11/18/2024    Joel Lang, DPM

My Surgical Experience as a Patient

I recently had an outpatient surgical procedure
under general anesthesia. While the procedure
itself went well and I have largely recovered, I
feel there are lessons I can share here regarding
this experience. I was told to show up early for
the procedure to complete about eight pages of
medical information forms and releases. So at a
time when I was most anxious about the procedure
itself, I had lots of forms to complete.

Between the time I was told in the office that the
procedure was necessary and the actual arrival at
the surgi-center for the procedure, I accumulated
several additional questions for the surgeon and
the anesthesiologist. Both were very busy with
their schedule at that time and had only limited
time to spend answering questions.

After completion of the procedure, while I was
groggy and lightheaded from the anesthesia, post
operative instructions (written and oral) were
given to my son (who is not a doctor) who
accompanied me. A prescription was electronically
sent to my local pharmacy to be picked up on the
way home, potentially delaying my return home.
Instead, I opted to go straight home. As a result,
my son had to make a separate trip to pick up my
prescription.

My follow=up appointment was given as part of my
post-op written instructions. There was no
opportunity for my input as per time and place. I
could not help but compare this procedure to my
procedure when I was in practice (now retired for
27 years). As further explanation, when in
practice, I was double board certified in foot and
ankle surgery and operated out of four different
hospitals. This was my procedure.

Except for simple nail and skin procedures
performed in the office, I always scheduled a
“pre-operative conference” with the patient days
before the procedure. It was there that the
patient filled out as much of the pre-op paperwork
as possible, including the surgical release form.
The procedure was described in appropriate detail
and all questions were answered in advance.

The patient was given written pre-op and post-op
instructions as well as a post-op prescription and
all were explained. Any questions were answered
at that time. The patient knew in advance what to
expect at surgery and afterward and had the
opportunity to get their medication in advance and
have it waiting at home for them after the
procedure.

Their post-op appointment was made at that time,
making it more convenient for the patient and
allowing them to arrange transportation in
advance.

This visit usually took about 20 minutes and was
included in the surgical fee and provided at no
additional cost.

After the procedure, a brief visit with the
patient was all that was necessary, indicating
that all went well (if it did) and what rare
complications were encountered, if any.

I believed that this showed the patient by word
and deed that my primary concern was for their
comfort and well-being. If this seems like too
much trouble, just know that in 37 years of
practice I never had a single mal-practice case,
despite a few really bad surgical outcomes.

I thought I would share this comparison with my
colleagues in the hope that some are inspired to
make their surgical patient encounters smoother
and beneficial for both parties.

Finally, I also had some unusual operating room
procedures that made the actual surgery more
efficient, take less time and made safer for the
patient. If anyone is interested, they can contact
me at langfinancial@verizon.net .

Joel Lang, DPM (retired), Cheverly, MD

Other messages in this thread:

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11/26/2024    Rod Tomczak, DPM, MD, EdD

My Surgical Experience as a Patient ( Ivar E. Roth, DPM, MPH)

We should all be thankful that Dr. Roth is an
enlightened member of the podiatric community who
is able to share with us what we shouldn't do, I
think. He has not been familiar with insurance
billing for some time, since he has converted to a
direct pay model, Somehow he is still an expert on
how the insurance panel members are unethical.
These providers are, after all, only interested in
making money. Dr. Roth has the ability to see into
a provider’s mind and discern their true
intentions without the use of phrenology, tea
leaves, or Tarot cards.

Unfortunately his psychic gifts do not extend to
today’s JBJS where a multicenter review of
orthopedic rehab modalities. Dextrose prolotherapy
has shown promise as a low-cost, efficacious, and
safe treatment for plantar fasciopathy. Either the
low-cost description was off-putting or the new
diagnosis of fasciopathy was strange and un-
recognizable.

This JBJS article also dedicates a significant
amount of ink to ESWT and its efficacy with the
addition of independent variables and their effect
on fascial thickness. Some physical medicine and
rehabilitation physicians seem to think these
modalities work. Unfortunately, these physicians
have not met our Dr. Roth, hero for the over-
billed but under satisfied patients. After all,
the patient in question made the mistake of seeing
another podiatrist. He is at fault for not
choosing Dr. Roth from the onset of his symptoms.
The common man-patient is so ill-informed.

I am somewhat distressed by the implications of
standard of care and gold standards when it comes
to evaluating a treating physician’s choice of
procedures and sequence of treatments along with
the changes in a plan. Does Dr. Roth hold himself
out as a gold standard expert, or a pay for
service expert? It would take a lot of chutzpa to
declare that any of the choices listed are below
the standard of care. Who is to decide when one
modality is unsuccessful and modify the treatment
plan to begin treatment with another? It seems Dr.
Roth is.

How long should one treatment be continued before
trying another modality which may be associated
with a remission of pain? And, can anyone
infallibly testify there is no lag time associated
with different treatments. Most rehabilitation
modalities do not work in minutes. After all,
hasn’t the literature concluded that plantar
fasciopathy is self-limited?

Rod Tomczak, DPM, MD, EdD, Columbus, OH

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11/22/2024    Charles Morelli, DPM

My Surgical Experience as a Patient (Ivar Roth, DPM, MPH)

Charles Morelli, DPM

I'd like to echo Dr. Roth's sentiment and
experience when it comes to the fact that "the
medical billing rip-off is rampant in medicine and
podiatry". Yes, every profession has their bad
actors, but sometimes you come across a with a
story that makes you shake your head. I'll try to
be brief.

A patient was seeing the same podiatrist every 6
weeks, for over 22 years. He was treating her for
a chronically ingrown nail, was cutting the corner
of her nail, charging her the $25.00 co-pay and I
imagine also billing her insurance carrier. She
called one day for an appointment and asked to be
seen as she was in pain, and felt it was an
emergency. According to the patient, no matter how
hard she pleaded, she could not be seen and this
angered her. She sought the services of another
podiatrist, and landed in my office.

When she presented with her problem of a painful
ingrown nail, she asked me if I could treat her
ingrown nail so she could feel better. I then
discussed other options with her and said that I
could do a procedure that could potentially make
this go away forever (chemical matrixectomy). She
looked at me as if I had three heads and was
amazed that this was even a possibility, as she
had never been given this option. I performed the
procedure. The patient was happy and I have never
seen her since.

As Dr. Roth said, "Unfortunately, this treatment
was about making money first and the patient last.
It is truly unbelievable that there are docs out
there ripping off not only the system, but their
patients, and making their patients suffer at the
expense of making an almighty dollar. Truly
listening to this patient made me disgusted about
the ethics of some of the younger doctors out
there in practice."

Let’s remove the word "younger" from Dr. Roth's
last sentence.

Charles Morelli, DPM, Mamaroneck, NY

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11/22/2024    Adam M Budny, DPM

My Surgical Experience as a Patient (Ivar E. Roth, DPM, MPH)

I read this post earlier today and quite honestly
I was perplexed, as I am one of the "insurance
podiatrists" who I believe represent the majority
of the profession, as opposed to a boutique/
direct pay" podiatrist (which seems to be Dr.
Roth's implied practice model?) I see nothing
wrong with billing a new patient visit or x-ray as
a diagnostic study.How else would a practice run
if you did not bill new/established visits of one
sort or another?

Specifically, in my experience and clinical
practice, stretching exercises are actually the
mainstay of management for plantar fasciitis and
all of my patients are given literature and HEP
for performing this at their initial visit.
Regarding shockwave therapy, this is also a well
accepted treatment option per the American College
of Foot and Ankle Surgeons Clinical Consensus
Document (Available at
https://www.acfas.org/research/clinical-consensus-
documents)

Specifically, regarding the treatments offered by
the podiatrist who saw this patient before you,
the panel reached consensus that the statements
for both stretching and extracorporeal shockwave
therapy (ESWT) are "safe and effective in the
treatment of plantar fasciitis” were appropriate.
Regarding Stretching from this document:

They found that "patients performing plantar
fascia-specific stretching exercises had superior
results in reducing the pain with their first step
in the morning and their highest level of pain.
Kamonseki et al (98) compared the effects of
stretching with and without muscle strengthening
of the foot alone or foot and hip on pain and
function in patients with plantar fasciitis. At 8
weeks, they found that all patients experienced
improvement in function and stability (98).
Equinus is quite common in patients with plantar
fasciitis; therefore, a strict stretching exercise
program will be beneficial."

Regarding ESWT from this document:
"A general observation across all studies was that
approximately 70% of patients with chronic or
subacute plantar fasciitis who underwent ESWT had
experienced meaningful improvement in their heel
pain at 12 weeks." And, "Because ESWT has few
negative consequences and the recovery time is
short, with patients typically walking and
returning to full activities within a few days,
the panel thought that ESWT is a valuable option
for providers treating heel pain"

In fact, I offer all of the options mentioned in
your clinical summary to my patients and some
individuals may still take months to get better.
The reason for bringing these counterpoints to
light is that there is NO treatment in my
experience (and as outlined in the Consensus
Document) that is 100% successful, and there is no
"cookie cutter" approach to treatment regardless
of your practice model being paid by an insurance
company or directly by the patient. Each patient
may react differently to these treatment
modalities and I do not believe there is a
specific order you are mandated to follow in
recommending management to the patient.

It also seems reasonable to suggest that after
failing all of the other options, surgery could be
considered as a legitimate choice. That being
said, do you charge patients when you offer a
steroid injection or fabricate orthotics? Are
these not ancillary sources of income for your
concierge type practice? I am not familiar with
how you would otherwise keep the lights on?

Adam M Budny, DPM, Altoona, PA

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11/22/2024    Allen M. Jacobs, DPM

My Surgical Experience as a Patient (Ivar E. Roth, DPM, MPH)

Dr. Roth expresses his "disgust" at the treatment
of plantar fasciitis by a colleague. He opines
that the "younger podiatrists" are motivated by
money rather than patient well-being. He states
that the patient consulted with an insurance
covered podiatrist rather than "me", (that is) Dr.
Roth. What was most disconcerting to me was the
statement that Dr. Roth reviews anything for the
purpose of making a judgment on the necessity of
care and, hopefully not, standard of care.

Dr. Roth is critical of the critical of the
utilization of ECSWT for the treatment of plantar
fasciitis. In point of fact, while I personally do
not employ ECSWT due to the general difficulty in
obtaining insurance coverage for this modality, it
is an acceptable and not-infrequently utilized
modality for the management of plantar fasciitis.
There is reasonable literature support for this
modality in the management of plantar fasciitis,
some of which was authored by Dr. Roth's own
residency directors. The standard of care
generally is inclusive of many approaches to any
particular pathology, including plantar fasciitis.
ECSWT is non-invasive, and may be helpful or
curative for plantar fasciitis. The fact that Dr.
Roth in his show me the money practice would
choose not to employ ECSWT doe not make this
treatment regimen inappropriate or "disgusting".
Nor does it provide a license to impune the
motivation of the treating podiatrist.

X-rays? Why would you not obtain radiographs in
some cases of heel pain ? There is Dr. Roth a
differential diagnosis in some patients who do not
present with seemingly textbook plantar fasciitis.
Similarly, orthotics are frequently not a covered
service for the treatment of plantar fasciitis.
The literature supporting the need for functional
orthotics in the management of plantar fasciitis
is supportive from a theoretical standpoint.
However, practically speaking from the clinical
standpoint the majority of the patients whom I
have treated for almost 50 years have successfully
resolved symptoms of plantar fasciitis without the
need for true custom orthotics, and have done
quite well with prefabricated pronation limiting
or shock-absorbing inserts.

Stretching The role of equinus and effort to
stretch the gastrocnemius and/or soleus muscles
and plantar facia are frequently an essential
component in the treatment of plantar fasciitis.
There is ample supportive literature advocating
the incorporation of stretching in the treatment
of plantar fasciitis. There has been increasing
employment of gastrocnemius recession in the
treatment of planta fasciitis. There are studies
indicating that stretching alone may resolve some
cases of plantar fasciitis. How many night splints
are dispensed by podiatrists for this purpose ?
Many I suspect.

Dr. Roth is critical of the failure to employ an
injection as a primary treatment. Why ? Injections
are invasive, they can be uncomfortable to the
patient, and may often provide only temporary
relief of pain. Furthermore, although uncommon,
potential complications such as infection, fat pad
atrophy, fascia rupture may occur. Personally, I
seldom find the need for injection therapy as
initial treatment for plantar fasciitis.

nti-inflammatories? There are potential side
effects such as renal, cardiac, gastrointestinal
to be considered. Personally I frequently utilize
steroids or NSAIDS for the treatment of plantar
fasciitis.

My point is this. WHAT YOU DO OR CHOOSE TO DO DOES
NOT DEFINE THE STANDARD OF CARE Dr. Roth. In
medicine, for any given pathology, there are
frequently many correct answers. Yes there are
some incorrect answers. If a patient tells you
they had an anaphylactic reaction to penicillin
you do not give them penicillin.

The fact that the patient failed to respond to
initial acceptable treatment by the treating
podiatrist does not lead to a conclusion that the
podiatrist was motivated only by money. What PM
readers can state 100% cure rate in the on-
operative treatment of plantar fasciitis?

In reviewing any chart with concern over prior
care, the question is was the treatment acceptable
under the circumstances. NOT WHAT YOU WOULD DO.
Hopefully, others reviewing medical records for
potential malpractice claims or payment reviews
maintain a greater understanding of the standard
of care than you appear to have. Suggesting that a
colleague was motivated by profit only because
they failed to management a patient in the same or
similar manner as you would have is a good reason
that individuals with such distorted thinking
should not be allowed to participate in legitimate
medical record reviews.

Allen M. Jacobs, DPM, St. Louis, MO