What's the easiest way to do a skin biopsy in the office?
I frequently talk to doctors and and they say really, I don't
have any time and I practice to do biopsies.
It's too kind of complex. I think the, the reason we don't
do things in our office is because they're they're complex
and there is no easy system. I'm a real big systems person.
I think systems make things a lot easier.
And I want to explain a little bit of my workflow for biopsies.
I'm doing this in a couple of first couple of reasons.
One is because I'm going to be doing a lecture at a upcoming
APMA meeting or not APMA, but one of our like mass APMA
meetings about biopsies. And I just hear that, like
someone said, like with our Rep anyway, who looks at my biopsy
because I do a lot more than others and I don't feel like I
do a lot more. And I had one of the doctors in
our office actually sent me a patient to do a biopsy on today.
And I'm like, this seems so, so easy.
So let me let me talk you through what what I do.
So first of all would be like the room prep.
So all of my rooms on the bottom drawer, they have like specimen
bags and they have those little formaldehyde filled little
containers. I don't know if it's saline or
formaldehyde. I think it's, I think it's
formaldehyde little containers. And then they have 2mm punch
biopsies. So that's really it. 99% of the
time that's what I'm using and my process.
So for example, there was a patient that came in today that
needed a biopsy and one of my colleagues sent sent them over
for the biopsy. But even if they didn't, so the,
the process is like if I see if someone needs a biopsy, I have a
little button in my, in my room. So I click the button or I open
the door and that triggers my staff.
They come in and say I'm going to do a biopsy.
And then what that triggers to my staff is that I need one CC
of Lyta with EPI and I need a consent for a biopsy and that's
about it. And they do them when they do
the, the lidocaine first and then they do the consent second.
The reason they do that is so I can do the lidocaine, have it
numbed up, and then they come and get consent and then I can
do it. I do it all when I'm sitting
there. So literally it takes like 30
seconds to numb them because I just do a little wheel
underneath the lesion and then I take that 2mm punch.
I do one punch and I'll take a little tissue number, cut that
out, second punch, pull it out, put some gauze in a Band-Aid and
I'm done. And then my staff, if they
haven't got consent, they'll come in and get consent.
So it's really the most concise way to do biopsies that I know
of. And it literally takes me like
10 seconds to say that to my staff, 10 seconds to numb them,
and maybe 10 seconds to do the biopsy.
So it really doesn't take that long.
It doesn't really add anything. They don't have to come back.
The only ones I would have them come back for would be like nail
matrix biopsies. Those can be a little bit more
time consuming and I like to plan those.
But and also nail sample biopsies are really easy.
I just take a little clipping of the distal nail.
I don't call that a nail biopsy. I just call it like a nail
pathology sample. When I do an actual biopsy, it's
usually for like a Milano Nikki or something I'm concerned of in
the toenail. So that's how I do it.
I'd love to know what other people do or why you're not
doing it. It's pretty easy to do as long
as the staff knows what's going on.
OK, so let's go into this day. This is a recording from a
Tuesday in the office. First patient, 63 year old man,
right plantar fasciitis. He's 50% better.
I don't need to see him back because he is he is feeling
better. So he's 50 or probably a little
bit more. Next was a 62 year old female
had right carry flex. She actually came in from a
referral from one of my colleagues wanting carry flex,
but actually I think she benefited from Onifix better.
So carry flex by the way, is that fake toenail you put on
that makes it look good? Onifix is for ingrown toenails.
Now I'm using this a little bit off label I find with some
patients with onycholytic nails. I trim back the nail and I apply
it at the base. So I find that a lot of times
nails get thicker because there's micro movement.
So when they're oncolytic or detached, they they move more
and then they get thicker to kind of mitigate that extra
movement and to make it more stable.
So I think by putting the Onifix, which is like this
little resin that I put on the nail that like it's like a speed
bump and I put that on there and then it's kind of stabilizes it
as if it was a multiple layered nail that stabilizes it as it
grows out. Sometimes it can help it to
reattach, but this is actually one of the more challenging
things that I treat, getting nails to reattach and I'm not
that good at it, but I that sometimes works for some of my
patients. OK, next patient was a 49 year
old man. He had left plantar fasciitis
with Aquinas. He got my Pelto special which is
the night splint foam rolling in morning stretch and he also got
Meloxicam and I'm going to see him back in four weeks for an
ultrasound. Impossible shockwave.
Next was a 56 year old female for bilateral foot pain.
She this is kind of a challenging one.
She has these weird pains and she requested PT today and
requested disability and I don't do a lot of disability like
short term disability. But she had to come back again
today requested that and I gave her PT So I'm going to see her
back after two months. Next was a 59 year old female
for left foot fracture. She has pain that continues so I
ordered an MRI after having her in a Cam boot.
So I'm going to see her back after the MRI.
Next was a 62 year old male for a diabetic foot exam.
I did that that was a those really tend to be lower Level 3
visits and I'm going to see him back in one year.
Next was a 60 year old female for right second Med head pain.
She got meloxicam and if it's not better at the next visit, so
possible like capsulitis, I'm going to see her back.
She's going to do contrast baths, meloxicam in different
shoes. I'm going to see her back if it
if it's not if it's hurting continues to hurt, I'm going to
get an ultrasound but I did not make a follow up for her.
Next was a 77 year old man had a right lateral hallux avulsion
and, and he also wanted nail care and I'm not going to
actually, he wanted to be back for three months for, for nail
care. So I'm going to be him back in
my nail care time Friday mornings.
Next was a 53 year old man for a left lateral foot biopsy.
That's the one I just talked about or for one of my
colleagues here. Next was a 80 year old female
for this was kind of a, this is a good patient.
So she had right midfoot arthritis.
I got X-ray, I got ultrasound, I did a ultrasound guided
cortisone injection to two of her joints, the second MC joint
and then avicular cuneiform joint.
And then I talked to her about gapped lacing and I scanned her
for orthotics and I talked to her potentially in the future to
do shockwave for the bone marrow oedema.
Once again, doesn't help with the arthritis, but sometimes can
help mitigate the symptoms if the orthotics aren't sufficient.
I'm going to see her back in two months.
So that was a good patient because of the orthotics.
Next patient was an MRI 68 year old female MRI follow up for
plantar fasciitis. She had a lot of things that are
MRI reviewed that. Now one little tip, this is what
I tend to do. I tend to review X-rays before I
see the patient. I review MRI's before I see the
patient and I don't always show them the X-rays or the MRI's.
Sometimes they do, but a lot of times the patients don't know
what I'm looking at and they don't understand and they get
confused and it'll ask me what those two little dots are
underneath the big toe, the sesmoids.
And so but for this one I did go over the report a little bit and
I gave her as well a couple of injections because of the
midfoot arthritis she had. She also had a midfoot arthritic
joint and I did 2 Cortisones and due to the pain and the
arthritis I put her in a Cam boot.
So I did some DME for her. I'm going to see her in one
month. Next was a 53 year old man for
left Hallux Limidus. I talked to him mostly about
shoe gear because I think it was more of a shoe issue that was
irritating him. I'm not going to see him back.
Got X-rays and things like that. Next was a this was an MVP
patient. So let me tell you about this.
This was a Medicare patient that has mass health.
So these ones, they Medicare pays 80% mass health.
The patient opts to pay for 20% because we don't take mass
health, which is like Medicaid bilateral foot pain, bilateral
plantar fasciitis, bilateral aquinus.
So they got foam rolling night splints bilaterally and then a
morning stretch. And this patient we talked about
doing either cortisone or shockwave if they're not better
in about four weeks. So it was good because of the
bilateral night splints. Now I frequently do.
If they have bilateral symptoms, I'll do bilateral night splints.
In the past what I used to do is I say OK, we're at one night one
side, one night the other side. But I have no issues with
insurance covering 2 of them so I tend to get them too.
Next patient was a 46 year old with bilateral Achilles
tendonitis. So I did bilateral shockwave #3
out of 6. She was really kind of concerned
so I had to spend a lot of time just calming her down.
I think insertional Achilles tendonitis is one of the more
challenging things I treat with shockwave, but she tolerated it
well and she is seeing some progress.
Next was a 40 year old man for a right matrixectomy on the
lateral side and she he also did the kit.
So one thing I've learned for a couple of things, I can depend
on my staff and I think they do a good job at explaining like
why they need an even up with their with every single walking
boot. Like the even up is that thing
that you strap on the shoe. So that adds an additional $30
or why they need the Amerigel kit.
Every time I do a matrixectomy that's adds another like $60.00.
So, but I find that if I present it to the patients and then hand
it off to the staff just to fulfill it, it works a lot
better than them coming in and having to explain it.
I find a lot of times the, the staff have a challenge with
doing that. So I find helping it helps them
if I prepare them, prepare this patient for that.
Next was a 69 year old man. He had 4 swift treatments and
here he's back for his three month follow up and he is
feeling much better. And so I got a box of tips out
of that one because I did a, a YouTube short for that patient.
So just so you know, if you do swift and you do short videos
and you send it to them, they will give you AI think a box of
tips or at 1 tip or I don't know how much tips, but that's what
they'll do next was a 18 year old man that had he had Down
syndrome. So he had bilateral pest planus,
posterior tibial tendon dysfunction, athlete's foot and
nail fungus. So he got, I sent him to hanger
because once again he has Medicaid and no I'm sorry, Blue
Cross and I can't do AFOS. So he's going to get bilateral
wishy braces from hanger. Unfortunately I can't do those.
And then he's going to get the Pelto special for fungus, which
is he's going to get tribenafin and he is going to get LFTS.
He's going to get the UV light and shoe spray and the biotin.
OK next patient was a 75 year old female for right ankle
sprain. Follow up her sprain was feeling
better. She had a ATFL issue and now she
had some pain in the sinus tarsi.
So I did a cortisone injection in sinus tarsi and this was all
after her PT. She's going to transition down
from the ankle brace into more of like a neoprene base and then
she'll follow up as needed. She originally had an ankle
brace dispensed. 39 year old female next for wart that had
kanthridin. She's on #4 I think of this
kanthridin treatment. Next was a 41 year old female
for left second met fracture. This was another MVP because she
had a second met fracture. I gave her meloxicam like I do
for most patients. I dispensed a Cam boot and I
used fracture care for this patient.
So a fracture care, yes, there's a 90 D global, but I'm going to
see her back in four weeks and hopefully that'll be it for the
follow up. Next was a 48 year old man for
right shockwave #4 out of 6 he has on the MRI he had some bone
marrow edema around the subtalar joint region and I did a focused
shockwave there and then the radial shockwave on the
peroneals. And then the last patient of the
day was a 61 year old man. His Now this is a, this is a
challenging 1. He got new orthotics.
He had done well with his old orthotics for nine years and
developed plantar fasciitis again and I got him the
orthotics. I did bilateral cortisone
injections because he's a butcher and he owns his own
butcher shop so he can't take time off of work.
He didn't have much improvement with the with the cortisone
injections and I was a little paranoid because when I saw him,
he wasn't getting better. And I always get a little
concerned when they when they get new orthotics.
And I was like, yeah, I use the same company.
And so usually I use forward motion.
And then, but in this case, he previously had Northwest.
So I ordered NW orthotics just to make him just like the other
ones. And then it kind of dawned upon
me and this is a kind of mistake I made a lot in the past.
So I want to, I want to share this with everyone.
Patients, if they get orthotics too soon when they have plantar
fasciitis, the orthotics don't feel good.
And I know this is kind of obvious.
That's why when I see a patient for plantar fasciitis, I don't
tend to scan them the first visit.
I do it when I'm doing shockwave.
I'll do it the third visit because hopefully by the time
they come in at the 6th week where they get in the 6th
shockwave, they'll start. They're actually already
starting to feel better because if you have plantar fasciitis,
nothing is going to feel good. Like no orthotic, in my opinion,
is going to really feel good. It doesn't do a great job at
taking down the pain. It does a really good job at
kind of offloading the fascia to help it prevent it from coming
back. So for him, I said, hey, you
know, you're going to, you're going to, you know, I would, you
know, it's nine years after you had it.
Before he had thickening of the fascia, I gave him options of
doing cortisone injections. This would be cortisone #2 on
bilateral heels, or you could do Shockwave.
And I said, you know, with the thickness of the fascia, I
really think shockwave would be the best.
And so this is kind of a challenge, I think, for some
people and for me actually, too. But let me explain how I do it.
So, so bilateral shockwave for six sessions ends up for me to
be about $3000. And that can be a big, a big, a
big value, a big amount. And for him, I, I basically
said, you know, I know it's hard for you to get here because of
time. So I was willing to see him
first patient so we could open up a store or even a little bit
before first patient at 8:00 AM for the six visits.
And then I also said, you know, it's for the six sessions, it's
bilaterally. So usually for one side, it's
2:50. So two sides is 500 per per
session. So that's 3000 and, and, and he
was aware and, and I, and I, and how I kind of explained, I said,
you know, the 3000 isn't usually the problem.
The problem is getting your butt here 6 times.
And that's really true. I think for people that have a
good job and that have their own business, it's not the 3000
because there is, I always say the 2082 to 85% success rate, it
speeds up the healing by 50%. That's how I explained
Shockwave. It's more getting there six
times. So I try to make it as easy as
possible for him to get to get into the office.
OK, so that was the day once again, I hope you guys found
this beneficial. I am putting together a
challenge, 6 month challenge for a group of doctors, a kind of a
select group that want to help get their practice to the
$1,000,000 mark. I want to be clear, this is
going to be more for doctors. This has been thinking about
this more for ones that are probably in the six or 700 realm
wanting to get to the $1,000,000 mark.
That's a little bit easier because if you're under that
amount, you're probably not busy enough.
Then if you're not busy enough, you might have a hard time
paying for it. But also you just need to work
more on marketing. As I've mentioned before, there
is either a, some this isn't, this isn't my idea.
I'm stealing this from Alex Harmozzi, but there's either a
supply issue or a demand issue. And it's a lot easier to deal
with a with a demand problem, I'm sorry, with a supply problem
than a demand. So demand problem, meaning there
is not enough demand and you have to really just if there's a
demand problem in your practice and you're not busy enough and
you have open slots, you have to do everything you can to fill
those up and that you have to learn.
So my favorite book for that is going to be $1,000,000 offers
and $1,000,000 leads. OK, so $1,000,000 leads will
help you to kind of fill that up.
I do have information also my practice Mastery Academy about
all of that. But then once you have the
demand filled in your, all your slots are filled, then you then
you have a supply problem, meaning you don't have enough
supply, you have too much demand and not enough supply.
And then what you do is you optimize.
So that's where you have to do all these other things to make
your, your practice more profitable.
And that's where I think my sweet spot is, is helping you
get your time back and doing it more profitable.
So that's what we're going to talk about in this in this
challenge. So if you're interested, go to
podiatrypracticemastery.com/challenge or you can shoot me an e-mail.
I'd love to share more about it. OK, Don at Podiatry practice
mastery.com. Thanks.
See you tomorrow.