Podiatry Management Online


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From: Elliot Udell, DPM


I’m questioning why podiatry does not have specialties as dentistry does. This ignores a rather large elephant sitting in our living room. Dentistry has true specialties. There are periodontists, oral surgeons, endodontists, pediatric dentists, etc. The one difference between dentistry and podiatry is that dental specialists limit their practices to their specialties. 


If one goes to an endodontist for a root canal, or an oral surgeon for an extraction, those dental specialists would never be caught filling a cavity or making a crown for that patient. If he or she did, they could kiss their referral base goodbye. Podiatry is different. There are those who have greater training in surgery, biomechanics, pediatrics, or dermatology but I have yet to hear of any of my colleagues, outside of the academic arena, who limit their practices to any one area of specialization. Perhaps Dr. Levy could offer us some insight into why podiatry has not generated the types of limited specialty practices that we see in dentistry and medicine.


Elliot Udell, DPM, Hicksville, NY

Other messages in this thread:



From: Robert Scott Steinberg, DPM, Brian Kiel, DPM


I reject Dr. Secord's assertions, or his referencing articles not in evidence, nor any links. I offer this article.


Robert Scott Steinberg, DPM, Schaumburg, IL


Dear Dr. Secord, please walk through a hospital E.R. maskless and laughing; then tell me how harmless COVID-19 is. Of course, a virus can pass through a mask, but it limits its dispersion. Denial of its virulence has killed thousands. The theory you espoused has been repeated by certain politicians but the opposite is stated by experts like Dr. Fauci. I think I will take his word for it.


Brian Kiel, DPM, Memphis, TN



From: Ron Werter DPM


I fully agree with Dr. Kiel. A few years ago, I was having an excellent conversation with a salesman in a major shoe store here in New York City. I finally asked him his name. He proudly responded, "It's on the sign in front."


It’s the same with us; whose name is on the front door? It’s your office, you make the rules. If the non-compliant person doesn’t like it, probably don’t want them as a patient anyway.


Ron Werter, DPM, NY, NY



From: David Secord, DPM


I had no choice but to laugh when I read the part of the post from Dr. Kiel which stated: "This is a life or death situation." I have several peer-reviewed papers residing on my hard drive which has fully explored the topic of a cloth or OR-type mask being able to stop something the size of a virus. All of them conclude that they are ineffectual. That they don't do anything is right on the box! We know that the death rate for the COVID-19 virus is around 0.1%, which puts it in line with every other seasonal influenza. We also know that we really don't have good numbers on the death rate, as everything shy of diaper rash has been listed as a COVID-19 virus death. We also know that we don't have good numbers for the population who has the COVID-19 virus, as the PCR test (by admission from the guy who invented it) is churning out a 95% false positive rate.


Are there people dying from this contagion? Yes. Is it more deadly than any other coronavirus seen each fall with a new seasonal influenza? Not according to the data. Is the hysteria we are reading, especially the absurd "Everyone has to wear a mask or we all die" hysteria believable? Not if you are sane. Wear a mask. Don't wear a mask. They are ineffectual against something the size of a virus.


David Secord, DPM, McAllen, TX



From: Connie Lee Bills, DPM   


I am shocked. I wouldn’t have actually touched the child, but definitely would have insisted that the mother deal with it immediately. I’ve had a similar situation during a procedure with a child. It was horrible.


Connie Lee Bills, DPM, Mt. Pleasant, MI 



From: Ivar E. Roth DPM, MPH 


I have found a simple way to solve this problem. When a problem occurs, I speak to both parties to get both sides and then and only then do I make a decision on how to handle the problem. I NEVER take either the patient’s word or my employee’s alone. Based on what I find out, I act accordingly. Surprisingly, it is about 50-50. My suggestion is never back the employee until you know for sure.


Ivar E. Roth DPM, MPH, Newport Beach, CA



From: Charles Morelli, DPM


Dear Mrs. _____:


This letter will serve as formal notice that we will no longer be able to provide foot care to you because of the following reasons: 

  • It has come to my attention that you berated a member of my staff  numerous times, after she had gone out of her way to assist you in attaining a copy of your previous MRI.

  •  After speaking with this staff member, she was both visibly and emotionally upset. She has worked here for close to 20 years and no one has ever spoken to her the way you had, especially when she was actively trying to help you attain another copy of your MRI images.

  • If you want the entire disc again, you will have to go to _______, pay $25.00 and they will be happy to give you another copy.         

It pains us to do this as we have known you for many years, but this behavior cannot be tolerated or condoned. As you have already chosen to see another practitioner to address your current condition, I will be happy to send him or her a copy of your medical records and upon receipt of your written request, I will forward a copy of those records to your new provider. As you have already attained the services of another doctor, I am under no legal obligation to continue providing you with treatment and wish you well.   


Charles Morelli, DPM, Mamaroneck, NY 



From: Jack Ressler, DPM


Dr. Dananberg brings up an excellent point with the experience he described. There are some very important points we can all learn from this encounter. First, and most important, is for the doctor to understand any underlying circumstances that could be involved in the patient’s life that may be causing their behavior. Understanding this can lead to a wonderful professional patient relationship that not only could last for years, but also lead to many referrals. I have had countless experiences as described by Dr. Dananberg. New patient protocol in my office involves having one of my assistants take the patient into a treatment room after they have been registered.


A brief history is done, followed by my assistant conferring with me before I go in the room. During our talk, my assistant will sometimes comment as to the patient’s condition, mood, or personality "quirks". This is of utmost importance because it is a signal to me that extra care or compassion is needed. I love to make patients laugh and feel comfortable. My goal is to have a patient leave the office feeling good both physically and mentally. Losing spouses or dealing with...


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



From: Allen Jacobs, DPM 


Customer is defined as an individual (or organization) purchasing goods or services. When doctors became “providers,” patients became customers. The enthusiastic utilization of urgent care centers by patients illustrates the declining value of the doctor-patient relationship in exchange for service convenience. How many new patients do you see because “you were on my list of providers”? How many patients do you not see because you are no longer a provider for a particular third-party payer? How many lectures or seminars do you attend about maximization of profit from your customers/patients? People have to a large extent changed. They demand convenience, are increasingly demanding, lacking courtesy, and social graces. Egocentricity has become the new normal.


No, the patient/customer is not always right. I have no hesitancy to discharge patients who are abusive to staff or office policy. My charge is to provide quality care and support. Neither I nor my office exist for any other purpose. Nor should yours. You have studied too much, sacrificed too much, worked too hard, and are bound by ethical charge to be treated with other than the respect which you have earned. Conversely, to paraphrase Sir William Osler, MD, once profit and business become your priority, you have lost the spirit for which you entered healthcare. Under those circumstances, you do indeed have customers not patients. You have a business not a medical practice. As such, the customer is always right.


Allen Jacobs, DPM, St. Louis, MO



From: Howard Dananberg, DPM


Many years ago, I had a new patient present for care. After my nurse's interview with him, she came out and said how angry and mean spirited this man was and wished me good luck. After our visit, we came out laughing and very friendly and she was shocked. It turned out that he only has a small interdigital corn, but his wife of more than 50 years who was recently deceased had exclusively cared for this.   


He was angry at her passing and that someone else was going to treat him. Once we both recognized the underlying cause of the anger, he turned into a long-term, wonderful patient for several years until he died. There are lots of reasons why patients are angry. Sometimes, finding the cause goes a long way towards resolving the basic issues.  


Howard Dananberg, DPM, Stowe, VT    



From: David E Gurvis, DPM


I find patients are rude to the staff for several reasons. Pain and anxiety are uppermost. Fear of what the doctor might do, especially if they are fearful that it might include a needle. Having stress at their workplace for having taken off to even see a doctor. Financial reasons. And many more. I agree with what Tim Shea, DPM has said as well. And I will always try to turn a “bad” patient into a “good” patient. However, some people are just naturally rude and feel superior to those they feel are working for them. This is how they interact with the world around them and they carry it into the office.


The older I get, the less I find I tolerate rudeness. Life, and the day at the office, is too short for that. I don’t work for patients. I work with patients. For those who cannot be “turned,” I find discharge is appropriate.


David E Gurvis, DPM, Avon, IN



From: Keith L. Gurnick, DPM


About 15 years ago, I had an issue with an adult female patient, a tough and very wealthy widow and locally well-known philanthropist who dropped in to my office one day without an appointment, requesting to be seen for a non-urgent visit. When we refused her request, she then demanded her medical records and prior foot x-rays on the spot. I am sure some of the readers have encountered this same or similar challenging situation once or twice in their careers.


When she was told that our policy was that we needed a couple of days’ notice to make copies of her chart and physical copies of her x-rays, and that we were not able to stop whatever we were doing to comply with her non-urgent requests, she made quite a scene in front of other patients and stormed out of the office, opening the reception room door so violently that it... 


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



From: Jane E. Graebner, DPM


One solution I have initiated in my office is creating a position called New Patient Coordinator. One of my 70+ year old employees whose only job prior to COVID-19 was visiting referral physician offices wanted to only work from home. Her duty is to call every new patient (or new problem which is someone who has been to our practice before but not recently and has a new foot/ankle problem) who are booked for one hour in our practice (1/2 hour with staff member and 1/2 hour with provider). She covers things like:

1) COVID-19 questions

2) Office location

3) Insurance coverage (to make sure we are in-network)

4) Referral source

5) Name they would like to be called

6) How they are completing their paperwork (i.e. portal, mailed, printed from website)

7) Confirming they are really a new patient (i.e. never been treated in our practice prior to this)


She even calls NPs after their first visit (within a week) and asks if they understand their treatment plan, etc. which gives us feedback about how we are doing. So far, this experiment has been good. Although the no show rate has not been lowered (which was my primary goal), the use of our portal has increased to 50% and the number of NPs who show up at time of appointment without any paperwork filled out has diminished as well, which helps keep us on schedule. You might want to try this for your practice.  


Jane E. Graebner, DPM, Delaware, OH



RE: Proposed Outpatient Prospective Payment System

From: Joseph Borreggine, DPM


The new proposed Outpatient Prospective Payment System (OPPS) rule is out. It looks like CMS is pushing ahead with its changes in how to document and determine E&M levels (No more H+P component, Medical decision-making DM, and time only) as well as significantly increasing reimbursement for office based E&Ms. Due to budget neutrality though, this increase is offset by an across the board decrease in the conversion factor of about 11%. This is going to result in a significant decrease in fees for many procedures which will include the routine foot care codes that are used quite frequently by podiatrists. If this proposed fee scheduled is approved, then the financial impact will be catastrophic. 


It is my understanding that the APMA is planning to make a comment to CMS on behalf of the profession. However, they will be just one comment that will provide a global statement with respect to the negative financial consequences it will have on the profession. Moreover, every podiatrist needs to consider leaving a comment on this proposed CMS fee schedule change. 


The more comments that are provided from this profession to CMS on this issue, the greater the chance that CMS may reverse their decision. Here is the link to do soPlease don't neglect this. Share it with friends and colleagues. These cuts could impact every specialty. It's not just our payments that would be jeopardized. The care received by our friends and families would also be at risk.


Joseph Borreggine, DPM, Port Charlotte, FL



From: Ben Cullen, DPM


I respectfully disagree with Dr. Gurnick. Not only is a mini-tightrope exceedingly difficult for an MPJ, if the underlying boney deformity is not addressed, it will do nothing for the long-term outcome. The 2nd and 3rd metatarsals are both elongated and medially angulated in this patient, causing the lateral deviation of the toes. Correctional osteotomies of the second/third metatarsal are necessary. This can be done distally with a translational Weil.


Although the metatarsal head may end up appearing laterally angulated to achieve the correction necessary, the digit will maintain it's position in the transverse position, and weight-bearing may be initiated sooner than with a proximal osteotomy.


Ben Cullen, DPM, San Diego, CA



From: Jay Kerner, DPM, Judd Davis, DPM


Thank you, Dr. Ricketti, for your phenol EZ Swabs. I’ve been using them for years and haven’t looked back.


Jay Kerner, DPM, Rockville Centre, NY


I contacted the manufacturer of our phenol years ago to find out how long it lasts since there was no expiration on the bottle. We were told that phenol really does not degrade if stored properly in a dark cabinet. I can confirm that it is effective for years as I've had several patients return for other foot issues after undergoing matrixectomies with it, and had no evidence of regrowth. I caution that if you buy it through a local compounding pharmacy, it may not have the same longevity though. I previously used some sodium hydroxide from a local pharmacy that was effective for no more than one month after it was made up, so I switched back to phenol.


Judd Davis, DPM, Colorado Springs, CO



From: Richard A. Simmons, DPM


Dr. Ricketti asks why more podiatrists are not using the Phenol EZ Swabs for P&As. I rarely do P&As anymore since my practice consists primarily of terminal hospice patients. Initially, it looks like the EZ Swabs are expensive; however, here’s another twist. Over the past few years, when I attended risk management lectures, the attorneys who have spoken tell us about the need for everything in the office to have an expiration date on it and to remove everything from the office whose expiration date has come and gone. If I remember the lecture correctly, once any bottle is opened, it immediately has an expiration date of 30-days.


If OSHA shows up at your office at 8 a.m., by law, they have to be allowed access. Attorneys are now representing physicians facing tens of thousands of dollars of fines for unmarked/non-dated products (injectables, creams, lotions, etc.) that are commonly used. So, if you have a disgruntled employee who you recently fired, they can get money by being a whistle-blower. The last lecture I heard about this was put on by the Academy of Continuing Podiatric Medical Education, August 29, 2019.


Richard A. Simmons, DPM, Rockledge, FL



From: Steven R Kravitz, DPM


There's no doubt that the virtual Zoom-type meetings have replaced relatively well the previous live presentations that were standard prior to the COVID-19. Going forward it's my suspicion, as a meeting planner as well as a lecturer, that some form of virtual continuing education will continue after the COVID-19 crisis. There are definite advantages to these venues as pointed out in the article by Dr. Udell.


However, I also strongly suspect that live conferences will return. There's a difference when watching a theatrical performance that's recorded live even when... 


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



From: Richard D Wolff, DPM, Keith L. Gurnick, DPM


Sun Pure Botanicals has 90% liquefied phenol 4 oz. for $34.57. I have no affiliation with this company.


Richard D Wolff, DPM, Oregon, OH


I purchased a 500 cc. bottle from Sigma-Aldrich Co. of St. Louis one month ago. It arrived very well packaged, well insulated in a box, and inside a protected metal can. I did some research and got lucky. I found their website and ordered off of it paying with a credit card. The price seemed really good to me. 


P9346-500ML Estimated to ship on 09/30/20   500 mL  $92.70

P9346-100ML Available to ship on 09/02/20 -  100 mL   $39.30


Keith L. Gurnick, DPM, Los Angeles, CA



From: Michael M. Rosenblatt, DPM


The COVID-19 crisis has unmasked a serious threat to our business travel world and has raised the question: “Is there more to life than bandwidth?” We recently "attended" a Zoom Bar Mitzvah of a son of a family member and the reception kept blinking on and off. The sound was poor and we could often not hear the participants. Some reception was very good, but you could never predict it.


I know there will be some who say that they use Zoom all the time and that it is excellent. Perhaps. But even if it is good, it begs the question: “Is fellowship and human interaction doomed to... 


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



From: Rahn A. Ravenell, DPM


The Podiatry Institute is offering hybrid conferences, virtual conferences, and virtual short courses. The virtual conferences are on Saturday mornings starting at 10am EST so as to not have West Coast colleagues waking up too early. These offer 5 hours of CECH each and are held monthly, with the next being on September 19th (the first occurred in August). On demand courses are being worked on, but have not been fully set up yet.


Disclosure: I am Immediate Past Chairman, Podiatry Institute BOD


Rahn A. Ravenell, DPM, Charleston, SC



From: David Gurvis, DPM, Carla R. Ross 


I also use 10% NaOH and recently had it made specifically for me by a local apothecary. The price was nearly the same as that from commercial suppliers. 


David Gurvis, DPM, Avon, IN 


10% sodium hydroxide is available to Talar Medical members through their partnership with Medline as well as through their channel partner Intalere and their partnership with CuraScript.


Carla R. Ross, Talar Medical



From: Samuel Mendicino, DPM


With respect, everyone is right. Look, we have tried to create a 3-year residency for all. But my only question is why not be double-boarded? Then this issue goes away.


Samuel Mendicino, DPM, Houston, TX



From: James R. Hanna, DPM


As the newly elected President of the New York State Podiatric Medical Association, it bothers me to see division within our profession. NYSPMA serves to represent all of its members regardless of level of training, board certification or any other factor. As an association dedicated to the advancement of podiatry, we wish to see that all of our members achieve their highest potential within the profession.


New York, unfortunately, has one of the most restrictive scope of practice laws in the country. NYSPMA has worked for many years and at great cost to improve the scope of practice in New York so that our members are able to practice to the full extent of their education and training. The legislative process is long and arduous; and at times, limitations have been imposed that were neither sought nor wanted by NYSPMA. For anyone to think otherwise suggests limited knowledge of the legislative process or not comprehending the relationship of NYSPMA to its members. To this day, we continue to work to improve and refine our scope of practice bill.


As a member-driven organization, NYSPMA fields committees that work to improve the practice of podiatry for all members. One of these is the Legislative Affairs Committee. Members from across the state work on this committee throughout the year and many also participate in Lobby Day, an annual event where we meet with state legislators in Albany to make the case for our improved scope of practice bill.  


James R. Hanna, DPM, President-NYSPMA



From: Christian A. Robertozzi, DPM


The posts on hospital privileging have valid points on both sides. There is a perspective that has been touched upon but its authority and influence are not being fully appreciated. That is the viewpoint from each hospital’s credentials committee. The purpose of the committee’s existence is to make sure that physicians get privileges only for what they are capable of doing.


For the last 3 years, I have sat on my hospital’s credentials committee (Newton Medical Center, Atlantic Health System). The hospital as well as the entire system are Joint Commission approved facilities. In order to maintain Joint Commission approval, the hospital must follow the protocols as set out by the Joint Commission. Each hospital has the right to decide who can have privileges and what...


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



From: Bryce Karulak, DPM


In response to Dr. Hecht’s comments, it does not matter whether or not we practice allopathic medicine. Most DOs practice allopathic medicine. What matters is MDs perceptions of us. They don’t see us as equals and they don’t bother many times to inform themselves of our training. When I spoke of allopaths, I was merely differentiating between MDs and DOs. Allopath and Osteopaths. Every osteopath I have encountered has been more open to what I offer.  


I have successfully reconstructed patients when a foot and ankle ortho in the area said nothing could be done for the patient. The ortho told all those patients to come back when ready for a BKA. However, referral patterns do not change. The allopaths are aware of my success but again, they protect their own. Our profession frankly does not because we don’t agree on what we are and how we fit in and serve in medicine. This disagreement affects younger practitioners with extensive training.  


I serve on a credentialing board and I see the difference between the way MD/DOs are treated and the way everyone else is. It’s is not the same. We are too small of a profession to make a significant path of our own. The only way forward is to join allopaths and osteopaths.


Bryce Karulak, DPM, Fredericksburg, TX

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