Practice Perfect 702
Video Roundtable - How Podiatrists are Dealing with the COVID-19 Crisis
Video Roundtable - How Podiatrists are Dealing with the COVID-19 Crisis
Watch the Roundtable Video Below
As with all things related to the COVID-19 pandemic, change is the one constant, and one of those changes is the realization that technology can be very helpful to keep us connected. Using a teleconferencing technology, we linked up several individuals around the country to have a great discussion about how each of us have responded to the pandemic, and I’d like to invite you to watch. Practice Perfect went video!
I was honored to be the moderator for a roundtable discussion about the effect of the pandemic on the podiatry community. We covered a variety of topics including how our practices have been affected, teleconferencing for patient care, changes in residency education, and personal responses to these ongoing challenges. On our panel were:
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Christopher Bromley, DPM, FACFAS - Department chair of Foot & Ankle Surgery at Vassar Medical Center in Poughkeepsie, New York and is the managing partner of a large multi-specialty practice in New York |
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Elliot Udell, DPM - Private practice in Hicksville, Long Island, New York and is president of the American Society of Podiatric Medicine. |
During the discussion important resources were described that will be very helpful to many healthcare providers, including the CARES Small Business Act and Telemedicine Resources. I invite you to watch this engaging discussion with our esteemed panelists and stay connected.
Transcript:
Jarrod Shapiro
Ok, alright now we're, we're good. All right. Thank you again. I really appreciate it. I apologize for that technical issue. Um, sometimes Zoom has weird issues with hosting and, um, I use a, the university's, you know, account, so it, um, it's supposed to be the full-blown version of it. Um, so, um, what we'll do is, uh, um, there is if you use this before, you know, there's a way that you can shut off your screen. Um, I'll ask you not to do that while we're doing the discussion. Um, it looks kind of strange. I'm basically just sort of recording the, the whole screen. Um, and then we'll see what the PRESENT guys will want to do with that. Um, so what we'll, what we'll do is, um, I'll make a short semi-formal introduction to the discussion, um, then I'll introduce myself.
Uh, then I'll ask each of you to introduce yourselves and we'll, I guess we'll kind of go in alphabetical order. So, um, uh, it'll be Chris. Um, he'll be first, then Marshall, Michael, Elliott, and Marie and we'll kind of go in that order. Um, then we'll move on to the discussion itself and I'll just moderate some. I have some prepared questions, but if this goes kind of organically, I think it'll, it'll be a nice way to go. Um, if you, uh, if you, uh, have, if you’re using a computer as opposed to the cell phone and you, you're welcome to mute yourself and then if you unmute yourself when you’re interested, you know, when you want to say something, I can see it. So, I if, um, I could always direct a question in your direction if you want. Um, and again, I think zoom works reasonably well. Uh, it's when like two people talk literally at the same time that they overlap each other, that, um, it can sound kind of funky, but for the most part I think it does a pretty good job and we can be somewhat conversational with this.
Um, so then at the end of the discussion as it seems like we're kind of getting towards a conclusion, I'll make a few comments and then we can sign off from there. Okay. So, any questions?
Marshall Solomon
Okay, let's do it.
Jarrod Shapiro
Absolutely. Okay. So, uh, so in case the present guys can actually do something with this. So just make a slight pause and then I'll, I'll start. So, a good day to everyone and welcome to our PRESENT podiatry round table. On the topic of the podiatric response to the COVID-19 pandemic. My name is Jarrod Shapiro and I'll be the monitor for today's discussion. We brought together a group of practicing podiatric physicians and surgeons from different regions of the country and in different practice environments, all of which had been affected by the pandemic. Our goals today is to provide colleagues around the country with some perspective and hopefully some helpful ways to deal with the ongoing crisis.
The format today will be a question and answer session covering a variety of topics. So, let's start with some introductions. I'll ask each of our panelists to introduce yourselves, including your geographic area of practice, the type of practice, and any other major components of your professional life, such as if you work with students or residents or do anything, um, different from kind of the average podiatrist. So, I'll start things off as I mentioned. My name is Jarrod Shapiro. I'm an associate professor at the Western University College of Podiatric Medicine in Pomona, California, Southern California. I'm in active clinical practice and the director of our clinic there and also the program director of the Chino Valley Medical Center residency program at Chino, California. Um, and I'm an assistant editor for PRESENT e-learning Systems where I write a weekly editorial called Practice Perfect. Uh, so now Chris, I'll send it to you for your introduction.
Christopher Bromley
Jarrod, I don't know how you remember all those things that you do. Yeah, thank you. Um, Chris Bromley, I’m in upstate New York, uh, upstate meaning North of the George Washington bridge, uh, 60 miles due north of the epicenter of COVID here in the East. I, uh, am in charge of a six-physician podiatric practice within a multispecialty group. I'm an adjunct professor at Kansas State, and work with, uh, undergraduate students and podiatric medical students as well as residents. Um, my specialty beyond my day to day practices. I run a consulting company called Influx Consulting and I also enjoy traveling and teaching with some of my colleagues. Dr Williams, Dr Troiano as well as Dr Shapiro. And this has obviously been a huge paradigm shift in my day to day work as well as the consulting and the teaching that we all love to do. So, we're honored to be here.
Jarrod Shapiro
Great. Okay, Marshall, let's go see your next one.
Marshall Solomon
I'm Marshall Salomon. I'm the chairman of the department of podiatric medicine and surgery at Beaumont, Farmington Hills. One of the eight hospitals in Beaumont Health. I'm also the program director of a PMSRRA program. I have 12 residents, four in each year. And, I am also, sort of a hybrid. I'm in private practice and I'm also employed by the hospital base running the podiatric resident clinics. I'm actively involved in the hospital serving on the executive board of the hospital. Also, the research, Beaumont Research Institute at Beaumont Health. And, um, we're in the other epicenter of the COVID. We're in, I'm in the Detroit, Michigan area just in a Northwest suburb of Detroit. Uh, I think we're the third largest right now with the number of reported cases and unfortunately this in, uh, caused by the virus.
Jarrod Shapiro
Great. Thanks. Michael, how about you?
Michael Troiano
My name is Michael Troiano. I'm the managing partner at the Center for Foot and Ankle Disorders in Philadelphia. I'm also adjunct clinical professor in the department of surgery at Temple University School of Podiatric Medicine. I am a co-medical director at the University of Pennsylvania wound care center. I also take foot and ankle trauma qual there and at Jefferson Northeast, which are the Jefferson University Hospital System at Penn Presbyterian. I work with 16 residents at Jefferson nine. We are in Philadelphia, which is apparently the next on the list to be the epicenter for COVID.
Jarrod Shapiro
Okay. Elliot, you're next.
Elliott Udell
Yes. My name is Elliot Udell, I'm a podiatrist in private practice in Hicksville in Long Island, NY which is the epicenter now in the United States of the COVID virus. I'm also the president of the American Society of Podiatric Medicine, which is the, oldest subspecialty organization in our profession. Dedicated to the surgical end of podiatry. And also, our focus that was on geriatrics as well as podiatric medicine. Uh, when I'm not practicing podiatry, I'm also an author and you can see my latest book on amazon.com.
Jarrod Shapiro
Thank you. And Marie, how about you?
Marie Williams
Yup, I'm in actually in Aventura, Florida, South Florida near Miami. I run a residency program and I’m the program director at Aventura Hospital and Medical Center. I have six residents and we are also working through this COVID virus situation. Um, I call it a day to day activity. Um, I'm not only a program director, but I work with all other residents. We have about 200 residents in our hospital and they come through our program as well as our office, I’m involved in teaching activities quite a bit, lecturing to them as well as to the residents. So very involved in education. That's one of my big things, foot and ankle surgery, trauma as well as wound care and limb salvage.
Jarrod Shapiro
Great. Thank you all again, for joining us. So, I'm going to start with some general practice questions. Let's go with that first. And Marie, why don't I start with you. Um, how has the COVID-19 pandemic effected your clinical practice kind of in general?
Marie Williams
Well, in general it has cut actually all our elective surgeries out. It has limited, our resident's ability to do, elective surgery in my own private practice, which I’m in, um, it has actually taken a practice that sees about 50 to 60 patients a day down to about 10 to 12. So, it does impact us, um, as well in the clinic or my practice or where the residents get, have a lot of experience. So, because of that, we're definitely limited in educational opportunities for the residents. Um, and, that is a concern right now as far as numbers go. My third years will graduate without any problem, so we'll see how the future holds.
Jarrod Shapiro
Elliot, how about you and you're in a slightly different practice situation. What's your like?
Elliott Udell
It's pretty bad. Uh,my practice basically as I've gone down to, where we're seeing approximately three patients a day and being that the governor in New York gets on television every day and the President of the United States on television every day telling you how dangerous it is to walk outside. And in my geographic area is where the epicenter is and you look to your left, look to your right, you're going to see someone who's infected. And we, uh, I've been pretty much closed down my office, at least for the next two weeks. Uh, and, uh, in most cases the patients will call me that they decided not to come in on their own. And in other cases, I’m just calling people and telling them, uh, you know, it's dangerous. Uh, I can't guarantee that there will be an infected person in the office as well. So why don't we just, uh, you know, not see, you know, not see patients the next two weeks and then see how it goes. Then if need be, I'll extend it more.
Jarrod Shapiro
Do you have a, a wound care or a key component to your practice?
Elliott Udell
Well, we do everything. I mean, we do everything. I mean, it's general medicine and wound care as well, but, uh, and this point in time, um, patients even with wound care issues have called me up and say they're afraid to come. I mean, they live and watch television and then they're being warned by authorities such as the governor of New York and other people not to leave the houses. It's dangerous. And they have very, very graphic portrayals on TV, people who are either very sick or dying. And unfortunately, at this point in time, uh, just last night 3 people who I knew passed away from the COVID virus. So then that really sent shivers down my back. I said, look, I'm going to just close the office until this thing gets under control a little bit. It's not worth my life. My families’ life seeing three patients a day, uh, and who probably won't show up anyway. So, for the most part patients are understanding of the situation.
Jarrod Shapiro
Chris, have you seen the same, um, the same kind of situation where you are?
Christopher Bromley
Well, it's, obviously I would agree with Elliot. I mean in New York, the, you know, the day to day, you know, on, you know, constant barrage of bad news, you know, its scared people away. Our practices, uh, the only real patients that we're seeing are all the wound patients that we manage in the practice. All the post ops and then the trauma. Um, because most of the podiatry offices around us were kind of smaller. A lot of them are not open. Um, so we reached out to the urgent care centers and our, our two local hospitals where we do, uh, you know, a call and reached out to them and asked the ERs and the trauma center and then also the urgent care if they want to triage us patients cause we are open, um, from eight to five every day. I mean my typical volume, very similar to Marie and I'm sure Elliot and Michael, I mean I, normally see 40 or 50 patients a day and I'm down to scheduled probably 10 or 12, and then patients will call in, you know, or the urgent care centers we'll want to triage patients. I mean what we've seen is that most, you know, what we see in our own ER when I was there, that most of the people who would normally come to the ER not going to the ER at all unless, unless they have COVID. Um, so we're trying to work with our, our local, you know, health care providers that take the load off, you know, those urgent care centers and the ER as much as we can. But it is unlike anything I've ever seen in 29 years of practice.
Jarrod Shapiro
Marshall, how about you in Michigan? What are you seeing?
Marshall Solomon
Well, it's uh, it's fluid in its dynamic. I'm in a group of five other podiatrists single specialty. Um, there has been a probably about an 80% drop off in patient volume in the private practice. At one point all the clinics in the hospital were closed initially. And as a result, because I'm in a group of five, five of us, we've been able to sort of um, individualized our days where we would have two practitioners in one day. We've taken one and we have really essentially only taken emergent, uh, patients that are either postoperative out of the hospital, um, high risk, uh, wound care and individuals that have trauma. So, in that regard, uh, it has had an effect, a sizeable effect. If you have a pretty busy practice like Chris and Marie’s, and Mike's, you're going to, um, go from a practice that is, has cashflow to zero and that affects all of your employees. We'll probably talk about this a little bit more. The hospital, pretty much, uh, the situation is it closed down. They're starting to reopen I think the week of the 13th. And we're just seeing those acute care patients. The biggest problem is patients that we see in the hospital in their subsequent follow up into the office or the clinic to be seen. They do not want to go to the hospital, do not, as Chris mentioned go to the emergency room, they feel it's a death sentence. And the closest they'll get to the hospital is to be tested in their car for COVID. And so the patients that challenges the patients that are sick, you know, the diabetics that we see that have, um, gangrene or, uh, cellulitis and infections that we have to come in and we have to operate on them. Do our I&D just do the amputations and subsequently follow them, keeps us busy. You know, to go through all that preparation in, and key universal precaution and in wearing our N 95 mask and a mask over our N 95 cause they're so precious. Um, it, uh, it is a challenge. Um, so it definitely has a, um, a physical, psychological, effect on all of us, our staff and even our patients. So, um, it is, it is, it's real.
Jarrod Shapiro
Yeah. Very much so. And so, in Southern California where I am, um, we basically had done exactly the same as far as the practice. Um, uh, as a university practice we're a little bit, uh, protected from the economic component because we have the university to absorb some of the impact that you'd normally see to, uh, a smaller practice. Um, but a hospital wise, uh, very much the same, our clinic is down to maybe we're kind of an average of somewhere between 10 and 15 patients a day. And just like the rest of you were seeing, um, uh, acute patients, wound care patients, uh, we, we're, we try to get our wound care patients really to come in. We try to be pretty convincing. Uh, you know, we want to try to keep things as calm as possible before, um, you know, they end up with a cellulitis or an abscess or something from not having come in to see us. So, we try to push them to come in. Um, and then the other aspect to the practice is we added, uh, tele-medicine into this for, uh, for a variety of other patients. Um, Michael, how about you? Have you guys started using that at all in your practice?
Michael Troiano
Telemedicine has been an absolute godsend for us. Uh, as you, you all have identified, uh, we see about, you know, I, I myself see about 60 patients in a day and then, and then my partners see about the same at different offices throughout the day. Those numbers are cut dramatically to inpatient or in physical, uh, face to face visits of about 10 to 15 a day. Uh, just emergent preop, postop and, uh, you know, as you pointed out, cellulites or what have you, that would otherwise make it to the ER. Uh, but the telemedicine visits have really changed the game because it's allowed us to keep an eye on people that we wouldn't otherwise, that that would have all already fallen through the cracks otherwise. So, case in point, uh, four or five days ago, uh, I did a tele-visit on a gentleman who was not making sense. He was kind of talking in circles and, uh, his, his daughter happened to be there, come to find out, he she we get, um, you know, call the ambulance, he has gas gangrene up to his leg. If that tele-visit didn't happen, you would no longer be alive. Uh, so telemedicine has, has been great for us, um, reaching people, reaching out to people. And I'll tell you today, we've been doing it for about three weeks now and today's the first time that we received payment, uh, because of, you know, the three-week lag or what have you. And we've been getting paid as we would for a normal office visit, which is, which is nice as well because, um, you know, anything to keep you floating at this point.
Jarrod Shapiro
Uh, yeah, I, I answered the same, uh, the same thing. And, uh, the decreasing the restrictions on, uh, on coding and getting reimbursement has been helpful. At least take some of the strain off of that. Uh, Marshall, what was your comment?
Marshall Solomon
Yeah, I think that, uh, there are rules and regulations regarding telemedicine even though they are relaxed. Um, you need to make sure that you adhere to those, making sure that it now the ENM essentially is a unit as opposed to, um, the, uh, actual physical exam and knowing the difference between just an audio and using video is important. Um, Medicare and CMS, CMS and Medicaid use your regular code numbers, your ENM in your privates. You use the new code numbers that they've assigned, the 99441s, 442s, 443s all based on time. But I think it's, it's fantastic. Uh, in that regard, we, uh, schedule those remembering it has to be patient initiated. So we even put on our website, um, that we do telemedicine and that if they want to speak to the doctor to contact through the office and then they just email us or they text us that we have a telemedicine appointment at 2:00 PM and they give us a number and we initiate the call. So that's how the protocol we, we're following with it.
Jarrod Shapiro
Yeah. Marie, did you guys, uh, do you, are you doing a similar type of thing?
Marie Williams
I'm doing telemedicine and it actually is a lifesaver. Um, we are picking up things that we normally wouldn't have over just a telephone call. Um, people are actually really, our patients love it because they get to be able to communicate with someone which they feel locked in and scared. So, it's been working out really well. We have scheduled appointments just like we would if they were in the office and um, it's, it's been easy. I thought it was going to be really difficult. It's been very easy. Um, you know, it's nice. You can see someone with an ingrown toenail, and you can tell them to soak it, here's an antibiotic. If it’s not better come in in three days, and then they call back and say, I'm all better. You're like, okay, that was great. You know, a little simple thing. Very easy.
Jarrod Shapiro
And how about protecting yourselves? Um, whether you're in the clinic or the hospital or are, um, are you guys doing anything different or are you wearing a certain kind of mask? Um, how about Chris? Maybe you can with that.
Christopher Bromley
So, you know, the PPE here in New York has been a real issue. Um, but you know, typically, uh, you know, minimize our exposure by using the appropriate PPE, the N95s, um, you know, full face shields. Um, we don't have as consultants going in access to the, you know, the air-controlled air filtered air systems, but it gets, um, you know, we're doing the best we can. And you know, interesting. Um, some of the studies that came out this week about looking at the, you know, the viral exposure in the air, how long the virus will stay in the air. And some of the places where the report indicated the highest viral concentrations were where the healthcare workers were taken and their PPE on and off in that right area. So, very, very, dangerous, um, to remember to, you know, almost like we get to that situation and when you're there, you don't even want to breathe. You just take a deep breath and take everything off and, you know, just get out and hazmat. And I think, you know, for anybody who's going out, uh, all of us on the call probably know this, but when you do get home and basically, you know, my wife makes me take everything off at the door, you know, the scrubs come off and get cleaned up and the shoes, you know, just, you know, the basic hand-washing stuff up. For those of us that are exposed, um, to patients, you know, making sure that we're not bringing any of this back into the home and putting anybody at risk. And I think, you know, Elliot said earlier that he's, you know, decided to close this office down because it wasn't worth three patients a week, which I totally agree with. Um, and then on the telemedicine, just to add my 2 cents, I think telemedicine, I would agree.
It's been very helpful. Uh, for us. I do have a hard time when we're looking at wounds, you know, I don't have the same, you know, the camera quality that the patient has on their side. It's, you know, to be able to really see and evaluate a wound, you know, I really feel at a slight disadvantage. Um, I have a big sports medicine practice and I, you know, I live as it is, those of you who've heard me speak, I live in an ultrasound surgically attached to me. So, it's a huge disadvantage to not have that diagnostic modality as part of the interaction. But it has been helpful. And I think in Mike's case, you know, with a patient who is obviously incoherent with gas gangrene when he was describing the symptoms, I thought maybe he was talking about he was on the phone with Harold, but I, um, I wasn't sure, but I think that, um, I think it's been very helpful. I think one, one point of interest and I think Marshall would probably agree it's really important in your documentation to put the, you have that you've got the patient's consent, they've agreed to this particular, you know, when your documentation. Um, so, so that, that's part of it. Um, I think it's really important that you do that. And I think being conscious of time, you know, this is really time driven. Uh, so you make sure you have, you know, lots of small talk, you know, really talk about their medications, their allergies, their past allergy. You know, you're getting, you're not trying to prolong it, but making sure that you include a review of their past medical history, meds and allergies is going to help you get to that time interval that you'd like to have and the patients appreciate. I say to them, listen, I'm in your chart now.
I'm going to read to you if any of these things changed. These are your, and then we get to the, you know, sort of talking about their subjective symptoms and, and then that sort of asking them for a closer look. So, I think those are some really, you know, good telemedicine, uh, tips. Um, and I would love to do more telemedicine. I, you know, I mean I think that maybe one of the things that will come out of this experience and one of the bright parts is, you know, those of us that are really, you know, active and, um, maybe we'll be doing telemedicine consults on patients in different parts of the country as we move, as we move forward. Because there are lots of places where there isn't great foot care. Um, and I'm more than happy to, you know, consult and then be able to, you know, refer to people and help colleagues, uh, provide the best level of care.
Jarrod Shapiro
It's a whole new world of technology. So, so Elliott, a question I have for you is, since you've closed the practice temporarily, do you have concerns about like the kind of overall viability of practice into the circumstances? Are you doing anything in particular different as far as like your staff go, uh, or you know, kind of how your practices is running to kind of keep staying stable?
Elliott Udell
Yes, but I didn't want to address the issue of a telemedicine design. I did two cases in telemedicine basically today. But, um, I have my, uh, question is about how, uh, effective this would be for podiatry in the long-term is we are a surgical specialty. Like what they, I saw it today on telemedicine. She had moved away. She had been a patient of mine for a long time and she moved to another area of New York and she is seeing other podiatrists in her new neighborhood and they all closed because of the virus, closed their offices down as she's having a paronychia. So I use the telemedicine to examine her toe and place her on soaks and antibiotics and told her at some point in time, she's going to need to see someone, either myself or someone more locally and she's going to get back to me in a couple of days, let me know how it's doing.
But one interesting point that we just raised is whether the telemedicine can be used to, uh, consult with patients in other parts of the country it’s a very great, interesting question that was just this raised, uh, how has that, uh, how does that, uh, jive with state licensure versus someone, let's say from, uh, Idaho who calls me and wants to do a telemedicine consultation? I'm only licensed in New York. Am I allowed to, uh, through a telemedicine consultation with someone who lives in another state? It's a very interesting question, which I never thought about until this discussion right now. Uh, then would have any, uh, feelings about that.
Marshall Solomon
Currently, currently everything is really relaxed, take for example in New York and say, asking for every physician they can in the United States to come and help during their crisis there. And then, uh, Cuomo stated that once we get this under control, they can move to Michigan and then they can move to California or, or Florida. So, uh, I think at this point its fluid. You got to understand that CMS has been scrutinizing telemedicine very heavily and all of a sudden, it's completely relaxed. So, this will probably be a statistical evaluation by CMS over the next month or two to see how much telemedicine, uh, has been. They'll probably do some studies to see how effective it is and as they have relaxed that they may tighten it again. So, we'll see what happens in the future. Uh, regarding telemedicine, it is part of medicine. I think it is a wave of future, how it will be, uh, expressed and how it will work within CMS and private insurers will, we'll know probably in about six months to a year, right?
Elliott Udell
Legally, legally…. Can we treat using telemedicine a person in another state and we're not licensed, personally licensed in, um, I guess that will probably be resolved at some time in the future. Um, legally so I'm just wondering about that.
Christopher Bromley
Um, on March 19th, uh, the federal government announced the relaxation of interstate tele-health, um, as part of the crisis. You know, we, as Dr Solomon said, you know, that they may roll some of that back, but the interstate use of telehealth is permitted at this time. I think it could be kind of hard to put the genie back in the bottle afterwards, but you know, we'll see. I mean, I think we would all agree those of us that have been in practice for many, many years. I think the idea of having one license, that would cover podiatrists from state to state. I mean, those of us, you know, that practice in the Tristate area, you know, it, it makes, it makes no sense to have to have a license in New York and New Jersey, Connecticut. I mean, I think it, I think what we want is the highest standard of licensure and the, and the correct training for podiatrists across the country and all specialties to be able to do that. I mean, I sit on a med exec for 15 years. I think it's ridiculous. Every time I sit there, the first Monday of the month and I have to listen to all that tele radiologists and cardiologists and, you know, all these meetings we have to approve. I think it's more than more than reasonable. Um, as our world is changing to be able to adapt to a changing world with better light, you know, better tele-health standards.
Elliott Udell
You know, I agree. I agree.
Jarrod Shapiro
It's a brave new world.
Marie Williams
Well, I think down the road it's going to be something that we're going to have to educate our fellow new students and residents coming out because we're learning it really on the job, sort of an on the job training right away. If you haven't been used to it, it's definitely different. And then you have to understand the liability. I mean there's all kinds of consents that are signed and I, I've kind of gone over all the consents and the patient has a consent. You have to make sure that they know that you're doing tele-health and um, I think there's going to be a whole new shift in some training when, when guys get out, because we're not, this is new. We're, we're kind of pioneers in this, to be honest with you. I've never done tele-health, (FIX SPACING)never even thought about it until about a month ago. And I, oh my God, I've got to open that up. I got to put that on my website, we got to roll this out. And, um, it's funny that patients are calling in asking for their, their appointment telemedicine appointment. And I think it's funny to me because I just never thought that that would be what we would do, but reality, well, let's see. HERE AS WELL
Christopher Bromley
It's like, it's an, it'd be like the Amazon revolution in medicine. I mean, we could tele-help a patient and sometime this afternoon if you live in a metropolitan area, the orthotics and the, and the prescriptions can show up at their house. I mean, you know, this, this, everybody's living with the ability to get this, you know, to get the medicines and treatment they need and in a very quick, quick and timely manner.
Marshall Solomon
Yeah, it's interesting because this Thursday following my patient care in the clinic, I have a special, um, uh, individuals from Epic are coming in to explain the rules within our, um, EHR, how we have to, uh, record all of this, both video and, you know, just audio and how it has to be placed into the medical record. So, we are actually establishing telehealth appointments within the clinic. So, it is just like Marie said, we're going to have to train our residents to this. They are going to have to do follow all of this and we're going to have to probably with our own EHR, in our private practice. If they're not Epic, which is 85% of the country, it will have to be the same thing. We'll have to adhere to the strict rules and regulations.
Jarrod Shapiro
So, it clearly is a kind of brave new world. Um, I'm wondering if, uh, outside of telemedicine, do you see any opportunities or, or are there new relationships that you're noticing that you're building, um, with the medical community around you? Uh, Michael, maybe you can kind of start with that.
Michael Troiano
I think that we are becoming fast friends with others in our, in our current situation. Um, everyone's struggling and, uh, I think, you know, if, if you're doing well, you're probably doing something that you shouldn't be doing at this point, you know, so I think this is the, the time where, uh, you're building relationships basically on commiseration, uh, as, as Chris said, going to the local, uh, urgent care centers is helpful, decompressing them a little bit. The ER staff, we've been advertising kind of nonstop, hey listen, turn your ankle. Uh, come on in. Don't flood the emergency room where they're taking care of very, very sickly patients, primary care doctors, the same thing. Um, and it's been successful, and I think that, uh, while this is a little bit of baptism by fire, the vast majority are doing what we need to do to, to make it. And um, hopefully we'll have some, some tight fast friendships when, when this is over and hopefully soon.
Jarrod Shapiro
Yeah. Marie, you've had a very long experience with working through the hospital systems in your area and having those, you know, kind of building those relationships. Have you seen any differences?
Marie Williams
I see a lot of caution between the medical doctors and the all of us caution. The infectious disease doctors are like, you know, here's what we want to do. This is the biggest change. Um, if an internist goes in the room, then they'll come out and tell everyone what's going on in that room. Therefore, the infectious disease guy doesn't go in and then the podiatrist doesn't go in. So, there's not eight or nine different specialties going in and out of the room. One doctor goes in, one guy comes out, gives everybody a report, infectious disease follows up via their antibiotics or whatever from what the infectious disease or the internist sees or vice versa. The infectious disease goes in the intern steps back. So, everyone's kind of doing it where maybe one group of guys are going into that. There's not a repeated like five doctors going in and out of the room keeping down a lot of the activity, especially in the COVID pending patients. And of course, COVID positive, pretty much keeping it to very limited a group of doctors going in and out. So, the residents, of course, they're not allowed in any of the floors that are COVID floors. The residents are not allowed, whether they're internal medicine, anesthesia residents podiatry residents, general surgical residents, they are not allowed to touch patients that are COVID positive until they're completely negative. They're not around. There are no residents are around. So that change has affected our podiatry faculty that always used residents for everything because they don't really know how to do anything. And they're like, how do I do a chart? I'm like, Oh my God. So it's been a lot of change for them. It's been a little hard. But the point is, is that when you relied so much on residents, now you're being your own. You know, you have to go in and do all your own work. It's, it's been a definite big, people want to stay away. It's, it's interesting.
Michael Troiano
It's kind of, I don't know, funny because that's the opposite. Here in Philadelphia, our residents are running the testing centers. They are in the front lines of the hospital. They're manning the emergency rooms, they're on a call schedule. Uh, particularly for COVIDs. So, uh, they're barely in our clinics anymore as their resources are being used, you know, for, for our surge.
Marshall Solomon
It's interesting and I, I agree with Michael. Uh, our residents there that have rotated through internal medicine and infectious disease and the other medical FIX SPACING
specialties have resulted in, um, them being, uh, rotated through with, uh, the services and they are seeing COVID patients. And, um, as a result, it, it, uh, is demanding on, on us. It just goes to show you what great training our residents are getting in their hospitals. And I think it, it creates internal medicine came to me and asked me as a program director, we need your residents. I said, okay. I sat down and you know, everybody's scared about this, but you know what? They volunteered. We even in our health system, they're thinking about the attendings getting redeployed to the other health, the other hospitals in the health system to help? It's a tremendous, everybody is on deck. Everybody is on deck. And I think this is going to just strengthen podiatry as a whole in our hospitals in that will then, uh, mature out to private practices and everything else. I think that this is an opportunity, um, to, uh, bring our profession up to, uh, being equal with the other practices. I've always felt that way for years. Jarrod knows that from when he was a resident with me and I, I honestly feel that right now, um, our residents are capable of doing the same things as the internal medicine residents are with direction and the attendings I'm working with, uh, the attendings I'm making rounds and, um, going into these, um, patient rooms we're using, we're probably so conscientious about universal precaution and taking, I'm sure I don't let my residents round on the patient without me. I don't want them going into the rooms twice and taking all of this into consideration. I think that it just is, it's strengthening all of us and our profession.
Jarrod Shapiro
That's a great segway into the, into education. So, let's talk a little bit about how you're working with residents or students. So, I guess let's start with students or, or any view actively working with students who are, have all the schools pretty much pulled the students mine in particular has, so they're not out on rotations.
Marie Williams
Um, or I need you cut all students until the end of June. No students from any specialty, just like our hospital, our HCA facility across the board is cut out all residents in COVID rooms. It's for some I know why because what happened was, um, one of the residents was tested positive and that caused doctors to become sick and it spread very fast in our hospital. So that's why they started to like limit exposure. And I'm started with the residents, but no students. And that's been a little rough too, but I think it's rough on the students. It's rough on all of us who are used to having students. We don't have them at all.
Jarrod Shapiro
Yeah, definitely. Elliott, do you work with uh, students or do you have like family practice residents who rotate into the clinic, into your office?
Elliott Udell
Uh, I can't, uh, uh, medical students actually rotate through my office from time to time. One of the medical schools and, um, they spend sometimes like a month in my office seeing what podiatry life is like, and then they get credits from their own medical school. So, uh, but the, at this point in time, I don't have any residents rotating through my office at all. And I, I would assume that, uh, they probably are furloughed as well because anyone of the medical schools, uh, are closed down and not allowing the students to go to class at all and they are forced to do online training. So, um, you know, and you were asking me before about my staff, uh, and the economic impact, uh, I have three people on hard times. They have been working part time and two of them, uh, basically, uh, picked up and left when things started getting hot and heavy couple of weeks ago. And one, um, uh, wants to come back very, very badly is very, very upset that we're closing the office. So, uh, I'm going to apply for the SBA loan or so that, uh, if she stays with me, I could pay her for the time that she's, uh, she's not working, you know, she's, she's a single mother and desperately needs some money badly. So, I'm going to try to work it out for her. The others, I have a feeling, probably will not come back at all.
They're very, very part time.
Marshall Solomon
You know, it's interesting that Elliott brings up, um, the uh, SBA, there are the SBA is uh, essentially the main application. Um, you should, um, I don't know how many of you have actually applied for it. We have, it's been, uh, our application is been in for about a week. We haven't heard anything yet, but the application essentially is two pages. The small business associates. Um, SBA plus you need to be prepared to, uh, supply them with a financial statement. So, you got to put your financial statement together. If you're a professional corporation, um, you have to, uh, you have to fill out additional forms. You have to also request for transcript of your tax return. This is one of the SBA requirements. And so that is the $250 billion, which they don't have enough of right now. That Congress is going back. In addition, you can apply for, the PPP, which is the, paycheck protection plan. And you need to understand the rules regarding that. Um, you have to maintain their salary or 75% of the salary, at least in the state of Michigan. It requires 75%. Uh, they can apply for unemployment, um, that will not affect the PPE. If they go on employment, the federal government will give them an additional $600 a week, which is probably more than they're going to get for their unemployment. And then there are county loan grants that you can apply for. Um, we have offices in Oakland County and Wayne County and there is application for a $10,000 grant that does not have to be paid back, which you can apply for too. Um, and so you should look for all of these, uh, majority of these, uh, are through your, your bank that you do business with. Unfortunately, uh, we've been on top of this. The bank doesn't have the rules and regulations from the federal government yet, so we're waiting on a list of, for them to, uh, contact us. Our application is already set, ready to submit online. Technically if they contact you and submit, you're supposed to have a check into your account in three days, but it's been a week so you can see how the government works. So, you can understand that this puts a lot of financial stress on, on the practices and you're competing of course, I don't know if it's actually competing, but you're competing with a lot of other businesses too. The guy that's running the mom and pop store and, and uh, so on and so forth. So, if you haven't applied for this, you certainly should apply for it. You're certainly entitled to, uh, do that. Understand one is a loan. The interest is very low. I think it's 0.5% on the SBA loan if I may be wrong about that. And the others are grants that you don't have to pay back. So, you should definitely look into that and start that process.
Jarrod Shapiro
That's great information. So, I'm going to, I'm going to push back to education now. Let's talk about residents. I think it's, um, I think it's fair to say that, um, all of us are involved with pretty high surgical volume residency program. So, if I, if I say none of you are really too concerned about your residents graduating this year, does that, does that ring true for all of you?
Marshall Solomon
Well, I personally, um, our volume, our volume was high enough that most of my, uh, PGY three residents met like that in January. There was one because of the rotation that he was supposed to go on, um, fell a little bit short. But the, um, CPME came out with the 15% reduction in numbers, which, uh, allowed him to match that which of course he was a little bit of a lazy lager. He ended up, uh, getting his additional cases in. But this will affect programs that have just, that are hovering around the MAV, the minimal MAV. And so, I think it was responsive, responsible by CPME to recognize this, how this is to go forward. We'll have to see what happens as residency directors. They keep us informed.
Jarrod Shapiro
Yeah. Uh, Marie, did you have a perspective on that?
Marie Williams
Yeah. Well we were fortunate enough to have our third-year residents fully complete all their numbers before all this started. What I'm concerned about is the fallout for the future, right? Cause we can graduate our residents; we have the decrease numbers and now we have the residents that are first year residents on rotation. They're already freaking out because they're losing, you know, three months of some elective cases. I personally am not a numbers person. So, for me, um, you know, I think that the reduction is, is good. It's going to help us not be fully stressed out. Um, and now when we get back rolling the third year, residents feel like they have to take more of the cases at the second in the first years can have. Um, and, and of course if a resident has all the numbers, but I feel they're incompetent in certain areas, I make them do the cases. So, um, it's not quite, I'm not quite a numbers person. I'm a quality person, so if they can't do it, if to do more of it, I don't care what year they are.
Marshall Solomon
That's competency. Marie we’ve been discussing this for 15 years
Marie Williams
We kind of talked about that.
Marshall Solomon
So, they go, it's interesting. It's interesting. It's an interesting point. When CPME came out with the statement that they were going to reduce it 15%, they also recited the part in 320. It stated it still depends on the residency in teaching faculty to determine competency of their, of their residents, not based on numbers. I've been barking at them for 10 years regarding that and I've been rebuffed about this. It has to take a COVID-19 pandemic for them to actually realize that competency is based by, is really determined by the teaching faculty, uh, of the residents. So yeah, I guess it goes full circle here.
Jarrod Shapiro
Yeah. Mike, have you seen the same thing with your, uh, was your program?
Michael Troiano
Our numbers are cut dramatically. At Presbyterian, we have a pretty interesting program because it's four years to begin with. So, numbers are never really a problem because you know, they have four years to do what other programs are doing in three. Um, with that said, that fourth year is meant to be like a fellowship year. So yeah, the, the fourth years are missing out on, on the, you know, fun reconstruction and stuff that they would normally be doing. But there's two, two things. Number one is, uh, there seems to be a mass appeal for graduation of residents early so they can help on the front lines. Um, so you know, there, there's a silver lining to the residencies because the residents are getting out and able to start their, their craft sooner. So rather than waiting until July or what have you, there'll be up and running much sooner. And the second thing is, you know, like, I think we can't lose sight of the fact that these cases, these patients are not going to go anywhere. Um, they were on our schedules for, in some case, months now, some cases months now. And it's not like when COVID goes away, so are the patients, there's going to be a need for surgery. There's going to be a need for reconstruction. There's going to be a mad rush to have so-and-so as case done first, so so-and-so can get out and enjoy the summer and play basketball and things like that.
Uh, and I think what you're going to start to see is hospitals kind of not functioning around the clock with certainly elective cases on Saturdays and Sundays as well with more availability and OR time and things like that. So, you know, we've been just trying to tell our residents, uh, stay healthy and, and, you know, do your best right now. And, and you know, it'll, it'll come back and serve you. And, uh, I really truly believe that, you know, this is, this is a finite period of time. This isn't forever. And, um, we're going to make up for it in one way or another. And, and you know, as long as those residents are home and, and practicing their rudimentary skills, like using a drill and suturing and all the things that keep you up and Adam, everything's going to be just fine in a few months. I'm certain.
Marshall Solomon
I think just as an added point, we're going to have a lot of smarter residents because they're, we're really jamming education down their throat. And it's an interesting topic because this is the third zoom, uh, event that I had. The first two were academic. So, I mean, I was talking to Jarrod earlier, you can express how you're using zoom, um, that promoting zoom alone, but how you're using this to educate your residents, uniformly
Jarrod Shapiro
Yeah, I'll bring that up. Um, Chris, are you guys doing anything different with your education, with residents are using online more? Anything like that?
Christopher Bromley
Yeah, I mean, you know, we've obviously like Marie, we suspended all the student interaction that we had, you know, on the undergraduate and medical. Um, the residency education. We're trying to do as much of the Zoom meetings online. You know, I, I let everybody know, look, we're not doing cases, but there's, this is a wonderful opportunity for you to learn how to do an ultrasound. You have an ultrasound and you have a foot. You know what I mean? These are, these are times where do you need to get really good at your other skills? Because all of us that have busy, even surgical practices realize, you know, there's some, there's so much more to be a great foot and ankle specialist and standing in the operating room. I mean, there's so many that need to learn and then be competent on, you know, look at what are your treatment protocols? How do you do these skills? You know, how great are you at taping? You know, what are, you know, all the things that you really need to be an expert. So, I think this is this, you know, we're not doing elective cases, but this is a great time to function. You know, and learn about the office, learn about billing, learning about all the things you need to know to be successful.
Jarrod Shapiro
Marie, you always have a very creative approach to educating the residents. Are you guys doing anything different than what you normally do?
Marie Williams
Not really at this point. I mean, we are doing, uh, there's virtual lectures that are being set up at hospital so we can actually get everybody tied into lectures that way. Um, I have all my residents doing skills, their own skills. Um, they report back to me one on one, um, and sometimes two and two to one, um, with our distancing. But, um, and they are coming in to see the post-ops in and out. But, um, we're not really changing too much from that point of view.
Jarrod Shapiro
Yeah. We're, we're pretty much the same. Um, the way that my program is structured, uh, we have two to three sort of distance, uh, rotations that the residents are, they're basically living at those areas. And so we have it set up so that when we do our academic sessions, which are on Monday and Thursday afternoons, um, are, we had already been using zoom through the university in order for everybody to get that, the, you know, the didactic portion of the education. So we continue that. Um, the only other thing I think I've done differently is we've added in a little bit more online lectures. Uh, we, we were using, um, you know, ACFAS has their on-demand lectures and PRESENT of course has theirs. And we were, we're using those, um, a little bit more heavily, but on those off days when the residents are not doing their regular academics and, um, just, you know, to add more work for myself, I had them, uh, also do, uh, like a, a Google Hangouts sort of discussion forum that can kind of run over a day or two days. And we kind of, uh, you know, look at a lecture and then talk about a topic. And I've tried to sort of delve a little bit more deeply into the topics. Um, and they seem, you know, the residents are so used to living online that it doesn't seem to have, you know, created any extra difficulties for them. So that, that seems like it's been okay. Other than the extra work for me to run a forum that that's a bit of extra work.
Marie Williams
One of the things that I just wanted to say, one of the other things that we're actually getting done is they started many research papers and then because of the day to day activities, they couldn't get that stuff done. We're really putting them in action on getting the papers done, doing their case reports or research and studies that have to get done. At least I know that is going to happen because they have the time to do it now and there no real excuse.
Marshall Solomon
Right, no Excuse
Jarrod Shapiro
This is a great time to write an IRB and to start your research like for your first year. It was absolutely great. Great time for that. Um, so let, let's shift to a kind of last section to this and let's talk about some like sort of personal life questions. Um, so instead of, uh, you know, how you're teaching or how you're practicing about you, your free time, I'll, I'll assume that maybe we all have a little bit more free time than we previously did. Uh, maybe not. Um, but our, our, I guess the question is, are you doing anything different in your free time than you had been previously? Um, Elliott, why don't I start with you on that?
Elliott Udell
Uh, yeah. Uh, as I said earlier that I'm an author, so, and, uh, I published a book which is available on amazon.com and I’m working on a sequel. I think people, and they asked me, uh, over the past years to work on a sequel to this and I never had the time. And now I'm almost finished with the sequel cause I've had, uh, unfortunately too much time on my hands and I've, uh, you know, working on it now I have to work with editors and everything and get it, uh, shape work as the point where it's actually get published. That's, that's what I've been doing in my spare time.
Jarrod Shapiro
Great. How about you, Chris? Do you have any spare time? I'm always surprised by how much you're doing. So, I, I have trouble believing you have all that much extra spread time. Even now.
Christopher Bromley
Well, it's, it's actually funny. I mean, I fly out of bed every morning at 5:15. It started bouncing around like Tigger, just going about my day. And, um, so my wife has insisted that I, that I don't do that since they don't have to be somewhere as early as I normally have to be. So, it's been nice to have breakfast in the morning and spend a little bit more time in the days where I would normally spend Wednesday and Friday operating. You know, I've spent some of the time, um, doing some of the consulting work, but really just spent more time at home. Uh, which is a total paradigm shift for me. I, you know, on an average week, probably would spend eight hours at home a week know now I'm here a lot more. So, it's, uh, it's, you know, it's been really great for my relationship, um, because we spend a lot more time together and my wife is not unhappy about the COVID change to my schedule at all. I mean, she's still afraid of COVID, but she's very happy to have me home and I'm not spending the weekend in different cities, uh, doing other things. So, there's been a blessing to it. Um, I think in nine months is going to be a lot of COVID babies around the world or a lot more divorces, one or the other, but hopefully not too much about you.
Jarrod Shapiro
Michael Are you noticing anything different for yourself? Oh, I think we lost your sound.
Marie Williams
Are you talking to me?
Jarrod Shapiro
Go ahead Michael
Michael Troiano
Wait, no, I don't have anything good to say honestly. Go ahead.
Marie Williams
Well, I hate idle time. So, what we did is decided to do some construction in my house. I built a wall in my bedroom, which is quite interesting, and I'm involved in painting my house, you know, things like that. These that you look at and go, Oh, that hasn't been done now we're just getting some of that home construction done. So, I kind of have fun doing that.
Jarrod Shapiro
Staying productive.
Michael Troiano
That's pretty crazy. My wife built a wall in our bedroom as well. Uh, right down the middle of the bed. I actually thought that your question, Jarrod, was purposely to, uh, identify how much drinking that I do now. Uh, my idle time and eating at fast food delivery. Of course, supporting local restaurants. Thank God for Peloton bikes.
Jarrod Shapiro
Yeah, yeah, absolutely. How about you Marshall?
Marshall Solomon
Well, uh, I finally got to the honey do list and I'm working on straightening out the basement. At least I get in 50 flights of stairs up and down, back and forth, and I'm doing a lot more walking. And then, um, I'm bingeing on Netflix. I mean, I'm up until two o'clock in the morning watching all these series. I mean, it just opens up a whole new world other than podiatry, you know, Suzanne always says to me, can't you do something other than podiatry? So, it's been, it's been good. It's great.
Michael Troiano
Enter the Tiger King. Huh? Carol Baskin. Nobody likes that lady.
Jarrod Shapiro
That is the show that is really trending. Everybody is talking about it. I think. I think every one of my residents is been watching the show.
Marie Williams
I do want to make a comment. One thing I noticed in my neighborhood, um, people are out walking all over.
Marshall Solomon
Oh yes.
Marie Williams
Everyone's out exercising and walking. I mean, it's hot here, so it's easy. But I was like, I wonder where those people are. Oh, they're your next-door neighbor. I'm like, wow. I didn't even know that. You know, like I'm starting to see the people in my neighborhood I had never met. It's kind of weird
Jarrod Shapiro
But as you stay succeed away from them all along the street, nothing. Absolutely. Okay, well on that note, I'm going to close out our discussion. Thank you all so much for your time. Um, I want to thank our panelists for your generous use of your time and your insights. I think it's been a really good discussion. Um, I, I hope all of these stay very healthy and you know, don't get sick. Please. You know, maintain your health as much as you can. Um, if anybody has any last comments and then we'll close out our session,
Marshall Solomon
Stay healthy, stay, stay healthy, stay well and stay sane.
Jarrod Shapiro
Great. Thank you all so much for your time. We really appreciate it. Have a good night.
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