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From: Todd Lamster, DPM


Since this topic has resurfaced, it is likely that some (or a lot) of us are grinding toenails. Many of my patients experience pain when cutting from the dorsal surface, or I find that the nail bed and hyponychium have become hypertrophied as well, reducing my ability to thin the nail due to risk of bleeding. Those of us using a rotary device would likely say that both hazards are reduced. In an effort to collectively end this practice of nail grinding (which I advocate), I ask my colleagues who are not using a rotary device to please detail your techniques for reducing toenail hypertrophy.  Specifically, address two items:


1) How to reduce a truly thick nail or dome-shaped nail structure without cutting through the elevated or thickened nail bed and hyponychium? 2) How to reduce the jagged edges that are the result of nail cutting using standard clippers? If hand instrumentation is used (as was suggested in an earlier post), what device is being used specifically?


Although this ongoing discussion may seem naive to some, I think now more than ever, it is important to standardize this process to reduce occupational risk and exposure.


Todd Lamster, DPM, Scottsdale, AZ

Other messages in this thread:



From: Jack Ressler, DPM


There is a fine line in dealing with a rude patient. On one hand, you do have to respect the patient’s opinions. Probably more importantly, you have to go to bat for your staff if they are right. I had a very interesting experience in my office where my staff member was both right and wrong on two different occasions. The first incident occurred when a patient did not get their way when making an appointment and ended up calling my receptionist an idiot. This patient did come back to the office after apologizing. It took all of two minutes for the patient to rehash this incident and again called my receptionist an idiot. I proceeded to tell the patient to leave and never come back. This was done before treatment. I must admit, dismissing a patient like this from my practice felt great, and was the first and only time I ever did that.


The second occasion occurred when the same staff member left a patient who was in severe pain in the waiting room because they were early for their appointment time. This patient did confront me in private while in the treatment room. I assured the patient that I will discuss this with the staff member. Although she was wrong, I made the mistake of asking her to come into the treatment room to discuss the incident in front of the patient. She had no explanation for her reasoning. Later in private, I diplomatically explained to her why she was wrong. She obviously was not in agreement because three weeks later, she quit citing this incident as her reason. In most cases, your staff is generally going to be right and they must be defended against unruly patients.


Jack Ressler, DPM, Delray Beach, FL



From:  Elliot Udell, DPM


I am a caregiver for my parents. This means taking them to a plethora of doctors. Many have signs saying that unless 24 hours notice of cancellation is given, there will be a charge. In my situation, between urgent care visits, doctors’ visits, and actual hospital ER and hospital admissions, we have had to miss many appointments. To date, none of the physicians we go to have "fined" us for missing appointments. If they did, we would have to choose a different doctor in the same specialty. 


Wearing the "shoe on the other foot", I am not thrilled when a patient does not show without notice, but we do not charge patients. We do keep a record of who tends to be a "no show" and if it is often, we will tend to "overbook" that patient knowing that there is a likelihood that the person will be a no show. 


Elliot Udell, DPM, Hicksville, NY



From: Dock Dockery, DPM


After running several 3-day full length continuing medical education webinars this year with the International Foot & Ankle Foundation, I can’t tell you how many podiatrists recently have whined about the fact that they have to sit through hours of virtual lectures, or how hard it is if they still have patients to see, or that it is difficult to get up early or stay up late (due to time zone differences), or why can’t they just pay and get the CME hours without having to attend the sessions. 


I realize that virtual medical meetings are different from the live ones that we’ve always known. I also know that many doctors sign up for the educational meetings and then spend most of their time in the exhibit hall, out in the corridors visiting with friends, or by the pool or beach, or even in the meeting facility restaurants and bars (and they still get their CME hours). So, it is difficult for meeting planners, like me, to make everyone happy, or satisfy all requests for certain time zones or even to just let everyone pick and choose the topic, time, and lack of monitoring that they want. 


For now, I recommend picking the online meeting that you want, schedule the appropriate time out from the office or family, attend the virtual meeting, and try to learn something new. Hopefully, next year, it will be back to more normal and you can attend live meetings again. 


Dock Dockery, DPM, Seattle, WA



From: Steven Selby Blanken, DPM


In 1995, I became double-board certified by ABPS (Foot Surgery) and by ABPO (Podiatric Orthopedics). Since then, ABPS changed its name to ABFAS but did not merge with another board. However, ABPO merged with another board, making it ABPOPPM. When that occurred, there were some grandfathering that was granted (just like ABPS did with the MIS board years prior). However, after much confusion and dismay, ABPOPPM did not grandfather all of its ABPO members, but did to most, but not all. 


ABPOPPM's re-certification process was very different from the original ABPO's process, and after one re-certification process, I decided that I would not do it again 10 years later. In my area, as in many, ABFAS (ABPS) was the main certifying board that enabled me to get onto hospital staffs for full privileges, including most surgery allowed by the state. It also helped me stay on my insurance plans. I feel ABFAS is the only board that is recognized by APMA that can actually get one the certification necessary for many hospital staffs. I hear they are trying out a better re-certification route as of this time, for which I commend them for this. I have maintained and plan to retain my ABFAS certification. I do not have any regrets dropping ABPOPPM now known as ABPM.  It really didn't give me much added benefit.     


Steven Selby Blanken, DPM, Silver Spring, MD



From: Michael Loshigian, DPM


It is certainly interesting to see the charged and emotional responses to Dr. Lombardi's inquiry from several of our profession's most influential members. Before you allow yourselves to be "triggered" and attack Dr. Lombardi, I would encourage all of you who feel that the inquiry is controversial, unfair, or dividing our profession to take a moment and reread his post.


The first part of his inquiry simply states that the ABPM is spending money to help a member get hospital privileges and that Dr. Lombardi's hospitals allow ABPM certified people to have hospital privileges that include admitting patients and performing wound care, etc. The "etc." implies they are credentialed to do more than wound care. "But not surgical privileges" implies...


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



From: Jeffrey Kass, DPM


Dr. Jacobs brings up some good points in his posting such as the fact that we unfortunately don’t have equivalent residency training among programs. In his defense of Dr. Lombardi’s query, he misses the main point. No one was stating that everyone should be granted privileges to “place an IM nail and fixator for patellar arthrodesis.” Dr. Lombardi clearly stated in his post “my hospitals have always allowed ABPM members to obtain admitting privileges... but not surgical privileges.” All doctors should only practice within their ability/skill set and seek help with areas that aren’t within their domain. 


I hope that anyone graduating from a three year program would be proficient with basic podiatric skills, i.e. hammertoes, bunionectomies, exostectomies, etc. To exclude these graduates from an OR due to not being board certified is ridiculous. We should be trying to elevate the profession by helping each other, not dividing the profession and excluding colleagues. Why not examine the root of the problem? 1) programs having unequal training 2) the low passing rate of the surgical boards. 


It amazes me why an anatomical location less than 12 inches has multiple boards to begin with. Finally, NYSPMA has spent hundreds of thousands of dollars, if not more, to try to advance scope of practice for all. It is disheartening to hear a member of the executive board doesn’t share this vision, particularly when members’ dues helped advance his scope. 


Jeffrey Kass, DPM, Forest Hills, NY



From: Bryan C. Markinson, DPM


I consider Drs. Charles Lombardi and Allen Jacobs my professional friends for many years. They have both treated me with tremendous respect which is mutual. I view both of them as esteemed members of our profession, and I am thankful for what they have done publicly on our behalf to elevate our profession. Their professional lives are largely involved with mentorship. Most importantly, I would have any member of my family treated by them without hesitation. They have both historically posted statements in this forum I have found patently outrageous, but sarcasm never offends me and occasional self-serving posts don’t usually offend me.


Dr. Lombardi, on August 3rd, asks what we may feel about his proclamation that ABPM certified (or really, non-surgical certified) podiatrists do not need and should not be granted surgical privileges in hospitals. Some may react with disdain, even disbelief at his directness. In view of current trends, certainly in about ten years, it may very well be that his vision will be...


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



From: Lee C. Rogers, DPM

Dr. Jacobs is incorrect. I did a surgical residency, namely a Podiatric Medicine and Surgery (PM&S) residency, I started in 2004 when all CPME-approved residencies were being standardized to be both medicine AND surgery.

However, I disagree that it is ABPM's certification (or ABFAS') that gives someone the authority to be granted surgical privileges. Legally, privileges must be based on education (DPM degree), training (residency), and experience (case logs). Training is key here. All DPM training is now standardized to a 3-year Podiatric Medicine and Surgery Residency (PMSR). So regardless if you are certified ABPM or ABFAS, your training in podiatric surgery entitles you to be qualified to do surgery. The last part is experience. If you have demonstrated the experience in doing surgical procedures, forefoot, rearfoot, melanoma, ulcers, whatever ... you should be granted the privilege to perform those procedures.


Lee C. Rogers, DPM, Algonquin, IL



From: Gino Scartozzi, DPM


I read Dr. Lombardi's post and am somewhat troubled by a member of the ABPM Executive Board putting forth such a position questioning defending a podiatric physician from discriminatory practices allegedly for hospital privileges denied on the basis of which board is accepted by the hospital. The APMA has stated its position on this numerous times regarding hospital privileges and boards recognized for privileges.


Board certifications in podiatric orthopedics, podiatric surgery, wound care, and other podiatric subspecialtes should be encouraged. However, there is a far cry from a "board certified" physician and the demonstration of one's clinical abilities, even in the surgical arena, Dr. Lombardi. Do all podiatric surgical procedures require board certification? A board certified physician provides "better" care? Nope... 


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



From: Lee C. Rogers, DPM


Dr. Lombardi asks what ABPM’s position is regarding the criteria for granting surgical privileges. Quite simply, the ABPM believes that hospitals should follow State law and Medicare Conditions of Participation when evaluating a podiatrist for surgical privileges, and those privileges should be based on their education, training, and experience, not their board certification. This opinion mirrors that of the APMA, which can be found in the "Hospital Credentialing and Privileging Resource Guide", on For further information, please see the ABPM’s Position Statement, "Hospital and Surgical Privileges for Doctors of Podiatric Medicine," published in JAPMA in 2019. 


That said, the ABPM is committed to providing the resources necessary to protect the credential from illegal discrimination. We encourage diplomates to contact the Board for assistance if they’ve experienced such discrimination in hospital or surgical privileges.


Lee C. Rogers, DPM for the ABPM BOD, Los Angeles, CA



From: Raymond F Posa, MBA


I would like to add to Bret’s comments regarding lectures. I have been lecturing to podiatrists for nearly 20 years and have had the pleasure of lecturing at conferences with Bret and his talent shows. Passion is the key element in an outstanding speaker. Anyone who has sat through a lecture given by an uninspired speaker knows it is drudgery.


But the missing element in today’s distant learning is the energy of the group dynamic. It is the audience that takes outstanding speakers to the next level. As a speaker, you feed off the energy of the audience, you can tailor each presentation based on the feedback from the audience and your read of the audience. This, in turn, allows each presentation to be unique in its own way. A canned webinar just can’t capture the energy and feedback of the audience. I know when I do Zoom conferences or record webinars, I find the lecture is always lacking without the energy of the audience.


Granted a lot of information can be conveyed via webinar and online lectures, but the energy and the rush of the audience is just not there. I for one can’t wait to go back to live lectures.


Raymond F Posa, MBA, Farmingdale, NJ



RE: Online Learning vs. Live Lectures?

From: Jack Sasiene DPM


This post is directed to all the states that do not allow all credits to be taken online. I registered for an in-person seminar for April (now postponed until October and that could still be in doubt). This seminar will be available online for those not comfortable to attend at this time. I presume, if things get worse, then they may make it only available online.  


When you call the Texas Department of Licensing and Regulation (TDLR), they say to ask the TPMA regarding any changes to CME requirements. TPMA says ask the TDLR! Many states allow for all credits to be taken online, while others only allow partial credits online. I guess they feel an online credit is not as good as those in person?  But that then creates a logical problem. If they aren’t equal, then none should be allowed! If one online credit is good for one CME, then they all should be good.


During this time, it is in the best interests of health and safety to at the very least temporarily correct this. If not, we all deserve an answer as to why. We would all love to hear an answer from those in charge.


Jack Sasiene DPM, Texas City, TX



From: Dennis Shavelson, DPM


Dr. Steinberg: As essential workers and others are finding out when wearing proper PPE masking for more than one hour a day, there is a reduction in the level of oxygen, causing hypoxia and hypercapnia. I submit the CDC take on that as evidence and ask you to counter with yours. 


Dennis Shavelson, DPM, NY, NY



From: Mark Spier, DPM


Sorry, indeed, Dr. Steinberg. If you disagree with experts from the CDC regarding their assessment of CO2 "build up" behind the mask, perhaps you can share with our readers your expert credentials in respiratory gas exchange dynamics as your DPM degree seems to preclude your cavalier dismissal of accepted science. 


A representative from the U.S. Centers for Disease Control and Prevention (CDC) told Reuters: “The CO2 will slowly build up in the mask over time. However, the level of CO2 likely to build up in the mask is mostly tolerable to people exposed to it. You might get a headache but you most likely [would] not suffer the symptoms observed at much higher levels of CO2. The mask can become uncomfortable for a variety of reasons, including a sensitivity to CO2 and the person will be motivated to remove the mask. It is unlikely that wearing a mask will cause hypercapnia.”  Here is the link.


Mark Spier, DPM, Reisterstown, MD



From: Robert Scott Steinberg, DPM


Sorry Dr. Spier, but CO2 does not "build up" behind the mask. Yes, there is a minuscule amount that may be retained within the mask, but since masks are exceeding loose-fitting, it could never be a physical problem, and most likely just a psychological one. I have a right to protect myself and my staff. I would refuse treatment of such a patient, and if it is an urgent problem, I would send them to the ED. We tell patients they must wear a properly fitting mask that completely covers their mouth and nose, made out of appropriate material. No pantyhose or bandana-like materials. 


Robert Scott Steinberg, DPM, Schaumburg, IL



From: Robert Scott Steinberg, DPM


Your surgical mask is not the cause of your low oxygen saturation. Look elsewhere. Here is some science


Robert Scott Steinberg, DPM, Schaumburg, IL 



From: Roy Perles, DPM


I never liked grinding toenails because of the inhalation risk of nail dust, difficulty sterilizing the burrs, and it's cost prohibitive to use fresh sterile burrs. Nail dust extractors are expensive, especially if you have to buy multiple units. About 15 years ago, my last Dremel drill broke, and that day I just picked up a sterile #15 blade, and with an alcohol-saturated gauze pad essentially "whittled" the sharp edges. I have not grinded a toenail since then.


At 15-25 cents per blade, you're delivering quality safe routine foot care with no risk of cross contamination from the re-use of burrs. There is a learning curve, but with practice, it's just about as fast as grinding. Occasionally, a patient may say, ''my other podiatrist grinded my toenails, why don't you?'' My answer is simple, ''You always get a sterile blade." I would ask the patient if their other doctor used a fresh sterile burr? Most patients replied ''no''. I am surprised that using a sterile scalpel blade for nail grinding has not been mentioned before.


Roy Perles, DPM, Cambria Hgts, NY



From: Gregory T. Amarantos, DPM


Prior to MIPS, we had MeaningLESS use. Unless you are an epidemiologist employed by the government, there has been no value to the populace at large. It is a way for those in the ivory towers to penalize those sheep who refuse to be led to slaughter.


Gregory T. Amarantos, DPM, Glenview, IL



RE: Grinding Nails During the COVID-19 Pandemic (Elliot Udell, DPM)

From: Bryan C. Markinson, DPM


I am surprised that it takes the COVID pandemic to raise old questions and concern about hazards of nail dust inhalation for those clinicians still doing nail grinding. For all of you new or young in practice, I beg you to read almost any article on the long-term hazards of nail dust inhalation, (not to mention what it does to your work environment) having nothing to do with COVID and the potential heath effects on clinicians that may not be evident for many years, and hope that you stop doing it ASAP. For older clinicians, to continue to do it is insanity in my opinion. I have not grinded a nail in 25 years and do as much nail care as anyone.


The occasional patient who complains about a sharp edge doesn’t fit into my reconstructive foot and ankle persona anyway. (Tongue in cheek just in case someone thinks I may be self-misrepresenting ). Nail dust extractors? Water jets? Use them when you assign your grinders to the hobby space in the garage. But don’t take my word for it. Take the time to read about it and remember the ill effects can take decades to manifest.


Bryan C. Markinson, DPM, NY, NY



From: Michael J Marcus, DPM


1.  For our patients who require nail debridements, I have recommended that mechanical debridements be performed with hand instrumentation only. Use of power instrumentation causing plume must be avoided if possible. Refrain at this time – two months from now things may be better. We haven't had any patient complain - just inform them and most should understand.


2. In surgery, my concern is with electrocautery and its plume. I attempt to avoid its use when possible. Use ties or just compress. Use close suction systems if needed. Treat all patients as if they are possible covids.


Michael J Marcus, DPM, Montebello/ Irvine CA



From: Elliot Udell, DPM


By and large, the transmission of this deadly virus has been found to be from inhaling respiratory droplets. The big "but" is that everyday things are changing with regard to how this virus can spread. What would make an interesting research project would be for some podiatrists to collect nails from patients infected with the coronavirus and have a lab determine if the virus is present on the toenails. If so, than grinding would be dangerous. 


Elliot Udell, DPM, Hicksville, NY



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: 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: 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



From: David S. Wolf, DPM


Kudos to both podiatrists in this reality TV series, who exemplify the finest in our profession. They will educate the public of the scope of our practice and will augment what the APMA has attempted to accomplish. We have all seen the pathology of these TV patients but at least now, it will be seen by millions of viewers. What a positive PR coup for our profession. Wish I would have thought of it.


David S. Wolf, DPM, (Retired) Houston, TX 

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