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11/30/2022
RESPONSES/COMMENTS (PM ARTICLES)
From: Bryan C. Markinson, DPM
In the last issue of PM, Josh White, DPM wrote an article proposing to inform how to tackle the obstacles to getting appropriately examined patients into diabetic footwear. Actually, instead of doing that, he simply reiterates the myriad of reasons why someone would not be engaged in the program. He further convinces me to stay away from anything other than prescribing, which I have been doing for many years since my early participation resulted only in problems. In fact, just simply prescribing and referring patients to a shoe provider has many attendant frustrating and time-consuming problems.
Increasingly, my most carefully detailed exam notes, and detailed prescriptions required from the shoe providers, end up with the dispensing of acceptable shoes, and useless foam inserts. Anything written for "custom molded" is met with we "don't do that anymore." Communications requests to the PCP for notes that are given to the patient always end up with me then having to redirect it myself or inform the patient that it is for the PCP.
It seems the only way to successfully have an office-based diabetic shoe program is to have a high-volume need, a dedicated individual in the practice for the fitting of off the self-shoes, and an available laboratory that will provide true custom footwear and inserts instead of a slab of thin pink foam.
Bryan C. Markinson, DPM, NY, NY
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12/14/2023
RESPONSES/COMMENTS (PM ARTICLES) -PART 1
From: James Koon, DPM
I closed my practice 8 years ago to join a multi-specialty clinic. I got one records request in the 7 years I had to keep the records. One. I called the requestor and was released from it as my contribution was nominal. I simply kept my server. My vendor, MacPractice, assured me that IF I ever needed a chart, they would be able to pull it off my server no matter how many software updates transpired. For a fee. I never needed it.
We did have some residual paper charts that I rented a storage space for and pared them yearly. I paid to have them shredded. I also sold my x-rays for the silver recovery. Both were an expensive and laborious endeavor. In retrospect, I should’ve just had a big bonfire and partied with friends.
Closing a practice takes longer than you think and costs more than you think. Bills come out of thin air for months. Banking costs, vendor contract terminations, x-ray equipment decommissioning costs, files, legal notifications, etc. I don’t envy anyone doing it. I love being an employed physician.
James Koon, DPM, Winter Haven, FL
12/14/2023
RESPONSES/COMMENTS (PM ARTICLES) - PART 2B
From: Robert D Teitelbaum, DPM
David Secord's posting recently about "allopathic" medicine and how DPMs are allopathic doctors was a great lesson in the real meaning and the corruption of common words that we use to describe our professional status. I would also like to bring up three words that have held us back professionally and consistently for 40 years and I have not seen them much talked about. Those three words are Routine Foot Care.
My thesis is this:
1.There is no complaint about foot pain that is routine. A patient who realizes that her bent second toe has a painful corn on the first joint that hurts in all shoes is in distress. They need someone to counsel them on the choices they may face and the treatments that are relevant. The patient wants our experience, knowledge, and ability to communicate. They want a plan of action--in other words they want...
Editor's note: Dr. Teitelbaum's extended-length letter can be read here
12/14/2023
RESPONSES/COMMENTS (PM ARTICLES) - PART 2A
From: Robert Kornfeld, DPM
Dr. Kesselman makes a powerful point. But it isn’t limited to DPMs as to under-valuing services. I am friends with many MDs and the ones who still accept insurance suffer the same issue. The system has conditioned patients to not want to pay for anything so doctors feel their services have no value. I used to share an office with a cosmetic dermatologist and a plastic surgeon. They collected enormous amounts of money every day from their patients, and my patients often refused to pay co-pays and deductibles.
I went to a direct-pay model almost 24 years ago. I decide what my services are worth. I set my own fees. Every patient pays my full fee at the time of the visit. My accounts receivable has been $0 all these years. And I have made almost double the net income on 8-10 patients daily than I made on 50 insurance patients daily. Honestly, it’s a choice. I do not work hard. My days are pleasant and stress free. No one has to be exploited and abused by insurance companies.
Robert Kornfeld, DPM, NY, NY
12/13/2023
RESPONSES/COMMENTS (PM ARTICLES) -PART 1
From Ron Werter DPM
Dr. Kobak has written an in-depth article in PM Magazine about closing a practice. There is one item I have a question about: preserving the charts. When we all had paper charts, we could put them in boxes and take them home or have a company store them for 7 years Now, most of us have an EHR which is administered by a vendor. What is the best way of retaining those charts? Are there known problems with asking the vendor to copy all the data and allow it to be accessible if you no longer have their program.
Ron Werter, DPM, NY, NY
12/13/2023
RESPONSES/COMMENTS (PM ARTICLES) - PART 2
From: Paul Kesselman, DPM, Mark Spier, DPM
The whole point of my last letter was to point out that we, as individuals, are partly if not totally responsible for setting our own self-worth. If we don't, who will? If we podiatrists, as Dr. Secord states, are allopathic physicians, then it’s time we start acting like ones.
Can you find me an MD or DO who will work for the kind of dollars DPMs line up and stab each other in the back to sign up for? And that is the crux of the problem. We think if we sign up for less, then we can become invaluable to the patient and carrier. In fact, that’s exactly the opposite of what happens. The carrier realizes we are so dependent on them, we become so desperate to retain their lifeline, that they pay us less and less. So who’s really responsible for this? Each of us!
Paul Kesselman, DPM, Oceanside, NY
I’m asking if the antipathetic allusion to allopathy is an anonymously announced alliterative allegory? Or is it not necessarily nuanced enough to notice now?
Mark Spier, DPM, Reisterstown, MD
12/12/2023
RESPONSES/COMMENTS (PM ARTICLES)
From: David Secord, DPM
"Much of what we have been talking about for the last four decades is the attempt to be treated as equals to our allopathic and osteopathic colleagues," says Dr. Paul Kesselman.
I like to comment on people in our profession referring to MD and DO medicine as allopathic and osteopathic and then putting ‘podiatric medicine’ in a separate category, as if podiatric medicine wasn’t allopathic medicine. The poll in question does this same thing. There are a certain finite number of medical theories out there, including allopathic, osteopathic, homeopathic, chiropractic, native American Indian pan-theistic naturopathy, witch doctors, Eastern Indian Ayurvedic medicine, and a few others. Allopathic medicine has as its basis the idea of pathology from disease state: bacteria, virus, prion, spirochete, genetic dyscrasia, etc.
Unless I missed something critical in medical school, that’s the disease model we in podiatry follow as well. As such, podiatric medicine IS allopathic medicine. Podiatry is often stated as wishing to contribute with "allopathic" providers in the area, as if WE were not allopathic physicians. One of the myopic tendencies in our profession is to separate ourselves in like manner from allopathy, which makes no sense to me. Podiatry follows the allopathic theory of medicine. We ARE allopathic physicians and referring to ourselves as podiatric physicians with similarities to allopathic physicians (as if allopathy means "MD", which it obviously does not) shows either ignorance of what the term means or is a strange form of self-denigration I don't understand.
David Secord, DPM, McAllen, TX
12/05/2023
RESPONSES/COMMENTS (PM ARTICLES)
From: Mark Ross, DPM
Dr. Rothenberg said, “Diabetic is a label and should be avoided. Compliance is authoritative and stigmatizing." To an old-timer getting ready to be put out to pasture, my response is, “The truth shall set you free.”
We accept great responsibility when treating diabetics, particularly those with infections, ulcerations, osteomyelitis, and gangrene. Compliance always affects outcomes. Failure is not an option, but can happen and when it does, the onus is on us.
The most important thing a doctor can tell their patient is the absolute truth. And patients know when the doctor is lying. Give the patients credit. When the patient is told they’re going to lose their toe which could very well lead to loss of limb, which could lead to death within five years, they are not dwelling on your choice of words. They are looking to the doctor to save them. And that is our job.
Mark Ross, DPM, Yardley, PA
12/04/2023
RESPONSES/COMMENTS (PM ARTICLES)
From: Janet McCormick, MS
I agree with Dr. Maleski that Medicare and insurance patients should not have services in a podiatry practice by an MNT. If a patient is in treatment, they are only within the scope of care for RFC by the podiatrist, period, and a podiatrist that is billing insurance and Medicare for services performed by an MNT is billing improperly and fraudulently. This is stated many times in the MNT program and graduates are instructed in this clearly. Sadly, some podiatrists bypass this when the client gets to the counter and bill the care anyhow to insurance or Medicare. I experienced this myself in a podiatry practice once and had to insist on paying for the RFC I had that day!
Since 1995, the patients who are eligible to have their RFC billed to insurance and Medicare have reduced in percentage dramatically due to a ruling by Medicare and have become...
Editor's note: Ms. McCormick's extended-length letter can be read here
12/01/2023
RESPONSES/COMMENTS (PM ARTICLES)
RE: Addition by Subtraction (Janet McCormick, MS)
From: Richard M. Maleski, DPM, RPh
In the past, I have opined in this space on the need for DPMs to use extenders for nail care. As I stated before, back in 2008, I inquired about this with our state society (PPMA). I was told that it was not within our license for a DPM to supervise nail care. For a DPM to bill for nail care services, the DPM MUST perform the service personally; the use of an extender would be insurance fraud.
Our PPMA representative even told me of a DPM who, at that time, was being taken to court for insurance, i.e. Medicare fraud, because he used a nail technician under his supervision and billed Medicare for nail debridement. My question to Ms. McCormick is how can we even discuss the merits of using such ancillary personnel if it is illegal, at least in Pennsylvania, to use nail care extenders? Or has the law changed that allows for this practice?
Richard M. Maleski, DPM, RPh, Pittsburgh, PA
11/30/2023
RESPONSES/COMMENTS (PM ARTICLES) - PART 3
From: Janet McCormick, MS
I agree with most of Dr. Roth's comments concerning extenders. Medical nail technicians (MNT) do leave for many reasons, as do other extenders in offices - few of us in business have the same staff as five years ago. To counter this, I provide podiatrists ways to keep them, such as suggesting an Educational Agreement and proper pay, and more. If they continue to leave, then I always make a suggestion toward an evaluation of staff management practices. I also suggest a friendly exit to all when and if it happens, that a well nurtured referral system can be very profitable on both sides between an MNT and a podiatry practice. Wise podiatrists who build this referral system see new clients from this collaboration on a continual basis.
Over the years, I have made comments comparing the dental scenario with dental hygienists, and podiatrists with extenders, and have mentioned that many years ago, dentists saw the handwriting on the...
Editor's note: Ms. McCormick's extended-length letter can be read here.
11/30/2023
RESPONSES/COMMENTS (PM ARTICLES) - PART 2
From: Gary Rothenberg, DPM
I would like to applaud Luke Hunter and Amanda Miller for their recent article posted from Podiatry Management. As a podiatrist who has a career dedicated to prevention of lower extremity complications among people with diabetes, any opportunity to share thoughts on the significant relationship between mental health and diabetes outcomes is welcome. However, I ask that we take this article to the next level and realize that language and words matter.
A lot of work has been done in the diabetes education space around the importance of appropriate and acceptable language in treating patients with diabetes. By the title of the article and even though people with diabetes are a significant part of podiatric practices, our field is slow to catch on to the significance of the words we use. "Diabetic" is a label and should be avoided when referring to people with diabetes. "Compliance" is authoritative and stigmatizing. There are excellent references that can help us all communicate in a more sensitive and effective way, especially important for our patients with diabetes and concomitant mental health issues. Robin Sharma said, ‘‘Words can inspire. And words can destroy. Choose yours well."
Lewis DM. Language Matters in Diabetes and in Diabetes Science and Research. J Diabetes Sci Technol. 2022 Jul;16(4):1057-1058.
Speight J, et al. Our language matters: improving communication with and about people with diabetes. Diabetes Res Clin Pract. 2021; 173.
Dickinson J, et al. The use of language in diabetes care and education. Diabetes Care, 2017; 40(12): 1790-1799.
Gary Rothenberg, DPM, Ann Arbor, MI
11/30/2023
RESPONSES/COMMENTS (PM ARTICLES) - PART 1
From: Paul Kesselman DPM
As an update on the very interesting issue of RPM and wearable technology, CMS recently had a call-in, a four hour meeting entitled Digital Technology and Diabetes. A very limited number of speakers spoke on a variety of topics, but mostly the NIH and inventors spoke about CGM (continuous glucose monitors). Some mention was made of wearable technology by some individuals from the NIH, CMS, and CDC.
Fortunately, APMA had registered me to speak at this meeting. The NIH speakers provided some time to discuss wearable technology but this was not limited to only socks and mats but also included potential use of "smart" orthotics and prosthetic devices as well as "smart" dressings. There was universal interest by these scientists who asked many questions on the impact wearables could have for reducing the significant costs our society bears in treating DM. It will be interesting to see where CMS takes this over the next few years.
Having podiatry invited to be part of the discussion with these preeminent scientists was certainly a big win and definitely shows we as a profession are part of this equation!
Paul Kesselman, DPM, Oceanside, NY
11/27/2023
RESPONSES/COMMENTS (PM ARTICLES)
From: Ivar E. Roth, DPM, MPH
I read Ms. McCormick's explanation of why we should have a nail extender work in our office. I would say be careful. I have been a proponent of extenders and have coined the term podiacurist which is a mani/pedicurist doing routine care in a podiatrist's office. The major problem with this has been that once these individuals have been trained by you, they get emboldened and then will leave you and start a routine foot care practice down the street. They will be in direct competition with you and usually take some of your patient load with them.
If Ms. McCormick, who I believe owns a training program for these individuals, had the ability to mandate that they must work under a podiatrist or lose their certification, that would go a long way. In reality, a program through a podiatry school could make this a real legitimate profession and would ensure that the certificate had value and protected the podiatrists.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
11/24/2023
RESPONSES/COMMENTS (PM ARTICLES)
From: Janet McCormick, MS
Dr. Hultman’s article, “Addition by Subtraction” is very interesting in that dentists began to ‘add by subtraction’ in their practices 6 decades ago: they embraced the training of dental hygienists to perform lower-level care they did not care to do: cleaning and x-rays. They eliminated these tasks almost completely from their practice rooms by delegating them to these trained professionals. Podiatrists should consider the same tactics in their practices.
As a former dental hygienist, I wonder why more podiatrists do not hire certified medical nail technicians to perform routine foot care. These nail technicians are advanced trained (and licensed) to perform the tasks of routine foot care in their services and can relieve the podiatrist of them to practice ‘real’ podiatry. While many podiatrists are doing so and enjoying the benefits of their decision, more continue to hold back.
These advanced trained nail technicians are special people who care about providing safe care within their scope of practice for persons who are chronically ill and/or elderly and have taken special training to do so safely. They wish to work directly for a podiatrist or to have a referral podiatrist to refer their aesthetic clients to who may need their care. Those of you who may need some support in this lower-level care in your office might give this some thought. Try delegating these tasks to a certified medical nail technician as dentists did to a registered dental hygienist. Most of you who do will never go back to performing those tasks except on those who specifically need you.
Janet McCormick, MS, Nailcare Academy, Naples, FL
09/28/2023
RESPONSES/COMMENTS (PM ARTICLES)
From: Jeff Pinsky, DPM
In response to Dr. Kobak’s piece on “Operation Nightingale”; scary stuff indeed, but he lost me at the end where he recommends we contact our legislators. Maybe I’ve gotten cynical in my old age, but the only way a legislator is going to read anything I write, is if it’s a check, and especially one made out to his/her re-election campaign.
Jeff Pinsky, DPM, Petersburg, VA
09/18/2023
RESPONSES/COMMENTS (PM ARTICLES)
From: Gregory T. Amarantos, DPM
As most of us have surmised, MIPS and "Meaningless Use" are nothing more than money grabs with big brother hovering over us. It is a long-term game…overburden the practice with documentation and clicks in the computer, increasing the cost to the practice, all the while having the medical profession grovel to stop a decrease in payments. Big brother is hoping to “starve” us out of private practice into socialized medicine, like taking lambs to slaughter. Talk to a Canadian and see how that system works.
Oh yes, and the autoworkers are striking for a 40% pay raise over 4 years.
Gregory T. Amarantos, DPM, Glenview, IL
06/14/2023
RESPONSES/COMMENTS (PM ARTICLES)
From: Alan Sherman, DPM
Barry Block, DPM’s editorial, “The American Board of Foot & Ankle Medicine and Surgery” advocating for a single unified certifying board for podiatry puts the issue into clear and sharp focus and demonstrates that the profession wants this. It is now up to the boards to work out a compromise.
I encourage all of us, both the rank and file and the leaders in our profession to call upon the boards to set a schedule of meetings, to come together and finally, get this done once and for all, for the good of the profession.
Alan Sherman, DPM, Boca Raton, FL
03/01/2023
RESPONSES/COMMENTS (PM ARTICLES)
From: Rosemay Michel, DPM
Dr. Abraham's review of Oxygen Saturation and the Pulse Oximeter: A number of observations/studies during the height of the COVID-19 pandemic (Sjoding, et al., N Engl J Med, Dec 2020; Stell, et al., BMJ Open Respir Res, Feb 2022; Crooks, et al., Eur Respir J, Apr 2022) have documented the inaccuracy of pulse oximeters in patients of color - this is an additional limitation.
Rosemay Michel, DPM, Fayetteville, NC
01/12/2023
RESPONSES/COMMENTS (PM ARTICLES)
From: W. David Herbert DPM, JD
I know that there is a movement to obtain parity with the medical profession. But I do not think that kissing the butt of the AMA is really the way to do it. I believe that making sure that a podiatrist is recognized as a physician and surgeon of the foot in every state is the way to achieve parity as seen by the general public. I know that this came about in Ohio in the 1970s. If podiatrists want to get into an interesting career, they should become lobbyists!
W. David Herbert DPM, JD, Billings, MT
12/06/2022
RESPONSES/COMMENTS (PM ARTICLES)
From: James H. Dolan, DPM
As the former Chief of Podiatry at Dartmouth-Hitchcock Medical Center, I am most proud of the addition of a diabetic shoe program to the wound center there. Tens of thousands of dollars would be spent over months to heal a diabetic foot wound. We would ring a bell and the team would clap in celebration as the patient was leaving with a healed wound. As I watched the patients walk away in worn out, poorly fitted shoes, I knew we could, and should, do better to try to decrease the odds of recurrence.
I am now in private practice and believe my most important job continues to be giving our diabetic patients the tools and information to best avoid ulceration. We are leaning into the diabetic shoe program with full understanding of the road blocks we will face. I appreciate Dr. White's thoughtful roadmap to avoid them.
James H. Dolan, DPM, Stratham, NH
12/05/2022
RESPONSES/COMMENTS (PM ARTICLES)
From: Jack Ressler, DPM
For many years, I fit and dispensed diabetic shoes and inserts to my qualifying diabetic patients. Besides being a nice profitable addition to my practice, I actually enjoyed the evaluation and fitting aspect. I did train office staff to do these tasks but I always remained involved with the process. I would get that occasional patient who would stockpile the shoes because of entitlement. Call me a poor businessman, but the brand I dispensed most regularly was SAS.
As most of you know, the SAS line was probably the most expensive shoes you could dispense that met Medicare regulations. Yes, my profit margin was not as good when dispensing those, but patient compliance was excellent. When my diabetic patients would come in for their podiatric care, I would rarely see them wearing anything else but the SAS shoes that I dispensed. It was very rewarding to see that! After several years of participating in the diabetic shoe program, I did stop doing so. This was because of all the bureaucracy that went along with it that was probably brought on by a great deal of fraud and abuse within this program. As in life, a few bad apples can spoil it for the rest of us.
Jack Ressler, DPM, Boca Raton, FL
12/02/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 2
From: Kenneth Jacoby, DPM
The letter by Dr. Kesselman was well written but a sad commentary on today’s situation. What are the APMA and other organizations doing about this sad situation? And this goes further than diabetic shoes. When I went into medicine 37 years ago, it was patient first, which still holds true, but there are more hoops required to get compensated.
Kenneth Jacoby, DPM, Elgin, IL
12/02/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 1
From: Josh White, DPM
I appreciate the letters written by Drs. Markinson and Kesselman regarding the article I recently wrote in Podiatry Management about why diabetic shoes aren’t prescribed more. While intended as a “How to” overcome obstacles to ensure patients are properly fit, it seems to have been perceived more as “Why not to”, get involved with footwear.
I wholeheartedly agree with Dr. Markinson’s conclusions that it’s best to have "a high-volume need", "a dedicated individual in the practice for the fitting of off-the-shelf shoes, and an available laboratory that will provide true...
Editor's note: Dr. White's extended-length letter can be read here
12/01/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART1B
From: Paul Kesselman, DPM
I have to mostly agree with Dr. Markinson's sentiments and publicly want to acknowledge that many years ago, Dr. Markinson often referred his patients to my practice for proper evaluation of shoes/inserts through the Therapeutic Shoe program, because his practice could not deal with the bureaucracy of the program. He and I am sure most continue to believe the program is theoretically needed, but from a practical office-based practice perspective is untenable.
Most podiatrists (and others), as opposed to pedorthists, do not offer custom molded inserts (A5513) simply because they don’t want to deal with the increased costs of the custom molded devices, while still receiving the exact same reimbursement as for custom milled (A5514) devices. Most pedorthists and some orthotists produce their own custom molded inserts in-house. But they too...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
12/01/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Elliot Udell, DPM
There is an elephant in the room that we are not addressing when it comes to diabetic shoes and inserts. It’s called "entitlement." The patients feel they are entitled to them and will do anything to get them once a year, even if they do not use them. We had one patient who was "Johnny on the spot" every January 1st for his shoes. He never seemed to be wearing the old ones. When confronted, he would say that he just left them at home by mistake. Was he really using them or selling them on the street corner or on E-bay? We'll never know.
Elliot Udell, DPM, Hicksville, NY
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