The Voice of Podiatrists

Serving Over 10,000 Podiatrists Daily

December 10, 2007 #3,113 Editor-Barry Block, DPM, JD

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Foot Surgery Requires The Right Procedure and the Right Surgeon: NY Podiatrist

The proper workings of the foot must be preserved or a doctor could do lifelong harm to a patient. "The foot has to function," says Stuart Mogul, a podiatric surgeon at Lenox Hill Hospital in New York City. "That's the No. 1 thing. The foot has to bear and transfer weight, and it has to last a lifetime." But Mogul says that there are many situations in which a foot can be operated upon safely, without a negative effect on the foot's function.

Dr. Stuart Mogul

And he says that just as important as choosing the proper procedure is choosing the right surgeon. Patients, he says, must do their homework in order to ensure that they trust their feet to a qualified expert. "They have to be very well-versed in orthopedic podiatry in general," Mogul said. "Now that it's out there, though, many people are raising up their hands and saying, 'I can do that too.'"

As a result, Mogul says, up to 10 percent of his practice is revision work, correcting the mistakes of prior foot surgery. "If the function of a foot is sacrificed, certainly pain -- and possibly long-term pain -- can be a problem. The patient certainly has to understand, if it is a cosmetic procedure, what the risks are," he said.

Source: ABC News [12/6/07]

Socks Make Ideal “Stocking Stuffers” – NY Podiatrist

While hanging up those stockings by the chimney this year, why not make one just for those typically neglected “stocking stuffers”…your feet? That’s the advice of Dr. Robert Rampino, president of the New York State Podiatric Medical Association representing over 80% of the podiatrists in New York State.

Dr. Robert Rampino

There are tons of fun socks on the market today, and many are below $10. For the sports person, nothing beats socks geared to the particular activity. Long socks for under riding boots make it “hot to trot” in the winter months. And hot-pack inserts for snow-shoes or skiers are a hot idea as well….For runners…socks to “wick away” the moisture beat wool for winter jogs. Speaking of running….runs happen…Give the women on your list everyday pantyhose or silky dress stockings to replace those that are “run” out.

Malpractice Case Challenges IA Podiatrist’s Qualifications

Daniel Day, of Dubuque, IA seeks monetary damages from Finley hospital, alleging it was negligent in granting staff privileges to Dr. Michael Arnz, a Dubuque podiatrist. Arnz was once a party to the case, but he has since been released following a confidential settlement.

The podiatrist used a circular frame device in July 2004 to stabilize Day's foot following a surgical procedure to correct a foot deformity caused by Charcot-Marie-Tooth disease, a neurological disorder that can cause damage in the extremities.

"Arnz was not board-certified in podiatry at this time," said Day’s attorney Timothy S. White, who asked the jury to consider evidence that Finley did not adequately ensure Arnz was competent to perform a procedure involving a circular frame, a fixation device.

Finley's attorney, Connie M. Alt told the jury Arnz was well-qualified at the time of the Day surgery and that he was "board-qualified," a distinction that indicates the podiatrist had taken a written examination but not an oral examination before a certification board.

Source: Erik Hogstrom, Telegraph Herald [12/6/07]

Query: H & P's versus "Clearance for Surgery"

I am looking for an accurate definition/description regarding H&P's and its relativity pertaining to actual clearance for surgery. It seems if you ask 10 DPM's you get 10 different definitions. I am division chief at our hospital in Ohio and need to write this for our Bylaws meeting since our hospital was recently purchased and needs this updated.

Because we are able to perform an H&P if the patient is on Lipitor, Lopressor or Glucophage, can we still "clear for surgery" since we do not manage hyperlipidemia, hypertension, or diabetes directly? I am also not clear whether there a difference when performing an H&P for 'admitting' a patient with cellulitis and 'clearing' a patient for surgery with cellulitis.

John Roseman, DPM, Massillon, OH

Query: Video Recording Informed Consents

I recently bought a Flip video and wanted to get the opinion of this group regarding an idea I had. Could I record the patient during a procedure consent discussion with their permission. For instance I could say, “Do you understand the procedure, risks etc.” “Do you feel that you are fully informed?”, etc. Would this be better than a written consent alone?

Marc Katz, DPM, Tampa, FL

Editor’s Comment: PM News does not provide legal advice. A well-documented informed consent provides a good defense to a charge of lack of informed consent. In that respect, a video-taped informed consent along with a written informed consent would provide highly persuasive evidence in your favor.

It should be noted that although “lack of informed consent” is almost always alleged in malpractice suits, it is rarely dispositive in the determining the outcome of a case.

RE: Unfavorable LCD For Advanced Tissue Products
From: Paul Kesselman, DPM

National Government Services (NGS), the Medicare contractor for Illinois, Indiana, Kentucky, and most of New York State, as well as the fiscal intermediary for many other states has just released a new local carrier determination (LCD) policy covering the use of advanced tissue products, such as Apligraf, Dermagraft, Integra and Oasis.

This new LCD is quite unfavorable to diabetic patients especially those who require the use of sophisticated products to close their wounds, and avoid potential amputations.

1) The LCD in general requires that wounds be a minimum size of 2 sq. cms. This would eliminate reimbursement for the treatment of a great number of foot-ankle wounds;

2) The LCD product articles are extremely restrictive, providing, for example, a 90-day global period for application of Dermagraft without the ability to be reimbursed for subsequent applications within the global period. This will, in most cases, make it financially impossible to provide these treatments to your patients, particularly in an office setting;

3) The LCD product article for both Dermagraft and Apligraf also indicates that NO application fee is payable if Dermagraft or Apligraf are simply covered with a dressing;

4) Neither the product article on Apligraf or Dermagraft include ICD-9 707.15 (ulcer of toe). This would eliminate the use of these products on the most stubborn of all ulcers frequently located on the digits; and

5) NGS posted only the LCD for comments during the comment period, but DID NOT post the product articles until the policy went into effect. This did not provide the wound care community with ample time to respond to this policy during the comment period.

In summary, I have found the new LCD contrary to current standards applied to wound healing, and these products' use. I would urge all practitioners and practices that perform wound care to read the entire LCD and its attached product articles in order to become familiar with this new policy.

I would, however ask that you NOT contact anyone at NGS or your current local Medicare carrier at this time. Many interested parties have already begun to formulate a response, and may be asking for your assistance at some time in the very near future. Certainly, if anyone has contacts at the American Diabetes Association, or are close to this congressional delegation, I would urge them to contact them.

The New York LCD and its attached articles may be found at Empire Medicare. com, follow the links to Empire Medicare Services, look up a policy (LCD), Part B New York (or New Jersey), search for drugs and biologicals and then the policy: LCD L26003.

For those in states covered by Administar, there are similar LCDs which may be found on their website: www.adminastar.com/index.html (choose Medical Policy; then choose biological products.

Paul Kesselman, DPM, Woodside, NY, pkesselman@pol.net

RE: Educating The Medical Community About Podiatry (Mike Boxer, DPM)
From: Multiple Respondents

Don’t underestimate the value of podiatric residencies in educating not just our graduates, but also the MDs in training. I have developed a strong MD referral base by doing all the usual “sweat equity” ways of educating the medical community with letters, progress notes, round table lectures and hospital committee work. It took years. Unfortunately, I have found that many MDs of my age (50) and older have a very ignorant, but strong negative connotation of podiatrists in general. It is part of their make-up. They never trained side-by-side with a podiatry student or resident. DPMs my age were training in small hospitals as it was rare for large hospitals to have a podiatric residency.

What has changed is that the 30-something age MDs have trained with the younger DPMs, and are now aware of our training and expertise. Today I get more referrals from younger MDs than I ever got from the old farts who just never accepted us as anything other than a chiropodist. For that, I thank the DPM residents and their program directors.

Pat Caputo, DPM, Holmdel , NJ, pat_caputo@alumni.rutgers.edu

I agree with Dr Boxer's viewpoint and always send the first visit from the referral to the referring physician. If surgery is planned, then a separate letter stating what we plan to do and send the patient back to the referring physician for the "pre-op medical optimization" of their patients. Two questions for Dr Boxer - 1. How many minutes does it take for you to perform your first time patient visit with all the ancillary testing for your complete examination including radiographs? and 2. Why send the letter with a lot of the past medical history/allergies/etc except if important to your evaluation and treatment? --because in my experience the referring physician knows their patient well enough to already have that information available in their office.

Joe Agostinelli, DPM, Niceville , FL, jmpa21@cox.net

Kudos to Dr. Boxer for his career-long efforts to educate the medical community concerning his comprehensive approach to patient evaluation and management. I too have made an effort to correspond with my referral sources in this regard. It is certainly a way to build a practice and gain trust from colleagues in other specialties.

There is one aspect of Dr. Boxer’s repertoire which I do not subscribe to, however. This would be the need to testify in malpractice litigation against the members of the same profession which he claims he is trying to promote. This becomes particularly egregious when the testimony concerns surgical procedures that he has conceivably never done and when the testimony is directed against hard working, board certified surgeons with infinitely more experience in this arena than him.

I suppose there aren’t too many lawsuits directed at DPM’s for improper H&Ps, Doppler exams or PT blocks. When a few more lawyers graduate there probably will be though, and then maybe Dr. Boxer can do what he apparently loves to do with some impunity.

Vincent Gramuglia, DPM, Eastchester, NY a2onpar3@optonline.net

PRACTICE FOR SALE (OR ASSOCIATE POSITION) - QUEENS, NY

Practice available. Terms available to work as an associate towards partner/ownership, or buy practice outright. Excellent opportunity for motivated podiatrist. Busy practice grossing $400K without surgery. Medicare 70%. Surgically trained podiatrist can significantly increase income. Close to hospitals and transportation. Call (646) 373-8921.

PRACTICE FOR SALE - SOUTH CAROLINA

Upstate SC practice of 25 years. Retiring. High Volume. 65% routine foot care, 35% surgery. Several nursing homes. Plenty of opportunity for growth. Grosses over $450,000.00 yearly. Hospital and Surgery Center privileges. Financials available upon request. Serious inquiries only! Beautiful area. Contact: Carolinafootdoctor@yahoo.com

PART-TIME PRACTICE FOR SALE - FLUSHING, NY

40 year old part time practice for sale. Priced for quick sale. Please contact me at footdoc60@gmail.com. Serious inquires only please

ASSOCIATE POSITION - SOUTHERN ILLINOIS

Tired of Nursing Home Care? Ready to join a well-established practice with 2 Board Certified Foot Surgeons? If you are a personable, ethical and responsible, hard-working podiatrist with interest in conservative care, including sports medicine, this may be the position for you. Competitive salaries, 401-K, health insurance, paid vacation and more. Please forward CV with references to nrussell@neondsl.com

ASSOCIATE WANTED – NEW YORK IMMEDIATE OPENING

Busy multi-dimensional practice; 70 miles north of New York City . Currently five (5)-doctor practice. looking to expand – all phases of podiatric medicine. contact: (845) 454-8308 EXT: 106

ASSOCIATE POSITION - VIRGINIA

Immediate opening. Multi-office practice, EMR, digital x-rays, sonography. Great opportunity for mature, well trained new or established surgeon. Hospital and surgery center privileges. ABPS eligible/certified. Full scope of foot and ankle care. Base salary, incentive, and benefits. Email CV to practice administrator at: mtrevor41@yahoo.com

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