Handling My First Shockwave Refund: Podiatry Care Lessons

I want to talk today about my first patient ever that has asked me for a refund for Shockwave. I've never really had that before, so I want to go kind of unbox that for you guys and then I'll go over my $1,000,000 minute. My name is Don Pelto. I'm trying to help you get your practice to the $1,000,000 mark and beyond. So this patient, she is a 65 year old female. She came in and I was looking at her note because she sent me a little message through our

medical record. She had been a patient that had sesmoid pain, sesmoiditis, did not have a sesmoid fracture. I was, I think I was probably Dr. #2 or 3. She saw before seeing me, I recommended Shockwave for her and I think she already had an orthotic that she was using to offload the sismoid. And she communicated to me, she said, hey doc, I saw three other doctors and so she saw other opinions in Boston. Some of them she had to wait like four months. I think most of them were

orthopedist. One of them did do Shockwave and, and they said, well, you probably shouldn't have had Shockwave because it's not good for, for sismoiditis. And if if anyone does shockwave, you know that shockwave I have both focused and radial and it works very, very well on

sesamitis. In her specific case, it didn't. And so I've never had a doctor do that, say, hey, you call the doctor up and ask for a refund. So I was kind of probing just to talk to her a little bit and say, OK, well, how are you doing? Are you totally better? It's been a couple years since I've seen you. Are you better? Oh, I'm not better.

OK, what's happened since then? Well, I had another two or three pairs of like orthotics that didn't work and the, and the, and the guy that I'm seeing now wanted me to go to his guy to get an orthotic to try to offload this test point. And he didn't want to do surgery on me, which which I don't think anyone would want to do surgery on her. So I asked, well, did the, did the orthotic people give you the money back and did the other doctors that didn't get you

better? I wasn't, I was nice about it. I was not being, trying to be mean about it. And she said that one of the, I think one of the orthotic, they

just charged the, the, the fee for making it and for the orthotic and they gave her like 50% back. And so I said, you know, I'm fine with that. I gave her, I said I can do 50% back for you. I do still believe I kind of stuck my ground. I think it was appropriate for her. In her case, it didn't work. But for a lot of patients it does work. So that was kind of a frustrating thing. I don't know if anyone else has had people ask for for for money back for Shockwave.

This is the first one I've been doing it in a long time. So I think a few, a few give backs are probably OK. I always joke because every time my partner has to do a cut a check for a refund, he always gets real pissed. He's the one that does more of the, the check writing and stuff like that. It's like, why do I have to do that? And then that's the, the, I guess the least valuable patients, right?

But in the in the end of things, I know some people like, so there's different ways of thinking about this. I kind of think of well, OK, 750 my actual 30% of what I get from that. So basically our take home here is usually 30%. So that is going to be 200 dollars 2-10 something like that.

And for the amount of stress that would cause me to kind of argue with the person and the bad will and everything else like that, I sometimes think it's better just to give the money back because you don't want the bad will that goes with it. You want, you want goodwill. And she said she was OK with the 50%. That's what she got from someone else. I'm I'm OK with that. I think there's some, I don't mind doing that. I don't know. Some people are blatantly against doing that.

Doesn't happen a lot. But I just, I wanted to talk through that with you. So my most valuable patient, it was actually a double patient. There was a 15 year old female and a 49 year old female. So it was mother and daughter. They both made an appointment. They found us online. The mother was really the most valuable patient. She had a neuroma on her right side. She had been seen in the Mayo Clinic, not not in Minnesota where I'm from, but some somewhere else.

And she'd got some cortisone injections and she's been having pain. She also had a couple of Ipks that were painful. So I did lesion destruction on the Ipks I did for the neuroma. I talked to her about anatomic shoes. She's had like a metatarsal pad. And I talked to her, Well, you can either do the cortisone, you can do the shockwave, or you can try like an orthotic in your

shoe. And she opted for the shockwave. So we are going to set up shockwave. So wish I don't do a ton of shockwave for neuroma, but from what I've read and from from the ones that I've done, you do it very light because it's a nerve. So you're trying to reduce the inflammation around that nerve. If you go too heavy-handed with the with the shockwave, it can actually aggravate the nerve. So she's going to set up six sessions of shockwave for that.

And then she had that the office visit in the X-rays and stuff like that. The daughter, she had bilateral Achilles tendonitis, not 15. She originally thought she had seavers. So she maybe was treated receivers in the past, very kind of tight calves. And I was able to once again, I'm just repeating myself here about this dynamic demonstration. So what I do is I take a orb or AB ball, which is like a foam

roller, but it's just smaller for my office, put their leg on it. And as I'm talking to them, I'm foam rolling the the posterior calf and the posterior tibial tendon, kind of rolling it back and forth. Basically what I did, I roll it back and forth and I have them do like 5 or 6 circles to the right and then 5 or 6 circles to

the left and then lift their foot and drop it down. And that is kind of loosening up the back of the calf. And, and what I find is usually that takes care of the institutional Achilles tendonitis and also helps with their plantar fasciitis. So basically I, I push and then I do that foam rolling and then I push after and there's less pain. So this is called a dynamic

demonstration. It really builds confidence in patients that, you know, doing the actual exercise is going to help them because it helped them. So she's going to do that. She's going to do my Pelto special. So reminder what that is? It's she's going to get bilateral night splints that she doesn't have to wear at night that wears in three hours a day. The reason she does bilateral is so she doesn't have to wear it 3 hours on one and three hours on the other.

No one has 6 hours a day. She's going to do a morning stretch and then that that foam rolling or the roller to start out. I got X-rays for her and I'm going to see her back in about four weeks to see how she's doing. OK, so getting into the rest of the day, the there was a matrix and 22 year old female with a matrix and she got the post op kit. I've started to I don't know how to say this nicely. That was maybe I won't say it nicely.

I've been trying to it's it's a training problem on my end about my staff. So I'm they're not always asking about soaking and, and the marriage gel kit. So I just tend to go through the marriage gel kit with the patients and then just my staff fulfill it versus having them go over the options. Many times when they're going over the options, they don't believe in it or maybe they think it's too expensive or whatever type of judgement call

that they're making. And I just think instead of soaking twice a day for 30 minutes, it's much easier to do the kit and it's you don't have to soak and things like that. So I find that when when I explain it and I just tell the patients, tell the staff to fulfill it or works better, it's probably a problem on me with training most likely because there we have a lot of new staff that are kind of coming in.

Next was a 48 year old female. This is kind of a drain. This patient was a drain and we have these patients. She has bilateral hallux nails that are only attached to the base. She's one that comes in every couple of months for Care Flex. So the Care Flex takes me a while. She was seeing Marjorie, my nail tech. For some reason, Marjorie is on vacation, ended up seeing me. She is kind of super paranoid about her toenails. She's currently on Terbenefin.

They're not reattaching, are growing out and reattaching. She had some green underneath the the nail, so we have carry flex on for too long and she swims every day. It's got a little superficial Pseudomonas infection, but she didn't want to go time without the nail on there because it's summer and she does karate. She wants her nails to look good for karate, so we can't really treat the Pseudomonas.

I talked to her about it. I said, well, maybe in the winter time or when you take a break and you want to put a

Band-Aid on it or something like that, then you would do either a dilute bleach or dilute vinegar soak to get rid of those. But I don't think it'll work with the carry flex on there. It wasn't all that bad. The greenness was just a little bit of greenness. So I tried to grind it down before I put on the carry flex. So that was a time drain. OK, time drain right there. Next patient was a 67 year old man. He had IP, KS, 1st and 5th Med heads bilaterally. He has orthotics.

They were quite painful. I, the bride of them, put salicylic acid, deadly lesion destruction. So the way I think about this, this is just the way I think about it. If it's a regular kind of callus, most people aren't really complaining about those, so I'll trim those down. I tend to make them pay if insurance doesn't cover $75. I tend to be nice the first time

someone comes in with these Ipks because they're really deep, they're really painful and I treat them as lesion destruction with possible wart, possible IPK, and because sometimes there may be a verrucas nature to it that that's what the people at Swift tell me and that's kind of what I think. And so when I do leads and destruction on them, I can do

that. Now I'm not going to do that every month or every three weeks or every three months to trimming off calluses and doing that. No, it's like a one time thing. If they come back in a couple years, I would do it again that way using the leads and destruction. I'm just kind of letting you know the way I think about it, you guys think differently, let me know. And then usually they're offloading with like an orthotic.

If they start to have to come back periodically for that, I would just charge them the $75 every time. But the first time I try to do it through kind of through insurance. Next patient was a 16 year old female. She was here with her mom. She had a bilateral warts and I went through my wart treatment

sheet and they opted for swift. So if you guys, I've, I've had a lot of not a lot, but I've had a couple of doctors say, hey, you know, I have a hard time explaining it and having patients choose Swift, they just kind of struggle with it. So I want to tell you what really helps me is my treatment sheet. So if you don't have my treatment sheet and you wanted to try to use it, feel free to use it. You just, it's like a Google

doc. You just change, put your logo on there and you don't have to use my logo. It, it really makes it simple. It says, well, you can do, I put Swift at the top. It's usually about four visits there a month apart. Doesn't hurt at all afterwards or you can do Canthrodin, which is usually A4 to 8 visits. It hurts a lot afterwards. Our laser which hurts during or you can do like a removal, which I would only do if there's like one or two, but it hurts and it takes about four or four or four

or six weeks to heal. So when I explained it that way and I say that yes, Swift costs, costs 250 a visit. But if you look at all the added up co-pays and lesion destruction codes that we're going to be billing your insurance, if you have a high deductible plan, usually Swift is just the, the best way to do it. Then I also say, you know, it doesn't always work at 4:00. So I do set up four once a month, so 1 Swift per month for four of them. And I see them three months

later like they recommend. But if it's not improving, like when we're in into the second or third or fourth, I usually will do combination. So I'll add on can thread in and then I'm not going to, I'm not going to double dip. I'm not going to, I'm going to charge them for the Swift. And then just because the can thread and I just drop a little

stuff on there. And then when they come back at three months, I might even do the Swift and the Kantharin, but this time build a Kantharin, you know what I'm saying? So I might switch it around that way to make it more feasible for the for the patients economically if they don't have a high deductible. And then they're also getting

Aldera or Carac topically. So this one, this girl's going to do the Aldera initially for a couple of weeks until she gets back from summer camp and then she's going to be seen in the office for the Swift. So that's kind of the way I think about it. Next patient was a 67 year old man that had a first intermetatarsal space, kind of like a possible neuroma in there.

Previously I'd seen him about 3 or 4 weeks ago for a cortisone injection to the first MPJ that was painful and I did the injection didn't really help that much. So this time I did it in the interspace. I don't exactly know what's going. I don't know if it's a neuroma or something like that. He does have a cyst in his first Med head.

He has some pain in that joint so we'll see how this helps him. Next was a 66 year old man that had a Melania and I did a nail sample for his Melania and it didn't. They couldn't really determine and they recommended a nail matrix biopsy and I did not why I explained it. I recommended that for him. I usually do a 3mm punch biopsy at the nail matrix. And so his melanonicia was the dorsal portion of the nail. So there's like top and bottom

parts of the nail. So I was going to do more of a proximal aspect of the biopsy at the nail matrix.

And the reason is because there was a black line, but there was also cracking of the nail. And I was concerned, but he just like didn't want to do that. And I'm not sure if it was because of his job or something else like that. So I did take a picture. I told him I'm concerned and he's going to come back in six months for an evaluation for that. So that one, unfortunately, is kind of a lower, lower visit patient. The biopsy would have been better, but he may be back for

that in the future. Next patient's a 49 year old. She had fungus on 2 nails on the right foot first and second. She also had bunions and tailors bunions. They weren't really bothering her. Her main issue was the nail fungus and she also had ingrown toenails. So sometimes those ingrown nails can make the nails look a little bit thicker. What I did for her is I took a nail sample.

I'm going to see her back in three months, three weeks to go over the nail sample and then we can start the process because I wasn't totally convinced that her nails had fungus in them. They could have been just thickened from the rubbing. Next was this is an urgent care patient. So just so you know, I think I've talked about this before. We do have an urgent care page now.

It's kind of cool because in my schedule now it tells me who comes in from the urgent care and because it comes in on my schedule that way. So it's kind of a neat, I can see this. This is kind of a complicated man. He's a 71 year old man. He got up and he just he was biking. He had like hemosiderin changes to his lower legs and he's he's reminds me of he's just he's an Italian, older Italian man and he just talks loud and just reminds me of like a gangster or

something like that. The only reason I'm thinking of gangster because I was I took my trip recently and I watched this gangster movie on the way back. But he had really bad planter. I think it's plantar fasciitis, but with like really no instigating incident and he had could just the tightness, but it's really, really painful. So I had for him.

I actually I did 2 cortisones. I did plantar medial heal and then the medial arch, which isn't all that common for him and I put him in a Cam boot because because he was in so much pain. So I'm going to give him a call today and see how he's doing. But he came in from urgent care and he just really couldn't walk and his wife was tired of listening him to complain him and complain. Another patient came in, 74 year old man.

I've been finding now I don't know if it's due to social media or due to our website or or something like that. He came all the way from New Hampshire to see us and he had flat feet bilaterally and he really couldn't tolerate any orthotic with an arch in the past. I, I did recommend a medial Blaze AFO because I think that one works well. It has some cut outs for those prominent, you know, medial aspects of the feet when their foot everything collapses in. But he, he wasn't interested in

that. But I did recommend that. And he had some like weird neuropathy pain. And he was recommended gabapentin by his, his PCP and they're also going to do a back MRI, which I agreed with. And, and I just kind of talked him off the Cliff with the gabapentin. I found a lot of patients are just fearful of the gabapentin, but I said you know, if your pain's mostly at night, just start it at night time. So then I'm not going to see him back. Next patient was a 51 year old female.

She had a right foot sprain and she had pain to the peroneals. So I did X-rays for her. I gave her NSAID's and if it's not better I'm going to be putting her into a boot. So I think it was just a sprain. I'm going to see her back as needed. The next was a 45 year old female that had plantar fasciitis #4 out of 6 for Shockwave. She's getting a little better. Next was a 78 year old man. This guy had a a right hallux

extensis. I've told you about this before in the past he had just like right foot that's like cocked up. I tried to do Nuboso splays for him and it didn't really work and he came in kind of wanting orthotics and and this happens, I don't know for you, but it happens for me quite a bit. So they, they want orthotics and then when they hear the price, they don't really want them.

So it's amazing how that desire can just totally change when, when someone hears about price and I there's a just kind of as a side note, I was talking, there's AI have a WhatsApp group of some people that talk about like a different business things podiatrist and this one doc, they're saying, you know, Hey, I'm not that good at doing orthotics. And she said, I think I was thinking about reducing the

price. And so if anyone's thinking about reducing price, I would, I would tell you, I would just recommend like don't reduce price. Get better at explaining orthotics like get better at, you know, practicing how, how to explain it in even if insurance doesn't cover it, which which is my case, you have to get better at explaining it in the value proposition.

You have to get better at doing them too, frankly, because the more orthotics you do, the more people you're going to have with problems with the orthotics, meaning they're not going to fit, they're not going to be comfortable. So you have to get better at troubleshooting the orthotics as well. If you want to do a lot of orthotics. It it, I always say you don't have to be good if everything is covered by insurance. It's like easy to give away stuff that's for free.

It's it's hard to to explain stuff in a way and be confident enough in your abilities for like shockwave and orthotics that it's going to work for the patient. So anyway, that's just my, my thought. Like don't, don't like cheaping yourself. We charge 600. I know that's maybe some people probably charge more like 800 or I've heard of 1000. We do 600 for our orthotics, but some are doing like less and they're wanting to reduce the amount. I don't think patients buy based on price.

Patients buy based on the confidence that you're able to show them in what you're recommending is going to work. OK, and you do what's best for them. Now, if you don't believe in the orthotics, then you can't offer them. You can't quote UN quote sell them because you don't believe in them. So you need to believe in them yourselves. You need to make sure these things are going to work and they're the best thing for the patient. OK, that's kind of my rant about orthotics.

Anyway, he didn't get the orthotics. Maybe I wasn't too confident that they would help his condition, which I really wasn't in his specific case. OK, next patient was shockwave #1 out of 6, this is a unique 1 and I did a little video on this patient. She had a year and a half old fracture of her 4th digit. Her 4th digit swelled up and the swelling never came down. The fracture never healed. She wasn't really treated. She was treated for a short time in a Cam boot.

But then you know, thinking well it's just a fourth toe and but The thing is just so swollen. And so due to this non union, I'm going to do 6 sessions of shockwave for this patient. So the other option was to take out the intermediate failings. So we're going to do the shockwave for her and we're going to, that usually kind of heals things in and then hopefully the swelling would come down because I think the swelling is there because it's trying to buttress the fracture.

Next patient was a 63 year old female left plantar fasciitis. This is one that I did that dynamic demonstration with the roller ball. We're going to do ice contrast pass. She also has nail fungus and I did a nail sample. I'm going to see her back in a couple of weeks. We're going to do an ultrasound for planter fascia. It doesn't get better.

I didn't jump right to shockwave for this patient because her her her symptoms weren't that long and they weren't that bad and I think she might be able to get better with the with the foam rolling. Next was a 68 year old man with a right posterior tibial tendonitis. Did shockwave #3 out of 6. He's starting to feel better. Next was Amri follow up for a gentleman 48 year old man. He had a kind of spontaneous pain on his second Med head.

MRI was done and it showed a possible kind of a planter avulsion fracture kind of from the planter plate region, but no planter plate tear. He had originally been in a Cam boot, but he wasn't very compliant with it. And so I said, hey guy, just try the Cam boot for about four weeks. If it's not getting better than the plan is going to be to do an MRI. And I'm sorry to do shockwave. I talked to him about doing shockwave. I think that would be the best

thing for him. I don't want to repair. He's a little bit of a hammer toe. I don't not a huge hammer toe. I said the OR we're going to hammer fix your hammertoe and we're going to pin it for five to six weeks and maybe do a planter play repair. This was the least valuable patient. The reason for this is because we use an MRI follow up and originally when I saw him, I used a fracture code. So he's still within that global window. So this one, I'm going to see him back in about four weeks.

Next was a right Achilles pain. She had a #2 out of 6 for Shockwave and she was one that had Achilles tendon repair by a local orthopedist. I think you put a little anchor in her Achilles and she had just been pain for like a year and a half. She tried grasped and she tried other types of treatments. She's very tight in there and, and she's the incision was on the like posterior medial Achilles and down to the heel. But her pain is lateral. So I think she has all because of her.

She's limping because it's hurting on one side, she's walking more on the other side. And now she has insertional Achilles tendonitis all around. And so we're doing shockwave #2 out of 6. She's actually my kids Taekwondo instructor or one of the instructors, not the main instructor. So she's hopefully she'll hopefully she'll get better. Although I have to look at her for a long time and after I charge her a lot of money. OK, so that was the day once again, I hope you guys found

this beneficial. I am putting together a challenge for some doctors I'd like to work with, like more people. I think it would give me more fodder for this content and it would help people with their practice. So if you're interested, shoot me an e-mail, don@podiatrypracticemaster.com, kind of tell me what your issues are. I think we all have issues. I have issues but I think sometimes having someone else you can talk to them about might

help. OK, happy to help you out and also gives me content for doing this podcast. Thanks for all that listen. I really really appreciate you listening to this podcast and sharing it with other podiatrists. I think I think more people could be listening to it. Not many people do. So please share this if you have fun, it's beneficial.