News From ACFAS

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Get a strong start to August with the newest ACFAS e-Learning podcast, “Healthcare – Future Leaders.” Two Fellows of the College interview Robert M. Pearl, MD, about what he sees as the future of healthcare in the United States under PPACA.

“It will be a change for the better,” says Dr. Pearl, “and a change for the worse. The determinant will be how we as doctors react — whether we are willing to become leaders in improving the quality and personalization of care to our patients, but in a way that makes care more affordable.”

Listen in to this inspiring and complimentary addition to the ACFAS e-Learning library! Dr. Pearl is CEO of the Permanente Medical Group and the Mid-Atlantic Permanente Medical Group, and a frequent lecturer on how to position a medical practice for success in this time of change. In July the ACFAS Board of Directors approved a new position statement on truth in advertising. Because presenting accurate and reliable information to the public is especially important in healthcare professions, this position statement addresses the need for members of the College to represent themselves and their abilities in a truthful and trustworthy manner at all times. Foot and ankle surgeons, as valued members of the healthcare team, should put their patients’ needs first and help them to make informed choices about their healthcare needs. Foot and ankle surgeons should also subscribe to high standards in regard to publicity about their services and their colleagues.

The full text of the statement can be found on the ACFAS website. ACFAS President Glenn M. Weinraub, DPM, FACFAS, expressed thanks to Senators Grassley and Schumer for their leadership in introducing federal legislation recognizing foot and ankle surgeons (DPMs) as physicians in Medicaid. The College applauded the action and pledged its support.

In a related matter, the furor over the debt ceiling may have cooled but many physician advocacy organizations are warning about the complicated timing of the work of the deficit reduction panel, which will have to offer $1.5 trillion in cuts by Nov. 23 and secure congressional passage by Dec. 23. This is the same timeline when Congress will need to find billions of dollars to again delay the 29.5% cut in 2012 Medicare physician reimbursements.
Find trusted instruction at ACFAS’ practice management/coding workshop in Las Vegas, Oct. 14–15, and get a unique, value-added benefit: a private consultation with ACFAS coding and billing expert Douglas G. Stoker, DPM, FACFAS. To schedule a coding consultation at the course, e-mail kristin.hellquist@acfas.org.

Visit the ACFAS website today for the full program and convenient online registration.
Apply by Sept. 1, 2011, for support for your research with the 2011 ACFAS Clinical and Scientific Research Grant. Fellows and Associate Members can receive up to $20,000 for research in podiatric foot and ankle surgery that will be of interest to members of the College.

The ACFAS Research Committee is encouraging use of a scoring scale, including the ACFAS Scoring Scale, which was recently fully validated by a volunteer ACFAS task force. Find the Scoring Scale, its Validation, the application and more information at acfas.org/grant.

Legal Briefs

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In Forest Ambulatory Surgical Associates vs. United Healthcare Insurance, a U.S. district court has ruled that the former, a healthcare services provider, cannot continue with its action against the latter, alleging the insurer underpaid or failed to pay for services the provider rendered to patients covered by United health plans. In granting United's motion to dismiss the provider's action, the judge found that the complaint failed because it did not reference the terms of the controlling Employee Retirement Income Security Act plans.

Foot and Ankle Surgery

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Researchers reviewed the outcome of distal chevron metatarsal osteotomy without tendon transfer in 19 consecutive patients (19 feet) with a hallux varus deformity following surgery for hallux valgus. All patients underwent distal chevron metatarsal osteotomy with medial displacement and a medial closing wedge osteotomy along with a medial capsular release. The mean hallux valgus angle improved from –11.6° pre-operatively to 4.7° postoperatively, the mean first-second intermetatarsal angle improved from –0.3° to 3.3° and the distal metatarsal articular angle from 9.5° to 2.3° and the first metatarsophalangeal joints became congruent post-operatively in all 19 feet. The mean relative length ratio of the metatarsus decreased from 1.01 to 0.99 and the mean AOFAS score improved from 77 to 95 points. In two patients the hallux varus recurred. One was symptom-free but the other remained symptomatic after a repeat distal chevron osteotomy. There were no other complications.


Researchers evaluated operative versus non-operative treatment of acute rupture of tendo Achillis. Eighty patients with an acute rupture of tendo Achillis were randomized to operative repair using an open technique (39 patients) or non-operative treatment in a cast (41 patients). Patients were followed up for one year. Re-rupture occurred in two of 37 patients (5%) in the operative group and four of 39 (10%) in the non-operative group. There was a slightly greater range of plantar flexion and dorsiflexion of the ankle in the operative group at three months which was not statistically significant, but at four and six months the range of dorsiflexion was better in the non-operative group, although this did not reach statistical significance. After 12 weeks, the peak torque difference of plantar flexion compared with the normal side was less in the operative than the non-operative group (47% vs 61%, respectively, p < 0.005). The difference declined to 26% and 30% at 26 weeks and 20% and 25% at 52 weeks, respectively. The difference in dorsiflexion peak torque from the normal side was less than 10% by 26 weeks in both groups, with no significant differences. The mean Short Musculoskeletal Function Assessment scores were significantly better in the operative group than the non-operative group at three months (15 vs 20, respectively, p < 0.03). No significant differences were observed after this, and at one year the scores were similar in both groups.

Practice Management

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Equipment leasing may be the solution to healthcare organizations' problem of complying with a federal directive for meaningful use of electronic health records, using diagnostic equipment, and exploiting technological advances in treatment options, without incurring high costs. Among leasing's benefits is the fact that medical practices can reduce its net costs by deducting the lease payments from income; 100 percent financing; immediate write-off of the dollars spent; the lessee's ability to add or upgrade equipment at any point during the lease term; the ease of upgrading or adding technology solutions; the leasing company's asset management responsibility; swift response to new opportunities with minimal documentation and bureaucratic obstacles; improved cash forecasting; flexible end of term options; easier financing than loans; tax benefits; and the bundling of "soft costs" such as training and support into the lease payment, making all costs associated with a technology acquisition easy to budget.


It can be argued that interactions that patients, their family members, and others have with a medical practice's staff can have the greatest impact on that practice, and consultant Ann Maloley says that a practice has to live up to its brand claim in order to achieve success. She says that communicating to employees what the brand really stands for is the first step in aligning staff with the brand. "To say you're patient-focused or to say you provide extraordinary care or exceptional service doesn't mean a whole lot to staff unless they can see it in what they do day to day," Maloley notes. She also says that being cognizant of employees' role in branding offers an opportunity to understand what a solid brand's key access and services are. Upon the establishment of the desired brand identity, the next step for physicians is to guarantee that the brand is reinforced by all practice members, which means that employees have to comprehend and accept the brand identity.


The social networking site LinkedIn can be helpful to physicians, with experts noting that a LinkedIn profile is easy to start, maintain, and keep up with colleagues and health industry news. LinkedIn also offers a way to keep tabs on new opportunities and even new patients. Experts suggest a range of tips for maximizing LinkedIn's value to physicians, including maintaining a current profile even if the doctor is not seeking a new job, as it supports the physician's continued relevance. Even if a doctor has no plans to interact daily with other LinkedIn users, maintaining a full profile will at the very least give people general information. MDSearch's Ed McEachern recommends that a LinkedIn profile should not be a cut-and-paste of a physician's curriculum vitae, but should be a clear description of what the physician does. The profile also should be made public, while the physician should recommend people for whom he or she would write a referral offline. Referral swapping is a practice to be avoided, and a strategy for soliciting recommendations should be developed. Engaging with discussion boards will help physicians establish a brand and build their reputation, and keeping the LinkedIn page separate from nonprofessional social media activities is critical. Finally, LinkedIn enables physicians to maintain a reading list as part of their profiles, and it also offers an opportunity to narrowly search for contacts or professional groups.

Health Policy and Reimbursement

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The American Medical Association and 91 state and specialty medical societies have submitted formal comments to the Centers for Medicare & Medicaid Services (CMS) expressing concern over the proposed changes to the e-prescribing penalty program. The comments express concern over applying physician penalties in 2012 based on the last-minute 2011 reporting requirement, not enough time to apply for an exemption from the 2012 penalty, and the lack of an additional reporting period in 2012 for physicians who couldn’t comply with the program requirements in 2011 through no fault of their own. The groups urged CMS to take advantage of President's Obama's recent call on federal agencies to reassess and streamline regulations.


The future of a national health system reform law initiative to investigate alternatives to the medical liability system is in a state of limbo as a result of the high potential for a legislative impasse between the divided Congress and President Obama on the additional $50 million program authorized by the health system revamping. The Health and Human Services secretary was authorized by the health reform law to provide demonstration grants to states to explore the "development, implementation and evaluation of alternatives to current tort litigation for resolving disputes over injuries allegedly caused by healthcare providers or healthcare organizations," but lawmakers must approve appropriations for the grants and the level of congressional backing for the program is unclear. Although the president did not call for funding specifically for the demo program, his fiscal 2012 budget request includes $100 million for states to reform the way they manage medical liability disputes, and Obama has conceded that physician concerns about lawsuits may encourage doctors to order more tests and care than is medically required.

Medicine, Drugs and Devices

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The next 14 months will bring generic versions of seven of the world's 20 best-selling drugs, including the top two: Lipitor and Plavix. The wave of expiring patents on brand-name drugs means generics will flood the market over the next decade, enabling patients, as well as businesses and taxpayers who help pay for prescription drugs through corporate and government plans, to collectively save a small fortune. As a result, the number of people jeopardizing their health because they cannot afford medicines should be significantly reduced.


Researchers examined what features of orthoses (design or hardness) influence the perception of comfort by using the 100-mm visual analog scale (VAS) and ranking scale. Twenty subjects were consecutively allocated to two experiments consisting of five sessions of repeated measures. Comfort measures were taken from four prefabricated orthoses in each session using the VAS (experiment 1) and ranking scale (experiment 2). Subjects in experiment 1 were also asked to rate each orthosis relative to their shoe using a criterion scale. Measures were taken in both walking and jogging. A soft-flat orthosis was found to be significantly more comfortable than all contoured orthoses, including one of the same hardness using both the VAS and ranking scale. Using the VAS, differences between the soft-flat and contoured orthoses were also found to be clinically meaningful for dimensions of overall comfort and arch cushioning (>10.2 mm). Perceived comfort of orthoses significantly differed between walking and jogging on the VAS but was not clinically meaningful. Comparisons between the VAS and criterion scale detected a VAS difference of 11.34 mm between orthoses judged as comfortable as my shoe and slightly more comfortable than my shoe. There was a VAS difference of 17.49 mm between orthoses judged as comfortable as my shoe and slightly less comfortable than my shoe.


The Mayo Clinic is building what could be the next generation of health information exchanges (HIE) with a group of healthcare providers in southeast Minnesota. Mayo will utilize natural language processing to identify terms in different electronic health records (EHRs) so that they can be mapped to a normative terminology, allowing the creation of databases that transcend the differences between the vocabularies in disparate EHRs. Open-source natural language processing software within a framework established by the IBM Watson Center will furnish additional context so that clinicians and researchers can put patient data from various sources to better use. The Mayo researchers have so far applied their new tools to records of 30 diabetic patients at Intermountain Healthcare and some 10,000 patients from the Mayo Clinic. Christopher Chute, MD, a Mayo Clinic epidemiologist and the principal investigator on Mayo's SHARP grant, anticipates that in the long term the tools Mayo is devising might be helpful in clinical trials and in triggering clinical decision support. He also notes that one day it might be possible to apply natural language processing to physician dictation, so that terms could be inserted into discrete fields in an EHR.