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06/09/2021    

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



From: Bryan C. Markinson, DPM


 



Dr. Herbert thinks that podiatrists should be able to provide primary care, right now! Really Dr. Herbert? He supports his belief by reminding us that nurse practitioners provide primary care. Indeed, they do. At least 20% of my patients in my hospital-based practice are cared for by nurse practitioners for their primary care needs. That is also increasing rapidly. I am all for advancing our profession, and it is not easy to be critical of anyone's position that supports advancement without appearing to be obstructionist. I'll risk it.


 


Dr. Herbert's assertion that "we can sure argue that our training in the medical and surgical sciences are much more intense and in depth than that of nurse practitioners" is not only preposterous but an embarrassment to have to read in a public forum. There is no valid way to even compare the educational experience of the NP and the DPM when the eventuality of providing primary care is the parameter being discussed.


 


I know not one single podiatrist, practicing as a podiatrist, or any RRA trained podiatry resident, who can perform as a provider of primary care, or come close to the knowledge and skill of a nurse practitioner engaged in the day-to-day practice of primary care. But don't worry Dr. Herbert, I know not one foot and ankle orthopedist who can perform primary care either or who would ever assert that they could be as good as a nurse practitioner providing primary care. Incredulous proclamations are not the way to go.


 


Bryan C. Markinson, DPM, NY, NY


Other messages in this thread:


06/25/2021    

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



From: Dennis Shavelson, DPM, CPed


 



Resistance Training (RT) is one area where there has been a dirth of reviewable evidence for the “Standard of Care” (SOC) for decades. This has led to the ability of those producing and marketing their equipment and methodology to claim “SOC” in the marketplace. Company websites and blogs claim that their free weights, machines, weighted wearables, and resistance bands are the best to own without justification.


 


Some years ago, I published a 21 page meta-analysis of RT: which reviewed the current evidence for all forms of resistance training. There have been 1,300+ readings of that article on ResearchGate alone to date. I have advocated for change in the misrepresentation of resistance training standard of care exactly as Dr. Jacobs suggests, with some level of success.


 


Dennis Shavelson, DPM, CPed, Tampa, FL


03/10/2021    

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



From: Bret Ribotsky, DPM


 



I feel I need to set the record straight on Dr Zinkin’s letter about Florida and the FPMA’s request to the Florida Board of Podiatric Medicine. Please see the minutes (page 4 under public comments) or listen to the audio file. You can see clearly that Dr. Zinkin and FPMA wanted to require in-person attendance and it was I who spoke up and requested all credits for this renewal cycle to be available on-line or in any way without a restriction. 


 


Everyone should also be aware that FPMA charges each member well over a few hundred dollars each year for providing CPME credits. Nothing of value is ever free.


 


Bret Ribotsky, DPM, Boca Raton, FL


02/12/2021    

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



From: John Moglia, DPM


 


I'm one of the silent majority content with my limited license but not content with the disparity in reimbursements, if they exist. My kid brother, a critical care surgeon, retired at 64 burnt out by the demands of his specialty and his low reimbursements. Years ago, when reimbursements were reasonable, whenever I would complain to him about the lack of acknowledgement and licensure limitations of my DPM degree, he would say just "laugh all the way to the bank."


 


However, I'm no longer laughing as reimbursements continue to decline. While legislation without proper training is not the answer for parity in scope for those who seek it, it might be more appropriate for approaching the insurance industry by our representatives. Who can we turn to for a realistic plan for the future? Can anyone reveal the actual disparity in reimbursements comparing DPM vs. MD? 


 


John Moglia, DPM, Berkeley Hts, NJ

02/08/2021    

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



From: Paul Betschart, DPM


 


Aside from a few orthopedic foot and ankle surgeons (who we have some turf overlap with), I have never felt a lack of respect or parity from any of the MD or DO physicians that I have interacted with over the course of 30 years of practice. Disparity with payments makes little sense as our overhead expenses are the same as that of other doctors. I consider myself a podiatrist with foot and ankle surgery as a subspecialty so to speak. I believe the more podiatry residents train in hospitals with other MD and DO physicians, the more respect our profession will get in the future. I leave it to our associations to battle the payors for parity on that level. We should all support these efforts with our associations as there is strength in numbers.


 


Paul Betschart, DPM, Danbury, CT

02/05/2021    

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



From: Sheldon Miller, DPM


 



Parity. Who cares about parity? I practice with a brilliant board-certified neurologist. Over the past 5 years, he has been increasingly treated like garbage from the insurance companies, Ciox, etc.  His reimbursements have gone down just like ours. If the public doesn't care about a life-saving doctor, they will never care about our profession (podiatry, specialty). I don't care what you want to call us, but we have to hold our own by ourselves. Getting paid with INCREASES annually shows respect. Pay me what I deserve and you can call me whatever you want to. 


 


Sheldon Miller, DPM, Rockaway Park, NY 


02/04/2021    

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



From: Randall Brower, DPM


 


I have to push back a bit regarding the whole parity argument. This argument is frankly old and tired. We are podiatrists. I did a 3-year residency in Detroit at DMC from 2001-2004. Yes, the first year, we did a 4-8 week course of internal medicine, ICU, ER, trauma, general, vascular and plastic surgery rotations. Yes, we have a very small overview knowledge of these general medicine and surgical specialties. But, Dr. Cox, what do you want to do with a parity degree?


 


We are both somewhere between 15-20 years in practice. Medications, disease management, and surgical approaches have changed significantly in the past 2 decades for all specialties. I think you might be overstating that you, or I, have vastly more knowledge in medical treatment of...


 


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

12/31/2020    

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



From:  Douglas Grimm, DPM



 


I think is a timely case study with the current discussion of fusions versus non-fusions. I also am finding colleagues who are performing Lapidus procedures on almost every patient. I recently had a 15 year old boy in the office who had a bunionectomy in February 2020 and he wanted the other foot done. As you can see for reference, the right foot shows he does have a very large bunion for a 15 year old. He was pleased with the appearance of the left foot after surgery as the first ray was straight but he wanted to know why the big toe joint has no motion and why he can't play basketball 10 months after surgery.


 


I have subsequently done a MICA MIS bunionectomy on the right foot which was completely pain-free in five weeks. The patient is now...


 


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


10/23/2020    

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



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

10/09/2020    

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



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 

10/08/2020    

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



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    


10/07/2020    

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



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.


09/10/2020    

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



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

09/08/2020    

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



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


08/13/2020    

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



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


08/05/2020    

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


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 

07/30/2020    

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



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

07/28/2020    

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



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


07/23/2020    

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



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 


06/25/2020    

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



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

06/11/2020    

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



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

05/25/2020    

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



 


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

05/22/2020    

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



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


03/04/2020    

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



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


02/03/2020    

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



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


01/31/2020    

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



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
PICA


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