When I started my podiatric practice, I opened it in a strip mall within my community. I saw value in placing my business in a convenient location. The space was attractive to me and patients, who benefitted from the convenient location, yards from a major highway and the abundance of parking outside the space. Being in a strip mall attracted patients who became aware of our practice for their foot and ankle needs, and it was easy for new patients to navigate.

I rented this space for 11 years while I built this practice, adding patients I treated out of this facility. The costs associated with remaining in this space increased, and the pandemic created an environment in which my overhead increased by 40%, making it apparent that I needed to prioritize looking at other options for my practice. I quickly learned that rent may not be the best option with real estate pricing going up, and I decided to get serious about building acquisition for my podiatry practice to stabilize my monthly expenses.

Purchasing a building for your business is a big task but also gratifying!

This journey's two most challenging components are finding the right real estate and obtaining financing. Finding a trusted professional to navigate this journey can be helpful. For some, this may come from their network and referrals from other professionals. Fortunately, in my case, my husband is a Business Banker, so I started this process on the right foot!

It was evident throughout this process that having a good financial institution and the right professional in my corner improved the outcomes.

In searching for the perfect spot, I quickly learned that I might benefit from exploring options that include smaller buildings or older homes that have been turned into offices vs. focusing on a larger building and subleasing space to tenants to make the cost of entry more affordable. I found a spot in which I could walk to from my home which seemed meant to be! I hired contractors to make the updates that were needed. It was rewarding to have the opportunity to ensure that my work environment had a homey feel. I have received lots of compliments from patients who appreciate the warm, inviting environment this new space has provided. There were times throughout the process that were a little stressful, but the contractors did a great job, and the project turned out great.

In reviewing the outcomes, I'm thrilled to report that I cut my overhead by half by purchasing real estate for my practice! I am making payments to myself, instead of a property management company or a landlord, ultimately increasing my wealth. The purchase of the building stabilized one of my most significant expenses, and I have reaped the benefits available from a tax perspective. I alleviated the worry of a landlord increasing my rent or not renewing a lease which would result in business interruption. 

Having real estate as an asset on my business books will be helpful for me down the road as I approach retirement. Generally, a health care practice is considered easier to sell when real estate is included because it increases the overall value of the sale, which may attract more buyers and command a higher price. It also opens up additional options when looking at retirement options which may include the sale of the property or leasing it and generating passive income.

Podiatrists in private practice may want their own building and could do some due diligence in their early years of practice.

For podiatrists who are just starting a business, getting a line of credit may be a good idea, as banks prefer lending money to businesses with some experience. A line of credit may be a great move to help with overhead costs, and it will help develop a relationship with the bank, which could help when it is time to get a loan, such as a real estate loan for your business.

Acquiring this property has yielded so many positive gains in my life that extend beyond numbers. I can confidently continue to serve patients in a community that I love being a part of. I get to remain close to home and access my family with ease. I am able to enjoy all the rich culture Pennsylvania has to offer. This decision has been such a positive experience that I am honored to share with others that may be considering purchasing property for their podiatry practice.

Shelly Levulis, DPM, specializes in foot and ankle surgery, wound care, and diabetic foot care. She graduated from Temple University School of Podiatric Medicine and practices in Edwardsville and Dallas, Pennsylvania. Dr. Levulis serves on the Board of the Pennsylvania Podiatric Medical Association.

The holiday season is a wonderful opportunity for small business owners to unite their employees, celebrate accomplishments, and show appreciation. In small businesses, where each employee plays a vital role, fostering a sense of community during this time can boost morale, strengthen relationships, and promote a positive work environment.

Here are seven ways small business owners can bring their workplaces together during the holiday season:

1. Host a Holiday Party or Gathering A holiday party is a timeless way to bring your team together to unwind, celebrate, and socialize outside of the typical work environment. Whether formal or casual, holiday gatherings encourage camaraderie and offer an opportunity for employees to connect.

Here are some ideas: Themed Parties: Add a festive twist with themed events like “Ugly Sweater” or “Winter Wonderland.”

Virtual Parties: Engage remote teams with virtual holiday games, trivia, and gift exchanges. Family-Friendly Events: Include families to create a more inclusive, community atmosphere.

2. Organize a Gift Exchange A gift exchange, such as Secret Santa or White Elephant, can also be a fun, lighthearted way to build camaraderie among employees during the holiday season. Here are some tips to keep to keep in mind during planning:

Set a Budget: Make sure to set a reasonable price range to ensure participation without financial pressure. Keep It Inclusive: Choose neutral themes to ensure everyone, regardless of their holiday traditions, feels comfortable participating.

Prioritize Thoughtfulness: Encourage personalized, creative gifts rather than focusing on price, making the exchange more meaningful.

3. Plan Holiday-Themed Team-Building Activities Holiday-themed team-building exercises are a fun way to boost engagement and bring employees closer together during this busy season.

Here are some ideas: Scavenger Hunts: Create holiday-themed contests with small, festive prizes.

Bake-Off Competitions: Encourage employees to share their favorite holiday treats.

Decorating Contests: Host office decorating contests with categories like “Most Creative” or “Best Holiday Spirit.”

4. Show Appreciation Through Thoughtful Gestures The holidays are a great time to express gratitude for your employees’ hard work. Thoughtful gestures, whether big or small, can make employees feel valued and appreciated.

Here are some ideas:

Personalized Notes: Send handwritten thank-you notes that acknowledge specific contributions from the year. Bonuses or Extra Time Off: Offer holiday bonuses or additional time off to show appreciation.

Recognition Awards: Host an informal ceremony to recognize outstanding employees with fun awards.

5. Give Back to the Community Together Incorporating a spirit of giving during the holidays builds team camaraderie and strengthens your business’s connection with the local community. Participating in charitable activities fosters a shared sense of purpose between you and your employees. Here are some ideas: Charity Drives: Organize donation drives for food, clothing, or toys. Volunteer Days: Plan a group volunteer event to support a local cause. Sponsor a Family: Partner with a local organization to sponsor a family in need during the holiday season.

6. Create a Festive Workplace Atmosphere Adding holiday decorations and festive elements to the office can enhance the holiday spirit, making the workplace warm, joyful, and inviting. This will boost employees’ moods and increase their excitement about coming to work each day. 

Here are some ideas: Decorate the Office: Add lights, garland, and holiday décor to communal spaces.

Seasonal Treats: Offer festive snacks like cookies or hot cocoa in the breakroom. Holiday Music: Play holiday music during lunch breaks or other casual moments to lift the mood.

7. Reflect and Celebrate the Year’s Achievements The end of the year is an excellent time to reflect on the team’s accomplishments. Celebrate successes, highlight key contributions, and acknowledge the hard work put in throughout the year. This will help employees feel appreciated and noticed for their contributions and efforts.

Here are some ideas: Year-End Recap: Share a presentation or memo highlighting major milestones and individual contributions.

Goal-Setting for the New Year: While celebrating achievements, start a conversation about goals for the coming year and encourage employee input. Bringing your team together during the holiday season fosters a sense of unity and belonging, enhances workplace morale, and leaves lasting positive impressions. Whether through holiday parties, team-building activities, appreciative gestures, or community involvement, small business owners can create an atmosphere of joy, reflection, and celebration. The festive season provides the perfect backdrop to strengthen workplace connections, reflect on the year’s achievements, and set the tone for a successful year ahead.

PaySmart is a payroll provider located in Mechanicsburg, Pennsylvania, supporting small businesses in the Central PA region. We are dedicated to helping small businesses take care of their payroll needs. To learn more information about how PaySmart may provide payroll solutions, please get in touch with us at 717-766-1777. Our New Client Concierge is waiting for you!

11 THINGS PATIENTS WANT FROM THEIR DOCTORS

Seventy-three percent of patients keep a "mental scorecard" on their likes and dislikes about their healthcare provider's office, a new study from EHR company ModMed and OnePoll found. 

LEARN MORE!

Who wouldn’t want a practice that operates with an equally distributed workload; synergistic work mentality, increased efficiency and productivity; improved office morale and less team burnout; trained hands to assist in more patient care thereby generating more revenue; professional customer service; and less time constraints on the practitioner allowing him/her more patient-focused hours? If you’ve ever given any thought to onboarding new staff in order to create some of these circumstances, don’t just JUMP IN and expect a miracle! It takes more than just a thought. It takes a plan.

The following is a six step outline that can help you put one together. 

Step One: Recruitment

• Where should we look to find new recruits?
  • Schools, social media, patients, eateries, internet job sites (Monster.com, Indeed, etc.), hairdressers, gym, anyone in hospitality (customer service positions, i.e. hosts, waitstaff, valet, front desks, etc.) Chat it up! Let people/patients know you are searching.
• How can existing staff help in the search?
  • Individuals tend to hang out with those who exhibit similar personalities. Ask your staff: “Are there more of YOU out there?” “What about the job attracted YOU?”
  • Staff input helps to evaluate the practice’s current staffing needs. Where is help most needed? In what ways do they see a new hire affecting workflow? (Good or bad)
  • Put an Employee Referral Program in place as an incentive for them to help.

Step Two: The Hiring, Interview, and Selection Process

• Assess application responses
  • Pay attention to “red flags” on resumes and eliminate those that do not meet your needs.
  • Follow up: Set up appointments for first interview.
    • Decide who will conduct this interview – Doctor or Manager
    • Use a standard questionnaire for consistency and fairness to compare apples to apples; take notes to review later.
    • Have your favorite interview questions ready. Refrain from asking illegal ones.
      • If you encourage an open dialogue with your interviewee, they may offer information you are not allowed to ask.
    • Initiate role playing scenarios – focus on behaviors, words, expressions.
    • Discuss basic job descriptions, wages & benefits, hours, travel.
    • Meet and greet staff; are first impression personality clashes obvious?
    • Highly recommended to set up a second interview for those who seemed promising! Learn as much as you can before pulling the plug on your selection.

Step Three: Orientation

• Conduct a facility walk-through with new employee on day one. Best to start them on a Tues or Wed as Mondays typically are a little too hectic.
• Formal introduction to staff and practitioners.
• Match peer mentor to new recruit.
• Assign email account and login info.
• Have new employee spend adequate time with Office Manager (or the like) to:
  • Review and sign all necessary work-related paperwork.
  • Explain workplace culture, set practice goals and milestones; help them understand the importance of their participation as a team player.
  • Set up a training schedule.
  • Review employee policies and handbook for rules; conduct and disciplinary actions; workplace safety.
  • Explain job, employee, and employer expectations.
  • Review the performance review process; how, when, why?
  • Present a thorough review and understanding of their detailed job description and responsibilities. Prioritize primary and secondary duties.

Step Four: Training (MAKE the time!)

• As part of active work duties, all new employees regardless of hired position should report to the following positions (requiring their focus for a one week period in each position) to shadow, understand associated tasks, and observe interactions of each role. This is mandatory and in coordination with the components of a Successful Proactive Training Model (described in detail below).

  Some observations entail:

  • Doctors (observe doctor-patient interaction, instruments, protocols, podiatric vocabulary and commonly treated conditions, supplies, etc.)
  • Medical Assistant (Proper patient rooming and exam room setup, sterilization, inventory, documentation responsibilities, etc.)
  • Receptionist (phone, scheduling, patient data, collections, patient communication, etc.)
• Components of a successful proactive training model:
  • Demonstrate task, 1) Explain HOW, 2) Clarify importance, 3) Encourage questions, 4) Trial Time to observe and monitor, 5) Allow them to perform task solo.
• Require note taking as a learning tool – notes should be checked daily for accuracy.
• Cross training.

Step Five: Job Expectations that should be reviewed regularly with ALL Staff/Team members (new and existing)

• Professionalism
• Risk Management
  • HIPAA Confidentiality/breaches/consequences
  • OSHA Compliance
  • Legal Scope of practice
• Communication Skills (The patient/Staff connection)
• Customer Service
• Basic knowledge of podiatric medicine
• Dealing effectively with difficult personalities
  • Demanding, Complainer, Perfectionist, Disrespectful, Chatterbox, RUDE…. Abusive?
• Competence, Accountability

Step Six: Retention

• GOOD MANAGEMENT and Leadership!
  • Incentives
  • Inspiring, fun work environment
  • Employee rewards, appreciation and engagement opportunities
  • Fair Compensation & Benefits
  • Growth Opportunities
  • Employee surveys: Because it is unlikely that every staffer is motivated by the same thing, the best thing to do is to ask and FIND OUT.

Turnover is expensive AND disruptive! A strong onboarding process will considerably increase the likelihood of a voluntarily longer-term, happier employee.

I had the opportunity to attend the national APMA CAC and PIAC meeting in Alexandria, Virginia, in November. I am your Pennsylvania Contract Advisory Committee (CAC) and Private Insurance Advisory Committee (PIAC) representative. A Contractor Advisory Committee Representative deals with Medicare changes to LCDs.

A Private Insurance Advisory Committee representative deals with changes in private insurance. Most of the 50 states attended this meeting.

We discussed multiple issues with Medicare and private insurance. The conversion factor this year is reduced by 2.18. However, this should have zero impact on podiatry payments. We hope this stays the same. I'll keep our membership posted with any changes.  

We discussed the proper use of modifiers, such as modifier 25, when a procedure and evaluation and management are done on the same day.  We also discussed callus care being kicked out on the same day as nail care for some insurances, like Aetna. APMA is working hard to continue monitoring this; supposedly, Aetna has fixed it. 

We discussed the new “Final Rule” in depth. This was passed to protect Medicare customers confused by Medicare Advantage plans. Advantage plans will no longer be able to offer less than what Medicare. So hopefully, the Advantage plans that only allow at-risk foot care four times a year will need to change this to the Medicare LCD guidelines in your area. 

Dr. Jeff Lehman talked to us about MIPS.

Members who want to file a QPP exception application must do sobefore January 2, 2024. You can find this application onwww.gpp.cms.gov. You will need to fill out why you have an extreme and uncontrollable circumstance that would not allow you to participate in MIPS this year.

I will keep our membership posted with any other further updates as APMA and PPMA continue to monitor issues with billing and reimbursements. Another great benefit of membership in PPMA!

Whether you are assessing an employee’s skills or developing them, role playing should have a significant place in both your hiring and training protocols. Unfortunately, this excellent exercise in effective communication remains underutilized and undervalued, resulting in ineffective hiring, unsuitable staff that have neither the skills nor the desire to succeed and if that wasn’t enough…frequent turnover which takes a hit on disturbance of normal functioning, team attitudes, and oh yes…profitability,

Role playing different common scenarios helps reveal many of the soft skills (like communication & interpersonal skills, time management – working under pressure, composure, compassion, self-motivation, decision making, creativity, adaptability and work ethic) that otherwise go undetected with your typical interview. It also brings to light some of their problem solving and customer service qualities. Sure as shooting, your applicant will come prepared. He/she are familiar with the types of questions and has spent time practicing all the right answers. If they’ve been at this for a while, chances are their acting skills are perfected. Their intent is to fool you into thinking they are the best candidate for the job. Maybe they are; maybe not. Don’t be fooled.

Here is a typical example of a rehearsed, verbal response:

· Interviewer: “There are times when our schedule sometimes run late. How would you handle an irritated patient who was waiting longer than she expected?”

Applicant: “Well, I would explain to her that there was an emergency that caused us to run a little late. I’d give her the option of waiting a little longer or reschedule her to another time.”

Perfectly canned response. She practiced it and delivered it with scripted confidence. But, what if the patient expressed continued discontent (as they many times do)? Satisfied? If you end the questioning there, you’ve really just only seen what the interviewer wants you to see.

Here’s what role playing will do with the same question, but asking the applicant not to recite her response, rather to act it out in real time.

· Interviewer: “There are times when our schedule sometimes run late. I’m going to be that irritated patient who was waiting longer than she expected and I’d like you to be my new assistant. Show me how you’d handle this patient’s complaint.”

Acting as the irate patient, don’t go easy on her. Be overly-sensitive. Demanding. Critical of not only her, but the practice. Say things like, “This isn’t the first time I’ve had to wait more than 30 minutes. How many times does this have to happen before this practice learns to schedule properly?” Ouch.

As the applicant takes on her new role, you observe her body language. Are the words she uses and the tone of her voice satisfying to you? Does she look you in the eye? Sound genuine? Does she remain composed even though the patient (you) give her a hard time or does she crack under pressure? Does she get defensive? Make up some flimsy excuse or worse yet, promise it will never happen again? Are her words congruent with her actions? Is she apologetic and empathetic? Is she able to calm the patient by thinking quickly on her feet to offer a satisfying solution? Finally, how would you feel as a patient having interacted with her, face-to-face?

The same rules can be applied during subsequent in-house routine training sessions or at a staff meeting where everyone can participate. Present various scenarios – in the treatment room, on the phone, responding to clinical questions, etc. Then, don’t just ask how they would handle each situation, but let

them show you. Of course, role playing is only one piece of the hiring and training puzzle; a piece you really don’t want to be missing. It can help to capture your star employee. Don’t underestimate its payoff.

Ms. Homisak, President of SOS Healthcare & Management Solutions, has a Certificate in Human Resource Studies from Cornell University School of Industry and Labor Relations. She is the 2010 recipient of Podiatry Management’s Lifetime Achievement Award and recently inducted into the PM Hall of Fame. Lynn is also an Editorial Advisor for Podiatry Management Magazine and recognized nationwide as

Have you thought that it is time you started thinking about becoming more organized, more efficient, and open to change?

If so, then follow along.

These easy tips will improve cash flow, increase marketing potential, strengthen staff competence, and even manage your time and systems.

Let the countdown begin!

10. Monitor the money handlers.

Introduce standardized money handling protocol and embezzlement safeguards. Regulate how each phase of the money is to be handled (patient collections, recording, receipts, end-of-day reconciliation, depositing) and by whom. It is also a good idea to conduct unannounced spot checks to start.

Note: Staff need to understand that financial safeguards are not implemented due to a lack of trust; rather, they are a necessary business mechanism. If anyone is uncomfortable or shows signs of resistance, consider it a red flag.

9. Stay “in the know” by receiving weekly and monthly financial data as well as quarterly productivity reports, including the status of account receivables, aging, credits and refunds, clean claims analysis, and denial/appeals progress reports.

8. Make sure your daily schedule indicates patient balances owed so the front desk staff can collect them at the time they collect patient copays. For more effective outcomes, encourage staff to be proactive in their collection efforts by stating, “Your copay/balance today is…” rather than asking, “Would you like to pay your past due balance today?”

7. Increase your market acumen. Ask yourself, “What makes our practice so special?” and build on your unique strengths. It wouldn’t hurt to get some insight into what your competitors offer that you do not.

6. Use your patient emails to stay in contact with them. (Think: practice updates, educational info, newsletters, birthdays, etc.)

5. BUMP UP staff training! Give staff the proper knowledge and tools to maximize their output to grow and succeed - in their career and your practice.

4. Tap into the staff’s strengths and talents in order to assign proper placement. A team that feels challenged and enjoys what they do will apply themselves in a much bigger way, whereas improper job placement creates a less energic, slower-paced employee.

3. When managing your appointment schedule, be realistic. If a procedure takes 30 minutes, do not schedule a brief 10–15-minute time slot. Time align your procedures so staff can schedule appropriately and keep an on-time schedule. And note your start time. Arriving and starting 10 minutes late is enough to snowball in a schedule backup. If you can’t be on time…BE EARLY.

2. Make the time to regularly review current operating systems. Monthly staff/office meetings are a very effective place to have this discussion. Ask for and listen to staff input. The front line is likely more aware of daily obstructions. Give their ideas a shot, innovate. And try new strategies for at least six weeks at least before invalidating their potential.

1. Send new patients to your website or portal to fill out their registration forms in advance of their visit. Don’t age-discriminate (for example, assuming Medicare patients cannot comply). Advise them to send forms electronically (the best) or ask if they have access to a computer/printer. Their cooperation will save a solid 15 minutes when they arrive, and you will receive a much more accurate/comprehensive health history as a bonus!

Bonus Tip: Don’t let those empty appointment times go to waste. PLEASE insist that your staff use a waitlist to at least attempt to fill cancelations and holes in your schedule. I can attest that patients scheduled weeks/months in the future would genuinely appreciate an opportunity for an earlier appointment.

Increasingly the feeling is the pandemic is behind us.  The Peterson-Kaiser Family Foundation Health System Tracker shows that as of December 2022, healthcare sector jobs are 1.2% higher than in February 2020 which was the previous peak.  All other job sectors are 0.8% higher in the same time span.   However, the pandemic’s impacts linger in many areas, particularly and acutely in Healthcare. 

The Peterson-Kaiser Family Foundation Health System Tracker shows Healthcare is nearly 4% under projected levels based on pre-pandemic growth rates. The Great Resignation hit Healthcare Providers very hard.  So too, many staff members resigned.  Patients are noticing.  A recent HealthDay/Harris Poll shows 25% of Americans have noticed or personally experienced the impact of staffing shortages in health care and more than half of respondents blamed staffing shortages for delaying them from receiving needed care.  Any Podiatry practice which is hiring for healthcare jobs is experiencing both existing staffing issues and recruitment challenges.  

Podiatry practices face several challenges in recruiting for any position.  Let’s just consider just four challenges practices have in hiring:

1. Aging Workforce

According to the US Department of Labor, workers 55 and over now make up 25 percent of the labor force — up from 13 percent in 2000.  Every resignation of a cherished “elder” employee stings.  Significant tribal knowledge is lost.  This impacts healthcare delivery in all facets of a Podiatry practice.  Medical experience is lost, and the reduced administrative prowess of front-office and back-office staff noticeably impacts day-to-day operations.

2. Burnout

There is unprecedented pressure on Podiatry facilities and staff.   The Association for Advancing Physician and Provider Recruitment reports one-third of physicians are considering retiring early which would exacerbate aging-related retirements.  Administrative burnout is real, too.  Burned out administrative staff are less proficient at their jobs and this leaves patients feeling overlooked and unhappy BEFORE they even get to see the Podiatrist.

3. Shortage of Qualified Individuals

Hiring for every role in a Podiatry practice is faced with a shortage of qualified individuals.  Data from the American Association of Colleges of Podiatric Medicine (AACPM) shows decreasing enrollment in Podiatry school since 2015.  Finding qualified associates can be a challenge, as a result.  Post-secondary vocational or technical education in administrative work is not as common as it once was.  Many Podiatry practices are faced with hiring people with no experience in healthcare administrative roles hoping they can develop into the dynamic, multi-tasking gatekeepers who greet patients in a positive and friendly manner.  A secondary impact of the shortage of qualified potential hires is longer hiring timelines. 

4. Hiring Costs

Months and months of inflation, the movement of calling for an increased minimum wage of $15 per hour, educational debt, and many other factors have driven up hiring costs for administrative staff who can make more in warehouse jobs.  The average medical school graduate owes $250,990 in total student loan debt.  This fact drives the decision making of potential Podiatry associates. Salaries are a significant portion of expenses for a practice.  All of this rests against the reality that when adjusted for inflation in practice costs, Medicare physician pay declined 20% from 2001 to 2021 according to the Federal Register, Medicare Trustee’s Reports and US. Bureau of Labor Statistics. 

Podiatry practices cannot function well without addressing hiring issues.  No doubt, this is made more challenging in an environment where candidates overwhelmingly hold most of the leverage.  

Here are four tips for creating a mindful and calculated approach to deal with the hiring process:

1. Recommit to Your Purpose

Podiatry practices furnish good work opportunities in a rewarding space.  Few medical specialties present the opportunity to see and connect so frequently with patients as Podiatry does. The patient base for Podiatry practices skews older in age. Podiatry practices are places of healing, but also social hubs for elderly patients.  The Podiatrist and their staff often are frequently the only social interaction some elders get.  It is important, enriching work for Podiatrist and staff.  That should shine through in job descriptions and interviews.  This recommitment emotionally helps with burnout. 

2. Work Can Be Ageless

As much as the aging workforce presents challenges, it is simultaneously presenting opportunities.  Workers are aging and CHOOSING to remain in the workforce longer as life expectancies grow, and inflation erodes Social Security and other fixed income assets.  Workers over the age of 65 comprise 7% of the workforce currently.  That is expected to grow to 23% in 2028.  The AARP and other organizations offer programs for connecting older workers to jobs.  In many cases, these older workers possess skill and experience in the highly complex administrative roles which benefit a Podiatry practice.

3.Permit Flexibility

Don’t unnecessarily fetter yourself to old paradigms.  For example, can a former full-time position be handled with two part-time hires?  This can build in resiliency in your workforce.  Your organizational knowledge won’t be one person deep.  Time off is built into two roles offsetting burnout.  Does a hire have to have healthcare experience?  Perhaps that over 55, former law firm receptionist trains up easily enough to be the friendly face your patients love and a multi-tasking beast of an employee administratively.  Can the former Vet Tech make a great Medical Assistant?  Challenge every assumption you’ve ever had regarding how you have executed hiring in the past. 

4. Be Candid and Direct with Job Descriptions

Too much focus can be placed on relevant experience as a surrogate for job qualifications.  Be clear about the specific responsibilities.  Make sure job descriptions reflect what your brand is (1. Recommit to your purpose).  Explain what you need from the role for which you are hiring and what the practice can provide them in return.  This will help you get focused batches of resumes for review. 

The challenges faced by Podiatry practices in hiring go beyond these scant few mentioned and are many.  Regardless of which negative, even panicky, feelings these challenges present, Podiatrists and Practice Managers will continue to have hiring needs and must develop plans to appropriately meet those needs.  It is perfectly fine and appropriate to feel stressed and overwrought with the task.  Acknowledge the difficulty and remember successfully negotiating the hiring process is essential to increasing your own morale, your employees’ morale and creating a workplace where everyone feels valued, more productive and engaged. 

That is a business which has better attractiveness to current and potential talent.   

It's wintertime; many people attribute their cold feet to the frigid temperatures outside. Although cold extremities may be due to the body's response to external temperature, they could also be a sign of malnutrition and systemic diseases that a podiatrist should identify and address in conjunction with another medical specialist. A thorough history and physical examination are necessary to pinpoint the cause of their pathology. Symptoms may include weakness and pain in the extremities, sensitivity to cold, color changes to skin, and numbness during warming periods. As podiatrists, we need to be aware of the many factors that may lead to cold feet in our patients and therefore dictate their course of treatment.

Vascular disease affects many people, especially those with a history of smoking or diabetes. Patients have narrowed or calcified blood vessels that cause poor blood outflow to the extremities. This may result in cold toes or feet. A medical history and clinical examination consisting of a thorough vascular exam are necessary. Symptoms may include pain at rest, a few steps or blocks upon ambulation, and cold feet that do not resolve with warming. Patients should have noninvasive studies to check the flow status in their lower extremities to assess the patency of the major arteries of the foot. A vascular referral might be needed, as well as an angiogram to determine the location of the occlusion(s). Untreated peripheral vascular disease can lead to ischemic changes and gangrene with chances of limb loss.

Another vascular phenomenon causing symptoms of cold feet is Raynaud's (disease and syndrome). In addition, trauma, cold, stress, or scleroderma can lead to vasospasms constricting vessels flowing to the feet. Symptoms include extreme sensitivity to cold temperatures and possible changes in color, such as blue or purple tones in the cold and redness when warmed. Treatment is warming the feet with socks or placing yourself in a room with higher temperatures. Some patients may also take more drastic lifestyle changes by relocating to states with warmer weather.

 Other culprits causing cold feet symptoms could be related to medications such as beta-blockers, migraine medications, and pseudoephedrine. These medications can cause constriction of blood vessels causing symptoms of cold feet.

           Peripheral neuropathy is a condition of degeneration of axons of distal nerves causing numbness or perceived coldness to the area once supplied by the nerve. Although common in patients with diabetes, it can also be seen in conditions such as alcoholism, malnutrition, hypothyroidism, and chemotherapy. Vitamin deficiency, such as that of B12 and folate, can cause demyelination of nerves leading to peripheral neuropathy. In addition, iron deficiency anemia, which is an iron deficiency, and therefore hemoglobin production, directly affects the amount of oxygen reaching tissues in the body. Thus, an appropriate amount of blood may not reach the far extremities and toes, causing symptoms of cold toes.

           Hypothyroidism, the 2nd most prevalent endocrine disorder after diabetes, is another culprit of cold feet. Patients unable to create sufficient thyroid hormone cannot thermoregulate their body temperature. Other systemic diseases that can lead to cold feet are hyperlipidemia, which damages and constricts blood flow through inflammation and atherosclerosis of arteries, and diabetes, which causes glycosylation and calcification. Therefore, it is crucial to get regular blood work and follow up with a primary care physician who can provide the appropriate referrals.   

            Symptoms of cold feet, while a cause of normal reaction of the body to decreasing external temperatures, should not be dismissed. They may indicate underlying vascular, systemic, or endocrine diseases that a specialist should further evaluate. Podiatrists are crucial in identifying factors that can lead to cold feet, so a multidisciplinary approach is recommended across multiple subspecialties.

Contributors:

• Jane Pontious, DPM Clinical Professor, Dept. of Podiatric Surgery TUSPM
• Kushkaran Kaur, DPM, MS

1. Kersting, Jonas, et al. "Guideline-Oriented Therapy of Lower Extremity Peripheral Artery Disease (PAD)–Current Data and Perspectives." RöFo-Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden Verfahren. Vol. 191. No. 04. © Georg Thieme Verlag KG, 2019.
2. Crockett, David, and Daniel Bilsker. "Bringing the feet in from the cold: Thermal biofeedback training of foot-warming in Raynaud's syndrome." Biofeedback and Self-regulation 9 (1984): 431-438.

As podiatrists, we all know how important proper footwear can be for our patients! It is equally as crucial as a podiatrist that we know the qualities that make up a running shoe to make the best recommendations to our patients. This article will serve as a review of shoe anatomy, essential running shoe technologies, and tips to help make the best suggestions for footwear for your patients.

1. Avoid the one brand fits all strategy.

Two of the biggest pitfalls are #1 suggesting the identical shoe to all the patients and #2 presenting a specific name brand and not a particular type of shoe. One big mistake people make with running shoe suggestions is giving the same suggestion to all of their patients. 

What we will see throughout this article is that different foot types and pathologies require other qualities in their footwear. So, if the identical shoe is recommended for all patients, then a subset of those patients will be in the wrong shoe. What we see is that there is significant variability in quality and also type of shoe within certain brands. It is not uncommon to see someone having been given just the name brand to get, and they often pick the worst shoe for their foot type from that name brand.

2. Gain an Understanding of Basic Running Shoe Anatomy to be able to make good recommendations that are customized for your patients.

Knowing the components and their purpose is critical to help you better understand running shoes.  

The Upper:

The quarter refers to the rear and sides of the upper that covers the heel. The heel tab, collar, and cuff are all extra pads and cushions to help protect the malleoli and Achilles. One of the essential parts of the quarter is the heel counter. The heel counter is a firmer material, either externally or as an insert, to reinforce and support the heel. This is why it is vital to counsel your patients to untie their shoes before they take them on and off. Stepping and pushing into tied shoes will damage the heel counter which impacts the integrity of the shoe. The size and firmness of the heel counter can vary. For instance, the heel counter will be stiffer and more prominent in a motion control shoe, as this can improve rear foot stability. In more minimalist shoes, the heel counter will still be present however may be thinner, smaller, and less firm.  

The Vamp refers to the part of the upper that goes from the toe box to the quarter. Most modern running shoes and many walking shoes will be a lightweight, flexible, and breathable materials. Most of these are woven knit or mesh. An essential part of the upper is the tongue. Of course, the tongue protects the foot from lace pressure. Tongues can either be free (meaning they are only connected at the distal edge) or gusseted. A Gusseted tongue is stitched in place or attached to the midsole by a flexible fabric. 

The purpose of a gusseted tongue is to protect the foot from dirt and debris entering the shoe. You will find this in many trail running shoes, hiking boots, snow boots, and work boots.

Outsole:

The outsole is commonly referred to as the tread pattern of the shoe. The treads used for traction will vary based on what type of surface the shoe is designed for. For example, a road running shoe will have small, low profile, uniform, shallow, lightweight, and flexible treads. On the other hand, trail running shoes, like snow tires, will have deeper treads for better traction. 

The outsole pattern is one of the significant differences between Road and Trail running shoes. Trail running shoes are further broken down into light versus technical trail shoes. Light Trail shoes will be for harder-packed trails and will have deep treads that a still lightweight and flexible. Technical trail shoes are for softer, muddier trails, so the footprints are much more profound, thicker, and firmer.

Last: 

The last is the form that the shoe was made on. There are three main types of lasts. The curve last is very common in lightweight and less supportive shoes such as racing flats and spikes. In a curved last, when looking at the shoe's footprint, there will be a lazy C-shaped curve bisecting the heel, curving toward the great toe. A straight last is found in motion control and orthopedic stability style shoes. They are heavier but more stable, with the bisection of the heel and the forefoot forming a straight line. Finally, most running shoes on the market are a Semi-curved last, a hybrid between the two. There are also differences in how the components of the shoe are attached.   In slip-lasting, the shoe's upper is glued and stitched directly to the midsole, which allows the shoe to be lighter. In comparison, with board lasting, the upper is attached to a board which is then placed on top of the midsole. This is used in more stability-type shoes, but the tradeoff is that it is heavier. There is also a combination lasting which uses a board last method in the heel and a slip last method in the forefoot, which allows for a stable heel and a more flexible toe.

Midsole:

The midsole is the part of the shoe that has seen the most change, advancement, and controversy in the past decade. This is also where we will start seeing more differences of opinion as to which type of midsole is best and where the current hot-button topics in footwear design are. The midsole is typically a shock-absorbing material such as polyurethane or EVA foam. Brands then also add their additional elements, such as air or gel. There are two essential terminologies when describing the midsole: the stack height and the offset (AKA drop). These terms are related but not the same, and it is essential to know the difference. 

Stack height refers to the amount of shoe material between your foot and the ground, essentially how thick the midsole is. A lower stack height will have a more natural ground feel with less cushioning. A higher stack means a more considerable amount of material for a more cushioned feel and a higher degree of shock absorption. The offset refers to the height difference of the midsole between the rearfoot and the forefoot. A low offset is defined as 0-6 mm.  A high offset is typically between 7-12 mm, meaning that the heel height is 7-12 mm higher than the height of the forefoot. However, a high-stack height shoe can have a low offset (a maximalist shoe), so it is essential to distinguish these terms. In the question of what type of heel offset and stack height are better, the answer is that it depends on several factors such as, but not limited to strike pattern, BMI, and injury history.  

One factor to consider is the foot strike pattern. Foot strike means what part of the foot contacts the ground first, the rearfoot, midfoot, or forefoot, when running. A shoe with a low offset and a low stack height lends better to a midfoot or forefoot strike. A low offset and high stack height shoe can also be appropriate for mid to forefoot strikers. A runner with a rear foot strike will need more shock absorption and cushioning at the time of a heel strike. Therefore, a rearfoot strike will typically be in a higher stack height and/or a higher drop shoe for better shock absorption. When looking at the different types of shoes (minimalist vs. maximal vs. traditional) in conjunction with foot strike patterns, it is not that one of these has more injuries. It is that they have different injury and force loading patterns.  

Someone who is a heel striker and wearing a higher drop shoe will place a more significant eccentric load on the quadriceps during running gait. They will have a higher vertical load but lower shear stress at the ankle, greater impact through the knees, hips, and back, and an increased degree of ankle dorsiflexion and knee extension at the contact phase of gait. These runners will potentially have an increased risk for anterior knee pain, tibial stress fractures, shin splints, and possibly plantar fasciitis. Someone who is a forefoot striker will shift the eccentric load away from the quadriceps and to the gastroc-soleus. They will have a more significant impact and shear stress at the ankle and MTPJs, higher max peak force, and more ankle plantar flexion and knee flexion at contact. These runners will potentially have an increased risk for calf muscle strain, ankle instability events, forefoot pathology, and, debatably, Achilles tendinopathy. There are two recommendations/theories that are starting to emerge. One is that if someone is switching to a shoe where the offset is > 4 mm different than their current shoe, it is advisable to transition to that new footwear to avoid overloading structures gradually. Another is that some suggest switching up the type of shoe and the foot strike pattern during running training to help prevent repetitive loading on the same musculature.

Arch Support:

There are several ways that arch support can be built into the running shoe design. One method is straight and board lasting.  In the more traditional type of running shoes, arch support was achieved using a medial post of higher-density material in the midsole to help prevent excess pronation. This was the key component defining a "stability" shoe. Stability shoes can be broken down into mild-moderate-high stability based on the volume and size of the higher-density medial midsole post. However, a couple of the running shoe brands are getting away from the medial posting and shifting more towards what is called a J-frame. This is a thinner J-shaped higher-density material insert in the midsole that wraps around the lateral heel and extends through the medial longitudinal arch. This higher-density material does not encompass the entire thickness of the midsole like the medial post does. Rather than push the foot out of pronation, this technology tries to stabilize the foot in a neutral position. Arch support can also be achieved by adding a rigid shank. The shank is a supportive structure integrated between the midsole and the outsole that runs through the area underneath the arch. A more rigid shank ensures that the shoe will not flex under the area of the arch, offering more stiffness and support through the midfoot.

Outsole/Midsole Stiffness and Rocker:

This is how much flexibility there is to bend between the heel and the toe. Traditional stability, motion control, and maximalist shoes tend to be stiffer. In comparison, a minimalist shoe will tend to be much more flexible. This is another debatable topic regarding which is best, and the decision is primarily based on individual needs. There has been limited data in a few studies that show that recreational runners and walkers who wear overly thin and flexible soles while also building distance too quickly can have an increased risk of forefoot pathology.  

There is a current trend in marathon race shoes to be extremely stiff. For example, a maximalist shoe with a carbon fiber plate in the midsole was used to run the first sub-2-hour marathon. As these shoes are being talked about more, it is essential to discuss with your patients that this type of stiff carbon fiber-plated marathon running shoe is designed for elite runners to improve their running economy during a long race, and they are not designed for everyday training shoes.  

A forefoot rocker helps transition the foot quicker to the push-off phase of gait and helps propel the body forward. Almost all running shoes will have a slight rocker, and the degree can vary quite a bit between brands and models. Another emerging trend in running shoes is to have more of a forefoot rocker built into the shoe. The rocker can start at the level of the toes, MPJs, metatarsal midshaft, or more proximal to encompass the entire forefoot. The more proximal the rocker begins, the more help the shoe offers to help propel motion forward. Shoes with a higher degree of forefoot rocker will benefit those patients with significant hallux limits and other forefoot pathology.  

Toe Box:

It is important to make patients aware that the width of the toe box frequently does not correlate with the width of the shoe. The difference in the last size in wide vs. regular-width shoes is the volume of the midfoot. Not all wide-width shoes have a wide toe box. When looking for a wider-toe box shoe, you must counsel your patients to look for specific brands and models, as this is more of a design feature and not a product of the shoe width. Patients with bunions, tailor's bunions, and interspace neuromas can benefit from a wider toe box. In recent years, with some of the newer running shoe brands that focus on a broader toe and more of an anatomically foot-shaped shoe becoming more popular, many other brands are starting to integrate this feature into some of their models.  

Types of Shoes:

After reviewing the basics of shoe anatomy, here is a breakdown of the various categories of shoes on the market.  

Minimalist Shoes: Lightweight, low stack height, low drop, with a more natural feel. This type of shoe lends towards the forefoot to midfoot strike. Very similar to a lightweight racing flat.  

Barefoot shoes: A minimalist shoe. It will have very little to no midsole, be very lightweight, have a 0 drop, and have outsole flexibility. Best suited for a small subset of forefoot strikers.

Maximalist Shoe: High stack height, firmer sole, low drop, forefoot rocker with a lightweight but cushioned bouncy feel. This shoe can be utilized with all foot strike patterns and is popular with forefoot pathology patients and those needing more shock absorption. They can be divided into neutral and stability models.

Traditional shoe: A moderate stack height and high offset shoe. These shoes are further broken down into neutral, stability, and motion control.  

Neutral shoe: has no additional arch support features built into the shoes. Traditionally recommended for a neutral foot type or mild supinator

Neutral Cushioned Shoe: a neutral shoe with additional shock absorbing and cushioning material, such as more air or gel incorporated into the midsole. For those runners needing more shock absorption, and traditionally recommended for over supinator's.  

Stability Shoe: It is further broken down to mild-moderate-high stability based on the components that add additional pronation support to the shoe. Traditionally mild to moderate overpronators.

Motion Control Shoe:  Will have all the features that add support and stability, a straight last, board lasting, rigid shank, and higher density extensive medial posting that wraps around to the lateral rearfoot. This type of shoe will be significantly more stable but also much heavier. Patients with severe overpronation, obesity, or instability in the rearfoot will traditionally be recommended this type of shoe.

3. Lastly, How to Make the Best Shoe Recommendations:

While discussing the various aspects of shoe anatomy, it has become evident that many factors go into shoe selection. Unfortunately, there is not a one size fits all approach, and the best way to make shoe suggestions is to individualize the recommendation to the specific patient. Historically and traditionally, we used solely foot type to determine what shoe a patient should be in, but it is more complicated than that.

The critical factors to consider are:

• Individual Needs
• Running Surface
• Foot Strike Pattern
• Foot Type
• Injury History
• BMI
• Experience Level
• Training Distance/Intensity
• Race/Performance Expectations

Sources:

• Metabolic and Performance Responses of Male Runners Wearing Three Types of Footwear: Nike Vaporfl y 4%, Saucony Endorphin Racing Flats, and Their Shoes. 
•  Hébert-Losier K, Finlayson SJ, Driller MW, Dubois B, Esculier JF, Beaven CM. J Sport Health Sci. 2020 Nov 29:S2095-2546(20)30163-0.
• Biomechanical Differences of Footstrike Patterns During Running: A Systematic Review With Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. Published Online: September 30, 2015Volume45Issue10Pages738-755. https://www.jospt.org/doi/10.2519/jospt.2015.6019
• Three-Dimensional Biomechanical Analysis of Rearfoot and Forefoot Running. Orthop J Sports Med. 2017 July 24;5(7):2325967117719065. doi: 10.1177/2325967117719065—eCollection 2017 Jul.
• Rearfoot, Midfoot, and Forefoot Motion in Naturally Forefoot and Rearfoot Strike Runners during Treadmill Running. Journal of Applied Sciences. Alessandra B. Matias 1 , Paolo Caravaggi 2 , Ulisses T. Taddei 1 , Alberto Leardini 2 and Isabel C. N. Sacco. Appl. Sci. 2020, 10, 7811.
• Hoenig T, Rolvien T, Hollander K. Footstrike patterns in runners: concepts, classifications, techniques, and implications for running-related injuries. Dtsch Z Sportmed. 2020, 71: 55-61. doi:10.5960/dzsm.2020.424
• Anatomy of a Running Shoe – with Infographic. Website: https://www.runningshoesguru.com/ content/anatomy-of-a-running-shoe-with-infographic/
• How to Pick the Best Running Shoes Website: https://www.runningwarehouse.com/ learningcenter/gear_guides/footwear/how_to_pick_running_shoes.html
• Guide: Flexible vs. Stiff Running Shoes. Website: https://runrepeat.com/guides/flexible-vs-stiff-running-shoes