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01/28/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Elliot Udell, DPM
Dr. Meltzer raises an often-discussed issue when he writes, "Should a non-surgical podiatrist refer his or her surgeries to a fellowship-trained orthopedist?" This question has been asked by many of our nonsurgical colleagues for as long as I can remember.
When a dentist needs to send a patient for complicated extractions or other dental surgery, he can be assured that the oral surgeon is not going to do fillings, cleanings, or make crowns and bridges. This is not always the case when a non-surgical podiatrist refers a case to a surgical podiatric colleague. In most cases, the doctor getting the referral will assume all podiatric care of the patient, including making orthotics, nail care, etc. Would referring foot surgeries to orthopedists be economically safer for the general podiatrist? Until podiatry reaches a level where podiatric surgeons only do surgery, can Dr. Meltzer's question be honestly addressed?
Elliot Udell, DPM, Hicksville, NY
Other messages in this thread:
02/26/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Thomas A. Graziano, DPM, MD
Dr. Whelan brings up some salient points when addressing the concerns over the future of podiatric medicine. Many years ago, the foot was neglected by the medical community and podiatry came into its own by filling that void. The current requirement for EVERY podiatry school graduate to complete a 3-year surgical residency has fostered the neglect of routine foot care. And now that void appears to be filled by nurses or non-podiatric ancillary staff. History may be repeating itself.
In 41 years in practice, I've seen the gradual decline in the public's perception and the insurance industry's devaluation of healthcare professionals. We are no longer perceived as doctors. We are now looked at by the insurance industry and to some degree by the public merely as "providers."
The recent survey on this forum demonstrating that if given the choice, over 43% would prefer a career path in osteopathic medicine is not at all surprising. Let's address the elephant in the room. A good friend of mine whose son just completed a DO family practice residency accepted an offer of 350K/annum as a hospitalist. And this for an 18 day/month work schedule. Perhaps the survey results and paucity of podiatry school applications might have something to do with the disparity between podiatry and osteopathic medicine.
Whether one agrees or not as to why the profession of podiatric medicine is at a crossroads right now, there's no doubt the writing is on the wall. 300 applications to all the podiatry schools sends a clear message. Dr. Whelan's comments may not only be insightful but may be a necessity in the very near future.
Thomas A. Graziano, DPM, MD, Clifton, NJ
02/21/2025
0RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Allen M. Jacobs, DPM
Dr. Roth has made the observation that some of the young residents and practitioners lack the drive and intensity to work longer hours and harder than his generation. Many of today’s younger doctors are smart and seek a much better work/life balance than did my generation. This is in my opinion a good thing not a bad thing. This generation wishes to reduce the stress and burnout that has afflicted so many healthcare providers in today’s world. The newer generation is not as motivated to generate maximum income, but rather maintain a good work balance while providing good care for their patients. They do not wish to engage in the long hours and sacrifices that our generation was taught to be part of being a doctor.
Work/life balance integration is important to many of our younger doctors. Older healthcare providers may not relate to this manner of thinking. However, younger doctors are anxious to limit commitment to being a podiatrist and set boundaries for their work hours versus...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
02/18/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
RE: American Foot Care Nurses
From: Chris Seuferling, DPM
I cannot speak for the rest of the country (though I imagine most states have similar concerns), but I am well-versed in Portland, Oregon's podiatry and foot nurse dynamics. I am also familiar with Portland Foot Care Clinic and its CEO Amarachi, RN. In fact, we have had multiple conversations at the state level and national APMA level to address this issue… even introducing Proposition language at the 2024 HOD (see my proposed language below). It did not gain the traction I had hoped for, but I’m told it’s on APMA’s radar.
With that said, I ultimately feel it’s an “us” issue, not a “them” issue….i.e.; it is a “Podiatry Identity” crisis and not a “Foot Nurse competition” one. Many times during the course of the year, I have the following conversation with a new patient…"Mrs. Jones, I noticed podiatrist Dr. X performed your ankle fracture surgery. Why are you not seeing...
Editor's note: Dr. Seuferling 's extended-length letter can be read here.
02/17/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Don R Blum, DPM, JD
Recommendation - please check with your state board of nursing to confirm whether or not this practice by an RN is within the scope of their license. Can they practice unsupervised? In their website under “what to expect”, they talk about 3-D imaging for orthoses. In Texas, there is a law specifying who may prescribe orthoses. Check your state “orthotic” law if you have one.
Are RNs allowed to prescribe orthoses in your state? Are nurses allowed to practice unsupervised to provide diabetic foot exams and diagnoses? Finally, are the American Foot Care Nurses billing insurance or is it strictly fee-for-service? Please do not just complain. Investigate what the state law is regarding nurse (RN) practice acts and scope of practice.
Don R Blum, DPM, JD, Dallas, TX
02/11/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Lawrence Rubin, DPM
Dr. Roth speaks words of wisdom when he implies that APMA should not be chided for inaction in helping members compete for patients in our present multi-provider crowded foot healthcare marketplace. Medical associations are all limited in what they can do by antitrust policies that prevent them from engaging in potential anti-competitive practices.
But that does not mean that podiatrists cannot do what other medical associations do when they support the formation of third-party independent practice associations (IPA) that create value-based standards of care and market their members to the public and insurance payers. There are legal requirements, but, for example, optometrists, dentists, and primary care physicians have profited from supporting the creation of specialty IPAs for many years.
Lawrence Rubin, DPM, Las Vegas, NV
02/10/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Lee C. Rogers, DPM
I have read the comments from my colleagues with interest. I would point out that this is a topic that has received much attention from the profession's leadership and deliberative bodies. It has been addressed at the APMA House of Delegates in the past several years and it is discussed at almost every BOT meeting. The APMA has been taking action to increase the number of applicants. While it is not the APMA's "job" to boost school enrollment, the APMA (and its components) fully understands the connection between reduced qualified applicants and reduced membership and the imminent threat to the profession.
The APMA has raised money to help better the brand of podiatry as a career choice through a separate foundation. Certainly, the entity primarily tasked with increasing applicants and enrollment is the AACPM. They have also taken this threat seriously and started the "Feet on the Street" campaign, funded by...
Editor's note: Dr. Roger's extended-length letter can be read here.
02/06/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Rod Tomczak, DPM, MD, EdD
Since late 2022, I have been submitting letters to PM News and Dr. Barry Block has graciously been publishing them for the profession to read. There have been two main topics my submissions have fallen into; 1. The issue of board certification and the ramifications between the haves and have nots and; 2. The severe decrease in the number of students in the podiatry classes at the eleven schools.
An honorable source who has nothing to gain by lying has informed me that as of last week there were approximately 300 applicants to all the podiatry schools. This may not include the Texas school in El Paso which has its own application service outside of AACPM. The number 300 refers to applicants going through AACPM. Schools offer acceptance and seats. We have been trying to tell the profession that there won’t be a need to address the first topic of conversation, board certification soon. There won’t be anyone to...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
02/05/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Steven Block, DPM
I agree that many in our profession refuse to refer to themselves as podiatrists. However, between 2000-2020, foot and ankle surgery reimbursement declined 49%. Since 2017, the consumer price index (CPI) increased 24%. Have reimbursement rates kept pace? Not even close. I performed a Lapidus/Akin on a 22 year-old female a few weeks ago and was paid $492. The same week, I needed an LED strip light replaced in my office. The electrician took 30 minutes and charged me $400.
Line workers at a local factory have a starting salary of $115,000. In 2023, the five largest insurance companies in the U.S. made over $465 billion. Year after year, they post record profits. The system is broken. Podiatry, and medicine in general, will continue to be devalued until we take a collective stand. The provider has become a pawn for the corporate monster. Aside from the effort, commitment, stress, liability, if DPM were listed on the NYSE, is there anyone foolish enough to invest $250,000?
Steven Block, DPM, Owensboro, KY
11/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Elliot Udell, DPM
Thank you Dr. Tomczak for showing us the article titled, "What’s New in Orthpaedic Rehabilitation”. The portion of the article on the use of dextrose prolotherapy was cited.
This therapy is by no means a new therapy, and reading the article cited, it did not seem to be superior to cortisone injections. The problem with prolotherapy is not whether it is efficacious or not. The problem is that many dishonest practitioners are overcharging for what amounts to an injection of dextrose. I had a young fellow many years ago who was going to one of these practitioners and was paying $600 for an injection. He was broke and could no longer afford it. I bought a bottle of the injectable for a couple of dollars and gave him the shots for free. He was a very happy camper. Although prolotherapy is not my first line of treatment, I have no problem using it if a patient really desires it and it is therapeutically indicated.
Elliot Udell, DPM, Hicksville, NY
10/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Doran Edwards, MD
I appreciate Dr. Bass's post and his enthusiasm for the Arche LEAP Vitals exam for patients with diabetes. There is one point of clarification that needs to be provided. Dr. Bass wrote, “if a provider has a diabetic patient (chronic illness) who may have exacerbation or progression, and this patient may need a prescription based upon the findings of the LEAP tests, the patient will then meet the requirements for an E/M service.”
The quick and efficient LEAP Vitals tests are all about skin integrity in this high risk population. We understand that “chronic illness” as well as “chronic illness with exacerbation” helps determine, in part, the level associated with the E/M service through medical decision-making (i.e. 99212 versus 99213). By no means does the patient need to exhibit exacerbation or progression of their diabetes to qualify for the LEAP Vitals tests, nor the ability to meet the medical necessity associated with an E/M billing. A prescription is also not required.
Any abnormal findings on the LEAP Vitals Exam, i.e dry and xerotic skin (L85.3) caused by sudomotor dysfunction, is a significant risk to a patient with diabetes. It therefore warrants a care plan, either an initial care plan or a change to a previous care plan that’s not working well. This change in medical condition alone provides the medical necessity for an evaluation and management service through the counseling of the patient on their risks associated with dry skin, and changing their treatment, even if only an over-the-counter skin care recommendation.
Doran Edwards, MD, Former DME MAC and PDAC Medical Director
10/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Alan Bass, DPM, CPC
As a certified professional coder and someone who has reviewed the Arche LEAP Vitals+ Program, I agree with Dr. Edwards’ assessment. The program provides the user with real-time physiologic findings. Following the guidelines for an E&M visit provided by the AMA, if a provider has a diabetic patient (chronic illness) who may have exacerbation or progression and this patient may need a prescription based on the findings when performing the tests within the program, the patient will meet the requirements for an E&M.
Disclaimer: I have no financial relationship with Arche Healthcare.
Alan Bass, DPM, CPC, Manalapan, NJ
09/19/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: David Secord, DPM
My experience was somewhat the opposite, in that an anchor for one of the local television stations happened into my office for a nail procedure, worried that it would keep her from wearing stylish (I would go with inappropriate, but there you go) dress shoes as part of her work and that everyone she knew assured her that the experience would be akin to a slow trip through hell. She was amazed that she didn’t feel the injection stick (ethyl chloride) and didn’t feel the injection (1% lidocaine with epi, 0.5% Marcaine plain, 8.4% sodium bicarbonate to buffer the injectable back to physiologic pH) and didn’t have any pain after the procedure (no tourniquet needed due to the use of epi in the block). She recommended that the anchor at another station in Corpus Christi see me, as she had the same problem and staved off the procedure for the same reasons. She had the same positive experience.
The two of them began a discussion with me about my practice and I mentioned that...
Editor's note: Dr. Secord's extended-length letter can be read here.
08/29/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Steven E Tager, DPM
I too am a life member of APMA. I also did not get solicited for my opinion on the APMA definition of podiatry. I will withhold my contribution this year.
Recalling something about "taxation without representation" comes to mind and who knows more about "history can teach us a lot" than those who lived it?
Steven E Tager, DPM, (Retired), Scottsdale, AZ
08/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: APMA Member
I am a life member of APMA who was solicited for a $150 voluntary contribution. I did not get solicited for my opinion on the APMA definition of podiatry. I think I'll withhold my contribution this year just like the Life Member in the August 27, 2024 PM News. That's only two of us withholding and it won't make much difference in the APMA budget, but perhaps other Life Members who have not sent their contribution might follow suit and join us. What our action does do is alert the younger members of APMA what the future holds in store for them. Perhaps APMA could count 3 out of 5 Life Members in determining our input.
Rod Tomczak, DPM, MD, EdD, Columbus, OH
08/06/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Richard Haas, DPM
I have been in practice 44 years and can’t understand why the APMA has not been able to make podiatrists physicians in the eye of the law. I have seen pharmacists giving injections and physical therapists giving wound care freaking our profession out.
Being recognized as a physician should have always been the most important goal of the APMA, not worrying if we are MDP or PMD, etc. Who cares about that if we are not recognized as physicians. Where does our dues money go? DOs and dentists seem to know what to do with their money in regards to political action for their members.
Richard Haas, DPM, Temecula, CA
07/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Greg Caringi, DPM
I have read this thread with interest. My OCPM classmate and Kern Hospital co-resident, Dr. Eric Lauf, took on this problem and published his research in 1982, "Manual dexterity: its importance in podiatry" (J Am Podiatry Assoc. 1982 Jun;72(6):291-8.). Since Eric passed much too soon (at the age of 47), I will recall this to the best of my ability. Eric had a friend at the Case Western Reserve Dental School. Even then, dental school admissions took spatial relationships and manual dexterity testing seriously. After observing their metrics, Eric tried to apply them to the students at OCPM.
Unlike dentistry, there was a poor correlation in podiatry. His research became of practical use when Eric introduced the use of the Purdue Pegboard Test (a psychomotor test of manual dexterity and bimanual coordination) as part of the screening process in selecting residents at Kern Hospital. I later began using the Purdue Pegboard at Suburban General Hospital when we selected our surgical residents. It became an important part of our selection process. On a personal note, this reminds me how great a loss it was to our profession when we lost Dr. Eric Lauf in 2001.
Greg Caringi, DPM - North Wales, PA
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
12/21/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Bret Ribotsky, DPM
Steve, as you and the readers of this forum know, nobody’s as hard on the establishment than me. At least monthly, I log onto the APMA E advocacy site and send letters to all my congressional leaders on many of the topics that APMA suggests. I have never seen a result of these form letters, but I guess APMA does (or I hope they would not pay for this service). It would be nice to see a report of how many others do this.
Barry provides this incredible forum where each of us can share our opinions. But over the last few years, I believe there’s only 20 to 30 people who have regularly written on this forum. I often received 30 to 40 emails/text messages after I post something, and when I encourage each of these people to write directly, so that their opinion can be included in the discussion, they all refrain from wanting to get involved.
Fortunately, we have a few great leaders. Paul, Elliot, Allen, Steven, Keith, Robert, Bryan, Joel, Jim, Michael, Richard, Ivar, and I’m sure a few more who will join me and write what we’re all thinking. Let’s not forget, “Our lives begin to end the day we become silent about things that matter." - Martin Luther King Jr.
Bret Ribotsky, DPM, Ft. Lauderdale, FL
08/08/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Lawrence Rubin, DPM
With reference to the post by Dr. Jacobs suggesting that "LEAP" be used in the future to "summarize the examination and treatment of the diabetic patient," it should be recognized that this may create confusion. "LEAP" is already in use in the government's HRSA amputation prevention program, as well as the Lower Extremity Amputation Prevention (LEAP) Alliance that was trademarked and registered as a 501(c)3 non-profit charity in 2009.
Lawrence Rubin, DPM, Las Vegas, NV
08/04/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Paul Kesselman, DPM
Dr. Jacobs, as usual, makes many important statements during his recent letter to the editor regarding the need for podiatrists and other healthcare providers to be afforded the opportunity to provide an annual comprehensive diabetic foot examination.
Unfortunately, the current system does not agree as it is not only not affordable but inaccessible to most. Let me explain. Screening examinations with rare exceptions are unfortunately non-covered services. In the case of diabetic foot screening, the only two screening examinations are coded under Loss of Protective Sensation, better known as LOPS (Initial G0245) or Subsequent (G0246).
These are widely under-utilized because...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
07/25/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Lloyd Smith, DPM
George is correct, but this problem has existed for at least 4 decades. Virtual education is the new reality and saves podiatrists thousands of dollars. I loved the meetings, the interaction, and the renewal of friendships of in-person meetings.
I understand the plight of the vendors. At APMA, we regularly discussed the annual meetings, the costs, the profits, and the need for corporate sponsorship. The companies always wanted greater access to the attendees. We always made every effort to increase exhibit hall attendance.
The new era of virtual meetings creates a new set of challenges. I’m sure the meetings’ leadership will do whatever it can to engage in discussions.
Lloyd Smith, DPM, Newton, MA
07/13/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: James Koon, DPM
I’ve billed 11730 maybe 5 times in a 25 year career. If it’s infected and clinically appropriate, 11750. If it’s just the corner, bang it out under ethyl chloride anesthesia. If it’s a recurrent problem, 11750. It’s moral, ethical, and almost always definitive.
Wouldn’t you want one and done if it were you?
James Koon, DPM, Winter Haven, FL
07/05/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Kathleen Neuhoff, DPM, DVM
I read Dr. Rosenblatt’ letter with interest and a bit of confusion. I transitioned my practice to a self-pay 3 years ago. Unfortunately, I did it two months before Covid and this combination made it financially very challenging. However, we persisted and are now doing well. We managed the Medicare issue by having the patients pay us (we do not accept assignment) and filing for them. We file only for appropriate covered charges and Medicare reimburses the patient. We do not file any appeals or deal with Medicare at all, other than filing the initial claim. We do provide fee sheets with ICD and CPT codes if a patient wishes to file themselves with their insurance.
I perform approximately 5 “major” surgeries per month (tarsal tunnel, bunionectomies, exostectomies, hammertoe repairs, etc.). Patients pay for these. There are a few who prefer to go to a practice which files their insurance for surgeries, and I happily refer them to one of my colleagues.
I took my staff with me to the IPMA and Midwest meetings. After attending them, my staff is incredibly grateful that they do not need to deal with the insurances…so am I! I think it would be very difficult to do a self-pay if you were a cardiac surgeon or a neurosurgeon, but it is very doable for podiatry. Perhaps I find it easier because I am also a veterinarian, and clients routinely pay bills that are more than a bunionectomy! If a podiatrist wants to have a contract with his/her patients rather than their insurance company, it can be done.
Kathleen Neuhoff, DPM, DVM, South Bend, IN
06/21/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Kim Antol
The X-Cel x-ray machine, (specifically designed for podiatry for use with film and chemistry) has been the podiatry standard and workhorse for DPMs for many, many years with numerous machines manufactured in the '80s still in use today.
Amazingly, these machines can be modified with today’s technology, (DR-ready) by replacing the 8-in. high Orthoposer base with a low 3½ in. one, ADA handicap-accessible base (unlike the AD2D system’s very high 8-in. base).
Old or new, together with today’s wide range of hospital-grade DR imaging plates and modest pricing makes the X-Cel still the podiatry standard.
Kim Antol, Sigma Digital X-Ray
05/23/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Jeffrey Carnett, DPM, Grad Dip Ed, MFA, Dip Ac
In regard to ABPM certification of non-USA trained podiatrists, I appreciate PM News for publishing our concerns as we have little opportunity to let the American podiatric community know of the true picture of practicing overseas. I have been in full time practice overseas since 1995, working in Asia and Australasia. In that time, I have worked with a consortium of DPMs who, like me, struggle with harassment and discrimination from non-U.S. trained podiatrists.
I have shared Dr. Garoufalis' explanation with this group and all see the actions to certify non-DPMs (U.S. trained) as providing an American credential to those with inadequate education and experience. We feel it is discriminatory and will only harm us further. It was an ill-conceived idea seemingly based on limited first-hand experience of the true situation DPMs face overseas. We are in the trenches and ABPM is selling the other side bullets to shoot at us.
This ABPM International program should not be supported by the American profession of podiatric medicine and surgery. I think the other APMA-approved Board should also be concerned about this as it too would affect credibility of any American certifying activity. This will be used by bachelor degree podiatrists to claim they are certified in surgery to their local authorities and unwitting public.
Jeffrey Carnett, DPM, Grad Dip Ed, MFA, Dip Ac
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