It’s interesting to search online for “podiatry general treatment” or “routine podiatry” because you get quite a lot of different ideas of what this consists of. I think we can all agree that most people don’t understand our full scope of practice, so confusing them further by offering “general treatment” and “routine podiatry” does not necessarily address their problems.

The term “General Treatment” (GT) must have started somewhere, possibly in the days of vocational training, and I think it is a term we should stop using. Likewise, the use of “Routine Podiatry” which seems to be more common in the UK.

I get that we are trying to distinguish between consultations relating to different aspects of our scope, but we are not considering our patient’s concerns or expectations. They don’t care how we classify our consultations when they simply want to know if we can help them.

Some websites list Fungal Nails on their general treatment page, but also offer specific specialist treatments for fungal nail infections. Others list ingrown toenails and cracked heels, whilst also offering PNA/TNA procedures under local anaesthetic, and paraffin wax baths.

If we expect to be seen as the go-to profession for foot and ankle conditions, then perhaps we need to offer condition specific appointments and treatment options.

Take plantar warts as another example. There are a number of highly specialised wart treatments in use across podiatry, some of which require local anaesthesia, and others which utilise specific equipment which is both costly and requires further training to use effectively. Wart treatments should never be considered as general or routine.

If you have read this far you may be starting to think I have a valid point. The trouble is going through the process of reclassifying your appointment systems and fees, training staff, updating your marketing material and a whole lot more. It has been a long held mantra in business – but I can’t find where it originated, that you don’t need more customers (patients) for your products (treatments), but you need more products (treatments) for your customers (patients). By reclassifying your appointments to be more specific to the condition or treatment, you are in fact offering more products, some of which your patients may not have been aware of.

At some point we have to work out what to call those consultations where you assist people with toenails and hyperkeratosis. For goodness sake be specific and descriptive.
Let’s start with the end in mind and consider the outcome that the patient expects.

We asked 165 new patients what outcome they were seeking from their podiatry appointment. They were able to tick more than one answer, and the results are below.

Even in the “other entries” nobody specified “General Treatment” even though lots did ask for “removal” of a problem.

So considering what people want, we need to be providing information in the form of diagnosis and treatment planning, along with pain relief. What this amounts to is comfort and empowerment. There is nothing General about that.

We could start calling our General Treatments or Routine Podiatry something like Nail and Skin Recomforting, or Hard skin and Toenail Reduction, even Digital Enhancement because that’s what our patients want.

How do you think you could redefine your consultations to better describe the desired outcome?

For motoring enthusiasts the 1930 Alfa Romeo 6C 1750 Gran Turismo is thought to have been the first GT vehicle. The year it was introduced, the 6C won every major racing event it entered. Each car wore custom bodywork from Europe’s finest coachbuilders, establishing the GT formula for decades to come. (source)

Telehealth Outline.

Here’s some info and resources that may help you if thinking of setting up Telehealth Consultations.
You will need a good internet/data connection, a fairly modern device with a good camera, a position with adequate lighting, a headset with a microphone to ensure good sound quality.

Bookings

Phone

Make a time, get all contact details and take payment by card over the phone if possible.

Online

Set up a telehealth appointment type and whatever parameters you need to limit the times available etc. In the confirmation email add a link to some type of payment system.
There are a number of integrated platforms that will take bookings and payments, and even link to video conferencing. Have a look at Simplybook which requires a subscription, or Setmore which has a fee version that integrates with Square.

Payment System

Card by phone

easy if you have facilities, or even taking a card at the beginning of the consultation.

PayPal

Allows you to request money from people by email. You can also send them an invoice. Lots of people have a PayPal account, but invoicing also allows them to pay by card.

Online Store

If you already have an online store in your website you could add an item “Telehealth Consultation” and direct people to make payment there.

Stripe

You can accept payments in the backend of your Stripe dashboard by adding a customer and then their card details. This method is not user friendly, but a possibility if you don’t have facilities to take cards over the phone.

Once booking and payment have been finalised then send the link to your chosen Consultation Platform.

Consultation Platform

Best to use what you are most familiar with so that you can guide your patient if necessary. The key requirement is end-to-end encryption to ensure privacy and confidentiality.

The patient will need to be familiar with using a smartphone or tablet. You should use a headset or phone headphones for the best sound quality.

Skype

Available on all platforms and requires users to have an id and login.

WhatsApp

Popular but once again requires users to register for the app

Zoom

Particularly good for multi-user, but the free version should be OK. You have to sign up but the patient doesn’t. They are getting absolutely smashed at the moment because of all the working from home, and I know some quality has suffered. You have to check the encryption settings for each call.

Doxy.me

A dedicated telehealth platform with a free version. You sign up, then give the patient the link to your online waiting room. I use this and think it’s great.

Facebook Messenger

No encryption.

Facetime

Encrypted but only available on Apple Devices.

Follow Up

Be sure to provide written information by email, and to do a phone follow up within 3 days.

In your email give a summary of the consultation, and include things like advice given, exercise plan, footwear prescription, and a shopping list of items recommended.

Watch this Webinar Replay on the P20 Conference Website https://www.p20.com.au/

Last year I was involved as a volunteer at the Invictus Games in Sydney.

For those that don’t know, the Games are an international sporting event for people who became injured or sick whilst serving in the Defence Forces. There were about 500 competitors from 18 different countries.

The events are categorised as Adaptive Sports, and enable people with varying needs to compete with each other.

My experiences were mostly behind the scenes, where I did get to meet many of the competitors without actually seeing them compete.

The week before I was at Olympic Park for some training, and a group from one of the countries had recently arrived. They were touring the precinct to orientate with the venues and facilities, and obviously excited about the days ahead. One person stood out as he was not joining in with the jokes and banter, but was facing away from the group, scanning the surroundings, and demonstrating the hyper-vigilance of a person who has been in a conflict zone. His shoulders were tense, his knees flexed, his brow furrowed, and he looked me in the eye as I walked towards the group. I smiled and raised my eyebrows in that way that says “Hi, you don’t know me but welcome, and I’m glad you’re here”, and at that moment he smiled back, shrugged his shoulders, and with a wry grin acknowledged that he needed to relax and enjoy himself. We didn’t speak, but that was OK because we had connected, and I began to realise what a huge and special experience was ahead of me.

My first shift was at the Tennis Centre, where there had been a deluge the night before, and though everything was dry, a lot of mulch had been washed over the pathways. Not a problem for most of us, but the tyres on the wheelchairs used for wheelchair tennis are very narrow and operate at very high pressure, so a lump of woodchip could cause a blowout. An hour with a big yard broom had everything tidy and ready for the competitors to arrive. The nature of the Invictus Games means that people can compete in as many sports at they like, and will often form mixed teams from a number of different countries, just so they can participate. This happened with a partnership between two men from the Netherlands and the United Kingdom, who had never met, but joined to play doubles at the games. There were news reports about these men as one was badly affected by the sound of a helicopter overhead which triggered his post traumatic stress. He was supported by his tennis partner, they hugged and sang songs together, and were joined by service dogs who played a big part in providing comfort to the competitors. After some time they continued their game, and afterwards behind the scenes, we provided somewhere quiet for them to be, and transport was arranged. Their team was appropriately called “Unconquered” as were all the multi-national teams.

I was also involved in the track and field events, and had a wonderful time at the Discus. Adaptive sports are for people with differing types of illness or injury to compete in the same event. The seated discus enables people with lower limb weakness or amputation to compete on a “level playing field”. The athletes are strapped onto a throwing platform, which is in turn shackled to the ground with strong chains and turnbuckles. They each take some practice throws, and then have 6 competition throws. It is logistically more difficult for them to take turns like at other athletic meets, so competitors need to be intensely focused for that time in the circle. The rest of the time they sit together in the shade, chatting, laughing, poking fun at the judges and each other, and even joining in with the music being broadcast around the stadium. It’s a very relaxed atmosphere for people that have obviously experienced some of the worst things that life can bring. There was time to chat, and the competitors were clearly enjoying their experience of Sydney and Australia, with tales of trips around the city, and visits to some of the popular sites.

The recognition that Australia has for its Military is demonstrated on ANZAC Day when we reflect on what it means to serve your fellow Australians, your community and your country. Whilst it is a solemn commemoration, we also take time to celebrate the freedoms afforded us by those that have served. The Invictus Games is as much a celebration of those freedoms, as it is reminder of the trauma and suffering that the competitors may have endured.

It was an honour to be able to give back a little to the people that have given so much more. My role was small, but I know I made a difference, and that feels right.

I was once told that I should be like a drummer.

You might be thinking of the wild noisy character at the back that’s difficult to control, but is always popular when they play a solo.

That’s sometimes the impression of drummers, but not what was intended.

I have both seen and played with drummers that realise their importance as part of the ensemble, and don’t feel the need to stand out. They lead the music from behind by setting the tempo, maintaining the rhythm, accentuating the big moments, then holding back and giving others the opportunity to shine.

Wynton Marsalis is a world renowned Trumpet player, composer and band leader, and last night he performed at the Sydney Opera House with his Jazz Orchestra and the Sydney Symphony Orchestra. What I found interesting was that even though he had written the symphony being performed, he was virtually invisible on stage. He sat on a low chair in the third row with the trumpet section, letting the music speak for itself, giving the other soloists their share of the limelight – and they deserved it!

As a business owner there are lessons to be learned from music and performance. If you are a single person in business, then you need to be both the front of stage soloist and the drummer, but if you have a team then you can decide.

Being the Frontman/woman puts you in the limelight, and makes the business all about you. You need a great ensemble or team behind you though to keep the momentum, and if one person doesn’t play their part, things can fall to pieces pretty quickly.

If you can lead from the back like a drummer, or from the centre like Wynton Marsalis, then you can make sure all the right things are happening at the right time.

You write the parts for everybody to play, set the pace and rhythm of your business, and make sure that all the members of your team have to opportunity to stand out.

Find out what parts they love to play, and give them a solo piece! This is the way you discover hidden talent, both in musicians and colleagues.

This chat with Tyson Franklin brought up some of my history, and some ideas about how to improve your business, whatever it may be.

The main points are listed in the show notes and include our thoughts on how your business is perceived by your patient/client/customer.

It’s well worth a listen to some of the other shows in this podcast with some of the people I admire in the industry. It’s an honour to be part of this great profession, and it’s no secret that they really are Podiatry Legends. (did you see what I just did?)

People Don’t know what we do

“It’s just my toenails” is the common response when I ask my patients if they are having any trouble with their feet.  Sometimes there is shock at our consultation fee because we are “only cutting toenails” after all.

Thankfully, many of our patients understand the true value of having a qualified and experienced team of podiatrists care for your foot health.

Apart from the fact that Podiatrists have a 3 or 4 year University Degree, we also spend many hours of our own time (and our own money) to maintain up-to-date knowledge about the best kind of treatment for your problems. We refine our diagnostic skills, and get updates on the latest medical and surgical procedures you may be having, and how they might impact your feet or the way you walk.

A typical day starts 30 minutes before the first appointment with preparation of the sterilising room. Our ultrasonic cleaner is filled with the correct amount of water and medical grade detergent, then de-gassed and tested to ensure that the instruments we use are properly clean before being sterilised. Likewise our steriliser undergoes a vacuum test prior to use every day to ensure it is functioning correctly. We collect referrals, medical imaging and pathology reports to be attached to patient files, and we ensure that the environment is clean and safe for patients. The ducted air conditioning keeps everything at a comfortable temperature.

We send out final reminders to people to confirm their appointments.

The first patient is a teenager born with an unknown genetic disorder. His gait is very unsteady, and he tends to trip and fall on uneven ground. We have fitted some orthoses to his shoes which have made a significant change to his stability when walking. He can’t tell me how it feels, but if it means he is less likely to fall and break a bone, then we are succeeding.

Next a lady comes in “for her toenails”. I ask her about the lump on the top of her foot which looks like it has been bleeding. She says it’s no bother but I don’t like the look of it. Writing to her GP suggesting further investigation and possible biopsy seems like a big fuss to the lady, but she reluctantly agrees to follow it up.

The next set of toenails belong to a man with a history of drug and alcohol abuse. He has no feeling in his feet and has not noticed the wound under his big toenail. We trim the nail as short as possible, cleanse and dress the wound, and arrange community nursing to follow up with regular dressings at home.

The 8 year old girl with a bleeding ingrowing toenail holds her dad’s hand tight as I examine her. If she doesn’t like what I’m doing she can yell “Jellyfish” and I will stop. With a surgical blade, patience, reassurance and 30 years of clinical experience the offending spike of nail is removed without a jellyfish to be seen. A short discussion and demonstration of how to cut toenails safely, and this little girl will be back at dancing later in the week. Luckily we didn’t have to use a local anaesthetic this time.

Next a concerned daughter brings her Mum who is mid-way through chemotherapy. The potent cocktail of cytotoxic drugs have affected her peripheral nerves so that she has next to no feeling in her feet. The chemo has also damaged her toenails and she has a wound under one of the nails. At this stage in her chemo her immunity is virtually non-existent, so she can’t fight the infection under her toenail, and it could become life threatening without strong antibiotics. I remove the offending toenail, apply appropriate dressings, and then spent the next 15 minutes arranging an urgent appointment with her already busy GP. If she can’t get in with her GP she will need to go to casualty.

A young woman limps through the door. She is lively and attractive, but in terrible pain. The surgery she had as a child to correct a congenital deformity was only partially successful, and now all she wants to do is get on with her life. She is a student with a part time job, but can’t work enough to make ends meet due to her foot pain. The treatment suggested by her specialist will be effective but is too expensive. We have to think outside the box to provide affordable treatment and keep her on her feet, and spend time discussing options including hospital treatment and how to access the National Disability Insurance Scheme. My fear is that the complexity of the system will mean that she does not get the treatment she needs. I spend time on the phone and writing letters to her doctors.

I’m running late now, and the next Gentleman has problems with mobility. It takes him 5 minutes to walk the few metres to my room because he finds it difficult to get his walker in and out of the car. The bandages on his legs have not been changed for a few days and the leg ulcers have been discharging. Consequently the skin on his feet has been moist and his socks and slippers are soaked. I have to clean his feet carefully before looking after his toenails which are embedded in his swollen toes. He leaves wearing one of our pairs of “spare” socks, with a note for the community nurses to review his wounds and dressings.

Admin Break: Catch up on letters and phone calls, and write reports to referring doctors. Ensure patient records are complete and up to date. Chat with admin staff to arrange our twice yearly service and calibration for the steriliser, and to check that monthly payments have been made for Income Tax, Superannuation, Workers Compensation, Professional Indemnity and Public Liability insurance, Goods and Services Tax, and that we have our Fire Safety Inspection certificate.

A man drops in with his elderly Mother’s new sandals. They need modifying because she has a stiff ankle and gets pain in her feet and back when she’s walking. I suggest we check her more thoroughly and work out the exact cause of the problem. It turns out that childhood polio has left one leg shorter than the other so I arrange medical imaging to assess the leg length difference exactly, and get the sandals modified correctly.

The local paper arrives and we see in the Death notices that one of our patients died last week. I have been caring for her for over 15 years, and know the names of her grandchildren and great grandchildren. Some of them have become patients. I make time to attend the funeral, because it helps me to resolve the fact that we do lose a lot of patients. I reflect on the time shared, the trust and confidence which develops where people often relate some of their most closely held experiences, thoughts and feelings.

Our online booking system is playing up…We’ve had a call from a frustrated patient who can’t log in. A quick check reveals a problem with one of our servers. I try everything before calling in IT support and discover that recent storms have damaged our modem and routers, so our internet is slow and intermittent. Thanks goodness it is a quick fix and we are back online the same day. Our use of the latest technology means that we can offer amazing service to our patients which includes online booking, instant claims to Medicare and health insurers, exercise plans delivered by App to your mobile phone, email and SMS reminders for your appointments, among many other small things that you wouldn’t notice.

Well our little server problem has eaten up my lunch break, so I throw down come cheese and biscuits, and take my cup of tea to my next consultation.

This seventy something gentleman is attending for assistance with his toenails and chronic tinea. As he tries to stand I notice his discomfort and he struggles into my room. Yesterday he stepped down a kerb to cross the road and felt something “Give” in the back of his ankle. It was OK at the time but today it is agony. Some simple tests indicate that he most likely has a tear in his Achilles Tendon, so he is immediately splinted in a cam walker and sent back to his GP for an orthopaedic referral. (Later scans indicated that immobilisation had likely prevented a complete rupture.)

Next I am reviewing a patient who has diabetes and has recently had the flu. She explained that her blood glucose levels have been “up and down”. Her skin and toenails are healthy, and using a doppler ultrasound probe we can assess that her peripheral circulation is adequate. On testing sensation however, it becomes apparent that she has lost feeling in her toes and most of her feet beyond the ankles. We tested light touch, temperature, vibration, and pinprick sensation, and all were absent, indicating significant nerve damage. Further assessment will be required by a specialist to be certain of the cause, however it is most likely a complication of poorly controlled blood sugar. I advise precautions due to the lost sensation, and write to her GP.

A colleague is concerned about performing ingrowing toenail surgery on an elderly lady who also has diabetes, and early dementia. She has been in pain for some months, and is not looking after herself very well. The best solution would be permanent removal of the nail, however healing may be an issue. We discuss the options, including the risks associated with not doing anything, and decide to remove the ingrowing part of the toenail under local anaesthetic, but not to cauterise the nail bed. This will give up to a year of relief, and should heal quickly, placing the patient at less risk of complication.

The National Disability Insurance Scheme is having some teething troubles, but we are starting to see lots of people who have previously been unable to access appropriate footcare, splints and shoes or boots. As we have specialist skills in gait assessment, we can identify the best way to assist people to walk safely and without pain. Today we fitted a young man with some new boots which were made to measure for him. The additional stiffness in the heel, and the specially designed soles mean that he can get around without damaging his feet.

Lastly one of Australia’s cycling champions calls in to collect his new carbon fibre orthotics. They are made from a 3D laser scan of his feet, and specially fitted to his cycling shoes at a laboratory in Melbourne. The efficiency gains that he experiences will hopefully give him a faster time in his races. We discuss any adjustments that he may need to make to his bike fit, and wish him well for the next big event.

To finish the day we must complete our report writing and clinical notes, send letters and exercise programs, check our stock, and re-confirm tomorrow’s appointments.

In short, when you visit a podiatrist it is never “just the toenails”. We use our knowledge and experience to make the best diagnoses and treatment goals, using the most appropriate equipment and technology, and we partner with our patients to achieve their hopes and aspirations, whilst often exceeding their expectations.

Trust

Recently I presented to a group of motivated Private Practice Podiatrists at the OSGO Live 2017 conference in Manchester. Whilst the session was entitled “Assessment and Diagnosis in Private Practice”, much of the subject matter was around building trust with your patients, and creating an environment where they were willing to engage and participate in the process.

To successfully assess a patient, they need to feel confident that they are in the right place, and that you are the right person to solve their problems. Contact with the patient prior to their consultation is essential, and should advise them of what to expect, addressing any concerns they may have. Remember that in all likelihood they have already been online and diagnosed themselves, and that you are simply providing a second opinion to Dr Google. Being direct and asking the patient if they have searched their symptoms online, or if they think they know what is wrong, is a good way to open the conversation about why they may or may not be correct, and to explain the process you will go through to in carrying out a proper and thorough clinical assessment.

Once you have established that you are more trustworthy than the websites they have visited, they will be more likely to share the full background and history to their condition, which gives you a better chance of a successful outcome.

During your discussions and assessment you may come across an elephant. We all sometimes encounter the “elephant in the room” – something obvious that people are often uncomfortable talking about.

It is important that as health professionals we are able to confidently give the elephant a pat and talk to it openly. Be willing to address issues like poor personal hygiene, obesity, mental illness or neglect.

Establishing the true motivation behind your patient’s visit is key to a successful outcome. Their fears and frustrations are the reason they are seeking help, not the skin, nail or musculoskeletal problem. For example, they may be afraid of losing fitness or becoming incapacitated, or they might be frustrated by their inability to participate or compete.

You will gain most of the information you need to make an assessment using just two things, your hearing and your eyesight. Actively listening, and letting your patient do most of the talking will always reveal more than second guessing what they are about to say. Wait for them to finish speaking before you ask your next question, and leave a few seconds of silence which will give them an opportunity to speak further. You may choose to make notes as they speak, but keep regular eye contact to show you are listening. Spend time on this, prior to any physical examination, and the knowledge you gain will facilitate a sounder diagnosis.

If you need to order further tests, or consult with colleagues, then be clear about the reasons why. Your patient should not be given the opportunity to think that you haven’t got a clue about their problem, but rather should feel that you are working hard on their behalf to get the most accurate diagnosis and most up to date treatment options.

Setting treatment goals should be based on real life functional outcomes such as playing a round of golf, or walking the kids to school; and not on clinical measures such as pain reduction or range of motion. Once your patients understand that you are also invested in those goals, you form a partnership, and they will respond more positively to your interventions and advice. This engages with their hopes and aspirations, which become real and tangible when they are shared with somebody who is equally committed in working towards them.

When things don’t go to plan, and your patients are not getting the expected results, it is a time that some of us can become defensive, or focus on the negative. At this point your patient is looking to you for guidance and leadership. Acknowledge that things aren’t going as well as expected, and reset the process of assessment and diagnosis. You patients need to understand that you are not giving up on them, and that you are working with them to find a solution. Focus on any improvement, and it will be amplified. Try to use that improvement to build a plan for further positive outcomes.

In summary, I had just 15 minutes to speak in Manchester, and probably bombarded people with too much information, the essence of which was this.

• Build trust
• Listen
• Make goals
• Form a partnership

Use the opportunities that Private Practice gives you to make the best diagnoses and treatment goals, with the most appropriate equipment and technology, and partner with your patients to achieve their hopes and aspirations, whilst exceeding their expectations.