Thank you for the very helpful information regarding office set up and networking in a small town. I just finished residency myself and will be opening up my own office next year after I finish a fellowship. All of the points you made are very valid. I am actually going to save the emails for future reference!
—Janice P. Clark, DPM
[email protected]
A nicely done presentation. I have only one suggestion. Please get rid of the DREMEL. That is so old fashioned chiropody and does not project a high class operation. There are many more sophisticated drills for $200-$300 that are quieter, less painful and more sophisticated.
I recently returned to practice after 7 years at one of our Podiatry Colleges. The office I bought had Dremel Drills which I utilized for the first few months. You cannot believe the response from patients who were intrigued with the look of the new drills and commented on how "up to date" my office was compared to the previous owner. They also commented on the smoothness and comfort while debriding nails.
The name of the drill is RAM SUPRA BLUE SET and it was $195 this past year. I ordered from STONE PODIATRY (Keith Bostwick is my contact and have dealt with him for over 30 years). (1-800-869-0900). It is quiet, has a foot pedal (rheostat) and multiple speed settings to accommodate even the thickest of nails with the correct burr. Above all else, it is comfortable for your patients.
The cost is very reasonable even for new podiatrist & is portable enough to take to the nursing home. It is much more professional looking and elevates your care from that of a "mechanic" to that of a surgeon.
Hope this is of assistance.
Keep up the fine work.
—Charles F. Ross, DPM
[email protected]
***Rural Towns***
I've enjoyed reading your transition to a new practice and glad things are going well for you. I'm considering also going to a smaller town to open up a solo practice or join a multispecialty group. Did you have a head hunter to find and discuss possibilities with groups in the area you were interested in? I'm trying to determine the best way to approach a multispecialty group? Any insight would be appreciated.
—Brian Gordon, DPM
[email protected]
Editor’s Response:
I did not use a headhunter to find my current employment. While in residency I contacted the rural health department in Oregon and stayed in touch with them throughout the following 2 years. I try to keep the contacts I make throughout my career. When the hospital hired a consulting company to help with establishing a provider-based clinic, they contacted the rural health office, seeing the importance of having a podiatrist, who told them about me.
Here’s how I would approach a multispecialty group. Search the areas you want to live, then look for these groups through an internet search, etc. See if they already have a podiatrist and/or orthopedist (call even if they do – they might need someone else). Call to speak to their clinic manager and gauge their possible interest. You may have to sell them to gain their interest.
The next step would be to meet with the practice administrators/staff. Here’s where you’ll show them that they can’t live without you. You’ll explain how profitable a podiatrist is to a practice with increased referrals, surgery fees, trauma, hospital fees from consults, office procedures, in-office dispensing, orthotics, diabetic shoes, new technologies, and community outreach among others. You’ll explain that it’s just better medicine to have such a highly trained and competent podiatrist as part of their practice. You’ll want to show them specific numbers in regards to profitability. For example, if you saw 20 patients/day you would be contributing “X” dollars of profit to the company. You will already have shown them your sterling personality and excellent patient skills.
It takes quite a lot of work, but is a viable career choice. Be sure to include realistic salary options and goals in your discussions. Good luck!
— Jarrod Shapiro, DPM
***
***Biomechanics/Orthotics***
Jarrod,
Thank you for your glowing recommendation. I appreciate that you are one of the
practitioners that values patient care over cost. It is the wisest financial move in the long run…since that is your reputation in the patient’s shoes. You deserve a great reputation because you share and live our core value “We make people better”.
BTW, up to this point, I have not given each doctor his own pair free, but you stated your case for a free pair so well, I will discuss this at our next executive meeting at Sole Supports and I believe we will change that policy (only for the doctor himself and give a professional discount for his family (which we already do)).
I think that the most important thing is that we are doing the research. There is an article coming out in this month’s JAPMA where we beat the best prefab 80% out of the box (and not reported in the paper….98% with a little gastroc stretching). This is a pain / quality of life study done at McMaster University in Hamilton, CA, which is the birthplace of evidence based medicine. Our profession needs more research showing the customs beat prefabs to save insurance coverage. The problem is that “Neutral” position orthotics have never been able to claim significant advantages over prefabs in RCT’s. We are also doing DM research using our product at UNLV medical center and basic kinematic research at U Conn and Quinnepiac U. in addition to what we are doing at GSU, GA tech, U of Bridgeport, U of the Pacific and Vanderbilt and the basic science stuff I am doing at the Smithsonian. We are soon to open a 2500 sq. ft. state of the art gait lab and research facility (about a 500K investment) and hope to start some research at several of the podiatry schools. A lot going on. We hope to usher Podiatry into a new era of biomechanical understanding.
Thanks for your support,
—Ed Glaser, DPM
***
Graduating from CCPM in 1974 from the Root world of Biomechanics and attempting to apply theory to practice until, like you I too converted to the Sole Support System not long ago. My clinical outcomes improved significantly as well as Biomechanics portion of my practice. Although it is not a perfect system, it nevertheless has exceeded my expectations. I definitely highly recommend it to my colleagues to think out of the box of traditional Biomechanics.
—Joseph Martin Quezada, DPM, Ithaca, New York
[email protected]
***
I would greatly disagree with you on Sole Support. He [Dr Glaser] admitted in a lecture in Ohio that he had not studied his ideas using any of the acceptable biomechanical instruments currently available including in-shoe sensor systems and motion analysis systems. It is all computer generated, theoretical ideas. His model does not include the function of the muscles, tendons and ligaments on the osseous structures and joints.
His model will not be tolerated by someone with a rigid flatfoot as he is trying to force something up in the midfoot that will not move. The idea of getting the 1st ray down to the ground? Mert Root described that very theory which is why Root Orthotics have the medial edge lateral to the 1st metatarsal. In addition, Howard Dannanberg has pioneered the 1st ray cut out several years before [Dr Glaser] and his big model of the subtalar joint.
I was skeptical of Sole Support when they wanted to charge me hundreds of dollars to learn their method of casting. Most people in biomechanics also do not feel foam boxes are the way to cast people. As far as working, the late Richard Schuster said that some people would claim their feet feel better if you stuffed their shoes with toilet paper! Why do you think Good Feet stores with their piece of [junk] OTC insoles for $200 have so much business? Talk to the PhD's in biomechanics (some are podiatrists some are not). I have sent [Dr Glaser’s] ideas to them and all have said the same thing: where is his proof?
I am disheartened that you would use this forum to promote one orthotic company. In 23 years of practice, working with colleges and high school athletes along with athletes with disabilities, one thing I have found out is there is no perfect, one stop orthotic lab. For severe diabetic problems I use Riecken Labs out of Evansville, Indiana, a non-podiatry lab. Still use Schuster labs for some leather orthotics for athletes. Also use Solo, Pro-Lab, Root and Bergman depending on the patient’s unique biomechanics and the activities they are using the orthotics.
Doug Richie lectured 10 years ago about plantarflexing the 1st ray during casting (using plaster) and having no fill between metatarsal heads 1 and 5 on the cast. Challenging Root's theories is nothing new. McPoil and his associate at Northern Arizona University are physical therapists with PhD in biomechanics. They lectured 10 years ago at the PFOLA meeting about changes in how we traditionally understand biomechanics based on findings from in-shoe and video gait analysis systems. They do not own, nor do they make their own orthotics. Most PhD's in biomechanics including podiatrists belong to the International Society of Biomechanics. I would recommend attending one of their programs or going to a PFOLA meeting before you make a decision that one orthotics lab is the way to go.
—Patrick J. Nunan, DPM
Fellow, ACFAS, ACFOAM, AAPSM
Past President, AAPSM
[email protected]
Editor’s Response:
I understand your concerns about Sole Supports and my editorial and greatly appreciate your involvement in our forum. A lively discussion and debate is essential for progress. The varied responses I’ve received from this editorial exemplify the highly controversial nature of foot and ankle biomechanics.
As far as the science, I’ll let the biomechanics experts argue the issue – which they seem to do with no small amount of rancor towards each other. In spite of all the research, though, the podiatric community has not seen any useful clinical studies on the subject. How can it be that one of my coresidents would use the term “biomagic” when referring to biomechanics? I have also never personally seen any “scientific” comparison of orthotics whether it is foam boxes vs neutral suspension casting or posting methods. During medical school I received much of my biomechanics training from the best: Scherer, Valmassy, etc. However, during this time no one ever directed us towards the literature for proof the way we are directed in surgery and medicine. “Where’s the proof” is a good question. I’d ask that from every orthotic company. Unfortunately, I am left with the anecdotal “this helps me where others haven’t.” I am waiting for the RCT that proves Root and colleagues correct. I may be uneducated on the subject and would greatly appreciate a reference list that we can publish that would put the issue to rest.
As far as my promoting one company I would respectfully disagree. As I mentioned in the article I am using this as my primary company, not my only company. For example, I use Prolab orthotics for my prefabricated orthotics and Ritchie braces. In my discussions I am somewhat constrained by the fact that I’m trying to make this an interesting read instead of a literature review of biomechanics. I’ll leave the decisions on what lab to use to the individual reader. As evidence to the honesty of both myself and PRESENT Courseware we are publishing these responses “as is” with edits only for readability..
I did not at any point state others should exclusively use Sole Supports. In fact, the thrust of the editorial was how one doctor chose an orthotic company. I believe my readers, as well as the podiatric community in general, are perfectly capable of making their own decisions when it comes to what kind of treatments to render. I would argue this is an editorial –an opinion piece. Readers can take my advice or leave it. That is the beauty of this forum.
—Jarrod Shapiro, DPM
***
Both cases show poor orthotic control. In both cases the patients are still pronating off the
orthotics. Either a poor casting was taken or the wrong type of orthotic was chosen. It looks like a combination of both. A more rigid orthotic with a deep heel cup is needed. The most important aspect of case #1 is there appears to be no extrinsic posting on the forefoot and rearfoot.
In cases of excess pronation and medial column instability it is essential to have extrinsic posting on both the forefoot and rearfoot if you plan to get the heel perpendicular to the supporting surface.
I think both sets of orthotics are unacceptable. This has nothing to do with the orthotic company. It is more a factor of poor orthotic choice by the physician.
—Steven H. Goldstein, DPM, DABPS, FAPWCA, DABDA
Director of Medical Education
The Academy of Continuing Podiatric Medical Education
[email protected]
Editor’s Response:
I agree that the orthotic cases I presented do not show complete control. I did mention this in the editorial with my thoughts of adding greater arch into the orthotics. I would disagree with extrinsically posting the rearfoot. I have found both shoe fit and tolerance problems for some of my patients with extrinsic rearfoot posts.
In spite of this “poor control” I found – anecdotally, mind you – that the symptoms are almost completely resolved. I print these pictures “as is” with no modification so readers can honestly appraise what I’m talking about. How often do we see “perfect” images in our presentations, whether they’re surgical or not? If you looked at the literature and national presentations alone you’d think there’d be no such thing as postoperative bunion problems! I’m not a perfect practitioner and don’t pretend to be. I’m sure my methods can use improvement, which I work on every day. However, my intent with my editorials is to present as honest a discussion as I can, whether I’m ridiculed or not. Thank you for your observations, which are highly valued by your younger podiatric colleagues. Please keep contributing.
—Jarrod Shapiro, DPM
***
I contacted your referenced company and they say they have to charge me for the starter kit of which I already have those supplies, and although I tell them I am a podiatrist they continually say they will try to find someone in my area to cast me. I know they know I'm a podiatrist because they said, as a practitioner, I am entitled to a discounted pair of orthotics but not a free pair. FYI.
—Jonathan B. Purdy, DPM
Foot Specialists of Acadiana
[email protected]
Editor’s Response:
Please see Dr. Glaser's comment above, "...you stated your case for a free pair so well, I will discuss this at our next executive meeting at Sole Supports and I believe we will change that policy (only for the doctor himself and give a professional discount for his family (which we already do))."
You can contact Dr. Glaser at [email protected].
—Jarrod Shapiro, DPM
***
I just graduated from a three year surgical residency this June and have to admit I don't have as much experience with orthotics as I would like. I recently read your article on Sole Supports. I contacted the company and received their info packet and dvd. I wanted to ask someone not affiliated with the company about fit of the orthotics in shoegear. I am just worried that the arch height of these orthotics may take up too much space in the patient's shoegear. Has this been an issue for you so far? Thanks for any input.
—Joe Griffin
[email protected]
Editor’s Response:
I have not had problems with shoe fit with this orthotic company. In my opinion Sole Supports fit into shoes the same as any other FFO. The same considerations are necessary. For instance, a full length topcover will not fit into a woman’s dress shoe (which are usually terrible for their feet, and they’ll wear in spite of my instructions not to). The arch height has not affected fit thus far in my practice. If they have a severe cavus foot with prominent dorsal architecture they’re going to have shoe-fit problems already which will make any orthotic therapy a challenge.
I’d recommend the same considerations for any FFO in regards to shoe fit. Consider sulcus or metatarsal length topcovers; thinner topcover material; intrinsic rearfoot posting (for other non-Sole Supports companies); and a heel cup with less depth. I always tell my patients who want a smaller orthotic that we’ll be trading control for shoe fit, which may affect their overall success.
—Jarrod Shapiro, DPM
***
***Multispecialty Practice***
I enjoy reading your articles every time they come out. As a 2nd year resident, I appreciate your perspective on issues that are so important to residents and young practitioners. I notice that you have moved to a position in a multispecialty practice and are employed by a hospital. How common is this? How would I go about finding out about these types of positions? I met an ex-resident from my residency program whose husband got a job at a hospital out of state and was able to work out a deal at the same hospital to have her employed as a podiatrist and she loves it. It has really piqued my interest into the ins and outs of this type of situation.
—Carmen B. April, DMP
[email protected]
Editor’s Response:
Great question. It sounds like your friend found a creative niche for herself. Everyone talks about the usual postresidency job paradigms such as associateship, starting one’s own practice, and multi-specialty practice. In reality there are many options available, and finding the right one is a matter of creativity and hard work.
Multispecialty practice for podiatrists is relatively common, although I don’t know any statistics. Take a look at the above editor’s response for more detail about multispecialty practice. If you’re looking to be a hospital podiatrist, which is a little different than my circumstance, I’d look for hospitals in your location and approach their CEO with your ideas to open a podiatry clinic. Obviously, if you want to spend most of your time in the hospital, dealing with wound care and trauma, you’ll need a hospital or hospital system large enough to support your practice. Anything is possible with time, patience, creativity, and fortitude. Good luck!
Thanks for the letters and keep them coming.
