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From: Name Withheld


Dr. Willner has worked very hard over the years to point out the Kafkaesque nature of the NPDB (as has the Semmelweis Society International). The only issue I take issue with would be his comparison of the NPDB to the work of Senator Joseph McCarthy. Once the Verona letters were in hand and translated/decoded, every, single individual named by McCarthy was not only identified as a Soviet plant, but had their Soviet handler identified as well. No such vindication is forthcoming for the NPDB. According to the GAO reports of 1990, 1993, and 2000, approximately 40% of the information in the NPDB is incorrect. I doubt that the percentage has improved over time. We are used to the inefficiencies of Federal Agencies, but name me another organization which could have as much as a 40% failure rate and still exist…and on the taxpayer dime?


It is very much the case that reports can and very often are arbitrary, simply punitive, and serve no purpose in the furtherance of “protecting the community”. A nice read on this would include:  B. Abbott Goldberg, The Peer Review Privilege: A Law in Search of a Valid Policy, 10 AM. J.L. & MED. 151, 154 (1984). I believe—from my own experience of the process and the lack of recourse once reported by an organization who made up the charges in retaliation for reporting a negligent homicide at their facility—that the NPDB is as malignant an organization as the EPA or the Bureau of Land Management and should be abolished. Every once in a while, a doctor prevails, but the Poliner cases out there are very rare.


Name Withheld

Other messages in this thread:



From: Scarlett Kinley, DPM


Liquid Rubber Appliance Laboratory (manufacturer of latex shields) of West Orange, NJ is an “old school” business still making this good device for high pressure and high-risk bone prominences for patients needing or desiring to avoid surgical treatment. They make several devices for nine areas of the foot. They send a paper invoice with the device and the positive cast; payment is by check only, I believe. 


Scarlett Kinley, DPM, Clearwater, FL



From: Hal Ornstein, DPM


Yes, you are correct, students are in need of practice management and a foundation for their future. With this is in mind, The Institute for Podiatric Excellence and Development (IPED) was created two years ago to motivate, inspire, and synergistically bridge the gap between podiatry students, residents, new practitioners, and seasoned veterans. Much focus of this non-profit podiatry association is to help students and residents with mentoring and resources. It is free to join.


A great resource and source of practice management information for students and residents is Podiatry Management Magazine, a wealth of knowledge. I suggest students and residents get a three-ring notebook and articles, categorize and keep these as a practice management resource for the future. They should also subscribe to PM News and read it daily. Take advantage of visiting practicing podiatrists at every opportunity and keep notes on points learned. Spend time in the back office, at the front desk, as well as in billing.


When at meetings, attend as many practice management lectures as possible. The hope is that the podiatry schools will provide more practice management classes to prepare the students for their future. If you are near a podiatry school or residency program, look to volunteer to speak with the students about practice management and open your door for visits. Together, we can all make a difference for the bright future of our profession.


Hal Ornstein, DPM, President, IPED



From: Brian Kiel, DPM


Using tube foam, cut alongside to allow it to fit over the hallux. Let the hallux extend through the end of the tube foam. Cut it so it extends proximally past the MPJ about 2-3 inches. Remove the tube foam and in a small bowl pour liquid latex over the tube foam and work it into the tube foam so it is soaked. Place on the hallux, cover with a plastic bag and then place the sock and shoe on the foot. 


Make your own latex bunion shields.


I tell patients to keep the shield on until bedtime and then gently loosen and suspend it on a pencil so it does not lie flat. The next day, they bring it in and I re-soak it in latex. Once this has dried, you can trim any excess off. If you want a thicker bunion shield, add a third dipping. I have had patients use these for several years. 


Brian Kiel, DPM, Memphis, TN



From: Steven J. Kaniadakis, DPM


This also seems to be a trend among other generic medications. Try writing as Merpergan Fortis. Although the two are essentially the same, some generics, even brand names, are sending limited to no supplies to pharmacies. For another example, CVS and several pharmacists reported that the manufacturer company named Mylan is not providing its generic supplies of some medications it typically delivers. 


Steven J. Kaniadakis, DPM, Saint Petersburg, FL



RE: Practice Management Education for Students/Residents

From: Paul Busman, DPM, RN


I had the opportunity to talk to a second year Temple podiatry student the other day. After chatting about her experiences and impressions of her education and podiatry in general, I asked her if, these days, they were giving students any education on the nitty gritty of running a podiatry practice in today's medical environment. She told me that she hadn't had anything formal in that area. 


Back in 1977, when I took over another practitioner's practice, things were relatively simple. Between the information I got from him during a brief preceptorship and the experience of his front desk person, whom I kept, I was ready to roll. I don't have to tell anyone here that as time went on, things got more and more complex in the area of running a practice to the point where, as I gather from PM News’ excellent newsletter, today's podiatry looks like more management and less podiatry. That's certainly how it felt to me when I retired from podiatry in 2007. 


If students aren't coming out of school and residency armed with management knowledge, how are they to survive? 


Paul Busman, DPM, RN, Frederick, MD



RE: Hardship Status for Non-APMA Members

From: Daniel Chaskin, DPM


Current members of APMA state societies can participate with a hardship status. Why can't this apply for non-members? One suggestion to boost membership in state societies is to allow for free or reduced membership dues for non-members who cannot afford to pay the full dues to join. 


Daniel Chaskin, DPM, Ridgewood, NY



RE: Cimetidine and Liver Damage

From: Richard Rettig, DPM


PICA just released a case study of a patient with hepatitis C that developed liver failure soon after being prescribed cimetidine (Tagamet) for off-label use for verruca. As podiatrists, we are aware of the anecdotal success of Tagamet for warts. Tagamet was the first H2 blocker approved in the U.S. It was followed later by Zantac (ranitidine) and then Pepcid (famotidine). It is presumed (anecdotally) that they all are equally effective in raising the immune response against warts. Tagamet and warts are ingrained in some of us just as Indocin and gout may be ingrained. In both cases, we can and should do better.


Indocin was one of the first NSAIDs and it was effective against gout. All the other NSAIDs are equally effective for gout, and the newer ones all have a much better safety profile. So there is no reason to prescribe Indocin for gout. Likewise, many podiatrists do not know that each of the successor H2 blockers have a much better safety profile. So much so that PCPs, even when these drugs were all prescription-only and commonly used, stopped using Tagamet altogether when the newer drugs were approved. 


According to the NIH regarding hepatotoxicity, cimetidine is rated "highly likely cause of clinically apparent liver injury." Ranitidine (Zantac) is rated "very likely but rare cause of clinically apparent liver injury" and famotidine (Pepcid) is rated "probable rare cause of clinically apparent liver injury." For those reasons, I suggest that Pepcid be used instead of Tagamet for off-label use in wart treatment (and that ibuprofen or naproxen be used for gout instead of indomethacin).


Richard Rettig, DPM, Philadelphia, PA



From: Charles Lombardi, DPM


1) Half of the dues Dr. Kass speaks of does not go to NYSPMA; it is in-actuality APMA dues we collect for them. 

2) The NYSPMA does NOT have sponsored speakers for lectures. The lectures are based on current areas of interest.

3) NO board member of the NYSPMA gets paid a dime from the Association or dues to meet numerous times a year at great personal expense.

4) NO board member of the foundation gets paid a dime to spend numerous hours coordinating the conference, meeting with legislators and insurance companies to help members and non-members advance the fight for their rights and the podiatry profession as a whole. Members get the conference credits for free because all these things COST MONEY.


Finally, Dr. Kass reminds me of the football fan sitting in the bleachers with a green face, yelling that the players are just bums who don't know what they are doing. He doesn't even have the courtesy to sit on the bench and pay his dues. He yells from the bleachers but benefits from the work the NYSPMA does on advocating on his behalf. 


Charles Lombardi, DPM, President, The Foundation for Podiatric Medicine


Editor's note: This topic is now temporarily closed.



From: Martin V. Sloan, DPM


Whenever cost of medication becomes an issue with my patient, I pull out my smartphone and go to the “GoodRx” app, click on it, and show the patient the options. Four or more pharmacies will pop up in your area with their coupon prices, usually SIGNIFICANTLY lower than what you’d expect. The app is free and available to everyone. 


Martin V. Sloan, DPM, Rockwall, TX



From: Allen Jacobs, DPM


Dr. Kass suggests that “most” podiatrists who are NYSPMA members are so only for access to CME credits. One wonders on what factual basis Dr. Kass draws this conclusion. Has he personally conducted a survey of the membership? 


There are many benefits to APMA membership. While I hold strong personal disagreements with some APMA policies, ultimately, they represent my profession. They are in effect my union. We, as a profession, cannot afford nor withstand divisiveness. If the only reason for membership in the APMA is to access CME credits, it is less expensive not to belong to the APMA, and satisfy the CME requirements while paying the increased "non-member fee." 


Finally, an observation from someone who has invested years of work and lost income and family sacrifice in both the APMA, ACFAS, and has "been around the podiatry block" for many years. The current NYSPMA leadership is as good as I have ever witnessed. In my opinion, the dues money spent by members is well spent. Yes there are problems. The NYSPMA leadership has been addressing those problems. The NYSPMA has also been proactive in identifying the future needs of its membership and working on those needs in order to protect the future needs of our patients and our profession.


Allen Jacobs, DPM, St. Louis, MO



From:  Ken Meisler, DPM


I agree with Dr. Kass that the NYSPMA meeting is not really "free" for members but paid for by our dues. However, I disagree with Dr. Kass saying that most people belong to the NYSPMA because they see value of getting their CME in one weekend. We belong to our state societies and the APMA because these are the groups that fight for us at the state and national level. Without these societies, I think we all know that we would be much worse off. A great example is the recent proposed changes in Medicare E&M codes that the APMA stopped from being implemented. 


The NYSPMA annual meeting is much more than just "getting your CME in one weekend". Nowhere can you see so many podiatry exhibitors in one place. Seeing many of these same companies on line is not the same. Plus, being around thousands of podiatrists is an exciting and informative experience and only possible at a few meetings a year. 


Most importantly, we should ALL join our local and state societies. Those of us that are not members benefit from the hard work of those groups. However, they also miss out on a lot of benefits they could get. If more people joined, the dues would go down also. Your state and local dues are monies well spent.


Ken Meisler, DPM, NY, NY



From: Jill Berkowitz-Berliner, DPM


Are you talking about the brand name drug or including generic terbinafine? The generic used to be on the $4 co-pay list at Target. When CVS bought Target, it went up to $5. As of 1/1/19, it is approximately $64, but with the pharmacist gag rule repealed, the pharmacist can use a coupon, making it approximately $24, according to one of my patients. 


Jill Berkowitz-Berliner, DPM, Mount Kisco, NY



From: Jeffrey Kass, DPM


I would like to respectfully challenge the assertion that NYSPMA offers free CME to their members at the NY Clinical Conference. Members pay $2,321 to be members. Claiming CME are free is a little silly. Most members belong because they see value in obtaining the required CME in the course of one weekend. Non-members can go claim that same weekend of credits for $949. Hence, NYSPMA is claiming the value of those CME is roughly $949. 


Jeffrey Kass, DPM, Forest Hills, NY



RE: CME in the 21st Century

From: Paul J. Liswood, DPM


The New York State Podiatric Medical Association (NYSPMA) offers free CME credits to our members at NY19, our clinical conference held each January. Our conference is one of the largest podiatry meetings.  We offer courses and hands-on workshops in both surgical and non-surgical topics, and is widely regarded as one of the best education events for podiatrists in the country. Being a member of NYSPMA also gives you access to additional educational and practice management opportunities, such as our coding and billing consultant and coding section on our website. 


NYSPMA is also looking to advance our members education and training to make them more valuable to insurance companies and state regulators. To that end, we have had discussions with officials at the NYS Department of Health (DOH) regarding increasing podiatrists' role in fall prevention, a stated goal of the New York State Prevention Agenda. NYSPMA is preparing a CME certifying course in fall prevention as a member benefit, and those members completing this course will have their names forwarded to DOH and insurance companies as podiatrists with advanced training in fall prevention. This will have a beneficial effect on those members and will strengthen podiatry. 


Paul J. Liswood, DPM, President, New York State Podiatric Medical Association



RE: CME in the 21st Century

From: Charles F. Ross, DPM


Having attended seminars, and having lectured as well at local, state, and the National for the past 45 years, I have noted significant changes in programs. We have parted ways with the foot care that created "our" specialty and the ability to perform a simple task that rendered patients relatively pain-free ambulation immediately after care. 


The predominant lectures today focus on surgical prcedures that were not even available when we were in training. I applaud all those who are 2 and 3 years surgically-trained practitioners and all that they have done to advance our profession - BUT- during my final years in practice and during my current employment at the VA, I can honestly state that...


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



From: Alan Sherman, DPM


I am interested in the issue that Dr. Silhanek raises regarding the limitation that some states impose on earning CME online or in print, and agree with her, that we should all be allowed to earn our CME in the most convenient and effective manner. Whether that be live or online will depend on the person. Although I do own and run PRESENT e-Learning Systems which delivers over 20,000 CECHs annually, as we run both live conferences and offer online CME, I have two dogs in this race and wish that both could win.


Most of all, I believe in freedom of choice and do object to states limiting how much credit is permitted to be earned online. Polling done by Barry Block and us clearly shows that podiatrists want freedom to earn their CME in that way that they feel provides the most convenience and effective learning. Having this data, why are the states still resisting? We should all make our opinions known to our state associations and boards of podiatry to get these regressive regulations changed.


Alan Sherman, DPM, CEO, PRESENT e-Learning Systems



From: Alison Silhanek, DPM


I have been thinking more about this.

1) I realize that the organizations that hold these conferences think they rely on the revenue generated by attendees. But here’s the thing: if they hired videographers to record the lectures and panel discussions, had the lecturers each create a short test that would confirm the viewer actually watched the lecture (like Podiatry Management does with its online CME articles) and charges a reasonable fee to take the test and thereby gain the CME credits, those organizations are gaining a revenue stream from podiatrists that they might not have otherwise reached. It’s a “win-win”. 

2) I don’t know how we would work to change the rules of the various state education departments. I’m just suggesting that, if many people agree with this idea, maybe our state and national organizations should try.

3) Regarding Dr. Steinberg’s reply, I have great respect for his opinion, but I do not see conferences as having much social benefit (for me) anymore. As a solo practitioner, if I have to shutter my office for a week, I would rather spend that week exploring the temples of Cambodia or the coastline of Croatia, but that’s just me. And then I would prefer to get my CME credits at 2 am sitting on my couch in my PJs. But his points are well taken as that might just be my own preference.


Alison Silhanek, DPM, Smithtown, NY



RE: Payment Disparity Between DPMs and MDs  (Jeff Kittay, DPM)

From: Ira Baum, DPM


Dr. Kittay is mostly correct. As long as we do not have MD or DO after our names, podiatry will be viewed differently by third-party payers and the general public. PM News has had discussions regarding changes to our degrees ad nauseum, and it’s a complex topic too long for this post. The other method, also discussed many times, is the legal avenue. Unfortunately, the profession either doesn’t have the money, the gastric fortitude, or a compelling argument to win a court battle to gain equal pay for equal service. Unless one of these two avenues is explored, nothing will change. Even if the future of podiatry is for all podiatrists to become affiliated with large single or multiple specialty groups, the financial future for podiatrists doesn’t look promising.


Ira Baum, DPM, Naples, FL 



From: Jeffrey Kass, DPM


Dr. Silhanek makes some excellent points regarding “CME in the 21st century”. One possible mistake in the posting was the statement “we, as are all physicians, are regulated to participate in a specific number of CME credits per year.” Once again, podiatrists are not considered physicians in this realm. In NY, podiatrists must log 50 credits per three years to renew their license (maximum of 25 home study). MDs in New York do not require any CMEs in New York.


This, in my humble opinion, should have been used as part of the podiatrists' argument for expanded scope. Podiatrists with their limited anatomy are always staying current, whereas MDs with a broader license don’t have to. Hence, the MD may not actually be up to date on advances in medicine.


I agree with Dr. Silhanek that one should be able to obtain all CME online if they so desire. There is no reason in the 21st century that one should have to pay for flights, hotels, etc. if they don’t want to. I am curious as to who sets the state rules for CME credits? Is this the Board of Podiatry for the particular state? 


Jeffrey Kass, DPM, Forest Hills, NY



From: Robert Scott Steinberg, DPM


At the CME meetings I attend, there are multiple tracks going on at the same time. I do not see how Dr. Silhanek knows who does or does not attend lectures! Getting together with colleagues should not be dismissed. I am not a fan of online CME. Oh sure, it's easy, maybe far too easy. Yes, it is cheaper. What I think is more problematic is the money being taken away from state associations when someone pays to attend non-member organizations' CME - part of what helps to keep our dues down is the money that comes from state association-sponsored conferences.


Robert Scott Steinberg, DPM, Schaumburg, IL



RE: Payment Disparity Between DPMs and MDs

From: Jeff Kittay, DPM


Though I have been out of practice for more than three years, I do read PM News regularly and am thrilled that I no longer have to deal with the myriad governmental intrusions and regulations that active practitioners must endure in attempting to make a living. That said, the argument made in several recent letters regarding the “payment parity” issue existed before I went in to practice in 1979 and apparently persists. No DPM, no matter how good his/her training, will ever receive the same payment for the same billed level of service as MD/DO trained physicians, and they should stop dreaming about “parity”. 


Until the degree students receive says MD/DO, insurers will assume, right or not, fair or not, that the level of training and expertise is NOT equivalent. How many DPMs are expert at...


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



From: Bret Ribotsky, DPM


I believe that Dr. Silhanek brings up an interesting discussion that we all need to entertain. A very common thought is that the purpose of obtaining credits is to maintain licensing and to keep privileges, while the truth is why we all need credits is to continue our knowledge, so that we can practice medicine at the highest level possible. We all have seen many who just show up to get the badges scanned. Whose fault is this? Should we blame the seminar for not having speakers charismatic enough to pack the room, or should we blame the state regulations for requiring so many credits each year?  


Do we really need a sales pitch on an expensive treatment with zero new research on onychomycosis, or a lecture from a politician (with no published research) who secured a position on a speakers bureau. To me, it's crystal clear who is to blame, and it’s the person you see each day in the mirror.  


The 21st century cure is something all should participate in. The seminar should have speakers and information that delivers incredible value. The attendees should be responsible for being in the room learning and this can be monitored via GPS and smartphone technology available. States should not judge CME by hours, but by content needed each year for practitioners to master. I can dream. 


Bret Ribotsky, DPM, Boca Raton, FL



RE: Payment Disparity Between DPMs and MDs

From: Tom Silver, DPM


It's sad to hear the responses to my initial post regarding MDs across the board getting paid a lot more for new and established office visits than the same visit codes I submit as a DPM. There had been a lot of prior discussion regarding when to use a level 3 or 4 visit for patients, but it still doesn't make much difference when MDs are getting up to 3 times what we get for every office visit!  


I did an analysis of insurance payments on all office visit codes for 2018, and we were paid approximately $95K for visits. And MDs would have been paid up to an additional $190K more for the same visit codes!  This is no small difference, especially for a solo practitioner and would really add up for group practices!


I don't think we can "just accept this because we don't have an MD degree" or are part of a large group that can negotiate fees. Hopefully, the APMA and state associations can work together for us to by putting the "group practice" pressure on insurance providers that is needed to change this gross discrepancy and gain some payment parity for us!


Tom Silver, DPM, Golden Valley, MN



RE:  CME in the 21st Century

From: Alison Silhanek, DPM


As I endeavor to collect my CME for hospital recredentialing, I have begun to re-evaluate the entire experience of CME. Specifically, the cottage industry that promotes “live” CME. I see this question as generational. After being in practice for 20 years, I fully see the value of not only CME but live workshops for certain learning experiences— surgical, biopsy, etc.


But we, as are all physicians, are regulated to participate in a specific number of CME credits per year. In my state of NY, it is required that a hefty percentage of those hours be live. I question this. To be frank, these conferences cost a lot of money; the same lecturers show up every time and those speakers end up benefiting in the long run more than attendees. (If you are a regular speaker and disagree, so be it.)


More importantly, most attendees at these live conferences skip the lecture and show up to have their badges scanned to get credit. At least with online courses (like those offered by Podiatry Management), one actually has to read the article and take an exam to get credit. Can’t physicians enter the 21st century already?


Alison Silhanek, DPM, Smithtown, NY



From: Richard M. Cowin, DPM, JD


I highly recommend the Facial Plastics Camera from The cost is $795. We utilize a label maker to print the patient's first initial, last name, and the date. We attach it to the foot and take the photo(s) which are stored on an SD card. We then remove the SD card from the camera and upload the images to the patient's EHR record. 


Richard M. Cowin, DPM, JD, Orlando, FL