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03/10/2021    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From:  Alan Sherman, DPM


 


The comment made by Cary Zinkin, DPM and the executive officers of the FPMA in response to this topic is not the complete story, and Dr. Sachs comment that they are replying to contained no misinformation. Zinkin leaves out that on Oct 9, the FPMA issued this announcement via email to FPMA members: “FPMA, on behalf of our members, sent a letter requesting the Board consider modifying the current CME rule to allow for up to 20 virtual hours during this biennium.” Since the Florida Board of Podiatry requires double that, or 40 hours of CME each biennium, the FPMA clearly first requested that the Board only allow 50% of CME to be earned online, and was granted that, as Dr. Sachs correctly states. 


 


It now appears in this comment that the FPMA has NOW revised their request, and has NOW requested that ALL CME required by the Board be allowed to be earned online. Good for them…they have come to the right decision after an early mis-step. And it should not be forgotten that for years, the Board only allowed 20% of CME to be earned online and it was only in response to COVID that the FPMA attempted to correct this regressive policy of the Board. It is my opinion that podiatrists in all states should have the freedom to choose how they obtain all of their CME. 


 


Disclosure: I co-run PRESENT e-Learning Systems 


 


Alan Sherman, DPM, Boca Raton, FL

Other messages in this thread:


06/25/2021    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Carl Solomon, DPM


 


This goes beyond commercial entities and advertising. Several years ago, I attended a presentation at one of our seminars. The speaker was a nationally recognized colleague and I believe the topic was infections. He posed a question to the audience (I don't remember specifically)...it was either "Do you ALWAYS order antibiotics for infected ingrown nails?"...or "Do you ALWAYS get a C&S before ordering any antibiotics?"...or  "Do you ALWAYS get x-rays for an infected ingrown nail?"...or "Do you ALWAYS administer Abx prophylaxis prior to bone surgery?" The specific question isn't the issue. He asked for a show of hands indicating who does. Of an audience of probably 150 attendees, very few raised their hands. He then scolded us, saying that the "standard of care" was that we should ALWAYS do that. 


 


Excuse me...didn't the response of that audience (assuming it's a fair representation for this locale) just define that the standard of care is that we do NOT always have to do whatever it was? How can someone who comes from a couple thousand miles away define what OUR standard of care is? When we let these things go unchallenged, there can be scary ramifications.


 


Carl Solomon, DPM, Dallas, TX

06/09/2021    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Elliot Udell, DPM


 


Comparing podiatric physicians to nurse practitioners and then asking why DPMs should not be allowed to practice full body medicine if NPs do it all day long, is an unfair comparison. Why? From the get-go, registered nurses are highly trained in full body medical practice. In the hospitals, they have and always will be responsible for general medical care under physician orders, 24/7. Nurse practitioners have to have a masters or doctorate on top of that intense training. According to the NP association, nurse practitioners see over 1 billion patients a year for general medical care. These men and women are highly trained. 


 


On the other hand, we DPMs are better trained in the medical and surgical aspects as it pertains to the lower extremities. The bottom line is that if I am going to my allergist or going to urgent care, I have no problem being evaluated by a nurse practitioner. At this point in time, I would have a problem being evaluated by a colleague of mine for a non-podiatric problem. Should the clinical training for podiatrists change and the amount of general medical clinical hours become on par with nurse practitioners, MDs, DOs, and well trained PAs, then I would have no problem allowing a fellow podiatrist to evaluate me for a GI, cardiac, or any other medical problem.


 


Elliot Udell, DPM, Hicksville, NY

02/12/2021    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Thomas Graziano, DPM, MD


 


Kudos to Dr. Markinson for his astute observations. While the first 2 years in podiatric medical school are on par with our medical student counterparts, the 3rd and 4th year are not mirror images. We cannot simply say as a profession that every DPM should be granted another degree because "in our opinion" we go through the same number of years in training. This discussion has been ongoing for decades within our profession. The only way I see this degree change happening is through traditional pathways.  


 


That means, as Dr. Roth points out, that podiatry schools will be absorbed by allopathic schools so that all students attending will attain an MD and decide on their specialty after graduation. Those who want to specialize in the foot/ankle/lower leg as podiatrists (it would be interesting to see how many) will do so after they obtain the MD. They will go through the exact same didactic and clinical externship education. The question of "parity" by our medical colleagues, hospitals, and the equally important insurance companies will never be an issue again.  


 


Thomas Graziano, DPM, MD, Clifton, NJ

02/08/2021    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Steven Kravitz, DPM


 


I find it interesting that for the past many years, the question of “parity” keeps arising. In the meantime, it also appears to me that the vast majority of podiatrists are satisfied with their practices. It probably is a quiet majority - those who do not participate in writing articles or comment in these kinds of publications have busy practices and are earning what they feel is a satisfactory income with a healthy family lifestyle. I understand the concerns many of my colleagues presented. I also think that their frustration is not related just to podiatry, but is in fact with all medicine.


 


Limitations of practice are generic and part of how we treat medicine today. Ophthalmologists refer cardiac questions to cardiologists and do not think about trying to treat...


 


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

02/05/2021    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From:  Allen Jacobs, DPM


 


In my opinion, the expressions of doctors Markinson and Agostinelli regarding the issue of “parity“ are spot on. Yes, there are frustrations inherent to the limited podiatry degree. It seems illogical that I can prescribe opioid analgesics and other potentially dangerous medications, yet I am not permitted to prescribe medical marijuana. It is intriguing that I can perform a Syme amputation or utilize an IM nail to stabilize a Charcot’s ankle but require an MD's signature to prescribe therapeutic footwear for a diabetic patient. It defies logic (to me) that a podiatrist is paid less than on orthopedic surgeon for the same service when, in fact, a 3-year residency and fellowship-trained podiatrist is better trained in foot surgery.


 


The parity argument is, to my thinking, a straw man argument. As a podiatrist, you are a limited licensed healthcare provider. You are not a “specialist”. You did not graduate medical school. Your training is not...


 


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

12/31/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Howard Osterman, DPM 


 


I will just say not all joints are equal. Not all sports are equivalent. 30 years of treating athletes has provided insight into this. Fusing a first metatarsal-phalangeal joint can be a damned if you do/damned if you don't scenario, but fusing a 1st met-cuneiform joint is another matter. I suspect this is where the controversy lies. Tennis, golf, basketball are really inhibited with fusion here. This is under-appreciated in mechanics. Sports medicine physicians have many patients who had to stop their desired sport because of this. These are the types of panel discussions at all of our AAPSM Stand Alone meetings. 


 


Dr. Jacobs, as always, makes some valid points, but those of us who treat mostly patients trying to maintain their continued level of sport are often left disappointed with the surgical result. I have many patients very pleased with a 1st met osteotomy and Akin that wasn't 'perfect' but left a much more desirable result than a 'perfect' Lapidus that stopped them from doing their sport.


 


Howard Osterman, DPM, Washington, DC

12/11/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Warren S Joseph, DPM


 


In response to Dr. Purdy’s comment about the Danish mask wearing study, it should be noted that this was only one study, versus many showing effectiveness of mask wearing, and significant limitations to that study have been elucidated by multiple sources. One of the most definitive resources is the Infectious Diseases Society of America which maintains an entire webpage dedicated to ALL studies about mask effectiveness that is continuously updated. The link to that page is here: Masks & Face Coverings for the Public 


 


These are their conclusions about limitations of the Danish study:


 


Limitations:


• 20% of the study population did not complete the...


 


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

10/23/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



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, well...you probably don’t want them as a patient anyway.


 


Ron Werter, DPM, NY, NY

10/09/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



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

10/08/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



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

10/07/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



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

09/08/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



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

08/13/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



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

08/05/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A


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

07/30/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



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

07/28/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



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

07/23/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



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

06/25/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



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.


06/11/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



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

05/25/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



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

05/22/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



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

03/04/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



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

02/03/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



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

01/31/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A


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

11/01/2019    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



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.
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