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From: Cary Zinkin, DPM


Dr. Sachs, Please allow me to clear up the misinformation that you have posted on this forum regarding Florida credits during the pandemic. Two weeks ago, along with the FPMA counsel, I attended the FL Board of Podiatric Medicine meeting and on behalf of the FPMA, its members, and non-members practicing in the State of Florida, I requested that the board drop the 8 credit limit on "at home" credits and allow all the full 40 credits to be taken live, virtual or online for this biennium. We discussed all the reasons that under these COVID-19 conditions, many podiatric physicians are still uncomfortable attending live meetings. 


The board agreed, and is in the process of approving our request for this biennium. The FPMA is always fighting for the protection of our members and our profession and as part of our mission, we will always provide quality and approved credits to our members for every renewal period. I would like to personally invite you to become a member and join our group of caring practitioners. I promise, that as a member, you will always receive accurate and timely information from the Florida Podiatric Medical Association.


Cary Zinkin, DPM and the executive officers of the FPMA

Other messages in this thread:



RE: Major Changes in Undergraduate Medical Education Over the Past Several Decades

From: Leonard A. Levy, DPM, MPH


Medical education in the U.S. and Canada has changed considerably in the last several decades. Among the major changes are the following:

  • Reducing medical school programs leading to the medical degree to three years. Since graduate medical education (i.e., residency) is many years in duration and includes virtually all the information, that would be part of the typical fourth year..

  • Introducing clinical medicine early in the curriculum.

  • Including medical information and activities into the basic science component of the curriculum.

  • De-emphasizing inactive learning by markedly reducing the number of lectures and employing problem-based learning (PBL) which typically takes place in small groups (e.g., 6-8 students led by a single faculty member). 

  • Employing objective structured clinical examinations (OSCE) in which students are asked to solve a problem in which they are faced with a simulated patient and are asked to solve a clinical problem. Students are evaluated as to how well they communicate/interact with patients, take a medical history, arrive at a clinical diagnosis, and come up with a treatment plan. The simulated patients are trained to act as if they were actual patients. The OSCE includes individual students interacting with a single patient, emulating a real patient-doctor interaction. How well the student performs is evaluated by a faculty member observing the activity via video and by the simulated patient who evaluates the student doctor for such activities as his/her communication skills. 

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



From: Elliot Udell, DPM


Dr. Kass is right on. If you attend an online program, you can listen to the lecturer, ask questions, and not have to worry about airline tickets, hotel expenses, and taking time off from work or away from the family. 


The only downside to not going to a live CME program is that you do not have the opportunity to meet with dozens of exhibitors and get to find out about new and exciting products that might help our patients. You also do not have the opportunity to socialize with colleagues from all over and, in some cases, visit interesting resorts.  


Unless state boards mandate that doctors must attend live CME conferences, I would not give up stock in Zoom and other online conference companies. They are all here to stay. 


Elliot Udell, DPM, Hicksville, NY



From: Jeffrey Kass, DPM


Personally, I feel there is no difference between online lectures or in-person lectures. Having participated in many online lectures this year, I was able to ask any questions that I would have asked if in person. The difference? I didn’t have to spend money on airline tickets, hotels, or other travel expenses. It is time to decentralize CME.


There are times where my personal preference is to attend conferences in-person but I remain steadfast in my opinion that the choice should be left to the doctor. 


Jeffrey Kass, DPM, Forest Hills, NY



From: Steven R Kravitz, DPM


I noted Dr. Ribotsky's comments for speakers for virtual meetings and some guidelines he suggested. Here are some comments modified from guidelines of the the Academy of Physicians in Wound Healing.


1. Slides - make sure there is good contrast so that the text can be seen easily especially on small devices such as the mobile phone. Suggest a font size of at least 24 points for PowerPoint.


2. Sitting or standing? If speaking from a live meeting, streamed through the Internet, then...


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



RE: Suggestions to Online Lecturers

From: Bret Ribotsky, DPM


I want to issue a very public thank you to all those organizations and people who stepped up in the past two years to allow DPMs to earn their CPME credits online. Personally, I feel we all learned a lot about online lectures. 


As one who has given 800+ live lectures in the past 30 years, I feel I can offer many of the online speakers a few suggestions. 1) Don’t talk down into your laptop camera (raise it up on books or a shelf) as looking up your nose it not that pleasant. 2) Stand up when talking, as this allows energy and passion to flow to your audience. 3) Pay attention to your background (lights and fans can be distracting). Everyone, please feel free to add to this list, as this way of learning will continue to be the future.


Bret Ribotsky, DPM, Ft. Lauderdale, FL



RE: AAMC Projections on the Adequacy of the Physician Workforce: What is the Potential Impact on Podiatric Medicine?

From: Leonard A. Levy, DPM, MPH


In June 2020, the Association of American Medical Colleges (AAMC) released a report concerning the adequacy of the physician workforce. It projects that physician demand will grow faster than supply, leading to a projected total physician shortage of between 54,100 and 139,000 physicians by 2033. It further stated that by 2033, there will be a shortage of primary care physicians of between 21,400 and 55,200 and a shortage across the non-primary care specialties of between 33,700 and 86,700 physicians including between 17,100 and 28,700 for surgical specialties, as well as between 9,300 and 17,800 for medical specialties.


This 2020 update was prepared before the COVID-19 crisis, so although it does not include any specific information or scenarios based on that crisis, it does include some lessons learned from...


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



From: Kathleen Neuhoff, DPM


I did not accept Medicare assignment for many years. During this time, I did evoked nerve tests on many diabetic patients. We had them sign ABNs and submitted claims to Medicare which they paid. After one year of payments, we stopped having patients sign ABNs. Two years later, Medicare sent me a notification advising me they paid those claims in error and wanted me to reimburse them for their payments. I replied that they had not paid me at all and the payments had been made to patients so they would need to collect from the patients. They never contacted me again and as far as I know, they never contacted any of my patients. I am fairly confident that if I had accepted assignment and been paid, I would have needed to pay a significant amount of money back.


I did accept assignment for a few years and found that, although my patient load increased slightly, my net income actually decreased and my hassle factor increased. So I returned to no longer accepting assignment. We still file for our Medicare patients since this is a requirement of Medicare, but we no longer have to fight the rejection battles.


Kathleen Neuhoff, DPM, South Bend, IN



From: Daniel Waldman, DPM


Over the past few years, I have also received more and more faxes from pharmacies (CVS accounts for probably over 90% of these faxes) stating that a patient expects to pick up the refill in a couple of days. When my staff calls the patient, they have no idea why this was sent as they have not requested the refill. I’ve called the pharmacists directly and they admit that the patient did not request a refill but the higher-ups at corporate management are instructing the refill request to be sent to physicians. When I asked the pharmacists why this is happening, they have flat out told me it’s all about corporate profits and they cannot do anything to change the system. The pharmacists seem genuinely interested in providing the best care but they are simply cogs in the machine of the corporations.


I wonder how many physicians simply sign off on these refill requests and patients are continuing to take medication that they no longer need. I have worked with a couple of law firms around the country about unsolicited/unauthorized faxes. A few years ago, I settled out of court with a company for a five-figure payout. This was not a pharmacy. Although class action lawsuits can be effective, they take many years and plaintiff awards are capped. The law firms make the majority of the payouts. Perhaps it’s time for congressional hearings?


Daniel Waldman, DPM, Asheville, NC 



From: Donald R Blum, DPM, JD


My dermatologist accepts Medicare assignment but does not accept other insurances. When you accept assignment, it is "ONLY" for services that you know are not excluded from coverage. For services that are excluded, you can accept payment at time of the service. 


If you follow the CMS rules and guidelines strictly, I think you should do okay. All services provided to diabetic patients (whether on Medicare or not) are not necessarily a covered service if the patient does not meet the class findings (Q7, Q8, Q9).


One more item - remember for 2022, there may be a decrease in the Medicare reimbursements (due to fee reductions and sequestrations).


Donald R Blum, DPM, JD, Dallas, TX



From: Brian Kiel, DPM


I don’t disagree with Dr. Ressler as to ON shoes being the hot fashion shoe but to call it or to refer to it as a running shoe is completely wrong. New Balance, Brooks, ASICS, and Saucony are running/walking shoes. These companies are using  technology to determine what needs to go into their products. ON uses eyes to determine theirs.


Our job is to guide our patients, and honestly my patients seem to appreciate and follow my recommendations as to the correct brand of shoes. ON shoes are fine to wear to the movies (whenever that is) but not as a replacement for proper athletic shoes.


Brian Kiel, DPM, Memphis, TN



From: Ron Freireich, DPM, Burton Katzen, DPM


We had this exact problem here in Ohio and we checked with our patients to see if they initiated the refills. They too did not request the refills.  We filed a complaint with the State of Ohio Pharmacy Board. The faxes quickly stopped.


Ron Freireich, DPM, Cleveland, OH


Unfortunately, with the single sheet faxes of today, even when you mark unsubscribe, they still keep coming and it is hard to stop. Many years ago, I was getting 3-4 faxes a day from one company advertising office furniture. At the time, we had a fax that used a paper roll, and I attached 3 pages together (top of the 1st one to the bottom of the last one) that said UNSUBSCRIBE, called the number and left for the night. Surprise!! No more faxes from them. I always had a vision of them not being able to get in the office the next morning because of the mass of paper blocking the door.


Burton Katzen, DPM, Temple Hills, MD



From: Brian Kiel, DPM


My premiums were going up significantly as well. My insurance company gave several options and I chose the one that does not increase my coverage by the cost of living. As a result, my premium was cut by 2/3. It is a chance to do this but I feel I will be able to cover any difference.


Brian Kiel, DPM, Memphis, TN



RE: ON Running Shoes

From: Jack Ressler, DPM


As podiatrists, we are always trying to recommend the best supporting athletic shoes to our patients. On several occasions it becomes very frustrating treating patients only to deal with their non-compliance due to "heavy or ugly" shoes. As an alternative, I have been researching "ON" running and athletic shoes quite extensively and have found several models to provide good support while checking the boxes of providing support and pleasing aesthetics. 


My philosophy has always been to get patients to purchase shoes that they will wear as opposed to them continuing to wear their Keds and other brands just because they feel good. Let's face it, getting them to wear Brooks Beast or Ariel, New Balance 1540 and others is not always an easy sell. As most of you know, ON shoes are setting the fashion world on...


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



RE: Autofax Pharmacy Refills

From: Keith L. Gurnick, DPM


My office often receives far too many faxes from pharmacies asking me to authorize prescription refills for my patients. This past year, before authorizing or declining the refill, I called or sent an e-mail to each patient, asking them if they wanted or needed the refill and if they had requested the refill. To my surprise, almost 100% of the time, the patient said they knew nothing about the fax, and had not initiated any request and they did not need the medication any longer.


My office is inundated with faxes on a daily basis from outsourced carriers asking for medical records, physical therapists who send cut and pasted medical records asking for my signature and a return fax to authorize continued care, and these unwanted faxes from pharmacies for prescription medication refills that were never requested by anyone. My office has to send back a reply fax to the pharmacy denying the request for the refill, or they will continue to send the faxes many times.


Any suggestions on how to curtail these endless unwanted faxes would be appreciated. I am aware that I could get rid of my fax machine but I also receive faxes (MRI reports, etc.) that are important such as insurance credit card payment vouchers and others. Can't something be done on a legislative level to stop the pharmacies from auto-faxing prescription refills when no one ever asked for the refill?


Keith L. Gurnick, DPM, Los Angeles, CA



From: Paul Kesselman, DPM


There are three issues with long-term care insurance.1) The state’s insurance commissioners give the carriers a free reign to increase their rates almost without restrictions. A doubling of rates in just a few years is usury. Perhaps the only choice you have to maintain your current premium is to reduce the benefit period or monthly allowance. That certainly is not what you signed up for.


2) Old policies sold back in the ‘70s or ‘80s allowed for lifetime benefits and once you started collecting benefits because of a covered illness or disability, you no longer had to pay for premiums. Unfortunately, that may no longer be the case. New policies have a limited benefit period (e.g. 36 months) and often a couple purchasing them has a shared benefit period. Thus, to purchase a new policy from a new carrier is likely not sage advice.


3) The last and equally damaging issue is that those who often can afford to pay the egregious premiums can afford them and may actually have sufficient funds so as not to require LTC coverage. Those who can't afford premiums ultimately end up on State Medicaid and perhaps can have some of the care augmented by pooled trusts and other venues by which families can protect senior's savings.


Paul Kesselman, DPM, Oceanside, NY



RE: Long-Term Care Insurance Increases

From: Bret Ribotsky, DPM


Keep your eyes out regarding your long-term care Insurance policy. In today’s mail, I received a letter from MassMutual Insurance company regarding my LTC insurance policy. They informed me that my monthly rate is increasing 25.98% for 2022 and 25.99% in 2023 and 25.98% for 2024, effectually more than doubling the premium cost.


If you are young and able to “shop for a new policy,” you might want to consider this, if you notice these changes coming your way.  


Bret Ribotsky, DPM, Ft. Lauderdale, FL



From: Kim Antol


Dr. Diamond: upon consulting with Apus for you, it appears the party you originally purchased your Apus PXP-15HF x-ray system from supplied you with a 3rd party software unrelated to the manufacturer. In searching, the only reference I could find to White Cap was related to music.


Kim Antol, Sigma Digital X-Ray



From: Michael M. Rosenblatt, DPM


The "limited license scenario" always seems to follow DPMs like a kind of shadow. It’s a throwback to the very old days when MDs thought that we would compete with them "without adequate training." Yet, if you ask resident directors (MD/DOs), they will tell you that their DPM residents are "excellent." 


When I first arrived in California and served as a volunteer for our earthquake emergency program at our over-55 community, I was warmly welcomed. One doctor, Harvey Slater, MD, who grew to become a close friend, announced without my asking him: "I had DPM residents for years at our hospital (where he was director of the burn unit), and they knew more than my other residents." 


Dr. Slater always welcomed them into his home during the High Holy Days, along with the other residents. I miss Harvey. He loved podiatry and made no secret of it. I remember his funny comment after I gave a classical piano music concert at our community auditorium: "Mike listened to his mother when she told him to practice." 


Michael M. Rosenblatt, DPM, Henderson, NV



From: Robert G. Smith DPM, MSc, RPh


First, early in my podiatric career, I wrote to the Florida Board of Podiatric Medicine and requested a declaratory statement centered on giving tetanus vaccines and boosters. I received a positive clarification validating my belief. My hope is that the readership will understand that the nationwide push for pharmacists to be allowed to vaccinate patients was orchestrated by both state and national pharmacy associations and endorsed by large chain pharmacy companies. Florida Medicare pays the pharmacy, not the individual pharmacist, $66.43 for the medication as well as $16.59 administration fee for a total of $83.02.


Prior to going to podiatric medical school as a pharmacist, I worked with the Florida state pharmacy board and state associations (FPA, FHSP) and at the time, U of Fla (my employer) to enhance the pharmacist’s midlevel role. I helped usher in...


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



From: Robert A. Dale, DPM


I am replying to another physician's question about which topical antifungal cream to use that won't be denied by insurance. I usually use clotrimazole cream or miconazole cream and it's not denied by any insurance. Miconazole cream usually seems to work better than clotrimazole. 


Robert A. Dale, DPM, Clarksburg, WV



From: Elliot Udell, DPM


Kudos to Dr. Simmons for bringing up an issue that has long affected and annoyed all of us. When we write a prescription for a topical antifungal, we never know if the patient's insurance company will either allow it, reject it, or hit the patient with a "million dollar" co-payment for it. The latter will generally result in either the patient and/or the pharmacy chasing after us to try to find an alternative antifungal that is covered with a reasonable co-payment. 


Since many topical antifungals are OTC products and many of our podiatry suppliers are happy to stock our shelves with them, dispensing these products is a good option. If the patient must get the medication via his or her pharmacy, one method that has worked well with us is to write for a specific cream and give the pharmacist permission to substitute an alternative topical antifungal that is covered by the patient's insurance company. This avoids calls back and forth from the pharmacy while the pharmacy staff searches for the product that will be covered. 


Elliot Udell, DPM, Hicksville, NY



From: David Alper, DPM


This is me working a COVID-19 vaccine clinic for 5-12 year olds in MA three weeks ago. I have a second one coming up this Monday. We vaccinated over 200 kids during the four hour session. Our MA Board of Registration wrote a regulation confirming that podiatrists are qualified to administer these.


Dr. David Alper administering COVID-19 vaccine


I have also worked flu clinics as a member of the Medical Reserve Corp of MA. Sadly, this does vary from state to state.


David Alper, DPM, Belmont, MA



From: Dieter J Fellner, DPM


Reinforcing the notion of a Cinderella service since time immemorial, the podiatric physician-surgeon is not 'permitted' to administer COVID-19 vaccinations. There is an extensive, and growing, online debate about the fact that those staff, with lesser training and education, yet legally empowered to do so, have no idea about aspiration, prior to injection. 


Increasingly, the intravascular injection is now linked to adverse health sequelae, such as increased coronary syndrome with a spike in myocardial infarctions. This important aspect of injection technique is second nature to all podiatrists. This is a global problem. Our 'leaders' are again failing the nations of the world adding to their catalogue of shame in managing this 'crisis'.


 Dieter J Fellner, DPM, NY, NY



From: Elliot Udell, DPM


This issue has been discussed for quite a few years in this forum. Why is it that pharmacists can administer many vaccinations and podiatrists and dentists who give injections all day long, cannot? During the height of the first wave of the COVID-19 pandemic, some states in the U.S., including my own, issued temporary permission for podiatrists to administer COVID-19 vaccinations but only under the supervision of one of the other professionals.


A number of our colleagues took advantage of this and generously volunteered their time giving shots at mass vaccination centers. The fact that this did not lead to allowing us to give flu and COVID-19 shots permanently, does not do justice to the public, especially in areas where a podiatrist or dentist is the only healthcare professional that some elderly people see.  


Elliot Udell, DPM, Hicksville, NY



From: Name Withheld (Canada)


Borders don’t change this situation. In Ontario, Canada, Pharmacists, RNs, NPs, and RPNs (who after their GED, complete a 4-semester college program) are permitted, by law to administer flu and COVID-19 vaccines but not so for podiatric physicians. A pharmacist said that they are paid $13 per jab. 


The container box has vaccines for up to 100 persons. ID is recorded from each individual and a laptop with access to the Internet and a printer are required. A crash cart with Epi-pens is also necessary to have on hand. The gross income made for a day administering 100 shots is $1,300. The real benefit is that it would be good PR for the podiatry clinic. It doesn’t happen. The pharmacy gets the public perception of providing a beneficial medical service.


Name Withheld (Canada)

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