News From ACFAS

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Barry Rosenblum, DPM, FACFAS, of Boston has been appointed by the Board of Directors to fill a two-year vacancy of the term left by the resignation of Brian B. Carpenter, DPM, pursuant to the bylaws. Rosenblum was the recipient of the 2019 Distinguished Service Award and currently chairs the Council on Journal Management. Rosenblum’s board appointment is effective immediately. Attention residency directors and faculty—the Residency Directors Forum is back again! As the profession of foot and ankle surgery evolves, directors need to ensure they are keeping up with the highest educational standards and best practices in teaching the newest generation. This Forum explores multiple topics to assist with those goals.

The Forum, co-hosted by ACFAS and the AACPM Council of Teaching Hospitals (COTH), is set for Tuesday, February 18 in advance of ACFAS 2020 in San Antonio. This year’s topics include human resources management decisions, social media, CPME standards and compliance, financial considerations for on- and off-campus providers and top malpractice issues. Finally, by popular request, attendees have an opportunity to hear updates on the CASPR/CRIP and clerkship processes, ACFAS news, PRR revisions and the CPME 320 re-write.

The Forum is complimentary and provides up to 3.0 Continuing Education Contact Hours (CECH). Interested in attending? Visit acfas.org to download the registration form. Registrations are due to the College by February 6. You now have three more infographic options for patient education: Post-Surgery Care Basics, Preparing for Your Surgery and What is a Foot and Ankle Surgeon. These new colorful informational graphics offer patients tips on how to best care for themselves after foot and ankle surgery; how to prepare for surgery and make recovery better; and explains who exactly foot and ankle surgeons are and when to see one.

These pre- and post-surgery infographics are especially helpful as you prepare patients for upcoming surgeries with tips on preparing their home, scheduling and planning the surgery and how to get around and back to work once it’s over. Once surgery is complete, patients can ensure they’re on the road to recovery with helpful information about pain relief, swelling reduction, proper weightbearing instructions and a list of post-op issues.

All these, plus a library of others on various topics, can be found in the ACFAS Marketing Toolbox at acfas.org/marketing. Infographics can also be displayed in exam rooms, printed out for waiting rooms, posted on social media and your practice website or printed out as flyers to include with billing statements or handed out at community health events.

Visit the ACFAS Marketing Toolbox for even more practice marketing tools to help promote your practice and the profession. Congratulations to our 2020 ACFAS Scholars! Every year, the College recognizes our Student Club Presidents from each of the podiatric medical school campuses for all the work they do throughout the school year on behalf of the organization.

Each ACFAS Scholar received a scholarship for $1,000 to defray his or her costs of travel and lodging to ACFAS 2020 in San Antonio next month. They also received complimentary registration.

This year’s scholarships are generously supported by Medartis.

AZPod:
Ross Groeschl, Class of 2021

Barry University:
Justin Carney, Class of 2021

CSPM:
Christopher Zimmer, Class of 2021

DMU:
Joseph Brown, Class of 2021

Kent State:
Deana Lewis, Class of 2021

NYCPM:
Michael Rutkowski, Class of 2021

Scholl College:
David Warciak, Class of 2022

Temple University:
Samuel Straus, Class of 2021

WesternU:
Rahim Khan* Class of 2020
*Rahim is not a club officer

Congratulations to these future leaders of the profession!

Foot and Ankle Surgery

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The study aimed to assess the effectiveness of extracorporeal shockwave therapy (ESWT) compared with sham controls in chronic insertional Achilles tendinopathy. A double-blind, randomized sham-controlled trial was conducted between 2016 and 2018 on patients aged 18 to 70 with chronic insertional Achilles tendinopathy. Pain, function and other complaints were assessed using visual analog scale (VAS) and VAS foot and ankle (VAS-FA) at preintervention and weeks two, three, four, six, 12 and 24.

Sixteen patients in ESWT and 15 patients in sham control groups had nonsignificant different baseline characteristics with preintervention VAS and VAS-FA. There was no significant difference in VAS, VAS-FA and its domains in the long term between the two groups. The ESWT group had significant improvement in VAS at weeks four to 12, and sham controls group had significantly improved VAS at weeks 12 to 24. Complications were found only after ESWT treatment.


The study examined what patient characteristics may be used to predict concomitant osteochondral lesions of the talus. A retrospective chart review was performed on 182 patients who underwent a primary Broström-Gould lateral ankle ligament reconstruction for chronic ankle instability from 2010 to 2014. Preoperative findings, magnetic resonance imaging and operative procedures were documented, and patients were divided into two cohorts based on whether they had or did not have a lesion.

Fifty-three patients had one lesion identified on preoperative magnetic resonance imaging; 40 patients had medial legions, 18 had lateral lesions and five patients had both. Female patients were less likely to have a lesion than male patients, while those who participated in sports were more likely to have a lesion than those who did not. Patients were less likely to have concomitant peroneal tendinopathy in the presence of a lesion.


The study aimed to assess how the level of deformity, the stage of the osteoarthritic process and the role of additional surgeries impact radiographic and clinical outcomes following an extra-articular medial closing supramalleolar osteotomy for treatment of post-traumatic valgus ankle osteoarthritis. A retrospective analysis of 56 consecutive patients who underwent an extra-articular medial closing wedge osteotomy for post-traumatic valgus ankle osteoarthritis was conducted. Subgroups were formed according to the pre-operative level of deformity and preoperative stage of ankle osteoarthritis, and additional surgical steps required to achieve a properly balanced hindfoot were noted.

Patients with a pre-operative supramalleolar deformity showed superior radiographic outcomes compared to patients with an intra-articular deformity. The pre-operative stage of ankle osteoarthritis significantly impacted radiographic outcomes but did not influence clinical outcome measures. An additional fibula was necessary for 55 percent of patients, and a calcaneus osteotomy was necessary for 23 percent of patients.

Practice Management

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A study in the Annals of Internal Medicine found physicians spend an average 16 minutes per patient using electronic health records (EHRs). Clinicians spent the most time in EHR performing chart review, which constituted about 33 percent of total time using the records; about 24 percent concentrated on documentation and 17 percent focused on things like laboratory tests. EHR deployment was meant to enhance chart review overall, as more complete charts and more rigorous review was linked to improved patient outcomes. The University of California San Francisco School of Medicine's Julia Adler-Milstein said, "Whether it's EHRs or anything else that is taking a doctor's attention away from the patient, patients should feel empowered to speak up if they feel that they have not been given the opportunity to share all pertinent information with their doctor or feel that their doctor might have missed something because their attention was directed elsewhere."


Setting the right tone on your practice's website is critical to attracting new patients. One mistake that practices often make in this area is leaving their website underdeveloped, out of date or incomplete. If your website falls into this category, gather your team and start planning improvements, potentially with the help of a marketing firm with medical practice-specific expertise related to web design. Another common mistake is vague or clichéd copy that fails to make a unique value proposition for the practice. When writing website copy, consider how you would explain the type of care you provide and why it is better than your competitors if you only had three sentences to do so. Run your response by your colleagues and others you trust, and if they affirm that it is credible and compelling, use the response to guide you as you modify the rest of your copy.

Make sure your website is easy for patients to navigate and quickly find what they need. This includes information about your doctors and their care philosophies, a list of the treatments you offer and the condition you treat, your contact information, insurances you accept, hospital affiliations, online appointment booking and quality metrics and outcomes data. Practice websites should generally try to offer patient testimonials, which can help foster connection and humanize the practice. Finally, search engine optimization is critical to helping consumers find your website. This is one area where a practice may need to secure assistance from an outside professional, who can audit your website and provide recommendations to ensure that your website copy includes keywords and phrases that will help your practice appear at the top of search results.


It is increasingly common for patients to demand a specific test or treatment. The most common reasons for this behavior are information patients get through the internet, conventional media, direct-to-consumer advertising and alternative healthcare providers. Physicians should know how to respond to this kind of situation in a respectful but firm way that emphasizes what's best for patients. First, determine whether the requested test or therapy is indicated by the standard of care for a reasonable physician.

If it is not or if you are not familiar with the test or therapy, do not provide it, even at the risk of a negative review. Instead, go over the risks, benefits and alternatives with the patient and advise them that their insurance company may not cover the test. If a patient requests a specific form of treatment, you are obligated to inform the patient of your best medical judgement, even if that conflicts with their desires. Overall, the most prudent course of action is to stay within your usual practice and document all discussions thoroughly.

Health Policy and Reimbursement

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Some plans sold by Blue Cross of Idaho can charge sick people higher premiums and limit coverage for preexisting conditions, which are prohibited under the Affordable Care Act (ACA). However, Idaho's policy prohibits insurers from entirely separating their ACA customers from the new enhanced short-term market. When insurance carriers propose rate changes, they start with an "index" rate that must reflect the combined medical costs of both their ACA plans and enhanced short-term plans, explains Idaho Department of Insurance Director Dean Cameron.

If the new plans bring enough healthy uninsured people back to the market, Cameron believes premiums for ACA plans could also be reduced. He says, "We're really trying to attract the healthy back in." The insurer received approximately 3,000 applications since it began marketing the plans on Dec. 1; it had anticipated 800 at most.


Long-term healthcare was among the issues discussed at the latest Democratic presidential candidate debate. Sen. Amy Klobuchar (D-Minn.) redirected a conversation about Medicare for All and the public option, shifting the focus to "long-term care—the elephant that doesn't even fit in this room." Klobuchar then discussed her own family's struggles when caring for her father. "We have to make it easier for long-term care," she said. "It's not just for the seniors— it's also for the sandwich generation, people trying to help their parents." The issue of long-term care has not gotten much airtime in the Democrats' debates, but there is considerable evidence that it is a growing problem as the baby boomers age into retirement. A 2016 report by the US Department of Health and Human Services projected that 52 percent of Americans turning 65 would develop a disability that required long-term services and supports.


More research is needed to evaluate and address disparities in access to health care and use of preventive clinical services, according to an independent panel convened by the US National Institutes of Health (NIH). The six-member panel—made up of experts in the fields of public health, nursing and medicine—called on scientists to examine interventions with multiple components and to engage stakeholders both in and outside of the healthcare system. "Ongoing disparities in the use of evidence-based preventive services, despite the wide availability of guidelines and improvements in insurance coverage, are a call to action for researchers and healthcare providers," said Tim Carey, professor of medicine at the University of North Carolina at Chapel Hill and chairperson of the independent panel that authored the report.

NIH convened the panel of independent experts for the Pathways to Prevention Workshop: Achieving Health Equity in Preventive Services in June 2019. The resulting report was published in the Annals of Internal Medicine along with a systematic evidence review that was commissioned for the workshop through the Agency for Healthcare Research and Quality.

Medicine, Drugs and Devices

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Drug companies Merck, Eli Lilly and Amgen are fighting a Trump administration rule that would require companies to disclose the list prices of their drugs in television advertising. The companies argue that the rule, which was blocked by a federal court in July, is outside the authority of the US Department of Health and Human Services (HHS). The Trump administration urged a federal appeals court to overturn that ruling, arguing that it does have the authority under the law to run the Medicare and Medicaid programs efficiently. HHS attorneys say that the advertising rule, which would only apply to drugs that cost at least $35 a month and are covered by Medicaid and Medicare, would force drug companies to compete and encourage patients to shop for better deals.

Drug companies argued that the ads would cause confusion because the list price, which is set by drug manufacturers, is often not what patients actually pay for their drugs after insurance is taken into account. Judges seemed sympathetic to this argument and also noted that the rule does little to address the real problem, which is the price of prescription drugs.


A study published in the Annals of Internal Medicine found that SGLT2 inhibitors, which are used to lower blood sugar in people with type 2 diabetes, may also lower the risk of gout, a type of arthritis that usually starts in the foot. The study, which was funded by Brigham and Women's Hospital in Boston, looked at 300,000 adults with type 2 diabetes who had recently been prescribed a SGLT2 inhibitor or GLP1 receptor agonists, another class of diabetes medications. It found that 636 of the nearly 152,000 adults taking an SGLT2 inhibitor developed gout, while 835 of the 144,000 people taking a GLP1 developed gout, meaning adults taking SGLT2 inhibitors were 36 percent less likely to develop gout.


Drug manufacturers are testing new methods to get paid for their most-expensive medicines, as resistance to escalating prices builds and improvements are made in collecting and analyzing patient data. With six-figure price tags growing increasingly common, drug companies are finding creative ways to get reimbursed, from installment plans to subscriptions to more complex value-based contracts that tie payment to when a drug helps a patient.

Drug manufacturers "understand that if they come to the market with superhigh-cost drugs and aren't willing to share the risk then they are going to face pushback and access challenges," said Michael Sherman, chief medical officer at Harvard Pilgrim Health Care. However, it remains to be seen how widely the innovative reimbursement programs will be adopted. Sherman and other health insurance officials worry the new efforts might give pharmaceutical firms cover to keep raising prices, limiting the overall impact on costs.