3.9 million in damages for prior malpractice judgments. Monroe County Hospital suspended Vito's privileges, but hospital CEO O.J. Booker said none of the operations cited in the lawsuit occurred at Monroe County Hospital.

Dr. George Vito

U.S. District Court Judge Ashley Royal ordered Vito and Foot & Leg Centers of Georgia to pay those damages in May 2007. In his decision, Royal said Vito was involved in evidence tampering, perjury, witness intimidation and wire fraud in a pattern of racketeering that dated back to 1999 and “continues to the present.” According to court documents, Vito has not paid any of the damages and remains in jail and was expected to stay there until he complies with the order, said federal court officials.

While his office is in Macon, Vito saw patients regularly in Forsyth and sometimes performed surgery at Monroe County Hospital. Hospital chief of staff, Dr. Patton Smith, said the medical staff has suspended Vito’s privileges and may do so permanently if the charges are confirmed. He said no medical board or agency has notified the hospital so they hope to get more concrete facts before taking final action.

Source: Griffin News

Some Ways to Avoid Failure - Part 1

Psychologists are finding more evidence suggesting that some people behave in ways that consistently result in failure. Some symptoms:

• Blaming others.This is often the first link in the failure chain. Avoid it by understanding your own potential and limitations. Admit errors and seek reasonable solutions to problems you've created.
• Lacking Focus. A clear focus is essential to taking control of your career and your life. Define what you want to accomplish, and work to meet written goals.
• Being poorly informed. Avoid acting impulsively. Gather facts before making decisions. Remember: Information is power that you should always have on your side.

Source: Dr. Charles Dickson, Hickory, NC

Query: Pre-op Screening for MRSA

Is anyone doing pre-operative nasal swabs to evaluate for carriers of MRSA? If so, what is your protocol/inclusion criteria? I have a feeling this will present medico-legal implications in our profession soon, especially when using any type of internal fixation and/or in the wound care arena.

Howard Schultheiss, DPM, Bel Air, MD

Query: Patient Cell Phone Policy

Although we have a sign posted, “Please turn your cell phones off,” patients still use them in the treatment rooms. What are the policies/responses by my colleagues when;
1. Cell phone rings while taking a history or performing treatment
a. patient answers and begins a conversation
b. patient answers and says, “ I’m at the doctor’s. I will call you back.”
2. While treating a patient you can hear another patient in the next treatment room talking loudly on their cell phone.

Dale Shrum, DPM La Quinta , CA

Query: Disability Exam and Rating Coding

I recently performed a work-related disability examination with rating (CPT 99455) for a Workers' Compensation company. I was the treating physician for the work-related injury.I received $97 allowable for CPT 99455 as mentioned above. Even though I do not see and treat many Workers' Comp patients, this payment seems awfully low to me. Is this considered appropriate? Is the code correct?

Charles Myers, DPM, Conway, SC

Response: Workers' Compensation rates are usually fixed by state statutes. If you, however, performed an independent medical examination (IME) for a third-party carrier (e.g., adjuster), those rates are subject to negotiations with each IME carrier. In addition, you should be compensated for any costs associated with dictation if you are using your own transcription service, as well as any testimony you may be asked to provide.

Be sure you have all those terms discussed in advance.

Paul Kesselman, DPM, Woodside, NY

Codingline subscription information can be found here

RE: Voltaren (Diclofenac) Gel (Richard A. Simmons, DPM)
From: Larry Kollenberg, R.Ph

The studies that were performed by the manufacturer Novartis were associated with osteoarthritis in the original clinical trials. Like any other NSAID, Voltaren is a drug that works as a prostaglandin inhibitor. The big advantage to this medication is that it only has about 10% systemic absorption. While it is 99% protein- bound, it is a minimal amount of drug that is circulating systemically, although the package insert will tell you not to administer with other NSAID's.

The average amount of drug used per dose is about 1 to 2 grams of gel. The concentration of the drug is 3%, so you have 3 to 6 mg. of drug that is being applied per dose. If 10% of that is absorbed, then about 300 mcg. is being absorbed. Neither the package insert or drug interaction programs show a contraindication with coumadin/warfarin. The reason why Novartis marketed this product is because for about 15 years it was compounded by pharmacists for practitioners and they found a significant market for it. Simply put, it worked for me back in the 90's when I was in practice, and made as a 5% concentration by a local pharmacist for me.

You will find that most insurance companies will ask you for prior authorization medical necessity paperwork, so expect that and have your "documentation ducks in a row.”. Cost-wise, it’s expensive to pay cash for the 100 gram tube.

Larry Kollenberg, R.Ph, DPM, Jacksonville, FL, lkollenberg@hotmail.com

RE: Degenerative Changes in 3rd Met-Cuneiform Joint (Jeffrey Kass, DPM)
From: Mr. Jeff Root

While pain at the 3rd met-cuneiform joint is somewhat unusual, there may be a logical mechanical etiology. Has Dr. Kass ruled out a congenital long 3rd met or a congenital short 2nd met? Either of these conditions can increase the weight-bearing function of the 3rd ray. Dr. Kass indicated that conservative treatments including orthoses have been attempted. Perhaps the proper orthotic prescription has not been attempted yet. Take a close look at a neutral position cast of the patient’s foot. If the patient’s negative cast demonstrates a plantar-flexed 3rd met when the heel of the cast is placed vertical, then it is important to balance the forefoot to the level of the 3rd met head. If the patient has a plantar displaced 3rd met and the cast was not balanced to this level, the orthosis will apply an unwanted dorsi-flexion force to the 3rd met. In some cases, a patient with 3rd met-cuneiform symptoms will demonstrate a hypermobile or dorsi-flexed (unstable) 1st and 5th ray, which contributes to overload of the central mets.

You may want to consider using a 3/16 inch Korex forefoot extension with a 3rd met cut- out on his orthosis. This can help to reduce compression forces at the base of the 3rd met. I would also recommend a very deep heel cup and a long rearfoot post with no motion (i.e., flat post). If you use a more rigid shell and a long rearfoot post with no motion, you may be able to reduce general motion within the foot and specifically at the 3rd met-cuneiform joint. This may restrict motion sufficiently to greatly reduce or eliminate his symptoms.

Mr. Jeff Root, President, Root Laboratory, Inc., jroot@root-lab.com

RE: Podiatrists With Outside Interests (Daniel Mendoza, DPM)
From: Multiple Respondents
.
Our editor wrote: "Think how boring it would be just to read about billing, coding, and clinical issues."

Really? I looked at some of the other e-newsletters I received last week. Not a single one included anything related to billing, coding or clinical issues, so I look forward to PM News to fill that void. If you find a news article that is very different than ones we have seen before, publish it, sans photo.

Robert Scott Steinberg, DPM, Schaumburg, IL, Doc@FootSportsDoc.com

Dr. Mendoza you should lighten up. Maybe what you need to do is lighten up your patient load and enjoy the fruits of your labor. You should be glad that you have a busy practice that occupies as much of your time as you let it. Not all of us are that lucky. Without outside interests and hobbies life becomes pretty stagnate.

PM News provides a wonderful service and is a well-rounded forum. Very simply, if you don’t like a section, don’t read it. At the very least, you don’t seem so overwhelmed as to not have time to comment on things you think are wasteful of your time. You should take that energy and put it into something that you feel passionate about and use it to your advantage. If it all has to be work with you, then think of his entering a pie-baking contest as podiatric marketing to the community – which it is.

Jon Purdy, DPM, New Iberia, LA, podiatrist@mindspring.com

The key to successful practice and a fulfilling life is to have outside interests. You will become more productive and will find that your practice becomes streamlined and more successful. I make time for my family and also play guitar, blow glass, scuba dive and do group meditation. Work hard and play hard! Life is more than a foot. Go ahead, live a little and read about others that live and you will be inspired.

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

RE: Practice Websites (Michael M. Rosenblatt, DPM)
From: Steven H. Goldstein, DPM

I am in total agreement with Dr. Rosenblatt about the benefits of having a practice website. In today's world where more and more patients are Internet savvy, this is a good way of promoting one's practice. I have some ideas which I felt were very beneficial to share. Since I wanted to attract patients to my site, I decided to use a catchy name for my site rather than my own personal name. As I was trying to build my cryosurgical practice, I thought footfreezer.com would be far more beneficial than just using my own name.

Another idea is to ask you web hosting company how much it would cost to get a sponsored link on Yahoo or Goggle. For about $120/quarter I was able to get a link. Next, come up with a list of numerous "catch phrases" that patients could type into a search engine that would direct them towards your sight. Examples I used were heel pain, foot pain, neuromas, and cryosurgery, just to name a few. Adding pictures of you and your staff can also be helpful.

A final point is that when someone contacted my website, I would respond to their request the same day. You would be surprised how many patients could not believe that I was willing to respond that quickly. This concept was extremely successful in getting patients from all over the United States to make an appointment for a consultation. The amount of income generated was far greater than the cost to set up the site.

Steven H. Goldstein, DPM, Royal Palm Beach, FL, stevefootdr1@cs.com

MINNESOTA - IMMEDIATE OPENING

Well-established practice with 8 offices in the Minneapolis metro area seeking a highly motivated PSR 24/36 trained podiatrist for a full time or part time associate position. ABPS certified, qualified or eligible preferred. Excellent income potential with benefits including health insurance, malpractice insurance, relocation expense, association dues, license fees, hospital dues, continuing education expense. Possible buy-in or buy-out in future. Heavy emphasis on surgery and sports medicine with minimal RFC. Please e-mail CV to footandankledoc22@hotmail.com

PRACTICE FOR SALE - MINNESOTA

Minnesota-2 well established prime office locations for sale in the Minneapolis suburbs. Great income potential with large MD referral base .Can purchase one or both offices together. 175k gross/ each office. Owner will help with transition. Please e-mail minnesotadpm@live.com

ASSOCIATE POSITION - CALIFORNIA

Looking for OUTSTANDING 3-year residency-trained Dr. July 2009. This is the first Concierge odiatry practice in the U.S. Applicant MUST have been in top 10% of their class, Have excellent residency training and personality to match, {the total package}. This practice is about excellence and service. Contact. Ivar E. Roth DPM/MPH, ifabs@earthlink.net 949-650-1147

ASSOCIATE POSITION – ILLINOIS

Quality Podiatry Group provides quality services to residents at long term care facilities. We are currently offering full-time or part-time positions for motivated ethical podiatrists. Immediate openings available. If interested fax curriculum vitae to 312 225-9366 or e-mail feetwork@aol.com

ASSOCIATE POSITION – VIRGINIA

Well-established 2-office private practice in central Virginia, completely automated, modern, full scope of foot and ankle care. Position requires hindfoot/ankle reconstructive and trauma surgery experience. External fixation experience helpful. ABPS BQ/BC. Competitive base salary, incentive plan, malpractice, health insurance, retirement plan, vacation & other benefits. Partnership option available. Forward CV and letter of intent to: admin@vfasa.com

IMMEDIATE POSITION AVAILABLE TN/GA

We're in search of a motivated, well-trained DPM who is great with patients. Our well-established multi-doctor, multi-office practice is located in Southeast Tennessee/North Georgia. Must have Tennessee or Georgia license. Please reply via email to ikraus@sprynet.com

ASSOCIATE POSITION – NAPLES

Immediate opening for full-time associate position in SW FL. Surgical practice seeking PSR 24+ trained individual who is self-motivated and must be BQ/BC in Rearfoot and Ankle Surgery. Current FL license a plus for immediate start. Ilizarov or AO fellow a plus. Please email CV to: KLAMDPM@hotmail.com

ASSOCIATE POSITION AVAILABLE – OCEAN COUNTY, NJ

Seeking a full-time associate for well-established practice in Toms River. Searching for a hardworking, ethical and well-trained individual. MUST be willing to do all aspects of Podiatry. Competitive salary and benefits package. Immediate opening available. E-mail CV to NJFeet@aol.com

ASSOCIATE POSITION AVAILABLE- NEW YORK

Full-time associate position in our well-established Midtown Manhattan and Forest Hills practices. Well-rounded practice with hospital based surgery and all phases of podiatric care. We are seeking PSR 24/36 trained podiatrist with good surgical background. Compensation to also include malpractice expenses. Forward CV to slurie@papapc.net or Fax to # 212-753-3521

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-773-342-4201 FAX 773-486-3548-E-Mail sschneider@homephysicians.com Visit our website

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

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