07/01/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: Observations on the Changing Face of Medicine
From: Elliot Udell, DPM
I have a patient who is a soon-to-be retired psychiatrist. Whenever he would come into the office, we would have discussions on many topics not related to psychiatry or podiatry. He was very well aware of all facets of general medicine. If I asked this physician a medical question, he knew the answer. He later told me that he works one day a week in the ER doing emergency medicine and this helps him keep up with the entire medical field. In another case, my former GI specialist who just retired was able to comment with interest and expertise on any medical issue aside from the GI system.
I am now faced with seeing a whole new battery of young specialists in different fields and if I ask them a question outside their specialty, their answer tends to be, "It's not my field, go to an appropriate specialist." I am seeing more and more of this happening and some of these doctors are board certified in internal medicine and if the question does not directly relate to their subspecialty, the wall in the room can give me a better answer.
As a podiatrist, this may be good. We are specialized and only responsible for the foot, and so many other young specialists seem to have developed amnesia to all aspects of medicine other than their own narrow specialties. Perhaps the degree given to these physicians should not be an MD or DO but for example, "doctor of orthopedics or doctor of oncology, etc. Being a doctor of medicine is becoming less and less relevant in today’s practice.
Elliot Udell, DPM, Hicksville, NY
06/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: A Rose by Any Other Name…
From: Rod Tomczak, DPM, MD, EdD
I hope all who read the letter by ACFAS and APMA have also looked at the history of the resolutions and position papers. It seems that in 2020 someone came up with the idea that if students of podiatric medicine could pass USMLE, they should be classified as physicians.
Out of the right side of their mouths, the MD officials are pushing our students to take the USMLE, and out of the left side, they are saying MD and DO passers of the USMLE can call themselves “physicians.” What seems very odd is that DOs can still take their COMLEX exam and be licensed as physicians.
This whole ploy is the biggest example of obfuscation I have ever seen. AOFAS would rather partner with Reiki practitioners than...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
06/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Elliot Udell, DPM
Kudos to Dr. Ribotsky for suggesting that there be some way of tracking podiatrists diagnosed with some form of cancer. As a cancer patient in remission, this issue is very close to me.
The medical community is grappling with another issue. Patients with breast and colon cancer are now presenting at very young ages. One patient of mine had his first colonoscopy at age forty and discovered that he had stage four colon cancer. Another young woman in her thirties is undergoing treatment for breast cancer. Are these caused by unidentified carcinogens or are people discovering these conditions earlier in life because of testing and awareness?
Elliot Udell, DPM, Hicksville, NY
06/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: Tom Brady’s Formula for Success (Allen Jacobs, DPM)
From: Jeffrey Trantalis, DPM
During my residency, I was taught, “if you do good honest work, the patients and income will follow.” Too many practitioners practice for only the short-term and instant financial gain.
Jeffrey Trantalis, DPM, Del/ray Beach, FL
05/21/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Robert Kornfeld, DPM
I think it is really unfortunate that Dr. Gottlieb quotes a book written by an economist/psychologist who characterizes self-employment vs. employment in an overly-generalized way. This does nothing to honor or include the reality that every direct-pay doctor that I know is really happy since leaving insurance-slavery or corporate employment. I would think with all of our collective intelligence that we podiatrists would stop cowering in our boots and stand up like adults for our professional experience. At some point, you need to dismiss the naysayers, who only see things from a negative lens.
As adults, we possess the power of choice. With intention, commitment and consistency, anyone who wishes to succeed in a direct-pay model will succeed. Dr. Gottlieb, it isn't fair to many of our colleagues out there who are miserable and read a post like this causing them to give up hope of achieving success and happiness outside of a system that exploits and abuses them. It feeds into fear and insecurity and has no place in these kinds of discussions.
I find it interesting as well as disturbing that not a single one of the naysayers here took the time to ask me or Dr. Roth exactly how we created successful practices and I'm certain they spent no time investigating the option. Dismissal comes from small-minded thinking. Success comes from an open mind, self-esteem, and an ability to shut out all the rhetoric of those who are too afraid to stand up to the monster that the system has become.
Robert Kornfeld, DPM, NY, NY
05/17/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Robert Kornfeld, DPM
Since this thread is still going, I would like to bring up a really important point that Dr. Meisler glossed over. Patients coming from these concierge practices were willing to pay directly when they came and were "surprised that they did not have to pay at the time of their visit." That should tell you something about the value they are experiencing in a direct-pay practice. That's number one.
Number 2, I agree with Dr. Meisler that eliminating poor payors will always make room for more value in the practice. However, it is important to note that as long as you continue to accept insurance, you will always be fighting an uphill battle. You will need to see a high volume of patients which means a large office, large staff, and high expenses. You will still have to navigate the slippery slope of...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
04/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: The Future of Podiatry - Part 2
From: Allen M. Jacobs, DPM
As we move forward (I should say you, as I'm on the 18th green and putting out), there must be a realistic examination of the future of medicine. As corporations and healthcare institutions continue to take over medical care, and insurers evaluate our care, the bottom line is cost-effectiveness. This is a major reason why NPs and PAs are replacing MDs and DOs as independent healthcare providers. This is a driving force for pharmacists beginning to provide healthcare. It is a driving force for urgent care centers replacing emergency departments, surgical centers providing services; we can site example after example.
Ultimately, insurance carriers want the least expensive medicine provided, whether it be testing, office fees, drug choice, or procedure selection. Industry, such as corporate-driven medicine, to the contrary, wants you for profit. You are evaluated by industry first and foremost by the profit you generate. The conflict between industry and...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
03/29/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: Podiatrists and the USMLE
From: Rod Tomczak, DPM, MD, EdD
I have recently heard from several DPMs that because we teach essentially the same curriculum as the MDs, “I’d bring Steps 1 and 2 USMLE to their knees.” It’s not what is taught in the podiatry schools that concerns me, it’s what is not taught that scares me.
In case anyone would like to explore what is not taught in the podiatry schools, I invite any podiatrist who figures we are just a month’s rotation in obstetrics/gynecology and a month’s rotation in psychiatry from an MD degree to explore the samples of USMLE Steps 1 and 2 which are posted at: Here and Here.
I think anyone who passes the two sample exams, can take a black Sharpie and cross out the word "Podiatric" in Doctor of Podiatric Medicine and become Doctor of Medicine.
Rod Tomczak, DPM, MD, EdD, Columbus, OH
03/15/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Paul Kesselman DPM
While there are not many 80+ year olds in leadership positions in podiatry, there is one here in NY for whom if I did not comment I would simply be ashamed. Dr. Arthur Gudeon has been a shining light in this profession here in NY for more than 60 years. He is 89 and shows no signs of slowing down. There are many podiatric bambinos who Arthur has mentored and yet he still finds time to practice and play tennis a few days a week. If not for Arthur, podiatry would certainly not be where it is today in NYS.
Paul Kesselman, DPM, Oceanside, NY
03/11/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Rod Tomczak, DPM, MD, EdD
I could not be more pleased than I am with the responses from Drs. Uro and Jacobs. I have never met Dr. Uro, but I’ll posit the two of us would get along famously. Dr. Jacobs was one of my trainers when I was a resident and we have been good friends from the first day. When I taught in Des Moines, he graciously took all levels of students, inspiring all of them to become excellent clinicians. When I had to make podiatric relevant decisions, I always thought WWJD, but refused to wear a bracelet advertising such.
I applaud Dr. Uro for having the courage to say he would not recommend podiatry to a college student today, in spite of the fact he loved the profession for 45 years. This begs the question why he would not recommend something he thinks was so...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
03/04/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Ivar E. Roth, DPM, MPH
I have been told by a very reliable source that the new schools opening is like a Ponzi scheme. There are funds available by the feds, etc. that allow these schools to be subsidized. Thus on paper, it can be a money-making proposition; however in reality, we do not have enough students to choose from, thus low enrollment and students with lower MCATs and GPAs are being admitted. We do not have enough residencies if all the schools were filled to capacity based on the number of podiatry schools now open. We are in a tough situation.
I hope everyone reading this post gets energized and goes out and speaks at a local high school or college and promotes our wonderful profession so we can grow in a positive direction for the future. I think our component societies should contact all local high schools and colleges and offer their members as speakers.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
02/16/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Ivar E. Roth DPM, MPH
I think you could sue for failure to refer to an appropriate medical doctor. If a generalist cannot figure out the problem, there is a duty to refer to a specialist.
Ivar E. Roth DPM, MPH, Newport Beach, CA
02/15/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Cynthia Cernak, DPM
My daughter was recently the patient of a family practice which failed to diagnose congestive heart failure. I was told by a malpractice attorney that we do not have a case, as a family practice is not qualified to diagnose this condition. The same daughter saw an optometrist for over 4 years, and they missed keratoconus, so now she is legally blind. Attorneys say she cannot sue optometrists, as they are not medically trained. But, yes they charge for an eye exam?
In conclusion, you cannot sue a store practicing podiatric medicine without a license. I doubt the GOOD FOOT store does any kind of exam. I doubt the patient is even asked to even remove their socks.
Cynthia Cernak, DPM, Kenosha, WI
02/14/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Dominic Bianco
Public knowledge and educating the public is really part of the answer. The other part is the patient has to feel confident and comfortable with their choice when seeking medical attention.
Retailers are now selling custom-made orthotics utilizing shippable impression kits. These start at $200. Originally, they were only available through podiatrists who were selling to their patients custom orthotics for $200 back in the 1980s. Now it seems these products are widespread, not just in custom orthotics but for all kinds of podiatry products.
Podiatrists, on average, are seeing 10-20 patients per day. Overseeing their practice and growing it takes a lot of...
Editor's note: Dominic Bianco's extended-length letter can be read here.
01/31/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2 B
From: Cosimo Ricciardi, DPM
I read with curiosity Dr. Ivar Roth’s comments on “practicing ethically” and not “chasing a dollar”.
Perhaps he could expound on his previous post on his ethical conversion of a patient’s $125 cash nail care office visit to a $3,525 cash office visit.
Cosimo Ricciardi, DPM, Fort Walton Beach, FL
01/31/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2 A
From: James Wilton, DPM
I read with some interest Dr. Allen Jacobs’ comments regarding "AENS surgeons operating on diabetic peripheral neuropathy with nerve decompressions". As a member of that society and director of the basic peripheral nerve surgery course, this is as far from the truth as can be stated. The surgeons that take our course for training have a much broader background in diagnosing, and conservatively and also interventionally treating peripheral nerve disorders. We do not advocate on any level the use of PSSD testing for the evaluation for peripheral nerve pathologies. We specialize in developing skills for our surgeon students in giving a complete neurologic extremity "hands-on" examination.
As the first DPM surgeon admitted to the American Society for Peripheral Nerve, it has been eye-opening seeing the difference in training between allopathic peripheral nerve surgeons and what is being taught in traditional podiatric residencies. I had excellent medical and surgical training through Dr. James Ganley, however peripheral nerve injuries and syndromes were not a part of my training. In having taught podiatric surgeons and international plastic surgeons over the past 20 years peripheral nerve surgery techniques and also diagnostic evaluation of patients, the current podiatric residency model falls way short of the allopathic model for plastic surgeons in these fields. It is through advanced training that the AENS offers, that podiatric physicians can become better diagnosticians and surgeons
James Wilton, DPM, Claremont, NH
01/30/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Daniel Chaskin, DPM
The point is that there is a clear bias against hospice patients receiving care as Medicare feels because they’re in hospice and at the end of life, they do not need the care. I agree that if one performs routine foot care for the chronic condition of PVD or diabetes, these diagnoses are likely listed on the hospice's list of diagnoses to make the patient eligible for hospice care. Thus, it might be difficult to justify a -GW modifier regarding procedure codes relating to routine foot care. Ulcer and wound care would be covered by hospice and likely not reimbursed by Medicare. If the -GW modifier is used, there might be a risk of an overpayment request if Medicare is billed for care that the hospice is supposed to provide.
The problem is when patients who are not likely to die are in the hospital. Some of them might be encouraged to go on hospice and lose their direct routine foot care benefits to be paid by Medicare to a private podiatrist, even if they are a diabetic with PVD.
Daniel Chaskin, DPM, Ridgewood, NY
01/29/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: H. David Gottlieb, DPM
I see the situation Dr. Udell posed, as well as many others, as no different than the many other meds we use for systemic distribution for foot-related problems. Antibiotics and antifungals given for foot issues are also effective for other co-existing infections. Oral anti-inflammatories for foot problems are effective for inflammatory and arthritic problems elsewhere. Orthotics not only help for foot pain and function but oftentimes back pains as well.
H. David Gottlieb, DPM, Baltimore, MD
01/26/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Donald R. Blum, DPM, JD
I don't quite understand this post. By your statement, it seems that you are frustrated, “Medicare insists that the foot care provided to our patients be medically necessary and this applies for hospice patients seen at home and in adult foster care homes.” Of course Medicare requires that foot care provided under the Medicare program or any other insurance meet the criteria set by that payer.
Just because patients are in hospice, cannot reach their toes, or have difficulty walking does not make certain care a covered service. Follow the CMS guidelines for your patients - that is - diabetes actively being treated by a PCP. PVD without palpable pulses, etc. (this is for palliative care). Surgical care involving a local anesthetic or could require a local anesthetic is a different story.
My question back - Which insurance payer covers care that is not considered MEDICALLY NECESSARY? Please clarify your concern.
Donald R. Blum, DPM, JD, Dallas, TX
01/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: Foot Care for Medicare Hospice Patients
From: Cary Wolf, DPM
I need help or advice on resolving an issue regarding the inability to service Medicare hospice patients in my house call practice. I work on a referral basis with hospice facilities, hospitals, and home care agencies. I and some of my colleagues received a competitive billing report from CBR Pepper Team on behalf of Medicare regarding submitting claims for foot care for hospice patients.
Medicare is discouraging us from treating hospice patients enrolled in the Medicare hospice program. They have instituted limits on the total number of patients we can treat, the amount of income generated from servicing these patients because they are in hospice. Medicare insists that the foot care provided to our patients be medically necessary and this applies for hospice patients seen at home and in adult foster care homes. These hospice patients have trouble walking or are bedbound in addition to being affected by their medical problems.
The hospice Medicare patients we see at home require this care and it is a medical necessity. The patients and family members are angry that their care has been halted. Politicians, AARP, and local and national podiatry associations have been contacted and are unable to assist.
Cary Wolf, DPM, West Bloomfield, MI
01/24/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Connie Lee Bills, DPM
I too had a patient come in with the Bronax shoe. It is not available in my size on Amazon, so I was unable to test it but was impressed as well. I don’t recommend it yet because of its limited availability, but I would like to see it more widely available! Thanks for bringing this up!
Connie Lee Bills, DPM, Mount Pleasant, MI
01/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: Wide Toe-Box Shoes
From: Kevin A. Kirby, DPM
I have followed the athletic shoe industry for over four decades and often recommend certain brands of athletic shoes for my patients with specific foot and/or lower extremity pathologies. Over the years, for my patients with hallux valgus-bunion deformities and intermetatarsal neuromas, I often have recommended the wide toe-box athletic shoe brand known as "Altra". Altras have the benefit of having a very wide toe-box but also are made with a minimum of heel lift (i.e., "zero-drop), which some patients find helpful while other patients don't seem to tolerate as well.
Just yesterday, one of my patients showed me an athletic shoe that she had purchased on Amazon.com with a wide toe-box shoe similar in shape to the Altra but with about a 10-12 mm heel-drop. I was shocked when she said that this brand of shoes, called "Bronax", only cost her $50 on Amazon. This Bronax shoe appeared to be an otherwise well-made athletic shoe which fit my patients' wide forefoot very nicely. Since the average cost for other wide toe-box athletic shoes, such as the Altra, are at least twice this price, both the patient and I were happy to find an apparently well-made athletic shoe with a wide toe-box that only cost $50 that could be easily purchase on-line.
Since I have no experience otherwise with this Bronax shoe brand, I can make no good recommendations other than my first impressions yesterday. I just wanted to inform my podiatric colleagues of this relatively inexpensive shoe option which may be of therapeutic benefit for their own patients who need a shoe with a wide forefoot to minimize their symptoms.
Kevin A. Kirby, DPM, Sacramento, CA
01/02/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Jay Seidel, DPM
I switched to T-Mobile 5G business Internet a few years ago and it has been great. It's a flat $50/month, and it has been very reliable and very fast.
Jay Seidel, DPM, Deerfield Beach, FL
12/21/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B
From: Rod Tomczak, DPM, MD, EdD
For most of the 1970s, I was either a podiatry student in Ohio or a resident in Philadelphia. There was a television advertisement for a financial company called E.F. Hutton where a broker spoke to a client who was sitting next to him in a filled Yankee Stadium. As the broker talked investments to his client, the stadium suddenly went silent and the narrator simply said, “When E.F. Hutton talks, people listen.” The information the broker was giving his client was so important it could silence Yankee Stadium. The concept was an admitted hyperbole, but clever, nonetheless.
I was lucky enough to have had both Allen Jacobs, one of my trainers, and Jim Ganley speak to me, and I listened. Both educators spoke to the “why” of facts being transferred from teacher to students in such a way that the “why” could be answered at least three times. Parents know the frustration of trying to answer a child’s...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
12/21/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Bret Ribotsky, DPM
Steve, as you and the readers of this forum know, nobody’s as hard on the establishment than me. At least monthly, I log onto the APMA E advocacy site and send letters to all my congressional leaders on many of the topics that APMA suggests. I have never seen a result of these form letters, but I guess APMA does (or I hope they would not pay for this service). It would be nice to see a report of how many others do this.
Barry provides this incredible forum where each of us can share our opinions. But over the last few years, I believe there’s only 20 to 30 people who have regularly written on this forum. I often received 30 to 40 emails/text messages after I post something, and when I encourage each of these people to write directly, so that their opinion can be included in the discussion, they all refrain from wanting to get involved.
Fortunately, we have a few great leaders. Paul, Elliot, Allen, Steven, Keith, Robert, Bryan, Joel, Jim, Michael, Richard, Ivar, and I’m sure a few more who will join me and write what we’re all thinking. Let’s not forget, “Our lives begin to end the day we become silent about things that matter." - Martin Luther King Jr.
Bret Ribotsky, DPM, Ft. Lauderdale, FL
