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01/30/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Ivar E. Roth, DPM, MPH
I could not agree more with Dr. Jacobs. I smell the rat also when using this new diagnostic test for neuropathy at a great cost to the patient and little extra, if any, diagnostic value. Unfortunately, many DPMS will gravitate to questionable new diagnostics and treatments to make an extra buck at their patients’ expense.
Practicing ethically should be every professional’s goal, not chasing the dollar as so many of our colleagues are doing.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
Other messages in this thread:
02/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: John Mozena, DPM
Dr. Daniel Jones brings up a great point! Maybe it’s time to revisit the idea of our specialty being absorbed by osteopathy or the allopathic schools. Is there really that much difference in our training these days? With so many medical and osteopathic schools, I’m sure there is room for our students and their money.
John Mozena, DPM, Portland, OR
02/13/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: James Koon, DPM
In response to a recent letter reflecting how much the Good Feet Store charges for inserts, it is my experience that they now charge about $1,500 for three different sets of pre-fabricated inserts matched to the patient after performing their manner of examination. Each pair is purported to be for a specific reason/activity/purpose.
On occasion, I will have a patient who has been in my practice for years show up one day complaining of continued heel/foot pain after having gone there and gotten these inserts with no improvement. I quit asking why they didn't come to me first, because what's done is done. Most of the time, the story goes that they developed the foot pain for which they got the inserts and went there because they thought they would help. And they must help an awful lot of people because there are franchise stores...
Editor's note: Dr. Koon's extended-length letter can be read here.
02/12/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Howard Bonenberger, DPM, Ivar E. Roth DPM, MPH
In response to patients who had similar problems with GFS inserts, I would write on an Rx pad "The devices (I never called them anything else) were not appropriate for the person's foot/ankle structure or their diagnosis. Please promptly provide a full refund. It always worked. Patients loved it, and they had me mold true Rx orthotics. Good for them and good for my practice.
Howard Bonenberger, DPM, Hollis, NH
My esteemed colleague asks how does Good Feet get away with charging $2,000 for an over-the-counter insert and some top covers. The answer is that they advertise and have salespeople work for them. Also, in general, the devices they sell work quite well. I am a big believer of supporting the arch maximally with an orthotic and the ones they sell do that. My patients LOVE the orthotics I make them and as I have said before are willing to pay a reasonable price for them... $850 for the first pair. I give a $200 discount on second pairs. I have a unique way I present orthotics to patients with which I have a 25% acceptance rate because they “get it”.
Ivar E. Roth DPM, MPH, Newport Beach, CA
02/08/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
RE: New PSSD Diagnostic Device
From: James Wilton, DPM
I have to read with some amusement this continuing line of thinking about the PSSD machine. I think a little education of the podiatric profession may be in line here. Two-point discrimination, which is what the PSSD machine does, was originally developed in the plastic surgery world for complex nerve repair, starting with battle wounds in the Second World War. Dr. Lee Dellon of Johns Hopkins University further developed the technology to look at what pressure threshold would be needed to determine two-point discrimination and also moving two-point discrimination, which are both significant diagnostic tools in looking at nerve regeneration. Two-point discrimination looks at nerve density and the innervation density of a particular area of skin that you are testing.
The brilliance of the PSSD technology is especially utilized in complex nerve repair cases where you are looking at re-innervation or in complex re-implantation procedures of arms, fingers, or toes. For basic screening for diabetic peripheral neuropathy, the hands-on clinical neurologic examination is the gold standard, utilizing hot and cold, vibratory thresholds, sharp and dull perception, and monofilament testing. As a screening tool, two-point discrimination is an excellent test using a wheel, and this is much more sensitive than monofilament testing. I hope this information adds some insight into this interesting thread.
James Wilton, DPM, Claremont, NH
02/07/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Howard Bonenberger, DPM
I wonder about the remaining 13% of patients with peripheral neurological involvement who ostensibly go undiagnosed or with a delayed diagnosis. What is the cost to them in time, advanced imaging, neurological consults, EMG, and potential degeneration of their health?
Do practitiners fret about recommending orthotics even when the patient must pay out-of-pocket? If not, is it because we believe that we are giving them our best advice? It is unfortunate that the discussion of abuse rises to the top in more than a few podiatry conversations.
Howard Bonenberger, DPM, Hollis, NH
02/06/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Ivar E. Roth DPM, MPH
I read Dr. Kravitz's thoughtful response, and I agree with him on several points. The first is that when one purchases or leases a piece of expensive diagnostic equipment, there is a great chance of over-utilization to justify its use and expense. The second is that new technologies should be looked at and incorporated into practices. In the case of the PSSD device, if Dr. Jacobs' 87% success with the standard test is correct, what patients would really want to pay $300 for a test with a free alternative that is that effective?
I see this new device as an excuse to bill patients for non-covered testing that is not necessary. It just gives doctors cover to charge and make money that is NOT in the patient’s best interest. Please ask yourselves if you would want to pay for a test when the free one is 87% effective.
This reminds me of unscrupulous podiatrists who take screening x-rays on all their new patients just to make sure nothing is missed. This includes patients who complain of ingrown nails, etc. While the insurance companies may pay inadvertently for an unjust x-ray CPT code, if the patient had to pay for these out-of-pocket, I think they would question why they needed an x-ray. I hope that some of our more recent graduates read my posts and understand that being ethical is first and foremost what we need to be as professionals and break the cycle of trying to make money at all costs.
Ivar E. Roth DPM, MPH, Newport Beach, CA
01/12/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Greg Caringi, DPM
I had an unusual relationship with Dr. Ganley. Since I was an OCPM graduate, I did not know him as a professor. He was a personal friend of Dr. Chauncey Roelofs, my first employer in Lansdale. Like myself, Dr. Ganley's first job out of the Navy was in Dr. Roelofs' original office in Phoenixville. He was introduced as a friend. We worked together training residents at our respective hospitals in Norristown.
His "residency" was the best fellowship a student could have at that time and his former residents have all had great success in our profession by following his lessons in podiatry and in life. As CPME requirements for residencies became stricter, ...
Editor's note: Dr. Caringi's extended-length letter can be read here.
01/11/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Frederic C. Spector, DPM
"Revere your teacher as you would heaven.” - A Hebrew proverb. Kudos to Dr. Jacobs for his tribute to Dr. Ganley. As a student at OCPM, I first became aware of his contributions by Dr. Dalton McGlamry in the mid-70s. All three of these doctors have been giants in our field and contributed to the success of countless podiatrists.
Frederic C. Spector, DPM, Savannah, GA
11/09/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Farshid Nejad, DPM
Bret, I could not agree with you more. The pious faith in our field has been our downfall. Healthcare has pivoted but the physicians have not. Our leaders are failing us. APMA wants our money and wants our voices to help make change, but is it really listening? As I said in my previous post, enough is enough. We as physicians need to make a stand against this bullying. Medicare Advantage plans just received another increase in pay from Medicare. This money does not trickle down to physicians. It lines the pockets of the executives of these plans. When LA Care has huge signage on a skyscraper in Los Angeles, next to US Bank, what does that say to you. How are they spending money that should be earmarked for us?
I challenge our leaders to set up a meeting with all the other medical associations and create a new path for us. The Writers Guild in Los Angeles also received a pay raise in addition to the other industry that Bret mentioned. Let’s get one too. And it better be in the double digits!
Farshid Nejad, DPM, Beverly Hills, CA
10/12/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Elliot Udell, DPM
What makes this discussion very interesting is that even though Drs. Cozzarelli and Jacobs disagree with each other, they are both correct. On one hand, Dr. Jacobs is correct. Krystexxa treats gout by lowering urate levels where allopurinol and others have failed. On the other hand, Dr. Cozzarelli points out that Krystexxa is marketed as a treatment for refractory gout and all podiatrists treat gout when it manifests itself in the foot.
The debate over whether podiatrists should be treating gout with xanthine oxidase inhibitors is an old one, but things have changed. With the exception of Krystexxa, the average DPM can easily learn how to prescribe the orals. It is very unfair to compare it to the management of diabetes which requires far greater clinical training.
When I first entered practice in the late ‘70s, when MDs owned their practices, it was common for podiatrists to treat acute gouty flare-ups and send the patient to internists for the urate-lowering drugs. In the past five or more years. internists, especially those working for corporations, resent when we send patients back to them for allopurinol or Uloric. When I lecture on the management of gout, I survey the audience. Half treat the hyperuricemia and half do not. Neither side is wrong.
Elliot Udell, DPM, Hicksville, NY
10/11/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: John Cozzarelli, DPM
Dr. Jacobs' comments on Krystexxa's FDA indication are not accurate. He references that it is indicated for the treatment of hyperuricemia.
Direct from the Patient Package Insert "INDICATIONS AND USAGE KRYSTEXXA® (pegloticase) is indicated, for the treatment of chronic gout in adult patients refractory to conventional therapy. Gout refractory to conventional therapy occurs in patients who have failed to normalize serum uric acid and whose signs and symptoms are inadequately controlled with xanthine oxidase inhibitors at the maximum medically appropriate dose or for whom these drugs are contraindicated.
Limitations of Use: KRYSTEXXA is not recommended for the treatment of asymptomatic hyperuricemia."
John Cozzarelli, DPM, Belleville, NJ
10/10/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: David E. Samuel, DPM, Gary Dorfman, DPM
The APMA has not gotten us equal pay for equal work in the 30 years I’ve been paying dues. That was and still is priority #1. At this point, does this really shock anyone we are left out of a package insert.
David E. Samuel, DPM, Springfield, PA
Keith: as you well know, the manufacturer of Krystexxa is just repeating history. They just don’t get it! Think back, were you ever detailed on Uloric or Zyloprim when they were first introduced. I know I wasn’t. I don’t know how many gouty patients the average podiatrist sees in a month, but when I was in active practice, I would see on average at least four or five. And generally, one half of those patients presented after they had seen their GP or internist who treated them with antibiotics for a “foot infection” with antibiotics.
Most of the time we diagnosed and medicated these patients based upon exam and history, even before we confirmed the diagnosis, with a serum uric acid or joint aspiration simply because of our experience with gout. I guess these manufacturers play the numbers and feel we don’t represent a sufficient monetary recognition…..that is, until we do!
Gary Dorfman, DPM. Dana Point, CA
09/25/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Steven Finer, DPM
Something is happening out there and it's not clear. Union participation is about 12% today, with teamsters, autoworkers, and government employees making up the majority. Unions took a major blow when millions of their dollars helped build Las Vegas. European countries have far greater medical union participation where the average salary is below $100,000. On a personal note, my MD, PhD Derm has retired, my ophthalmologist sold out to a large group, and my G.I. did the same. To put frosting on the cake, my internist switched groups as his former employer pushed more and more patients on him. I won’t say not to try, but we are grains of sand on a very large beach.
Steven Finer, DPM, Philadelphia, PA
09/15/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
RE: The Relationship Between APMA and CPME
From: Bret Ribotsky, DPM
The profession has been told for decades that APMA and CPME are separate companies, without any conflict of interest between them. I am a life member and remain a fan of APMA and the Council on Podiatric Medical Education (CPME). Many years ago, I served as the chair of the liaison Committee on Podiatric Medical Education. Today, it’s time to pull back the curtain and be honest, as change sometimes requires some discomfort and full disclosure.
1) The council’s office sits within APMA's physical office.
2) their phones are answered by the same receptionist when you call.
3) the current IRS form 990 form lists the executive director of CPME as a paid employee of the APMA.
The finger-pointing and blame game needs to come to an end. I attended the first summit on the board certification process and subsequently have spoken with the leadership or executive directors of the boards. So far, it has been a very disappointing investment. A resolution can be adopted that would appease the great majority of the issues facing DPMs today, and start us now on a better track for the future. Let’s put the egos aside, stop the game of blame, and all sit down at the table with a bunch of people who have “no dog in the fight” and solve this problem. If we do not take steps today, the profession that you’re all deeply invested in will sunset in the near future.
Bret Ribotsky, DPM, Fort Lauderdale, FL
Editor's note: APMA's and CPME's response appear in the next section.
09/07/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Robert Scott Steinberg, DPM
PAs doing procedures skin to skin? Was this included as part of their credentialing process? Did the department chair recommend this PA have those privileges? Could anyone imagine defending this in a malpractice case?
Robert Scott Steinberg, DPM, Schaumburg, IL
09/06/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Allen Jacobs, DPM
Dr. Rubin notes that podiatrists, in deference to alternative healthcare providers, maintain the ability to provide "optimal preventive and therapeutic foot-care". Optimal care is more than selling diabetic shoes and toenail reduction. It is evaluation and treatment of or referral for treatment of neuropathy, vascular disease, dermatological disorders, gait abnormalities, and off-loading of areas predisposed to ulceration. It is active treatment of onychomycosis. The question you must ask yourself is whether or not you do indeed provide “optimal care" .
Allen Jacobs, DPM, St. Louis, MO
08/18/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Dhaval Amin, DPM
I’ve never met Dr. Kass, however I think every podiatrist in my peer group would agree with every single point he has made. Frankly, I think those bullet points should remain on the front page of PM News indefinitely; or until the endless four-to-five letter podiatry-focused organizations produce results. All of us are tired of paying dues; it’s time to see results. Whoever wants to keep collecting dues, tackle Dr. Kass’ list. The organization that gets it done first, well that is the one that should keep getting our money and support. Let the results speak.
In fact, unless we’re discussing how as a profession we plan to tackle these issues, frankly we don’t need to be concerned with anything else. The podiatrists coming into this profession - most are hurting and feeling trapped. Our leadership needs to show them this was the best career decision they made; because if you ask around, an overwhelming majority will say it’s the worst decision of their lives.
Thank you! I hope you continue to bring the awareness we need.
Dhaval Amin, DPM, East Orange, NJ
08/16/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Lloyd S. Smith, DPM
I have made this statement in many venues during my APMA years as a board member (1994 -2005). Podiatry would likely have ceased to exist without the commitment of the APMA. No other organization advocates in the U.S. Congress and State legislatures for podiatrists on a daily basis.
No other organization sits on the AMA CPT and RUC committees except for APMA. We all know the CPT system we use for coding. RUC is the AMA committee that values each code. Medicare and in turn the private insurance industry uses these values to create our reimbursement. I participated in the RUC process for over 15 years and this process is exhaustive.
Lloyd S. Smith, DPM, Newton, MA
08/15/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Robert Boudreau, DPM
Dr. Rubin, I’ll go one step beyond your challenge of asking Dr. Davis to elucidate what problems he is having. My question to Dr. Davis would be, How are you going to help solve those problem(s)?
Robert Boudreau, DPM (Retired),Tyler, TX
08/14/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Lawrence Rubin, DPM
In a recent response to comments made by Dr. Eddie Davis concerning the value of the APMA, in my opinion, Dr. Virbulus rightfully responded by giving us many valid reasons that clearly demonstrate APMA's value. I am a Life Member of APMA, and in the past was a member of its Health Policy Committee and Public Relations Committee. I have great appreciation for my life member status. That said, I have the feeling that Dr. Davis has things he would like APMA to do that he feels are not presently being done. I know that many other members and non-members have suggestions on how APMA can improve its overall value, including me.
Wouldn't it be prudent for someone to ask Dr. Davis to state his suggestions for ways APMA can give its members more value? So, I will ask him here to express his thoughts, and I hope he responds.
Lawrence Rubin, DPM, Las Vegas, NV
08/02/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: Jon A. Hultman, DPM, MBA,
Dr. Karulak mentioned that part of the problem with scope advancement when comparing nurse practitioners to podiatrists was that there are 355,000 nurse practitioners compared with 18,000 DPMs. In reality, only half of those DPMs actually choose to join their state and national associations – organizations that represent the only mechanism available to DPMs to protect and advance their specialty.
DPMs purchase relatively expensive malpractice insurance to protect against malpractice claims but they do not purchase the relatively inexpensive “insurance” to protect and advance their careers. I don’t think anyone would feel comfortable practicing without malpractice insurance, but I’m not sure how anyone feels comfortable practicing without a state and national association around to protect and advance their career. At some point, these associations will cease to exist given their declining memberships.
Jon A. Hultman, DPM, MBA, Los Angeles, CA
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