I want to talk today about my first patient ever that has
asked me for a refund for Shockwave.
I've never really had that before, so I want to go kind of
unbox that for you guys and then I'll go over my $1,000,000
minute. My name is Don Pelto.
I'm trying to help you get your practice to the $1,000,000 mark
and beyond. So this patient, she is a 65
year old female. She came in and I was looking at
her note because she sent me a little message through our
medical record. She had been a patient that had
sesmoid pain, sesmoiditis, did not have a sesmoid fracture.
I was, I think I was probably Dr. #2 or 3.
She saw before seeing me, I recommended Shockwave for her
and I think she already had an orthotic that she was using to
offload the sismoid. And she communicated to me, she
said, hey doc, I saw three other doctors and so she saw other
opinions in Boston. Some of them she had to wait
like four months. I think most of them were
orthopedist. One of them did do Shockwave
and, and they said, well, you probably shouldn't have had
Shockwave because it's not good for, for sismoiditis.
And if if anyone does shockwave, you know that shockwave I have
both focused and radial and it works very, very well on
sesamitis. In her specific case, it didn't.
And so I've never had a doctor do that, say, hey, you call the
doctor up and ask for a refund. So I was kind of probing just to
talk to her a little bit and say, OK, well, how are you
doing? Are you totally better?
It's been a couple years since I've seen you.
Are you better? Oh, I'm not better.
OK, what's happened since then? Well, I had another two or three
pairs of like orthotics that didn't work and the, and the,
and the guy that I'm seeing now wanted me to go to his guy to
get an orthotic to try to offload this test point.
And he didn't want to do surgery on me, which which I don't think
anyone would want to do surgery on her.
So I asked, well, did the, did the orthotic people give you the
money back and did the other doctors that didn't get you
better? I wasn't, I was nice about it.
I was not being, trying to be mean about it.
And she said that one of the, I think one of the orthotic, they
just charged the, the, the fee for making it and for the
orthotic and they gave her like 50% back.
And so I said, you know, I'm fine with that.
I gave her, I said I can do 50% back for you.
I do still believe I kind of stuck my ground.
I think it was appropriate for her.
In her case, it didn't work. But for a lot of patients it
does work. So that was kind of a
frustrating thing. I don't know if anyone else has
had people ask for for for money back for Shockwave.
This is the first one I've been doing it in a long time.
So I think a few, a few give backs are probably OK.
I always joke because every time my partner has to do a cut a
check for a refund, he always gets real pissed.
He's the one that does more of the, the check writing and stuff
like that. It's like, why do I have to do
that? And then that's the, the, I
guess the least valuable patients, right?
But in the in the end of things, I know some people like, so
there's different ways of thinking about this.
I kind of think of well, OK, 750 my actual 30% of what I get from
that. So basically our take home here
is usually 30%. So that is going to be 200
dollars 2-10 something like that.
And for the amount of stress that would cause me to kind of
argue with the person and the bad will and everything else
like that, I sometimes think it's better just to give the
money back because you don't want the bad will that goes with
it. You want, you want goodwill.
And she said she was OK with the 50%.
That's what she got from someone else.
I'm I'm OK with that. I think there's some, I don't
mind doing that. I don't know.
Some people are blatantly against doing that.
Doesn't happen a lot. But I just, I wanted to talk
through that with you. So my most valuable patient, it
was actually a double patient. There was a 15 year old female
and a 49 year old female. So it was mother and daughter.
They both made an appointment. They found us online.
The mother was really the most valuable patient.
She had a neuroma on her right side.
She had been seen in the Mayo Clinic, not not in Minnesota
where I'm from, but some somewhere else.
And she'd got some cortisone injections and she's been having
pain. She also had a couple of Ipks
that were painful. So I did lesion destruction on
the Ipks I did for the neuroma. I talked to her about anatomic
shoes. She's had like a metatarsal pad.
And I talked to her, Well, you can either do the cortisone, you
can do the shockwave, or you can try like an orthotic in your
shoe. And she opted for the shockwave.
So we are going to set up shockwave.
So wish I don't do a ton of shockwave for neuroma, but from
what I've read and from from the ones that I've done, you do it
very light because it's a nerve. So you're trying to reduce the
inflammation around that nerve. If you go too heavy-handed with
the with the shockwave, it can actually aggravate the nerve.
So she's going to set up six sessions of shockwave for that.
And then she had that the office visit in the X-rays and stuff
like that. The daughter, she had bilateral
Achilles tendonitis, not 15. She originally thought she had
seavers. So she maybe was treated
receivers in the past, very kind of tight calves.
And I was able to once again, I'm just repeating myself here
about this dynamic demonstration.
So what I do is I take a orb or AB ball, which is like a foam
roller, but it's just smaller for my office, put their leg on
it. And as I'm talking to them, I'm
foam rolling the the posterior calf and the posterior tibial
tendon, kind of rolling it back and forth.
Basically what I did, I roll it back and forth and I have them
do like 5 or 6 circles to the right and then 5 or 6 circles to
the left and then lift their foot and drop it down.
And that is kind of loosening up the back of the calf.
And, and what I find is usually that takes care of the
institutional Achilles tendonitis and also helps with
their plantar fasciitis. So basically I, I push and then
I do that foam rolling and then I push after and there's less
pain. So this is called a dynamic
demonstration. It really builds confidence in
patients that, you know, doing the actual exercise is going to
help them because it helped them.
So she's going to do that. She's going to do my Pelto
special. So reminder what that is?
It's she's going to get bilateral night splints that she
doesn't have to wear at night that wears in three hours a day.
The reason she does bilateral is so she doesn't have to wear it 3
hours on one and three hours on the other.
No one has 6 hours a day. She's going to do a morning
stretch and then that that foam rolling or the roller to start
out. I got X-rays for her and I'm
going to see her back in about four weeks to see how she's
doing. OK, so getting into the rest of
the day, the there was a matrix and 22 year old female with a
matrix and she got the post op kit.
I've started to I don't know how to say this nicely.
That was maybe I won't say it nicely.
I've been trying to it's it's a training problem on my end about
my staff. So I'm they're not always asking
about soaking and, and the marriage gel kit.
So I just tend to go through the marriage gel kit with the
patients and then just my staff fulfill it versus having them go
over the options. Many times when they're going
over the options, they don't believe in it or maybe they
think it's too expensive or whatever type of judgement call
that they're making. And I just think instead of
soaking twice a day for 30 minutes, it's much easier to do
the kit and it's you don't have to soak and things like that.
So I find that when when I explain it and I just tell the
patients, tell the staff to fulfill it or works better, it's
probably a problem on me with training most likely because
there we have a lot of new staff that are kind of coming in.
Next was a 48 year old female. This is kind of a drain.
This patient was a drain and we have these patients.
She has bilateral hallux nails that are only attached to the
base. She's one that comes in every
couple of months for Care Flex. So the Care Flex takes me a
while. She was seeing Marjorie, my nail
tech. For some reason, Marjorie is on
vacation, ended up seeing me. She is kind of super paranoid
about her toenails. She's currently on Terbenefin.
They're not reattaching, are growing out and reattaching.
She had some green underneath the the nail, so we have carry
flex on for too long and she swims every day.
It's got a little superficial Pseudomonas infection, but she
didn't want to go time without the nail on there because it's
summer and she does karate. She wants her nails to look good
for karate, so we can't really treat the Pseudomonas.
I talked to her about it. I said, well, maybe in the
winter time or when you take a break and you want to put a
Band-Aid on it or something like that, then you would do either a
dilute bleach or dilute vinegar soak to get rid of those.
But I don't think it'll work with the carry flex on there.
It wasn't all that bad. The greenness was just a little
bit of greenness. So I tried to grind it down
before I put on the carry flex. So that was a time drain.
OK, time drain right there. Next patient was a 67 year old
man. He had IP, KS, 1st and 5th Med
heads bilaterally. He has orthotics.
They were quite painful. I, the bride of them, put
salicylic acid, deadly lesion destruction.
So the way I think about this, this is just the way I think
about it. If it's a regular kind of
callus, most people aren't really complaining about those,
so I'll trim those down. I tend to make them pay if
insurance doesn't cover $75. I tend to be nice the first time
someone comes in with these Ipks because they're really deep,
they're really painful and I treat them as lesion destruction
with possible wart, possible IPK, and because sometimes there
may be a verrucas nature to it that that's what the people at
Swift tell me and that's kind of what I think.
And so when I do leads and destruction on them, I can do
that. Now I'm not going to do that
every month or every three weeks or every three months to
trimming off calluses and doing that.
No, it's like a one time thing. If they come back in a couple
years, I would do it again that way using the leads and
destruction. I'm just kind of letting you
know the way I think about it, you guys think differently, let
me know. And then usually they're
offloading with like an orthotic.
If they start to have to come back periodically for that, I
would just charge them the $75 every time.
But the first time I try to do it through kind of through
insurance. Next patient was a 16 year old
female. She was here with her mom.
She had a bilateral warts and I went through my wart treatment
sheet and they opted for swift. So if you guys, I've, I've had a
lot of not a lot, but I've had a couple of doctors say, hey, you
know, I have a hard time explaining it and having
patients choose Swift, they just kind of struggle with it.
So I want to tell you what really helps me is my treatment
sheet. So if you don't have my
treatment sheet and you wanted to try to use it, feel free to
use it. You just, it's like a Google
doc. You just change, put your logo
on there and you don't have to use my logo.
It, it really makes it simple. It says, well, you can do, I put
Swift at the top. It's usually about four visits
there a month apart. Doesn't hurt at all afterwards
or you can do Canthrodin, which is usually A4 to 8 visits.
It hurts a lot afterwards. Our laser which hurts during or
you can do like a removal, which I would only do if there's like
one or two, but it hurts and it takes about four or four or four
or six weeks to heal. So when I explained it that way
and I say that yes, Swift costs, costs 250 a visit.
But if you look at all the added up co-pays and lesion
destruction codes that we're going to be billing your
insurance, if you have a high deductible plan, usually Swift
is just the, the best way to do it.
Then I also say, you know, it doesn't always work at 4:00.
So I do set up four once a month, so 1 Swift per month for
four of them. And I see them three months
later like they recommend. But if it's not improving, like
when we're in into the second or third or fourth, I usually will
do combination. So I'll add on can thread in and
then I'm not going to, I'm not going to double dip.
I'm not going to, I'm going to charge them for the Swift.
And then just because the can thread and I just drop a little
stuff on there. And then when they come back at
three months, I might even do the Swift and the Kantharin, but
this time build a Kantharin, you know what I'm saying?
So I might switch it around that way to make it more feasible for
the for the patients economically if they don't have
a high deductible. And then they're also getting
Aldera or Carac topically. So this one, this girl's going
to do the Aldera initially for a couple of weeks until she gets
back from summer camp and then she's going to be seen in the
office for the Swift. So that's kind of the way I
think about it. Next patient was a 67 year old
man that had a first intermetatarsal space, kind of
like a possible neuroma in there.
Previously I'd seen him about 3 or 4 weeks ago for a cortisone
injection to the first MPJ that was painful and I did the
injection didn't really help that much.
So this time I did it in the interspace.
I don't exactly know what's going.
I don't know if it's a neuroma or something like that.
He does have a cyst in his first Med head.
He has some pain in that joint so we'll see how this helps him.
Next was a 66 year old man that had a Melania and I did a nail
sample for his Melania and it didn't.
They couldn't really determine and they recommended a nail
matrix biopsy and I did not why I explained it.
I recommended that for him. I usually do a 3mm punch biopsy
at the nail matrix. And so his melanonicia was the
dorsal portion of the nail. So there's like top and bottom
parts of the nail. So I was going to do more of a
proximal aspect of the biopsy at the nail matrix.
And the reason is because there was a black line, but there was
also cracking of the nail. And I was concerned, but he just
like didn't want to do that. And I'm not sure if it was
because of his job or something else like that.
So I did take a picture. I told him I'm concerned and
he's going to come back in six months for an evaluation for
that. So that one, unfortunately, is
kind of a lower, lower visit patient.
The biopsy would have been better, but he may be back for
that in the future. Next patient's a 49 year old.
She had fungus on 2 nails on the right foot first and second.
She also had bunions and tailors bunions.
They weren't really bothering her.
Her main issue was the nail fungus and she also had ingrown
toenails. So sometimes those ingrown nails
can make the nails look a little bit thicker.
What I did for her is I took a nail sample.
I'm going to see her back in three months, three weeks to go
over the nail sample and then we can start the process because I
wasn't totally convinced that her nails had fungus in them.
They could have been just thickened from the rubbing.
Next was this is an urgent care patient.
So just so you know, I think I've talked about this before.
We do have an urgent care page now.
It's kind of cool because in my schedule now it tells me who
comes in from the urgent care and because it comes in on my
schedule that way. So it's kind of a neat, I can
see this. This is kind of a complicated
man. He's a 71 year old man.
He got up and he just he was biking.
He had like hemosiderin changes to his lower legs and he's he's
reminds me of he's just he's an Italian, older Italian man and
he just talks loud and just reminds me of like a gangster or
something like that. The only reason I'm thinking of
gangster because I was I took my trip recently and I watched this
gangster movie on the way back. But he had really bad planter.
I think it's plantar fasciitis, but with like really no
instigating incident and he had could just the tightness, but
it's really, really painful. So I had for him.
I actually I did 2 cortisones. I did plantar medial heal and
then the medial arch, which isn't all that common for him
and I put him in a Cam boot because because he was in so
much pain. So I'm going to give him a call
today and see how he's doing. But he came in from urgent care
and he just really couldn't walk and his wife was tired of
listening him to complain him and complain.
Another patient came in, 74 year old man.
I've been finding now I don't know if it's due to social media
or due to our website or or something like that.
He came all the way from New Hampshire to see us and he had
flat feet bilaterally and he really couldn't tolerate any
orthotic with an arch in the past.
I, I did recommend a medial Blaze AFO because I think that
one works well. It has some cut outs for those
prominent, you know, medial aspects of the feet when their
foot everything collapses in. But he, he wasn't interested in
that. But I did recommend that.
And he had some like weird neuropathy pain.
And he was recommended gabapentin by his, his PCP and
they're also going to do a back MRI, which I agreed with.
And, and I just kind of talked him off the Cliff with the
gabapentin. I found a lot of patients are
just fearful of the gabapentin, but I said you know, if your
pain's mostly at night, just start it at night time.
So then I'm not going to see him back.
Next patient was a 51 year old female.
She had a right foot sprain and she had pain to the peroneals.
So I did X-rays for her. I gave her NSAID's and if it's
not better I'm going to be putting her into a boot.
So I think it was just a sprain. I'm going to see her back as
needed. The next was a 45 year old
female that had plantar fasciitis #4 out of 6 for
Shockwave. She's getting a little better.
Next was a 78 year old man. This guy had a a right hallux
extensis. I've told you about this before
in the past he had just like right foot that's like cocked
up. I tried to do Nuboso splays for
him and it didn't really work and he came in kind of wanting
orthotics and and this happens, I don't know for you, but it
happens for me quite a bit. So they, they want orthotics and
then when they hear the price, they don't really want them.
So it's amazing how that desire can just totally change when,
when someone hears about price and I there's a just kind of as
a side note, I was talking, there's AI have a WhatsApp group
of some people that talk about like a different business things
podiatrist and this one doc, they're saying, you know, Hey,
I'm not that good at doing orthotics.
And she said, I think I was thinking about reducing the
price. And so if anyone's thinking
about reducing price, I would, I would tell you, I would just
recommend like don't reduce price.
Get better at explaining orthotics like get better at,
you know, practicing how, how to explain it in even if insurance
doesn't cover it, which which is my case, you have to get better
at explaining it in the value proposition.
You have to get better at doing them too, frankly, because the
more orthotics you do, the more people you're going to have with
problems with the orthotics, meaning they're not going to
fit, they're not going to be comfortable.
So you have to get better at troubleshooting the orthotics as
well. If you want to do a lot of
orthotics. It it, I always say you don't
have to be good if everything is covered by insurance.
It's like easy to give away stuff that's for free.
It's it's hard to to explain stuff in a way and be confident
enough in your abilities for like shockwave and orthotics
that it's going to work for the patient.
So anyway, that's just my, my thought.
Like don't, don't like cheaping yourself.
We charge 600. I know that's maybe some people
probably charge more like 800 or I've heard of 1000.
We do 600 for our orthotics, but some are doing like less and
they're wanting to reduce the amount.
I don't think patients buy based on price.
Patients buy based on the confidence that you're able to
show them in what you're recommending is going to work.
OK, and you do what's best for them.
Now, if you don't believe in the orthotics, then you can't offer
them. You can't quote UN quote sell
them because you don't believe in them.
So you need to believe in them yourselves.
You need to make sure these things are going to work and
they're the best thing for the patient.
OK, that's kind of my rant about orthotics.
Anyway, he didn't get the orthotics.
Maybe I wasn't too confident that they would help his
condition, which I really wasn't in his specific case.
OK, next patient was shockwave #1 out of 6, this is a unique 1
and I did a little video on this patient.
She had a year and a half old fracture of her 4th digit.
Her 4th digit swelled up and the swelling never came down.
The fracture never healed. She wasn't really treated.
She was treated for a short time in a Cam boot.
But then you know, thinking well it's just a fourth toe and but
The thing is just so swollen. And so due to this non union,
I'm going to do 6 sessions of shockwave for this patient.
So the other option was to take out the intermediate failings.
So we're going to do the shockwave for her and we're
going to, that usually kind of heals things in and then
hopefully the swelling would come down because I think the
swelling is there because it's trying to buttress the fracture.
Next patient was a 63 year old female left plantar fasciitis.
This is one that I did that dynamic demonstration with the
roller ball. We're going to do ice contrast
pass. She also has nail fungus and I
did a nail sample. I'm going to see her back in a
couple of weeks. We're going to do an ultrasound
for planter fascia. It doesn't get better.
I didn't jump right to shockwave for this patient because her her
her symptoms weren't that long and they weren't that bad and I
think she might be able to get better with the with the foam
rolling. Next was a 68 year old man with
a right posterior tibial tendonitis.
Did shockwave #3 out of 6. He's starting to feel better.
Next was Amri follow up for a gentleman 48 year old man.
He had a kind of spontaneous pain on his second Med head.
MRI was done and it showed a possible kind of a planter
avulsion fracture kind of from the planter plate region, but no
planter plate tear. He had originally been in a Cam
boot, but he wasn't very compliant with it.
And so I said, hey guy, just try the Cam boot for about four
weeks. If it's not getting better than
the plan is going to be to do an MRI.
And I'm sorry to do shockwave. I talked to him about doing
shockwave. I think that would be the best
thing for him. I don't want to repair.
He's a little bit of a hammer toe.
I don't not a huge hammer toe. I said the OR we're going to
hammer fix your hammertoe and we're going to pin it for five
to six weeks and maybe do a planter play repair.
This was the least valuable patient.
The reason for this is because we use an MRI follow up and
originally when I saw him, I used a fracture code.
So he's still within that global window.
So this one, I'm going to see him back in about four weeks.
Next was a right Achilles pain. She had a #2 out of 6 for
Shockwave and she was one that had Achilles tendon repair by a
local orthopedist. I think you put a little anchor
in her Achilles and she had just been pain for like a year and a
half. She tried grasped and she tried
other types of treatments. She's very tight in there and,
and she's the incision was on the like posterior medial
Achilles and down to the heel. But her pain is lateral.
So I think she has all because of her.
She's limping because it's hurting on one side, she's
walking more on the other side. And now she has insertional
Achilles tendonitis all around. And so we're doing shockwave #2
out of 6. She's actually my kids Taekwondo
instructor or one of the instructors, not the main
instructor. So she's hopefully she'll
hopefully she'll get better. Although I have to look at her
for a long time and after I charge her a lot of money.
OK, so that was the day once again, I hope you guys found
this beneficial. I am putting together a
challenge for some doctors I'd like to work with, like more
people. I think it would give me more
fodder for this content and it would help people with their
practice. So if you're interested, shoot
me an e-mail, don@podiatrypracticemaster.com,
kind of tell me what your issues are.
I think we all have issues. I have issues but I think
sometimes having someone else you can talk to them about might
help. OK, happy to help you out and
also gives me content for doing this podcast.
Thanks for all that listen. I really really appreciate you
listening to this podcast and sharing it with other
podiatrists. I think I think more people
could be listening to it. Not many people do.
So please share this if you have fun, it's beneficial.