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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.
Other messages in this thread:
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
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.
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.
08/06/2021
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Jeff Pantano, DPM
One of the reasons is there isn’t (or at least I don’t know about it) a true authority/college which focuses on biomechanics and CME. You can attend one of hundreds of surgical CME meetings but not so much for biomechanics. After the classroom, maybe you get lucky and one of your residency attendings is a “biomechanical specialist”, but that’s it. I actually contacted the APMA to put together a lecture series for additional information in residency. They did do one lecture which was very nice of them. If you don’t grasp it in school, it seems like you are out of luck. I am two years into private practice and I’d benefit greatly in all aspects of my clinic with more knowledge of biomechanics. I just feel like the help isn’t there and if it is, it’s hidden.
Jeff Pantano, DPM, Milton, MA
08/05/2021
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Doug Richie, DPM
The post from Dr. Simmons propagates several misconceptions which are becoming pervasive in our profession about podiatric biomechanics. Biomechanics is not sports medicine. Biomechanics has been, and should continue to be, the cornerstone of all aspects of podiatric practice, particularly reconstructive foot and ankle surgery. And if "medical-economics" explains the demise of interest in biomechanics among students and practitioners, I ask Dr. Simmons to compare the reimbursement for a custom ankle-foot orthosis to any common surgical procedure we perform to correct the adult acquired flatfoot. Not only is mastery of biomechanics crucial to the selection of proper surgical intervention for this disorder, it is also fundamental to implementing a proven non-operative intervention which happens to pay the bills better than just about anything else we do in clinical practice.
Doug Richie, DPM, Long Beach, CA
10/28/2020
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Ivar E. Roth DPM, MPH, W. David Herbert DPM, JD
Kudos to Dr. Kalish. Experience trumps many clinical pathways. When you have the experience, you have wisdom that a book cannot teach you.
Ivar E. Roth DPM, MPH, Newport Beach, CA
I appreciated Dr. Kalish's comments about evidence-based medicine and experience-based medicine. This is somewhat like the arguments against anecdotal evidence and double-blind statistical study-based evidence. I have successfully convinced a jury that another name for evidence-based evidence is cookbook-based evidence and that they must completely rely on the author of the particular cookbook, who I was successfully able to discredit.
Because rules and laws regarding the evidence that can be presented to a jury in a trial vary by state, my argument would have not worked in every state. I do believe that anecdotal experiences of a very experienced surgeon can be useful in clinical situations, even though the accepted evidence-based evidence may be contrary to it.
W. David Herbert DPM, JD, Billings, MT
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
02/19/2020
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 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
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.
10/17/2019
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
05/31/2019
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Allen Jacobs, DPM
Dystrophic nail changes may be secondary to repetitive micro-trauma. Mallet toe and hallux hyperextension deformity are common examples of such etiologic factors. Fungal infection may occur as a comorbidity or without associated trauma. Dermatopathology laboratory testing can, in many cases, establish the fungal and or traumatic etiology and therefore suggest treatment options. I would suggest that such testing would be considered prior to EHL tenotomy for "spoon toe". Perhaps dermoscopy or other studies in the future will prove helpful.
Additionally, whether performed distal to the extensor hood or not, the development of flexion deformity of the hallux IPJ and hallux hammertoe are possible over the long-term. It seems appropriate to provide long-term clinical outcomes showing the absence of such iatrogenic deformity. Ultrasound, MRI, or other studies demonstrating re-establishment of the continuity and function of the EHL would also be appropriate. Long-term study of the eventual result with reference to the toenail appearance, texture, associated pain, etc. would also be helpful.
Dr. Katzen correctly notes that treatment of onychomycosis with laser therapy or the use of oral antifungals is not typically appropriate absent confirmatory testing. Furthermore, as noted by Dr. Katzen, any traumatically induced contribution to the observed nail dystrophy should be recognized and appropriate intervention offered to the patient. The induction period for iatrogenic deformity is not always immediate. Short-term success will not guarantee long-term success.
Allen Jacobs, DPM, St. Louis, MO
05/29/2019
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Richard M. Cowin, DPM
Back in the 1980s, the federal government announced that they were seeking Preferred Practice Guidelines (PPGs) (aka Clinical Practice Guidelines) for all medical specialties for their National Guidelines Clearinghouse. In this announcement, they went one step further and stated that if the various medical specialties groups didn’t produce these on their own, the government would produce these documents for them. Doctors were rightfully concerned about how these untrained and informed bureaucrats might draft these documents and to their credit, many medical specialty groups went on to produce such guidelines.
The first podiatry organization to research, draft, and submit their PPGs to the National Guidelines Clearinghouse and to have such guidelines approved was the American College of Foot & Ankle Surgeons. However, the Board of Trustees for the Academy of Ambulatory Foot Surgery (now the Academy of Minimally Invasive Foot and Ankle Surgery) under the leadership of their then president, now prominent healthcare attorney, Lawrence Kobak, DPM, JD, felt that...
Editor's note: Dr. Cowin's extended-length letter can be read here.
03/26/2019
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Robert Scott Steinberg, DPM
Sorry, Dr. Trench, but I can't agree with your ideas! I own the foot. You want me to only own part of the foot. Added to that, we will spend the next 50 years explaining our fractured-in-half profession to patients and physicians. That's not going to happen. The residency program at Norwegian American Hospital, headed by Louis Santangelo, DPM, teaches both podiatric medicine and surgery. We have a three times a week foot and ankle clinic at the hospital. Residents also rotate through attendings' offices. In addition, Norwegian American Hospital hosts a twelve-slot family practice residency program, giving our podiatric residents further immersion in medicine.
So, be careful before you break something.
Robert Scott Steinberg, DPM, Schaumburg, IL
12/21/2018
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Dieter J Fellner, DPM
Dr. Epstein asks: “it is recommended that diabetic patients should have a baseline ABI performed? Recommended by whom, I ask?”
Answer: The American Society of Vascular Surgery recommends that any diabetic patient aged 50+ should have baseline ABIs.
We perform ABIs accordingly and have the vascular surgery team visit the office for follow-up, as necessary.
Dieter J Fellner, DPM, NY, NY
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