07/02/2024    Keith L. Gurnick, DPM

RE: Victory! AMA Removes Offensive Social Media Post

When will our national and state associations bring
us real victories? I preface this post as a 42
year dues paying member of the APMA, California
Podiatric Medical Association and Los Angeles
County Podiatry Association. It is always good news
when our associations fight for us and win the
battles to right the wrongs. Quick action to
eliminate the AMA's irresponsible, inaccurate and
defamatory social media hit piece against our
profession should be commended.

The CPMA recently was victorious against Blue
Shield who was planning to cut allowable payment by
50% for an E/M or consultation when billed
at the same encounter (same date of service) as a
minor procedure. These are two recent actions
successfully undertaken where we prevailed. But is
not losing the same as winning? We all know there
have been tremendous gains for our profession made
in the past. Isn't it time, now to try for more
gains for our membership, in addition to putting
out these irritating forest fires one at a time.

When will these same associations really step up,
and get tough and fight for our membership and get
us some additional progress and gains?

Hospitals are trying to reduce podiatrists’
privileges at a time when we should be fighting to
expand them. Insurances are getting away with
reducing payments (with take it or leave it
contracts) for services that are
so low I do not know how young and other private
practice podiatrists can make a profit after paying
all the bills we are bombarded with every single
day.

Bunion surgery payments of $350-$700 with a 90 day-
global. Blue Cross in Los Angeles allows $77 for a
"real" toenail avulsion and then has the audacity
to send out a "fishing" letter to educate
podiatrists about what is and what is not a 11730
or a 11750. We need to get higher reimbursements
for what we do to stay in business and to be able
to pay our bills. I just did an osteochondroma
excision on an 11 year old girl and was allowed
$308 by Aetna.

Why are custom foot orthotics not a Medicare
covered service, a service we provide that is
certainly medically necessary in our aging Medicare
population? They pay for a walker boot or a night
splint or a drop foot brace when needed, why not a
foot orthotics?

Keith L. Gurnick, DPM, Los Angeles, CA

Other messages in this thread:

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07/04/2024    Daniel Chaskin, DPM

RE: Victory! AMA Removes Offensive Social Media Post (Allen Jacobs, DPM_

I have a difference of opinion than Allen Jacobs,
DPM

1. Podiatric Medicine mandates knowledge beyond the
foot. Podiatrists who specialize in Podiatric
Medicine act as gatekeepers similar to internists
so long as physical evaluations are in conjunction
with the provision of podiatric treatment. Both an
internist and podiatrist can treat a foot
condition, find the underlying cause of this foot
condition and make a referral to the correct
specialist to treat the underlying systemic cause.

2. The way medicine is practiced today is not in
the best interest of patients. Podiatrists should
have knowledge beyond their own specialty. For
example, a podiatrist could serve as a primary
point of contact for individuals with kidney
problems. For example, a podiatrist might order
renal function tests to check kidney function.
Kidney issues could be the underlying cause of
toenail conditions, swollen feet, etc.... The
podiatrist can then decide if it's necessary to
refer the patient directly to a nephrologist or a
different specialist.

3. If a patient's foot symptoms suggest possible
heart failure, a podiatrist can arrange for an
electrocardiogram (EKG) and blood tests to see if a
cardiologist should be consulted.

4. It's important to note that not every patient
will have a medical doctor (MD) to refer them to.
Moreover, if a podiatrist needs to refer the
patient to the correct specialist, it might be
beneficial for the podiatrist to first conduct all
the necessary tests to accurately diagnose the
systemic causes of foot symptoms. The patient
receives the most appropriate care and is referred
to the right specialist. This is one major reason
why a podiatrist should have knowledge beyond the
foot.

5. The APMA should advertise podiatrists as being
in a position of a gatekeeper with knowledge beyond
the foot.

Daniel Chaskin, DPM, Ridgewood, NY

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07/03/2024    Allen Jacobs, DPM

RE: Victory! AMA Removes Offensive Social Media Post (Robert Steinberg, DPM)

Quite some years ago, I served as the scientific
chairman, assisted by Ray Esper DPM, for the APMA
scientific meeting for three years (Disney,
California, Las Vegas, and Boston). At that time,
the scientific meeting was held concurrently with
the House of Delegates. At the Las Vegas meeting, I
had invited a number of nationally respected
medical school faculty members to lecture. I was
rather upset at the fact that it seemed to me that
the House of Delegates was receiving priority over
my needs for the academic faculty. Although I did
not voice my concern, I was indeed upset about
this.

James Ganley was one of the individuals I had
invited to speak. With his usual insight, he sensed
that I was upset. He asked me to take a walk with
him through the exhibit hall. He asked me “Allen,
you any good at politics?”. I told Dr. Ganley
absolutely not. I have an inability to negotiate if
I feel someone is wrong and willfully
misrepresenting facts or willfully distorting
facts. Dr. Ganley looked at me and said “neither am
I“. He then said. “you know, neither one of us is
good at politics. But we do need politicians. We
need them to move the profession forward and to
protect the profession. We need good people to do
the things that you and I do not do.”

Ray Esper and I met with John George, who was
either APMA president or on the board of APMA at
that time. We spoke to the need to separate the
national scientific meeting from the House of
Delegates meeting. He agreed, and got the ball
rolling.

Recently, we have seen some increasing criticism of
the APMA by contributors to p.m. news. I must say
at the outset that I am in general agreement with
them. However, complaining does not solve the issue
of poor political representation by our national or
local organizations

Anyone who knows me well knows I am incapable of
participating in politics. However, I tell the
residents with whom I work that they must get
involved and change things. If you are
dissatisfied, then you must vote out your current
delegates. You must be more involved in your state
societies. You must demand action by the officers
and board members both locally and nationally or
you must take action and remove them. You must get
involved if you have the ability to do so. In the
“old days“ the APMA officers and presidents were
generally individuals academically accomplished,
who moved on to politics later in their life. They
had established bona fides. They were people like
Irv Kanat, Earl Kaplan, Dalton McGlamry, Arthur
Helfand. They were academics first and politicians
later.

We need good politicians. I agree that in the last
number of years we have had individual officers
with relatively little or no academic or
professional accomplishment. I personally believe
it is acceptable to be a full-time politician so
long as you do a good job of it, moving the
profession forward, academically and politically. I
agree with other writers they have failed in this
regard. I believe that the APMA has become somewhat
self-serving relegating the needs of our profession
second to their own personal political and
financial needs. Some of the concerns of our
membership are beyond the control of the APMA, and
are issues which confront all of medicine, just not
podiatry.( As an example, reduced payments for
services rendered, increasing pre-authorizations).
At the local level, as they say, all politics are
local. You need to take the time to get involved at
the state level. You need to hold your national
delegates accountable or remove them. You need to
hold your executive directors accountable or remove
them. If your seminars fail to provide you with the
education you require and fail to satisfy your
educational needs vote out the people who are
responsible for the construction and content of
these meetings. Get involved. The editor of PM
Magazine has told you this for years and it is
true. If you do not get involved, you do not have
the right to complain. hold people accountable. Dr.
Ganley said it best, we need good politicians.

Allen Jacobs, DPM, St. Louis, MO

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07/02/2024    Allen Jacobs, DPM

RE: Victory! AMA Removes Offensive Social Media Post

There is an old joke that goes something like this:
what is the difference between an internist, a
surgeon, a psychiatrist, and a pathologist? The
answer: an internist knows everything but does
nothing, a surgeon does everything but knows
nothing, a psychiatrist knows nothing and does
nothing, and a pathologist knows everything and
does everything, but it is too late.

It is difficult to believe that the AMA position
statement, obviously driven by AOFAS, will have any
significant impact on your practice. Your medical
colleagues who refer to you regularly are well
aware that you are not an MD. They are well aware
that you did not go to medical school. By virtue of
referrals of patients and trusting you with the
care of their patients, by action, they respect
your diagnostic and therapeutic abilities.
Otherwise, they would not refer their patients to
you.

This suggestion that we pursue legal action in my
opinion is unfounded and likely not supportable.
Much of what was stated in the AMA position,
whether you want to agree or disagree, was true.

I believe it was about 1968 or so when Bob Dylan
released the song “the times they are changing“.
Reference has been made to this relevant to
medicine in some of the correspondence to PM News.
Indeed, the times are changing. Osteopathic
physicians are become fully incorporated into
medicine. Physician assistants and nurse
practitioners have increasingly been increasingly
permitted to provide unsupervised diagnostic and
therapeutic interventions.

Years ago, when I was a residency director and
chairperson of a podiatry service at a relatively
large hospital in St. Louis, I served on the
credentials committee of that hospital. Controversy
arose when a local DO orthopedic surgeon who had a
successful sports medicine practice applied to our
hospital privileges. The MD orthopedic surgeons
were in an uproar. In some ways, I thought it was
ironic that here I was, a DPM with full privileges
at the hospital, supervising a fully integrated
residency program, and a DO with training which was
closer to that an MD than was mine was, being
subjected to this scrutiny. The chairman of the
committee was an Ivy League trained neurologist
complete with a bowtie. He pointed out to the
committee that the applicant had not graduated.
Medical school, did not pass standard medical
boards recognized by the MDs, did not complete an
MD recognized orthopedic residency, and had an
unrecognized certification in orthopedics. He was
opposed to the application.

I stupidly interjected my thoughts. I noted that
there were very qualified and some unqualified
doctors with all degrees, and that in my opinion
each individual should be evaluated by their
individual competency and experience and not by
degree. The chairman looked at me said “Jacobs, you
are a podiatrist. I understand that you are good at
what you are good at. But you are a technician.
Medicine is a learned academic profession “. The
osteopathic DO was denied privileges.

Personally, being an old guy 50 years in practice,
I do not believe that an MD degree is required to
provide exceptional care of foot and ankle
pathology. Someone needs to explain to me how
increased knowledge of spasmodic dysphonia will
improve my ability to perform a proper
bunionectomy. Someone needs to explain to me how
increased knowledge of cerebellar pontine angle
tumors will improve my ability to manage plantar
fasciitis. I would much rather future podiatrists
spend extra time learning about peripheral vascular
disease, rheumatic disorder manifestations of the
foot and ankle, lower extremity dermatological
disorders, than spending any time on an obstetrics
rotation or gastroenterology rotation.

The times they are indeed changing. Perhaps MD
model of education is the former gold standard. In
some ways, the podiatry education model is ideal
for its intended purposes. Education is intensely
focused on various diagnoses and treatments that
will constitute the actual practice of podiatry.

Several weeks ago, I happened to have two patients
admitted to the hospital in septic shock resulting
from diabetic foot infections. One of the patients
had multiple significant comorbid conditions. I was
called to treat the foot via incision and drainage
and eventual amputation. I was sitting in the
doctors’ lounge reviewing the chart and a first
year podiatry resident walked by. I grabbed him and
said let’s look at the chart together. I want to
make a point to you. We went over all the medical
notes by the various specialists. Each one stayed
in their own lane.

Then nephrology notes reflected fluid, and
electrolytes and renal function. Not a word about
anything else. Ditto infectious disease. The
pulmonary specialist made comments restricted to
pulmonary function. It went on and on and on. I do
not understand why you would expect, the podiatrist
to have extraordinary capability or knowledge
beyond their own specialty when it is clear that is
not a reflection of how medicine in today’s world
is practiced. Dr. Kesselman made the point
regarding “functional equivalence“ and that is in
fact the case. We are functionally equivalent to an
MD when it comes down to what it is we do and what
it is they do.

I had two patients this week that required below
the amputation. I consulted the orthopedic surgeon
for the amputations. And again I pointed out to the
chief resident the following: the orthopedic
surgeon said in his notes essentially when the
medical problems are stabilized call me, and I will
do the amputation. Not a word about any of the
medical problems. Nor was this required.

Some of the residents (not all) coming from the
three year programs today are extraordinarily well
trained, and I would put them up with any resident
in any medical specialty. They know what they do
not know, they know when to appropriately refer,
they are sensitive to the overall medical status of
these patients. They are indeed “functionally
equivalent“ to our MD colleagues.

As for the AMA, this will not affect your
relationships whatsoever. My first class at PCPM in
1969 was “introduction to Podiatry “. Dr. Jerome
Shapiro stated day one “Do not ever forget that MD
means my domain “.

Podiatry has come too far even during the 50 years
of my practice and observations, to go backwards.
That will not happen. You are now on hospital
staffs, you are at major teaching hospitals. Should
you choose to do so you can participate in
orthopedic groups, treat major trauma, and if so
inclined, participate in major reconstructive
surgical procedures. This is a reflection of the
competency which you have demonstrated. Practice
good medicine. Continue educating yourself daily.
Practice ethical medicine. No statement from the
AMA is going to reverse those referrals which you
receive so long as you follow these guidelines.

Allen Jacobs, DPM, St. Louis, MO