September 17, 2013
Just an update on Derek Jeter. Jeter is out for the rest of the season with complications from his ankle fracture last fall. He came back before the All Star Break just to pull his thigh muscles. He then came back just to reinjure the ankle. What happened?
Jeter played in the playoffs with a stress fracture. He was going to his right for a ground ball and the ankle snapped. He underwent surgery with Dr. Richard Anderson and has never gotten completely able to return to the game for any length of time. This should be a cautionary tale for normal people and athletes. Do not play on stress fractures.
A stress fracture is a small incomplete break in a bone. It is like a stick that has not quite cracked all the way through. Rest and immobilization will normally heal the bone in 4-6 weeks. If there is more stress, the bone will completely fracture and require surgery or longer immobilzation. Jeter would have been back to action for the whole 2013 season if he did not play in the playoffs.
I admire Derek Jeter. He is the captain and wanted to lead his team. This is when the training staff should have said no. Why the surgery went so badly, I have no idea. Most people would have healed and gotten back to normal activity in about 8-12 weeks. Baseball players should have responded within 6 months.
Good luck getting back for next season.
September 3, 2013
Students return to school today. All the public schools open for classes today and there are a lot of sad youngsters today. Many students also start being more active and playing school sports. What should you do as a parent?
Different activites require different muscles. It is important to gradually build up endurance and strength even for little ones. Do not allow the athlete to start running long distance without gradually building up the distance. Most coaches will gear practice to this goal, but here is some advice.
1. STRETCH- This is the easiest way to avoid pulls and tears. 10 minutes before and after activity.
2. START SLOW- Encourage a short distance and timing for the first week.
3. PUSH THROUGH- Youngsters will be sore and tired. Encourage them so they do not quit.
Good luck to all.
August 13, 2013
Podiatry has a new problem. There are 86 Podiatric Medical Students that do not have residencies for next year. The average person in the community does not care. Podiatrists should be appauled. The fingers are being pointed everywhere, and I have my finger as well.
Why is this important? Almost all states now require a 3 year surgical residency to obtain a license. These 86 students now have a useless degree as they cannot practice. They have an average of about $200,000 debt without a way of paying back their loans. The podiatry schools have basically ruined the financial lives of 86 people. Why did this happen?
I graduated podiatry school in 1990 and completed a 1 year residency. Most programs were 1 year with a few 2 year programs. There were only two 3 year residencies in the entire country. ( I think???) Hospitals that were unfriendly to podiatrists used the 3 year minimum post graduate training as a way to keep them off staff. The Podiatry community decides to make 3 year residencies to combat this problem and ungrade training. This sounds great, but what happened?
The problem is multifaceted. First, 3 year residencies are difficult to set up and almost require a large teaching hospital to be involved in the process. Second, the community wrongly predicted an increase in residency spots over the last 5 years. Third, the schools continued to accept more students while the residencies never increased. Fourth, is arrogance of the podiatric leaders.
Arrogance is the correct word. It was a great thing to upgrade podiatric training. The problem is making it a requirement for licensure. Some students do not want to perform ankle reconstructions and complicated rearfoot cases. The 3 year residencies stress surgical cases with the 3rd year for ankles and rearfoot procedures. Most community podiatrist make their living on non-surgical podiatry and forefoot cases. Why the dicotomy?
The people making the rules are heavily surgical podiatrists. They almost want a private club to compare the flatfoot cases that they perform. There was no reason to make it a requirement for licensure. This was stupidity. Setting up a 1 year program for the 86 students would be relatively easy. It could be set up at smaller hospitals and provide very good training for 90% of podiatric procedures.
The Council on Podiatric Medical Education and the APMA should quickly work to alter licensure requirements. I would be happy to set up a 1 year program by next year to aid the students. A 3 year program is just too difficult.
July 23, 2013
The summer is in full swing. Last week, temperatures were in the high 90's. Certain foot problems become prominent at this time of year.
Athletes foot becomes common. The heat leads to more foot sweat and more fungal foot infections. It usually starts to itch between the toes and then turns red and blisters. The first treatment would be to dry the and clean the areas. Powder will help at first. Many over the counter products work well such as Lamisil cream and Micatin. The itch will respond to hydrocortisone cream. Worse cases require care in the office.
The hot weather leads to wearing poor shoes and sandals. Stress fractures become common. The foot will become painful with no explanation. The top of the foot will swell and hurt when you are weightbearing. This requires professional treatment.
Lastly, poison ivy and dermatitis become common. People are out in the elements and come in contact with all kinds or plants. Normally this will follow a branch pattern. It will blister and be extremely itchy. Home treatment consists of hydrocortisone cream and Caladryl. More severe cases require an office visit.
Stay healthy this summer. Enjoy the sun and weather.
July 16, 2013
We have seen a host of diabetic foot infections this summer. Diabetics get neuropathy as a side effect of the disease. This is a lack of sensation to the feet that can lead to not feeling anything in the foot. The insensate foot does not recognize problems such as pressure points, foreign bodies, and other trauma. This leads to a sore on the foot.( Diabetic ulcer)
The ulcer can be of various depths. It usually starts being shallow but can eventually infect the bone and deeper areas. As the ulcer becomes deeper, the chance for infection increases. The infection starts at the ulcer and then can advance to the bone or up the foot. It becomes imperitive to place the patient on antibiotics to stop and eliminate the infection.
The other need to control severe infections is called incision and drainage. The idea is to drain the infection surgically and allow blood supply to attack the infection. Antibiotics can not get the closed off infections. The greatest drugs will not work if there is no way for the bood to get there. The area needs to be opened up in the operating room and allowed to be cleaned and irrigated.
Ulcers are very frustrating to treat. We can do everything corectly but have a poor result. Please come in for normal exams. Preventing the ulcer is our main goal.
July 2, 2013
I am tired of Dr. Oz. I have patients every day asking me whether the remedies seen on his show actually work. He has experts come on his show and propose new supplements and treatments for a host of pathology. Some of the foot stuff is treatment of fungal nails and leg cramps. I will address this here.
Vicks vaporub is the biggest news from Dr. Oz. Others have proposed using this old congestion remedy on fungal toenails. There have been mixed results on several studies. My thought is that the vaporub softtens and dissolves the nail allowing more of the nail to be cut back. Killing the fungus? I doubt it. It certainly is not anywhere in the same ballpark as oral Lamisil tablets. Lamisil is about 75% successful.
The bar of soap in the bed trick? A bar of ivory soap in the bed is supposed to take away leg cramps. I have no idea why this would work. Leg cramps are usually due to overuse or low electrolytes such as potassium. A bar of soap does not address either of these issues. Perhaps it has a placebo effect or changes bed positions. I DON"T KNOW!!!!! It can't hurt, I guess.
There are many other products exposed on the Dr. Oz show. My advise is to take it with a shaker of salt. The guests have a financial reason for being on the show. Products can become very profitable just by Dr. Oz giving it the nod. Good luck.
June 18, 2013
The Diabetic Shoe Program has been around for more than 5 years. The idea is for Medicare to pay for inlay depth shoes as a way of preventing ulcerations and amputations in the diabetic population. Each diabetic ulcer costs the health care system over $30,000 in cost. This buys a lot of shoes.
Over the years, the criteria for shoes has become more difficult. Now, we must provide things such as a verification of diabetes from the primary care physician and chart notes of diabetic treatment in the last 6 months. This adds to the office work in my office, but it is fine. My problems lies in the rejection rate and reasons for rejection.
I received a statistical analysis from a government consultant. I am being rejected a little over 20% of the time for shoes. The national average is over 30%. At first, this sounds fine. I am 10% less than the national average. In further thinking, this means that 1 out of 5 shoes are being rejected. Some are mistakes in my office, but most have no explanation. We have appealed the decision, but they are still rejected for something that we have on record. IT MAKES NO SENSE.
Medicare needs to decide whether it wants to cover shoes or not. Covering the shoes but rejecting 30% for a whim does not make sense. Please write your Senators and Congressmen concerning this issue. A pair of shoes is a lot cheaper that amputating body parts.
June 4, 2013
New medical devices are coming out all the time. Medical equipment manufacturers are putting out new products on a quarterly basis. These range from new screw sets to new implants for various conditions. Advertisements are placed in podiatry journals. Representatives are sent to our offices to inform us of the great new products. What is the problem?
The problem is that doctors are human. It is like giving kids a new toy. Doctors like to play just like all of us. We tend to want to use the new equipment before asking some important questions. First, what is the cost? Many of the new products are very expensive. I have used items that I have no idea of the cost until the patient complains when they have a huge copay. There are times that the advantage of the product does not outweigh the cost. Second, is how many have worked? Not all new products perform as well as expected.
A perfect example is hammertoe implants. There are now a variety of implants to place in the small toes to correct a hammertoe deformity. Presently, I correct hammertoes by resecting bone at the joint and placing a K-wire across the joint. It is a 15 minute procedure and the K-wire is very inexpensive. Now comes the implant. It doubles the time of the procedure and the cost is about $2000. You do the math for insurance companies. Operating room time is expensive. $2000 per toe will eventually make insurances look hard at covering the procedure at all. Are the results better? Maybe.
Doctors much be dilligent in deciding which new products are worth the trouble and cost. Cost effectiveness is going to be a big issue for many years to come.
May 28, 2013
Many people have no idea of the full range of procedures that we perform. Podiatrists have the ability to treat ailments up to the knee in the state of Michigan. The ankle has become somewhat of a specialty for me in recent years.
I perform ankle arthroscopy and ankle stabilizations on a regular basis. Arthroscopy is looking inside the ankle joint with a camera and repairing things such as synovitis, cartilage fractures, and bone fragments. It is done through 2-3 small incisions and has a recovery time of a month. An MRI may be negative, but the camera can see things that the MRI cannot see. The ankle is a very tight small joint making arthroscopy more difficult. Many general orthopedists avoid ankle arthroscopy and refer them to doctors like myself.
Ankle stabilization is another specialized procedure that I perform on a regular basis. Patients have chronic ankle sprains that leads to increased motion to the ankle. The idea is to rebuild the ligaments and prevent further sprains. The procedure is outpatient and requires about 4 weeks of casting and a total recovery time of about 6-8 weeks.
Check out the specialty area of the website for more information. Keep Midland Family Footcare in mind for all ankle problems.
May 21, 2013
Starting this website about 2 years ago is one of the smartest things that I have done in 22 years of practice. The number of hits continue to increase each month. It brings in about 10-20 patients per month for a very reasonable cost. The economic reasons are far from the most important reasons.
Doctors were originally teachers. The origin of the word comes from the latin word meaning "to teach". This site allows me to educate a large amount of people about a host of topics. Besides the Podiatric part of the website, I can share frustrations, life experiences, practice management, and hosts of things with an interested public.
Please inform me of things that you would like me to cover. Any suggestions to improve this site would be greatly appreciated. I apologize now for all the rants to come in future blog entries. Thank you for your support.
May 7, 2013
Wound care is becoming a bigger part of the practice. There is a dramatic increase in the diabetic population leading to increasing diabetic ulcers. An ulcer is an open sore on the foot. It is usually caused by pressure and a lack of sensation to the bottom of the foot.
Diabetics get neuropathy in which they cannot feel the feet. A blister starts in a pressure area. A normal individual would feel the blister and get off the spot. A diabetic keeps walking on the same spot leading to a full thickness sore. Once an ulcer starts, it is difficult to close and keep closed.
The key to ulcer care is reduce pressure while the body heels the sore. We use special shoes, padding, and even wheelchairs to deweight the foot. Then, wound care consists of all kinds of products being placed on the sore. There are even artificial skin graft products that are used.
Wound care centers are popping up all over the place. These are clinics devoted to the treatments of all kinds of wounds. Mid-Michigan Medical just started the Gratiot Wound Center in Alma. They have many specialists just for the treatment of wounds and ulcers. They also use hyperbaric oxygen chambers in their treatment options.
Hyperbaric oxygen is the use of oxygen chambers to increase the amount of oxygen in the blood. The idea is to have more oxygen get to the wound and heal. While I am not convinced that this makes any difference, it is an alternative for difficult wounds.
My advice is to prevent ulcers in the first place. Diabetic shoes and proper care can eliminate some of these problems. When the ulcer happens, quick and aggressive treatment is needed. Time is a huge factor in the outcome.
Plantar fasciitis has taken its' toll in the sports world. Joachim Noah of the Chicago Bulls missed game 1 of the playoffs and is now playing in pain. Albert Pujols of the St. Louis Cardinals is now on the disabled list for the same problem. Plantar fasciitis in a professional athlete is a whole different problem.
Professional athletes put tremendous strain on the bottom of their foot in their activities. Noah is trying to land after jumping 30 inches off the ground. Pujols is trying to stretch at first base and run the bases. These are activities that the average person can avoid doing their whole life. These athletes make millions of dollars for their talents.
Injecting a professional athlete is dangerous. Steroids can weaken the fascia leading to partial ruptures. This does not happen in the normal population. Athletes run a much higher risk. Surgery such as an Endoscopic Plantar Fasciotomy (EPF) will sideline these athletes for months. The average person is doing well at 3 weeks. They are not trying to compete at a high level.
I'm sure Noah and Puhols are being ultrasounded to death. They are receiving PT treatments around the clock. A removable cast and rest would be of great value. Shockwave therapy might be an interesting option for these athletes. It is non-invasive and may be tolerated well.
Good luck to the trainers. It is a difficult problem.
April 9, 2013
Michigan is a very tired state today. We all stayed up late watching Michigan lose to Louisville in a very exciting championship game. I want to analyze the game, but I just want to congratulate the Wolverines on a great season and a great run in the tournament.
The thing people were talking about last week was Kevin Ware. He is the Louisville player who had his leg explode on national TV. Actually, his tibia and fibula broke in half and stuck out of his skin. Did you see him on the sidelines last night? This is truly a medical wonder that he is doing so well.
Ware was coming down on the leg for a rebound and it just snapped. Now it is reported that he had a stress fracture in this area and was playing. Once again, stress fractures are very dangerous. The chance of this injury on a healthy athlete is extremely rare. The stress fracture allows this gruesome event to happen. It is basically an accident waiting to happen.
Derek Jeter and Kevin Ware should be examples of playing with a stress fracture. Jeter is still not back with the Yankees. Rest and immobilization are the only answer.
April 2, 2013
Educating the public has always been a stuggle for Podiatrists. Only 2% of the population uses Podiatric care. Many people do not even know what a Podiatrist is. I get asked if I treat kids all the time. I politely inform them that this would be a pediatrician. Why the problem?
Podiatry is a relatively small medical specialty. Feet are considered a private problem and patients are less likely to talk about their problems than some other specialties. One of the biggest problems is that not every Podiatrist perform the same function. Some of us specialize in different aspects of the profession. Some do more surgery, while some more into sports medicine. No wonder that the public confused.
Here are some pointers about my practice:
1. My license allow treatment of the bones of the ankle and the soft tissue up to the knee.
2. I treat all ages of patients. I enjoy treating children very much.
3. I perform surgery both in the hospital and in the office.
4. I treat fractures of the foot and ankle. I treat them conservatively (casting) or surgically.
5. I treat a lot of sports related problems. From tendinitis to sprains, it is all treated in the office.
6. I treat infections of the foot and leg both in the office or in the hospital.
Please spread the word. This website is my poor attempt at letting people know the scope of Midland Family Footcare.
March 26, 2013
Winter is being stubborn this year. The cold weather has stayed with us the entire month of March. Easter expects to be in the low 50's which will seem warm.. Baseball starts next week, hopefully, not with snow on the ground. My daughter even starts outdoor soccer practice this week. These are all the "rights of spring" in Michigan.
It is very important to warm up on those cold early spring days. Muscles are tight and cold. Many people are starting activities for the first time in months. Even kids should stretch a minimum of 10 minutes being activity. Stretching should be gradual and non-aggressive. DO NOT BOUNCE!!! This can actually rip muscle fibers and tendons.
Wear warm clothes when stretching to allow the mucles to warm. A slow jog and walking should be done before running in any sport. Calves and hamstrings are usually the tightest areas. Please take it easy at first. Overuse too early in the season will hurt later. Watch any college or professional team. They have fitness coaches that insist on proper stretching.
February 27, 2013
We are almost into March and the snow should be ending soon. Soon, people will start being more active as the weather improves. It is a good time to think about investing in new shoes as you put the winter boots away.
Athletic footwear runs a huge gamut. There specialized shoes for almost anything. Running shoes now are divided into the style of running and the type of foot structure. Aerobic shoes are available just for the hour of this specialized activity. What should the average person who just wants a pair of shoes for a host of activities do?
I recommend cross-trainers for most people. A cross trainer is an "in-between" shoe. It provides the stability of a walking shoe, but is lighter. The sole will flex like a running shoe, but it gives more lateral stability. They will even hold up for general activities very well.
As far as brand names, I prefer Avia, New Balance and Saucony. In reality, any of the name brands will perform well for the average person. Most cross-trainers are between $40-$80. They are carried in major chain stores as well as specialty stores. Treat yourself to a new pair of shoes.
February 19, 2013
February 12th is a national holiday in my mind. It was the start of Baseball Spring Training which means the winter is winding down. I was also vindicated as to a previous blog that I posted in October. Derek Jeter admits to playing on a stress fracture in his fibula during the playoffs. This led to the fracture when he went to his left in extra-innings against the Tigers in game one of the ACLS.
Many people have commented on my blog posting. Some wrote in agreement and some calling me an idiot. The action taken by Jeter was just traumatic enough to cause a fracture without a previous problem. This is normal course of this type of injury. Stress is caused to the bone by the pulling of ligament, tendon, or just stress to the bone. The bone reacts with a small crack that does not extends all the way through the bone. If stress is reduced, the bone will heal and not go on to a true fracture. If the bone if further stressed, it will crack all the way through.
The most common stress fractures that I see are in the metatarsals and the calcaneus. I treat these ailments fairly aggressively. I place the patient in either a removable cast or hard cast. I have seen too many stress fractures crack all the way and lead to pain and disability.
Jeter is a first ballot hall of famer. He will probably achieve 4000 hits by the time he is done. In this case, he chose to roll the dice and lost. Good luck Derek. Leave it to Jeter to probably be back by opening day.
February 11, 2013
Foot injuries are in the news again, Pau Gosol of the LA Lakers suffered a partially torn plantar fascia. He will be out for about 6-8 weeks while the fascia heals. This a devastating blow the the Lakers who may not even make the playoffs. It is a far cry from the team that was supposed to compete for a title with Dwight Howard and Steve Nash being added this season.
The plantar fascia is divided into three bands and basically supports the arch and holds in the 4 layers of muscles on the bottom of the foot. Plantar fasciitis is a much more common entity in which the fascia gets pulled and inflamed. This is the typical "heel spur" problem. A torn fascia has torn fibers that must either scar together with time or be surgically repaired. The average patient is immobilized in a removable or hard cast for about 4 weeks and usually is fine.
Pau Gosol is a different story, He is 7 feet tall and playing in the NBA. There is tremendous force stretching the fascial bands every time he jumps. I would suspect doing a surgical repair if more than 50% of the fascial band is torn. Reinforcing the band with a collagen matrix may also be necessary. Aggressive physical therapy would be started a few weeks after repair.
Gosol is one of the most skilled big men in the game. Good luck to getting back on the court.
February 5, 2013
I have written about board certification in the past. I am presently board certified by the American Board of Podiatric Medicine (ABPS) in Foot Surgery. This basically means that I presented cases that I performed in practice and passed an oral and written examination. It is another step in achieving one more acronym after your name. It does not assure that I am a good surgeon, just that I could pass the standards to attain the certification.
Now, the ABPS wants to change the certification to the American Board of Foot and Ankle Surgery. I kinda like the name change since people have no idea what Podiatric Surgery means. The real answer is WHO CARES. The general public has enough trouble understanding "Board Certification". We have numerous boards just in Podiatry. Now, there is board certification in things such as Podiatric Sports Medicine, Wound Care, Podiatric Orthopedics, etc... The general public is not going to notice the change.
I recently gave my opinion to make the change. The cost is estimated at $1 million. I'm sure there are a lot of legal expenses involved. This is actually a small amount of money considering the number of Podiatrists involved in the ABPS. This could probably be better spent promoting Foot Surgery in general, but WHY NOT.
Doctors get caught up in changes like this. It was an honor to attain my credentials. Passing the ABPS exam was challenging and showed a certain amount of dedication to Foot Surgery. In the real world, it allows a little easier access to hospital privileges and that is about it.
My patients will be so excited that my tag line will be Lawrence Sternberg DPM; board certified in Foot Surgery by the American Board of Foot & Ankle Surgery. Patients just want professional care in a pleasant environment.
January 28, 2013
I attend a seminar every spring in Livonia, Michigan. It is sponsored by the American College of Lower Extremity Surgery (ACLES) and the Kent State School of Podiatric Medicine. I am going to be lecturing of the Use of Regenerative Collagen Matrix in Ankle Surgery. Lecturing allows me to share information with my collegues as well as spur my interest in the educational aspect of medicine.
Regenerative Collagen Matrix is simply an artificial patch that can be used to reinforce a tendon, or ligament. I use this while strengthening ankles, repairing tendons, or addressing joint problems. It is made of cadaver skin that is processed to make it a safe, strong material. I have been using various products for over 10 years.
Lecturing is something I have not done on a wide scale for a long time. I used to lecture to students and residents when I just started private practice. I have decided to get more involved since my children are now older and I have more time. I have always enjoyed speaking and it gets me excited about my profession. Who knows, maybe I would enjoy teaching after all.
January 22, 2013
I just finished the residency interviews for Genesys Regional Medical Center last week. The goal is to find 2 residents for the next year. All podiatric residencies are now 3 years and are a very competitive process. Genesys is considered a very strong program so there were applicants from all 7 Podiatric schools.
After 2 days of interviewing about 38 students, I have a few comments about the process.
1. Most of the students would make fine residents. They are well educated and knew a great deal of information. In addition, most were polite and eager to learn. Congratulations to the schools.
2. The process is adequate but not great. I thought our interviews were fair and I was amazed at the amount of information that can be gained in a 20 minute interview. However, some programs continue to put the candidates through unnecessary regiment of questions. If the idea is to find the best person for the spot, why torture 27 year olds?
3. There is a residency shortage. There will be 40-50 students that do not have a residency spot so they will have difficulty practicing in most states. Podiatry cannot allow students to accrue over 200K of debt and then not allow them to practice.
4. The selection of residents is very inexact. We tried to be very objective, but much is based on a general impression of the candidate. Performing the externship was the biggest factor among the committee.
Thank you to my fellow podiatrists for a nice trip to the Dallas area.
January 08, 2013
Home remedies and over the counter products are a huge marketplace. Pharmacies have a complete aisle of foot products to choose. Many simple foot problems can be treated at home. I will try to point out some better products to choose at the store.
Almost all injuries respond to the RICE treatment. This is rest, ice, immobilization, and compression. The thermal ice packs provide much more long lasting cold therapy than ice cubes. They are also a lot less messy. Ace bandages and coban type products are an easy way to compress the foot and ankle. The amount of pressure can be changed easily and are inexpensive.
Athletes foot is a huge marketplace. The shelf is full of different products. I draw the line between killing the fungus and merely changing the environment. Powders such as Gold Bond, Desinex, etc change the environment. Drying the area will help but not as effectively. Products such as Micatin, Lamisil, and any clotrimazole product is much more effective. A hydrocortisone product can be added if there is itching.
Ingrown toenails and fungal toenails are more difficult to treat at home. Products for ingrown toenails usually are topical anesthetics to kill the pain. They do not get rid of the nail. Soaking in a drying agent such as epsom salts may drain the infection and make it feel better. Other drying agents such as domoboro and avino work a little better. Antifungals are very ineffective for toenails. A small area may be eradicated with a fungal nail product but most require internal medication.
I hope this gives everyone a start. I know that our busy schedules make coming to the podiatrist difficult. Trying an over the counter before coming to see a podiatrist is a good, logical choice.
December 28, 2012
The New Year is almost upon us. Very few people actually follow through on resolutions that they make on January 1st. I promise myself that I will get down to college weight, but thus far it has not happened. It is a good time to reflect on the past year and contemplate the upcoming one.
Midland Family Footcare had a good year. We treated more patients than ever before. We also performed more surgeries than in the past. We have survived another year of the ever changing health insurance industry. Diabetic shoes are becoming increasing hard to meet the Medicare criteria. We get rejected for no apparent reason. Doctors must continue to see more patients to get reimbursed the same money as the year before.
The "fiscal cliff" is a daunting reality for the new year. Across the board cuts will make insurances scramble for new rules and regulations. No one has any idea to it's effects of the health industry. It cannot be good news. Keep a close watch on Washington for the exact changes. I'm sure Lansing will make their own changes as well.
On a personal note, our Footcare Family grew with the birth on London Lawrence. This is Penny's newest grandchild. Babies are always precious and we wish her parents the best.
Thank you Midland and Tri-cities for another year. I look froward to many more years treating the podiatric needs of the area.
December 18, 2012
The cold weather is just about to start here in Mid-Michigan. Before the snow starts falling, prepare for the sub zero days early. Podiatry is no different. From our recommendations for patients to getting to the office through the white stuff, the winter presents some problems.
Waterproof boots are a necessity. Wet feet get colder and more likely to freeze a lot faster. Frostbite sets in to wet feet at a dramatically faster rate. Absorbant socks also prevent moisture from touching the skin. Stay away from synthetic blends. Cotton and wool absorb water and sweat much better than items such as nylon. Even toe warmers should be used when being out in the elements.
The office is open except for extreme snow days. I travel a long way but have only missed a handful of days due to weather since 1996. Snow storms of more than 8-10 inches may lead to closing the office. It is always a good idea to call. The snow service is in place and we will do our best to keep the walks clean and safe. Sometimes the weather hits us quickly, so let us know if things get slick.
My last advice to patients with difficulties walking is to reschedule on the bad days. I would much rather change the appointment than have to pick someone up from the parking lot. We can usually get someone in the same week. Stay home on the wintry mix days.
Happy holidays and have a safe New Year.
December 11, 2012
Podiatrists have done a terrible job in educating the public. Less than 2% of the population uses a Podiatrist for treatment. Other specialties have a much wider use among the general public. Many people do not even know what a Podiatrist does. " Does he treat children?" is a common reflection at parties. Even patients have no idea that I treat all ailments of the foot and ankle. Someone I perform an ingrown toenail procedure goes somewhere else for an ankle sprain. What can we do?
First, the website is a good start. It provides information that represents all areas of the practice. I make a real effort to point to areas that relate to general health and events. I try to stress topics that point out the vast range of services that Podiatrist's provide. For almost 2 years, this website has informed and enlightened.
Second, stop competing with each other so much. Dentists learned a long time ago that it is better to expand the patient population. We spend too much time enlarging our advertising budget to compete with other doctors in town then to expand the 2% population. We need to get more of the population to come to a Podiatrist for injuries such as tendon pulls, ankle sprains, and fractures. Most of these go to urgent care, family practice or the emergency room. Podiatrists handle these better and more more efficiently.
Third, be proud of our practices. Like most people, Podiatrists undervalue their ability. We are very talented and provide excellent care of the foot and ankle. From toenail treatment to ankle arthroscopy, we provide quality care that allows our patients to have a more active and healthy life.
December 4, 2012
Second opinions are a very important part of a medical practice. Many patients question or do not fully understand the information presented at a medical office visit. There is a certain level of stress when first presented with the news that you may require treatment and/or surgery. My blood pressure goes up just when I enter my doctor's office. It is a good idea to ask questions from a neutral party.
A second opinions are not an insult to your physician. I actually welcome a fresh perspective on the problem from another professional. It also reassures that my treatment plan is acceptable to someone else. The second opinion also opens up some new ideas to the patient that I may have not considered.
When going for a second opinion, tell the physician that you are there for that purpose. You do not have to tell the new physician who you are seeing for treatment. That is totally up to the individual. Bring all the information that you can. This includes x-rays, test results, other reports, etc... This will prevent the new physician from needing to repeat the tests. Also, make a list of questions that you want answered. This makes the whole process more efficient.
Most insurances pay for second opinions. Just be aware that some physicians will try to take over the care of the problem from the first physician. This is strictly your choice. I try very hard not to take over the care. This was not my job in a second opinion situation.
November 12, 2012
Podiatry is a very small profession compared to the entire medical establishment. Our national organizations have a much harder time pushing podiatric policies than the APMA. Part of the problem is just inherent to a small specialty and some is the organizations themselves. I want to address one case in point.
I will be conducting residency interviews for Genesys Health Park this January. The interviews are done in centralized location so that students only need to fly to one location. This makes a lot of sense since a 4th year podiatry student may want to interview at programs all over the country. Back in 1990, I had to fly to multiple centralized places. The country was broken up into about 5 regions, and programs could interview in various regions looking for residents. I applaud the one location idea.
What would make a good location? First, the middle of the country would make sense since it is a shorter flight than to either coast. Second, a large airport that is easily accessible from most parts of the country. Third, a hotel that is by the airport and can accommodate the amount of people required. Almost all major airports have a host of hotels with free transporation to the airport and conference facilities. Remember, the idea is to save time and money. Welcome FRISCO, TEXAS.
The interviews are in Frisco, Texas about 30 miles outside of Dallas. A Dallas airport hotel makes some sense, since Dallas/Fort Worth is a major hub. Frisco requires a long cab ride or renting a car. A shuttle is available at $44 per person each way. At least a city hotel would provide the entertainment/ nightlife of a major city. The hotel is not inexpensive which could be a saving grace. It simply makes no sense.
Once again, the national organizations make decisions that make no sense. I hope the American Podiatric Medine Association (APMA) can make better choices for heathcare in Washington.
November 6, 2012
I was recently asked an interesting question relating orthotics and barefoot running. I mentioned that barefoot running increases the strength of the intrinsic foot muscles while orthotics will weaken the muscles by supporting the foot more. So, why in the world would we want orthotics?
My best analogy to this issue is eyeglasses. Eyeglasses weaken the existing eyesight but allow for the person to see better. The intrinsic muscles of the foot stabilize the arch and forefoot but have only a small effect on the rest of foot function. It is more important that the entire foot function better as a mechanism than the intrinsic muscles. I idea of a functional orthotic is to allow the abnormal foot to function more efficiently. The efficient foot requires less muscle support therefore eliminating stresses on the foot that can cause pain and injury.
The effect of using the small muscles in the arch is very small. In a competitive world of running, this may provide some benefit. The average person with plantar fasciitis will be much happier with support of the arch and elimination of pain.
October 20, 2012
People watching game 2 of the Yankees vs. Tigers saw Podiatry in action. Derek Jeter fractures his ankle without real contact. He was setting himself for a throw and suddenly he was on the ground. What happened?
Jeter had a bad ankle. He was used as a designated hitter in the first game with a sore foot and ankle. The real truth is that he had a stress fracture of the lateral malleolus. The outside bone of the ankle probably had a small crack in the bone. The extra stress of setting himself caused the stress fracture to break through the bone completely. All of a sudden, Jeter has an ankle fracture though the outside bone.
The best analogy is a small crack in the windshield spreading across the windshield without anything really happening. This is why we protect stress fractures. A few weeks of rest can avoid potential need for surgery or 6=12 weeks of casting. Jeter had surgery this Thursday. Good luck to Jeter in his recovery. Good luck to the Tigers in the World Series.
October 12, 2012
Bunionectomies are one of the more common podiatric procedures. They are also one of the surgeries that people are concerned about the outcome. I hear horror stories from patients every week. I am not sure of the cause of the misinformation.
A bunion deformity (hallux abductovalgus) is a condition in which the great toe moves over toward the second toe. The bone on the inside of the foot moves out causing a large bump to the inside of the foot. The shoe rubs on the bump and the bone becomes sore and the joint is not alligned properly. How do we fix it?
Most bunionectomies require removal of part of the first metatarsal and correction of the angle between the first and second metatarsals. A cut is made through the first metatarsal and the end of the bone is moved toward the outside of the foot. This cut is held in place using 2 screws. This is outpatient surgery and has a very high success rate.
Why the misconception? I'm not sure. Fixation has become much better over the years. Patients do not have to be non-weight bearing as years ago. There is less casting than 15 years ago. Most patients are back in a shoe in 3-4 weeks. The post-operative pain is well controlled with tylenol #3 or vicodin for the first week.
Ask us more about correction of bunions. Check out more detailed information under conditions on the site.
October 8, 2012
New medical devices are being introduced every week. More types of implants and fixation systems are being made available all the time. Many of the new systems provide improvements to even the most basic surgeries. This is the case with the TenFUSE PIP Allograft.
This product is used for hammertoe surgeries which is one of the most common procedures that we perform. It is a bone graft that fits in between the toes to allow better correction and fusion of the toes. It eliminates the need for a wire to be used that sticks out of the toe.
There have been metal implants that have been used for the same purpose. They were difficult to insert and could fail and break. The TenFuse will absorb like bone and is easy to insert into the toe during surgery. It should also not increase the surgical time substantially.
Ask us about the new implant at your next visit.
October 2, 2012
The foot injury bug just hit my New York Jets. Santonio Holmes went down Sunday with a possible Lis Franc's injury to his foot. Kevin Smith of the Lions went down with a dislocation of the Lis Franc's joint a few year ago. What is this injury?
Lis Franc's joint is in the middle of the foot and joins the long bones (metatarsals) to the rest of the foot (tarsus). It is termed the tarso-metatarsal joint and actually represents many joint articulations. The joint is responsible mainly for adapting to the ground on impact. It absorbs stress and moves the foot to provide better function.
It is very unlikely that the normal person dislocates this joint in normal activity. There are ligaments on top and bottom of the foot that make this very stable. The problem is that athletes put enough force on this area to sublux or dislocate this area of the foot. Once the ligaments are disrupted, stability is hard to achieve with treatment.
Treatment consists of immobilization in mild cases, and surgery in severe cases. It is an awful injury for an athlete. They will miss an entire season if not a career. Kevin Smith was never the same.
Santonio Holmes is still being evaluated. His MRI is being sent to Dr. Richard Anderson for further opinion. Good luck to Santonio. Come back soon. The Jets need you badly.
September 18, 2012
Foot orthotics are a large part of my practice. These are foot inserts that allow the patient's foot to function better and eliminate various foot problems. I use orthotic devices for problems such as plantar fasciitis, metatarsalgia, neuromas, tendonitis, and many other entities. The thing to remember is that not all orthotics are the same.
Over the counter orthotics are available all over the place. Foot inserts can be purchased in drug stores, chain stores, athletics stores, and at all chiropractors. These are strictly an already made device that comes in different sizes to fit the shoe. Even the Dr. Scholl orthotic computer just picks out the right device out of the six available based on a force plate diagram. These will help many problems but is hardly the same as a custom orthotic.
A custom orthotic is based on a model of your foot. I make a plaster mold of the foot that is then digitized to build the device. The device is then heat molded to an actual model of the foot. I also have tremendous choices as to the device. The material can range from a very stiff graphite to an extremely flexible plastizote. The device can be padded in a variety of ways. The device can be placed in a number of different positions depending on the patient's problems. There are a number of other decisions that are made for all devices.
The best analogy is to eye glasses. One can purchase OTC glasses at Walgreens for a small amount of money. This hardly solves the eye problem as much as a prescription pair of glasses. The glasses are made to the exact prescription, and a wide range of frame choices are available.
Orthotics are a great solution to many problems. Just remember, not all orthotics are the same.
September 11, 2012
It is always a sad day on the anniversary of 9/11. Eleven years have past since that awful day. We can all remember where we were when the planes hit the World Trade Center. Being born and raised just East of NYC (Wantagh, NY), I lost someone I knew from high school. I also had people close to me severely affected by the terrorist event. From NYC police officers that had to comb through the rubble to friends that had to walk uptown to get out of lower Manhattan, I knew many people involved.
Things have changed in eleven years. We have to take our shoes off at airports. We cannot carry a bottle of water through security at airports. The TSA conducts security checks rather than private companies. The Department of Homeland Security was started. We allowed the Patriot Act that allowed the government to infringe on our liberties in the hope to be safer. My point is that the world is different based on 1 day: 9/11.
The next time you hate taking your shoes off at the airport, think of Brian McDonald. He was climbing the North Tower as an EMT for the NYC Police Department. He never got to go home to his wife and two children that day. I need to go to the 9/11 Memorial to honor his memory. RIP.
August 28, 2012
I have finally completed the process of getting privileges at Great Lakes Bay Surgery & Endoscopy Center. This process always takes months and needs to go through a host of committees. This will allow me to perform surgeries in Midland.
The Great Lakes Bay Surgery & Endoscopy Center is located at 4228 Bay City Road. It is directly in front of the skating center just south of the Valley Plaza Resort. It is a new facility that just started last year and boasts two surgery suites. I will be performing surgeries on Wednesday afternoons at least once a month.
I will continue to use Mid Michigan Hospital- Clare as my primary surgical location on Friday mornings. I also continue to perform surgeries at Genesys Health Park and The Surgery Center of Health Park in Grand Blanc. Patients are always surprised as to the quality of the facility in Clare. The surgical unit was opened about 3 years ago. It is state of the art including the ability to teach directly from the OR through video conference. The staff enjoys my patients and goes beyond the norm to treat patients well while in the hospital.
I look forward to joining the staff at Great Lakes Bay. It should provide patients for another option for outpatient surgery.
August 14, 2012
Laser treatment for fungal toenails is getting a lot of attention in the Podiatric community. There are many systems now available to perform laser procedures on fungal toenails. They claim various success rates, some up to 70%. What is the problem?
The problem is that all the studies are funded by the manufacturer. Many of the studies use Lamisil tablets in conjunction with the laser treatment. Some use multiple treatments over many months. The real answer is that no one knows if it really works.
Over the years, podiatric procedures get very popular for a short time and then fade. The FAD phenomenon is very prevalent in medicine. Laser treatment of nails may be one of these entities. The idea is to kill the fungus in the nails by using certain wavelengths of light. The laser is just a concentrated light beam based on one or a few wavelengths of light. It is strictly a local procedure to the nail plate. It is not addressing the fungus under the nail or at the nail bed area.
My biggest reservation is that is lucrative for the manufacturer of the machine and to the physician. The manufacturer stands to make millions of dollars promoting the devices. The physician can charge hundreds to thousands of dollars for each patient. It is also a cash procedure since insurance companies do not feel it is effective. It is largely cosmetic at this point.
I will continue to treat fungal toenails with oral medication, topical medication, and debridement. I will continue to wait for evidence based studies are laser treatment. Once more knowledge is obtained, it may provide another option.
July 31, 2012
The Summer Olympics are upon us. I love the Olympics. For 2 weeks, the world cares about swimming, judo, archery, synchronized diving, and other fringe sports. I love hearing the sacrifices that these athletes make just to get to London. Stories of people not making the team in Beijing and still training for 4 more years just for this shot at the gold are heartwarming.
Has anyone noticed all the foot injuries that are talked about. Missy May Trainer, the gold medal beach volleyball player, tore her Achilles tendon in Dancing with the Stars. She never tears it diving on the beach, but while dancing. Two of the US male gymnasts have severe ankle issues including a repaired achilles tendon. Yao Ming is not competing for China due to chronic stress fractures in his foot. Podiatry is all over the London Games.
These are elite athletes in London. Most have the best training and conditioning that is possible. Why so many foot and leg problems? Simply, the human body wasn't meant to do many of the competitions. The ankle was not meant to come off a high bar and twist four times. That is what is great about the Olympics. We marvel at the physical feats that are possible. Athletes are willing to put their bodies at risk.
While watching the games, check out all the ankle and foot tapings that are on the athletes. Look for the lower extremity problems that will occur and continue to marvel at these great athletes.
July 24, 2012
Health insurances still amaze me. They will implement a radical change in policy and only send one small bulletin to explain the change. Molina Healthcare is now requiring prior approval for almost all podiatric procedures. We were informed of this change in one small notice. The change occurred on April 1, 2012 but we just found out that we have been rejected for the last 3 months this week.
Prior approval requires us to tell Molina what procedure needs to be performed before it is performed. This means that a patient must wait for the treatment to be performed for several days or a week. The patient must be evaluated and then seen back for the treatment. This is a logistical nightmare for the office and a waste of time for the patient.
Insurance companies do this for several reasons. First, many practitioners will not do the paperwork correctly so the company will never pay on the claim. Secondly, it can delay payment for a long time allowing the company to hold on to the payment. Thirdly, it makes the doctor approve every procedure and many will get lost in the translation.
My recourse is just to no longer accept Molina in the office. We are one of two Podiatrists in the entire Mid-Michigan area to accept the plan. This would leave a large hole in their coverage. I have a sense of community responsibility and would hate for Mid Michigan to be without proper foot care. The other option is to put up with this new rule. We are going to try to comply, so bear with us.
July 10, 2012
We are now in the dog days of a very hot summer. Temperatures last week were at 100 degrees. We are also half way through the year. July also means that many insurance policies start a new year and many patients have changes in their policies.
Many companies shop their insurance every year. Large companies offer several choices in policies that usually begin July 1st. Try to obtain as much information concerning the new health care insurance. Make an educated choice. Check with human resource employees at your company concerning policies. Check online to see whether you are receiving the coverage that is appropriate for you and your family.
My staff will try to alert patients as to coverage for podiatric services. We tend to know the major provider information but we are not insurance experts. The same company can offer great coverage on 1 policy and poor coverage on another. It is the patient's responsibility to know their insurance.
My advice is to research your choices. Once the policy starts, you are stuck for a year. Make a decision as to how much coverage is appropriate, and to how high deductibles are. Knowledge is a wonderful thing.
July 2, 2012
In 21 years in private practice, I have taken out a host of foreign objects from the foot. Pencils, needles, wood, dog hair, rubber from tennis shoes, etc... have all managed to find itself inside the foot. Most of these are preventable by just wearing shoes.
Stepping on a foreign object occurs all the time. Usually, it does not penetrate the skin. Many things such as wood splinters and small pieces of glass lodge in the skin surface and can be removed fairly easily. If it gets through the skin, foreign bodies are quite challenging.
First, many objects do not show up on x-ray. Wood only shows up if it is painted. Glass only shows up if it is coated with lead. Clear glass is not visible. Even if it shows up on x-ray, finding small items is difficult. The items gets lost in fatty tissue and tends to get surrounded by scar tissue. The body tries to wall it off from the body and/or push it out. I have seen pieces of wood come out in a blister years after the original puncture wound.
Second, foreign bodies get infected easily. The item is certainly not sterile. It also tends to degrade once exposed to bodily tissues and fluids. All this makes infections more severe and more common.
My advise is to wear shoes. Shoes may prevent me looking for "a needle in the haystack" inside of your foot.
June 19, 2012
Lymphedema treatments are getting a lot of publicity recently. Lymphedema treatment clinics are popping up in many communities and most visiting nursing organizations are becoming involved in treatment plans. What is it?
Lymphedema is tissue swelling that makes the extremities swell. Excess fluid in the body is drained through a extensive network of lymphatic ducts. If these get obstructed, swelling occurs. The swelling can cause pain and ulcerations to the skin. Many cancer treatments in which lymph nodes are removed can obstruct the lymphatics. In addition, congestive heart failure and liver problems can lead to extensive lymphedema.
Treatments have always consisted of compression of the legs through stockings or wraps. Putting pressure on the part will force fluid back toward the heart. Now, there are additional treatments. Nuclear medicine teasting is now available to pinpoint the area of obstruction. A radioactive tracer is injected into the extremitity and a camera can trace the flow.
Other treatments exist such as message, and pneumatic compression. Special braces are also available to continue compression therapy. Ask us to evaluate swelling of the legs at your next appointment.
June 12, 2012
The has been an MRI epidemic in the last few years. I have patents requesting an MRI before I even evaluate their problems. Doctors are ordering MRI's for simple conditions just to confirm the pathology. The problem is that the MRI costs close to $1000 just for a foot. Why is this happening?
An MRI is Magnetic Resonance Imaging. The idea is to put the body part in a very strong magnetic field and do a computerized x-ray of the part. Structures show up differently when scanned in a magnetic field. This technique gives CT scan like images that includes all tissues, not just bone. It gives a wealth of information. The problem is that it is almost too much information.
Reading an MRI of the lower extremity is difficult. There are so many structures to evaluate that things can be missed. In addition, there are all kinds of abnormalities that are picked up that have nothing to do with the problem. We term these incidental findings.
Why the problem? Why all the MRI's? There are several reasons. First, it is like the new toy. It gives lots of information and allows the doctor to visualize the problem. Second, it is more available. MRI centers are everywhere now that the investment is much lower. The cost of the machine continues to drop. Third, is malpractice. The first thing a malpractice attorney askes is "What does the MRI show?".
I order an MRI for ankle issues, since plain x-ray does not evaluate ankle pathology very well. I also order an MRI when a patient has not responded to normal treatment. It is an excellent resource to rule out additional problems. I do not order it for most normal problems. It is just not cost effective.
June 5, 2012
Endoscopic and arthroscopic procedures have grown tremendously over the last 5 years. The most well known is the cholecystectomy. This is the removal of the gall bladder using a camera and several small incisions. I presently perform 3 procedures using a camera.
1. Endoscopic Plantar Fasciotomy- A release of the fascia on the bottom of the foot using 2 small incisions. This is done for plantar fasciitis (heel spurs) and has a recovery time of 2-3 weeks.
2. Ankle Arthroscopy- This provides evaluation of the ankle joint using a camera and 2 small incisions. Many joint problems can be repaired with a recovery time of about 3 weeks.
3. Endoscopic Gastrocnemius Recession- This releases the calf muscle to allow more motion at the ankle. This is done for chronic achilles tendinitis. It has a recovery time of about 3 weeks.
These 3 procedures are highly successful and allow early weight bearing and a few weeks to recover. They are all done on an outpatient basis. There is more information on the website.
May 29, 2012
Several patients are complaining about their orthotic devices squeaking in their shoes. The thermoplastic device moves in the the shoe causing a noise with every step. It doesn't affect the function of the device but is very annoying. Here is some advice.
1. Sprinkle powder in the shoe. The movement of the device will be less noisy.
2. Place a soft insole in the shoe. A simple flat shoe liner will decrease the movement of the device.
3. WAIT. The orthotic will build a groove in a shoe that will stop the movement.
4. Change shoes. Tighter fitting shoes will cause less movement of the device.
May 8, 2012
I have just attained surgical privileges at Great Lakes Bay Surgery and Endoscopy Center here in Midland. I will continue to perform most surgeries at Mid Michigan Hospital-Clare as well as Genesys Regional Medical Cnter and the Surgical Center at Health Park. This will mark the first time that I can perform surgeries at a facility in Midland since I started in 1996. HOORAY!
I have discussed my troubles with Mid Michigan Hospital-Midland in the blog before. The funny part is that they can really use my business. The Reicker Surgery Center, which is part of the hospital, is closed on several days during the week for lack of cases. The hospital is not allowing employed surgeons to take their cases to the new Great Lakes Center, yet they are still having problems filling the OR. Why would a hospital turn down cases when they are empty? I have no idea.
When I started in 1996, all patients that required surgery drove an hour down to Genesys Health Park in Grand Blanc. Genesys was brand new and a state of the art facility. Very few patients objected to the hour drive and were impressed by the service at a teaching hospital. In 2004, I started performing surgery at Mid Michigan-Clare just to offer another closer alternative. This has been great with a new surgical unit being established about 3 years ago. Once again, patients have been willing to drive 30 minutes for surgery and are generally impressed by the personal attention in Clare. The hospital staff are wonderful to me and my patients.
I hope that Great Lakes Bay Surgery Center works out well. It is a new facility located on Bay City Road just in front of the ice arena. Thank you to all my patients that have been driving a few miles since 1996.
May 1, 2012
Just as update on Ryan Howard. I wrote about a month ago (March 13) about the ruptured achilles tendon that Howard suffered on the last play of the Phillies season last year. He had it fixed but then developed an infection in the tendon. It sounds like he is finally healing.
The post-operative infection was opened and drained. It probably required removal of previous fixation devices and resutured. Howard saw a specialist and was released to start baseball activities. He will be back to first base probably in early June. The original surgery was performed in October.
This is a cautionary tale. Ryan Howard is a world class athlete that affords him the best care available. Even, the best care can have complications and take 7-8 months to recover. Surgeries can have complications and patients must be aware that there are no guarantees.
April 24, 2012
This entry is geared for other Podiatrists and medical personnel. I just received something very interesting from a medical representative. This representative sells a subtalar joint implant. This is basically a device that stops pronation in flat-footed individuals. The typical MBA implant has been around for well over 15 years and I have used various forms of this implant in children over the years. The difference this time is that there is a legal opinion concerning billing the implant on top of the brochure.
The printed sheet explains that "per legal counsel and opinion, HyProCure is a product to correct TaloTarsal Dislocation." What?? I have dealt with products that suggest the billing procedures for the device, but never a legal opinion and explanations to document the condition in the medical chart. It even mentions to chart talotarsal dislocation-partial as a diagnosis. This is a huge problem in the medical industry.
First, anyone who has dealt with expert testimony knows that I can find a legal or medical opinion that the earth is flat without looking very hard. Calling a flat foot (pes valgo planus) by the term talotarsal dislocation is very misleading. A dislocation implies a joint that is out of joint. The subtalar joint may be misalligned, or even subluxed, but dislocated? Really?
The more disturbing part of the information is that is states that talotarsal dislocation can be responsible for a myriad of problems including bunions, hammertoes, and tailor's bunion deformities. I agree that pes valgo planus can be a factor to many conditions, but this is a dangerous assumption. This opens the door for inserting this fixation device in every bunionectomy or hammertoe procedure. The cost is staggering.
The new healthcare bill is being debated in the Supreme Court. Practitioners and hospitals may be facing deep cuts in reimbursement. The last thing Podiatry needs is promoting expensive, elective procedures on the basis of a legal opinion. This is entirely my opinion, but I am not going to be a practitioner to test this legal opinion in an audit or malpractice case. Good luck to that poor soul.
April 10, 2012
Pardon our parking lot for the next few weeks. The winter has taken it's toll on the the asphalt. The main drain to the lot is right in front of the office. This has allowed a sink hole to start by the drain resulting to 2 very deep holes in the asphalt.
A patch was placed in the holes but will not serve as a permanent solution. Yeager Asphalt is going to be cutting out a 10 foot by 10 foot square and then reinforce and repave the area. Since this a very small job, the asphalt company will fit us in around their schedule. Orange cones are placed in the area to avoid injury.
Please avoid the area and be careful. Thanks for your patience.
March 27, 2012
The early warm weather has let Michiganders wearing summer clothes early this year. It feels good to put on shorts and a tee shirt after a mild winter. People are also taking off the winter boots and slipping into sandals and flip-flops. There are a lot more options for summer than in the past.
First, flip-flops are never a good idea. They have been shown to cause everything from foot to knee and hip disorders. They do not control the foot in anyway. Flip-flops are only held on by the toes causing the extensors muscles to work very hard. They also offer very little protection for the foot.
Birkenstock type sandals offer a nice alternative. The conform to the arch with a leather foot bed. The are held on well across the instep. The drawback is the cost and the fact that water destroys the sandal.
Sports sandals are waterproof and fairly inexpensive. The cup the heel and are held on by the instep. The drawback is that the foot bed in rubber and does not conform to the arch. They also tend to slip and are not very deep.
Welcome to the world of orthopedic sandals. Dr. Comfort, which we presently use for our diabetic shoes, is introducing a new sandal. It is a combination of a birkenstock type sandal that is made out of water resistant material. The are deep and control the foot well. We will be getting samples soon.
March 20, 2012
Wound care is becoming a very commercial industry. Wound care centers are present in many hospitals, as well as private centers opening in many cities and communities. What is a wound care center?
Wound care refers to the treatment of primarily decubitus ulcers, diabetic ulcers, and venous stasis ulcers. These are open wounds caused by a variety of factors. The idea of a wound care center is to offer a multi-disciplenary approach to the wound. A surgeon can clean the ulcer. An endocrinologist could manage the diabetes. An infectious disease specialist can manage antibiotics. An internal medicine doctor could control the swelling due to congestive heart failure and kidney disease. In a perfect world, this makes a ton of sense. This is not a perfect world.
I refer a fair number of wound to clinics. Sometimes ulcers do not respond in the office and wound care centers provide a more advanced and aggressive form of treatment. I have realized recently that the wound cater treatment for a certain type of ulcer is always the same and very costly. A superficial culture of an open wound will always grow bacteria. The correlation of this culture to an actual infection is extremely low. However, all patients' are placed on 6 week IV antibiotics therapy. Even negative bone biopsies are placed on 6 weeks antibiotic therapy based on cultures taken through the ulcer.
From the outside, why not antibiotics? It can't hurt. On the contrary, antibiotics for 6 weeks can have pronounced side effects. Many diabetics all ready have kidney damage. This makes it much worse. Colitis is very common from many antibiotics. Read the side effect profile on these drugs and patients' would be scared.
Almost all centers use artificial skin grafts. Some products recommend weekly applications of the product. What's the problem? COST!!! Each application costs over $1200 just for the product. Add physician's cost and facility cost and at least double it. In Michigan, most insurances only allow applications every 3 weeks. This still will run over $3000 per month.
I also question the use of hyperbaric oxygen. The studies are very sketchy about the effectiveness. The local area units have even less scientific evidence of working. It is also very expensive and time consuming.
As a Podiatrist that deals with wound care, I have probably not been aggressive in using advanced methods. Most ulcers close with proper wound care and eliminating the cause of the ulcer. I try simple solutions such as wound gels, antibiotic creams, etc... for a few months. New studies show that if an ulcer does not contract 50-60% in the first month, the outcome is not favorable. I am going to start jumping to artificial skin products more quickly and will do more deep cultures and biopsies.
My final word on the subject is that most ulcers do not require advanced wound care modalities. This should be left for the difficult wounds. It seems that wound care centers jump to advanced therapy all the time. All cases must be treated individually. This is being lost.
March 13, 2012
An ankle injury has me puzzled. Ryan Howard is the all world first baseman for the Philadelphia Phillies. He tore his Achilles tendon on the last play of the Phillies' season when they lost to the St. Louis Cardinals. He had it repaired and should have been more than ready for the start of Spring training. Now, the doctors' say he is infected.
There are many different procedures to repair an Achilles tendon rupture. In a professional athlete, I would suspect the use of an artificial graft, fixation system, or tendon transfer. Surgical sites usually get infected within the first week after surgery, not 5 months later. Even low grade infections will show signs of problems within the first few weeks. What happened?
An infection at this stage would be fairly rare. I am guessing that whatever artificial implants that were used must be the culprit. This is seen after joint replacements where bacteria can live on the implant with little consequence for a long time. The problem with these infections is that they are walled off from the body. The implant sometimes needs to be removed which is devastating for a normal patient. I can't even imagine the damage to Ryan Howard.
Howard is probably on IV antibiotics with the doctors hoping the infection resolves. I am guessing that the next step would be removing the infected fixation device which would weaken the tendon and possibly cost him months to the season. Remember, this is all speculation since the details are a well kept secret. Philly fans, take a deep breath and pray.
February 28, 2012
Diabetic shoes are becoming a problem. The Diabetic Shoe Program requires more and more documentation every year. As previously discussed, the regulations now requires us to obtain treatment records from the primary care physician (PCP) showing active treatment of diabetes. It also requires a prescription for the shoes, certification of risk factors from the PCP, documentation of ordering and dispensing, and perhaps my first born. While only kidding about my child, this is problematic.
Prepayment audits are increasing around the country. This is when the agents for Medicare do not pay until they look at the documentation. Presently, the Medicare agents (CMS) only see the paperwork if we are audited after the fact. The problem with this system is that any mistake in the variety of steps leads to denial of the claim. A chart note from the PCP in which the diabetes is not addressed because it has been stable for 10 years denies the claim.
CMS is trying to end the Diabetic Shoe Program by making it extremely difficult to adhere to. Presently, we are not ordering the shoes until a very detailed checklist is completed. Thank you to the PCP's of the Tri-City area for helping us with this problem. The ordering time is increasing since obtaining the documentation can take up to 2 weeks.
Midland Family Footcare will continue to order shoes for it's diabetic patients. It saves feet and is excellent preventitive medicine. Letters to US Representitive Camp or Senators Levin and Stabenow would not hurt.
February 24, 2012
Electronic media is everywhere. Look around and practically everyone has a smartphone. The fact that the internet is available in the palm of your hand, anywhere in the country is extraordinary. How could this help you with your feet?
First, information about feet and foot problems is everywhere. Starting with webMD, the internet has general sites and very specific sites concerning any pathology. Surgeries and procedures can be viewed on you tube and other sites immediately. Patient's can educate themselves within a short time to understand their problems.
Office visits can be done over the computer. With webcams, scanners, etc.., many patients could benefit from a virtual office call. This is being done and many insurances will cover this type of office visit.. The patient presents to a web conference with the physician. Questions can be answered and areas can be visually examined. The thing that is lost is the ability to touch the patient which is significant.
If anyone is interested in a virtual office visit, let the office know. It could be an interesting alternative for busy patients in the future.
February 14, 2012
We have run into a new problem this year. Medicaid is switching policies to straight Medicaid and putting subscribers on a "spend down account". A spend down account means that the individual has made too much money to qualify for medicaid benefits. The medicaid benefits will not go into effect until this person spends a certain amount of money on medical expenses. What's the problem?
The problem is that the computer lists them as having Medicaid intact. We check insurance coverage on the appropriate website when a patient makes an appointment. The computer shows Medicaid benefits are in force, but actually this should be a cash patient. In a perfect world, the patient learns about this situation and pays the bill. In reality, we have an irate patient.
The Medicaid recipient should know that they are on a "spend down account". They should tell us that they have no insurance for the visit and payment plans could be implemented. There is no way for us to know the situation, so the patient will be billed for all services.
Midland Family Footcare accepts Medicaid, Midland Health Plan, Molina, and Central Health Plan in large part as a community service. We feel that quality footcare should be available to the Mid-Michigan area regardless of economic situation. We will have to rethink this policy if patients are not honest with "spend down accounts".
On a different note, I would like to update the whole Gronkowski situation for the Patriots. He was a shell of himself in the Super Bowl with the high ankle sprain. Now, he had arthroscopic surgery for the injured ankle. My guess is that he injured the medial talar dome inside the ankle. This was an evertion sprain and makes the most sense. The high ankle sprain would not need arthroscopic surgery. He should be fine by spring workouts depending on the severity of cartilage damage.
On a side note, quick recovery to Chauncey Billips. The NBA guard tore his achilles tendon. Billips was an important cog in those great Pistons teams a few years ago. Get better quickly Mr. Big Shot!
February 7, 2012
Ingrown toenails are still very misunderstood. Patients' have a ritual to get a piece of nail out every month. Some patients' believe that there is no way to stop the problem. This is far from the truth.
An ingrown nail is simply the nail not knowing when to stop growing along the side of the nail. The nail digs into the skin starting a foreign body reaction like a piece of wood is next to the nail. It results in inflammation, pain, and finally in localized infection. Antibiotics can get rid of the infection, but it will not get completely better until the nail is removed.
The side of the nail is removed under local anesthetic. Yes, this is a shot. The base of the nail is then burned using a chemical. The nail will stop growing along the side 90% of the time. The procedure takes less than 15 minutes and will stop years of agony.
There is a definite genetic component to ingrown nails. Some nails do not know where to stop growing. This runs in families. Shoes and cutting the nail wrong can aggravate the problem but does not really cause the ingrown nail. Check out our info site for ingrown nails for more information.
January 31, 2012
The biggest story to this year's Super Bowl is Rob Gronkowski's ankle. Gronkowski is the 6'7" monster that the Patriots call a tight end. He is Tom Brady's favorite target and an impossible match up for the opposing team to cover. His ankle may decide the biggest sporting event of the year. Foot and Ankle Injuries are in the news again.
Gronkowski got hurt in the AFC Championship Game against the Baltimore Ravens. His foot got stuck in an everted position (heel shifted outward). He got tackled putting stress to the inside of the ankle and leg first. This is opposite of most injuries that effect the outside ligaments first. The force first hits the inside ligaments (deltoid ligaments) and posterior tibial tendon. It then puts stress to the upper part of the fibula (outside ankle bone).
The Patriots are calling it a high ankle sprain. This is probably the upper leg injury to the outside of the fibula. The x-rays are negative. There may also be tendonitis or even a hematoma to the inside if the leg due to the pulling of the posterior tibial tendon and muscle. The only treatment is R.I.C.E. (Rest, Ice, Elevation, Compression). He has been walking around in a removable walking cast.
Good luck to Mr. Gronkowski. He will probably play but will be limited. Cutting side to side will be the problem even with the ankle braced/taped and the pain blocked. I would be out forever, but I am not an NFL player that runs a sub 5 second 40 yard dash.
January 24, 2012
Cosmetic Podiatry is becoming popular in some major cities. Much is devoted to increasing the padding to the bottom of the foot. Many women experience pain in high heeled shoes since it puts extra pressure to the ball of the foot. Injections can be performed to increase the fat pad avoiding pain in certain shoes.
The primary agent is called Sculptra. It is absorbable suture that will stimulate collagen formation in the atrea. A large lump will form in the area over time that protect the bone. This is the same substance that plastic surgeons use to fill sunken facial defects. It is simple, but requires several injections over a 4-6 week period of time. It also will only last for 6 months to a year.
The main drawback to the procedure is the cost. It is a cosmetic procedure and insurance will not cover any part. The cost would be somewhere in the $1000-$1500 range depending on the extent of the problem. I am trying to determine if there is a demand in Midland for this procedure. Please let us know if anyone is intrested.
January 17, 2012
Foot and ankle injuries are once again in the news. Dwayne Wade of the Miami Heat has both a lateral ankle sprain and plantar fasciitis. Wade was out for several games with the heel problem and now will be out for a few weeks with a lateral ankle sprain.
Professional athletes, especialluy basketball players, have a unique presentation with plantar fasciitis. They tend to tear the actual fascia rather than just pull it away from the bone. The average person does not exert enough force the rip the actual fibers. A basketball player jumps over 30 inches off the ground and land in awkward positions. The treatment is also more difficult due to the extreme force.
The lateral ankle sprain is also difficult in athletes. Wade hurt the ankle by coming down in a bad position on to a hard slippery surface. The ankle allows him to cut from side to side. This is extremely important for a slashing guard such as Wade. Immobilization and physical therapy will get Wade back to the court in a few weeks. He will still require a brace for a few more weeks.
Keep an eye out for more athletic injuries. Email me to comment on some of the athletic problems.
January 10, 2012
Plantar fasciitis is one of the more common problems that I encounter in the office. I have written before about this problem in my blog as well as having a lot of information on the site. My emphasis today is NIGHT SPLINTS.
Many practitioners prescribe or dispense night splints for plantar fasciitis. The idea is to keep the bottom of the foot stretched out at night. This should prevent contracture of the fascia at night. I object to the entire premise.
Most people have more than 10 degrees of dorsiflexion (move the ankle upwards). If this is true, then a night splint is not stretching the fascia in the normal individual. It also assumes that people sleep with a severely plantarflexed foot. Again, this is not an accurate premise.
My biggest objection is that they are uncomfortable. Sleeping is difficult for many people. Restricting the ankle with a plastic shell makes it more difficult get a good night sleep. The dorsal night splints irritate the the tendons on the front of the ankle. Studies have very mixed results concerning the effectiveness under the best circumstances.
Why prescribe them? First, it is a recognized treatment. The first thing a malpractice lawyer will say is "Why didn't you use a night splint?". Second, they are profitable to dispense in your office. Again, this is just my opinion.
January 2, 2012
Happy New Year!! A new year is upon us. It should be an eventful year with a Presidential election, Summer Olympics, European Soccer Championships ( I know that only I care). Healthcare changes still remain up in the air.
President Obama's health care changes are still up in the air. The courts are still considering certain parts of the bill. Medicare rates were increased a very small amount. The Armageddon of a 20% rate cut was averted in the short time.
Remember that Medicare deductibles started again on January 1, 2012. Private insurances do not always run with the calendar year. Patients should be aware of their deductibles and their deductible periods. Most health policies require that a certain amount of money is paid personally until the insurance will pay a claim. This is termed the DEDUCTIBLE. Please do not blame us for this inevitability of insurance. It is same concept with deductibles for automobile accidents.
December 27, 2011
I hope everyone had a wonderful holiday. Even though there was very little snow up North, my family went skiing for a few days. Just a few minutes in the ski boots made my tailor's bunion hurt.
A tailor's bunion is a deviation of the 5th metatarsal that leads to a bump sticking out of the side of the foot. The 5th toe drifts inward, and the bone sticks out just beneath the base of the toe. The bone rubs in the ski boot causing inflammation and pain around the area.
My simple solution was to pad the area with a silicon tube that I had in my car. There are many other types of pads to try. Stretching of the shoe or boot can help as well. Surgery to repair the problem is the only permanent solution. I am certainly glad I had my pads in the car.
Happy Holidays to all. Happy New Year come this weekend.
November 29, 2011
Welcome to the holiday season. Christmas is less than a month away and the winter is looming. Podiatry and the winter bring new concerns. Frostbite and slip and falls become very common.
Frostbite is the freezing of the tissues that results in crystallization of the water inside the tissues. This usually affects the tips of the toes and fingers. This occurs since the blood flow is poorest in these areas. Severe frostbite can lead to gangrene and amputation.
In Midland, I mainly see mild frostbite termed chilblains. The toes become painful and swollen for apparently no reason. Further examination reveals someone shoveling or snow blowing with only normal shoes. The patient usually presents with reddened toes that are ready to explode. Eventually they become normal, but it a slow and painful process.
Slip and falls are harder to prevent. A michigan winter will have it's fair share of ice and snow. I see a lot of ankle injuries that are easily treated in the office. The ankle fractures normally go to the emergency room.
So, what do we do as Michiganders?
1. Wear insulated boots when out in the elements. People with normal circulation will be well protected from frostbite to the toes by keeping them dry. Wet feet lose their heat much more quickly. Buy toe warmers on those sub-zero days.
2. Get a boot with a rubber sole and a tread. Don't use fashion boots or slip on boots as the mainstay. Get as much traction as possible.
3. People with poor circulation or fall risk should stay inside on the bad days. Avoid the situation. Come back out when the conditions improve.
Good luck to all in enjoying the holiday season. Stay safe and healthy.
November 22, 2011
Thanksgiving is almost upon us. The winter is coming soon and hunting is in full force. This is also a very interesting season for Podiatry. Why?
First, hunting season translates to gout season. Gout is a condition where too much uric acid builds up in the blood. The increased uric acid causes crystals to form in a joint ( most commonly the great toe) and this causes extreme pain and swelling. The typical gout patient is a man in their forties and fifties that wakes up in the middle of the night with a big, hot, red toe.
Gout is also caused by increased alcohol consumption and eating heavy red meat meals. What is deer camp all about? The change in diet leads to a dramatic increase in gout attacks. Treatment is fairly simple including w medications and steroid injections.
The other increased condition is ingrown toenails. College students come home for the holiday weekend and parent discover severe ingrown nails. Many students do not realize that all colleges have student health clinics. Most college towns also have Podiatrists close by. The truth is that students feel weird about getting health care on campus. They rather put up for a swollen toe for months. The correction is simple and can be done in the office under local anesthetic.
I have advise for both group of patients.
HUNTERS- Drink a lot of water and eat a better diet in deer camp. Throw in a little chicken and turkey and load up on water out in the woods.
COLLEGE STUDENTS- Do not be afraid of medical care on campus. Make sure your parents supply you with your health insurance information. Prepare of health history on your computer so the process is less daunting.
November 15, 2011
The NFL has a new injury to talk about. Matt Schaub, quarterback of the Houston Texans, is out for the season with a LisFranc injury of the foot. What is this?
LisFranc's joint in the foot is termed the tarsometatarsal joint. It is the midfoot where the long bones of the foot meet the middle of the foot. Simply, it if the instep of the foot. This joint is held together by a series of ligaments on top and bottom of the bones as well as long ligaments to the bottom of the foot. This produces a very stable series of multiple joints that are very hard to injure. Football changes all this.
Heavy impact during the football game can cause enough stress to shift some or all the bones in this area. The front of the foot usually shifts upwards and can separate the middle of the foot. Immobilization followed by surgery is probably the correct treatment to Matt Schaub. The bones can be put in place, but the ligaments will be permanently damaged. A quarterback will probably be fine after about 3-6 months. Running backs and wide receivers may not be so lucky. Remember Kevin Jones of the Lions. He was never the same.
November 1, 2011
Warts are a common problem that we see in the office. This problem is termed "verrucae plantaris" and seem like a simple problem. However, they are very frustrating.
Warts are caused by the papilloma virus. The virus puts down a small lesion in the skin that can cause pain and spread. The problem is that treating the small lesion is like treating a symptom and not the viral cause. There are tons of treatments including acid, liquid nitrogen, needling, yeast injections, laser, blunt excision, and various other topical items. This plethora of options means that all warts respond to any one treatment.
Warts are very individualized. Some people repond well to simple acid treatments and some would only respond to a bomb to the foot. My philosophy is to be more aggressive with younger patients and if there is pain. I recommend surgical excision for painful warts or any warts over 1.0 cm. in diameter. If the wart is painful, excision gets rid of the wart quickly.
Excision of the wart takes about 15 minutes and can be done under local anesthetic in the office. I use combination acid therapy on other lesions. Any treatment has a high risk of the wart coming back. The idea is to combat the wart until the virus leaves the patient's system.
Try to treat warts when they are small and do not let them spread. Over the counter treatments will work when they are small.
October 11, 2011
The are common misconceptions concerning bunions and bunionectomies. This is a very common disorder that we see in the office. The public has deemed the surgery "unacceptable:, "horrible", or many other negative adjectives. The truth is far from the perception.
A bunion deformity (hallux valgus) is a skeletal deformity in which the great toe is shifted toward the 2nd toe and there is a bump on the inside of the foot. There are different outpatient procedures that can be performed depending on the severity of the deformity. The average recovery time is 4-6 weeks. Some require casting for 6 weeks, but most procedures do not require casting and allow some ambulation through the healing process.
These are the types of patient comments that I see in the office:
1. "My friend had it done , never walked again"- I do not know where this misconception came from. Patients are usually back in a shoe at 3-4 weeks. In 20 years, all of my bunionectomies have walked again.
2. "They did it with a laser."- This is actually Podiatry's fault. Some practitioners make the skin incision using a laser. This is strictly a marketing tool. The laser cannot be used to cut the bone since it burns bone. There is no advantage to using the laser for the skin incision.
3. "Just pop it back"- A bunion deformity progresses slowly over many years. It is not a dislocation of the toe and cannot simply be popped back into place.
4. " My friend had it done and was better in 3 days"- Maybe the friend had a injection for the pain or had a different problem. Even minimal incision surgery would have a longer recovery time.
5. "The pain was unbearable- worse than a kidney stone."- Bunionectomies certainly have pain after the surgery, but not to this level. Most of my patients require narcotic medication only for a few days. The foot is usually sore for 3-5 weeks. There is very little pain as long as the patient is not walking.
I hope this clears up some of the issues. A bunionectomy is a very successful outpatient surgery. There are risks involved in any surgery, but they are very low for this procedure.
September 20, 2011
Midland Family Footcare is changing billing services. Since 1993, we have done the billing internally through our affiliation with an office in Orchard Lake, Michigan. Our computer services have changed several times over the years, but the system has remained stable. This all changed in July.
We have switched to using an outside billing service. From a business standpoint, there are good points and bad points of the switch. From the patients point of view, it should make very little difference after the initial change.
In order to simplify the transition, most small balances have been written off. This is a loss of revenue, but it allows only one set of bills to be sent from the new service. Larger outstanding balances will be pursued by a collection service to expedite the transition. In these economic times, we are very understanding of financial hardship. We will continue to work with patients with financial problems, but patients must keep in touch.
I ask for your patience during the next few months. I'm sure there will be billing mistakes on our end during the fall. It should get better as our new system is installed.
September 6, 2011
Barefoot running has become popular over the last few years. Many manufacturers are now making shoes that simulate barefoot running. They allow the toes to separate almost as a glove does for the fingers. They are very flexible and allow the foot to mold more to the ground. Like anything, there are good points and bad points.
1. The foot becomes a better adaptor. It can adapt to uneven surfaces better than a normal shoe.
2. The intrinsic muscles of the foot function better. All the small muscles of the foot can be active allowing less stress on the muscles above the ankle.
3. Better sensory awareness.. The foot will be able to feel the ground allowing the body to process the position on the foot better.
1. Poor shock absorbancy. Barefoot running is great on soft surfaces, not on concrete. There will be added shock to the ball of the foot that can lead to stress fractures.
2. Increased motion to joints. Joints are not as well protected and will increase sprains and strains.
The bottom line is to try it. Get a pair of the new shoes and give it a try. It will probably be a fad that goes away, but give it a whirl. If it makes people run more, I am all for it.
August 30, 2011
There was just a study released concerning flip flops. It shows that chronic use of flip flops can lead to back, hip and knee pain in long term term use. No kidding.
Flip flops are completely flat and provide no arch support at all. In addition, they are held on only by the toes. This makes all the tendons of the front of the foot work harder leading to tendinitis of the anterior muscle group. The rest of the tendons much work harder to support the arch all leading to one thing. PAIN.
Sport sandals or Birkenstock type sandals are not perfect. A lace up athletic shoe is much better for supporting the foot. The sandal at least has some arch support and is held on the foot by a heel cup and forefoot strap.
I always recommend wearing supportive lace up shoes when possible. On those 100 degree days, please try a sports sandal. There is more cushioning and some arch support. Your body will notice the difference.
August 23, 2011
Many physicians are changing their insurance policies in the individual offices. As the Health Care Reform Act may lead to drastic cuts in reimbursement, each doctor must decide on a course of action. Washington is threatening 20 percent pay cuts, which would destroy a small practice like Midland Family Footcare.
Presently, Midland Family Footcare tries to accept most insurances. We participate with Medicare assignment. We are preferred providers for Blue Care./Blue Shield traditional, PPO, HMO, and senior HMO. Almost all plans force us to accept the recommended amount for a procedure. This keeps the patients resonsibility fairly low with most insurance plans. The Health Reform Act may change all this.
If the 20% pay reduction is a reality, Midland Family Footcare would need to stop accepting the recommended amounts as full payment. We would set a charge, accept the insurance payment, and then pass the additional amount to the patient. Many practices are doing this right now, but we have always tried to participate with insurances.
This policy is in no way active. Just thought I would put it out there in light of the economic problems in Washington.
August 18, 2011
The podiatric injury bug has bitten again in the NFL. This time it is the Lions that take the blow. All the experts are picking a big improvement year and I can actually envision a 9-7 season for the silver and blue. This is not the way to start training camp.
Mikel Leshoure, the 2nd round runningback from University of Illinois, ruptured his left achilles tendon during training camp. Leshoure was supposed to give some downhill running to complement the speed of Jahvid Best. This hope ended quickly.
A torn achilled tendon is a serious injury for anyone but especially problematic for a runningback. This achilles tendon is the rope that you can feel behind the ankle. It allows the foot to go downward against the ground is reponsible for pushing off the ground and jumping. It is made up of many fibers and can tear partially or completely.
A total rupture will leave a fatty area between the tendon and will be able to feel the defect. The person will come in the office unable to bear weight with the foot hanging down. They will usually describe a sensation like hitting hit be a baseball bat. A partial tear will be painful but not completely limit use of the foot and ankle.
A professional athlete will require the tendon surgically fixed as soon as possible. The surgery has improved over the last few years with the invention of better anchor systems and reinforcement materials. However, there is a fairly high incidence of rerupture in athletes.
Goof luck to Mikel in his recovery. The Lions need you badly next season.
August 2, 2011
It has been a hot summer. Most of the days are over 85 degrees with a stretch last week close to 100 degrees. In the office, this kind of weather causes swelling at a rapid rate.
The summer months brings out swelling to patient's legs at an alarming rate. Some of this is caused by the increased stress on the heart and the kidneys in the warm weather. Some is caused by people sitting more in the oppressive heat. Swelling in the legs can be avoided.
1. Keep hydrated- Drink enough water to replenish the water loss
2. Elevate the legs- Keep the feet up to allow gravity to get the fluid back to the heart
3. Compression stockings- These are now available over the counter and are effective. Try 20-30 mm Hg below knee type
Good luck this summer. Swelling can be a sign of more serious problems and continued swelling should be evaluated by a family physician. General swelling can cause sore to the legs and tired legs and feet.
July 19, 2011
Did everyone watch the Women's World Cup Soccer? It was a great final game even though the US team had every chance to win the game before penalty kicks. Did everyone notice the podiatric problem that happened in the first few minutes of the game.
On the very first scoring chance for the US in the first few minutes of the game, Lauren Cheney got hurt. She was rushing to goal from the left wing and a defender rolled her ankle on the way to goal. Cheney played the first half but the never had the same pace for the next 40 minutes. She came out at halftime with a bag of ice on her ankle and unable to play. What happened?
The television replay suggest a typical inversion sprain. The ankle bent inward as it was hit by the defender. The anterior fibular ligament gets stretched and starts to swell and become painful. She probably had the ankle taped or supported, so there was enough support to keep playing the rest of the half. At halftime, trainers probably examined the ankle, removing the compression and support. Once this happens, the pressure is released and the ankle becomes more swollen and much more painful.
Again, this is speculation from watching on my couch on ESPN. Players are risking their career by playing hurt, but Cheney's only chance to return to the field would have been to keep the ankle compressed at halftime. Allowing a fit substitute to enter the game was the right move, but this must have been crushing for Lauren Cheney. The Women's World Cup only happens once every four years.
Thank you US Women's Soccer Team for a great 3 week run. CONGRATULATIONS JAPAN.
July 12, 2011
Yao Ming has retired from the NBA largely due to foot injured. Yao's career only lasted 8 years and he missed over half of his games in the last 3 years. Yao was the centerpiece to the Beijing Olympics and is largely responsible for global growth of basketball in China. What happened?
The easy answer is that his foot structure could not absorb the force of a basketball career. Ming suffered from stress fractures to his feet. A 7 foot 5 inch basketball player puts tremendous froce along the ball of the foot especially if he has a high arched foot (pes cavus). The force must have just been too much.
Orthotics prophylactically might have helped originally. A flexible device with a large metatarsal raise could reduced the force to the ball of the foot. Once the fracture occurred, surgery with a 4 hole plate and bone stimulator might have been the best bet.
All this is mute. Yao Ming will go down as a potential hall of fame player that career was shortened by injury. Bill Walton and Sam Bowie were two other big men that suffered the same fate. What a shame.
July 5, 2011
The economy has caused many people to go without health insurance. There is a fairly substantial percentage of the population that is under insured or totally without health care coverage. Now, before I get political and into the quandary of National Health Care, let me relay a story.
I have a patient present to my office with an infected right foot. The patient is diabetic and has diabetic neuropathy (loss of feeling) and stepped on a piece of wood a few weeks ago. He went to the Emergency Room, which was the right thing to do, and they x-rayed the foot, and sent him home with antibiotics. The foot was not cultured, opened surgically, set up for IV antibiotics, etc... A day later, the gentleman's foot has an odor that I can smell from the waiting room.
How can this happen? I was very confused as to the reason that the hospital ER sent this patient home. Did the foot get worse in the last 24 hours. Was there no abscess 24 hours ago? Did they think it was a gout attack? Then the reason became clear. He had no hospitalization insurance.
I performed and incision and drainage in the office of his right foot, did a culture, changed the antibiotics, and prayed a lot. His foot has progressed well, but he was very lucky. This could have led to amputation and permanent disability. This patient works 40 hours a week, but needs to rely on a Medicaid Plan for his health care needs. The Plan let him down.
What is wrong with this situation? First, the hospital will go bankrupt if it accepts all patients with this problem. The bill if they admitted him would have been at least $20,000. It would take a long time for this patient to pay this bill. Second, the health care plan cannot be blamed since this is the arrangement it has with the sources that fund the program. Third, I was put between a rock and a hard place. My office treatment was not optimal and certainly could be ripped apart by a good malpractice attorney. I recommended that the patient be admitted under my care but allowed him to be treated as an outpatient.
This is just a microcosm of the problem. What is the solution? I'm not sure. I am sure that in 2011 , in the United States, this should not happen.
Electronic medical records (EMR) are real buzz words around the medical community. Mid-Michigan Hospital has recently integrated a new system for all their hospitals. President Obama has made this a key part of the health care reform act. The US Government is offering incentives to doctors to integrate an EMR/EHR system. Just what is it?
EMR is just a computer program and system to allow all items that used to be in patients chart to be on the computer. All patient information, medications, allergies, chart notes, lab reports, etc would be accessed by anyone in the computer network at anytime. This eliminates the majority of paper that is needed for a present day chart. The program also provides information to help the medical staff such as medication interactions, specific diagnoses for each problem, etc... On a whole, the EMR is a wonderful thing. However, there are drawbacks.
The best part of an EMR system is that all practitioners can have immediate access to all the information for a patient. It allows seeing all reports in the system at once and can pick pieces of information out easily to compare. There will be no more waiting for medical records to deliver the chart to the right department. EMR will also save money by eliminating the paper, and the need for copying documents. I also have no doubt that care will be improved as communication between doctors is much easier with an EMR system.
The downside is mainly the cost of the system. Hospitals will spend millions of dollars just on the computers and software packages. Scanning the paper documents into the new system is also expensive and time consuming. There is also a huge learning curve for the medical staff to use the system. It will temporarily slow down care and staff may become more concerned with pleasing the EMR than treating the patients.
The cost of a system for a small office such as Midland Family Footcare is about $30K. I am looking into a web based system that is much less expensive, but has it pitfalls as well. Practice fusion (www.practice fusion.com) looks like an intersting alternative to $30K price tag.
EMR is a necessary step for our health care system. Everything is going digital, so must health care. Just remember to make sure that your information is secure. Identity theft is huge. Also, for the medical people, it is a small step backwards at first to allow a leap forward.
One more thing. Malpractice lawyers are going to love the EMR systems. I will cover the law thing at another time.
June 21, 2011
I forget just how pretty Midland is this time of year. I had a few extra minutes last week and went to Pizza Sam's for lunch. The food is pretty good but the outside eating is priceless. As I am eating my turkey sub, yes I am trying to lose weight, I look down Main Street and see such a quaint little picture. People are out for lunch. Mothers are yelling at their kids. Teenagers are riding their bikes too quickly down the street. It was wonderful.
I need to take more opportunities to enjoy the downtown area. The Dow Diamond is right down ther block. Outdoor eating gives a taste of spring before the warm weather sets in. Check it out.
June 7, 2011
The internet has changed medicine and podiatry forever. Patients have a vast array of knowledge at their disposal 24 hours a day. Not very long ago, people would have a Merck Manual and then have to go to the library to look up a certain condition. Now, hundreds of websites can provide information and even point patients to a diagnosis based on their symptoms. Many of my patients have self diagnosed themselves before coming to the office and are usually correct. There is a downside.
The websites are not always correct. First, there is a lot of misinformation on the World Wide Web. No one is policing the information to fact check everything. Second, the websites only go by symptoms that you respond to. Patient complaints are a unreliable method of leading to the right diagnosis. Third, no testing is available so nothing can be confirmed or ruled out.
I love the internet in general. It is a great resource for general information. You can even watch videos and learn about an upcoming procedure. It can be a scary thing for medicine at times. Symptoms can point to life threatening illnesses when the correct diagnosis is something benign. Learn about the problem but see a heath professional for the diagnosis and treatment.
As an aside, YouTube has a great collection of Podiatric procedures to view for the interested patient. A word of warning. They are surgical procedures that are not edited for the average patient. Lots of blood!!!! Dr. Patrick DeHeer, a classmate of mine from Indianapolis, has done a great job posting videos.
May 31, 2011
Warm weather has finally reached Mid-Michigan. Everyone is going to start heading to the beaches, lakes, and ballparks in the community. We have a very short window for nice weather, so take it easy and remember a few things.
Podiatry tips mainly deal with shoegear, Please wear sandals or beach shoes around the water areas. I get to take wood, glass, shells, and garbage out the foot for the next few months. I just took a sewing needle out the foot as the person was not wearing shoes. Our sandy and rocky areas are prone to all kinds of foreign bodies. JUST WEAR FOOTWEAR.
In general, the hot weather requires more water. Dehydration can lead to major illnesses and death. Sweating in the sun requires consistent water intake. Keep a bottle of water handy and get some shade during the middle of the day. Remember, if you stop sweating, be aware that you may be dehydrated. Alos, alcohol and caffeine increase dehydration. They are diuretics and are no substitute for a bottle of water.
Have a great summer, but be careful and smart.
May 24, 2011
Sometimes conditions are presented in the office that cannot be addressed in the community setting. Midland is a community of 40,000 people with a regional medical center that can service most illnesses. Every once in awhile, patients require being sent to a tertiary care hospital. How does this work, and when is it necessary.
New procedures are an obvious example. New, high risk procedures are usually first available at University Hospitals or major national medical centers. It is a teaching situation, and a larger setting can afford the risk to develop the procedure. The best example in my practice is Ankle Implants. This a replacement surgery for the ankle. Presently, 4 types of implants are available in the United States, but trying to find a surgeon who perform them is difficult. My patient may have to go to Mayo Clinic, Cleveland Clinic, or Duke University to find a specialist. I would arrange the consultation even thousands of miles away.
Another example is rare diseases. Sometimes a patient is referred for diagnosis purposes or treatment of a rare illness. I had a patient with dramatic neurological problems that were progressing and it required a consult to the University of Michigan for an accurate diagnosis.
The point is that help is available. Finding the place for the help may be outside of the community.
May 10, 2011
I am now a fellow of the American College of Lower Extremities Surgeons (ACLES). This is just one more designation to put after my DPM degree. Now I can put down things like "Board Certified by the American Board of Podiatric Surgery", " Fellow of the ACLES", "Attending Podiatrist at Mid-Michigan Hospital and Genesys Regional Medical Center", etc.. on my CV (Drs. resume). All this shows basically nothing.
While these designations are nice for my ego, they do not indicate my level of competence as a Podiatric physician. The doctors with the most impressive credentials are in academia, which does not lend to clinical excellence. The public should be aware of credentials, most importantly a state license and any sanctions against that licensure. This can be evaulated easily through the State's website. Personal recommendations and physician referrals are a better way to pick a doctor than the number of initials after the name.
In truth, picking a doctor is a crap shoot. Find a doctor that you can work with and trust. I can name several Podiatric physicians who have wonderful credentials, but who I would not let touch my foot.
April 26, 2011
I will be closed Friday, April 29th to attend a Podiatry conference in Livonia. Podiatrist in Michigan must earn 150 credits every three years to qualify for a license. These are termed Continuing Medical Education (CME) credits and they are manditory in most states. It sounds like a reasonable idea, but is it?
First, the conferences get old. I have seen the same lectures on the same subjects over and over again. Much of the material is interesting but has little relevance to my practice. Many of the topics are esoteric and give the lecturer a chance to impress us with their knowledge. For example, wound care is a big topic. Instead of spending time talking about patient care, the biochemistry of the product is discussed. WHO CARES?
Second, the medical climate is not great. The conferences cost hundreds to thousands of dollars. Closing the office also loses the office money and patients. I am lucky that the conference is relatively local, but other conferences require hotels and travel expenses. In present economic times, that is not smart.
Third, online courses are good enough for colleges and MD/DO programs. Podiatrists are only allowed a very small amount of online credits. Why?? Online programs make a lot of sense with the technology available. They are interactive and could require a brief quiz after a topic. There is no travel cost or time off from work.
Just food for thought as I ponder another year at the Livonia Marriot.
April 11, 2011
Board certification is an entity that most people outside of the medical community have no idea of its meaning. Doctors always use the term "board certified". What is it?
A board is an organization that certifies that a doctor has met the qualifications for a specific specialty. The qualifications are usually passing an exam in the specialty and practicing for a certain length of time. Podiatry has a variety of different boards just to confuse the issue.
Podiatry has surgical boards, sports medicine boards, wound care boards, primary podiatry and orthopedic boards and probably some that I do not know about. Remember, being board certified has nothing to do with the outcome of procedures. It is just one more set of conditions for the doctor to meet.
I am presently board certified in Podiatric Surgery by the American Board of Podiatric Surgery. This is the most widely recognized board for this certification. I needed to submit cases, pass a written and an oral exam. Does it make me a better surgeon? NO!!
The weather is finally changing here in Mid Michigan. Pretty soon, people will start with being more active and participating in recreational activities. I thought I would lend a few tips so people do need to see me in the office and/or emergency room.
1. Start slow. Most of us have been pretty sedentary all winter. Just because you were running 3 miles last October doesn't mean that you start out with 3 miles.
2. Stretch and stretch some more. Muscle pull and strains can be avoided by warming and stretching the muscles. Stretch before and after exercise/
3..Check your footwear. Maybe it is time for a new pair of shoes, cleats, boots, etc...
4. You are not 18 anymore. The body gets stiffer and less repairable as one gets older. You might not be able to score on a single from second in the local softball game. DO NOT TRY.
I hope this helps. Go out and play.
March 29, 2011
Why am I not a member of the Michigan Podiatric Medicine Association? Patients ask this question occasionally and I never really give them a good answer. I have finally decided to come somewhat clean.
I used to be a member when I first went into practice in the early 1990's I felt that a professional organization gave a voice to podiatry in the state. Podiatry is a small piece of the entire medical community. It is equivalent of the American Medical Association for allopathic physicians. I quickly became disillusioned with its purpose and continue to object to many of its purposes.
My biggest objection to the MPMA is with its leadership. The same small group of Podiatrists control the entire show. While this is true of many local organizations, the MPMA use their titles to promote themselves. The leadership become auditors for the insurance companies while actively participating with the MPMA. A conflict of interest? YOU BET!
How can an organization try to negotiate with the insurance companies when they work for the company? They cannot. The biggest joke is in the following example. A high ranking MPMA official also is an auditor for Blue Cross/ Blue Shield of Michigan (BCBSM). A friend of mine is having issues with BCBS over certain billing practices. The same high ranking official also runs a consulting business to aid in audits of this kind. My friend hires this MPMA official to consult and guess what happens? You guessed it. The problem went away.
Coincidence, maybe? Probably not. Let's face it. There are a limited number of auditors for Podiatry and they all know each other. You do the math.
Certainly, my allegations are not fact. They are observations for 20 years of practicing in Michigan. I will continue to discuss the problems with the MPMA periodically. Stay tuned.
Is everyone watching the NCAA Basketball Tournament? Foot injuries is again in the news. Kyrie Inving, a guard for the Duke Blue Devils, has returned to basketball after being out since December. He is one of the best prospects in college basketball as a freshman and can be a lottery pick this year for the NBA this year. His injury was a dislocated great toe.
A dislocated great toe is a very difficult injury for a athlete. The great toe allows lift off of the foot and is extremely important in jumping and running. Unlike a lesser toe, the great toe is held in place my a series of sesamoidal ligaments beneath the toe joint that make it more stable. This is the reason why it is a rare injury but harder to heal.
The treatment is to put it back in place and then rest and rehab the toe. CBS showed a whole clip of the swimming pool exercises that Kyrie endured for is toe. Once again, feet are very important.
March 15, 2011
Medicaid is back for Podiatry. All of the Michigan Medicaid plans are now covering foot care by podiatrists in the state. This is wonderful for patients on Medicaid plans, but what about the doctor.
Medicaid patients represent about 15-20% of my practice but only 5% of the income. This is due to the low reimbursement rates on these plans. They generally pay less than 50% of a medicare rate for a procedure. Most physicians in Midland DO NOT accept medicaid plans. Economically, it does not make a lot of sense to welcome back these patients. Midland Family Footcare has never been about the economics.
I accept Medicaid patients since they need care. People that have financial problems still have foot problems and should be provided quality care. Medicine should never be guided by the type of insurance that a patient presents to the office. We also treat cash patients the same as private insurance patients.
The problem is perception. The community sometimes equates taking medicaid as an inferior doctor or an office that is struggling. Midland Family Footcare has been in Midland since 1994 and I have been part of the practice since 1996. We take Medicaid due to a community need for foot care. We are a practice with a social conscience.
A personal annoyance is certain family physicians. I have some family physicians that will refer Medicaid patients since I accept the insurance, but reserve other referrals for other Podiatrists in town. I should be rewarded for accepting low reimbursement plans not penalized. My social responsibility should be a drawing point to the practice and not a detriment.
March 8, 2011
Prescription drug addiction has become rampant over the last 10 years. High profile cases such as Brett Favre and Heath Ledger have brought some attention to the problem but not enough. It is becoming epidemic even in Midland.
Addiction to Vicodin, oxycotin, percocet, lortab, etc.. has become problematic in my practice. I use these narcotic medications after surgeries and for patients who has sustained traumatic injuries. I find myself looking for alternative motives in many patients. Over the years, I have patients that have received narcotic pain medicine only to find out they were an addict.
Why is this a severe problem in the U.S.? First, it is cheap!!!! Many patients have prescription plans that cover narcotics so it basically costs the co-pay. Even paying cash for a vicodin prescription is relatively cheap compared to drugs such as cocaine. Second, it is easy to get. There are so many doctors and so many ailments that patients can con physicians easily. They are also accessible online through internet pharmacies.
I have tried to be very cautious when prescribing narcotics. I monitor the usage closely and change patients to non-narcotic medications quickly after surgeries. I consult with pharmacies to check other prescriptions that the patient may have filled. Even with my diligence, I'm sure I get taken on a monthly basis. It is just sad.
March 4, 2011
Stress fractures are in the news now that basketball is moving to center stage. Yow Ming is the most famous victim of big men getting stress fractures, but this ailment can ruin many careers and occur in non athletes as well.
A stress fracture is a partial fracture that does not go all the way through the bone. Think of a stick being partially cracked. The most common area is the metatarsal area of the foot but is also common in the heel. All of a sudden there will be swelling and pain in area that had no injury. It is caused by overuse and additional stress to the bone.
X-rays will show a small fluffy reaction at the site but usually does not become visible for weeks after the injury. Even a CT scan and MRI can miss the stress fracture at first. A bone scan will show the area quickly but can be misleading.
In most cases, rest and immobization will heal the area in several weeks. In professional athletes, this is a much bigger problem. The sport requires severe continual stress to the feet. Imagine the pressure of a 7 foot basketball player jumping 40 inches off the ground. This is why surgery is usually performed to place a screw or plate across the site.
March 1, 2011
Patients are asking about health care changes under the new healthcare bill. The healthcare reform act by congress is being phased in over a long period of time. There will eventually be a better funding and expansion of the Medicaid program for lower income families. There will be an elimination of pre-existing conditions clauses from health care policies. From the practitioners standpoint, not a whole lot has changed.
Every year, reimbursements change for different procedures. Certain procedure codes are altered or modified every year. This year is no different. The biggest change is the amount of paperwork required for diabetic shoes to be covered by medicare. It is almost a joke.
Medicare patients need to remember that the first $160.00 must be paid by the patient or a secondary insurance. This is why patients seen in January may receive a most larger bill than other times in the year. Alos, Medicare covers 80% of most procedures leading to a 20% co-pay. We are required by law to persue the 20%. It also allows the office to survive.
Patients have told me that there is a lawsuit against Sketchers concerning the claim that it will make you lose weight and increase the shape of the rear end. The Sketchers in question are an athletic shoe with an accentuated rocker bottom sole.
The rocker bottom sole is nothing new. Rockport has been using it for years to decrease the amount of heel strike and propulse the foot forward faster. Sketcher just made the process more pronounced. The heel is higher shifting the weight forward to quicken easy take off to the forefoot. There would be decreased need for power in the calf muscles and I suppose an increased need for the gluteal (rear end) muscles to become stro nger. The losing weight makes no sense. The increased energy involves is so small that the claim seems just silly.
Once again, beware of advertising claims. The Sketcher is not a bad shoe. It is the same idea as the spring heel shoe. The advertising is at best MISLEADING.
February 16, 2011
There is finally a thaw in the weather. The snow is melting and spring seems to be coming soon. People are going to begin activities and hurt themselves very soon.
It is dangerous to start exercising too quickly and for too long at first. Besides heart problems that can cause pain and death, the body needs time to get used to increased activity. Many bouts of tendonitis and stress fractures can be avoided by building up activity slowly. Start with a walk rather than a run. Start with a mile not 6 miles the first day.
February 9, 2011
I really enjoy talking about sports injuries since they get so much attention in the news and in the sports pages. The most recent is Maurkice Pouncey of the Pittsburgh Steelers. He suffered a "high ankle sprain" against the Jets and was unable to play in the Super Bowl.
A high ankle sprain is actually a separation of the two leg bones above the ankle (tibia and fibula). A normal ankle sprain involves the ligaments at the outside of the ankle and usually has a much quicker recovery time. A high ankle sprain involves the syndesmosis (a group of fibrous tissue) between the bones that gets torn. This can actually lead to a separation of the joint itself and sometimes need a screw to be placed across the bone horizontally.
This type of injury is usually a 4-6 week recovery time with casting and physical therapy. It was no surprise that Pouncey did not play 2 weeks after the injury.
February 8, 2011
Many patient are asking about the Dr. Scholl Custom Orthotic. The idea is that it scans the foot and does a pressure map of your foot after you answer questions Their software then selects the right insole for the patient. This is a big advancement in the over the counter orthotic business but NOT custom.
Custom orthotics mean that the actual device is custom made to the patient's foot. It can be digitally scanned or molded to achieve a model of the foot. The Dr. Scholl device merely points the patient in the right direction for the choice of about 5 different insoles. It is an interesting learning tool to find out where excess pressure lies in the foot.
Many patients will respond well to an over the counter device but it will not take the place of a custom device. Most custom devices are made of polypropylene or graphite and ensures the shape of the orthotic will not change. The over the counter devices will gradually flatten and wear out in 6 months.
The problem with new technology is that not every method or new product passes the "test of time" test. There are always new products and new procedures being tried in the United States. In podiatry, many new techniques are put forth by the manufacturer. By promoting the procedure, the company stands to make huge profits. The problem is that the procedures turns out to be problematic.
The most recent example is the "tightrope" procedure. This product was meant to be used for high ankle sprains, but suddenly it is being promoted for all bunionectomies. Their own lecturer acknowledged that he came up with this on a whim for a special patient. The manufacturer runs with it and suddenly everyone is using them for bunionectomies. The problem is they did not work.
The idea is to tie the first two metatarsals together permanently to push the first bone in. How can this possibly last?
My advise to patients is to research any new procedures themselves or have their doctor provide information concerning the procedure. Knowledge is a wonderful thing.
January 25, 2011
I am beginning my blog to inform and discuss my practice and the health care world. Things have already changed for 2011. First, podiatry is again covered by Michigan Medicaid. We are beginning to welcome back patients that desperately need care and were neglected by the public aid system for over a year. Hopefully, this gets funded beyond October 2011.
The other side of the coin is Medicare. Medicare has instituted new guidelines for diabetic shoes that make the paperwork much more difficult for the office. We now need to obtain chart notes concerning the patient's diabetic care for the last 6 months along with a host of information for shoe coverage. We continue to bill shoes but please be patient. MISTAKES WILL HAPPEN.
Medicare has eliminated certain procedures as well from coverage under the plan. Certain patients will now be charged cash for certain procedures. Remember, this is not our policy change, it is Medicare policy.
Each year is a change. Since 1996, when I became part of Midland Family Footcare. , the Medical climate has changed for both Midland and the country. Medicare funding is a national problem. We will continue to try to provide quality foot care at a reasonable cost to you and your insurance company. Our office is more cost effective than other specialists and certainly the emergency room.
One of the biggest problems in our office is informing the public of all the services that we provide. Podiatry has done a poor job informing the public of its role in the health care system. Everyday, a patient says "I didn't know you did that".
Podiatrists treat every age group and just about every illness with the foot and ankle. We are part dermatologists, part orthopedists, and part biomechanics experts. We perform nail care to ankle surgery. The whole idea of the website is to try to publicize the broad scope of treatments at Midland Family Footcare.
The snow is supposedly coming. They started with 8-12 inches and the world is coming to an end. Now, 2-4 inches and a little wind. What is the deal?
The winter presents problems for footware. People should change from their boots to normal shoes when indoors. Boots tend not to be as supportive, especially waterproof winter boots, and can lead to tendonitis and plantar fasciitis. Just bring nice clean shoes with you to work and it will eliminate many problems.
Frostbite is a distinct problem with the winter. Exposed toe can freeze within minutes. Feet should be kept warm and dry. Water accelerates frostbite dramatically.
February 1, 2011
The storm is actually going to happen. The office will be closed Wednesday 2/2/11 due to the winter storm. Patients will be scheduled to Friday and today. It will be a good day to curl up with a good book and look at a fire. Winter is not so bad.
The question always comes up in the office as to why I use Mid Michigan Clare as my primary hospital. I also perform surgery at Genesys Health Park and the Surgery Center at Genesys Health Park, but Clare represents about 90% of my hospital cases. The answer I always give is that Mid Michigan Clare provides me block time on Friday mornings which makes scheduling cases easier. While that is entirely true, it is not the full story.
Mid Michigan Hospital Group runs three hospital centers which operate somewhat independently. Mid Michigan-Clare welcomed me with open arms about 7 years ago. They have improved their podiatric equipment, built a new surgical suite some 2 years ago and have been a joy to work with. Mid Michigan-Midland is a different story.
The Midland branch welcomes my lab work, nuclear medicine cases, CT scans, MRI, doppler exams , etc... but has always found a way to keep me off staff. The bylaws for the podiatric staff require a 3 year residency. When I graduated Podiatry School in 1990, there were only 3 three year residencies in the country. There is also a requirement of a letter of recommendation that must be obtained from a member of the podiatry staff. Think about this. A letter must be obtained from the people preventing you from getting on staff. AN UTTER JOKE!!!
I have offered letters of recommendation from a host of medical professionals on staff. I have offered to only have surgical privileges and no inpatient duties but again was told NO. Except for not wanting competition for the podiatry group on staff, there is no good reason for this action. In fairness, podiatrists are not the only specialty that finds it impossible to break the closed medical staff.