For a long time I've believed that my practice philosophy is unfortunately more unique than universal. There shouldn't be anything special about my practice. Yet, for many of the nearly forty years since I've begun seeing patients I've been told I'm the last resort, the best, the only one to see. Of course this could never be verified for any doctor, and I would have a big problem if I let myself believe that, though it's sobering to have such responsibility in patients' eyes. Now that I'm trying to put it in words, I guess the best way to concisely describe the guiding light of my approach is doing everything possible to put your best interests first.
My ability to formulate what "your best interests" means is based on certain factors. I have to get to know you a little, so when we first meet, we'll chat about your family, your work, your trip in to my office, someone who referred you, etc. This gives me an idea of the best way we can communicate, and just breaks the ice. I want you to feel comfortable and get to know me as well. It helps.
I have to get an idea of your lifestyle, both long-term and immediate. Like how important walking or certain sports are to you, or how adapted you are to the activities you want to do. I have to determine if your work, or your family requirements, like taking care of a big family or an ailing husband, put excessive strain on your injury, for example.
When I'm satisfied with that, we'll get into your injury. Most times it's best to tell me exactly what the problem is first, then give me a detailed list of things that may have contributed to it. That's usually the best order to do it, because I thus will have a feel for how the subsequent information flow I want you to give me should be directed. Things will click better in my brain if we do it in this order. If you think some other order is best, we'll try. The information flow I'll want will include anything pertinent, like accidents, surgeries you've had, other parts of your body causing you to shift weight to the injury, changes in shoes, any orthotics or heel lifts, any change in activity, or sport, or body weight, dance teachers, tennis courts, running surfaces, changes like that. Even if you never come to see me, you should always approach your life, at least from an orthopedic point of view, as a "living history." Changes like these can trigger problems. As soon as you feel a problem starting to roost, think chronologically about such factors. You might be able to avoid the doctor, or at least help a doctor figure out your problem.
Then I'll want to know what treatments you've had, and your response to them. If something helped, it'll help me to figure out your problem and how your tissues respond. If something hurt in a treatment plan, likewise. You may not even be aware of these factors before you come visit me. It's my job to pluck them out.
We'll do our best to figure the current status of your injured and uninjured tissues. I'll use my eyes, my hands, my fingers, my practiced ability to sense temperature, and tissue quality, and feel irregularities in your tissues. We'll check your strength and flexibility. I'll ask you to walk, and I'll look for blatant or subtle aspects of your gait which may be big-time clues in getting you better (see some of the case histories on this site). I may ask you to demonstrate how you dance or run. I'll look at any necessary additional sources, such as MRIs, X-rays, bone scans, nerve studies, blood tests, CAT scans, or letters from consultants. If I don't think the data package is complete, I'll order what's needed.
I'll check the angle of your bones, shapes of your bones, motion in your joints, length of your legs, status of other problems or tissues, whatever is necessary to complete the picture. All this to see how bad the injury is, whether it's worsening or healing, and why.
Now for that big "why" I just mentioned. If your tissues should be healing, but they're not, there may be a gremlin in the mix. Every problem has a reason. Most often the reason begins to evince during the history, which I must allow to develop and evolve along a free path, yet keep shepherded in a coherent direction. Maybe something you're doing, either on your own or thanks to some therapy, is perpetuating your injury. The reason may indeed lie in the string of injuries or treatments you've had before you come to see me. Or maybe you've been asked to do certain therapy and you haven't done it. Maybe you've been asked to do certain therapeutic exercises and you're either doing them incorrectly, or you were shown them incorrectly. We may go there, too.
Maybe some shoes, slippers, or even orthotics you were given are peppering your life in such a way as to sustain your injury. Maybe there's been a change in your bone density, or some systemic illness or some medication or even dietary foible is making your problem look orthopedic but it actually is not. Perhaps there's a systemic arthritis or other condition, like Lyme disease, which should be taking you to a rheumatologist or infectious disease expert instead of a podiatrist. Don't worry, you may not realize any of these things when you come in for your visit. It's my job to be acutely aware of these possibilities, and hone your history and physical exam to make the necessary discoveries.
I have to be ready to click upon any of these factors. I can't describe how my mental flowchart starts, or why a visit takes me in any particular direction with any particular patient, but I can say I will not be satisfied until I have arrived at your diagnosis and the reason for your problem and I will tell you if I'm not satisfied.
After all of the above, and quite possibly even more, I'll attempt to nail down both your diagnosis, or exactly what your injury is, and its cause. Now we can get to work.
We must decide the most likely, quickest, safest, and if possible, cheapest way to get you better. We have to determine if this will be just a short-term fix, or will things like orthotics, exercise prescriptions, shoe caveats, heel lifts, avoidance of certain activities or sports, etc., become more or less part of your life for some duration. I may perform prolotherapy, a simple injection technique I frequently perform under ultrasound guidance, to restore stability to sprained ligaments, tendons or plantar fasciitis. I may refer you to interventional radiologists to perform more elaborate techniques best done by more than one doctor. And I have to figure if I'm the right doctor for you, or do you need consultations with other doctors, or to be better off in the hands of another doctor, or surgeon, as we proceed.
Finally, I have to put this whole package together and see if the urgency you had displayed, or the depression you may be experiencing, is commensurate with the degree of difficulty I think it will take to get you better. Some people have low pain thresholds, some high pain thresholds. Each of these situations can be a double-edged sword. If you experience a lot of pain for relatively little tissue damage, it's my job to point out that there is but little damage, and turn your sensitivity problem into a bit of reassurance that you likely will get better easily. If you have a high pain threshold, I must guide your approach to your treatment so that you "pull back on the reins" a bit. Otherwise, you may incur so many cumulative injuries here and there that the whole thing mushrooms into something more difficult to rescue.
While we're talking about pain thresholds, let me offer that pain-killer and anti-inflammatory medicines have limited value when treating many injuries, especially if you take them while you continue doing whatever is causing the injury. An early-stage injury should not be treated with anti-inflammatories alone, or you can take your small amount of tissue damage and keep beating it up until it turns into something you'll have to deal with long-term. This especially happens as we get older, but it's a crime to let it happen in youth. Thus, you may keep your injury from yelling at you at first, but masking it will only coax the injury to scream and be more difficult to ultimately calm down. If you take anti-inflammatories, it's of supreme importance to figure out why the injury occurred, do whatever has to be done about that, and cut back on your activities till it heals, before gradually going back to hot and heavy activity.
This is what I meant in my first paragraph by in "your best interests." And this is what I mean by "there shouldn't be anything special about my practice." Isn't this the way you expect to be treated when you go to a doctor?
I will tell you what I believe I'm good at, and what I think you'd be best treated by someone else for.
I'm most confident at treating mechanical aches and pains. The whole list of sports, dance, and walking-related problems you'll see linked on hundreds of other podiatry websites. But you won't see links to definitions and treatment plans for these myriad injuries here. By all means, visit those doctors with links. I sincerely hope they get you definitively better for ever. But if the doctors you've seen can't get you better, please call me.
I believe I'm good at defining a diagnosis, and spotting the reason for a person's problem. Why? Because I believe there is a reason for every diagnosis. Thus I do not feel it is a waste of effort to seek a reason.
You may be referred to me for orthotics. Don't be disappointed if I tell you to forget about orthotics. If they're not right for you, I'll tell you. If you've had 33 pairs of unsuccessful orthotics and you show them to me, I'll probably try to help you without orthotics. But don't be surprised if I ask to adjust an old pair of orthotics that never worked for you. I love running into my shop and turning a disaster into an instantaneous success. If I think you need a 34th pair, you might not detect the courage it takes me to tell you, but you can count on my giving you an explicit, soup to nuts reason.
I may prefer to give you pristine or modified over the counter orthotics or a cheap slip-on ankle brace, or some exercises. I may simply advise you to change to a higher or lower heeled pair of shoes. It's a pleasure when this gets someone definitively better who'd expected to pay hundreds of dollars for orthotics.
If I think you need surgery, or rather, that surgery would be the most likely way to get you best, fastest, I'll tell you. I don't do surgery, though I did one of the best podiatric surgical residencies in the U.S. Despite the vaunted status of the residency, when I started my practice I didn't feel adequately prepared to decide who should have surgery and who shouldn't. That's one reason I started this Sherlock Holmes-y job and didn't become a surgeon. Now I know who should consider surgery over conservative treatment, but I did not acquire this realization till years after the surgical expertise of the residency had dulled.
Other things I don't like to do? Though I love salvaging nails from unnecessary surgery, and teaching patients the right way to cut them, I don't love treating severely ingrown toenails. I'll do them, and be certain to do a thorough job. I just don't like them. I love dermatology, was tops in my class in dermatology, but not being a surgeon, I don't biopsy, so I might refer you.
Don't be surprised if I refer you to a different doctor for many things (except investigative things). I refer approximately 5% of initial patients without treating them. After we have our visit, I feel it best that I don't assume their management. Some come back to me after they've cleared up important possibilities with consultants, some are best only in the hands of the consultants. I refer about 20% of patients while I'm still in charge of their case for consultations with specialists, physical therapists, or diagnostic services. Recently a patient said to me "Are you competitive? Are podiatrists competitive?" My response just came automatically, "I'm not competitive. If I think there's someone who can treat you better than I can for any problem, I'd sure better refer you to them. Otherwise, I'm doing you a disservice, no?"
Ulcers?I have a love/hate relationship with ulcers. I'm extremely strict at getting rid of the cause of an ulcer. I had wonderful training in my residency, and this mixed with my love of improving contact forces gives me a high degree of confidence when I exorcise a mechanical cause for an ulcer. The problem is ulcers require frequent visits and I may not have a convenient spot in my schedule for you available at your required frequency. I'll see you to eliminate the cause of your ulcer, but may refer you to another podiatrist or a wound management specialist for your repeat visits. I'll probably ask you to return to me at critical junctures to make sure things are going according to plan.
While we're talking about appointments, I hate being tardy. I like to run on time, and I have acquired a cadre of patients who love counting on being seen on time so they can get on with their day. If you're late beyond the minimum time required for me to treat you without seriously inconveniencing the succession of subsequent patients counting on their appointment time, you may be asked to reschedule. Unless I have an unalterable obligation that evening, I will be delighted to stay late for you and ask my secretary to stay so I can see you that day after my regularly scheduled patients. I'll come in early or stay late for you.
And I don't take insurance. We'll be happy to fill out your insurance form, and fight for you to get reimbursement in the form of letters of medical necessity or phone calls to your insurer. I remember several days when my secretary seemed to be on the phone all day long to help one patient get reimbursed.