There is no need to compare dentistry to podiatry in this debate. Dentists are not defined as physicians nor do they have any competition among the medical community. Our closest colleague and competitor, orthopedics, has gone through its own transitions over the years. Originally a specialty in addressing pediatric deformities (the Greek derivation meaning “straight babies”) has transitioned to anything bone related in all age groups.
I find it a difficult argument to claim three years of residency isn’t a sufficient amount of time to learn the surgical and medical conditions related to the lower extremity. Orthopedics learns the surgical and medically related treatments of the entire body in four years. The first of five years concentrates on general surgery and medicine. Once an orthopedist’s standardized residency is completed, they may choose to do additional training in specialized areas or concentrate their practice on specific areas of their basic training.
Change is inevitable and our profession has not kept up. It should be obvious at this point, an MD degree will be our only acceptance into the medical world, fair or not. Aside from that, not having standardized training in ALL aspects of lower extremity care, and one single certifying board, is foolish, to say the least.
I purchased the Swift immunotherapy device in August of 2019. I found that I had a significant amount of patients, both adult and pediatric, with lesions that often times were referred from dermatologists and colleagues specifically for CO2 laser excision after failing various conservative treatments. I had a 16-year-old patient scheduled for CO2 laser excision in September of 2019. I called his parents after purchasing the device and recommended that we try the Swift procedure before CO2 laser excision. After three treatments, all of the patient’s lesions (greater than 30 on both feet) resolved.
The Swift device can cause discomfort. This discomfort is far less than surgical excision. I find it is extremely helpful to prescribe EMLA cream and apply this for 5 to 8 minutes prior to Swift treatment. Patients feel discomfort/pain in the form of heat. Once the treatment is over, the discomfort dissipates. The patient can exercise or go about their activities of daily living immediately post treatment without any discomfort.
The device is very easy to use. It is extremely effective in pediatric patients with young, healthy immune systems. I often find that lesions are completely resolved after 3 to 4 treatments. In adult patients, with older immune systems, often times they need between four and six treatments.
Disclosure: I recently became a consultant for the Swift device company.
I like to consider myself a progressive podiatrist. I try to add something to my practice at least yearly that brings a certain polish and a new technology to the office. This past year after seeing the initial advertisements for the Swift Emblation unit, I just couldn’t resist bringing it into my office, as I find verrucae to be extremely frustrating entities to treat (as I’m sure many podiatrists and dermatologists do as well).
I could not be happier with my decision to add this to my treatment armamentarium as the results and adoption by my patients have been nothing short of miraculous. I have no problem stating that my resolution rates for my verruca treatments with Swift Emblation is over 90%. The treatment is extremely well tolerated by my patients. It has been a great addition to the office.
Disclosure: I am a consultant for Saorsa North American distributors of Swift.
Not every nurse practitioner is trained in treating from the ankle down. The same applies to MDs and DOs. When managed care first began, insurance companies put tremendous pressure on primary care doctors not to send patients to specialists, or risk being docked in some way. A patient finally was referred to me by a very good internist in my area. He had been treating her for over six months for tinea pedis to no avail. He finally used his better judgment and sent the patient for a podiatry consult. I had to diplomatically explain to the patient that the reason why her internist's treatment did not cure her foot problem was that even the best of antifungals do not have any effect on interdigital hyperkeratoses.
The last few words spoken by [Dr. Jacobs'] patient have been my mantra for the 37 years that I have been in practice. Instead of the APMA producing Johnny Sorefoot Balloons and the like, I have always felt, and feel even stronger today, that it is an absolute MUST that the “lay-public” be educated about what a podiatrist can do. For someone in this day and age to ask a podiatrist that question is a "Shonda" (Yiddish expression meaning something terrible).
Just like the AMA has done a miserable job on educating the public about the declining reimbursement, we have done a poor job regarding our education and abilities. We MUST be better at telling everyone what a podiatrist can do, and do it better than anyone else, or we will not survive.
“Although lasers are approved by the FDA for onychomycosis” is not entirely correct. The FDA states that lasers may be used as adjunct therapy to supplement accepted management protocols for the treatment of onychomycosis. In fact, the FDA published policy on the matter advises not to claim that lasers are a cure for onychomycosis, but provide only temporary improvement in the appearance of the toenail. At-risk populations in which the treatment of onychomycosis is considered necessary (e.g.- diabetics, PAD patients, immunosuppressed patients) are denied appropriate treatment when lasers are employed, while subjected to potential risks.
The FDA approved the safety of lasers, not the specific employment of this modality for onychomycosis. And yes, while speciation is not required as lasers are not “species specific," some confirmation of fungal infection would seem appropriate prior to treatment.
I was evaluating a post-op Austin-Akin patient today. She told me that she watched the show. Her exact words were; “I’m impressed. I had no idea podiatrists did such complicated things.”
This discussion is a critically important one, especially because my professional path brought me to a deep understanding of human physiology, the foundations for health and healing, and a never-ending focus on understanding mechanisms of pathology BEFORE symptoms are treated. I pursued a path in functional medicine for foot and ankle pathology because it provides a means to heal pedal pathology AND improve the health of the patient. This has been my path and my passion since 1987 (I am a 1980 graduate of NYCPM). My career has been extraordinarily satisfying because the healing is in medicine, not surgery. Of course there’s a place for surgery, but without a true mechanistic approach to healing, we correct one issue but leave our patients open to future pathology.
Podiatry has always struggled with itself. In our zeal to be accepted as ”real doctors”, we focused on pushing ourselves into hospital operating rooms. Unfortunately, that...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
Dr. Udell states he has no idea why orthotic labs stopped sponsoring biomechanics at conferences and podiatry schools. As the owner of a prescription foot orthotic laboratory I can shed some light on the subject. The short answer is that there is no/inadequate return on investment. Sponsorships are essentially a marketing expense for most businesses. If an orthotic lab can’t benefit from a sponsorship or if it can’t afford to fund one for altruistic purposes, then they are unlikely to do so.
The economics of the custom foot orthotic manufacturing industry have changed over the years. There was a time when the exhibit halls at podiatry conferences had many foot orthotic labs in attendance. That is no longer the case. In fact, exhibitors at podiatry conferences are down in general. It's extremely expensive to exhibit, sponsor speakers, or to otherwise financially support educational content. As Dr. Richie indicated, foot orthotic labs have relatively meager budgets and have watched their profit margins shrink for many years, in part, because podiatry has become more of a surgical specialty. Unless that trend changes, you are not likely to see orthotic labs support biomechanics like they once did.
Doug, in an ideal world, corporate entities would have no say in what is presented at medical conferences. We do not live in an ideal world. When I lecture at podiatry conferences, I don't always get paid and I have sometimes paid for my own room, board, and transportation, and given multiple lectures. Why do I do this? To be of service to my profession and the public it serves. There are others like me.
Unfortunately, this model is not sustainable even for me. Many conferences including ones that I have chaired cannot afford to subsidize all of its speakers or depend on all of its speakers to lecture for gratis. Hence, they have to turn to the corporate world for help or scrap the seminar. As for podiatry labs, when I started practice back in the 70's, Langer labs, Schuster labs, and other labs did sponsor biomechanics at conferences and at the schools. Why did they stop? I have no idea.
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: 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.
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.
If there are podiatry residents out there thinking of committing suicide, then they probably should NOT have been accepted to podiatry school and pushed through, by school administration, to graduate in the first place. There is nothing stressful about podiatry residency training when you compare it to being an internal medicine resident, general surgery resident, orthopedic resident, etc.
The stakes are higher in those training programs. They just are. Intern residents from these specialty tracks are dealing with patients with more diverse pathology. Intern residents in these specialty tracks are actually medically managing these patients, dealing with complications during inpatient care. Things that most podiatry residents don't have to deal with...
Editor's note: Dr. Bellezza's extended-length letter can be read here.
The active ingredient in Control III is benzyl ammonium chloride, so it is the same active ingredient as in Benz-All. I haven't heard anyone mention the use of ultrasonic units to assist with removal of any debris and other benefits. A hot bead sterilizer also is beneficial. Both of those steps prior to placing instruments in cold disinfectant have worked well for 30+ years. I applaud those who have the staff and system in place to autoclave all instruments all day long.
In a small solo practice, it’s hard to implement. I do believe if we saw a deleterious effect to a patient, based on instrument care, we would change our office procedures. It's an individual choice based on the clinical experiences within our own facilities. Instrument care and practices and procedures may be better or worse from facility to facility. Patients often comment on our cleanliness versus that of other doctors’ offices. We should not embolden trial attorneys with only one acceptable methodology.
Maryland offers an inactive status license. For $50 a year, if I ever decide to resume practice, I would need to update all my CMEs. If I did not renew my license at all, if I needed to go back into practice, I would need to re-apply, including taking the national boards. Although I do not intend to resume practice, paying the $50 a year is a nice insurance policy in case my situation changes.
When will podiatrists realize that having a DPM license will never allow you the privileges of your counterparts in the MD/DO arena. It doesn’t matter how many courses or certifications of training in marijuana dispensing you take, at the end of the day, you are still a podiatrist. I have advocated and others have advocated for getting a dual license DPM and MD/DO license. Until the schools offer an avenue to obtain these licenses, podiatrists need to recognize their limitations. MD/DOs rule the land! Final word.
I actually took the 4-hour certification course for this at my local hospital, for a fee. Afterward, I logged onto the PA Department of Health and the medical cannabis website to register my practice with the Commonwealth. It was then that I discovered I was not permitted to register since I was not an MD/DO.
I comprised a thorough letter to my local representative, who is now the Speaker of the House of PA, discussing the issue why podiatry should be included and the qualifying conditions we manage on a daily basis. He responded immediately, agreeing with me, and stated he would look into it. Three weeks later, I received a call from the PA Department of Health, letting me know podiatrists cannot register at this time, and no expected approval date has been set. So, back to square one again, I suppose.
I agree with Dr. Kass that the NYSPMA meeting is not really "free" for members but paid for by our dues. However, I disagree with Dr. Kass saying that most people belong to the NYSPMA because they see value of getting their CME in one weekend. We belong to our state societies and the APMA because these are the groups that fight for us at the state and national level. Without these societies, I think we all know that we would be much worse off. A great example is the recent proposed changes in Medicare E&M codes that the APMA stopped from being implemented.
The NYSPMA annual meeting is much more than just "getting your CME in one weekend". Nowhere can you see so many podiatry exhibitors in one place. Seeing many of these same companies on line is not the same. Plus, being around thousands of podiatrists is an exciting and informative experience and only possible at a few meetings a year.
Most importantly, we should ALL join our local and state societies. Those of us that are not members benefit from the hard work of those groups. However, they also miss out on a lot of benefits they could get. If more people joined, the dues would go down also. Your state and local dues are monies well spent.
Ken Meisler, DPM, NY, NY
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B
RE: Payment Disparity Between DPMs and MDs
From: Dan Klein, DPM
I have read from many podiatrists that they are upset about the difference in pay by insurers. When will podiatrists realize that as a podiatrist, you will never share the same turf as our counterparts and therefore not be recognized as such. Podiatrists have and will always be classified as allied health providers. Until MDs and DOs cannot provide our services, you will never see us providing a unique service. We will gladly be accepted into hospitals for our services, but the patient is not classified as a podiatry patient versus a medical patient. The reimbursement rates to the hospital are the same.
If you are unhappy with the podiatry reimbursement fees, you must get an MD or DO degree. This appears to be the only avenue open to us for equal pay! This is our future, love it or leave it!
Dan Klein, DPM, Fort Smith, AR
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B
RE: Payment Disparity Between DPMs and MDs
From: Ira Baum, DPM
When I founded and participated in a podiatric LLC, Florida Foot and Ankle Associates in the early 2000s, two fellow board members and I had the opportunity to meet with the president of one of the major healthcare insurance companies. At the meeting, we were given a lesson in rudimentary business practice, supply and demand. There we learned about a podiatrist’s place on the ladder of importance of our service compared to other specialties.
Due to our position, negotiating improved reimbursements was not successful. Pleading our case based on our cost-saving quality of care, even offering an internal review committee to ensure the objectives, fell on deaf ears. Even adding in the concept of critical mass did not move the needle. Maybe things have changed for single specialty podiatric groups, but even if they have succeeded, unless all podiatrists are positively impacted, it does nothing to improve the podiatric profession as a whole and, in fact, will fractionalize it over time. In other words, the key to success of large podiatric groups is inclusivity, not exclusivity. Bad apples will be identified quickly and easily, and they will learn to conform to standards or be excluded from the group.
Ira Baum, DPM, Naples, FL
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B
RE: CMS' Discrimination Against Podiatrists
From: Jeffrey Kass, DPM
The Sept. 10th deadline is around the corner. CMS has proposed some devastating reimbursement policies that could cripple some practices. The single code for E&Ms has already been discussed. More devastating is the visit and procedure rule. CMS is proposing to reduce the lower allowed amount by 50% of either the E&M visit or procedure when billed the same day with a -25 modifier.
If anyone values their financial future, you must take action! I have provided the link to write a complaint in your own words (Some feel sending repeated templates has less effect.). This is not the time to make assumptions that because you belong to an association, the problem will be taken care of for you. This is the time to take two minutes out of your day to potentially save thousands of dollars from being taken out of your pockets for the hard work you perform. Please spare the moment.
Thank you to everyone who participates and tries to make a difference.
Dr. Hofacker asks if the type of billing he saw on his patient's invoice from another podiatry office is the norm. No, it is not, at least not with podiatrists I bill for in various parts of the country. The Medicare allowed amount for a 11308 in Ohio is $190.97 when performed in an
office setting. Leaving aside whether or not this was actually performed (I doubt it was, and should have been billed in the 1105X range, if at all), it would appear several things could be at play here to result in this patient having such an outrageous bill.
Without seeing the actual invoice, my guess is one of two things (or both) is going on: 1. The podiatrist she saw is not contracted with her insurance company, and she has no...
Editor's note: Ms. Happel's extended-length letter can be read here.
Dr. Adam Siegel states that “looking at the profession as a whole... a large proportion of our profession applies 99212 in addition to the routine foot care codes in an attempt to suck a few more dollars out of Medicare.”
This is an insult for which Dr. Siegel should forthwith render an apology and retraction. Many patients who present to the office of a podiatric practitioner for nail care do so with concurrent illnesses such as PAD or diabetes. The majority of such patients have concurrent potential limb threatening pathology for which evaluation and appropriate intervention may interdict the progression of...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
I recently interviewed associates with three years of residency training. The spectrum of graduates training was from excellent to below average. One may ask how a graduate of three years of surgical training could be average or below average. The answer is that many programs just do not have the surgical load or variety that is necessary to come out as a fully trained “surgeon”. Many whom I interviewed felt they needed an additional year as a fellow to feel confident. Sadly, three years of training may NOT adequately prepare graduates for practice and or sitting for the boards. From what I saw from the current crop of residents is that many were under-trained and not ready to become full scope podiatric “surgeons”.
I am not sure if all the negative comments about Costco orthotics are well guided. I, like most of my colleagues, watch shark tank - and I say kudos to the people who came up with the idea. It's rather ingenious, and from a business point of view, I think they will make money. I think it's ludicrous to point to the inferiority of the product without having seen it or tried it. That is sheer jealousy. Some of my colleagues have been known to have their secretaries cast patients, yet no one is up in arms over that. I'm not sure that I can even agree who the experts are or if there are any when, as Dr. Shavelson points out, there are no studies proving anything.
The more important question is - should the profession have been able to deem orthotics prescription products to be prescribed only by doctors, and did the profession let us down in that regard? What exactly is the Costco process? When the operator is quizzing the patron on what ails, can this be construed as a medical exam that the operator should not be doing?
I for one would not want to be the doctor who gets inspected and has to then prove how much of this product I bought to match the patient load and requirements of changing it on a 2 to 4 week basis depending on whom you listen to.
In addition, I would then have to show proper paperwork as to the change in schedule and process of how instruments were utilized in the setting. Gas or steam sterilization seems to me a more definite way to avoid this quagmire with any board of any state.
Richard J. Manolian, DPM, Cambridge, MA
Podiatry Management •1062 E. Lancaster Ave, Rosemont Plaza Ste 15 F, Bryn Mawr, PA 19010