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RE: The Relationship Between APMA and CPME (Bret Ribotsky, DPM)

From: Keith D. Cook, DPM, Sylvia Virbulis, DPM


Dr. Ribotsky is correct that the Council on Podiatric Medical Education shares office space with APMA and that CPME staff are APMA employees. APMA provides administrative support to CPME. APMA and CPME have never attempted to obfuscate that arrangement. In fact, the CPME bylaws, a public document, clearly outline the relationship between CPME and APMA.


CPME operates as an independent, autonomous organization with a strict firewall between its accreditation activities and APMA. It stringently applies the same requirements to APMA educational activities as it does to other providers’ activities.


The US Department of Education recognizes CPME as the accrediting agency for the schools of podiatric medicine. The Department of Education has clear requirements that CPME operate independently of...


Editor's note: This extended-length response can be read here.

Other messages in this thread:



From: Lawrence Rubin, DPM


I agree with Dr. Steinberg. From what I have observed and have been told, the curriculum in our schools has not kept up to the standards for today's podiatric physicians and surgeons to become successful in practice. A glaring, practical example applies to information that pertains to a podiatrist's personal financial success. It is my understanding that there is little if any classroom content on practice management and "The Business of Podiatry."


I don't find this surprising. Having been a podiatrist for 66 years, I have observed a long-time reluctance of our schools to include practice management and podiatric medical economics educational curricula. For example, right now, our entire healthcare reimbursement system is dramatically changing from a fee-for-service model to a value-based care model. In fact, in a recent issue of APMA News, there was a very informative article advocating podiatric practices transition from fee-for-service to value-based care.


I doubt whether current podiatry students are being informed that their future insurance reimbursement for spending an hour of preventive services, providing chronic care management (CCM) for a patient who suffers from lower extremity conditions such as diabetic peripheral neuropathy and peripheral artery disease. This already surpasses what they can earn in an hour for providing most surgical procedures that include post-operative care. Knowing this might influence a student to not become financially dependent upon providing major surgical procedures, especially if they are elective. Or, maybe even go, “Direct Care” and not accept anything other than cash payment. Who would deny that, forewarned is forearmed?  Our students deserve to be better prepared for the future.


Lawrence Rubin, DPM, Las Vegas, NV



From: Narmo L. Ortiz, Jr., DPM


According to an article published on March 27, 2023, in, "the latest figures put overall medical school enrollment at 96,520, an almost 18% increase over the past decade. This surge has been made possible by increasing class sizes, the opening of more medical schools, and government intervention to add Medicare-supported graduate medical education positions, and is a welcome response to the projected shortage of physicians in the coming years."


While those statistics apply only to MD schools, on the March 21, 2023 informational article on, "There are very few podiatry schools. According to the American Association of Colleges of Podiatric Medicine (AACPM), there are only 11 DPM programs in the U.S. as of 2023. As a result, the overall number of applicants is lower than those who apply to MD programs. The AACPM reports that there were just 910 applicants to DPM programs in 2021, a tiny fraction of the 62,443 people who applied to MD programs that year."


So, it still begs the question to ask what is our profession, the APMA, and all of the other podiatric professional organizations doing to increase awareness to the public, colleges, and universities on the career of podiatric medicine and surgery in order to increase the number of applicants?


Narmo L. Ortiz, Jr., DPM, Davenport, FL



From: Rod Tomczak, DPM, MD, EdD


As much as we all know that The Good Feet Store (TGFS) is practicing podiatry without a license, it is difficult to do anything about TGFS. Complaints to the podiatry board or medical board often fall on deaf ears. The boards have no influence over TGFS since boards only intervene with licensed professionals. One might accuse TGFS with practicing podiatry without a license but the podiatry board is essentially impotent. 


Practicing podiatry or medicine without a license comes under the aegis of the law enforcement branch of the government after a board determines the law was broken. Hence, the police or sheriff would have to arrest the owner of the store or the dispenser of the orthotic for practicing medicine, go through a legal process, and issue a fine or short jail term for a first offense. Actually, I defer to the DPM/JDs in the profession to correct me, but this is what I've been told is the process in most states. Pushing readymade orthotics doesn't really endanger the public like practicing plastic surgery without a license and is not worth the legal effort.


Rod Tomczak, DPM, MD, EdD, Columbus, OH



From: Allen Jacobs, DPM


Dr. Kravitz is making reference to what is generally termed the technological imperative, a concept first elucidated by Victor Fuchs in his textbook Economics and Policy. The technological imperative generally refers to an inclination to utilize a technology that has the potential for some benefit, however marginal or unsubstantiated that potential is. It is fueled by an abiding fascination with technology, the general expectation that newer is better, and unfortunately, at times, there are financial or other professional incentives driving the use of relatively unproven technologies. It is driven at times by what Sir William Osler, over 100 years ago, referred to as “pseudoscience”.


Podiatry like medicine in general, is an industry-dominated profession. We rely on industry for the medications we utilize to...


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

This topic is now temporarily closed.



From: Jack Ressler, DPM


The last response to the query by Heather Kaufman, DPM was quite the character assassination of Ivar Roth, DPM. The thoughts expressed by Dr. Kaufman, "The hypocrisy and arrogance that drips from every word of his posts like slime down a wall is nauseating" was off base and extreme. Although on the surface, Dr. Roth's treatment plan of turning a $125 debridement service into a $3,000 plus visit seems extreme, I'm assuming a detailed treatment plan to address the patients fungal nail condition is incorporating medication and probably the use of a series of laser treatments. 


The bottom line is that his patients are paying cash. I'm sure he gives his patients a detailed explanation of the course of treatment along with other options. Seeing that he is practicing in a liberal state like California, he is not holding the proverbial gun to his patients' heads forcing them into their decisions. I am sure Dr. Kaufman is an asset to the podiatric community. Going off on a fellow podiatrist like she did is not helping our profession.


Jack Ressler, DPM, Boca Raton, FL



From: Heather Kaufman, DPM


I am finding it difficult to hold my tongue any longer as I read the posts submitted by Ivar Roth. The hypocrisy and arrogance that drips from every word of his posts like slime down a wall is nauseating. He bombasts about ethical patient care in the same sentence in which he brags about billing $3K+ to a patient coming in for $125 nail care because he (as a "favor" to the patient) "pointed out" and "educated" that patient about all the things that were wrong with their foot. 


He likely convinced them they needed thousands of dollars of additional products/services. Or, when he tries to argue that he is more qualified than a pain specialist to implant spinal cord stimulators for patients with pain not responding to pain medications. Yes, take the Abbott course Dr. Roth and implant such a device. I would love to be the expert witness for the plaintiff on that case! 


Heather Kaufman, DPM, Anchorage, AK



From: Cynthia Cernak, DPM


I was not responding to the value of the PSSD, the machine which was introduced so many years ago when we had so few examinations except for clinical vibratory, Semmes-Weinstein, and nerve conduction study/EMG. I no longer have the machine or use it. The question was billing and abuse with the Medicare system. 


My response was it was never covered by Medicare. That should have been made clear at the time that the machine was used. Unfortunately, that was not the case with the person that I was responding to. I absolutely agree with everything Dr. Jacobs said. Many abuse the system, trying to charge for nerve testing. My response was not the value or lack of value of the PSSD machine, but the billing of what was done. 


 Cynthia Cernak, DPM, Kenosha, WI



From:  Steven Kravitz, DPM


Dr. Jacobs’ post to pay tribute to Dr. James Ganley is an absolute pleasure to read. Thank you Dr. Jacobs for taking the time to articulate this and to Dr. Block for publishing and helping it gain some traction and attention, so that many have the ability to read it. There are a lot of lessons in it, and Dr. Jacobs' beautifully touches the surface describing attributes, nuances, and the ability to get to feel who Dr. Ganley was, and why he is recognized as an icon. Humble with humility, brilliant, without exception compassionate for others, a sense of balance in life, and ability to enjoy other aspects outside of his profession... sailing being just one of them.


One important point that comes out as you read the tribute is how much Dr. Ganley appreciated and enjoyed being a podiatrist. There's too much negativity today about our profession and...


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



From: Joe Agostinelli, DPM


I am writing this after reading Dr. Allen Jacobs’ thoughts on Dr. James Ganley three times. That brought back memories from 1977-1981 during my time at PCPM; during that time, Dr. Ganley lectured mostly on pediatrics to our class. Dr. Jacobs’ comments are “spot on” as to the influence Dr. Ganley had on his students! Personally during my 23 years in the USAF, we had Dr. Ganley speak to our armed forces DPMs several times. We had one particular seminar where Drs. Ganley and E. Dalton McGlamry lectured a full day, each back to back.


I still remember the "pearls of knowledge" from both of these giants of our profession. Dr. Ganley would sit in a chair on stage, reflecting back on his few slides - but was talking to us rather than lecturing about various topics. He always mentioned the medicine/surgery education and training he received as a corpsman in the U.S. Navy, and like all of our armed forces DPMs, his experiences in the military mirrored ours as far as our training with and working with orthopedic...


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



From: Paul Kesselman, DPM


Many of us have been saying this for years and it starts and ends with the absurd laws which prohibit doctors from really unionizing in a manner in which they can collectively bargain and strike. Under the current structure, these powerful tools are kept at a distance and all we can do is gripe and act independently but not with a collective force that a real union can effect. Without the ability to collectively bargain and possibly strike, we are in effect powerless to stop this continuous downward spiral. Nurses, residents, and others in healthcare can unionize and have walked out on the picket line. Physicians must find a way to fight back and get that right back! This downward spiral cannot be allowed to continue.


So yes the UPS driver and others with some seniority can make almost as much as a family practitioner and actually eclipse them with overtime. They additionally have no worries about liability, who may or may not show up for work, and all the other responsibilities a small business owner has to saddle.


Even employed physicians have to work harder, longer hours to keep up with absurd EHR requirements to see more patients in less time and are effectively being paid less per patient as they are on an hourly or RVU cycle. We are now in parallel with our colleagues in the former Soviet Union, where the joke was that bus drivers made more than doctors. Well, that joke is now at our doorsteps and it is no longer funny!


Paul Kesselman, DPM, Oceanside, NY



From: Gary Dorfman, DPM


In no way was I inferring that a podiatrist should take over the responsibility of treating a systemic condition such as gout. I agree with Dr. Jacobs 100%. However, diagnosing, providing appropriate labs, and providing relief for a patient with acute manifestations of the affliction is well within our scope of practice. And so is, obviously, an appropriate referral to an MD or DO physician. A podiatric physician should be familiar with all forms of medication and treatment available to patients; but the pharmaceutical houses should likewise be aware of, and inform the public of, who can provide or refer those services.


I also understand Dr. Gurnick’s consternation. It can be very frustrating when podiatry is left out of the equation entirely. Keep in mind that Krystexxa is an IV medication. The very fact that a podiatrist received information on the medication, will allow the podiatrist to discuss in an intelligent manner the pro’s and con’s of the medication if he or she is asked.


Gary Dorfman, DPM, Dana Point, CA



From: Allen Jacobs, DPM


Horizon has marketed a number of products to podiatrists, including a variety of anti-inflammatory medications as well as Krystexxa. They have regularly provided speakers to podiatric seminars, both physicians and podiatrists. Prior to the acquisition of Krystexxa by Horizon, I had the opportunity to meet with the prior manufacturers in New York. Those attending the meeting included multiple APMA officers as well as other podiatrists.


Krystexxa is an IV administered medication with a not insignificant risk of infusion reaction and anaphylaxis. It is used to treat hyperuricemia. Although we as podiatrists diagnose gout and treat the acute exacerbations, the etiology of hyperuricemia and lowering of uric acid or the treatment of the underlying disorders causing hyperuricemia are not what we as podiatrists...


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



From: Gregory T. Amarantos, DPM


I must preface my statement with the fact I love my profession and have been both blessed and fortunate over the years. I have the best patients and enjoy practicing. Years ago, I was a podiatrist who knew some business. Now I am a businessman who knows some podiatry. Altruistically, we enter the medical profession to help others, but over the years we have been forced to become businessmen due to the changing Medicare rules, the insurance industry, and the large hospital systems. For them, it is business and one cannot compete in the same arena while thinking like doctors. We need to think like them.


Over the years, I have thought a 2 week “blue-flu” would wake up the nation. Obviously, emergent care would still be provided. It would be incumbent upon the leadership to present a forceful response to the public outcry of...


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



From: Lawrence Kassan, DPM


I agree with Dr. Bardfeld's post regarding doctors going on strike. In fact, I recommended it in a post several months ago. Interestingly, there were doctors at a Brooklyn Hospital who went on strike earlier this year. They must have settled the strike VERY quickly because it was in and out of the news within a day. I think it would be interesting for this forum to take a poll as to how many DPMs would be willing to test the water with a one week strike that targets a specific insurance carrier. 


Hopefully, this would serve as a wake-up call to these insurance CEOs making multimillion dollar bonuses that they only exist because we agree to participate with them. Obviously, whatever we have been doing up until this point has not been working. 


Lawrence Kassan, DPM, Philadelphia, PA



From: Ivar E. Roth DPM, MPH


I have been offering routine foot care since I began practicing 38 years ago after completing a 3 year surgical residency program. Lately, and I am not sure why, there has been a huge increase in new patient calls for routine care. I am averaging 4 new patients a day who just want their nails and calluses trimmed. Today again, I had one of those patients request that I make her orthotics after I explained why they would help her. Believe me, routine care is bringing in lots of pathology to my office. Two others wanted to have treatments for their fungus nails. While it has taken years to develop this following, I think that the other podiatrists in town have abandoned this care, and I am now thankfully the recipient.


Lastly, I call my extended care nail techs “podiacurists” as they all are former pedicurists converted to medical nail techs/podiacurists who I have trained to do nails and callus care. I sincerely hope that any podiatrist who want to get busier get the word out that you do routine care; you will not regret that decision.


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



From: Richard J. Manolian, DPM


This shouldn’t come as a huge surprise to the podiatry community at large. I’ve written about this at least twice before in PM News. Practice economics are real. Look at it from the younger graduate perspective; when you consider the G0127 code for routine foot care.


This code pays about $10 nationally, and if I’m wrong, please correct me. So in order to pay one employee who earns $40,000 and if your practice consists of 25% routine foot care, that’s 20 patients who need to be seen per week just to cover that one expense, which could be one whole day just to cover that person’s salary.


Richard J. Manolian, DPM, Southbridge, MA



From: Elliot Udell, DPM


Dr. Rubin is dead on target when he questions whether podiatrists trained in foot surgery are no longer addressing non-surgical foot problems. This discussion is linked to the ongoing discussion on nurses who are starting foot care clinics. As a profession, we are like ostriches with our heads buried in the sand; we don't want to see that other non-doctoral level professions can and will encroach on all facets of foot care. Those who feel that their professions are secure because they only do surgery have their heads buried deeper in the sand. 


In my local hospital, PAs working in the operating room have told me that the general surgeons often allow them to do procedures "skin to skin." It is a matter of training and we could see future clinics run by physician assistants, trained by orthopedists and podiatrists, delivering high levels of foot care without the need of a podiatrist. It's only a matter of time until this happens. We have had many discussions over the years about non-podiatrists casting for and dispensing orthotics. It hit home when I witnessed my own physical therapist taking impressions for and ordering orthotics for his patient and the order was placed at a lab that promotes itself to our profession. What is the solution? Until there are legal statutes put into place, we simply have to love and be good at taking care of feet, and happy patients will refer others to podiatrists for foot and ankle care. 


Elliot Udell, DPM, Hicksville, NY 



From: David Secord, DPM


Every one of the points presented by Dr. Kass is legitimate, concerning, and continues to degrade our profession. The solution would be a class action lawsuit and would portend a leveling of the playing field if we had about 10 million to spend on a retainer and associated billable hours to fight this clearly illegal discrimination. Although a few people have offered a solution in operating as a concierge practice, the fear of the unknown and the questionable economic strata makes that a difficult choice for most. 


The salient question—as I see it—is “how do they get away with this?” The answer is “because they can and we let them.” The fix is in legally, as any organized pushback on this by our organized profession (en masse) refusing to take insurance anymore could lead to charges under the provisions of the Sherman-Taft Antitrust statute from 1890. We envy the dental profession, in that they were able to organize and largely avoid the strictures of the insurance companies, but as long as a majority of our providers take falling reimbursement in an age of rising costs, they will continue to stick it to us with impunity. It reminds me of the Pogo cartoon, wherein the character states, “We have met the enemy, and he is us.” 


David Secord, DPM, McAllen, TX



From: Jeffrey Kass, DPM


6) Eliminate the “mafia MIPS tax” - I have yet to hear how this information was collected and used in any meaningful way. All this does is create an unnecessary burden on the doctor. It is nothing more than a legal way to steal a doctor’s income. 

7) Medicare payment reductions must end - I am sick and tired of being threatened every year that Medicare is reducing payment to physicians. I believe this upcoming year, the threat is a 3.4% reduction. The medical profession needs a mouthpiece to scream from the rooftops that doctors require an 8% increase. 


I know of no other occupation whose salaries consistently get reduced. Threats of reductions are happily met with payment freezes, and this is considered a victory. This is nonsense. Physician reimbursements are not keeping up with inflation. All office supplies have skyrocketed since covid. Minimum wage keeps rising. Gov’t raises taxes and makes up new ones every so often. 


I understand that some of these issues mentioned aren’t podiatric-specific. But, podiatry as a profession should help in some form of round table discussion with the other medical disciplines to help solve these issues. Doctors really need to find a way to unionize.


Jeffrey Kass, DPM, Forest Hills, NY



From: Paul Kesselman, DPM


Some corrections are required to clarify the DM, ultrasound, and CTP issues:


1) Same or Similar and DME: APMA has been very proactive since the date this policy reared its ugly head. APMA has met with every medical association involved with DME. We have submitted multiple rounds of documentation to attempt to resolve this. I have worked with AOPA on their bill to be sure it would not be harmful to DPMs and rather be supportive. APMA has been calling for a ban on drop ship orthotics for years and this is now part of the proposed legislation.


2) APMA has a seat on the DME Medicare MAC councils which meets with all four DME MACs. Having this ability we have made sure that...


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



From: Eddie Davis, DPM


Dr. Rubin asked me to suggest means by which APMA can improve its overall value. Dr. Rosenblatt opined that APMA has done as well, if not better than AMA and “their specialty Boards.”


AMA does not have a large membership base. AMA financial support is largely derived from publishing revenues and database sales About 15 to 18 percent of MDs belong to the AMA.


I believe that Dr. Rosenblatt was thinking about...


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



From: Michael M. Rosenblatt, DPM


I am writing this comment in defense of APMA. Although I have been retired for many years, I am aware of their outreach efforts through reading their Journal and Podiatry Management. I recall the years when Congress enacted an enormous attack against physicians of all kinds, “felonizing” hundreds of previously legal business activities. Unfortunately, the major physicians’ political arms did absolutely NOTHING to mitigate the horrible damage done against doctors.


APMA was hardly in any position to fight against Congress. But the AMA and their specialty boards had the power. But they folded like a cheap suit purchased at the now defunct K-Mart. This, despite millions of dollars of dues paid to them by MDs.


If you think any other professional organizations are better than APMA, you are sadly mistaken. APMA is at least as good or better. And I speak as a previous critic of APMA. Continue your dues. They are trying.


Michael M. Rosenblatt, DPM, Henderson, NV



From: Ivar E. Roth, DPM, MPH


Dr. Karulak states that we are not big enough as a profession to institute change to our state scopes of practice. How about if the APMA studies which is the most likely state to expand privileges and focus not only the state association resources, but also the national on this one state? Once we get the first state to upgrade our privileges, work on the next state, and so on with the easiest first. With the mighty power of the national behind a single state, we could make this happen.


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



From:  Ben Pearl, DPM


I have always thought of Allen Jacobs, DPM as the Kurt Vonnegut of podiatry. His sharp witted writing and lectures also include similar thoughts on the trajectory of where things are going; in this case CME meetings. I agree that it is not a valuable use of time to have a series of infomercials. I do think that vendors need to have value to support meetings. I would like to see more open discussion and debate within a CME program so it is not just a highlight reel of best cases and scenarios. Industry and technology they represent do have a place on the podium, but it should be done in a thoughtful manner. Science has to be at the core but it is okay to have case studies that have some relevance as part of the discussion. 


To think that many solutions that work will be able to come up with funding for meaningful studies is not living in reality. If it were that easy, there would be more double-blinded randomized controlled studies. That is not to say that these trials are not an important piece, but everything is relative in the practice of medicine. 


Ben Pearl, DPM, Arlington, VA



From:  Allen Jacobs, DPM


The recent commentary regarding the state of post-graduate education for CME is noted. His participation in seminar programs and his products for the betterment of patient health are appreciated. Like Mr. Cioe, I miss the days of the large scientific gatherings such as the great Hershey seminars, the old Connecticut state meetings, and do enjoy the few remaining similar programs such as the NYSPMS annual meeting.


Peter, Paul, and Mary popularized the Bob Dylan song The times they are a changin. So too has podiatry post-graduate education. CHEC is first and foremost to serve the doctor, not the exhibitor. My own seminar, the St. Louis Podiatry Seminar, has increased in registration every year since going...


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

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