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From: W. David Herbert DPM


I have two cousins who many years ago became dentists. Today, there are individuals called "denturists" in some states who can take dental impressions and make dentures without a dental referral. In a couple of states, dental hygienists can practice privately, and in one state can even fill a tooth without a dentist's supervision. In a number of states, a certified nurse anesthetist may practice independently without medical supervision. Also, in some states, a physical therapist does not have to have a doctor's referral to see a patient.


Any person rendering a service that can be construed as the practice of medicine will be held to a medical standard of care while so doing. This is true in all of the jurisdictions that I am familiar with. I still say it is more important that a podiatrist be defined as a physician than that he or she be granted an unlimited scope of practice. You do not find orthopedic surgeons delivering babies or ophthalmologists performing bunion surgery, even though it is in their technical scope of practice. They are limited primarily because of liability issues.


W. David Herbert, DPM, JD, Billings, MT

Other messages in this thread:



From: Sara Tradup


We have our old x-ray films recycled and they will pay you for the silver content and provide you with a certificate of destruction. We use B/W Recycling – they will even cover the shipping costs to send x-rays to them as long as you have at least 50 lbs of films. We have used them three times so far over the years, with great service every time


Sara Tradup on behalf of Peyman Elison, DPM, Surprise, AZ



RE: Lack of Podiatric Authors in Our Journals 

From: Bryan C. Markinson, DPM


Many have lamented and seek answers on the lack of high quality peer-reviewed published podiatric research. Some blame the colleges, others blame APMA. I take a different view. Why does there have to be blame on any level? The importance of original academic research in medicine is self- evident. However, it is still a minority in all fields who churn out the research. 


Be that as it may, since 1977, when I started podiatry school, there was NEVER a milieu for research in any of our colleges. Original research is much more complicated than one might think, and very costly. Since working in a very research-oriented academic institution, I can tell you that “research” is done on weekends and nights, with armies of...


Editor's note: Dr. Markinson's extended-length letter can be read here.



From: Kathleen Neuhoff, DPM


I am a veterinarian as well as a podiatrist. As a requirement for achieving board certification, it was necessary to submit two papers suitable for inclusion in a peer reviewed journal in addition to the usual case presentations and two days of testing. One of the reasons this was done many years ago was because the feeling in veterinary medicine is that one of the main differentiating factors between a profession and a trade is the production and publishing of research. If such a requirement became a part of the board certification requirements for podiatry, I am sure we would see a rapid expansion of research!


Kathleen Neuhoff, DPM, South Bend, IN



From: Name Withheld


Kudos to Ms. McCormick for bringing this issue to light regarding continued use of chemicals to "disinfect" podiatry instruments. From what I recall, most of those chemicals only sterilize an instrument after 6-8 hours or more of being immersed. Since most podiatry offices are turning over a patient every 15-30 minutes, there is serious potential for spread of onychomycosis, MRSA, Hep C, etc. from patient to patient if these chemicals are utilized. 


There will be others that disagree, but there is no excuse to not have an autoclave and sterilize every instrument between patient use! Autoclaves are not that expensive and we have advanced beyond chiropody. Those that are still using chemicals are no better than some of the pedicure salons that...


Editor's note: Name Withheld's extended-length letter can be read here.



From: Janet McCormick, MS


The EPA-approved label on Benz-All says weekly. It does not say, however, if Benz-All is rendered ineffective by bioburden, meaning it might or probably needs to be changed earlier. The EPA requires that hospital disinfectants kill certain benchmark microbes and Benz-All does that. Many disinfectants, however, are tested for further levels of kill, and these are added to the label as "label dressing" since no disinfectant at this level kills everything. In other words, it's designed to improve sales. Keep in mind that there are many organisms it does not kill, but that is true of every disinfectant, no matter the brand. Only sterilization kills them all = use of an autoclave.


There are those that say disinfection is the okay-level of care for podiatry instruments unless you are performing invasive treatments. But any treatment can cause any level of invasion by instruments (in any type of care - podiatry or otherwise), even by accident, so any procedure must be performed under aseptic conditions Doesn't that call for sterilization of instruments in podiatry? Even in the offices? I am always shocked when I go into a podiatry office and there is no autoclave! But it happens way too often! In a survey of podiatry offices in my area, 4 out of 6 offices did not have an autoclave. 


Janet McCormick, MS, Frostproof, FL



From: Richard J. Manolian, DPM


I for one would not want to be the doctor who gets inspected and has to then prove how much of this product I bought to match the patient load and requirements of changing it on a 2 to 4 week basis depending on whom you listen to.


In addition, I would then have to show proper paperwork as to the change in schedule and process of how instruments were utilized in the setting. Gas or steam sterilization seems to me a more definite way to avoid this quagmire with any board of any state.


Richard J. Manolian, DPM, Cambridge, MA



From: Name Withheld 


A few years ago, a well-respected practitioner passed away in an untimely manner. He had a long standing practice that was busy from day until night, a modern office in a building affiliated with a top hospital and well-trained staff. His practice continued in the interim with help from volunteers, but when his family tried to sell it, they could not get a reasonable offer for the practice; not even an unreasonable one.


Instead, someone who purported to be “a friend” opened up a new office in the same building and poached the patients with a blitz of advertising. Setting up the new office and the professional marketing campaign cost maybe 20% of what he would have paid the family. Within a couple of months, he enjoyed the same busy practice, in a modern office, affiliated with a top hospital and with a well-trained staff. And he had paid pennies on the dollar.


I came to believe at that moment, after decades in this business, that a practice has no inherent value. It is no longer the “retirement account” waiting for us. If I had it to do over, I wouldn’t consider buying a practice. I would open one near an older practice and with marketing’s help become the newest, best-trained, most modern option available. Face it. Patients love the next new thing. Only our older patients look for long-term relationships, and they aren’t going to help sustain a practice. Patients these days look on Yelp for ratings to make their healthcare choices!


Name Withheld



From: Robert Fridrich, DPM


In late 1970s, I gave those flu shots due to an epidemic in Cleveland.


Robert Fridrich, DPM Retired, Green Valley, AZ



RE: PC vs. LLC vs. PLLC (Marianna Blokh, DPM)

From: Joseph Borreggine, DPM


I suggest you review these articles that I found through a simple Internet search: Article 1, article 2. And after reading them, then I would decide. But before you do so, know that President Trump’s new tax (law) makes an LLC more attractive than a PC by helping to reduce your pass through income in an LLC by 20%. The corporate tax rate has also dropped from 35 to 21%. 


This article helps explain the new tax rules for 2018 for pass through income: But, when all is said and done, a good CPA and tax attorney must be consulted to secure the best advice.


Joseph Borreggine, DPM, Charleston, IL



From: William D. Spielfogel, DPM, Vito J. Rizzo, DPM


This is an excellent initiative by NYSPMA and it is great that the Board of Trustees is being proactive in its advocacy for podiatry. They are an example of an organization advocating for its membership and trying to get a seat at the table.


William D. Spielfogel, DPM, NY, NY 


In our rapidly changing healthcare delivery paradigm, it is imperative that there be opportunities to help define what a particular category of healthcare provider can offer to contribute to the problems facing our population. Policymakers need to be educated on the facts as they relate to outcome statistics and verified cost factors. Many of these policy considerations are determined in a federal or centralized system. Podiatry’s first advocate should be the APMA. As experience has demonstrated, podiatry seems to be not permitted “a seat at the table”, and this profession is often caught needing to try to fix policy shortcomings after the fact. This has proven to be bad policy. 


I applaud the effort of the NYSPMA, which has been the leading advocate for progressive healthcare policy specifically as it relates to podiatry and to the communities we serve. NYSPMA led the charge, resulting in the Thompson Reuters Study which demonstrated the value of podiatry in the care of lower extremity manifestation of diabetes. NYSPMA has been trying for years to have care measurements developed specifically for podiatry, which could then force payers to better consider podiatry as a key partner in many healthcare scenarios. This effort in population health is the next phase of what has been a multi-year and ongoing effort to demonstrate the need for podiatry’s inclusion in a myriad of ongoing and pressing healthcare issues. The opioid crisis, fall risk, and the ever present concern with the ever rising costs of managing the effects of diabetes are areas where it has once again been shown that with podiatry on the team better outcomes and lower costs result. 


I encourage APMA, and all of its individual components, to carefully consider and then support the work of NYSPMA as a national effort. In the big picture, it will help podiatrists and their patients throughout the nation, and not just in New York.


Vito J. Rizzo, DPM, Bay Shore, NY



RE: Historical Perspective on Podiatry

From: Bruce Lebowitz, DPM


Since retiring, I have become a docent at a Johns Hopkins museum. As such, I have learned a great deal of history. When I entered classes at MJ Lewi Podiatry school, I learned that in 1912 organized medicine had ignored the foot. Dr. Lewi helped create the school in order to fill the gap. I’ve now learned more about the state of medical care in the late 19th and early 20th centuries.


Johns Hopkins University and medical school were founded at the end of the 19th century as a result of Mr. Hopkins' will which allotted some 71/2 million dollars toward that end. Nevertheless, the U.S. economy took a fall at the same time, making it impossible to get the school off the ground. As it turned out, the Hopkins board found a donor willing to shell out the extra millions. Mrs. Garrett, a wealthy philanthropist, donated the funds with a couple of strings attached. One, women would have to be admitted every year. Second, there would have to be students accepted who had achieved academically in college.


She did this because she well knew the state of medical care in this country was awful. She knew too that there were American medical schools graduating doctors who could not read or write. So, podiatry began out of need around the same time as academic medicine did. How’s that for parity? 


Bruce Lebowitz, DPM, Baltimore, MD



From: Brian Kiel, DPM


First of all, if one is to publicly praise and justify the actions of Joseph McCarthy, why are you ashamed to let us know who you are. He was publicly disgraced and proven to be a liar and was the precursor to the same political hate game we are seeing today. This "withheld" person is looking for ghosts under every bed and is obviously a proponent of the extreme right wing political persuasion. I disagree with his basic premise, but he has every right to espouse it, just don't do it behind a curtain. What are you ashamed of if not your views?


Brian Kiel, DPM, Memphis, TN



From: Mike Kempski


I work on the insurance side of medical malpractice and have twenty five years of experience. In the early years of the Data Bank, the doctors had great concerns about entries against them. The concern was so intense that the carriers responded by changing their policy language as it relates to the settlement of claims. The change was the policies stated they won’t settle a claim without your consent to do so. However, I don’t think there was much reason to be worried. There’s very limited access to the Data Bank. For example, the general public (your patients) can’t access it. Medical malpractice insurance carriers can’t. Hospitals can. But they’re always very reluctant to revoke privileges. How has it hurt physicians?


Mike Kempski, Plymouth Meeting, PA



RE: Regulation for Power over Physicians and Surgeons

From: Michael M. Rosenblatt, DPM,


The abuse of physicians is clearly a byproduct of progressive liberal rule of the United States. Ostensibly, it is "couched" in regulation to raise the standard of care and "limit" damage by "incompetent or dangerous physicians." The regulations and their promulgators always say this is for the public good. It has nothing to do with the public good or protection. It is entirely regulation for POWER over doctors and professionals. It creates "boards of review" who are not qualified in most cases and also exposes physicians to "Star Chamber" procedures and accusations with absolutely no civil rights. 


Make no mistake: Regulation is for power. It has no intent or purpose otherwise. It also creates boards and employment for non-professional people and expands government into every aspect of our personal and professional lives. Physicians must be careful for whom they vote. Bigger government means lack of rights without improvement in opportunities. Marxism is a byproduct of big government. This country has been on a rolling slope toward cultural and professional Marxism with Democrats in control. 


The "members" of these various committees are fools if they believe they are on the "right side." It is only a short step, under accusation of another person who wishes to take away your rights, your profession, and your be ON the other side and become a target yourself. 


Michael M. Rosenblatt, DPM, Henderson, NV  



RE: Best Way to Study for 10-Year Forefoot Boards

From: Mark L Miller, DPM


I just recertified last year for the second (and last) time—the Goldfarb Board Review Course was all I needed. I took the class over a weekend and then took the test the next week. Everything was fresh in my head and the test was not bad at all. As one of the instructors in the course said, "the recertification test is testing what you do every day."


Mark L Miller, DPM, McLean, VA



RE: Rules of Evidence and Professional Practice

From: W. David Herbert DPM, JD


Anyone who is interested in determining who can do what to whom in a medical sense should review the appropriate licensing acts of all medical type providers in states like Montana, Alaska, and Minnesota. I also recommend that they review the scope of practice of naturopaths in states where they are licensed. Not too long ago, I was contacted by several state legislatures about the issue of nurse anesthetists obtaining hospital privileges on hospitals that only employed anesthesiologists. The unlimited scope of practice of nurse anesthetists was not the issue. Only the politics involving who was granted hospital privileges in the larger hospitals was the issue. In states where they are allowed to practice independently, many nurse anesthetists have larger incomes than many primary care physicians.


In a medical malpractice case in some states, nurses can testify against physicians and vice versa depending on the issue. In a lawsuit involving medical providers, it will be your malpractice carrier that will determine whether you are covered or not. How it is in Florida is not how it is everywhere when it comes to the practice of anything that might be related to medicine.


W. David Herbert DPM, JD, Billings, MT 



From: Don Steinfeld, DPM


Kudos to Brian Markinson. We should all remember that every interaction we have is an opportunity to promote podiatry as a profession and ourselves. What a positive outlook he has. It’s so easy to fall in step with negative thinking and negative thoughts. This is a great way for all of us to start the new year on a positive note. 


Don Steinfeld, DPM, Farmingdale, NJ



From: Janet McCormick


Every time I hear discussions about nurses taking over podiatry, I think of how wayyy-back-when dentists said to each other "hummm, this may happen." The difference between them and podiatrists is the dentists organized to make certain it didn't. Thus, was borne the dental hygienist (the legislation snatched it away from the potential of nurses doing this work without the dentists) who does the work the dentists do not want to do, are educated to do it correctly, and are legally the only ones who can (other than dentists). But these dental hygienists CANNOT under legislative law do so in any state (that I know of) except under the direct supervision of a dentist. And it was all put through by the state dental associations. I have discussed this with many podiatrists over the years, even suggested organizing and getting the restriction developed, but they never got it!! So, now, it is too late. 


Think about this: no patient can have their teeth cleaned, have x-rays, etc. EXCEPT in a dental office or clinic - wherever, they must have a dentist on staff. And the patients have no choice of where to have this work performed. Wouldn't you love that? But alas, you are too late, I fear.


Janet McCormick, Frostproof, FL



From: W. David Herbert, DPM


The posting about the scope of practice of nurses reminded me of what happened to a podiatrist I knew who went to medical school and became a board-certified family practice doctor. The hospital he had privileges at would not let him perform foot surgery or deliver babies. The problem primarily was that he was no longer a licensed podiatrist and also he was not an obstetrician. Also his malpractice carrier would not cover him for these activities. I think that is it more important that podiatrists in every state be able to refer to themselves as podiatric physicians. I believe it will not be possible for nurses to claim that they are physicians.


W. David Herbert, DPM, JD, Billings, MT



From: David N. Helfman, DPM


Having personally consulted and currently engaged with the VC/Private Equity (PE) world and founder of Extremity Healthcare, I would like to add some very important and direct points to Hal’s comments on podiatry and VC. Podiatry has always been a bit behind other specialties when you look at other healthcare consolidations. 


The main reasons that PE firms have not been able to really see value in podiatry as a platform investment is because the successful PE firms saw podiatry groups as too loosely affiliated, were concerned about integration issues, compliance issues, and the ability to... 


Editor's Note: Dr. Helfman's extended-length letter can be read here.



RE: ABPM Wound Certification

From: Randolph C Fish, DPM


Parity is here, why take a step backwards? Lately, I have seen several advertisements from the ABPM touting their new examination for certification in wound care. Since the ABPM is a CPME-approved board, I am concerned that someone will perceive that this particular certification is worth more than it is. This is not a board certification. It is, rather, recognition for demonstrating an added skill set called a “Certificate of Added Qualification” (or CAQ for short). There are several exams in the marketplace offering a similar certificate. Whereas the ABPM certificate is for podiatrists only, other groups offer podiatrists the same certification as allopathic and osteopathic physicians, giving parity to DPMs, MDs and DOs in the wound care field. 


The certification I prefer is through the Council for Medical Education and Testing (CMET). It is a non-profit, physician-specific examination that has certified DPMs, MDs, and DOs on the same level for the past 10 years. By numbers alone, it is the largest and most widely accepted certification of its kind in the United States. Selecting a certification process is important, and being certified by the same organization that certifies all physicians is a step forward. Anyone who recognizes the need for parity in the wound care arena will look to the APWH and CMET certification.  


Disclaimer: I have no financial  interest in either the APWH or CMET. 


Randolph C Fish, DPM, Tacoma, WA



RE: ABFAS Board Exam Pass Rate is Disparaging (Joseph Borreggine, DPM)

From: Don Peacock, DPM


The complaints regarding the ABFAS board certification process are completely unwarranted. I say this not to be elitist but to recognize that we all should strive to remain independent. I feel empathy for anyone going through the board certification process. I remember it well and it was challenging. However, I do not feel sorry for anyone complaining about it. The experience should be difficult and will make you more knowledgeable in the end. Complaining about it is silly and serves no purpose. You should prepare and do your best; and like a boxer, you need to be strong enough to give and take a punch. 


I will be taking the recertification exam in 2018 and I plan to study and pass it. If I do not...


Editor's note: Dr. Peacock's extended-length letter can be read here.



RE: ABFAS Board Exam Pass Rate is Disparaging (Joseph Borreggine, DPM)

From:  Name Withheld


I am glad that there is some discussion about the ridiculously poor pass rate of the ABFAS Exam. The objective data posted comparing our pass rates with our orthopedic colleagues absolutely should be taken into consideration. I attended a great residency program where I obtained solid training, both didactically and practically, with surgical requirements more than tripled in all categories. I never had difficulty with any of the board exams taken through podiatry school. I have established myself in my community quickly and built up a practice with good referral sources and the respect of my fellow medical colleagues at the facilities I am an attending at. 


I passed 3 of the 4 ABFAS Part 1 exams on my first attempt, but had to retake the forefoot computer-based problem solving exam 5 times. In this period of time, I studied specifically for the format of the CBPS exam, spoke to the staff of ABFAS administering the exam (who to their credit was very responsive and open to helping in any ethical way they could). I am almost to the portion of submitting cases which, after hearing other examples of respectable surgeons who have failed this portion, makes me very nervous.


The system needs an overhaul which would absolutely cost ABFAS money since it did cost me thousands of dollars to even get to this point with the many retakes of CBPS. It's an excellent business strategy for ABFAS to continue to fail that many people, but unfortunately it is at the expense of the next generation of our profession. 


Name Withheld



From: Adam Siegel, DPM


Dr. Williams mentions that we must “not be inferior to that of our MD colleagues.” So I suppose the solution is to do what most podiatrists seem to do: overcompensate in an effort to unnecessarily prove something to an audience that does not exist. If orthopods see a suitable pass rate as 90%, podiatrists should aim to set our pass rate at a comparable level. After all, it is completely up to the board to determine what arbitrary score is considered “proficient.”


Adam Siegel, DPM, Lutz, FL



From: Name Withheld 


This certifying board is a bit of a monopoly that every podiatry student has to deal with to progress to the next level of their career. This certification process is exorbitantly expensive and arbitrary. The rules continually change which apply to everyone except those already certified? I passed all the written exams and (first time every exam) and interviewed well at the time the decision was made that new applicants would no longer be allowed to select their cases to submit for certification. It was at that same time the decision was made that applicants would log their cases as is done in residency. 


I played the game and paid the small fortune over the years only to be told that my cases that they selected were not up to their standards. I was told that I could pay more money next year and hope they pick better cases. I continually see plenty of cases from providers certified by this board which have resulted in suboptimal outcomes. I will often end up doing the revisions to improve the health and welfare of the public. There are other boards who value your dollar and I recommend that route for those who value their time and money. In closing, I have seen some excellent work from colleagues with many different certifications. I have no hard feelings toward ABFAS and I am happy that I chose a different certifying board.


Name Withheld