Clinical Presentation Skills: Owning and Operating a Successful Private Practice in Today’s Healthcare Climate

By: Daniel T. Hall IV, DPM

With the ever-mounting changes in healthcare and how physicians practice, I wanted to share my experience as a young owner of a private practice. While this may seem like a distant goal, you may be contemplating this type of practice structure. In today’s day to day work environment, it is imperative to know the obstacles you may face. The number of today’s solo practitioners are dwindling in favor of hospital-based employment, multi-specialty groups and/or larger podiatry groups. This could be due to the vast amount of responsibility put upon the doctor. Choosing your electronic medical record subscription, obtaining insurance prior authorizations before office and hospital procedures, navigating treatments around high patient deductibles, and increased in-office overhead expenses could all become daunting tasks. It is no wonder we are seeing reports of physician burn-out at an all-time high. So how does one successfully manage all of these variables and still provide the highest quality of medical care to our patients as a solo practitioner? The answer is simple. Evolve.

Let me explain a bit further. As my father used to tell me, “You can’t know where you are going, until you know where you have been.” As with any practitioner who is seeking advice on how to successfully own a private practice, I always begin with a few questions.

1. How are you generating new patient referrals? Furthermore, how are you keeping your current referring physicians?

There has never been a more competitive time to practice medicine, most notably as a specialist such as podiatry. And many other fields, namely family medicine and internal medicine are feeling a similar burden. The number of hospital-based physician employees and hospital-owned practices are at an all-time high. As a result, some of our best referral sources eventually may no longer be sending us patients if a podiatrist is employed within the same healthcare system. Nurturing referral sources is an important aspect of private practice.

2. Do you have a strong online web presence with positive physician reviews?

Let me give you an example. You are traveling to New Orleans for a conference and a friend recommends a great restaurant in the French Quarter. How many of us are going to search that restaurant on our phones or tablet before making a reservation? Nearly all of us. What if the restaurant had several bad reviews? Would we still go? Some of us probably would not despite our friend’s glowing recommendation. And today’s healthcare climate is no different. In fact, according to Practice Builders, nearly 80% of patients will change their mind about a medical practice after reading a bad review. Patients today are having to pay more money out of pocket for their medical treatment as deductibles rise. It is understandable for patients to be more selective with their physicians moving forward.

3. Do you have active social media engagement (i.e. Facebook, Instagram, Twitter) that is highlighting the strengths of your practice?

The internet has changed the way we all experience healthcare both as physicians and patients. We must evolve and adapt to keep pace with the current digital world. Without a strong online web presence, your practice is going to suffer the consequences. Being active in social media will strengthen the presence of your practice.

4. What criteria are you using to hire your staff, and how are they trained?

“Behind every great physician, there is a great staff.” How is your office staff greeting patients? How are they handling uncomfortable patient situations? Are they courteous and empathetic? Is your software “staff-friendly” regarding scheduling appointments and handling balances?

These are all important questions that every solo practitioner and their staff should be able to answer. Attending podiatry conferences and utilizing the multitude of online resources available will help one stay abreast to the changes that directly affect the practicing podiatrist. The American Board of Podiatric Medicine also serves as a excellent resource and offers access to a vast network of board certified podiatrists that are dedicated to uplifting our profession and offering guidance for private practitioners.

 

ABPM Directors Inducted into the Royal College of Physicians and Surgeons of Glasgow

(L-R) Drs. Lee Rogers, W.E. Chagares, Gina Painter and Jim Stavosky

(L-R) Drs. Lee Rogers, W.E. Chagares, Gina Painter and Jim Stavosky

American Board of Podiatric Medicine Directors, Drs. W.E. Chagares, Gina Painter and James Stavosky, were inducted into the Royal College of Physicians and Surgeons of Glasgow (RCPSG) in a ceremony on November 22, 2018. Also in attendance were Drs. Matt Garoufalis and Lee Rogers, both currently Fellow Faculty in Podiatric Medicine of the Royal College which sponsored the new inductees.

The RCPSG was founded in 1599 by surgeon Peter Lowe, and its membership has contained notable figures in the history of medicine, such as Joseph Lister who first described the principles of aseptic surgery 150 years ago.

Source: PM News, Online

ABPM Director Advocates for Podiatry Specialty in Romania

Stefan Minovici (CEO of the Romanian American Business Council), Dr. Andrew Pavelescu, Daniel Kline, and Dr. Lee Rogers, November 5, 2018.

Stefan Minovici (CEO of the Romanian American Business Council), Dr. Andrew Pavelescu, Daniel Kline, and Dr. Lee Rogers

November 5, 2018 – Dr. Lee Rogers, ABPM Director and Chair of the CAQ in Amputation Prevention and Wound Care Sub-Committee, spoke at the United Nations Millennium Hilton for the Romanian American Business Council about the wave of diabetes and amputations in Romania and the need to establish the specialty of podiatry to address this growing problem.  He cited American data on the success of podiatrists and teams in preventing limb losses and reducing costs in diabetes.

The audience consisted of the Romanian Secretary of State, Minister of Health, Ambassador to the UN, Ambassador to the US, and other government and healthcare leaders from Romania.  US Surgeon General Dr. Jerome Adams also spoke to the Council.

ABPM Board of Directors Announces Additional Pathway for Certificate of Added Qualification in Amputation Prevention and Wound Care!

The American Board of Podiatric Medicine has announced a third pathway for its diplomates to achieve a Certificate of Added Qualification (CAQ) in Amputation Prevention and Wound Care.  Now ABPM diplomates who have an office-based practice can be eligible to sit for the CAQ exam by submitting 10 wound care cases for review by the committee.  Previously, the only way to be eligible to sit for the CAQ exam was to either have completed a CPME-approved fellowship in limb salvage or wound care, or have documented 1000 hours of wound care experience in a hospital setting.

Lee Rogers, DPM and Chair of the CAQ Sub-Committee, stated “This new pathway gives ABPM Diplomates the opportunity to demonstrate their limb salvage and wound care knowledge by obtaining a CAQ”.

Diplomates should be mindful of specific deadlines associated with the third pathway.  To allow for the full case submission process, those diplomates interested in testing in this cycle using the case review pathway should submit their applications and cases no later than November 20, 2018. For those not submitting cases, the application deadline is December 14, 2018. 

For more information regarding the ABPM CAQ in Wound Care and for all deadlines, examination dates and applications, please visit https://www.abpmed.org/pages/exam-info/caq-amputation-prevention.

Note: The CAQ in amputation prevention and wound care is issued solely by the ABPM to its diplomates.  The Joint Committee on Recognition of Specialty Boards (JCRSB) of the Council on Podiatric Medical Education recognizes the certification process of the ABPM but has not developed a recognition process for certificates of added qualification.  Therefore, at this time the ABPM’s recognition by the JCRSB does not extend specifically to the CAQ

The American Board of Podiatric Medicine (ABPM) offers a comprehensive board qualification and certification process in podiatric medicine and orthopedics. Increasingly hospitals, surgical centers, managed care organizations and insurance carriers require board certification. ABPM is the only board recognized by the Joint Committee on the Recognition of Specialty Boards, under the authority of the American Podiatric Medical Association to certify in podiatric orthopedics and primary podiatric medicine.

ABPM Diplomate, Dr. Stephanie Hook, Elected to the NYSPMA Board of Trustees

Stephanie Hook, DPM

Stephanie Hook, DPM

“I have always had a heart for moving our profession forward. Being elected to the NY State Podiatric Medical Association Board of Trustees is a huge honor and opportunity,” said the newly elected Board of Trustees member, Stephanie Hook, DPM.

As a member of the Board, Dr. Hook will help their mission of supporting excellence in the practice of podiatric medicine and surgery by creating awareness of the profession’s role and value.  This includes supporting lobbying efforts for podiatric related bills, particularly those striving for parity in the medical community, and ongoing work to promote public understanding of podiatry, the level of training required, and specific expertise podiatrists can provide in overall health. She will also serve on the Insurance and Legislative Affairs committees and chair the Awards committee.

Dr. Hook has known since she was a teenager that she wanted to be a podiatrist. “I always knew I wanted to be a doctor, but after having a podiatric procedure when I was in high school and in observing what they did and learning about the profession, I knew then and there that I wanted to be a podiatrist. I know that is pretty young, but I just knew.”

She attended the Ohio College of Podiatric Medicine (now called Kent State University College of Podiatric Medicine) and did her residency at Sisters of Charity Hospital/Catholic Health System in Buffalo.  “I picked my residency pretty much based on the informal conversation I had with the residency director at the reception during the more formal interview weekend. I was the only one at the reception, which ended up being a great way for me to learn a lot about the residency led by Dr. Joseph Anian.  “I remember liking what he said both about the program and life outside the residency.”   For Dr. Hook it ended up being “a great experience.”   “We were part of the program for all residents and were not singled out as the ‘podiatry residents,’ which I have heard can sometimes happen at some institutions.”

Both in school and during residency Dr. Hook was involved in the State Associations and advocating for the profession.  “I think achieving parity and continuing to establish standards for all states is an ongoing process,” stated Dr. Hook, “but one that also needs ongoing attention and support.”

Dr. Hook worked in a podiatric practice for eight years before moving to Syracuse Orthopedic Specialists (SOS), an orthopedic practice near her home in Nelson, NY.   “I love my job,” she says.  “This is exactly the kind of practice I wanted to be part of.  It is collaborative, ethical, we provide our patients comprehensive care, and we treat our patients like they are family.  I love that I can refer cases to other in-house orthopedists and vis versa.”  One of the things Dr. Hook loves best is that this practice has opened her up to a variety of different cases ranging from sports medicine to diabetic foot care to being a part of the Acute Limb Salvage team at St. Joseph’s Hospital.  SOS is comprised of 31 orthopedic physicians and podiatrists, Dr. Hook was the first woman to become part of this practice.  “While I am proud to be part of the group, I don’t like to single out the gender piece, because I am just one of the team.”

Dr. Hook explains that her group is very active in the community providing trainers for local high school sporting events and tournaments, participating in local health fairs where she has been able to lecture about foot health, as well as sponsoring several community events and charities. “It was important to me to be part of an active and caring group,” she explains.

Shortly after completing her residency, Dr. Hook became ABPM certified. “I think it is really important that podiatrists get certified as early as possible because patients and practices are looking for that credential,” said Dr. Hook.  “Nearly every day I hear patients say, ‘I looked you up online and saw that you had your board certification, etc.’ – it’s not just a nice-to-have anymore.”  Dr. Hook selected the ABPM certification because she felt it was the most comprehensive. “In my opinion, it is much more well-rounded and demonstrates your understanding of biomechanics, medicine and surgery – not just biomechanics and medicine as it relates to surgery.”

While Dr. Hook sees the future of podiatry as very promising, she says she also knows there are pockets within all healthcare professions where financial gain can compromise integrity and optimum patient care. She wants to remind all those entering the field that if you do what you love (as cliché as it may sound) the financial rewards will be there – and be there honestly.   This is something she is very passionate about.   “Follow your heart, do what you love, and you will end up doing the right thing for yourself, your patients, your family and your lifestyle,” she shared.  “We are lucky to be in a profession where we can make choices about our day and the kind of life we want to lead.”

Dr. Hook enjoys sports, photography, travel and spending time with her husband, stepdaughter, and three dogs.  She is also proud to be a part of the DPM Mentors Network.  Enjoy more about Dr. Hook in one of the Syracuse Orthopedic Specialist videos.

Clinical Presentation Series: Forming a Differential Diagnosis

By: Dr. Nicole DeLauro, Director, ABPM

A healthy 30 year old male presents with right forefoot pain present for two weeks. The patient is an avid runner, and runs approximately 3 to 5 miles a day. He describes the pain as aching and throbbing. The pain continues throughout the day. He does have relief when resting. He has tried to abstain from running and admits to changing his shoes. He has had minimal improvement. He denies any other treatments.

What is your diagnosis?

As physicians we are forced to be investigators. We have to ask the correct questions regarding the complaint, form a diagnosis, and provide a treatment plan. To do this, we need to formulate a “differential diagnosis.”

The differential is a list of potential diagnoses compiled based on the complaint. It is important not only to determine the best treatment plan but also to treat patients in a timely fashion. The differential helps to narrow down more than one probable cause for the patient’s pain. Your differential can be based on the well known acronym, “NLDOCAT.” What is the nature and characteristic of the pain? Is it burning, shooting, aching, dull, etc? This helps you determine if it’s arthritic, neurological, vascular or musculoskeletal in nature. Once we know which system in involved, focus on the location. What structures are in the area? What nerves, tendons, ligaments, bones, and/or joints are located there? Does it radiate to any surrounding area? The duration of the pain helps decipher if it is an acute complaint secondary to potential trauma or chronic in nature. What makes the pain better or worse? Is it aggravated by activity or rest? Better in or out of shoes? Worse at the beginning or end of day? Does shoe gear alleviate or aggravate the pain? What treatments has the patient tried and has there been any improvement?

Once you have the answers to these questions, the differential is easy to devise. This methodical approach will help you avoid pitfalls and provide better care for your patients. Based on this approach, what differentials do you have in mind? You should be thinking about stress vs. occult fractures, bursitis, metatarsalgia, tendonitis, sprain, and even neuroma. The symptoms can also be aggravated by the patient’s foot type, biomechanical gait pattern,  and even improper shoe gear.  Further questioning, clinical examination, and diagnostic studies will help to lessen the amount of differentials and ultimately attain a definitive diagnosis.

As a young physician, you have the tools to alleviate complaints based on your final diagnosis and gain a patient’s trust and confidence in your care. Your patients will have done their own research before they walk through your door, and expect a certain quality of care. In order to constantly exceed these expectations, you must maintain the highest level of expertise and excellence within the profession. Having  a methodological approach towards your evaluations, and being board qualified and/or certified upholds this level, and informs your patients that you have been tested and challenged extensively within your specialty. This message, when conveyed to patients will solidify their confidence in you as their physician and create a lasting doctor-patient relationship.

Meet New ABPM Executive Director, Dr. James Stavosky

James Stavosky, DPM

James Stavosky, DPM

“Enjoy what you do every day. Be quick to listen, and slow to talk and anger.” These are the words that Dr. James Stavosky, the new Executive Director of ABPM, lives by. He enjoys golfing, fly-fishing and playing tennis with his two sons and his wife (who he refers to as his best friend.) Another thing Dr. Stavosky enjoys? His career in podiatry.

In his 35 years of experience in podiatry, Dr. Stavosky has built an impressive career focusing on wound care. Besides running his own private practice in Daly City, California, he is also the Chief of Podiatric Surgery at Seton Medical Center, the Medical Director of Wound Care at Seton Medical Center, and a Professor of Podiatric Medicine at California School of Podiatric Medicine.

How he found podiatry and how his career took surprising turns

Dr. Stavosky didn’t always know he was destined for a thriving career in wound care. He was first introduced to podiatry during graduate school at The University of the Pacific, where he worked as a student trainer. His advisor at the time “introduced me to her podiatrist, and he set me up to meet and work with some very progressive DPM’s in the area.” From there, he set on a course to study sports medicine.

Later, as a doctorate student at the California School of Podiatric Medicine, Dr. Stavosky got even more involved in the profession. “I volunteered to work on Saturday free clinics every week, and I was a TA for classes,” he says. “Plus, I attended all CME education seminars put on by CSPM—I even volunteered to work AV at those seminars.”

During his residency, even though he initially set out to work in sports medicine, Dr. Stavosky discovered his true passion was elsewhere. “I also developed an interest in foot and ankle surgery, but then found my calling in wound care,” he says.

After completing his residency, Dr. Stavosky worked in academic medicine as a volunteer until he was hired full-time as a professor. He began his career in a full-time position at the Seton Medical Center, teaching four days and tending to private patients two half-days per week.

His career took a turn for the better when he was given the opportunity to take over the wound care department. “No one else wanted to do it, but it put me on the map nationally,” he says. So, from 1987-1998, he was the Department Chair and professor at the Seton Wound Care (Medical) Center.

In 1998 Dr. Stavosky was appointed Chief of Podiatric Medicine and Surgery and opened a full-time private practice.

Board Certification

 Dr. Stavosky was a founding member of ABPM (then ABPOPPM), in 1993. Sitting for this certification was highly important to him, “first for academics, and later for medicine and wound care.”

He is also certified with ABFAS, which he pursued because he “was teaching in the surgery department at CCPM, but in the process realized just how important podiatric medicine was.” He went on to become Chair of the podiatric medical department as a result.

Although the sequence of Dr. Stavosky’s board certifications began with ABFAS, he notes “I would now do it the other way around.”, and advises his students and residents as such.

Teaching the next generation

 In addition to helping patients through his work in wound care, Dr. Stavosky notes that he’s most proud of his experience teaching.

His advice to aspiring podiatrists: “Enjoy what you do, it’s the greatest job in the world. If you don’t want to spend time in a particular facet of podiatry, such as surgery, there’s a tremendous amount elsewhere that our specialty offers, like wound care or sports medicine.”

Along with his academic position he does his best to stay involved in the podiatric community. “I volunteer as faculty for residents and students for both ABPM and ABFAS and am, or have been, on each of their Board of Directors.” He’s also on the Board of Directors at the alumni associations of the California School of Podiatric Medicine and The University of the Pacific. Plus, he lectures on wound care around the country.

What he plans to bring to ABPM

 Dr. Stavosky doesn’t take his latest honor and challenge as the Executive Director of ABPM lightly. He looks forward to “taking our organization, ABPM, to yet another level in the future.  He plans to “guide the ABPM Board of Directors and continue to grow our membership,” along with “getting even more young practitioners involved at the committee and director levels.  With our significant increases in membership, especially over the past five years, we’ve experienced a demographic shift.  We’re getting younger.”

He has ambitious plans, but if Dr. Stavosky’s career proves anything, it is that he is capable of achieving some impressive goals.

Clinical Presentation Skills: Evaluation and Management

By: Nichol Salvo, DPM

When a patient presents in any medical setting for initial evaluation, it is easy to focus on your area of specialty. That being said, having “tunnel vision” may cause you as the clinician to falter. A concerted effort must be made to consider the patient’s co-morbidities that factor into the etiology of their current lower extremity condition. How will this play into the treatment plan?

Consider the following case and the importance of whole patient consideration:

A 68 year-old male presents to the emergency department complaining of increased pain in the right foot with new onset edema and malodor. The patient indicates that pain was his initial symptom which presented approximately three days prior. The patient has a past medical history significant for DM, CKD, stage 3 lung cancer currently treated with chemotherapy, and major depressive disorder. Upon triage, the patient is noted to be febrile at 100.4 degrees Fahrenheit with all other vitals normal. The right foot is noted to have an ulceration to the right sub first metatarsal head with surrounding boggy, necrotic desquamation, heavy with foul odor. The right foot is noted with palpable pulses. The patient denies any knowledge of ulceration to the foot. Labs were obtained by ED staff and the white blood cell count is noted to be 16.1. Radiographs obtained reveal subcutaneous emphysema localized to the plantar medial and plantar central midfoot.

It is clear that an emergent incision and drainage is required to save the extremity. It is easy to get lost in the emergent conversion and transfer from ED to OR. The patient will require consent and it is discussed with the patient that given the circumstances, conservative options are not an option. However, what are the other details that must be considered with the current plan? What other questions will you need to present to your attending?

The patient is diabetic.

  1. What is the hemoglobin A1c? The patient should be advised during the time of consent whether this will impact his outcome.
  2. What is his current serum glucose? Is it elevated and must you consider a concomitant ketoacidosis?
  3. Is the patient NPO? When did the patient last eat or drink and will anesthesia have to be modified?
  4. The patient is on chemotherapy to treat his lung cancer. What are the other pertinent lab values? What are his neutrophils, platelets, hemoglobin, hematocrit, etc.? Based on this review, does the patient necessitate a type and screen in anticipation of a transfusion?
  5. Given his CKD and need for antimicrobial therapy, what is his kidney function at this time? Does your planned antibiotic regimen require renal adjustment to accommodate creatinine clearance?
  6. The patient may potentially require some level of amputation in addition to the planned incision and drainage. Is the patient’s depression managed or should mental health services be consulted to assist the patient in processing and managing the magnitude of what he is facing?
  7. Given his diabetic and malignant state, what is his nutrition status? Have you considered how to optimize his long-term healing by consideration of albumin and pre-albumin?

Having thought of these questions and their answers will not only provide a complete presentation but , also render better patient care. Considering the whole patient when treating the lower extremity is a necessary and critical component of your evaluation and management. There are almost always other things to consider.

 

Explained: Pathology Specific Biomechanical Exam Templates

By: Dr. Stephen Geller, Director, ABPM

Have you ever given someone something you thought would help only to find them using it in a completely unexpected manner? This is exactly what happened when the American Board of Podiatric Medicine provided residency directors with a full-page comprehensive biomechanical examination form. This checkbox form contained hip-to-toe measurements, both non-weight bearing and weight bearing, and in gait. The unexpected outcome was that these forms separated biomechanical examinations from the physical examination performed for most complaints. In reviewing these forms at residency on-site evaluations, there were inadequacies that led to misinterpretations of the examination findings or lack of supporting documentation for the given diagnosis.

CPME 320: Standards and Requirements for Approval of Podiatric Medicine and Surgery Residencies, (the document governing residency programs) contains multiple MAVs, including biomechanical examinations. These biomechanical cases are defined as: “…direct participation of the resident in the diagnosis, evaluation, and treatment of diseases, disorders, and injuries of the foot, ankle, and their governing and related structures by biomechanical means. These experiences include, but are not limited to, performing comprehensive lower extremity biomechanical examinations and gait analyses, comprehending the processes related to these examinations, and understanding the techniques and interpretations of gait evaluations of neurologic and pathomechanical disorders.” At no point does this definition state that a biomechanical examination is from the hip to the toe.

Patient’s present with a specific complaint and not all pathology requires a hip-to-toe examination to be comprehensive relative to the causative factors. Residency training is to impart advanced knowledge so that when in practice, the graduated resident will be able to perform pertinent aspects of the biomechanical examination and identify all contributing factors. This information is used to minimize risk of complications in plan of care. First year residents will be less familiar with the presenting pathology and require more guidance through a more thorough exam to identify those causative factors. A senior resident may require less guidance and identifies all causative factors much faster.

With the development of electronic medical records (EMR), the use of forms that are separate from the electronic documents is increasingly difficult. To bring the biomechanical examination into the physical examination where it belongs, EMR templates for pathology specific biomechanical examinations have been created. These templates consist of: Pes Planus; Pes Cavus; Hallux Valgus; Hammertoe, Lesser Metatarsal and Intermetatarsal Pain; and Proximal Examination. The templates are modular being combined to comprehensively evaluate the pathomechanics of a specific patient. For example, a patient complaining of neuroma symptoms with a low arch would begin with the Pes Planus template and where indicated insert the template for Hammertoe, Lesser Metatarsal, and Intermetatarsal Pain. If at the completion of this examination the findings do not fully explain the pathomechanics of the foot, then the Proximal Examination template is added.

 

Meet ABPM Director, Stephen Geller, DPM

Stephen Geller, DPM

Stephen Geller, DPM

Dr. Geller has been a Diplomate of the ABPM since 1997, and a board director since 2015.  He currently serves on the ABPM Examination Committee as sub-section Chair for the Qualification examination, and has been a committee member since 2008.  In fact, the ABPM App originated from the qualification examination committee under Dr. Geller, when a style guide and item writing manual were created for consistency in our examination processes. Dr Geller’s hard work with ABPM is also highlighted in the new pathology specific biomechanical exam templates now available through ABPM.

I am proud of the accomplishments ABPM has made in a short time. The importance of medicine in daily practice cannot be emphasized enough. In my opinion, Podiatrists need to be the best physicians in the hospital. I think it’s part of our training to listen carefully and examine thoroughly, putting us in a position to make diagnoses before other physicians get to see the patient. “

Dr. Geller has also served as an ABPM representative to the Council on Podiatric Medical Education (CPME) Residency Review Committee (RRC) for two terms, remaining as an at-large member of the RRC. He is an ABPM representative to the Collaborative Residency Evaluator Committee (CREC) and is a residency program evaluator for the ABPM, ABFAS, and CPME.  Dr. Geller holds clinical appointments at many of the colleges of podiatric medicine and is a past president of the Arizona Podiatric Medical Association.  Dr. Geller earned his Master’s Degree in Medical Education and completed a 13-year tenure as the founding Director of Podiatric Medication Education at Maricopa Medical Center in Phoenix, AZ.  His clinical practice has been recognized in Phoenix Magazine’s “Top Docs”, as well as one of “America’s Top Podiatrists” by the American Research Council.

 

 

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