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05/18/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1
From: James J DiResta, DPM, MPH
The results to this week’s polling is puzzling. CDC recognizes that some 60% of the U.S. population has had COVID-19 which would appear to me a conservative number, yet the poll results show 65% of respondents stating they have not had COVID-19, which begs the question why is being a podiatrist "protective"? It would seem to me with our level of exposure, we would be as high if not higher than the CDC data.
James J DiResta, DPM, MPH, Newburyport, MA
Other messages in this thread:
05/02/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Paul Kesselman, DPM
Recently, I met a young intern doing his PGY-1 prior to starting his five-year residency in general surgery. He is faced with almost $400K in debt from medical school and more from undergraduate school. Between the two, he can easily amass $600K or more in debt. A neighbor graduating from high school will amass $500K in debt from his undergraduate degree and then more from his anticipated pursuit of a legal degree.
It is no wonder that more and more young students are moving away from traditional degrees in healthcare and moving to shorter degree paths with easier career paths. PA and NP are far shorter than MD/DO and DPM degrees with much less stress, easier lifestyles, and nice salaries. Nurse anesthestists command $150+ salaries after a four year BSN and a year or two of...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
05/02/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: Shashank Srivastava, DPM
I understand the points that Dr. Hofacker is making and all are very good. That said, I personally feel that it is not reasonable to expect 17 year old high school kids to want to know they want to be podiatric surgeons at such a young age. I remember how I was at that age, and no way could I have made such a commitment. I think a certain level of maturity and some life experiences are required before making this commitment.
The problem is if they decide at 22 years of age that they want to do something different (common sentiment among that age group), there is no turning back and lots of debt and possible resentment. Unlike allopathic or osteopathic physicians, we cannot just simply change specialties and do different residencies and fellowships. There is no turning the ship around.
Shashank Srivastava, DPM, Rockville, MD
06/14/2023
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Patrick J. Nunan, DPM, Steven Kravitz, DPM
I find it interesting that a person commenting that the profession itself is its own biggest threat, once testified against ankle privileges for podiatrists on behalf of orthopedic surgeons in his state. At that time, I was vice president of that state association and heard his testimony firsthand. Was not the question asking for forces outside of the profession?
Patrick J. Nunan, DPM, Beaufort, SC
Dr. Tomczak points to an age old question that faces not just podiatry, but all fields of medicine. There's too often a disconnect between the pride of being in medical practice, the economics that drive that practice, and the realization that all of us have a limitation of education. At the end of the day the primary focus must be whatever is best for the patient.
I just had a paper accepted by The Journal of Wound Care (due October 2023) that addresses this very issue. It describes a simple vascular procedure that went wrong, causing...
Editor's note: Dr. Kravitz's extended-length letter can be read here.
06/14/2023
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: William A. Wood, DPM, MPH, Robert Kornfeld, DPM
The greatest existential threat to our profession is the lack of a national practice act license uniting the profession.
William A. Wood, DPM, MPH (retired), Chicago, IL
Other than the fact that podiatry has never been a cohesive unit, I believe the biggest existential threat is participating with health insurance. There will be no end to the erosion of income over time. Podiatrists work like dogs and are being exploited by insurance companies. So who is to blame? Clearly, insurance companies because they figuratively rape doctors. BUT, this is not a new story. It is the continued participation/cooperation/acceptance of this madness that is also to blame. And that is something every podiatrist can change. Otherwise, they can continue working as the underpaid employees of the insurance companies that they are.
Robert Kornfeld, DPM, NY, NY
05/19/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1C
From: Elliot Udell, DPM
Dr. DiResta is correct in noting that two surveys taken on how many people have contracted COVID-19 may be totally inconsistent with each other. Expect more of this. When COVID-19 first became a pandemic, the strain caused severe morbidity and mortality. The only way of knowing if a person had the disease was to go to a public testing site, hospital, or urgent care facility. The results were documented and made public. Today, things have changed.
The strain today is more contagious but less virulent. Many are also vaccinated. People are, thankfully, not dying or winding up on ventilators as frequently. The symptoms for many people may mimic a mild cold. There is also an ample supply of home testing, the results of which, remain private and undocumented. Hence, today, we can only get rough estimates from government agencies and other surveys and the results from multiple studies may indeed vary.
Elliot Udell, DPM, Hicksville, NY
05/19/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1b
From: Alan Sherman, DPM
There are some very good reasons why we podiatrists should have a lower incidence of COVID than the general population. Doctors, in general, are among the most vaccinated population. We podiatrists are so well educated in infectious disease and the precautions that we need to take to keep our staff and patients safe. We spend so much time in operating suites where the principles of antisepsis have been followed long before COVID.
I don’t find it surprising that our incidence of COVID as a group is lower than average, but rather, that it is a testament to the policies that were put into place and the practices that were diligently followed in our offices and clinics, as well as in our personal lives.
Alan Sherman, DPM, Boca Raton, FL
05/19/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: Gary S Smith, DPM, Al Musella, DPM
James DiResta wondered why the PM News polling showed a negative 65% for having had COVID-19. I would remind him the question was "Have you ever tested positive for Covid?", not have you ever had COVID-19?
Gary S Smith, DPM, Bradford, PA
That shows that podiatrists understand and implement infection control. Most of the MDs I know also never caught it.
Al Musella, DPM, Hewlett, NY
05/17/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Dennis Shavelson, DPM
The biggest mistake we made as a profession continues to be to ask “Is it covered?” as a prerequisite to care. The second biggest mistake has been the simultaneous abandoning and minimizing of lower extremity biomechanics. We have neglected our inherited claim to be the best orthotic and closed chain professionals that Drs. Root, Langer, and Dananberg gifted us by instead becoming amateurish, uneducated, and unskilled.
This year, I tearfully retired as a DPM. How did we let this happen?
Dennis Shavelson, DPM (retired), CPed, Tampa, FL
05/12/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Steven Finer, DPM
I applaud Dr. Kornfeld’s personal journey. I did not have the guts to do what he did and accepted Medicare. I always made a living .However, those 1978 fees adjusted for inflation are the same as 2022. My son could easily have gone into medicine but is in the business world. None of my friends' children chose medicine. My personal physician is leaving the big group as more and more patients are pushed on him. My excellent dermatologist looks tired and harried as the big group pushes him to do more. None of their children have gone into medicine and both sets are husband and wife MDs.
Steven Finer, DPM, Philadelphia, PA
04/05/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Kenneth Meisler, DPM
Dr. Kass stated "like Dr. Meisler does with ultrasound guidance," he injects "into the region of the neuroma...is a pretty easy location to find without ultrasound." I agree that to be in "the region" is pretty easy. I do not inject into "the region of the neuroma." I inject directly into the body of the neuroma. I have done this for about 15 years after reading a study performed this way at the Hospital for Special Surgery. I have found injecting directly into the neuroma under ultrasound guidance is more effective than injecting in the region of the neuroma, which I did for 25 years. It is difficult to do even with ultrasound guidance. There is a definite learning curve.
I think you will be surprised where you are injecting as you watch yourself under ultrasound. Eventually, it becomes quite easy. Injecting directly into the neuroma also reduces complications such as fat necrosis and skin discoloration because the firm body of the neuroma holds the steroid or alcohol within it after the injection. A comprehensive review of the literature on ultrasound guided vs. non-ultrasound-guided injections in the Orthopedic Journal of Sports Medicine concluded that ultrasound-guided injections are overall more accurate than landmark-guided injections. I perform all neuroma injections under ultrasound guidance even if the insurance company will not pay for it. I cannot ethically do an injection without it if I know I am capable of being more accurate with ultrasound; that's just me.
Kenneth Meisler, DPM, NY, NY
04/05/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: Steve Tager, DPM
Maybe these posts about neuroma treatment are not truly representative of what the nation’s podiatrists do for this condition. I am reasonably certain that as physicians, we all try to achieve positive outcomes and do what we feel is mutually beneficial for our patients when it comes to treatment regardless of the problem. Fifty plus years of doing all that has been discussed, from steroid injections, dehydrated alcohol, DTL sectioning, excisions from both above and below, etc. Nothing compares to the success rate I’ve experienced by simply reversing the pathomechanics of lateral column overload. My experience continues to tell me that restoring rearfoot function anywhere close to anatomic neutral gives the foot optimal opportunity to heal itself.
How many times have we sat in front of a pair of feet and identified good upper and lower leg alignment, with the plantar surface of both feet trying to face each other? Is it not possible that...
Editor's note: Dr. Tager's extended-length letter can be read here.
01/05/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Henry Stark, DPM
Almost by definition, temperature in the human foot is normally less than core body temperature. I think we can all agree that there is no need for double-blinded studies to determine this to be a fact. During a hyperuricemic episode, it is believed that urate crystals coming out of solution from a “saturated” plasma concentration, precipitate in these naturally cooler, distal articular regions which initiate the gouty attack. In conjunction with other therapeutic measures, many podiatrists utilize posterior tibial blocks to induce a temporary, localized sympathectomy for increased perfusion as well as the analgesic effect. Yet, the Arthritis Foundation, most all rheumatologists, as well as most of my colleagues would argue that ice (rather than mildly increasing the temperature of the site) is appropriate therapy for the ACUTE phase of the attack.
Dr. Levy appears to suggest (as do I) that consideration towards increasing perfusion (and perhaps warming of the affected area of the gouty attack) rather than ice may be more appropriate. Yes, ice is an analgesic in this situation, yet its use seems counterintuitive since it decreases temperature, perfusion, and would tend to prolong and enhance localized urate crystal formation. I am aware that once a gouty attack has begun, uric acid concentration in the plasma often has already decreased. Why would ice be the recommended therapy simply for analgesic purposes, when it may cause further, localized urate crystal formation?
Henry Stark, DPM, Lake Park, FL
01/04/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1
RE: Have you received your COVID-19 vaccination yet? (Adam M Budny, DPM)
From: Robert Scott Steinberg, DPM
I am not sure of Dr. Budny's point. Is he rationalizing his decision? Here is what I do know. "The general recommendation is to get the vaccine, even if you were previously infected," said Dr. David Thomas, a professor of medicine and director of the infectious diseases division at the Johns Hopkins University School of Medicine. "There are some nuanced questions that we don't have the answer to yet, but from what we know now, it's the right call to get the vaccine."
Everyone be as safe as you can. You owe it to your family, your patients, and yourself.
Robert Scott Steinberg, DPM, Schaumburg, IL
12/23/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Elliot Udell, DPM
Dr. Tritto questions the use of posterior tibial nerve blocks in light of the fact that there are no published studies supporting their efficacy. The point he is making is well taken. Even though the late Dr. Marvin Steinberg, who was regarded as the father of modern podiatric medicine, showed that by blocking the posterior tibial nerve, a patient could be rendered almost asymptomatic within minutes, there are no studies published in any peer-reviewed journals supporting it. Why?
Studies cost megabucks and no pharmaceutical company will invest millions of dollars into showing that PT blocks are helpful, when there is no way they will make money off of the procedure. What makes it worse is that most insurance companies will not pay for PT blocks because there is no research. Could there be research and publications on PT blocks? Sure! Our professional associations along with our colleges of podiatric medicine would have to fund the research without corporate sponsorship. If enough of us want it to happen, maybe it will.
Elliot Udell, DPM, Hicksville, NY
12/23/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: Allen Jacobs, DPM
Dr. Tritto correctly notes that little if any EBM exists to support the utilization of a PT block as adjunctive management of acute gout. While I personally do not employ a PT block, it should be recalled that medicine is both an art and science. The use of a PT block is reasonable in a effort to relieve the pain and suffering of acute gout. NSAIDs, colchicine, steroids take time to work.
I employ a wide V block apex proximal around the joint dorsally, using lidocaine or bupivicaine with epi. I go see other patients, return and then inject the joint. Patients are very appreciative for the immediate pain relief. No patient has yet refused due to a "lack of evidence". If all of medicine were restricted to EBM, we would be very limited indeed. And remember, EBM includes practitioner experience.
Allen Jacobs, DPM, St. Louis, MO
07/06/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1
From: Steven Kravitz, DPM
The recent PM News poll reflected that wound care was by far the least impacted aspect of podiatric practice by the current COVID-19 pandemic. Surgery was affected nearly 60%, routine foot care nearly 30% affected, but wound care less than 2% affected. Additionally, I continue to have numerous contacts with multiple podiatrists in private practice and wound healing centers throughout the country.
My personal general impression is that the majority report that 75 to 80% of the pre-COVID-19 patients are returning, and there's an increasing number indicating the return approximating 100%. Most recently, a new finding is that some practices are reporting is much as 120% pre-COVID-19 because they picked up patients from surrounding practices that have been closed or otherwise had patients referred to them.
These observations exclude...
Editor's note: Dr. Kravitz's extended-length letter can be read here.
07/03/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Estelle Albright, DPM
Thank you Dr. Markinson for your advice: I will further refine my methods of nail care with improved type face masking, and face and head cover, similar to operating in the OR. Currently, I mask and glove, wear glasses, and use sharp, sterile-bagged double action bone cutters for hard nails and use Miltex 40-226A nail nippers for non-dystrophic nails. I do not grind nails.
I treat fungal or dystrophic nails medically with oral antifungals and/or nail softeners, or surgically with matrixectomy or nail avulsion. My aim is cure, not maintenance. Granted, this is not an option for some patients, but for most, be the physician that you are: Treat with your best knowledge and skills.
I use a 12 month treatment plan for non-surgical nail fungus patients. This includes ketoconazole shampoo for foot washing, topical antifungals, environmental clean- up/disinfection instructions, patient education/brochures, and UV light shoe disinfection with SteriShoe/similar device. I have a very good cure rate. Many of these patients had severe, chronic nail and skin infection (often since military service, or with poor circulation or diabetes). Patients are happy and grateful to be cleared of the infection. I follow patients at 4, 8 and 12 months. I think that ultimately podiatry will endorse protection like I see at my dentist's office; this is surely the path of the future.
Estelle Albright, DPM, Indianapolis, IN
07/03/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: Steven Finer, DPM
I find that statistic of 34% quite shocking. From day one, in the prehistoric era in 1976 and onward, I had a Sanivac and an air cleaner in the treatment room. I modified the tube myself, adapting vacuum store parts to deliver suction to the drill head. Patients would look at the air cleaner and assume it was an air conditioner or a dehumidifier. When I would arrive at the office, I would always touch surfaces to see that they were cleaned.
Disclosure: I have no financial relationship with Sanivac.
Steven Finer, DPM, Philadelphia, PA
07/02/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Bryan C Markinson, DPM
A simple search of the global microbiological, occupational science, radiological, and infectious disease literature dating back 2-3 decades will reveal a plethora of citations in the potential dangers and actual incidence of respiratory illness from inhaled nail dust and the microbes that tag along with it. A British NHS study reveals 4x the incidence of asthmatic-type illness among podiatrists.
If Dr. Moglia won’t be convinced until he sees dramatic numbers of lung cancer cases, which he won’t, then he should stop wearing seat belts and bicycle helmets. And another word to the wise, should any podiatrist be immunocompromised by any number of medical issues and or
treatments, the risk is...
Editor's note: Dr. Markinson's extended-length letter can be read here
02/25/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Don Peacock, DPM
Residents need to be trained in surgery. During school, we are taught how to assess a patient from a biomechanical standpoint and how to cast for orthotics. We certainly are taught how to administer palliative care and even contact casting. We are taught how to interpret vascular exams and do rotations through vascular departments while in school.
We were also taught how to do ingrown nails in school. I did ingrown nails with phenol procedures while I was in school. These things can easily be taught in a busy podiatric medical school clinic. In our fourth year, we do rotations through the various disciplines that we pick or we rotate through podiatric surgery residencies that perform both...
Editor's note: Dr. Peacock's extended-length letter can be read here.
02/25/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: David G. Armstrong, DPM
Can we move from "care" to "closure"? Can we work to doctor these wounds rather than just nurse them? I have read with some interest the dialogue and discourse regarding the above. It has prompted me to (politely) suggest a small change in syntax. I notice that many of my friends and colleagues use the term "wound care". I think that's great. However, I think it somehow abrogates our responsibility to take action-- surgical action-- to treat these patients.
The fact of the matter is that physicians and surgeons literally and figuratively washed their hands of taking care of tissue loss in the mid-1800s following the germ theory. They turfed it to Florence Nightingale and her colleagues. Our nursing colleagues have been doing a historically spectacular job in nursing these wounds (addressing pain, addressing appropriate dressings, etc.) for the last 150 years. It is not until very recently that we have begun to doctor these wounds as well as nurse them - i.e. angiogenesis, tissue coverage, reconstruction, regeneration.
We in podiatry have the capacity to do this pretty dang well along with our colleagues. I urge all of us to consider this. In addition to caring for these folks, can't we work toward closure?
David G. Armstrong, DPM, Los Angeles, CA
02/24/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: Lee C. Rogers, DPM
The PM News Quick Poll is very timely since CPME is currently rewriting the standards for podiatric medicine and surgery residencies (Document 320). Wound care currently represents a large and rapidly growing area of practice for podiatrists. There is an urgent public need for knowledgeable, skilled providers to care for lower extremity wounds, to reduce the rate of amputations. This is reflected in the PM News Quick Poll where 95% of almost 800 respondents declare the need for mandatory, and specific, wound care training in podiatric residencies.
The APMA BOT, in 2019, wrote a letter to the 320 Re-Write Committee, in part, expressing the opinion that there be a larger emphasis on wound care in standardized residency training. Additionally, the ABPM recently published a position statement on residency training declaring, "Wound care should be a required, separate, and defined residency training experience."
It is the responsibility of the CPME 320 Re-Write Committee to respond to the community of podiatric educators, public health officials, and associations to ensure that residents have adequate, standardized training to address the public need for lower extremity wounds.
Lee C. Rogers, DPM, BOD, American Board of Podiatric Medicine
02/21/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Joe Agostinelli, DPM
I respectfully disagree with Dr. Peacock’s comments on doing away with waste of time rotations and only teaching surgery to our podiatric residents. I come to this because of my background as a DPM in the USAF for 23 years in orthopedic clinics, then 13 years in private practice with a large orthopedic surgical group as their DPM.
During my first assignment at a USAF hospital that trained 25 orthopedic surgeons, I quickly realized the need to become a “good doctor first“, then a surgeon after that. The four years of podiatry school gave us the background in biomechanics, surgery, palliative care, etc. and the mostly...
Editor's note: Dr. Agostinelli's extended-length letter can be read here.
02/20/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Michael M. Rosenblatt, DPM
Robin Lenz, DPM recently wrote a letter explaining how important wound care issues are and should be a part of every DPM residency. I strongly agree. Some years before I retired, I heard an orthopedist who routinely used Achilles Tendon lengthening and gastrocnemius recession to treat very severe diabetic ulcerations, even for patients with very poor circulation. He presented sound evidence that this should be a “part of podiatric care” for diabetic ulcers. He made the point that DPMs should be doing MANY more of these than presently done. He also used some tendon releases in other tendons, but most of his surgery was gastroc recession and Achilles tendon lengthening.
When questioned about malpractice risk for patients with very poor circulation, he provided data that showed virtually NO...
Editor's note: Dr. Rosenblatt's extended-length letter can be read here.
02/20/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: Don Peacock DPM, MS
I agree with everything Dr. Robin Lenz states in his post. The only exception I have is regarding time spent in rotational programs. A surgical residency should be dedicated to surgery of the foot and ankle and lots of it. The wound care procedures such as total contact cast are skills to be learned in school and practice. In our area, nurses apply the total contact cast and they are good at it.
Residents should be taught surgery and the non-useful rotations should be dropped. My residency was surgical and I am grateful for it. In today's rotation-style residencies, the residents are wasting their time. We are creating a number of residency-trained podiatrists who do not receive adequate surgical training - even with some 3-year programs.
Don Peacock DPM, MS, Whiteville, NC
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