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05/15/2024
RESPONSES/COMMENTS (NON-CLINICAL)
From: Ivar Roth, DPM, MPH
After reading Dr. Kornfeld’s response, I can again add some context to why my income dropped for such a long time. As a rare third-year residency-trained podiatrist back when I went full direct pay, my practice was mostly surgical. When patients called, they were not ready to pay out-of-pocket for surgery, and so my income took a major hit. The good thing was I had saved up for this transition. I agree with Dr. Kornfeld that the transition, if properly planned, can be shorter but as the original direct pay podiatrist, I had no guidance on how to make the transition.
I do remember calling Dr. Kornfeld and asking him how he was doing, and I remember that he was off private insurance companies but still taking Medicare, so that may be a way to transition; but I had decided to go for it and delisted/ opted out from Medicare completely. I still maintain that this type of practice is only cut out for those relatively few podiatrists who have the full spectrum of skills required to go direct pay and have the full love of our profession at heart. This type of practice requires diligence and hard work above and beyond the typical practice.
Ivar E. Roth DPM, MPH, Newport Beach, CA
Other messages in this thread:
07/01/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: Observations on the Changing Face of Medicine
From: Elliot Udell, DPM
I have a patient who is a soon-to-be retired psychiatrist. Whenever he would come into the office, we would have discussions on many topics not related to psychiatry or podiatry. He was very well aware of all facets of general medicine. If I asked this physician a medical question, he knew the answer. He later told me that he works one day a week in the ER doing emergency medicine and this helps him keep up with the entire medical field. In another case, my former GI specialist who just retired was able to comment with interest and expertise on any medical issue aside from the GI system.
I am now faced with seeing a whole new battery of young specialists in different fields and if I ask them a question outside their specialty, their answer tends to be, "It's not my field, go to an appropriate specialist." I am seeing more and more of this happening and some of these doctors are board certified in internal medicine and if the question does not directly relate to their subspecialty, the wall in the room can give me a better answer.
As a podiatrist, this may be good. We are specialized and only responsible for the foot, and so many other young specialists seem to have developed amnesia to all aspects of medicine other than their own narrow specialties. Perhaps the degree given to these physicians should not be an MD or DO but for example, "doctor of orthopedics or doctor of oncology, etc. Being a doctor of medicine is becoming less and less relevant in today’s practice.
Elliot Udell, DPM, Hicksville, NY
07/01/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Has APMA Appointed Future Action Strategists?
From: Lawrence Rubin, DPM
At all times, healthcare professional organizations responsible for public outreach and relations usually have appointed future actions strategists. These qualified persons constantly monitor the standing its members have in changing aspects within the healthcare marketplace, including any significant changes in reimbursement issues.
I have been a member of APMA since 1958, and I am hoping that the APMA has done now what it has done in the past by appointing qualified strategists during these rapidly changing times (such as was done prior to change of the name of the profession from chiropody to podiatry). If it has, these strategists are realizing that the quickly advancing Medicare spearheaded transition from fee-for-service reimbursement to value-based care (VBC) is already devaluing payment for elective, "non-life threatening” surgery, and it is increasing the reimbursement value of prevention and chronic disease management E/M services. In podiatric medicine, chronic diseases include, but are not limited to diabetes peripheral neuropathy (DPN) and peripheral artery disease (PAD).
I am concerned about this because recent board certification discussions that appear to ultimately put, "most of all of podiatry's eggs in one surgery basket" could, to say the least, be counterproductive for the profession of podiatry.
Lawrence Rubin, DPM, Las Vegas, NV
06/28/2024
RESPONSES/COMMENTS (NON-CLINICAL)
From: Dominic Bianco
The title of “Dr.” signifies a person’s capability for analytical thinking and problem-solving, beyond just the academic qualifications displayed on a wall. No doctor, whether a brain surgeon or a dentist, should look down upon podiatrists or any other medical professionals. Considering there are approximately 18,000 podiatrists compared to 250,000 dentists in North America, podiatrists face significantly less competition.
With a population of 579 million people in North America and only 18,000 podiatrists, it is clear that podiatrists are in high demand. However, many podiatrists do not reach their full potential due to various factors such as financial setbacks, personal challenges, or a lack of passion for their work. It is crucial for podiatrists to find their niche and make their practice work to the best of their ability.
Every podiatrist should feel proud and assured of their success, having achieved a level of brilliance that many, including myself, deeply admire.
Dominic Bianco, CEO, Bianco Instruments LLC
06/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: A Rose by Any Other Name…
From: Rod Tomczak, DPM, MD, EdD
I hope all who read the letter by ACFAS and APMA have also looked at the history of the resolutions and position papers. It seems that in 2020 someone came up with the idea that if students of podiatric medicine could pass USMLE, they should be classified as physicians.
Out of the right side of their mouths, the MD officials are pushing our students to take the USMLE, and out of the left side, they are saying MD and DO passers of the USMLE can call themselves “physicians.” What seems very odd is that DOs can still take their COMLEX exam and be licensed as physicians.
This whole ploy is the biggest example of obfuscation I have ever seen. AOFAS would rather partner with Reiki practitioners than...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
06/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Podiatrists Self-Identifying as" Dr." or "Physician"
From: Carl Solomon DPM
Putting aside the discussion of whether or not podiatrists are physicians, I’d like to express some thoughts about how we address ourselves in that context. I can hardly recall an instance in which one of my MD/DO friends addressed him/herself as “physician”. When asked, or introduced, it’s “I’m an oncologist, orthopedist, rheumatologist, general surgeon…”, whatever. My dentist friends aren't too proud to be identified as a dentist...perhaps when appropriate, oral surgeon. Not physician.
And when I see the use of the term “Dr.” written in front of somebody’s name without other explanation, almost without exception, that’s a de facto acknowledgement that “I am not an MD”. This was personified on the sign-in sheet at one of my hospitals’ Dept. of surgery meetings. Everyone signed in simply with their name, with the exception of two, each of whom signed “Dr. Xxxxx”. You can guess…
A podiatrist may achieve some level of recognition by assigning him/herself the title of "Dr." or "physician", and the inference is that it represents being an MD. But oftentimes once the details come out, the concealment of the identity as a podiatrist makes it apparent that there is a low level of self-esteem associated with such identity. So whatever special recognition may have been achieved by initially identifying as a Dr. or physician, is actually negated. On the other hand, if one is humble and is acknowledged by another party as being a doctor…podiatrist, the level of recognition will remain high. If you can’t take pride in being a podiatrist, you should have spent the time and effort doing something else!
Carl Solomon, DPM, Dallas, TX
06/26/2024
RESPONSES/COMMENTS (NON-CLINICAL)
From: Stefan Feldman, DPM
I wholeheartedly agree with Dr. Ribotsky about forming a cancer registry for podiatrists. I too, am a cancer survivor, finding out I have lung cancer following my retirement after 41 years of practice. I am a lifelong non-smoker and can only guess what the source of my cancer is, but I think of all the carcinogens I was exposed to during my working days. My advice to younger practitioners is to protect yourself from radiation exposure and assure the air quality in your environment is as free of carcinogens as possible. Check your homes and offices for radon, considered the leading cause of lung cancer in non-smokers, and also consider having a low dose CT screening scan of your lungs if over 50 years old.
Stefan Feldman, DPM, Spring Hill, TN
06/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) -PART 2B
Dr. Ribotsky brings up an excellent point about developing a cancer registry within our profession. What becomes very concerning to me is the point he brings up about the dangers of podiatrists and their assistants breathing in nail dust, a known carcinogen. With all the OSHA regulations medical practices must adhere to, regulations regarding inhalation of dangerous nail dust does not seem to be a concern of OSHA.
I've been manufacturing and selling a nail dust extractor system for many years and I cannot begin to tell you the frustration I have when I see the infinite regulations physicians must adhere to while the nail dust produced by one of the most common procedures podiatrists do is not addressed. I have sold many vacuum units throughout the years but would conservatively estimate that 80-90% of podiatry practices doing routine podiatry do not incorporate nail dust extraction systems.
Dr. Ribotsky brings up an excellent idea about forming a cancer registry. Unfortunately, it may be an uphill battle when governmental agencies such as OSHA make demands on offices that are borderline ridiculous, while known airborne carcinogens such as nail dust go completely unregulated.
Jack Ressler, DPM, Boca Raton, FL
06/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: AI and Podiatry
From: Lawrence Rubin, DPM
As podiatry board certification matters are bringing the profession closer and closer to there being mainly surgery limited practices, we'd better figure out a way to combat present and future bad AI public information. Let's say a footsore person gives AI this question: "Where can I go to get this big, red, sore bunion taken care of?"
It surely will not be to the benefit of the patient or podiatric surgeon for the AI answer to be, "Go to the Walgreens store nearest you. Ask the pharmacist where you can find bunion shields to reduce pain and inflammation caused by shoes and also Tylenol for bouts of intense pain." Forewarned Is Forearmed. We have to prepare ourselves to deal with AI. It’s good to see that APMA will have a lecture on AI at its August meeting.
Lawrence Rubin, DPM, Las Vegas, NV
06/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Elliot Udell, DPM
Kudos to Dr. Ribotsky for suggesting that there be some way of tracking podiatrists diagnosed with some form of cancer. As a cancer patient in remission, this issue is very close to me.
The medical community is grappling with another issue. Patients with breast and colon cancer are now presenting at very young ages. One patient of mine had his first colonoscopy at age forty and discovered that he had stage four colon cancer. Another young woman in her thirties is undergoing treatment for breast cancer. Are these caused by unidentified carcinogens or are people discovering these conditions earlier in life because of testing and awareness?
Elliot Udell, DPM, Hicksville, NY
06/24/2024
RESPONSES/COMMENTS (NON-CLINICAL)
RE: Podiatric Cancer Registry
From: Bret M. Ribotsky, DPM
It seems that a week does not go by when I don’t hear of another colleague coming down with some type of cancer. I first wrote about this over 10 years ago on this forum asking APMA to develop a registry just to keep track of podiatrists who have come down with this awful disease. Wouldn’t it be great if we could draw some correlations to find out maybe something that our profession is exposed to is causing problems? Why would our organization not do this?
If it’s determined that chronic exposure to nail dust is carcinogenic, wouldn’t that be something that all providers should be aware of? I’m old enough to remember that Rohadur (a thermal plastic) has a correlation with testicular cancer among podiatrists. This is something that was identified approximately 40 years ago and since those days, the use of that material for biomechanical orthotics was discontinued. I believe we all need to start acquiring data so that correlations can be drawn into the future. Let’s all be safe.
Bret M. Ribotsky, DPM, Ft. Lauderdale, FL
06/21/2024
RESPONSES/COMMENTS (NON-CLINICAL)
From: Allen Jacobs, DPM
I suggest that PM News readers read this discussion examining the role of profit-making in medicine.
Allen Jacobs, DPM, St. Louis, MO
06/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: Tom Brady’s Formula for Success (Allen Jacobs, DPM)
From: Jeffrey Trantalis, DPM
During my residency, I was taught, “if you do good honest work, the patients and income will follow.” Too many practitioners practice for only the short-term and instant financial gain.
Jeffrey Trantalis, DPM, Del/ray Beach, FL
06/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: Allen Jacobs, DPM
I suggest this article for all PM News readers.
Allen Jacobs, DPM, St. Louis, MO
06/19/2024
RESPONSES/COMMENTS (NON-CLINICAL)
From: Jeffrey A. Ross, DPM, MD
I would like to echo Dr. Jacobs’ sentiments on Tom Brady's views on success.
I agree that we should all find a spiritual peace in treating our patients. We should make a commitment, strive for excellence, look for positive reinforcement from our patients, and be proud of the profession you chose, and hope that you can perform with this ethic for many years. It will make you a more successful and happier practitioner.
Jeffrey A. Ross, DPM, MD, Houston, TX
06/18/2024
RESPONSES/COMMENTS (NON-CLINICAL)
RE: Tom Brady’s Formula for Success
From: Allen Jacobs, DPM
Tom Brady made some comments at his induction ceremony into the Patriots’ football Hall of Fame which I believe summarize what it takes to be successful in podiatry practice. By successful, I do not necessarily mean financially wealthy, but successful in the truest spiritual sense of why you are a healthcare provider.
“To be successful at anything, the truth is you do not have to be special. You have to be what most people aren’t: consistent, determined, and willing to work for it. No shortcuts. If you look at all my teammates here tonight, it would be impossible to find better examples of men who embody that work ethic, integrity, purpose, determination, and discipline that it takes to be a champion in life. “
Allen Jacobs, DPM, St. Louis, MO
06/07/2024
RESPONSES/COMMENTS (NON-CLINICAL)
From: David Chung, DPM, Greg Cohen, DPM
I was recently able to get monocholoracetic acid from Lab Alley. It has worked well for verruca lesions.
David Chung, DPM, Forest Grove, OR
I have been purchasing monochloracetic acid and other chemicals from Delasco Dermatology Supplies for many years. They’re reliable and reasonably priced.
Greg Cohen, DPM, Brooklyn, NY
06/06/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Jack Ressler, DPM
Why pay someone thousands of dollars to evaluate your own practice when all they are going to do is look over your numbers without even making an in-person evaluation of your office? They will offer to come out and evaluate your practice but at an even higher price. You can save money up front and sign a contract with other companies that will charge you a percentage of your sale price but you are at their mercy and cannot control the extent at which they advertise your practice. Signing with one of these companies gives them complete control of the sale of your practice even if you find your own buyer. I doubt they will give you exclusions.
Who better to value your practice than yourself? It is you who know your patients, staff, physical office set-up, demographics, and numbers better than anyone. The valuation of your practice comes down to one simple thing and that is the number a potential buyer is willing to pay. When I sold my main practice in 2016, I advertised it in the classified section of this forum. I did all of the work myself and paid a very reasonable amount for advertising and...
Editor's note: Dr. Ressler's extended-length can be read here.
06/06/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Hal Ornstein, DPM
I highly recommend Mike Crosby, CPA of Provider Resources as a practice appraisal expert. He has performed this service for hundreds of podiatry practices and been doing this for many years. He is responsive, knowledgeable, and fair to all parties involved.
Hal Ornstein, DPM, Howell, NJ
05/22/2024
RESPONSES/COMMENTS (NON-CLINICAL)
RE: The Future of Podiatry (Alan Sherman, DPM)
From: Elliot Udell, DPM
Dr. Sherman is correct. Concierge medicine is a great business model for internists. One of my patients asked me for advice on this matter. His internist's practice was being flipped into a concierge practice and sought my advice on what to do. I went over the list of meds and conditions that this doctor was treating him for. It was extensive and he was happy with the way the doctor was managing all of his complex medical issues. My advice to him was to stay with the doctor if he could afford the 2k a year.
My own internist went into concierge. In my case, I only saw him for check-ups and most of my medical visits, at that time in my life, were to my allergist. Even today, most of my visits are to specialists. In my case, it did not pay and I easily found a substitute internist. To make matters worse, my medical insurance did not recognize concierge practices and I would have to pay cash for each visit in addition to the 2k annual fee.
The bottom line is that concierge medicine is working well for the internists involved but may or may not be workable for every patient.
Elliot Udell, DPM, Hicksville, NY
Editor's Note: This topic is now closed.
05/21/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Alan Sherman, DPM
A correction is needed in the Elliot Udell comment on concierge practices. I'm sure it was just a typo. The concierge doctor that is charging the $2,000 annual fee to 1,000 patients is making $2,000,000 before submitting their first insurance claim, not $200,000. Concierge practice magnificently improves the business model for running an internal medicine practice. It's brilliant.
Most limit their practices to no more than 600 patients ($1,200,000) so that they can provide good high quality service to them all. Here in Boca Raton, Florida, it has gotten hard to find an internist who is not concierge. This was all a solution for and a reaction to the poor service that high volume internists were generally delivering to patients before the concierge model evolved.
Alan Sherman, DPM, Boca Raton, FL
05/21/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Robert Kornfeld, DPM
I think it is really unfortunate that Dr. Gottlieb quotes a book written by an economist/psychologist who characterizes self-employment vs. employment in an overly-generalized way. This does nothing to honor or include the reality that every direct-pay doctor that I know is really happy since leaving insurance-slavery or corporate employment. I would think with all of our collective intelligence that we podiatrists would stop cowering in our boots and stand up like adults for our professional experience. At some point, you need to dismiss the naysayers, who only see things from a negative lens.
As adults, we possess the power of choice. With intention, commitment and consistency, anyone who wishes to succeed in a direct-pay model will succeed. Dr. Gottlieb, it isn't fair to many of our colleagues out there who are miserable and read a post like this causing them to give up hope of achieving success and happiness outside of a system that exploits and abuses them. It feeds into fear and insecurity and has no place in these kinds of discussions.
I find it interesting as well as disturbing that not a single one of the naysayers here took the time to ask me or Dr. Roth exactly how we created successful practices and I'm certain they spent no time investigating the option. Dismissal comes from small-minded thinking. Success comes from an open mind, self-esteem, and an ability to shut out all the rhetoric of those who are too afraid to stand up to the monster that the system has become.
Robert Kornfeld, DPM, NY, NY
05/21/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Podiatry/Chiropody and Surgery
From: H. David Gottlieb, DPM
Surgery has been part of podiatry's DNA since its founding. While looking through some old pictures, I found some I took of my uncle's 1933 graduation picture from the Illinois College of Chiropody and Surgery. l am happy to share this picture if anyone needs confirmation that Surgery was part of the College's name and our profession's scope. Additionally, if you review back issues of Chiropody Reports or its defunct successor Podiatry Reports, you will also find many articles regarding surgical procedures of the foot. They may not be talar-calcaneal fusions, etc., but surgery has been a part of the average chiropody/podiatry practice from the beginning.
The concept of pay at time of treatment is also not new. Back then, medicine of all types was cash only. My father, who joined his brother's practice in 1943, has related to me that he would co-sign bank loans for his surgical patients. He rarely if ever had a default since the patients were so grateful that their pain was gone.
What's old is again new. I believe that medicine and surgery in the U.S. should be practiced along the model created by the Veterans' Health Administration. Call it the Civilians' Health Administration, dispense with the insurance companies as well as all other government-run health entities. Pay us a fair salary, reasonable working hours, evidence-based treatment protocols. Cash-only could still exist and even thrive for those with the knack for it.
H. David Gottlieb, DPM, Baltimore, MD
05/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) -PART 3B
From: Steven E Tager, 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...
Editor's note: Dr. Tager's extended-length letter can be read here.
05/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) -PART 2
RE: Podiatrists as Gatekeepers
From: Daniel Chaskin, DPM
Some internists perform physical evaluations including ordering and interpreting blood tests. If a systemic disease is found, an internist can refer to a cardiologist, nephrologist, or appropriate specialist. The internist can be sort of like a gatekeeper who refers. Podiatrists can do the same regarding any systemic disease with podiatric findings such as foot edema, brittle toenails, etc.
Daniel Chaskin, DPM, Ridgewood, NY
05/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Employed vs. Self-Employed Doctors
From: H. David Gottlieb, DPM
I recommend everyone reading this to also read a fascinating book by the Nobel Prize winner in economics - author Daniel Kahneman. The book is called Thinking, Fast and Slow.
There is a relevant passage regarding the statistical likelihood of financial success, a topic currently being debated here. I quote from page 257: "More generally, the financial benefits of self-employment are mediocre: given the same qualifications, people achieve higher average returns by selling their skills to employers than by setting out on their own. The evidence suggests that optimism is widespread, stubborn, and costly."
One should keep this in mind before setting out on their own.
H. David Gottlieb, DPM, Baltimore, MD
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