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Go With the Flow Increasing patient flow and revenue through your busy Podiatric office. . We all come to these meetings to find the “secret”, the “key” to running a successful practice while keeping patients happy and compliant, staff in check and referrals and reimbursements flowing. .

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Go With the Flow

Increasing patient flow and revenue through your busy Podiatric office.


We all come to these meetings to find the “secret”, the “key” to running a successful practice while keeping patients happy and compliant, staff in check and referrals and reimbursements flowing.

nothing worth working for comes easy and so
Nothing worth working for comes easy and so. . .
  • Today we will show you how to
    • Treat your patients efficiently and effectively
    • Improve patient satisfaction and compliance
    • Increase practice revenue
      • AND, MOST IMPORTANTLY. . . . . .
before we begin
Before we begin. . .
  • Let's discuss the importance of staff members (podiatric assistants) playing an essential role in your office as a “Doctor Extender.”
  • This should become a goal of every practitioner, whether a solo practice or large group.

Podiatric Assistants can not only perform a multitude of tasks while “assisting” the doctor. They can be properly trained to become an integral part of the entire patient experience.

how many doctors have their assistants
How many doctors have their assistants. .
  • Drawing injections
  • Setting up procedures
  • Reviewing and preparing surgical consents
  • Thoroughly evaluating patients
  • Performing diagnostic testing
  • Performing PT (ultrasound, TENS, etc.)
  • Performing vascular testing
there s more
There's more
  • Taking and developing X-rays
  • Casting and dispensing orthotics
  • Casting and ordering custom AFOs
  • Running your entire Diabetic shoe program
  • Dispensing all DME items
  • Managing compliance documents
  • Performing orthotic adjustments
wait there s still more
Wait, there's still more. . .
  • Participating in and documenting your comprehensive diabetic foot exams
  • Assisting with office procedures
  • Foreseeing what will be needed (DME) to adhere to patient protocols.
  • Introducing appropriate IOD products before you step foot in the room.
make sure you take the time to train your staff and allow them to shadow you yes you the doctor
Make sure you take the time to train your staff and allow them to shadow you, YES, “YOU”, the doctor. Shadowing is Key
lead by example
Lead by example
  • Make sure protocols are set in place, understood and carried out by all the members of your staff.
  • Demonstrate how you want particular tasks done, procedures set up, and protocols followed through.
  • Explain the “science” behind the methods.
  • Allow your staff to practice a skill and perfect it before trying it out on your patients!
respect and be respected
Respect and be respected
  • Treat each member of your staff with respect.
  • Acknowledge their accomplishments loudly and criticize their faults softly.
  • Make sure your staff feels appreciated and they will appreciate you in return.
educated and well trained staff has many benefits to your practice
Educated and well trained staff has many benefits to your practice.
  • Highly trained, well versed, confident staff influences your patients to
    • Be more compliant
    • Purchase more IOD products
    • Refer more friends and family members
    • Grow your practice
you are the captain of the ship

You are the steering wheel that financially drives your practice, but without a solid engine (your highly trained staff), you will never move forward.

You are the captain of the ship
first impressions
First impressions
  • What does your reception area, not “waiting room” say about your office?
  • Is it filled with outdated magazines and dead plants?


    • Does it give a proper representation of your practice?
be aware of what your patients are seeing
Be aware of what your patients are seeing.
  • Reception area décor
  • Magazine selection
  • Television channel selection
  • Receptionists choice of attire and hairstyle
  • Cleanliness of treatment rooms
    • These all give your patients an idea of what your practice is all about.
patient checks in
Patient checks in
  • Have your patients fill out their New patient encounter forms ahead of time.
    • Ask them to go to your website (no matter what age)
      • OR
      • Mail out paperwork ahead of time so it's done prior to their arrival

Only when their appointment is made within 1-2 days should they be wasting time filling out forms in your office.


Have your patients bring copies of medication lists, allergies, past medical history and surgeries. It saves time and assures that your staff is inputting accurate history upon evaluation.

educate and inform
Educate and inform
  • The assistant can play a key role in “breaking the ice” for these skeptical patients.
  • Informational packets (like CDFE informational kits) educate patients while making them aware of complications that may arise from lack of podiatric care.

Products to discuss with your diabetic patients. Only offer medical grade or physician only formulas. . . .



So, don't “SELL” simply OFFER the products they need for all of their foot and ankle care.

how long has this condition existed
How long has this condition existed?
  • Training staff to ask the right questions is essential.
    • “How long have your nails looked like this?”
    • “Are your nails painful?”
    • “Has there been any injury to the nails?”
    • “Do you have regular pedicures?”
the pick a color theory
The pick a color theory
  • Many women who complain of thickened, discolored or incurvated nails state that this condition began after going for regular pedicures.
  • “I thought they knew what they were doing, I pay $45 for my pedicure!”
  • Pick a color applies to everyone, and that's not always a good thing!
the assistant doesn t diagnose
The assistant doesn't diagnose.
  • Patients will often ask “what do you think it is? Is it that fungal thing like on the commercials with that nasty little animal?”
    • The assistant should always state that we see this type of condition all the time, but only the doctor will be able to tell exactly what it is.
the good news is

If the doctor does diagnose your condition as a fungal infection, we have all the products you need to treat your nails and prevent re infection right here in our office.

The good news is. .
explain the course of treatment
Explain the course of treatment
  • While treating the patient, the DPM has the opportunity to discuss the possible causes for infection, and the treatment options.
    • Give them the treatment options, discussing the importance of their involvement through use of your choice of topical or oral anti fungals as well as periodic debridement.
less hassle for your office staff billing department
Less hassle for your office staff/billing department
  • By offering products with unconditional money back guarantees, the patient deals directly with the manufacturer of the product rather than requesting money back from you.
    • Try it out for yourself. Have a staff member “test” out the refund process to make sure it is hassle free.
and you know they don t listen
And, you know they don't listen
  • You know that when you instruct your female patients NOT to polish their fungal nails, they aren't going to listen.
    • Regular nail polishes contain harsh chemicals which don't allow the nail to breathe causing discoloration and changing the appearance of even the healthiest nail.
bring your own polish
Bring your own polish
  • Once your assistant has introduced the “pick a color” scare tactic and you have reinforced it. . .
    • Discuss the importance of bringing their own polishes, buffers, and files when they get their manicures and pedicures.
pricing is important
Pricing is important
  • With any item or product dispensed in your office that is also available online, make sure your pricing is better. Example- Dr.'s Remedy nail polish sells for $16-17 per bottle, not including shipping in the U.S.
    • Sell it for $15 per bottle (saves $$$) and they can pick it up conveniently at the time of their visit.
let s talk specials
Let's talk “specials.”
  • Everyone loves a bargain.
  • Perception is reality.
  • Buy something, get something free is always an eye catcher.
  • Try changing “specials” by season and watch your products move even faster.
product education
Product education
  • Before increasing your in office dispensing (IOD), you must educate your staff.
    • Start with a limited inventory and grow with patient requests and needs
    • New items can be tried without incurring huge costs (order 2 or 3 of a new item to see how well they move- shoe laces, sock aides, shoe horns, etc).
hal s method
Hal's method
  • Throw everything in the middle and have your staff explain what the products are, how they are used and how they should be applied.
    • Create a price list and be sure it is always updated.
    • Menu type price lists are less intimidating and allow you to offer without selling.
asking the right questions is key
Asking the right questions is key
  • Upon evaluation, the assistant should very quickly be able to assess the situation and anticipate the course of treatment and protocol to be followed for this patient.
    • What brings you into the office today?
      • “My left heel is killing me.”
    • How long has this been going on?
      • “For about 3 months.”
And. . .
  • Has the condition improved, worsened or remained the same?
    • “It seems to be getting worse.”
  • Was there an injury or any changes in your routine when this pain began?
    • “No injury, but I am on my feet a lot more at work than I used to be.”
and still
And still. . .
  • Do you wear any type of orthotic or arch support?
    • “I tried those gel inserts at the pharmacy, they didn't help very much.”
  • Have you tried any icing or stretching exercises?
    • “I did try icing a couple of times, only helped a little though.”
  • Do you have pain when you first get out of bed or upon standing?
    • “I feel like I am 90 years old when I get up.”
the protocol has been established
The protocol has been established
  • At this point, after X-Rays have been taken or diagnostic ultrasound has been performed, the assistant is able to prepare everything the doctor will need to treat the patient before the doctor enters the room.
    • Nightsplint has been prepared
    • Injection drawn (if part of protocol)
    • Biofreeze is placed on table
    • Casting material is ready to go
    • Stretching instructions are printed
the doctor will be right with you
The doctor will be right with you.
  • Without diagnosing, the assistant is able to prepare all that is needed to treat this patient in a timely manner, assuring compliance and visit maximization.
    • The doctor can now simply glance through the chart note (or take a look at the products and DME items that have been prepared) and get right to the matter at hand (without duplicating information already given upon thorough evaluation.)
the doctor finishes up and the assistant returns
The doctor finishes up and the assistant returns
  • The nightsplint is dispensed to the patient.
    • The technique to dispensing plays a major role.
    • Keeping the patient's goals realistic is important with compliance and satisfaction
    • Assuring the patient understands the “process/protocol” is key.
do you have any questions
Do you have any questions?
  • Before the assistant leaves the room and the patient checks out, the question is always asked. . .
    • This assures that the patient doesn't feel rushed, or confused
    • And, it avoids phone calls later in the day.

The patient checks out with a sense of satisfaction. They understand their condition and course of treatment.

patient is hesitant
Patient is hesitant
  • The assistant rooms the patient (with his mother) and asks him to remove both shoes and socks.
    • “Why do I have to take off both my shoes, my warts are only on one foot?”
we always remove both shoes and socks
We always remove both shoes and socks.
  • The assistant explains that the doctor likes to compare one foot to the other. This way he can make sure there is nothing on the “good” foot.
    • The patient agrees and removes both shoes and socks.
    • The mother holds her nose and states “Uggghhh, he has the smelliest feet in the world.”
the assistant puts things in perspective
The assistant puts things in perspective.
  • Seeing that the patient is somewhat embarrassed, the assistant states the facts.

The doctor will come in and shave down some of the dead skin surrounding what we think may be warts.

    • He will be able to determine what they are with more certainty once he gets a better look.
explaining in a way that they understand
Explaining in a way that they understand.
  • If the doctor determines that these are warts, he will decide on the best method of treatment.
  • No matter what method of treatment is used, we find that the process is expedited when our patients take a proactive approach.
you re not alone
You're not alone
  • Many patients who come in with conditions like these have a few things in common.
    • Their feet sweat (a lot)
    • They start with one wart and end up with several.
    • They are uncomfortable because of the callused skin that has formed around the warts.
explain the science in their terms
Explain the science in their terms
  • A wart is a virus, sort of like the common cold and can enter through the smallest break in the skin.
  • Because a wart is a virus, it can spread (and quickly).
  • Warts also like damp environments and so people with sweaty are the perfect host!
for the convenience of our patients
For the convenience of our patients. . .
  • Because so many of our patients suffer from the same condition, we offer all of the products needed to treat warts at home (in addition to coming for regular visits) right here in the convenience of our office.
    • Drying agent
    • Buffing pad
    • Wart treatment
not that we want to see you go
Not that we want to see you go. .
  • We find that when our patients use these products together and come see us every 2-3 weeks (so the doctor can re evaluate and treat their condition), they have much better results (and faster).
the dpm enters the room and the patient is ready
The DPM enters the room and the patient is ready
  • Now that the DPM is ready to treat, the patient and his mother are prepared and understand exactly what to expect.
    • The doctor merely reinforces the ideas that the assistant has introduced.
    • The patient and his mother are optimistic and understand that they need to take an active role in the course of treatment.
checking out
Checking out
  • The patient has been treated and he and his mother proceed to check out.
  • They make a follow up appointment and purchase the supplies that have been set out for them.
  • The have been fully educated and are confident that they have chosen the right facility for their foot care needs.
so many of the products in your office go hand in hand
So many of the products in your office go hand in hand.
  • Think about all of the common conditions you see everyday.
    • Which products do you recommend over and over again?
    • How many of these products work better when used in conjunction with another?
    • Could you offer better pricing to your patients if they purchased more than one product together?
or simply appeal to a specific demographic
Or, simply appeal to a specific demographic
  • Buy 2 nail polishes, get a polish remover FREE!! (people, especially women, LOVE FREE!!)
    • Make this your fall special, your spring special, your Mother's day special, your Valentine's Day special
give a discount for kits
Give a discount for kits
  • As your patient is educated about the appropriate product for their condition, make sure they know the individual price, then explain the discount.
    • Sal gel - $18
    • Ostiderm - $20
    • Buffing pad - $8
    • Wart kit ONLY $42!!!!!!!!!!!
try it and you ll love it
Try it and you'll love it!
  • Have your patients try on Crocs Rx with a medical grade orthotic in one shoe and nothing in the other.
    • “It feels like a slipper with an arch support.”
    • Who should wear Crocs? Anyone with feet.
    • Offer a discount (Crocs $40, Power steps $60) Together- $89!!!!!
let s take a look back at that heel pain patient
Let's take a look back at that heel pain patient...
  • Upon returning for his three week follow up, the assistant greets the patient from the reception area with a positive tone.
    • “Hi, Mr. ________ Are you feeling better?
    • “Actually, I am” the patient replies as he enters the treatment room.
positivity counts
Positivity counts
  • When you greet your patients (especially for follow up of pain), make sure it is with assurance that they are feeling better.
  • Keeping goals realistic, even if they only express mild to moderate improvement, be enthusiastic.
  • “You know, you've had this pain for a while, and getting better can take some time.
are you following the doctor s instructions
Are you following the doctor's instructions?
  • Make sure that your assistant is re-enforcing the treatment protocols (icing, stretching, resting, etc)
  • If the patient has followed the “program” so far and is improving somewhat
    • OR
    • Is significantly improved, if you haven't already. . . .
to truly get better you have to follow the next step
To truly “get better.” . . . you have to follow the next step
  • Discuss with your patient how important proper support is in their every day activities.
  • If they have made mild/moderate improvement, take it to the “next level.”
  • If they have made significant improvement, take the preventative approach.
either way
Either Way. .
  • Your patient should leave his follow up feeling physically better, mentally educated and prepared to take the next step in their overall foot health.
  • Just follow the protocol and let the patient know that they have chosen the right facility for all of their foot and ankle needs.
but what if they argue
But, what if they argue??
  • And, you know a certain percentage will.
  • So, give them the choice without any pressure.
  • Allow them to make a conscious decision to not follow through with their treatment.
  • Tell them that you will be here if (but you know it's when) they ever change their mind.
when properly trained
When properly trained. . .
  • Assistants can be trained to recognize who belongs in orthotics (WHO DOESN'T?)
  • They can also be trained to cast in any technique you prefer to obtain the truest negative of your patient's feet.
  • And, they should also be able to dispense, instruct and if need be modify the devices.
teach them the basics
Teach them the basics.
  • You were highly trained in biomechanics.
  • Your assistants probably were not.
    • BUT
    • You can once again, teach, show and watch them go.
    • Consider the time you would take to cast and dispense orthotics to your patients (now add in instruction, and modifications).
now consider this
Now consider this. . .
  • How many other patients could you have treated during this time?
    • The answer is . . . . . . . . A LOT!
    • Delegation of tasks that can be carried out by staff members makes sense.
    • Now let's see how an assistant should dispense orthotics, we will cast later.
good afternoon mr here are your custom orthotics
Good afternoon, Mr. _____, here are your custom orthotics.
  • All assistants should know first hand what it takes to become adjusted to orthotics.
  • This first rate knowledge will allow them to educate your patients more effectively and assure that their expectations are kept realistic.
  • So, fit your deserving staff with their own!
how do you get the word out
How do you get the word out?
  • Marketing for custom orthotics can be fun and allow you to grow your overall practice.
  • If a man comes in for shin splints and ends up with custom orthotics that resolve his condition, his wife is sure to have her own made (offer discount for family members, or second pairs.)
invite local referring docs
Invite local referring docs
  • We all have our favorite referring docs.
  • They appreciate that fruit basket at Christmas, but what they really need is a pair of custom orthotics.
  • By making a pair of custom orthotics for your favorite PCPs (for free), you are raising awareness and greatly increasing orthotic revenue in your office.
cash for clunkers
Cash for Clunkers
  • Once every couple of years, do what the car dealerships do and give your patients a discount for turning in their old orthotics and having new ones made.
  • Send letters awaring your patients that as we get older, our feet tend to change.

Pose questions like, “When was the last time you had your orthotics checked” and “Are your orthotics as comfortable as they used to be?”

now it gets really good
Now it gets really good!!
  • Our next patient opens up the door to DME galore (wow that rhymes!)
  • Orthotics are a great way addition to any practice (whether starting a program or improving and growing it), but now it's time to truly give your patients custom care. . .
    • THE SUSPENSE > >>>>>>>>>>>>>>>
patient 5 ankle pain
Patient 5. Ankle pain
  • Ankle pain and conditions are tricky.
  • Lots of DPMs aren't crazy about the idea, because most problems aren't black and white (in other words, you can't see something definitive through X-ray).
    • BUT, the good news is, patients with ankle pain, swelling and other types of related conditions are a protocol followers dream!
the first type
The first type
  • Assistant rooms the patient (middle aged man) with chief complaint “my ankle hurts sometimes.”
  • She evaluates the patient and finds the following complaint “My friends and I play basketball in a men's league on Thursday nights and afterwards my right ankle always feels achy and tired.”
is this only when you are playing
Is this only when you are playing?
  • The patient answers yes, and says that at work and during normal activities he does not experience any discomfort.
    • “Do you wear any type of orthotic or insert in your shoe or compression bandage around your ankle?”
    • “I tried an insert from the store and it didn't help much, but then I decided to use an ACE bandage during a game and it felt a little better.”
let s take some x rays just to make sure nothing is out of place
Let's take some X-Rays, just to make sure nothing is out of place.
  • The assistant brings the patient to the orthoposer and takes three ankle views according to the location of pain.
  • She pulls the X-rays up on the monitor in the treatment room and tells the patient the doctor will be right in.
  • She leaves the treatment room and knows to prepare the following braces. . .
the doctor is clued in and has everything at his fingertips
The doctor is clued in and has everything at his fingertips.
  • The doctor goes in and reviews the X-Rays with the patient. He explains that there are no evident fractures, but he feels this may be a tendonitis due to instability of the foot and ankle.
    • We have just the thing for you.
    • He explains the science behind his brace of choice.
the assistant returns
The assistant returns
  • The assistant places the brace on the patient's foot/ankle and instructs him on proper use and care. She warns him that it may take a little getting use to and instructs him that he will return to the office in 3 weeks to relay his progress.
when he comes back 3 weeks later
When he comes back 3 weeks later. . .
  • At this point, you have three possible outcomes.
    • 1. He is feeling some relief with the brace, so logically you move him up to the next level of ankle brace.
    • 2. He is feeling 100 percent better and you tell him to use the brace as needed.
    • 3. He is not improved at all and you send him for an MRI.
    • Any way you slice it, you have answers for your patient.
so let s say he feels some relief from the brace
So let's say he feels some relief from the brace.
  • If you are following protocol, you have started him with an L1902 (aircast or gauntlet style brace) or L1906 (multiligamentous brace).
  • Now it's time to bring out the next level, the L1971 (some type of non custom brace that serves as an orthotic as well as an ankle stabilizer (a favorite is the Ossur Rebound with stability strap).
bring him back in 3 weeks and see
Bring him back in 3 weeks and see.
  • Chances are, if he has done well with the aircast or other similar brace, he will do very well with the rebound.
  • Here is your opportunity to cast him for orthotics as his tendonitis has calmed down from immobilization.
  • He sees the benefit of a foot orthotic as well as the need for stabilization of his ankle with increased activity.
you have given your patient choices
You have given your patient choices.
  • But, let's say that this patient had more of a chronic condition.
    • PTT dysfunction
    • Chronic sprain
    • Charcot foot
    • What happens then??????
start off at a higher level
Start off at a higher level.
  • Start this patient with a Rebound or Velocity brace and show them the benefits of this “one step below custom” brace.
  • Make sure to keep goals realistic with chronic foot and ankle conditions.
  • Assure that your staff is giving proper break in instructions and is documenting that they have done so.
keep them in the brace for a bit
Keep them in the brace “for a bit.”
  • After about a month, bring the patient back and check their progress.
  • Once it has been decided that this type of brace is improving their symptoms (somewhat), but the condition will only worsen over time, take the next logical step
  • Move them into a custom brace.
custom afos
Custom AFOs
  • Custom ankle foot orthoses can be tricky but will significantly improve the quality of life for your patients if the proper style is selected.
  • None of this can happen without proper casting.
  • Staff members should be doing all casting for AFOs (YES, WE SAID ALL CASTING)
train your staff the right way
Train your staff the right way
  • There are many techniques for casting of custom AFOs.
  • You probably have a “favorite” way that you learned in school.
  • This may not be the easiest method for your staff, so simplify the process.
  • STS socks make life easy and produce great results.
make sure they understand why
Make sure they understand why
  • When teaching your staff proper casting techniques (or having someone else teach them), make sure they understand why it is so important to cast in a neutral position and capture the most accurate “negative” of the patients foot and ankle.
  • Bad casts keep patients from having the device they need and slow reimbursement into your practice.
practice makes perfect
Practice makes perfect!
  • Watch here as we cast a “patient” for an Arizona brace. . . . . . .

Now, be brave and join us as we cast eachother.

  • You know what they say. . . . (see above!)