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02/08/2019
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Charles Morelli, DPM
I am curious as to why almost 30% of respondents either said no or are unsure regarding being able to prescribe medical cannabis, when there is a plethora of data that supports its benefit for a myriad of conditions. If you are unaware of its benefits, then do some research and you will see how it can be an adjunctive therapy for many of your patients.
I have numerous patients, mostly in their 70s and 80s who I now have to refer out to the proper doctor or physiatrist in order to be evaluated and then be granted a medical marijuana card to then be able to go to a dispensary for this medication to treat their pain. These are usually patients who have tried everything, or are unable to take NSAIDs and/or acetaminophen for whatever reason, who we do not want to necessarily prescribe opiates to, and now have a cream or oil that is addressing their pain. We are not treating Alzheimer's or epilepsy, or veterans with PTSD or other central neurological disorders, but I have seen it be quite effective for diabetic neuropathy as well as arthritic and other types of joint pain as well as fibromyalgia.
Certainly more education is needed as it pertains to proper dosing and what vehicle is best for administering this, but to not recognize this as proper medication for some is to turn a blind eye to its potential. We want parity, and this will just be one more thing that will propel us into the mainstream.
Charles Morelli, DPM, Mamaroneck, NY
Other messages in this thread:
02/15/2025
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From : Elliot Udell, DPM
Dr. Harvey writes that during most of his career imaging for neuromas was not readily available, and he removed most of them based on clinical evaluation. In 2025, where we do have imaging available, could a podiatrist get into trouble if he or she does not order these tests and post-op findings show that the patient did not have a neuroma?
Could the patient say in court, "hey doc, you operated on me and it turned out to not be a neuroma and you could have known that by sending me for appropriate tests?" Perhaps some of the legal experts could weigh in on this.
Elliot Udell, DPM, Hicksville, NY
Editor's comment: PM News does not provide legal advice. According to the FDA, the definition of stand of care is "Treatment for a disease that is accepted and widely used by doctors." Although the PM News Quick Poll is not scientific, it is likely that not imaging prior to neuroma surgery fits that definition.
02/13/2025
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: Allen M. Jacobs, DPM
Dr. Lullove implies that it is near malpractice to remove a suspected interdigital neuroma without confirmation of the diagnosis with pre-operative advanced imaging. Simply stated, his position is not only contrary to the standard of care (as reflected in PM News), it is contrary to published studies addressing this issue.
Numerous studies have demonstrated that the accuracy of clinical diagnosis of an interdigital neuroma is sufficient such that advanced imaging is seldom required (e.g.: Pastides, et al, Foot and Ankle Surgery 18 (1) 2012, Mahadevan, et al., JFAS 54 (4), 2015, Owens, et al., Foot and Ankle Surgery, 17 (3), 2011.) The clinical diagnosis has been shown to be safe and reliable. Advanced imaging is indicated when the diagnosis is unclear or...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
02/13/2025
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Pete Harvey, DPM
It was Dr. Rubin who first taught me about Mulder’s sign. He is correct. It is highly accurate. Dr. Lullove has valid points. However, over 50 years, I have removed hundreds of neuromas with no imaging. My schoolmates would say the same. In the first half of my career, imaging was not widely available.
Pete Harvey, DPM, Wichita Falls, TX
10/25/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: William Beaton, DPM
I wish to second all of the comments made by Dr. Caringi. From the time I graduated from podiatry school to this day, I have always had an in-office laboratory where I have made orthotics dating back to leather and cork through Rohadur, Polydor, and now finally Carbonfiber.
Yes, we have lost that aspect of our practice to the OTCs, pre-fabs, and yes even some of the laboratory produced accommodative orthotics. It is a shame that podiatrists don't control the true biomechanical physician crafted corrective orthotics market.
William Beaton, DPM, Saint Petersburg, FL
10/25/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Irv Luftig, DPM
I graduated from OCPM in 1980 with Greg and practiced near the Toronto area for over 40 years until I retired in 2002. My practice was a successful one with thousands of loyal patients, standing out from almost all of the others within a 50 mile radius using the same mantra as Greg's. Proper biomechanical exam, non-weight-bearing plaster casting of each and every orthotic patient whether they were 8 years old or 80 years old. I was lucky enough to have a 3 year residency, surgically trained (with fellowship) podiatrist come up from the U.S. to take over my practice when I retired. He practiced in the U.S. for 5 years before coming up here to settle.
It took a full year of hammering away at the importance of biomechanics as an adjunct to all his surgical training. It took awhile but it sunk in. He had virtually no training in biomechanics. I was shocked but was relentless, teaching and mentoring about the principles of gait analysis, a thorough biomechanical exam, and...
Editor's note: Dr. Luftig's extended-length letter can be read here.
10/25/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Paul Slowik, DPM
I read Dr. Caringi’s letter with a bit of sad remorse. Biomechanics was a very important aspect of the DPMs’ training “back in the day”. Like Dr Caringi, I also performed a biomedical exam, gait analysis, and did plaster of Paris impressions. For the most part, all of my orthotics were custom made, meaning I listened to the patient and made individual adjustments. Rarely, no two devices were identical. Sometimes I had to make adjustments over and over again until I got it just right.
The patient had a true prescription which could be the basis for further devices. One size fits all is a travesty to our profession. Patients with severe deformities need those to function. Not all patients are surgical candidates. Patients would gladly pay several hundred dollars if you could make a device that really works.
And by the way, at least in California, orthotics are not considered a real prescription hence a class action suit would be fruitless.
Paul Slowik, DPM, Makawao, Maui, HI
05/03/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Ivar E. Roth, DPM, MPH
I read Dr. Kesselman’s response. While I understand his thinking, here are my old school thoughts concerning student loans. Any student can easily reduce their loan dependence by working part time during their schooling or on summer breaks. Also decreasing debt is easy; spend less and scrimp during school and residency. Too many students today think nothing of drinking $6 Starbucks whenever they want and living above their means. Maybe you must reduce rent by sharing an apartment.
There are lots of ways to spend less and or supplement your income. There is nothing wrong with a little struggle but today’s students to me seem to be entitled to a certain lifestyle that maybe they can’t afford. What I am trying to say is that where there is a will there is a way. The same goes for wanting to just get a 9 to 5 job. If you want to really excel, try the concierge/ direct pay model, and make as much as you feel you deserve. Yes, it will be difficult at first but in the long run, you are the boss of your future not just an employee happy to get yourself a cost of living increase each year.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
05/02/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: Shashank Srivastava, DPM
I understand the points that Dr. Hofacker is making and all are very good. That said, I personally feel that it is not reasonable to expect 17 year old high school kids to want to know they want to be podiatric surgeons at such a young age. I remember how I was at that age, and no way could I have made such a commitment. I think a certain level of maturity and some life experiences are required before making this commitment.
The problem is if they decide at 22 years of age that they want to do something different (common sentiment among that age group), there is no turning back and lots of debt and possible resentment. Unlike allopathic or osteopathic physicians, we cannot just simply change specialties and do different residencies and fellowships. There is no turning the ship around.
Shashank Srivastava, DPM, Rockville, MD
05/02/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Paul Kesselman, DPM
Recently, I met a young intern doing his PGY-1 prior to starting his five-year residency in general surgery. He is faced with almost $400K in debt from medical school and more from undergraduate school. Between the two, he can easily amass $600K or more in debt. A neighbor graduating from high school will amass $500K in debt from his undergraduate degree and then more from his anticipated pursuit of a legal degree.
It is no wonder that more and more young students are moving away from traditional degrees in healthcare and moving to shorter degree paths with easier career paths. PA and NP are far shorter than MD/DO and DPM degrees with much less stress, easier lifestyles, and nice salaries. Nurse anesthestists command $150+ salaries after a four year BSN and a year or two of...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
06/14/2023
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: William A. Wood, DPM, MPH, Robert Kornfeld, DPM
The greatest existential threat to our profession is the lack of a national practice act license uniting the profession.
William A. Wood, DPM, MPH (retired), Chicago, IL
Other than the fact that podiatry has never been a cohesive unit, I believe the biggest existential threat is participating with health insurance. There will be no end to the erosion of income over time. Podiatrists work like dogs and are being exploited by insurance companies. So who is to blame? Clearly, insurance companies because they figuratively rape doctors. BUT, this is not a new story. It is the continued participation/cooperation/acceptance of this madness that is also to blame. And that is something every podiatrist can change. Otherwise, they can continue working as the underpaid employees of the insurance companies that they are.
Robert Kornfeld, DPM, NY, NY
06/14/2023
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Patrick J. Nunan, DPM, Steven Kravitz, DPM
I find it interesting that a person commenting that the profession itself is its own biggest threat, once testified against ankle privileges for podiatrists on behalf of orthopedic surgeons in his state. At that time, I was vice president of that state association and heard his testimony firsthand. Was not the question asking for forces outside of the profession?
Patrick J. Nunan, DPM, Beaufort, SC
Dr. Tomczak points to an age old question that faces not just podiatry, but all fields of medicine. There's too often a disconnect between the pride of being in medical practice, the economics that drive that practice, and the realization that all of us have a limitation of education. At the end of the day the primary focus must be whatever is best for the patient.
I just had a paper accepted by The Journal of Wound Care (due October 2023) that addresses this very issue. It describes a simple vascular procedure that went wrong, causing...
Editor's note: Dr. Kravitz's extended-length letter can be read here.
05/19/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: Gary S Smith, DPM, Al Musella, DPM
James DiResta wondered why the PM News polling showed a negative 65% for having had COVID-19. I would remind him the question was "Have you ever tested positive for Covid?", not have you ever had COVID-19?
Gary S Smith, DPM, Bradford, PA
That shows that podiatrists understand and implement infection control. Most of the MDs I know also never caught it.
Al Musella, DPM, Hewlett, NY
05/19/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1b
From: Alan Sherman, DPM
There are some very good reasons why we podiatrists should have a lower incidence of COVID than the general population. Doctors, in general, are among the most vaccinated population. We podiatrists are so well educated in infectious disease and the precautions that we need to take to keep our staff and patients safe. We spend so much time in operating suites where the principles of antisepsis have been followed long before COVID.
I don’t find it surprising that our incidence of COVID as a group is lower than average, but rather, that it is a testament to the policies that were put into place and the practices that were diligently followed in our offices and clinics, as well as in our personal lives.
Alan Sherman, DPM, Boca Raton, FL
05/19/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1C
From: Elliot Udell, DPM
Dr. DiResta is correct in noting that two surveys taken on how many people have contracted COVID-19 may be totally inconsistent with each other. Expect more of this. When COVID-19 first became a pandemic, the strain caused severe morbidity and mortality. The only way of knowing if a person had the disease was to go to a public testing site, hospital, or urgent care facility. The results were documented and made public. Today, things have changed.
The strain today is more contagious but less virulent. Many are also vaccinated. People are, thankfully, not dying or winding up on ventilators as frequently. The symptoms for many people may mimic a mild cold. There is also an ample supply of home testing, the results of which, remain private and undocumented. Hence, today, we can only get rough estimates from government agencies and other surveys and the results from multiple studies may indeed vary.
Elliot Udell, DPM, Hicksville, NY
05/18/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1
From: James J DiResta, DPM, MPH
The results to this week’s polling is puzzling. CDC recognizes that some 60% of the U.S. population has had COVID-19 which would appear to me a conservative number, yet the poll results show 65% of respondents stating they have not had COVID-19, which begs the question why is being a podiatrist "protective"? It would seem to me with our level of exposure, we would be as high if not higher than the CDC data.
James J DiResta, DPM, MPH, Newburyport, MA
05/18/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 2
From: Paul Betschart, DPM
I tried to dissuade my son from a career in medicine for many of the same reasons presented. I guess the calling was too great as he is graduating from medical school next weekend. As a DO, he may well be an employee and not have the business challenges of solo practice.
Paul Betschart, DPM, Danbury, CT
05/17/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Dennis Shavelson, DPM
The biggest mistake we made as a profession continues to be to ask “Is it covered?” as a prerequisite to care. The second biggest mistake has been the simultaneous abandoning and minimizing of lower extremity biomechanics. We have neglected our inherited claim to be the best orthotic and closed chain professionals that Drs. Root, Langer, and Dananberg gifted us by instead becoming amateurish, uneducated, and unskilled.
This year, I tearfully retired as a DPM. How did we let this happen?
Dennis Shavelson, DPM (retired), CPed, Tampa, FL
05/12/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Steven Finer, DPM
I applaud Dr. Kornfeld’s personal journey. I did not have the guts to do what he did and accepted Medicare. I always made a living .However, those 1978 fees adjusted for inflation are the same as 2022. My son could easily have gone into medicine but is in the business world. None of my friends' children chose medicine. My personal physician is leaving the big group as more and more patients are pushed on him. My excellent dermatologist looks tired and harried as the big group pushes him to do more. None of their children have gone into medicine and both sets are husband and wife MDs.
Steven Finer, DPM, Philadelphia, PA
03/23/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Vince Marino, DPM
Although I have used them in the past, they are no longer available as the FDA quashed their use since they are injectable biologics. The FDA is requiring the companies go through more hoops. Here is an excerpt from the FDA notice sent to the public:“…warning to consumers in FDA’s July 2020 Consumer Alert:
•Regenerative medicine therapies have not been approved for the treatment or prevention of COVID-19, acute respiratory distress syndrome, or any other complication related to COVID-19.
• Regenerative medicine therapies have not been approved to treat autism, macular degeneration, blindness, chronic pain, or fatigue.
• Regenerative medicine therapies have not been approved to treat any neurological disorder, such as multiple sclerosis, amyotrophic lateral sclerosis (ALS; Lou Gehrig’s disease), Alzheimer’s disease, Parkinson’s disease, epilepsy, or stroke.
• Regenerative medicine therapies have not been approved for the treatment of any cardiovascular or pulmonary (lung) diseases, such as heart disease, emphysema, or COPD.
• Regenerative medicine therapies have not been approved for the treatment of any orthopedic condition, such as osteoarthritis, tendonitis, disc disease, tennis elbow, back pain, hip pain, knee pain, neck pain, or shoulder pain [emphasis added by poster].
FDA has repeatedly notified manufacturers, clinics, and healthcare practitioners of the need for Investigational New Drug applications (INDs) to legally administer these products and to ensure safety measures are in place prior to administration.” So the results of the poll may be skewed.
Vince Marino, DPM, San Francisco, CA
04/05/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: Steve Tager, DPM
Maybe these posts about neuroma treatment are not truly representative of what the nation’s podiatrists do for this condition. I am reasonably certain that as physicians, we all try to achieve positive outcomes and do what we feel is mutually beneficial for our patients when it comes to treatment regardless of the problem. Fifty plus years of doing all that has been discussed, from steroid injections, dehydrated alcohol, DTL sectioning, excisions from both above and below, etc. Nothing compares to the success rate I’ve experienced by simply reversing the pathomechanics of lateral column overload. My experience continues to tell me that restoring rearfoot function anywhere close to anatomic neutral gives the foot optimal opportunity to heal itself.
How many times have we sat in front of a pair of feet and identified good upper and lower leg alignment, with the plantar surface of both feet trying to face each other? Is it not possible that...
Editor's note: Dr. Tager's extended-length letter can be read here.
04/05/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Kenneth Meisler, DPM
Dr. Kass stated "like Dr. Meisler does with ultrasound guidance," he injects "into the region of the neuroma...is a pretty easy location to find without ultrasound." I agree that to be in "the region" is pretty easy. I do not inject into "the region of the neuroma." I inject directly into the body of the neuroma. I have done this for about 15 years after reading a study performed this way at the Hospital for Special Surgery. I have found injecting directly into the neuroma under ultrasound guidance is more effective than injecting in the region of the neuroma, which I did for 25 years. It is difficult to do even with ultrasound guidance. There is a definite learning curve.
I think you will be surprised where you are injecting as you watch yourself under ultrasound. Eventually, it becomes quite easy. Injecting directly into the neuroma also reduces complications such as fat necrosis and skin discoloration because the firm body of the neuroma holds the steroid or alcohol within it after the injection. A comprehensive review of the literature on ultrasound guided vs. non-ultrasound-guided injections in the Orthopedic Journal of Sports Medicine concluded that ultrasound-guided injections are overall more accurate than landmark-guided injections. I perform all neuroma injections under ultrasound guidance even if the insurance company will not pay for it. I cannot ethically do an injection without it if I know I am capable of being more accurate with ultrasound; that's just me.
Kenneth Meisler, DPM, NY, NY
01/20/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Michael J Marcus, DPM
A year ago, we dealt with the uncertainty of this virus. Some thought it would be no different than the common flu, others considered it more potentially problematic. Now a year later, over 400,000 lives have been lost in the U.S. as a result of this virus. In my area of the country-LA- 95% of our inpatients are covid positive. Every day, I hear about a death from COVID. Our ICUs are flooded. Three or four patients seem to code very day.
The development of this mRNA vaccine is nothing short of a miracle. Many hospitals are making it mandatory for new employees. The PM News survey is very discouraging to me. I could think of no reason not to be...
Editor's note: Dr. Marcus' extended-length letter can be read here.
01/07/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Leonard A. Levy, DPM, MPH
Carl Solomon, DPM, indicates that the foot is warm during a gouty attack. However, it is actually the area surrounding the inflammation that is warm. This is due to what are among the cardinal signs of inflammation which the ancients characterized as redness (rubor), swelling (tumour), heat (calor;), pain (dolor), and loss of function (functio laesa). The first four of these signs were named by Celsus in ancient Rome (30–38 B.C.) and the last by Galen (A.D 130–200) (source: Hurley JV. Acute inflammation. Edinburgh, London: Churchill Livingstone; 1972).
These are local responses to cellular injury marked by capillary dilation, not the larger vessel dilation caused by blocking sympathetic nerve fibers of the posterior tibial nerve. The block causes an increase blood flow to areas distal to the nerve block, which is a much more significant increase in fluid (i.e., blood) than there may be in an area of inflammation. Indeed, the block (and the vasodilation) lasts significantly longer when the anesthetic agent includes epinephrine. Thus, the patient gets immediate pain relief during the time it takes for the traditional anti-gout agents to be used.
Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL
01/05/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Henry Stark, DPM
Almost by definition, temperature in the human foot is normally less than core body temperature. I think we can all agree that there is no need for double-blinded studies to determine this to be a fact. During a hyperuricemic episode, it is believed that urate crystals coming out of solution from a “saturated” plasma concentration, precipitate in these naturally cooler, distal articular regions which initiate the gouty attack. In conjunction with other therapeutic measures, many podiatrists utilize posterior tibial blocks to induce a temporary, localized sympathectomy for increased perfusion as well as the analgesic effect. Yet, the Arthritis Foundation, most all rheumatologists, as well as most of my colleagues would argue that ice (rather than mildly increasing the temperature of the site) is appropriate therapy for the ACUTE phase of the attack.
Dr. Levy appears to suggest (as do I) that consideration towards increasing perfusion (and perhaps warming of the affected area of the gouty attack) rather than ice may be more appropriate. Yes, ice is an analgesic in this situation, yet its use seems counterintuitive since it decreases temperature, perfusion, and would tend to prolong and enhance localized urate crystal formation. I am aware that once a gouty attack has begun, uric acid concentration in the plasma often has already decreased. Why would ice be the recommended therapy simply for analgesic purposes, when it may cause further, localized urate crystal formation?
Henry Stark, DPM, Lake Park, FL
01/04/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1
RE: Have you received your COVID-19 vaccination yet? (Adam M Budny, DPM)
From: Robert Scott Steinberg, DPM
I am not sure of Dr. Budny's point. Is he rationalizing his decision? Here is what I do know. "The general recommendation is to get the vaccine, even if you were previously infected," said Dr. David Thomas, a professor of medicine and director of the infectious diseases division at the Johns Hopkins University School of Medicine. "There are some nuanced questions that we don't have the answer to yet, but from what we know now, it's the right call to get the vaccine."
Everyone be as safe as you can. You owe it to your family, your patients, and yourself.
Robert Scott Steinberg, DPM, Schaumburg, IL
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