04/23/2008    Robert Hall, DPM, Paul Kesselman, DPM

Podiatrists Vs. Orthopods

RE: Podiatrists Vs. Orthopods
From: Robert Hall, DPM, Paul Kesselman, DPM

While "scope of surgical residency training"
i.e., DPM: 1-3 yr vs. ortho: 5 yr often appears
to be the mantra/rationale as to why only
orthopods are qualified to perform foot surgery
(especially rearfoot), they have an interesting
quirk. Pts on HMO's (Read: low reimbursement)
needing foot surgery and referred to orthopods
OFTEN are told they need to see a podiatrist.
Those with indemnity ( Read: higher
reimbursements) insurance are not. Conclusion-
reimbursement is often the overriding factor-
Duh?

Robert Hall, DPM, Ft. Lauderdale, FL,
robertkhalldpm@bellsouth.net

Dr. Mullens experiences and incredibly well-
written letter should become part of every
podiatric practices office manual. All of us in
practice more than 20 years could fill a large
library of battles weve gone through with
orthopedic surgeons, general surgeons and many
other MD practitioners.

One experience with a neighborhood internist
who didnt come to the phone for podiatrists
taught me the power of my patients intellect.
The patient was shocked that her doctor would
not talk to her podiatrist. She called her
internist and told him if he didnt speak with
me that would tell her more than she ever needed
to know about how much he cared about her. The
internists receptionist reluctantly called my
office back and put him on the phone. After a
few visceral remarks on his part, I asked if he
wanted to continue this dialog or wished to
discuss our common patient.

Leaving him no one to argue with, we discussed
this patient and I obtained the medical
information (and clearance) I needed. Thus begun
a reasonably civil relationship with this old-
schoolMD who only saw podiatrists as non
physicians and who likely was taught this
behavior from his mentors. Old habits do die
hard but he finally did come around. After
several of these types of conversations and good
experiences communicated to him by his patients,
he finally began referring patients to me and
eventually other podiatrists.

Another experience was at a hospital where
privileges for wound care and foreign body
removal were restricted to the general surgeon
and orthopedic owners. The only board certified
vascular surgeon at the hospital as well as the
rest of the medical board went to bat for us
after 20+ podiatrists threatened to leave the
hospital and go to one down the block.
The general surgeon owners eventually recanted
after one went to a Harvard Wound Careseminar
and were taught more about wound care than he
could ever imagine, by DPMs. Today that same
hospital has a HBO center where podiatrists are
the supervising physicians and a podiatric
residency is about to start.

As for privileging, I wonder how many
orthopedists could get credentialed for foot
surgery using the standards they require for
DPMs. That is, how many bunions and hammertoes
should the orthopedists be required to perform
during their residency and year to year in order
to obtain and maintain their privileges to
perform those procedures. Performing a knee, hip
or shoulder arthroplasty is not the same as
performing a finger or toe arthroplasty. (One of
my hospitals requires separate credentialing for
hand surgeons).

Lesson learned, DO NOT get suckered into an
emotional battle and DO NOT respond viscerally.
Your best weapons are your education, outcome
data, physician friends and most importantly
your patients.

Paul Kesselman, DPM, Woodside, NY,
pkesselman@pol.net

Other messages in this thread:

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04/22/2008    Jerry Cosentino, DPM, Michael M. Rosenblatt, DPM

Podiatrists Vs. Orthopods

RE: Podiatrists Vs. Orthopods
From: Jerry Cosentino, DPM, Michael M.
Rosenblatt, DPM

I agree with Dr. Purdy's comments completely. I
believe that the best defense is a good offense.

Years ago, as Chief of our section in Podiatric
Surgery at a local hospital in Tampa, I received
an application for privileges from Dr. Harold
Vogler. The chief of the orthopedic department
wanted to restrict Dr. Vogler's privileges based
on his degree, Doctor of Podiatric Medicine.

Dr. Vogler's response was a good one. In
essence, Dr. Vogler proposed that we define the
extent of privileges based on experience and
frequency of the performance of these
procedures. We should require a minimum number
of performance of each privilege requested, such
as triple arthrodesis, ankle fusions, base
osteotomies, etc., be completed over the last
several years, and each surgeon present
operative reports for documentation. No
experience, no privileges.

Needless to say, after reviewing Dr. Vogler's
experience and performance frequency of quite a
number of extensive and complicated foot, ankle
and leg procedures, the issue was dropped
immediately and he was granted the privileges
requested.

We need to think about re-opening this approach,
in regards to the extent of privileges allowed
each surgeon on a national level, by our
representatives in the APMA and state
associations. This will also reduce the
hospital's liability, by restricting non-
experienced surgeons, and I am sure patient
advocacy groups would support our position by
requiring experience and training documentation.
Outcome results and comparative patient
satisfaction, I am sure, will also favor our
profession.

Let's "roll up our sleeves" and confront this
issue head on. Following guidelines such as
these will ensure that patients receive the best
lower extremity care, and podiatric surgeons
will be the primary physicians authorized and
qualified to do foot, ankle and lower leg
procedures. It will be tough to handle the
tremendous increased workload, but am confident
that our profession will be able to handle it.

Jerry Cosentino, DPM, Tampa, FL,
gcosenti@tampabay.rr.com

I enjoyed the beautifully written letters on this
subject, and especially those of Dr. Mullen.
While we
must fight for our political position and be
constantly vigilant, it is also essential to
remember
the help we got (and still get) from co-
operative MD
orthopedists. I too have a story:

In an unfortunate lawsuit against me, an
orthopedist
in my community was slated to testify against
me.

My attorney asked me if I knew any local
orthopedists
who would support my position. I contacted
another
local orthopedist who after he reviewed the
chart,
indicated that he would support me in the case,
including by testifying on my behalf.

After this information was relayed to plaintiff's
attorney, opposing orthopedist dropped from the
case.
It went to immediate settlement at very modest
cost.

I have no idea if the friendly orthopedist
contacted
his colleague or not, nor did I inquire, since
it was
not my business.

I should also mention that even though we worked
on
shared patients, I had NEVER met my "friendly
orthopedist" in person!

Some people are willing to only look at the
merits of
a situation separate from other factors,
including
difference in professional degree.

We dare not generalize to suggest that all
medical
doctors are against us. That would be dreadfully
untrue, and separate us from valuable and
necessary
support.

Michael M. Rosenblatt, DPM, San Jose, CA,
ROSEY1@prodigy.net

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04/21/2008    Richard Gosnay, DPM

Podiatrists vs. Orthopods (Multiple Respondents)

RE: Podiatrists vs. Orthopods (Multiple
Respondents)
From: Richard Gosnay, DPM

I wholeheartedly agree with all of the previous
commentaries. Obviously, I do not find their
thoughts to be mutually exclusive. My training
was similar to what Dr. Purdy described in that
the podiatry residents in my program served as
the ortho (and vascular) residents. This
experience lead me to be sympathetic to Dr.
Mullen's message. We worked for many podiatrists
and many orthopods. While several of the
podiatrists were gifted surgeons, teachers and
mentors, I must honestly acknowledge that
several went out of there way to belittle the
residents and the residency program. Conversely,

I am not exaggerating at all when I state that
every single orthopedic surgery attending
treated me like a valued and respected colleague
in training. I will always be grateful to all of
my attendings (podiatric and orthopedic) who
must have seen something in us that motivated
them to generously invest effort toward our
careers.

While I find it difficult to think of orthopedic
surgeons as our adversaries, I would be foolish
to ignore some of the institutional, political
maneuverings that are attempted against our
profession. Wasn't it just last year that
congress considered a bill (promoted by the AMA,
not just orthopods) that would have reserved the
title, doctor, to MD's and DO's? We need to be
vigilant and always be prepared to fight
relentlessly for all the privileges that we have
earned. I try to be nice about it, but I will
not back down from any confrontation about our
qualifications and rights. As Dr. Jacobs
recently wrote, it is ridiculous for us to try
to ingratiate ourselves to and gain acceptance
from narrow-minded people who have no intention
of ever considering accepting us. For my
relatively short podiatric career, this has come
down to two activities. First and foremost, I
give as much as I can to PPAC every year.

We have professional staff who are skilled at
promoting our profession much better than we
rank-and-file podiatrists can. We need to fund
them so that they can approach every
confrontation with the resources that they need
to help us. Second, I am very willing to discuss
anything with any physician or surgeon without
being defensive or insulting. This might end up
being confrontational at times; But, as Dr.
Mullen suggests, those confrontations should
always be on the high road, not in the gutter.

Sure, I've done some redos from orthopods. But
I've started amusing myself with a little game
that I suggest others might try. When the
patient is well on the way to recovery, I
revisit the experience with the previous
surgeon. Usually, after I've gained the
patient's trust, he will soften up and admit
that he just might have been horribly non-
compliant with his previous surgeon!

Dr. Mullen's admonition for us to be positive is
brilliantly illustrated by Dr. Kornfeld's story
about the aggrieved rheumatologist. Who knows,
this doctor may have had a legitimate gripe. I
find rheumatologists tend to be pointy-headed
intellectual types who love discussing signal
transduction events in activated T-cells without
focusing on the patient's problem at hand. This
is often a subject of discussion in my home, as
my wife is a rheumatologist who is convinced
that we surgeons are monkeys that are trained to
mindlessly perform procedures!

Just between us podiatrists, I can try to see
the rheumatologist's point of view. It is
possible that he prescribed Enbrel not so much
for acute symptoms, but rather to limit
development of joint erosions and improve the
patient's long-term prognosis. If that is the
case, it is easy to understand why he would not
want his therapeutic goals undermined. But
instead of behaving like Dr. Mullen, he got
defensive and lowered himself to simple-minded
insults. It is difficult to respect him.

Our profession will suffer if we are not
vigilant about protecting what we have earned.
But most of our orthopedic surgery colleagues
are potentially great friends if we conduct
ourselves always on the high road. We only make
ourselves look bad (and reinforce prejudices
against us) when we get defensive and stoop to
behaving vindictively.

Richard Gosnay, DPM
Danbury, CT glabroushead@gmail.com

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04/19/2008    Barry Mullen, DPM

Podiatrists Vs. Orthopods

Re: Podiatrists Vs. Orthopods (Dr.'s Rosenblatt
and Purdy)

I too, share the same mutual respect for both
Dr.'s Rosenblatt and Purdy. The troubles they
cite within their medical community is
apparently what separates us. I believe, to some
extent, there are reasons for it. By no means do
I infer that my respected colleagues don't
deserve, through the provision of their care and
training history, the same excellence in
reputation within their medical community, that
I enjoy within mine. It's their past REACTION
to that medical community, or at least some
component of it, and how, from a personal level,
drawing lines in the sand, inferring battle, and
doing so through retaliatory banter strikes,
that sinks oneself to the same level of those
you abhor.

The end result is you ostracize yourself farther
from the
very community you seek acceptance from!
Additionally, please don't presume that
avoidance of verbal retaliation is akin to
avoidance of fighting necessary political
battles to retain our rightful place in
the "medical marketplace". Nothing can be
further from the truth! I'm a huge advocate and
supporter for any political endeavor that
further advances podiatric medicine foster its
mission of achieving privileges for health care
provision commensurate with the education,
training and experience any given podiatrist has
achieved. I've personally been there and done
that.

Anyone who attended Region III several years ago
will recall that I stood before the entire group
to bring this exact point up to then president,
Dr. Glenn Gastwirth and he'll certainly attest
to it. My largest concern 3-4 years ago is akin
to what Dr.'s Rosenblatt and Purdy have
responded to and brought to light now, only my
concerns stemmed from the insurance end, where
medically necessary and appropriate podiatric
services were being denied by health insurance
carriers which were medically accepted and
within the scope of our licensure. Yes...There
are myriads of political battles that need to be
won.

Those victories are ultimately
achieved by our leadership and their political
contacts at the urging of their constituents and
our leadership, not retaliatory mudslinging. Our
professional obligation, is that when one
encounters unjust situations, as in the examples
cited by Dr.'s Rosenblatt and Purdy, to notify
and educate the appropriate state society
appointed leaders so they can assist you win
your battle. If victory cannot be achieved on
the state level, then we have leadership in
place at the national level to further assist
the cause. If the law is on our side, then by
following the proper protocol, that leadership
will ultimately tap into our political contacts
to
further that cause, if necessary, to ensure that
justice prevails. AND...if the law isn't on our
side, and we have the components in place to
prove that it should be amended, then we, as a
profession have the obligation to ensure we
amend those inequities to preserve the future
for our younger, podiatric brethren.

Dr. Rosenblatt's comments about orthopedists
doing what they can to denigrate podiatry are
noteworthy
and shouldn't be taken lightly. Ultimately, he
finally hits the nail on the head when he
indicates how APMA's legislative leadership
needs to step to the forefront and win those
battles. Unfortunately, where I believe he's
compromised his position is when he cites
numerous examples of orthopedist's performing
archaic
procedures and the horrible outcomes produced.
Dr. Purdy cites examples of orthopedists
attempting to convince hospital administrators
that our training is inferior. This is EXACTLY
when YOUR outcomes and quality care delivery
should be brought to light to prove them wrong!
That is EXACTLY when the podiatric core
curriculum taught at the various podiatric
medical schools should be revealed as well as
the CURRENT state laws commensurate with that
training. The veracity of any given allegation
is only as strong as its proof. In this country,
the accuser is responsible for providing that
proof. In that specific example, state laws
currently exist that clearly delineate core
podiatric hospital privileges. Any given
podiatrist having trouble w/ this component of
his/her professional career need merely tap into
the podiatric hospital affairs committees that
exist to assist podiatrists attain the
wrongfully denied or reduced privileges they
incur. I'm living proof!

In 1985, when all else failed, I had to threaten
to sue the hospital that I initially attempted
to gain privileges
at. I was successfully assisted by Dr. Jeffrey
Wolf, then New Jersey's Hospital Affairs
Committee chairman. More recently, we needed to
change the hospital's archaic bylaws to be more
reflective of the podiatric medical and surgical
training advancement our profession has
achieved, as well as our rightfully attained
physician status.

Lastly, the actual podiatric surgical privileges
at our hospital were recently amended to reflect
current state regulations for podiatry. THAT is
the value of APMA and its state component
societies and when properly utilized, extremely
effective. I was very passionate and determined
to attain, both for myself and my neighboring
colleagues, that which was rightfully
ours...So...I've fought these battles and
won...BUT, in doing so, I never got mad, I never
became vindictive against my accusers, and in
maintaining the high road, gained further
respect and admiration from within my medical
community.

It was that same medical community, comprised of
M.D.'s and D.O.'s who, despite having been
threatened over 20 years ago in potential
lawsuit, now voted, nearly unanimously
(presumably, the 4 negative votes came from the
4 person orthopedic group who initiated the
stonewalling in the 1st place) to grant the
requested privileges and bylaws changes we
sought. I, along with the assistance of NJPMS'
leadership had set the precedent that
podiatry was going to be treated equally and I
merely used the law to attain the equity I
sought. AND...it is those same physicians within
the medical community that continue to provide
referrals to our practice and help it grow.

"Mutual respect and peace" IS happening within
medical communities between podiatrists and
orthopedists. I'm living proof of it, and so are
many of my colleagues. This is attained in
exactly the manner I previously described in my
1st post. As an example, I was just recently
asked to join, as an equal partner, a multi-
speciality surgery center group. The impetus for
that decision was created by an orthopedic
colleague whom I have an excellent working and
professional relationship with. I can cite
numerous other examples of other podiatric
colleagues enjoying similar experiences. I
assure you, we did not attain our equality
through bashing those with which we hoped to
join as equals. Of course there are
always "sophomoric (I like that word...it helped
my son on his SAT exam) outliers", like the
orthopods 20 + years ago who tried to stonewall
not only my addition to the hospital's active
medical staff, but curtail my surgical
privileges as well. In their
respective times, both arguments were presented,
and in each instance, I prevailed. I prevailed
because I had the law on my side! AND, equally
importantly, I had previously won the confidence
of the medical staff because of how I
professionally conducted myself and from the
quality of podiatric medical care I provided for
their patients.

Please forgive me if I sound like I'm
patronizing you...but for ALL of your own
goods...the way to deal with bullies is to
ignore their slander. The way to "fight back" is
to convince the public and anyone else
positioned to judge a dispute to consider the
source. Therefore, simply refer those in a
position to influence your professional future
by evaluating the FACTS. Have them review: 1)
State law relative to the issue(s) being brought
forth; 2) YOUR podiatric medical training; 3)
YOUR outcomes; 4)YOUR quality health care
delivery; 5)YOUR professional demeanor; 6) YOUR
medical community reputation from YOUR patient
testimonials; and lastly, 7) YOUR fiscal
contribution to the hospital through income
provision derived from YOUR care
w/in that setting...You've cited competition for
healthcare dollars and how orthopedists are
doing everything within their power to
monopolize that scenario...well hospitals face
the same competitive marketplace issues that
health care providers do, so use that to your
advantage! Trust me, they can ill afford to lose
your business! When ALL of this is accomlished,
then in reality, who looks like the emotional,
paranoid child
throwing a hissy fit because he's scared stiff
of an equally competent medical colleague who's
professional territory overlaps his own...and
who looks like the polished healthcare
professional that he really is?!

Vindication is ultimately attained from the just
executive decisions made which favor those who
present a well conceived, logical argument that
disproves false allegations. In the aftermath,
the losers have revealed their true self-
worth...which of course, is contemptible and
frankly, rather sad. Defeat them enough times by
using the legal system and eventually, the bully
wears down...but then, having achieved victory,
don't stomp them, rather, extend the olive
branch and embrace them. THAT's how you
demonstrate YOUR self-worth and help preserve
your place in this crazy, competitive, medical
marketplace by gaining the respect of those
around you. I believe I've said about everything
I possibly can on this issue. I can only hope
and pray my colleagues are listening because I
want the same success for you as I currently
enjoy!

Barry Mullen, DPM
Hackettstown, NJ
yazy630@aol.com

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04/18/2008    Jon Purdy, DPM

Podiatrists Vs. Orthopods (Barry Mullen, DPM)

I take a different stance in response to doctor
Mullens comment to walk awayfrom derogatory
comments made by our orthopedic colleagues. I
have much respect for doctor Mullen, but there
are certainly times when simply walking away is
not an option. In a one-on-one conversation
its easy to turn the other cheek. When it
comes to the public, political, or professional
arena thats a different story. I have made my
own personal strides to befriend my orthopedic
colleagues in my community. Having worked three
years in residency functioning as both an
orthopedic and podiatric resident, I feel more
than qualified to comment. In my residency we
had full time orthopedic staff with no residents
other than ourselves. We gave lectures and
performed all surgeries with them. We were well
respected and mutually accepted. That is not
the case in my community.

Up to this point, podiatry has been doing
extraordinary work in its contribution to
science and the public. We have not leveled
attacks against anyone. Unfortunately, as we
rise to the top, we find ourselves affronted. I
agree that within our offices we do the best we
can for our patients, and share with our
colleagues. When an orthopedist is trying to
convince hospital administration to view my
training as inferior, it IS time to prove my
equality, if not superiority. When the
orthopedists attack my career at the legislative
level, again, it is time to prove my equality or
superiority. This is not philosophical banter,
this happening NOW!

Whether it is a podiatrist or an orthopod, there
will always be those located throughout the bell
curve. Extraordinary training does not guarantee
great outcomes either. Both podiatrists and
orthopods have many strides to make in the
equality of foot and ankle training and its
delivery. It would be nice to do this with
mutual respect and peace but that is not the
case currently. I say make your individual
professional strides in an honorable and
professional manner. However, when one party
wants to draw a line in the sand, we better
prepare our troops for battle on the legislative
front. There is no wasted energy here, and
walking away is not an option.

Jon Purdy, DPM, New Iberia, LA,
jpurdy@mindspring.com