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From: Allen Jacobs, DPM 


Customer is defined as an individual (or organization) purchasing goods or services. When doctors became “providers,” patients became customers. The enthusiastic utilization of urgent care centers by patients illustrates the declining value of the doctor-patient relationship in exchange for service convenience. How many new patients do you see because “you were on my list of providers”? How many patients do you not see because you are no longer a provider for a particular third-party payer? How many lectures or seminars do you attend about maximization of profit from your customers/patients? People have to a large extent changed. They demand convenience, are increasingly demanding, lacking courtesy, and social graces. Egocentricity has become the new normal.


No, the patient/customer is not always right. I have no hesitancy to discharge patients who are abusive to staff or office policy. My charge is to provide quality care and support. Neither I nor my office exist for any other purpose. Nor should yours. You have studied too much, sacrificed too much, worked too hard, and are bound by ethical charge to be treated with other than the respect which you have earned. Conversely, to paraphrase Sir William Osler, MD, once profit and business become your priority, you have lost the spirit for which you entered healthcare. Under those circumstances, you do indeed have customers not patients. You have a business not a medical practice. As such, the customer is always right.


Allen Jacobs, DPM, St. Louis, MO

Other messages in this thread:



From: Ron Werter DPM


I fully agree with Dr. Kiel. A few years ago, I was having an excellent conversation with a salesman in a major shoe store here in New York City. I finally asked him his name. He proudly responded, "It's on the sign in front."


It’s the same with us; whose name is on the front door? It’s your office, you make the rules. If the non-compliant person doesn’t like it, probably don’t want them as a patient anyway.


Ron Werter, DPM, NY, NY



From: Ivar E. Roth DPM, MPH 


I have found a simple way to solve this problem. When a problem occurs, I speak to both parties to get both sides and then and only then do I make a decision on how to handle the problem. I NEVER take either the patient’s word or my employee’s alone. Based on what I find out, I act accordingly. Surprisingly, it is about 50-50. My suggestion is never back the employee until you know for sure.


Ivar E. Roth DPM, MPH, Newport Beach, CA



From: David E Gurvis, DPM


I find patients are rude to the staff for several reasons. Pain and anxiety are uppermost. Fear of what the doctor might do, especially if they are fearful that it might include a needle. Having stress at their workplace for having taken off to even see a doctor. Financial reasons. And many more. I agree with what Tim Shea, DPM has said as well. And I will always try to turn a “bad” patient into a “good” patient. However, some people are just naturally rude and feel superior to those they feel are working for them. This is how they interact with the world around them and they carry it into the office.


The older I get, the less I find I tolerate rudeness. Life, and the day at the office, is too short for that. I don’t work for patients. I work with patients. For those who cannot be “turned,” I find discharge is appropriate.


David E Gurvis, DPM, Avon, IN



From: Jay Kerner, DPM, Judd Davis, DPM


Thank you, Dr. Ricketti, for your phenol EZ Swabs. I’ve been using them for years and haven’t looked back.


Jay Kerner, DPM, Rockville Centre, NY


I contacted the manufacturer of our phenol years ago to find out how long it lasts since there was no expiration on the bottle. We were told that phenol really does not degrade if stored properly in a dark cabinet. I can confirm that it is effective for years as I've had several patients return for other foot issues after undergoing matrixectomies with it, and had no evidence of regrowth. I caution that if you buy it through a local compounding pharmacy, it may not have the same longevity though. I previously used some sodium hydroxide from a local pharmacy that was effective for no more than one month after it was made up, so I switched back to phenol.


Judd Davis, DPM, Colorado Springs, CO



From: James R. Hanna, DPM


As the newly elected President of the New York State Podiatric Medical Association, it bothers me to see division within our profession. NYSPMA serves to represent all of its members regardless of level of training, board certification or any other factor. As an association dedicated to the advancement of podiatry, we wish to see that all of our members achieve their highest potential within the profession.


New York, unfortunately, has one of the most restrictive scope of practice laws in the country. NYSPMA has worked for many years and at great cost to improve the scope of practice in New York so that our members are able to practice to the full extent of their education and training. The legislative process is long and arduous; and at times, limitations have been imposed that were neither sought nor wanted by NYSPMA. For anyone to think otherwise suggests limited knowledge of the legislative process or not comprehending the relationship of NYSPMA to its members. To this day, we continue to work to improve and refine our scope of practice bill.


As a member-driven organization, NYSPMA fields committees that work to improve the practice of podiatry for all members. One of these is the Legislative Affairs Committee. Members from across the state work on this committee throughout the year and many also participate in Lobby Day, an annual event where we meet with state legislators in Albany to make the case for our improved scope of practice bill.  


James R. Hanna, DPM, President-NYSPMA



RE: DEA Registration Fees to Rise (Richard Rettig, DPM)

From: Brian Kiel, DPM


We are repeatedly bombarded with the concept of podiatrists having an MD license but then there are complaints about a fee for DEA license costing less than $300 a year. That’s $25 a month. Don’t eat lunch one day a month. Can you see orthopods complaining about this. Please!


Brian Kiel, DPM, Memphis, TN



From: Judith Rubin, DPM


Surely, there is a chemist in the profession or in one of the smaller Pharm labs that can make it cheaper. I had a bad neuroma in 1986 in my left foot, third interspace. I used the combo of .5% Marcaine and alcohol 7 times in my left foot. I never had surgery and never had a problem again. This combination has worked on thousands of my patients. I am sounding the alarm for the pharmacologists or chemists that are in our profession to make an affordable denatured alcohol. 


Judith Rubin, DPM, Cypress, TX



From: Jeffrey Kass, DPM


I have used 4 percent dehydrated alcohol injections in my practice ever since attending the first podiatric dermatology and plastic surgery seminar given by Dr. Dockery in Chicago. This treatment became my primary treatment when steroids were not working consistently and I was seeing patients coming to me for second opinions which MRIs revealed plantar plate ruptures. 


Since giving these injections, I think I have done one decompression as there is no need to do surgery due to the effectiveness of this treatment. I have the utmost respect for Dr. Peacock, who is an incredible teacher, and would love for him to expound on the damage caused by this injection. I can’t recall any patient complain of any side-effect from this injection. (I give 1ml, inject directly between met heads, series of three injections every two weeks). There are published articles of radiologists giving much higher concentrations under ultrasound guidance directly into the neuroma. If a patient has pain and the pain is eliminated with no complaint of post-injection pain or numbness, what is the damage to the nerve? I think a patient would have a complaint if the nerve is damaged, no? 


Jeffrey Kass, DPM, Forest Hills, NY



From: Howard R. Fox, DPM


This whole mess started when Belcher Pharmaceuticals won approval for its version of the drug Ablysinol for use in treating hypertrophic obstructive cardiomyopathy. Because hypertrophic obstructive cardiomyopathy is a rare cardiac illness, Belcher Pharmaceuticals won orphan designation, which means no other pharmaceutical company could manufacture denatured alcohol until Belcher’s patent expires in 2025. Supply companies have run out of their old stock of denatured alcohol and are forced to stock the Blecher product Ablysinol at its ridiculous orphan drug price.


I expect denatured alcohol will once again become available at a more reasonable price in 2025.


Howard R. Fox, DPM, Staten Island, NY



From: Marc A. Benard, DPM


I agree with Dr. Ribotsky with respect to a distinct absence in gait analysis and applied biomechanics, as well as his indicating “… are we losing the skill to determine the difference between open chain kinetics and closed chain kinetics pathology? If so, how can correct surgical procedures be explained?” I can attest that I observe this deficiency at close hand through my didactic lectures to residents both in person and recently via webinars, as well as through on-site observation at Operation Footprint (formerly The Baja Project for Crippled Children) during patient screenings, grand rounds, and intra-operatively. I’ve also engaged in discussion with program directors on the problem.


In truth, the problem has always existed, if my 43 years of dealing with the issue holds any validity. Fundamentally, the partitioning of “biomechanics” and “surgery” fractionated the...


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



From: Charles Morelli, DPM


You asked to "detail your techniques for reducing toenail hypertrophy". It has nothing to do with technique and all to do with having sharp instruments. If, and only if, your instruments are sharp, can this be done relatively easily and without pain to the patient. A dull instrument will do a less than optimal job and be painful for the patient if you are trying to reduce nail thickness. That being said, I do grind nails, have used a vacuum extractor for the past 30 years, and I now also wear a mask and will continue doing so, long after COVID is gone. I'd be embarrassed to have some patients leave my office without my doing that, but that is just me, as I know others will disagree. 


Charles Morelli, DPM, Mamaroneck, NY



From: Richard Goldstein, DPM


We have been very pleased with our purchase of the Swift machine. We purchased it in November 2019 and are on track to pay for it in full this year. So far, the results have been incredible, especially on recalcitrant warts. We are still working on our process. Some people need local anesthesia and some have not, but either way they are tolerating it. I was really glad to be an early adopter and I feel that within the next few years, microwave technology will be the treatment of choice for warts. I also feel like we have only touched the surface of what medical microwaves can be used for.


Richard Goldstein, DPM, NY, NY



From: Thomas A. Graziano MD, DPM


I decided to buy this new modality/technology because I believe in its mechanism, i.e. stimulating one's immune system to "naturally" eradicate the virus. My experience with the modality has been very favorable. Initially, I was seeing patients who had multiple unsuccessful attempts utilizing different modalities (surgical excision, chemo, cryo, etc.). At the onset, I must admit that I was questioning whether or not anything was happening during treatment, for as advertised, there is no smoke, no visible burn, or heating of the tissue. Don't be discouraged though; this is a very powerful therapeutic modality.


It is not painless. At times, it is necessary to administer local anesthesia, often a PT nerve block if the warts encompass a large region or subdermally in sensitive areas. Each treatment requires that the operator use a new tip. Each tip costs around $75, so be mindful of that if you’re charging a “case fee.” The mechanism of action relies on an intact immune system, so those patients with compromise in this area may require more treatments or be recalcitrant completely. Typically in patients with healthy immune systems, even those who have been resistant to other forms of treatment, from 3 to 5 sessions may be required. "Virgin" solitary warts can be handled in 1 to 3 treatments.


Thomas A. Graziano MD, DPM, Clifton, NJ



From: Steve E. Abraham, DPM


My wife was a nurse practitioner. She worked in the orthopedic department at the hospital and was trained in orthopedic surgery. She learned about orthopedics and podiatry and had a really good knowledge base in both. After a while, her knowledge of orthopedic problems above the ankle was greater than mine. This included joint injections, knee and hip replacements, shoulder procedures, fracture care, and trauma. Our difference was the exposure we got. The things I did I got very good at and had much greater expertise than she did. Yet, she was exposed to so much more after she graduated and started to work.


It is not a question of who knows more, or who is better, the reality is we are all a team and each specialty provides appropriate care based on education, knowledge, and integrity. As a podiatrist, I give really incredible, high-level care to my patients, I treat the problems they come to me for. So did my wife, as a nurse practitioner, in the job she had. There is no competition because we did not compete with each other. We can all learn from and teach our colleagues and become better.


Steve E. Abraham, DPM, NY, NY



From: Alan Sherman, DPM


Dr. Allen Jacobs in a recent letter said, “I was evaluating a post-op Austin-Akin patient today. She told me that she watched the (My Feet Are Killing Me) reality show. Her exact words were; “I’m impressed. I had no idea podiatrists did such complicated things.” This just goes to show you how different a patient’s perspective can be from a physician’s. I’m wondering what she saw on the show that seemed more complicated than the intricate surgery that she had done by Dr. Jacobs. Maybe she meant, “unusual” or “serious” or “rare” or “bizarre”, but complicated? We should all be more aware of how different a patient’s perspective can be from our own.


By the way, keep an eye out for media segments that Drs. Ebonie Vincent and Brad Schaeffer did on the Dr. Oz Show, TMZ, DailyQ, Good Day, and recently, they filmed a segment for the Tamron Hall Show which aired on Friday at 1PM. These two podiatric reality superstars have been quite busy talking up podiatry to a huge national audience.


Alan Sherman, DPM, Boca Raton, FL



RE: My Feet Are Killing Me Cable Series

From: Keith L. Gurnick, DPM


To all of us who are watching or will watch the new show made for TV, "My Feet Are Killing Me" Cable Series, please understand that this is a made for TV show and is for the purpose of  entertainment to viewers. Don't expect to see on television that every patient is greeted, examined, diagnosed, and treated as if you were their doctor in your practice or office. Patients for these types of shows are cherry-picked for various reasons, and filming is edited down to produce a final product without  doctor involvement. 


Do not assume that what you see on TV is the full extent of the treatment. Do not expect many of the patients to exhibit the problems that most of us encounter. These might seem to the TV audience to be extreme and often include unusual back stories for the patient or their families  to make the show more interesting. 


Keith L. Gurnick, DPM, Los Angeles, CA



From: Brent D. Haverstock, DPM


It would seem that if podiatry is to become a branch of medicine (MD/DO), the APMA would have to meet with the American Medical Association (AMA) and the American Osteopathic Association (AOA) to see if there is a desire to see this happen. If there were an agreement, the schools of podiatric medicine would have to close. The APMA and AMA/AOA along with the Accreditation Council for Graduate Medical Education (ACGME) would establish appropriate training programs.


I suggest a 5-year commitment to become a podiatric surgeon and 3-years to become a podiatric physician. Podiatric medicine and surgery would have a single certification board with specialist certificates granted as either a podiatrist or podiatric surgeons. Medical students (MD/DO) could consider podiatry or podiatric surgery as their career path. This is the only way to...


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



From: Leonard A. Levy, DPM, MPH


Elliot Udell, DPM, asks a great question, namely, “Could you offer us some insight into why podiatry has not generated the types of limited specialty practices that we see in dentistry and medicine?” I served a total of 14 years as dean and then president of the then California College of Podiatric Medicine. For another 14 years, I was founding dean of the College of Podiatric Medicine and Surgery of the then University of Osteopathic Medicine and Health Sciences (Des Moines, Iowa). I just spent 17 years as associate dean of the Nova Southeastern University (NSU) College of Osteopathic Medicine learning in detail the intricacies of a DO curriculum. I just completed a year serving of the curriculum committee of NSU’s new allopathic medical school and currently serve as an interviewer of applicants to that school.


I was successful in modifying the pre-clinical aspect of podiatric medical education at the California and Des Moines podiatric medical schools and led the way in California to a podiatric medical residency that was 2 years in duration, virtually unheard of at that time. But the profession for years kept focusing on preparing DPMs who were qualified podiatric surgeons. While vital, it is time to expand that narrow perspective and provide graduate medical education that leads to the production of highly qualified podiatric physicians comprehensively training, experienced, and certified in the relatively neglected area of medicine related to the pedal extremity.


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL



From: Alan Sherman, DPM


The always erudite Elliot Udell’s call to orthotic companies to support biomechanics education is currently being generously met by Scott and his son Robert Marshal of KLM, Michael Friedman of Redi-thotics, and Pavel Repisky of 8Sole, all of whom sponsor podiatric education. 


Doug Richie, DPM shared an important point: for podiatrists, there is so much more to biomechanics than orthotics. While all corporate entities working in the podiatry space should do their share, I would add that while we all appreciate corporate sponsorship, we can’t and shouldn’t ever rely on it to choose what is taught at the colleges or at the post-graduate level.


Alan Sherman, DPM, Boca Raton, FL



From: Ira Baum, DPM


I couldn’t agree more with Dr. Ritchie. Without mastering the fundamentals; one can never become a master. Techniques to cure a deformity develop from understanding the root causes. With the exception of congenital deformities, abnormal lower extremity mechanics play a primary factor. John Wooden, the immortal UCLA basketball coach and philosopher, once said “If you only try to learn the tricks of the trade, you will never learn the trade.” The trade of being an expert podiatrist/foot and ankle surgeon is understanding the cause of the pathology and applying the solution. 


Regarding foot/ankle surgery - without understanding the biomechanical fault causing the deformity, even the surgeon with the greatest hands will fail most of the time. I say most of the time because in golf lingo, "Even a blind squirrel finds an acorn once in a while." Learn what our masters in biomechanics have uncovered and you’re on your way to becoming an expert. Regarding who sponsors lectures at symposiums is an issue, but whatever the solution, lower extremity biomechanics should be an integral part of most conferences, and all surgical conferences.


Ira Baum, DPM, Naples, FL



From: Norman Rubin, DPM, David E Gurvis, DPM


My partner of thirty years tragically committed suicide just as we had sold our practice and were about to retire. He was financially secure and was looking forward to his retirement. In addition to being my partner, he was my best friend. You would have thought that if anyone should have seen the warning signs early on, I would have seen them.


About a month before he committed suicide, however, I noticed a significant change in his personality. I spoke with my partner about my observations, but he insisted that he was doing fine. Nevertheless, I was concerned and...


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


I was also at the memorial service for one of my oldest friends. I have known him for over 30 years. I am also a colleague of Dr. DeHeer and know he is prone to action, not simply talk. When he speaks of suicide prevention in doctors, he is speaking from a position of knowledge and caring. I personally know he cares about others. I don’t know Dr. Bellezza, but I find his comments very offensive and lacking any care or understanding of human psychology.  


Were we able to weed out those who might become depressed later, I would support giving them the ability to accept counseling or medication as necessary, just as I would anyone suffering. However, to prevent someone from entering podiatry school simply because they may have depression is untenable. To simply say we should weed them out, besides being impossible, shows no ability, in my opinion, to exhibit sympathy for those suffering from depression.


David E Gurvis, DPM, Avon, IN



From: Peter Bellezza, DPM


Dr. DeHeer, my original message was to point out that if you want to design a research tool to predict behavior/suicidal ideation in the podiatric residency training model, you have to consider the disparity of training between the individual podiatry residency programs, the training disparity between podiatry residency training vs other med/surgery specialties and the disparity in student preparedness for residency training when comparing the DPM vs. the MD/DO medical education system. If you think there is no disparity in any of the above, then that’s an entirely different debate.


Residents who work longer hours are going to have social factors that can come into play that could increase the potential suicidal ideation. That’s obvious. For residents that have succumbed to suicide, was it really because medicine (the work) drove them to it? Or are we dealing with individuals with extensive histories of anxiety, depression, substance abuse, etc. that entered the field of medicine? These are important questions to ask. 


Understanding the medical and social history of residents may be important screening tools to better identify residents who are at risk during residency training. I look forward to reading the data you produce. I apologize if I offended you and others with my initial response. 


Peter Bellezza, DPM, Bristol, CT



From: Patrick DeHeer, DPM 


Yesterday, as I stood in the hallway at a memorial service for a respected Indiana podiatric physician, Dr. Belleza's response to my post on PM News came to mind as I watched my colleague's wife cry throughout his memorial service and his son sing beautiful hymns. My colleague called me looking for help two days before he chose to take his own life. Our conversation ended on a positive note as I offered some ideas and suggestions to assist him in his time of need. We were not best friends, but we were professional colleagues for more than 25 years. This explains him reaching out to me. 


The Tuesday, after I learned of the incident, I emailed about 30 leaders within the podiatric profession to assist getting our survey out to podiatric residencies so we can, in fact, examine if suicidal ideation in podiatry is similar to that of our allopathic and osteopathic colleagues. Shortly after my initial email, I was informed of four other DPMs committing suicide (one third-year student, one resident, one attending at a residency program, and...


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



From: Elliot Udell, DPM


Doing a survey among podiatric residents and maybe even all podiatrists could reveal important and maybe even life-saving information. That being said, I suspect that the data will reveal that there is a much lower percentage of suicidal ideation among podiatric residents than among MD and DO residents. Why? Although podiatric residents work as hard as any other residents, we do not deal regularly with patients that might be dying of a disease.


When I was a student, I attended an inquest at a hospital rotation. A child died. Present at the autopsy were the pathologist, the pediatric resident, and I as an onlooker. When the pathologist was finished raking the pediatric resident over the coals using 20/20 hindsight, I was afraid that that resident would jump off the roof of the hospital.


With the exception of missing severe vascular disease or a melanoma, we don't deal regularly with life-threatening diseases which could cause us mental anguish. Nevertheless, the survey that Dr. Deheer is working on could tell a totally different story.


Elliot Udell, DPM, Hicksville, NY



From: Allen Jacobs, DPM


With reference to the issue of sterilization vs. disinfection of nail cutting instruments, there is a difference between the theoretical and practical. Do you disinfect your exam chairs between patients? How about counter-tops between patients? Your Doppler probes or blood pressure cuffs between patients? Do you wear sterile gloves while handling your autoclaved nail cutters? Do you discard all multi-dose vials 28 days after initial use? Do you terminally clean exam rooms in which you perform invasive procedures?


I was trusted by the Missouri Podiatric Medical Society to prepare and present sterilization and disinfection protocols to the state society members, as such training is required every 2 years in Missouri. In fulfilling that obligation, I conducted...


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

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