News From ACFAS

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As reported here last week, on Jan. 20 ACFAS sent a cease and desist letter to an M.D. who was seen in an Internet video making erroneous and disparaging remarks about the education and training of podiatric surgeons. The M.D’s attorney responded to ACFAS on Jan. 28.

The attorney said the four minutes of his client’s comments about DPMs was excerpted from a one-hour video prepared by a third party on an unrelated subject. The attorney said his client has not authorized or distributed the video, and the actual distributor of the video remains unknown. The attorney also said the M.D. asked one Internet site to remove the video, which was done, but it may remain on other Internet site(s).

“These types of remarks surface from time to time in this viral Internet age,” says ACFAS President Michael S. Lee, DPM, FACFAS. “The College always responds as quickly as possible and usually with positive results. Instead of responding to this incident, I suggest ACFAS members ‘respond’ by continuing what they do best — by demonstrating their proven leadership, training and expertise every day with every patient. That evidence is hard to dispute.”
ACFAS staff met with representatives of 20 other medical specialties in Washington, D.C., last week to discuss areas of mutual concern and advancement related to the private insurance market and specialist reimbursement issues. Key issues discussed related to accountable care organizations, medical home models and private payor quality initiatives, similar to the Medicare PECOS model, to incentivize physicians to report quality data. The group is chaired by staff from the American Academy of Neurology Professional Association. ACFAS will host the group’s annual meeting in 2012.
Clearly related to efforts to boost support for long-thwarted, AMA-backed legislation requiring all healthcare providers' advertisements to clearly designate their qualifications, the AMA has released a survey showing patient confusion on the credentials of healthcare professionals. The telephone survey asked 850 randomly selected people for their responses in November 2010.

The survey noted that 68 percent of patients thought podiatrists are medical doctors and 11 percent said they were unsure. AMA stated that their survey overwhelmingly showed that patients believed that only licensed medical doctors should be able to use the title "physician," (93 percent), and support legislation in their states to require advertising materials clearly designate the provider's level of skill, education and training (87 percent). Only half the respondents said they find it is easy to identify who is a licensed M.D. and who is not by reading what services they offer in their advertising or marketing materials.

The AMA reports that several states including California, Arizona and Illinois are now enacting legislation that would prohibit misleading and deceptive advertising by healthcare professionals. More information is available here.
The ACFAS headquarters office in Chicago is closed due to severe winter weather on Wednesday, Feb. 2, 2011.

Foot and Ankle Surgery

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Researchers investigated the underlying cause of ankle valgus deformity after an Ilizarov tibial lengthening. They reviewed 74 bilateral Ilizarov tibial lengthenings in 37 patients with the mean follow-up of 45 months. Valgus deformity developed in 8 percent and fibular nonunion developed in 14 percent of the cases in this cohort. Proximal migration of the lateral malleolus of >5 mm was associated with valgus talar tilting. Bifocal tibial lengthening, rapid distraction rate of the fibula (>1 mm per day) and a fibular nonunion were factors associated with proximal migration of the fibula of >5 mm. The researchers suggested earlier intervention with bone-grafting if bone formation in the fibular distraction gap is compromised.



Researchers assessed the cross-sectional relation of planus foot morphology to ipsilateral knee pain and compartment-specific knee cartilage damage in older adults. The study, of 1,900 adults in their 50s or older, found that those with the flattest feet were 31 percent more likely than other study participants to say they had knee pain on most days. And they were 43 percent more likely to show damage to the cartilage at the inside of the knee.



“Bridle procedure” (tibialis posterior tendon transfer to tibialis anterior, peroneus longus and intermediate cuneiform) for correction of drop foot deformity was investigated in 53 consecutive patients with standardized questionnaires, physical exam, pedobarography and dynamometric muscle function tests. The average follow-up was 6.5 years.

The mean ankle range of motion became 8° dorsiflexion and 15° plantar flexion. Most patients achieved plantigrade foot and gait without orthotic devices. Maximum dorsiflexion torque averaged a third of the non-operated leg, according to reduced muscle diameter and strength of the transferred muscle. Plantar pressure distribution during gait was not significantly altered. Most patients were satisfied with the operative results and reported a significant increase in quality of life.

Practice Management

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About a third of physicians in the United States are over 65, and that proportion is expected to rise. As doctors in the baby boom generation reach 65, many are under increasing financial pressures that make them reluctant to retire. While many physicians retain their skills and sharpness of mind into advanced age, they are not immune to dementia, Parkinson’s disease, stroke and other ills of aging. Some experts warn that there are too few safeguards to protect patients against those who should no longer be practicing. A 2005 study found that the rate of disciplinary action was 6.6 percent for doctors out of medical school 40 years, compared with 1.3 percent for those out only 10 years. In 2006, a study found that in complicated operations, patients’ mortality rates were higher when the surgeon was 60 or older.



State licensing boards, hospitals, and medical groups are turning to continuing medical education (CME) programs to curb inappropriate physician behavior and prevent future transgressions that could lead to more serious charges. In such instances, mandated CME course subjects may include physician-patient communication, anger management, maintaining appropriate boundaries between professional practice and personal life, and correct prescribing and recordkeeping.

Federation of State Physician Health Programs President Peter Mansky says the most effective corrective programs educate physicians without humiliation, allowing them to retain their dignity and self-esteem. Doctors are often disciplined for committing recordkeeping errors, including overbilling and under-billing. CME courses are designed to help doctors recognize issues and get advice on billing and coding, and they are trained to keep thorough notes on patient visits so they have a record if their clinical judgment and treatment techniques are called into question.



Current government financial incentives stand to primarily benefit hospital systems and large medical groups. Practices seeking to maintain independence should approach investments requiring significant overhead or long-term commitment with caution. When such opportunities come up, they should seek available joint venture options or organize an arrangement with a rapid and inexpensive exit that will permit others to shoulder most of the risk. Physicians who join large groups should keep the divorce clause in mind because if a large group medical practice breaks up, those members who are able to move to an independent or more profitable practice will be in a much better position to keep their patient bases (and independence) if they have negotiated the right to continue practicing in their geographic areas without significant interruption.

New regulations slated for enactment in 2013 will supply Medicare bonus funds to integrated organizations comprised of medical groups, hospitals, and outpatient facilities that treat at least 5,000 patients with favorable outcomes, and doctors participating in such plans will probably see greater compensation and access to additional marketing and referral patterns. Physicians should also keep in mind that contract provided to a doctor by a hospital, healthcare plan, HMO system, or group practice is almost always open to negotiation. It therefore pays for the physician to be wary of false deadlines, misrepresentations, and unfounded assumptions during the negotiation process.

Health Policy and Reimbursement

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Maryland's highest court has affirmed a lower court ruling that prohibits physicians from referring patients for imaging procedures conducted by members of that referring physician's group. According to a 1993 state law, physicians in Maryland are restricted from self-referral for MRI, CT and radiotherapy. This limitation was commonly circumvented by a group practice exemption, wherein physicians would refer patients to undergo scans completed by other physicians within the referrer's group.

In 2006, however, Maryland's Board of Physicians rejected an in-group referral for an MRI scan ordered by an orthopedic surgeon. In response, 13 physician groups filed suit, backed by amicus curiae briefs filed by the American Academy of Orthopedic Surgeons and the American College of Surgeons. On Jan. 24, the Court of Appeals affirmed the Circuit Court ruling that entitled the Board of Physicians to deference in interpreting the law, thereby upholding the law's ban on group referrals. The court also clarified the law's "direct supervision" exception, ruling that, for "outside entities," referring physicians must be "personally present within the treatment area when the service is being performed," and must either provide or directly supervise the service.



Rep. Phil Gingrey (R-Ga.) sponsored the Help Efficient, Accessible, Low-Cost, Timely Healthcare Act to cap noneconomic damages at $250,000 in malpractice cases; the legislation has bipartisan support in the House. However, the bill has been introduced multiple times in the past and is expected to continue facing challenges in the Senate. Traditionally, Democrats do not want to impinge on the jury system by imposing noneconomic damage caps, but in President Obama's State of the Union address, he signaled a willingness to consider tort reform measures that speed up the nonadversarial resolution of cases.



The publisher of The Wall Street Journal has filed suit in the U.S. District Court for the Middle District of Florida to overturn a decades-long court order barring public access to a confidential Medicare database. The suit claims that access is essential to rooting out fraud and abuse in the government healthcare program. The American Medical Association successfully sued the government in 1979 to keep secret how much money individual doctors receive from Medicare. The filing comes after a series of articles in the Journal about abuses of the Medicare system. The articles were based on computerized Medicare records that represent part of the broader database at the center of the 1979 case.

Medicine, Drugs and Devices

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A move by U.S. pharmaceutical firm Hospira Inc. to stop producing thiopental sodium is generating criticism from the medical community. Protests over use of the anesthetic for lethal injections drove the decision, but healthcare providers warn that the drug is still critical for surgeries involving certain high-risk patients. Because newer drugs introduce side effects that can cause major complications for elderly, pregnant, and other certain classes of patients, thiopental sodium remains the preferred anesthetic under those circumstances. The American Society of Anesthesiologists (ASA) and the American Society of Health-System Pharmacists each expressed concern over Hospira's decision. The ASA called it "an unfortunate irony" that many more patients would be put at risk and perhaps even die "as a result of not having the drug available for its legitimate medical use."



The White House has decided to start a billion-dollar government drug development center to facilitate the creation of new medicines. The job of the new center, to be called the National Center for Advancing Translational Sciences, will be to do as much research as is necessary to attract drug company investment.



The FDA gave its approval to market leeches as medical devices in 2004, and their use appears to be growing to help preserve tissue by aiding blood flow. For example, when a Maryland man's foot had been dragged along the pavement and badly damaged in a motorcycle accident, trauma doctors used leeches to keep blood moving in and out of a new skin flap sewn onto the victim's foot. Leeches also can get blood flowing to amputated digits that are reattached. And because their saliva has a natural anesthetic, some doctors now are looking to use them to ease pain.



Researchers have developed nanoparticles containing keratinocyte growth factor (KGF) fused with elastin-like peptides to accelerate healing in chronic wounds such as pressure sores and diabetic foot ulcers. A fusion protein was developed from recombinant KGF and elastin-like-peptides. Laboratory experiments showed that the fusion protein retained the wound-healing properties of both elastin and KGF and that it rapidly and efficiently self-assembled into nanoparticles in response to a simple increase in temperature. When applied to deep skin wounds in genetically diabetic mice, the nanoparticles accelerated healing by stimulating the formation of both surface epithelial tissue and thick fibrous connective tissue.