Hey guys, Don here. Welcome to Podiatry practice.
Master. I'm going to go over the
$1,000,000 minute. So these are things that I go
over that would help what things that help me get to the
$1,000,000 mark and beyond. So I, I'm still struggling a
little bit with my new medical record of, of writing down all
the patient information. I think it's because I'm more
preoccupied with my charting right now that I am like
documenting these things. I just, a lot of times just want
to get, get done. It used to be a little bit
easier. The, the print out of the
patient list was a little bit easier.
The, the newer 1 doesn't leave me enough room.
So I'm, I'm trying a different 1.
So I'll go over the main ones here.
So the first one was a 53 year old female.
They got a Lamisil booster. They originally had tinipedis.
Things are doing better. So kind of medication management
that's continuing with this medication.
Next was a 45 year old man. He got the Pelto special.
So that night splint foam rolling morning stretch due to
plantar fasciitis and we're starting a shockwave number one
out of three. The reason I'm doing less versus
the like the 6th probably because I think I prejudged this
patient, frankly, I, I, and also I think he only had pain for a
couple of months and so that's why I put it down to three.
I'm trying to do more 6, but I'm still finding that my tendency
of if they haven't had it longer, I'm starting on with a
lower number and then I can do more later.
I also did an ultrasound same day.
I think there's a big key with doing shockwave and doing it the
same day and along with the ultrasound.
I find that when I'm doing ultrasound the same day, I can
show them the anatomy on one side, the other, and that's
really my number one thing that helps explain to patients that
the anatomy is different. That's the reason for the
shockwave. And then if I can start the
shockwave the exact same day, it really speeds things up with
patients adherence because they already start the process and
then they'll continue on with the other treatments.
It makes it much more efficient for them.
I think in the past I used to, I was like I was too busy and I
was kind of scheduling things out.
I just find if if I can take the five to seven minutes and just
do it that day, it's much better to start treatment same day when
you're doing when you're doing shockwave.
So just so everyone knows when I talk Shockwave, we have two
radial machines and then we have a focused and a soft wave.
So we have radial in both offices and then one of our
offices focused and one of them has a soft wave when we kind of
use them interchangeably. And my results seem to be
interchangeable at this point. Just so you guys know, next was
a 73 year old female, kind of had a bad ankle sprain and I put
them in an ankle brace and I'm going to follow up in about 3
weeks with possible ultrasound to look at the ligaments.
I, I don't, I didn't do the ligaments the first day just
because of all the swelling and I was going to do it at the
follow up one. It might be more of a like a
confidence level on my, on my end of things looking at the
lateral ankle ligaments and maybe I should be doing it the
first visit for these patients. But I, I, I wasn't doing the
ultrasound. If anyone was really good at
ultrasound looking at the ligaments, let me know if you do
it the first visit. I'd like to know what other
people are doing next. Was this is that that anterior
calcaneal kind of beak fracture that we're doing?
We're #5 out of 6 for this female.
She's feeling better kind of getting out of her Cam boot.
I'm hoping that's healing in there.
I'm going to do #6 next time and I'll get an X-ray at that time.
Next was a 62 year old. This is a woman that came in.
She had previously had a kind of a midfoot fusion, first, second,
third, my cuneiform joints. And that was about four years
ago. That that surgery looks solid
and she is here now. She had a ankle sprain and she
fractured her fibula. So I put her in a tall Cam boot.
She's a very active like pickleball player, at least
pickleball. I tend to find that they're
really active and they want to do anything they do they can to
get better faster. And so for her, I am doing 4
sessions of, of shockwave, both to get down the swelling, but
also to help kind of heal things a little bit faster with the,
with the focused shockwave. So we're going to be doing that
for her. Now.
This would be kind of an MVP most valuable patient because of
the shockwave for this patient, because you get the, you get
the, the non operative fracture treatment, you get the office
visit, you get the Cam boot and then you get the four sessions
of shockwave. Who are the ones that are
wanting to do shockwave for fractures?
It's usually the ones that are in a hurry to get back to
activity. Now, can the shockwave heal the
bone faster? It might heal a little bit
faster, but what the research shows is that return to play or
return to activity is speeded up.
And for her, this is what's important.
So because we know it's longer than the six to eight weeks that
takes to heal this the return to activity because of the the
tissue around it as well. So I'm going to be treating the
tissue around with the radial and then the fracture side
itself. And then I think you might speed
it up maybe 20% with the fracture healing, but the return
to activity will be increased that that's anyway the way I
understand it. I'd like to know what other
people think about this. Shoot me an e-mail
don@podiatrypracticemastery.com if you have any comments on
these things or if you guys practice a little bit different
and I will share it with with other people.
Next was a, this was a patient that had a fourth and 5th digit
maceration. I want to talk through this one.
So 4th and 5th digit maceration kind of have toes that were
tight been that way for years kind of has a bunion, tailor's
bunion that are pushing the toes together.
So the kind of the take away to make this like kind of more of a
larger check is when I, when I originally when she came in,
there was a Cellulitis. So I put her on antibiotic.
There was an ulcer. So I had to briided the ulcers
was ulcer to bribe the first time had lambs wool betadine
dried out. Second visit today wearing kind
of wider shoes. Maceration is getting better and
we, I talked to her about possibly doing an arthroplasty
in the future because the toes, the bones are kind of rubbing
against each other. So I, I think the mistakes I've
made in the past is when there was a maceration in there, I
just kind of curetted some of the maceration out, but I did
not debride the ulcer. So in this case, debride in the
ulcer really kind of brings up the level of the visit,
especially with the antibiotics. And then instead of just like,
OK, C maceration or a lot of these ulcers, I think we're
seeing the ulcers, we're dividing the ulcers, but we're
maybe treating them as calluses or not billing fully.
So I think this is something just to keep keep in mind.
And I think a lot of times, frankly, it's because the
documentation is, is challenging and we're doing it because we're
lazy, because it's easier just to trim a callus and, and even
though it is an ulcer and but the documentation for the ulcers
a little bit more challenging. So just something to to kind of
think about. Next was a 13 year old.
I did an Ind for an ingrown toenail.
No follow up. Next was a 35 year old.
This was a this fibular sesmoidectomy.
She had a little bit of sutures, some vicryls that were kind of
coming out of the incision. So I removed those.
She's still kind of recovering from that.
Next was a 55 year old that a partial nail avulsion and
debrided a couple of the nails. Next was a 69 year old female
with posterior tibial tendonitis.
So this is kind of a challenging one.
She has a lot of ankle arthritis, midfoot arthritis,
but what's hurting her is the posterior tibial tendon.
And she thought she had gout. So she had a kind of a slightly
elevated uric acid and she was treated kind of with gout with
like a Medrol dose pack. But where her pain really is is
the medial ankle towards the tendons like the posterior
tibial tendon, maybe the flexor digitorum.
I did an ultrasound today. I saw some thickening and
effusion around those tendons and she's going to be going on a
vacation. So I, I did a little bit of
cortisone in that area and I talked to her about when she
gets back from vacation to start shockwave.
So that'll be, I'm going to see her back in about four to six
weeks. I tend to, if I do cortisone, I
don't do shockwave for four to six weeks to get that out of
their system. And then I'll start some
shockwave because you know, she has kind of a Pez planovalgus
type of a foot and versus like a surgical repair.
I think getting her with a shockwave with that tendon and
then getting her into some type of an AFO would if she's willing
to do that, either AFO or an orthotic.
I find a lot of times females are quite vain and are not
wanting to wear the AF OS. They do a little bit better with
a more of a stability orthotic. Next was a 72 year old.
This is a female that has she had a cyst trained twice and she
had a bilateral bunion. So she had said there was a
ganglion over the bunion. It didn't really come back.
She she said she didn't want to get X-rays.
So this was 1. I don't know if I was just busy
or what. Usually patients come in a lot
of times they tell my staff they don't want X-rays.
I can usually have them get X-rays when I talk to them
explaining that to them. I, I sometimes find when
patients have a strong accent, I have a hard time being more kind
of authoritative with them or telling them what they need
because of, because, because of the language barrier.
I find sometimes this language barrier can be a challenge like,
and, and so this, this patient, she was, I have a lot of
Albanian patients and I just, I just find it hard with the, with
the accent. Maybe I'm afraid they're not
understanding me why they need the X-rays, but she does need
X-rays. She just did not want to do them
yesterday. And, and, and then I then I get,
I get struggle with the accent and I just kind of go on and,
and OK, forget about it. But probably would have been
better to get the X-rays, at least some baseline X-rays for
her. She said she had them somewhere
else. That's why she didn't want to
repeat them and she was worried more about the quote UN quote
cyst. But she does know me from the
hospital. She works at the hospital and
she's wanting to consider bunion surgery, but maybe just not
today. So I, I did not get the X-rays
today. Probably for practice management
would have been better to get those X-rays.
And she did bring a friend with her that had bunions as well.
So we talked to her about her friends bunions as well.
Next was a 82 year old female. She had kind of like 2nd and 3rd
digit hammer toes that were dorsally dislocated or
contracted and she had painful second metatarsal head and a
callus down there. So I trimmed the callus but I
really said she needed more work with that second metatarsal.
There's really no fat pad underneath there.
So we talked to her about orthotics.
She didn't, I think she was a little upset.
I think she might have been waiting a little bit.
And this was one that was kind of a struggle when they're
waiting and you feel bad because you're already you're already
starting behind and they're already frustrated.
So I didn't do much for her and I felt like she wasn't too
pleased. So I'm probably going to call
her and make sure she's doing OK today.
So these are those ones that, you know, she came in, I didn't
really help her that much. She didn't have much of A callus
down there. And I actually felt guilty for
charging her for the callus because I was running behind.
So these are I'm just kind of sharing kind of the emotions
that I feel throughout the day. And so for this one, I feel like
I didn't do too much. I, I didn't, I didn't she feel
like she was connecting with me. She was kind of like
standoffish, you know, wanted to get out of there, you know, very
curt in her in her responses. And then the last patient was a
onycolytic nail bilaterally that this patient kind of got it
snagged on something. I didn't trim it all the way
back to where it was attached. And in a couple weeks she'll
come in for a carry flex. And I actually had another
patient that came in for bilateral carry flex as well
this day. So this was the day I think the
MVPS were these would tend to be the shock waves that I was doing
for these patients. And I feel like now that things
are calming down with the new medical record, I'm able to
focus more on and these types of patients once again, I'm doing
a, a new kind of a, a section in Podiatry management and, and the
next article is going to be on how to get a new associate busy.
So I'd like to know if, if you've had associates and if
you've been successful getting them busy, what you kind of did?
Because I think one of the struggles when doctors are
starting out, they don't have very many patients.
And how do we get them busy besides just kind of giving it
time? Do you throw money at AdWords?
Do you have them get out into the community?
What, what is it that you do to get the patients busy?
If, if, if you have good tips or things that don't work, let me
know. Okay, So I can include that
newsletter. Shoot me an e-mail
don@podiatricpracticemastery.com. Also, just let me know how
you're liking this if you find this beneficial.
Okay, have a great day.