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From: Gary S Smith, DPM


I came across advertisements from the late 1800s for snake oil and I was struck by the almost identical claims of cure by CBD oil dealers. I heard CBD oil repels giant emu attacks so I keep a bottle in my office. It works too! I haven't seen one emu!


Gary S Smith, DPM, Bradford, PA

Other messages in this thread:



From: Tim Shea, DPM 


What a great question Dr. Simmons presents. My associate and I are both above 60+ and we were wondering why we were short of breath after about 4-5 patients, especially if we were talking. I think it is a combination of re-breathing CO2 and not getting as much O2 volume through the masks. We may try to have O2 available in the office. Thank you Dr. Simmons.


Tim Shea, DPM , Concord, CA



From: Dennis Shavelson, DPM


In changing our focus and training towards surgery, as a profession, we are forced to become more and more vestigial regarding closed-chain lower extremity biomechanics. In medicine, a surgeon’s card reads that he/she is a surgical specialist. A physiatrist's card reads rehabilitation specialist, and a dermatologist's reads skin specialist, etc. They can and do consult outside of their specialty at a lesser level, but remain dedicated to one or more specialties. They consult with other specialists when their training and experience falls short of the problem at hand by putting the patient in the hands more expert than their own.


I can count the number of biomechanical consultations that I have received from surgeons in my 40+ years of podiatry on nine or ten fingers. Instead, I have fostered relationships where I can confidently refer the few surgical cases I am asked to consult on and in return, I am called upon to assist them biomechanically pre- and post-op. In summary, in becoming podiatric foot and ankle surgeons, we are practicing a stunted version of biomechanics and orthotics without incentivizing non-surgical podiatric consultants in integrative biomechanics, making DPMs like me more and more vestigial.


Dennis Shavelson, DPM, NY, NY



From: Marc A. Benard, DPM


I agree with Dr. Ribotsky with respect to a distinct absence in gait analysis and applied biomechanics, as well as his indicating “… are we losing the skill to determine the difference between open chain kinetics and closed chain kinetics pathology? If so, how can correct surgical procedures be explained?” I can attest that I observe this deficiency at close hand through my didactic lectures to residents both in person and recently via webinars, as well as through on-site observation at Operation Footprint (formerly The Baja Project for Crippled Children) during patient screenings, grand rounds, and intra-operatively. I’ve also engaged in discussion with program directors on the problem.


In truth, the problem has always existed, if my 43 years of dealing with the issue holds any validity. Fundamentally, the partitioning of “biomechanics” and “surgery” fractionated the...


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



From: Elliot Udell, DPM


Thank you Dr. Markinson for once again reminding us of the non-COVID-19 risks associated with grinding toenails. Several responders have legitimately asked how to adequately soften nails so as to properly debride them without the use of an electrical drill. 


As an allergy sufferer, I had to limit nail grinding very early in my career. I coughed and wheezed, even with the use of dust extractors. When papers came out showing that breathing in nail dust was an occupational hazard, I took all of the drills and extractors to the nearest dumpster. Some papers showed that the dust remains in the air for over 11 hours. 


There are ways to soften nails so that they can be adequately debrided. Spraying the nails with "Three Way Solution", often works. Another way is to dispense some of the nail softening products and insist that the patients use them daily between visits. We get great results with Bako's 40% urea nail gel as well as other products such as Formula 7. We have found that if the patients use these as well as other urea containing nail products, there is no need to mourn the use of nail grinding devices. 


Elliot Udell, DPM, Hicksville, NY



From: Charles Morelli, DPM


You asked to "detail your techniques for reducing toenail hypertrophy". It has nothing to do with technique and all to do with having sharp instruments. If, and only if, your instruments are sharp, can this be done relatively easily and without pain to the patient. A dull instrument will do a less than optimal job and be painful for the patient if you are trying to reduce nail thickness. That being said, I do grind nails, have used a vacuum extractor for the past 30 years, and I now also wear a mask and will continue doing so, long after COVID is gone. I'd be embarrassed to have some patients leave my office without my doing that, but that is just me, as I know others will disagree. 


Charles Morelli, DPM, Mamaroneck, NY




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.


Rachel Balloch, DPM, Avon, CT



From: Richard Goldstein, DPM


We have been very pleased with our purchase of the Swift machine. We purchased it in November 2019 and are on track to pay for it in full this year. So far, the results have been incredible, especially on recalcitrant warts. We are still working on our process. Some people need local anesthesia and some have not, but either way they are tolerating it. I was really glad to be an early adopter and I feel that within the next few years, microwave technology will be the treatment of choice for warts. I also feel like we have only touched the surface of what medical microwaves can be used for.


Richard Goldstein, DPM, NY, NY



RE: 40th Anniversary OCPM Class of 1980

From: Tom Silver, DPM


I too would like to take a moment to "wax nostalgic" to offer congratulations to all my OCPM classmates on the 40th anniversary of our graduation. It's hard to believe it has been so many years! I hope you too have fond memories from school days and that many of the hopes and dreams for the future that you had back then have been fulfilled! 


Tom Silver, DPM, Minneapolis, MN



From: Alec Hochstein, DPM


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. 


Alec Hochstein, DPM, Great Neck, NY



From: Thomas A. Graziano MD, DPM


I decided to buy this new modality/technology because I believe in its mechanism, i.e. stimulating one's immune system to "naturally" eradicate the virus. My experience with the modality has been very favorable. Initially, I was seeing patients who had multiple unsuccessful attempts utilizing different modalities (surgical excision, chemo, cryo, etc.). At the onset, I must admit that I was questioning whether or not anything was happening during treatment, for as advertised, there is no smoke, no visible burn, or heating of the tissue. Don't be discouraged though; this is a very powerful therapeutic modality.


It is not painless. At times, it is necessary to administer local anesthesia, often a PT nerve block if the warts encompass a large region or subdermally in sensitive areas. Each treatment requires that the operator use a new tip. Each tip costs around $75, so be mindful of that if you’re charging a “case fee.” The mechanism of action relies on an intact immune system, so those patients with compromise in this area may require more treatments or be recalcitrant completely. Typically in patients with healthy immune systems, even those who have been resistant to other forms of treatment, from 3 to 5 sessions may be required. "Virgin" solitary warts can be handled in 1 to 3 treatments.


Thomas A. Graziano MD, DPM, Clifton, NJ



From: Paul M Taylor, DPM


Thank you Sam Bell for your note regarding the PCPM class of 1970. I have been retired for a few years but still follow what is happening in podiatry. The changes over the last 5 years, including scope of practice, surgical procedures, electronic records, new medications, public recognition, group and mega-practices, and now COVID-19 exceed what happened over the previous 45 years.


Congratulations to this year’s class; you have an exciting and challenging time ahead of you.


Paul M Taylor, DPM, Silver Spring, MD



RE: 50th Anniversary of PCPM Class of 1970

From: Sam Bell, DPM


Please permit me a moment to wax nostalgic. I want to offer congratulations to my 27 classmates on this the 50th anniversary of our graduation. I know it’s a cliché, but it really did go by in the blink of an eye. I hope you are all well 


Sam Bell, DPM, Schenectady, NY



RE: Employees Not Wanting to Return to Work

From: Ron Werter, DPM


The question has come up as to why an employee would want to return to work if they are getting full salary plus $600 for not working. The rules may have changed in many years but I seem to remember that if you’re on unemployment, you still have to look for a job and not refuse to take a reasonable offer. So if you the employer offers your resistant furloughed employees their job back and they refuse, I assume that you could let unemployment know about that and the employee would have to have a discussion with unemployment. I am not a lawyer and my opinion may be incorrect but it may be worth an inquiry.


Ron Werter, DPM, NY, NY



From: Eddie Davis, DPM,


Few healthcare professions have not attempted to increase scope of practice throughout the years. We need to take the focus off other professions that are striving to increase autonomy and scope and look at our own profession. If one considers our current scope of practice and then consider our level of training, we probably have the most training relative to scope of any health profession. 


We are foot and ankle specialists but have more training in general medicine, pharmacology, rheumatology, dermatology, infectious disease, neurology, and orthopedics than mid-level practitioners who are treating the entire body in those areas. The mid-level practitioners traditionally treat the entire body under MD/DO supervision but such supervision is minimal in many venues. That trend has been driven by managed care and government cost-saving initiatives.


A bill was introduced into the Washington State legislature years ago to allow DPMs to practice as physicians assistants for areas outside the foot and ankle but was opposed by that state's podiatry association. I think that such an expansion makes sense. Of course, it would be great to adopt an MD or a shortened pathway to an MD but that is a process that requires development. The PA option not only is easier to achieve, based on our training, but politically feasible due to the high demand for mid-level practitioners.


Eddie Davis, DPM, San Antonio, TX



From: George Jacobson, DPM


By simplifying the documentation, fraud and abuse is more easily identified. A family member’s in-law was a former army intelligence officer and spent 35 years as an insurance investigator for a large private insurer. Years ago, he told me his simplest slam dunk cases. They consisted of medical doctors who over-utilized high level visits and there couldn't have been enough time in the day to have seen that volume of patients billed for at that level of service. They requested money back and sometimes claimed intentional fraud in the big cases.  


This will be even easier to uncover with electronic appointment books and records. How could one bill all CPT 99204, 99205, 99214, and 99215 where the schedule shows patients were seen every 10 minutes? You'll have to be cognizant that the appointments scheduled match the time allotted for the visit, especially if you are in a high volume practice.


George Jacobson, DPM, Hollywood, FL 



RE: We Are Showing We Have a Cure for the Coronavirus

From: Robert D Teitelbaum, DPM


I do not know why no one has spoken of the great hope that we can have that this Covid-19 virus is not going to be the modern day version of the Bubonic plague. Eighty percent of the cases are mild. They are mild because those patients have developed antibodies to the virus that are effective in dealing with the virion.


We are worried that it will take one or two years for an effective vaccine to be available when we already have a virostatic or virocidal cure that most patients are walking around with. It might be very effective to find and analyze these antibodies to see how they are effective. Also, children (not infants) do very well against the virus, some say because they have yet to abuse their lungs with various smoke sources, and their immune systems are robust. Also, one can't help but feel for those people who rely on Humira or Enbrel, when now susceptibility to infection takes on a more sinister tone.


Robert D Teitelbaum, DPM, Naples, FL



From: David E Gurvis, DPM


All the other specialties have an unlimited license to practice. They can work on the feet as they choose without specialized training. Recently, I treated  a terrified 19 year old who had a toenail partially removed in the ER a month ago. Why was he terrified? Because the ER doc ran a needle up under his nail to anesthetize the area. As it was infected, guess what didn’t work. I did a normal and typical toe block. Sure it still hurts but…guess who is coming back next time to me vs. the ER?


They, the unlimited specialties, are legally allowed to do anything. They can drill and fill teeth if they want to. It’s legal. They know they are no good at it, so they don’t. Feet? Well, not so much respect and the “I can do that” attitude prevails. We get the patients in the end regardless of who (mis)treats them first. After doing well once they are in our office and educating them….that’s the way to fight this. 


David E Gurvis, DPM, Avon, IN



From: Elliot Udell, DPM


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.


Elliot Udell, DPM, Hicksville, NY



From: Steve E. Abraham, DPM


My wife was a nurse practitioner. She worked in the orthopedic department at the hospital and was trained in orthopedic surgery. She learned about orthopedics and podiatry and had a really good knowledge base in both. After a while, her knowledge of orthopedic problems above the ankle was greater than mine. This included joint injections, knee and hip replacements, shoulder procedures, fracture care, and trauma. Our difference was the exposure we got. The things I did I got very good at and had much greater expertise than she did. Yet, she was exposed to so much more after she graduated and started to work.


It is not a question of who knows more, or who is better, the reality is we are all a team and each specialty provides appropriate care based on education, knowledge, and integrity. As a podiatrist, I give really incredible, high-level care to my patients, I treat the problems they come to me for. So did my wife, as a nurse practitioner, in the job she had. There is no competition because we did not compete with each other. We can all learn from and teach our colleagues and become better.


Steve E. Abraham, DPM, NY, NY



RE: Coronavirus in 2020 (Elliot Udell, DPM)

From: Daniel Chaskin, DPM


The coronavirus could be deadly for those patients with a weak immune system. This is why a podiatric exam might shed light on the above questions. Capillaroscopy using a dermatoscopy may lead a podiatrist to suspect a possible autoimmune disease. Blanched toes may indicate blood disorders such as anemia which may be a podiatric manifestation of a weak immune system.


Daniel Chaskin, DPM, Ridgewood, NY 



From: Hartley Miltchin, DPM


They have discontinued the foot moisturizing cream because of poor sales in the foot category.  The CeraVe SA cream used on other parts of the body is the exact same formula.


Hartley Miltchin, DPM, Toronto, Canada



RE: ABPM Non-Recognition of Residencies (William E. Chagares, DPM)

From: Daniel Chaskin, DPM


GME funding is linked to the fewest years needed for the certification process. Why can't such funding co-exist with an additional alternate path of 30 years' or 20 years’ experience in practice? The public is hurt by excluding qualified podiatrists from board certification with the experience and the knowledge to pass a certification exam. This would be a win-win situation for all experienced podiatrists who never got a residency match.


Daniel Chaskin, DPM, Ridgewood, NY



From: Supna Reilly, DPM


The enPuls unit is extremely effective and has been a wonderful source of revenue for our office. We do 6 treatment sessions spaced 2-3 days apart, and charge $100/session. Literature suggests the efficacy of shockwave to be around 80%, and we have found that to be the case in clinical practice as well. It tends to be an easy sell for patients who don't want to go the surgical route or have plateaued in their progress. The customer service on the unit is also unparalleled. I recommend this unit.


Supna Reilly, DPM, Chicago, IL



From: Kevin A. Kirby, DPM


The “Pose Method” and “Chi Running” are styles of running popularized over the past decade where coaches teach runners to try to land more on their forefoot, and not on their heels, during running. These two running “methods” were created by individuals who have sold books, produced videos, and have trained coaches to teach runners on “the proper way to run”. Neither of these running methods, which have likely made their creators lots of money, have been shown to be more “natural”, more metabolically efficient, or less injury-producing than other running styles.


Pose and Chi running became popular during the barefoot running fad of 2009 to 2015, where many self-proclaimed “running form experts” on the Internet asserted, without supporting scientific research evidence, that...


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



From: Stephen Kominsky, DPM


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. 


Stephen Kominsky, DPM, Washington, DC


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