The Voice of Podiatrists

Serving Over 10,000 Podiatrists Daily

December 14, 2007 #3,117 Editor-Barry Block, DPM, JD

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CA Podiatrist Named Consultant to “FIFA Medical Centre of Excellence”

Dr. Howard Liebeskind, team podiatrist to the US World Cup and National Teams, has been named podiatric consultant to the FIFA Medical Centre of Excellence at the inauguration of the football/soccer medicine facility in Santa Monica, CA. In his position, he will manage the podiatric needs of many of the finest soccer players from North America, Mexico, and Central America.

From Left to Right: Prof. Dr Jiri Dvorak, FIFA Chief Medical Officer; Howard F. Liebeskind D.P.M., Team Podiatrist US National Teams; Bob Bradley, Head Coach, US National Soccer Team; Bert Mandelbaum MD, Team Physician US National Team .

The FIFA Medical Centre of Excellence (Santa Monica) is the only multidisciplinary clinic of its kind in the Americas and is directed by US National Team Physician, Bert Mandelbaum, M.D. FIFA has accredited five further official medical centres around the world with a view to ensuring that players on all continents know where to go for expert care in football/soccer medical care.

“I am privileged to be a part of the Santa Monica Orthopaedic and Sports Medicine Group and its internationally recognized football/soccer medicine program”, said Dr. Liebeskind. “Our group’s collective passion for soccer is equaled only by our desire to provide world class care to each and every athlete we evaluate and treat.”

NY Podiatrists Help Keep Rockettes Kicking

If getting in shape for the New Year will be tops on your Resolution list for 2008, “Start with your feet,” says Manhattan-based Dr. Louis Galli, Jr., a podiatrist for Madison Square Garden/Rockefeller Center’s Rockettes and a member of the New York State Podiatric Medical Association.

Dr. Louis Galli

Dr. Galli believes many back, hip and knee problems can develop from faulty foot function. “The lower extremities act like a chain. If the first links-your feet and ankles-are unstable, chances are the other links-your knees, hip and back-may become unstable."

Dr. Galli and his associate, Dr. Elisa Kavanagh, begin the grueling holiday show season with the Rockettes with an assessment of their feet. The assessment includes an analysis of gait. “Something as simple as how a person walks can reveal biomechanical difficulties,” says Dr. Galli. “When a dancer stresses her body, she often can’t afford to be sidelined.” According to Dr. Galli, a podiatrist can minimize pain and damage by changing the way a dancer’s foot moves. Dr. Galli often bandages, uses in-shoe supports and sometimes even casts a foot injury so a Rockette can keep performing.

Medicare Package Might Not Pass This Year; Not Included in AMT Bill

Legislation that would prevent middle-class U.S. residents from paying the alternative minimum tax (AMT) heads to the House floor on Wednesday, but it does not contain Medicare provisions that would delay a scheduled 10% physician fee cut, CongressDaily reports. The House's decision to move forward with the AMT measure "derails one of the best vehicles for a Medicare package this year and increases the likelihood" that the Medicare physician fee cut will take effect Jan. 1, 2008, according to CongressDaily.

Source: Vaughan/Johnson, CongressDaily, Via American Health Line [12/12/07]

Query: Patient Who Returns After Being Discharged

I recently discharged a patient from my practice. She had been a non-compliant diabetic who was not making a real effort to control her diabetes or take care of her feet. In other words, I felt she was a "ticking time bomb" that would become a disaster that I would have to clean up eventually. I sent her a certified letter stating that I felt she would be better served by another doctor and that we would see her only on an emergency basis for up to 30 days. I did not provide a specific reason in the letter for her discharge.

She returned to the office today wanting to know why she had been discharged. I have instructed the Staff to just say, "I don't know why, but I can help you find another doctor if you'd like." The patient implied that she would keep returning until we gave her a satisfactory answer. Any advice on how to proceed?

Name Withheld

Editor’s Comment: PM News does not provide legal advice. You acted correctly in sending the patient a certified letter discharging her. The practical thing to do is to tell the patient why she is being discharged. The most important step you can take is to document her non-compliance.

RE: Digital X-rays or Fluroscope? (Kevin Pham, DPM)
From: Marc Katz, DPM, Charles M. Long, R.T. (R)

I have been using fluoroscopy for a number of years and think it is the way to go. You have instant images that go directly into an EMR system. You will easily cover your costs. You no longer need chemicals, darkroom and all of the other hassle. You can get unusual angles and zoom into the area for an enlarged image. I have been able to pick up early osteo and stress fractures by enhancing the image and zooming. Also, the patients really like seeing the image and getting a copy.

One word of caution. Beware of the used Mini C-Arm company at the podiatry conferences. I was burned and received an over-priced poorly functioning machine and then the company turned around and bought back my machine from GE when GE sold me a new machine. So my 30K machine was bought back for 7K and will be sold to you next! Fortunately, I made my purchase back in scans.

I bought a new GE - OEC miniview 6800. It was well worth the money.

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

A fluoroscope or C-arm should never be used as a substitute for a radiograph to obtain a diagnosis. While they have improved resolution over earlier models, and they are great in surgery, C-arms are not design for general radiography.

There are several inherent factors in an image intensifier design that degrades image sharpness. These factors are more evident on less expensive designs that do not use advanced phosphor technology. Spatial (detail) blurring occurs due to differences in the phosphor plate depth. Noise occurs due to low mA output. And because the frame rate is averaged while scanning to eliminate noise in the image -motion unsharpnesses occurs. Short source to image distance induces geometric unsharpnesses. Static images from a C-arm are acceptable as surgical confirmation or medical reference but it is generally understood that is the intention of C-Arm images.

Substituting a C-arm for general radiography could also violate the ALARA concept. (As Low As Reasonably Achievable) (Use the least dose to achieve an acceptable image.) While one could argue digital radiography increase patient exposure over film, there is the fact that you obtain a diagnostic image, that can be manipulated -eliminating repeats, and lowering exposure over time. When you fluoro a patient -typically the exposure is 10 to 20 times longer then a standard radiograph exposure. This is due to time needed to "look" at the anatomy. Combine longer exposures with the shorter skin -tube distance you get a much higher dose rate to the patient. Typically a foot radiograph is taken at less than 1 second.

Charles M. Long, R.T. (R), Manager Clinical Applications, 2020Imaging,
Crystal Lake, IL

RE: Malpractice Case Challenges IA Podiatrist’s Qualifications (Lee Rogers, DPM, Eugene Batelli, DPM)
From: Multiple Respondents

Specifically regarding Dr. Batelli's concerns about the ABPS loosing credibility if every podiatrist is certified. No one is asking that all podiatrists be certified but all podiatrists should be allowed to take the examination. Every podiatry student is allowed to sit for the National Board examinations and not everyone passes. The weeding process needs to be built into the examinations and not into an exclusive club criteria deciding who takes the exam and who is shut out. It is time for ABPS to take a hard look at its certification process.

Vincent J. Mandracchia, DPM, MHA, Des Moines, IA , vmandracchia@broadlawns.org

The discussion on this matter in PM News is interesting but may have missed the point. The legal issue raised was apparently a suggestion that ABPS certification is required for the utilization of large external fixation. I can guarantee that this suggestion was directed by a podiatric colleague, not initiated by a lawyer. The problem is potentially quite serious in a global sense. What if juries or third party payers are lead to believe that without rearfoot/ankle boards a practitioner is not qualified to perform say, surgery for a Haglund's deformity, tarsal tunnel surgery, or a plantar fascial release ?

There is certainly a transition period following residency during which a practitioner must acquire cases for board qualification prior to sitting for the boards, making such doctors vulnerable to unscrupulous claims of incompetency for lack of board certification. Diametrically, many residents list C on their surgical logs yet have had minimal participation in particular cases, so that counting cases allegedly performed as a resident does not necessarily guarantee success.

PM readers have an ethical obligation to truthfully call it the way it is, when asked to do so. Do not suggest that the lack of board certification implies incompetence. And do not suggest that board certification guarantees competence. Honestly evaluate each situation on its individual merits. If successfully litigated, this case could affect YOUR ability to obtain privileges in the future

Allen Mark Jacobs DPM, St. Louis, MO, allenthepod@sbcglobal.net

Dr. Rogers implies, or at least I infer, that he believes this suit would not have occurred had Dr. Arnz been ABPS certified. The ABPS' seemingly interminable, sometimes, dead-ended, pathway to certification is not responsible for the suit against Finley Hospital or Dr. Arnz. Nor is Dr. Arnz' lack of ABPS certification a causative factor in this suit. A physician's credentials are irrelevant in establishing a bona fide malpractice claim against him.

The suit against Dr. Arnz, stated to be a malpractice claim, alleges there occurred a negligent act, a breach of the standard of care. There can be no liability unless the plaintiff has been harmed. The suit against Finley Hospital arises from the same incident, but this suit argues that Finley Hospital negligently permitted Dr. Arnz to perform a surgical procedure for which he had no expertise. Dr. Arnz could have been certified for each screw and pin put into the patient. The claim would still assert that Dr. Arnz lacked the necessary expertise for this procedure. Otherwise, there'd have been no deviation from the standard of care.

This suit does have the potential to cause real harm to this profession. Some people, particularly the attorneys and department chiefs at Finley Hospital, may come to the absurd conclusion that ABPS certification offers some degree of insulation against malpractice claims. What they should learn is that privileging must be based on experience and judgment, not organizational affiliations.

Although many podiatrists object to the ABPS' certification processes and policies, relatively few have bothered to vocalize their objections. We have allowed the ABPS to do just what it has done, and continues to do. Many still subscribe to those same policies, still paying the fees to line up for a run through the ever-changing gauntlet, hereby continuing to empower the ABPS. If you don't agree with the ABPS' policies, go somewhere else.

Howard L. Lazar, DPM, JD, Bloomfield Hills, MI, howardlazar@comcast.net

RE: Outside Billing Service? (Tracey G. Toback, DPM)
From: Juliet Burk, DPM

I use SMB currently. We began using them in August because my billing person was in intensive care for the better part of three months--which illustrates the vulnerability of in office billing. SMB has not added diagnoses to our nail claims--in fact, they asked us specifically to review our charts for class findings when Medicaid began denying onychomycosis debridement with a secondary diagnosis of pain. We really like the daily billing totals we receive, separated by provider and location. We can also view online a breakdown of codes billed for each patient. I wonder if their costs are too high, but they have relieved such stress from our practice and added such clarity to our practice situation day to day that my husband and partner has sworn never to go back to in-office billing.

Juliet Burk, DPM, Tahlequah, OK, julietburk@gmail.com

ASSOCIATE POSITION – VIRGINIA

Must have Virginia license. Requires 24 to 36 month Residency. Permanent position with potential buy in. Includes all phases of Practice excluding nursing homes. Competitive Salary and Benefit package. Please send Resume including salary requirements and availability date to needpodjob@yahoo.com

ASSOCIATE PART-TIME POSITION MARYLAND

Part-time, Leading to a full time position. A well-established, successful podiatry group in Washington Suburban area of Maryland , Ownership opportunity. Surgery Center on-site. Great office staff. Flexible schedule. Great opportunity. Biomechanics and or Surgical residency experience preferred. Fax Curriculum to 240 465 0332. Email pmrypmry@yahoo.com. Call 240 604 4564.

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

FULL OR PART-TIME POSITION WANTED – LOS ANGELES COUNTY

Well-trained podiatrist looking for a full or part-time position in Los Angeles County area. Professional, motivated, courteous and interacts well with patients and staff. Recently completed Kaiser 3-year surgical training program. CV and letters of recommendation available upon request. samiam_dpm@yahoo.com or 818-693-4790.

A well-established, ethical solo podiatry practice wishes to expand its current surgical services by hiring a full time associate with PSR-24/36 training which includes strong surgical rear-foot and ankle reconstruction, diabetic limb salvage (AZ is a no amputation state) and ER trauma. ABPS qualified/certification required. Applicant must be personable and caring to patients. Practice in an office base within a state-of-the-art orthopedic surgical hospital environment and plenty of future expansion capabilities for a bright, eager, reliable associate. Email complete CV with current references and photo to footdoc352@cox.net

PRACTICE FOR SALE-CENTRAL WYOMING

Come enjoy the great outdoors. Growing practice. Established referral patterns. Full hospital privileges available. No nursing home care. No HMO’s. Few PPO’s. Great opportunity for surgical growth for the right individual. Currently grossing $200,000+ with 20 hours patient contact. E-mail for more info at mvfc@wyoming.com

ASSOCIATE POSITION - CHICAGOLAND AREA

We are a large multi office practice that covers from the Chicago area to Northwest Indiana. We are currently looking for two hard working motivated individuals to join our practice in these two areas. It is a long-term opportunity with unlimited growth potential in all phases of podiatry for the right person. Please contact for more information @ m-lacey@footexperts.com

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists. We are located in Chicago and Northwest Indiana. 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 -- www.homephysicians.com

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