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From: Brian Kiel, DPM


The recent posting regarding a patient not wearing a mask was wrong in so many ways. This is a life or death situation. It is not a hoax and it is not a situation that is negotiable with a patient. The safety of the doctor, the staff, and the other patients is of paramount importance and anyone who comes into my office comes with that understanding. We post the rule on the outside of the door. If someone comes in without a mask we will offer one. If refused, they will be told once and then escorted out.


There is no alternative and that is absolute. Let them sue. I would rather them sue than a patient that contracted COVID-19 and sued us for allowing a non-masked person into the office. There should be no discussion or trying to talk to these people. It's your office; you make the rules. 


Brian Kiel, DPM, Memphis, TN

Other messages in this thread:



From: Ivar E. Roth DPM, MPH, W. David Herbert DPM, JD


Kudos to Dr. Kalish. Experience trumps many clinical pathways. When you have the experience, you have wisdom that a book cannot teach you.


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


I appreciated Dr. Kalish's comments about evidence-based medicine and experience-based medicine. This is somewhat like the arguments against anecdotal evidence and double-blind statistical study-based evidence. I have successfully convinced a jury that another name for evidence-based evidence is cookbook-based evidence and that they must completely rely on the author of the particular cookbook, who I was successfully able to discredit.


Because rules and laws regarding the evidence that can be presented to a jury in a trial vary by state, my argument would have not worked in every state. I do believe that anecdotal experiences of a very experienced surgeon can be useful in clinical situations, even though the accepted evidence-based evidence may be contrary to it.


W. David Herbert DPM, JD, Billings, MT



From: Bryan C. Markinson, DPM


Although I wish Dr. Levy did not invoke my name in his initial correct comments on this article, the response by Dr. Kalish has degenerated the conversation to a level that I hope to put to rest with this post. There are certain accepted and widely practiced surgical oncology principles that neither the youth of Dr. Levy or the "judgment call of the experienced surgeon" as Dr. Kalish stated, can ignore, dispute, or change.


Neither Drs. Levy, Kalish, or I are musculoskeletal oncologists, the specialty which is charged with the expertise and knowledge and research regarding the initial management of...


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



From: Andrew I. Levy, DPM


It is impossible to underestimate the credentials of the authors of this article. I found it interesting but lacking several important surgical consideration factors. Dr. Bryan Markinson has taught us numerous times that is important to obtain a biopsy before excising a mass. The importance of finding out whether something is malignant or benign before surgically excising it can make a major impact on surgical procedures and/or subsequent referrals. Should the excised mass be found to be malignant, then the opportunity to treat the area is limited because of the change in identifiable margins.


I was surprised with this large mass that there was no mention of an MRI to evaluate the extent of the mass before the dissection began so that appropriate surgical planning can be made for following the mass to its extents. I was also surprised that there was no mention of an intra-operative frozen section biopsy being obtained before the mass was excised as well as looking at the clinical photograph that there is no suture marker to identify orientation for the pathologist; such as proximal, distal, or dorsal. 


Andrew I. Levy, DPM, Jupiter, FL



From: Larry Kobak, DPM, JD


Just a word on Ms. Cascardo's excellent article on physician discipline. It references that New York's Office of Professional Medical Conduct (OPMC), part of the Department of Health, is responsible for physician discipline; that is correct. However, the Office of Professional Discipline (OPD), part of the Department of Education, is responsible for disciplining podiatrists in New York. The process, for podiatrists, has some real differences.


Larry Kobak, DPM, JD, Uniondale, NY



From: Jeffrey D. Lehrman, DPM


Jim shared three concerns. I will take these one at a time.


1. Device needs to be “medical device” category by FDA


Page 43 of the 2020 CPT® Professional book states (directly copied and pasted): "the device used "must be a medical device as defined by the FDA.” CMS has stated the same thing in a bunch of places, but to save space, I will only provide the most recent. In the CY 2021 Medicare Physician Fee Schedule proposed rule, just released earlier this month, on page 130, they state: (directly copied and pasted):


For CY 2021, we are clarifying how...


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



From: Jim Collins


I just read the August 2020 Podiatry Management article written by Dr. Jeffrey Lehrman. I'm writing to kindly request supporting documentation for statements on the second page. The bottom portion of the first and second column suggests that devices need to be designated the status of medical device by the FDA, that they must have a HCPCS code with payment rates assigned, and that they must be validated by randomized controlled trials. I have not seen any of these standards shared by anybody else and I have not seen them in any of the written guidance issued by CMS, the AMA, or the MACs. 


The definitions of the codes specifically list weight and blood pressure as examples of physiologic data. Weight scales and blood pressure cuffs are the predominant way to measure these physiologic parameters. These pieces of equipment have not been designed as medical devices by the FDA, there are no associated HCPCS codes, they do not have designated reimbursement amounts, and there are no randomized controlled trials focused on these two pieces of equipment.


Jim Collins, Saratoga Springs, NY



From: Alan Sherman, DPM


After reading the carefully presented case made by APMSA President Israel Bowers, I am compelled to agree with his conclusion that the CSPE, the Clinical Skills Patient Encounter, Part II of the APMLE, and the American Podiatric Medical Licensing Exam, should be cancelled this year. The dueling issues seem to be the profession’s need to verify the competency of 4th year students vs. the safety impact on these students of all physically traveling to a central location to take the exam during COVID and their need to be focusing on education rather than traveling and testing.


There is no doubt that the clinical education of 4th year students has been severely impacted by COVID-19. Taking them away from any clinical training, now or while they are in residency, is undesirable. By Mr. Bowers' reporting, the APMA requested the exam be cancelled, followed in turn by the FPMA, the CPMA, the PPMA, and the AACPM making the same request. A survey showed that 95% of students believe the exam should be cancelled. Mr. Bowers' specific and well-articulated concerns are...


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



From: Amol Saxena, DPM


Dr. Hultman’s article is spot on! It’s good to have a reminder. Thanks for writing and sharing.


Amol Saxena, DPM, Palo Alto, CA



From: Kenneth Rehm, DPM


I read the well written responses to my article “The Birth of Podiatric Sports Medicine” in the comment section of PM News by the highly esteemed podiatric physicians Drs. Richard Bouche, Gary Dorfman, Mark Landry, and Lloyd Smith. My regret is that I appeared to highlight one pioneer over another and that was not my intent.


As I said in the second paragraph of my article: “The impetus for most of the interest in sports medicine by podiatrists back then arose out of the running boom and the development of the American Association of Podiatric Sports Medicine. Doctors George Sheehan, Robert Barnes, John Pagliano, Richard Gilbert, and...


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



From: Gary Dorfman, DPM


As Earl Kaplan, DPM is honorarily known as the “Father” of podiatric surgery, so should Robert Barnes, DPM be noted as the “Father” of podiatric sports medicine. Aside from the fact that Bob was the founder and first president of AAPSM, his profound relationship with the U.S. Olympic Track and Field Team brought great recognition to podiatry. Bob recruited me in 1962 in his efforts to get podiatry recognized by the sports community and I know how hard he worked to get us established in the sports world.


Richard, “Dick” Gilbert, DPM was certainly a shining light as well in getting us the recognition we deserved, especially with his association with the San Diego Chargers, when no podiatrist at that time had any affiliation with a professional sports team. He certainly deserves recognition as well for his contributions.


Can we agree, that both Dr. Barnes and Dr. Gilbert are true icons in the field of podiatric sports medicine.


Gary Dorfman, DPM, Dana Point, CA



From: Lloyd Smith, DPM, Mark Landry, DPM, MS


Bob Barnes was our mentor for many years. He was always there as we began a new specialty and then flourished. Those years were instrumental to my life. Thank you for honoring Dr Barnes.  


Lloyd Smith, DPM, Newton, MA


I knew both Drs. Barnes and Gilbert. Dr. Gilbert was active with the San Diego Chargers back in the ‘70s and ‘80s and travelled with them. A weekend at the Chiefs, he extended his stay to lecture to Kansas City residents.


Dr. Barnes visited OCPM in the 1973-74 school year and helped start the first student chapter for sports medicine. Moreover, Dr. Barnes organized and started the American Academy of Podiatric Sports Medicine and, in my opinion, is deserving of the title “Father of Podiatric Sports Medicine.”


Mark Landry, DPM, MS, Overland Park, KS



RE: Setting the Record Straight

From: Rich Bouche, DPM


I am an American Academy of Podiatric Sports Medicine (AAPSM) past president and recently retired sports podiatrist/surgeon who has been documenting the history of the AAPSM for the past 25 years.  I read with interest an article that was published in the September, 2019 issue of Podiatry Management entitled, The Birth of Podiatric Sports Medicine: The Academy and Now Board Certification. In this article, there is reference in the text citing Richard Gilbert, DPM’s initial idea for board certification in PSM. Accompanying this text is a picture of Dr. Gilbert on the front page with a legend that reads: Richard Gilbert, DPM, The Father of Podiatric Sports Medicine.


The reason for this letter is to bring to your attention to what I see as a significant error by the author Kenneth Rehm, DPM related to use of this title for Dick Gilbert, DPM. Though Dr. Gilbert’s contributions were significant, he should not be considered the “father” as this title deservedly should be reserved for Robert Barnes, DPM, who was the primary founder of the AAPSM, spearheaded the formal establishment of the AAPSM in 1970, and was first president of the organization in 1975-1977. Out of respect for Bob Barnes, DPM, and for historical accuracy, this fact should be clarified. 


Rich Bouche, DPM, Seattle, WA



From: Larry Kobak, DPM, JD


Two separate incorporated podiatrists may share overhead costs as long as each is contributing the fair market value of their share of the overhead. It can vary based upon the hours each uses the office or the amount of space each uses within the office. Once you vary the amount paid each month based upon how much each independent contractor earns, you risk running afoul of federal and state Anti-Kickback statutes. I strongly advise you to have an experienced health law attorney set up an arrangement that will "pass muster" with the authorities. 


Larry Kobak, DPM, JD, Uniondale, NY



From: Thomas Fitzgerald, DPM 


I read Lawrence Kobak, DPM, JD’s article. He does not discuss an incorporated podiatrist paying for practice expenses on a percentage of gross earnings basis with another incorporated podiatrist. I understand that an incorporated podiatrist is not subject to the same rules as a sole proprietor.


If using a percentage of gross receipts is illegal, would paying a fixed, agreed upon amount avoid the insurance audit risk? I would appreciate Dr. Kobak’s opinion. 


Thomas Fitzgerald, DPM, Rohnert Park, CA



From: Joseph S. Borreggine, DPM


This survey does not surprise me one bit. Why wouldn't a graduating doctor of podiatric medicine (DPM) want to be a "foot and ankle surgeon" instead of just a general podiatrist? It seems to me that it has nothing to do with what a podiatrist is trained "to do", but what a podiatrist "can do". This debate will continue to linger as long as there are “podiatrists who perform foot and ankle surgery” versus “foot and ankle surgeons who are podiatrists.”


This clash has been a divisive situation in our profession going all the way back to the early 1940s when podiatrists were organizing groups like the American College of Foot and Ankle Surgery and then in the late 1970s establishing the National Board of Podiatric Surgery (NBPS), then renamed the...


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



From: Ty Hussain, DPM


Responding to Dr. Udell's comment about dentists having multiple sub-specialties, its point is that they are able to maintain defined specialties mainly due to one factor: how they get reimbursed vs. the rest of the medical field. I have long said that dentistry was the smartest of all medical care due to the simple fact that the majority of the patients nationwide acknowledge that dental care is a cash transaction. Yes, there is dental insurance, but the majority of the population does not carry that, and dentists for the longest time have kept themselves out of the insurance rat race to keep it a cash business.


Therefore, you can have dental specialties that can charge so much money for a procedure, knowing they will be paid upfront. Can we say that about podiatric medicine, that has strived to be like our MD colleagues and wants to be part of every insurance to get reimbursed 80% of Medicare and be content? This is what causes that podiatric surgeon who wants to only perform ankle surgeries, but due to low reimbursement, wanders into general podiatric care. Our field is based on relying on third-party payors. Changing ourselves to a cash basis is a tough hill to climb.


Ty Hussain, DPM, Evanston, IL 



From Elliot Udell, DPM


Perhaps, someone out there can answer a question that has been posed for years with no legitimate answer. Why has dentistry has been able to maintain clearly defined specialties and podiatry has not? In dentistry, there are oral surgeons who would never dream of filling a cavity or making a crown. There are periodontists who do gum surgery and endodontists who do root canals. Sure, some general dentists will do an extraction and some will do root canals, but you would never find an oral surgeon, endodontist, or periodontist encroaching on the turf of the general dentist. 


Far be it from for me to say that podiatrists are unethical or there is anything that prevents us from maintaining clearly defined specialties. It's obvious. It has to do with the economics of healthcare as it pertains to podiatry. Since I started my first days in our profession, the idea of having true specialties ala dentistry has always been espoused, but it has never gone beyond the realm of just being a good idea. What can we do to change the economic environment so as to have true specialties in our profession?


Elliot Udell, DPM, Hicksville, NY



From: Doug Richie, DPM


Regardless of what type of practitioner today's podiatric resident "wants to be", the fact of the matter is that current podiatric residency training programs do not prepare residents to manage common musculoskeletal foot and ankle problems with non-surgical interventions. 


I believe this would fall under the scope of "general practice" podiatry which Dr. Sherman refers to. Dr. Jacobs uses the term "primary care podiatry" and cites the training current residents receive in the fields of rheumatology, dermatology, vascular disease, endocrinology, and neurology. How does training in these disciplines prepare the podiatric resident to evaluate and treat plantar heel pain and metatarsalgia, the two most common musculoskeletal conditions which present to the podiatric practitioner?


In this regard, Dr. Jacobs states that current residents have "excellent understanding" of biomechanics and kinesiology. If they do, this understanding came from 4 years of podiatric medical school and not from a 3-year surgical residency program. Even if this were true, training and hands-on experience in implementing non-surgical treatment of common musculoskeletal foot and ankle problems is sorely lacking in today’s podiatric surgical residency programs.  


Doug Richie, DPM, Long Beach, CA



From: Lawrence Oloff, DPM 


I believe this dialogue about “advanced foot and ankle vs. general practice podiatrist” espoused by Dr. Sherman misses many key points. It bothers me that after all the progress that I have seen our profession make, there are still advocates that want to have our profession take two steps back. I have been involved with podiatric medical education for forty plus years and continue to do so today as a residency director. These are my observations.


Completing residency does not force its graduates to perform advanced surgery, or for that matter any surgery at all. The extent of one's practice is purely up to the discretion of each graduate of a residency program. Residency just allows its graduates to provide basic competency in the care of their patients, both as generalists and as surgeons. Finishing a residency is just the beginning of obtaining competency as a...


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



From: Elliot Udell, DPM


Thank you, Dr. Zanbilowicz, for questioning what kind of studies should be enough to let us subject our patients to new and often expensive, out of pocket treatments. The article referenced from the New York Times is on target.


One way of determining whether a new, expensive product should get our clinical attention is whether major insurance carriers will pay for it. Peddlers of these products at medical conventions will argue with this point of view. Over the years, however, insurers such as Medicare and other major carriers will not pay for a treatment where the evidence supporting it is clinically questionable. Sometimes, when new research says that a treatment is questionable such as with ECSW therapy, Medicare stopped paying for it and dozens of shockwave providers ceased to exist. 


On the other hand, if a treatment is supported by large studies from many reputable study centers and the evidence is clear that the treatment will help patients, it will not be long before insurance carriers will be forced by public outcry to pay for it. So where does this leave us? In our practice, we may offer a new treatment that may be promising if it is inexpensive and, of course, safe. On the other hand, to our own financial detriment, we will not sell a treatment that will cost the patient "a thousand dollars" or more if the preponderance of evidence does not support it. 


Elliot  Udell, DPM, Hicksville, NY



From: Alan Sherman, DPM


Why am I not surprised that in 40 years, none of Dr. Jacobs’ residents have told him that primary care practice is their first choice, despite 25% of residents telling us in our polling that they intend to be general practice podiatrists? That is precisely the reason that I conducted an anonymous poll where residents could give us honest answers. A resident would never, ever reveal this perceived “failure” to Dr. Jacobs. He is apparently among the residency directors who think that the more surgery a resident does, the more accomplished s/he is as a human being.  


The poll data is not “alleged” or in dispute because Dr. Jacobs says it is. I’d like to dispel another assertion that Dr. Jacob naturally falls into in his comments – that this is a question of surgical vs. non-surgical podiatrists. It never was. All podiatrists do some surgery. This is a question as to how much they do. I prefer to represent it as advanced foot and ankle surgeon vs. general practice podiatrist. As this issue continues to be defined by podiatrists across the country, I would advise all to beware of those like Dr. Jacobs using the term primary care practice or non-surgical podiatrist. No one, least of all me, wants to take surgery away from any podiatrist. I simply want to direct our residency and other training resources to train all podiatrists in the skills that they will be using in practice.


Alan Sherman, DPM, Boca Raton, FL



From: David E. Gurvis, DPM


There is room for all of us in all of our capacities. Some will make it as surgeons. I know several groups who will not do routine care, or biomechanics, or dermatology, etc. and some will morph into more generalists and still earn a great living and be just as satisfied. I do many surgical procedures and I do them well. I am limited in my training and send the complicated stuff out to the surgical groups. 


My comments are regarding surgical vs. conservative care. Maybe because of finances, or training, it seems many of the surgeons no longer offer any...


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



From: Allen Jacobs, DPM


In 40 years of working alongside podiatric residents as a residency director and mentor, never have I heard any resident tell me that primary care practice represented their first choice. Never. Particularly now when we have outstanding three-year residencies and fellowships, I have yet to meet a resident who desired non-surgical practice at the completion of such training. I have long been a strong advocate of advancing education in the non-surgical aspects of podiatry and continue to do so. However, the comments of Dr. Sherman and his alleged survey results are simply not consistent with my experience in working with residents to this day.


I should further like to point out that as a result of the excellent training which our residents now receive, most...


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



From: Michael M. Rosenblatt, DPM


I read with interest the recent polls of newly graduated residents, in which the majority answered that they want to practice mostly surgery in their work. I understand this. Many years ago, I felt the same way. Because I owned my own Medicare Certified Surgical Center, there was (I suppose) a financial incentive for doing more surgery. But that is not how it turned out. The physical aspects of surgery require an enormous amount of energy that, as you age, you become less able and willing to exert. I was also a co-resident director and shared responsibility for teaching new podiatry residents surgery.


I had a surgical program at a VA hospital where I was exposed to a great deal of surgery, besides foot and ankle procedures. Even now, I am astonished at the...


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



From: Adam Zanbilowicz, DPM, MSc, BA


As we have learned that tendonitis is rarely an "itis", many of our treatment options for fascia and tendons have been shown to be ineffective. This has created a perfect opportunity for unproven therapies to be incorporated into treatment algorithms. But we must only consider these modalities as a last resort. I read Dr. Woodley's article, hoping to finally hear of a quality study that demonstrates efficacy. Sadly, the abstract of the only article referenced concludes "that the literature appears to be inconsistent and thus far, inconclusive." 


This was my conclusion after reading as much primary research I could find... Many successful case studies, but higher quality studies demonstrating equivocal results. The New York Times published a wonderful article with principles of avoiding pitfalls of poor studies -- a worthwhile read: Worried About That New Medical Study? Read This First


Adam Zanbilowicz, DPM, MSc, BA, Nanaimo, Canada

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