A TENS Unit For Heel Pain? Questioning The Ethics Behind Some ‘Practice Management’ Lectures

Allen Jacobs DPM FACFAS

I have had the opportunity to listen to so-called "practice management" presentations at a number of state and APMA component society meetings. To be quite frank about it, the content presented is nothing less than offensive as it advocates profit motive over patient care. What is even more shocking in my opinion is the seeming growing relationship of the APMA with these programs.

It is one matter to instruct practitioners on proper coding and effective management of an office, alert practitioners to changing health care opportunities or advocate other legitimate practice opportunities. It is quite another to advocate selling everything but the kitchen sink to every vulnerable patient. Effective practice management is one thing. Fleecing a patient is another. I wonder how the individuals who advocate some of the "practice management" protocols at our meetings sleep at night, knowing that their primary motivation is based totally on profit and not patient care.

One particular program addresses “protocols” for the treatment of plantar fasciitis. Have you seen or heard this program? Before the patient walks in the examination room, your office staff has already checked on benefits for the patient such as TENS units, physical therapy, orthotics, braces, shoes, etc. TENS units? For heel pain?

All patients are to get X-rays, diagnostic ultrasound and injections of the heel under ultrasound direction. All patients receive an immediate temporary orthotic, which requires several follow-up visits to gradually increase extrinsic posting. After all, we all know that rapidly putting anyone into 4 degrees of rearfoot varus can result in untoward disaster.

Everyone gets as much physical therapy as the insurance ...er ... the patient will tolerate. Then there are more injections. Then there is the real orthotic. Do not forget to sell them the shoes that the orthotic requires. Oh yeah, on the way out, have the patient pick up the night splint, CAM walker and brace.

Did I forget the topical lotions and potions? These are required to get the skin in shape for the mandatory low energy ESWT (provided at a reduced fee for the first three treatments), the radiofrequency coblation or the endoscopic heel spur surgery.

And a TENS unit for heel pain?

I guess they have not heard of platelet-rich plasma (PRP) yet or that would be included. One might also think about socks that make the orthotic more effective by increasing the coefficient of friction between the sock and the orthotic (orthosock?).

In short, sell the patients everything that they or the insurance will pay for.

I often wonder how proud these people are of themselves. I like making a nice living but I do so by hard, honest work.

What bothers me beyond the shear lack of ethics advocated, in my opinion, by these people is the average podiatrist who wonders why we are constantly fighting exclusion from various health care plans and why we are not seen as equals by many insurance carriers.

Simply stated, if you practice in this manner, you cost too much.

This is not providing the patient with the best care regardless of cost. This is providing the doctor with the most profit regardless of need.

Our profession has many legitimate leaders in practice management who pass on wonderful ideas, information and ethical proposals for increasing practice bottom lines.

If you have heard the aforementioned presentation at a meeting, I would love to hear your comments. I would like to extend these comments but I have to go. I have some heel pain patients that need some TENS units. Maybe I can also sell a kitchen sink or two.


Dr. Jacobs,

Bravo on an excellent article. It has been my experience that this is indeed the case.

We are caught in a no win situation here I'm afraid. The youger generation of practitioners have more and more debt to cover and insurances are paying less and less. How to make a living? I whole heartedly agree with you that the example you give in your article is fleecing the population and that this borders on the unethical. I would like to see at least some thought involved in the treamtent of the patient rather than how much money you can squeeze out of the insurance companies. There are ways to do this AND stimulate your income.

This also reminds of the situation with Custom Orthotics. At one time many insurances did cover this conservative treament. Unfortunately, this was abused, to the degree where people with ingrown toenails were getting orthotics, beacuse their pes planus was causing their nails to get ingrown (!). Most insurances don't cover orthotics anymore.

I love it when a man of character steps up. Dr. Jacobs has done just that. Too many podiatric "business men" were admitted in schools with the wrong motivation. Many of them are fighting the change for broader licensure and responsibility. To them, podiatry as it is, is "a nice business with an impressive title". Dr. Jacobs is right, efficiency is one thing, exploitation another. Robert Bijak,DPM

Thank you...........

I wondered if it was just me that was offended by the podiatric business. To be fair I think it is the medical business. I see this same mentality with other medical areas. I had (past tense)a partner recently that I would advise to treat his patients like family. Heaven help the family of many of us. It seems to me that we need to use those things that work the best without unnecessary financial trauma. Certainly there are times when we need multiple modalities but generally not. Dr. Jacobs is most appreciated by this podiatrist. Thank you.

Holman, DPM

Dr. Jacobs,

Great article. I am recent PMS36 graduate and had interviewed couple "profits motivate" private practices, never a big fan. I ended up taking a job at the VA hospital.

Dr. Jacobs,

We must look at every situation from every angle. I realize you want to hold onto your patients and keep them coming back to your office for your office visit billing. We need to create miracles these days with limited visits due to insurances. Unfortunately, podiatrists and chiropractors get slammed.

What about the school of thought that we need to do everything we can to get the patient better? I think people sleep just fine at night if they believe they are helping.

I believe there are too many DPMs who feel threatened that their patient won't return to the office for you to bill because they got more relief from either the TENS unit or orthotic.

Just another school of thought. I'm sure if I spent or my parents spent thousands of dollars putting me through school and I was losing control of my patients I would be upset too.


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