Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
Mountain View Medical &
Surgical Associates,
Madras, Oregon

Provide the Most Comprehensive Care

When I was a student on a clerkship rotation, I observed a resident examining a patient with plantar fasciitis. During the exam, the resident examined the entire foot, as we would all do. Though, I kept thinking the resident seemed to be looking for other areas of pain that had nothing to do with the plantar fasciitis. I was suspicious; it seemed the resident was looking for new pathology to treat, as if the plantar fasciitis wasn’t enough. I remember thinking the resident was just looking for more surgical cases, not necessarily trying to take care of the patient.

I remained suspicious several years later, until I realized just how close-minded I had been at the time. In the years since my clerkship, I've had the chance to both observe and be that physician that has provided more comprehensive care to his patients. This is one of the characteristics I've seen in the best doctors: global care.

Let's take an example to illustrate. The other day I had a new patient complaining of an ingrown toenail. During the interview, it came out that the patient had a long-standing contralateral dropfoot deformity for many years after lumbar back surgery. The surgery had been successful in relieving his back pain, but unfortunately, left him with an L4 to S1 motor and sensory neuropathy. After attempted physical therapy, he was told nothing else could be done to help his dropfoot, so he managed the best he could over the years. During our conversation, he discussed the occasional trips and falls as his right foot dragged on the ground. Luckily, he had suffered no more than bruises. Amazingly, no one had even mentioned AFOs to him. After a thorough examination, including a full neurological evaluation confirming the nature of his dropfoot, I not only took care of his ingrown toenail, but also prescribed an AFO (I’m in the process of obtaining a DME license – my practice did not have one previously). As the simple result of my thoroughness and willingness to spend a few extra minutes with my patient, I had provided comprehensive care beyond my patient's expectations.

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As a side note, consider the income generation off this one patient if I'd had a DME license. I would have billed not only the E&M code and nail procedure code, but also the AFO code as well as future follow-up visits. For the surgically inclined, if his AFO didn't work out, he could undergo an ankle fusion. Additionally, once this patient realizes the improvement to his quality of life and walking restitution, he'll be more likely to refer other patients to me. All this from an ingrown toenail. All this from comprehensive care.

Let’s take another common example. Many podiatrists are consulted to take care of palliative care needs in the hospital. Although debriding diabetic toenails is no one’s favorite job, consider the opportunities here for comprehensive care. First, realize the importance of this job. You’ve decreased a patient’s ulcer risk by simply debriding nails and calluses. Second, the potential exists to find other pathological entities with a good exam. I’ve often found preulcerative and frankly ulcerated limb-threatening lesions on many patients during my examination. You may have just decreased the BKA statistics by one patient by simply taking a few extra seconds to thoroughly examine your patient. Third, this is your chance to educate the diabetic patient. We know education is the key to prevention. Fourth, this patient may qualify for ancillary services such as diabetic shoes. Fifth, your "toenail" patient has a family and friends, and they have foot problems too. I see many patients brought in by a family member, only to have that family member slip off their shoe and ask me about their foot problem. Another new patient!

Do you provide the most comprehensive care possible? Ask yourself some of the following questions. If you answer “no” to any of these, then consider if you’re truly as comprehensive with your care as you think.

Do you allow patients time to tell their story? Do you listen? Do you ask open-ended questions?
Does your staff check a full set of vital signs (height, weight, blood pressure, pulse rate, respiratory rate, temperature, pulse oximetry)? I’ve caught quite a few undiagnosed hypertensives.
Do you ask a review of systems? This is also important for documentation and coding purposes. If you’re going to prescribe an NSAID you’d better be aware of gastric diseases and coronary heart disease, for example.
Do you perform a full lower extremity podiatric exam or a “focused” exam only relating to the complaint?
Are you aware of associated deformities or pathologies that may contribute to the primary complaint? For example, do you evaluate for leg length discrepancies, pronation, hallux limitus, and ankle equinus in your plantar fasciitis patients? Do you at least Doppler patients with non-palpable pedal pulses? Do you check popliteal and femoral pulses? Do you check for carotid bruits in patients with PAD? You may just save someone from a stroke. Do you check patients’ heart, lungs, and abdomen in new onset extremity swelling? Do you check other body sites in suspected dermatologic lesions? Do you treat hyperhydrosis in patients with tinea pedis or verruca? The list goes on and on….
Do you communicate concerning findings immediately to the PCP? How impressed will your referring doctors be if you find the CHF exacerbation or the occluded carotid artery before they turn into massive complications? Remember, if you find something abnormal, you must at least send patients for the appropriate follow-up.
Do you send new patient and update letters to the primary care doctors (even if they didn’t directly refer your patient)? When they see your letter and the excellent care you provide, they’ll start referring.
Do you provide any ancillary services in the office such as arterial testing, ultrasound, nerve testing, durable medical equipment, etc? These provide patient convenience and profitability.
Do you stay current on the most recent advances in podiatric and general medical care? If not you’re probably not providing the most comprehensive care.

These are all “value-added” services that will help you stand out from the crowd. No one’s perfect. You’re bound to miss a step or rush through an exam here and there. Strive to maintain a consistent practice style, think through the pathology in front of you instead of knee-jerk cookbook treatments, and provide your patients with the world-class service you’ve been trained to perform.

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Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]