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08/11/2020
RESPONSES/COMMENTS (NEWS STORIES)
From: Tilden H Sokoloff, MD, DPM
Congratulations to Touro president Dr. Alan Kadish and NYCPM president Mr. Louis Levine on the signing of a Membership Agreement. That is the beginning of a terrific affiliation that hopefully leads to a dual DPM, DO Degree program. I was Co-Chairman of the Board of Trustees of CCPM and negotiated the affiliation of CCPM and Touro University. Touro got its start at CCPM In San Francisco. Leonard Levy DPM, MPH was the Dean and created a place for Touro to have a freshman DO class admitted at our Eddy Street location. The students sat side by side (DPM, DO) for the first two years of basic science.
G-d bless Bernard Lander, a visionary and great friend who has passed away. His legacy is strong and the University has prospered. I am so sorry CCPM did not stay the course at Touro University. It was a gateway to Dr. Lander’s vision of a dual degree pathway for podiatric physicians. Leonard is now the retired Associate Dean for Research and Innovation at Nova College of Osteopathic Medicine. We have a long rich history with Touro University.
Tilden H Sokoloff, MD, DPM, Ketchum, ID
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12/08/2022
RESPONSES/COMMENTS (NEWS STORIES) - PART 1B
From: Ivar E. Roth DPM, MPH
I completely agree with Dr. Laps that bunion surgery should be a last resort. I review far too many complications cases where the patient had no or little complaints and the doctor basically insisted they should have surgery. I remember when I was an extern at Kern hospital (where Dr. Laps was trained) that the reason not to do both feet at the same time was different. It was to do one procedure a day or week for the patient to exhaust their leave time, and for the doctor to milk the insurance company so they would get the full fee on each procedure rather than be paid the multiple procedure fee if all the surgery was done at the same time.
Ivar E. Roth DPM, MPH, Newport Beach, CA
12/08/2022
RESPONSES/COMMENTS (NEWS STORIES) - PART 1A
From: Philip Wrotslavsky, DPM
Dr. Laps discourages having both feet done together. This published study is worth taking a look at to help get a better insight into doing both bunions at once. Unilateral versus bilateral first ray surgery: a prospective study of 186 consecutive cases--patient satisfaction, cost to society, and complications. Robert Fridman, et al. Foot Ankle Spec. 2009 Jun.
Abstract: Many studies have evaluated bilateral versus unilateral surgery in large joints, but limited research is available to compare outcomes of bilateral staged foot surgeries versus synchronous bilateral foot surgery. In total, 186 consecutive cases of first metatarsal-phalangeal (MTP) joint surgery were prospectively included in this study; 252 procedures were performed: 120 were unilateral or staged bilateral operations, and 66 were synchronous bilateral operations. Patients were evaluated at 6 and 12 weeks for specific early complications and surveyed about their return to work, activities of daily living, footwear requirements, satisfaction, and reasons for choosing staged or synchronous surgery. In addition, a cost analysis was performed on all surgical scenarios. Student t test showed no statistical significance between groups in all clinical settings to a 95% confidence level.
Complication rates were similar and few in all situations. Patients were very satisfied when choosing bilateral synchronous surgery and would elect to repeat it the same way 97% of the time. The economic costs to the health system average 25% greater when patients undergoing first MTP joint surgery have the procedure performed one foot at a time. Combined with the time lost from work, this reveals a significant economic cost to both society and patient.
Philip Wrotslavsky, DPM, San Diego, CA
11/10/2022
RESPONSES/COMMENTS (NEWS STORIES) - PART 1B
From: Ivar E. Roth, DPM, MPH
Going barefoot at home is a bad idea. Sooner or later you’re going to suffer an injury due to that recommendation. I guess the older you get, the wiser. While going barefoot might sound like a great idea, experience has shown me that it is not. Additionally, the more often you support your feet, the better your feet will function with the extra benefit of less injuries and accidents.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
11/10/2022
RESPONSES/COMMENTS (NEWS STORIES) - PART 1A
From: Robert D Teitelbaum, DPM
Dr. Kuizinas' observations may have validity for many patients but I find that in my Florida practice, going barefoot is problematic. Many people move down from the Northeast where they commonly have wall to wall carpeting and fall in love with some tiles that are very common here. It's warm, airy, and sunny, and they go barefoot quite often. In a short time, they're in my office complaining of heel pain. They are middle aged, and it's America, so many of them are overweight. I have to straighten them out when it comes to this subclinical stress they're putting themselves under. I find that half of the cure for heel pain syndrome is 'between their ears'. I straighten them out by telling them, "You get away with everything when you're younger, and nothing when you're older."
To be sure, there are many Floridians who have gone barefoot their entire lives and get away with it, possibly from their intrinsic muscles getting a great workout from early in life. But I don't see many of them in my office for that condition.
Robert D Teitelbaum, DPM, Naples, FL
06/28/2022
RESPONSES/COMMENTS (NEWS STORIES)
RE: Insulin Costs Outpacing Financial Resources for 4 in 5 Patients
From: Steven Kravitz, DPM
80% of diabetics or caretakers for someone with DM face credit card debt averaging $9,000 due solely to the cost of insulin. More than 60% have decreased the usage of insulin because of the cost, increasing multiple risk factors. The results are from the survey by CharityRx. The insurance industry, drug industry, and insurance regulators must look at this looming problem carefully. The risk involved with these patients is significant, potentially increasing morbidity tremendously. Secondarily, the resultant medical consequences can increase costs to the healthcare system.
This is just one of many aspects facing the elderly and anyone on a fixed income with any medical condition. The current rate of inflation, increased cost for food products, and decrease in the efficiency of the supply chain continue to make it more difficult for geriatric patients. Physicians are not given enough credit for the vast majority who care about their patients and independent of reimbursement concerns, put a hand out to help someone get the medical attention they need. More information can be found in: Forbes Healthcare, Deb Gordon. June 20, 2022.
Source: Report from the Academy of Physicians in Wound Healing Newsletter, June 23, 2022
Steven Kravitz, DPM, Winston-Salem, NC
05/05/2022
RESPONSES/COMMENTS (NEWS STORIES) - PART 1B
From: Allen Jacobs, DPM
The suggestion that hyperbaric oxygen is the “nectar of the gods” is incredulous. The retrospective studies examining the utilization of HBO for the management of DFU are at best controversial. The largest published retrospective studies demonstrate no benefit to system HBO, and no benefit whatsoever to topical HBO. Such studies have demonstrated no reduction in amputation rates, or advantage of HBO to comprehensive wound care.
The International Working Group on the Diabetic Foot's most recent recommendations stated that the indications for systemic HBO were “weak”, and for topical HBO non-existent. HBO therapy is never performed in a vacuum, and is...
Editor's note: Dr. Jacobs' extened-length letter can be read here
05/05/2022
RESPONSES/COMMENTS (NEWS STORIES) - PART 1A
From: Steven Kravitz, DPM
The news story quoting Dr. Adams references the increase in diabetes and the need for advanced therapies. There is very good evidence that demonstrates that the commercial aspect of wound healing products (and medicine in general) has driven up wound healing costs tremendously without the need to do so. William Marston, MD did a good study on venous ulcers, demonstrating 96% healed with simple compression therapy care. However, the reality is that other studies demonstrate as much as 80% of the time providers utilize advanced healing products. Only a couple of years ago, a major wound healing company was forced to pay back fines in excess of millions of dollars due to over-utilization of HBO.
We have to start "practicing what we preach" and use the most cost-effective, efficacious treatment to handle patient care. Otherwise, the government will apply increasing restrictions on how we practice and treat patients. The government tends to do this anyway; there's no reason to give them fuel for more ammunition.
Steven Kravitz, DPM, Winston Salem, NC
01/04/2022
RESPONSES/COMMENTS (NEWS STORIES) - PART 2
From: Jay Kerner, DPM
Suggesting an anti-inflammatory diet to patients with gout, inflammatory arthritis, diabetes, etc. is good medicine. Suggesting cherry juice, turmeric, bananas, watercress, and low fat milk products as gout preventatives is, however, in the realm of alternative medicine. Though there have been individual studies suggesting the effectiveness of cherry juice as a gout preventive, there are recent studies that show it has no effect. There are papers now questioning the role of purines in initiating gouty attacks.
There are no studies for these foods for any pathology with the strength of the vitamin D3 or anti-inflammatory diet studies. Advising patients to take them based on ‘recent studies’ is more a belief or exaggeration than evidence-based medicine...regardless of ‘epigenetic factors’.
Jay Kerner, DPM, Rockville Centre, NY
01/04/2022
RESPONSES/COMMENTS (NEWS STORIES) - PART 1
From: David S Wolf, DPM
Kudos to Dr. Ivar Roth for his innovated treatment for both humans and dogs. What a positive marketing opportunity for our profession to educate the population of what a podiatrist aspires to.
David S Wolf, DPM (Retired)
10/11/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 2
From: Herbert Abbott, DPM
Dr. Gurnick, having performed tens of thousands of these procedures over the span of a 30 plus years career, and having performed them on both of my own two great digits as well, I must say that Dr. Greenberg is SPOT ON! I am quite sure that he does a thorough informed consent as well, and the patient is aware of all risks, benefits, and alternatives. His wording is “usually,” and he is absolutely correct - any of my colleagues would agree. As for your results, I cannot comment other than maybe you are not doing the procedures correctly?
Herbert F. Abbott, DPM, New York, NY
10/11/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1
From: Tom Silver, DPM, Steven Finer, DPM
I was disturbed to read the article about Dr. Morris Stribling getting $1,000 of opioids stolen from his office and, as a result, he has added a physical security team on his property and urges others to lock up all controlled substances. I see no reason why any podiatrist should have opioids available in their clinic. You are just asking to be robbed at gunpoint or have your office broken into if patients that are seeking drugs know that you have them.
When narcotics are needed, they should only be prescribed through a pharmacy and on a very limited basis. The bigger question I would ask this doctor is why does he carry opioids in his office and how much is he prescribing to his patients?
Tom Silver, DPM, Minneapolis, MN
The storage policy for drugs may vary from state to state. However, it is expected that drugs should be stored in a safe and that there is a dispensing legend. The legend should show patient name, name of drug, and number of pills dispensed. Personally, why take the risk? If needed, write a prescription. The break-in may have been avoided as who knows what is stored in that office.
Steven Finer, DPM, Philadelphia, PA
07/07/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1B
From: Elliot Udell, DPM
Dr. Rotwein asks the question as to whether podiatrists should teach non-podiatrists how to cast for orthotics. There is a bigger "elephant siting in the room." What we should really be asking is whether any of us have any problems doing business with certain orthotic labs that spend a lot of time, money, and effort teaching and marketing orthotics to chiropractors, physical therapists, and other non-podiatric healthcare professionals?
This issue came to my attention last year when a local chiropractor called me and asked for my opinion on whether she should take training and utilize a certain orthotic lab to make foot orthotics for her chiropractic patients. What was extremely bothersome is that same company advertises heavily to our profession and sponsors lectures at our seminars.
Elliot Udell, DPM, Hicksville, NY
07/07/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1A
From: Irv Luftig, BSc, DPM
After 41+ years in practice, I've seen my share of colleagues, myself included, teaching podiatry students/residents/younger podiatrists the finer points of what makes our profession so specialized and necessary. Dr. Abe Plon took me under his wing and set me on a wonderful path back when I was a student in the 1970s and again after I started practicing in the early 1980s.
I've never had an orthopedic surgeon I work with show me how to do a hip, or a total knee or shoulder replacement. I've never had a nuclear cardiologist show me how to catheterize a heart. That would be a ludicrous expectation. Why are podiatrists like Dr. Overstreet teaching practitioners who never stepped inside a podiatry classroom to take our places. It makes no sense.
Irv Luftig, BSc, DPM, Hamilton, ON, Canada
07/06/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1C
From: Keith L. Gurnick, DPM
It is not at all surprising that some general practitioners, nurse practitioners, and others would feel comfortable performing similar foot care that podiatrists routinely provide, after sitting in on a lecture or watching and learning from a podiatrist performing procedures such as a toenail trimming, callus debridement, ulcer and wound care, toenail avulsions, or even a matrixectomy or a fluid cyst aspiration. After all, we podiatrists, with our four-year podiatry education and three-year residencies, were all educated and trained to do these same procedures. What is alarming, however, is when they think they are clinically competent after the brief "SODOTO" (See one, do one and teach one) method of teaching and learning skills. The fact is, if you don't know what you are doing as a healthcare provider, you are going to cause some problems. And guess who will be called to bail out these non-specialists? Any and all of these routinely provided procedures have the potential for adverse risks, complications, and bad outcomes.
If others are going to do the procedures, they must be equally able to manage the patient afterwards, whether with good or bad outcomes. Non-podiatrists, those with extremely limited specialty specific education in the foot and ankle who perform these type of foot and ankle procedures, should never be held to a "lower standard" of care simply because they are not podiatrists.
Keith L. Gurnick, DPM, Los Angeles, CA
07/06/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1B
From: Dennis Shavelson, DPM, CPed
Podiatry has forsaken evidence-based biomechanics, functional foot orthotics and their root causes that Dr. Root, et al. implanted into our profession in the 1970s. Subtalar joint neutral, pronation, hyperpronation and Root’s biomechanical examination are evidenced to be flawed and not useful to make biomechanical decisions. A 2017 study determined that “none of the deformities suggested by the Root method correlated with altered kinematics” and was “no longer valid for clinical practice.”
In the past, shoemakers, arch support fabricators, physical therapists, orthopedic surgeons, chiropractors, and orthotic labs openly brought us up to biomechanical speed. But currently, the exciting drive to elevate podiatry to be on par with MDs and DOs has supplanted non-surgical bio-architecture and biomechanics in importance as an acculturation of the DPM.
I gave warning about the future of biomechanics in a 1989 article. Using a 3 degree varus heel wedge and “posting to cast” is no longer the standard of care when it comes to biomechanics and custom foot orthotics. Instead, we are fast becoming the standard of care of orthopedic foot surgery, wound care, and regenerative sports medicine as we continue to acculturate podiatry. Should other professions draw a line in the sand to prevent that from happening?
Dennis Shavelson, DPM, CPed, Tampa, FL
07/06/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1A
From: Jeff Root
Dr. Rotwein asks if you would teach a non-podiatrist how to cast for orthotics. I suggest that the answer to that question depends on who and why you might want to teach others to cast for orthotics. If the podiatrist is skilled at casting and is capable of training a non-podiatrist such as an office assistant to properly cast, then the answer might be yes. In this scenario, the podiatrist can personally evaluate the cast or scan of the foot and can prescribe an appropriate orthosis for their patient.
However, in my opinion it would be inappropriate to train a non-podiatrist to cast if that person was not qualified or was not working under the supervision of someone who is qualified to prescribe, dispense, and provide any necessary post-orthotic follow-up. Successful foot orthotic therapy requires both a quality cast or scan of the foot and an appropriate prescription that is specific to the individual patient’s condition and needs.
Jeff Root, President, KevinRoot Medical
07/05/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 2
From: Todd Rotwein, DPM, Lawrence Rubin, DPM
I would ask my esteemed colleagues, where exactly would you draw a line? Would you teach non-podiatrists how to cast for orthotics?
Todd Rotwein, DPM, Hempstead, NY
I agree with Dr. Markinson that podiatrists should not withhold information about podiatric approaches to patient care from other health professionals. Similarly, I find it very disturbing that some podiatrists openly tell me they will not provide preventive diabetic annual comprehensive foot exams, because wound care is their practice's "bread and butter." I realize that this opens up a whole can of worms regarding what is and what is not ethical professional conduct, but ignoring these realities helps no one.
Lawrence Rubin, DPM, Las Vegas, NV
07/05/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1
From: Allen Jacobs, DPM
I read with interest the decision in the state of Pennsylvania that a podiatrist may act as supervisor for a CRNA. Based on my prior experience, I suggest that one approach this with caution as an example of being careful for what you wish for.
Some years ago, I acted as a defense expert in a wrongful death case. In this particular state, absent the physical presence of an anesthesiologist in the operating room, the “surgeon“ was responsible for the actions of the CRNA. In this particular case, the nurse anesthetist gave a medication by bolus which was contra-indicated. The podiatrist was busily performing an excision of a ganglionic cyst. Unfortunately, the patient expired.
In addition to suing the anesthesia group, the podiatrist was also held liable due to the fact that...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
07/02/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 2B
From: Robert Scott Steinberg, DPM, Bryan C. Markinson, DPM
I think some of my colleagues are being quite naïve, or their egos have gotten the better of them! There was a time when DPMs owned orthotics.
If you don't respect our specialty, find another profession.
Robert Scott Steinberg, DPM, Schaumburg, IL
I need to point out some wrong conclusions by Dr. Ribotsky. Firstly, prior to coming to Mount Sinai, I ran a private solo community practice for 16 years, and taught anyone and everyone who asked anything they wanted to learn, believing in that ethic long before I came to Mount Sinai. It brought me more patients, never less. I do agree that academic center practice is different from community practice. Still, I cannot imagine ever that teaching a nurse practitioner or a PA coming back to hurt me by losing patient volume...and in his last statement, about nurse practitioners replacing us.
I know Bret for many years, and when he was actively practicing podiatry, I know for a fact that he never worried about that, as I do not. As the nurse practitioner or similar professionals get more and more into podiatric care, it has nothing to do whatsoever with what podiatrists are teaching them, but rather what practice enhancing opportunities exist that podiatrists continue to trivialize or downright ignore.
Bryan C. Markinson, DPM, NY, NY
07/02/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 2A
From: Ben Pearl, DPM, Stephen Peslar, BSc, DCh
The medical world is a big interconnected ocean; even more so in the age of the Internet. My experiences have led me to the conclusion that teaching is noble, but it is best to know your environment. Know whether you are swimming with the dolphins or the sharks.
Ben Pearl, DPM, Arlington, TX
I worked in a publicly funded foot clinic with 2 other podiatrists. We provided hands-on training to nurses. It seemed to go well. When 2 podiatrists retired, applications for funding 2 positions were filed with management, while the podiatrist and 3 foot care nurses were still at the foot clinic. Then a budget cut occurred and the podiatrist was downsized. Now there are 3 foot care nurses at the foot clinic. They refer patients to their PCPs when a foot problem or lesion requires advanced treatment or examination or radiographs. In retrospect, perhaps if the podiatrists did not train the nurses, then 3 podiatrists would still be working at the foot clinic.
Stephen Peslar, BSc, DCh, Toronto, Ontario, Canada
07/02/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1
From: Alan Ng, DPM
Interesting post by Marc Jones, interesting how he takes one year to post for open payments. He doesn’t understand that investing in a company when they start up is a risk. That money sits for years hoping that it does well and we get lucky. Every other year, the amount made on that site was a fraction of what was made in 2019. Most of those payments were from speaking and teaching. While someone like Marc is sitting at home, those of us who work with industry are away from our families designing or teaching other physicians new techniques or better ways to perform surgery.
Alan Ng, DPM, Denver, CO
07/01/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 2B
From: Kathleen Satterfield, DPM
I was surprised to hear my friend Bret Ribotsky’s take on educating other healthcare providers as to the ways of podiatric care. My experience has been the opposite. In the early 2000s, I wrote a BHPR grant that called for cross-training between family practice physicians and podiatric residents at UT Health Science Center in San Antonio and it was generously funded. Our residents learned how to recognize common health problems they could treat as did FP residents learn how to take care of basic foot problems and more importantly when to refer to us for more complicated care.
It had exactly the opposite effect than what Dr. Ribotsky said. The Podiatric Service got more referrals as did the FP department but both were more accurate and useful. Unfortunately I left UTHSCSA before I had an opportunity to write up the study results but anecdotally they were positive. An internist may know how to perform an ingrown nail avulsion but that does not necessarily mean they are prepared to do it, comfortable to do it, or even want to do it.
I respect my colleague Dr. Ribotsky very much but my experience does not mirror his. In my experience, if interprofessional education teaches my colleagues to do what I do, it may instead make them respect my skills and say “You are the expert here. Please go ahead and do what you do best.”
Kathleen Satterfield, DPM, Pomona, CA
07/01/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 2A
RE: WA Podiatrist Trains Nurses in Medical Grade Footcare (Bryan Markinson, DPM)
From: Bret Ribotsky, DPM, Sheldon Nadal, DPM
Editor's note: Dr. Ribotsky's video response can be viewed by clicking here.
I agree with Dr. Markinson’s point of view. I think that by sharing your knowledge with other medical professionals, you are more likely to gain a fan and more referrals than lose referrals.
Sheldon Nadal, DPM, Toronto, Canada
07/01/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 1
From: Marc Jones, DPM
Dr. Ng expressed his frustration in hospitals beginning the trend that was started by ASCs of making physicians use “cost-effective” implants. Why is he concerned with this? You don’t have to look any further than openpaymentsdata.cms.gov. In 2019, Alan Ng made $661,755.13 from biomedical companies, including Paragon 28, Zimmer, and Wright among others. 83% of that money came from ownership or investment interest in the companies and another 13% in consulting fees. If this trend continues, he himself will stand to lose a lot of money if the expensive implants cease to be used in the hospital setting. It is hard to believe that he is concerned about patient outcomes.
Marc Jones, DPM, Spokane, WA
05/21/2021
RESPONSES/COMMENTS (NEWS STORIES) - PART 2
From: Randall Brower, DPM
This article about flip-flops does a huge disservice to our profession. There is absolutely no "good" flip-flop on planet earth! Flip-flops require the foot to over-flex the toes, engage the Achilles too early during gait, and lead to neuromas, hammertoes, foot cramping, and Achilles tendinitis along with PT tendinitis among other over-use syndromes. Marketing gimmicks like "fit-flops" or arch-support flip-flops are terrible for our feet.
I thought I would be preaching to the choir, but I guess not in this case. It's frustrating that podiatrists have been suckered in to marketing gurus who couldn't care less about feet. There are no biomechanical reasons we should be advocating for flip-flop usage. We, as foot health specialists, should only advocate footgear that is healthy for our feet.
Randall Brower, DPM, Avondale, AZ
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