Podiatry Management Online


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From: James J DiResta, DPM, MPH


Many graduating podiatric medical students would benefit from an Intensive Podiatric Medicine Residency option. Providing this option for our graduates who do not want to be surgeons can have real value IF done correctly. That would work if we were able to engage Dr. Levy in this process in creating such a program, i.e. a 3-year residency curriculum in "podiatric medicine" that could provide for training in areas of general medicine, obstetrics, psychiatry, and make up for those clinical deficiencies our graduates presently have, provide for an allopathic or osteopathic medical school to sponsor the program so the resident can be provided a DO or MD degree, and get the residency in "podiatric medicine" ACGME recognized with accreditation.


I know those are considerable barriers to cross. As a profession, we may need to financially support such an effort in the initial roll out. We would need our students to take and pass the USMLE step 1 which we have known for some time is essential no matter what we do going forward. The completion of this type of residency would provide equal footing with our medical and surgical colleagues for OUR profession "podiatric medicine". Dr. Levy has provided alternative pathways for DPMs to the DO degree before. Perhaps this time, we can obtain a successful solution in a time span equal to that of our podiatric surgically approved programs and that would provide the value many of our graduates want who do not expect to be reconstructive foot and ankle surgeons. 


James J DiResta, DPM, MPH, Newburyport, MA 

Other messages in this thread:



From: Steve E Abraham, DPM


I had two patients who needed special attention for mask issues! Both were deaf and communicated by reading lips. I explained as much as I could by writing on a pad, and at times I felt like taking my mask off and just talking. I resisted and did the right thing.


Steve E Abraham, DPM, NY, NY



From: David Gurvis DPM


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


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


David Gurvis DPM, Avon, IN



From: Richard M. Maleski, DPM, RPh


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


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



From: Alan Bass, DPM


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


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


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



From: Brian Kiel, DPM


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


Brian Kiel, DPM. Memphis, TN



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

From: Daniel Chaskin, DPM


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


Daniel Chaskin, DPM, Ridgewood, NY



From: Alan Bass, DPM


I heard about the Swift device in 2019 and I leased it in November 2019 while at the AAPPM conference in Daytona. I leased it specifically because of one patient with recalcitrant interdigital warts. I have been very happy with my decision. I leased the unit for 5 years. I have had very good results with several patients in this short period of time. The unit is very easy to use. The treatment protocol is very easy to follow. I have heard from other DPMs that they are also happy with their investment.


Disclosure: I am a consultant for Saorsa, the distributors of Swift.


Alan Bass, DPM, Manalapan, NJ



From: Joseph Borreggine, DPM


Who are we kidding in this profession about the education, training, and experience of a podiatrist (not a foot and ankle surgeon who is a podiatrist) versus a nurse practitioner (NP)? Well, we all know the answer. So, I will leave it there. But, what we are not getting is that the NP is fighting to obtain a full and unlimited license comparable to an MD or a DO. Here is the proof, and we are not.


Moreover, podiatric physicians are not even considering this as a potential and viable possibility for the profession. Yes, we have the plenary license stature in California as a "physician and surgeon", expanded areas of practice on the lower extremity in...


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



From:  Paul Busman DPM, RN


Disclosure - I am not totally unbiased, as my wife is an adult nurse practitioner. That said, I do not believe that this is typical of nurse practitioners in general. NPs do not get certified as general nurse practitioners. They get specific certifications including adult nurse practitioner, family nurse practitioner, psych nurse practitioner, gerontology nurse practitioner, etc. An adult NP could work in a nursing home without the gerontology certification although they might want to add the additional class and clinic work to add that second certification. Just as in podiatry, the profession has changed much over the years, and a nurse practitioner might not have had as extensive training as a more recent graduate, although that might be balanced by years’ worth of experience working in the chosen field.


In the situation cited by Dr. Finer, the nurse practitioner in question could have been a recent grad adult nurse practitioner working in her first employment. She would have had exposure to pressure ulcers in general during her training, but perhaps not foot ulceration in particular. She obviously did the right thing in asking for advice which will improve her practice. The nurse practitioner's education can't realistically encompass comprehensive expertise in all fields of medicine. Much specific knowledge is obtained once in the chosen field, as a doctor does during internship.


Paul Busman DPM, RN, Frederick, MD



From: David Krausse, DPM


I hope that the new TLC show is helpful in spreading the good work of podiatry around and I hope that the 2 podiatrists featured make good decisions and help their patients. That being said, does it not bother anyone that neither of these doctors are board certified in surgery? 


David Krausse, DPM, Flemington, NJ



From: Jonathan Michael, DPM


With all my respect to the Drs. on the show, I was not impressed at all by the performance that highlights our profession. In one instance, the doctor says I have never seen anything like that and I really do not know how I am going to treat you. Then he made the patient custom sandals when I was expecting some sort of surgical intervention. In the other instance, the Dr. removed a fungus nail that was done distally and crumbled; in my opinion, it should have removed proximal first to avoid the struggle to remove it in pieces. I think that did more harm than good to our profession. 


Jonathan Michael, DPM, Bayonne, NJ



RE: Source for Radiesse 

From: Allen Jacobs, DPM


Saying that “I’ve used this technique or product a bizillion times without any problems” may not be a positive defense for unindicated use. It is analogous to drunk driving, or never stopping at a red light. Most intoxicated people, or those who ignore traffic signals, are not in auto vehicle accidents while driving drunk or ignoring a red traffic signal. However, driving while drunk or ignoring a red light raises the statistical RISK of an accident. Should such an accident occur, you will likely be held accountable. Safe means safe for studies and indicated utilization.


Stating that you “took a course” at some seminar is like implicating the bartender for your intoxicated driving. Taking a “course” at some podiatry seminar does not provide you with a special exemption for the provision of ethical, standard of care treatment to your patients. 


I suggest that at a minimum, patients be informed that the use of the medication or technique has not been studied nor is FDA-approved, and that appropriate verifiable consent be obtained.
Allen Jacobs, DPM, St. Louis, MO



From: Allen Jacobs, DPM


My understanding of Radiesse is that it is not approved for, nor are there FDA studies for, the use of this calcium hydroxylapetite product for the foot and ankle. Experience in facial and hand soft tissue augmentation has demonstrated that Radiesse may be associated with vascular occlusion, downstream embolization, and tissue infarction, among other complications. The manufacturers recommend that Radiesse be utilized for indicated pathology in studied areas (face and hands), and by those TRAINED and EXPERIENCED in its use. Perhaps the reluctance to provide this product is not "anti- podiatry", but rather the responsibility of the manufacturer to not distribute the product for indications not FDA-approved. 


Furthermore, by undertaking Radiesse injection for foot and ankle augmentation, the podiatrist assumes a substantial potential medical-legal liability should a significant adverse sequela occur. Hiding behind a dermatologist to provide Radiesse could further legally implicate the distributing dermatologist in a ruse to provide a podiatrist with a medication for unindicated purpose. Having another podiatrist testify that in their opinion Radiesse may be used sans FDA studies and approval, and having the manufacturer testify that the dermal filler was not made for nor indicated for the purpose used, and that they (the manufacturer) would not knowingly provide ANY healthcare provider with Radiesse for non-indicated use, may be problematic. Caveat emptor!


Allen Jacobs, DPM, St. Louis, MO



From:  Jack Ressler, DPM


Before I sold my main practice, I researched practice brokers and interviewed a few. The bottom line is that you pay them several thousand dollars to give your practice a "valuation" and even more money when/if they sell your practice. Don't think for a minute that they come out to see your practice first. They will, but you pay extra for that service. I cannot speak for all practice brokers but the ones I spoke with have you sign an agreement that gives them exclusivity of selling your practice. This means they are in the driver’s seat as to how much and what type of advertising they want to do to promote your practice. They do not have to do too much work. The work they do, you pay for. 


Yes, you can still get a buyer on your own, but when under contract with the broker, you still pay their commission. Nobody knows your practice or can sell it better than you! Take some time and look into advertising your own practice. If a sale is pending, then contact a lawyer for further guidance. I sold my own practice and the only advertising I did was on PM News


Jack Ressler, DPM, Delray Beach, FL



From: Allen Jacobs, DPM


CBD topical preparations appear to be very helpful for symptomatic treatment of musculoskeletal disorders (e.g. arthritis, tendinitis ). I offer this has an alternative to those patients in whom oral NSAID therapy is not appropriate or concerning, e.g.: renal concerns, cardiac concerns, anticoagulation therapy, history of GI pathology). Typically, high NSAID risk patients are given the choice of topical NSAIDs, CBD topical, or no treatment. I personally use the CBD products from EBM pharmacy. The results have been excellent. I prescribe CBD topical daily.


Disclosure: I have lectured for EBM pharmacy in the past.


Allen Jacobs, DPM,  St. Louis, MO



From: Leonard A, Levy, DPM, MPH


Brent D. Haverstock, DPM said, "It would seem that if podiatry is to become a branch of medicine (MD/DO), the APMA would have to meet with the American Medical Association (AMA) and the American Osteopathic Association (AOA)..." This remark and so many others from podiatric physicians seem to indicate that the "appetite" for DPMs to acquire an MD or DO degree is rapidly increasing. However, before any meetings take place with the AMA or AOA and the APMA, it is essential that strategic planning take place to determine exactly what the profession needs to do and what needs to be done to get there. 


Such an activity must, at the least, include representation from the APMA, the Association of Colleges of Podiatric Medicine, representatives of the current licensing examination body (i.e., American Podiatric Medical Licensing Examination), and the bodies within our profession that represent both the accreditation of undergraduate podiatric medical education and graduate podiatric medical education (i.e., residency training). 


It would be a disaster if such a plan was not properly developed and members of our profession were not on the same page. Our effort needs to be one having a uniform voice devoid of bickering by individuals and groups in the profession. The strategic plan developed should be articulated in a document containing the background of the proposal, the state of the profession, including its current education and training, and a detailed description of what is being proposed. I suggest that the time is ripe to undergo such an effort but that it needs to be done very carefully. This formal process must begin now.


Leonard A, Levy, DPM, MPH, Ft. Lauderdale, FL



From: Alan Sherman, DPM


I’m confused by Leonard Levy’s most recent message in this discussion in the October 31, 2019 #6,539 issue, in which he refers to the “highly controversial proposal to have two specialty boards in the podiatric medical profession (i.e., podiatric surgery and podiatric medicine”. It’s not a proposal. We currently have these two specialty boards, ABPS and ABFAS. What we don’t have is two medical specialties. We have two specialty boards that represent one specialty, podiatry, and that structure is what is confusing the public and the medical establishment.


The proposal made by Jeff Robbins, DPM, supported by myself, Joe Borreggine, and now Brent Haverstock, DPM, is that our two specialty boards MERGE and form one board with sub-specialties, including advanced foot and ankle surgery and...


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



From: Richard D Wolff, DPM


For the past 12 years of practice, I have had zero residual nail dust in my treatment rooms, but I understand where you are coming from. During my first two years of practice, I had the same issue. When I moved to a different office, I had a central vacuum system installed. The vacuum is in a closet and shared by all treatment rooms. The rooms are connected to the vacuum via 2" PVC pipe above the ceiling tiles. The noise is contained to the closet, which has 2" thick foam added to the walls. 


I bought a cone nozzle (#ACC-SHEATH) from Jan L. It attaches directly to the end of a Dremel Multi-Pro and has a 1/2" tube connection. I also bought a reducer from Allegro Vaccums. It reduces the 2" outlet down to 1/2". The last item was a piece of 1/2" vinyl tubing I purchased from the local hardware store. There is strong suction noise in the treatment room, but no motor noise. The vacuum also serves as a floor vacuum for each room and we vacuum in between patients. No nails, no dust. I Dremel every patient. It is still going strong after 12 years of heavy use. I'm guessing I have about $1,500 in the system.


Richard D Wolff, DPM, Oregon, OH



From: Pete Harvey, DPM


I use Telemed out of Atlanta. My fee is $119/month and well worth it. However, that fee does not include scheduling, but they do offer that service. My service is automated and they tell the patient the office is closed and to call during regular hours.


If it is an emergency, they advise the patient to call the ER. If I get an after-hours call, they send a text to my phone with the patient’s problem, and a blue "click-on" to call the patient back.


Pete Harvey, DPM, Wichita Falls, TX



From: Steven J. Kaniadakis, DPM


It seems that podiatry school programs are pushing for students to get more biomechanics instruction from their residency programs and other post-graduate programs. Podiatrists have  typically been very well versed in these (and other) subjects, including reading and understanding x-rays and radiology, surgery skills, etc. 


Generally, podiatrists have been very well educated before residency and other post-grad programs compared to other medical school students. Even some practicing MD physicians do not even know which way to hold an x-ray (unless they were in a radiology residency or fellowship specialty program). However, generally speaking, MDs are much better versed in labs, etc. 


Steven J. Kaniadakis, DPM, St. Petersburg, FL



From: Elliot Udell, DPM


Dr. Borreggine is correct. One does not need to make an appointment to see a doctor in order to acquire a set of custom foot orthotics. This is not new. Making and dispensing foot orthotics has never been a practice which required a medical license. Orthopedic shoe stores, chiropractors, and physical therapists have been dispensing custom orthotics for years. What distinguishes a podiatrist from a "Joe Blow" working in a shoe store dispensing orthotics is our training in biomechanics. It’s the knowledge and training that enables the podiatrist to add corrections into a custom orthotic that distinguishes us from shoe store employees and others who make foot orthotics.


To this end, it would be great if the orthotics labs could roll back the clock and once again subsidize lectures on biomechanics and foot orthotics at every one of our conventions and at every one of our schools. That would once again make a real difference for our profession as well as the general public.


Elliot Udell, DPM, Hicksville, NY



From: Dave Williams, DPM


I have used HelloRache for about a year and have been happy with their services. They use ZOOM as their video chat and it hasn’t failed yet. My scribe can hear us clearly and we can hear her. She has direct access to my EHR and creates a “draft” note for me to review and sign later. She is based in the Philippines, but the company’s main office is in Arizona. All scribes have medical experience. You can interview your scribe before you hire them. You pay HelloRache every 2 weeks and they take care of the rest. 


Dave Williams, DPM, El Paso, TX



From: Justin Sussner, DPM


Last summer, I had the pleasure of getting a perfect bull’s eye on my back. My PCP put me on the standard dose of doxycyline. I went to my local chain pharmacy, who happily filled it and took $60 from me, the allowed amount on my insurance. 


About 2 months later, my wife was diagnosed with Lyme disease, and was given the exact same prescription. She went to our local mom and pop pharmacy who, when looking up the insurance info, stated "this isn't right", and then ran our info without insurance, and, for about $10, gave us the same doxy, same quantity.  


The moral of the story is: always look up your medication costs before walking into a drugstore, and it always pays to know a good locally-owned business.


Justin Sussner, DPM, Monroe, NY



From: David Gurvis, DPM


While neither solidly pro nor against “Medicare for all”, I would ask Dr. Hrywnak to back up some of his statements. A few pro and cons as I see them, in no particular order.


While true that Medicare as it is now handles the older population from the young healthy 70 year old to the chronically ill 65 year old, that would change as it would then include the young and healthy as well as the older and ill and everyone in between. As always, the young or the healthy would fund the ill.


As to taxes, yes, they would go up and in many cases... 


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



From: Raymond Posa, MBA


VoIP is Voice over Internet Protocol; basically, your voice communications are transmitted over the Internet instead of the traditional phone lines. That service is called POTS which stands for plain old telephone service. In the early days of VoIP, there were issues with voice quality, but those days are long gone. The quality of VoIP is top notch and the systems have all the advanced features any practice could want.


One of the biggest differences between VoIP and traditional phone service is price. VoIP tends to be much less expensive. Another huge plus with VoIP is its portability. If you were to move your...


Editor's note: Raymond Posa's extended-length letter can be read here.


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