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05/18/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1


RE: Should DPMs Charge a PPE Fee?


From: Bret Ribotsky, DPM


 


As I watch my colleagues begin to open in post-COVID times, I wonder if anyone is charging a PPE fee to patients? I see that the dental profession is charging a “fee” for all the extra costs needed to provide care. I have read statements on the American Dental Association (ADA) webpage that show a collective action to charge for these extra costs. 


 


I see that this topic is not (yet) covered on the APMA COVID webpage. While the profits (margins) have continued to decrease to the podiatric physician, I worry how this added cost (if not passed through) can be absorbed at the current reimbursement rates. I recognize that the logistics (insurance contracts, etc.) need to be worked through, but we all know that in a crisis, there is always an opportunity.  


 


Bret Ribotsky, DPM, Boca Raton, FL

Other messages in this thread:


06/22/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1B



From: Lee Rogers, DPM


 



The American Academy of Family Practice has a useful preparedness checklist for physician offices during the COVID-19 pandemic. 


 


Lee Rogers, DPM, Las Vegas, NV

06/22/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1A



From: Larry Schuster, DPM


 


My waiting room used to be a major social gathering place as patients would enjoy seeing friends and relatives every few months before or after their visits. I have seen offices where they placed tape over every other chair to allow for some social distancing. Of course, chairs would have to be cleaned before and after each seating as we do in our treatment rooms. 


 













Note: Magazines have since been removed



 


My simple solution is pictured above, anti-social, simple but effective. We take each patient directly to a treatment room. Fortunately, we have 5. Scheduling is very carefully done and no patient actually comes in contact with another. Everyone is masked and universal precautions have always been followed. 


 


Larry Schuster, DPM, Parsippany, NJ

06/10/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1



From Ron Werter, DPM


 


It’s great that you continued to pay your employees for not coming to work. I did that for a few weeks, but then we both realized that they would make more money by going on enhanced unemployment. Do your employees realize that they are losing money by your continuing to pay them? 


 


The upside is that you can have them come back to work immediately when you re-open, whereas I have to negotiate with my employees because the enhanced unemployment ends on July 31 (Unless, of course, reduced hours will still allow them to collect the extra money). 


 


Ron Werter, DPM, NY, NY

06/08/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1


RE: Loyalty and the Coronavirus Pandemic


From: Dieter J Fellner, DPM


 


In these troubled days, so many podiatry (and other) businesses let go of their staff, sometimes with indecent haste. I want to share the business and life philosophy of one of NYCs' young entrepreneurs, Louis Rossman. He is in the electronic repair business. And here is what he has to say about it:


 


"People said I'm a good employer - I am telling you I am not. I paid all of my staff who chose to stay home, even before I got PPP stuff. If you were one of those full time people, and you chose to stay home during that time period, I paid it in full. That was BEFORE the PPP loan went through; before I even knew there was a PPP thing. That is not because I am a kind, benevolent, and good-hearted man. That is because...


 


Editor's note: Dr. Fellner's extended-length letter can be read here. Louis Rossman's complete YouTube video can be viewed here. The referenced text starts at about 14 minutes. Note: This video contains some course language.

05/06/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1


RE: HHS Stimulus Payments


From: Paul Kesselman, DPM


 


For those of us who have been fortunate enough to receive the first round of HHS Stimulus payments, be aware that a second round was released early last week. However, you must actively attest to the first round first. Without attestation, you will not be eligible for these grants. If you don't attest but do not arrange for returning the money you did receive within 30 days, you will have been considered as attesting.


 


While most of this may already be considered old news, my prediction has come true of government auditors being hot on the trail to ensure that you have spent this "grant" money appropriately. Recently, the Trump administration announced that in fact there will be an accounting of this money by appropriate federal agencies, including but not limited to OIG. The message here is to be sure the grant money is not transferred to a personal account and that the money you received stays in a business account and is used to pay business expenses only.


 


Paul Kesselman, DPM, Woodside, NY

05/05/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1


RE: COVID-19 and Social Office Spacing


From: Keith L. Gurnick, DPM


 


We will all have to come up with our own individual ideas and solutions to address the multitude of complex new "social spacing" issues that will confront us moving forward. Each practice will need to figure out how to best facilitate the flow of staff, suppliers, patients, and deliveries in and out of their offices to maintain a safe and healthy work environment.


 


My solo practice is located on the 7th floor in an 18-story medical building directly next door to a hospital, all on the same property. We have put up signs and taped off waiting room chairs to allow for social spacing. In addition, we have added additional folding chairs in the hallway just outside our waiting room door, thus expanding my reception room into the hallway just a bit. In addition, we are now keeping the reception room door open at all times so patients will not need to touch the door knob to enter or exit the office.         


 


PM News would be a great forum to hear what others are doing, will be doing, or are considering to address the issue of social spacing in our medical practices.


 


Keith L. Gurnick, DPM, Los Angeles, CA

05/04/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1



From: Vince Marino, DPM


 


Dr. Neuhoff should consider herself very lucky. I wonder if she banks with a small bank that is also an SBA lender. I bank with Bank of America and it has been a true nightmare - multiple changes in the applications, absolutely no way to contact them with questions or status updates. Total silence. As a result, I have applied for the second round with 7 different lenders trying to hedge my bets. The big banks (B of A, Wells Fargo, JP Morgan/Chase, etc.) catered to their big clients first to reap in the billions in fees they collected (6 billion from the first round are conservative estimates) - that coupled with the glitch in the program allowing entities such as Shake Shack, Ruth Chris Steak House, nd McDonalds to name a few to use each franchise as a different entity with less than 500 employees. Congratulations to Dr. Neuhoff. I wish the rest of us luck.


 


Vince Marino, DPM, Novato, CA

04/29/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1


RE: New Study of Famotidine for COVID-19 and Possible Relationship to Verruca Treatment


From: Steve E. Abraham, DPM


 


A few years ago, I wrote an article for Podiatry Management about cimetidine for recalcitrant verrucae. I had mixed responses. 50% of the patients who used cimetidine for warts had complete resolution in 4-6 weeks of oral treatment. Alas, about 50% had no response and needed more aggressive treatments. I used this for children to avoid pain.


 


I had a relative who used high doses of oral cimetidine for herpes infection, and after 6 weeks, it cleared up. A serological test was positive at the time the skin lesion was excised by a dermatologist, and 6-8 weeks later, the serology test was negative. Were all of these "anecdotal" conclusions merely coincidence? Perhaps. 


 


Yet, I read this morning about a study for the treatment of severe illness due to COVID-19 using high doses of intravenous famotidine, the active ingredient in Pepcid, a drug in the same family as cimetidine. It was hypothesized that cimetidine affected H2 receptors and activated an immune response to the virus. This study on famotidine will be with 1,200 subjects-patients. This may add credibility to the use of cimetidine for warts.


 


Steve E. Abraham, DPM, NY, NY

04/28/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1



From: Vince Marino, DPM


 


From all I have heard, most landlords have been very understanding- especially if you usually pay your rent on time and are a problem-free tenant. I have three office locations and the landlords in all three have been understanding. One landlord is Sutter Health, and we are in their medical office building adjacent to the hospital. They have allowed us to defer the rent (except for still being required to pay the operating expenses they have built into the rent, so about 50% reduction). We are dividing up the rent we are deferring and spreading it out over the life of the remaining lease.


 


The other office is pure retail space, and that landlord is giving us 3 months of not paying rent but they are adding 3 months onto the end of our lease, so in essence – 3 months free.


 


The third office is a sublease from a group of spine surgeons, and since they got a 50% reduction from their landlord, they are giving us also a 50% reduction in the rent.


 


Vince Marino, DPM, Novato, CA

04/24/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1A


RE: Employees in the COVID-19 Pandemic (Jill Hagen, DPM)


From: Brian Kiel, DPM, Jeffrey Worman, DPM


 


Let me get this straight. The doctor wants her office manager to work for free 20 hours a week so the doctor can have an income and then calls the employee lazy for getting $300 more in unemployment than her salary. I can’t imagine how little her salary was but I say - why would she not? 


 


Brian Kiel, DPM, Memphis, TN


 


It is my understanding that the amounts currently being paid for unemployment are being bolstered to help people during this crisis. It is also my understanding that normal unemployment wages are far less than the standard 40 hour work week pay. More importantly, in my mind, is that Dr. Hagen's logic that any employee would simply do a "mitzvah" for 20 hours a week with the promise of "this being remembered when this whole disaster is over." You can't read possibly read that sentence and think that makes sense. I have VERY loyal employees who are dedicated to me and my practice, and they are compensated for such. To expect them to do it for 20 hours/week for free is completely laughable.


 


Jeffrey Worman, DPM, Largo, FL

04/23/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1


RE: Employees in the COVID-19 Pandemic


From: Jill Hagen, DPM


 


After much consideration, I closed my office on 3/13/20 due to COVID-19. One employee was 5 months pregnant, so I had to put her on unemployment. Then, I decided to put all my employees on unemployment. I asked my office manager if she could help me out 20 hours per week to keep me up-to-date with accounts receivables. I told her she would be doing a “mitzvah” (good deed) and it would be remembered when this whole disaster is over.


 


Then she got accepted for unemployment. Her unemployment benefit came out to be $300 more per week than if she was working 40 hours per week. She proceeded to tell me that if I need her to help, I must pay her for the extra hours she puts in. I told her no thanks. This government is crazy. It’s nice that people are getting compensated, but why is our government paying people for sitting on their asses at home more than if they went to work? Does this make sense? There’s no incentive to work, so these lazy employees won’t even help in a disaster situation. What happened to the good people in this world?   


 


Jill Hagen, DPM, Englewood, NJ

04/21/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1B


RE: Appreciation for Those Who Stepped Up in the Pandemic


From: William H FitzPatrick, DPM


 


I would like to add to the appreciation we’re giving to all the frontline workers during the pandemic. In addition, I’d like to add a big "thank you" to APMA and PICA for their financial concessions to members and professionals. Also, a big thank you to the IT, digital x-ray, EHR, advertising, vascular, and others of our vendors for giving us contract fee reductions. They won’t be forgotten when normalcy returns and we continue our business associations.


 


William H FitzPatrick, DPM, Albuquerque, NM

04/21/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1A


RE: Podiatric Residents and the COVID-19 Pandemic


From: Amira Mantoura, DPM, Mike Piccarelli, DPM


 


Residents currently serving in hospitals with high volume COVID-19 patients will be some of the best trained ever. There is no substitution for the experience gained by playing in a live game. Thank you for stepping up. We are all proud of you.


 


Amira Mantoura, DPM, Stamford, CT


 


I applaud all of the residents, attendings, and nurses who have answered the call for help with the COVID-19 outbreak at their respective hospitals. 


 


As the program director for Richmond University Medical Center Staten Island, NY, I particularly would like to thank my residents (one of whom was infected and has thank-God recovered and is back at work) for stepping up when called on. They are working 12-hour shifts, 6 days per week in the epicenter of the outbreak in NYC. Even with the overwhelming nature of the work, they have shown remarkable resolve in all that they have done. 


 


Mike Piccarelli, DPM, Staten Island, NY

04/20/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1


MN Podiatrist Concerned about Lack of PPE in Long-Term Facilities 


 


Long-term care facilities remain a topic of concern amid the coronavirus pandemic. Podiatrist Jengyu Lai, DPM, Chief Manager of the Rochester Clinic, travels to those types of facilities in the Rochester area. Some are not allowing visitors at all, even specialists, while others only allow specialists like him in. According to Dr. Lai, he has to always check to his temperature and answer questions when entering each facility while also putting on new personal protective equipment (PPE) and that he started wearing masks before they were mandatory at the facilities. He says that since residents don't have many visitors (if any), residents are always excited to see him.


 













Dr. Jengyu Lai



 


Lai has concerns about the level of PPE supply at these facilities saying, "My concern is most of them do not have enough protection gear, especially like masks. Even though they want to go out, most of them have to use the surgical masks but they have to re-use them. Some do have the homemade masks but they only have one and you can't really have just one. You really need to wash them, clean them, and to alternate."


 


Source: Zach Fuller, KTTC [4/15/20]

04/17/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1C


RE: Cutaneous Manifestations of COVID-19


From: Stacy Witfill, DPM, Annette Joyce, DPM


 


My sister is a dermatologist and knows of colleagues both podiatrists and Derms who are seeing this presentation in people of all ages. In most, it is the ONLY symptoms the patient has developed during the course of their disease. I have instituted a careful screening process for anyone who calls with a recent onset of ischemic type issues, rashes, blisters, etc. The hope is to recognize it via telemedicine first for triage to a testing facility to rule out COVID-19.  As far as actual management, it seems to be self-limiting, but the normal topical agents we would use for transient ischemia not due to actual blockage can be helpful - topical nitroglycerin, topical nifedipine, oral aspirin use. COVID-19 does affects multiple organ systems not just the lungs. 


 


I also read an article written by a gastrointestinal specialist that helps outline the cellular mechanism and the thrombotic microvascular effects.  


 


Stacy Witfill, DPM, Dunnellon, FL 


 


There are of course so many unknowns about COVID-19. The latest dermatology research suggests emerging lesions, possibly due to vaso-occlusion which can appear similar to pernio or chilblains. These petechiae or livedoid eruptions can provide an early clue to diagnosing a COVID-19 positive patient. Please consider registering YOUR cases in the COVID-19 dermatology registry below as a means for all healthcare workers to gain knowledge and understanding of this new skin phenomenon. The American Academy of Dermatology (AAD) has created a simple site with a 5 minute questionnaire to submit your lower extremity skin cases.


 


Annette Joyce, DPM, Sykesville, MD

04/17/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1B


RE: Cutaneous Manifestations of COVID-19


From: Bryan C. Markinson, DPM


 



There has been much discussion about the livedoid podiatric skin manifestations of COVID-19 initially sparked by preliminary reports out of Europe and recent presentations in podiatry encounters in the United States. I would like to point out that at this time that so far there is no confirmed connection, just an association, and these presentations had no correlation with severity of COVID-19 respiratory decline. However, historically, viral infections definitely present with skin manifestations and it makes sense that COVID-19 should be no different. Be aware that the skin issues reported in Europe are not confined to the feet, as all extremities and the trunk areas were also prominent. This may be an important question to ask about in patients with foot lesions.


 


The question of referring patients for testing have come up, based on the presentation of foot lesions. Clearly, the critical issue with COVID-19 is the rapid decline in respiratory function necessitating heroic measures for survival. Still, widespread testing is lacking and it is the onset of respiratory symptoms that still drives the need for initial testing. In the coming weeks, routine testing for back to work plans may be the rule, but we are not there yet.


 


With that in mind, AND THIS MAY CHANGE, I would be hesitant to recommend patients with the only symptom of a livedoid eruption on the feet for COVID-19 testing at this point. Patients should be given supportive treatment for blistering lesions and referred for systemic therapy if vasculitis appears prominent. Otherwise, it is logical to assume that the lesions will resolve as the symptoms of COVID-19 infection resolve in most cases.


 


Bryan C. Markinson, DPM, NY, NY


04/16/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1A



From: Name Withheld by Editor


 


I just wanted to share a recent case (2 weeks ago) in my practice similar to the article mentioned by Dr. Chris Stewart. This is a 17 year old male who presented with very similar findings; itchy, painful, purplish spots on his toes, otherwise asymptomatic. 


 












Cutaneous Manifestations of COVID-19

04/14/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1A



From: Barry H. Block, DPM, JD


 


You can sterilize N-95 masks by putting them in an oven at 158 degrees Fahrenheit for 30 minutes. If you use the respirator type mask, be sure to keep the plastic part up. Because oven temperatures can vary, I suggest trying this technique on a single mask before sterilizing multiple masks.


 


Barry H. Block, DPM, Forest Hills, NY

04/14/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1



From: Adam Ullman


 



Several doctors have reached out to me about using SteriShoe products to clean surgical masks. First, please know that UVC only sanitizes what it comes in contact with; it will not treat shadowed areas and may not get organisms between layers if the mask has layers. Beyond that, UVC is a potent germicide that renders all microorganisms sterile.


 


I looked for UVC dosage amounts for COVID-19 and have not found this data. With that said, the times set for our SteriShoe products were established based on testing organisms that are tested as part of testing disinfectants. If you use a UVC device to clean a surgical mask, you should know a few things: 1) The variables for UVC potency are based on...


 


Editor's note: Adam Ullman's extended-length letter can be read here.


04/13/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1


RE: Re-using Surgical Masks (Catherine Yack, DPM)


From: Brian Kiel, DPM, Michael M. Rosenblatt, DPM 


 


I bought a desktop UV light to sterilize my masks. I have N95 masks that I have always used for laser surgery. Since there is a shortage, I put them under the light twice a day. Make sure you get UV-c as it does not penetrate skin and is much safer. I ordered it from Larson Electronics. I have no financial interest in this company.


 


Brian Kiel, DPM, Memphis, TN


 


Because I use a VPAP machine every night, I use an ozone generator to clean out and "sterilize" my equipment., I have an inexpensive model called a Leel CPAP Ozone cleaner. The problem is that they are currently sold out. However, there are others available (at least for now) at various prices. I cannot give you any scientific advice about the effectiveness of ozone generators, but I believe if you look it up, they kill viruses very successfully. Some might be concerned about a residual peculiar smell of ozone. I air them out each morning. The masks do NOT smell and are very fresh, like new. I just put them into a bag (that usually comes with the device) and "gas them up." I treat them for about 30 minutes. I cannot imagine viruses tolerating the ozone. 


 


Michael M. Rosenblatt, DPM, Henderson, NV 

04/10/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1



From: Raymond F Posa, MBA


 


As an IT professional, [I find] this issue has been the number one concern for my clients which are comprised of physicians and attorneys. The solution I recommend for my clients is Zoom. I realize Zoom had some bad press recently, but know that the issues were caused by users not properly configuring the security settings; also on April 6, 2020, Zoom put out a comprehensive security update to address many of the security issues.


 


Zoom offers several levels of their product from a basic free version to paid subscription versions. For many, the basic free version will get the job done very nicely. It is easy to use for both you and the patients. For the patients, they need only go to the...


 


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

04/08/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1


RE: Reducing Expenses During the Pandemic 


From: Lancing Malusky, DPM


 


While we are all "sheltering in place" with family, a 2 or more car family only needs one car for groceries, etc.  Your insurance expense can be greatly reduced by calling your agent and have any unnecessary vehicles placed in storage. This suspends your collision and liability, but theft is still covered. A simple call to your agent can put a vehicle in or out of storage at any time.  


 


Lancing Malusky, DPM, Kettering, OH

04/07/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1B



From: Vincent Gramuglia, DPM


 



I could not agree with Dr. Sokoloff more. I am perplexed by individuals who in the middle of a disaster feel that is an appropriate time to discuss such ridiculous nuances. These individuals are volunteering their time and they will perform to the level of their competence. Maybe they’re just monitoring patients and maybe they are getting elbow deep in their medical care. What difference does it make what rotations they had or what experience they have in these situations? Aren’t police officers who apply tourniquets to bleeding limbs or deliver babies on the highway also in over their heads? We’re not talking about an elective case in a surgery center right now; we’re talking about an unprecedented global disaster.


 


Having said this I will never understand what prompts certain individuals at moments like this to criticize the selfless actions of others. These residents are true doctors, not paralyzed by their insecurities, who likely are more equipped to provide these services than 80% of dermatologists, ophthalmologists, orthopedic and plastic surgeons. I am privileged to work alongside these remarkable people and I take offense to those who succumb to the absurdity of their pet peeves.


 


Vincent Gramuglia, DPM, DVA NY Harbor 


04/07/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1A



From: David Armstrong, DPM


 


I wholeheartedly agree with Dr. Sokoloff’s comments vis a vis the evolution of our specialty. We are one of the few (if any) specialties that seems to want to “pre-credential” itself. We seem to draw odd anatomic Mason-Dixon lines at obscure joints. We have many different boards for the same anatomy. We really need to stop this. It is, frankly, slightly embarrassing. Podiatric surgery is a surgical specialty in the USA. There may be a spectrum of surgical activity - like in any surgical specialty. However, we need to consolidate in this peri- and post-pandemic era. 


 


We should leave credentialing to the hospitals and base it on our surgical experience and training— like in any other specialty. I see this happening more and more, which is heartening. We should also team up to do our part to a) keep folks out of the hospital during this unprecedented time and b) dive in to help care for inpatients if we so choose. Here’s to Dr. Theodoulou and Dr. Sokoloff and the others who have trained and continue to train the next generation of men and women focused on helping people move through the world a little better.


 


David Armstrong, DPM, Los Angeles, CA

04/06/2020    

RESPONSES/COMMENTS (CORONAVIRUS PANDEMIC) - PART 1


RE: Potentially Devastating Effect of COVID-19 on Podiatric Medical Practices


From Leonard A. Levy, DPM, MPH


 


Minimal information is in the press about the effect of COVID-19 on health professional practices, especially their economic well-being and even the contemplation of closure. Patients are not showing up for appointments and cancelling non-urgent visits. It is reported that hospitals are cancelling elective procedures, a significant source of income for orthopedic surgeons, cardiologists, and gastroenterologists. This has escalated dramatically in the second half of March.


 


What has not been discussed is how it may be affecting podiatric medical practices. A major symptom of how healthcare practices are slowing down is the significant drop-off of claims at health insurers. Because of increasing concerns, actions designed to keep practices viable have been compiled by...


 


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