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RE: Failure to Diagnose PAD 

From: Allen Jacobs, DPM


Increasingly, I have observed that plaintiff attorneys specializing in litigation involving care of the elderly are looking at podiatry care. One major area is the failure to diagnose and treat or refer for treatment geriatric patients with PAD. 


The argument being advanced is as follows; the patient is qualified for care by a podiatrist by virtue of class findings consistent with PAD. Therefore, why was the patient not referred for vascular studies or to vascular surgery or interventional cardiology? Given advanced age and the common presence in elderly patients of comorbidities with which PAD is associated, a potentially compelling argument is that


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

Other messages in this thread:



RE: Affordable Amniotic Membrane Product (David E Gurvis, DPM)

From: Beth Pearce, DPM


Clarix Flo from is a terrific alternative for a cost-effective injectable. I have seen very good outcomes/great results in plantar fasciitis, Achilles tendonitis, and in mild to moderate hallux limitus. I’ve also used it with success in post-traumatic neuralgia and non-healing wounds, particularly in regions of sclerotic and indurated tissue.


The “sheet form” is called NEOX. The product is comprised of both the amniotic membrane and umbilical cord which retains higher concentrations of the active HC-HA/PTX3 complex. Studies have shown its beneficial usage in plantar fasciitis {FAI 2015 Feb;36(2):151-8 & FAI doi:10.1177/2473011417S000174) as well as facet, wrist, and knee OA { Clin Case Rep. 2019; 00: 1– 3; Medicine. 2019; 98: e14745; Pain physician. 2018;21:E289-E305}.


Beth Pearce, DPM,  St. Augustine, FL 



From: Martin M Pressman, DPM


I agree with Dr. Allen Jacobs completely. The use of graded pulses (+1 thru +4), capillary filling time, and hair growth as the standard podiatric documentation, while necessary, is simply not enough. Hand-held Doppler evaluation is an inexpensive method of determining the quality of pulses: monophasic, biphasic, or triphasic. Documenting the presence and quality of the three foot pulses with a Doppler and referring to a vascular consult or ordering vascular ultrasound imaging/ABI for absent or monophasic sounds would save limbs and time spent in depositions for a missed diagnosis of PAD.


Martin M Pressman, DPM, Milford, CT



RE: Standard of Care for Sterilizing Nail Nippers

From: Allen Jacobs, DPM


The so-called "standard of care" is generally defined as that which the average podiatrist would do under the same or similar circumstances. The most recently completed PM News survey indicates that greater than 57% of respondents utilize cold sterilization for nail care instrumentation. Therefore, cold sterilization is the standard of care for nail care instrumentation between patients.


Theoretical arguments regarding the potential benefits of alternatives do not change the existing standard of care. The potential medical-legal implications of this survey, particularly to those caring for large numbers of institutionalized based populations, is very important. 


Allen Jacobs, DPM, St. Louis, MO



From: Charles Lombardi, DPM


ABOS requires submission of all cases done in the last two years. Then they require you to come down and defend your cases (that they pick). This process is repeated in re-certification. That is why most orthopedists don't want difficult cases in their window.


Charles Lombardi, DPM, Flushing, NY



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


Dr. Udell's post reminded me of an incident about 4 or 5 years ago at our community hospital. The wound care nurse at the hospital, who also worked part-time for a home nursing service, apparently took some training course for routine foot care and started advertising, with the hospital's blessing, her availability for nail care and corn/callus care. My understanding was that she could not bill any insurance, cash only. 


I became familiar with her since I worked closely with her on some wound cases, and therefore felt comfortable talking to her about her new "business". She told me that she stopped after a few patients because she didn't realize how difficult it was to adequately provide... 


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



RE: Less Strict Criteria for ABFAS Board Certification

From: John Moglia, DPM


I believe the ABFAS criteria for certification is too restrictive. I was certified over 20 years ago with less restrictive criteria and would not qualify today. There should be a compromise in criteria with no compromise in quality. Why not follow our American Board of Orthopedic Surgery (ABOS) colleagues’ path to certification with no specific case requirement? Our leaders must resolve this issue for the survival of the profession as certification is now mandatory for hospital and insurance participation. 


John Moglia, DPM, Berkeley Hts, NJ



RE: Are podiatrists turning their backs on podiatry?

From: Elliot Udell, DPM


At an executive board meeting, last week, of the American Society of Podiatric Medicine, one of our board members, a former president of the APMA apprised us of the following: There is at least one nursing association that is already training members on how to treat patients with foot problems. What he was driving at is that if our profession is now training our podiatric residents on how to do complex foot and ankle surgical procedures and if these graduates have no interest or training in managing corns, calluses, warts, foot arthritis, nail problems, etc., there is another profession waiting in the wings to take over.


If some of you envision a scenario where podiatrists will only do bone surgery and have one of these nurses attend to all other aspects of foot care, I hate to ruin your fantasy. In all likelihood, these nurses will be performing all foot care procedures at MD and DO medical centers with no obligation to refer surgeries to podiatrists. The more likely future scenario is that the well trained podiatric surgeon will be sitting in his or her office playing solitaire waiting for a patient to walk in off of the street asking for a triple arthrodesis.


Are we ready and willing to encourage patients to seek non-surgical foot care from non-podiatrists? What can we do about it? 


Elliot Udell, DPM, Hicksville, NY



From: Daniel Chaskin, DPM


Consolidating podiatric medical boards with foot and ankle surgical boards would be a positive first step to prevent what I believe is discrimination by hospitals, against podiatrists who are board certified in podiatric medicine.


Unfortunately, some hospitals require board certification in surgery. If podiatrists lack these credentials, they can be excluded from a hospital's operating room. 


Daniel Chaskin, DPM, Ridgewood, NY



RE: Preventing Suicides of Podiatric Residents 

From: Ernest L. Isaacson, DPM


Thankfully, I don’t personally know anyone who has committed suicide, but I’m pretty sure there are a whole lot of factors outside of work stress that lead someone to the unspeakable horror of taking their own life. And while we are on the subject, characterizing a podiatric residency as “not stressful” is presumptive and dumb. Back in the day, we took in-house call every third night and covered orthopedics at night without the support of orthopedic surgeons or PAs. Yes, we did medically manage patients - in addition to four months spent as medical, then surgical interns. Don’t presume to know what stresses or demons others carry or the burden others assume in caring for patients.


Besides we can screw people up plenty - ever had a less than perfect surgical outcome or had a patient lose a leg despite your best efforts? If that’s not stressful to a doctor of any initials, perhaps said physician should not have been advanced from school through residency. This discussion should be continued, but not in this forum - as great as it may be. This is a matter that should be studied by residency directors and others leading our field. If we don’t know causes and numbers, it’s time to obtain that data. Better to be proactive now, then reactive after a horror story. 


Ernest L. Isaacson, DPM, NY, NY 



RE: Preventing Suicides of Podiatric Residents 

From: Gwen S Greenberg, DPM


Robyn Symon is a documentary film maker who has been a champion of physician and medical student suicide prevention. She has created a film called Do No Harm which she has presented at many medical conferences and hospitals. She will be coming to our local hospital in September. As the parent of a second year medical student and a first year internal medicine resident, this is really scary. Here is the trailer for the video. A screening can be scheduled at this website:


Gwen S Greenberg, DPM, Allentown, PA



From: Jon Purdy, DPM


Board certification, in this day and age, is a requirement to maintain insurance contracts and hospital privileges in almost all cases. Unlike days past, when certification was a badge of honor and optional, today, not becoming board certified can mean the end of a physician's practice.


Like any political world, our profession is intertwined among our state, the APMA, and multiple certification boards. To challenge this, especially on a state society level, is a political hot potato. Even individuals appear to be fearful in using their names in posting commentary. The APMA, through the HOD, in conjunction with the CPME, gives the green light to the boards of their choosing. It then follows that... 


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



From: David S. Wolf, DPM, Thomas DeBenedictis, DPM


Years ago, an expert practice management podiatry guru posited, “We don’t just sell hot dogs, we have a grocery store.” In today’s medical world, the “hot dogs”(foot surgery) pales in reimbursement to the “grocery store” (steroid injections, ingrown toenail procedures, orthotics, etc.). That’s only one of the benefits of our profession which gives us treatment options to best serve our patients.


David S. Wolf, DPM (Retired)


Reading the posts about our professional identity, I remember a quote I heard Ed McMahon say to a question he was asked about after becoming successful in his own profession. "Why did he not leave Johnny Carson?" I guess to understand this, it is necessary to know who these two men were. Ed McMahon was the announcer for Johnny Carson who was the star of the "Tonight Show" for many years. Ed McMahon on his own became famous announcing commercials, game shows, and interviews. When asked this question, he looked intently at the questioner and his quote was, "Never go too far from the well!' 


Maybe, we as a profession, can advance in many differing areas, but is it wise in the long run to abandon the areas that gave us the opportunity to expand in the first place? Surely, we can work together and share according to what we want to do as podiatrists, but why turn our backs on colleagues who helped to establish our areas of specialties and are a great source of referral. 


Thomas DeBenedictis, DPM, Union City, NJ



From: Norman Rubin, DPM, David E Gurvis, DPM


My partner of thirty years tragically committed suicide just as we had sold our practice and were about to retire. He was financially secure and was looking forward to his retirement. In addition to being my partner, he was my best friend. You would have thought that if anyone should have seen the warning signs early on, I would have seen them.


About a month before he committed suicide, however, I noticed a significant change in his personality. I spoke with my partner about my observations, but he insisted that he was doing fine. Nevertheless, I was concerned and...


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


I was also at the memorial service for one of my oldest friends. I have known him for over 30 years. I am also a colleague of Dr. DeHeer and know he is prone to action, not simply talk. When he speaks of suicide prevention in doctors, he is speaking from a position of knowledge and caring. I personally know he cares about others. I don’t know Dr. Bellezza, but I find his comments very offensive and lacking any care or understanding of human psychology.  


Were we able to weed out those who might become depressed later, I would support giving them the ability to accept counseling or medication as necessary, just as I would anyone suffering. However, to prevent someone from entering podiatry school simply because they may have depression is untenable. To simply say we should weed them out, besides being impossible, shows no ability, in my opinion, to exhibit sympathy for those suffering from depression.


David E Gurvis, DPM, Avon, IN



From: Andrew Levy, DPM 


I feel a need to add another voice of support to Doctor DeHeer's concerns and important consideration for finding ways to prevent suicide among our residents and our peers. We too have suffered the sadness of this tragedy in our community, in our professional ranks, and with our professional colleagues in other fields. I discussed this today with a patient who is director of a post-doc program in our community, and they also have that problem as well. This is, unfortunately, ubiquitous to all of our societies. 


While we search for the appropriate tools to study the phenomenon and assess different tools to help fight the problems through mentorship, referral to physician services, or the importance of enlightening our fellow colleagues, the important work must...


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



From: Alan Sherman, DPM


Jeff Robbins, DPM’s call for debate on the issue of what constitutes a “specialty” board in CPME 220 and 230 (CRITERIA AND GUIDELINES FOR RECOGNITION OF A SPECIALTY BOARD FOR PODIATRIC MEDICAL PRACTICE) is interesting and part of the broader discussion in the profession as to what podiatrists actually are in 2019, and what we wish to work toward being in the years ahead. It’s about our very identity, something that we’ve struggled with as we’ve proudly built our profession in the last 50 years into what it is today. 


Jeff’s interest as head of podiatry in the VA system is, of course, an interest that we all should share, as the VA policy is like Medicare policy, in that it tends to trickle down to...


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



From: Robert Scott Steinberg, DPM, Irwin B. Malament, DPM


Dr. Bellezza's comments underscore the need for all the colleges of podiatric medicine to immediately add a full year course on mental health (psychology/psychiatry). So far, the Scholl College of Podiatric Medicine has refused. The Illinois Podiatric Medical Association has reported they have had multiple meetings with the college, and all the college does is kick-the-can-down-the-road.  


Robert Scott Steinberg, DPM, Schaumburg, IL


I applaud Dr. Deheer's survey regarding suicide prevention in podiatric residents. This should be extended to all physicians in practice as well. I recently lost a good friend and former class-mate who committed suicide last week. We talked 4 days before he did this and never attempted to reach out that there was a problem I could help him with or talk about.


We are all under a lot of stress these days with practice and family. A lot of issues are under the surface and if we are proactive, possibly we could avoid these tragedies.


Irwin B. Malament, DPM, Indianapolis, IN



From: Rikhil Patel, DPM


I think the situation where young DPMs refuse to do routine care or podiatric medicine is a personality issue more than a training issue. I graduated in 2013 and did a 3-year PMSR -RRA residency and a fellowship in reconstructive surgery and limb salvage. But I understand that we as podiatrists still have skillsets that we are all taught in school (or should be) to help people non-surgically. 


My callus and nail patients are steady revenue, good people, and great referral sources. I think that instead of trying to separate our field, we must understand that as new graduates enter practice and older ones retire every doctor (in all fields) has a particular area of interest or limitations. My bottom line, if you have people wanting their callus shaved, take the 30 seconds to do it, bill if it is within guidelines, and make a patient happy. 


Rikhil Patel, DPM, Naples FL/Annapolis MD



From: Peter Bellezza, DPM


Dr. DeHeer, my original message was to point out that if you want to design a research tool to predict behavior/suicidal ideation in the podiatric residency training model, you have to consider the disparity of training between the individual podiatry residency programs, the training disparity between podiatry residency training vs other med/surgery specialties and the disparity in student preparedness for residency training when comparing the DPM vs. the MD/DO medical education system. If you think there is no disparity in any of the above, then that’s an entirely different debate.


Residents who work longer hours are going to have social factors that can come into play that could increase the potential suicidal ideation. That’s obvious. For residents that have succumbed to suicide, was it really because medicine (the work) drove them to it? Or are we dealing with individuals with extensive histories of anxiety, depression, substance abuse, etc. that entered the field of medicine? These are important questions to ask. 


Understanding the medical and social history of residents may be important screening tools to better identify residents who are at risk during residency training. I look forward to reading the data you produce. I apologize if I offended you and others with my initial response. 


Peter Bellezza, DPM, Bristol, CT



From: Jessica Tabatt, DPM


Thank you, Dr. Bellezza, for showing us that there is still an unfortunate stigma surrounding mental health that prevents people from seeking the care they need. If a person is stressed, you cannot tell them that they are not, nor should they not be stressed. This would be like telling me that I am not hungry because you are not hungry.  


I took my residency and now my current career seriously. Even though my patients are not dying, I still have their health and well-being under my care, which can be very stressful at times.


Jessica Tabatt, DPM, Brainerd, MN



From: Ira Baum, DPM


I respect Dr. Swedlow's call to maintain podiatric medicine as the primary service provided and surgery as a subspecialty. He cites a time in which the care of the foot and ankle was of no interest to a significant number of orthopedic and general surgeons, and podiatric primary care was not piecemealed into other subspecialties in medicine. The profession has evolved from those years of palliative care when podiatrists couldn't perform surgery or write Rxs. Today, all podiatrists seeking specialty residency training are afforded the opportunity and most states require it. His argument that podiatrists still provide unique services is like saying all orthopedists only do surgery. They don't. Some inject and Rx for plantar fasciitis. 


General surgeons and dermatologists provide wound care. Dermatologists provide treatment for onychomycosis and other skin disorders of the feet, orthotists/retail stores provide orthotics and footgear and yes, pedicurists participate in what we consider palliative care. Insurance companies know this and that's reflected by our low reimbursement levels. Following Dr. Swedlow's argument to its logical conclusion seems to me to be the absorption of podiatry into allopathic/osteopathic medicine. The movement to absorb podiatry into those disciplines has been around for many years, only to be met with strong resistance. So where does that leave "podiatric medicine"?  From my perspective, it doesn't seem to be headed in the right direction.


Ira Baum, DPM, Naples, FL



From: Patrick DeHeer, DPM 


Yesterday, as I stood in the hallway at a memorial service for a respected Indiana podiatric physician, Dr. Belleza's response to my post on PM News came to mind as I watched my colleague's wife cry throughout his memorial service and his son sing beautiful hymns. My colleague called me looking for help two days before he chose to take his own life. Our conversation ended on a positive note as I offered some ideas and suggestions to assist him in his time of need. We were not best friends, but we were professional colleagues for more than 25 years. This explains him reaching out to me. 


The Tuesday, after I learned of the incident, I emailed about 30 leaders within the podiatric profession to assist getting our survey out to podiatric residencies so we can, in fact, examine if suicidal ideation in podiatry is similar to that of our allopathic and osteopathic colleagues. Shortly after my initial email, I was informed of four other DPMs committing suicide (one third-year student, one resident, one attending at a residency program, and...


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



From: Larissa Paulovich, DPM


Dr. Bellezza’s lamentable letter implies that the stressors of our training programs are the only reason why a resident would commit suicide, and ignores that 1 in 12 Americans suffer from depression and 18% from anxiety.


So your opinion is that a resident “suck it up” and ignore their depression because they want to appear “tough” or don’t want to be stigmatized since it’s “just podiatry”. But I’d like you to combine that feeling with the following scenario: A “lowly DPM resident” is overworked because their senior residents “already took all that call as first years” so they’re now on call for 38 days straight; they’re also feeling pressure from their spouse for not being around; in the back of their mind they’ve had to put off the $200,000 student loan bill at 6.8% interest yearly because... 


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



RE: Call for National Debate on CPME 220 and 230 on a Single Board Certification within Podiatry

From: Jeffrey M. Robbins, DPM


It has become clear to me after a rather long crisis conversation with the Office of General Council and a Congressional office earlier this year, that we do ourselves no favors by continuing to claim that podiatric medicine and surgery are two distinct practice types. By our own definitions, they are not (see CPME 220 Definitions of Specialization and Certification.)


Podiatry is a procedure based profession, and regardless of how sophisticated the procedures are, they are all considered surgical codes by the standard in the industry, Current Procedure Terminology (CPT). 


What I am suggesting is a board certification process that uses...


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



From: Samuel S. Mendicino, DPM 


I find it sad that in discussing the suicide issue, people are arguing that our residents do not suffer the same stress as other residents and therefore this is not a concern. Does it matter? One is too many! Having someone say that a resident “should be happy” because they are doing what they “signed on for” demonstrates a common theme in our country: mental  health and illness is not understood or for most even a concern.


I have had family members and friends who have attempted and committed suicides. Even in the absence of a suicide, depression and other forms of mental illness affect many Americans. It can be the cause of many of our nation’s problems. Crime, drug addiction, alcoholism, gun violence, homelessness, ruined lives, and yes suicide can often be traced back to mental health issues. Having dealt with the mental health system, I can assure you that it has severe flaws.


Residents have more stress than just residency. They have the same stresses of student loans, family, career, and yes some have a genetic predisposition to mental health issues as MD or DO residents do. Remember, mental illness is a disease that is often chronic and no different than diabetes or hypertension. It often requires lifetime treatment and can have a devastating effect on the patient and their families.


Samuel S. Mendicino, DPM, Houston, TX

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