News From ACFAS

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The ACFAS Nominating Committee seeks experienced members to serve on the College’s Board of Directors. If you are an ACFAS Fellow, believe you are qualified and would like to help lead the profession, send your nomination application by September 9.

Visit acfas.org/nominations for the nomination application and complete details on the recommended criteria for candidates. For more information, contact ACFAS Executive Director J.C. (Chris) Mahaffey, MS, CAE, FASAE, at mahaffey@acfas.org or (773) 693-9300. Questions regarding eligibility criteria should be directed to Nominating Committee Chair John S. Steinberg, DPM, FACFAS at john.steinberg@medstar.net or (202) 444-3059.

The Nominating Committee will announce recommended candidates to the membership no later than October 23. Candidate information and ballots will be emailed to all voting members no later than December 7. Electronic voting ends on December 22. New officers and directors will take office during ACFAS 2020, February 19-22, 2020 in San Antonio.
The 2020 Residency Directors Forum is set for Tuesday, February 18, 2020 in advance of ACFAS 2020 in San Antonio at the Henry B. Gonzalez Convention Center. This year's event will be co-hosted by ACFAS and the Council of Teaching Hospitals (COTH).

Make this not-to-be-missed event your CPME and hospital requirement for faculty development. Attendees will earn 2.5 CME hours.

Session content will include discussions on choosing and teaching millennial residents; best practices dealing with negative reviews; at-risk residents; avoiding harassment claims; proper social media usage; CPME compliance; resident hours; and malpractice claims.

Plus, back by popular demand, attendees will have one-on-one direct access to representatives from COTH, CPME, AACPM, ABFAS, ABPM and PRR.

This is just a taste of the content to be presented at this year’s Forum. Watch your email for more event details and registration information in early fall. Hitting the airways August 1 on the ACFAS e-Learning Portal, the latest podcast, Management of Chronic Achilles -- Insertional vs. Non-Insertional.

Listen to the panel as they share their insights on this topic.

Access this podcast at acfas.org/e-learning, and visit the e-Learning Portal often for more ways to earn CME on the go.

Foot and Ankle Surgery

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The report describes a study that aimed to determine the epidemiology of isolated syndesmotic injuries in professional football players. The study looked at 15 consecutive seasons of European professional men's football between 2001 and 2016, collecting data on match play and training data from a total of 3677 players. Linear regression was used to analyze seasonal trends for isolated syndesmotic injury incidence, isolated syndesmotic injury proportion of ankle ligament injuries and isolated syndesmotic injury burden.

The study found an isolated syndesmotic incidence of 0.05 injuries per 1000 hours of exposure, or one injury per team every three seasons. Injury incidence during match play was 0.21 injuries per 1000 hours of exposure, which was 13 times higher than injury incidence during training, which was 0.02 injuries per 1000 hours of exposure. Out of the 1320 ankle ligament injuries registered during the 15 seasons, 7 percent were diagnosed as isolated syndesmotic injuries. An annual increase in injury incidence was observed, but no significant annual change of injury burden was observed. 74 percent of the injuries were contact related, and the mean absence following an isolated syndesmotic injury was 39 days.


A recent comparative study investigated immediate postoperative opioid pill consumption and prolonged use in patients undergoing operative correction of hallux valgus (HV). The investigation studied 137 patients, 86 percent of whom were female, undergoing outpatient HV correction procedures with five surgeons over a one-year period. 26 percent of the patients underwent primary chevron osteotomies, 57 percent underwent primary proximal osteotomies, 7 percent underwent soft tissue-only procedures with or without a first proximal osteotomy and 9 percent underwent first metatarsophalangeal arthrodesis.

At a patient's first postoperative visit, opioid pills were counted and standardized to the equivalent number of five-mg oxycodone pills and linear regression analysis was performed to determine whether any procedure categories or patient factors were independently associated with postoperative opioid consumption. Overall, patients consumed a median of 27 pills, and a total of 1.5 percent of patients demonstrated prolonged opioid use. The study found no significant difference in postoperative opioid intake between the four procedures, including when subdivided into those with and without lesser toe procedures. The factors associated with higher opioid pill consumption were higher preoperative visual analog scale pain levels (p = .042) and younger patient age (p = .042).


Some have described the obliquity of the first metatarsal-medial cuneiform articulation as an atavistic trait of human foot morphology. The articulation is commonly proposed as a relative risk factor for developing the hallux abductovalgus (HAV) deformity. A recent investigation aimed to provide descriptive normative radiographic data on a series of first metatarsal-medial cuneiform articulations and to correlate these findings to other radiographic parameters commonly used to define the HAV deformity. Researchers analyzed a consecutive series of 136 weight-bearing foot radiographic projections from subjects without a history of foot/ankle injury or surgery. They measured parameters including the first intermetatarsal angle, hallux abductus angle, tibial sesamoid position, Engel's angle and two measures of obliquity in the transverse and sagittal planes.

These measurements were considered as continuous variables, depicted against each other on frequency scatter plots and analyzed with Pearson correlation coefficients. Only one bivariate comparison, Engel's angle versus Obliquity, demonstrated a weak negative correlation (Pearson –0.259; p=.002). The investigation did not demonstrate a significant or clinically substantial relationship between the obliquity of the first metatarsal-cuneiform joint and common radiograph parameters of the HAV deformity. These results may potentially indicate function, rather than structure, in the developmental pathogenesis of the HAV deformity.

Practice Management

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Medical practices must do all they can to ensure that their sexual harassment policies are comprehensive and effective. By outlining the rules and consequences for violating them, employers are better prepared to effectively respond to claims. Workplace litigation attorneys Jennifer Lee-Cota and Kirstin Story say that a good policy starts with a clear statement against sexual harassment, which fosters a respectful environment and empowers victims to come forward. The policy should clearly define sexual harassment, provide examples and articulate clear reporting procedures that inform employees of their rights.

The policy should then outline the investigation process and make it clear that all complaints will be promptly and thoroughly investigated. To further encourage reporting, the policy should provide anti-retaliation assurances and include a confidentiality statement. Make sure that the policy is distributed to all employees, who should then be required to provide a written acknowledgement that they have received, read and understand the policy.


Medical practices nationwide are increasingly turning to management service organizations (MSOs), which enable non-physicians and/or investors to manage medical practices in states where the corporate practice of medicine is otherwise unauthorized. MSOs may work with existing medical practices or start a new practice in collaboration with a physician. When starting a new practice, physicians should consider hiring a lawyer, identify what their role will be, review their expected commitments to the MSO and seek out appropriate and fair market value compensation. Physicians also need to be aware of what liabilities they would take on.

A physician who owns the professional entity for the benefit of the MSO should be properly insulated from personal legal responsibility. Many MSOs will reserve the right to require physicians to transfer ownership of the professional entity to any individual of their selection at any time. MSO documents typically do not allow the physician to depart without an extensive notification period or a financial penalty. Ideally, physicians will have the right to make professional decisions and be allowed to promptly depart if he or she feels there are compliance concerns that are not being addressed. Noncompete or restrictive provisions can affect physicians who may have a separate professional practice.


According to the American Medical Group Association (AMGA) 2019 Medical Group Operations and Finance Survey, integrated system and independent practice operating margins improved from 2017 to 2018. The AMGA survey used data from for-profit and not-for-profit medical groups across the U.S. representing more than 15,300 providers from an even mix of integrated systems and independent practices. It found that median total investment (loss) per physician in integrated systems decreased by 21 percent, from $243,918 in 2017 to $201,042 in 2018, while total profit per physician improved from $2,396 to $2,510 in independent practices.

The 2019 AMGA survey was redesigned to analyze performance at various levels and provide information on the prevalence of certain operational best practices. The 2019 version of the survey includes data benchmarks on revenue cycle metrics, access information, clinic staffing details, advanced practice provider to physician ratios by specialty and benchmarks for both independent practices and integrated system.

AMGA noted that due to a growing number of physicians in most organizations, organizations are looking to ensure their practices are operating at an optimal level. AMGA said its findings emphasize that both integrated and independent practices must understand process orientation and individual line-item variances before they can improve. AMGA also named electronic medical records, telehealth programs and scribes as the main resources organizations are using to bring about meaningful change.

Health Policy and Reimbursement

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U.S. Departmenet of Health and Human Services (HHS) Secretary Alex Azar called for a more "patient-centered" approach to paying physicians in a recent speech. Azar said the current approach is procedure-centered and oriented around the Medicare physician fee schedule. The current system does not provide an incentive for physicians to help patients stay healthy, according to Azar. The new Medicare primary care payment models that the U.S. Centers for Medicare and Medicaid Services rolled out in April is a better system, Azar suggested. The models require doctors to assume varying levels of risks for their patients' healthcare costs. Azar said HHS is very close to proposing new rules that will free up opportunities for information sharing, care coordination and value creation.


The American Telemedicine Association (ATA) says a growing number of states are expanding telehealth coverage and reimbursement. Since 2017, 40 states and the District of Columbia adopted major policies or received awards to expand telehealth coverage and reimbursement, according to ATA. Meanwhile, a recent American Well survey found that physician adoption of telehealth increased 340 percent between 2015 and 2018. The report reveals that 36 states and the District of Columbia have parity policies for private payer coverage, 21 states and the District of Columbia have coverage parity policies in Medicaid, 28 states have Medicaid payment parity policies and 16 mandate payment parity for private payers.

Medicine, Drugs and Devices

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According to a new analysis of data from 31 previously published studies, published in the Annals of Internal Medicine, up to one in four people in the United States use antibiotics without a prescription. The analysis also found that almost half of people had stored antibiotics for future use or intended to do so and often obtained these antibiotics from friends or relatives, pet stores, flea markets, health food stores or online. The study found that people who did not have health insurance or access to a regular doctor or clinic were more likely to take antibiotics without a prescription.

The findings highlight one factor contributing to the rise of antibiotic-resistant infections. When used unnecessarily or incorrectly, antibiotics can harm both the patient and the community by increasing the risk of antimicrobial resistance, which has already rendered a number of treatments ineffective. Part of the problem is that doctors often prescribe antibiotics for viral infections, whose symptoms can be mistaken for bacterial infections. Researchers emphasize that patients need to understand that antibiotics are not harmless if taken without a prescription.


In a study of 291,234 physicians, researchers found that physicians at private practices are lagging behind those at group practices and hospitals in electronic-health record (EHR) use and health information technology adoption overall. Comparing rates of attestation and attrition among independent versus integrated physicians from 2011 to 2016, researchers found that 49 percent of independent physicians who attested to meaningful use at least once during the program, compared to the 70 percent of integrated physicians who did so. In addition, only 50 percent of the independent physicians that attested to meaningful use between 211 and 2013 did so in 2015. These findings point to a “growing digital divide” between independent and integrated physicians, the roots of which are unclear.


Members of the U.S. Senate Finance Committee announced a bipartisan proposal to lower prescription drug costs that could save $100 billion in costs to government healthcare programs, on which the committee will vote on Thursday. A White House spokesman expressed support for the package, which aims to keep drug prices down by requiring pharmaceutical companies to pay rebates to Medicare if they raise prices of drugs more than the rate of inflation. The proposal would also cap out-of-pocket costs for the self-administered prescription drugs covered under Medicare's Part D, as well as changes to the program's Part B, which covers physician-administered drugs.