Podiatry Management Online


Podiatry Management Online
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From: Dennis Shavelson, DPM


I reviewed the RESA website. They have a homogeneous proprietary plan using software, an algorithm, a technician, and a scanning method developed by a cyclist + engineers to create what they value as a $199 product. Remember the Soles 3-D printed orthotics that DPMs were dispensing that is now out of business having lost $30 million. 


I welcome the competition from Costco that will help educate the foot and postural suffering public towards the need for customized orthotic props. My insult comes from Costco stating that the DPM product is worth $300 when mine are...


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

Other messages in this thread:



From: Allen Jacobs, DPM


CBD topical preparations appear to be very helpful for symptomatic treatment of musculoskeletal disorders (e.g. arthritis, tendinitis ). I offer this has an alternative to those patients in whom oral NSAID therapy is not appropriate or concerning, e.g.: renal concerns, cardiac concerns, anticoagulation therapy, history of GI pathology). Typically, high NSAID risk patients are given the choice of topical NSAIDs, CBD topical, or no treatment. I personally use the CBD products from EBM pharmacy. The results have been excellent. I prescribe CBD topical daily.


Disclosure: I have lectured for EBM pharmacy in the past.


Allen Jacobs, DPM,  St. Louis, MO



From: Leonard A, Levy, DPM, MPH


Brent D. Haverstock, DPM said, "It would seem that if podiatry is to become a branch of medicine (MD/DO), the APMA would have to meet with the American Medical Association (AMA) and the American Osteopathic Association (AOA)..." This remark and so many others from podiatric physicians seem to indicate that the "appetite" for DPMs to acquire an MD or DO degree is rapidly increasing. However, before any meetings take place with the AMA or AOA and the APMA, it is essential that strategic planning take place to determine exactly what the profession needs to do and what needs to be done to get there. 


Such an activity must, at the least, include representation from the APMA, the Association of Colleges of Podiatric Medicine, representatives of the current licensing examination body (i.e., American Podiatric Medical Licensing Examination), and the bodies within our profession that represent both the accreditation of undergraduate podiatric medical education and graduate podiatric medical education (i.e., residency training). 


It would be a disaster if such a plan was not properly developed and members of our profession were not on the same page. Our effort needs to be one having a uniform voice devoid of bickering by individuals and groups in the profession. The strategic plan developed should be articulated in a document containing the background of the proposal, the state of the profession, including its current education and training, and a detailed description of what is being proposed. I suggest that the time is ripe to undergo such an effort but that it needs to be done very carefully. This formal process must begin now.


Leonard A, Levy, DPM, MPH, Ft. Lauderdale, FL



From: Alan Sherman, DPM


I’m confused by Leonard Levy’s most recent message in this discussion in the October 31, 2019 #6,539 issue, in which he refers to the “highly controversial proposal to have two specialty boards in the podiatric medical profession (i.e., podiatric surgery and podiatric medicine”. It’s not a proposal. We currently have these two specialty boards, ABPS and ABFAS. What we don’t have is two medical specialties. We have two specialty boards that represent one specialty, podiatry, and that structure is what is confusing the public and the medical establishment.


The proposal made by Jeff Robbins, DPM, supported by myself, Joe Borreggine, and now Brent Haverstock, DPM, is that our two specialty boards MERGE and form one board with sub-specialties, including advanced foot and ankle surgery and...


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



From: James J DiResta, DPM, MPH


Many graduating podiatric medical students would benefit from an Intensive Podiatric Medicine Residency option. Providing this option for our graduates who do not want to be surgeons can have real value IF done correctly. That would work if we were able to engage Dr. Levy in this process in creating such a program, i.e. a 3-year residency curriculum in "podiatric medicine" that could provide for training in areas of general medicine, obstetrics, psychiatry, and make up for those clinical deficiencies our graduates presently have, provide for an allopathic or osteopathic medical school to sponsor the program so the resident can be provided a DO or MD degree, and get the residency in "podiatric medicine" ACGME recognized with accreditation.


I know those are considerable barriers to cross. As a profession, we may need to financially support such an effort in the initial roll out. We would need our students to take and pass the USMLE step 1 which we have known for some time is essential no matter what we do going forward. The completion of this type of residency would provide equal footing with our medical and surgical colleagues for OUR profession "podiatric medicine". Dr. Levy has provided alternative pathways for DPMs to the DO degree before. Perhaps this time, we can obtain a successful solution in a time span equal to that of our podiatric surgically approved programs and that would provide the value many of our graduates want who do not expect to be reconstructive foot and ankle surgeons. 


James J DiResta, DPM, MPH, Newburyport, MA 



From: Richard D Wolff, DPM


For the past 12 years of practice, I have had zero residual nail dust in my treatment rooms, but I understand where you are coming from. During my first two years of practice, I had the same issue. When I moved to a different office, I had a central vacuum system installed. The vacuum is in a closet and shared by all treatment rooms. The rooms are connected to the vacuum via 2" PVC pipe above the ceiling tiles. The noise is contained to the closet, which has 2" thick foam added to the walls. 


I bought a cone nozzle (#ACC-SHEATH) from Jan L. It attaches directly to the end of a Dremel Multi-Pro and has a 1/2" tube connection. I also bought a reducer from Allegro Vaccums. It reduces the 2" outlet down to 1/2". The last item was a piece of 1/2" vinyl tubing I purchased from the local hardware store. There is strong suction noise in the treatment room, but no motor noise. The vacuum also serves as a floor vacuum for each room and we vacuum in between patients. No nails, no dust. I Dremel every patient. It is still going strong after 12 years of heavy use. I'm guessing I have about $1,500 in the system.


Richard D Wolff, DPM, Oregon, OH



From: Pete Harvey, DPM


I use Telemed out of Atlanta. My fee is $119/month and well worth it. However, that fee does not include scheduling, but they do offer that service. My service is automated and they tell the patient the office is closed and to call during regular hours.


If it is an emergency, they advise the patient to call the ER. If I get an after-hours call, they send a text to my phone with the patient’s problem, and a blue "click-on" to call the patient back.


Pete Harvey, DPM, Wichita Falls, TX



From: Steven J. Kaniadakis, DPM


It seems that podiatry school programs are pushing for students to get more biomechanics instruction from their residency programs and other post-graduate programs. Podiatrists have  typically been very well versed in these (and other) subjects, including reading and understanding x-rays and radiology, surgery skills, etc. 


Generally, podiatrists have been very well educated before residency and other post-grad programs compared to other medical school students. Even some practicing MD physicians do not even know which way to hold an x-ray (unless they were in a radiology residency or fellowship specialty program). However, generally speaking, MDs are much better versed in labs, etc. 


Steven J. Kaniadakis, DPM, St. Petersburg, FL



From: Elliot Udell, DPM


Dr. Borreggine is correct. One does not need to make an appointment to see a doctor in order to acquire a set of custom foot orthotics. This is not new. Making and dispensing foot orthotics has never been a practice which required a medical license. Orthopedic shoe stores, chiropractors, and physical therapists have been dispensing custom orthotics for years. What distinguishes a podiatrist from a "Joe Blow" working in a shoe store dispensing orthotics is our training in biomechanics. It’s the knowledge and training that enables the podiatrist to add corrections into a custom orthotic that distinguishes us from shoe store employees and others who make foot orthotics.


To this end, it would be great if the orthotics labs could roll back the clock and once again subsidize lectures on biomechanics and foot orthotics at every one of our conventions and at every one of our schools. That would once again make a real difference for our profession as well as the general public.


Elliot Udell, DPM, Hicksville, NY



From: Dave Williams, DPM


I have used HelloRache for about a year and have been happy with their services. They use ZOOM as their video chat and it hasn’t failed yet. My scribe can hear us clearly and we can hear her. She has direct access to my EHR and creates a “draft” note for me to review and sign later. She is based in the Philippines, but the company’s main office is in Arizona. All scribes have medical experience. You can interview your scribe before you hire them. You pay HelloRache every 2 weeks and they take care of the rest. 


Dave Williams, DPM, El Paso, TX



From: Justin Sussner, DPM


Last summer, I had the pleasure of getting a perfect bull’s eye on my back. My PCP put me on the standard dose of doxycyline. I went to my local chain pharmacy, who happily filled it and took $60 from me, the allowed amount on my insurance. 


About 2 months later, my wife was diagnosed with Lyme disease, and was given the exact same prescription. She went to our local mom and pop pharmacy who, when looking up the insurance info, stated "this isn't right", and then ran our info without insurance, and, for about $10, gave us the same doxy, same quantity.  


The moral of the story is: always look up your medication costs before walking into a drugstore, and it always pays to know a good locally-owned business.


Justin Sussner, DPM, Monroe, NY



From: David Gurvis, DPM


While neither solidly pro nor against “Medicare for all”, I would ask Dr. Hrywnak to back up some of his statements. A few pro and cons as I see them, in no particular order.


While true that Medicare as it is now handles the older population from the young healthy 70 year old to the chronically ill 65 year old, that would change as it would then include the young and healthy as well as the older and ill and everyone in between. As always, the young or the healthy would fund the ill.


As to taxes, yes, they would go up and in many cases... 


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



From: Raymond Posa, MBA


VoIP is Voice over Internet Protocol; basically, your voice communications are transmitted over the Internet instead of the traditional phone lines. That service is called POTS which stands for plain old telephone service. In the early days of VoIP, there were issues with voice quality, but those days are long gone. The quality of VoIP is top notch and the systems have all the advanced features any practice could want.


One of the biggest differences between VoIP and traditional phone service is price. VoIP tends to be much less expensive. Another huge plus with VoIP is its portability. If you were to move your...


Editor's note: Raymond Posa's extended-length letter can be read here.



From: Judith Rubin, DPM


I too took the boards in 1988 and thank God passed the first time. Now taking the Boards is almost impossible. One of my associates handed in his cases, some from residencies and some from private practice. His cases were rejected because of ridiculous things such as a cavus foot in which he performed a Dwyer osteotomy. They wanted to know why he didn’t do NCS and EMGs. Really? I think the whole thing was ridiculous. That’s my opinion. 


Judith Rubin, DPM, Cypress, TX



From: Richard M. Maleski, DPM


I have not used the Epifix Micronized Amniotic membrane allograft for plantar fasciitis, but I have used the Epifix Amniotic Membrane for wound healing, and I have not had a good experience with Mimedx. When I was being sold on the graft, the sales rep and someone in their home office who helped us get the pre-authorization assured me that we would only be responsible for what we were actually reimbursed, and they were aware that the patient was insured through Medicare/Medicaid.


Needless to say, I wasn't reimbursed the full cost of the graft, and Mimedx now insists that it is not their policy to only accept what was reimbursed. I paid them what I was paid, had dozens of communications with them, sent them copies of the EOB as proof of payment, had my billing service send them the EOBs, but they continue to harass me about the balance. Maybe it's just me, but I would not take any billing advice from them. Be forewarned.


Richard M. Maleski, DPM, Arnold, PA



From: Joseph Borreggine, DPM


“Practice burnout” is not the issue, but rather it is the fact the we are just “too late to the game”. We figured that our practices would exist for many years and when it was time to “retire”, then we would sell it off for a hefty sum and enjoy the fruits of our labor in our sunset years. 


Unfortunately, this is not the case because all the young DPMs over the last ten years have chosen to make their careers into a “vocation” rather than an...


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



From: Neil Scheffler, DPM 


One of these clinics is in my area in SW Florida. They run full-page ads in the newspaper for free seminars on stem cell therapy, (no mention of chiropractic in the ads). I took my painful shoulders and knees with me and went to one of these "seminars" held in a meeting room of a nearby hotel. The nurse practitioner was the speaker, but first they showed a video of actor Mel Gibson with a story of how he flew his father out of the country for stem cell treatment before it was available in the U.S. and had a miraculous cure.


The NP seemed a bit upset that she could not practice independently in Florida and had to have an MD on board. It appears the MD has no patient contact, the visits are in the chiropractor's office, and the NP does the treatment. Follow-up physical therapy is done by the chiropractor and staff.


I asked about what they used to direct the injection, hoping to hear diagnostic ultrasound. Instead the answer was that "I aim the needle where you point to the pain." I asked about platelet rich plasma and was told they are looking into that now. And then we were told of the special pricing for seminar attendees. Only $5,000 for an injection. 


Neil Scheffler, DPM (retired), Estero, FL



From: James DeWitt, DPM


I have been prescribing balance AFOs for patients at risk for falls since 2011 and have found them to be an important and effective component of my comprehensive fall prevention program. I conduct a fall risk assessment with any patient who has admitted to falls/unsteadiness or whom my staff and I observed demonstrating a balance deficit as they ambulate about the office.


I refer you to the randomized controlled trial by Bijan Najafi, et al. from November 2018 published in Gerontology entitled "Effectiveness of Daily Use of Bilateral Custom-Made Ankle-Foot Orthoses on Balance, Fear of Falling, and Physical Activity in Older Adults: A Randomized Controlled Trial". I feel that podiatry has a tremendous opportunity and is very well positioned to make a difference in this rapidly developing medical issue. I would be happy to answer any questions you may have.


James DeWitt, DPM, Wyoming, MI



From: Nicholas A. Ciotola, DPM 


We tried this for a short period since it dovetailed well with our MIPS reporting. I found them to be poorly tolerated. The AFOs are cumbersome and don't fit easily into patients' shoes. This is extremely problematic in a deconditioned patient. I did have one patient with a reducible equinovarus deformity who found the AFO helpful, but the feedback was lukewarm to unfavorable. You will need to spend time responding to patients' complaints and returning the AFOs to the lab for adjustments. If you really want to help your fall risk patients, a PT referral can go a long way. Establish a relationship with a home nursing agency to set up home PT if needed. Your patients will return to you with a spring in their step.


Nicholas A. Ciotola, DPM, Methuen, MA



From: W. David Herbert, DPM, JD


It was the first day or two that I spent at OCPM in the fall of 1972 that our dean Abe Rubin, DPM told us why real doctors (i.e.. MDs) did not consider podiatrists real doctors. He stated they said this because podiatrists did not deliver any babies during their training. Dr. Rubin stated that beginning with our class, that would all change!


I remember spending 6 weeks in an externship at an osteopathic hospital in Texas in the fall of 1975. While there, every Wednesday I observed podiatric surgery. For 24 hours a day, one of us was on call for assisting on obstetric deliveries. I remember assisting on 27 deliveries while I was there. I am not sure this experience made me feel more like a real doctor when I graduated. I do know that it convinced me that I would not have become an obstetrician even if I was able to!


W. David Herbert, DPM, JD, Billings, MT



RE: Using the DPM Degree Outside of Podiatry 

From: Ty Hussain, DPM


I have to commend all these great physicians and their inputs as to basically answer our question of who we are and where our profession is headed. I would love to be on a panel at any of our national or regional meetings as this topic and anything relevant to it will draw crowds by the thousands.


After reading much of what has been stated, the need for DPMs to be equal or this so called parity to our MD colleagues will only begin with us having the initials MD behind our names. That being said, discussion has now led us to...


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



RE: Using DPM Degree Outside of Podiatry 

From: Robert Kornfeld, DPM


In the almost 39 years since I graduated from NYCPM, it is my assertion that very little has changed in the world of parity with MDs and DOs. I will also say that very little has changed in podiatric medical education in terms of teaching our students cause and effect. We still focus on attacking symptoms and when we fail, we turn to surgery. The reality is that if every podiatrist understood the reasons why patients presented to his/her office with a problem, we would be light years ahead in our transition to parity. 


Here is an example: I lectured to a group of podiatric residents. I asked them what could be the underlying cause of...


Editor's Note: Dr. Kornefld's extended-length letter can be read here.



From:  Paul Kesselman, DPM


Over the last 35 years, I have seen many DPMs who left the profession and did quite well with the DPM degree as part of their resume. Several have gone into teaching at the HS or university level and have excelled, receiving numerous awards, grants for research, etc. 


Others may have started in the "cellar" of pharmaceutical sales and go onto become national directors, national physician education liaisons, far surpassing the average incomes of most MD/DO/DPMs. These gifted individuals no doubt would have excelled at anything they chose to do, but the fact was their DPM degree and educational background did get them in that first door which...


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



From: Leonard A. Levy, DPM, MPH


As we all know, preparation for podiatric medical practice today includes undergraduate podiatric medical education and, as part of a continuum, 3 years of residency training. Not too many years ago, the DPM completed podiatric medical school and perhaps a year of residency. As a result, education and training took just four years, and perhaps for a relatively small core of graduates, another year of training. Today, much more general medicine and surgery is a standard part of podiatric medical school which is significantly increased in the three years of residency that follows. 


But in spite of our greatly expanded education and training and the fact that there is virtually no difference in how we practice when compared to specialists in medicine such as ENTs, ophthalmologists, dermatologists, the recognition we receive is still considerably less. This lack of recognition often...


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



RE: Using a DPM Degree Outside of Podiatry (Allen Jacobs, DPM)

From: Ira Baum, DPM 


Allen Jacobs, DPM makes reasonable points regarding podiatric medical school education. I’m sure the education in medical school is more comprehensive, as is their training, compared to podiatric medical school. Where I take issue with his position is the pride, excellence, and credibility podiatrists should exercise, not legislate our way to another degree. I don’t think that’s the core problem. The core problem is the disparity in reimbursements for the same Dx and Tx, and how institutions deal with podiatrists. Yes, there are prominent extraverted podiatrists that are treated as equals by MDs and DOs, but that’s not the primary concern. I’m certain that even the “prominent” podiatrists have confronted professional discrimination by doctors’ insurance companies, hospitals, and other institutions.


Ira Baum, DPM, Naples, FL



From: Tip Sullivan, DPM


For the immediate complaints--


1- Remove the screw in the second metatarsal and shorten the second met.

2- Repair the plantar plate. Remove the base of the second proximal phalanx only as the last resort. This foot is biomechanically unstable and you can bet that the second toe will not stay where you want it. 


I would also discuss repair of the 1st MTPJ (the sesmoids are not in good position) as well as some soft tissue adjustment at the 3rd MTPJ. You need to follow this up with functional orthoses.


Tip Sullivan, DPM, Jackson, MS

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