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From: Harry A. Harbison, DPM, Elliot Udell, DPM


I always find it interesting that podiatrists seem to think "custom orthotics" are a prescription-requiring item. Please be aware that in-shoe orthotics (i.e.- ala Root style) do not require a prescription in any state or province in the USA. There are no requirements that a "medical professional" be involved in the fabrication of these items. To have these items paid for under a third-party payor may require some sort of "prescription" for medical necessity documentation.


Harry A. Harbison, DPM, Long Beach, CA


We use a scanner in our office to send images to a lab. It's not rocket science and I had no delusions that non-podiatrists would use the same technology. Chiropractors, orthotists, and PTs are making custom orthotics and some use the same labs that we use. Now it's Costco.


The question we should be asking is how to manage the patient who gets a custom set of orthotics from Costco and then asks us to make adjustments to help manage his or her foot problems. I already encountered this problem in my office and wonder how others will approach this problem.


Elliot Udell, DPM, Hicksville, NY

Other messages in this thread:



RE: Using DPM Degree Outside of Podiatry 

From: Joe Agostinelli, DPM


I have been following this discussion closely and would like to present comments from experiences in my 23 year USAF active duty military career and then 14 years in private practice as a DPM in a large orthopedic surgery/sports medicine group. Ultimately, it is not the "degree" that allows other than podiatry utilization, but the "person." 


While in the military, I found that when it came to additional duties such as - ACLS instructor and affiliate faculty, trauma management lectures, executive committees of medical staff, chief of surgical services (including orthopedics), etc., my actual degree did NOT matter! It was the...


Editor's note: Dr. Agostinelli's extended-length letter can be read here.



From: Simon Young, DPM


Bottom line... we have a limited license. MD/DO/NP/PA all seem to be able to treat the whole body (give or take). We can't even give a flu vaccine in NYS. My local pharmacist can. Others can be hired in hospitals and by insurance companies. Unless there is a special niche, or someone wants specialized opinions, we don't fit the majority of needs. Unless we are able to increase our scope of medical (not surgical)  practice, we are stuck. 


Simon Young, DPM, NY, NY



From: Allen Jacobs, DPM


Several years ago, podiatric students from California took the USMLE examination. In point of fact, the podiatry students performed horribly in the examination. The results of this testing was to test the current status of general medical education in the podiatry schools. I suspect that medical students would fail the podiatry national boards.


If the objective of podiatry school is to prepare students to pass the USMLE examination, a restructuring of the current state of education within the podiatric colleges would be required. This would involve more than simply adding coursework in three areas. Clerkships and rotations would also have to change. Students and residents would have to...


Editor's note: Dr. Jacobs' extended-length letter can be read here.



From: Robert Scott Steinberg, DPM


At the CME meetings I attend, there are multiple tracks going on at the same time. I do not see how Dr. Silhanek knows who does or does not attend lectures! Getting together with colleagues should not be dismissed. I am not a fan of online CME. Oh sure, it's easy, maybe far too easy. Yes, it is cheaper. What I think is more problematic is the money being taken away from state associations when someone pays to attend non-member organizations' CME - part of what helps to keep our dues down is the money that comes from state association-sponsored conferences.


Robert Scott Steinberg, DPM, Schaumburg, IL



From: Spencer F. Dubov, DPM


In response to Dr. Smith’s article concerning proper attire in the office, it has always been my view and experience of 55 years in practice, especially running courses in “Practice Administration”, that proper business attire sends a positive message to your patients of respect for them, yourself, and your profession. Wearing a white lab coat requires a business shirt and tie, or surgical scrubs. Nothing short of that is acceptable. When you visit a lawyer, his dress code is a suit and tie. Why would anyone want to present with a lesser appearance as a podiatric physician? The key is to “Dress for Success!” 


Spencer F. Dubov, DPM (Retired), Naples, FL



From: Brian Carpenter, DPM


I think this is a very important question/observation by Dr. Borreggine. Dr. Saxena mentions George Liu, DPM recently ran for the ACFAS board (and won) on the platform that DPMs need to do more research and start maintaining registries which I 100% agree with. 


One thing that Dr. Saxena did not mention is that we have a very large and powerful society, The American College of Foot and Ankle Surgeons, which states that part of its mission/vision “is to advance and improve standards of education.” The college has over 300 volunteer leaders serving on committees and serving on educational faculties. One of their strategic initiatives is to “advance scientific and clinical research to maintain leading edge competency among our members“ and “deliver superior continuing medical education to enhance competency at every level of professional training.” 


Just as with the residency programs, the College is rewarding those with little to no academic experience or background and placing them into leadership and educational roles. Good examples of this are at the Annual Scientific Meeting in Memphis next month. They have 12 speakers who have never published in the Journal of Foot and Ankle Surgery (JFAS), the College's own journal. There are currently 4 members on the Board of Directors and 52 committee members who also have not published in the JFAS. For us to truly gain parity in medicine, we have to be doing the work of the other medical professions, and research and publishing are at the top of the list that we are lacking in.


Brian Carpenter, DPM, Fort Worth, TX



From: Barbara Hirsch, DPM


In 2015, the Maryland Board of Podiatric Medical Examiners initiated a change in the state regulations to go from 50 CME allowed online to only 25 online CMEs allowed online. I am the only Maryland state licensed podiatrist who commented against this proposed change to the state (during the allowed comment period). I felt it was ridiculous to decrease the amount of online CME allowed for various and obvious reasons, the main one being cost. Even a "local" seminar can require travel costs, lodging costs, and high fees.


I provided examples of what it costs to attend many seminars. I provided an example of the exact same seminar offered online (a taping of the seminar) and live. The only difference was the cost. The state of Maryland has limited CME seminars, and one cannot always attend due to personal reasons.  


The MPMA used to have a "Day of Science" but this has not been done in a few years (it was used as an example of "Free" CME credits for a live seminar as one "excuse" for the change in the requirements. I was not only thinking of myself, I was thinking of anyone else who has monetary issues/concerns, physical issues, family issues, etc. I only wish that other Maryland state licensees had similar concerns for their colleagues. Allowing 50 CME online credits let everyone do what was best for them. Limiting online CME credits to only 25 was a step backwards. 


Barbara Hirsch, DPM, Rockville, MD



RE: Enough Already with Time-Consuming Chart Requests (David P. Luongo, DPM)

From: David E Gurvis, DPM


I recently had a request for 50 charts to be reviewed. That was a very unusual request, but that is not my question. The insurance company said if I wanted to give them access to my online EMR, they could log in and review those charts in that fashion.  


While that sound convenient, more so than printing them all out, it just sounds risky as it relates to privacy concerns. Has anyone allowed an insurance reviewer into their EMR? Is that even legal?


David E Gurvis, DPM, Avon, IN



From: George Jacobson, DPM


After Kevin Kirby, DPM reviewed Hoka shoes a few years ago and discussed this new concept of maximalist shoes, I bought four pairs. The superior shock absorption helps my low back significantly while walking 4 miles in an hour.  At $130 each, not all patients can afford them. I don't like that the Clifton II (which I wear) only comes in a D width. I had to go up one size to a 9D, but this has worked for me with thick moisture wicking socks. The Clifton is a more flexible shoe.  


For plantar fasciitis, I recommend that patients pick a model with a rigid forefoot and shank (as just mentioned in PM's article by Dr. Kor). They have worked out well for OR techs, postal employees, and others with standing jobs. I am not a runner, so I can't comment. With many other companies now jumping on the maximalist bandwagon, perhaps Dr. Kirby can comment. If you Google "maximalist shoes", you'll see there are a lot of other brands. 


George Jacobson, DPM, Hollywood, FL



From:  Tip Sullivan, DPM


Dr. Borreggine paints a pretty grey picture for podiatry. I can’t really opine if he is right or wrong. I can say that I take care of feet better than any NP, MD, DO, or PA that I know of - all the way from nails and calluses to flatfoot reconstructions. I don’t think I am special or alone - I think we all do!


It seems obvious to me that we as a profession are not going to change the things our government does by bitching and moaning about it. It will take action to save our profession; action by our associations and by each individual podiatrist. You may ask: What can I do? The answer for me is don’t accept Medicare as payment for any office work. If you develop a good reputation locally, you will be able to financially get by.


Tip Sullivan, DPM, Jackson, MS



From: Simon Young, DPM


Reading these posts, you get the impression that podiatry is a major contributor for the downfall of our medical system. We are such a measly small percentage of the total pie. If I am not mistaken, Medicare paid less than $2 billion for foot care. 


We just lost five F-16 fighter jets which each cost over $100 million, yet nobody blinks. We spend well over $2 billion for one airplane, yet nobody blinks. Yet, if we spend the same amount of money on the well-being of our tax-paying citizens, there is a huge uproar. 


We spend $trillions...


Editor's note: Dr. Young's extended-length letter can be read here.



From: Elliot Udell, DPM


Dr. Lloyd's sentiments about how a hospital could make close to 9K on a toenail procedure is something that all Americans should be concerned about. We hear day in and day out how our healthcare system is "going to hell in a hand basket" and we all wonder why. Dr. Lloyd just got a small peek as to what is going on. There was an expose in the New York Times about how some GI offices are gaming the system by having in-office surgical suites. They are charging more than 10K for a ten-minute endoscopy.


A patient of mine who is a medical doctor himself told me that when he goes to his dermatologist for a check-up, he always finds at least six lesions to biopsy. The list can go on and on. The physicians involved can all justify their ways of making their livings. If the government, however, does not rein it in, the entire healthcare system will go under, causing only the economically elite to be able to afford coverage. This will result in a conversion to complete socialized medicine ala what they have in Canada or England.


Elliot Udell, DPM, Hicksville, NY



From: Joseph Borreggine, DPM


This battle for parity will wage only until those that are "protecting" the podiatry profession from our independent and identifiable autonomy cease to exist. We are no longer the profession that we once were. We are well-trained and educated in the field of foot and ankle medicine and surgical orthopedics and have continued to evolve through these past many years from palliative care podiatrists to foot and ankle surgeons. 


However, this profession will forever be recognized as a "lesser than" an MD/DO medical profession as long as we continue to educate our students with the current curriculum model that we have been using for years. The Council on Podiatric Medical Education (CPME) will never be equal to the American Council on Graduate Medical Education (ACGME), and hence...


Editor's note: Dr. Borreggine's extended-length letter can be read here.



From: Name Withheld


I would like to respond to Dr. Kiel by noting that $750,000 were not gross charges, but gross revenue for the practice. I bill out about 1.25 million myself. I would like him to recalculate his formula.


Name Withheld



From: Tea Nguyen, DPM


I think most of us have been in a similar situation. The best way to go about it may be to learn on your own and share your knowledge with faculty in an open nonjudgmental way. Start with saying things such as, "I'd like to know what you're thinking. Can you explain what your thought process was? I'm not sure I completely understand, or I've read somewhere that this was one kind of approach. What do you think about it?" Be wise with your approach and the words that you use because you never want to come off as condescending, insubordinate, or closed-minded. You'll see that residency is about learning what to do but also what not to do; so if you follow through on the patients and realize the outcome was not optimal, realize that was an educational opportunity. What better way to learn than through someone else's mistake? However if patient harm occurs often, then that's an issue to take with your residency director.


The advice that I valued the most from my senior residents at the time was learn as much as you can, read as much as you can, and learn from a lot of people. That way, you'll have all the tools necessary to develop your own style when you begin to practice. In the meantime, try to enjoy the process, both the good and the bad.


Tea Nguyen, DPM, Novi, MI



From: Jeffrey Kass, DPM


Dr. Klein - great idea. When you succeed in getting ten podiatrists signed up, give me a call. It will never happen. Unfortunately, most of our colleagues are too apathetic, or think the issue will resolve itself, or they are protected as they are in an IPA, or work for a hospital, or are part of an orthopedic group, etc. But, rest assured, we will suffer for not striking, and it will cost the profession (all of medicine) in the long run....I say this with confidence as the current state of medicine is already ridiculous and a joke and "believe you, me", as my Grandfather would say, "it's not getting better."


Haven't you heard the latest? It's called "value-based care" - that's code word for "capitation." I was just in Times Square for the NY Podiatry Conference. The pedi-cabs have a sign "three dollars a minute". I wonder if podiatry will be making that much in the value-based care model.


Jeffrey Kass, DPM, Forest Hills, NY



From: Name Withheld 


I couldn't agree more. It is incredibly unfair and frustrating. I was contacted by my hospital a week ago. They told me they were going to revoke my privileges after the past two years because I wasn't board certified. I politely asked them to review my situation as I do not have enough cases to sit, and I have 7 years to sit for the board. After much discussion,  they said it was hospital policy, but  they agreed to let me continue.


When I asked about the status of the other 8 podiatrists on staff (much older), they said, "they were all grandfathered in..." WHAT?? Imagine by anger! They are unproctored/minimally trained podiatrists who never became board certified, yet I have to jump through these hoops of obtaining 6 week out x-rays from patients who sometimes don't return for their final check up... and I can't pass the case selection process because of this! This process needs to change. 


Name Withheld 



From: Robert Kornfeld, DPM


Dr. Kass posts a lesson in futility. It is NOT testicular fortitude that makes a cash practice successful (although it is an important ingredient). It is a business plan. The one that he mentions is about as anemic as anything I have ever heard. You cannot decide to go cash and then expect patients to pay you for what they can get elsewhere for less money. That is simply professional suicide. 


On the other hand, the way to thrive is to lower the water (your expenses) and raise the bridge (your income). A savvy businessman knows that to succeed, you need to ...


Editor's note: Dr. Kornfeld's extended-length letter can be read here.



From: Jeanine Jones Moss, DPM


Contact the health clinics in your area that provide free medical care to the uninsured or under-insured. They will appreciate any time you can volunteer because podiatry services are usually under-represented when medical volunteers are requested. The clinics will usually provide all of the supplies and space you will need. 


Jeanine Jones Moss, DPM, Mcdonough, GA 



From: Paul Kruper, DPM


The local physicians here are contracting as employees at a reimbursement rate of $55 per patient with no benefits, no overhead, and no surgery headaches with multiple job offers. 30 patients/day provides a salary of $429,000. Keep the 3 year residency and give me an allopathic license and I will send all my bunions to the podiatrist willing to do surgery for $300. I continue to be amazed at the number of podiatrists who want to be surgeons so bad they will work for free.


Paul Kruper DPM, Kingsburg, CA



From: George F. Jacobson, DPM


We require the co-pay to be paid prior to the patient being brought back into the treatment room. The co-pay on several of these plans goes towards the office visit (E&M). If a procedure needs to be done, I tell them that it will go towards their deductible and give them the amount due today. They sign this estimate. Most pay the additional amount, but some say they'll send it in.


It would be better to collect before the procedure, but that is a bit tacky. Last year, the government didn't inform us of non-payment of premium by the patient until after 3 months. Therefore, some patients might not even have active insurance. I just got the first one of these (4 visits). These patients may also forfeit the privilege of having me treat them in the future.


George F. Jacobson, DPM, Hollywood, FL



From: Jordan R. Stewart, DPM


The issue of high deductible plans is certainly impacting all medical practices. The only way to combat this issue is to collect for all services provided on the date of the service. This is best accomplished by keeping a spreadsheet with the fee schedule for the procedures you commonly perform. We check each and every patient’s benefits before they are seen and we tell them how much of their deductible is remaining and what services it applies towards. We notify patients of the office policy before they come to the office. Most patients abide by the policy, yet there are some who leave the office or cancel their appointments as they don’t plan on paying. 


As far as I am concerned, these are the same patients whom you are currently sending bills. At the end of the day, this comes down to a business decision. The reality is that we are doctors, but we are also in business. This process takes lots of work on the front end, but it is well worth it as you accounts receivable will be very low. If you want to survive in practice, this is the only way to go, and I would apply this towards co-insurance as well. If patients have overpayments, we simply refund the money through our bank’s online bill pay. Patients love this part.


Jordan R. Stewart, DPM, Timonium, MD



From: Bret M. Ribotsky, DPM


It is the times we are living in. Things cost more, and we physicians earn less. There are antibiotics that we often use that cost well over one-hundred dollars a day. There are medications for treating Hep-C that cost over $30,000 for a course of treatment, and then there are cancer treatments that between chemotherapy and radiation therapy can clearly go above $250,000. I share the frustration that when I prescribe one of the new anti-fungals, my patients are paying for all the research (this time {thankfully} DPMs were involved) and the FDA hoops required.  


What I tell my patients is that; in the treatment of onychomycosis, if you want the best chance at a cure, the research reports that oral and topical treatments are available and the costs of the orals are ' $25 dollars and the cost of the topicals are about 20 times that. It's their choice (assuming that there are no medical issues preventing treatment). Research on lasers showing results are forthcoming, but today, I explain the options and the costs. It’s the patient's decision. I also tell the patients that I have never seen a death certificate state that the cause of death was fungal toenails.    


Bret M. Ribotsky, DPM, Boca Raton, FL,



From: Lawrence M. Rubin, DPM


I graduated from the Illinois College of Podiatric Medicine in 1958, but I embarked on the road to becoming a podiatrist in 1954, when the college's name was the Illinois College of Chiropody and Foot Surgery. You no doubt recognize the fact that I am an "old timer." Age does not assure wisdom, but it does help to put a perspective on things that relate to the long-term welfare of our beloved profession. 


I agree with Dr. Kiel and Dr. Ryder. Please do not abandon so-called "routine foot care" ("routine" being the term that denigrates the service that can save the feet and legs and sometimes the...


Editor's note: Dr. Rubin's extended-length letter can be read here.



From: Michael L. Brody, DPM


E-PHI includes among other things: retinal scans, facial geometry, biometric information, and any other information that could be uniquely utilized to identify an individual. 


Ray Posa states that we should "Feel free to document wounds with a smartphone." Ray stated that a picture of a wound is not e-PHI if the name of the picture is randomly generated. I agree that his interpretation of the rule has merit and validity. But an interpretation of the rule that a picture of a wound is e-PHI is also potentially...


Editor's note: Dr. Brody's extended-length letter can be read here

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