One of the more amazing things I have had the opportunity to witness in my practice lifetime is the acceptance of a method of correcting clubfoot I was taught in Podiatry school. At that time orthopedic surgeons did extensive surgery to correct clubfoot which was traumatic to then  child (and parents), and often caused problems later in life. Since podiatrists at that time were much less surgically oriented than orthopedic surgeons, we were taught the Ponseti method for clubfoot correction. Since then I wondered why parents subjected their babies to extensive surgery when the Ponseti Method corrected the problem simply and with minimal future problems.

Enter the internet! Parents found out about the Ponseti Method – and demanded it! And guess what – now the relatively unknown Ponseti Method is the standard treatment for clubfoot deformity!

The Ponseti Method has been accepted as the “gold standard treatment for clubfoot” by both the American Academy of Pediatrics and the National Institutes of Health. They note this method is “very easy on the child and effective in 95% of cases.”

I have reprinted below an article from Kaiser Health News  as heard on NPR’s Morning Edition January 7, 2014

Mary Snyder found out at her 19-week ultrasound that her unborn baby had clubfoot. Both of the fetus's feet were completely turned inward, forming the twisted U-shape typical of clubfoot. The condition is one of themost common birth defects, affecting about 1 out of every 1,000 babies, but that was little comfort to Snyder.


Alice Snyder was born with clubfoot, a common birth defect.

Alvien Lee/Sinai Hospital

"It was terrifying," remembers Snyder, who lives in Towson, Md. "It was very emotional. We did a lot of testing and everything to make sure she was going to be OK, but you never really know until you see them when they're born."

Just a decade ago, up to 90 percent of babies like Snyder's daughter Alice were treated with surgery that usually had to be repeated several times. That created a buildup of scar tissue that often left patients with a lifetime of chronic pain, stiffness, arthritis and medical bills. But with the help of a simple, noninvasive solution and an Internet campaign led by parents, the course of treatment and likely outcomes have changed completely.

Alice, who is now 6, has a checkup every year with Dr. John Herzenberg, an orthopedic surgeon at Sinai Hospital in Baltimore. Alice happily follows the doctor's instructions, walking back and forth across the exam room, then on her tippy toes, and finally with her feet turned out like a duck.

To the untrained eye, Alice looks perfectly normal. Her feet are turned out as if they'd been that way since birth. She has never had surgery.

Instead, Herzenberg used what's called the Ponseti Method. Doctors begin by applying a series of full-leg casts to slowly turn out the infant's flexible feet. Casts are changed weekly for three to eight weeks.

Before applying a final cast, which stays on for three weeks, a small incision is made in the Achilles tendon. Then the child wears a special set of boots connected by a bar at night for a few years to make sure the feet stay in the right position — think of it as a retainer worn after braces are removed from teeth.


In 2008, Alice showed off the brace she wore at night to keep her feet from turning in.

Alvien Lee/Sinai Hospital

"In the past, before I learned Ponseti, guaranteed I would literally have had to do a surgical operation to take apart and put together the entire foot," says Herzenberg, looking at a photo of Alice's feet at birth, which formed a bowed U-shape beneath her tiny torso.

The casting technique was developed by Dr. Ignacio Ponseti at the University of Iowa in the 1950s. The Spanish physician discovered that if an infant's feet were slowly turned out over the first few months of life, the foot could be coaxed into a normal position.

Unlike the traditional surgical method, the Ponseti method is pretty much painless, and patients who receive it usually have a complete recovery, with no long-term discomfort. It also costs less. Ponseti spent the next 50 years tirelessly trying to get other doctors to accept it, but with little success.

"People were falling over themselves to do fancy invasive surgery, and this one strange old guy who speaks softly with a Spanish accent in Iowa was getting sort of ignored by the drumbeat of people who were in favor of surgery," says Herzenberg, who is one of the foremost practitioners of the Ponseti method today.

Surgeons are trained to operate, explains Herzenberg, and usually that's the way they make money. The Ponseti method brings in a lot less for orthopedists. For about 50 years, the technique mostly stayed in Iowa.

But then something new came along: the Internet.

When Jennifer Trevillian's daughter was born with clubfoot in 2000, the doctors said surgery was inevitable. "He started talking about her pending surgery before he physically examined her foot," Trevillian remembers.


At age 6, Alice's feet look normal.

Jenny Gold/Kaiser Health News

Trevillian started researching the condition on her new dial-up connection. There wasn't much. But she did find a few other parents talking about another option on iVillage, and a new Yahoo support group called NoSurgery4ClubFoot. A few days later, she traveled with her daughter from the family's home in Chatham, Mich., to Iowa to see Dr. Ponseti.

"In the amount of time that we would have just been waiting for her to be big enough to tolerate the anesthesia for the reconstructive surgery she was supposed to have, Dr. Ponseti completely corrected her foot," says Trevillian.

Trevillian joined the small but growing group of parents evangelizing about the Ponseti method online. She built a few websites telling her daughter's story, and she stayed active on the fast-growing Yahoo group. Parents began following each other's advice — choosing to abandon doctors who insisted on surgery and often traveling long distances to find a Ponseti practitioner.

"The way that the clubfoot treatment pendulum has swung is really a classic example of supply and demand — because once parents found out about it, they demanded it for their kids, and it really forced the medical industry to rethink the Ponseti method," says Trevillian.

Herzenberg agrees. "Clubfoot is a real prototype for how the Internet has changed medicine and how parents have been the driving force in many ways," he says.

Today, the Ponseti method is now almost always the treatment of choice for clubfoot and is recommended by the American Academy of Orthopaedic Surgeons. When it is done correctly, 97 percent of children born with clubfoot never need invasive surgery.



Monday, 17 October 2016 17:08

Technology and Increasing Medical Costs

Technology and medicine have a tortured history. Medicine has been one of the last segments of our society to be brought into the computer age. And those of us who provide patient care on a daily basis are suffering every day with electronic medical records. Not only do we waste time creating the electronic records – we waste time trying to find relevant information buried under mounds of garbage!

Older doctors are having a particularly difficult time with the transition to electronic medical records. Doctors are retiring in record numbers and there are already shortages developing which are becoming more acute with increasing numbers of people insured. Why isn’t there a grandfather clause exempting doctors over a certain age from economic penalties for not adopting electronic medical records?

One other simple thing that could be done to streamline medical care is that all insurance cards should have a metallic strip encoded with every patient’s insurance information in a standard format that could be read by all electronic medical records. Just like you use an electronically encoded credit card or ATM card this card could simplify data entry and reduce mistakes.

Forgive me if I am cynical and suggest a reason why this has not been done by insurance companies. The reason I suspect is the claims payers want us to make mistakes. Every mistake on an insurance claim delays payment and allows them to hold onto their money a little longer. If insurance companies make it difficult enough some claims might just fall through the cracks! We have had some companies put multiple addresses on insurance cards and whichever one you pick seems to be the wrong one! And while electronic clearing houses were supposed to solve these problems not every insurance company uses an electronic clearinghouse. Even those companies who do use electronic clearinghouses have managed to confuse things so much that our offices make mistakes. So we spend more time filing insurance claims. Of course this raises our costs and reduces the payers expenditures. Good for the bottom line of the insurance company making quarterly statements to their shareholders and bad for medical practitioners actually providing medical care.

If there was a genuine desire to improve medical care and simplify things for medical offices, then every patient’s medical history, claims information , etc. would be read from their insurance card and directly entered into our electronic medical record systems! That would reduce our clerical expenses and more importantly reduce medical errors!
These are just a few simple things that could be done to start to improve medical care and reduce medical costs. Let’s see if anything happens!

Monday, 10 October 2016 15:28

Locker Room Talk

With the phrase “ locker room talk” in the news lately I just had to make a comment - please bear with me. I’m in the gym usually four times a week. I’ve talked to a lot of guys in the locker room. And I guess I’m fortunate because the gym where I go has a good class of people and I’ve never ever heard disparaging remarks about any group of people. There was one time though when I did hear remarks very similar to the ones that are in the news this week.

The incident happened some years ago when I was serving my residency. A married attending doctor in the doctors lounge was bragging to the young resident doctors about his extramarital sexual relationships - or I should say “conquests.”

Two things occurred to me at that time -- after I got over my disgust. Number one was that if this person thought so little of his marriage vows that he would violate them for personal gain, how could anyone trust him in any commitment? This is someone who would violate a profound personal promise for personal gain. The second thing is if you were to violate your marriage vows for your personal gain isn’t it supremely stupid to brag about it? This is someone bragging that you can not trust him. He will do whatever he wants regardless of his promises to you. How stupid is it to tell everyone you are untrustworthy?

No I’ve not heard much locker room talk from guys bragging about infidelity. Just recall that one time many years ago and recently on TV.

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