The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

September 29, 2008 #3,360 Editor-Barry Block, DPM, JD

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TUSPM Podiatrist Provides Shoe-Buying Advice

Choosing shoes for children can sometimes be a challenge. Children often prefer fashion over comfort. Parents tend to weigh on the side of practicality and cost. All personal preferences aside, Kieran Mahan, D.P.M., a podiatrist with Temple University School of Podiatric Medicine, recommends looking for a shoe with some flexibility (the front of the shoe should bend slightly when walking) and a moderate amount of stiffness at the back (to support the heel). He prefers a supportive sneaker or Oxford because these shoe styles provide comfort and support in the classroom and on the playground.

Dr. Kiernan Mahan

Mahan also recommends choosing a shoe with breathable materials to prevent buildup of moisture inside the shoe, which can increase the risk of athlete’s foot. Children who select synthetic materials or shoes that don’t readily breathe should have more than one pair, then rotate their use to allow each pair to dry out thoroughly. Mahan discourages passing shoes down through the family or wearing someone else’s shoes because infections, like athlete’s foot or plantar warts, can be carried in the shoes and transmitted to the new wearer.

Source: WSOCTV.com [9/26/08]

Failure to Timely Diagnose Charcot Foot (New Jersey)

Facts: The plaintiff in her late 50s, a diabetic with peripheral neuropathy, contended that clinical signs including deformations in the bone, the collapse of the arch, an increase in pain and swelling and redness, should have led to a timely diagnosis of Charcot's Joints, a degenerative condition that can result in the breakdown of bones and tissues of the foot. The plaintiff also contended, that she was sent for a bone scan three to four months later and that the defendant should have realized that early stages of the condition were evident. The plaintiff maintained that if diagnosed after the bone scan, more conservative treatment modalities such as the use of a total contact cast would probably have enabled the condition to resolve in the absence of surgery and the implantation of hardware which will permanently cause increased pain and difficulties ambulating.

The defendant maintained that the clinical signs prior to the bone scan were consistent with diabetes and peripheral neuropathy and denied that the failure to diagnose the condition this time constituted a deviation. The defendant also contended that he recognized the early stages of the condition after the bone scan was taken and acted appropriately by prescribing a walking boot and referring her to her family physician.

The plaintiff underwent the surgery approximately one year later.

Result: The case settled prior to trial for $ 300,000.

Plaintiff’s Expert: Christopher Connor, DPM, Cherry Hill, NJ

Source: New Jersey Jury Verdict Review & Analysis, Volume 29, Issue 2

Bush Signs Legislation To Expand ADA Protections

President Bush on Thursday signed legislation that expands protections under the Americans with Disability Act, the AP/Kansas City Star reports. Lawmakers introduced the legislation in response to a series of Supreme Court decisions, which took effect in 1990, that limited the scope of ADA. In cases heard in 1999 and 2002, the Supreme Court ruled that individuals who could compensate for their disabilities with medications, medical devices or prosthetics did not qualify for protection under ADA.

The legislation states that the Supreme Court erred by "eliminating protection for many individuals whom Congress intended to protect" under ADA. In addition, the legislation states that courts should not consider the effects of "mitigating measures" -- such as medications, hearing aids, and artificial limbs -- in the determination of a disability, and that "an impairment that is episodic or in remission is a disability if it would substantially limit a major life activity when active."

Source: AP/Kansas City Star via American Health Line, [9/26/08]

The Power of One Page

Set brevity as your goal whenever you write. Train yourself to think in terms of one-page letters and on-screen e-mail messages. The shorter your message, the more likely your recipient is to read it and to understand it clearly.

What if you simply cannot limit your message in that way? Add an introductory page that provides an overview and shows the reader where to look for more details.

Source: Adapted from Ten Tips to Get Busy People to Respond to Your Messages by Bonnie Budzowski

Editor's note: This is the reason that PM News sets a 300-word limit on posted letters.

Query: Painful, Stiff Toes

I have a 28 y.o. female patient who presented three months ago with the chief complaint of painful swollen, stiff toes 2,3,4 left foot only. She experiences immediate pain and discomfort without any apparent cause. She recently stopped taking birth control pills and health is completely unremarkable. We are now 6+ months and symptoms are not improving. Her toes are swollen with limited movement available at both the PIPJ and DIPJ. Pressure indentations are noted from pressure within toe box. I advised her to take additional digital radiographs today for comparison but, opted to start with labs first. I ordered 1. Complete metabolic panel, 2. ESR and 3. RA. Any additional advice would be greatly appreciated.

Harry Cotler, DPM, Soldotna, AK

Query: Thank-You Notes and HIPAA

If one of my patients refers a friend, can I send the original patient a thank-you letter naming the new patient that she sent or is that a HIPAA issue?

Adam B. Klein, DPM, Lynbrook, NY

Editor’s comment: PM News does not provide legal advice. The purpose of HIPAA is to protect the privacy of personal health information (PHI). Assuming a patient indicates that he or she was referred from a patient of yours, no privacy problem is at issue since the new patient received your name from your existing patient. Naturally, your letter should be limited to a thank-you and not discuss any medical of other PHI matter concerning the referred patient.

RE: Nerve Conduction Testing In Office (Rory Cohen, DPM)
From: Greg Mowen, DPM

I have been using Brevio NCS system for about 5 yrs and have been only fairly satisfied. I like the reimbursement and low cost of performing the exam but still I am not always confident of the results. I think the error rate can be high with Brevio. To be fair, in the literature there are many references of high error rates with any NCS in the lower extremity due to the small diameter of many of the nerves we are testing. That being said, when the test is combined with a good clinical exam and good quantitative sensory testing then often a more complete picture of a nerve problem is formed.

Greg Mowen, DPM, Margate City, NJ, gregmowen@comcast.net

RE: Onychodystrophy (Dale Smith, DPM)
From: David E. Gurvis, DPM

I had also thought the discoloration in the nails pictured was possibly consistent with that observed from dark nail polish use. The recommendation given to allow the discoloration to outgrow is good, as is the use of a base coat to prevent further discoloration.

Two tricks I have also used are Polident soaked or fresh squeezed lemon juice soaked cotton ball compresses on the nail plate several times a week. This often will bleach out the discoloration and does not seem to damage the nail plate.

David E. Gurvis, DPM, Avon Podiatry, deg1@comcast.net

RE: Network vs. Non-Network (Mark Levine, DPM)
From: Brandon Macy, DPM, Bob Kornfeld, DPM

Of course, the easy answer is to stop participating in these plans which pay a fraction of what we used to get paid 15-18 years ago. Sadly, it is also not practical, especially since it would be a major undertaking to get all/most of the practitioners in a given area to sign on. It is to Dr. Frankel's credit, along with the remaining members of that group, that he was able to put together one such group in Illinois.

I find it interesting that we have been told over the years that our charges must be the same, regardless of a patient's insurance coverage. Insurance companies, on the other hand, are allowed to pay at a different rate, according to who is a member of the plan, along with their individually contracted rate. Doctors and hospitals in more rural areas have more leverage to negotiate, whereas in the more concentrated areas of service, there is absolutely no negotiating leverage unless you are a part of a large group.

It would seem reasonable to me that insurance companies pay based on the same limit regardless of network participation, but they'd more likely just drop the out-of-network payment to 30 cents on the dollar as well. It is hard enough to get one insurance company to pay for SOME 1st MPJ implants, no sense in trying to get them to treat everybody fairly and equitably. And their lobbyists have deeper pockets than the medical profession, so appropriate remedial legislation isn't coming anytime soon, either.

Brandon Macy, DPM, Clark, NJ, bmacydpm@comcast.net

Editor's Note: Dr. Kornfeld's extended- length letter appears at: http://www.podiatrym.com/letters2.cfm?id=22219&start=1

RE: Tuna Fish on Ganglionic Cysts!

Today, I had a patient in to review her MRI of a ganglionic cyst over 1.5 cm in diameter on her lateral rearfoot. She stated that the technician taped what looked like a "fish oil" pill as a marker over the ganglion before the scan, and over the next several hours the ganglion just started getting smaller.

Thinking the fish oil had something to do with this, she then told me she has been packing the area over the cyst daily with canned tuna fish, and it has been working. Today, the cyst that has been bothering her for months is gone. Yes, there was an odor to her foot. Something to think about the next time you bite into that tuna sandwich.

Nick Przystawski, DPM, Leesburg, FL

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ASSOCIATE POSITION – CONNECTICUT

Full or part-time position available for a podiatrist licensed in CT. This practice encompasses wide variety of patients including Diabetic wound care and general podiatric care. Must be willing to cover all aspects of the practice including nursing homes and house calls. Please e-mail CV to RPMDPM@aol.com

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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 full-time podiatrist in a multi practice location in the Chicagoland and Northwest Indiana area. Must have two years of surgical residency. Please e-mail resume to d-kitchens@footexperts.com

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