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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
Other messages in this thread:
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
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
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
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