02/08/2024    Allen Jacobs, DPM

New PSSD Diagnostic Device (Steven Kravitz, 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 treat our patients,
various orthopedic devices which we utilize in
surgery, wound care products for ulceration
management. Unfortunately, we also rely on industry
for grants for postgraduate, education, support,
research, grants, donation to colleges and support
of CME programs.

The effects of biased marketing results in an
impact on knowledge and attitude and behavior of
practitioners, and Resident. At times it is an
inability to identify claims of industry when new
products or theories are introduced. Recent
examples would include the use of poly vinyl
alcohol implants for the treatment of hallux
limitus, the utilization of suture button
techniques for bunion correction, the plethora of
skin graft substitutes many of which have no true
unbiased RCTs to support their utilization.

The unrestricted access of corporate, sponsored
speakers and consultants to CME programs and
resident education results in a positive attitude
toward the new technologies, increased awareness,
and at times increased preference for these
unproven products, and rapid irrational adaptation
of new drugs and devices. Often times this results
in the prescription of fewer generic drugs or the
abandonment of standard of care and the abandonment
of techniques, such as basic wound care, for more
expensive alternatives, which have no proven
superior benefit.

It must remembered at all times that the goal of
industry is to profit from sales. It must remember
that industry has an incentive to influence
potential customers, and therefore a conflict of
interest exists between industry, whose goal is to
maximize profit, and the podiatric physician, whose
goal is safe and effective care for the patient.

Lapidus or MIS bunion correction? Expensive wound
care products versus basic standard of care?
Expensive topical antifungals vs. oral antifungal
therapy for the treatment of onychomycosis ? PSSD
vs electro diagnostic studies versus clinical
diagnosis fo for the diagnosis of neuropathy?
Complex fixation for distal metaphyseal osteotomies
in bunion correction vs. single screw or K-wire
fixation?

The technological imperative is driven by recency
bias, a general “newer is better“, peer pressure,
profiteering, conflict of interest, among other
factors. The objectivity of industry marketing can
never be taken for granted. Industry
sponsored speakers allowed to present at our CME
conferences, with “unrestricted, educational,
grants” should, in my opinion, be subjected to
greater scrutiny and restraint. The ethical issues
involved in allowing a corporate sponsored speaker
who is also a consultant or paid speaker, for that
corporation are considerable.

The utilization of new technology and medication
should be guided by ethical considerations.

As any experienced podiatric physician/surgeon
knows, full well, today’s truth is tomorrow’s
fallacy. Dr. William Osler would begin each year’s
course in internal medicine by stating “gentleman,
half of what I am about to teach, you will be
proven not to be true in the next 10 years. The
problem is that I do not know which half that will
be”

Allen Jacobs, DPM, St. Louis, MO

Other messages in this thread:

---

02/05/2024    Elliot Udell, DPM

New PSSD Diagnostic Device (Steven Kravitz, DPM)

Dr. Kravitz wrote, "The big lesson here is not just
PSSD but developing a practice model that
selectively chooses treatments that are
efficacious..."

I remember being at a family Thanksgiving dinner. I
was a kid. My uncle was a local general
practitioner and my father was a local pharmacist.
My uncle said to my father, "Bernie, they are
trying to sell me a new diagnostic modality. It's
expensive and I don't know if it will help my
patients and will patients be willing to pay for
the testing?"

My father asked what the testing was called. My
uncle said. "An electrocardiograph." My father
replied that he did not know if the device would
amount to anything.

Over my many years of attending and lecturing at
podiatry conferences, I have seen many modalities
advertised to us as the upcoming EKG devices of our
profession and the sales reps even give out phony
codes and assure us that insurance companies will
pay us well for using the devices. Unfortunately,
for many, including myself, money went from our
pockets to theirs and the devices went from our
treatment rooms to dusty closets. On very rare
occasions a winning diagnostic or treatment
modality emerged.

What will be the next EKG of our profession? As the
song goes: "It's not for me to say."

Elliot Udell, DPM, Hicksville, NY