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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: Alan Sherman, DPM


The just concluded PM News poll showed that only 26.30% of responders think their state allows them to earn ALL (100%) of their CME online, and 42.81% of responders think their state limits them to earning only 1-25% of their CME credit online. This is just plain inaccurate. In fact, 30 of 50 states or 60% allow podiatrists to earn ALL (100%) of their CME online and only 11 of 50 states or 22% limit CME earned online to less than 25%. 


The PM News poll had a small sampling of 327 of the entire podiatric community and that may explain why the results are inaccurate. It may also be that podiatrists don’t know what their state allows. These statistics that I quote are researched, compiled, and maintained as a service to the profession on the PRESENT Podiatry website. The reality is, that while 40% of states do limit you as to how many CMEs you can earn online, the majority allow you to earn ALL CME online. It’s notable that Connecticut and Montana currently have no CME requirement at all for podiatrists.


Alan Sherman, DPM, PRESENT e-Learning Systems



From: Alan Sherman, DPM


I’ve been following the discussion on CME in the 21st Century with great interest, as well as the current poll that PM News is running, “What percentage of your CME requirement does your state allow you to take online or in print?" The response rate is low for PM News polls…and I believe that is because so many podiatrists don’t know how many credits their state board allows them to earn online. We keep an up-to-date list of state CME requirements including how many credits each state allows to be earned online and I think podiatrists would benefit from knowing this link. 


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



From: Al Musella, DPM


This is a very important topic that is going to affect the future of our profession. Like most of us in practice for over 10-20 years, I have never been denied acceptance into an insurance panel. In the old days, the insurance plans sought us out and tried to get us to participate in their plans.


However, it is very hard for the younger generation to get into these panels. My son joined my practice recently. When he applied as an individual, he was refused by most of the insurance plans. Only by applying as a member of...


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




From: Joseph Borreggine, DPM


Dr. Anderson, I must applaud your ability to use CPT 99214 on the majority of patients that require an E/M code. You opine that we, as podiatrists, are too "routine" with our E/M coding and should use 99214 more than we are doing. I agree that it is under-utilized, but to use it for the majority of patients that require an E/M code is a little too presumptuous. 


I would consider using due diligence when using this code or even CPT 99215. The fact that the most frequently used E/M CPT code by podiatry is CPT 99213 is based on... 


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



From: Randy Anderson, DPM


I am truly saddened by the results of the poll regarding the use of CPT codes 99211-99215. The use of EMR, for the most part results in a physical exam that easily reaches the level of 99214, so the difference in the codes is the level of medical decision-making, unless of course you use the time spent with the patient method. So, based on the results of the poll, my question to my colleagues is do we as a profession really value our skills so poorly? When we treat a patient with multiple medical problems does our decision-making not rate even a moderate complexity?


I use CPT 99214 for the majority of my EM charges. For all patients, I evaluate their...


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



From: Ben Cullen, DPM


I strongly recommend that no one use phrases in their dictation such as the statement by Dr. Musser. The legal department at my hospital says that: "The physician's signature on the record is the physician's confirmation that the information is accurate and complete. A disclaimer cannot be used to evade that responsibility. Simple, overlooked typos may be explained in court; however, a blanket attempt to avoid responsibility for the content of the record is a plaintiff attorney's dream."


Ben Cullen, DPM, San Diego, CA



RE: Should podiatrists be allowed to trim fingernails? 

From: Christopher A. Orlando, DPM


I'm reading the various opinions about fingernail trimming. Unfortunately, this is a sad testimony  to our image with the general public. We hold ourselves up to be podiatric physicians and surgeons with extensive training who provide state-of-the-art medical and surgical care that is superior to that of orthopedists. There has been talk about a DPM-MD degree. Yet the public continues to perceive us as nail trimmers. 


Many times, patients come in for medical and orthopedic issues, and in the course of the encounter, they say "by the way, can you trim my toenails?" It’s hard to say no. It has nothing to do with the purpose of the visit. Getting paid extra for it is irrelevant. I find it demeaning. Trimming fingernails sinks us even lower. How can we achieve parity with orthopedists when our global image is so poor? I'm out of ideas. Any suggestions? As Dr. Leonard McCoy of Star Trek would say, "I'm a doctor not a… (manicurist)!"


Christopher A. Orlando, DPM, Hartsdale, NY


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



From: Elliot Udell, DPM


Dr Kass raises a good point. Why shouldn't podiatrists be allowed to cut fingernails when manicurists with no college education are permitted to do so? I looked up what a manicurist must do to be licensed in my state. He or she must take a 250-hour course and then pass an exam. There are also separate licensing fees as there are with any other profession. 


The solution to those who feel impelled to cut someone’s fingernails in a state where it is out of scope for podiatry can choose to take such a course at one of the cosmetology schools, pass the exam, pay the licensing fees, and then if a patient asks you to cut his or her fingernails, you will be able to do it  without worrying about violating the law.


Elliot Udell, DPM, Hicksville, NY



From: Jeffrey Kass, DPM


The question posed on PM News is whether or not podiatrists should be allowed to cut fingernails. Most have chimed in that they should be allowed; some admit to doing this already. Those that say you can’t, due to the law, appear to agree that we should be able to. It would seem logical that a profession so deeply rooted in nails be able to treat the nails irrespective of the hand or foot. 


Leadership in the profession should duly take note of what and how their constituents feel about these topics. On previous occasions, flu shots and acupuncture have also been brought up. Podiatry as a profession should always look to do what we are trained to do. The fact a manicurist can cut fingernails with no education whatsoever and we can’t is illogical. 


Jeffrey Kass, DPM, Forest Hills, NY



RE: What do you charge for a pair of typical custom orthotics? (Joel Lang, DPM)

From: Matthew Richins, DPM


My billed amount for custom orthotics is $600. I personally guarantee them by giving the patient their full amount back if I cannot resolve their pain after three adjustments. In twelve years of private practice, out of multiple thousands of orthotics, I have refunded two. Many patients do not come back, but as physicians, it is our goal for them not to come back! I am confident they are satisfied; else they would return for adjustments and eventual refunds. Here, in rural Missouri, most do not walk away from $600.


I have not had a need for a plantar fasciotomy in years because I take the time to deliver a quality product to my patients. Since $600 is the cost to avoid the finance, pain, downtime, and risk of surgery in my office, if the guys down the road start charging $625, I will raise my price to $700. You should indeed get what you pay for.


Matthew Richins, DPM, Joplin, MO



From:  George Jacobson, DPM


I believe in what Dr. Lang expounded. A good pearl of success for me has been to utilize strappings as an indicator for potential orthotic success. If a patient consistently felt better after each strapping (3 weeks), then there is a good chance that an orthotic manufactured from holding the foot in the same position as the strapping will succeed. Even with that caveat, I could never get used to an orthotic myself. 


Last year at a meeting, Light Orthotics were fabricated for me, and I wore them with no ill effects. I saw an advertisement on PM News for them, but I had never followed up. For the first time in 30+ years, ...


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



RE: What do you charge for a pair of typical custom orthotics?

From: Jill Berkowitz-Berliner, DPM


Different doctors charge different fees for their orthoses based on many factors: lab fees, time spent casting in plaster/foam/scanning, staff and doctor time, storage, etc. Some (i.e. in NYC) charge ridiculously high amounts. I am always happy to give patients a discount if OTCs have not helped, or do not "fit" their feet, and they don't have coverage for custom devices (which is, as we know, an increasing problem). 


That aside, I do not see why it is "bad" if the orthoses work, and the patient does not come back. Aren't we supposed to help our patients? Isn't a "cure" a good thing? They will likely refer friends and family, so the good will goes on and on. Eventually, the orthoses will need refurbishing, or the patient may want a second pair. We give a significant discount on additional pairs, since I don't need to make another negative (our lab scans their positive and stores it indefinitely). Patients appreciate that. 


Jill Berkowitz-Berliner, DPM, Mount Kisco, NY



From: Jack A. Reingold, DPM


I think Dr. Lang's response is probably typical of that of many podiatrists. I do not mean to single Dr. Lang out (I appreciate that he took the time to write them), but I have to disagree with his line of thinking. Perhaps the survey is how much is a typical custom orthotic worth? I personally feel that an orthotic that doesn't work is worth about $2.00 (for the materials) and one that works is priceless (at least to our patients).


An orthotic is just a piece of plastic or cork or whatever. It alone is almost worthless. However, when you add in your time, expertise and produce a functioning device, it is worth much more! When I charge for an orthotic, it is not for the device, but for...


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



From: Joel Lang, DPM


I was not surprised by the results of the recent poll regarding the fees for orthotics. While orthotics are a useful tool in the spectrum of podiatric treatments, the fees reflect that they 

represent more of a profit center. Here were the results:

  •  90% of responders charge more than $300

  •  40% of responders (the largest group) charge $400-$500

  •  20% of responders charge $500 or more (I wonder what the upper limit is).

I may be old fashioned, but my mentors taught me that...


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



From: Martin V. Sloan, DPM


Regarding this week’s survey question about being eligible to participate in MIPS in 2018, I wish there was a 5th optional answer, “I don’t know”. The more I read, the more confused I am with MIPS. Ditto for MAPS, MOPS, and MACRA. I’m not a computer guy. I’m a foot guy, saving soles one foot at a time since 1984. 


Martin V. Sloan, MS, DPM, Abilene, TX 



From: Elliot Udell, DPM


The initial results of the survey being conducted on PM News indicate that the majority of podiatrists are not giving tetanus injections. The questions that should be asked is "why not?"


Let me preface this by saying that in our practice, we used to give tetanus vaccinations to patients presenting with puncture wounds along with a history of not having had one in ten years. We stopped doing this when the cost of storing the vaccine, which has a short shelf life, became overwhelming. That being said, I often wonder if we are professionally obligated to bite the stiff economic bullet and make this available for patients with puncture wounds. The window of opportunity for vaccinating a patient who sustains an infected puncture wound and contracting tetanus is very short, and if we miss that opportunity and the patient does indeed develop the disease, are we liable?


What we do now in our practice is that we send the patients to an internist or to urgent care for the shot, but what if those sources are not available on the day the patient presents with the puncture wound? Could I be held responsible for not giving the injection?


Elliot Udell, DPM, Hicksville, NY



From: Harvey F. "Bunny" Brown, III, DPM, Ivar Roth, DPM, MPH


The term we use here in Arkansas is: podiatric physician and surgeon. 


Harvey F. "Bunny" Brown, III, DPM, Little Rock, AR  


To avoid confusion, I now say I am a podiatric foot and ankle surgeon. I did three years of a surgical residency so I think that is a fair description.


Ivar Roth, DPM, MPH, Newport Beach, CA



From: Ivar E. Roth DPM, MPH


I would like to take exception to Dr. Harvey’s comments about Saturday office hours. I too did not have Saturday office hours(for over 30 years), until recently. My kids are off in college now and I decided that I wanted to expand my practice.


The only practical area for growth was to open up Saturdays, which I decided to do. Patients LOVE the convenience and it is our “casual” dress attire day. It is a big hit and I plan on opening up Sundays also now. Of course, I cannot work 7 days a week and I do not plan to. It will be a great opportunity to hire some younger practitioners who are eager to work and improve their finances. I see this as a win/win for everyone. I am curious as to how many  other practices out there are open on Sunday?


Ivar E. Roth DPM, MPH, Newport Beach, CA



From: Joel Lang, DPM


It is interesting that the current poll concerns Saturday hours. When I first started out, I did have hours on Saturday morning 9 AM to 1 PM. I think this is helpful for any new practitioner with lots of debts and bills and not so many patients. 


However, as my practice progressed, I gradually cut down on Saturdays. After a while, I worked only every other Saturday. Then the following year, I worked only one Saturday a month. The following year, I cut out Saturday hours completely. I think this is a good plan for any new practitioner in private practice as his/her Saturday patients gradually become adjusted to the new scheduling.


The best advice I got going into private practice was to "Practice on your first day the way you would like to be practicing 20 years from now, because it is hard to change once practice habits are formed."


Joel Lang, DPM (retired), Cheverly, MD



From: J. Scott Rosenthal, DPM


I agree with Dr. Roberts that attire is a personal decision and varies greatly with the locale and spirit of the office and patient population. I am admittedly one of those shameful podiatrists who dresses casually with slacks and a button down shirt. No tie, no white coat, no scrubs. Never have I had a patient question my attire, except for the few times when I happen to wear a tie for a meeting, when they often ask, "Why are you so dressed up?"    


J. Scott Rosenthal, DPM, Los Angeles, CA 



From: Narmo L. Ortiz, Jr., DPM


Once again, PM News visits the issue of what office attire our colleagues wear in the office. Nevertheless, when a colleague expresses his or her "feelings" on the issue in this forum, and blindly shames or belittles his or her colleagues for what attire they choose to wear in their office, it is very unbecoming and unprofessional. It speaks volumes about the person who claims to be a "professionally dressed" doctor.


Narmo L. Ortiz, Jr., DPM, Lakeland, FL



From: George Jacobson, DPM, David S. Wolf, DPM


My experience is exactly as Dr. Charles Morelli describes it but I still wear an embroidered lab coat over the scrubs.  We also pay for the staff's uniforms (embroidered scrubs ). I let them pick matching colors that they coordinate on different days of the week and with holidays. 


George Jacobson, DPM, Hollywood, FL


In my experience, patients don’t care how you are dressed or how much you know; they want to know how much you care.


David S. Wolf, DPM  (Retired)  Houston, TX



From: Jerry Roberts, DPM


Physician attire is a regional decision. I’ve practiced in areas where wearing a tie is a requirement and the absence is considered unprofessional. I’ve also worked in areas where scrubs are worn by many and wearing jeans with or without a lab coat is common. The primary focus is establishing trust with your patients while delivering the care they need. Any attire that detracts from this goal, whether it’s too formal or too casual or otherwise inappropriate, makes quality care more difficult to deliver. 


Jerry Roberts, DPM, Somerset, KY



From: Charles Morelli, DPM


When I first got into practice 28 years ago, I wore slacks, a dress shirt, tie, a new lab coat and $200 shoes. After the first year seeing my dry-cleaning bill soar into the thousands of dollars, I quickly changed how I dressed. If I was a primary care physician who did nothing more than check my blood pressure, listen to my lungs, look in my ears, etc., and then call in his nurse to do everything else, I too might dress in a shirt, tie, and a lab coat. In my practice as with many of us, I am continually exposed to not only wounds and bodily fluids, but also things like Betadine, silver nitrate, and gentian violet that can turn an $80 pair of slacks in to garbage (not to mention the shoes). The PCP does not, nor does any other doctor who does not do what we do.


I now wear clean, professional scrubs, embroidered with my name as well a crisp lab coat. I never dress “casually” as if I am going to leave and rush to my second job at Walmart. When I had my kidney transplant and met the man who was going to save my life, I assure you I didn’t care how he was dressed; or she for that matter. He walked into the room in scrubs and his hospital issued lab coat was professional, and he proceeded to take my history. Quite frankly, it was a comfort to see my surgeon dressed as a surgeon.


Charles Morelli, DPM, Mamaroneck, NY



From: Alison Silhanek, DPM


Professional versus “casual” dress. I just don’t understand this argument. I have been in practice 20 years, so perhaps I can now be considered old and out of touch. I have seen the general trend in U.S. dress towards very casual. Adults wearing pajamas when buying groceries. But I was surprised at the percentage of PM News respondents who listed that they dress casually for work. The highest percentage was those respondents who wear scrubs to work.


As a surgeon, I suppose I understand that, though I wear professional clothes in the office. As a woman, I feel that no woman, regardless of body type, looks good in scrubs, but maybe that’s just me. Regardless, I see my primary care physician and cardiologist and they wear professional attire. Why should we as podiatrists dress less professionally?. And for those who voted that they dress “casual”? What the heck is that? Are you now working as a teller at Walmart? For all your schooling and residency, you dress casually? Shame on you. Have some dignity and pride in being a doctor. Period.


Alison Silhanek, DPM, Smithtown, NY