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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
Other messages in this thread:
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
06/25/2024
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
06/20/2024
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
06/06/2024
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
05/21/2024
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 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
05/17/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Is the Limited License of Podiatric Physicians Costing the Healthcare System More Money?
From: Bret Ribotsky, DPM
I had an opportunity this week to attend a pharmaceutical-sponsored county podiatric meeting here in South Florida, and the speaker was from out of state, a well known expert, discussing wound care grafts to apply. The lecture showed multiple pictures of completely or almost completely granulated wound beds to which they were applying a placenta graft tissue weekly at $2,500 per application, up to a total of $25,000 per application. When I queried why not just put a split-thickness skin graft over this wound, I learned that it was not within the podiatric license in the state in which this person practiced.
This got me thinking, is our limited license actually costing the system more money because of the inability to apply all the best medical practices by limitations of licensing? I know that while I practiced, I often would apply a split-thickness skin graft on a fully granulated wound bed. I was quite happy with then using additional products as needed, if necessary, What do others think about using these expensive grafts where the company makes all the money and the doctors do not?
Bret Ribotsky, DPM, Fort Lauderdale, FL
05/10/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Richard M. Maleski, DPM, RPh
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 healthcare 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 have done everything possible to keep ourselves included. And by being included in this payment model, we have been able to expand our status within...
Editor's note: Dr. Maleski's extended-letter can be read here.
05/07/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Kathleen Neuhoff, DPM
It is unfortunate that local providers turfed their patients to Dr. Tomczak. However, in our area, this kind of turfing is rampant among those who accept insurance. Most of our local Latino population does not have insurance and many providers will not see them at all.
Ironically, when I accepted insurance, I was taken to task by the administration of our local hospital because I gave a significant discount to all religious leaders (rabbis, priests, ministers, nuns, etc.). I was advised that I was in violation of the contracts with my insurance carriers and had to “cease and desist”. Now that I have no contacts with insurance companies, I have restored these discounts. I also see large numbers of patients who have no insurance and am able to provide care for them at a cost they can afford.
Some of these patients are very sad. For example, Wednesday I saw a gentleman who had had an ingrown nail for months. He had been unable to find anyone to treat him until the local” free” clinic sent him to me. He is an uncontrolled diabetic and had osteomyelitis of the entire distal and part of the proximal phalanx. I had him admitted to the hospital which will end up eating the cost, and I will probably need to amputate at least his hallux. We have failed this patient at a huge cost to him and to our healthcare system. I do not think this is an issue of self-pay vs. insurance providers. It is a loss of the patient care mentality which should guide all of us.
Kathleen Neuhoff, DPM, South Bend, IN
05/07/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Greg Amarantos, DPM
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...
Editor's note: Dr. Amarantos' extended-length letter can be read here.
04/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: The Future of Podiatry
From: Allen M. Jacobs, DPM
A recent article published in KevinMD.com, written by a St. Louis plastic surgeon, Dr. Samer Cabbabe, caught my attention. I 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...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
04/09/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: Edward S. Orman, DPM
I have also used Quick Books for about 30 years. Initially, it was 3-5 years before I had to get a new version. Over the years, the price more than doubled. In 2023, I looked into QB online and ended up purchasing that. I thought I was saving money but was lied to multiple times about the cost. It ended up being more expensive. It's a completely different program, which I didn’t like, with a steep learning curve. I eventually went back to QB desktop. These companies are pigs and don’t care about their clients.
Edward S. Orman, DPM, Perry Hall, MD
04/09/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Richard Rettig, DPM, Kim Antol
Quicken is a great product, and the most expensive version is $5.50 per month first year, then about $120 per year. Since you are outsourcing payroll (good idea), you never needed Quickbooks in the first place. Unfortunately, you cannot convert your Quickbook files to Quicken.
Richard Rettig, DPM, Philadelphia, PA
If all you need is a simple program to print checks....Quicken should do the trick for under $100. Not subscribing to online versions and options will save you from annual fees.
Kim Antol, President, Sigma Digital X-Ray
04/09/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Jeff Root
You might want to consider using Quicken Classic Business and Personal if your accounting needs are fairly basic as you suggest. I believe the annual subscription fee is around $120 and costs about half that for the first year. You can set up custom income and expense categories and run income and expense reports that should satisfy your basic accounting needs. You might even be able to import some of your historical data from Quickbooks but you should check with Quicken or Quickbooks support about that first. I have been using Quicken for my personal accounting needs since the 1980s and used Quickbooks for business purposes for many years. I have been very satisfied with Quicken and they have excellent customer support.
Jeff Root, President, KevinRoot Medical
03/29/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Ivar E. Roth, DPM, MPH
As I have mentioned before, I agonized for quite a while if I should charge a credit card fee. I have been doing so for the last 6 months with very little opposition.
For the few patients who complain, I usually just waive the fee to make them happy. In the end, I am saving tens of thousands of dollars per year which is a nice bonus.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
03/29/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Connie Lee Bills, DPM
We started this about a month ago. Patients are more likely to pay cash or check when faced with a 3.5% fee. My optometrist started it about two months ago and spurred me to follow suit.
I checked with the local credit union and they said HSA cards can be used for the fees as long as they are from a healthcare registered facility. Everyone should be doing this.
Connie Lee Bills, DPM, Mount Pleasant, MI
03/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: The Value of Podiatric Biomechanics
From: Jeffrey Trantalis, DPM
As podiatrists, we appreciate the skills involved in providing non-surgical options. For example, a large majority of my patients were Boeing workers who stood hours on their feet. A majority were treated with conservative care using biomechanics, an area which most podiatrists understand and appreciate. We are able to treat symptoms from the foot to the lower back. I worked for a back surgeon, and after a year he fired me because I was helping his patients that he wanted to do surgery on. This said a lot about the benefits of biomechanics. The sad and unfortunate consequence is these patients will not likely walk into your office.
While a student at ICPM, I personally benefited after being diagnosed with a pelvic rotation and a relative limb-length difference. This allowed me (with lift and orthotic therapy) to successfully be able to run 4-5 miles a day to improve my health. As podiatrists, we are more than just surgeons. We provide a lower extremity alternative. Another area is young women with femoral anteversion. Many women would otherwise have to undergo surgery, but with orthotics can lead a very athletic and productive life. The difficulty for podiatrists is that a lower back patient is less likely to walk into your office. That is the proverbial $64,000 question. I feel that as podiatrists we can offer much more to our patients.
Jeffrey Trantalis, DPM, Delray Beach, FL
03/06/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Michael Uro, DPM
I just read Dr. Rod Tomczak’s response to “A Short History of Podiatric Discontent and Frustration”. I whole-heartedly agree with all he had to say. I have enjoyed practicing podiatry for 45 years. I was fortunate enough to have enjoyed the era before managed care...a time when we were paid 2/3s more for surgery than we are today. The reimbursements for surgery today are an insult to the training, experience, and risks that podiatric surgeons take every time they walk into an operating room.
When I came to Sacramento, I was welcomed by the podiatric, MD, and DO communities. I am grateful to those mentors such as Mitch Mosher, DPM, Larry Gerelli, DPM, Randy Sarte, DPM, and...
Editor's note: Dr. Uro's extended-length letter can be read here.
03/06/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Robert Scott Steinberg, DPM
"A significant portion of the older podiatric profession are the notional progeny of chiropodists. For many of us, the first exposure to our future profession was afforded by individuals with the letters DSC behind their names." - Tomczak
I highly doubt your statement to be true. Where did you get your statistics? I do not believe there are many 80+ year-old practicing DPMs in any leadership roles in their state or the APMA. If there were, things would not be so messed up!
Robert Scott Steinberg, DPM, Schaumburg, IL
03/04/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Change Clearinghouse Cyberattacks
From: Ben Pearl, DPM
Recent delays in insurance payments due to the Change Clearinghouse cyberattacks have created a strain for physicians’ practices that rely solely on insurance payments for revenue. As of late this week, it is unclear when this national issue affecting physicians will be resolved.
Hopefully, the insurance glitch will be short-lived. It helps to have strategies to counterbalance the delay in cash flow if it continues.
Ben Pearl, DPM, Arlington, VA
02/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 B
From: Lawrence Rubin, DPM
I agree with Dr. Steinberg. From what I have observed and have been told, the curriculum in our schools has not kept up to the standards for today's podiatric physicians and surgeons to become successful in practice. A glaring, practical example applies to information that pertains to a podiatrist's personal financial success. It is my understanding that there is little if any classroom content on practice management and "The Business of Podiatry."
I don't find this surprising. Having been a podiatrist for 66 years, I have observed a long-time reluctance of our schools to include practice management and podiatric medical economics educational curricula. For example, right now, our entire healthcare reimbursement system is dramatically changing from a fee-for-service model to a value-based care model. In fact, in a recent issue of APMA News, there was a very informative article advocating podiatric practices transition from fee-for-service to value-based care.
I doubt whether current podiatry students are being informed that their future insurance reimbursement for spending an hour of preventive services, providing chronic care management (CCM) for a patient who suffers from lower extremity conditions such as diabetic peripheral neuropathy and peripheral artery disease. This already surpasses what they can earn in an hour for providing most surgical procedures that include post-operative care. Knowing this might influence a student to not become financially dependent upon providing major surgical procedures, especially if they are elective. Or, maybe even go, “Direct Care” and not accept anything other than cash payment. Who would deny that, forewarned is forearmed? Our students deserve to be better prepared for the future.
Lawrence Rubin, DPM, Las Vegas, NV
02/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 A
From: John Mozena, DPM
Dr. Daniel Jones brings up a great point! Maybe it’s time to revisit the idea of our specialty being absorbed by osteopathy or the allopathic schools. Is there really that much difference in our training these days? With so many medical and osteopathic schools, I’m sure there is room for our students and their money.
John Mozena, DPM, Portland, OR
02/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 C
From: Daniel Jones, DPM
If there is one thing that schools are good at, it's taking money. With the federal government fully subsidizing all education at ANY cost, there is no incentive for schools to consolidate. And if you already have an MD or DO school set up, why not cast a larger net to get more money?
Perhaps the conversation with applicants goes something like this, "Oh, I'm sorry, you didn't have good enough grades to get into our medical program. Why not apply to our DPM program? You can be a foot and ankle surgeon! By the way, that will be 60,000 dollars a year for the next 4 years."
Who wouldn't start a program? 90% of the classes are the same. You only need to hire one or two podiatry professors and use the existing machinery already set up for your med students, and your med school now makes an extra million a year. Until CPME denies new schools from popping up, the number will continue to grow. Would that be a restraint of trade violation? Probably. So we will keep adding more schools as numbers of applicants dwindle to a point it's no longer sustainable, and podiatry gets absorbed by the allopathic and osteopathic professions.
Daniel Jones, DPM, Casper, WY
02/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1 B
From: Narmo L. Ortiz, Jr., DPM
According to an article published on March 27, 2023, in collegiategateway.com, "the latest figures put overall medical school enrollment at 96,520, an almost 18% increase over the past decade. This surge has been made possible by increasing class sizes, the opening of more medical schools, and government intervention to add Medicare-supported graduate medical education positions, and is a welcome response to the projected shortage of physicians in the coming years."
While those statistics apply only to MD schools, on the March 21, 2023 informational article on tiberhealth.com, "There are very few podiatry schools. According to the American Association of Colleges of Podiatric Medicine (AACPM), there are only 11 DPM programs in the U.S. as of 2023. As a result, the overall number of applicants is lower than those who apply to MD programs. The AACPM reports that there were just 910 applicants to DPM programs in 2021, a tiny fraction of the 62,443 people who applied to MD programs that year."
So, it still begs the question to ask what is our profession, the APMA, and all of the other podiatric professional organizations doing to increase awareness to the public, colleges, and universities on the career of podiatric medicine and surgery in order to increase the number of applicants?
Narmo L. Ortiz, Jr., DPM, Davenport, FL
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