The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

December 08, 2009 #3,721 Publisher-Barry Block, DPM, JD

A service of Podiatry Management http://www.podiatrym.com
E-mail us by hitting the reply key.
COPYRIGHT 2009- No part of PM News can be reproduced without the
express written permission of Kane Communications, Inc.

Correction

In the December 7th issue of PM News, we published the photograph of a different Dr. Scott Clark. Here is the correct photo.

Dr. Scott Clark

CA Podiatrist Discusses Remedies for Tired, Aching Feet

"Many fashionable shoes now are narrow and pointy at the toe," says podiatrist Dr. Carolyn McAloon, adjunct clinical professor at the California School of Podiatric Medicine at Samuel Meritt University in Oakland. "They can cause pain and calluses and redness in the toes." All that, she says, comes from squishing feet into too-small, oddly shaped spaces. High heels put immense pressure on the ball of the foot, which can pinch nerves. Toes can develop corns from rubbing against the shoe. "After a while," McAloon says, "the toes are going to complain."

Dr. Carolyn McAloon

When they do, make amends with this ritual: Soak feet in warm water and mineral salts. That soaking, McAloon says, helps increase circulation, soothe tired muscles and soften hard calluses, which can be removed with a pumice stone. Finish with a hydrating cream. Then, do some stretches, such as rotating the ankles and flexing and pointing the toes -- this will help stretch calf muscles and Achilles tendons, which can get stiff (those stretches can also be done while sitting with high heels on). Finally, ice the feet to reduce any swelling.

Source: Jeannine Stein, Los Angeles Times [11/22/09]

UA Podiatrist First to Perform New Skin-Grafting Procedure

Surgeons from the University of Arizona Department of Surgery Southern Arizona Limb Salvage Alliance (SALSA) performed a first-ever “micrografting skin expansion” procedure on a diabetic foot wound at University Medical Center last week. The procedure, designed to replace certain types of skin grafting, takes a much smaller amount of grafting than previously required.

Micrografting Skin Expansion

The procedure involves taking a small skin specimen from the patient. Then, using a special device, the skin is finely minced and spread on the wound, covering the surface many times wider than the skin sample itself.

Dr. David Armstrong

Micrografting skin is not a new technique, but the procedure performed by David G. Armstrong, DPM, PhD, UA professor of surgery and SALSA director, and his vascular surgery team was the first ever using a technique made possible with a new device developed by Elof Eriksson, MD, PhD, of Harvard University. “In many cases, we can take a postage stamp-sized piece of skin and expand it to 10 or more times its previous area,” he said. “We’re excited to see what the potential of this new procedure brings our highest-risk patients.

Editor's Note: PM News is proud to present excerpts from Meet the Masters.

Bret Ribotsky: What is your greatest challenge in podiatry?

Dr. Guido LaPorta

Guido LaPorta: The greatest challenge in podiatry is to continue to improve the level of education at the podiatry colleges so that graduates are more ready for the residency experience. I am still at a loss as to why most graduating podiatry students have not been inundated and trained extensively in the history and physical.  Some say that a total history and physical is not an absolute necessity for much of what we do.  My answer is that, in the real world, when you function in a hospital, not being able to a history and physical sets you apart. Everybody else can do it: the admitting nurse, the physician assistant, the patient's own physician, the oral surgeon, etc. The only ones that cannot seem to do H&Ps are podiatrists, and that still bothers me. I think that it is one area that the colleges need to stress more.
 

Dr. Kerry Zang

Meet the Masters is broadcast each Tuesday Night at 9 PM (EST). This week's show features podiatric surgeon and inventor Dr. Kerry Zang . You can register for this event  by clicking here

Query: Heel Pain in Marathoner

I saw a healthy 40 year old gentleman yesterday with severe heel pain. He has been training for the last 12 months to run a marathon which is Saturday December 12. The heel pain began five months ago, but has recently escalated over the past two weeks. He had severe pain after his last long-run, 10 days ago. He has been wearing sturdy OTC insoles, professionally-fit sneakers in good condition, has done stretching, and is using a Strassburg sock. After refraining from running for one week, he attempted to run two miles yesterday. He relates mild start-up sorenesss, but was able to complete two miles uneventfully. He had significant post-static pain. He has no significant medical history and takes no regular medications. His exam reveals posterior medial tubercle pain and pain extending along the medial and central bands of the plantar facsia in his midfoot.  He has a neutral foot and the x-rays are unremarkable.

I have had a candid discussion with him reviewing his options (including postponing his run and considering a different marathon in several months), risks of treatments, and reasonable expectations.  He is determined to run. I have placed him in a CAM walker and started physical therapy. I prescribed a Medrol dosepak and discussed re-assessing the Wednesday before race day and probably using an injectable steroid at that time. I was hoping for some feedback from others who have had patients in similar situations. I would also be interested to get opinions about the most effective timing of a soluble steroid injection for this patient. 

Scott Whitman, DPM, Charlotte NC

RE: Critical Limb Ischemia (Wm. Barry Turner, BSN, DPM)
From: Multiple Respondents

In treating critical limb ischemia, you should also have a cardiologist and a cardio-vascular surgeon involved. To answer your question, we use Plavix and Pletal. That combination is usually prescribed by the cardiologist.

Neil Burrell, DPM, Beaumont, TX, nburrell@gt.rr.com

I would say that there is a good reason that you should not prescribe either medication alone or in combination.  In my experience, that would best be handled by another physician.  I would work closely with the patient's vascular surgeon and/or PCP to manage this aspect of the patient's medical care. This is a more responsible and safer option for the patient and the podiatrist.

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

In our office, we don’t treat a patient’s critical limb ischemia. We treat patients with it. Those patients should be treated for their ischemia by a vascular surgeon and should have regular check-ups by them, (or at least, very regular suggestions in your office notes that those patients should seek consultation from a vascular surgeon.) Certainly, start the ball rolling with orders for non-invasive vascular testing and then follow up with a vascular consultation. Even an MRA, CTA, or CO2 Angio would be appropriate, but again, be aware that those with LE vascular issues could certainly have similar issues with their renal arteries, and thus, careful evaluation of renal function is important prior to any dye being used for some of these studies. The last thing you need is this patient also going into renal failure with the study.

It is likely that any reviewer looking at a case where a podiatrist or any other non-vascular specialist was treating ‘critical limb ischemia’ without the training or ability to intervene, whether it be with stents, bypass, etc, I doubt would turn out ok. Obviously, if after appropriate thorough evaluation by vascular, with clear documentation that no surgical or interventional options were available for that patient, it seems reasonable that both drugs could be used, but I would still defer that to vascular to prescribe. Sorry, I am not saying we cannot handle these issues, but not very realistic in the environment we live in, that is if you want to practice for a lot longer or have a lot more time on your hands and the staff to deal with the complexity of what it entails to manage these patients. 

David E. Samuel, DPM, Springfield, PA,  desamuel@comcast.net
 

EBM (Robert Kornfeld, DPM, Michael Turlick, DPM)
From: Elliot Udell, DPM, Dwight L. Bates, DPM

I want my family's doctors to practice evidence-based medicine as taught in "Evidence-Based Medicine--How to Practice and Teach EBM" by David L. Sackett, Sharon E. Straus, et al. If everyone would read this delightful little book, we could be sure that we are all talking about the same thing. This would eliminate some of the hostility in our discussion. 

Dwight L. Bates, DPM, Dallas, TX, dlbates04@yahoo.com
 
Dr. Kornfeld makes a good point when he asks: "Is your idea of medical practice to perform treatments that are mandated by EBM and not your clinical judgment?"
 
Dr. Turlick also makes good sense when he writes: "If the same panel reviewed the effectiveness of treatments for verruca, it is likely that they would find very little level-1 evidence for the vast majority of treatments for pedal verruca."
 
So, what value does evidence-based medicine have in clinical practice? A great deal. Theoretically, 100% of the way we practice should be based on medical evidence. The problem, however, deals with the validity of what we call "evidence." We clinicians practice with a handicap. Not all of the evidence on any medical issue exists. In many cases, the data published on a particular treatment is not clinically decisive. There are often conflicting findings coming out of different research centers. Not every important paper gets published, and there is often no funding to do research on techniques that don't lead to the creation of a patented pharmaceutical. Hence, we would all love to say we practice evidence-based medicine but it may not be in any of our lifetimes that we will see decisive research on every facet of every disorder that we treat. This, however, does not mean that we throw the baby out with bath water. We use the best data that is available at the moment that we are treating a patient to help us make our best clinical judgments. 
 
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

RE: Late-Arriving Employees (Name Withheld)
From: Multiple Respondents

Chances are that your employees are abusing their freedom because they can. What is the consequence for arriving late? Sounds like there is none, so the solution is simple. Develop and implement a policy (if you don't already have one) that deals with tardiness and along with it - disciplinary actions for non-compliance. I'm understanding (from the excuses comment) that you already know they are arriving late, so a time clock is not telling you something you don't already know. A time clock is only going to record their tardiness, not manage it. YOU need to do that.

Lynn Homisak, PRT, Renton, WA,  lynnprt@msn.com

Fire them. Problem solved. I also have a small office. I have three women who work with me. When each of them was hired I had very few conditions. They had to: 1) be nice to the patients. 2) be reliable - which meant be on time and not miss work. Two of my staff have been with me about 10 years; the third we picked up about a year ago. Everyone is on time and courteous to the patients. I am constantly being complimented on how nice the girls are in the office.

In this economy, there are plenty of people who would love to work. If employees come in late, they don't respect their job or you. 
 
Jeffrey Kass, DPM,  Forest Hills, NY, jeffckass@aol.com

Employee accountability, and the ability to track it are the keys to helping ensure accuracy and effectiveness. There are many low-cost electronic time-keeping systems available. I don’t have one to promote, but a simple online search should be all it takes. Most of these can be used in conjunction with accounting software and payroll services. It also gives you a great way to track time off for vacations and sick days.

It sounds like all you need is the simple function of requiring them to swipe in with their time cards. There are a number of ways to make this a positive addition to the practice. With this type of system, you can eliminate confusion as to how much time off an employee has left on an annual basis. This will also eliminate any misunderstandings concerning time worked.

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

RE: Variations of Practice Patterns in Podiatric Medicine (Michael Turlik, DPM)
From: Shay E. Fish, DPM

Guidelines have their place in medicine. However, I don't think cost-reduction necessarily follows. "Guidelines" frequently produce increased consumption (cost) in third-party payer systems. More likely, a reduction might occur if we were all paying for our own "routine" guidelines, just as we do for home and auto. The politics (shifting from a "saves lives" to a "saves money" focus) underscores what happens when healthcare is administered by government. The future "judgment' referred to by Dr. Turlik may be acceptable for government or insurance goals; but the public's judgment is a reflection of the personalized service we provide to them, which requires a willingness to practice independently.

My prediction is that the money allocated by the Obama administration/Congress (especially when determining "routine" guidelines) will be an exercise in politics. The more apt use of that money would be in determining the effectiveness of government. The money saved by avoiding more failed, politically-engineered experiments might be used to fund high risk health insurance pools for those who are truly destitute.
 
Shay E. Fish, DPM, San Antonio, TX, fishdpm@aol.com

RE: Improper Fixation for Surgery (Jury Verdict Reporter)
From: Jeffrey Kass, DPM

I would like to commend Drs. Wolf and DeLauro for their defense work. I can read these jury verdicts 1,000 times and not understand why some DPM's sell out their own. I can understand it if there was clear-cut malpractice, which I didn't feel this case had.

I do feel that plaintiffs' experts should be held accountable for "testimony for the sake of money" that is not 100% accurate.
   
Jeffrey Kass, DPM, Forest Hills, NY, jeffckass@aol.com

RE: Healthcare Reform (Joseph Borreggine, DPM)
From: William Reider, DPM

Joseph Borreggine, DPM in the article Health Care Reform: Another View (PM Nov/Dec 2009) states that "the country has the best healthcare in the world." This is certainly not for the 47 million people who lack healthcare insurance. He correctly states that America's healthcare industry's costs represent 17% of this country's gross domestic product (GDP). This is much too high and is unsustainable. In other developed countries their GDP runs about 8%.
 
He states that the American Medical Association is in the process of developing ICD-10 with the federal government to be implemented in 2012, implying that this is undesirable. The alternative would have physicians out of the process; a sure recipe for disaster for the medical professions.
 
Podiatric medicine has always advanced by being part of new healthcare systems and regulations. The APMA, like the AMA and the American Nurses Association must swim with the tide and not against it. 
 
William L. Reider, DPM, Boca Raton, FL, Wlrdpm@aol.com

ASSOCIATE POSITION - NORTHERN VIRGINIA/DC SUBURB

Excellent associate practice opportunity leading to partnership for PSR 24-36 foot and ankle surgically-trained physician. Currently 4-doctor/2 office practice in fast-growing area, expanding to 5 doctors. Hard working, personable, highly-motivated individuals needed. Great opportunity with excellent salary and benefits. No nursing homes. Top hospitals. Fax CV with references to 703-491-9994

ASSOCIATE POSITION - HUDSON VALLEY, NY

Excellent opportunity for a three-year surgically trained foot and ankle physician. We are a high-volume, diversified, multi-office practice utilizing state-of-the-art modalities. Ample growth opportunities for a personable and highly-motivated DPM with ability, and a desire to teach and take ER call. If interested, please forward CV to: healthyfeet4ever@yahoo.com

ASSOCIATE POSITIONS - INDIANA/OHIO

PrimeSource Healthcare is a leading provider of mobile, on-site healthcare services at long-term and skilled nursing facilities. Our exceptional growth has created an immediate need for traveling, independent contractors of podiatry services in Indiana/Ohio. Earn between $175k and $225k per year. E-mail CV to kwright@pshcs.com. Visit us at pshcs.com.

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 f-massuda@footexperts.com

ASSOCIATE POSITION - NASHVILLE TN

Excellent practice opportunity-associate leading to partnership for PSR-36 trained physician. Well-established and growing state-of-the-art practice located in Nashville area. Hard-working, personable, highly-motivated individual needed. Bilingual-Spanish/English a huge plus.  Great opportunity with excellent salary and benefits. If interested, forward CV to NashvilleFootDoc@gmail.com

PRACTICE WANTED- NYC/LI AREA

I am an ABPS board certified podiatrist seeking to purchase a well established practice. I am looking for the current practitioner to help with the transition. All offers will be considered. Complete confidentiality will be upheld. Please contact poddr45@yahoo.com for more information. This advertisement is not affiliated with a broker.

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

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.

ASSOCIATE POSITION- TAMPA BAY AREA, FL 

Excellent opportunity for a hard working, ethical and outgoing podiatrist to join a vibrant, successful and growing podiatric medical and surgical practice. A Florida license and a minimum 2-year residency are required. Salary commensurate with training plus benefits. Email CV to podiatryfl@yahoo.com

PRACTICE FOR SALE - CENTRAL SOUTH CAROLINA

Practice grossing $400,000 annually based on one full-time doctor with two offices. Surgery is currently about 10-15% but can easily be increased. Medicare makes up 52% of revenues. May be able to take over practice with no money down. Interested parties email to footdocsc@gmail.com

SEEKING ASSOCIATE - MIAMI FL

Buy-in and purchase if you are interested. Well-rounded practice (EMR, Digital X-R) seeing 250+ pts/wk .30 yrs same location. Competitive salary +benefits + incentives. I am winding down my practice after 30 yrs. Will feed you my surgical load until you generate your own. Send resume to doctorinhialeah@aol.com

PODIATRISTS CHICAGO/NW IND/BALTIMORE/WASHINGTON, DC

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 Jake Shimansky, Director of Physician Recruitment. Phone-773-342-5221 FAX 773-486-3548-E-Mail jshimansky@homephysicians.com www.homephysicians.com

PM News Classified Ads Reach over 12,000 DPM's and Students

Whether you have used equipment to sell or our offering an associate position, PM News classified ads are the fastest, most-effective way of reaching over 12,000 DPM's. Write to bblock@podiatrym.com or call (718) 897-9700 for details. THIS OFFER DOES NOT APPLY TO BUSINESSES PROVIDING PRODUCTS OR SERVICES. Note: For commercial or display ads contact David Kagan at (800) 284-5451

• To Post a message, send it to:    bblock@podiatrym.com
• Notes should be original and may not be submitted to other publications or listservs without our express written permission.
• Notes must be in the following form:
  RE: (Topic)
  From: (your name, DPM)
  Body of letter. Be concise. Limit to 250 words or less). Use Spellchecker
  Your name, DPM City/State
• Subscribers are reminded that they have an ethical obligation to disclose any potential conflicts of interest when commenting on any product, procedure, or service.