The Voice of Podiatrists

November 06, 2006 #2,733 Editor-Barry Block, DPM, JD

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CA Podiatrists Evaluate $15 Starbury Basketball Shoe

The lavish ride is somewhat out of sync with the radically affordable $14.98 Starbury One basketball shoe Stephon Marbury is promoting. Dr. Bob Baravarian, chief of podiatry at Santa Monica-UCLA Medical Center. At the Foot & Ankle Institute in Santa Monica, where he’s co-director, Baravarian takes the shoe for a spin in the waiting room. Hopping around in blue scrubs, Baravarian jogs a few laps down the hall and then comes back into the room. “I’ve really been wanting to try these out,” he says.

Dr. Bob Baravarian

He sits down, takes off the shoe and examines it closely. He puts one hand on the toe and the other hand on the heel and gives it a good twist, like a dish rag. His colleague Dr. Gary Briskin, co-founder of the institute and an assistant clinical professor in the School of Medicine at UCLA, pops in and tries on the shoe next. He then takes it off and gives it a good twist as well. Apparently twisting a shoe is like thumping a watermelon. The way it twists tells a lot about the stability. Baravarian finds the shoe to be a little soft, though Briskin finds it “a lot soft.” That’s a key point. The softer, or more flexible, the shoe is, the less support it will provide.

Dr. Gary Briskin

The high degree of torsion could cause pronation problems for people with low arches, Baravarian says. Pronation, a condition in which the ankle turns inward, can cause bunions, tendinitis and plantar fasciitis over time. But he says a simple fix for this is to buy a stiff insole, available at sporting-goods stores.

Source: Janet Cromley, Los Angeles Times, 11/5/06

Medicaid Reimbursement to “Inch Up” in 2007

Next year -- for the second straight year -- at least two dozen states will increase their Medicaid reimbursement rates to doctors, a departure from years of stagnant pay. These states will provide an average rate increase of 2% to 3% overall, according to Vernon Smith, PhD, one of the authors of an annual 50-state Medicaid survey released in October by the Health Management Associates and the Kaiser Commission on Medicaid and the Uninsured.

At least 24 states are increasing rates in the upcoming fiscal year, with three undecided. In 2004, only nine states increased Medicaid payment rates, Dr. Smith said. Of those nine states, three are increasing rates for 2006 and 2007, two increased rates for 2006 only, and two are increasing rates for 2007 only.

The states upping their rates are generally applying them across the board to all physicians and others, unlike previous years when most targeted the increases, Dr. Smith added. No states were planning Medicaid cuts when the survey was conducted in the summer -- also a first since the initial survey report in 2002. Still, in many jurisdictions, even a large across-the-board jump isn't enough to compensate for years of level or reduced payment rates.

Source: Doug Trapp, AMNews [11/6/06]

Query: The Use of ESWT for the Treatment of Painful Neuromas

I have had three patients with painful intermetatarsal neuromas who were not responding to injection therapy, orthotic therapy, and physical therapy. One was non operable because of medical reasons and the other did not want surgery. The presence of all lesions was confirmed not only with physical examination but with MRI. We tried extra corporeal shockwave therapy and in all three cases the patients became symptom free. Has anyone else tried ESW for the treatment of neuromas? Three cases does not constitute a major study. I am wondering if anyone else has data on this.

Elliot Udell, DPM, Hicksville, NY

Query: Indocin

Has anyone else having scripts for Indocin, Indocin SR, or indomethacin generic filled for their chronic and acute gouty patients. I have been advised by numerous pharmacies that the drug is no longer available and is not in production as a brand or generic substitution. I have tried contacting Merck and Forte pharmaceuticals who hold the rights to the drugs, but I have l received no answer.

Michael Felicetta, DPM, Toms River, NJ

RE: Fentanyl (Duragesic) Patch (Charles Morelli, DPM)
From: David M. Schwartz, DPM, RPh

Fentanyl (Duragesic) Patch

Long-acting narcotic opiate analgesics should not be used in acute pain settings. The fentanyl patch, lasts approximately 72 hours and takes approximately 8 hours to have full analgesic effect.

The acute post-operative perils of these pharmacokinetic and dynamic properties include a lack of analgesia immediately post-operatively, and risk of over-narcotizing, resulting in respiratory depression in an opiate naive patient. This is especially dangerous if this happens after the patient leaves the monitored healthcare setting.

Similar to Oxycontin, long-acting narcotics should be used in chronic pain treatment settings, with short acting opiates for breakthrough pain.

David M. Schwartz, DPM, RPh, Rockwall, TX, txfootdr@yahoo.com

RE: Retired Doctor Writing Prescriptions For Family Members
From: Multiple Respondents

In New Jersey any podiatric physician who is retired CANNOT write for any prescription. Without an active license you donot carry malpractice and therefore you are in violation. A reprimand and severe fines are imposed.

Jim Ricketti, DPM, Former Member, NJ State Board Of Medical Examiners, Hamilton Sq, NJ, drj4foot2002@netscape.net

In Tennessee, there is a state law saying you cannot prescribe any drugs to a family member, except in extreme emergency. In the past six months, the state board has fined and reprimanded a podiatrist for prescribing allergy meds to himself and birth control pills to his wife because it was not within his scope of his practice. The law is very strict in this sense. Self and family prescribing here has become a big focus of state investigators.

Name Withheld

RE: Staff Dating Policy (Richard Boone, Esq., Sam Bell, DPM)
From: Michael M. Rosenblatt, DPM, James M. Petko, DPM

While our staff is in our office working for us (all), we expect and define a certain "standard" of behavior that includes everything from bathing regularly and wearing deodorant, to non-disclosure of private patient file data.

But there are limitations. Certainly, as treating doctors, we deliberately limit our OWN contact with patients or previous patients and the question remains: "Do staff also have the same restrictions we have?"

I think the answer is no. That said, most staff members don't really understand the ramifications of dating or socially seeing patients or previous patients. For example, they don't realize that a "disgruntled" patient can sue you, even if their anger has nothing to do with your own treatment.

I think it is possible to "discourage" this kind of interaction without rejecting it entirely. To me, that is the best balance. Just be sure your staff understands that what they do reflects on you as much as them, even on off hours.

Michael M. Rosenblatt, DPM, San Jose, CA, ROSEY1@prodigy.net

The issue about staff dating patients is about maintaining healthy professional boundaries. Like it or not, that employee is an extension of you and the practice. This is the problem. Patient A is status-post reconstructive surgery in your practice and is having difficulty with the foot for whatever reason. What if your staff member who recently became involved is not so good in the personal relationship department and the relationship falls apart. More relationships fail than succeed when starting.

Regardless, it's not uncommon in break-ups to have one of the parties become angry because they feel they've been mistreated.Now you have a problem. A patient working through a complication in surgery or treatment stresses the patient and the doctor. It's not inconceivable the patient may decide to go elsewhere because they feel uncomfortable crossing paths with the staff member.

An unhappy patient, no matter what the reason, is a potentially dangerous patient. Transference is a very common human response in many relationships. Person A does you wrong, and now you take it out (consciously or unconsciously) on person B. This is Psychology 101. You don't want the doctor to be on the receiving end of that transference. How about the issue of loose lips, do you really want that patient knowing some of your personal foibles, information that staff members inevitably pickup after working with you for awhile? Not good, it diminishes you professionally.

My office policy is no dating allowed. When I hire, I look the employee directly in the eye and I make it very clear that " I strongly discourage dating and/or fraternization with patients outside the office setting because it creates problems for me and the practice. Is this a problem?" Regardless of the issue, I advise the staff person, if you create a problem for me or the practice, I will fire you. A good hire 'gets it'. I've had no problems.

James M. Petko, DPM, Falls Church, VA., footdoc@erols.com

Ed Note: This topic is now closed

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HOUSE CALL PRACTICE OPPORTUNITY- CHICAGO / NORTHWEST INDIANA

Chicago-Home Physicians specializes in house calls to the elderly homebound. Full and part-time positions available in Chicago/Northwest IN. Competitive Compensation, including malpractice. Contact Scott Schneider. Phone-773-292-4800. Fax-773-486-3548. E-mail sschneider@homephysicians.com www.homephysicians.com

PSR-24 RESIDENCY POSITION SOUTHEASTERN MI

Available for recent graduates or former PPMR/RPR or PSR-12 residents. this is a major teaching affiliate of Michigan State University college of Osteopathic Medicine and serves 17 residency and fellowship programs. Active podiatric clinics in wound care, limb salvage, foot and ankle surgery, medicine and orthopedics. competitive salary and benefit package. meded@pohmedical.org

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