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04/23/2024 Allen M. Jacobs, DPM
The Future of Podiatry
A recent article published in KevinMD.com, written
by a St. Louis plastic surgeon, Dr. Samer Cabbabe,
caught my attention. I would suggest that his
discussion on the corporatization of medicine is
thought provoking. Many of his conclusions are, in
my opinion, applicable to podiatry. Dr. Cabbabe
concludes his article with certain recommendations
for the future of quality medical care. I will
paraphrase some of these with podiatry relevance
and additionally share my personal opinions.
1. Curriculum changes are needed to focus on non-
clinical aspects of medicine, including insurance,
leadership, business, and other political aspects
of medical care delivery. Medicine is a business,
and practice survival as well as decision-making
regarding employment require knowledge and good
information. The business of medicine must be taken
seriously by the colleges and residencies.
2. The author suggests that medical schools be
shortened to a 3 year curriculum, and/or an
increase in 6 year combined college and medical
school programs be considered. This would result in
decreased debt to the student. In my opinion, there
is no reason for podiatry to not consider this
pathway. The necessary regulatory mandates should
be reconsidered. I believe this may be useful in
attracting students to podiatry.
3. The benefits of podiatry as the provider of foot
and ankle services should be heavily marketed. It
has not been. Many state societies (and the APMA)
have large coffers sitting in the bank doing little
but collecting interest. Why not a campaign
advocating the benefits of podiatry care in areas
such as diabetic foot, geriatric care, wound care,
sports medicine, foot surgery? Increasingly, NPs,
PAs, PCPs, PTs, CPEDs, DCs, and of course
orthopedists are attempting to provide such care.
Absent surgery by the foot and ankle orthopedist,
these alternative providers do so at the expense of
patients, who receive inferior care by these
providers and suffer the resultant complications
and sequela. More money must be spent to lobby for
podiatry-led foot care. It should be done so in an
effective manner.
4. State societies must take the lead in marketing
and protecting and advancing podiatry interests.
Sadly, is clear that the APMA is incapable of doing
so. All politics are local as they say. Studies
which demonstrate the benefits of podiatry are
published, cited in PM news, read by a few. Then
what ? We pat OURSELVES on the back, and nothing
changes.
5. There are only so many podiatry jobs in VA's,
orthopedic groups, medical groups and health care
systems. Perhaps the declining number of applicants
to our colleges and therefore future graduates will
solve this problem with employment available for
all the decreasing number of graduates. However,
there will be increasing needs for podiatry
services (e.g.: ageing population, diabetes,
increasing sports participation, PAD) and as a
result we shall either provide the needed care or
abrogate this care to others. We will need more
primary care podiatrists, not 100% "surgeons".
I suggest rethinking of the mandatory 3 year
medical/surgical residency model. 3 years of
podiatry college, 2 years medical residency or 3
year surgical residency +/- fellowship. The medical
(primary care) residencies should be increasingly
office based, as are family medicine residencies.
We should consider the dental model.
The theoretical is not practical. The average PA or
NP in many states have an average salary higher
than the average podiatrist according to some
studies. Alternatively, we as a profession can
elect to surrender primary care foot services to
others and hold ourselves out as surgeons only. To
some extent, we are already traveling this road,
which I believe to be a mistake.
6. We must increase instruction in the ethical
practice of medicine. This must begin in the
colleges and be reinforced during residency
training and continue at our CME programs. It is
past time that the states and CPME and APA restrict
corporate influence and allow advocacy of unproved
techniques and devices and medications to be
presented to students, residents, and
practitioners. APMA officers and BOD members, as
well as any organization providing CPMA approved
CME, should not be allowed to maintain conflicting
interests in determining CME content. The overt
dominance of industry in our CME programs is at
this point not acceptable.
Allen M. Jacobs, DPM
Other messages in this thread:
10/22/2025
RESPONSES/COMMENTS (THE FUTURE OF PODIATRY) - PART 1B
From: Daniel Chaskin, DPM
It seems to me that if a podiatric resident did not eat lunch yet, this is a valid complaint. As a podiatrist in private practice, I have the right to choose not to have lunch if my patient load gets too crowded. I choose to ensure my schedule does not interfere with my lunchtime. Podiatric residents should have the right to choose to eat lunch without being criticized for being hungry.
Furthermore, they should get as much sleep as needed to maximize their ability to work without making podiatric medical mistakes. Sleep is important for anyone to function to the best of their ability. If every residency director allowed residents to get up to 8 hours of sleep when needed, enough time to eat, perhaps patient care given by podiatric residents would improve.
Daniel Chaskin, DPM, Ridgewood, NY
10/22/2025
RESPONSES/COMMENTS (THE FUTURE OF PODIATRY) - PART 1B
From: H. David Gottlieb, DPM
My experience interacting with externship over the last 20 years is that there has always been a mix of student intellect, abilities, and desire to excel. Over the last few years, I have seen a widening of the bell curve. The best students on the whole are better and the students at the bottom even worse. Additionally, the students who have been accepted to 'my' program in Baltimore have all shown either above average to exceptional intellectual ability.
Over 20 years, I have noted changes in overall attitudes towards work both from CPME requirements as well as in generational shifts. CPME is now mandating, on average, limited working hours very different from the past. The days of allowing residents to work 16 or 18 hour days are over. Do I agree with that? No. But, you know, it is what it is. I learned to deal with it (with a head shake nearly every day). I suggest others do as well. The work gets done, cases are covered.
Stop beating up on our future. Learn to adjust to reality or YOU will be the one left behind (and consider self-pay practice as was done years ago).
H. David Gottlieb, DPM, Baltimore, MD
10/21/2025
RESPONSES/COMMENTS (THE FUTURE OF PODIATRY)
From: Ivar E. Roth, DPM, MPH
Wow, Dr. Feinman hit the nail on the head with his assessment of the quality of students rotating through his program. How sad, but according to my inside sources this is a reality.
Besides poorly qualified students being accepted into the schools, the complacency factor is a whole other matter. There needs to be a shake-up or Dr. Feinman is correct that patients will request other providers, and our reputation will take a dump as a profession.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
10/20/2025
RESPONSES/COMMENTS (THE FUTURE OF PODIATRY)
RE: We Need New Leadership and a New Direction
From: Ross B. Feinman, DPM
Unfortunately, in the last five years, the talent coming out of the podiatry schools is dismal at best! It's time that the schools either be consolidated and half of them closed, or let the MD or DO schools take them over. For far too long, these schools have been run as a business rather than a beacon of higher education. There are too many schools and the students who are coming to the hospitals and rotating are sadly not qualified to work at a sub shop. There are a few exceptions; some of the students that I have had the chance to work with have shown some aptitude, some eagerness to learn, but for the most part, they're looking at their phones the whole time waiting to get done, lack preparation before any cases, and complain that they haven't eaten lunch yet!
The profession is at a crucial time right now. If something doesn't change soon, orthopedists and PAs are going to overtake our profession. In the past, we heard all these ramblings of ortho and nurse practitioners. We weren't as concerned at the time because we were the most qualified to treat the foot and ankle, but if you take a look at the graduates coming out, I can't blame patients if they want to seek other practitioners! It's the 4th quarter and we're down a lot of points with time running out. We need new leadership and a new direction, or all the hard and innovative work of the past will crumble like a house of cards.
Ross B. Feinman, DPM, Walled Lake, MI
10/16/2025
RESPONSES/COMMENTS (THE FUTURE OF PODIATRY)
From: Ivar E. Roth DPM, MPH
I have mentioned this before; the reason for the low student retention numbers of the matriculating classes in general is that the schools basically are allowing everyone in, and if the student can pass, they move on and, if not, they drop out. It really is that simple.
Ivar E. Roth DPM, MPH, Newport Beach, CA
10/14/2025
RESPONSES/COMMENTS (THE FUTURE OF PODIATRY)
RE: Obituary for the DPM Degree
From: Rod Tomczak, DPM, MD, EdD
The obituary can now be completed and a necrology constructed. It’s time to sit Shiva, recite the Kaddish, and assemble the musicians for Mozart’s Requiem. The mourning is not for podiatry, it is too strong, stronger than the 70 or 80 years of Psalm 90. The mourning is for the DPM degree. Podiatry is a philosophy much stronger than three initials and will continue to be with us for a long time.
But what we have learned in the last months is that the youth opting for our profession want a plenary license, not the parochial one we have possessed and have thrived under. They want a seat at the adult medical table. How do we know this? Eighty-seven percent (87%) of the podiatrists who answered the survey in PM News stated concerning a professional degree they wanted the option of having a DO degree to practice podiatry or at least have the option of choosing podiatry as physicians with a DO degree. Only 13% said...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
09/27/2025
RESPONSES/COMMENTS (THE FUTURE OF PODIATRY)
RE: A Short Allegory Chapter 2
From: Rod Tomczak, DPM, MD, EdD
Steve Winans was the de facto leader of the unofficial group that sat around the pot belly stoves at the seed store dropping peanuts in their Cokes or Dr. Peppers. He was up every morning before dawn and worked tirelessly all day. He found work where there wasn’t any work. He learned these characteristics from his dad who was the same way. The thing about Steve was that he had more than a touch of big city in him, something the other farmers didn’t have, and he saw things in a way the other farmers of Agronomy’s Best (AB) didn’t see them. If he hadn’t been born and raised in AB, you would have sworn he was placed in AB, Iowa by Witness Protection. He was the only guy who could tell you how to sink a large yacht in the middle of Iowa.
Greg Samsa, on the other hand, very smooth in his hand tailored suits and ostrich non-work boots was the elected chairman of the Agronomy’s Best Fine Arts Commission, (ABFAC) by the other members of the Commission. They did make all the important decisions for AB. The population of AB didn’t want to be...
Editor's note: Dr. Tomczak's extended-length letter can be read here. Chapter 1 can be read here.
09/25/2025
RESPONSES/COMMENTS (THE FUTURE OF PODIATRY)
From: Kim G. Gauntt, DPM, MS
Excellent story! How may I ask, could it have hurt, to have the APMA “leadership” actually sit down and discuss the recent query about a different path for our residencies to be legitimized than what we have now. What is it that we don’t know? Why, on such an important topic, was the membership at large not invited to discuss before a decision was made? Loss of autonomy, really?
Was it not, just the week before, that our same APMA president was publishing a rebuttal letter to the orthopedic group who sorely misrepresented podiatry and our training in a public forum?
Would it not be much more difficult to deny our training if our programs were recognized by the same body as theirs? Just asking.
Kim G. Gauntt, DPM, MS, Hillsboro, OR
09/23/2025
RESPONSES/COMMENTS (THE FUTURE OF PODIATRY)
RE: A Short Allegory - Chapter 1
From: Rod Tomczak, DPM, MD, EdD
There is a town in Iowa called Agronomy’s Best, or AB for short. It’s called that because the soil in AB is the richest in Iowa, if not the whole USA, based on per acre production and value of the crop. Besides that, during the winter of 1954, the farmers were at the feed store sitting around the three pot-bellied stoves dropping peanuts in their soft drinks and complaining about government oversight, the cost of farm equipment, seeds, fertilizer, and low reimbursement for soy beans and corn.
The group came up with an investment idea. The town was going to purchase all the TV shows they had become fond of. They obtained the rights to the I Love Lucy Show, The Adventures of Ozzie and Harriet, a number of soap operas, a show called The 20th Century, Leave it to Beaver, and the like, and all in perpetuity. The town of AB sold rights to some other small towns to show the programs on a limited basis, and made a lot of money. Well, the town built a library, a museum, a concert center, an athletic facility with a pool for the town, subsidized the newspaper called the AB News by advertising their...
Editor's note: Dr. Tomczak' extended-length letter can be read here.
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
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