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04/22/2019    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Michael Schneider, DPM


 


Keep your license at least for a few years. You never know what may come your way. 


 


Michael Schneider, DPM, Denver, CO

Other messages in this thread:


07/01/2020    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Tiffany Kildale


 


Thank you, Dr. Udell, for serving as a mentor in the Mentor Network! Your service to the future of the profession is invaluable, and we’re grateful to have you.


 


APMA strongly encourages virtual shadowing, for both the comfort level of the prospective students, as well as mentors participating in the network. While the Mentor Network was briefly suspended during the height of pandemic in April, an email was sent to mentors in the network upon reopening, encouraging them to meet with prospective students via Zoom, FaceTime calls, or other virtual platforms. We encourage physicians to limit in-person interaction as a way to minimize risk and limit the number of people physically present in an office based on local capacity guidelines. Students have been made aware that in-person shadowing is not a guarantee, as every office has different rules and guidelines regarding reopening.


 


Thank you again for taking the time to talk with students considering a career in podiatry—you are encouraged to do so at your own comfort level!


 


Tiffany Kildale, APMA Career Development Manager

06/29/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: David Gurvis DPM


 



Wearing a mask in the office will not lower your O2 saturation (hypoxemia) nor cause an increase in CO2 (hypercapnia). There are some slight differences with the wearing of a well fitted N95 mask but even those are most likely non-consequential, but there are no current recommendations or need to wear an N95 mask in the office. Regardless, there should be no reason for supplemental O2 from wearing a normal face mask in the office. You can find many well written articles on line but I will offer just one.  


 


My goal here is not to put anyone down, but there is too much information out there and too many people refusing to wear masks and that is just one, of many, excuses they are making. As a disclaimer, I am forced to admit that never in our history have so many needed to wear masks for so long during a day so that there may be some conditions wherein a mask may cause hypercapnia or hypoxemia, but I propose they are rare.


 


David Gurvis DPM, Avon, IN


06/29/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Robert Scott Steinberg, DPM


 


Your surgical mask is not the cause of your low oxygen saturation. Look elsewhere. Here is some science


 


Robert Scott Steinberg, DPM, Schaumburg, IL 

06/26/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Tim Shea, DPM 


 


What a great question Dr. Simmons presents. My associate and I are both above 60+ and we were wondering why we were short of breath after about 4-5 patients, especially if we were talking. I think it is a combination of re-breathing CO2 and not getting as much O2 volume through the masks. We may try to have O2 available in the office. Thank you Dr. Simmons.


 


Tim Shea, DPM , Concord, CA

06/26/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Advanced Beneficiary Notification


From: Paul Kesselman, DPM


 


CMS has announced today that providers should continue to use the current ABN despite the March 2020 expiration. A new form is currently awaiting approval and should be released later this summer, which should be good for 3 years.


 


Paul Kesselman, DPM, Oceanside, NY

06/25/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B



From: Dennis Shavelson, DPM


 


In changing our focus and training towards surgery, as a profession, we are forced to become more and more vestigial regarding closed-chain lower extremity biomechanics. In medicine, a surgeon’s card reads that he/she is a surgical specialist. A physiatrist's card reads rehabilitation specialist, and a dermatologist's reads skin specialist, etc. They can and do consult outside of their specialty at a lesser level, but remain dedicated to one or more specialties. They consult with other specialists when their training and experience falls short of the problem at hand by putting the patient in the hands more expert than their own.


 


I can count the number of biomechanical consultations that I have received from surgeons in my 40+ years of podiatry on nine or ten fingers. Instead, I have fostered relationships where I can confidently refer the few surgical cases I am asked to consult on and in return, I am called upon to assist them biomechanically pre- and post-op. In summary, in becoming podiatric foot and ankle surgeons, we are practicing a stunted version of biomechanics and orthotics without incentivizing non-surgical podiatric consultants in integrative biomechanics, making DPMs like me more and more vestigial.


 


Dennis Shavelson, DPM, NY, NY

06/25/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Marc A. Benard, DPM



 


I agree with Dr. Ribotsky with respect to a distinct absence in gait analysis and applied biomechanics, as well as his indicating “… are we losing the skill to determine the difference between open chain kinetics and closed chain kinetics pathology? If so, how can correct surgical procedures be explained?” I can attest that I observe this deficiency at close hand through my didactic lectures to residents both in person and recently via webinars, as well as through on-site observation at Operation Footprint (formerly The Baja Project for Crippled Children) during patient screenings, grand rounds, and intra-operatively. I’ve also engaged in discussion with program directors on the problem.


 


In truth, the problem has always existed, if my 43 years of dealing with the issue holds any validity. Fundamentally, the partitioning of “biomechanics” and “surgery” fractionated the...


 


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


06/25/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: DEA Fee Proposes Increase of 21%


From: Paul Kesselman, DPM


 


If things were not financially taxing for all providers right now, the government has found another instrument to take some hard-earned money from healthcare practitioners and any entity involved in the distribution or manufacturing of controlled substances.


 


The DEA is now proposing a 21% increase ($731 to $838) for the triennial registration. This is especially outrageous for many podiatrists or healthcare providers who have chosen to discontinue performing procedures or seeing patients where prescribing...


 


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

06/24/2020    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Steven E Tager, DPM


 


No Bret, you're not alone. I have experienced the very same emotional response at almost every seminar attended over the last 54 years of my practice life. Frustrated, I've reached my limit and no longer wish to hear about the surgical exploits that continue to evolve in favor of newer and better procedures. It's possibly for the best that it has taken its toll on me, for it has forced me to think more about cause and effect, what works and what doesn't, and to do it without doing harm.


 


Credit for my actions must go to Drs. Mert Root, John Weed, and Bill Orien for an eye-opening education, giving me the insight to evolve and learn on my own. Recognizing that surgery may well be the answer for many. I too am concerned that many procedures performed today (and yesterday) are without considering the underlying bio-mechanical etiology.    


 


Steven E Tager, DPM, Scottsdale, AZ

06/23/2020    

RESPONSES/COMMENTS (NON-CLINICAL)


RE: Where Did Biomechanics, the Foundation of our Profession, Go?


From: Bret M. Ribotsky, DPM


 


Over the past few months, I have been spending many hours on webinar after webinar and two significant observations have become crystal clear to me. 1) It’s incredible how bright and surgically talented the young presenters are with their operative skills and 2) The foundation that separated our profession from orthopedics has been overlooked. From lectures on bunion surgery discussing hypemobility of the 1st met-cuneiform joint to hammertoe surgical reconstruction, there is ZERO discussion on the biomechanical etiology of these conditions.   


 


Gait analysis and applied biomechanics are what has and will make our profession catapult forward. I often ask about the biomechanics on these webinars, but the question, if chosen is barely answered. With ABPOPPM (now ABPM) and ACFAOM (now ACPM) dropping the word “orthopedics”, are we losing the skill to determine the difference between open chain kinetics and closed chain kinetics pathology. If so, how can correct surgical procedures be explained? As a past president of ACFAOM (1999-2001) I am very worried with the direction our profession is going. Am I alone?


 


Bret M. Ribotsky, DPM, Boca Raton, FL

06/12/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Richard M. Maleski, DPM, RPh


 



Although I am now retired, while I was still practicing, I was gradually reducing the number of nail patients that needed grinding. I had many patients use either Vicks VapoRub or BenGay Rub on their nails a few days before their appointment. These inexpensive and readily available products work extremely well to soften the nails. They contain menthol and /or methyl salicylate; both are salicylates, and thus both are keratolytic. I practiced in a low income area and I was never comfortable with office dispensing of higher priced products, and very often PA Medicaid didn't cover urea products. Practically everyone could afford Vicks VapoRub. We all know that these products aren't useful as antifungal agents as many people believe, but they work remarkably well to soften the nails. That, in addition to sharpened nail nippers, will reduce the need to grind most of the nail patients.


 


Richard M. Maleski, DPM, RPh, Arnold, PA


06/12/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Roy Perles, DPM


 


I never liked grinding toenails because of the inhalation risk of nail dust, difficulty sterilizing the burrs, and it's cost prohibitive to use fresh sterile burrs. Nail dust extractors are expensive, especially if you have to buy multiple units. About 15 years ago, my last Dremel drill broke, and that day I just picked up a sterile #15 blade, and with an alcohol-saturated gauze pad essentially "whittled" the sharp edges. I have not grinded a toenail since then.


 


At 15-25 cents per blade, you're delivering quality safe routine foot care with no risk of cross contamination from the re-use of burrs. There is a learning curve, but with practice, it's just about as fast as grinding. Occasionally, a patient may say, ''my other podiatrist grinded my toenails, why don't you?'' My answer is simple, ''You always get a sterile blade." I would ask the patient if their other doctor used a fresh sterile burr? Most patients replied ''no''. I am surprised that using a sterile scalpel blade for nail grinding has not been mentioned before.


 


Roy Perles, DPM, Cambria Hgts, NY

06/11/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B



From: Elliot Udell, DPM


 


Thank you Dr. Markinson for once again reminding us of the non-COVID-19 risks associated with grinding toenails. Several responders have legitimately asked how to adequately soften nails so as to properly debride them without the use of an electrical drill. 


 


As an allergy sufferer, I had to limit nail grinding very early in my career. I coughed and wheezed, even with the use of dust extractors. When papers came out showing that breathing in nail dust was an occupational hazard, I took all of the drills and extractors to the nearest dumpster. Some papers showed that the dust remains in the air for over 11 hours. 


 


There are ways to soften nails so that they can be adequately debrided. Spraying the nails with "Three Way Solution", often works. Another way is to dispense some of the nail softening products and insist that the patients use them daily between visits. We get great results with Bako's 40% urea nail gel as well as other products such as Formula 7. We have found that if the patients use these as well as other urea containing nail products, there is no need to mourn the use of nail grinding devices. 


 


Elliot Udell, DPM, Hicksville, NY

06/11/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Charles Morelli, DPM


 


You asked to "detail your techniques for reducing toenail hypertrophy". It has nothing to do with technique and all to do with having sharp instruments. If, and only if, your instruments are sharp, can this be done relatively easily and without pain to the patient. A dull instrument will do a less than optimal job and be painful for the patient if you are trying to reduce nail thickness. That being said, I do grind nails, have used a vacuum extractor for the past 30 years, and I now also wear a mask and will continue doing so, long after COVID is gone. I'd be embarrassed to have some patients leave my office without my doing that, but that is just me, as I know others will disagree. 


 


Charles Morelli, DPM, Mamaroneck, NY

06/11/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Alan Bass, DPM


 


Let me begin by saying that this is my opinion only. In the last 25+ years of practice, I have seen some, if not most, of the governmental programs that have been rolled out by CMS. I understand that CMS has tried to reinvent how physicians practice medicine and guide them towards providing quality care. Even without this push from CMS, I believe that all physicians have tried to provide quality care to patients. Are there physicians out there who have tried to “beat the system”? Sure, but I believe that most physicians have always tried to do the right thing.


 


The MIPS system, as it currently is, and what it is morphing into in the coming years is about one thing, data gathering. It was the same thing with Meaningful Use. The Meaningful Use program was supposed to move physicians away from quantity and towards quality. Did it do that? Not at all. What did it do? All it did was...


 


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

06/11/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Gregory T. Amarantos, DPM


 


Prior to MIPS, we had MeaningLESS use. Unless you are an epidemiologist employed by the government, there has been no value to the populace at large. It is a way for those in the ivory towers to penalize those sheep who refuse to be led to slaughter.


 


Gregory T. Amarantos, DPM, Glenview, IL

06/10/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1D



From: Michael M Rosenblatt, DPM 


 



Bryan C. Markinson, DPM, warned us about the risks of grinding nails and breathing in the detritus and fomites that erupt in that “cloud.” He states he has not ground nails for years. I practiced during the HIV-AIDS crisis. I treated infections, did open debridements, and ground nails for those patients. Those who grind nails all recall the experience of accidentally touching the nail groove with the spinning grinder and erupting into a shower of blood that would go into our face, nose, eyes, and mouth, even if partially covered by a mask and eye protection.


 


Unfortunately, avoiding this is not an easy answer. Sometimes hypertrophic, fungal nails are a real problem in fitting into footgear for diabetics and other fragile patients. Removing thse nails surgically is not always an answer, as some of these people have very poor...


 


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


06/10/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C



From: Jack Ressler, DPM


 



I cannot give an answer as to the effects concerning catching COVID-19 by inhaling nail dust during debridement. I have included a short video we made a few years ago which shows the difference between using and not using a nail dust extraction system. This video shows the amount of nail dust that becomes airborne during debridement. As you can see, the amount of particles/dust that is produced is very concerning. The video shows the difference in the amount of nail dust produced with and without using our nail dust extraction system. I am sure eventually there will be studies showing the possibilities of contracting COVID-19 from inhaling nail dust particles during debridement. Even without that threat, we all know the significant health hazards to ourselves, staff, and patients breathing in nail dust during patient care. 


 


Jack Ressler, DPM, Delray Beach, FL


06/10/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Brian Kiel, DPM


 



I have not used a drill to grind nails in at least 35 years. When patients ask if I will do so or ask why not because their other podiatrist did so, my answer is always the same. The nail dust is aerosolized and there is no way to prevent it from getting into the environment; therefore it is in the air that we and the patient breathe, and on the chair in which they sit. I tell them I don’t want them breathing in or sitting in someone else’s nail dust. This resolves the problem in 99.9% of the cases. In those that it doesn’t, I am happy to refer them elsewhere as I don’t think it appropriate to endanger my or my staff's health. 


 


Brian Kiel, DPM. Memphis, TN


06/10/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Todd Lamster, DPM


 


Since this topic has resurfaced, it is likely that some (or a lot) of us are grinding toenails. Many of my patients experience pain when cutting from the dorsal surface, or I find that the nail bed and hyponychium have become hypertrophied as well, reducing my ability to thin the nail due to risk of bleeding. Those of us using a rotary device would likely say that both hazards are reduced. In an effort to collectively end this practice of nail grinding (which I advocate), I ask my colleagues who are not using a rotary device to please detail your techniques for reducing toenail hypertrophy.  Specifically, address two items:


 


1) How to reduce a truly thick nail or dome-shaped nail structure without cutting through the elevated or thickened nail bed and hyponychium? 2) How to reduce the jagged edges that are the result of nail cutting using standard clippers? If hand instrumentation is used (as was suggested in an earlier post), what device is being used specifically?


 


Although this ongoing discussion may seem naive to some, I think now more than ever, it is important to standardize this process to reduce occupational risk and exposure.


 


Todd Lamster, DPM, Scottsdale, AZ

06/09/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B


RE: Grinding Nails During the COVID-19 Pandemic (Elliot Udell, DPM)


From: Daniel Chaskin, DPM


 


I would like to thank Elliot for his suggestions. If T. Rubrum or Candida dust were to bind to the ACE-2 receptors, there might be possible problems with too much vasoconstriction, etc. Combine this with COVID-19 and there just might not be enough receptors to convert angiotensin 2 to a more benign form.


 


Daniel Chaskin, DPM, Ridgewood, NY

06/09/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A


RE: Grinding Nails During the COVID-19 Pandemic (Elliot Udell, DPM)


From: Bryan C. Markinson, DPM


 



I am surprised that it takes the COVID pandemic to raise old questions and concern about hazards of nail dust inhalation for those clinicians still doing nail grinding. For all of you new or young in practice, I beg you to read almost any article on the long-term hazards of nail dust inhalation, (not to mention what it does to your work environment) having nothing to do with COVID and the potential heath effects on clinicians that may not be evident for many years, and hope that you stop doing it ASAP. For older clinicians, to continue to do it is insanity in my opinion. I have not grinded a nail in 25 years and do as much nail care as anyone.


 


The occasional patient who complains about a sharp edge doesn’t fit into my reconstructive foot and ankle persona anyway. (Tongue in cheek just in case someone thinks I may be self-misrepresenting ). Nail dust extractors? Water jets? Use them when you assign your grinders to the hobby space in the garage. But don’t take my word for it. Take the time to read about it and remember the ill effects can take decades to manifest.


 


Bryan C. Markinson, DPM, NY, NY


06/08/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Michael J Marcus, DPM


 



1.  For our patients who require nail debridements, I have recommended that mechanical debridements be performed with hand instrumentation only. Use of power instrumentation causing plume must be avoided if possible. Refrain at this time – two months from now things may be better. We haven't had any patient complain - just inform them and most should understand.


 


2. In surgery, my concern is with electrocautery and its plume. I attempt to avoid its use when possible. Use ties or just compress. Use close suction systems if needed. Treat all patients as if they are possible covids.


 


Michael J Marcus, DPM, Montebello/ Irvine CA


06/08/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Elliot Udell, DPM


 


By and large, the transmission of this deadly virus has been found to be from inhaling respiratory droplets. The big "but" is that everyday things are changing with regard to how this virus can spread. What would make an interesting research project would be for some podiatrists to collect nails from patients infected with the coronavirus and have a lab determine if the virus is present on the toenails. If so, than grinding would be dangerous. 


 


Elliot Udell, DPM, Hicksville, NY

05/28/2020    

RESPONSES/COMMENTS (NON-CLINICAL)


RE: NY Podiatrist Authors a Light-Hearted Novel from a Glorious Era Long Gone


From: Steven Kravitz, DPM


 


I recently read a novel by Dr. Elliot Udell titled Monticello: A Borscht Belt Catskills Tale. During the 60s, 70s, and into the 80s, the New York Catskills mountains was a vacation haven for a large Jewish resorts, with 2,000 rooms and more, top headliner evening entertainment, endless amounts of kosher foods and activities for the entire family. Along with this were small bungalows, less expensive hotels and motels to fit anyone's budget so they could enjoy the winter and summer away from the city.    


 


The novel uses the metaphor of a simple childhood story to share with the reader a brief moment of going back in time and getting the feeling of this innocent time and place. There's a good bit of subtle humor in a number of the passages that make it an enjoyable diversion without having to take a plane or travel to spend a lot of money to destinations unknown. Sit down in your favorite chair to take a quick voyage and get away from it all.


 


Steven Kravitz, DPM, Winston-Salem, NC
ASPMA


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