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RE: Radiesse is Now Available for Podiatrists

From: Bret Ribotsky, DPM


As was first reported weeks ago in PM News, there was the inability of DPMs to purchase Radiesse to use for injections for pedal soft tissue temporary augmentation (PSTTA). This issue has been resolved. After meeting with the new CEO of Merz and his leadership team, what should have been a simple process became as difficult as walking through a minefield. It began with corporate compliance and federal regulations that were in place to make it unable to sell to a provider (DPM) where no FDA-approved indication existed within our scope of practice. 


This is behind us now. Any DPM who has received approved training, such as attending a DERMFOOT workshop, is now eligible to purchase this product. It is hoped that a series of training seminars can be done nationally to give this opportunity to all who are interested.


Bret Ribotsky, DPM, Boca Raton, FL

Other messages in this thread:



From: Kevin A. Kirby, DPM


From a mechanical perspective, the decision on whether a joint should be fused, or not, is not that difficult. One simply needs to ask the question, “Will my patient benefit biomechanically more from sparing the joint or from fusing the joint during their daily weight-bearing activities?”


In order to arrive at a good biomechanical decision as to whether a joint fusion or a joint-sparing procedure is best for the patient, one must consider a number of factors. First of all, we must ask if fusing the joint is absolutely necessary in order to render the patient asymptomatic, to perform their daily weight-bearing and sports activities without pain, and to prevent progression of deformity over time. We must also consider whether...


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



From: Howard Osterman, DPM 


I will just say not all joints are equal. Not all sports are equivalent. 30 years of treating athletes has provided insight into this. Fusing a first metatarsal-phalangeal joint can be a damned if you do/damned if you don't scenario, but fusing a 1st met-cuneiform joint is another matter. I suspect this is where the controversy lies. Tennis, golf, basketball are really inhibited with fusion here. This is under-appreciated in mechanics. Sports medicine physicians have many patients who had to stop their desired sport because of this. These are the types of panel discussions at all of our AAPSM Stand Alone meetings. 


Dr. Jacobs, as always, makes some valid points, but those of us who treat mostly patients trying to maintain their continued level of sport are often left disappointed with the surgical result. I have many patients very pleased with a 1st met osteotomy and Akin that wasn't 'perfect' but left a much more desirable result than a 'perfect' Lapidus that stopped them from doing their sport.


Howard Osterman, DPM, Washington, DC



From:  Douglas Grimm, DPM


I think is a timely case study with the current discussion of fusions versus non-fusions. I also am finding colleagues who are performing Lapidus procedures on almost every patient. I recently had a 15 year old boy in the office who had a bunionectomy in February 2020 and he wanted the other foot done. As you can see for reference, the right foot shows he does have a very large bunion for a 15 year old. He was pleased with the appearance of the left foot after surgery as the first ray was straight but he wanted to know why the big toe joint has no motion and why he can't play basketball 10 months after surgery.


I have subsequently done a MICA MIS bunionectomy on the right foot which was completely pain-free in five weeks. The patient is now...


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



From: Richard A. Simmons, DPM


I just checked and Gill Podiatry has the product for sale. You can also contact a compounding pharmacy in your area to make this for you. One caveat: remember under OSHA rules that once you open the bottle, you have thirty days to use the product at which point you must discard the contents. The bottle must be clearly labeled as to the date it was opened.


Richard A. Simmons, DPM, Rockledge, FL


You could have this made up at the histology department of a nearby hospital.


Frank J. DiPalma, DPM, Athens, GA



From: Steven Kravitz, DPM


The study reported by Dr. Purdy is interesting, but it does not appear to be responsive to anything I wrote in my original article on facemasks wearing or my commentary to Dr. Purdy’s reply. I appreciate and agree with much of what Dr. Weisenfeld stated in his post. Interactive discussion on these and other issues is of benefit. We should all feel free to voice our points of view but also make sure in doing so we do not misrepresent the initial article that we are addressing.


My original article was a review of a host of different scientific manuscripts on the efficacy of filtration from respiration regarding facemasks. In that regard, it is a...


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



From: Joseph Weisenfeld, DPM


Dr. Purdy - asking people to wear a mask and wash their hands is not about shutting down the economy or freedom. Quarantining and closing businesses is a separate issue. Unfortunately, they are being linked by anti-maskers for a political statement/agenda, such as in your last paragraph.


It took decades, in opposition to clear evidence, to allow limiting smoking. Costco and Walmart do not allow smoking (and they require masks) to protect their employees (and customers). This has nothing to do with devastating livelihoods or seizure of rights and freedoms. Please pick the right battle to fight.


Disclosure: I am a long-time stockholder of both Walmart and Costco and support these policies to protect their employees. 


Joseph Weisenfeld, DPM, Staten Island, NY



RE: COVID Registry Update Needed

From: Bret M. Ribotsky, DPM


Earlier this year, we all recall the media reporting the pedal manifestation “COVID toes/feet”. At that time, I joined with other visionaries in our profession like Drs. Armstrong, Harkless, Wenstrup, and Positano and dermatologist Marta Rendon when Drs. Michael Nirenberg and Marc Brenner created the first COVID-19 Foot Registry. Its goal was to be an open place for data tabulation and reports to be shared. Just a few days after the announcement and the creation of the webpage, this topic in our profession became political.  


APMA and Dr. Vlahovic worked together to bypass the efforts of Drs. Nirenberg and Brenner and arranged a venture with dermatology. Ultimately, APMA decided to support (a non-DPM group) and intensively market registry controlled by the dermatology profession. Recognizing that two competing registries were not what was best, the “podiatrist group” went silent. So, now that COVID wave 2 is upon us, what have we learned? I have not seen any Registry reports. Can APMA update us all on this valuable information?


Bret M. Ribotsky, DPM, Boca Raton, FL



From: Warren S Joseph, DPM


In response to Dr. Purdy’s comment about the Danish mask wearing study, it should be noted that this was only one study, versus many showing effectiveness of mask wearing, and significant limitations to that study have been elucidated by multiple sources. One of the most definitive resources is the Infectious Diseases Society of America which maintains an entire webpage dedicated to ALL studies about mask effectiveness that is continuously updated. The link to that page is here: Masks & Face Coverings for the Public 


These are their conclusions about limitations of the Danish study:



• 20% of the study population did not complete the...


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



From: Jon Purdy, DPM


Here’s an interesting study showing mask usage does not lower infection rates.


Jon Purdy, DPM, New Iberia, LA



From: Dennis Shavelson DPM 


For about 8 months now, I have been involved as a professional associate with a company that has been proactive in preparing for the time when doctors' offices can take and get paid for both COVID-19 antibody and antigen testing. This company has worked with institutions and countries to supply tests for years and years. Their clients are fully prepared, licensed, and certified to offer these tests, seamlessly now that the FDA granted an emergency use authorization (EUA) in October. My place in the organization is to mentor and service those who qualify to test but are not familiar about the how, what, when, and why of this matter to get on board this important and profitable train.


Currently, the only test DPMs, MDs, and DOs (depending on state law) can perform is the 15 minute rapid antibody finger stick test (no antigen test yet but coming). It is taking about two weeks to become certified and to organize practice(s) to see if it can maintain FDA- and CLIA-compliance. This is working well in urban areas due to the high demand for antibody testing (not reimbursable) but my suggestion is to get involved on this level early, especially if you are having difficulty re-opening during COVID-19 because it will place you on the tarmac for the antigen EUA that will happen so that many more will take advantage of it.


Disclaimer: I am a consultant in this industry and have a profit motive.


Dennis Shavelson, DPM, NY, NY



RE: Harassment from Ciox Heath for Chart Requests

From: Jack Ressler, DPM


I received a chart request from Ciox health for patient charts. I called them to verify the email of where I need to send an invoice for this service. I sent an invoice as per their protocol. I did not receive any confirmation, but still continue to get ten page faxes requesting charts to the point of feeling harassed. As a group, is there any recourse we can take to prevent this repeated barrage of requests? They call from various telephone numbers and try to negotiate a price per chart, which I tell them is not negotiable. They follow-up with more faxes. If this isn't harassment, I don't know what is.


Jack Ressler, DPM, Delray Beach, FL



From: Robert Scott Steinberg, DPM, Brian Kiel, DPM


I reject Dr. Secord's assertions, or his referencing articles not in evidence, nor any links. I offer this article.


Robert Scott Steinberg, DPM, Schaumburg, IL


Dear Dr. Secord, please walk through a hospital E.R. maskless and laughing; then tell me how harmless COVID-19 is. Of course, a virus can pass through a mask, but it limits its dispersion. Denial of its virulence has killed thousands. The theory you espoused has been repeated by certain politicians but the opposite is stated by experts like Dr. Fauci. I think I will take his word for it.


Brian Kiel, DPM, Memphis, TN



From: Ron Werter DPM


I fully agree with Dr. Kiel. A few years ago, I was having an excellent conversation with a salesman in a major shoe store here in New York City. I finally asked him his name. He proudly responded, "It's on the sign in front."


It’s the same with us; whose name is on the front door? It’s your office, you make the rules. If the non-compliant person doesn’t like it, probably don’t want them as a patient anyway.


Ron Werter, DPM, NY, NY



From: David Secord, DPM


I had no choice but to laugh when I read the part of the post from Dr. Kiel which stated: "This is a life or death situation." I have several peer-reviewed papers residing on my hard drive which has fully explored the topic of a cloth or OR-type mask being able to stop something the size of a virus. All of them conclude that they are ineffectual. That they don't do anything is right on the box! We know that the death rate for the COVID-19 virus is around 0.1%, which puts it in line with every other seasonal influenza. We also know that we really don't have good numbers on the death rate, as everything shy of diaper rash has been listed as a COVID-19 virus death. We also know that we don't have good numbers for the population who has the COVID-19 virus, as the PCR test (by admission from the guy who invented it) is churning out a 95% false positive rate.


Are there people dying from this contagion? Yes. Is it more deadly than any other coronavirus seen each fall with a new seasonal influenza? Not according to the data. Is the hysteria we are reading, especially the absurd "Everyone has to wear a mask or we all die" hysteria believable? Not if you are sane. Wear a mask. Don't wear a mask. They are ineffectual against something the size of a virus.


David Secord, DPM, McAllen, TX



From: Connie Lee Bills, DPM   


I am shocked. I wouldn’t have actually touched the child, but definitely would have insisted that the mother deal with it immediately. I’ve had a similar situation during a procedure with a child. It was horrible.


Connie Lee Bills, DPM, Mt. Pleasant, MI 



From: Ivar E. Roth DPM, MPH 


I have found a simple way to solve this problem. When a problem occurs, I speak to both parties to get both sides and then and only then do I make a decision on how to handle the problem. I NEVER take either the patient’s word or my employee’s alone. Based on what I find out, I act accordingly. Surprisingly, it is about 50-50. My suggestion is never back the employee until you know for sure.


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



From: Charles Morelli, DPM


Dear Mrs. _____:


This letter will serve as formal notice that we will no longer be able to provide foot care to you because of the following reasons: 

  • It has come to my attention that you berated a member of my staff  numerous times, after she had gone out of her way to assist you in attaining a copy of your previous MRI.

  •  After speaking with this staff member, she was both visibly and emotionally upset. She has worked here for close to 20 years and no one has ever spoken to her the way you had, especially when she was actively trying to help you attain another copy of your MRI images.

  • If you want the entire disc again, you will have to go to _______, pay $25.00 and they will be happy to give you another copy.         

It pains us to do this as we have known you for many years, but this behavior cannot be tolerated or condoned. As you have already chosen to see another practitioner to address your current condition, I will be happy to send him or her a copy of your medical records and upon receipt of your written request, I will forward a copy of those records to your new provider. As you have already attained the services of another doctor, I am under no legal obligation to continue providing you with treatment and wish you well.   


Charles Morelli, DPM, Mamaroneck, NY 



From: Jack Ressler, DPM


Dr. Dananberg brings up an excellent point with the experience he described. There are some very important points we can all learn from this encounter. First, and most important, is for the doctor to understand any underlying circumstances that could be involved in the patient’s life that may be causing their behavior. Understanding this can lead to a wonderful professional patient relationship that not only could last for years, but also lead to many referrals. I have had countless experiences as described by Dr. Dananberg. New patient protocol in my office involves having one of my assistants take the patient into a treatment room after they have been registered.


A brief history is done, followed by my assistant conferring with me before I go in the room. During our talk, my assistant will sometimes comment as to the patient’s condition, mood, or personality "quirks". This is of utmost importance because it is a signal to me that extra care or compassion is needed. I love to make patients laugh and feel comfortable. My goal is to have a patient leave the office feeling good both physically and mentally. Losing spouses or dealing with...


Editor's note: Dr. Ressler's extended-length post can be read here.



From: Allen Jacobs, DPM 


Customer is defined as an individual (or organization) purchasing goods or services. When doctors became “providers,” patients became customers. The enthusiastic utilization of urgent care centers by patients illustrates the declining value of the doctor-patient relationship in exchange for service convenience. How many new patients do you see because “you were on my list of providers”? How many patients do you not see because you are no longer a provider for a particular third-party payer? How many lectures or seminars do you attend about maximization of profit from your customers/patients? People have to a large extent changed. They demand convenience, are increasingly demanding, lacking courtesy, and social graces. Egocentricity has become the new normal.


No, the patient/customer is not always right. I have no hesitancy to discharge patients who are abusive to staff or office policy. My charge is to provide quality care and support. Neither I nor my office exist for any other purpose. Nor should yours. You have studied too much, sacrificed too much, worked too hard, and are bound by ethical charge to be treated with other than the respect which you have earned. Conversely, to paraphrase Sir William Osler, MD, once profit and business become your priority, you have lost the spirit for which you entered healthcare. Under those circumstances, you do indeed have customers not patients. You have a business not a medical practice. As such, the customer is always right.


Allen Jacobs, DPM, St. Louis, MO



From: Howard Dananberg, DPM


Many years ago, I had a new patient present for care. After my nurse's interview with him, she came out and said how angry and mean spirited this man was and wished me good luck. After our visit, we came out laughing and very friendly and she was shocked. It turned out that he only has a small interdigital corn, but his wife of more than 50 years who was recently deceased had exclusively cared for this.   


He was angry at her passing and that someone else was going to treat him. Once we both recognized the underlying cause of the anger, he turned into a long-term, wonderful patient for several years until he died. There are lots of reasons why patients are angry. Sometimes, finding the cause goes a long way towards resolving the basic issues.  


Howard Dananberg, DPM, Stowe, VT    



From: David E Gurvis, DPM


I find patients are rude to the staff for several reasons. Pain and anxiety are uppermost. Fear of what the doctor might do, especially if they are fearful that it might include a needle. Having stress at their workplace for having taken off to even see a doctor. Financial reasons. And many more. I agree with what Tim Shea, DPM has said as well. And I will always try to turn a “bad” patient into a “good” patient. However, some people are just naturally rude and feel superior to those they feel are working for them. This is how they interact with the world around them and they carry it into the office.


The older I get, the less I find I tolerate rudeness. Life, and the day at the office, is too short for that. I don’t work for patients. I work with patients. For those who cannot be “turned,” I find discharge is appropriate.


David E Gurvis, DPM, Avon, IN



From: Keith L. Gurnick, DPM


About 15 years ago, I had an issue with an adult female patient, a tough and very wealthy widow and locally well-known philanthropist who dropped in to my office one day without an appointment, requesting to be seen for a non-urgent visit. When we refused her request, she then demanded her medical records and prior foot x-rays on the spot. I am sure some of the readers have encountered this same or similar challenging situation once or twice in their careers.


When she was told that our policy was that we needed a couple of days’ notice to make copies of her chart and physical copies of her x-rays, and that we were not able to stop whatever we were doing to comply with her non-urgent requests, she made quite a scene in front of other patients and stormed out of the office, opening the reception room door so violently that it... 


Editor's note: Dr. Gurnick's extended-length post can be read here.



From: Jane E. Graebner, DPM


One solution I have initiated in my office is creating a position called New Patient Coordinator. One of my 70+ year old employees whose only job prior to COVID-19 was visiting referral physician offices wanted to only work from home. Her duty is to call every new patient (or new problem which is someone who has been to our practice before but not recently and has a new foot/ankle problem) who are booked for one hour in our practice (1/2 hour with staff member and 1/2 hour with provider). She covers things like:

1) COVID-19 questions

2) Office location

3) Insurance coverage (to make sure we are in-network)

4) Referral source

5) Name they would like to be called

6) How they are completing their paperwork (i.e. portal, mailed, printed from website)

7) Confirming they are really a new patient (i.e. never been treated in our practice prior to this)


She even calls NPs after their first visit (within a week) and asks if they understand their treatment plan, etc. which gives us feedback about how we are doing. So far, this experiment has been good. Although the no show rate has not been lowered (which was my primary goal), the use of our portal has increased to 50% and the number of NPs who show up at time of appointment without any paperwork filled out has diminished as well, which helps keep us on schedule. You might want to try this for your practice.  


Jane E. Graebner, DPM, Delaware, OH



RE: Proposed Outpatient Prospective Payment System

From: Joseph Borreggine, DPM


The new proposed Outpatient Prospective Payment System (OPPS) rule is out. It looks like CMS is pushing ahead with its changes in how to document and determine E&M levels (No more H+P component, Medical decision-making DM, and time only) as well as significantly increasing reimbursement for office based E&Ms. Due to budget neutrality though, this increase is offset by an across the board decrease in the conversion factor of about 11%. This is going to result in a significant decrease in fees for many procedures which will include the routine foot care codes that are used quite frequently by podiatrists. If this proposed fee scheduled is approved, then the financial impact will be catastrophic. 


It is my understanding that the APMA is planning to make a comment to CMS on behalf of the profession. However, they will be just one comment that will provide a global statement with respect to the negative financial consequences it will have on the profession. Moreover, every podiatrist needs to consider leaving a comment on this proposed CMS fee schedule change. 


The more comments that are provided from this profession to CMS on this issue, the greater the chance that CMS may reverse their decision. Here is the link to do soPlease don't neglect this. Share it with friends and colleagues. These cuts could impact every specialty. It's not just our payments that would be jeopardized. The care received by our friends and families would also be at risk.


Joseph Borreggine, DPM, Port Charlotte, FL



From: Ben Cullen, DPM


I respectfully disagree with Dr. Gurnick. Not only is a mini-tightrope exceedingly difficult for an MPJ, if the underlying boney deformity is not addressed, it will do nothing for the long-term outcome. The 2nd and 3rd metatarsals are both elongated and medially angulated in this patient, causing the lateral deviation of the toes. Correctional osteotomies of the second/third metatarsal are necessary. This can be done distally with a translational Weil.


Although the metatarsal head may end up appearing laterally angulated to achieve the correction necessary, the digit will maintain it's position in the transverse position, and weight-bearing may be initiated sooner than with a proximal osteotomy.


Ben Cullen, DPM, San Diego, CA

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