Podiatry Management Online


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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

Other messages in this thread:



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: 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



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.



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: George Jacobson, DPM


There are far too many variables and negative assumptions being made in the responses to this question. Insurance plans have limits and exclusions that will affect our treatment both as patients, as well as our patients' choices for non-covered services and service limitations. I am currently getting physical therapy and needed pre-approval which could have been denied causing a change to my doctor's treatment plan. If I need more therapy after my limit has been reached, my treatment plan may again be altered by my doctor or I could pay out-of-pocket, which most of my patients wouldn't do or could not afford. We all know what other "covered" treatments are available.  


Another nuance to "therapy limits" is the decision to "waste" visits on "minor" injuries as they may be needed later for major rehabilitation post-stroke, joint replacement, etc. Many years ago, these were separate therapies but they were all lumped together by Medicare, further reducing Medicare's benefits and exposure. We can use up someone's therapy benefits for plantar fasciitis and they could have a stroke and need speech therapy, occupational therapy and/or physical therapy, but now their treatment plan must change because of their insurance coverage. Therapy is just one example. We should not be so quick to judge this survey's outcome as it is too broad a question to warrant the condemnations posted. It is a far different situation from the ethics and warranted condemnation for performing or changing procedures just to meet certification requirements.  


George Jacobson, DPM, Hollywood, FL



From: Tip Sullivan, DPM


Two situations come to mind: A) First MTPJ fusions: If you own or are partners at an out-patient non-hospital affiliated surgery center where there is no specific compensation for implants, there is a big issue here. An insurance company will not pay any extra for a locking plate; therefore, those people get cross screws. Which is better for the patient? Read the literature and decide for yourself. Many years ago, I tried to give the patient a choice to pay out-of-pocket for the extra cost of a locking plate because I felt that it was more stable. I found out very quickly that insurance companies did not allow this to happen.


B) Arthroeresis: Need I say anything about this? It is an awesome procedure for the right patient (and this is one of those things I decide intra-operatively). The implant paid for is if it is done at the hospital but not at an independent outpatient center. So you do an Evans, which also works well. Which is better for the patient? Before I learned this lesson, I was doing flatfoot reconstruction at my own outpatient facility. I can tell you that I lost a ton of money before I looked at the numbers.


I have recently been forced financially to discontinue surgery at my own facility because of low facility reimbursement vs. the cost of doing business in a small solo practice. I will continue to do “the right thing” for my patients, but the hospital lobby and the insurance business have literally made it impossible for a small-time facility like mine to be profitable. 


Tip Sullivan, DPM, Jackson, MS



From: Jon Purdy, DPM


I too am amazed at the results, but not surprised. It’s no surprise that one may stray from their principles when faced with the possibility their career may end if certification is not met. That is the unfortunate reality we live in these days. What is just as unfortunate is the “requirement” of case diversity and site- specific numbers imposed by our certification boards. Because of this physician admission, many boards have dropped these requirements. Our own American Board of Multiple Specialties in Podiatry (not currently accepted by the APMA) does not have these requirements, nor does The American Board of Orthopaedic Surgery.


Surveys such as this, reveal the stark reality of influence our boards have over the careers of podiatrists, and how certification rules influence public and physician safety. There are many examples in life, where the goal of protection leads to unintended consequences of quite the opposite. Even more eye-opening is the documented statistic that surveys asking respondents to admit fault or dishonorable actions only reflect those willing to admit to it. The number is certainly higher.


Jon Purdy, DPM, New Iberia, LA



RE: What overall grade would you give the Affordable Care Act? 

From: Edward Fischman, DPM


I agree with the doctors who think the ACA has gone way beyond what was needed and has in fact cut into our ability to keep up with overhead increases. It has forced many young practitioners out of practice and will continue to do just that. We experience patients who deny themselves the care they need or postpone it as they see deductibles and co-pays rise considerably.


All that was needed was to force insurance companies to accept people with pre-existing conditions. All the rest was icing on the cake to make insurance companies more profits.  


Edward Fischman, DPM, Jupiter FL


Editor's note: This topic is now temporarily closed. No further responses will be published.



RE: What overall grade would you give the Affordable Care Act? 

From: Robert Kornfeld, DPM


All of the discussion about what "grade" to give the ACA is truly missing the point. Look at the name of the Act. It is called the Affordable Care Act. That is all it is. It does not say "Effective Health Care Act". It does not say "Disease and Pathology Prevention Act". It says Affordable. Period. There is nothing in the word affordable that could possibly have any long-term positive impact on the health of the American public. 


Will it save a few pennies now? Perhaps. But quite frankly, in the long run, as the health of the American public continues to decline...


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



From:  Duane E Kratzer, Jr., DPM


I retired from the VA system 3 years ago and, thank goodness, did not have to deal with the mess perpetrated on the American public known as Obamacare. During the campaign of 2012, Sarah Palin brought up Obamacare death squads, groups who would determine if certain age groups would be able to get treatment for certain conditions, and she was called every name in the book. Last week, I spoke to a woman who is 68 years old. Four years ago, she was diagnosed with uterine and ovarian cancer and received radiation, chemotherapy, surgery, and is now cancer-free. Her doctor told her that she was fortunate that she started treatment before age 65 because if she had started after age 65, he would not, under Obamacare and threat of losing his medical license, be able to continue her medications.


He stated that he would be forbidden to even write for the medication and that the pharmacy would refuse to fill it. As a 67 year old retiree, I think that constitutes a death sentence under Obamacare. "Death squads" do exist and for that failure to protect ALL citizens, I would give Obamacare a great big "F".


Duane E Kratzer, Jr., DPM,  Austin, TX



From Gary S Smith, DPM


Adam Siegel, DPM said he gave the ACA an "A" rating because of the benefits it gave him towards his healthcare. He makes a great point of discussion, which really defines the pros and cons of the ACA. There is no doubt that it has provided great benefits to some people, especially people with pre-existing conditions. The other side is that since I am self-employed, the amount I pay for my insurance has doubled. The effect on my practice and also my three sons in college has been noticeable.


All across America, people are not getting the care they need or engaging the healthcare system due to their high deductibles. The average person has to take money out of their tight family budgets to pay the increase in personal healthcare costs due to the ACA. So, really the big question is, Dr. Siegel, What makes you so special? I sympathize with your health concerns but could you please explain why it is mine and every other person in this country's responsibility to pay for your meds? Why do people have to get less care, have less money for college, less money for their own medications, and less money for their families just so you can have a very expensive medication? I'm not trying to be uncaring, but you brought up the analogy, so please explain to us now what makes you so special?


Gary S Smith, DPM, Bradfors, PA



From: Simon Young, DPM


Sammy software allows you to print prescription on paper so patients can shop around. You still get the credit for e-prescribing.


Simon Young, DPM, NY, NY



From:Chuck Ross, DPM


I have been following the recent discussion relative to the number of students vs. the number of available residency slots and suspect that at some time this may become a horrible legal entanglement for the profession. As a member of the teaching staff at my hospital, I have residents who are in a 3-year medical residency program who rotate through my office. I have learned that MDs, too, do NOT have an ample number of residencies for ALL graduates, and medical schools are increasing the numbers of students entering with discussion about “new” medical schools due to the lack of primary care and internal medicine physicians.


There are also limited numbers of specialty residencies. The main difference is that, as was pointed out earlier, a podiatry graduate has no where to go without the residency, while an MD graduate has many more options. I have no idea where the prevailing winds might blow if a class action suit were initiated, but I would hate to see that much time and money involved in our defense. Solutions are not easy, but do need to be reviewed in an attempt to find an amicable resolution. This could be a bad rap for encouraging future students to seek out such a wonderful fulfilling profession.  


Chuck Ross, DPM, Pittsfield, MA 



From: Jeffrey Kass, DPM


I congratulate Dr. Weil on bringing this suit. I notice in Dr. Forman's response though he changes the verbiage of his own statement. He first uses the words custom-fit orthotics and then asks how many podiatrists make custom orthotics in this manner. It appears to me the question revolves around the definition of custom fit vs. custom orthotics. Can a pre-fabricated device, if there are a few versions, qualify as a custom fit? I think this is the heart of the question that a jury will have to decide.


Other good points to bring up are whether the devices if custom can be dispensed without the patient/client being see by a doctor? Does Dr. Scholls enter into a doctor/patient relationship when the patient or consumer step onto the scan? What if the patient/customer picks out the wrong device and it causes harm? There is no question that I side with Dr. Weil and wish him the utmost luck in this endeavor.  While, I am told associations cannot back him in the suit, I am wondering if individual podiatrists can?


Jeffrey Kass, DPM, Forest Hills, NY



RE: Do You Consider Yourself a Workaholic (Marc A. Platt, DPM)

From: Gregory K. Eirich, DPM


All doctors are workaholics to some degree, but nobody stands outside the OR at 11:00 pm on Friday night and tells you how noble you were for doing that surgery. We all care for our patients, but was it necessary to do the case on a Friday night at the expense of your family? Your patients love and appreciate you, but your family has your back. No one has ever laid on their death bed and said, "I wish I would have worked more."  


Gregory K. Eirich, DPM, Tustin, CA



From: Myron Bergman, DPM


I do not schedule a separate comprehensive diabetic foot exam. I perform this exam on every patient, diabetic or not, on every visit. I think this is what most of us do. 


Myron Bergman, DPM, Somerville, NJ