09/14/2019    Joseph Borreggine, DPM

Welcome to the Future of Podiatry

Who needs a podiatrist when you can just buy a
pair of custom orthotics on your own? Soon not
one insurance will pay for orthotics, but what
does it matter anyway? A new class of DPMs are
now entering the profession with the mindset
that they are only “foot and ankle” surgeons.

They opine that general podiatry is truly passe’
and is beneath the DPM degree. All the time and
money invested in their degree that was earned
along with the required 3-year surgical
residency is far beyond the general practice of
podiatric medicine.

Podiatry will soon just sink into the waters of
oblivion because of those who are being
relegated to provide these same type services at
a lesser cost (APN, FNP or PA) or general foot
care put into the hands of those non-medical
individuals to provide palliative foot care (LPN
and nursing aides) with no cost all.

The podiatry profession has lost sight of its
original foundation as a specialty in medicine
all in exchange for a new identity. Change is
good; I do not disagree, but when a podiatrist
who has been in practice over 30 years can no
longer recognize the occupation of podiatric
medicine that they entered long ago, then
something is wrong.

Yes, independent practice is dead and replaced
by guaranteed salaried and benefit positions in
corporate or hospital settings, but to
ignorantly give the services that used to be
exclusively provided by podiatric medicine in
exchange for RVUs is disheartening.

Understanding that certain services once paid
for in an office setting like DME, x-rays, and
wound care supplies are usually not part of a
typical compensation contract can certainly
affect the employed podiatrist ability to
generate a minimally acceptable revenue base.

Hence, administrative pressures cause a
physician to make clinical choices to meet those
financial expectations all in the name of the
corporate bottom line.

So, welcome to the future of podiatry and
medicine in general because it is here to stay.

Joseph Borreggine, DPM, Charleston, IL

Other messages in this thread:

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10/03/2019    Loretta Logan, DPM, MPH

Welcome to the Future of Podiatry (Paul Kesselman, DPM)

As chair of the Department of Orthopedics and
Pediatrics at the New York College of Podiatric
Medicine (NYCPM) I feel it is necessary to
respond to your recent comments regarding the
current state of orthopedic training at the
schools of podiatric medicine. While I agree
with the consensus that the younger
practitioners entering practice have placed
surgery at the head of their treatment plans,
the first sentence in point #1, “The
undergraduate level of biomechanical training is
apparently shameful as compared to when I was at
ICPM 1977-1981” was particularly troubling.

I would be happy to share curriculum documents
with you which show the evolution and expansion
of orthopedic training from the time of then
NYCPM chair Dr. Richard Schuster, and modified
to its current design by successive chairs and
my predecessors, Drs. Joseph D’Amico, Edward
Rzonca, Mark Caselli, Justin Wernick, Russell
Volpe and myself. I will assert that among the
colleges of Podiatric Medicine, NYCPM
consistently stands out as being a school that
the students feel is “orthopedically heavy”, due
to the rigorous classroom and clinic sessions
delivered throughout the 4-year curriculum.

While we no longer ‘build (custom orthoses, in-
house) from scratch’ from a neutral position
cast, students are well-trained in casting and
fabrication detail for fully prescription
devices and are able to complete on the fly
prescriptions using modifiable “blanks” to which
they add posting, accommodation and other
standard orthosis additions and features in our
orthotic laboratory.

In response to your statement in point # 2, “Do
students have any idea about orthotic materials,
construction, how to cast (or scan correctly). I
dare say no!”, I emphatically say yes! Our
students have didactic lectures and workshops on
casting, materials, footwear/pedorthics and
orthotic fabrication delivered by clinicians who
bring decades of experience to the craft. Our
students also have over 500 hours of clinical
rotations dedicated to biomechanics/orthopedic
sciences and where full biomechanical exams and
observational gait analysis are taught and
routinely used to evaluate and treat both adult
and pediatric patients. Our gait lab, which
features current pressure mapping and video
technology serves to assess patients whether for
orthopedic prescription, diabetic or pre-
surgical evaluation. It is our belief that this
academic and clinical experience better serves
orthopedic education (and the patient) than
would time spent creating plaster molds, et al…
especially considering that orthotic labs have
also largely abandoned this in favor of digital
and cad-cam technology.

I will also point out that NYCPM consistently
leads in post-graduate education in orthopedic
sciences. The annual Richard O. Schuster
Biomechanics Seminar is an event unlike any
other in North America and routinely showcases
not only NYCPM faculty but highly regarded
clinicians from around the country. NYCPM
faculty participate nationally in exam
development (APMLE and specialty board),
evaluation of residency training standards and
continuing education events where their
expertise and passion for this domain is
evident.

Hopefully, the information above will address
the second statement in that same initial
paragraph that your description of the
‘shameful’ state of podiatric orthopedics is
based merely on your “…query of student
residency interviews or externships over the
past 10 years.” Could your frustration in
questioning these particular students and their
unacceptable responses be reflective of the
fourth sentence in the same paragraph regarding
the opinion that Dr. Aronson voiced stating it
would take a ‘minimum’ of five years to master
the subject?

During the 2018 Richard O. Shuster Biomechanics
Seminar, I presented “An Analysis of the
Biomechanics/Orthopedics Curriculum in the
Colleges of Podiatric Medicine.” My research
involved reaching out to each of the schools to
obtain information on their curriculum in
Biomechanics/Orthopedics from as far back as
they could take me to the current day. My
analysis concluded that the level and quality of
training in the colleges of Podiatric Medicine
showed that biomechanics/orthopedic sciences is
being taught and with rigor and dedication at
all schools. As a faculty member at one our
sister institutions stated “the concern is at
the handoff point (residency training) where the
importance or expertise in biomechanics may be
diluted or lost.”

Yes, there are issues with regard to residency
programs not placing enough emphasis on the
biomechanical exam as part of the pre-surgical
workup (though I imagine that there are some
programs who do this quite well.), however that
is something that the Council will need to
address. And yes, this is something that clearly
needs to be accomplished as soon as possible.

While your letter does highlight several areas
of deficiency within our field, I wanted to take
this opportunity to address item # 1 and state
unequivocally that there is nothing shameful
about the biomechanical training at NYCPM. I
hope this provides you with a better
understanding of our approach here at NYCPM,
where we strive to carry on the legacy of some
of the iconic figures in podiatric biomechanics
who have gone before us. I assure you it is a
responsibility that is not taken lightly.

Loretta Logan, DPM, MPH, NY, NY

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09/20/2019    Robert Kornfeld, DPM

Welcome to the Future of Podiatry (Paul Kesselman, DPM)

Dr. Kesselman's 10 points are right on the
money. I had a patient who came to me for a
second opinion recently. She had seen a young
podiatrist who recommended surgery for an "IPK"
sub 5th met head (metatarsal osteotomy). When
she came to my office, the lesion was quite
large and apparently had not been debrided. When
I began to debride the lesion, I felt a click on
my scalpel.

Further debridement revealed a piece of glass in
the patient's foot which I easily removed. I
told her she did not need surgery. She was very
grateful but very angry that a doctor would
recommend surgery without appropriate
examination of the area of chief complaint. He
x-rayed her foot and told her she needed
surgery. There was no recommendation for
conservative care of any kind.

I have been a podiatrist for over 39 years and
in private solo practice for 37 years. In that
time, I have seen a once viable, growing, and
incredible profession sink to new lows every
year. In my opinion, the 3-year surgical
residencies have done much to diminish our
medical skills and our rational approach to
differential diagnosis. I've done thousands of
surgeries in my career, but never without
careful consideration to the mechanism of
pathology.

I do believe the current path will eventually
destroy the profession of podiatry. It isn't my
problem, however. I am at the tail end of a
great and lucrative career that I fashioned on
my own so that I could be the best podiatrist I
could be without influence from insurance
companies and Medicare. I have a niche practice.
I do not accept insurance of any kind. I work
smart and not at all hard. I attempted many
times to bring this information to the
profession but was ignored by all the Colleges
of Podiatric Medicine (as irrelevant). My
practice is medical, not surgical at this point.
Podiatry wanted to feel like "real" doctors and
pushed the surgical agenda to self-destruction.

I attend the Schuster Biomechanics Seminar at
NYCPM every year and gain invaluable knowledge
from some of our most revered biomechanics
experts. That has done more for my practice than
my scalpel ever did.

I wish the future of podiatry the best of luck,
but in my opinion, you have shot yourselves in
the foot.

Robert Kornfeld, DPM, Robert Kornfeld, DPM

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09/19/2019    Paul Kesselman, DPM

Welcome To The Future Of Podiatry

I applaud each and every one of you for
providing your excellent comments on this
matter. I have to agree with all of you, but
your comments did not go far enough. At the risk
of receiving a rash of unfriendly mail, the
following "top ten" need to be pointed out:

1) The undergraduate level of biomechanical
training is apparently shameful as compared to
when I was at ICPM 1977-1981. This is based on
my query of student residency interviews or
externships over the past 10 years. Biomechanics
was the "calculus" of undergraduate medical
training. Dr. Don Aronson told us that it would
take us a minimum of 5 years to master this
subject and my classmates were no doubt
challenged by this subject.

At the same time, we knew we had to master this
complex topic it if we were to become skilled
surgeons. We also had Drs. Weil, Sorto, Smith,
Aronson and others on the faculty and could look
at the other schools to see the masters of
biomechanics at the other schools (Ritchie,
Subotnick, Kirby, Langer, Root, etc.) who were
publishing texts and articles at an amazing pace
and speaking at seminars. So, we had our fair
share of mentors who we could look to for advice
and guidance;

2) Intermixed with my course on biomechanics was
a course on orthotic fabrication, so I learned
how to cast properly and understand all the
intricacies of orthotic fabrication. Do students
have any idea about orthotic materials,
construction, how to cast (or scan correctly). I
dare say no! As a consultant to many orthotic
labs, the main frustration faced by lab owners
regarding their relationship with their clients
is poor casting (foam or scanning) technique and
most providers under 50 having little idea of
what device(s) are appropriate for which
pathologies. More than one lab owner has told me
that they won't deal with certain clients
anymore;

3) The residency programs I participated with as
faculty (and my post graduate preceptorship) all
required biomechanical examinations on just
about every elective (and some non-elective)
surgical cases. Now that number has dwindled to
a handful over three years. I did more in a one-
year preceptorship than is required and
performed in a 3-year surgical residency today.
This is shameful and irresponsible!

4) At this year’s APMA National, I spoke on 21st
century biomechanics with other distinguished
faculty. The room should have been packed, but
it was far from it. Most were practitioners over
50. So, where have all the young DPMs gone? Do
they really think that surgery is the salvation
of the profession and the only way they can make
a living? As I close in on clinical retirement
and have for the most part hung up my surgical
scalpel, I can tell you that surgery is not the
best way to make a living in this profession
(but then many of you already know that).
Unfortunately, that message has never been
received by the younger members of our
profession;

5) Prior to the APMA National, I reached out to
many laboratories and faculty members at the
podiatry colleges. I heard back from a few
regarding participating in some sort of blue-
ribbon panel to discuss the issues (it is really
a crisis) our profession faces w/regards to the
position of the profession with regards to
biomechanical leadership. This never got off the
ground due to a paucity of responses. Other labs
have tried this and for the most part failed. I
applaud the few (Dr. Decaro, etc.) who continue
to persist at providing either lecture tracts or
full day workshops, but these are too far and
few;

6) There are other medical associations
representing other orthotic providers, which do
provide an incredible amount of research at the
University level, produce well written papers in
journals and speak at their national
conferences. I am amazed at their
professionalism and dedication and their results
are startling. If our profession doesn't do
something soon, we will no doubt have lost (if
we have not already) our kingpin position as
authorities on lower extremity biomechanical
experts. I will be reporting back in a few weeks
on this year’s conference with some updates;

7) I agree with Dr. Udell that it is
unsustainable for him (or any speaker) to have
to pay their own way to conferences. He
neglected to offer the opportunity costs of not
seeing patients in their own practices. While I
applaud his commitment, this is not sustainable
on a regular basis and to his point, thus this
requires the laboratories to sponsor faculty;

8) I agree with Dr. Ritchie that is not the
orthotic industry's sole responsibility to
foster undergraduate education in biomechanics.
That is square at the feet of those who develop
undergraduate podiatric medical curriculum.
Continued training for residents in biomechanics
needs to be dealt with by those involved in
developing graduate medical education
curriculum. And the laboratories also need to be
committed to the future by participating in
undergraduate and graduate training, fostering
meetings and all need to get involved in moving
research to the University level.

9) APMA and Certification boards also need to
also commit themselves to working with all those
mentioned in whatever way they can to get this
issue moving!

10) Working together, if each podiatric college
could foster the development of just one master
student in biomechanics every four years, our
profession would be capable of providing an
exemplary number of masters in biomechanics
within the next decade.

After writing this letter, I had a conversation
with two colleagues which did provide some
further insights on this subject:

Josh White informed me that CCPM is developing a
fellowship in the memory of Paul Scherer along
with a just announced Biomechanical Symposium.
Larry Santi provided information that CPME is
now developing new criteria for residency
programs with more biomechanics requirements as
part of the residency curriculum.

It is my hope that others will add more positive
comments about what their companies, schools,
associations etc. are doing.

Podiatry (both the profession and its corporate
partners) needs continued helpful cooperative
dialog to resolve this crisis. I am hopeful that
this will resonate positively among our
leadership!

Paul Kesselman, DPM, Woodside, NY

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09/18/2019    Dale Feinberg, DPM

Welcome to the Future of Podiatry (Joseph Borreggine, DPM

Dr. Borreggine’s excellent analysis of the future
of podiatry hit the nail right on the head. He
had been prognosticating that the demise of
private practice was coming and now he has put
out the word that private practice is dead,

I started reading the tea leaves about seven
years ago when the implementation of Obamacare
started affecting my practice. Denial of payment
for the medically necessary diabetic shoes was
the opening shot in the war with Big Brother that
we have unfortunately lost. Things have continued
to go downhill every day and has now culminated
with 90% of podiatrists feeling some level of
burnout. I am not burned out, I’m bummed out!

I love our profession, but it is becoming harder
and harder to stay afloat and I feel that I’m
paying out-of-pocket to enjoy my hobby. Yes, a
few of us are transitioning to newer models of
employment but you’ll never know the level of
freedom and joy that self employment brings.

I have recently been telling patients that when I
retire my much needed podiatry skills would
become a lost art. I recently had a patient
present to my office for a new set of custom
orthotics. When I inquired why he didn’t have
these made back home he told me that no one makes
them anymore. Another patient was so happy that I
removed a painful callous as she had difficulty
finding a Podiatrist to do it. A neighbor in
California asked me to remove his painful heloma
molle as his podiatrist had retired and it took
six months to get a foot appointment at his
health plan. Don’t even get me started on
dystrophic mycotic nails. If you are in the front
lines of private practice you know these things
to be true. Supergroups and orthotic lab support
at meetings will not save us.

In closing I am reminded of an op-ed article Dr.
Bret Ribotsky wrote ten years ago comparing the
reported average yearly DPM income to that of a
school teacher. He made the argument that the two
incomes were in fact equal when you took into
account years of deferred income, educational
costs, cost of loan repayment, malpractice
insurance, and practice costs let alone no funded
retirement, paid days off and a summer off from
work.

I am counting the days until I get Medicare. My
house is paid for and I have no kids in college.
I will ride my Harley into the sunset and I wish
you all the best of luck.

Dale Feinberg, DPM, Yuma, AZ