December 2012

Keeping Patient Wait Times Down In Your Office

By Brian McCurdy, Senior Editor

In the midst of a busy day treating one patient after another, things inevitably threaten to throw your practice’s well-oiled machine off balance. How can your office avoid the pitfalls and keep things running smoothly so patients have reasonable wait times?

   For Jonathan Moore, DPM, the key is delegating and teaching key staff members how to know which slots in the schedule should go to new patients and which should go to established patients, given that new patients require extra time. To this end, Dr. Moore recommends scheduling software so one can adjust time blocks within the schedule, saying this can help better negotiate a busy schedule with appointments that vary in length.

   David Helfman, DPM, says it can speed up the process if patients go to the practice website to complete their paperwork and send it to the office prior to their visit. If possible, he suggests verifying patients’ insurance before they present to the office so the staff can prepare a chart and patients understand their benefits prior to seeing the doctor.

   “Making sure that activities that can happen out of the patient room do happen out of the patient room can help improve efficiency,” says Dr. Moore, a managing partner of Cumberland Foot and Ankle Centers of Kentucky. “We have many of our patients pick up orthotics, ankle foot orthotics (AFOs) and shoes in our retail center shoe store. There my staff is trained to get the patient ready and fitted before the doctor comes over to watch the patient and assess the products.”

   Similarly, Kevin McDonald, DPM, says his office has protocols for the most common diagnoses and keeps commonly used items (such as injections, wound products and biopsy kits) in the treatment rooms so there is less wasted motion.

   What common patient behaviors lead to longer waiting times and what can DPMs and staff do to correct those?

   Certain patients, such as the elderly, those with retinopathy due to diabetes and those with attention deficit disorder, may have a hard time filling out paperwork, says Dr. Helfman, the CEO and founder of Village Podiatry Centers in Atlanta. “It’s good for staff to ask the patient: ‘Would you like help filling out the paperwork?’ in a non-judging manner,” he suggests.

   Dr. McDonald notes several types of patients who can throw off the schedule. Some need extra time to tell their story and he will work on such patients while they talk, scheduling them at the end of the morning or end of the afternoon. He also says some children need extra TLC to endure a procedure and he will give nurses and parents “time to talk to the child about getting through the little boo boo.”

   “We have found it is better for everyone (and more profitable for us) to provide comprehensive and deliberate care to fewer patients than to provide rushed and sloppy care to too many patients,” says Dr. McDonald, one of the managers of the NC Podiatric Physicians and Surgeons Group in Concord, N.C. “If we have a busy period, we will start earlier, shorten lunch or extend the afternoon rather than simply cram someone in to an already full schedule.”

Study: Arthroscopy Effective For Some Ankle Osteoarthritis

By Danielle Chicano, Editorial Associate

A new study, published in Knee Surgery, Sports Traumatology, Arthroscopy, concludes that arthroscopic treatment is a favorable option for select patients with mild to moderate osteoarthritis.

   The study looked at 63 patients with mild to moderate ankle osteoarthritis who received arthroscopic treatment. Researchers used the Visual Analogue Scale and American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score to note patient improvements after surgery for up to two years. The largest improvements, researchers note, occurred after six months, with a decline thereafter.

   Todd Haddon, DPM, typically sees patients with ankle arthritis two to three times per week in his practice. Many of these cases are post-traumatic, requiring “fairly aggressive conservative treatment” explains Dr. Haddon, a Fellow of the American College of Foot and Ankle Surgeons.

   “Initial surgical options in our practice typically include an ankle-joint arthroscopy with debridement and microfracture with occasional use of particulate juvenile articular cartilage grafting,” adds Dr. Haddon.

   In regard to certain risk factors affecting procedural results, Dr. Haddon agrees with the study authors that body mass index (BMI) and large intra-articular lesions correlate with poor outcomes.

   “There have been several patients I have treated with arthritis that have made significant improvements in pain with weight loss alone prior to any surgery,” Dr. Haddon adds. “In addition, patients that smoke seem to not do as well, particularly when any bone grafting is taking place.”

   Similarly, Jesse Burks, DPM, sees ankle osteoarthritis very often in his practice, noting arthroscopy is beneficial with patients who have failed more conservative measures but may not require a larger procedure such as arthrodesis or replacement.

   “I always counsel patients that the arthrosis typically progresses and a more definitive procedure may very well be needed,” explains Dr. Burks, a Fellow of the American College of Foot and Ankle Surgeons who practices in Little Rock, Ark.

   Dr. Haddon also reminds patients to be realistic with their expectations following this type of surgery, noting as of yet, arthroscopy is just one treatment and not a cure.

   “As the article suggests, complete, 100 percent (recovery) is not often realistic and even significant gains may not be permanent,” adds Dr. Haddon. “Make sure patients are aware that arthritis is progressive and will often come back, causing difficulties again in the future.”

Is A Uniportal EGR System Effective For Gastrocnemius Equinus?

By Brian McCurdy, Senior Editor

A recent study in the Journal of Foot and Ankle Surgery notes that a one-portal endoscopic gastrocnemius equinus recession (EGR) system has potential in treating equinus, with advantages over a two-portal system.

   The study focused on 53 patients who received 60 uniportal EGRs. Patients’ mean preoperative range of ankle dorsiflexion was -2.9 degrees (± 1.9 degrees) while their post-op dorsiflexion was 12.8 degrees (± 1.7 degrees), an increase of 15.7 degrees, notes the study. The authors note four complications but no incidences of wound dehiscence or delayed healing, painful scar formation or infection.

   When compared to open procedures and other endoscopic techniques, study author Stephen Schroeder, DPM, cites numerous advantages to the uniportal EGR system. He notes one can easily perform this with the patient in the supine position, saving time, whereas open procedures need to occur with the patient prone or in an awkward frog-leg position.

   Dr. Schroeder also says the uniportal procedure lasts about four minutes from skin incision to closure and has far superior cosmesis when compared to an open procedure, which he notes is very important to a lot of patients. He adds that the lessened scar tissue theoretically should lead to an easier rehab.

   Furthermore, the uniportal approach is less likely to create neurovascular complications in comparison to a two-portal approach, notes Dr. Schroeder, the Chief of Podiatric Surgery at Peace Health Southwest Washington Medical Center in Vancouver, Wash. His EGR system provides better visualization and comes with a retractable blade, which he says is more accurate and leads to fewer complications. He notes the system in his study also protects the neurovascular structures and provides clear visualization of the aponeurosis before transection.

   The uniportal EGR does have a learning curve and Dr. Schroeder notes that improper portal placement and poor visualization can be potential problems with some systems.

   “I think these patients will do excellent” in the long term, says Dr. Schroeder. “The gastrocnemius recession has been well studied and is proven to be very efficacious in the treatment of gastrocnemius equinus. This safe EGR technique is a simple adjunct to the gastrocnemius recession, which allows the surgeon to perform the procedure more efficiently and with better cosmetic results for their patient.”

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