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relationship between time a Dr. gives you and his ability

Posted by elliott on 8/12/01 at 08:09 (056409)

Is this relationship generally proportional or inverse? That is, do you ever wonder if the Dr. you can get in to see right away and gives you more time is one who is less in demand because he/she is held in less esteem and knows less? And the great Dr. who everyone is trying to get in to see cannot give you more than the requisite 15 minutes, if that (so ironically, perhaps cannot zone in on your specific problem due to lack of time committed)? I read the discussion of what the optimal doc visit should be. I hate to tell you, but IMHO no doc worth his salt can really afford to spend an hour with you. Are we a loser either way?

Regarding PF, as a starter (someone might have suggested it already), maybe the doc should at the least hand out at the first visit an as yet nonexistent standard carefully-constructed pamphlet issued, say, by a podiatric association, long and in great detail, with recommended self-help treatments. Then when you come back, you tell him/her what you've tried and he/she directs you further. (Or would they be unwilling to produce such a pamphlet due to loss of business or claiming it's impossible?)

Re: relationship between time a Dr. gives you and his ability

Dr. Zuckerman on 8/12/01 at 08:29 (056414)

Most doctors office and associations do have pamphlets about heel pain and or pf.

Interesting thing about spending time with the patients ( one hour) At one itme in my career I couldn't spend one hour . I had two office say 60-70 patients per day and did surgery during that day also.

Ok today . I will and can spent the one hour with a patient. I have made a decision that I am not going to become a part of the HMO followers that makes you see alot of patients and see this patient out the door type of practice

The big university doctor who has the reputation due to being associated with that hospital has to do this cause he is under contract and if the hospital is on the hmo contract then he has to be on it.

So in my opinion within reason don't go to the big name hospital doctor who is on the hmo program. if you can afford it. go to a doctor who has experience and who will spend the time with you. Now if you are the type that doesn't need this time then that's ok, but make sure you have read, understood and are willing to take an active role in your own health whether it be feet, or any other part of YOUR body

Re: relationship between time a Dr. gives you and his ability

elliott on 8/12/01 at 09:52 (056425)

The pamphlets currently in a doc's office are a joke. It's just a page or two describing what it is and two sentences on what to do about it. I'm talking about something which would, among other things, describe stretches in great detail. One can try almost anything oneself other than shots, custom orthotics, or surgery, and would come to the dr. for these or additional direction and guidance on the self-help.

Re: relationship between time a Dr. gives you and his ability

Julie on 8/12/01 at 10:05 (056427)

This is not a good idea. Exercise for therapeutic purposes can't be learned from a pamphlet however detailed the instructions. They need to be taught and monitored by someone who knows the principles of good stretching. This must be someone - doctor, physical therapist - who works with the patient and can see and correct if need be what s/he is doing.

Re: relationship between time a Dr. gives you and his ability

Bg CPed on 8/12/01 at 10:17 (056429)

This is a good question. It depends on the Dr and his ability/skill and the way his office is run. HMO puts lots of pressure to mill out pt AND spend less money eg cat scans, mri, therapy, etc. From a foot standpoint, since they are comlex structures that have many moving parts they are not easy to treat in many cases.
That is why I think many Ortho guys would rather do a total hip,knee, or acl stuff rather than work on feet. It takes years to become skilled at dx and tx of feet. I know some great surgeons that are very business like and cold. Some are gregarious and fun but may not be as skilled. Some are in between, just like the real world of carpenters, teachers etc.
I always say you dont want the Dr to be hard to deal with but if it is surgery, you dont have to go to dinner and golg with the guy so go with skill and experience.
Usually a good Ortho can have a pretty good idea of the problem in the first 10 minutes in most cases. THE KEY IS what their skill level is regarding correct dx and tx, thats the hard part. You can get an answer fast or after an hour of hand holding and chit chat,but ones opinion could be spot on and the other could be way off.Many of the good Ortho are booked far out and hard to get into. That can also be found in one that is not the best around, simply being busy is not always a good indication of skill.

A good Dr should ask some questions, and listen some, but have the experience to make the correct dx. I realize that many foot pain pt have been thru the mill, and may have a negative feeling about Doctors being to rushed and not caring. One aspect I have seen with some of these pt is the have a bag full of orthotics and shoes. Or they have a 1/2 in thick pile of papers off the internet and want to go over EVERY single one.

This is not to say that being an informed pt is bad. But a good Dr has seen your problem a million times. If he shakes your hand listens for 5 minutes and wants to inject the sore spot then that is somebody I would avoid. Being a pt you want to get in to see the Dr fast. The Dr and his staff dont want to make you wait 4 months for an appoint. The Dr prob does surg 2-3 days per week. If they are good they will be busy. They also have to spend more time these days screwing around with paper work.

My suggestion to you if you are a patient Do your homework on choosing the Dr. Ask your Pedorthist Orthotist, Family Dr, Phys Thereapist, etc. Sometimes the guy at the not so famous hospital that doesnt do tons of self promotion may be better than the guy that drives around town in a Bentley and 'does all the famous people and athletes'.

Bring in 2 pair of shoes you wear most often, not a bag full of slip ons and dress shoes, thats part of the reason your going to see a foot spec in the first place!
Bring what orthotics you have already, even if they dont work and you couldnt wear them. It gives a chance to see what did or didnt work and change it.
Stay focused on the when,how and what of your foot problem. Some pt will start with a story from 20 years ago and go on about what other Dr did or didnt do right. Try to keep it short and sweet. Ask questions that are to the point and bring a note pad if it helps.

If your problem goes back a way, write down on a note pad a day or two before your appoint what you have done in the past that helped or hindered your foot. How many injections you have had over what perions. If ise or heat helped. Therapy helped or not. Keep it simple, sometimes you want to get all of your thoughts out and you are concerned the Dr wont make time. That can sometimes make you forget something that is important.

Get to your appointment about 10 minutes early. DONT go 45 min early then complain at 10:05 how you have been there so long when you had a 10:00 to begin with. Dont show up late either, then expect to be seen fast, it is not fair to the office or the other pt that get bumped. I know some offices make you wait too long and that is not right either

Have your insurance info and or referal paperwork ready and with you. It is not the office persons job to hunt down or call other offices for your paperwork. Your ins card is not a visa platinum. Learn what coverage you have and dont have before you go in. A Dr office is no more expected to eat charges than a restaurant or auto repair.

Hope this helps, it is rather long. Sorry if it sounds a little cranky but it is good info and it will make the office and the Dr easier to deal with. They are regular people too. Treat them like you want to be treated and in most cases everyone will be happy.

Lastly If the receptionist or other person is rude point it out to the Dr when you are in the room. They like to know if the gatekeeper for their business is pre-frosting patients before they are seen

Re: relationship between time a Dr. gives you and his ability

Ed Davis, DPM on 8/12/01 at hrmin (056442)

It is important to train staff well. The APMA national convention is next week. I am going and so is one of my staff members who is a certified podiatric assistant. It is expensive paying for her plane ticket to Chicago and seminar fees but the impact on her training and level of professionalism makes it well worth it.

We try to use 'smart' use of time by using a combination of the doctor and highly trained assistants to give good patient care.

Some practices are high volume because the doctor is in demand and some are high volume due to the number of HMO contracts.
Ed

Re: relationship between time a Dr. gives you and his ability

Ed Davis, DPM on 8/12/01 at hrmin (056444)

A lot of the pre-printed pamphlets are written with a lot of generalities and are very 'milk-toast.' I sue the pamphlets as an introduction to new things and for their art work. Gradually, we hope to produce more pamphlets 'in house.'
Ed

Re: aren't all the giant orthopedic surgeons that way?

elliott on 8/12/01 at 12:17 (056450)

It takes two months to see them, you get a little more time on your first visit only, and then the big yes or no decision as to surgery must be made. But if you really need surgery...

Re: Detailed Written Instructions

Glenn X on 8/12/01 at hrmin (056470)

I think Elliott is on to something important here.

(With the very significant exception of the very recent experience I shared in a post or two a week ago) --- in the more than three years I've been working through this PF thing, I have NEVER received what I consider capable instruction or guidance on what is arguably one of the most critical elements of effective PF treatment: stretching.

My first podiatrist suggested I do the runners stretch and also stand on the edge of a step and bounce. He demonstrated both maneuvers once. He said do these once or twice a day. End of instruction.

I've had subsequent doctors (3) also instruct me to stretch in similar manners, or in another circumstance, tell me stretching is the last thing I should do. I've gone to PT practitioners twice. In my experience they too are ill-equipped to recommend proper stretching regimens customized to the 'level of PF' one might be dealing with. They tend to know what they've learned about stretching, but lack creativity in thoughtfully adapting that learning to patient needs. In all cases too, any handouts I've gotten have been sketchy at best, and often are copies of copies of copies, utterly lacking in professionalism.

Even on this hugely informative web site, ferreting out good stretching advice or instruction is difficult. And I would hope that in fashioning a PF flow chart, where a junction points the user to increased flexibility, there is a companion teaching aid describing a hierarchy of flexibility instructions in great detail.

In that teaching aid I would sure like to see such things as:

A list of stretching routines, increasing in aggressiveness from passive non-weight bearing to full-weight stretches, hanging off the step (if that is ever advised). Say something like:

1) Toe stretches bend forward / back
2) night splint
3) Foot dorsiflexed by muscle power alone (Julie stretches)
4) Foot rotated by muscle power (Julie stretches)
5) Foot dorsiflexed by resting on wedge under desk
6) Fascia stretched after fascia massage -- one hand on heel, one hand on ball of foot
7) Foot dorsiflexed (sitting) pulling a rubber Theraband or similar material around ball of foot
8) Foot dorsiflexed (sitting) pulling a towel or rope around ball of foot
9) Foot dorsiflexed (standing) leaning against a table, feet side-by-side
10) Foot dorsiflexed (standing) leaning against a wall (runners stretch) one foot at a time
11) Foot dorsiflexed (standing) leaning against a wall (runners stretch) one foot at a time -- knee bent
12) Foot dorsiflexed standing on an angled wedge
13) Foot dorsiflexed standing on the edge of a step
14) Foot dorsiflexed doing toe lifts on the edge of a step
15) ?? There are no doubt other subtleties we need to identify. And this hierarchy needs work.

For each routine we need instruction on:
How often it should be done. Before getting out of bed? Several times a day? Daily? Every other day? ? ?
How long should the extension be held? 10 Secs, 15, 20, 30 Secs? More?
How slow the rep. ?
How many reps at each iteration?
Do we move in and hold for a count, then move in a notch further?
Some suggest several holds for just 2 Secs each. Is that wise?
How much tension (short of pain) do we invest in the stretch?

How do we best (and do we) warm the muscles before the stretch? Heating pad (how long)? FootFlexes? Theraband flexes (how many)? Toe lifts (how many)? Calf and/or fascia massage?
What criteria do we use to determine when we move to the next level of aggressiveness.
What's the typical time to anticipate working on each level of aggressiveness before moving to the next?
On what previous levels should we continue to work even after we've moved up a level?
Should we be wearing shoes? Orthotics?
Is taping advised before stretching?
When do we know we're overdoing it? Underdoing it? Doing it right?

I think the ideal PF stretching handout (maybe 20 pages) would have a cover table where the doctor and/or therapist could check the boxes of those exercises being prescribed, and note the frequency, number of reps, duration, etc. A couple of interior pages could describe techniques generic to all stretching. A page just on terminology and measuring flexibility would be helpful. Each subsequent page would have detailed instructions for each separate routine with illustrations, cautions, etc, and room for additional notes by the treating health-care provider. Adding a $20 or so charge for this teaching aid would not be unreasonable. Just having such a reference available would encourage and enlighten a more thoughtful approach to this whole flexibilty arena.

Re: aren't all the giant orthopedic surgeons that way?

Ed Davis, DPM on 8/12/01 at hrmin (056512)

Please finish your sentence.
Ed

Re: relationship between time a Dr. gives you and his ability

Dr. Zuckerman on 8/12/01 at 08:29 (056414)

Most doctors office and associations do have pamphlets about heel pain and or pf.

Interesting thing about spending time with the patients ( one hour) At one itme in my career I couldn't spend one hour . I had two office say 60-70 patients per day and did surgery during that day also.

Ok today . I will and can spent the one hour with a patient. I have made a decision that I am not going to become a part of the HMO followers that makes you see alot of patients and see this patient out the door type of practice

The big university doctor who has the reputation due to being associated with that hospital has to do this cause he is under contract and if the hospital is on the hmo contract then he has to be on it.

So in my opinion within reason don't go to the big name hospital doctor who is on the hmo program. if you can afford it. go to a doctor who has experience and who will spend the time with you. Now if you are the type that doesn't need this time then that's ok, but make sure you have read, understood and are willing to take an active role in your own health whether it be feet, or any other part of YOUR body

Re: relationship between time a Dr. gives you and his ability

elliott on 8/12/01 at 09:52 (056425)

The pamphlets currently in a doc's office are a joke. It's just a page or two describing what it is and two sentences on what to do about it. I'm talking about something which would, among other things, describe stretches in great detail. One can try almost anything oneself other than shots, custom orthotics, or surgery, and would come to the dr. for these or additional direction and guidance on the self-help.

Re: relationship between time a Dr. gives you and his ability

Julie on 8/12/01 at 10:05 (056427)

This is not a good idea. Exercise for therapeutic purposes can't be learned from a pamphlet however detailed the instructions. They need to be taught and monitored by someone who knows the principles of good stretching. This must be someone - doctor, physical therapist - who works with the patient and can see and correct if need be what s/he is doing.

Re: relationship between time a Dr. gives you and his ability

Bg CPed on 8/12/01 at 10:17 (056429)

This is a good question. It depends on the Dr and his ability/skill and the way his office is run. HMO puts lots of pressure to mill out pt AND spend less money eg cat scans, mri, therapy, etc. From a foot standpoint, since they are comlex structures that have many moving parts they are not easy to treat in many cases.
That is why I think many Ortho guys would rather do a total hip,knee, or acl stuff rather than work on feet. It takes years to become skilled at dx and tx of feet. I know some great surgeons that are very business like and cold. Some are gregarious and fun but may not be as skilled. Some are in between, just like the real world of carpenters, teachers etc.
I always say you dont want the Dr to be hard to deal with but if it is surgery, you dont have to go to dinner and golg with the guy so go with skill and experience.
Usually a good Ortho can have a pretty good idea of the problem in the first 10 minutes in most cases. THE KEY IS what their skill level is regarding correct dx and tx, thats the hard part. You can get an answer fast or after an hour of hand holding and chit chat,but ones opinion could be spot on and the other could be way off.Many of the good Ortho are booked far out and hard to get into. That can also be found in one that is not the best around, simply being busy is not always a good indication of skill.

A good Dr should ask some questions, and listen some, but have the experience to make the correct dx. I realize that many foot pain pt have been thru the mill, and may have a negative feeling about Doctors being to rushed and not caring. One aspect I have seen with some of these pt is the have a bag full of orthotics and shoes. Or they have a 1/2 in thick pile of papers off the internet and want to go over EVERY single one.

This is not to say that being an informed pt is bad. But a good Dr has seen your problem a million times. If he shakes your hand listens for 5 minutes and wants to inject the sore spot then that is somebody I would avoid. Being a pt you want to get in to see the Dr fast. The Dr and his staff dont want to make you wait 4 months for an appoint. The Dr prob does surg 2-3 days per week. If they are good they will be busy. They also have to spend more time these days screwing around with paper work.

My suggestion to you if you are a patient Do your homework on choosing the Dr. Ask your Pedorthist Orthotist, Family Dr, Phys Thereapist, etc. Sometimes the guy at the not so famous hospital that doesnt do tons of self promotion may be better than the guy that drives around town in a Bentley and 'does all the famous people and athletes'.

Bring in 2 pair of shoes you wear most often, not a bag full of slip ons and dress shoes, thats part of the reason your going to see a foot spec in the first place!
Bring what orthotics you have already, even if they dont work and you couldnt wear them. It gives a chance to see what did or didnt work and change it.
Stay focused on the when,how and what of your foot problem. Some pt will start with a story from 20 years ago and go on about what other Dr did or didnt do right. Try to keep it short and sweet. Ask questions that are to the point and bring a note pad if it helps.

If your problem goes back a way, write down on a note pad a day or two before your appoint what you have done in the past that helped or hindered your foot. How many injections you have had over what perions. If ise or heat helped. Therapy helped or not. Keep it simple, sometimes you want to get all of your thoughts out and you are concerned the Dr wont make time. That can sometimes make you forget something that is important.

Get to your appointment about 10 minutes early. DONT go 45 min early then complain at 10:05 how you have been there so long when you had a 10:00 to begin with. Dont show up late either, then expect to be seen fast, it is not fair to the office or the other pt that get bumped. I know some offices make you wait too long and that is not right either

Have your insurance info and or referal paperwork ready and with you. It is not the office persons job to hunt down or call other offices for your paperwork. Your ins card is not a visa platinum. Learn what coverage you have and dont have before you go in. A Dr office is no more expected to eat charges than a restaurant or auto repair.

Hope this helps, it is rather long. Sorry if it sounds a little cranky but it is good info and it will make the office and the Dr easier to deal with. They are regular people too. Treat them like you want to be treated and in most cases everyone will be happy.

Lastly If the receptionist or other person is rude point it out to the Dr when you are in the room. They like to know if the gatekeeper for their business is pre-frosting patients before they are seen

Re: relationship between time a Dr. gives you and his ability

Ed Davis, DPM on 8/12/01 at hrmin (056442)

It is important to train staff well. The APMA national convention is next week. I am going and so is one of my staff members who is a certified podiatric assistant. It is expensive paying for her plane ticket to Chicago and seminar fees but the impact on her training and level of professionalism makes it well worth it.

We try to use 'smart' use of time by using a combination of the doctor and highly trained assistants to give good patient care.

Some practices are high volume because the doctor is in demand and some are high volume due to the number of HMO contracts.
Ed

Re: relationship between time a Dr. gives you and his ability

Ed Davis, DPM on 8/12/01 at hrmin (056444)

A lot of the pre-printed pamphlets are written with a lot of generalities and are very 'milk-toast.' I sue the pamphlets as an introduction to new things and for their art work. Gradually, we hope to produce more pamphlets 'in house.'
Ed

Re: aren't all the giant orthopedic surgeons that way?

elliott on 8/12/01 at 12:17 (056450)

It takes two months to see them, you get a little more time on your first visit only, and then the big yes or no decision as to surgery must be made. But if you really need surgery...

Re: Detailed Written Instructions

Glenn X on 8/12/01 at hrmin (056470)

I think Elliott is on to something important here.

(With the very significant exception of the very recent experience I shared in a post or two a week ago) --- in the more than three years I've been working through this PF thing, I have NEVER received what I consider capable instruction or guidance on what is arguably one of the most critical elements of effective PF treatment: stretching.

My first podiatrist suggested I do the runners stretch and also stand on the edge of a step and bounce. He demonstrated both maneuvers once. He said do these once or twice a day. End of instruction.

I've had subsequent doctors (3) also instruct me to stretch in similar manners, or in another circumstance, tell me stretching is the last thing I should do. I've gone to PT practitioners twice. In my experience they too are ill-equipped to recommend proper stretching regimens customized to the 'level of PF' one might be dealing with. They tend to know what they've learned about stretching, but lack creativity in thoughtfully adapting that learning to patient needs. In all cases too, any handouts I've gotten have been sketchy at best, and often are copies of copies of copies, utterly lacking in professionalism.

Even on this hugely informative web site, ferreting out good stretching advice or instruction is difficult. And I would hope that in fashioning a PF flow chart, where a junction points the user to increased flexibility, there is a companion teaching aid describing a hierarchy of flexibility instructions in great detail.

In that teaching aid I would sure like to see such things as:

A list of stretching routines, increasing in aggressiveness from passive non-weight bearing to full-weight stretches, hanging off the step (if that is ever advised). Say something like:

1) Toe stretches bend forward / back
2) night splint
3) Foot dorsiflexed by muscle power alone (Julie stretches)
4) Foot rotated by muscle power (Julie stretches)
5) Foot dorsiflexed by resting on wedge under desk
6) Fascia stretched after fascia massage -- one hand on heel, one hand on ball of foot
7) Foot dorsiflexed (sitting) pulling a rubber Theraband or similar material around ball of foot
8) Foot dorsiflexed (sitting) pulling a towel or rope around ball of foot
9) Foot dorsiflexed (standing) leaning against a table, feet side-by-side
10) Foot dorsiflexed (standing) leaning against a wall (runners stretch) one foot at a time
11) Foot dorsiflexed (standing) leaning against a wall (runners stretch) one foot at a time -- knee bent
12) Foot dorsiflexed standing on an angled wedge
13) Foot dorsiflexed standing on the edge of a step
14) Foot dorsiflexed doing toe lifts on the edge of a step
15) ?? There are no doubt other subtleties we need to identify. And this hierarchy needs work.

For each routine we need instruction on:
How often it should be done. Before getting out of bed? Several times a day? Daily? Every other day? ? ?
How long should the extension be held? 10 Secs, 15, 20, 30 Secs? More?
How slow the rep. ?
How many reps at each iteration?
Do we move in and hold for a count, then move in a notch further?
Some suggest several holds for just 2 Secs each. Is that wise?
How much tension (short of pain) do we invest in the stretch?

How do we best (and do we) warm the muscles before the stretch? Heating pad (how long)? FootFlexes? Theraband flexes (how many)? Toe lifts (how many)? Calf and/or fascia massage?
What criteria do we use to determine when we move to the next level of aggressiveness.
What's the typical time to anticipate working on each level of aggressiveness before moving to the next?
On what previous levels should we continue to work even after we've moved up a level?
Should we be wearing shoes? Orthotics?
Is taping advised before stretching?
When do we know we're overdoing it? Underdoing it? Doing it right?

I think the ideal PF stretching handout (maybe 20 pages) would have a cover table where the doctor and/or therapist could check the boxes of those exercises being prescribed, and note the frequency, number of reps, duration, etc. A couple of interior pages could describe techniques generic to all stretching. A page just on terminology and measuring flexibility would be helpful. Each subsequent page would have detailed instructions for each separate routine with illustrations, cautions, etc, and room for additional notes by the treating health-care provider. Adding a $20 or so charge for this teaching aid would not be unreasonable. Just having such a reference available would encourage and enlighten a more thoughtful approach to this whole flexibilty arena.

Re: aren't all the giant orthopedic surgeons that way?

Ed Davis, DPM on 8/12/01 at hrmin (056512)

Please finish your sentence.
Ed