12/30/2019 Hosted by Bret Ribotsky, DPM
Earl Horowitz, DPM Interview on Meet The Masters
Bret Ribotsky: Good evening everyone. It is 9
o’clock and Welcome to Meet the Masters. It is
your host Bret Ribotsky. It is the April 19th
and we have an incredible evening this evening.
I would like to thank Dr. Comfort for helping
making this all possible. Next week’s guest is
Dr. Vicky Driver, Boston, reach expert and we
will talk about cutting edge technologies that
are soon to come out. Without further ado let
me get to today’s true master Dr. Earl Horowitz
almost had every position I think that exist in
our profession. He has practiced for 52 years.
He is originally from the Temple University
School of Podiatric Medicine which was the
original Temple University School of Podiatric
School. He did his residency in the old St.
Luke’s Hospital and Philadelphia General
Hospital. He started the first surgical
residency program in the State of Florida. He
has been past president of American College of
Foot and Ankle Orthopedics, the precursor to the
American College of Foot and Ankle Orthopedics
and Medicine. He has been president of the
Florida Podiatric Medical Association. He has
been on the board of directors of the DPM
malpractice insurance company for over 20 years.
I can go on for about a half hour describing
this person but lets hear from him live. Dr.
Horowitz, welcome to Meet the Masters.
Earl Horowitz: Thank you very much for having me
Bret.
Bret Ribotsky: Well, we all feel very fortunate.
First question I would like to ask everybody,
how do you define success?
Earl Horowitz: Well, success is a many face
thing, one of course everybody looks at is the
economics of success, but success is what you
feel you have gained from what you do and more
important is what the patient feels that you to
offer. If you satisfy the patient’s needs, that
is the success and that is a big-big picture of
what the patient needs, not necessarily what you
need or an insurance company needs or the
government needs.
Bret Ribotsky: That is how you personally do it
based on the patient’s results.
Earl Horowitz: 90% of that is definitely true
and that means you have to look for things that
help the patient not necessarily what is
available all the time. You have got to look
for things that will make that patient more
satisfied with the service that you are
offering.
Bret Ribotsky: How did you choose podiatry.
Earl Horowitz: Well, I have to tell a cute
story. I was in the small fish business with my
father, so I went from one selling business to
another. That is the story I tell everybody,
but I got involved really, my wife at that time
my girlfriend went to a doctor in _____, who was
rather important in our profession back in the
late 40s and early 50s with a wart and I had no
idea what a podiatrist was or a chiropodist at
that type and he convinced me to look into
podiatry and it effected my business sense of
profession that was small. You would move
around and do things and he offered an
opportunity that there were not many people in
it and it made me feel that this was something I
have to get involved much quicker than the rest
of organized medicine at that time.
Bret Ribotsky: Four or five people send me e-
mails asking me how did you get the nickname
boots.
Earl Horowitz: It goes back to the situation
when my parents were from New England and they
called me Earl, I was born in New York and
everybody oil instead or Earl and at the time
the Irish expression for a cute boy was boychik
and quite of few of my parents’ friends could
never pronounce boychik and they came out like
bootcee-bootcee, so the nickname boots stuck and
whatever reason my mother’s name is pearl, and
if you ever call my house and get my father on
the phone and ask for Earl, he yells Pearl there
was someone on the phone for you. I always
became boots and it has nothing to do with
podiatry or anything like that.
Bret Ribotsky: Oh, how cute. Early, in your
career, you got involved in education. You kind
to felt that was something unique and you kind
of created in some capacity, ran for many years
to precursor to the big meeting in Florida
called the SAM meeting science and management,
that was called the PIP meeting. How did that
get started? How did you got started in
education?
Earl Horowitz: Yeah, that was I went to a
meeting called the big D years ago and it
actually was in Philadelphia but they called it
a big D at the time and the speakers were all
management people and they just started to click
in my mind that this is something that podiatry
really needed. There were a lot of people at
the time that were rather involved, we are
trying to tell people how to practice and
everything and I decided to run through the
Florida Podiatric Medical Associates where it
really was not called that time, it was Florida
Podiatry Association. The idea putting on a
just a management program, everything was to do
with management only, not really anything
scientific per se and I was very fortunate that
one of my first speakers that I was to get the
first time he ever spoke podiatry by the
gentleman by the name of Bob Lavoy and Lavoy
just set everything going for the next 15 years
of practice management, the name of the game for
podiatry especially in the late 50s, 60s, and
70s, changing people’s minds and practice,
became a very big and important thing at the
time that we finished 15 years of doing, we
probably were the premier practice management
program in the United States for podiatry.
Bret Ribotsky: And that has blossomed to be an
incredible meeting on to itself. Podiatry
really was not allowed in the hospitals, can you
give some of metamorphosis that took place in
some of the things, how they transformed.
Earl Horowitz: Well, when I got out in 1959 and
did sort of a residency, went to first in the
Hospitals at St. Luke’s and then Philadelphia
General and I came to Jacksonville, Florida and
I was amazed there is no real hospital opened
anytime, so I got involved with the osteopaths
in our particular community and they are a very
small, actually was house not a hospital that
they did their work with and few podiatrists and
the osteopaths decided we were going to build a
hospital in Jacksonville to be proud of, 108 bed
hospital at that time and was originally AOA
approved hospital, which later became a joint
commissioned approved hospital but we all got
together and decided that podiatry had a place
in hospitals as more younger podiatrists started
to come into the Jacksonville but it was the
podiatrist that helped really push the idea of
getting an osteopathic hospital. The osteopaths
were trying to get into the AMA hospitals a
little luck at that time. So, we came in and I
was fortunate because I was sort of founding
father to get on the board of directors of that
hospital and after a short of period of three
years became the chairman of the board. I think
I was the first podiatrist that was ever
chairman of ward of a hospital and then during
that time I started the first surgical residency
at that hospital for podiatry too.
Bret Ribotsky: Around what time did this all
take place.
Earl Horowitz: In the early 60s and mid 60s.
Bret Ribotsky: So, this is kind of like almost
pre-cursing the current experience.
Earl Horowitz: Well, it was a civic hospital
before that. The civic hospital was before our
hospital took place. They were the ones that
really got everything started, Earl Kaplan and
his group there was really the main porch to get
podiatrist into surgery and into hospitals at
the same time too.
Bret Ribotsky: For people who do not know
Jacksonville, Florida also has Mayo clinic as
well as a big University of Florida Hospital ….
Earl Horowitz: Right Mayo and …… about five
other hospitals too.
Bret Ribotsky: It is on the cutting edge of what
is out there. You seem to get involved in you
know every opportunity and every crisis that
came down the pike in this profession. You seem
to be kind of there as a beacon and a glowing
light when malpractice insurance was difficult
for podiatrists to get involved. You kind to
got involved to helping create the insurance
company.
Earl Horowitz: Well, we started that in Florida
because insurance, actually the reason all of us
got involved in malpractice insurance was the
fact that Florida, the companies decide to they
were not going to insure and so you had to
develop your own actual insurance companies and
we started the Florida Podiatry Trust and then
it became DPM. Actually started with about
$500,000, just barely made the requirements and
ended up with about a 20 million dollar company
when they finally sold out 20 years later but it
served the great purpose for Florida podiatrists
and established many of the norms that we accept
today such as defending podiatrist against
Medicare problems and state board problems as
well as malpractice. We defended an
interpretation by Medicare where they asked back
from about 200 podiatrist about eight million
dollars or something like that and we actually
won the case to prove that Medicare was
misinterpreting the law and we were the main
people that aided all the podiatry, we took them
on as a civil suit from all the podiatry even
though many of them were not clients at that
time and won that case and establish a principle
of malpractice company getting involved in the
podiatrist even for Medicare problems.
Bret Ribotsky: Incredible, the PICA accord ……
Earl Horowitz: PICA bought out DPM ….
Bret Ribotsky: …. reversed into it and the whole
country has benefited as a result of those
steps.
Earl Horowitz: We feel definitely, that’s true.
Bret Ribotsky: At some point, you keep to have
not disagreement with the organizational side of
board certification of podiatry and you kind of
involved was involved in different set of
boards.
Earl Horowitz: Okay, I got many calls when I got
involved with this, how can you be calling and
doing this. I was president of the American
College of Foot Orthopedics and I was associated
with the American College of Foot Surgeons , all
the necessarily things but I felt there were so
many people being left out and as the time went
on even more so being out and they are being
left out even today with this 2015 concept and
three year residency. What happen to these
people that do not have all of the
qualifications that have the qualification
because they have got practice experience. What
are these people do, just were not up to date
and feeling that they needed board
certification. The window closed rather quickly
in a short period of time for them to take the
APMA board, so we decided to organize a means
for them to get there certification. This led
to us knowing many steps further than the APMA
board and getting approval by NOCA and ANCI,
which none of the APMA boards have. We have
national …..
Bret Ribotsky: What is NOCA and ANCI
Earl Horowitz: NOCA is National Association if
Crediting Boards and ANCI to get the actual you
know …..
Bret Ribotsky: They are crediting agencies ….
Earl Horowitz: They are crediting agencies for
loads of different things and it took us five
years to get approval from NOCA and ANCI every
they come in, they examine everything to the
point and honestly California’s Board, we would
like to make sure that our people and our boards
can be advertised in California and we have five
times in front of the California boards. The
state of California sent this to our office to
New York and approved it so much so that they
wrote us a letter saying that we do it better
than the APMA boards as to the correct
psychometrician method of testing and fair
testing of the doctors and we were the first
ones in the primary care, foot surgery, and also
diabetic foot and wounds and now we are doing
one called limb salvage to get the podiatrist
certified in that. We feel that podiatry should
be certified. It is all not joining the groups
where physical therapists are and nurses are and
that is why we organize these and each one has
its own examination and requirements.
Bret Ribotsky: I am sure you had to be a javelin
catcher for a lot of this when you know the APMA
Boards and ABPS and ABPOPPM are credential by
the CPME which is under the auspice of APMA but
not really it has its own stand alone
certification. How did this make confusion in
the profession that already had a lot of
alphabet confusion? How did that play out?
Earl Horowitz: Well again the lack of and
honestly I feel the lack of realizing that there
are so many people out there that are effected.
At that time could not get in to insurance and,
could not get on a hospitals because they did
not take the exam in time or did not have all
the requirements because they have been in
practice for 20 or 25 years and I have always
felt equivalency should be a part of the
evaluation of anybody taking it. If a person
has been practicing 30 years and did not have a
residency, isn’t 30 years equal to something
that a residency has. They have the experience.
They have been treating people. They should be
allowed at least to take these exams and that is
why the boards were developed in the beginning
to.
Bret Ribotsky: I have gotten a number of e-mails
from people who are realizing that there are 70
smart people who will not get a residency this
year and ….
Earl Horowitz: Yes.
Bret Ribotsky: A bunch from last year that are
left over and now we have a 150 students to give
or take a few who cannot get a license in most
dates, not alone just board certification
because we have raised the moral of it. What
are your thoughts?
Earl Horowitz: My thoughts are they should have
never gone to a three year residency without
having enough residencies available. To me it
is ridiculous to help people going into a
profession that may not get a residency and they
cannot even take a state license. This to me
was very poor planning by the APMA people to try
to advance our profession by taking three steps
backwards and it is something that they should
be definitely re-look into. These people
deserve to get some way of taking a residency or
some form of equivalency that will allow them at
least to take state board as well as being able
to take some forms of certification. They put
in their time. They have been stalled the bill
of goods and that podiatry is out there for them
and they cannot even take advantage. I think
this was a very, very serious miss by APMA.
Bret Ribotsky: I am going to hold straightened
out some points before the end of the year. One
of the big things I have known about you for my
20+ years of knowing you is this dare to be
different. If everyone is running one way, you
run the other way and I respect that so highly
and somehow I follow that. Coming about when
did you first decide you know you are not going
to be a sheep and you are going to go
differently. You are going to make your own
practice?
Earl Horowitz: Well I think that goes back to my
even when I was doing the residency, I would go
around to different offices to see what was
going on and I decided that I was going to take
certain directions of rehabilitation. Certain
directions I got very involved with circulation
even as a resident and this felt that this was
great field to get involved within and got into
testing and talked about testing through the
years of vascular testing but dare to be
different is more than just a statement. It
means you go looking for things that the people
aren’t doing only because it is necessary. When
you see results, when you hear things about all
the decrease in amputation because of the way we
are treating wounds then you check the
statistics and find there is not a decrease in
amputation. There are still 80,000 to 100,000
amputations a year. With everybody getting up
and say oh we are doing wonders with this and
that, something is wrong somewhere because
nobody is willing to really look into and change
the mythology of the treatments that are going
on now. We are cloning, we are going into what
I call we treat people by insurances, by code
numbers, by government.
Bret Ribotsky: Lets go delve into that. You
know if something is covered, we seem to treat
it. If something is not covered, we seem to I
guess leave it alone. What are your thoughts?
Earl Horowitz: And I feel dare to be different
believe or it not I look for things that are not
covered because I feel that this is a excellent
way to develop a cash flow because it is
necessary in the treatment phase. Just because
it is not covered does not mean it is not
necessary and in many cases it is more than
necessary. So looking for things that are not
covered offer you the opportunity of treating
things without the rules and regulations that
are set by specially Medicare. You know if you
do not change a wound, getting better in 30 days
suddenly you start the treatment which is apart
because most of the wounds we see are and they
are not going to change in 30 days. It takes a
lot more because of the underlining problem
being circulation, so there are many, many
things that I do not have to go through and
doing things that because it is not covered
under insurance, government rules or what have
you and I do not always follow the advise that
you get on podiums because after a while you are
here year after year meeting after meetings
saying that nobody is really changing it. That
is dangerous for our profession and also for the
patient because you are not getting the chance
of really trying things out that may be better
than what is going on now.
Bret Ribotsky: So where would you say the rule
is, the big push now is evidence based medicine.
We are looking for you know proof that something
happens and that is where insurance world and
that is where the attorneys are looking. If you
are not following within that, I guess you used
the term clone accepting outside. Who do you
differentiate yourself? How did the niche and
thought process develop?
Earl Horowitz: There are multiple ways you can
prove evident base and in my case circulation is
very easy proved by just doing the vascular
testing, you can prove you are getting results
and I asked that question that the last can be
on the meeting _______ vascular people part of
PICA program, I said how come you do these
vascular procedures but what I tested was laser
Doppler to see if the perfusion is getting
there. We do not see the results and the answer
is that is true. Just because it is through a
procedure does not mean the proof of
vascularization is perfusion. You have got to
get some blood to where it suppose to be going
and just because the technique is successful
does not mean the end result is successful, so
there are multiple ways you can……
Bret Ribotsky: Let us go down your vascular
thing for a second and dug a little deeper into
that. In the last year or two, there has been
an association between organized podiatry and
the vascular surgery society and Dave Armstrong
has championed this toe and flow, so as soon as
we identify a vascular pathology, went sent to a
vascular surgeon who really only has one tool,
right invasive stenting or bypass.
Earl Horowitz: I find that concept of the toe
flow an offense only because we are just as much
a part of flow and in many cases as far as I am
concerned, we do actually more of the flow than
the vascular surgeon does. Does that mean that
patient walks into your office that has got a
vascular problem, you got to automatically sent
it to a vascular. Remember the terminology that
it is vascular surgeon and not a vascular
specialist. He is a vascular surgeon and I have
a whole program that breaks this apart and shows
that we are part of the flow as the toe is and I
think it is a shame of peoples…
Bret Ribotsky: Lets delve into that for a
second. How do you evaluate somebody in your
office because I know you have unique modalities
that you are offer and you know that patients
fly from all over to see you. Break it down for
us.
Earl Horowitz: I break it up into a four phase
thing. I call it prevention, diagnosis,
treatment and then prevention again. The
prevention part that every single patient that
walks into the office, you do some kind of
vascular testing that the simple Doppler test
you listen and remember peripheral vascular
disease is not just arterial, it is venous,
arterial and lymphatics systems involvement and
that is why this is a tremendous field, so…
Bret Ribotsky: How did this differentiate from
screening because screening everyone that is not
covered?
Earl Horowitz: Well that is not right. It is
part of my initial examination or part of the
examination. I do not charge for that
screening. I charge for the examination, so it
is not a question, this leads remember, you kind
of have that leads to. You got to prove why you
are going to do the next phase that we get into
and this has been the data information that I
have so the next time they come in, I can have
some data on what was the last time they were
in. Like It gets involve with - stop smoking.
You know from the very beginning there is not
much type of pathology but if I found pathology,
we move with the phase II that is testing.
Testing includes plethysmography in all its
phases, ABIs, pulse time recording,
photoplethysmography, laser Doppler, regular
Doppler and also ultrasound or sonography duplex
scan.
Bret Ribotsky: Do you have an entire almost a
vascular lab I will say?
Earl Horowitz: 100% so but I do take …
Bret Ribotsky: And there is something that you
do or do you have a vascular technician that you
have hired?
Earl Horowitz: I learned and did most of this
all myself and I taught it for years all these
things but lately I am firmly believing that a
vascular tech should be a part of your practice
or someway coming into your practice and help
you or if you still do not want to do that but
you have as much knowledge as a vascular surgeon
as because he is going to same test you do. He
is going to do most tests, you can do them, the
learning curve is not that difficult but if you
want to use the vascular tech, it will make you
a lot of extra capable for veins, arteries,
lymphatic systems, testing and you could be
treating on the things while he is doing that
but you are doing the same things. It gives you
the opportunity to decide what you want to do,
how you interpret the results.
Bret Ribotsky: So how do you choose which
modality to do on somebody. When did they get a
laser Doppler or when did they get..?
Earl Horowitz: Well laser Doppler is the finest
piece of equipment that every podiatrist have
because it really evaluates perfusion more than
any other testing and it is much better than the
oxygen one.
Bret Ribotsky: Is that reimbursable as a laser…
Earl Horowitz: Yes it is reimbursable. I do may
be five or six tests. They only pay literally
as if you are doing one test for that but I do
not worry about that because I am the one that
get the information that is necessary from it,
so I _______ more of a larger vessels what is
going on? I can get some information about the
smaller vessels, _______ and these are all
little _______ but my laser Doppler definitely
gives me the information about perfusion which
is very important. My ultrasound and duplex on
the arterial side gives me information about the
degree of stenosis, you know how much blood is
going through the stenotic vessels and the
blockages. For years I was able to determine
about 92% to 95% accuracy. You can even find
the DVT with a pocket Doppler. You can find
valvular insufficiency by just compression. So
there is nothing you cannot _____, information
data that makes you decide whether you want to
send if it is an acute condition to a vascular
or you want to go to the next phase which I call
is the treatment phase .
Bret Ribotsky: Okay, did you make the
determination after diagnosis of whether they
need bypass or stenting?
Dr. Earl Horowitz: Bypass, stenting or whether
you want to do the ______ procedure if you feel
that is the correct thing to do or you have a
chance of doing conservative therapy that may
get same result or better result because of the
inability for vascular procedures happen to many
diabetic or many ______ lower extremity not all
they can ______ vascular surgery no matter what
the procedure is and the results are not always
favorable. These patients still become more
knowledgeable about who and what should be sent
to the vascular surgeon.
Bret Ribotsky: Let’s take the arterial side of
the tree. What can you do to increase profusion
or increase arterial flow when problem is
identified?
Dr. Earl Horowitz: Okay. Concept is called a
push pull method. This has been written up too.
You are trying to push blood through getting the
large vessels to take more blood through them
and you are pulling through the venous system
back _______ get. Remember every arterial
problem has a venous problem, every venous
problem has some form of an arterial problem.
We decrease venous pressure by decreasing the
swelling or something similar that, you will
increase arterial profusion so they work
together. So I use the circulated move to one
of the greatest things that have happened in the
field of vascular treatment is trying the heart
rate. So when 10 diastolic pressure reaches the
calf it will compress at the perfect timing,
push the blood through to the capillaries. They
do help get the blood through the capillary and
at the same time they can press on the leg
causing the venous pressure to decrease by
pushing the venous pressure. It is acting as a
muscle pump with ______. 40 minute treatment is
like walking 10 to 15 miles of blood pushes and
80 minute treatment can be as much as walking 25
miles of blood pushes. This averages to walk
quarter of a mile and out pushing blood is a
_____ walking 25 miles in an 80 minute
treatments, then to open up the capillaries I
use Microvac _______.
Bret Ribotsky: Before we get to that, just talk
about circulator pump for a second that has been
out many-many years. Whatever ______ never
called on.
Dr. Earl Horowitz: It is actually out for over
30 years. There are lot of reasons why it is
never called on. Most of it is relationship not
being covered in the majority of the states by
Medicare which does involve to me under sense
that this is one of the things that I dare to be
different with and off patients _______. It has
been weeks at a time in my office, it maybe more
than that than it is in the state of _______ and
we offer that we can improve we can get that and
our success rate is extremely high compared to
vascular surgery.
Bret Ribotsky: Given the example with the
insurance company to have somehow decided that a
treatment modality is not as good as the ______.
I am sure there is research and they have
arguments on both sides but _______. What do
you charge for, I mean is there standard fee ?
Dr. Earl Horowitz: What the circulated boot. It
depends on the degree of pathology involved and
I do not do anything less than three months. I
_______ less than three months at a time and it
depends on how many times.
Bret Ribotsky: How often the treatment done?
Dr. Earl Horowitz: How long it is done. It
ranges from 40 minutes to 90 minutes, depends
upon the condition.
Bret Ribotsky: Is it everyday or couple times a
week?
Dr. Earl Horowitz: It depends on condition.
What I am trying to say, if it is ready to
amputate I may see them four times a week. It
sometimes needs to be seen twice a day.
Bret Ribotsky: Twice and what is the fee for?
Dr. Earl Horowitz: It ranges from anywhere from
about $3,000 up to it could be $6000 depending
on how many times we ______.
Bret Ribotsky: As per treatment program.
Dr. Earl Horowitz: Per treatment program fee and
that is what in three months increment.
Bret Ribotsky: Okay, so I mean there is a good
pearl for people out there who were, you know,
looking for something to you know possibly add
to our profession.
Dr. Earl Horowitz: I can explain a little
practice management involved. You have to get
involved with understanding that many doctors do
not look at amputation as a dangerous terrible
thing to people as much as it is a problem.
When a _______ offers nothing to pain and the
way it is treating the leg, when everybody is
saying if you don’t do this you are going to
lose your leg and you are going to lose it even
if we do this to hear a lot of. When they come
in to our office we say we think we can save
this and they will turn to you and say well you
know the dollar involvement. It is not covered
by insurance. I will bring in the family
because the loss of a leg is not an individual
thing. It is a family thing. We have the whole
family come in and I discussed what they can do.
Families come up with the money, churches,
synagogs can come up with the money, even the
State of Florida has come up with the money to
treat these patients. Relatives from California
pay for a relative in Florida to take care
because in honesty families do not want to first
of all see a person lose the leg and then when a
person loses the leg he becomes a dependent on
family much more so than he ever would be if he
would walk around, especially in the senior
citizens so there is a family involvement.
Bret Ribotsky: Have you published this in the
results?
Dr. Earl Horowitz: Pardon?
Bret Ribotsky: Have you published this in the
results on the ……..?
Dr. Earl Horowitz: No but the why I do not there
is a wonderful study and I have never seen the
study like this by gentleman. The doctor that,
his name is Dillon and _____ two year study, not
five year study, but a 15 year study of the
circulated boot and all these that it is cured,
the gangrenous part that it saved 15 years of
study for this. The people come in they do not
believe it until they see the x-rays. We have
taken osteomyelitic bone because we could inject
in this boot. We also have a bag thing that we
put in antibiotic solutions and isotonic
solutions to watch the wound and flush it with
antibiotics. We also pump syringe full of
antibiotics right into the wound itself and with
the blood supply coming in, we have found that
we can set osteomyelitic bone where most people
attempting to take out the bone or cut it out,
we have found that it actually becomes calcified
and actually becomes a solid bone again and even
______ do that and it stops the biomechanical
dysfunction that you find after amputation. So
there are a lot of things that come into play
which we do not hear about because no one is
really working on pushing more circulation and
getting more profusion down there.
Bret Ribotsky: Okay so after you do that then
you talked about Microvasc and can you explain
that and where its role is?
Dr. Earl Horowitz: Well the Microvasc is a
sporadic current that I found and people did
some of the work with and I had the opportunity
to working with it for about, you know six
months before I actually decided that this was
the best muscle electrical stimulation machine
that I have found. It does dilate the
capillaries, aides in muscle contracture and
seems to increase the amount of profusion along
my circulator boot. So I do both of these
things. Do not forget when you increase
circulation, it is not just for the diabetic it
is for the arthritic. We get more motion in the
joints by increasing blood supply and the
electrical stimulation getting more profusion
because of the capillary flow increases with the
use of the Microvasc. Both of them worked
wonderful together and in many cases the
Microvasc for those who are interested can be
covered by Medicare but again if they do not
cover it, it is certainly something that you can
add to your cash flow type of practice.
Bret Ribotsky: Wonderful. I would like to open
up the floor to some questions. If anybody
likes to ask one live please go ahead and hit
the star and six command and we will get your
question in live. I have got a lots of e-mails
and I think a lot of this has to do with dare to
be different and when you are practicing outside
of your local podiatrist community because you
are doing things a little bit different and you
look at things little bit different. How has
this local community dealt with this? They kind
of support that. Okay, I got this patient let
me send it over to Dr. Horowitz or perhaps they
treated it differently?
Dr. Earl Horowitz: I think you get a very
interesting point. I do not think initially
even to any great degree that your fellow
colleagues are a great aid in developing your
dare to be different because they look at things
differently than you do. I think the idea of
marketing yourself, marketing what you do,
getting to the people, the public itself that
needs to, I put on seminars in the office about
you know, what I do with the circulated boot,
treating of neuropathies with increasing
circulation, we bring them in. We have 15 or 20
people who at least do it once month and we have
at least 15 or 20 people in the community that
come in and they say thank you very much because
they have been looking for somebody that is
different. They do not know where to go. They
are not getting the information that would make
it possible for them to say well I go to go to
him. You have to get out and educate the people
towards what you are doing. No matter what you
get involved with. It does not have to be this.
The podiatry requires a marketing concept that
does not necessarily means that you market it to
your fellow colleagues as well as you market it
to the peoples that need it.
Bret Ribotsky: You bring up a unique term, niche
podiatry and you know, this holistic integrated
view of healthcare is growing exponentially. I
had the pleasure to lecture at the American
Academy of Antiageing Medicine and this 5,000
doctors, MDs sitting in this room trying to soak
the brain with things that we were thought many
years ago was woo to medicine and now they are
coming with some science in this antiageing
stuff. How me about niche podiatry. What other
areas that people out there can be looking for
this might be ultimate head against the Obama
Healthcare System.
Dr. Earl Horowitz: Well, Mitch podiatry really
goes back to podiatry itself. Years ago when I
first got up everybody had the magic pad or you
know, the _______ or you know, you couldn’t go
on someone’s office because he didn’t want to
pay his treatment. Then it became the next
phase that people got niche with 50 or 60 and
into the 70s was no question about it was
surgery. Surgery became that everybody wanted
to get involved, be it ______ surgery, ulcer
surgery whatever you have and the next niche
that you can talk about was some degree of
management in doing this thing. People were
involved in case fees until the insurance
companies came out and this became another niche
type of thing everybody followed. Then came the
biomechanical niche when root is development.
Everybody was getting involved with that. Doing
that, let the more orthotics and sports
medicine. The niche now, you know a board
certification became sort of a niche that
everybody had to get into. Hospitals became a
niche that you had to get into and today’s niche
probably you have to say is wound care. So we
have always had niches but it requires a
different concept. You have got to know how to
train your staff. You have got to know what
niche requires from you in the sense of
equipment, your commitment to it and what you
want to do but niche concept of podiatry can
lead you into a path of economic security
because you will be the only one doing or have a
practice that people come to you from all over
and at the same it is very satisfying because
you are enjoying. You know you have put this
thing together that people really need and you
are not depending upon insurance per se although
that may be a niche tool that everybody is now
treating things just because it is covered by
insurance or government regulations or something
like that. So in essence there are multiple
sides but think niche is the type of thing that
people can get involved with, more towards a
cash type of flow practice and more towards
satisfying what the patients need.
Bret Ribotsky: It is a unique perspective. We
are all thinking something unique, different and
it is interesting to see that the niche can be
the majority. If majority is wound care, we can
have a niche in the majority.
Earl Horowitz: It is well but the breakdown of
that is how you treat it, like I treat wounds
differently than other people treat wounds
because I am involved with the circulation part
on an conservative basis of making that a part
of the wound so that is my niche wound care.
You can subspecialize a niche in different
things. There are people getting into rearfoot
surgery that is their particular niche in
surgery. You can sub-specialize niches too but
in general look for something that people need
no matter what it may be and I feel very
strongly about peripheral vascular disease.
This is one of the pandemic things. It is
becoming the forerunner, if you are going to
find peripheral vascular you are going to find
cardiovascular so you can help awful lot of
patients from heart attacks everything that is
involved. I think it is a wonderful niche to
get involved with. It does require special
equipment. It does require getting involved
with testing. It does require standing out a
little alone for a while and watch your …
Bret Ribotsky: I think you make a good point.
At the last couple of meetings at the ACFAS
meeting couple of weeks ago in Fort Lauderdale
and mid West meeting in Chicago, there were
invasive cardiologists or invasive radiologists
who were giving lectures on stenting and things
that could be actually done now which is pretty
incredible in the lower extremity but the
essence of that was they were trying to persuade
podiatrists to buy certain vascular testing
equipment so that once we found the pathology we
could then send it to another physician who
treats it.
Earl Horowitz: Correct. There is a place as
they say for these type of procedures but the
end result as I questioned at the SAM meeting is
what your results of the profusion after you
______ you open the vessel, how long does the
vessel stay and what you do after this to keep
the vessel open which I do very little. You can
show or may be you could not but there are very
few orthopedic procedures done, forget the foot,
or the whole body that does not have a followup
physical therapy. Why does not the vascular
surgeon have a followup of doing things
associated with keeping the flow going?
Bret Ribotsky: Like a heart surgeon will have
them in a cardiac rehab.
Earl Horowitz: Correct. They do not have that
benefit. Many times I have treated open wounds
that they left open even, you know where they
have gone in and do some bypass that I cannot
believe it or even taking _______ to do heart
surgery forgetting that leg is a part of that.
It is amazing the attitude towards it is to do a
surgery and that is it and they actually will
tell you well if it does not work we will do it
again and again. After a while that becomes not
the answer to the problem. The answer to the
problem is to try to get more perfusion down
there by conservative means. The push pull
method is one of the greatest things to me that
has come out. You are trying to push blood
through, you are trying to pull it through no
matter whether you do surgery or whether you do
conservative care and the cost factors that you
want to save by not doing excessive surgery is
phenomenal. You go into the cost factors of
doing these stents and everything else is pretty
high if you do not have to do that. The real
essence of this is that we can be a great
catalyst in making vascular surgery more
successful by repairing the patient, by getting
more capillaries open, and by afterwards
treating it so that it stays open.
Bret Ribotsky: So with the exception of the
Microvasc and the compression circulatory boot,
what else can we do, I think you really
intrigued couple of people. I got two or three
e-mails when you talked about the cardiac rehab,
vascular rehab. What kind of equipment, what
kind of ….. they need?
Earl Horowitz: As I say they can get the
circulatory boot into the office, Microvasc to
do these type of systems will be a great aid and
also exercise. You know you kind of keep your
loop which is a new field of style coming,
getting more of the areas that will help the
muscles to develop so that we can get more
capillary flow by getting more capillaries down
there. The other thing is that we are trying to
do more of is, it is radiofrequency and laser
through the great saphenous vein which is
becoming something of a norm, that a lot of
podiatrists are doing or if you do not get
somebody to do it, by doing that you decrease
the venous pressure and increase the amount of
blood flow coming into the office and how many
swollen legs do we see in the office. Everyday
nothing is being done even from the sense of
Unna boots or stockings or these closure of the
great saphenous, less saphenous and perforator.
Do not forget venous ulcers are the most common
ulcers and most of them are associated with a
perforator that you can close within a five
minute period of time.
Bret Ribotsky: So it is interesting that we have
kind of looked at the foot and somehow stopped
looking up the leg. All of us look at swollen
legs at given time and we probably make
recommendations for support stocking but it
seems to stop there. Do you think it is for
patients to come in, for some sort of, tell them
they need to walk and give them a chart. I do
not say total like physical therapy but vascular
therapy. How would somebody incorporate that to
their office? Would that be something that you
will include in the insurance side of it because
it is …you can have evaluation of management
visits or is it something…
Earl Horowitz: You can include the evaluation
even with some of the treatments with insurance
but the big thing is that this is a chronic
condition. You just don’t treat them one time
and you say buy this. It is part of the
practice control, practice management of the
vascular patient. We bring them back every six
months after they are treated, every year, just
because an ulcer closes does not mean that
condition is cleared up or cured. As a matter
of fact you have poor circulation and a lot of
the ulcers they close, they barely close, any
tissue will breakdown because they do not have
enough blood supply coming there. So this is
something you end up making a practice out of
bringing these patients in, taking care of them
biomechanically, routine care, even surgery to
eliminate pressure are all part of the vascular
nature and by the way your surgery, I do not
care of what surgery you do, I do not care what
shape the patient is in, you increase
circulation of the patient, you are surgical
results are going to be much better no matter
what surgery you do especially rearfoot surgery.
Bret Ribotsky: Again if anybody like to ask a
question live please hit the star and six
command. What would happen if you missed one of
these things? Like somebody has got a budget,
they wanted to buy a piece of equipment and they
kind of think whether they should get a
Microvasc or circulatory boot or what is the
cost of set up of a lab let us say.
Earl Horowitz: Step first is to get yourself
involved with testing. Treatment is very
important but you have got to find out what you
want to do and I firmly recommend that you get
some form of testing for multiple reasons. One
is to find out what is wrong, two is to see your
end result and to make sure the final thing is
the prevention so it does not come back to you,
always test to see what is going on. As they
say you have got a lab …
Bret Ribotsky: So what type of equipment that
people start with?
Earl Horowitz: For sure some form of the
plesthysmorgraphy where you have got pulse
volume recording, photo, Dopplers, that type of
piece of equipment and learn the various tests
that can be done with it. I can even do
________, I can find out they have got autonomic
neuropathy from a vascular test. There are many
things you can do with the test that you do not
think about. Initially even a pocket Doppler,
little things that is your basic test, when they
come in, if you hear any kind of stenosis, be it
valvular insufficiency this leads to further
testing. Then you get involved with the
treatment phase. You have to go around and find
out ...
Bret Ribotsky: Is there a place for an MRA and
magnetic resonance imaging technology?
Earl Horowitz: These are little more especially
important if one wants to have surgery done and
awful lot of the testing that the vascular
surgeon has done is based on once you find the
blockage and once you find that you feel you
cannot get the collateral circulation, or you
cannot push through the blockage or you feel
that surgery should be done that is what the
vascular surgeon with the results you have to
show what is going on. He will get more
involved with the technical testing that is used
for surgical procedure and there are loads of
different ones for that.
Bret Ribotsky: One of the question somebody just
sent from Tennessee asked about since you have
such experience being involved in the board of
malpractice company for twenty years, when
somebody is now practicing outside of standard
rank and file podiatrist and now you are talking
about possibly they could lose a limb somewhere
along this course and the late you send them to
vascular surgeon the late to do something more
invasive. How do you protect yourself or how do
you make sure that this does not occur?
Earl Horowitz: Okay of course I can give you the
simple answer, it would be, get good results,
but the other answer is most of these things
that I have talked about are not really outside
of it. They are just not as commonly done. So
you can always get people that are doing these
procedures, rarely if ever do I do a procedure
that nobody else has ever done or nobody else
has got result. That made me go into that
direction because as a result somebody else has.
If I have any problem with the circulatory boot,
I bring in three year study to show how the
circulatory boot has been used, Mayo Clinic is
using the circulatory boot. There may be 15 to
25 centers around the whole country that are
using it and I am just a part of that
circulatory boot system. If not thousand doing
it, I am still on the outside of the usual
treatment but still in all it is a part of the
treatment phase in the United States or Europe
or wherever it may be that has been accepted or
been used for years but not in a great majority
of cases and it is not cloned at this time or
talked about in any great majority of our
seminars or things like that.
Bret Ribotsky: Is there any seminar you know of
where people can go to learn a little bit more
about this vascular side of our practice?
Earl Horowitz: To my own, for years we have been
booking on whole seminar about this thing, how
to develop a diabetic foot wound practice within
your own office, how to develop circulation
situation, they are in fact many going on to be
truthful. Of the vesicular seminars you go to
are all based on surgery, very few if any start
to talk about other side of it. If you look
into the literature there are few men around the
country that are starting to push the concept
and not only podiatrists, even some vascular
people that are pushing the concept.
Bret Ribotsky: There are very few vascular
medicine people, I mean internal medicine people
who do an extra year of vascular medicine.
Earl Horowitz: Yeah, that used to be the main
field when I got back in the 1959 and 1960.
There were no really vascular surgeons. They
were vascular specialists. These were people of
internal medicine that did the work and that
suddenly disappeared. Everything became
vascular surgery versus the idea of doing
conservative work after surgery and before
surgery, where surgery cannot be done. These
patients were left out in that field and it is
tremendous field out there because of that.
Bret Ribotsky: Pretty incredible, tell me where
do you think nerves are today. I mean there is
actually a sub-organization American Society of
Nerve Surgeons or Podiatric Nerve Surgeons. It
is a group under APMA now. Steve Barret is
involved in that. He talked a couple of weeks
ago on this show about that and specialty of
nerves? It seems that ….
Earl Horowitz: I think it is a wonderful thing.
I think that the need for the specialty like we
should have a society and be pushing more and
more about veins and doing the evolution of
great saphenous vein and lesser saphenous and
perforators in the calf. Just like these nerve
surgeries affect what we see. There is nobody
doing a lot of the work that we see. We think
it is being done, but if you investigate it you
find a very few or very little work is probably
being done about the nerves that are entering
into the foot and need for it and also very
little work is being done by the podiatrists
specifically about vein work. Matter of the
fact we got people, you got OB/GYN, you got GPs,
and you got other people trying to vein closure
sclerotherapy, where there is really the field
for the podiatrist and we should fight to get
our laws. We are really doctors of the lower
extremity, we are not just ankle doctors or foot
doctors. I mean you would not think about an
orthotics is affecting your foot. You think
about affecting your knee, your back, and a hip.
We should be thinking more along those lines and
to how we affect, because everyone of us see in
our office so much pathology that we do not
treat. That it is almost criminal that we are
pushing this aside, because either it is not
covered by Medicare or it is questionable
whether we can do this or not. It gets to a
point that we have so much more to offer, the
lower extremity profession that we are really in
than we are really offering. Anybody that just
cuts corns and trims nails of the patients,
because it is covered by Medicare. When the
patient is complaining and I get it commonly
certainly. For years I have been telling my
podiatrist I have got this pain in my leg when I
walk. I got this burning and tingling and he
says come in every two months to have my nails
cut. I mean we are missing the boat on so many
things that are there for us only because it is
not covered by insurance. We got to get out of
just the insurance coverage and realize
patients, especially in today’s market are
willing to pay for something where they can get
results.
Bret Ribotsky: Well, I think that is incredible.
It is kind of amazing to see your incredible
passion with 52 years of practice.
Earl Horowitz: 52 years of young practice.
Bret Ribotsky: Yeah, I mean what keeps you
energy up?
Earl Horowitz: I think it is my wife. No it is
a desire really, I have felt all these years
that I have something more to give and every
time I say well you know I will give it
something else comes up and I am back into it
again. I guess I have a feeling….
Bret Ribotsky: Did you have any mentors when
during your course? I know you have been the
mentor for so many people.
Earl Horowitz: Oh sure, you know it started when
I first started with Earl Kaplan and his group
and some of the practice management people,
Dillon with the circulator boot. You name and
there are loads of people. Sherwin Levy with
late approach practiced years ago. These were
all, Burny Hirsch was in practice. These are my
old time people that we were all involved with.
We all went out to try to help podiatry. There
was a feeling that people needed our help. May
be we were sort of felt too big for our
purchase, but we felt the podiatry needed
practice management help and still many of us
got involved in trying to show what can be done
and put on …...
Bret Ribotsky: Do you think it has become a
rotatory may be around 20, 30, or 40 years ago
where people seem to work together feel one and
one is three. It is still there today or do you
think it is different?
Earl Horowitz: I think it is there, but I hate
to say it, it is being replaced by codes. We
are more interested in making sure we get
everything we can out of a code so we are in
learning from other people what they are doing?
How they are approaching things and we accept
too much of the people that are constantly the
same people on the podium. You know I have
nothing against them. I think they are doing
fine, but they kind of get new ideas and years
ago we used to have meeting. We get 10 to 15
people together in a hotel room and we give a
lecture there to 10 to 15 then we go around the
country doing this not just getting on a podium,
but there we have had the interplay with these
15 people. I have learnt as much from them as I
presume they learn from me. I think I have
learned more by going around and doing these
things, because it was not insurance code every
person comes out what is the code, is the most
common thing. Whether it is covered by Medicare
is the next most common thing. It is not do you
get these results. Have you talked to the
patient about this? What are they saying? You
know one of the things that I never forget is
the greatest thing that you do when you are
examining a patient is you listen and take a pen
and write notes. You do not tell them what it
is going to be, what the code is or anything
like that. You listen to their problem and then
make sure you write down your notes, so the most
important thing is the pencil or a pen in the
treatment of the patient.
Bret Ribotsky: You have ears and one mouth.
Earl Horowitz: I know.
Bret Ribotsky: So as we are close to the end
here, I want to get a good understanding because
your passion is so incredible. Where do you see
the future? What can podiatrists be doing in
this new healthcare environment that is
upcoming?
Earl Horowitz: Well I see my own opinion is,
number one is we as a profession better look at
like this residency thing and things like that.
We better not lean forward to meet medicine’s
needs as much as our own needs of the students
coming out. It is not fair for them to come in
to a profession when they cannot even take an
exam. Two is I think the realization is that
when we are going to get into success
economically more and more things that removes a
cash flow, be it products that we have get
involved with, treatments that are not covered.
We have to learn to make it important to the
patient. You know I always used this statement
that why I got involved with the circulator boot
and saving amputees. All you have to do is look
into the eyes of a person that walked into your
office and say they are telling me I am going
have to have my leg amputated. I do not want it
amputated. He is not giving me any other
choice. Can you help me? And when I say to him
I think I can help you. We will work out into
it. They breakdown and they start to cry. They
hug you and kiss you. You do not realize what
you can do for these patient until you see this.
You asked me what keeps going, that is what
keeps me going.
Bret Ribotsky: Here we go, one quick question, I
got somebody out there wanted to ask a question.
Let me get in, we have 45 seconds.
Chuck Perry Hi, this is Chuck Perry, Cambridge
Ohio.
Bret Ribotsky: Yeah, welcome Chuck.
Chuck Perry: Boots I came down to see you about
three years ago after your last seminar and I
was wondering I spent a few days with you and I
was truly inspired and I wanted to ask you if
and when you are going to have another seminar
and one other question of topic is I admire your
constant energy. You know I have to admit that
after a day in the office here I do not see that
many patients may be 20 to 25 a day. I am
exhausted. I do not want to talk podiatry. I
do not want to see podiatry. I flop on the
couch and watch television and I know you have a
saddle boat down here, but what do you do for
all these years to avoid that.
Earl Horowitz: Very good question my friend and
thank you. You are making me think about
putting on a seminar again by the way. I think
it is just a matter of coming home and I sit
down, I do photography, sailing, and tennis all
the things, but in the a long run I end up on a
computer looking up what I can do for an ulcer
or something like that I have not done. It is
just an enthusiasm that I have and I relate it
mostly to patients that tell me please do not
retire. That keeps me going more than anything
else. I am going to be 79 years old and I look
forward to practicing at least till I am 85.
Thank you for asking.
Bret Ribotsky: Thank you Chuck. If you had a
crystal ball and you could alter the educational
experience of podiatry. What would you change?
Earl Horowitz: Oh boy, I would add more of the I
guess it would be may be more things that are
necessarily just based around surgery in their
education. I think there is a definite need for
surgery, but I do not think they do enough
things to show all the other things that
podiatry can get involve with, so that the
students and people coming out do not feel
cheated if they can’t do all the surgery they
think they can do for multiple reasons and there
are other things they can get involved with.
Bret Ribotsky: Magnificent, I guess to end this
up I would like to ask you what is your mission
at this point? I mean you are 79 years young.
There is not much left that you can do in
podiatry. What is your take in the next five
years? What would you say you are going to be
doing?
Earl Horowitz: Just say healthy and keep
practicing that is one of the best thing I can
do and I will tell you this much. There are
still things that every now and then come into
my office, whatever it may be, and I say you
know may be I do not look into this. You still
have to have a desire to look into things, not
to just fall into the trap of doing things by
role. You got into think and want to push
yourself to the point. There is always
something out there that you can do better.
Bret Ribotsky: With that Chuck you did not sit
on the couch. You listen to us tonight, so I
want to give you that accolade. Chuck was
resident of mine many years ago.
Earl Horowitz: Oh. I remember him coming to the
office too.
Bret Ribotsky: But I want to thank you all again
this was brought to you by Podiatric Success
whose mission is magnify the podiatric
experience to provide and present cutting edge
technology and strategies in order to pulsate
your career and the experience in day to day
practice of extraordinary healthcare. Dr.
Vickie Driver next week. Boots I would like to
give you the final goodnight to everybody.
Earl Horowitz: Goodnight and again thank you
very much for having us and podiatry is a
wonderful profession. Keep it going guys.
Bret Ribotsky: Magnificent, thank you. Horowitz
what do think about being on Meet the Masters.
Earl Horowitz: Well I think first of all the
idea is the fantastic idea, because it gives you
an opportunity to express things that you can
always do and different people get an
opportunity to express how they would things.
As I say the seminar system in our organizations
today are for better or for worse, we see the
same people all the time and this gives an
opportunity for other people to present ideas
and concepts that are not always found either
written or in the seminars and the method that
you are using, I think is an excellent method.
You deserve a lot of credit with putting it on
this way.
Bret Ribotsky: Magnificent, thank you.
