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From: Estelle Albright, DPM


I am surprised from the survey that so many podiatrists are still grinding nails. To those podiatrists who are still grinding fungal toenails: Please consider the considerable risks to self and staff caused by nail grinding: lung granulomas, and fungal sinus or lung infections caused by aerosolization of fungal nail particles or spores. Also, consider the risk to staff for cleaning, disinfecting, and sterilization procedures of re-usable burrs.


I am of the opinion that we, as physicians, should instead treat the infection medically or surgically. There are many safe oral and topical antifungal meds available, as well as surgical treatment of fungal nails. If none of these are an option, consider double action bone cutters to debride thick nails. These do a very decent job on thick, hard nails and are easier on your hands. For ingrown edges, Miltex 40-22A ultrafine nail splitters are excellent for simple nail edge avulsions.


Estelle Albright, DPM, Indianapolis, IN

Other messages in this thread:



From: Dan Michaels, DPM


We have banned all forms of grinding of nails. We use Miltex double-action nail nippers with straight jaws for debriding nails. These are very similar to double-action bone cutters. Patients are satisfied with this. You can get the thickness and the length with this method. You don't put yourself at risk of inhaling any irritants this way, and you can sterilize (with autoclave) your instruments when done. I published my instrument preparation protocol in PM News (and in Podiatry Management Magazine) a few years ago.


Dan Michaels, DPM, Frederick, MD



From: Elliot Udell, DPM


When literature out of England came out many years ago showing that podiatrists who grind mycotic nails were at risk of developing pulmonary problems, I took all of my drills and tossed them in the pail. Being an allergy sufferer, even the expensive vacuum systems did not prevent me from wheezing after doing a nail grinding.


How did my patients react to this change? Some left for other podiatrists, but most stayed. I explained to them that not only will they be breathing in their own mycotic nail dust, but they will be breathing in the infected dust from every other patient we saw in the last 12 hours.


I also believe that there are OSHA laws that require that a treatment room be left unused after grinding infected nails for a period of 8-12 hours. This makes sense and I do not regret not grinding toe nails. We all took the oath to help and do no harm, and grinding mycotic nails dances on the border of violating this oath.


Elliot Udell, DPM, Hicksville, NY



From: W. David Herbert DPM,JD


Well over 20 years ago, I was appointed to the committee of podiatry examiners for the state of Wyoming. I was really surprised at the lack of knowledge about basic anatomy and biomechanics some of the examiners demonstrated. Some of these podiatrists had completed several years of residency training. If a lower pass rate on the board exam will mean that only better prepared individuals will obtain hospital privileges, I believe that this will ensure that the podiatric profession will be more widely accepted as the foremost authority on the treatment of the foot and ankle.


W. David Herbert DPM, JD, Billings, MT



RE: Will eliminating the ACA mandate help podiatry? (Joel Lang, DPM)

From: Bryan Markinson, DPM


Dr. Lang seems to intimate that it is obvious that podiatry as a profession is better off with the ACA mandate requiring the purchase of health insurance. I am not so sure. My vantage point is from an academic medical center-based practice which is a full-time private practice and a part- time hospital clinic practice. The private SPECIALTY practices largely do NOT participate with most plans offered on the health exchange, which is also true of most of the community-based podiatrists (this is a supposition that I cannot verify). 


The specialty clinics largely do participate with the exchange plans, which seem to be nothing more than...


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



RE: Will eliminating the ACA mandate help podiatry? (Joel Lang, DPM)

From: Judd Davis, DPM


I must respectfully disagree with Dr. Lang's assessment of the ACA. Since he is retired, I suspect he is not seeing the reality of the ACA in a private practice setting. I am one of the 34% who feel the ACA has been a massive failure for the following reasons: 


1) Most of the ACA plans have huge deductibles, essentially providing catastrophic coverage only. Many of the people who sign up for these plans are completely unaware of this and surprised to find their entire...


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



From: Joel Lang, DPM


In a recent PM News Quick Poll questioning if podiatrists would be better off without the Affordable Care Act, I was astounded to discover that 34% thought they would be better off and another 27% were unsure. 


Without the ACA, the Congressional Budget Office, a non-partisan governmental agency estimated that 13-26 million people will lose their health insurance. The currently debated tax bill has been rated by the same agency to increase premiums by 10% and result in...


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



From: Robert Scott Steinberg, DPM


What positive change would the elimination of the ACA bring for a podiatrist in practice? I really would like to know.


Robert Scott Steinberg, DPM,  Schaumburg, IL



From: Adam Siegel, DPM


Maybe I am young and naive, but can someone please explain why paper charting is better than an EMR? A properly organized and implemented EMR can save a practice thousands of dollars a year (even after taking into account the costs for the EMR). Jon Hultman, DPM's book The Medical Practitioners Survival Handbook should be required reading for anyone still using or wishing they were still using paper. Pay close attention to chapter three where he gives you hard numbers on how much money you can save (hint: it's a lot).


Adam Siegel, DPM, Lutz, FL



From: Lenny La Russa, DPM


I prefer EMR. I can make a more comprehensive note in a fraction of the time dictating into SamNotes with Dragon Dictate. It is also easier to comply with MIPS.


Lenny La Russa, DPM, Americus, GA



From: Richard M. Adams, DPM 


For the past three years, I have been using a company based in Little Rock, AR called MedOptim. They are a remote, electronic-based scribe service so there is no need to have another person crowding the exam room. They enter all pertinent information directly into my EHR and are literate in many, many different EHR formats. My only responsibility is to review and proofread/sign my notes. The service is fantastic!  Not only have they made my life easier, but they remind me when I forget to "dictate" certain aspects of the patient encounter, thereby adding another layer of accuracy to my notes. They are highly recommended.


Disclosure: I have no financial interest in MedOptim or any surgical scribe service.


Richard M. Adams, DPM, Granbury, TX



From: Paul Kesselman, DPM


Last week's poll on proper HCPCS coding definitely illustrates the need for greater education for all orthotic providers. I agree with Dr. Blanken that despite the many court battles (even more than the California case cited by Dr. Blanken) in defending the use of L3000 (all of which we have won), there appears to be a general absence of knowledge of over 25% of those brave enough to respond to this poll. That is, more than a quarter of our colleagues are unaware of the correct code to use, with greater than 5% of the opinion that L3030 (custom fitted orthotic) is the correct code. 


For those unaware, L3030 is the code used to describe a pre-fabricated device which is then...


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



From: Steven Selby Blanken, DPM


It is amazing to see that 16% of the profession use the wrong code for foot orthotics. Most of us know about the problems years ago that happened with Blue Cross of California with trying to retract money for the L3000 code. They eventually lost and had to pay back all the podiatrists. Most podiatrists who dispense proper foot orthotics should be using the L3000 code for each foot.


Steven Selby Blanken, DPM, Podiatry Consultant, Performance Laboratories



From: Joel Lang, DPM 


In the last PM News retirement plan survey, I noted that about 11% of podiatrists have no retirement plan. That is really bad – and it’s all in the “thinking”. 


I suspect the majority of those 11% are new practitioners who either think they can’t afford to put money away at this time because of their low income and high student loans, or those who are short-sighted and think that the need for retirement funds 30-40 years down the road is not...


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



From: Ken Malkin, DPM                              


As a delegate to the APMA House of Delegates, I actually asked for the straw poll from our delegates. There was no deep thoughtful discussion before the vote, just a number of events that occurred during the meeting making it clear that the 4-4-3 year model of training young podiatrists should lead to a more enhanced scope of practice. My first comment to those 10% who voted against a name change was that they were a bunch of dinosaurs.


One young bright New York delegate, Andy Shapiro, said he was one. Since then, I have heard many more opinions against the name change that I think have merit. On Thursday, APMA sent an email to its members explaining that a long process was planned before anything is POSSIBLY proposed. So stay tuned.  Sorry, I was wrong and caught up in the moment. 


Ken Malkin, DPM, Boynton Beach, FL



From: W. David Herbert, DPM, JD,  Eric J. Lullove, DPM


I believe the better way to go would be to change the name to "The American Association of Podiatric Physicians and  Surgeons (AAPPS)." There would be no restrictions on pursuing an expanded scope of practice because of the specificity of the name.


W. David Herbert DPM, JD, Billings, MT


While I can respect the need to eventually make a name change with regard to the American Podiatric Medical Association, I am not sure that the name change to the American Association of Foot & Ankle Specialists is appropriate. My recommendation to the APMA would be to take a page out of big business….hire a PR Firm to re-brand the APMA to something that will hit on social media, the Internet, marketing, and BRAND podiatrists to a degree and level that the AMA, AAOS, SVS, and other organizations have built.  


If we all learn one thing from the last presidential election — branding is everything. Messaging follows. If this is the best name we can come up with, fine, then run with it. Otherwise, walk the name back and figure out a better name to rebrand ourselves. 80% of Americans own a smartphone. Do the math. If someone is looking for a DPM, most bets would be it is on their smartphone. Brand the APMA to something that is easily searchable, readable, and palatable.


Eric J. Lullove, DPM, Boca Raton, FL



From: Brian Kiel, DPM


There is no medical specialty called foot and ankle specialists. There are podiatrists and orthopedic surgeons who specialize in the ankle as well as the foot, but no school gives a degree in the foot and ankle. This change completely eliminates the word that defines who we are. Now, if the desire is to mask who we are and pretend to be something we are not (hint-hint), then this might work, but I am a podiatrist and want to be known as one. Thirty or forty years ago, the general public was not as familiar with the word podiatrist, but now not only they but the medical profession knows us as such.


We get MD referrals who tell their patients that they need to see a podiatrist, not a foot and ankle specialist. If we become foot and ankle specialists, what is to separate us from orthopods? Nothing. We are podiatrists; we treat the foot and ankle in various ways and the constraints of what we can do is often limited by law. All of us are not ankle surgeons, and to imply that we are is not good for the profession. What we do, we do well. No other profession comes close. Let’s not hide who we are.


Brian Kiel, DPM, Memphis, TN



From: Marc Jay Pinsky, DPM


I feel a possible name change for the APMA is a bad idea! It is not in our profession’s best long-term interests. The name: American Podiatric Medical Association carries with it “professionalism” – as does the: AOA, AMA, and ADA. “Podiatric” can be considered all encompassing! Whereas “foot and ankle” connotes a finite scope. No room is left for professional expansion. If the name change goes through, then any state wishing to expand their scope of practice into the leg or above, will be hampered by our national association’s name. 


“Why should we allow you to treat into the lower leg, when your own national association states you are just foot and ankle specialists?” How will we answer that? In Virginia, we are allowed to treat wounds on the entire “lower extremity”. We plan other scope expansions in the...


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



From: George Jacobson, DPM


Although this is what podiatric training entails, as podiatrists it would be unethical and deceiving to the public. As a former Ethics Chairperson (1990s) for Broward County Podiatric Medical Association, it is both unethical and a violation which could lead to a fine to advertise or be listed in a directory without identifying that you are a podiatrist. The individual would be reported to the State Board. Simply using DPM after your name would suffice, but listing your name as Dr. Top Surgeon would not. It's a bit disturbing reading this. 


Saturday, Allen Jacobs, DPM, lectured at Westside Regional Medical Center in Plantation, FL about ethics. He specifically pointed out to the residents in attendance the power and responsibilities imparted by...


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



From: Mark Phelps


I highly suggest any podiatrist and/or physician who performs surgery in the scope of any ASC and/or hospital to look into the SurgiStim and NeuroStim. The SurgiStim is an exciting breakthrough in non-narcotic post-op pain management. The NeuroStim is being used with chronic pain and neuropathy patients. Study after study is demonstrating the efficacy of using both devices over similar products in double-blind, placebo controlled studies. I have attached a synopsis of many research studies done on these products. Additionally, these are covered by most private insurers.


Disclosure: I currently educate and distribute these devices to a variety of physicians, including podiatrists. 


Mark Phelps, President, Partner Marketing



From: Tom Silver, DPM


There is no question that some patients can benefit from opioids but they need to be prescribed judiciously. I had knee arthroscopy a few years ago. The orthopedist said it would be a very simple procedure and no big deal, but gave me a prescription for 50 oxycodone with instructions to take 2 every 4 hours post-op until gone. This is criminal!  


I have done extensive forefoot surgery with some patients needing little to no pain meds post-op although every patient's pain tolerance varies. I typically prescribe 12-16 oxycodone or hydrocodone post-op, which is usually more then enough for most patients until the next post-op visit and occasionally a second Rx is needed.  I try not to give a patient any more than they really need. It's a red flag if they are quickly asking or demanding more "pain pills". Typically, we all know when something doesn't smell right, and we shouldn't be that patient's drug dealer!  


On the other hand, if someone is really having that much pain post-op, then either we need to look for other causes of the pain (tight dressing, infection, etc.) or try other methods of pain management besides narcotics. Pain management is one of the fastest growing areas for research and training in medicine today...and for good reasons. I highly recommend reading the book Dreamland: The True Tale of America's Opioid Epidemic by Sam Quinones, as this will make you think twice about every narcotic prescription you write!


Tom Silver, DPM, Minneapolis, MN



From: Elliot Udell, DPM


The heart of this problem is not whether we should or should not be prescribing opioids. The real question is what conditions we as podiatrists should or should not be treating with opioids. 


No one will argue that after a major surgery, a patient will need medications to control his or her pain. In some localities, leaving a patient in pain by under-medicating the patient, post- operatively, is considered an act of negligence. The salient question is whether...


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



RE: -FX Modifier for X-ray Films

From: Greg Caringi, DPM


My office manager tells me that she has been adding the -FX modifier to our Medicare x-ray claims since January 1, but it has consistently been rejected by our clearinghouse as an invalid modifier. Is anyone else experiencing this problem?


Greg Caringi, DPM, Lansdale, PA



From: Joseph Borreggine, DPM


This is a sound campaign promise, "Repeal and replace Obamacare". But, alas like most campaign promises, they cannot be fully met or even executed without the full support of the Congress. The problem with this promise is that it is ideological to believe that a government 

bureaucracy will be repealed, let alone replaced. I have never seen that happen. 


All the entitlement programs including Welfare, Public Aid, and other government benefit programs like Medicare and Social Security are all tightly held by politicians to be "sacred cows" of the...


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



From: Ron Werter, DPM


I ask those who voted that it will benefit us, what do you know that I don't? Do you think that the insurance companies will suddenly increase their payments to us? Do you think they will lower deductibles? Will they have more out-of-network benefits and payments? Will there be less restrictions and prior approvals needed? Will we go back to 1987?


I'm not asking if you felt the ACA was good or bad; I'm asking what it is that you think the insurance companies, who have figured out how to get more money from us at all times, will do to give us a better income. 


Ron Werter, DPM, NY, NY 



RE: How many times in 2016 did a technology problem (EMR, digital x-ray) cause you to be unable to access a patient's chart or to take an x-ray? ( Al Musella, DPM)

From: Elliot Udell, DPM


Dr. Musella states: "Imagine if a company like Practice Fusion got hacked or went out of business." A technology company going out of business is not an imaginary scenario. We have seen many companies either go out business, discontinue a product, or invent a new one and refuse to support older versions of the product. Many of us who invested in Medinotes can remember when they were bought up by another company only to be put out of business. This can happen with computer software and hardware as well as any new diagnostic or therapeutic modality that we might choose to invest in. The therapeutic benefit of any device has little to do with how it succeeds in the marketplace.


Regarding EHR software where notes are stored in "the cloud," if a company should go belly-up, you could lose all of your patients records. Hence, it is advisable to either make back-up copies of all patient records or make paper copies of medical records. As for investing in new expensive diagnostic or therapeutic technologies, digital x-rays being only one of many, any investment is a gamble. The good news is that some of these technologies can greatly enhance healthcare. The bad news is that if a company goes bust, you are still obligated to pay the balance of your lease, even if the product can no longer be used.


Elliot Udell, DPM, Hicksville, NY
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