Podiatry Management Online


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From: Elliot Udell, DPM


Dr. Borreggine is correct. One does not need to make an appointment to see a doctor in order to acquire a set of custom foot orthotics. This is not new. Making and dispensing foot orthotics has never been a practice which required a medical license. Orthopedic shoe stores, chiropractors, and physical therapists have been dispensing custom orthotics for years. What distinguishes a podiatrist from a "Joe Blow" working in a shoe store dispensing orthotics is our training in biomechanics. It’s the knowledge and training that enables the podiatrist to add corrections into a custom orthotic that distinguishes us from shoe store employees and others who make foot orthotics.


To this end, it would be great if the orthotics labs could roll back the clock and once again subsidize lectures on biomechanics and foot orthotics at every one of our conventions and at every one of our schools. That would once again make a real difference for our profession as well as the general public.


Elliot Udell, DPM, Hicksville, NY

Other messages in this thread:



From: Ivar E. Roth DPM, MPH


Dr. Stephen Epstein has a good idea... why not allow the taped version of a conference to be accessed online anytime for CME credits?


For us who sleep eat and breathe podiatry, we need afterhours and weekend access.


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



From: Daniel Chaskin, DPM


The joint statement by Dr. Lombardi and Dr. Markinson is a positive first step. But, arbitrary discrimination is still present. To unify our profession, all discrimination must stop. There are 2 types of certifications. 1. Completing an approved CPME certified residency training program. 2. Becoming board certified. 


The joint statement did not mention about the failure to complete a certified residency training program. Some older podiatrists received informal training by the cases they assisted. Some taught podiatry residents who became residency directors. To demand a certified residency program be completed is both arbitrary and age discriminatory against older podiatrists who did not have the ability to obtain such training.  


Daniel Chaskin, DPM, Ridgewood, NY 



From: Robert Scott Steinberg, DPM


I am not surprised by all the vitriol about boards. It has been a hallmark of our profession, and the inbred attitude of I'm better than you are; stuff I have witnessed for far too many years. More upsetting is the apparent lack of a basic understanding of hospital privileges credentialing. JCAHO is very strict. I can't imagine what they would do if they came into a hospital and while reviewing physicians' privileges, seeing "board certified", and the board not identified. Credentialing requires hospitals to verify with every board. 


The day after podiatrists finish their 3-year program, they can apply for privileges and get them. There is a time frame for completing board requirements, which a hospital can extend. If a podiatrist fails a board exam, what in reality actually changes the next day? Are they suddenly unqualified? Department chairs can and should observe new surgeons just getting on staff. 


And, what about the continued complaints about the boards? They fall on deaf ears. If a podiatrist who does not pass the boards the first time happens to be sued, can failing their boards be used against them?


Robert Scott Steinberg, DPM, Schaumburg, IL



From: Kenneth L Hatch, DPM


Dr. Pressman hit the nail on the head. The public and hospitals should not be misled by podiatrists claiming board certification without stating which board they are referring to. The informed patient is very aware that board certification refers to a certain level of skill and training. The public deserves a truthful statement from ANY doctor. In Maryland, any statement referring to podiatric board certification must specify which board when advertising or printing stationery. When I see ABFAS when looking to refer out of my area, I am very confident that I am sending my patient to someone well trained. 


Kenneth L Hatch, DPM, Annapolis, MD



From: Martin M. Pressman, DPM


I have been reading with great interest the back and forth of some of our finest thought leaders and I think they all have valid points. However, I think there are broader issues that need to be addressed. Here are some facts: 1. Hospitals are free to grant privileges based on individual training, experience, and competency with or without board certification. 2. CPME and JCRSB recognize only one SURGICAL board for podiatrists...ABFAS. 3. ABPM is not the surgical board for podiatry.


If you do not agree with these statements, then this discussion is over! If you are reading this, then you have accepted the above statements as true. The questions that get to the essence of this debate do not need to...


Editor's Note: Dr. Pressman's extended-length letter can be read here.



From: Bret M Ribotsky, DPM


It seems that the “common nerve” has been pressed once again: surgery vs. non-surgery, and today there is no 4% elixir that we can inject for a cure. It returns us to the primal podiatric question: Who are we? Seeking this answer has been what the past 35+ years has been all about. We have had expensive comprehensive projects, The Selden Report, Project 2000, and many, many more seeking the answer. This has been the question since my first day in podiatry school in 1984.


Back then, the top of the class became surgeons, and the rest just were left out. While Allen, Charlie, and the many other great contributors to our profession have pointed out that all training is important, it should be clear that most great leaders strived for certification in every boards they could. At a great cost in money and time, driven to be the best we could be, many of us became certified in...


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



From: Richard M. Maleski, DPM, RPh


My question is not to the ABPM BOD, but to the graduating residents. Why not take the ABFAS certification test? If you want to have surgical privileges, then get board certified by our profession's surgery board! This really shouldn't be a question of who is qualified to do a particular procedure. There are many DPMs in my generation who, like me, have been involved in residency training, residency genesis, hospital privileging, and opening up hospitals to podiatrists for surgery.


Doing these things requires a thought process that needs to consider the overall well-being of the patients, the community, the individual podiatrists, the hospitals involved, even the hospital administration. It's just not the podiatrist or the podiatry profession. There is a responsibility to...


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



From: Allen Jacobs, DPM

There is very significant clinical experience heterogeneity within the “three-year” podiatric residencies. Both the surgical and medical education is variable from program to program. The completion of a three-year residency in no manner guarantees either surgical or medical expertise. Therefore, the board certification process in both medicine and surgery. Having been in active practice for greater than 40 years, and having participated in post-graduate education, residency training, reviewing malpractice claims, and my activity as an ABFAS examiner, I  suggest the following for consideration.

The DPM degree carries many trusted responsibilities to the public, the state, healthcare entities, and to fellow practitioners. The DPM degree confers a trust. This trust includes the determination of qualifications for board certification in medicine as well as surgery. A podiatrist struggling to perform...


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



From: Dieter J. Fellner, DPM


Dr. Lombardi's question to the ABPM raises an interesting point. Such a concern would be founded, one might assume most assuredly, on a sound scientific basis. I will be extremely interested then to see the scientific evidence. 


Could it be true that three year residency-trained ABPM boarded surgical podiatrists fare so poorly in the surgical arena as to be denied surgical privileges by a hospital. All of the hard-gained surgical training in a three year residency will then amount to nothing.


Can a three year residency trained, and ABFAS boarded podiatrist outperform his brethren so magnificently that...


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



From: Elliot Udell, DPM


When live conventions became, at least temporarily, a thing of the past, it was hard to imagine how online programs would be a substitute. Could you discuss, ask questions, get to shmooze with some of the speakers, visit booths, etc.? It is true that the first few attempts at providing Zoom programs where the speakers and attendees were not in the same room lacked something.  


Because this problem has affected all aspects of American life, from school children to college students to doctors learning the latest techniques, society was forced to improve online learning at lightning speeds. In three months, we have come a long way. Even news media talk shows which featured panels of speakers fumbled in the beginning when they went into a format where people were not in the same room with each other. They corrected these problems fast. 


Today, things are much better. I am taking a ten-session course right now on dealing with upsets in the news, the virus, medical practice, personal life, etc. Needless to say, the course is packed. The technology for this course has gotten so good that it is in some ways better than courses given by the same school in live format. Bottom line, I miss attending and lecturing at live seminars, but I think that online programs in their current and future formats will be here to stay. 


Elliot Udell, DPM, Hicksville, NY



RE: Online Learning vs. Live Lectures?

From: Bret Ribotsky, DPM


I’m sure I’m not alone in missing the way it was just a few months ago. Attending seminars, asking questions, and discussing issues at the hotel bar into the late-hours of the evening, that’s how I have learned. I’ve had the privilege to give over 750 lectures in 48 states and ten counties, and there is a feeling that has not been reproduced via on-line learning. I remember in the early 2000s sitting in a hotel lounge with Warren Joseph and the late Harry Goldsmith (my mentors) as we discussed how our styles of lecturing, while totally different, were all very effective. 


What was the common thread? I believe that night, after a few drinks each, we all agreed on one common denominator, passion. Warren, Harry, and I were collectivity masters in holding an audience’s attention with our passion. Today’s online learning, to me, is missing the passion. Am I alone? 


Bret Ribotsky, DPM, Boca Raton, FL



From: Robert Scott Steinberg, DPM


Dr. Spier, with all due respect, did you read the whole article? An unnamed person from the CDC, with qualification to comment, had an opinion. The article concluded: VERDICT Partly false. Toxic levels of CO2 are dangerous but it is unlikely that wearing a face mask will cause hypercapnia.   


I have been doing surgery for 44 years. I have never suffered a headache while wearing a mask during surgery. I have not experienced a headache wearing a mask during this pandemic. I have never heard another surgeon complain of headaches due to wearing surgical maks, Let me offer this article to quash any notion that the CO2 thing is a thing. 


Robert Scott Steinberg, DPM, Schaumburg, IL



From: Tom Silver, DPM


I think those that are worried about CO2 build-up are either over-thinking or imagining it. We have all worn surgical masks in the OR for hours at a time without any problems. A tie-on surgical mask is what I currently wear in the office all day long. They are more comfortable than cone, ear loop, N95, or KN95 masks without fogging up eye glasses.


As for those who refuse to wear a mask for any reason whatsoever, we have face shields available for them to wear which we disinfect afterwards. A recent study showed that those that don't wear a mask have about a 17% risk of getting infected with the virus and those that do wear one have about a 3% I will stick with my comfortable tie-on surgical mask. Enough said!


Tom Silver, DPM, Minneapolis, MN



From: Steve E Abraham, DPM


I had two patients who needed special attention for mask issues! Both were deaf and communicated by reading lips. I explained as much as I could by writing on a pad, and at times I felt like taking my mask off and just talking. I resisted and did the right thing.


Steve E Abraham, DPM, NY, NY



From: David Gurvis DPM


Wearing a mask in the office will not lower your O2 saturation (hypoxemia) nor cause an increase in CO2 (hypercapnia). There are some slight differences with the wearing of a well fitted N95 mask but even those are most likely non-consequential, but there are no current recommendations or need to wear an N95 mask in the office. Regardless, there should be no reason for supplemental O2 from wearing a normal face mask in the office. You can find many well written articles on line but I will offer just one.  


My goal here is not to put anyone down, but there is too much information out there and too many people refusing to wear masks and that is just one, of many, excuses they are making. As a disclaimer, I am forced to admit that never in our history have so many needed to wear masks for so long during a day so that there may be some conditions wherein a mask may cause hypercapnia or hypoxemia, but I propose they are rare.


David Gurvis DPM, Avon, IN



From: Richard M. Maleski, DPM, RPh


Although I am now retired, while I was still practicing, I was gradually reducing the number of nail patients that needed grinding. I had many patients use either Vicks VapoRub or BenGay Rub on their nails a few days before their appointment. These inexpensive and readily available products work extremely well to soften the nails. They contain menthol and /or methyl salicylate; both are salicylates, and thus both are keratolytic. I practiced in a low income area and I was never comfortable with office dispensing of higher priced products, and very often PA Medicaid didn't cover urea products. Practically everyone could afford Vicks VapoRub. We all know that these products aren't useful as antifungal agents as many people believe, but they work remarkably well to soften the nails. That, in addition to sharpened nail nippers, will reduce the need to grind most of the nail patients.


Richard M. Maleski, DPM, RPh, Arnold, PA



From: Alan Bass, DPM


Let me begin by saying that this is my opinion only. In the last 25+ years of practice, I have seen some, if not most, of the governmental programs that have been rolled out by CMS. I understand that CMS has tried to reinvent how physicians practice medicine and guide them towards providing quality care. Even without this push from CMS, I believe that all physicians have tried to provide quality care to patients. Are there physicians out there who have tried to “beat the system”? Sure, but I believe that most physicians have always tried to do the right thing.


The MIPS system, as it currently is, and what it is morphing into in the coming years is about one thing, data gathering. It was the same thing with Meaningful Use. The Meaningful Use program was supposed to move physicians away from quantity and towards quality. Did it do that? Not at all. What did it do? All it did was...


Editor's Note: Dr. Bass' extended-length letter can read here



From: Brian Kiel, DPM


I have not used a drill to grind nails in at least 35 years. When patients ask if I will do so or ask why not because their other podiatrist did so, my answer is always the same. The nail dust is aerosolized and there is no way to prevent it from getting into the environment; therefore it is in the air that we and the patient breathe, and on the chair in which they sit. I tell them I don’t want them breathing in or sitting in someone else’s nail dust. This resolves the problem in 99.9% of the cases. In those that it doesn’t, I am happy to refer them elsewhere as I don’t think it appropriate to endanger my or my staff's health. 


Brian Kiel, DPM. Memphis, TN



RE: Grinding Nails During the COVID-19 Pandemic (Elliot Udell, DPM)

From: Daniel Chaskin, DPM


I would like to thank Elliot for his suggestions. If T. Rubrum or Candida dust were to bind to the ACE-2 receptors, there might be possible problems with too much vasoconstriction, etc. Combine this with COVID-19 and there just might not be enough receptors to convert angiotensin 2 to a more benign form.


Daniel Chaskin, DPM, Ridgewood, NY



From: Alan Bass, DPM


I heard about the Swift device in 2019 and I leased it in November 2019 while at the AAPPM conference in Daytona. I leased it specifically because of one patient with recalcitrant interdigital warts. I have been very happy with my decision. I leased the unit for 5 years. I have had very good results with several patients in this short period of time. The unit is very easy to use. The treatment protocol is very easy to follow. I have heard from other DPMs that they are also happy with their investment.


Disclosure: I am a consultant for Saorsa, the distributors of Swift.


Alan Bass, DPM, Manalapan, NJ



From: Joseph Borreggine, DPM


Who are we kidding in this profession about the education, training, and experience of a podiatrist (not a foot and ankle surgeon who is a podiatrist) versus a nurse practitioner (NP)? Well, we all know the answer. So, I will leave it there. But, what we are not getting is that the NP is fighting to obtain a full and unlimited license comparable to an MD or a DO. Here is the proof, and we are not.


Moreover, podiatric physicians are not even considering this as a potential and viable possibility for the profession. Yes, we have the plenary license stature in California as a "physician and surgeon", expanded areas of practice on the lower extremity in...


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



From:  Paul Busman DPM, RN


Disclosure - I am not totally unbiased, as my wife is an adult nurse practitioner. That said, I do not believe that this is typical of nurse practitioners in general. NPs do not get certified as general nurse practitioners. They get specific certifications including adult nurse practitioner, family nurse practitioner, psych nurse practitioner, gerontology nurse practitioner, etc. An adult NP could work in a nursing home without the gerontology certification although they might want to add the additional class and clinic work to add that second certification. Just as in podiatry, the profession has changed much over the years, and a nurse practitioner might not have had as extensive training as a more recent graduate, although that might be balanced by years’ worth of experience working in the chosen field.


In the situation cited by Dr. Finer, the nurse practitioner in question could have been a recent grad adult nurse practitioner working in her first employment. She would have had exposure to pressure ulcers in general during her training, but perhaps not foot ulceration in particular. She obviously did the right thing in asking for advice which will improve her practice. The nurse practitioner's education can't realistically encompass comprehensive expertise in all fields of medicine. Much specific knowledge is obtained once in the chosen field, as a doctor does during internship.


Paul Busman DPM, RN, Frederick, MD



From: David Krausse, DPM


I hope that the new TLC show is helpful in spreading the good work of podiatry around and I hope that the 2 podiatrists featured make good decisions and help their patients. That being said, does it not bother anyone that neither of these doctors are board certified in surgery? 


David Krausse, DPM, Flemington, NJ



From: Jonathan Michael, DPM


With all my respect to the Drs. on the show, I was not impressed at all by the performance that highlights our profession. In one instance, the doctor says I have never seen anything like that and I really do not know how I am going to treat you. Then he made the patient custom sandals when I was expecting some sort of surgical intervention. In the other instance, the Dr. removed a fungus nail that was done distally and crumbled; in my opinion, it should have removed proximal first to avoid the struggle to remove it in pieces. I think that did more harm than good to our profession. 


Jonathan Michael, DPM, Bayonne, NJ



RE: Source for Radiesse 

From: Allen Jacobs, DPM


Saying that “I’ve used this technique or product a bizillion times without any problems” may not be a positive defense for unindicated use. It is analogous to drunk driving, or never stopping at a red light. Most intoxicated people, or those who ignore traffic signals, are not in auto vehicle accidents while driving drunk or ignoring a red traffic signal. However, driving while drunk or ignoring a red light raises the statistical RISK of an accident. Should such an accident occur, you will likely be held accountable. Safe means safe for studies and indicated utilization.


Stating that you “took a course” at some seminar is like implicating the bartender for your intoxicated driving. Taking a “course” at some podiatry seminar does not provide you with a special exemption for the provision of ethical, standard of care treatment to your patients. 


I suggest that at a minimum, patients be informed that the use of the medication or technique has not been studied nor is FDA-approved, and that appropriate verifiable consent be obtained.
Allen Jacobs, DPM, St. Louis, MO

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