I believe the podiatry field is in a crisis. With the aging of the baby boomers, we have seen an explosion of patients with diabetes and non-invasive foot care into our offices. At the same time, co-pays are rising steadily while reimbursement decreases bit by bit, and insurance companies are refusing more claims. The results are higher workloads but lower income and profit in our practices. Unfortunately, this duality results in a rise in practice failures. What can we do to solve this dilemma?
To stop these trends from overwhelming us, we must look at what other medical specialties are doing to reduce their non-invasive workloads while enhancing their profits. We should look at what dermatologists and plastic surgeons are doing with the use of practice extenders in their practices. While this business model is new to these practitioners, it appears to be working smoothly, is very profitable and facilitates the addition of new patients on a regular basis without any extra effort on the part of the physicians.
Dermatologists and plastic surgeons are hiring licensed aestheticians to perform patient preparation, patient education, non-invasive care, facials and post-treatment follow-up. Then the aesthetician makes the patients’ appointments for regular aesthetic care, bringing them back into the practice on a regular basis to “maintain their skin.” Such maintenance includes injections and peels. 
As a result, these patients do not go elsewhere for future treatment care because they are familiar with the practice and the monthly visit for routine skin care is ingrained into their lifestyle. This routine care has the patients considering the practice as the place they will always go for services.
This business model also works in podiatry offices. About 10 years ago, I began working with medical nail technicians (MNTs) who were interested in raising their standards of infection control. I taught classes, gave speeches at conventions and allowed them to come into my office to observe.
In doing so, I learned a few things. These licensed nail technicians have superior dexterity, are already familiar with the feet so one can easily train them to work in podiatry offices, and the patients love them. When trained properly and under direct supervision, licensed nail technicians can debride a nail and perform callus reduction better than anyone else, even podiatrists. Meanwhile, we are off somewhere else performing more services and making more money.
The medical nail technicians are not just cosmetically trained. They are already licensed as nail technicians, eager to work in our offices and have taken advanced training to prepare them for this work.
Graduating MNTs have taken an advanced course (10 modules) online (see http://www.medinail.com ) that is designed to train them in: proper aseptic care (including the use of an autoclave); diseases and disorders of the feet; working with at-risk patients; and much more. Students must pass an exam. Graduates subsequently take part in a five-day internship in a participating podiatry office to be trained in the practical aspects of the information they learned during the course. After completing the internship, they receive the MNT certificate and are ready to go to work in a podiatry office.
The people interested in taking this course are caregiver-type nail technicians. Most are highly experienced in performing pedicures and prefer performing these services over all others in their field. They also are highly motivated toward working in a medical setting and have found it very rewarding to take the advanced training toward reaching this goal.
There are several scenarios for the utilization of MNTs who work in podiatry offices and each is according to the practice and the personality of the podiatrist. Some are listed below.
Assistant only. In this scenario, the MNT would perform debridement, callus reduction and noninvasive services in the podiatry office to relieve the podiatrist of the time these services take in his or her practice. The podiatrist does the consultation and then introduces the MNT, who performs the care.
Pedicurist only. The podiatrist refers patients to the MNT for monthly pedicures to ensure the safety of the patients during these cosmetic services. The office can also solicit people outside of the current podiatry practice patients for pedicures. Doing so may potentially lead to new patients when they come into the office for cosmetic pedicures.
Nursing home assistant. The MNTs can take the pressure off the podiatrists when they are working in nursing homes by performing noninvasive care and allowing the podiatrist to see more patients.
Technicians performing all of the above. In this scenario, the MNT performs medical assistant duties and cosmetic pedicures, according to the office schedule.
Podiatrists often start the MNT in one of these roles and then increase the work relationship to another level after seeing the benefits of having him or her in the office. Utilization of an MNT seems to “grow” on podiatrists quickly.
While podiatrists may be ready to incorporate an MNT into their practice as an assistant, few of us know how to set up an office to offer pedicures. However, with minimal suggestions, one can accomplish this in short order. Janet McCormick, MS, is proficient in aiding podiatrists in reworking their physical facility, designing their marketing and in hiring an MNT. She will readily provide support for one to accomplish this endeavor.
Making this change has worked for me as a new way of practicing. I currently have a MNT working for me and I am enjoying the experience as well as the additional income.
I have found the MNT to be very valuable in supporting my laser care, even to the point of expanding my profits. The MNT cannot use either one of the laser models directly on the feet. In my state, I must be the one to hold the laser. However, the MNT can get the toenails ready by performing the necessary debridement and other care needed prior to the procedure.
This reduces the amount of face time I need to spend with these patients. Accordingly, I can see other patients while the MNT is prepping the laser patient. If it were legal for the MNT to perform the laser care in my state, she would be performing the service after receiving appropriate training. (The MNT course provides a good introduction to the philosophy of the care.) In your state, the MNT may be able to perform the laser treatment care.
There is one more thing these technicians can do that we have not had in our offices before. They can bring unencumbered, non-insurance dollars into our offices by performing pedicures. Patients can enjoy safe and relaxing pedicures in our offices by a licensed nail technician who is trained to work aseptically with at-risk patients through a structured course.
These pedicure services are cash services that are immediately paid in full. The technician can then recommend good foot care products for these patients that will improve the comfort and appearance of their feet.
One of my pet peeves over the years has been the infected nails that I routinely see on patients who have had pedicures in salons that do not perform proper infection control. It especially concerns me when at-risk patients are going into these salons as there has been many recorded incidences of injury, even death. I feel that at-risk patients should not be having pedicures in nail salons unless they have been proven to perform aseptic pedicures.
For these reasons, in addition to the increased income, I find that offering pedicures in my office by my MNT is important for my patients. I intend to add another MNT and market “safe pedicures” to the public as podiatrists are finding this brings many potential patients into their offices. If the MNT notes an “out-of-normal” nail or foot condition, the podiatrist reports to the pedicure chair for a quick consultation. This brings a new patient to the medical side of the practice. Many times, patients go immediately to the medical rooms for treatment if there is time on the schedule for a consultation.
It is time podiatrists take a look at how other specialties are adding profits to their practices and how their methods can work in our practices. Their enhancement of profits through physician extenders works in their offices. Why not ours?
The truth is, physician extenders such as MNTs are out there for us now. They are trained and available. They can reduce our stress levels and go a long way toward facilitating additional profits in our practices.
Dr. Spalding is in private practice at Area Podiatry Centers with four offices in Tennessee.
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