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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:


02/24/2020    

RESPONSES/COMMENTS (PM ARTICLES)



From: Joseph S. Borreggine, DPM


 


This survey does not surprise me one bit. Why wouldn't a graduating doctor of podiatric medicine (DPM) want to be a "foot and ankle surgeon" instead of just a general podiatrist? It seems to me that it has nothing to do with what a podiatrist is trained "to do", but what a podiatrist "can do". This debate will continue to linger as long as there are “podiatrists who perform foot and ankle surgery” versus “foot and ankle surgeons who are podiatrists.”


 


This clash has been a divisive situation in our profession going all the way back to the early 1940s when podiatrists were organizing groups like the American College of Foot and Ankle Surgery and then in the late 1970s establishing the National Board of Podiatric Surgery (NBPS), then renamed the...


 


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

02/21/2020    

RESPONSES/COMMENTS (PM ARTICLES) - PART 1A



From: Ty Hussain, DPM


 


Responding to Dr. Udell's comment about dentists having multiple sub-specialties, its point is that they are able to maintain defined specialties mainly due to one factor: how they get reimbursed vs. the rest of the medical field. I have long said that dentistry was the smartest of all medical care due to the simple fact that the majority of the patients nationwide acknowledge that dental care is a cash transaction. Yes, there is dental insurance, but the majority of the population does not carry that, and dentists for the longest time have kept themselves out of the insurance rat race to keep it a cash business.


 


Therefore, you can have dental specialties that can charge so much money for a procedure, knowing they will be paid upfront. Can we say that about podiatric medicine, that has strived to be like our MD colleagues and wants to be part of every insurance to get reimbursed 80% of Medicare and be content? This is what causes that podiatric surgeon who wants to only perform ankle surgeries, but due to low reimbursement, wanders into general podiatric care. Our field is based on relying on third-party payors. Changing ourselves to a cash basis is a tough hill to climb.


 


Ty Hussain, DPM, Evanston, IL 

02/20/2020    

RESPONSES/COMMENTS (PM ARTICLES)



From Elliot Udell, DPM


 


Perhaps, someone out there can answer a question that has been posed for years with no legitimate answer. Why has dentistry has been able to maintain clearly defined specialties and podiatry has not? In dentistry, there are oral surgeons who would never dream of filling a cavity or making a crown. There are periodontists who do gum surgery and endodontists who do root canals. Sure, some general dentists will do an extraction and some will do root canals, but you would never find an oral surgeon, endodontist, or periodontist encroaching on the turf of the general dentist. 


 


Far be it from for me to say that podiatrists are unethical or there is anything that prevents us from maintaining clearly defined specialties. It's obvious. It has to do with the economics of healthcare as it pertains to podiatry. Since I started my first days in our profession, the idea of having true specialties ala dentistry has always been espoused, but it has never gone beyond the realm of just being a good idea. What can we do to change the economic environment so as to have true specialties in our profession?


 


Elliot Udell, DPM, Hicksville, NY

02/19/2020    

RESPONSES/COMMENTS (PM ARTICLES) - PART 1B



From: Lawrence Oloff, DPM 


 


I believe this dialogue about “advanced foot and ankle vs. general practice podiatrist” espoused by Dr. Sherman misses many key points. It bothers me that after all the progress that I have seen our profession make, there are still advocates that want to have our profession take two steps back. I have been involved with podiatric medical education for forty plus years and continue to do so today as a residency director. These are my observations.


 


Completing residency does not force its graduates to perform advanced surgery, or for that matter any surgery at all. The extent of one's practice is purely up to the discretion of each graduate of a residency program. Residency just allows its graduates to provide basic competency in the care of their patients, both as generalists and as surgeons. Finishing a residency is just the beginning of obtaining competency as a...


 


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

02/19/2020    

RESPONSES/COMMENTS (PM ARTICLES) - PART 1A



From: Doug Richie, DPM


 


Regardless of what type of practitioner today's podiatric resident "wants to be", the fact of the matter is that current podiatric residency training programs do not prepare residents to manage common musculoskeletal foot and ankle problems with non-surgical interventions. 


 


I believe this would fall under the scope of "general practice" podiatry which Dr. Sherman refers to. Dr. Jacobs uses the term "primary care podiatry" and cites the training current residents receive in the fields of rheumatology, dermatology, vascular disease, endocrinology, and neurology. How does training in these disciplines prepare the podiatric resident to evaluate and treat plantar heel pain and metatarsalgia, the two most common musculoskeletal conditions which present to the podiatric practitioner?


 


In this regard, Dr. Jacobs states that current residents have "excellent understanding" of biomechanics and kinesiology. If they do, this understanding came from 4 years of podiatric medical school and not from a 3-year surgical residency program. Even if this were true, training and hands-on experience in implementing non-surgical treatment of common musculoskeletal foot and ankle problems is sorely lacking in today’s podiatric surgical residency programs.  


 


Doug Richie, DPM, Long Beach, CA

02/18/2020    

RESPONSES/COMMENTS (PM ARTICLES) - PART 2B



From: David E. Gurvis, DPM



 


There is room for all of us in all of our capacities. Some will make it as surgeons. I know several groups who will not do routine care, or biomechanics, or dermatology, etc. and some will morph into more generalists and still earn a great living and be just as satisfied. I do many surgical procedures and I do them well. I am limited in my training and send the complicated stuff out to the surgical groups. 


 


My comments are regarding surgical vs. conservative care. Maybe because of finances, or training, it seems many of the surgeons no longer offer any...


 


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


02/18/2020    

RESPONSES/COMMENTS (PM ARTICLES) - PART 2A



From: Alan Sherman, DPM


 


Why am I not surprised that in 40 years, none of Dr. Jacobs’ residents have told him that primary care practice is their first choice, despite 25% of residents telling us in our polling that they intend to be general practice podiatrists? That is precisely the reason that I conducted an anonymous poll where residents could give us honest answers. A resident would never, ever reveal this perceived “failure” to Dr. Jacobs. He is apparently among the residency directors who think that the more surgery a resident does, the more accomplished s/he is as a human being.  


 


The poll data is not “alleged” or in dispute because Dr. Jacobs says it is. I’d like to dispel another assertion that Dr. Jacob naturally falls into in his comments – that this is a question of surgical vs. non-surgical podiatrists. It never was. All podiatrists do some surgery. This is a question as to how much they do. I prefer to represent it as advanced foot and ankle surgeon vs. general practice podiatrist. As this issue continues to be defined by podiatrists across the country, I would advise all to beware of those like Dr. Jacobs using the term primary care practice or non-surgical podiatrist. No one, least of all me, wants to take surgery away from any podiatrist. I simply want to direct our residency and other training resources to train all podiatrists in the skills that they will be using in practice.


 


Alan Sherman, DPM, Boca Raton, FL

02/18/2020    

RESPONSES/COMMENTS (PM ARTICLES) - PART 1A



From: Elliot Udell, DPM


 


Thank you, Dr. Zanbilowicz, for questioning what kind of studies should be enough to let us subject our patients to new and often expensive, out of pocket treatments. The article referenced from the New York Times is on target.


 


One way of determining whether a new, expensive product should get our clinical attention is whether major insurance carriers will pay for it. Peddlers of these products at medical conventions will argue with this point of view. Over the years, however, insurers such as Medicare and other major carriers will not pay for a treatment where the evidence supporting it is clinically questionable. Sometimes, when new research says that a treatment is questionable such as with ECSW therapy, Medicare stopped paying for it and dozens of shockwave providers ceased to exist. 


 


On the other hand, if a treatment is supported by large studies from many reputable study centers and the evidence is clear that the treatment will help patients, it will not be long before insurance carriers will be forced by public outcry to pay for it. So where does this leave us? In our practice, we may offer a new treatment that may be promising if it is inexpensive and, of course, safe. On the other hand, to our own financial detriment, we will not sell a treatment that will cost the patient "a thousand dollars" or more if the preponderance of evidence does not support it. 


 


Elliot  Udell, DPM, Hicksville, NY

02/17/2020    

RESPONSES/COMMENTS (PM ARTICLES) - PART 1B



From: Michael M. Rosenblatt, DPM


 


I read with interest the recent polls of newly graduated residents, in which the majority answered that they want to practice mostly surgery in their work. I understand this. Many years ago, I felt the same way. Because I owned my own Medicare Certified Surgical Center, there was (I suppose) a financial incentive for doing more surgery. But that is not how it turned out. The physical aspects of surgery require an enormous amount of energy that, as you age, you become less able and willing to exert. I was also a co-resident director and shared responsibility for teaching new podiatry residents surgery.


 


I had a surgical program at a VA hospital where I was exposed to a great deal of surgery, besides foot and ankle procedures. Even now, I am astonished at the...


 


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

02/17/2020    

RESPONSES/COMMENTS (PM ARTICLES) - PART 1A



From: Allen Jacobs, DPM


 


In 40 years of working alongside podiatric residents as a residency director and mentor, never have I heard any resident tell me that primary care practice represented their first choice. Never. Particularly now when we have outstanding three-year residencies and fellowships, I have yet to meet a resident who desired non-surgical practice at the completion of such training. I have long been a strong advocate of advancing education in the non-surgical aspects of podiatry and continue to do so. However, the comments of Dr. Sherman and his alleged survey results are simply not consistent with my experience in working with residents to this day.


 


I should further like to point out that as a result of the excellent training which our residents now receive, most...


 


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

02/14/2020    

RESPONSES/COMMENTS (PM ARTICLES) - PART 2



From: Ty Hussain, DPM


 



The article written by Dr. Sherman is a point-making introduction to our continued education in our residencies. This is something that I have been talking with residents and others alike for the past 5-7 years. Regardless of numbers and percentages, we as a profession have evolved significantly with surgery at our helm and reaching as far as above the ankle as we could. I am involved with multiple residency programs at our local facilities and can evaluate residents and their comfort level in the surgical atmosphere. 


 


I agree with most residents that the inclination to be great surgeons is enthusiastic in the beginning, but as time goes on, the lack of surgical cases leads to the question, "how much surgery do I need to be doing?" Our training of residents and the demand to have a 3-year program to have parity with our MD colleagues are actually not productive. I have discussed the possibility of podiatric medicine and surgery needing only a 2-year residency which will encompass rotations and podiatric medicine along with surgery. But those who wish to specialize in surgery can then proceed to attend a fellowship program which will enhance their strengths in being a podiatric surgeon, which by the way, will actually define the fellowship programs going forward. Those who wish to be in general podiatric care have had some surgical experience. Just going through motions to finish a program is not defining our existence.  


 


Ty Hussain, DPM, Evanston, IL


02/14/2020    

RESPONSES/COMMENTS (PM ARTICLES) - PART 1



From: Adam Zanbilowicz, DPM, MSc, BA


 


As we have learned that tendonitis is rarely an "itis", many of our treatment options for fascia and tendons have been shown to be ineffective. This has created a perfect opportunity for unproven therapies to be incorporated into treatment algorithms. But we must only consider these modalities as a last resort. I read Dr. Woodley's article, hoping to finally hear of a quality study that demonstrates efficacy. Sadly, the abstract of the only article referenced concludes "that the literature appears to be inconsistent and thus far, inconclusive." 


 


This was my conclusion after reading as much primary research I could find... Many successful case studies, but higher quality studies demonstrating equivocal results. The New York Times published a wonderful article with principles of avoiding pitfalls of poor studies -- a worthwhile read: Worried About That New Medical Study? Read This First


 


Adam Zanbilowicz, DPM, MSc, BA, Nanaimo, Canada

02/13/2020    

RESPONSES/COMMENTS (PM ARTICLES)



From: Alan Sherman, DPM


 


In response to Martin Pressman, DPM’s comments on my Article “What Kind of Podiatrist Do Today's Residents Want to Be?”, I can’t help but agree that the original survey response was small at 58 out of 1,000 invited. I have more information now that 127 responses have come in. The percentages have stayed about the same. 88 out of 127 or 70% intend to be advanced foot and ankle surgeons, while 38 out of 127 or 30% intend to be general practice podiatrists. If the dual track 3rd Year were offered, 95 (residents) or 75% would choose the advance foot and ankle surgery track and 30 (residents) or 25% would choose the general practice podiatry track.


 


These additional data strengthen the case that as many as 25% of podiatric residents are being given training that they don’t wish to or intend to use, including working on cases that could have...


 


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

01/29/2020    

RESPONSES/COMMENTS (PM ARTICLES)



From: Jeffrey Kass, DPM


 


In the article “Welcome to the NY Clinical Conference”, the executive board of NYSMA was asked “what is the biggest challenge facing podiatric medicine in 2020?” The board responded mentioning “the new healthcare landscape is providing podiatric medicine with great opportunities.” After mentioning podiatric medicine another four times in the same paragraph, the concluding sentence was “however [this], will only happen when the profession proudly endorsed the skills, education, training, and degree of its members.”


 


One of the biggest challenges I see is the fact that podiatric medicine has been left behind by New York unlike its podiatric surgery counterpart. The scope of practice in New York has been increased to the tibial tuberosity for those board qualified/certified in RRA by the ABFAS. The ABFAS podiatrist has been given the right to practice not only podiatric surgery but podiatric medicine as well. Yet, the board certified podiatrist in ABPM can’t advance their scope. 


 


The profession needs to stay unified. Why should those with the skills, education, and training not be allowed to advance their scope? NY podiatry has been fragmented into two professions. This has created a dangerous landscape within the profession. Rather than staying unified, some are using the “surgical criteria” against their fellow colleagues in areas of credentialing and privileging. Before we ask “others” to respect the profession, we need the respect of each other within the profession. I wish the NYSPMA executive board all the luck in 2020 and hope they are successfully able to gain advanced scope for all licensed podiatrists. 


 


Jeffrey Kass, DPM, Forest Hills, NY

12/17/2019    

RESPONSES/COMMENTS (PM ARTICLES) - PART 1B



From: Dale Feinberg, DPM


 


I took my friend aside and we did discuss how the impressions for her custom prescription orthotics were made. It was interesting to me that she retired with a degree in mechanical engineering. She stated that the podiatrist took a pronated impression in a pink foam box while the chiropractor did a full biomechanics exam including gait evaluation before using an ipad scanner and writing a custom prescription for the devices. She said she wondered why there was such a difference in completeness of her competing exams but was only interested in which orthotics felt the best, and that she now recommends all of her tennis friends to her chiropractor. 


 


Finally, she told me her sister had a bunionectomy with perfect results done by a local podiatrist, and her best friend had a similar procedure performed by a well renowned local orthopedic surgeon with poor results. When she asked her friend why she didn’t see her sister's podiatrist, she was told the orthopedic surgeon was a medical doctor. 


 


Dale Feinberg, DPM, Yuma, AZ

12/17/2019    

RESPONSES/COMMENTS (PM ARTICLES) - PART 1A



From: Jeff Root


 


Dr. Udell asks, “Should we deal with any orthotic lab that is owned by podiatrists, and is actively marketing their orthotics and training to chiropractors, physical therapists, and other non-podiatric professionals?" As the owner of an orthotic lab that doesn’t market to other specialties, I believe that podiatrists should do what they believe is in the best interest of their patients, even if that means using an orthotic lab that markets to other specialties. 


 


That said, I know of no other specialty that possesses the level and depth of education and training in non-surgical and surgical treatment of the foot and ankle and who also can provide other critical diagnostic tests and treatment such as imaging, prescription drugs, etc. While there are some individuals in other specialties who are very capable of providing good quality foot orthotic therapy, they do not possess the same range and quality of services that a podiatrist can provide. It is unfortunate that many consumers and patients do not understand the difference in the qualifications between podiatrists and other providers of foot orthotic therapy. That is why it is important to educate the public so they can determine who may be the best provider for their foot and ankle care.


 


Jeff Root, President, Root Lab, Inc.

10/18/2019    

RESPONSES/COMMENTS (PM ARTICLES)



From: Leonard A. Levy, DPM, MPH


 


Alan Sherman, DPM, concluded that a single podiatric board is what is needed to “eliminate current confusion as to what a podiatrist is.” Allopathic and osteopathic physicians, prior to the middle of the 20th century, overwhelmingly were general practitioners. Now, virtually all these graduates enter residency training leading to qualification in a specific specialty. As a result, the numerous specialty boards have training requirements and examinations that assure the public as well as members of these professions that they are qualified in their specialty.


 


Podiatric medicine also evolved considerably in the last several decades, creating the specialties of podiatric surgery and, yes, podiatric medicine. Both are quite complex, requiring significant graduate medical education called residency training. Unfortunately, we still hear members of our profession refer to...


 


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

10/17/2019    

RESPONSES/COMMENTS (PM ARTICLES) - PART 1B



From: Ira Baum, DPM, Naples, FL


 



I don’t think a unified board would do anything to mitigate confusion regarding the services podiatrists provide to the public. I also think it would be a disservice to those podiatrists who received specialized training in surgery. Here’s the obvious dilemma: a majority of states require at least 2 years of post-graduate training in a certified residency program. So how can the profession satisfy state laws requiring the minimum residency training and differentiate non-surgical from surgical training?


 


Additionally, DPMs, by definition, are doctors of podiatric medicine and surgery, so the definition of our degree needs to be addressed. I’m sure there are many other hurdles that would need to be addressed before changes in board status, training, and meaning would be rational.


 


Ira Baum, DPM, Naples, FL


10/17/2019    

RESPONSES/COMMENTS (PM ARTICLES) - PART 1A



From: Jeffrey M. Robbins, DPM


 


It is gratifying to see at least some comments on my original call for a single board. It is painfully obvious that change is hard and opinion strong on this topic. However, the future requires growth and development; otherwise it stays stagnant which will move us backward as the rest of the progressive world passes us by. We are only as good as our weakest link. Let’s make sure we have a high standard and strengthen all the links in our chain, keeping in mind that we are a procedure-based profession regardless of the simplicity or complexity of those procedures.


 


Jeffrey M. Robbins, DPM, Cleveland, OH

10/16/2019    

RESPONSES/COMMENTS (PM ARTICLES)



From: Alan Sherman, DPM


 


Like Amol Saxena, Joe Borreggine, and Jeff Robbins, I too would like to see a single board that represents all podiatrists. One single board would help eliminate the current confusion as to what a podiatrists is. I call on the two boards to begin talks to move this process forward. I think we can achieve a single merged board with a well-constructed 5-year plan. I agree with Dr. Saxena that we need to be training all podiatry students to take the USMLEs.


 


I have spoken to Kathy Satterfield, the new Dean of the Western University School of Podiatry and she is a strong advocate of this. I’m sure the other deans aren’t far from this view. We can run pilot projects, test the students to assess current education gaps, expand the curriculum, do remediation, and...


 


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

10/15/2019    

RESPONSES/COMMENTS (PM ARTICLES)



From: Joseph Borreggine, DPM


 


I have to agree with Dr. Saxena who is a very well respected and honored colleague in the podiatric profession. He should be considered the quintessential model of what a podiatric physician should be. I am proud to know him not only as a fellow podiatrist, a classmate, but as my friend.


 


Not only is Dr. Saxena a pioneer in podiatric surgery, but he is one of the world’s renowned sports medicine physicians. On top of that, he is a podiatric residency director and runs a very well-respected and sought out...


 


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

09/12/2019    

RESPONSES/COMMENTS (PM ARTICLES)



From: Ray Posa, MBA


 


I just read Michael Brody’s article in the September issue of Podiatry Management. As a leader in the podiatry world, podiatrists look to Podiatry Management as the ‘source’ for all things podiatry and they rely on the information provided. I have to point out several factual errors and outright wrong advice that he has provided to the readers in Michael Brody’s recent article.


 


First, in the first column Michael states that “Both LabCorp and Quest are ‘covered entities’ in that they do not have a direct relationship with patients.” This is exactly the opposite of the...


 


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

09/06/2019    

RESPONSES/COMMENTS (PM ARTICLES)



From: Allen Jacobs, DPM


 


A few thoughts on the article by Dr. Johnson on venous ulceration:


 


1. A considerable number of presumably “venous ulcerations" are in fact arterial-venous ulcers. The recognition of unrecognized arterial disease may explain some venous ulcers recalcitrant to seemingly appropriate care. Additionally, the co-existence of arterial disease may predispose the patient to ischemic injury from compression therapies typically utilized for the management of venous insufficiency related ulceration.


 


2. Additionally, venous ulceration may be associated with malignancy, most commonly SCC, and conversely, cutaneous malignancy may present with features typical of venous ulceration. Recalcitrance to care for a maximum of 12 weeks, excessive granulation tissue, atypical presentation or location, or rolled borders should concern the clinician and biopsy considered. There is no data to suggest that biopsy impairs venous ulceration healing.


 


3. Proximal obstruction, or venous flow impairment, such as May-Thurber syndrome, is indeed a consideration in all patients. Those who undertake to treat venous ulceration are obligated to perform a complete history and examination relevant to venous, lymphatic, and arterial disease.


 


4. Remember, simply removing a wound care product from its packaging following a "debridement" does not a wound care specialist make.


 


Allen Jacobs, DPM, St. Louis, MO

07/16/2019    

RESPONSES/COMMENTS (PM ARTICLES)



From: James D. Stough, DPM


 


I read the article “The Employment Contract” with interest. I am currently hospital employed and in the middle of renegotiating my contract terms. Most hospitals adhere to the MGMA data as their guidelines for salary and wRVU reimbursement. One of the main details to an employment contract is the dollar amount reimbursed per wRVU earned in excess of the base salary. I was curious to see if any PM News readers knew what the MGMA data suggested regarding the dollar amount reimbursed per wRVU; specifically, the dollar amount for the median, 75th percentile, and 90th percentile. I have the information on how many wRVUs must be earned annually to clarify where you fall on the table, but not the suggested dollar amount per wRVU. Any information would be appreciated. 


 


James D. Stough, DPM, Enid, OK

06/04/2019    

RESPONSES/COMMENTS (PM ARTICLES)



From: Elliot Udell, DPM


 


Dr. Jacobs is 100% correct when he asserts that many so-called clinical guidelines are merely protocols set up by self-appointed committees that are  often subsidized by and are beholden to the needs of a drug company. There is more to this story. Clinical guidelines rarely, if ever, enter a conversation between doctor and patient. I have never had a patient ask me to discuss clinical guidelines. Where clinical guidelines might come into play would be in a court room where the plaintiff's attorney would accuse a defendant of being negligent because he or she did not follow the recommendations of that ad hoc, drug-funded committee. 


 


The problem, however, is how do we establish correct and incorrect protocols, especially in a court room setting? The standard way is for each side to have their expert witness in court and most often you would have an "expert " on either side say that the treatment in question is "right or wrong" based solely on his his or her own private opinion. Very often, these courtroom "expert witnesses" are mere clinical bullies rather than true defining experts on what is clinically correct. 


 


So the questions stands. If "kangaroo court" committees described by Dr. Jacobs are no good and guidelines defined by the "clinical bully on the block" are not acceptable, what better methods can our community come up with to establish true clinical guidelines?


 


Elliot Udell, DPM, Hicksville, NY
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