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10/05/2020
RESPONSES/COMMENTS (NON-CLINICAL)
From: Elliot Udell, DPM
Thank you Dr. Klirsfeld for starting a very interesting discussion. For starters, we all have to accept that many patients who come to our offices are in pain and are stressed out. People exhibit this in different ways and sometimes take it out on staff. It's important to meet with staff and let them know that unless the situation is extremely odious, approach all patients with the old adage: "the customer is always right." Sometimes just listening to a patient who is "ranting and raving" can calm things down.
It is also important to determine if the staff member who is complaining about a rude patient has a "low boiling point" for patients who may have gotten up on the "wrong side of the bed" that day and may need an ounce of TLC. Such staff members may need to be trained on how to deal with difficult patients or need be have their jobs terminated. There are programs available online that can help train all of us with dealing with difficult people in trying situations. My staff and I are taking one such program right now. If anyone is interested in any of these courses, contact me personally and I will be happy to furnish you with leads.
Elliot Udell, DPM, Hicksville, NY
Other messages in this thread:
09/15/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Keith L. Gurnick, DPM
Frustrating as it may be, there are still some medical specialists who are so full of themselves that they feel comfortable giving patients mis-information on topics where they have little expertise or experience. In the world of custom prescription foot orthotics, this is also commonplace. Trying to educate these "experts in everything" is a noble effort, but I prefer to pick and choose my battles and fight the battles I know I can win. I would rather spend my time educating my patients than educating the doctor who probably made a quick off-the-cuff remark anyway.
Patient education should have been done in advance, not retroactively when the concern or complaint was presented. Regarding a refund. If a patient wants their money returned, the reason is inconsequential. I would give the money back; it happens so infrequently it does not matter. If the orthotics have already been dispensed, I would first get the orthotics back, and if they have not been made, I would cancel the order. If they have been made but not dispensed, I would pay the lab fee, and I now have a brand new unused set of orthotics to show the next patient what a custom prescription foot orthotics looks like.
Keith L. Gurnick, DPM, Los Angeles, CA
09/15/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: Increased Risk of Fatal Falls
From: Paul Kesselman, DPM
A recent article in September 7, 2025 NY Times entitled "Why Are More Older People Dying After Falls," is a must read for every physician, no matter their specialty. The NY Times article points out a three-fold increase in fatal falls over the last thirty years. This compared to a decreased or steady number of fatal falls per capita in other countries.
The reason cited by both the NY Times and its source is the increased reliance on Fall Risk Increased Drugs (FRID) in the U.S. JAMA News while a much lengthier read, provides a substantial amount of statistical analysis and is the foundation of the findings cited in the NY Times article..
Having no other motive but to decrease falls in our most fragile patients, it is imperative to...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
09/13/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1D
From: Burton J. Katzen, DPM
When I was in practice and was confronted with this problem comparing orthotics/Hyprocure to store bought arch supports, I would try to educate the patient in layman's terms the difference between pronation and simple flattening of the arch, telling the patient that the majority of the problem was not the height of the arch, but the amount of abnormal motion that occurred when the foot beared weight.
I would demonstrate this by forcefully "shoving" my fist into the patient's arch and showing that I could still easily pronate/evert, or in their words, "flatten" the foot from the sub-talar joint, imitating what an arch support did. I would then lock in the heel with just my thumb to show that I could no longer pronate the foot to demonstrate the difference in control.
I also would never knock a store-bought orthotic telling the patient that, "Hey, The reason Dr. Scholl was rich is because store-bought arch supports do work for many people just like store-bought readers do work for some patients, but other patients need professional care." Also, in my experience, most of the patients I came into contact with had already tried the store bought orthotics.
Burton J. Katzen, DPM (Retired), West Pam Beach, FL
09/13/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: David S. Wolf, DPM
I can understand your frustration—and fortunately not very common. When I was in practice, I would have taken the high road in these situations and re-focus the conversation on patient education. I explained the purpose of the custom orthotics, the biomechanics involved, and why we recommended them based on their specific foot structure and pathology.
If they’re still not receptive and demanding, I would make a refund. For every one non-compliant patient, there were too many to count compliant patients. Ultimately—is the time, energy, and potential negative review worth the fee? And most importantly, I wouldn't let one orthopedist's opinion shake your confidence in the value of what we do.
Sometimes, it’s just better to give a refund and move on to the next treatment room. Say to yourself before you walk in, "It's showtime"-and make that patient feel like they are the only patient you have. Patients don't care what you know, they just want to know that you care (Bernie Hirsch, of blessed memory).
David S. Wolf, DPM, retired
09/13/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Dieter J Fellner, DPM, Ivar E. Roth, DPM, MPH
Custom orthoses cost hundreds more than OTC devices, and current evidence shows they don’t correct bunion deformity and are not superior to pre-fabs for most common foot pain. However, that doesn’t make them “bogus.” Orthoses can reduce pain and plantar loading, and custom devices are appropriate for patients with complex foot structure or failed OTC trials. For early bunions with over-pronation, they won’t reverse the deformity, but they can reduce symptoms and mechanical stress—which is a valid treatment goal. Our job is simply to match the level of support to the patient’s needs, not to oversell either option.
I guess the question, then, is what unique biomechanical findings does the patient have, to warrant the added expenditure?
Dieter J Fellner, DPM, NY, NY
I would call up the orthopedist and make an appointment to go speak to him. Here is a way to turn a lemon into lemonade. In this meeting, explain what you are doing and why it is preferred to an OTC insole. Hopefully, you can get him to send to you all of his foot patients who need orthotics. It is certainly worth the effort in my opinion. Or make a pair for him gratis. I recently made a pair for an orthopedist in town, and now he sends me ALL his orthotics that he was sending to Hanger.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
09/13/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Carl Solomon, DPM, Bret Ribotsky,, DPM
My response has always been that custom orthotics vs. off-the-shelf are akin to prescription eyeglasses vs. "readers' purchased at the drug store. I told patients that it probably wouldn't hurt to try the OTCs and occasionally with a little luck, they may help some. But although there are no guarantees, the custom orthotics (like prescription eyeglasses) are more likely to be effective since they are custom-fabricated to address a specific problem. In actual practice, it hasn't really happened but If a dissatisfied patient elects to change their mind and cancel them before lab fees are incurred, I suppose I'd give them a refund. Otherwise, if based upon someone else's criticism alone, I would not.
Carl Solomon, DPM, Retired, Dallas, TX
This is an incredible opportunity to turn lemons into Limoncello. I dealt with this often when I first started practicing a long, long time ago. What I would always do is call the orthopedics office, set up an appointment to either meet him for breakfast or dinner, and spend the time to show him how custom biomechanical orthotics can reduce the pain in a patient’s knees and prolong his knee replacements and hip replacement by realigning the forces. Every time I did this, I was able to generate an additional 20 to 50 pairs of orthotics a year from each orthopedist.
Bret Ribotsky, DPM, Fort Lauderdale, FL
08/25/2025
RESPONSES/COMMENTS (NON-CLINICAL)
From: Joel Lang, DPM
Many years ago, when I first came under the tutelage of Dr. Charlie Turchin, one of the first things he taught was to remove all the springs from clippers and nippers. His reasoning was that you get a better precision and feel for the tissue you are cutting through without having to first overcome the resistance of the spring.
I admit that at first it seemed awkward and difficult and required a different grip on the instrument. My 4th finger became the spring. Once mastered, it did give me a better feel for the tissue. I never used a spring on an instrument for the remainder of my 32 years of practice. Try it!
Joel Lang, DPM, Retired, Cheverly, MD
08/22/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Dominic Bianco
While it may be more reasonable to change the springs in-house, it can be a daunting and dangerous task. Through my 50 years of providing quality service to podiatrists, I have probably changed and installed well over a million nail nippers springs. Things can happen. Screws can break, screwdrivers can cut your hand, especially a screwdriver that is thin enough to properly loosen and tighten the very small screws.
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Screwdriver injury |
Nail cutters are usually sharp; they can also cut you. I’ve been wounded by screwdrivers many times. This one being the worse case. We have thousands of springs and nipper screws in stock and we can also make custom size springs for any instrument, if needed.
Dominic Bianco, CEO Bianco Instruments LLC
08/22/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Keith Gurnick, DPM
In my office, I keep a small box filled with used, worn out or broken instrument spare parts, and screws from broken tissue nippers and nail trimmers with broken springs. Often, when a spring breaks on a tissue nipper or a toenail clipper, I can easily replace the broken part quickly and simply with a similar part that I saved, and am able to locate in the box. Otherwise, the broken instrument goes into the box, or into the trash, and I will purchase new ones.
However, if you have broken two out of four new nail nippers, either the quality of the nipper is poor (Pakistani stainless steel vs. German stainless steel) or you are using too small of a clipper on too thick a toenail, or you may be heavy-handed or rushing, or you might just need a larger nail clipper, or you may need to "adjust" or "modify" your toenail clipping technique.
Keith Gurnick, DPM, Los Angeles, CA
07/31/2025
RESPONSES/COMMENTS (NON-CLINICAL)
From: Paul Kesselman, DPM
Thank you, Dr. DiResta, for pointing out the fact that APMA discontinued their sponsorship of the Dartmouth MPH program. I was totally unaware of that, but the fact remains that when it was in place, it provided graduates who went onto non-clinical careers or it simply improved those individual's status in whatever clinical programs they were involved with. Now that Becker's has published the story I wrote about where both MD and DO programs are offering dual programs for medicine and MPH or MBA, perhaps it is time that APMA reassess its importance. Perhaps APMA, if it cannot afford to sponsor this program itself, can partner with other private enterprises which have profited from podiatry well over the years to offer such scholarships to individuals interested in one of these programs.
I have been made aware for some time that APMA has serious financial issues. Having been a member of various committees over the years as well as...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
07/30/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: William Wayne Egelston, DPM
I too enjoy the posts in PM News. Whether one agrees with the authors or not, doesn't detract from their insightfulness. I appreciate the dialogue presented by Drs. Kesselman and DiResta and others on this topic. Considering how things are evolving for podiatrists with diminishing numbers of qualified (academically prepared) applicants, likelihood of schools (some or all) closing and increasing number of MD/DO schools on the horizon. It would seem to me a likely scenario might be that future applicants matriculate to MD/DO schools (domestic/foreign), complete orthopedic residencies and foot and ankle fellowships (or others), then train physician extenders (LVN, RN, NP, PA, etc.) in C&C, nail care, and primary podiatry. I see this as a more plausible pathway than watching our decline and obsolescence.
I see this as I, along with other DPMs at Kaiser (California), functioned in...
Editor's note: Dr. Egelston's extended-length letter can be read here.
07/30/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Rod Tomczak, DPM, MD, EdD
Dr. DiResta gets it! It's not because he mentions me or my ideas about the DO path to an unrestricted license but because of his observations concerning the DPM degree NOT being a starting point to move forward. It is a starting point to move laterally. You can have an MHA, MPH, or a PhD in healthcare, but try to aspirate a knee and see how far a master's degree gets you.
Get the DO degree, then enough ACGME-approved residency time to get an unrestricted license, followed by an APMA fellowship in podiatry from Temple, Touro, LECOM, DMU, or UTRGV. Now you can move forward from your starting point.
Rod Tomczak, DPM, MD, EdD, Columbus, OH
07/29/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: AOFAS and Podiatry
From: Jeffrey Trantalis, DPM
The American Orthopaedic Foot & Ankle Society (AOFAS) was started in Chicago in 1969. The organization officially added “Ankle” to its name in 1983 to reflect a broader clinical and surgical focus. I was practicing in The State of Washington during this time. One of their goals was to put podiatrists out of business. The irony and sad part of all this is that some of the orthopedists were trained by a podiatrist at Harborview Hospital. Now they have their own institution teaching our profession to orthopedists. The bottle has been opened and now we are paying for it.
Jeffrey Trantalis, DPM, (Retired), Delray Beach, FL
07/29/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: James DiResta, DPM, MPH
I normally enjoy comments from Dr. Kesselman on the blog, but I do believe he has missed the mark on his recent entry regarding the DPM degree. I can also speak to his comment on the fellowship program at Dartmouth which had been a positive initiative for the profession, but it is simply not true that this is just getting started in the world of allopathic medicine. I completed the program at Dartmouth from 2002 thru 2004 in the initial MPH class and was taught by several MD/MPH faculty. I chose Dartmouth because of their initiative to change the business of what we knew as healthcare delivery and, for both good and bad, they were influential in forming the Affordable Care Act (Obamacare) and the development of what we know today as an Accountable Care Organization (ACO). They continue to be a leader in healthcare delivery innovation.
What I don't think Paul realized is that with present financial constraints on APMA, they have chosen to place their priorities elsewhere and discontinued funding for this fellowship program. This program provided the opportunity for fellows like...
Editor's note: Dr. DiResta's extended-length letter can be read here.
06/26/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: James DiResta, DPM, MPH
While I don't disagree with the need for podiatry to visit more colleges to gain more exposure to potential applicants, I am more concerned about the watering down of our applicants' strength to schools of podiatric medicine. The problem as we have stated over and over is how can we possibly get enough qualified students is this diminishing pool. Schools of osteopathic medicine are growing exponentially. For example, have you ever heard of Debusk College of Osteopathic Medicine? It has two schools in Tennessee now and a third opening in Florida in 2026. Did you know MSU has three campuses now of osteopathic medical students. How about Meritus School of Osteopathic Medicine in Maryland? How about The Edward Via College of Osteopathic Medicine (VCOM) now in four campuses!
There are 43 osteopathic schools listed but in reality there are presently 69 campuses and many more coming. The mean MCAT of all their schools for 2024 is 502.43 and falling. Several of the schools are below...
Editor's note: Dr. DiResta's extended-length letter can be read here.
06/26/2025
RESPONSES/COMMENTS (NON-CLINICAL) -PART 1B
From: Ivar E. Roth, DPM, MPH
Kudos to Drs. Tomczak and now Saxena. I have written this in PM News before without any evidence, but as told to me from my son who recently graduated. He said a good number of students in his class should never have been allowed to be accepted in the first place. A fair number dropped out after the first and second year, but he felt that there were many in his class that just graduated who were barely hanging on and probably should have been weeded out.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
06/24/2025
RESPONSES/COMMENTS (NON-CLINICAL) -PART 1
From: Amol Saxena, DPM, MPH
Mic drop for Dr. Tomczak! Makes me think of the Jack Nicholson line, "You can’t handle the truth." Promoting podiatry is one thing and lowering standards to fill seats is another. Kudos to him for doing the research and pointing out the current data available.
Amol Saxena, DPM, MPH, Palo Alo, CA
06/23/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Other Non-MD, Non-DO Doctor Healthcare Providers
From: Rod Tomczak, DPM, MD, EdD
I thought it might be interesting to look at the data surrounding other non-physicians, but in a non-judgmental view, of course. Draw your own conclusions but be sure to refrain from rash judging anyone blowing their own horn about how hard they work and the good they do. A lot of the following data had large ranges, so I used the Jethro Bodine average technique. For those who aren’t familiar with Jethro, it went something like; “Cipher, carry, naught, naught, carry, cipher, etc…”
Doctors of Chiropractic
There are 18 accredited chiropractic colleges in the U.S. with 2,800 first year students right now. In 2023, approximately 2,700 students were awarded a Doctor of Chiropractic degree. Tuition per year averages about $30,000 and the average income is $89,000 per year. Average admission GPA is 3.38 and a school can suffer loss of accreditation if they admit anyone with a GPA below 3.0. Most accredited chiropractic schools offer...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
06/13/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Alan Sherman, DPM
It is gratifying to see the last two messages from Drs. Pressman and Tomczak supporting the need for some kind of dual track 3-year residency training program to best meet the training needs of both predominantly surgical and medically oriented podiatrists. We are all proud of what our profession has accomplished in the development of the standardized 3-year surgical residency model. It seems to be producing excellent foot surgeons that are well respected in medical delivery systems, well employed, and well rewarded financially. But these two individuals seem to agree with me that it is time to catch our breath and assess whether these training programs are the best that we can do in training ALL the podiatrists that the U.S. population needs to provide for their foot care needs in the decades ahead.
My main concern is that a resident’s time is well spent training in the work that they will be doing after their 3 years are up. Believe me, I know that restructuring what was years in the making will be difficult. But perhaps some programs are already well suited to offer more clinic-based outpatient training for residents heading for more medically oriented office-based practice? And where does wound care, which occupies so much of podiatry practice, fall in this dual track system? I’d like to hear opinions of other PM News readers.
Alan Sherman, DPM, Boca Raton, FL
06/13/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Compensating for Podiatric Surgeons Who are Not Trained In General Podiatry
From Elliot Udell, DPM
There has been a great deal of discussion on how to compensate for a lack of training in general podiatry at some of our 3-year residency programs. The issue is that many who complete these programs are masters in foot and ankle surgery but are not trained in how to manage patients with "corns, calluses, warts, ingrown toenails, and other "bread & butter" pathologies.
When I did my residency many years ago, we treated patients at a hospital-based general podiatry clinic several days a week, managed all foot emergencies in the ER, and assisted podiatric surgeons and orthopedic surgeons in the operating room. Many programs today, as has been well pointed out, are strong in surgical training but lacking in general podiatry training. The root of the problem may be that these programs may not have standing general podiatry clinics. If that is the case, these programs can work with general podiatrists and have residents rotate through their offices in order to master the non-surgical aspects of our profession.
Elliot Udell, DPM, Hicksville, NY
06/12/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Martin M Pressman, DPM
Thank you, Dr. Tomzack for not burying me. I do remember my trip to Ohio State to review your program. Things have indeed changed and evolution continues in spite of the inertia. In the last PM News, there was an interesting article by Jarrod Shapiro, DPM about surgical vs non-surgical podiatry. The article is apropos to the issue at hand. As I see it, the unified 3-year residency has brought podiatry to parity with medicine with respect to post-graduate training hours. Of course this is not the solution to all issues with respect to the profession's duality (medicine vs surgery). Medicine struggled with this issue when GI docs started endoscopy and cardiologists and radiologists became interventionalists.
Somehow they solved the issues between cardiac surgeons, vascular surgeons, and general surgeons and their respective medical colleagues. Disparate training algorithms, yet somehow they work together. I saw that at Yale for 25 years. I do not have a solution for this profession's problems, but I am sure that solutions exist. Perhaps the 3-year training model can have a medical model leading to an optional approved foot surgery fellowship for those PM trained DPMs who want or need to do surgery. The surgery done in the podiatric medical model plus a one year fellowship perhaps could lead to ABFAS foot surgery certification. There is an answer that could satisfy all parties involved. This probably will not stop the turf battles that seem incurable within medicine and podiatry. The answer is NOT to allow our medicine board to certify in surgery!
Martin M Pressman, DPM, Summerville, SC
06/12/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Martin M Pressman, DPM
Dr. Kesselman asks why podiatry was “not even listed” in the AMA article on scope creep of lesser trained (post graduate hours/residency) providers. The article does not mention podiatry for good reasons. Our training hours are consistent with most MD and DO post-graduate programs. I have been part of the “parity movement” for all of my 50-year professional career. I have seen the AMA/Orthopedic partnership fight every advance podiatry has made and call it the derogatory term “scope creep”. This article was based on measuring competence and patient safety on hours of post-graduate training. (Pedagogically sound?) In all comparisons, the article stresses the lack of training hours for the professions listed. The fact that podiatry was not on the list is simply because our training has reached “parity”.
Of course, the AMA article does say one must go to an MD/DO medical school to be a physician. I am also fairly certain no orthopedic input was sought by the author or we would have somehow been number one on the list. In the end, not being on this list or even mentioned in an AMA article on scope creep is, in my view, a reluctant acceptance of our training model.
Martin M Pressman, DPM, Summerville, SC
06/11/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Rod Tomczak. DPM, MD, EdD
I would like to comment on the letter by Martin Pressman, DPM. In the spirit of true transparency which I insist upon, Dr. Pressman was one of my trainers at Metropolitan Hospital in Philadelphia where I completed a two-year residency beginning in 1977. I am neither afraid to bury or praise podiatrists who have influenced my life.
When I arrived at Ohio State University from Des Moines CPM in 1995, there were two foot and ankle care givers for the 35,000 faculty and staff plus their families who were self-insured by the University’s prime care, 55,000 students and outside patients. The two foot and ankle physicians were the chair of the department, Sheldon Simon, MD and myself. I asked him if I could start a surgical residency program shortly after arriving. He told me...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
06/11/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Paul Kessleman, DPM
I hope Dr. Pressman can answer a question or two about the reference AMA article. I agree that the three-year 4/4/3 model may have helped elevate us to the point where podiatry is no longer negatively noted in this interesting article. Unless I am missing something, however, I failed to see in the reference article any mention of podiatrists at all. The physicians who were listed were MDs, DOs, even optometrists and naturopathic physicians.
I guess the good news is that nothing was noted negatively about DPMs, but where does that leave us if we are not even listed? I am sure those of us who read the AMA article would appreciate some interpretative explanation for this. Or if I missed something, please let me know.
Paul Kesselman, DPM, Oceanside, NY
06/03/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Alan Sherman, DPM
Dr. Jacobs has somehow gotten the impression that someone is arguing for less than 3 years of residency training for podiatrists, so he continues to argue that we need 3 years of training. I don't know how he has gotten the impression that any of us want to reduce the length of residency training. I have not seen anyone express that opinion and I have certainly not expressed it. He is arguing, strongly, against no one. And he regales us with an, admittedly, heroic recounting of his treating a life-threatening necrotizing fasciitis and making sophisticated decisions regarding IT. Good for him. I admire him. But how many podiatrists or for that matter, MDs/DOs want that kind of practice?
Most podiatrists would gladly refer that patient to him or the other minority of DPMs or MDs/DOs who want to treat that high risk, critically ill patient. We speak in this forum about the danger of prospective students reading negative opinions and criticism about the profession. But what do you think is the impact on that student with reading that treating this type of patient is what they will be doing as a podiatrist? How does that affect their inclination to apply to podiatry school? My opinion is that we need a few heroic foot surgeons like Dr. Jacobs in each community who do these types of cases, with the rest referring those cases to them. All DPMs need not be created in his image. We need a variety of podiatrists to treat the cross-section of patients who see podiatrists, and their training should be appropriate for what they actually do treat.
Alan Sherman, DPM, Boca Raton, FL
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