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RE: Knowledge Level of Nurse Practitioners 

From: Steven Finer, DPM


I am mostly retired, but still see patients at a local nursing home. I was approached by a nurse practitioner (NP) and asked to see a diabetic with "foot problems." The NP's knowledge ended at medications for diabetes and neuropathy. She had zero information on pressure ulcerations, off-loading, or foot structure. I explained some basics for treatment and management of this patient and she thanked me. Is this the norm for this group? Most other NPs that I have worked with seem to know heart, lungs, kidney, etc. but have no skills in Ortho. Derm, PT, or treatment of feet. 


Steven Finer, DPM, Philadelphia, PA

Other messages in this thread:



From: Daniel Kormylo, DPM


I have used Rick Pruzan for all my Midmark repairs. He is a great guy and certified by Midmark. He is based out of Northport, NY


Daniel Kormylo, DPM, Rocky Point, NY



From: Corey Fox, DPM


We use Henry Schein. Sometimes repairs can be onsite, other times it will have to be boxed up and shipped out. If you're lucky, they may have a loaner. When it comes time to buy a new autoclave, don't wait until this one is completely dead. Keep the old one serviced and operational for times like this. They do NOT make things like they used to.


Corey Fox, DPM, Massapequa, NY



From: Alan Bass, DPM


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


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


Alan Bass, DPM, Manalapan, NJ



From:  Craig H. Thomajan, DPM


I can report good to excellent results with this technology. I have been using Swift therapy for native and recalcitrant plantar verruca for approximately 6 months. Generally speaking, the younger the patient, the stronger the immune system, the less treatments are required. We see visual improvement in dermatoglyphics after one treatment regardless of the number of lesions presenting. We have used the system approximately 50 times with no adverse side-effects, no scarring.  


The device is simple to use. We have found that using a needleless injector to deliver a small aliquot of anesthesia prior to the therapy allows us to start at maximum wattage to deliver the energy needed to elicit an immune response with little to no pain. We are averaging resolution between the second and third treatment.


Craig H. Thomajan, DPM, West Lake Hills, TX



From: Paul Busman DPM, RN


For me, the point is moot since I'm no longer in practice but it seems to me that charging a fee to recover the extra cost is reasonable. A podiatry practice is different from a dental practice in that due to the nature of a dental practice, the dentist is literally and figuratively in the patient's face. Drills and water spray can aerosolize contaminated droplets, raising the danger of cross-infection. This also means that they probably need more time and labor to disinfect the entire treatment room and all of its equipment between cases. That said, I'm getting a new crown placed next week and I'll gladly pay the extra $15.


For podiatry, may I suggest charging a fee to cover the actual cost of masks, face shields, and other disposables? Let the patients know that you are just charging what those items cost you and that you're not trying to profit from a bad situation. 


Paul Busman DPM, RN, Frederick MD



From: Elliot Udell, DPM


Yes, podiatrists as well as dentists, will incur lots of extra expenses with protective gear as well as a mandate to not see too many patients at once. The problem with comparing podiatry with dentistry is that, by and large, dentistry is a "cash for service" profession, whereas podiatry and most of medicine is regulated by insurance companies. For those podiatrists who do not take insurance assignment, by all means, charge extra for masks, gloves, and whatever; but for most of us, it would be mighty hard to get an extra Lincoln off of a Lincoln penny from most carriers.


Elliot Udell, DPM, Hicksville, NY



From: Richard J. Manolian, DPM


In regard to Dr. Flippin’s post, so why are we going to go to the extent of forgiving student loans? Because we have a pandemic and you should therefore be discharged of all federal loan responsibility? The government is not in the position of predicting whether calamity will occur and therefore forgive a loan due to it.


The government can provide temporary assistance to aid in recovery. Otherwise, we would never make any progress in this country for all the possible problems that can and will occur.


Richard J. Manolian, DPM, Cambridge, MA



From: Martin Pressman, DPM


I don’t know for sure what the diagnosis is in this case. That said, High on my list is neuroma. Neuromas need to be 4mm before they are visible on MRI. Intermittent forefoot  pain that is severe with “ fullness” sounds to me like a neuroma. Diagnostic nerve block may help and test interspaces for hypoesthesia sharp/dull. Neuromas are great pretenders!


Martin Pressman, DPM, Milford, CT



From: Joseph Borreggine, DPM


Since every podiatrist in the country will be affected by the COVID-19 pandemic financially in an unprecedented way, then federal assistance may have to considered. This can be obtained through an SBA loan program which will cover necessary business expenses, needed inventory, payroll, and outstanding liabilities. 


This may be your best option to keep your practice afloat until things return to “normal”.  Here is the SBA site online. What is interesting is that the ADA is lobbying Congress to help protect dental practices from undue financial stress at this time. They recently stated, “The ADA will be working to ensure that those provisions will benefit our dentist owners.” 


I wonder what the APMA and the ACFAS are doing to fight for the same thing for podiatry? 


Joseph Borreggine, DPM,  Port Charlotte, FL



From: Robert Kornfeld, DPM


I graduated from NYCPM in 1980 and I am still practicing. I’m responding to this thread just to offer another perspective. The evolution of podiatry during my years in practice has taken away our practice freedom and has forced us to constantly scramble for legitimate income. Between insurance companies not wanting to pay a fair and reasonable fee, to malpractice, to patients ripping us off, not to mention the ongoing parity issue, podiatry is no longer what I would consider an attractive profession. Around 25 years ago, I saw what was coming and it came. I hated it. I wanted out of the craziness. But I had been focused in the field of holistic medicine and really was loving the doctoring part of my practice.


So I concentrated my efforts and training and built a niche practice in holistic/functional medicine. Then I quit Medicare and all insurance participation and switched to... 


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



From: Paul Busman DPM, RN


After 30 years in solo private practice, I took the radical step of leaving podiatry and becoming an RN following, which I worked for 10 years as an OR circulating nurse. I've related my reasons previously on this forum but I'd be glad to share them in more detail with Dr. Lucarelli or any others who are curious. Obviously, this is not a choice for everyone, but for me at that time, it was a real life-changer, in a good way. 


Paul Busman DPM, RN, Frederick, MD



RE: Practice Interruption Insurance and Coronavirus

From: Don Steinfeld, DPM


As a podiatrist of 1980s vintage, I’m aware that I could conceivably have a medical problem which could keep me out of my office for two weeks or perhaps more. However, a new threat emerges. If one of our patients comes to our office in good health and finds out shortly thereafter they are infected with coronavirus, we may have to be quarantined and perhaps close our offices for two weeks or maybe more.


When I had to close my office for two weeks due to super storm Sandy, I was able to recoup two weeks of lost income. Now is the perfect time to review your BOP (business owner’s policy) to make sure that you have business interruption insurance. It’s also a good time for us all to think about which of our colleagues we can rely upon to cover us in times of need. We are all brothers and sisters.


Don Steinfeld, DPM, Farmingdale, NJ



RE: E/M 99202-99215 Office Visit Codes and Guidelines Due to Change Jan. 1, 2021

From: Lawrence Rubin, DPM


I believe many podiatrists reading PM News may not be aware of the complete change in Medicare Evaluation and Management (E/M) coding and payment guidelines for new and established patient office visits due to be implemented January 1, 2021. The new guidelines that will be explained in the 2021 CPT are simpler and more flexible, but each medical specialty, such as podiatry, will have to adapt the guidelines to its unique E/M content characteristics. The change will have special importance to practices whose EMR systems are geared to "fill in the blanks" to document the level of care needed for choosing the correct code under the discontinued guidelines.


Notably, the new system eliminates history and physical exams as elements for code selection and allows you to choose whether your documentation is based on medical decision-making or total time spent by you and/or your staff members.


The AMA is urging its members to begin preparing for this change now. It has an online teaching system in place and is advising all medical practice managers to familiarize themselves with the details of the new guidelines and coding definitions. Hopefully, both the APMA and its affiliated state organizations as well as local podiatric groups will sponsor educational seminars and workshops. January 1, 2021, will be here in just 9 months.


Lawrence Rubin, DPM, Las Vegas, NV



From: Joseph Borreggine, DPM


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


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


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



From:  Paul Busman DPM, RN


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


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


Paul Busman DPM, RN, Frederick, MD



From: Lorraine Loretz, DPM, MSN, NP


Knowledge of the foot and related specialties varies greatly among primary care providers, regardless of credentialing. NP classes and clinical rotations focus on internal medicine, family practice, geriatrics, and pediatrics. Exposure to Ortho and other surgical specialties is minimal during NP school, and most NPs who work in these fields receive post-grad training on the job and through continuing education. 


Working in vascular surgery as a dually-credentialed DPM/NP, I am fortunate to be involved with NP/MD post-grad education and often deliver lectures or workshops on my areas of expertise, especially on the diabetic foot. The education is very much appreciated by all providers: NPs, PAs and MDs. I think the important thing with your experience is that the NP knew to reach out to you for help, and was grateful for the information you imparted.


Lorraine Loretz, DPM, MSN, NP, Worcester, MA



RE: Podiatry Needs to Step Up

From: Bryce Karulak, DPM


Podiatry has fought for decades to be recognized as the leader in the foot and ankle. While I believe that the most recently trained podiatrists are the leaders in all that is foot and ankle, most of the public seems to still think orthopedists are. I always thought that when it came to things such as ingrown toenails, bunions, and hammertoes, we would be the experts. Yet, when I read an article that references the new show, My Feet are Killing Me, I see that only orthopedists (AAOS) are referenced as the experts in ingrown nails and bunions. Are you kidding me? 


While many reading this article and the link may feel this is a failure of the journalist, I believe this is a failure of podiatry as a whole. It should not even be a question of who is better trained to treat ingrown nails or bunions. How is the word podiatry or the professional designation DPM not once mentioned anywhere in the article? Why are we not on the forefront of the public’s mind when it comes to feet? There is no doubt that orthopedists are uneasy about podiatry getting this much exposure. But, podiatry needs to step up. We need to ride the wave. What is our plan to be the leaders? We always talk about change, but never follow through.


Bryce Karulak, DPM, Fredericksburg, TX



RE: Safety Net for Podiatrists in Crisis

From: Mark E Weaver, DPM


I feel PM News is the most important podiatry blog. There is, however, a vacuum in the area of podiatry camaraderie. There are personal, natural, and man-made disasters in the country every month. California fires, Puerto Rican earthquakes, Floridian hurricanes, Mid-western floods, and major boating and auto accidents. I know that I had local podiatrists who would come to my aid in a personal crisis, But, in a local or statewide crisis as noted above, there is strain on all the local professionals in their own practices. Do we have, or do we need a system to provide assistance for our colleagues that have had unfortunate circumstances?


I have recently retired, but I feel I still have reasonable skills and time that is not unlimited but more available for several years to come to help in cases of emergency. And, for example,...


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



RE: Zimmer enPuls Shockwave (Supna Reilly, DPM)

From: David Zuckerman, DPM


I wrote an article on this technology. The Zimmer EnPuls isn't FDA-approved. It has no approval for shockwave indications. I am not aware of any results reported except for doctors’ observations. The Zimmer enPuls is a class 1 device, not a class 3 device. FDA-approved ESWT devices have undergone evidence-based studies that are double-blind, randomized, placebo-controlled studies with multicenter evaluations. While the Zimmer enPul may work, it isn't a shockwave device per FDA Class 1 classification.


I am not saying it can't help your patients. It may be right for your practice, but you should understand and know whether a device is FDA-approved or FDA-cleared and for what indications.  


David Zuckerman, DPM, Cherry Hill, NJ



From: William E. Chagares, DPM


The eligibility criteria for access to board certification are set by CPME. This includes the length of post-graduate training required. The APMA HOD, CPME, and recognized specialty boards worked together to create more uniform residency programs of greater complexity and length. This is reflective of the training and education required to accommodate the public need for podiatric practitioners.


There has consistently been adequate, publicly-advertised time for access to certification by graduates of the archival program types of shorter length. Furthermore, GME funding of training programs is linked to the fewest number of training years eligible to access the certification process. This is critical in keeping podiatric residencies fully funded by GME, and thus maintaining viability for the future of our profession. The profession and key stakeholders who are responsible for maintaining a standard of training commensurate with current practice, have consistently endeavored to move forward while allowing adequate opportunity for those from older training models to access the certification process.


The ABPM encourages everyone to reply to CPME's call for public comment during revisions to Document 320 (Residency Training Standards). There was a public comment period for revisions to Document 220 (governance of specialty boards - JCRSB) which was adopted in October 2019. This would have been an appropriate time and place for comments regarding access to board certification.


William E. Chagares, DPM, President, American Board of Podiatric Medicine



From: Jeffrey Kass, DPM,


I agree with the absurdity referenced in the post by Dr. Gertsik. This is a prime example of the divisiveness within our profession. My solution for Dr. Gertsik is to get boarded by the American Board of Medical Specialties in Podiatry. 


Two years of residency would allow you to sit for their board, and 20 years of clinical practice would equate to two years of residency. From your post, it sounds like you would qualify based on your training or years in practice. 


Jeffrey Kass, DPM, Forest Hills, NY



RE: ABPM Non-Recognition of Residencies

From: Vladimir Gertsik, DPM


Since primary podiatric medicine, podiatric orthopedics, and other names are gone (with their respective residencies), it is time to acknowledge that most non-surgical podiatrists are pretty much the same. Some see more kids than others, some do more orthotics than others, but we are still mostly podiatrists. I appreciate the name change. But what I do not appreciate is the stubborn refusal of the Board to recognize their own residency types (now obsolete but nevertheless CPME-approved at their time). 


All podiatrists who have in good faith completed a residency program should have a pathway to board qualification. ABPM does not recognize its own residencies! Why should these pathways ever be closed? This is absurd. If a 2-year residency was acceptable 20 years ago, why is it no longer acceptable? Do 20 years of practice count for anything? Apparently not. What are these boards trying to prove, and to whom? Since there is no logic in all this, I feel that this board is not legitimate.  


Vladimir Gertsik, DPM, NY, NY



From: Joe Boylan, DPM


I never was an advocate of the “Pose Method” regarding the foot strike; forefoot to forefoot. It does help with upper body posture. In my view, a forefoot to forefoot gait for most runners would predispose one to a host of overuse injuries.


An exaggerated heel-toe gait (as we do when walking) is also not recommended. The ideal foot strike is on the plantar heel/mid-foot (almost like a shuffle). 


Joe Boylan, DPM, Ridgefield, NJ



RE: Investing in the Future of Podiatry

From: Allen Jacobs, DPM


Over the last several years, I have observed the commendable efforts of the New York State Podiatric Medical Association in promoting our profession and encouraging recruitment of students to enter the field of podiatry. Each year, the NYSPMA offers a one-day program for college career counselors and premedical advisors introducing them to podiatry. A hotel room, meals, and an excellent program are provided. This includes a tour of the exhibit hall and attendance at a lecture. Students, residents, young and older practitioners, as well as local thought leaders provide a brief synopsis of their experiences and perspective. Additionally, college students are given conference and exhibit hall tours and discussions regarding podiatry as a potential choice for patient care.


Might I suggest that each state society and regional conference take responsibility for doing the same. Yes, some effort and money is required. However, from my observation, it would appear that participation of each state society, possibly with the assistance of a college of podiatric medicine, could potentially serve as an excellent means of student recruitment. Organizations holding scientific conferences, for example ACPM, ACFAS, DermFoot, PRESENT, and many others, should consider the same. There is no crime investing in the future of podiatry. 


Allen Jacobs, DPM, St. Louis, MO



From: David Krausse, DPM


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


David Krausse, DPM, Flemington, NJ


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