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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

Other messages in this thread:



From: Dennis Shavelson, DPM, CPed


I was waiting for some innovative DPM to come up with new terminology that would completely eliminate "Biomechanics" from the podiatry dictionary. Here is the first: Durability.


What we actually need is new terminology for "subtalar joint neutral" and "pronation" (as other professions are accomplishing) in order to evolve biomechanics parallel to how we have evolved foot surgery, wound care, and regenerative medicine.


Dennis Shavelson, DPM, CPed, Tampa, FL



From: John M. Giurini, DPM


Thank you, Dr. Mullens. I could not agree with you more. I would go one step further: Stop the insults altogether. Unfortunately, society, from the highest levels of government to social media to town halls and school boards have forgotten how to discuss and debate issues rationally. This type of rhetoric makes no one look good or better, especially the individual handing out the insults. Dr. Mullens got that part right. As a profession, let's raise our standards above the unfortunate "new normal". Let's show other professionals and the public (yes, they read this). that we are able to disagree without being disagreeable.


John M. Giurini, DPM, Boston, MA



From: Stephen Musser, DPM, Ivar E. Roth DPM, MPH


Well done and written. I agree with every point you mentioned. For those of our colleagues who have been practicing less than 8 years, you will come to find this advice is well thought out and true.


Stephen Musser, DPM, Cleveland, OH


Congrats on your retirement George. Thanks for your advice. I would add though, that if you are conservative and do NOT sell surgery, you should inform patients and let them make the decision to have surgery or not; you will save yourself a lot of headaches. You will do less surgery, but since the patient made the decision, you will be safe from criticism.


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



From: Ron Freireich, DPM


Dr. Kass mentions a few of the many expenses that are rising, and this trend is certainly going to get worse. The other side of this perfect storm which has been brewing for many years is continued decreased reimbursements. Dr. Kass is 100% correct in saying that this model is not sustainable. The difference between healthcare and what other businesses are doing is that we cannot pass our increased expenses onto the consumer.


Not only are new graduates not going to be able to pay back student loans but they, along with everyone else in healthcare, are going to be unable keep up with paying any of their bills. It’s a no-brainer; when expenses are more than payments….it’s over.


Ron Freireich, DPM, Cleveland, OH



From: Barry Wertheimer, DPM, W. David Herbert, DPM, JD


Just a "thank you" to Dr. Daniel for his thoughts on what is good for America and not just podiatric medicine. Does anyone really think this country will survive with the course the left is on? It baffles me to think anyone who is capable of thinking rationally could accept the direction we are going.


Barry Wertheimer, DPM, Southern Pines, NC


I completely agree with Wes Daniel DPM about our national debt. I disagree with how long it will take to feel the effects of it. I received my DPM in 1976 and remember the inflation of the late 70s. I think what we will be experiencing starting now and continuing for who knows how long will definitely be much worse.


W. David Herbert, DPM, JD, Billings, MT



From: Cindy Medders, CMA


Our practice uses the J-Vac. We have ordered over 30 J-Vac units throughout the years. These units have been highly efficient, economical, and virtually maintenance-free. Dr. Ressler has always given us great customer service. These units were designed and sold by Jack Ressler, DPM, who is a practicing podiatrist.


Cindy Medders, CMA, Atlantic Foot and Ankle



From: David Secord, DPM


"I believe there are at least a dozen states which allow nurse practitioners to practice independently, which also includes full rights to write prescriptions. I believe changing a state’s practice act to allow podiatrists to treat the foot and ankle medically and surgically and also provide primary care may be politically feasible in some states." - Herbert


If you look at the infographic, the cause is being pushed that an NP is just as capable as a doctor or PA. Whether we, as physicians, agreed with this or not appears to have no bearing on the future of the NP and healthcare.


David Secord, DPM, McAllen, TX



From: Al Musella, DPM


We just ran into this. It looks like we can still download the 835 response file for free. The Medicare website has a free program that can print reports from these files.    


Al Musella, DPM, Hewlett, NY



From: Gretchen A. Lawrence, DPM


The North Carolina Foot and Ankle Society did provide a free series of webinars this year. Thanks to Jean Kirk and DeCarlos Dial, DPM and the residents of Wake Forest Baptist Hospital, the members of our state society got some free CME hours and face time among our members via Zoom. Also, the physicians from Triangle Vascular Care donated their time and expertise to better our society members.  


Finally, PICA always has free CME for their members because we can never have enough education on the legalities of our profession. And our society also provided a lecture on “Opioid Prescribing Patterns of Foot and Ankle Surgeons” to fulfill our state‘s opioid prescriber training for the year provided by the Wake Forest Baptist Residency Program. They are currently conducting research on this topic to better our profession and protect our patients here in the tar heel state! Thank you all!


Gretchen A. Lawrence, DPM, Shelby, NC



From: Steven Finer, DPM, Jack Ressler, DPM


Sorry, Dr. Malusky but carpet in treatment rooms is old school. When you visit your dermatologist, ophthalmologist, or internist - look down. You will see some form of tile which is washable.The C and C rooms should be vacuumed. Nothing will drive a patient away than stepping on an old toenail.


Steven Finer, DPM, Philadelphia, PA


I built out my last office in 2013. I selected rectified 24” ceramic tile. It was a great selection and we were always getting compliments from the patients. Rectified tile allows you to almost butt the tile edges up to each other which allows for a very narrow grout line (around 1/16”). Go with the largest tile possible, at least 24” to 36”. They do make larger but it becomes more costly to install. With larger rectified tile, the floor looks almost like a large sheet, providing your selection doesn’t have too much pattern or veining. Larger tile also makes the rooms appear bigger.


When choosing a ceramic tile, it is better to get a ceramic tile from either Italy or Spain as opposed to a Chinese product. Chinese ceramic tile tends to warp which will raise the corners of the tile edge. I used a Chinese ceramic tile and some of the edges of the tiles were slightly raised. It was never a problem and I’m the only one that really noticed it. The larger the tile, the more warping could occur. Flooring in an office is often a second thought but careful selection will make for a great appearance and provide long-lasting wear and satisfaction.


Jack Ressler, DPM, Delray Beach, FL



From: Howard Dananberg, DPM


Here are my pearls for this discussion.


A good deal of pronation is retrograde, i.e., forefoot to rearfoot. Using various sized 1st ray cut-outs works wonders and permits a reduction in amount of rearfoot posting required.


The length of the orthotic shell is of paramount importance. Making sure that it ends PROXIMAL to the metatarsal heads improves the comfort of the shell.


The addition of fascia grooves makes the device far more comfortable, particularly in cavus feet.


Don't cast patients the day they present. Their feet are invariably swollen so the accuracy of the fit will be compromised if casting is performed too soon. Consider some type of temporary orthotic or several taping visits to reduce swelling prior to impression casting. 


Howard Dananberg, DPM, Stove, VT



From: Richard J. Manolian, DPM, Greg Caringi, DPM


The best pearl is a complete and thorough biomechanical exam. Then the rest will fall into place like a glove.


Richard J. Manolian, DPM, Cambridge, MA


My classmate brings-up an interesting subject. We were trained in Root biomechanics by Drs. Forman, Spencer, and Tax. I still follow those principles with non-weight-bearing neutral plaster impressions with basic measurements. The pearl that I learned many years ago was to indicate to the lab "no cast correction." I will also write, fabricate orthotics to full-casted arch height. This is especially important for orthotics fabricated for a cavus foot type. I often see "custom" orthotics that do not at all look like the patient's foot in neutral position. Is it because of blue foam boxes, poor technique, or a generation of podiatrists not trained to do the job properly?


Greg Caringi, DPM, Lansdale, PA



From: Ivar E. Roth, DPM, MPH


I have been speaking with an esteemed colleague recently and the answer is simple. We are a medical specialty. This means that at some point, the podiatry schools need to be absorbed and made into allopathic medical schools or dissolved. This will not be an easy task but it is necessary. At that point, ALL medical students will have the opportunity to become podiatrists by doing a podiatric medicine and surgery residency. There should be fellowships for those that want to specialize. This will open up the door for a more robust profession which will have equal footing in the medical arena. The time has come.


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



From: John Chisholm, DPM


Dr. DiResta nailed it on so many aspects of this difficult, confusing topic; most importantly, on the best, simplest strategy for achieving true parity - changing the licensure of DPMs to a plenary, unrestricted license in all 50 states, and the need for podiatric medical students to take and pass a national medical licensing exam such as USMLE or COMLEX.


Although many readers are respected and treated as equals by their medical and osteopathic colleagues, there still exists many, many types of unfair, discriminatory codes and statutes that restrict our ability to practice to the full extent of our education and training. As a specialty, we may have achieved parity in our personal practice lives but we are still licensed far below our place in the house of medicine. Dr. DiResta is also spot on regarding the level of knowledge and training of recent graduates of 3-year residency programs. Podiatrists are the only group that completes a 4-4-3 model of education besides MD and DO. The final product of that model is indistinguishable from an MD and DO within their chosen field of specialty. 


And finally, MD=DO=DPM is achievable. The only way that a podiatrist will ever get an MD or DO degree is to graduate from an MD or DO medical school. Working to change our licensure as DPMs to a plenary, unrestricted license retains our unique identity and perspective as foot and ankle specialists, while allowing us to practice consistent with our education and training. 


John Chisholm, DPM, Chula Vista, CA



From: James DiResta, DPM, MPH


I always find the comments related to parity for podiatrists on PM News to be so interesting but unfortunately of such little value. I can't help but equate this to the "cowboy" activity of my early years in practice when EBM equated to "in my hands". Probably the lowest level of evidence, yet we listened to this as dogma, and yes we truly knew no better. Yet, today some of our most esteemed colleagues, and I might add some of the brightest in our profession, reflect on their own experiences alone when commenting on this topic and we need to be mindful of this before arriving at any conclusion.


The bias in their comments and the diversity of opinions on this topic are largely influenced by one’s age, previous and present level of training, provider practice experiences, socioeconomic status, and a host of other biases. What we ought to be doing is looking directly at our present cohort of podiatric medical students and ask ourselves if are we making their careers less valuable because...


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



From: Jon Purdy, DPM


I echo Dr. Cox’s sentiments. In residency, I too was treated as a medical equal and did six months of internal medicine alongside the medical residents. We were expected to perform no differently than they.


Anyone in practice knows the vast differences in state laws. In a few states, a podiatrist can do soft tissue procedures on the hand, where in my state, I can’t trim a fingernail. The podiatrist is also aware of anatomic barriers that cross the legal procedural boundary, which at times may be necessary to perform in the OR. It really is rather strange that a podiatrist can perform reconstructive surgeries, but if an infection traverses the ankle, the surgeon is in a legal dilemma as to how to proceed. To a more profound extent, many podiatrists can’t even give an injection elsewhere in the body but a pharmacist can.


There are numerous other reasons to become mainstream physicians such as achieving meaningful use, payer parity, medical community acceptance, as well as joining forces in legislative struggles. To affect change necessitates a change in our training, which I think is paramount in this day and age of medicine. I’ll leave the logistical debate to others.


Jon Purdy, DPM, New Iberia, LA



From: Bryce Karulak, DPM


I share Dr. Cox’s frustration and also agree. When I was in school (2008-2012), I remember an APMA representative coming to speak to us. He basically said that we are dust in the grand scheme. At best, we could be a dog ear in a bill but it usually gets pulled out along the way.  


There are 290,000 NPs in the US. There are 18,000 podiatrists. I think we can draw our own conclusion as to why much does not happen on the national or state stage. We will never go away because we are so badly needed by the public, but we will not likely achieve parity because we are just too small to pull weight.  


Bryce Karulak, DPM, Fredericksburg, TX



From: Name Withheld,


Dr. Dorfman asks, "Why would you subject anyone to the possibility of contacting COVID-19 for an exam to soon be extinct." Than answer is MONEY. State Boards are not responding quick enough with the expansion of allowing 100% of CME for the next biennium for the same reason. Our associations’ funding comes from seminars.


Name Withheld


Hello. Hello. We are experiencing a pandemic! Truly, wouldn’t it be more reasonable to postpone all re-certification examinations until we are all out of this crisis? Other than the monetary loss, what else is lost? Why jeopardize our doctors with the added stress at this time. Our certifying boards should be cognizant of the need to improve physician well-being, especially in times like these.


Michael J Marcus, DPM, Montebello, CA



From: Jack Ressler, DPM


Sending charts to Ciox or the other companies is a big inconvenience, no matter the price you ask. Dr. Moglia, you should reconsider raising your price. At $10/chart, Ciox might agree to pay that, causing you and your staff a great deal of work, especially if a larger chart number pull is requested. When I get a call from Ciox to negotiate a cheaper price, it seems that $20/chart is their limit, if indeed they pay at all. Obviously as mentioned many times, do not send charts until payment is received. If you are still doing paper charts, I would not start any copying or chart preparation until you see the check. 


On a final note, in my opinion, do not let their staff in your office to copy your charts. They do not belong in your office. I have heard stories about some of these companies getting a little nosey in doctors’ offices. Obviously, you are not hiding anything but you never know what they can hear from your staff or a patient passing in the hallway. Do not look at this as an opportunity to make some extra money. I do not think it is worth your time.


Jack Ressler, DPM, Delray Beach, FL



From: Mark Weaver, DPM


It has been published that these multiple requests from insurance companies for our records is so that they can upcharge for what they are being paid for procedures we have not billed for. If this is true, and they are not looking for fraud (which seems correct), we must be under-billing. Maybe, if they are getting paid more for our services than WE bill for, we should be privy to that and bill those services we performed as well. If they get paid, should WE not be paid too? 


And, more importantly, if I got a huge number of requests ,I would look at my billing policies. Remember, these dudes only make money from paperwork, not patient care. It is just paperwork; they provide no patient care. They do nothing for the patient, the quality of care, and probably nothing for the improvement of healthcare in the country. They profit by BILLIONS of dollars. Don't believe me? UnitedHealthCare is in the top 5% of profitable companies on the S&P over the last ten years; CNBC in 2019 gave them the #1 best profit investment over ten years. This is not an opinion, but actual numbers, black and white.


Mark Weaver, DPM, Fort Myers, FL



From: Alan Bass, DPM


Like most of us, I have been inundated with chart requests from Ciox. I have now put together a standard letter and invoice that I email back to them. I also include a W-9 (one email response from them was to include that for payment). For the first time ever, I received a payment from them for one of the chart requests. I have also heard from another colleague that they received a payment as well. Stick to your guns; do not send any charts until payment is made.


Alan Bass, DPM, Manalapan, NJ



From: Jack Ressler, DPM


There is a fine line in dealing with a rude patient. On one hand, you do have to respect the patient’s opinions. Probably more importantly, you have to go to bat for your staff if they are right. I had a very interesting experience in my office where my staff member was both right and wrong on two different occasions. The first incident occurred when a patient did not get their way when making an appointment and ended up calling my receptionist an idiot. This patient did come back to the office after apologizing. It took all of two minutes for the patient to rehash this incident and again called my receptionist an idiot. I proceeded to tell the patient to leave and never come back. This was done before treatment. I must admit, dismissing a patient like this from my practice felt great, and was the first and only time I ever did that.


The second occasion occurred when the same staff member left a patient who was in severe pain in the waiting room because they were early for their appointment time. This patient did confront me in private while in the treatment room. I assured the patient that I will discuss this with the staff member. Although she was wrong, I made the mistake of asking her to come into the treatment room to discuss the incident in front of the patient. She had no explanation for her reasoning. Later in private, I diplomatically explained to her why she was wrong. She obviously was not in agreement because three weeks later, she quit citing this incident as her reason. In most cases, your staff is generally going to be right and they must be defended against unruly patients.


Jack Ressler, DPM, Delray Beach, FL



From:  Elliot Udell, DPM


I am a caregiver for my parents. This means taking them to a plethora of doctors. Many have signs saying that unless 24 hours notice of cancellation is given, there will be a charge. In my situation, between urgent care visits, doctors’ visits, and actual hospital ER and hospital admissions, we have had to miss many appointments. To date, none of the physicians we go to have "fined" us for missing appointments. If they did, we would have to choose a different doctor in the same specialty. 


Wearing the "shoe on the other foot", I am not thrilled when a patient does not show without notice, but we do not charge patients. We do keep a record of who tends to be a "no show" and if it is often, we will tend to "overbook" that patient knowing that there is a likelihood that the person will be a no show. 


Elliot Udell, DPM, Hicksville, NY



From: Dock Dockery, DPM


After running several 3-day full length continuing medical education webinars this year with the International Foot & Ankle Foundation, I can’t tell you how many podiatrists recently have whined about the fact that they have to sit through hours of virtual lectures, or how hard it is if they still have patients to see, or that it is difficult to get up early or stay up late (due to time zone differences), or why can’t they just pay and get the CME hours without having to attend the sessions. 


I realize that virtual medical meetings are different from the live ones that we’ve always known. I also know that many doctors sign up for the educational meetings and then spend most of their time in the exhibit hall, out in the corridors visiting with friends, or by the pool or beach, or even in the meeting facility restaurants and bars (and they still get their CME hours). So, it is difficult for meeting planners, like me, to make everyone happy, or satisfy all requests for certain time zones or even to just let everyone pick and choose the topic, time, and lack of monitoring that they want. 


For now, I recommend picking the online meeting that you want, schedule the appropriate time out from the office or family, attend the virtual meeting, and try to learn something new. Hopefully, next year, it will be back to more normal and you can attend live meetings again. 


Dock Dockery, DPM, Seattle, WA



From: Steven Selby Blanken, DPM


In 1995, I became double-board certified by ABPS (Foot Surgery) and by ABPO (Podiatric Orthopedics). Since then, ABPS changed its name to ABFAS but did not merge with another board. However, ABPO merged with another board, making it ABPOPPM. When that occurred, there were some grandfathering that was granted (just like ABPS did with the MIS board years prior). However, after much confusion and dismay, ABPOPPM did not grandfather all of its ABPO members, but did to most, but not all. 


ABPOPPM's re-certification process was very different from the original ABPO's process, and after one re-certification process, I decided that I would not do it again 10 years later. In my area, as in many, ABFAS (ABPS) was the main certifying board that enabled me to get onto hospital staffs for full privileges, including most surgery allowed by the state. It also helped me stay on my insurance plans. I feel ABFAS is the only board that is recognized by APMA that can actually get one the certification necessary for many hospital staffs. I hear they are trying out a better re-certification route as of this time, for which I commend them for this. I have maintained and plan to retain my ABFAS certification. I do not have any regrets dropping ABPOPPM now known as ABPM.  It really didn't give me much added benefit.     


Steven Selby Blanken, DPM, Silver Spring, MD

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