The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

September 10, 2009 #3,645 Publisher-Barry Block, DPM, JD

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Congratulations to Keith Daniels , DPM of Flint, MI , winner of PictZar® Digital Planimetry Software - Wound Measurement on Digital Photographs (Value $850).

We encourage you to participate in this important survey at www.podiatrym.com/survey Completing this anonymous survey provides us with valuable data, which we will publish in the February 2010 issue of PM. It also makes you eligible to win thousands of dollars of valuable prizes. Enter by sending Question #43 (no answer necessary) to bblock@podiatrym.com along with your name and address.

This week's prize is registration to the 2010 Alaska Practice Management Cruise.  Learn about this once-in-a-lifetime adventure seminar by going to www.podiatrym.com/alaska (Value $495).

This is also your opportunity to vote for the next DPM and Non-DPM inductees into the PM Podiatry Hall of Fame. 

Laser Effective in Treating Onychomycotic Nails: FL Podiatrist

Unsightly toenail fungus has just met what could be its worst enemy. "Fungal nail, or onychomycosis, is probably one of the most common problems in podiatry," said podiatrist Dr. Eric Weinstein. It's also tough to fight. Dr. Weinstein has heard of all sorts of remedies.

Dr. Eric Weinstein

"I've heard Vicks Vapor Rub, Clorox, tea tree oil, and aloe leaves. You name it, people have tried it on their nails, but very few have any success. At the most, approximately 8 percent success rate with topical antifungals," said Weinstein.

Enter the Pinpointe Laser, cleared by the Food and Drug Administration in 2008. "The laser essentially kills any fungal debris underneath the nail instantly with the beam," said Weinstein. Every nail is lasered, even if it doesn't look infected. It takes 8 to 12 months to see the full results - the length of time for nails to grow out.

Source: KING 5 News [9/7/09]

Barefoot Running Not for Everyone: TUSPM Podiatrist

Podiatrist Howard Palamarchuk, director of sports medicine at Temple University’s Gait Study Center, says he believes that running shoes might not always be beneficial. “We encase our feet in a box, and those muscles never develop,” Palamarchuk said.  But he added: “As a medical practitioner who specializes in the foot, I’d say there are some people who should not even attempt to run barefoot.”

Dr. Howard Palamarchuk

These include diabetics and others who do not have full feeling in their feet (peripheral neuropathy), as well as people with certain conditions — including club foot, very high arches, or legs that differ in length — that prevent their feet from absorbing shock well.

Source: Karen Knee, Philadelphia Inquirer [9/13/09]

Alleged Unnecessary Bunion Surgery (New York)

Facts: On Feb. 11, 2002, plaintiff Susette Ryniec-Schilia, 51, a chemist, presented to defendant podiatrist, complaining of worsening pain in her right foot. Ryniec-Schilia had had pain on and off for five years. Defendant ordered an x-ray, diagnosed hallux rigidis and mild hallux valgus, and advised her that the only definitive way to treat the condition was surgery.

On March 14, 2002, Defendant performed a Waterman osteotomy with a chielectomy. Ryniec- Schilia's pain became severe three months later. Ryniec-Schilia sued defendant, alleging that he failed to treat her conservatively and that he negligently performed an unnecessary surgery. She said that he had not told her of any alternative to surgery.

Ryniec-Schilia claimed that defendant should have treated her first with orthotics, a shoe change, physical therapy, steroid injections and pain medication. According to her later treating surgeon, Dr. Michael Parentis, defendant should have operated only if those measures did not provide relief and even then should have performed only a chielectomy, not an osteotomy.

Defendant argued that he had properly advised the plaintiff of her options and that the surgery he performed was not unnecessary. He denied departing from any standard of care. He said that she had told him that her pain had recently become constant, which the plaintiff disputed.

Result: Verdict-Defendant

Plaintiff's Experts: Joseph Carbone, DPM; Rochester, NY; Michael Parentis, M.D.; Buffalo, NY Romanth Waghmarae, M.D.; Buffalo, NY; Ronald R. Reiber, Ph.D.; Buffalo, NY

Defendant's Expert: Charles Coyle, DPM; Rochester, NY Shari Withiam-Leich, M.D.; Buffalo, NY, Thomas Lombardo Jr., M.D.; Buffalo, NY

Editor's note: The full text of this report can be read  at: http://www.podiatrym.com/letters2.cfm?id=28735&start=1

Easy Hiring

Don’t be upset if your practice turns to a temp agency to ease the burden of hiring new staff. Recognize temporary assignments for what they are: auditions, for both you and the temporary workers.

Key: Look for workers who stay positive, upbeat and enthusiastic about whatever assignments you throw their way. If they take time to ask questions about your practice and to learn about the profession, that’s a bonus. If you also see them making friends and building a network within the workplace, consider making the arrangement permanent.

Source: Adapted from “Turn Temp Job Into More,” by Laura T. Coffey, St. Petersburg Times via Communication Briefings

RE: PSR-24 Discrimination

I have been denied staff membership at one hospital, and at another hospital I am unable to perform “rearfoot” surgical procedures. Their bylaws require 3 years of training. I currently perform numerous “rearfoot” procedures at other hospitals and believe my PSR-24 residency training was superior to most 3-year programs. I am board qualified in forefoot and rearfoot/ankle surgery. It was my understanding that a PSR 24+ did not become a true 3-year program until 2005 (PM&S-36). What can I do? 

Name Withheld

RE: Calcaneal Ostectomy and Fat Pad  (Chris Seuferling, DPM)
From: Multiple Responses

Wright Medical conducts an intensive seminar on the indications and merits of GraftJacket. I recently attended such a conference in Denver. GraftJacket has been recently used by podiatric surgeons to replace atrophic fat pads under the metatarsals as well as the heel with pretty excellent results. I would suggest contacting your local Wright Medical rep for further information.

Godfrey Viegas, DPM, Crystal Lake, IL, gviegas1234@sbcglobal.net

I think this would be a great case to use Podiasil (liquid injectable silicone), however, I believe it is currently only available in Europe. Stephanie Wu, DPM wrote an article on this topic following the work of Sol Balkin, DPM. Perhaps Dr. Wu can provide feedback on whether or not it will ever be commercially available in the U.S.
 
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com

This seems to be an excellent case for an AHB muscle flap if the patient is an acceptable candidate. I have used this flap many times in cases like this and they are very effective. So far, I have never had this flap fail. Of all the flaps that I do, this is one of the most reliable, especially if you can get a primary closure. Make sure that your vascular status is reasonable and that the patient is not a smoker (or can at least stop for a while).

Muscle Flap, Immediately Post-op

The incision is along the arch to harvest the muscle. The muscle has two main arterial supplies and the distal one can be tied off allowing the muscle to be rotated into the heel. This is now 3 years post sx with good padding and no recurrence.
 

After flap has been transferred, bringing an excellent vascular bed, and allowing healing by secondary intention.

I have used GraftJacket on patients with painful poor fat pad and associated bursa, etc. but never on a diabetic for the purpose of ulcer prevention.
 
Tip Sullivan, DPM, Jackson, MS, tsdefeet@msfootcenter.net
 

RE: Post Alcohol Injection Complication

This 75 year old male patient with a history of polio on his right side since a child was seen by a podiatrist in South Florida. He was diagnosed with a neuroma and received an injection of cortisone mixed with alcohol into the 3rd intermetatarsal space. I was consulted by the Internist after the damage was done.

Post Alcohol Injection Complication

Please, please be careful with alcohol injections; they are not benign. This patient will get a series of debridement, antibiotics, VAC therapy, and a skin graft. I am hopeful that the damage will be limited.
 
Bret M. Ribotsky, DPM, Boca Raton, FL, ribotsky@yahoo.com

RE: Leg Pain (Brent Rubin, DPM)
From: Michael McCormick, DPM

The symptoms and case history of this patient most closely resemble superficial venous thrombophlebitis. I have seen a good number of cases of this that have been sent to vascular labs where the primary concern and only pathology tested for was DVT and this pathology was missed. The primary complaint is almost always superficial tissue pain and mild swelling, and frequently occurs after airplane travel or extended periods of sitting in a car with the knees bent. The condition may actually feel worse with compression treatment due to mechanical compression of the inflamed veins and can be distinguished from arterial issues by having the patient walk and determine if they can perform their usual distance. If so, it's probably not an arterial issue.

Careful duplex ultrasound examination of the painful region will usually reveal the clotted vein. Calf muscle veins can also thrombose and although technically a DVT, will not present the acute danger level as a popliteal vein or femoral vein DVT and will spontaneously resolve with compression, walking, and aspirin bid. Ask about a history of familial clotting disorders to be sure that additional anticoagulation therapy isn't warranted.

Michael McCormick, DPM, Venice, FL, venicefootclinic@comcast.net

RE: Prescribing Pain Medicine to an Addicted Patient (David E. Gurvis, DPM)
From: Richard Gosnay, DPM, Elliot Udell, DPM

The scenario presented does not call for our quibbling about the interpretation of our scope of practice or the possibility of regulators harassing us. This medicine is being prescribed for narcotic addiction treatment, not foot pain. I have a fairly good imagination, but I can't come up with a justification for a podiatrist to treat narcotic addiction. (I also can't justify any other medical profession doing so when the patient sees a pain specialist.) And what kind of pain specialist treats addiction with high dose narcotics to be prescribed by a podiatrist? A pain specialist who has had his DEA license revoked? A pain specialist who has reason to believe that this is a particularly problematic patient? A kook?
 
I suppose it would be up to a jury to decide if the practice and associated podiatrists would be responsible in the event of an overdose. If I were on that jury, defense would be a tough sell. I use narcotics for acute and sometimes prolonged post-op pain. But some of these patients are much more complex than just foot and ankle pathology. Once I send a patient to pain management, I won't write for narcotics anymore. And I would never consider treating addiction in the first place because I am not trained or licensed to do so.
 
Richard Gosnay, DPM, Danbury, CT, glabroushead@gmail.com

The issue is not whether you agree or disagree that we should be able to prescribe opiods. In certain localities, there is a double standard. Pain management can prescribe them but primary care cannot, without subjecting themselves to potential trouble. As for the case I gave, there is nothing missing. I did help this physician in doing research to show that opioids are an option for sickle cell anemia pain, and he used these published papers in his defense.
 
You are correct that there seems to be something wrong if in certain geographic areas the only ones allowed to prescribe opioids for chronic pain are pain management specialists. 
 
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

RE: Destruction of Multiple Warts (Tony Poggio, DPM)
From: Jeffrey Kass, DPM

For clarification purposes, when Dr. Poggio states, "the choice of codes is based on the collective sum of warts treated," he is implying that this is irrespective of whether the warts are on one or both feet. In his question, Dr. Rameas was pointing out that he had treated some warts on the left foot and some on the right foot. This does not matter when dealing with this particular code as far as I understand it.
 
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com
 

OFFICE SPACE/ MRI RENTAL – NYC, LI

Turn-key space available, daily, monthly; East 60th off Park Ave, East 22nd St. off 3rd Ave, Hicksville and/or Plainview Long Island. JACHO-certified operating rooms available, as well as all surgical equipment and anesthesia. Extremity MRI Rental. Stark compliant. All exams read by board certified radiologist. Call for details. 516 476-1815

ASSOCIATE POSITION - DALLAS/FORT WORTH AREA

Seeking well-trained ABPS board certified/qualified foot surgeon for surgical practice with national foot/hand/orthopedic surgery group. Excellent salary/benefits. E-mail CV and cover letter to: slb99@pdq.net

ASSOCIATE POSITION - CHICAGO AREA

Join one of the most successful, long-established podiatry practices in the Chicago area, with excellent salary and benefits. We have an immediate opening for a full-time podiatrist in a multi practice location in Chicago. Must have two years of surgical residency. Please e-mail resume to fmassuda@footexperts.com

HELP WANTED! NEW JERSEY
 
Busy podiatry practice located in northern New Jersey looking for a full time associate for an excellent opportunity for employment!
Please E-mail resume to njfootdoc@hotmail.com

ASSOCIATE POSITION - FREDERICK, MD
 
Well-established and growing 2 office state-of-the-art practice located in medical/professional buildings. EMR, Digital X-ray, Ultrasound, DME provider, etc. Competitive Base Salary plus bonus, malpractice, health insurance, etc. PSR 24 minimum/Board Qualified or Certified with ability and desire to take ER call. If interested, forward CV to DOCSBNB@aol.com

ASSOCIATE POSITION – LONG ISLAND

Busy Wantagh, NY office. Motivated, preferably board certified, hard working, experienced in all phases of Podiatry. F/T, P/T hours available. excellent salary, call 516 242-7540 or Fax Resume 516 826-9036 or email jobke@aol.com

LOCUM TENENS POSITION – PHOENIX, AZ

Locum Tenens position available in West Valley Phoenix office beginning September 15th. Salary negotiable. One to two days a week in a friendly and casual office. Please direct all inquiries to drlaurel@cox.net

ASSOCIATE POSITION – NORTH CAROLINA

Very busy practice in Western North Carolina, seeking Full-time Associate with hospital and surgical training. If interested please fax resume to 828-252-2272 or e-mail to mfas828@aol.com

EQIPMENT FOR SALE - ORTHOTIC FABRICATION SYSTEM

Amfit Orthotic Insole Fabrication System with Footfax SL Contact digitizer- For Sale Machine, Laptop, rolling bag, small inventory of shoes, insoles, all cords, parts and hardware Asking $10k.OBO! Please contact Jeff at Jhunt@psbank.net for further information, pictures.

ASSOCIATE POSITION - NY (MID-TOWN MANHATTAN & WESTCHESTER COUNTY)

Multi-office, well-established medical/surgical practice with on premises OR, digital x-rays, vascular testing, sonogram, F-scan, bone density testing, fluoroscopy & NCV. Additionally, EMR with voice recognition charting coming soon, and many other perks are available. We are looking for personable, well-trained & well-motivated individual. Patient base available for immediate in-office productivity. If you are new or ready to change locations, contact us ASAP to discuss opportunities. Send resume and cover letter to terri.bobson@verizon.net

POSITION AVAILABLE IMMEDIATELY - IOWA

Looking for Board Certified/Board Qualified Foot and Ankle Surgeon to join a very busy hospital-based practice. We see over 6000 patient visits per year in the county hospital and take all lower extremity trauma call. Must be 2yr residency trained minimum, with trauma experience or willingness to learn. You will be joining a group of 4 dynamic, hard working podiatrists who enjoy great benefits, pay for performance options and a great Midwestern lifestyle. Please send your CV and letter of interest to: Dr. Denise Mandi, Section Chief, Foot & Ankle Surgery, Broadlawns Medical Center, dmandi@broadlawns.org

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.

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

ASSOCIATE POSITION – CENTRAL FLORIDA

Growing practice east coast of central Florida looking for full or part-time associate willing to buy into practice. PSR 24/36 Please contact: pfk4@yahoo.com.

PM News Classified Ads Reach over 11,500 DPM's and Students

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