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02/12/2025
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Lawrence Rubin, DPM, Eric J. Lullove, DPM
Let's not forget the 30 second Mulder's sign test for neurofibroma. When you learn the two different compression techniques for providing it (shown on video), count on having near 100% accuracy.
Lawrence Rubin, DPM, Las Vegas, NV
This question really shook me with the answers posted as of Sunday. For over 50% of respondents to say that “Yes” to remove a neuroma without ANY imaging is amazing. In today’s world of advanced ultrasounds, MRI, and even 3D CT models — to not image a patient prior to surgery just to make sure you are doing the correct thing — but to make sure that the complaint is TRULY the pathology is disheartening. While I know the issues of “cost” and “defensive medicine” will come up — you would NEVER see a general surgeon or orthopedic surgeon EVER remove any part of human anatomy without imaging.
To those over 50% of DPMs who are answering, “Yes” — ask yourself what happens if you operate and it’s a Schwannoma? Nerve sheath tumor? Hemangioblastoma? It just could be a ganglion cyst. Either way, getting definitive advanced imaging would be a lifesaver. What if you don’t have privileges to remove a malignant tumor? What if you don’t have privileges to remove a neural tumor? How can you be 100% sure you’re acting according to scope and standard of practice by NOT ordering an MRI/ultrasound?
Ask your malpractice carrier what happens next. Ask yourself would YOU rather your doctor order the MRI or US to MAKE sure it is what it is they are removing? Do the correct thing for your patients. One more step before jumping to the OR before a quick surgery usually demands prudence and patience.
Eric J. Lullove, DPM, Coconut Creek, FL
Other messages in this thread:
03/04/2025
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Jay Grife, DPM, JD
Dr. Tomczak is 1,000% on target but I believe he underestimates the negatives of the DPM degree. Our DPM schools do not disclose the negatives that a graduate must endure. The schools preach terms as "physician" which some graduates subscribe to in resumes without disclosure of podiatry. Some graduates emphasize they graduated medical school omitting their DPM background. The survey Dr. Tomczak quotes is enlightening and his conclusions cursory. I suggest that it can be extrapolated to a nationwide consensus that DPM school entrants aren’t 5 star or even 2 star students. For the most part, our schools accept the remainder of MD and DO rejections. It is not a formula for progress.
An example from a DPM I just spoke to: he graduated undergrad with a 4-year degree, went to DPM school for the ensuing 4 years and completed a 3- year residency and 1-year fellowship. I asked how he enjoyed being a DPM to which he responded in summary, "I no longer do any surgery, despite being enticed to join numerous hospital staffs. I do wound care and routine foot care and don’t worry about insurances, rounds, surgical complications, or malpractice." As he drove away in his Bentley convertible, he waved.
Jay Grife, DPM, JD, Saint Johns, FL
02/20/2025
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Michael Krischer, DPM
Looking at this week’s survey, less than 13 percent of respondents so far would pick the current system of 4 years of podiatry school with a three-year residency. Nearly half would pick 4 years of DO training with a 4-year residency. Why are we contemplating why the application pool is so low for an option the majority of respondents (87%) would not take.
If a student came to me and asked if they should apply to podiatry school, even though I love my career, I would caution them to explore other options as well. If you graduate as a DPM and complete your residency, you are pigeonholed into podiatry forever. With an unlimited degree you have so many more options to pursue. And there is no longer a significant time differential with podiatry being a 7-year commitment.
Michael Krischer, DPM, Durant, OK
02/19/2025
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Evan Meltzer, DPM
I’ve been reading about the diagnosis and treatment for neuromas published in PM News with great interest. As a retired “old timer,” I never used soft tissue imaging for diagnosis. My initial treatment usually consisted of a steroid injection into the affected webspace. If that resolved the problem, then the patient’s pain was probably caused by some type of inflammatory process.
After doing about 450 neuroma surgeries, I stopped counting. In those few cases that turned out to be one of Dr. Neuhoff’s “spacectomies,” I found that most of these few patients still had relief. I don’t recall the coding for the decompression of a nerve, but I was reimbursed for that procedure. In conclusion, I agree with my older colleagues that imaging is not necessary for the diagnosis of neuroma.
Evan Meltzer, DPM, Rio Rancho, NM
Editor's note: This topic is now closed
02/18/2025
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Kathleen Neuhoff, DPM
On the rare instances that I need to take a neuroma patient to surgery, I have relied on clinical diagnosis. In fact, as a resident, I saw patients who had had an MRI and who received a “spacectomy” because the neuroma was not visualized. Fortunately, I rarely have this problem because most patients respond to strapping followed by orthotics.
For those who refuse orthotics, I use a cryosurgical unit to freeze the affected nerve. This is an office-based procedure requiring a 1 cm dorsal incision. Patients can return to work in one to two days.I have been doing them for over 20 years with no complications except about a 10% recurrence rate. Most of those patients are happy because it usually takes two to three years to recur and we just repeat. I consider this safer than a steroid injection and less painful than chemical ablation.
Kathleen Neuhoff, DPM, South Bend, IN
02/17/2025
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Eric J. Lullove, DPM
Dr. Jacobs alleges that what I wrote implies "that it is near malpractice" to not obtain advanced imaging or ultrasound before surgical excision. In no way did I imply that it was malpractice. My point was to relay that the discovery that advanced imaging was NOT performed in these cases may open up the treating DPM to litigation - regardless of the evidence-based literature.
I take offense to the fact that Dr. Jacobs references scientific studies with low power and low populations, and justifies his remarks as "established evidence-based" medicine, and implies that I am not adhering to the standard of care, and then alleges that I am giving plaintiff attorneys ammunition for ideas that blatantly were already there before my comments.
It is not Dr. Jacobs' right to assert how one provider sees a pathology and decides to treat one way versus another. To assert that my personal views of space-occupying mass lesions and the need for additional imaging is based on my diagnostic needs that is not the standard of care is not for him to decide my patient's comfort and need before electing to have a surgical or non-surgical decision. To assert that I am not adhering to the standard of care is arrogant, but also insulting. Like I said, an act of prudence and maybe less arrogance is required for our profession, considering the potential harm a missed diagnosis and subsequent litigation can hurt all of us.
Eric J. Lullove, DPM, Coconut Creek, FL
02/15/2025
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From : Elliot Udell, DPM
Dr. Harvey writes that during most of his career imaging for neuromas was not readily available, and he removed most of them based on clinical evaluation. In 2025, where we do have imaging available, could a podiatrist get into trouble if he or she does not order these tests and post-op findings show that the patient did not have a neuroma?
Could the patient say in court, "hey doc, you operated on me and it turned out to not be a neuroma and you could have known that by sending me for appropriate tests?" Perhaps some of the legal experts could weigh in on this.
Elliot Udell, DPM, Hicksville, NY
Editor's comment: PM News does not provide legal advice. According to the FDA, the definition of stand of care is "Treatment for a disease that is accepted and widely used by doctors." Although the PM News Quick Poll is not scientific, it is likely that not imaging prior to neuroma surgery fits that definition.
02/13/2025
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Pete Harvey, DPM
It was Dr. Rubin who first taught me about Mulder’s sign. He is correct. It is highly accurate. Dr. Lullove has valid points. However, over 50 years, I have removed hundreds of neuromas with no imaging. My schoolmates would say the same. In the first half of my career, imaging was not widely available.
Pete Harvey, DPM, Wichita Falls, TX
02/13/2025
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: Allen M. Jacobs, DPM
Dr. Lullove implies that it is near malpractice to remove a suspected interdigital neuroma without confirmation of the diagnosis with pre-operative advanced imaging. Simply stated, his position is not only contrary to the standard of care (as reflected in PM News), it is contrary to published studies addressing this issue.
Numerous studies have demonstrated that the accuracy of clinical diagnosis of an interdigital neuroma is sufficient such that advanced imaging is seldom required (e.g.: Pastides, et al, Foot and Ankle Surgery 18 (1) 2012, Mahadevan, et al., JFAS 54 (4), 2015, Owens, et al., Foot and Ankle Surgery, 17 (3), 2011.) The clinical diagnosis has been shown to be safe and reliable. Advanced imaging is indicated when the diagnosis is unclear or...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
01/15/2025
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: H. David Gottlieb, DPM
I for one, am always uncomfortable whenever I walk around my house without shoes or sandals on. I have seen so many patients with foreign bodies in their foot over the last 42 years that I am always nervous when walking with bare or socked feet. And I NEVER suggest that my patients do so.
H. David Gottlieb, DPM, Baltimore, MD
01/14/2025
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Lawrence Rubin, DPM
Having been a podiatrist and loving it for 66 years, it saddens me to read in PM News that only 42.86% of today's podiatrists are very satisfied with their choice of podiatry as a profession. I believe it would be enlightening to have comments from those who are disappointed in aspects of the profession to express their reasons, and what, if any, recommendations they have for positive change.
I truly believe that podiatry can solve all the negativity of its present problems if we all unite and work together to overcome this present high state of dissatisfaction.
Lawrence Rubin, DPM, Las Vegas, NV
12/30/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Kevin C. McDonald, DPM
I read with interest with results of the poll on the biggest threat to our profession. I don’t feel that advanced practice nurses and orthopedic surgeons are threats at all, compared to the lack of applicants to podiatric medical school.
There are no easy answers to this problem but I would like to see a university-affiliated podiatry school develop a six-year program to become a podiatrist after graduating high school. The medical education (and clinic time) could begin in the second year of the program. Additional components could be a) work-study programs for podiatry students as medical assistants in podiatry offices and b) the development of a “Diabetic Foot Center of Excellence” at the school to specialize in great care for diabetic feet and to perform research supporting and proving that podiatry care is a valuable and cost-efficient part of the care of people with diabetes.
The purpose of this program would be to a) increase the length of time for podiatric medical education and b) lower the net financial and time costs of becoming a podiatrist. Letter writers to PM News often advocate for national PR and advertising programs to enhance our status, but I feel that money spent on research proving the value of our work would be a better investment on a national basis.
Kevin C. McDonald, DPM, Concord, NC
10/31/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Paul Kesselman, DPM
Each state has or does not have licensing laws pertaining to the regulation of certain services. Orthotics and prosthetics are no different. Providing custom fabricated, custom fitted or over-the-counter orthotics are prime examples where state regulations not only differ but often completely clash.
One example, here in NY where just about everything is highly regulated, one may scratch their head when they find out that there are no state licensing requirements for providing custom orthotics or prosthetics. This means anyone can hang a shingle out and sell custom orthotics and prosthetics. No formal schooling, training or certification, or license required. Across the Hudson River, you cannot provide custom orthotics or prosthetics without having either a...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
10/28/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Kathleen Neuhoff, DPM
I think that a class action suit to prevent distribution of orthotics is ludicrous. We voluntarily gave up the fabrication of orthotics. When I first started practice, nearly every podiatrist cast for orthotics and most made them on their premises. Now, I am the only local practice which makes our own orthotics in my office and, from my work with podiatric residents, very few know how to cast (with ANY method). There is a huge need for orthotics and if there is a void in fulfilling this need, someone will step in to fill the void. We cannot expect to have our cake and eat it too!
Kathleen Neuhoff, DPM, South Bend, IN
10/25/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Irv Luftig, DPM
I graduated from OCPM in 1980 with Greg and practiced near the Toronto area for over 40 years until I retired in 2002. My practice was a successful one with thousands of loyal patients, standing out from almost all of the others within a 50 mile radius using the same mantra as Greg's. Proper biomechanical exam, non-weight-bearing plaster casting of each and every orthotic patient whether they were 8 years old or 80 years old. I was lucky enough to have a 3 year residency, surgically trained (with fellowship) podiatrist come up from the U.S. to take over my practice when I retired. He practiced in the U.S. for 5 years before coming up here to settle.
It took a full year of hammering away at the importance of biomechanics as an adjunct to all his surgical training. It took awhile but it sunk in. He had virtually no training in biomechanics. I was shocked but was relentless, teaching and mentoring about the principles of gait analysis, a thorough biomechanical exam, and...
Editor's note: Dr. Luftig's extended-length letter can be read here.
10/25/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Paul Slowik, DPM
I read Dr. Caringi’s letter with a bit of sad remorse. Biomechanics was a very important aspect of the DPMs’ training “back in the day”. Like Dr Caringi, I also performed a biomedical exam, gait analysis, and did plaster of Paris impressions. For the most part, all of my orthotics were custom made, meaning I listened to the patient and made individual adjustments. Rarely, no two devices were identical. Sometimes I had to make adjustments over and over again until I got it just right.
The patient had a true prescription which could be the basis for further devices. One size fits all is a travesty to our profession. Patients with severe deformities need those to function. Not all patients are surgical candidates. Patients would gladly pay several hundred dollars if you could make a device that really works.
And by the way, at least in California, orthotics are not considered a real prescription hence a class action suit would be fruitless.
Paul Slowik, DPM, Makawao, Maui, HI
10/25/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: William Beaton, DPM
I wish to second all of the comments made by Dr. Caringi. From the time I graduated from podiatry school to this day, I have always had an in-office laboratory where I have made orthotics dating back to leather and cork through Rohadur, Polydor, and now finally Carbonfiber.
Yes, we have lost that aspect of our practice to the OTCs, pre-fabs, and yes even some of the laboratory produced accommodative orthotics. It is a shame that podiatrists don't control the true biomechanical physician crafted corrective orthotics market.
William Beaton, DPM, Saint Petersburg, FL
10/24/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Greg Caringi, DPM
After closely following PM News for many years, I know my commentary is not new and unfortunately reflects the feelings of many podiatrists who are now at/near retirement age. These thoughts have been woven into many previous threads.
Many say that the early growth of podiatry was because our profession filled patient needs not being adequately addressed by other medical and surgical specialties. When podiatry was still struggling for recognition and parity, we were all encouraged to learn and use those skills to make us stand out as specialists who could offer options that were not readily available from other medical specialists, such as...
Editor's note: Dr. Carigni's extended-length letter can be read here.
07/26/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Kenneth Meisler, DPM
After 35 years of practice, I made the decision to charge patients who do not cancel at least 24 hours in advance. The fee has gradually risen over the past 10 years from $40 to $75. I wish I had done it 25 years earlier. This was never done to get income for the missed appointments; it was always to try to get patients not to cancel last minute. Every new patient receives and signs a form stating our cancellation policy at the same time as they fill out their new patient intake forms. 99% of patients sign the cancellation forms. When patients call to cancel the same day, we remind them of the cancellation policy and about 1/3 of the patients say "OK, I'll make it." That alone makes the policy worthwhile.
Unfortunately, we also get people who just don't show up for their appointment and don't call. We call those patients and depending on their reason for not showing and not calling, we frequently forgive the first time. If a patient has a history of no-shows, we will not let them schedule another appointment until the $75 no-show fee for the last visit has been paid rather than let them pay it at the time of their first visit.
I tell patients we instituted this rather than overbook to make up for cancellations. I also think that most patients respect you for it and frequently patients say, "I'm fine paying it. I realize it was my fault." We receive thousands of dollars in "no-show" payments a year.
Kenneth Meisler, DPM, NY, NY
07/03/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Wenjay Sung, DPM, Joel Feder, DPM
Congrats on the name change and new logo, but what color blind agency came up with this color by committee scheme? It’s like if old podiatrists asked AI “what colors do young people like?” but vomit green and puke yellow were already taken. But congrats on the name change.
Wenjay Sung, DPM, Arcadia, CA
I agree with Dr. Steinberg's Congratulation on the change of the "Illinois Podiatric Medical Association" to the "ILAPPS". But why is the logo missing the "Winged Foot" on the caduceus? And in keeping with modern medicine, it should really be "The Staff of Aesculapius with a Foot".
Joel Feder, DPM (Retired), Sarasota, FL
07/02/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Robert Scott Steinberg, DPM
I am shocked that more 50% of respondents think "podiatrist" is a good enough descriptor. I wonder what their average age is. Were the respondent DPMs from the U.S. or podiatrists from other parts of the world?
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ILAPPS logo |
In January, the Illinois Podiatric Medical Association began doing business as the Illinois Association of Podiatric Physicians and Surgeons (ILAPPS), and with it, we adopted a beautiful new logo.
Robert Scott Steinberg, DPM, Schaumburg, IL
05/03/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Ivar E. Roth, DPM, MPH
I read Dr. Kesselman’s response. While I understand his thinking, here are my old school thoughts concerning student loans. Any student can easily reduce their loan dependence by working part time during their schooling or on summer breaks. Also decreasing debt is easy; spend less and scrimp during school and residency. Too many students today think nothing of drinking $6 Starbucks whenever they want and living above their means. Maybe you must reduce rent by sharing an apartment.
There are lots of ways to spend less and or supplement your income. There is nothing wrong with a little struggle but today’s students to me seem to be entitled to a certain lifestyle that maybe they can’t afford. What I am trying to say is that where there is a will there is a way. The same goes for wanting to just get a 9 to 5 job. If you want to really excel, try the concierge/ direct pay model, and make as much as you feel you deserve. Yes, it will be difficult at first but in the long run, you are the boss of your future not just an employee happy to get yourself a cost of living increase each year.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
05/02/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Paul Kesselman, DPM
Recently, I met a young intern doing his PGY-1 prior to starting his five-year residency in general surgery. He is faced with almost $400K in debt from medical school and more from undergraduate school. Between the two, he can easily amass $600K or more in debt. A neighbor graduating from high school will amass $500K in debt from his undergraduate degree and then more from his anticipated pursuit of a legal degree.
It is no wonder that more and more young students are moving away from traditional degrees in healthcare and moving to shorter degree paths with easier career paths. PA and NP are far shorter than MD/DO and DPM degrees with much less stress, easier lifestyles, and nice salaries. Nurse anesthestists command $150+ salaries after a four year BSN and a year or two of...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
05/02/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: Shashank Srivastava, DPM
I understand the points that Dr. Hofacker is making and all are very good. That said, I personally feel that it is not reasonable to expect 17 year old high school kids to want to know they want to be podiatric surgeons at such a young age. I remember how I was at that age, and no way could I have made such a commitment. I think a certain level of maturity and some life experiences are required before making this commitment.
The problem is if they decide at 22 years of age that they want to do something different (common sentiment among that age group), there is no turning back and lots of debt and possible resentment. Unlike allopathic or osteopathic physicians, we cannot just simply change specialties and do different residencies and fellowships. There is no turning the ship around.
Shashank Srivastava, DPM, Rockville, MD
05/01/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Rich Hofacker, DPM
I was surprised when I read that only about 1/3 of our profession is in favor of a 6 year college/podiatry school option. In an ideal world, a 4 year undergraduate degree, a 4 year podiatry degree, followed by a 3 year residency would still be preferred. However, it is not an ideal world any longer. The enrollment in our podiatry colleges is down, which means the selection pool for good candidates is not good and some of the schools may have to consider closure, if the current situation does not reverse itself.
I have 4 children, all of whom had the bedside manner and the work ethics to become outstanding physicians. However, they all chose different career paths, which is more than fine, but it is the reasoning behind their decisions which still bothers me. The two main reasons that they told me for not considering medicine/podiatry were the cost and the amount of extra years of schooling.
I think that we need to still investigate the 6-year college/podiatry school option. We may be losing some good potential students to carry on in our noble profession.
Rich Hofacker, DPM, Akron, OH
03/26/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Steven Finer, DPM
This week’s poll covers disability insurance. As to new practitioners, when you buy this product make sure you understand the meaning of disability. For example, some policies may state that should you have a life-threatening situation, you could still teach and therefore be denied coverage. The policy should state that upon the fact of not being well with a serious medical condition, you will collect. Years ago, I bought the wrong policy, and a few years later turned that in and bought one with the proper definition.
Steven Finer, DPM, Philadelphia, PA
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