Podiatry Management Online


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From: Howard Dananberg, DPM


Many years ago, I had a new patient present for care. After my nurse's interview with him, she came out and said how angry and mean spirited this man was and wished me good luck. After our visit, we came out laughing and very friendly and she was shocked. It turned out that he only has a small interdigital corn, but his wife of more than 50 years who was recently deceased had exclusively cared for this.   


He was angry at her passing and that someone else was going to treat him. Once we both recognized the underlying cause of the anger, he turned into a long-term, wonderful patient for several years until he died. There are lots of reasons why patients are angry. Sometimes, finding the cause goes a long way towards resolving the basic issues.  


Howard Dananberg, DPM, Stowe, VT    

Other messages in this thread:



From: David Secord, DPM


I had no choice but to laugh when I read the part of the post from Dr. Kiel which stated: "This is a life or death situation." I have several peer-reviewed papers residing on my hard drive which has fully explored the topic of a cloth or OR-type mask being able to stop something the size of a virus. All of them conclude that they are ineffectual. That they don't do anything is right on the box! We know that the death rate for the COVID-19 virus is around 0.1%, which puts it in line with every other seasonal influenza. We also know that we really don't have good numbers on the death rate, as everything shy of diaper rash has been listed as a COVID-19 virus death. We also know that we don't have good numbers for the population who has the COVID-19 virus, as the PCR test (by admission from the guy who invented it) is churning out a 95% false positive rate.


Are there people dying from this contagion? Yes. Is it more deadly than any other coronavirus seen each fall with a new seasonal influenza? Not according to the data. Is the hysteria we are reading, especially the absurd "Everyone has to wear a mask or we all die" hysteria believable? Not if you are sane. Wear a mask. Don't wear a mask. They are ineffectual against something the size of a virus.


David Secord, DPM, McAllen, TX



From: Charles Morelli, DPM


Dear Mrs. _____:


This letter will serve as formal notice that we will no longer be able to provide foot care to you because of the following reasons: 

  • It has come to my attention that you berated a member of my staff  numerous times, after she had gone out of her way to assist you in attaining a copy of your previous MRI.

  •  After speaking with this staff member, she was both visibly and emotionally upset. She has worked here for close to 20 years and no one has ever spoken to her the way you had, especially when she was actively trying to help you attain another copy of your MRI images.

  • If you want the entire disc again, you will have to go to _______, pay $25.00 and they will be happy to give you another copy.         

It pains us to do this as we have known you for many years, but this behavior cannot be tolerated or condoned. As you have already chosen to see another practitioner to address your current condition, I will be happy to send him or her a copy of your medical records and upon receipt of your written request, I will forward a copy of those records to your new provider. As you have already attained the services of another doctor, I am under no legal obligation to continue providing you with treatment and wish you well.   


Charles Morelli, DPM, Mamaroneck, NY 



From: Keith L. Gurnick, DPM


About 15 years ago, I had an issue with an adult female patient, a tough and very wealthy widow and locally well-known philanthropist who dropped in to my office one day without an appointment, requesting to be seen for a non-urgent visit. When we refused her request, she then demanded her medical records and prior foot x-rays on the spot. I am sure some of the readers have encountered this same or similar challenging situation once or twice in their careers.


When she was told that our policy was that we needed a couple of days’ notice to make copies of her chart and physical copies of her x-rays, and that we were not able to stop whatever we were doing to comply with her non-urgent requests, she made quite a scene in front of other patients and stormed out of the office, opening the reception room door so violently that it... 


Editor's note: Dr. Gurnick's extended-length post can be read here.



From: Ben Cullen, DPM


I respectfully disagree with Dr. Gurnick. Not only is a mini-tightrope exceedingly difficult for an MPJ, if the underlying boney deformity is not addressed, it will do nothing for the long-term outcome. The 2nd and 3rd metatarsals are both elongated and medially angulated in this patient, causing the lateral deviation of the toes. Correctional osteotomies of the second/third metatarsal are necessary. This can be done distally with a translational Weil.


Although the metatarsal head may end up appearing laterally angulated to achieve the correction necessary, the digit will maintain it's position in the transverse position, and weight-bearing may be initiated sooner than with a proximal osteotomy.


Ben Cullen, DPM, San Diego, CA



From: Richard A. Simmons, DPM


Dr. Ricketti asks why more podiatrists are not using the Phenol EZ Swabs for P&As. I rarely do P&As anymore since my practice consists primarily of terminal hospice patients. Initially, it looks like the EZ Swabs are expensive; however, here’s another twist. Over the past few years, when I attended risk management lectures, the attorneys who have spoken tell us about the need for everything in the office to have an expiration date on it and to remove everything from the office whose expiration date has come and gone. If I remember the lecture correctly, once any bottle is opened, it immediately has an expiration date of 30-days.


If OSHA shows up at your office at 8 a.m., by law, they have to be allowed access. Attorneys are now representing physicians facing tens of thousands of dollars of fines for unmarked/non-dated products (injectables, creams, lotions, etc.) that are commonly used. So, if you have a disgruntled employee who you recently fired, they can get money by being a whistle-blower. The last lecture I heard about this was put on by the Academy of Continuing Podiatric Medical Education, August 29, 2019.


Richard A. Simmons, DPM, Rockledge, FL



From: Christian A. Robertozzi, DPM


The posts on hospital privileging have valid points on both sides. There is a perspective that has been touched upon but its authority and influence are not being fully appreciated. That is the viewpoint from each hospital’s credentials committee. The purpose of the committee’s existence is to make sure that physicians get privileges only for what they are capable of doing.


For the last 3 years, I have sat on my hospital’s credentials committee (Newton Medical Center, Atlantic Health System). The hospital as well as the entire system are Joint Commission approved facilities. In order to maintain Joint Commission approval, the hospital must follow the protocols as set out by the Joint Commission. Each hospital has the right to decide who can have privileges and what...


Editor's Note: Dr. Robertozzi's extended-length letter can be read here



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

From: Joel Lang, DPM


In the final analysis, the registration costs less than a dollar a day. Isn't it worth it to have the flexibility to prescribe narcotics when indicated, rather than to explain to a patient that you don't have the necessary DEA registration? It diminishes your standing for the patient who will wonder why you don't have what all his/her other doctors have. Additionally, the cost is such a small percentage of gross/net as to be inconsequential.


How many years did the profession fight to get the right to prescribe narcotics? When I graduated from the New York college, that option was not even available. Narcotic prescribing was not even part of the curriculum.


Joel Lang, DPM, (retired) Cheverly, MD 



From:  Brian Kiel, DPM


Dr. Secord is absolutely correct that this is not really sclerosing. The term is used by podiatrists to describe the injection of 4% alcohol/local anesthetic. We bill this as a CPT 64455, injection of a local anesthetic. I do think this procedure is very effective but it is not sclerosing; the term differentiates this for clinical diagnosis of a neuroma.


Brian Kiel, DPM, Memphis, TN



From: Anthony Hoffman, DPM


I have a couple of scenarios in which I like the ability to offer the series of 4% alcohol sclerotherapy injections. The first scenario is for injection of a nerve other than a Morton's neuroma (it happens to be a branch of the lateral calcaneal nerve around the lateral wall of the calcaneus) where there is no need to do a decompression in that there is no entrapment of the nerve. The other scenario is a patient who is not a surgical candidate for various reasons. Having 4% alcohol in our treatment armamentarium is beneficial. By the way, FFF enterprises charges $11,000 for 10 vials (and they will not send only 1 or 2; you have to purchase 10.)


Anthony Hoffman, DPM, Oakland, CA



From: Elliot Udell, DPM


Dr. Roth asks a good question when he questions why certain companies are charging so much money for sclerosing alcohol. He should also ask why the cost of masks and gloves have skyrocketed in price. I took a deep breath when I called a supplier yesterday to re-order disposable masks and was told that the price went from $5.95 a box to $35 a box. Gloves also went up 20%. The question is whether this is allowable supply and demand or are these examples of companies ripping off consumers. If it’s the latter, especially during the pandemic, government agencies need to look into this, and we as consumers need to make these agencies aware of what is happening. 


Elliot Udell, DPM, HIcksville, NY 



From: Dennis Shavelson, DPM


In changing our focus and training towards surgery, as a profession, we are forced to become more and more vestigial regarding closed-chain lower extremity biomechanics. In medicine, a surgeon’s card reads that he/she is a surgical specialist. A physiatrist's card reads rehabilitation specialist, and a dermatologist's reads skin specialist, etc. They can and do consult outside of their specialty at a lesser level, but remain dedicated to one or more specialties. They consult with other specialists when their training and experience falls short of the problem at hand by putting the patient in the hands more expert than their own.


I can count the number of biomechanical consultations that I have received from surgeons in my 40+ years of podiatry on nine or ten fingers. Instead, I have fostered relationships where I can confidently refer the few surgical cases I am asked to consult on and in return, I am called upon to assist them biomechanically pre- and post-op. In summary, in becoming podiatric foot and ankle surgeons, we are practicing a stunted version of biomechanics and orthotics without incentivizing non-surgical podiatric consultants in integrative biomechanics, making DPMs like me more and more vestigial.


Dennis Shavelson, DPM, NY, NY



From: Elliot Udell, DPM


Thank you Dr. Markinson for once again reminding us of the non-COVID-19 risks associated with grinding toenails. Several responders have legitimately asked how to adequately soften nails so as to properly debride them without the use of an electrical drill. 


As an allergy sufferer, I had to limit nail grinding very early in my career. I coughed and wheezed, even with the use of dust extractors. When papers came out showing that breathing in nail dust was an occupational hazard, I took all of the drills and extractors to the nearest dumpster. Some papers showed that the dust remains in the air for over 11 hours. 


There are ways to soften nails so that they can be adequately debrided. Spraying the nails with "Three Way Solution", often works. Another way is to dispense some of the nail softening products and insist that the patients use them daily between visits. We get great results with Bako's 40% urea nail gel as well as other products such as Formula 7. We have found that if the patients use these as well as other urea containing nail products, there is no need to mourn the use of nail grinding devices. 


Elliot Udell, DPM, Hicksville, NY




I purchased the Swift immunotherapy device in August of 2019. I found that I had a significant amount of patients, both adult and pediatric, with lesions that often times were referred from dermatologists and colleagues specifically for CO2 laser excision after failing various conservative treatments. I had a 16-year-old patient scheduled for CO2 laser excision in September of 2019. I called his parents after purchasing the device and recommended that we try the Swift procedure before CO2 laser excision. After three treatments, all of the patient’s lesions (greater than 30 on both feet) resolved.


The Swift device can cause discomfort. This discomfort is far less than surgical excision. I find it is extremely helpful to prescribe EMLA cream and apply this for 5 to 8 minutes prior to Swift treatment. Patients feel discomfort/pain in the form of heat. Once the treatment is over, the discomfort dissipates. The patient can exercise or go about their activities of daily living immediately post treatment without any discomfort.


The device is very easy to use. It is extremely effective in pediatric patients with young, healthy immune systems. I often find that lesions are completely resolved after 3 to 4 treatments. In adult patients, with older immune systems, often times they need between four and six treatments.


Disclosure: I recently became a consultant for the Swift device company.


Rachel Balloch, DPM, Avon, CT



From: Alec Hochstein, DPM


I like to consider myself a progressive podiatrist. I try to add something to my practice at least yearly that brings a certain polish and a new technology to the office. This past year after seeing the initial advertisements for the Swift Emblation unit, I just couldn’t resist bringing it into my office, as I find verrucae to be extremely frustrating entities to treat (as I’m sure many podiatrists and dermatologists do as well).


I could not be happier with my decision to add this to my treatment armamentarium as the results and adoption by my patients have been nothing short of miraculous. I have no problem stating that my resolution rates for my verruca treatments with Swift Emblation is over 90%. The treatment is extremely well tolerated by my patients. It has been a great addition to the office. 


Disclosure: I am a consultant for Saorsa North American distributors of Swift. 


Alec Hochstein, DPM, Great Neck, NY



From: Elliot Udell, DPM


Not every nurse practitioner is trained in treating from the ankle down. The same applies to MDs and DOs. When managed care first began, insurance companies put tremendous pressure on primary care doctors not to send patients to specialists, or risk being docked in some way. A patient finally was referred to me by a very good internist in my area. He had been treating her for over six months for tinea pedis to no avail. He finally used his better judgment and sent the patient for a podiatry consult. I had to diplomatically explain to the patient that the reason why her internist's treatment did not cure her foot problem was that even the best of antifungals do not have any effect on interdigital hyperkeratoses.


Elliot Udell, DPM, Hicksville, NY



From: Stephen Kominsky, DPM


The last few words spoken by [Dr. Jacobs'] patient have been my mantra for the 37 years that I have been in practice. Instead of the APMA producing Johnny Sorefoot Balloons and the like, I have always felt, and feel even stronger today, that it is an absolute MUST that the “lay-public” be educated about what a podiatrist can do. For someone in this day and age to ask a podiatrist that question is a "Shonda" (Yiddish expression meaning something terrible).


Just like the AMA has done a miserable job on educating the public about the declining reimbursement, we have done a poor job regarding our education and abilities. We MUST be better at telling everyone what a podiatrist can do, and do it better than anyone else, or we will not survive. 


Stephen Kominsky, DPM, Washington, DC



From: Allen Jacobs, DPM


“Although lasers are approved by the FDA for onychomycosis” is not entirely correct. The FDA states that lasers may be used as adjunct therapy to supplement accepted management protocols for the treatment of onychomycosis. In fact, the FDA published policy on the matter advises not to claim that lasers are a cure for onychomycosis, but provide only temporary improvement in the appearance of the toenail. At-risk populations in which the treatment of onychomycosis is considered necessary (e.g.- diabetics, PAD patients, immunosuppressed patients) are denied appropriate treatment when lasers are employed, while subjected to potential risks.


The FDA approved the safety of lasers, not the specific employment of this modality for onychomycosis. And yes, while speciation is not required as lasers are not “species specific," some confirmation of fungal infection would seem appropriate prior to treatment.


I was evaluating a post-op Austin-Akin patient today. She told me that she watched the show. Her exact words were; “I’m impressed. I had no idea podiatrists did such complicated things.” 


Allen Jacobs, DPM, St. Louis, MO



From: Robert Kornfeld, DPM


This discussion is a critically important one, especially because my professional path brought me to a deep understanding of human physiology, the foundations for health and healing, and a never-ending focus on understanding mechanisms of pathology BEFORE symptoms are treated. I pursued a path in functional medicine for foot and ankle pathology because it provides a means to heal pedal pathology AND improve the health of the patient. This has been my path and my passion since 1987 (I am a 1980 graduate of NYCPM). My career has been extraordinarily satisfying because the healing is in medicine, not surgery. Of course there’s a place for surgery, but without a true mechanistic approach to healing, we correct one issue but leave our patients open to future pathology.


Podiatry has always struggled with itself. In our zeal to be accepted as ”real doctors”, we focused on pushing ourselves into hospital operating rooms. Unfortunately, that...


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



From: Jon Purdy, DPM


There is no need to compare dentistry to podiatry in this debate. Dentists are not defined as physicians nor do they have any competition among the medical community. Our closest colleague and competitor, orthopedics, has gone through its own transitions over the years. Originally a specialty in addressing pediatric deformities (the Greek derivation meaning “straight babies”) has transitioned to anything bone related in all age groups.


I find it a difficult argument to claim three years of residency isn’t a sufficient amount of time to learn the surgical and medical conditions related to the lower extremity. Orthopedics learns the surgical and medically related treatments of the entire body in four years. The first of five years concentrates on general surgery and medicine. Once an orthopedist’s standardized residency is completed, they may choose to do additional training in specialized areas or concentrate their practice on specific areas of their basic training.


Change is inevitable and our profession has not kept up. It should be obvious at this point, an MD degree will be our only acceptance into the medical world, fair or not. Aside from that, not having standardized training in ALL aspects of lower extremity care, and one single certifying board, is foolish, to say the least.


Jon Purdy, DPM, New Iberia, LA



From: Jeffrey Root


Dr. Udell states he has no idea why orthotic labs stopped sponsoring biomechanics at conferences and podiatry schools. As the owner of a prescription foot orthotic laboratory I can shed some light on the subject. The short answer is that there is no/inadequate return on investment. Sponsorships are essentially a marketing expense for most businesses. If an orthotic lab can’t benefit from a sponsorship or if it can’t afford to fund one for altruistic purposes, then they are unlikely to do so.


The economics of the custom foot orthotic manufacturing industry have changed over the years. There was a time when the exhibit halls at podiatry conferences had many foot orthotic labs in attendance. That is no longer the case. In fact, exhibitors at podiatry conferences are down in general. It's extremely expensive to exhibit, sponsor speakers, or to otherwise financially support educational content. As Dr. Richie indicated, foot orthotic labs have relatively meager budgets and have watched their profit margins shrink for many years, in part, because podiatry has become more of a surgical specialty. Unless that trend changes, you are not likely to see orthotic labs support biomechanics like they once did.


Jeffrey Root, President, Root Laboratory, Inc.



From: Elliot Udell, DPM


Doug, in an ideal world, corporate entities would have no say in what is presented at medical conferences. We do not live in an ideal world. When I lecture at podiatry conferences, I don't always get paid and I have sometimes paid for my own room, board, and transportation, and given multiple lectures. Why do I do this? To be of service to my profession and the public it serves. There are others like me.


Unfortunately, this model is not sustainable even for me. Many conferences including ones that I have chaired cannot afford to subsidize all of its speakers or depend on all of its speakers to lecture for gratis. Hence, they have to turn to the corporate world for help or scrap the seminar. As for podiatry labs, when I started practice back in the 70's, Langer labs, Schuster labs, and other labs did sponsor biomechanics at conferences and at the schools. Why did they stop? I have no idea. 


Elliot Udell, DPM, Hicksville, NY 



From: Andrew Levy, DPM 


I feel a need to add another voice of support to Doctor DeHeer's concerns and important consideration for finding ways to prevent suicide among our residents and our peers. We too have suffered the sadness of this tragedy in our community, in our professional ranks, and with our professional colleagues in other fields. I discussed this today with a patient who is director of a post-doc program in our community, and they also have that problem as well. This is, unfortunately, ubiquitous to all of our societies. 


While we search for the appropriate tools to study the phenomenon and assess different tools to help fight the problems through mentorship, referral to physician services, or the importance of enlightening our fellow colleagues, the important work must...


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



From: Robert Scott Steinberg, DPM, Irwin B. Malament, DPM


Dr. Bellezza's comments underscore the need for all the colleges of podiatric medicine to immediately add a full year course on mental health (psychology/psychiatry). So far, the Scholl College of Podiatric Medicine has refused. The Illinois Podiatric Medical Association has reported they have had multiple meetings with the college, and all the college does is kick-the-can-down-the-road.  


Robert Scott Steinberg, DPM, Schaumburg, IL


I applaud Dr. Deheer's survey regarding suicide prevention in podiatric residents. This should be extended to all physicians in practice as well. I recently lost a good friend and former class-mate who committed suicide last week. We talked 4 days before he did this and never attempted to reach out that there was a problem I could help him with or talk about.


We are all under a lot of stress these days with practice and family. A lot of issues are under the surface and if we are proactive, possibly we could avoid these tragedies.


Irwin B. Malament, DPM, Indianapolis, IN



From: Larissa Paulovich, DPM


Dr. Bellezza’s lamentable letter implies that the stressors of our training programs are the only reason why a resident would commit suicide, and ignores that 1 in 12 Americans suffer from depression and 18% from anxiety.


So your opinion is that a resident “suck it up” and ignore their depression because they want to appear “tough” or don’t want to be stigmatized since it’s “just podiatry”. But I’d like you to combine that feeling with the following scenario: A “lowly DPM resident” is overworked because their senior residents “already took all that call as first years” so they’re now on call for 38 days straight; they’re also feeling pressure from their spouse for not being around; in the back of their mind they’ve had to put off the $200,000 student loan bill at 6.8% interest yearly because... 


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



From: Peter Bellezza, DPM


If there are podiatry residents out there thinking of committing suicide, then they probably should NOT have been accepted to podiatry school and pushed through, by school administration, to graduate in the first place. There is nothing stressful about podiatry residency training when you compare it to being an internal medicine resident, general surgery resident, orthopedic resident, etc. 


The stakes are higher in those training programs. They just are. Intern residents from these specialty tracks are dealing with patients with more diverse pathology. Intern residents in these specialty tracks are actually medically managing these patients, dealing with complications during inpatient care. Things that most podiatry residents don't have to deal with... 


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


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