05/23/2024 Robert G. Smith, DPM MSc, RPh
Congressional Votes Can Affect the Future of Podiatry
As PM News readers remember, the Congressional
House on December 12, 2023, voted 386-37 to pass
legislation (H.R. 4531) that would reauthorize key
SUPPORT Act programs for patients with substance
use disorder and permanently extend required
Medicaid coverage for medication-assisted
treatments.
A highlighted summary as well as specific text of
HR 4531 gives podiatric physicians with a DEA
registration number the autonomy they need to
fulfill their 8-hour DEA-MATE required training
from CPME approved courses.
The House sent HR 4531 to the Senate received by
the senate Senator-Dr. Bill Cassidy (orthopedic
physician) as the sponsor to be added as part of
the text SB 3106 read twice and referred to the
committee on Health, Education, Labor, and Pension
on December 13, 2023. A concern is felt as this
Senate bill is reviewed on All Info - SB.3106 -
118th Congress (2023-2024): SUPPORT for Patients
and Communities Reauthorization Act of 2023 |
Congress.gov | Library of Congress and
https://www.govtrack.us/congress/bills/118/s3106
no action has been recorded.
Further, the prognosis for this SB 3106 is recorded
as only 4%; thus, our professional’s autonomy
regarding fulfilling our 8-hour DEA-MATE required
training from CPME approved courses is in jeopardy.
Coupled with the fact that both houses are only in
session for 54 days and the Senate on its own is
only in session for 15 days for the rest of
calendar year 2024 will undoubtedly impact passing
SB 3206.
I have called and emailed Senator Cassidy
expressing the need for action on this legislation
without a response. I hope podiatric professional
organizations will again request their membership
to notify Senator Cassidy as well as their own
Senators to move this legislation through committee
to a roll call vote.
APMA has posted a letter to the eAdvocacy website
that makes it easy for all of us to take action to
push for passage of this important bill.
https://apma.quorum.us/campaign/51145/ Please do
your part to resolve this issue for the profession
and send a pre-written letter to your US Senators
today and every day until the bill gets a vote!
Robert G. Smith, DPM MSc, RPh, Ormond Beach, FL
05/20/2024 Steven E Tager, DPM
The Future of Podiatry (Kenneth Meisler, DPM)
Reflecting on numerous comments in this thread, I
offer this as it may be of benefit to those in
need. Altruistic as it may be, at least for me, the
desire to help others along with a little prestige
(at the time) may have been the prime motivation
for entering medicine. That, along with my own foot
and back issues led me to a podiatrist who
absolutely motivated me to pursue a career in
podiatry. Podiatry, allopathic medicine, dentistry
or whatever, all have experienced the tyranny of
the insurance industry. Strength in numbers (and I
mean $$) by the carriers have manipulated us
(collectively all medicine and dentistry) as well
as our patients, into the current system using
everything and anyone possible to accomplish
increased profits. Their greed and unbridled
aggression for the almighty dollar has squeezed the
life out of our collective private practices.
Recently retired, I reflect on my 56-year journey
in podiatry. Successful? Yes, I certainly think so.
How and Why? Early in my career, I met two
physicians who had a profound effect on my life.
The first was Merton Root, DPM who educated me as
to the how and why of multiple foot problems.
Slowly, and I mean very slowly, I came to realize
that common conditions we treat, if caught in time,
can be markedly improved and often reversed if the
foot is held in anatomic neutral or as close to it
as possible. The body, with its own ability to
heal, now takes over with the optimum ability to
function as close to normal or near normal as
possible thereby reversing the prime etiology of
many presenting signs and symptoms. Perhaps this is
the explanation for some of the bunion deformities
returning post op and some not so much even after
considerable consideration was given to the
appropriate procedure.
The second physician I met was in a book entitled
Psycho-Cybernetics by Maxwell Maltz. MD. My take
home message from this book was “you are who you
think you are” and if you can project your ultimate
image, start acting and looking like that image
ASAP. Those two messages became a learned behavior
and made me what I am today….ie happy and
successful in my own mind.
Starting my private practice career in RI I found
it unimaginable that 90+ percent of the population
was covered by BCBS. Only two plans were available.
A & B and both paid very poorly compared to other
states based on visiting other pods in both New
England and others practicing in other parts of the
country. After 16 successful years in RI, we left
for Silicon Valley. Maybe a mid-life crisis? Who
knows, but in California the reimbursement for
services were commensurate with my skills, or so I
thought. Starting over was a bit unnerving but
nevertheless accomplished since failure was not an
option. It soon became apparent that reimbursement
for our services by a variety of carriers was going
the way of Medicare instituted a few years back.
Slowly the insurance industry took hold paying just
over, and in many cases, just under Medicare
allowances. Got Ya! The end in sight. And then came
the PPOs, HMOs, capitation and you know the rest.
Fed up with insurance companies determining my
worth, I sold my practice to a highly qualified
employee, capitalized on the real estate boom, and
moved to a seaside community on the Monterey Bay.
The absolute frustration of declining reimbursement
by insurance carriers for services rendered in the
face of inflation and the lack of appropriate cost
of living increases made absolutely no sense to me
and the private practice model currently in use.
Circumstances as they were, gave me an opportunity
to join a practice as a consultant. This ultimately
led to returning to private practice. BUT this
time, no longer would I accept payment from any
insurance company!! Given the success of my
biomechanical expertise (Thank you very much Dr.
Root) I no longer chose surgery as an option and
would refer out those cases in need. I was stunned
and amazed that limiting my practice to lower
extremity biomechanics, general podiatry and minor
office surgery as needed based on a fee for service
platform was an eye opening experience. Patients
were informed prior to their initial visit that
this was a fee-for-service practice and no longer
accepted any insurance. Sure, there were those that
went elsewhere because of insurance coverage and
that was fine. Patients with conditions clearly not
within the scope of my new practice were referred
to others prn.
Interestingly, I noted that patients who paid for
services at the time they were incurred were far
more appreciative than many of those in my prior
insurance-based model. Because of my biomechanical
education, I found my NICHE. Helping to keep the
foot function around what I believed to be anatomic
neutral appeared to not only help the foot but
helped a variety of other concomitant LE
complaints. Successful conservative management of
the foot soon led to helping those with knee, hip
and back problems. The word spread and I soon began
to enjoy success in podiatry without insurance
constraints.
In summary, having experienced the transition from
both the insurance based private practice model and
the non-acceptance of all insurance, I can say for
certain that finding one’s niche and excelling at
it has value to both the practitioner as well as
the patient. Sure, it’s not for all. Lifestyles
differ, and we all accept that just like our
individual practice styles differ along with our
own subspecialties within podiatry. Criticizing the
manner in which others practice (as noted in this
format) does no good at all. If the shoe fits, wear
it. If not, go elsewhere.
Keep in mind, we ALL offer “foot care” which is
exactly what every insurance dependent practice
offers. For me, that translated into offering
something special and different that set me apart
from others in my area. My style of practice now
achieved after all these years (thank you Dr.
Maltz) in combination with my post-doctoral
biomechanics education (thank you Dr. Root) I had
the tools to continue practicing podiatry my way.
My objective was simply to educate my patients to
the best of my ability as to cause and effect and
then provide treatment options and alternatives
when appropriate. With positive realistic outcomes,
success in private practice was again soon
realized.
An Afterthought: Salmon swimming upstream don’t
make it. Fighting amongst ourselves is
counterproductive. We continue the salmon approach
and fight the upstream establishment. It’s time for
podiatry to merge with medicine and its individual
specialties. Fight back and take control of our
future. No longer should we allow insurance
carriers to dictate medical care of our patients.
Do we not know what’s in the best interest of our
patients? Should we not rely on our years of
training? Have we totally allowed the abdication of
decision making to corporate America? Look where we
are today.
Are we better off? Private practice and personal
one on one care has all but gone. Personally, I
believe the APMA has failed us. Their job, from my
perspective, is to educate the public, inform and
educate. In my tenure, It has never happened.
Therefore, the merger of podiatry into mainstream
medicine is essential. Podiatry will NOT be lost.
Has Ob/Gyn, dermatology, proctology, urology
orthopedics, psychiatry neurosurgery been lost with
an MD degree? Oddly, they all have MD after their
names followed by their unique specialties. WHY NOT
AN MD degree followed by whatever podiatric
specialty of choice?
I now rest my case with the hope that my journey
characterized in this thread will be of some
positive value to others.
Steven E Tager, DPM (retired), Scottsdale, AZ
05/16/2024 Robert Kornfeld, DPM
The Future of Podiatry (Kenneth Meisler, 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
fee reduction and claim denials. You will still
receive chart requests, periodic audits and in many
cases, demands for refunds from insurance
companies. You will still have your services
devalued by the system. You will continue to deal
with prior authorizations and high accounts
receivable. None of that changes.
However, I strongly disagree with Dr. Meisler that
a limited number of podiatrists can succeed in this
payment model. That is a statement that comes from
a lack of information and knowledge about the way
this works. If all you offer in your practice is
exactly what every insurance-dependent practice
offers, you will have a very hard time succeeding.
It is not about a reputation as an excellent
"provider". You are not "providers'.
That's what insurance companies call you so they
can eventually replace you with non-doctor health
professionals who will work for less than you do.
You are doctors. It is about establishing a
reputation as a doctor who can offer everything
that insurance-dependent doctors offer, but also
possesses expertise in a niche that can make a
difference in the lives of those who have not been
helped by conventional approaches. I find it
disturbing that so many podiatrists dismiss direct-
pay and effectively close down a potent way to get
out of the horrors of insurance or corporate
employment.
I have spent many years seeing 8-10 patients daily
and made much more than I did seeing 50-60
insurance patients and burning out in the process.
If you allow fear to rule your decisions, you will
forever be a slave to the system. It's a choice.
Robert Kornfeld, DPM, NY, NY
05/13/2024 Robert Kornfeld, DPM
RE: The Future of Podiatry (IVAR Roth, DPM, MPH)
While I am in full agreement with Dr. Roth about
the joys of direct-pay, I completely disagree with
his assessment that only 5-10% of podiatrists are
cut out to be direct-pay practitioners. My
experience was that I had only one year where my
income dropped and that is because I dropped out of
everything all at once. It rebounded in year 2, but
that is NOT the way to create a successful direct-
pay practice. I do agree you need to provide
services that are unique so that you eliminate the
competition from insurance-dependent practices. But
any podiatrist who desires to can create a
successful direct-pay practice by first getting
expertise in a niche. Then, drop your lowest payors
and start seeing your niche patients for direct-
pay.
As you build your brand and are consistent with
marketing, they will come. And you will be
surprised at the number of phone calls you will get
asking what you do differently. I speak directly to
all new patients so that they know I am accessible
and I know they were given the right information.
And when I speak to patients directly, my
conversion rate is over 90% of callers become
patients.
I implore podiatrists to stop shaking in their
boots. The longer you allow the exploitation and
abuse from insurance companies or corporate
employers, the longer you will be miserable. Don't
ask your accountant. He will base his opinion on
your current financial status. And if he tells you
can't afford to do it, then that is all the more
reason that you should since you have no financial
security in the current insurance-dependency model
you are practicing.
Clearly, the current model is killing the income of
well-trained and bright podiatrists who have
willingly become victims of the system. The fact
that Dr. Udell had the audacity to question the
ethics of direct-pay doctors is an admission of his
fear and jealousy. It is the most absurd statement
I have ever heard about this practice model. And
Dr. Rubin states that you should outsource your
billing to RCM companies who will also be siphoning
off of your income. And that does not change the
low fees and administrative burdens that come with
a high volume insurance practice.
I have been in podiatry for a very long time. I
started NYCPM in 1976. Back then, I was astonished
at the low self-esteem of this profession, but I
was confident it would improve as we became better
at what we did both surgically and medically. Yet,
all these years later, in spite of our education
and training, a lot of you out there cannot even
say that you are podiatrists. You tell people you
are foot and ankle surgeons or wound care
specialists or sports medicine doctors, but somehow
the word podiatrist is left off of your sound bite.
That is the ultimate in shame and insecurity.
Practicing a direct-pay model has not only elevated
my self-esteem and joy of being a podiatrist, but
it has afforded me a lifestyle that leaves me
feeling relaxed, confident and able to do whatever
I want. And that is what you all deserve. Not the
bullshit you deal with every day.
Robert Kornfeld, DPM, NY, NY
05/10/2024 Richard M. Maleski, DPM, RPh
RE: The Future of Podiatry (Elliot Udell, DPM)
The recent thread in this forum on the future of
podiatry has been extremely interesting and
thought-provoking, with the most recent emphasis on
the pros and cons of direct pay versus the more
typical insurance dominated practice model. Let's
not lose our historical perspective on this. Back
in the 1960s, with the advent of Medicare,
everything in health care changed. Prior to that
virtually all practices were direct pay, and the
only insurance coverage was Major Medical,
sometimes referred to simply as "hospitalization."
When Medicare came around, our profession clamored
to be included.
There are colorful stories of the behind closed
doors antics that went on inside politicians'
offices to assure that podiatric services would be
covered. Since then, any time there has been a
change, such as the emergence of managed care, we,
along with every other medical group has done
everything possible to keep ourselves included.
And by being included in this payment model, we
have been able to expand our status within the
medical community at large.
At this point in time, we are arguably, the pre-
eminent provider of diabetic foot care, including
major surgical interventions and wound care of the
lower extremity. My own practice followed that
trajectory, and I dare say that I would not have
had the opportunity to treat those patients if I
was not on their insurance plan. I believe our
entire profession has followed that same path. By
treating these patients effectively, we have shown
to the medical community that we are truly a
necessary cog in the healthcare machinery.
As with everything, there are changes in medicine,
some good and some bad, and we must constantly re-
evaluate our own personal positions as well as the
position of our profession. Maybe that includes
more emphasis on a direct pay model or maybe it
doesn't, but regardless we need to keep a long-term
perspective of the past to properly evaluate where
we go in the future.
Richard M. Maleski, DPM, RPh, Pittsburgh, PA
05/08/2024 Robert Kornfeld, DPM
The Future of Podiatry (Rod Tomczak, DPM, MD, EdD)
After the thread on The Future of Podiatry, many
DPMs emailed me who are disgusted and fed up with
insurance-dependency and hate going to work. Yet,
most of them said the same thing to me, "My
patients will never pay me!" This is testimony to
the fact that many of you do not believe your
services have any value. And that is the crux of
the reason why you all stay in the system and
suffer.
The reality is simple. If you accept insurance and
your patients have very little out of pocket
expense when they see you, why would they pay you?
You are all correct. Those patients may like you,
but the only reason they come to you is because
they can come on insurance.
Your current insurance-pay patients are NOT your
patient avatar. What you all do not realize (and I
have experienced a very successful practice because
of it), is that in addition to your own practice,
every podiatry, orthopedic, rheumatology, PM&R,
neurology, dermatology, etc. practice has patients
they have failed in your city or town. So many of
your own you don't know about because they just
stop coming to you and you are too busy to inquire
as to why. There are also many patients who will
come to you because they don't have to wait for an
appointment and appreciate being seen at the exact
time of their appointment. Or they feel honored and
cared for because you have extended visits with
them to truly get to the bottom of what is going on
for them. There are many other reasons patients
will willingly pay you directly.
To make the uninformed, fear-laden statement that
no one would pay you is not only wrong, but totally
self-deprecating. The fees charged by doctors who
collect directly from their patients are not just
based on expenses. They are based on the time spent
and the value delivered. As I have said, I honestly
believe insurance will be the death of podiatry.
And because I travel in the direct-pay circles, the
movement amongst MDs and DOs who are leaving
insurance-dependency is gaining lots of momentum
and every one of them that I speak with is
celebrating their new found autonomy and freedom.
Does it take hard work to build this kind of
practice? Absolutely. But the hard work is
temporary. But if you continue to practice in a
system that exploits and abuses you and every day
you go to work is a hard day filled with stress,
then that type of hard work is permanent!
Unfortunately, too many of you only know managed
care or corporate employment. I went into practice
when the only insurance was indemnity coverage. We
were paid VERY WELL and I went to work every day
feeling proud and honored to be a podiatrist.
Managed care (in reality managed payments) has done
nothing positive for health care in this country
and has been responsible for ruining the lives of
countless doctors. In this day and age, a very busy
schedule is not the sign of a successful doctor. It
is the sign of a compliant doctor willing to work
for peanuts per patient.
It's all a choice. Adults can make choices that
serve them well in spite of their fear of change in
order to create a happier, healthier and more
satisfying life. Or not.
Robert Kornfeld, DPM, NY, NY
05/08/2024 Allen M. Jacobs, DPM
RE: The Future of Podiatry (Elliot Udell, DPM)
Dr. Udell posits his belief that direct pay medical
care may be, in his opinion, unethical.
Furthermore, Dr. Kornfeld felt the need to offer a
defensive posture to his endorsement of the direct
pay model of healthcare. As to the latter, Dr.
Kornfeld is the messenger, not the message. He
suggests, with good reasons, that the direct pay
model may be a preferable means by which to
practice podiatry. There is no need for Dr.
Kornfeld to assume a defensive posture personally.
The direct pay model has been increasing adopted in
many areas of medicine, such as primary care,
plastic surgery, dentistry, and many specialties
within medicine. Those who practice traditional
insurance based medicine already practice direct
pay medicine to some extent. You charge patients
for increasingly large copays. You charge patients
for their deductibles. You charge for uncovered
services. You charge for uncovered dispensed
products. Therefore, the concept of direct patient
payment for services provided in the traditional
insurance-based health care model is not foreign to
your practice.
Dr. Udell questions the ethics and morality of
direct pay (and by implication I would assume
concierge medicine or boutique style medicine). The
AMA, the American Academy of Family Physicians, the
Institute of Clinical Bioethics, and many others
have carefully examined the provision of direct pay
and concierge medicine. All have issued policy
statements on this matter. They have all concluded
that direct pay models are NOT inherently
unethical. The principle of patient autonomy is not
violated by direct pay, so long as the patient
understands that services which are covered by
traditional insurance are also available to that
patient, and that the patient understands this and
willingly without undue coercion elects the direct
pay model.
As for beneficence and non-maleficience, the direct
pay model to not relieve the provider of the
obligation to provide standard of care diagnostic
and theraputic services. If anything, the relevant
studies demonstrate that patients receiving direct
pay care do indeed obtaining better care, as treat
patient receives more time with the health care
provider, and are likley to have greater counseling
and preventive care. In the traditional insurance
based model, you may now bill for time and medical
complexity and decision, making, which may help you
to provide some of the benefits of direct pay care.
With direct medicine you are providing better care,
not necessarily better medicine.
Dr. Udell to his great credit provides free or
reduced fee services to under-insured patients. The
direct pay model does not prohibit a practitioner
from doing the same. In fact, in some circumstances
this may be to the advantage of patient and
provider. For example, there is regulatory fiat
which prohibits you from waiving co-payments or
deductibles or lowering fees in Medicare patients.
You can do so with direct pay without violation of
any law.
The most challenging arguments against direct pay
lie in the ethical principle of justice. Does this
create a two-tiered medical care system, i.e.-those
who can and cannot afford to pay. What do you
already do now with patients who cannot pay for
uncovered services such as laser or orthotic
management? What do you do now with uninsured or
underinsured patients in need of your care? What do
you do now when the patient cannot afford to pay
for a product you which to dispense?
With regard to the healthcare provider, every
available study demonstrates the high rate of burn-
out and frustration among doctors. Doctors and
patients both are not satisfied with rushed
appointments. How often to you regret not having
the ability to spend more time with a patient? How
often do you desire to provide additional services
which are uncovered but which you believe would
benefit a patient? How many diagnostic errors occur
because of rushing through a schedule of patients
on any given day?
In summary, the suggestions by Dr. Kornfeld that a
direct pay model provides benefits to both
podiatrist and patient are well supported in
studies examining this question. That is a fact.
Allen M. Jacobs, DPM, St. Louis, MO
05/07/2024 Greg Amarantos, DPM
The Future of Podiatry (Rod Tomczak, DPM, MD, EdD)
I find it interesting how a post can be
interpreted from a different lens and
diametrically opposing conclusions are reached. In
reading Dr. Tomczak's response to Dr. Roth, I read
Dr. Roth's post differently.
While we should believe we are providing the best
possible care, we have to face the facts, in
private practice, our treatment protocols are at
least partially driven by the insurance company
policies. I do not read any impugning of the
profession. Dr. Roth should believe he is
providing the best care, as should you and I.
Cash frees the practitioner from the shackles of
the insurance company policies. Think of the man
hours used on "meaningless use/MIPS" and the like.
Dr. Roth reminds me that medicine made a deal with
the devil years ago and I wish I had the
intestinal fortitude to have become a fee for
service provider.
Dr. Kornfield is correct, altruism does not pay
the bills. There is a disconnect in medicine
between an institutionally employed physician and
the private practitioner because the rules favor
the institution. Think "facility fees" which is an
upcharge of up to 30% in Chicago. In private
practice we do not receive a facility fee, thus
are behind the eight-ball by 30% when we walk in
the door. The employed physician is not worried
about staffing, expenses and the like, thus
altruism is a noble thought. The same cannot be
said of private practice.
Doing no harm and our call to do good do not have
to conflict. Not paying the bills does everyone
harm. Those in the ivory tower have to face the
facts. Forty years ago an osteotomy bunionectomy
was reimbursed at approximately $1,800. Today the
same procedure reimburses $800, not taking into
account inflation. Frankly, not a sustainable
model and thus, one is forced to change how they
practice medicine.
Why must our profession be jealous of others and
not be comfortable in our own skin? I applaud
Drs.Roth, Kornfield, Tomczak, Jacobs and other
members of our profession. We can all be
successful in different ways. After all, what
really defines success and better patient care?
Gregory T. Amarantos, DPM, Chicago, IL
05/06/2024 Robert Kornfeld, DPM
The Future of Podiatry (Rod Tomczak, DPM, MD, EdD
Here is another "defensive" post which completely
misses the point of what I shared. So, Dr. Tomczak,
since you dragged me back into this discussion, let
me enlighten you as to where I come from. First of
all, I did deviate from conventional medicine long
ago as I found that functional medicine did a far
more reliable job of getting my patients well,
especially the chronic pain patients who had been
failed by many other doctors. I was so happy with
this paradigm that I put a seminar together for our
profession to teach what I had already learned.
This was back in 2002. I wasn't so upset that they
did not go over well and few sought to learn it.
What I was more disgusted by was the level of
vindictiveness in this profession.
Podiatrists who never met me and had no idea what I
was doing for my patients chose to slander me
online. Local podiatrists told patients very
negative things about me, again, with no clue as to
what I was doing in my office. My own NYSPMA also
put me in harm's way back then. So I decided to
step away from podiatry and do my own thing. I was
invited to speak at a few seminars and conventions,
but that was short lived. And I went along happily
enjoying my practice and helping patients that were
continually failed by conventional methods without
stress and $0 accounts receivable.
About 2 years ago, I began getting lots (and I mean
lots) of emails from podiatrists who were burnt out
by the system, disgusted with the meager payments
and huge administrative hassles from insurance and
were basically at their wits end and were asking me
for help. And why would that be, Dr. Tomczak?
Because they took an oath to do no harm? Because
they took an oath to help to the best of their
abilities? Because they weren't trained well? No.
It is because whether you wish to admit it or not,
podiatry, like all medical specialties, is a
business. And when the business cannot pay the
bills, altruism goes by the wayside. This is the
reality that today's podiatrists are dealing with.
And as long as you allow insurance companies to be
in charge, they will continue to exploit you. And
you will have nothing to fall back on but your
altruism.
As for the comment by Dr. Roth (which I second)
regarding being a better doctor, that is absolutely
my experience. Your insecurity caused you to miss
the point there as well. He (and I) and every
podiatrist I know that is running a direct-pay
practice feels that they are a better doctor now
than they were before. And that is because a low
volume practice affords you the ability to spend
lots of time with each patient. The work-ups are
more thoughtfully planned and implemented. There is
lots of time to educate your patients and develop
deeper and more meaningful relationships. And every
patient gets all of you. And that leads to much
better patient compliance. Not to mention the fact
that there is enormous waste in paying employees
simply to have them chase after the money you are
owed by insurance companies. You may believe that
you are practicing to the best of your ability, but
I opine that simply because of the high volume
required to stay solvent in today's medical
"system", I can assure you that you are not
practicing to your best capabilities.
So let's grow up. Stop taking everything you hear
from myself or Dr. Roth as an attack against you or
other podiatrists that accept insurance. We post
about it because we know that our lives changed for
the better once we changed to a direct-pay model
and we want to share this with all of you because
we care about this profession. But sadly, this many
years later, this is still an extremely insecure
profession who quickly get their backs up against
the wall instead of being inquisitive and trying to
learn more. And that is your loss.
Robert Kornfeld, DPM, NY, NY
05/03/2024 Rod Tomczak, DPM, MD, EdD
The Future of Podiatry (Ivar E. Roth, DPM, MPH)
In the current debate concerning direct pay for
services rendered versus acceptance of insurance
and being a provider, two thoughts trouble me
greatly from a meta-ethical point of view. I have
tried to find a redeeming tone in each of them and
have delayed responding to ensure I am not just
shooting from the hip. The implications of these
two statements are to say the least profound,
especially for our podiatric students and younger
more impressionable readers.
Dr. Roth, who was among the the first podiatrists
to switch to a fee-for-service medical
reimbursement system claims that it works for him
because he provides the best care possible to his
pay for service patients. In order to be
successful, he must provide these cash patients,
“… great service and great professional care.”
Dr. Roth goes on to say, “No one in their right
mind is going to pay you to do something that
every other doctor down the street can do.” Is he
insinuating that he performs better care because
he does what he does for cash at time of service,
or does he mean that those practitioners who
accept insurance are not as good a provider as he
is? Is he impugning the majority of the
profession?
I have emphasized to every student and resident I
have ever taught, and there have been many of them
that they must do their best for every patient
they encounter. Is he saying that cash money
drives him to do a better job or that it allows
him to do a better job. He is definitely saying
that every podiatrist who accepts insurance is not
able to render the quality of care he delivers.
It seems he does not care that he has alienated
the majority of our profession and some
extraordinary practitioners with his self-
aggrandizing rhetoric.
Dr. Kornfeld has also made a couple astounding
statements that give pause to reflect on what he
really wants us to take away from the discourse.
He states, “Profit in a podiatry practice should
not be secondary. It needs to be primary. This is
a business. ALTRUISM DOES NOT PAY THE BILLS “(Dr.
Kornfeld’s capitalization). We have been entrusted
with a sacred privilege to care for someone else’s
health and welfare.
In my ethical world the patient and the treatment
I provide comes first. Nothing supplants our care
for the patient who has entrusted their physical
well-being to us. Nothing, simply nothing. When
I walked into the operating room, the rest of the
world was on the other side of those operating
room doors and it remained there. There were no
thoughts about remuneration. If there is the least
bit of conflict or confusion, that person does not
belong in the operating room. The very same holds
true for every person in that operating room. If
profit is the driving force behind one’s day, I
say transition to becoming a stockbroker.
I started this letter using the word meta-ethics
which refers to how and what we think about the
term good. Is “good” simply that which is desired
or desirable? To practice non-maleficence is not
the same as practicing beneficence. Non-
maleficence means to do no harm and beneficence is
our call to do good. The good we are talking about
is not the good of consequentialism but rather an
action that brings about agape. We all must define
what good means and what we mean by doing good,
thus our personal meta-ethic. The process requires
significant and often painful reflection if on is
to be honest with one’s self. After years of
practice it is easy to lie to ourselves and
believe we are practicing virtue.
Patients were referred to me, especially at Ohio
State Medical Center who had no insurance, were
indigent, were infected with HIV and immigrants
from Africa. They had been seen by a local
podiatrist who told them through an interpreter
that Dr. Tomczak has some special equipment at
Ohio State and could better treat that ingrown
toenail. I ask Drs. Roth and Kornfeld to search
your heart of hearts and answer whether or not you
would treat these patients, or as they say in the
vernacular, “Turf them to Tomczak.”
Rod Tomczak, DPM, MD, EdD
05/01/2024 Allen M. Jacobs, DPM
The Future of Podiatry (Robert Kornfeld, DPM)
"Profit first decision making" in medicine has
nothing to do with direct pay medical practice.
Many plastic surgeons, dentists, veterinarians,
concierge practices are but a few examples of those
who engage in direct pay medical practice. Dr.
Kornfeld has presented reasonable and cogent
arguments to endorse the direct pay model of
practice. There is no more greed inherent to the
direct pay model than exist in the traditional
billing of third parties for medical care rendered.
Your misinterpretation of the commentary which I
made on this subject is the suggestion of a need
for you to reexamination your own motivation for
the practice of podiatry. The concept of avarice
appeared in your mind, not mine. Dr. Kornfeld's
thoughts and philosophy on direct pay are well
taken and acknowledged as such.
Regardless of the payment model, ethical behavior
and unethical behavior are what they are.
Unnecessary surgery, the irrational use of
expensive wound care products, the choice of non-
generic medications with no proven advantage to
generic medications, the suggestion that all
postural complaints require functional orthotics,
are a small representation of profit first
thinking.
Direct pay or not, medical decision making should
be founded upon what is needed and what is in the
best interest of a patient. How much and in what
manner a patient is asked to pay for such
consideration is a different manner. Direct pay or
not, any medical decision should be such to attempt
to limit potential harm to a patient. These are two
of the basic tenets of medical ethics. Direct pay
medical practice and ethical medical practice are
not mutually exclusive. Conversely, traditional
medical care billing has clearly served as the
terrain in which fraud and abuse have proliferated.
To repeat the words of Sir William Osler: "you have
entered this profession to make a living. But in
doing so this must be a secondary consideration".
When I make rounds with the residents, I point out
to them that they are likely young and healthy. It
is not until they are ill, lying in a hospital bed,
and dependent upon others for limb or life-saving
decision making, that they can fully appreciate the
power and position they hold as a healthcare
provider. That patient desires and deserves a first
consideration of the best care indicated for their
health, not the most profitable to the health care
provider. I suggest that until you are on the
receiving end of serious medical care, this concept
of your ethical responsibility is not fully
appreciated.
Allen M. Jacobs, DPM, St. Louis, MO
04/30/2024 Ivar E. Roth, DPM, MPH
The Future of Podiatry (Allen M. Jacobs, DPM)
I “think” based on knowing how Dr. Jacobs has
articulated himself in prior posts that his
statement “for profit first” means the “greedy”
direct care docs out there like Dr. Kornfeld and
myself. I have a very good perspective concerning
direct care practices as I was the first
podiatrist to adopt this philosophy in the current
insurance driven practice environment.
To explain the direct care concept correctly one
must understand that we accept no insurance
coverage at all, no Medicare, medical or any
private PPOs, etc. To me it is the purest form of
medicine as you must do a great job or else the
patient is not going to be coming back. Why would
a patient pay for services out-of-pocket when they
can get the same or similar by using their free
insurance coverage. The answer is that you as a
direct care provider must offer at least the
following two services in an exemplary manner.
That would be great service and great professional
care. No one in their right mind is going to pay
you to do something that every other doctor down
the street can do. So you must be the best of the
best or offer services that no one else offers
with either new cutting edge technology and or
like myself offer a cure for fungus toenails or my
Paincur procedure for pain, etc.
Direct care forces you to be the best you can be
and a patient advocate. To me there is no cleaner
way to practice it is simple and straight forward
you get paid for every service you provide. It
really is not about the money it is about giving
great care and service and feeling like you have
made a difference in someone’s life.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
04/29/2024 Robert Kornfeld, DPM
The Future of Podiatry (Allen M. Jacobs, DPM)
My esteemed colleague, Dr. Jacobs states, "For-
profit first" thinking is the reason we are
burdened with pre-authorizations, insurance
payment reductions for services rendered, and
denials for services. Money-first thinking denies
access to healthcare, treats healthcare as a
commodity rather than a right, and creates a
conflict between doctor and patient.” He is
actually not talking about doctors here. He is
referring to the middlemen (insurance companies
and private equity corporations) who suck off the
knowledge and expertise of doctors. It is they
that have created the mess we are in. Doctors
clamber for ways to augment their insurance
payments with non-covered services. This is not
selfish “for profit only” motivation. This is
survival.
I personally am not an advocate of putting money
before patients. They are and have always been my
priority. But to be honest, there is no way I
would still be practicing podiatry if I did not
move to a direct-pay model. To do what we do, we
deserve to be paid very well. I quit insurance way
back in 2000. I was seeing 50-60 patients daily
and at the end of the month, there was not much to
show for my hard work. Sorry Dr. Jacobs, but
insurance companies have ruined everything that
medicine should stand for.
One thing I will say is that when all of the
tenets of medicine were laid down, there were no
insurance companies. Perhaps it is easy to defend
this mentality when an entire career was built on
accepting insurance and it is too late to move
into another practice model. But I have no
interest in serving the greed of insurance
companies. I would rather take care of my
patients, my family and myself. And that was the
point of my post.
Additionally, these middlemen force doctors into
high volume - high expense practices that lead to
high levels of stress, dissatisfaction and
burnout. Do you not think it is a huge waste of
money to employ 2 or 3 people just to chase after
money that insurance companies withhold? This is
a broken system. Enough with the calls for
altruism!
Robert Kornfeld, DPM, NY, NY
04/25/2024 Allen M. Jacobs, DPM
The Future of Podiatry (Robert Kornfeld, DPM)
The commentary of Dr. Kornfeld with regard to the
need for profitability in maintaining practice
survival is appreciated. He has long represented a
particular view on non-insurance based patient
care which has been successful for himself and
others. Medicine, including podiatry, differs from
other "ordinary businesses". The practice of
medicine is a calling, with a duty to care for
patients as the foundation upon which all other
business concerns emanate.
The practice of medicine is based upon the four
cornerstones of medical ethics; beneficence, non-
maleficience, autonomy, and justice. "For-profit
first" thinking is the reason we are burdened with
pre-authorizations, insurance payment reductions
for services rendered, and denials for services.
Money first thinking denies access to healthcare,
treats healthcare as a commodity rather than a
right, and creates a conflict between doctor and
patient.
The American College of Physicians in a policy
paper published September 7, 2021 noted that
profit motive in medicine has contributed to a
bloated, complex, and fragmented health care
system. Personal enrichment should never represent
the primary determinant of decision making in
patient care. In my opinion, students and
residents witness profit-first unethical behaviors
which not only go unpunished, but are rewarded.
They see that doctors are a generally autonomous
group who self-discipline, meaning no discipline.
Students and residents therefore assume unethical
behaviors as being acceptable and "normal", and
profit-first thinking proliferates through the
profession. This continues as post-graduate
education allows industry driven unproven
therapies to be presented at our CME programs,
again a reaffirmation that profit-first behavior
is the acceptable norm. Doctors are entitled to a
fair reimbursement for their services. However, in
conducting the business of podiatry patient well-
being is always the priority.
In medicine, the golden rule, do unto others that
which you would have done to yourself "prevails.
Alternatively, the platinum rule; " do not do to
others that which you would not do to yourself ".
There is nothing immoral to making money in a
legitimate manner. In many ways it is admirable to
do so, when accomplished in an ethical manner. The
people in medicine that I personally admire the
most are those who have been dedicated educators,
dedicated political leaders, and not those who
simply accumulated wealth at any cost to patients,
profession or society.
It is for these reasons that I believe legitimate
business education be incorporated into the
education of our students and residents.
Allen M. Jacobs, DPM, St. Louis, MO
04/24/2024 Robert Kornfeld, DPM
The Future of Podiatry (Allen M. Jacobs, DPM)
While I agree with almost everything Dr. Jacobs
stated in his post regarding the future of
podiatry, there are some issues that I think need
to be re-visited. No doubt, the APMA and
affiliated State Societies have done a very poor
job getting the public to understand what it is we
do and how well trained we are to do what we do. I
also believe they completely missed the boat in
advocating for podiatrists. In a HUGE way. And I
say this after 42 years in my own private practice
(the past few decades as a non-member).
The “business” of medicine should not rely on
insurance issues. Those issues have been created
by insurance companies in order to exploit and
abuse doctors for their gain. Likewise, private
equity corporations employ doctors and still, like
insurance companies, have a profit motive, not a
health care motive. They, too, will exploit and
abuse their employees for profit. Therefore, the
only way that you will ever see logical, fair and
appropriate insurance reimbursements is for
doctors to stop cooperating, stop participating
and let medicine go back to a free market. In this
way, insurance companies are out of business. If
they want back in, they’ll have to come up with a
fair reimbursement model but at the same time,
leave the standard of care up to the doctors. Not
this nonsensical standard created for nothing
other than to maximize their profits. Free market,
as you know, has its fees controlled by
competition.
It would be best if patients paid their way, had a
catastrophic plan in place for major medical
events and we never went back to insurance-
dependency. Indigent patients will still have
Medicaid coverage and seniors will still have
Medicare coverage.
As for “cost-effective” medicine, this is a
misnomer. What we need is for there to be high
value in the services we provide, independent of
cost. What a patient spends is up to them. There
are literally billions of dollars wasted every
year on services that are limiting cost, and that
leads to limitations in value realized by
patients. Let’s help our patients in the most
effective way possible. That means we need to
learn patient optimization and not focus on
“better modalities, surgeries and therapies”. The
answer lies in an efficient immune system. Not in
a better laser, etc.
So residencies should allow for the comprehensive
assessment of each patient’s unique epigenetics
and genetics. Every podiatrist should be well
versed in why the patient crossed the morbidity
threshold, not just the pedal diagnosis. And they
should learn how to manage the underlying
mechanisms of pathology outside of simply looking
at biomechanics. We have really missed the boat as
medical experts in our field.
And I must say this OUT LOUD. Profit in a podiatry
practice should not be secondary. It needs to be
primary. This is a business. ALTRUISM DOES NOT PAY
THE BILLS. There is no reason for anyone to put in
the time it takes to be educated and trained to
practice podiatric medicine and surgery just to
realize that all of your non-doctor friends and
relatives are making a lot more money that you
are. Sorry, but this does not cut it. For what we
do , the value we offer the public as to their
health and lifestyle, we should be paid very well.
I honestly believe this push for altruism has been
used as an excuse for staying stuck in a fear mode
and not exercising the power that we truly have as
doctors. It’s an excuse we have invented so we can
rationalize doing what we do for peanuts.
As I see it, the future of podiatry looks bleak.
Little by little, fees or salaries won’t sustain
us. Other allied professions will usurp a lot of
our current expertise and limit our market share.
The surgery-only mentality has done much to
destroy our foot and ankle medical expertise and
has created a new generation of podiatrists sorely
lacking in fundamental medical diagnostic skills.
If you want to secure your future as a podiatrist,
you had better look outside the box that you have
been stuffed into. Become your own advocate. Get
yourself free from reliance on employment or
insurance reimbursement. There’s a whole new world
out there that is waiting for you and will welcome
you once you make the choice to step into it. But
the current direction we are in is guaranteed to
crash and burn and leave you stranded without
sustenance. And that is an absolute shame.
Robert Kornfeld, DPM, NY, NY
04/24/2024 David Secord, DPM
The Future of Podiatry (Allen M. Jacobs, DPM)
In an arena of increasing knowledge base and
technocracy, the expansion of the knowledge base
expected by tomorrow’s patient also increases as
does that patient’s expectation that you are not
simply seeing a wallet to pick clean upon their
visit. As Allopathic physicians and surgeons, I
believe that our destiny is to either follow the
Osteopathic school of medicine (adopt the
Allopathic standards of education and testing for
licensure) or fade into oblivion.
I’m unclear as to how you trim a year off medical
school and keep the same level of education in the
World of expanding knowledge and expectations. As
such, I believe that our future is a four-year
degree, followed by a year of internal medicine
internship and five years of surgical exposure to
hone skills and knowledge and a year of fellowship
in lower extremity trauma and care. There are
many, many more of them than us, and we should
either join the established crowd on the boat or
expect to be left at the wharf.
For those who have managed to divorce themselves
from the slavery of insurance reimbursement via a
concierge practice, the ship has docked. For the
grand majority, this is not an option. I deeply
respect Dr. Jacobs and his position within the
profession, but don’t believe that the public will
accept a “cut-rate” doctor as a solution to access
to care, reimbursement issues or student debt.
Although only hinted at by Dr. Cabbabe, the push
in his monograph’s conclusions for obligatory and
unavoidable socialized medicine is fairly clear.
His tone seems to hint that this is the ultimate
solution to our problems.
As one estimate on the cost of “Medicare For All”
was $98 trillion dollars, I can’t see how a
Country with a National Debt of $34 trillion—and
counting—could possibly institute this. Following
either the Canadian or UK National Health Service
model for cost containment via denial of timely
care and services would do very little to assuage
the public’s doubt that the healthcare industry
cares about them in any way. If you look at the
burnout rate for physicians within the NHS over
pay and frustration, it is voluminous and dwarfs
the rates in the United States.
A study a few years back surveyed physicians
within the NHS and six of eight said that if they
had an option, they would do something else for a
living. When I practiced in Saudi Arabia, the
number of physicians from the UK, Canada and
Australia was amazing. All of them had homes and
families in their host Countries but practiced in
Riyadh because of the advantages of exiting the
NHS, despite being away from their families for
months at a time. Their numbers were truly legion
and impressive. They hated Socialized medicine and
the low bar of care delivery it wrought so much
that the cost of only seeing their families three
or four times a year was worth it, both
financially and professionally.
My experience while in Riyadh was very influential
upon my disdain for Socialized Medicine and I
fully admit to such. Aiming for the goals outlined
by Dr. Cabbabe to deal with NP nursing care
encroaching upon medicine and managed care seeing
patients as wallets to be picked clean while
delivering as little care as possible doesn’t seem
to be a viable alternative to the current
situation. His enthusiasm for EMR is puzzling as
well. I don’t know anyone who is as effusive in
their love of electronic medical records as Dr.
Cabbabe, with most of the physicians I know and
with whom I work seeing the process as cumbersome,
time-consuming, counter-intuitive and a general
waste of time.
The administration at the clinic system where I’m
employed is constantly attempting to end the “cut
and paste from the previous note” epidemic seen by
providers to simply get through the day and
complete records. That is a huge unintended
consequence of the EMR anchor around our necks and
no good can come of it. We are at a crossroads in
our profession and serious discussions as to where
we should steer the vessel to avoid the maelstrom
are needed. Pax.
David Secord, DPM, McAllen, TX
04/23/2024 Allen M. Jacobs, DPM
The Future of Podiatry - PART 2
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 MD's and DO's an 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, 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 payor (
and your personal desire to maintain a profitable
practice) creates a conflict that ultimately makes
you the proverbial sacrificial lamb. You are damned
if you do, damned if you don't.
Patients already blame doctors for increasing
copays and deductibles and uncovered services.
These problems will continue to increase into the
future. As a practitioner, you will have to
determine the appropriate path to follow. Does a
patient require an expensive non-generic medication
when a generic medication would be expected to
provide the same result without increased risk?
Does a patient require expensive fixation for
osteotomies or arthrodesis procedures when these
devices provide to proven and published advantage
in healing? Do all postural complaints or concerns
require formalized orthotics as opposed to
prefabricated supports? Do all ankle sprains
require a CAM walker boot Do the majority of
wounds require expensive wound care products?
The goal of industry is first and foremost profit.
As Sir William Osler noted over 100 years ago,
although you entered medicine to make a living,
this should at all times be a secondary
consideration. Industry driven considerations and
corporate-driven medicine as your employer
encourage more expensive medicine. The
retrospective studies on this subject are clear.
The loser is not only the patient. It is you. If
you cost too much, providers may eliminate you as a
provider. If you fail to make an adequate profit,
your employer may eliminate you. Remember, what is
legal may not be ethical, and what is ethical may
not be legal.
Today's podiatry college graduate is entering a
difficult world in which to practice. A common
denominator is the influence of industry on your
decision making for podiatry care. To borrow from
Sir William Osler, do not become enslaved by
industry created pseudoscience. When you cost more
for the same or similar service, without proven
benefit to a patient, you are adversarial to the
interest of the insurer, as well as your profit
first employer. When new technology is introduced,
the first question Dr. Jack Schuberth always asks
"exactly what is the problem that you are solving?"
Frequently, solutions in search of a problem are
expensive. Ethical behavior includes not only your
interactions with the patient, but also your
interaction with follow podiatrists and the
profession as a whole. Included in these
interactions are truthful and scientifically based
(ie: legitimately studied and published)
endorsements of new pharmaceuticals, techniques,
and devices. 510K approval means nothing.
Your survival in practice as well as ethical care
of patients and your responsibility to society
demand cost-effective care. To do otherwise will
decrease your value to patient and provider and
employer, and could endanger your future.
Allen M. Jacobs, DPM
10/03/2019 Loretta Logan, DPM, MPH
Welcome to the Future of Podiatry (Paul Kesselman, DPM)
As chair of the Department of Orthopedics and
Pediatrics at the New York College of Podiatric
Medicine (NYCPM) I feel it is necessary to
respond to your recent comments regarding the
current state of orthopedic training at the
schools of podiatric medicine. While I agree
with the consensus that the younger
practitioners entering practice have placed
surgery at the head of their treatment plans,
the first sentence in point #1, “The
undergraduate level of biomechanical training is
apparently shameful as compared to when I was at
ICPM 1977-1981” was particularly troubling.
I would be happy to share curriculum documents
with you which show the evolution and expansion
of orthopedic training from the time of then
NYCPM chair Dr. Richard Schuster, and modified
to its current design by successive chairs and
my predecessors, Drs. Joseph D’Amico, Edward
Rzonca, Mark Caselli, Justin Wernick, Russell
Volpe and myself. I will assert that among the
colleges of Podiatric Medicine, NYCPM
consistently stands out as being a school that
the students feel is “orthopedically heavy”, due
to the rigorous classroom and clinic sessions
delivered throughout the 4-year curriculum.
While we no longer ‘build (custom orthoses, in-
house) from scratch’ from a neutral position
cast, students are well-trained in casting and
fabrication detail for fully prescription
devices and are able to complete on the fly
prescriptions using modifiable “blanks” to which
they add posting, accommodation and other
standard orthosis additions and features in our
orthotic laboratory.
In response to your statement in point # 2, “Do
students have any idea about orthotic materials,
construction, how to cast (or scan correctly). I
dare say no!”, I emphatically say yes! Our
students have didactic lectures and workshops on
casting, materials, footwear/pedorthics and
orthotic fabrication delivered by clinicians who
bring decades of experience to the craft. Our
students also have over 500 hours of clinical
rotations dedicated to biomechanics/orthopedic
sciences and where full biomechanical exams and
observational gait analysis are taught and
routinely used to evaluate and treat both adult
and pediatric patients. Our gait lab, which
features current pressure mapping and video
technology serves to assess patients whether for
orthopedic prescription, diabetic or pre-
surgical evaluation. It is our belief that this
academic and clinical experience better serves
orthopedic education (and the patient) than
would time spent creating plaster molds, et al…
especially considering that orthotic labs have
also largely abandoned this in favor of digital
and cad-cam technology.
I will also point out that NYCPM consistently
leads in post-graduate education in orthopedic
sciences. The annual Richard O. Schuster
Biomechanics Seminar is an event unlike any
other in North America and routinely showcases
not only NYCPM faculty but highly regarded
clinicians from around the country. NYCPM
faculty participate nationally in exam
development (APMLE and specialty board),
evaluation of residency training standards and
continuing education events where their
expertise and passion for this domain is
evident.
Hopefully, the information above will address
the second statement in that same initial
paragraph that your description of the
‘shameful’ state of podiatric orthopedics is
based merely on your “…query of student
residency interviews or externships over the
past 10 years.” Could your frustration in
questioning these particular students and their
unacceptable responses be reflective of the
fourth sentence in the same paragraph regarding
the opinion that Dr. Aronson voiced stating it
would take a ‘minimum’ of five years to master
the subject?
During the 2018 Richard O. Shuster Biomechanics
Seminar, I presented “An Analysis of the
Biomechanics/Orthopedics Curriculum in the
Colleges of Podiatric Medicine.” My research
involved reaching out to each of the schools to
obtain information on their curriculum in
Biomechanics/Orthopedics from as far back as
they could take me to the current day. My
analysis concluded that the level and quality of
training in the colleges of Podiatric Medicine
showed that biomechanics/orthopedic sciences is
being taught and with rigor and dedication at
all schools. As a faculty member at one our
sister institutions stated “the concern is at
the handoff point (residency training) where the
importance or expertise in biomechanics may be
diluted or lost.”
Yes, there are issues with regard to residency
programs not placing enough emphasis on the
biomechanical exam as part of the pre-surgical
workup (though I imagine that there are some
programs who do this quite well.), however that
is something that the Council will need to
address. And yes, this is something that clearly
needs to be accomplished as soon as possible.
While your letter does highlight several areas
of deficiency within our field, I wanted to take
this opportunity to address item # 1 and state
unequivocally that there is nothing shameful
about the biomechanical training at NYCPM. I
hope this provides you with a better
understanding of our approach here at NYCPM,
where we strive to carry on the legacy of some
of the iconic figures in podiatric biomechanics
who have gone before us. I assure you it is a
responsibility that is not taken lightly.
Loretta Logan, DPM, MPH, NY, NY
09/20/2019 Robert Kornfeld, DPM
Welcome to the Future of Podiatry (Paul Kesselman, DPM)
Dr. Kesselman's 10 points are right on the
money. I had a patient who came to me for a
second opinion recently. She had seen a young
podiatrist who recommended surgery for an "IPK"
sub 5th met head (metatarsal osteotomy). When
she came to my office, the lesion was quite
large and apparently had not been debrided. When
I began to debride the lesion, I felt a click on
my scalpel.
Further debridement revealed a piece of glass in
the patient's foot which I easily removed. I
told her she did not need surgery. She was very
grateful but very angry that a doctor would
recommend surgery without appropriate
examination of the area of chief complaint. He
x-rayed her foot and told her she needed
surgery. There was no recommendation for
conservative care of any kind.
I have been a podiatrist for over 39 years and
in private solo practice for 37 years. In that
time, I have seen a once viable, growing, and
incredible profession sink to new lows every
year. In my opinion, the 3-year surgical
residencies have done much to diminish our
medical skills and our rational approach to
differential diagnosis. I've done thousands of
surgeries in my career, but never without
careful consideration to the mechanism of
pathology.
I do believe the current path will eventually
destroy the profession of podiatry. It isn't my
problem, however. I am at the tail end of a
great and lucrative career that I fashioned on
my own so that I could be the best podiatrist I
could be without influence from insurance
companies and Medicare. I have a niche practice.
I do not accept insurance of any kind. I work
smart and not at all hard. I attempted many
times to bring this information to the
profession but was ignored by all the Colleges
of Podiatric Medicine (as irrelevant). My
practice is medical, not surgical at this point.
Podiatry wanted to feel like "real" doctors and
pushed the surgical agenda to self-destruction.
I attend the Schuster Biomechanics Seminar at
NYCPM every year and gain invaluable knowledge
from some of our most revered biomechanics
experts. That has done more for my practice than
my scalpel ever did.
I wish the future of podiatry the best of luck,
but in my opinion, you have shot yourselves in
the foot.
Robert Kornfeld, DPM, Robert Kornfeld, DPM
09/19/2019 Paul Kesselman, DPM
Welcome To The Future Of Podiatry
I applaud each and every one of you for
providing your excellent comments on this
matter. I have to agree with all of you, but
your comments did not go far enough. At the risk
of receiving a rash of unfriendly mail, the
following "top ten" need to be pointed out:
1) The undergraduate level of biomechanical
training is apparently shameful as compared to
when I was at ICPM 1977-1981. This is based on
my query of student residency interviews or
externships over the past 10 years. Biomechanics
was the "calculus" of undergraduate medical
training. Dr. Don Aronson told us that it would
take us a minimum of 5 years to master this
subject and my classmates were no doubt
challenged by this subject.
At the same time, we knew we had to master this
complex topic it if we were to become skilled
surgeons. We also had Drs. Weil, Sorto, Smith,
Aronson and others on the faculty and could look
at the other schools to see the masters of
biomechanics at the other schools (Ritchie,
Subotnick, Kirby, Langer, Root, etc.) who were
publishing texts and articles at an amazing pace
and speaking at seminars. So, we had our fair
share of mentors who we could look to for advice
and guidance;
2) Intermixed with my course on biomechanics was
a course on orthotic fabrication, so I learned
how to cast properly and understand all the
intricacies of orthotic fabrication. Do students
have any idea about orthotic materials,
construction, how to cast (or scan correctly). I
dare say no! As a consultant to many orthotic
labs, the main frustration faced by lab owners
regarding their relationship with their clients
is poor casting (foam or scanning) technique and
most providers under 50 having little idea of
what device(s) are appropriate for which
pathologies. More than one lab owner has told me
that they won't deal with certain clients
anymore;
3) The residency programs I participated with as
faculty (and my post graduate preceptorship) all
required biomechanical examinations on just
about every elective (and some non-elective)
surgical cases. Now that number has dwindled to
a handful over three years. I did more in a one-
year preceptorship than is required and
performed in a 3-year surgical residency today.
This is shameful and irresponsible!
4) At this year’s APMA National, I spoke on 21st
century biomechanics with other distinguished
faculty. The room should have been packed, but
it was far from it. Most were practitioners over
50. So, where have all the young DPMs gone? Do
they really think that surgery is the salvation
of the profession and the only way they can make
a living? As I close in on clinical retirement
and have for the most part hung up my surgical
scalpel, I can tell you that surgery is not the
best way to make a living in this profession
(but then many of you already know that).
Unfortunately, that message has never been
received by the younger members of our
profession;
5) Prior to the APMA National, I reached out to
many laboratories and faculty members at the
podiatry colleges. I heard back from a few
regarding participating in some sort of blue-
ribbon panel to discuss the issues (it is really
a crisis) our profession faces w/regards to the
position of the profession with regards to
biomechanical leadership. This never got off the
ground due to a paucity of responses. Other labs
have tried this and for the most part failed. I
applaud the few (Dr. Decaro, etc.) who continue
to persist at providing either lecture tracts or
full day workshops, but these are too far and
few;
6) There are other medical associations
representing other orthotic providers, which do
provide an incredible amount of research at the
University level, produce well written papers in
journals and speak at their national
conferences. I am amazed at their
professionalism and dedication and their results
are startling. If our profession doesn't do
something soon, we will no doubt have lost (if
we have not already) our kingpin position as
authorities on lower extremity biomechanical
experts. I will be reporting back in a few weeks
on this year’s conference with some updates;
7) I agree with Dr. Udell that it is
unsustainable for him (or any speaker) to have
to pay their own way to conferences. He
neglected to offer the opportunity costs of not
seeing patients in their own practices. While I
applaud his commitment, this is not sustainable
on a regular basis and to his point, thus this
requires the laboratories to sponsor faculty;
8) I agree with Dr. Ritchie that is not the
orthotic industry's sole responsibility to
foster undergraduate education in biomechanics.
That is square at the feet of those who develop
undergraduate podiatric medical curriculum.
Continued training for residents in biomechanics
needs to be dealt with by those involved in
developing graduate medical education
curriculum. And the laboratories also need to be
committed to the future by participating in
undergraduate and graduate training, fostering
meetings and all need to get involved in moving
research to the University level.
9) APMA and Certification boards also need to
also commit themselves to working with all those
mentioned in whatever way they can to get this
issue moving!
10) Working together, if each podiatric college
could foster the development of just one master
student in biomechanics every four years, our
profession would be capable of providing an
exemplary number of masters in biomechanics
within the next decade.
After writing this letter, I had a conversation
with two colleagues which did provide some
further insights on this subject:
Josh White informed me that CCPM is developing a
fellowship in the memory of Paul Scherer along
with a just announced Biomechanical Symposium.
Larry Santi provided information that CPME is
now developing new criteria for residency
programs with more biomechanics requirements as
part of the residency curriculum.
It is my hope that others will add more positive
comments about what their companies, schools,
associations etc. are doing.
Podiatry (both the profession and its corporate
partners) needs continued helpful cooperative
dialog to resolve this crisis. I am hopeful that
this will resonate positively among our
leadership!
Paul Kesselman, DPM, Woodside, NY
09/18/2019 Dale Feinberg, DPM
Welcome to the Future of Podiatry (Joseph Borreggine, DPM
Dr. Borreggine’s excellent analysis of the future
of podiatry hit the nail right on the head. He
had been prognosticating that the demise of
private practice was coming and now he has put
out the word that private practice is dead,
I started reading the tea leaves about seven
years ago when the implementation of Obamacare
started affecting my practice. Denial of payment
for the medically necessary diabetic shoes was
the opening shot in the war with Big Brother that
we have unfortunately lost. Things have continued
to go downhill every day and has now culminated
with 90% of podiatrists feeling some level of
burnout. I am not burned out, I’m bummed out!
I love our profession, but it is becoming harder
and harder to stay afloat and I feel that I’m
paying out-of-pocket to enjoy my hobby. Yes, a
few of us are transitioning to newer models of
employment but you’ll never know the level of
freedom and joy that self employment brings.
I have recently been telling patients that when I
retire my much needed podiatry skills would
become a lost art. I recently had a patient
present to my office for a new set of custom
orthotics. When I inquired why he didn’t have
these made back home he told me that no one makes
them anymore. Another patient was so happy that I
removed a painful callous as she had difficulty
finding a Podiatrist to do it. A neighbor in
California asked me to remove his painful heloma
molle as his podiatrist had retired and it took
six months to get a foot appointment at his
health plan. Don’t even get me started on
dystrophic mycotic nails. If you are in the front
lines of private practice you know these things
to be true. Supergroups and orthotic lab support
at meetings will not save us.
In closing I am reminded of an op-ed article Dr.
Bret Ribotsky wrote ten years ago comparing the
reported average yearly DPM income to that of a
school teacher. He made the argument that the two
incomes were in fact equal when you took into
account years of deferred income, educational
costs, cost of loan repayment, malpractice
insurance, and practice costs let alone no funded
retirement, paid days off and a summer off from
work.
I am counting the days until I get Medicare. My
house is paid for and I have no kids in college.
I will ride my Harley into the sunset and I wish
you all the best of luck.
Dale Feinberg, DPM, Yuma, AZ
09/14/2019 Joseph Borreggine, DPM
Welcome to the Future of Podiatry
Who needs a podiatrist when you can just buy a
pair of custom orthotics on your own? Soon not
one insurance will pay for orthotics, but what
does it matter anyway? A new class of DPMs are
now entering the profession with the mindset
that they are only “foot and ankle” surgeons.
They opine that general podiatry is truly passe’
and is beneath the DPM degree. All the time and
money invested in their degree that was earned
along with the required 3-year surgical
residency is far beyond the general practice of
podiatric medicine.
Podiatry will soon just sink into the waters of
oblivion because of those who are being
relegated to provide these same type services at
a lesser cost (APN, FNP or PA) or general foot
care put into the hands of those non-medical
individuals to provide palliative foot care (LPN
and nursing aides) with no cost all.
The podiatry profession has lost sight of its
original foundation as a specialty in medicine
all in exchange for a new identity. Change is
good; I do not disagree, but when a podiatrist
who has been in practice over 30 years can no
longer recognize the occupation of podiatric
medicine that they entered long ago, then
something is wrong.
Yes, independent practice is dead and replaced
by guaranteed salaried and benefit positions in
corporate or hospital settings, but to
ignorantly give the services that used to be
exclusively provided by podiatric medicine in
exchange for RVUs is disheartening.
Understanding that certain services once paid
for in an office setting like DME, x-rays, and
wound care supplies are usually not part of a
typical compensation contract can certainly
affect the employed podiatrist ability to
generate a minimally acceptable revenue base.
Hence, administrative pressures cause a
physician to make clinical choices to meet those
financial expectations all in the name of the
corporate bottom line.
So, welcome to the future of podiatry and
medicine in general because it is here to stay.
Joseph Borreggine, DPM, Charleston, IL
09/25/2018 Steven Selby Blanken, DPM
Student Recruitment - The Future of Podiatry (Gary Smith, DPM)
I am the grandson of a podiatrist/chiropodist
(M.L. Selby, DPM), I am a TUSPM grad of 1990,
and have a son, Brandon Selby Blanken, TUSPM
Class of 2020. We were and are proud to be
podiatrists. I am very happy my son picked the
field I am in and hopefully he will join me in
around 5 years. As SGA acting president at
TUSPM, I find my son very active in the affairs
of our profession along with student
recruitment.
There is now a push for all students at all the
schools to go visit their undergraduate schools
and educate them about our field. I have been a
mentor for years and helped recruit over 10
students to podiatry schools. None of them are
mad at me for it. You see, if you go out and get
it, and learn as much as you can, you can be
successful in our field. Picking podiatry means
that the student knows what they will be when
they receive their doctorate.
The MDs and DOs do not. That is a huge thing to
many as it was to me and my son. Regarding the
residencies, I do believe that not all
Podiatrists should be podiatric surgeons, but
they are all given the opportunity to be exposed
to the training. I do believe there should be
more in-office rotations exposing the residents
to more day to day operations, as well as
practice management teaching, in order to
becoming a well-rounded DPM.
I am shocked to see how many graduates of
programs have no idea on how to do daily in
office podiatry care, but can put the best
external fixative device on a foot that I have
ever seen. I feel that any podiatrist who comes
out and says, "I am going to do nothing but
surgery and manage high risk feet everyday, but
do almost no general podiatry may be subject to
failure. This is what we do, we manage and treat
all aspects of foot and ankle care. Enjoy the
field, don't be narrow-minded and most
importantly, give back to your profession. Help
out your former schools to the best you can.
Learn the "business of podiatry" and you will
succeed.
Steven Selby Blanken, DPM, Silver Spring, MD
09/22/2018 Alan Sherman, DPM
Student Recruitment - The Future of Podiatry (Gary S Smith, DPM)
I wanted to respond to the message from Gary
Smith, DPM, which was very negative toward
current podiatric education and contained some
inaccuracies. First of all, while the number of
applicants to podiatry schools has declined in
recent years, and this is a big problem for us,
applications have actually gone up for medical
schools (increasing by 6.2% from 2015 to 2016,
and they have become more competitive.
I do agree with his statement, “Podiatry was
much more marketable when graduates could choose
to be a podiatrist or a podiatric surgeon.” Our
drive to make every podiatrist an advanced foot
surgeon, which has been a front cover selling
point used by the schools to attract more
candidates, may be having the reverse effect.
Perhaps we would attract more applicants if a
less surgically oriented education track were
offered? I have long believed that every
podiatrist doesn’t want to be an advanced foot
surgeon, shouldn’t be an advanced foot surgeon,
and yet our single track residency programs
continue to emphasize surgery.
Even after 3 years of residency training in
which surgery is a large focus, the recent poll
done by PM News demonstrated that only 23.17% of
podiatrists identified themselves primarily as
surgeons. Most of us identify ourselves as
“Podiatrists” or “Foot and Ankle Specialists”.
I do think 3 years is the correct length for our
residency programs, but that every podiatrists
doesn’t want or need to be an advanced foot
surgeon. In fact, I don’t think that the public
needs every podiatrist to be an advanced foot
surgeon. The PM News polls confirm what many of
us have been feeling for years - that while we
all do surgery, and deserve recognition for the
training that we get, the credentials we achieve
and the fine work that we do in that discipline,
very few podiatrists are primarily surgeons, nor
should most podiatrists primarily be surgeons.
If we all were primarily surgeons, who would do
ALL THE REST of the important work that we do in
solving the world's foot health issues. The
volume of medical podiatry, the work we do as
physicians, not as surgeons, far exceeds the
volume of surgery needed by the public.
Shouldn’t podiatric residency training reflect
that
Alan Sherman, DPM, CEO, PRESENT e-Learning
Systems
09/19/2018 Brian Butler, DPM
Student Recruitment-The Future of Podiatry
Dr. Jon A. Hultman’s article, Student
Recruitment-The Future of Podiatry Is in Your
Hands, clearly addresses the fact that Podiatry
faces a student “recruitment crisis” that “could
signal the beginning of the end for the
profession.” Despite a period of remarkable
progress for podiatry, our schools are now
encountering a host of student recruitment
challenges from the increasing numbers of new
American medical school seats (3,000 new seats
since 2012), off-shore medical schools,
physician assistant programs, nurse practitioner
programs, and the new interest in American
medical schools offering tuition free programs
such as New York University now provides. These
challenges are real and the trajectory is
detrimental to the viability of our schools.
Dr. Hultman’s article should be required reading
for the trustees of our nation’s podiatric
medical schools. The trustees have the fiduciary
responsibility to ensure that their schools are
realizing their full potential for service under
their state charters. The student recruitment
crisis must be addressed by the trustees if our
schools are to remain viable. However, a robust
student recruitment strategy, no matter how
energetically implemented, will not enable our
schools to contend with their educational
competition.
The viability of our schools must be secured by
changing our school charters to offer the Doctor
of Medicine degree. Only the trustees of our
podiatric medical schools have the standing to
petition their state governments for changes to
their school charter. Podiatrists today
independently practice like any other medical
specialist. Our schools provide a curriculum
analogous to allopathic medical schools and our
graduates complete three-year residency programs
in podiatric medicine and surgery. Podiatry has
evolved into a unique American medical specialty
providing essential services to the American
people. Unless our schools are positioned to
continue to recruit qualified students, all of
this progress is at risk. It is incumbent on
the trustees of our podiatric medical schools to
initiate charter change discussions with their
respective state governments. It is the trustees
of our schools who have the future of podiatry
in their hands.
Brian Butler, DPM, Brooklyn, NY
