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02/12/2020
RESPONSES/COMMENTS (PM ARTICLES)
From: Martin M. Pressman, DPM
I would like to comment on Dr. Sherman's article "What kind of podiatrist do today's residents want to be?" Dr. Sherman invited about 1,000 residents to take his survey. A review of the results indicates that 58 answered the survey. Using my calculator, 34% of 58 residents answered that they would prefer to be general podiatrists. That translates to 20 people out of the 1,000 residents. The response to a "dual track" residency indicated that 26% of the 58 people would have opted for that type of residency. That would be 15 people. These numbers are not dispositive and are too small to suggest that change is required.
The answer to the question posed is not answered by this survey and no conclusions may be drawn from these small numbers. Those residents who chose to do "general podiatry" will do so at their own discretion, bringing to the table the best foot and ankle training available after finishing their 36 month training. Nothing here precludes the discussion of curriculum for training programs. Let's keep this evidence-based.
Martin M. Pressman, DPM, Milford, CT
Other messages in this thread:
12/14/2023
RESPONSES/COMMENTS (PM ARTICLES) -PART 1
From: James Koon, DPM
I closed my practice 8 years ago to join a multi-specialty clinic. I got one records request in the 7 years I had to keep the records. One. I called the requestor and was released from it as my contribution was nominal. I simply kept my server. My vendor, MacPractice, assured me that IF I ever needed a chart, they would be able to pull it off my server no matter how many software updates transpired. For a fee. I never needed it.
We did have some residual paper charts that I rented a storage space for and pared them yearly. I paid to have them shredded. I also sold my x-rays for the silver recovery. Both were an expensive and laborious endeavor. In retrospect, I should’ve just had a big bonfire and partied with friends.
Closing a practice takes longer than you think and costs more than you think. Bills come out of thin air for months. Banking costs, vendor contract terminations, x-ray equipment decommissioning costs, files, legal notifications, etc. I don’t envy anyone doing it. I love being an employed physician.
James Koon, DPM, Winter Haven, FL
12/14/2023
RESPONSES/COMMENTS (PM ARTICLES) - PART 2B
From: Robert D Teitelbaum, DPM
David Secord's posting recently about "allopathic" medicine and how DPMs are allopathic doctors was a great lesson in the real meaning and the corruption of common words that we use to describe our professional status. I would also like to bring up three words that have held us back professionally and consistently for 40 years and I have not seen them much talked about. Those three words are Routine Foot Care.
My thesis is this:
1.There is no complaint about foot pain that is routine. A patient who realizes that her bent second toe has a painful corn on the first joint that hurts in all shoes is in distress. They need someone to counsel them on the choices they may face and the treatments that are relevant. The patient wants our experience, knowledge, and ability to communicate. They want a plan of action--in other words they want...
Editor's note: Dr. Teitelbaum's extended-length letter can be read here
12/14/2023
RESPONSES/COMMENTS (PM ARTICLES) - PART 2A
From: Robert Kornfeld, DPM
Dr. Kesselman makes a powerful point. But it isn’t limited to DPMs as to under-valuing services. I am friends with many MDs and the ones who still accept insurance suffer the same issue. The system has conditioned patients to not want to pay for anything so doctors feel their services have no value. I used to share an office with a cosmetic dermatologist and a plastic surgeon. They collected enormous amounts of money every day from their patients, and my patients often refused to pay co-pays and deductibles.
I went to a direct-pay model almost 24 years ago. I decide what my services are worth. I set my own fees. Every patient pays my full fee at the time of the visit. My accounts receivable has been $0 all these years. And I have made almost double the net income on 8-10 patients daily than I made on 50 insurance patients daily. Honestly, it’s a choice. I do not work hard. My days are pleasant and stress free. No one has to be exploited and abused by insurance companies.
Robert Kornfeld, DPM, NY, NY
12/13/2023
RESPONSES/COMMENTS (PM ARTICLES) -PART 1
From Ron Werter DPM
Dr. Kobak has written an in-depth article in PM Magazine about closing a practice. There is one item I have a question about: preserving the charts. When we all had paper charts, we could put them in boxes and take them home or have a company store them for 7 years Now, most of us have an EHR which is administered by a vendor. What is the best way of retaining those charts? Are there known problems with asking the vendor to copy all the data and allow it to be accessible if you no longer have their program.
Ron Werter, DPM, NY, NY
12/13/2023
RESPONSES/COMMENTS (PM ARTICLES) - PART 2
From: Paul Kesselman, DPM, Mark Spier, DPM
The whole point of my last letter was to point out that we, as individuals, are partly if not totally responsible for setting our own self-worth. If we don't, who will? If we podiatrists, as Dr. Secord states, are allopathic physicians, then it’s time we start acting like ones.
Can you find me an MD or DO who will work for the kind of dollars DPMs line up and stab each other in the back to sign up for? And that is the crux of the problem. We think if we sign up for less, then we can become invaluable to the patient and carrier. In fact, that’s exactly the opposite of what happens. The carrier realizes we are so dependent on them, we become so desperate to retain their lifeline, that they pay us less and less. So who’s really responsible for this? Each of us!
Paul Kesselman, DPM, Oceanside, NY
I’m asking if the antipathetic allusion to allopathy is an anonymously announced alliterative allegory? Or is it not necessarily nuanced enough to notice now?
Mark Spier, DPM, Reisterstown, MD
12/05/2023
RESPONSES/COMMENTS (PM ARTICLES)
From: Mark Ross, DPM
Dr. Rothenberg said, “Diabetic is a label and should be avoided. Compliance is authoritative and stigmatizing." To an old-timer getting ready to be put out to pasture, my response is, “The truth shall set you free.”
We accept great responsibility when treating diabetics, particularly those with infections, ulcerations, osteomyelitis, and gangrene. Compliance always affects outcomes. Failure is not an option, but can happen and when it does, the onus is on us.
The most important thing a doctor can tell their patient is the absolute truth. And patients know when the doctor is lying. Give the patients credit. When the patient is told they’re going to lose their toe which could very well lead to loss of limb, which could lead to death within five years, they are not dwelling on your choice of words. They are looking to the doctor to save them. And that is our job.
Mark Ross, DPM, Yardley, PA
11/30/2023
RESPONSES/COMMENTS (PM ARTICLES) - PART 3
From: Janet McCormick, MS
I agree with most of Dr. Roth's comments concerning extenders. Medical nail technicians (MNT) do leave for many reasons, as do other extenders in offices - few of us in business have the same staff as five years ago. To counter this, I provide podiatrists ways to keep them, such as suggesting an Educational Agreement and proper pay, and more. If they continue to leave, then I always make a suggestion toward an evaluation of staff management practices. I also suggest a friendly exit to all when and if it happens, that a well nurtured referral system can be very profitable on both sides between an MNT and a podiatry practice. Wise podiatrists who build this referral system see new clients from this collaboration on a continual basis.
Over the years, I have made comments comparing the dental scenario with dental hygienists, and podiatrists with extenders, and have mentioned that many years ago, dentists saw the handwriting on the...
Editor's note: Ms. McCormick's extended-length letter can be read here.
11/30/2023
RESPONSES/COMMENTS (PM ARTICLES) - PART 2
From: Gary Rothenberg, DPM
I would like to applaud Luke Hunter and Amanda Miller for their recent article posted from Podiatry Management. As a podiatrist who has a career dedicated to prevention of lower extremity complications among people with diabetes, any opportunity to share thoughts on the significant relationship between mental health and diabetes outcomes is welcome. However, I ask that we take this article to the next level and realize that language and words matter.
A lot of work has been done in the diabetes education space around the importance of appropriate and acceptable language in treating patients with diabetes. By the title of the article and even though people with diabetes are a significant part of podiatric practices, our field is slow to catch on to the significance of the words we use. "Diabetic" is a label and should be avoided when referring to people with diabetes. "Compliance" is authoritative and stigmatizing. There are excellent references that can help us all communicate in a more sensitive and effective way, especially important for our patients with diabetes and concomitant mental health issues. Robin Sharma said, ‘‘Words can inspire. And words can destroy. Choose yours well."
Lewis DM. Language Matters in Diabetes and in Diabetes Science and Research. J Diabetes Sci Technol. 2022 Jul;16(4):1057-1058.
Speight J, et al. Our language matters: improving communication with and about people with diabetes. Diabetes Res Clin Pract. 2021; 173.
Dickinson J, et al. The use of language in diabetes care and education. Diabetes Care, 2017; 40(12): 1790-1799.
Gary Rothenberg, DPM, Ann Arbor, MI
11/30/2023
RESPONSES/COMMENTS (PM ARTICLES) - PART 1
From: Paul Kesselman DPM
As an update on the very interesting issue of RPM and wearable technology, CMS recently had a call-in, a four hour meeting entitled Digital Technology and Diabetes. A very limited number of speakers spoke on a variety of topics, but mostly the NIH and inventors spoke about CGM (continuous glucose monitors). Some mention was made of wearable technology by some individuals from the NIH, CMS, and CDC.
Fortunately, APMA had registered me to speak at this meeting. The NIH speakers provided some time to discuss wearable technology but this was not limited to only socks and mats but also included potential use of "smart" orthotics and prosthetic devices as well as "smart" dressings. There was universal interest by these scientists who asked many questions on the impact wearables could have for reducing the significant costs our society bears in treating DM. It will be interesting to see where CMS takes this over the next few years.
Having podiatry invited to be part of the discussion with these preeminent scientists was certainly a big win and definitely shows we as a profession are part of this equation!
Paul Kesselman, DPM, Oceanside, NY
11/24/2023
RESPONSES/COMMENTS (PM ARTICLES)
From: Janet McCormick, MS
Dr. Hultman’s article, “Addition by Subtraction” is very interesting in that dentists began to ‘add by subtraction’ in their practices 6 decades ago: they embraced the training of dental hygienists to perform lower-level care they did not care to do: cleaning and x-rays. They eliminated these tasks almost completely from their practice rooms by delegating them to these trained professionals. Podiatrists should consider the same tactics in their practices.
As a former dental hygienist, I wonder why more podiatrists do not hire certified medical nail technicians to perform routine foot care. These nail technicians are advanced trained (and licensed) to perform the tasks of routine foot care in their services and can relieve the podiatrist of them to practice ‘real’ podiatry. While many podiatrists are doing so and enjoying the benefits of their decision, more continue to hold back.
These advanced trained nail technicians are special people who care about providing safe care within their scope of practice for persons who are chronically ill and/or elderly and have taken special training to do so safely. They wish to work directly for a podiatrist or to have a referral podiatrist to refer their aesthetic clients to who may need their care. Those of you who may need some support in this lower-level care in your office might give this some thought. Try delegating these tasks to a certified medical nail technician as dentists did to a registered dental hygienist. Most of you who do will never go back to performing those tasks except on those who specifically need you.
Janet McCormick, MS, Nailcare Academy, Naples, FL
12/02/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 2
From: Kenneth Jacoby, DPM
The letter by Dr. Kesselman was well written but a sad commentary on today’s situation. What are the APMA and other organizations doing about this sad situation? And this goes further than diabetic shoes. When I went into medicine 37 years ago, it was patient first, which still holds true, but there are more hoops required to get compensated.
Kenneth Jacoby, DPM, Elgin, IL
12/02/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 1
From: Josh White, DPM
I appreciate the letters written by Drs. Markinson and Kesselman regarding the article I recently wrote in Podiatry Management about why diabetic shoes aren’t prescribed more. While intended as a “How to” overcome obstacles to ensure patients are properly fit, it seems to have been perceived more as “Why not to”, get involved with footwear.
I wholeheartedly agree with Dr. Markinson’s conclusions that it’s best to have "a high-volume need", "a dedicated individual in the practice for the fitting of off-the-shelf shoes, and an available laboratory that will provide true...
Editor's note: Dr. White's extended-length letter can be read here
12/01/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART1B
From: Paul Kesselman, DPM
I have to mostly agree with Dr. Markinson's sentiments and publicly want to acknowledge that many years ago, Dr. Markinson often referred his patients to my practice for proper evaluation of shoes/inserts through the Therapeutic Shoe program, because his practice could not deal with the bureaucracy of the program. He and I am sure most continue to believe the program is theoretically needed, but from a practical office-based practice perspective is untenable.
Most podiatrists (and others), as opposed to pedorthists, do not offer custom molded inserts (A5513) simply because they don’t want to deal with the increased costs of the custom molded devices, while still receiving the exact same reimbursement as for custom milled (A5514) devices. Most pedorthists and some orthotists produce their own custom molded inserts in-house. But they too...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
12/01/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Elliot Udell, DPM
There is an elephant in the room that we are not addressing when it comes to diabetic shoes and inserts. It’s called "entitlement." The patients feel they are entitled to them and will do anything to get them once a year, even if they do not use them. We had one patient who was "Johnny on the spot" every January 1st for his shoes. He never seemed to be wearing the old ones. When confronted, he would say that he just left them at home by mistake. Was he really using them or selling them on the street corner or on E-bay? We'll never know.
Elliot Udell, DPM, Hicksville, NY
11/29/2022
RESPONSES/COMMENTS (PM ARTICLES)
From: Paul Kesselman, DPM
This month's issue of Podiatry Management contained a very well written article by Dr. White, detailing the benefits of prescribing and dispensing therapeutic (not diabetic) shoes to diabetic patients. I commend him for writing this article and agree that providing therapeutic shoes is necessary. Unfortunately and it pains me to say this, I believe the time may have come where I can no longer support providing this service.
Lost in this well written article are the main reasons why multiple types of providers (not just podiatrists) have voluntarily withdrawn from providing this valuable service. Increasing audits by the DME MAC, RAC, and MRC, often conducted by auditors without clinical expertise, have simply resulted in...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
10/05/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 2
From: Vuncent Gramuglia, DPM
The knowledge of biomechanics and its application in our evaluation and management of podiatric pathology particularly with regard to elective foot and ankle surgery is essential. Unfortunately, current understanding of the relationships between the forefoot and rearfoot are sometimes like visiting the Wizard of Oz. Does equinus cause pronation or does medial column instability result in Achilles contracture in an attempt to stabilize the medial column during mid-stance? The proper function of the peroneus longus and posterior tibial tendon may be more important than obsessing over the amount of eversion of the calcaneus which is very often neutral to slightly inverted.
The efficiency of the 1st MPJ and stability of the medial column described by Shavelson as the “kickstand of the foot” is a very interesting commentary on where to focus your attention when you are performing surgery or prescribing orthotics. This fresh perspective, I believe, may serve as a simple way to view the foot/ankle biomechanically and to improve our surgical decision-making; thereby making outcomes more predictable and successful.
Vincent Gramuglia, DPM, Bronx, NY
10/05/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 1
From: Elliot Udell, DPM
Several years ago, I was given the honor at an APMA national meeting to be one of the judges of the posters that were displayed. I spent many hours reading every poster. Most were really great and showed that podiatry has the ability to merge science with medical practice. I was really proud of my profession and those that did the research. Unfortunately, there were few, if any, posters that dealt with biomechanics and foot orthotics.
Dr. Kesselman is correct. There is waning interest in that part of podiatry and it probably is a Catch-22. On one hand, it is not as lucrative as surgery and on the other hand because we are not doing the research, we don't have the ability to approach insurance companies and insist that they make it lucrative. Dr. Kesselman, I, and others can complain until the cows come home about this but we seem to be beating a dead horse. It is what it is.
Elliot Udell, DPM, Hicksville, NY
09/21/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 1B
From: William Beaton, DPM
Be careful what you ask for in payment for orthotics from insurance companies. Many of us remember when we were appropriately reimbursed for bunion/hallux valgus surgery $2,000. +/- as compared to the current reimbursement rate with the 90-day follow-up. That is what happens when insurance companies control free enterprise with participation contracts and make us providers for their insureds. This past week, I counted 19 advertisements on Facebook for all different kinds of orthotics to cure from plantar fasciitis to low back pain from $39.00 to $250.00. This is a sad state of affairs, creating confusion for the general public.
William Beaton, DPM, Saint Petersburg, FL
09/21/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Jeff Root
I’m glad to hear that Dr. Roth has had success with the MASS theory of foot orthotic therapy. I have spoken to other podiatrists who claim to have had success with it and others who did not experience adequate success and abandoned the MASS approach as a result. I have also spoken to podiatrists who have had tremendous success with Root’s approach and others who have had less than satisfactory results. How can one explain these contrasting experiences and outcomes? Part of the answer to that question is the fact that there is variability between and how clinicians examine a patient, cast or scan the foot, and in the devices that they order for their patients. In addition there is variability between custom foot orthotics made by different manufacturers who, in many cases, claim to subscribe to the same manufacturing theories and protocols.
Fortunately, my father Merton Root did not have a vested interest in the commercial manufacture of...
Editor's note: Jeff Root's extended-length letter can be read here.
09/16/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 2
From: Elliot Udell, DPM
The argument as to why many insurance companies do not pay for orthotics is an old one. Dr. Roth may have hit on the reason when he writes that he tells his son, a podiatry student, that when he graduates, he should forget all that he learned in biomechanics and subscribe exclusively to Dr. Glaser's theory.
There are so many great biomechanics sages in our profession. There was Root, Weed, Orion, Schuster, Langer, and currently Shavelson, Glaser, and others. The list goes on and on. The never-ending problem is that all of these wise doctors' theories differ from each other. Hearing their lectures made believers out of the listeners, but insurance companies looking over their shoulders see conflicting theories and there is little evidence-based medicine to prove one theory from another.
The solution is for our labs to do what drug companies do. Invest in research, publish the research, and only then can the APMA and others go to Medicare and other insurance companies with credible reasons why patients should be entitled to be covered for their orthotics. We know that our patients feel better with orthotics, but that alone doesn't cut the mustard in the world of insurance.
Elliot Udell, DPM, Hicksville, NY
09/15/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 2
From: Ivar Roth, DPM, MPH
I would like to help Jeff Root understand what Dr. Shavelson meant. First, Dr. Root did give us the “language” which is still useful today but more in a historical perspective.
I have spoken to Dr. Shavelson in the past and I understand where he is coming from and I will try to interpret with my own twist his and my understandings. While Dr. Shavelson and I may disagree on what to call his biomechanical theory, I believe he is RIGHT ON. I subscribe to the MASS theory of orthotic lingo as opined by Dr. Ed Glaser. For those of you unfamiliar with Dr. Glaser’s theory, I would highly recommend that you...
Editor's note: Dr. Roth's extended-length letter can be read here.
09/15/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 1
From: Lance Malusky, DPM
That was an excellent article on including "I'm sorry!" into a conversations with a patient with an untoward result. I don't believe that PICA actually recommended that phrase, but they did recommend numerous actions to protect you from a lawsuit, and to mitigate damage to one's medical reputation. As soon as I saw an issue, such as a regrowing phenol nail, or bunion, I "followed" Dr. Baum's 4 R's. These actions were instilled by PICA's monographs and seminars over the years. As a practitioner's primary duty is the patient's welfare, recognizing a problem early and advising the patient on a course of action is necessary.
My surgical consults and permits always had a list of potential generic complications, including "death." Luckily, I could always say that never happened, and that defused the remaining scenarios as less intimidating. I always made sure that each patient, and interested family member, had a chance to read the surgical permit, which also had a blank space for specific issues with each surgical case. They would sign both copies, and retain one copy with post-op instructions sheets. (The unalterable photocopy with an original signature was the one I kept in the paper file). Hospital cases always signed at a late consult date, prior to the surgery date.
An unspoken advantage of the "Apology" discussion is the activation of the statute of limitations regarding a malpractice suit (one year in Ohio). This can be implemented in the patient chart in detail. The doctor discusses and documents the poor result, his remorse without admitting some specific "guilt,"and encourages a mutual responsibility to participate in actions for remedy. As far as monies, I would offer a redo for an occurrence less than one year post-op, but still bill insurance, and agree to write off any balances.
Lance Malusky, DPM, Dayton, OH
09/12/2022
RESPONSES/COMMENTS (PM ARTICLES)
From: Dennis Shavelson, DPM
Podiatry cannot remain tagged to the biomechanical and orthotic genius of Dr. Root and the gifts he gave us 45+ years ago. Subtalar joint neutral, rearfoot valgus, and over-pronation have had their runs. Podiatric promises that our orthotics cannot fulfill have dampened our orthotics in the eyes of other professions, the insurance companies, and patients as well. No podiatric orthotic places a patient in subtalar joint neutral. We have no proven definition of our orthotics, how to cast them, and what their goal sets. “Happy patients”, a doctors promise of success and anecdotes do not promote insurance acceptance.
Happy Feet gets $1,000 in cash for their OTC orthotics, so I dispense devices that are uncovered by all insurance because I want more income streams that I professionally own and control. My inserts are guaranteed to holistically provide stability, support, strength, symmetry, and balance to a patient's feet, not just reduce pronation and relieve heel pain. We need labs that do not accept “post to cast” as an Rx for a device with a 3 degree rearfoot post as correction. We need to provide a cut and paste biomechanical algorithm between doing nothing and foot surgery that has great evidence-based outcomes.
I retired as a DPM last year and practice as a certified health coach and CPed. I am cash only and am proud to state that I am podiatry-trained and experienced in biomechanics and human movement, but I am no longer a podiatrist.
Dennis Shavelson, DPM (retired), CPed, Tampa, FL
08/10/2021
RESPONSES/COMMENTS (PM ARTICLES) - PART 1B
From: Robert S. Schwartz, CPed
For most of the last 48 years, I’ve had the privilege of providing education and training to third year students at NYCPM. As I explain to them, the shortcut to biomechanics is the “Worn shoe evaluations, shoes-on, shoes off!” Our worn shoes tell our story. The Eneslow worn shoe evaluation form is used clinically. It’s a great tool to easily train staff and create and develop a biomechanical and forensic approach. The most efficient way to achieve this is to start assessment with patients still wearing their shoes while standing. Then, the shoes can come off for further study, along with an evaluation of the feet and body.
Disclosure: I am the President and CEO of Eneslow Pedorthic Enterprises.
Robert S. Schwartz, CPed, NY, NY
08/10/2021
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Paul Kesselman, DPM
Two years ago at the APMA 2019 National, Karen Langone, Jeffery Ross, and I provided a morning session on 21st Century Biomechanics. Not more than 75 DPMs attended that session with most being over the age of 45. Few young podiatrists attended this while other surgical courses were being offered. During the intervening two years, I have posted a similar letter as Drs. Ritchie and Kirby, and have met with Dr. Shapiro, whose recent article has spurred this most recent conversation. Two years ago, rather than receiving letters of support on actions by which to resolve the issue, I received several letters from academia, defending the courses they taught at their various podiatric institutions, rather than acknowledgement that there was an issue. Several orthotic laboratories did, however, acknowledge the "problem".
Dr. Kirby's recent letter is spot on and is identical to what I was taught over 40 years ago while a student at ICPM. Unfortunately, the current students today lose much of what they are taught from the biomechanical perspective because...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
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