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RE: Preventing Suicides of Podiatric Residents

From: Patrick DeHeer, DPM


According to a recent study, “In the United States, approximately one physician dies by suicide every day. Training physicians are at particularly high risk, with suicidal ideation increasing more than 4-fold during the first 3 months of an internship year. Despite this increase, to our knowledge, very few efforts have been made to prevent the escalation of suicidal thoughts among training physicians. This study demonstrates that a free, easily accessible, brief [web-based cognitive behavioral therapy (wCBT)] program is associated with reduced likelihood of suicidal ideation among medical interns. Prevention programs with these characteristics could be easily disseminated to medical training programs across the country."


We created a survey based on the survey used by the St. Vincent internal medicine and family practice residencies to examine their residents' well-being. I believe the updated study is critically important. The podiatric profession can either continue to stick our heads in the sand on this topic or examine how it is affecting our future by helping to disseminate this survey. 


APMA has agreed to help get the survey out to podiatric residents, and I hope your various organizations will join APMA's efforts to examine our own profession. I will be using my bully pulpit to get the word out. I hope we can help to disseminate our survey to the podiatric residency community. We plan to collect the data and present it to key stakeholders to hopefully develop a podiatric-specific wBCT. 


Patrick DeHeer, DPM, Indianapolis, IN

Other messages in this thread:



From: T. Nat Chotechuang, DPM


Our intake form simply asks, "Gender: ________" and the patient fills in the blank however they wish.


T. Nat Chotechuang, DPM, Bend, OR 



From: Kevin C. McDonald, DPM


I do ANS and sudomotor testing in my office on occasion, as it is available on my ABI vascular testing device. The test involves heating up the soles of the feet and measuring a) the dilation of the small blood vessels beneath the skin and b) the sweat response (as a measure of the function of the sudomotor nerves controlling the sweat glands). A decreased response indicates damage to the autonomic nerves on the soles of the feet while the absence of a response indicates a complete loss of autonomic nerve function. 


Sudomotor testing is considered "investigational" and thus non-covered by the vast majority of insurance companies. I hope that this changes because ANS/sudomotor testing has advantages over epidermal nerve biopsies including a) no injections, b) no wounds, c) immediate, quantified results, d) measuring the nerves of the feet rather than the nerves of the lower legs, and e) a much lower cost. In summary, it's a good test but it's typically not covered by insurance.


Kevin C. McDonald, DPM, Concord, NC



From: Elliot Udell, DPM


Dr. Moore is being very astute in asking whether a new modality is covered by insurance companies. Every year, like clockwork, there is some new diagnostic or therapeutic modality being promoted at our conventions. Very often the sales reps will swear that the new device is covered by insurance and gullible practitioners find out, too late, that the codes given by the salesperson is really specific for a different modality, and under an audit the practitioner will have to pay back all that he or she received. 


In most cases when this happens, the doctor will have little recourse because the manufacturer is long out of business. The bottom line is this: Yes there are new and exciting modalities being developed that can help our patients. As Dr. Moore has done, before becoming a buyer, we need to give a "shout out" and find out whether the device is therapeutically beneficial and whether it will be legitimately covered by insurance companies. 


Elliot Udell, DPM, Hicksville, NY



RE: The Rebalancing of Podiatric Medical and Surgical Residency Education

From: Alan Sherman, DPM


Chuck Ross started an interesting discussion triggered by his attending the always excellent Richard O. Schuster Memorial Seminar in biomechanics last week. He makes the statement that the concern regarding the lack of emphasis on biomechanics should be focused on the 3 years of residency education, where he notes that there is a “dramatic lack of a continuum once students graduate and enter residency programs, with few exceptions as the emphasis is solely upon surgery.”


Allen Jacobs shares his experiences with speaking to residents, “that it is distinctly uncommon to see gait analysis performed on most patients, including those being evaluated for...


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



From: Bob Hatcher, DPM


This website for Charlotte's Web has a variety of CBD products plus information on production and cost.


Bob Hatcher, DPM, Raleigh, NC



From: Todd Lamster, DPM


I respectfully disagree with a recent post from my colleague Dr. Werter. A bone surgery of any kind, whether it be a simple exostectomy or joint reconstruction, is much different than a P&A in terms of wound depth and potential for infection. An OR should be much cleaner than anyone's office, and in today's age of drug resistant bacteria, anything we can do to limit post-operative infection (especially osteomyelitis) should be considered and most likely carried out. With respect to anesthesia, light sedation to perform the digital block and keep the patient comfortable during the surgery is a good thing. 


In patients who have very high anxiety, it is proper and a necessary course of action. What about the pediatric patient who is screaming, crying, carrying on about "the shot" before doing a toenail procedure? I have taken quite a few of these patients to the OR simply to make sure that I can actually carry out the procedure safely and efficiently. In those cases, sedation for a P&A is absolutely necessary!  Lastly, pain is VERY subjective. We all know this. 


Patients' pain varies widely from the simplest skin closure or P&A to the most complex reconstructive procedure. Post-operative pain, in my opinion, tells you very little about the surgery, the technique, or the surgeon. I never tell patients in absolute terms how much or how little pain they should expect after any procedure I perform. Manage the patient, the pain, the wound, and move on.


Todd Lamster, DPM, Scottsdale, AZ



From: Keith L. Gurnick, DPM, Allen Jacobs, DPM


It would be a better and more accurate and honest representation of who he is if his nameplate read "Brad Wenstrup, DPM" and not "Dr. Brad Wenstrup". That alone would do a lot to promote podiatry. Typically, nameplates for medical doctors read “MD," not "Dr.” 


Keith L. Gurnick, DPM, Los Angeles, CA


Yes, I was proud of Brad Wenstrup’s actions in the recent impeachment hearings. However, that pride was as an American not as a podiatrist. Dr. Katzen points out that the name plate states “Dr.” not DPM. I watched numerous interviews in all of which representative Wenstrup refers to himself as a surgeon, a doctor, or as a healthcare provider. The term podiatrist or podiatry never is utilized. While I am personally proud that a fellow podiatrist has risen to such prominence, and while I would believe that Dr. Wenstrup is likely in a position to assist the advancement of our profession, Brad Wenstrup, DPM on that plate would have been nice. His self-identification as “doctor” may be appropriate, but let’s not anoint him as an ambassador of podiatry. 


Congresman Wenstrup is typical of today’s students who “graduated medical school" or have “ Dr.” prefixing their name. The issue is not whether you are a graduate of a podiatric medical school, whether you are a “foot and ankle surgeon”, or if you are a doctor. The issue is that ultimately you hold a DPM degree. Not MD. I ask how in the world do you expect recognition of the DPM degree and the excellent care the DPM provides when no one hears or is aware of the degree and the training and excellence in care which that degree represents.


Allen Jacobs, DPM, St. Louis, MO



From: Robert Scott Steinberg, DPM


We are using Transworld Systems. Easy to use.


Robert Scott Steinberg, DPM, Schaumburg, IL



From: Allen Jacobs, DPM


CBD topical preparations appear to be very helpful for symptomatic treatment of musculoskeletal disorders (e.g. arthritis, tendinitis ). I offer this has an alternative to those patients in whom oral NSAID therapy is not appropriate or concerning, e.g.: renal concerns, cardiac concerns, anticoagulation therapy, history of GI pathology). Typically, high NSAID risk patients are given the choice of topical NSAIDs, CBD topical, or no treatment. I personally use the CBD products from EBM pharmacy. The results have been excellent. I prescribe CBD topical daily.


Disclosure: I have lectured for EBM pharmacy in the past.


Allen Jacobs, DPM,  St. Louis, MO



From: Steven Finer, DPM


I recently purchased Quantum Rub at a seminar. It contains polarized CBD, menthol, and various herbs and oils including vitamin E. My wife has used it after our trips to the gym. She said that it helps with generalized soreness, not strong pain. Naturally, this is anecdotal evidence. It seems all rubs contain menthol for their cooling effect. Many can contain ingredients that produce warmth and new evidence shows it may speed healing. As to the claim of polarization, it is unproven. Ingested CBDs in the form of pills and gummies may be taken off the market due to lack of standards. I personally prefer Voltaren gel on a limited basis, as there is some systemic absorption.   


Steven Finer, DPM, Philadelphia, PA



From Paul Kesselman, DPM


I have also been attempting to secure new blood on several committees which I participate in both at the state and national level. While I understand the newbees have other priorities (raising kids, etc.), the future of this profession cannot be dictated (nor should we want it to be dictated) by generations who came before you. We have come a long way since I came back from Chicago in 1981 but there are many more roadblocks ahead, for which we need a younger person's stamina and perspective. Please consider Dale's invitation to participate in whatever way you can. The future of this profession needs your contributions!


Paul Kesselman, DPM, Woodside, NY



RE: Shortage of PMSR/RRA Programs

From: Daniel Chaskin, DPM


Currently, there are two residency models. Model number one is a PMSR. Upon completion of this model,  podiatrists are unable to become licensed to treat the ankle (with the exception of contiguous foot wounds) throughout every state in our country. Model number two is a  PMSR/RRA which does allow a path for a podiatrist to possibly qualify to medically and surgically treat the ankle. 


The problem is that there is a shortage of PMSR/RRA programs. Some podiatrists only are able to participate in a PMSR. A PMSR/RRA is required to ultimately allow podiatrists to medically treat the ankle in all states throughout our country. Medically treating the ankle regarding conditions such as melanoma, etc. is so important. Podiatric medicine includes the excision of melanomas on the ankle. Even if PMSR podiatrists actually completed a PMSR and became board certified in podiatric medicine, they still could not medically treat the ankle regarding conditions such as excision of melanoma. This may be one reason to replace all PMSRs with PMSR/RRAs.


Daniel Chaskin, DPM, Ridgewood, NY



From: Leonard A, Levy, DPM, MPH


Brent D. Haverstock, DPM said, "It would seem that if podiatry is to become a branch of medicine (MD/DO), the APMA would have to meet with the American Medical Association (AMA) and the American Osteopathic Association (AOA)..." This remark and so many others from podiatric physicians seem to indicate that the "appetite" for DPMs to acquire an MD or DO degree is rapidly increasing. However, before any meetings take place with the AMA or AOA and the APMA, it is essential that strategic planning take place to determine exactly what the profession needs to do and what needs to be done to get there. 


Such an activity must, at the least, include representation from the APMA, the Association of Colleges of Podiatric Medicine, representatives of the current licensing examination body (i.e., American Podiatric Medical Licensing Examination), and the bodies within our profession that represent both the accreditation of undergraduate podiatric medical education and graduate podiatric medical education (i.e., residency training). 


It would be a disaster if such a plan was not properly developed and members of our profession were not on the same page. Our effort needs to be one having a uniform voice devoid of bickering by individuals and groups in the profession. The strategic plan developed should be articulated in a document containing the background of the proposal, the state of the profession, including its current education and training, and a detailed description of what is being proposed. I suggest that the time is ripe to undergo such an effort but that it needs to be done very carefully. This formal process must begin now.


Leonard A, Levy, DPM, MPH, Ft. Lauderdale, FL



From: Robert Scott Steinberg, DPM


Yes, the train has left the station, and I hope for good. Those who think differently just don't get it. Just as we get our schools to move to a complete set of courses, matching those of medical students, the last thing we need is to divide us into tiny pieces, each of which will be ignored and lost on other physicians and patients.


More than anything else, doctors of podiatric medicine need to become a stable, cohesive profession, and anyone attempting to divide us should be shown the door.


Robert Scott Steinberg, DPM, Schaumburg, IL



From: Alan Sherman, DPM


I’m confused by Leonard Levy’s most recent message in this discussion in the October 31, 2019 #6,539 issue, in which he refers to the “highly controversial proposal to have two specialty boards in the podiatric medical profession (i.e., podiatric surgery and podiatric medicine”. It’s not a proposal. We currently have these two specialty boards, ABPS and ABFAS. What we don’t have is two medical specialties. We have two specialty boards that represent one specialty, podiatry, and that structure is what is confusing the public and the medical establishment.


The proposal made by Jeff Robbins, DPM, supported by myself, Joe Borreggine, and now Brent Haverstock, DPM, is that our two specialty boards MERGE and form one board with sub-specialties, including advanced foot and ankle surgery and...


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



From: Charles M Lombardi, DPM


All this musing about two separate training programs is amusing to someone who has been around for some time and has been intimately involved in the progression of this profession. In 2000 or 2001, the CPME ad hoc committee to rewrite the 320 document recommended to the HOD and the community of interest three separate programs: A 2-year surgical, a 3-year surgical, and a 2-year primary podiatric care program. The APMA HOD and the community of interest REJECTED it outright, stating that ALL podiatrist must be trained the same. Some of the SAME people that were opposed to a separate primary podiatric care program are now in favor of it. The ABPS argued against a unified program, but lost the battle.


Now looking back, the unified program allowed many states to change the scope of practice laws because one of the arguments against us was a lack of unified training. Much good came from that decision. I was always in favor of two separate training tracks, but that train has left the station. To hear the SAME people who were opposed to a separate training program in 2001, but now say our profession must have two separate training programs are in psychiatric terms schizophrenic. Our profession would be considered a schizophrenic profession by lawmakers.


Charles M Lombardi, DPM, Flushing, NY



From: (David Laurino, DPM)


I partnered with a veteran in the VA (virtual assistants) world and created Bottleneck Medical. It has been a game changer and helped me get back about 10-12 hours/week, increased revenues, decreased my stress and burnout, and made it more enjoyable to see patients versus being a glorified secretary or court reporter. Ultimately, isn't that what it's all about? 


It's a vicious cycle. We’re trying to be patient-centric in a data driven world. It's an uphill, stressful, painful, and never-ending battle. My massive burnout hit about 3 years ago and I knew there had to be a better way. I went on a search for answers and discovered that virtual assistants were the answer to my biggest issues creating my burnout: lack of time, energy, money, and overall quality of life.


Disclosure: Dr. Laurino is co-founder and managing partner of Bottleneck Medical Virtual Services


David Laurino, DPM, Chandler, AZ



From: Brian Kiel, DPM


I have used Entrada as my virtual scribe service and it is wonderful. I have no charts to take home nor any on weekends. When I leave the office, my charts are done. 


Brian Kiel, DPM, Memphis, TN



From: James J DiResta, DPM, MPH


Many graduating podiatric medical students would benefit from an Intensive Podiatric Medicine Residency option. Providing this option for our graduates who do not want to be surgeons can have real value IF done correctly. That would work if we were able to engage Dr. Levy in this process in creating such a program, i.e. a 3-year residency curriculum in "podiatric medicine" that could provide for training in areas of general medicine, obstetrics, psychiatry, and make up for those clinical deficiencies our graduates presently have, provide for an allopathic or osteopathic medical school to sponsor the program so the resident can be provided a DO or MD degree, and get the residency in "podiatric medicine" ACGME recognized with accreditation.


I know those are considerable barriers to cross. As a profession, we may need to financially support such an effort in the initial roll out. We would need our students to take and pass the USMLE step 1 which we have known for some time is essential no matter what we do going forward. The completion of this type of residency would provide equal footing with our medical and surgical colleagues for OUR profession "podiatric medicine". Dr. Levy has provided alternative pathways for DPMs to the DO degree before. Perhaps this time, we can obtain a successful solution in a time span equal to that of our podiatric surgically approved programs and that would provide the value many of our graduates want who do not expect to be reconstructive foot and ankle surgeons. 


James J DiResta, DPM, MPH, Newburyport, MA 



From: Ira Baum, DPM 


Dr. Levy speaks from experience and knowledge, but the practical response from Dr. Purdy would be more effective and efficient. Taking into consideration the healthcare environment today with respect to student debt, years in training, and reimbursement schedules for podiatrists, it doesn’t make a lot of sense to pursue a regional specialty that other medical professionals serve based on a system specialty. There was a time for that type of specialty, but that time has passed. The train has left the station.


The obvious obstacle to transitioning DPM to MD/DO is the solid structure of the podiatric medical systems. Until those systems realize the future of the profession and see the value for those in leadership positions of our associations, educational institutions and boards to change, podiatrists' recognition will remain unchanged, and our war for parity will be never ending. Unfortunately, it is the grassroots podiatrists who will suffer for their inaction. I strongly recommend those in leadership positions to consider these points and begin to explore options and opportunities for change.


Ira Baum, DPM, Miami, FL



RE: Pennies Add Up

From: George Jacobson, DPM


When I was in elementary school, my father taught us to think of a penny as 1% of a dollar. In a world where a bank gives us a fraction of a percent, one percent is a lot. Several insurance companies are now sending us payment via a credit card that is faxed to our office. We have to key it in which costs us more than just "swiping" the card. To give up another 2-3.5% to save them the cost of sending out a check is pathetic. Every year there is another expense or way we lose income. The expenses ALWAYS go up, yet the reimbursements somehow go down. I still pick up pennies.


George Jacobson, DPM, Hollywood, FL



From: Kim Antol


The Apus PXP-15HF is manufactured by Poksom in Korea and distributed nationally by United Radiology Systems in Deerfield IL. Unfortunately, Pokom discontinued the product about 5 years ago, but United Radiology (their U.S. component) may still be able to help.


You say “the x-ray images are diminishing.” This may not actually be an issue with the x-ray generator, but rather your old DR (direct radiology) plate, which is typical of some of the early systems that were sold.


Kim Antol, President, Sigma Digital X-Ray



From: Steven Finer, DPM, Jim Steinberg, DPM


When I was in full-time practice, I had these small drill engines attached to Sani-Vacs via black vinyl tubing. We had reamers to clean the tubing. In addition, we had Honeywell cleaners with charcoal filters. We had no problem in 40 years.  


Steven Finer, DPM, Philadelphia, PA


There has been a lot of input about air purification, not filters. Nail dust can only be extracted from a room or entire office if you treat the air itself. There is only one way to successfully do this and it is by ozonation and ionization. Remember, air can only be cleaned when it gets to a filter. Ozone cleans the air by using O3 to change the chemical structure of impurities and ions attack the negative change of neutral particles in the air (nail dust). Look into Alpine Industries on the Web, it makes sense.


Jim Steinberg, DPM, The Villages, FL



RE: APMA Young Physicians' Institute

From: R. Andrew Pavelescu, DPM


On October 11-13, along with fellow young member Dr. Jeff Kagan (PGY-1), I attended the APMA Young Physicians' Institute in Nashville, TN. As a member of the APMA Young Physician Leadership Panel, I met with fellow panel members prior to the main YPI program for a strategic planning session. Here the panel discussed key and imminent problems facing young DPMs and established working goals for the next two years. The leadership panel is composed of young podiatrists from across the country, who serve as the intermediaries between the APMA Board of Trustees and the membership at large. The primary goal of the YPLP is to advocate on behalf of all young DPMs.


The formal APMA YPI program took place October 12th and 13th. Attendees representing a wide variety of component states had the opportunity to partake in lectures and workshops focused on building leadership skills. This is a phenomenal yearly program whose goal is to help build the next generation of leaders in podiatry!


R. Andrew Pavelescu, DPM, Fresh Meadows, NY



From: Richard D Wolff, DPM


For the past 12 years of practice, I have had zero residual nail dust in my treatment rooms, but I understand where you are coming from. During my first two years of practice, I had the same issue. When I moved to a different office, I had a central vacuum system installed. The vacuum is in a closet and shared by all treatment rooms. The rooms are connected to the vacuum via 2" PVC pipe above the ceiling tiles. The noise is contained to the closet, which has 2" thick foam added to the walls. 


I bought a cone nozzle (#ACC-SHEATH) from Jan L. It attaches directly to the end of a Dremel Multi-Pro and has a 1/2" tube connection. I also bought a reducer from Allegro Vaccums. It reduces the 2" outlet down to 1/2". The last item was a piece of 1/2" vinyl tubing I purchased from the local hardware store. There is strong suction noise in the treatment room, but no motor noise. The vacuum also serves as a floor vacuum for each room and we vacuum in between patients. No nails, no dust. I Dremel every patient. It is still going strong after 12 years of heavy use. I'm guessing I have about $1,500 in the system.


Richard D Wolff, DPM, Oregon, OH


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