Established DPMs To Teach Residents Online

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By Brian McCurdy, Associate Editor

Podiatric residents will have access to the expertise of a diverse range of established DPMs thanks to a new series of online lectures. Podiatry Online founders Alan Sherman, DPM, and Michael Shore, DPM, have created PRESENT (Podiatric Residency Education Services Network) Residency Courseware, which will bring lectures to all residency programs through the Internet. Podiatric residents will now be able to access 52 weekly hour-long lectures online, beginning August 1. The goal of the program is to “equalize the access to high quality formal teaching materials by the nationwide community of podiatry residency programs,” says Jay Lieberman, DPM, the editor and director of content development for the courseware. “We need to achieve a higher uniform standard for didactic education in podiatric residency programs. We can look forward to the day that hospital credentials committees can review the application by a podiatrist for staff privileges and be truly confident that they know what he or she has been trained to do.” Among the nation’s 295 podiatric residency programs, there are “enormous variations” in the amount and nature of formal teaching performed, according to Dr. Sherman. He also notes that a survey of residency directors found most directors have difficulty fulfilling their lecture responsibilities — one hour a week — and they assign many lectures to residents. PRESENT helps residents fulfill the educational requirements of the Council on Podiatric Medical Education’s Document 320, according to the group’s Web site, www.podiatricresidency.com. The program has noted podiatrists on its advisory board and an editorial board composed of members of the Council of Teaching Hospitals (COTH) Executive Board. “We have been successful in getting incredible lecturers,” says Dr. Sherman, noting most of the DPMs the group has asked have agreed to participate. How Can This Program Help The Profession? Douglas Richie, Jr., DPM, who will provide a lecture on adult-acquired flatfoot for PRESENT, says the program will be “a valuable asset to any residency training program. “This will enable podiatric residents to have access to insights and opinions from clinicians outside of their own program,” comments Dr. Richie, an Adjunct Clinical Professor of Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College. “All too often, a residency program has a group of faculty or attendings who follow the same philosophy of practice. There may not be a lot of diversity or exploration of new treatment approaches in such settings,” says Dr. Richie. “With this new Internet-based education program, a large group of clinicians will participate with a wide variety of insights, experience and philosophies which can enable the resident-student to develop his or her own treatment pathways based upon a broad base of information.” Dr. Richie says the online courseware offers busy residents the convenience of listening to lectures whenever their schedules permit. Annual subscriptions cost $1,500 per resident and there are discounts based on the number of residents in a program. Dr. Sherman notes many residency directors are unaware of the generous government funding earmarked for educational services such as PRESENT. He notes the Council of Teaching Hospitals “has taken an active role in making residency directors aware that their hospitals have the funds to pay the fees and should be spending these funds on high-quality educational materials.” PRESENT has several corporate sponsors (led by Dermik Laboratories and Medicis) and Dr. Sherman says he expects all 52 lectures to be sponsored. Dr. Shore says PRESENT may be a key step in achieving a higher common ground between the various podiatric residency programs. In speaking to residency directors at the annual meeting of COTH, Dr. Shore asked them to “look at PRESENT courseware as an educational tool that will form the building blocks for curriculum and standardization, to bring about equality between our training programs and those of the MDs.” Study Examines Combination Therapy For Onychomycosis By Brian McCurdy, Associate Editor While there have been anecdotal reports in recent years of employing combination therapy to treat onychomycosis, the interim results of a new ongoing study provide a closer look at this therapeutic approach. The 48-week, randomized, blinded study, the abstract of which was recently presented by Aditya Gupta, MD, PhD, at a meeting of the American Academy of Dermatology, involved eight centers and three groups of patients with severe onychomycosis. Patients in two of the groups received oral terbinafine (Lamisil, Novartis) for the initial 12 weeks, with or without topical ciclopirox (Penlac, Dermik) continuing for 48 weeks. Those in the third group received ciclopirox for the entire 48 weeks and received terbinafine for the first four weeks and weeks nine through 12. According to the abstract, some patients taking both ciclopirox and terbinafine “converted to KOH and or a negative culture as early as week four” and most of the patients on the combination regimen had negative cultures by week 8. Among those taking only terbinafine, cure rates by culture or KOH were lower in the early treatment stages, according to Dr. Gupta, an Associate Professor in the Division of Dermatology, Department of Medicine at the Sunnybrook and Women’s College Health Science Center and at the University of Toronto. “These results suggest that combination therapy with terbinafine and ciclopirox lacquer may enable culture-negative results to be obtained sooner compared with terbinafine monotherapy,” concludes Dr. Gupta in the abstract. Commenting on the Gupta study during a recent lecture at the Western Podiatric Medical Congress, Warren Joseph, DPM, noted the differences in outcomes four weeks into treatment. Dr. Joseph, a Fellow of the Infectious Diseases Society of America, said that the negative culture rate was 27 percent for those who used terbinafine alone for four weeks whereas the negative culture rate was 89 percent after four weeks of ciclopirox and terbinafine. John Mozena, DPM, has found combination therapy effective in his onychomycosis empirical trials and says Dr. Gupta’s study validates the “forward-thinking” physicians who have argued that such combination therapy would be effective. As Dr. Gupta notes, the mechanisms of oral and topical antifungal complement one another. Dr. Mozena, a Fellow of the American College of Foot and Ankle Surgeons, concurs. He says while ciclopirox functions through chelation of trivalent ions, the mode of destruction of terbinafine involves cell wall synthesis by blocking squalene production. “These independent actions have now been shown to be additive in their effects, thereby increasing the efficacy of both medications in leading to a higher patient satisfaction rate,” notes Dr. Mozena. Editor’s Note: For more information about onychomycosis, see the continuing education article, “A Guide To Treatments For Onychomycosis,” on page 61. Malpractice Measure Passes In Texas By Brian McCurdy, Associate Editor Texas physicians will receive some relief after the recent passage of a malpractice bill that caps noneconomic damages. The bill, which takes effect in September, places a noneconomic cap of $250,000 on a lawsuit against a single practitioner sued individually or against a single health care institution. When more than one institution is involved in the suit, the cap for all health care institutions, including all people and entities involved, is $500,000 for each claimant. “Podiatrists usually have a lower malpractice suit frequency so they should not be affected as much as higher risk/higher damage award specialties, such as neurosurgery and OB/GYN,” says attorney Jeffrey Cohen. “Still, in the whole, it is a positive development for podiatrists.” Richard Pollak, DPM, MS, practices in Texas and agrees the law is a good move that will help contain premium costs. He says he pays about $11,175 a year and his costs have only increased a little. Dr. Pollak says it’s rare for Texas doctors to pay settlement costs out of their own pockets. He notes that the cap allows practitioners to only have to carry enough insurance to meet the cap as opposed to being insured for millions of dollars. “News like this is pretty exciting. I think it’s worthy legislation,” notes Dr. Pollak. “We can avoid some of these problems going on in the eastern states.” Cohen says meaningful non-economic damage caps should have a beneficial effect regarding the cost of malpractice insurance since it should slow rate increases. Caps should also force plaintiff attorneys to screen more closely for frivolous lawsuits because they would drive down the profit. However, Cohen notes meaningful tort reform must include more vigilant and effective peer review, which should include such things as external review, strengthened immunity for participants and review by qualified physicians within the specialty of the reviewed physician. As Dr. Pollak notes, attorneys have been running newspaper ads in Texas requesting those with malpractice lawsuits to bring them to attorneys before September 1, when the caps take effect. Federal Malpractice Cap Fails In Senate Although malpractice caps passed in Texas, the United States Senate refused to consider a similar federal cap, as this issue went to press. Senate Democrats opposed a Republican-backed bill that would have capped noneconomic damages at $250,000, based on California’s MICRA program. New APMA President Elect Grateful For Honor By Brian McCurdy, Associate Editor As the American Podiatric Medical Association (APMA) meets this month in Washington, D.C. for its annual scientific meeting, it does so with a new president elect in Lloyd Smith, DPM. The Chairman of the APMA Health Policy Committee, Dr. Smith says he is “deeply grateful” to the membership, calling his office “the highest honor our profession can offer.” As the American Podiatric Medical Association (APMA) meets this month in Washington, D.C. for its annual scientific meeting, it does so with a new president elect in Lloyd Smith, DPM. The Chairman of the APMA Health Policy Committee, Dr. Smith says he is “deeply grateful” to the membership, calling his office “the highest honor our profession can offer.” Dr. Smith, who practices in Newton Centre, Mass., notes he is committed to supporting the association’s strategic plan and will encourage the membership to act accordingly. “I hope to see the key areas of policy and practice, public relations and corporate development continue their positive growth,” he says. An active proponent of HIPAA preparedness, Dr. Smith believes the majority of DPMs are implementing the privacy standards outlined in the APMA Privacy Manual. He does express concern, however, that the looming deadline for transaction standards may “severely impact” the association members’ financial well-being. “Podiatrists must get proactive with their practices, their vendors and their payers to ensure their practices will be compliant,” with HIPAA regulations, implores Dr. Smith. “If they fail to heed this advice, payments after the deadline of Oct. 16, 2003 will cease and those practices not in compliance will suffer severe financial hardship.” In the area of scientific research, Dr. Smith is particularly interested in extracorporeal shockwave therapy, which he calls “the most compelling advance in the treatment of heel pain that has been seen. “I trust that the ongoing double-blind studies will confirm the validity of that treatment so that the epidemic of heel pain sufferers will benefit,” says Dr. Smith. Since 1994, Dr. Smith has been a member of the APMA Board of Trustees and is also an advisor to the Health Systems Committee and the Coding Committee. From 1992 to 1994, he was President of the Board of Trustees of the Fund for Podiatric Medical Education. He is on the surgical staffs of hospitals which include Beth Israel Deaconess Hospital, Newton-Wellesley Hospital, St. Elizabeth’s Hospital, all of which are in the Massachusetts area. Clarification In the July continuing education (CE) article, “Managing Ulcers on the Charcot Foot,” the sidebar on page 79, entitled “A Brief Historical Overview of Charcot,” should have contained the following passage: “In 1868, neurologist Jean-Marie Charcot described the degeneration of ligaments and joint surfaces in a particular patient population. His work was conducted during his clinical experience with patients of tabes dorsalis and other neurological disorders at the Salpetriere Hospital in Paris. It was concluded that many of the vast changes observed were secondary to a loss of neurologic sensation in these patients.” In Brief Moore Medical Corporation has obtained the exclusive rights to distribute Tripod Labs’ line of six over-the-counter topical foot care products. The products include: Nailstat® Formula for fungal nails; Plantarstat™ for plantar and common warts; and Flexstat™, a topical pain reliever.

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