CANADIAN PROSPECTS/info

Canadian Prospects

I write this comment simply to inform prospective Canadian podiatry students, current residents and anyone else who wishes to practice in Canada regarding the situation and future prospects for podiatry in Canada.

This is not being written to start a flame war or put down anyone who may have previously commented on podiatry in Canada. The only reason I write this is because I am a Canadian DPM practicing in Canada and have received questions from current and prospective students and also visiting students who are completely misinformed about the situation here. I have also read the comments on the forums and find them to be false or misinformed.

I wish to address issues that I feel affect podiatric education and Canadian students.

First off, yes there is a school of podiatry in Canada. It is open now and has been for a few years. The entire program is in French and the only province (state) that you can practice podiatry with a degree from this school is Quebec. The school’s degree is not recognized in Alberta, Ontario and BC. Will the school change to English instruction ever? No, currently there are no plans for bilingual instruction based on the charter of the school.

Second, as a DPM can you practice in the province of Ontario? No. Since 1993, DPMs are not allowed to practice podiatry in Ontario. This includes any border cities such as inter provincial eg Ottawa-Hull or international such as Windsor-Detroit. You cannot be a podiatrist in Hull and also be one in Ottawa after 1993. One person tried this and was found guilty of misrepresentation I think.

What can a DPM do in Ontario? In order to practice, you must sit for and pass the Chiropody exam and you will then be licensed to be a chiropodist. You must pay an annual fee to the Chiropody association. You will be able to prescribe and manufacture orthotics, and perform nail and skin care. You cannot refer to yourself as a Doctor, you cannot advertise as a foot doctor. You cannot prescribe medications, you cannot perform surgery of any kind. You cannot bill the provincial government for any service as OHIP (Ontario health insurance program) does not recognize chiropody or podiatry (it used to reimburse for patient visits) and so you must private bill the patient (not as easy as it sounds).

Are there plans to allow DPMs back to Ontario. Yes and no. The DPMs want back in, but no one else wants them back. The chiropodists have changed their name and designation to Podiatrists so now they are in charge of feet, not DPMs. My guess, DPMs will be back in Ontario sometime after 2020. But its just a guess.

What if you really wanted to be in Ontario, can you live on orthotics alone? You could try and you may even succeed, but its getting harder. Why? Because although private insurance companies do cover orthotics, the reimbursement amounts are quite low on some plans (blue cross pays out $200) and the sheer competition from other providers is immense. Orthotics are unregulated in Ontario and most of Canada. What does this mean? The following can give a person orthotics: physiotherapists, occupational therapists, chiropodists, podiatrists, MDs, orthotists, pedorthists, and even a layperson can dispense orthotics based on the insurance involved.

How will all these people dispensing orthotics affect me, after all, I am a podiatrist and the best trained for care of the feet? A friend of mine who lives in a major Canadian city, lets say Toronto wanted to sell/dispense orthotics. He chose a very busy intersection to set-up his office. There was no other provider around when he started. Also he was really into biomechanics so no surgery, no basic care, just biomechanics and orthotics. He would spend one hour per patient. He would do the plaster cast himself. He even had a grinder in the back and jars of cement glue for modifications. His orthotics were a work of art.

Within one year of his setting-up he had a chiropractor start across the street selling orthotics and shoes. The orthotics were done by a scanner from TOG. Total patient interaction time 15 minutes, and everything done by the office assistant including scanning. Then a physiotherapy group started in the same medical building as our friend. In this case the physios got referrals for rehab from the other doctors in the building and would give patients orthotics (by footmax scanner) immediately as part of the treatment plan. So the orthotics referrals to our friend really started to drop.

Lastly, a massage therapist started diagnolly across the intersection and as a final nail in the biomechanic coffin, she massaged the feet and then foam box casted the patient for orthotics. She sold custom orthotics for $125.

This all killed our friend’s business and keep in mind, my friend had the best orthotics in terms of quality and biomechanics, but he didn’t have all the extras. Are you going to do all the extras? Most likely not. So what did our friend do? He joined the physio group as their orthotics specialist. Is he happy? Maybe. Does he make good money? No. He has to give a cut back to the main group and he has to use a scanner. Will he move? Most likely. Where will he go? He wants to try the US, but no deal because cannot get a visa.

Where can you practice in Canada as a DPM? Manitoba, Saskatchewan, Quebec, Alberta, British Columbia are fine. Maritime provinces unknown to me at this time.

British Columbia: majority of DPMs live and practice in Victoria and Vancouver. If you try to open here it will be difficult at first (eg 5 years). BC MSP (medical service plan) does cover basic podiatry for underprivileged persons, you can bill MSP $23 per visit. It also partially covers some basic surgery. No hospital privileges allowed in BC (although some DPMs have access to hospitals, this will end when they retire), no major rearfoot surgery, no prescribing narcotics (across Canada). No plans from the Ministry of Health to ever re-instate hospital privileges to DPMs. Therefore anything surgical you do must be in your own clinic.

Alberta: There were plans for a School of Podiatric Medicine at the University of Alberta. This was in the initial plans for the new campus, but the school is now on indefinite hold. Why is it on hold? No funding. There is a large deficit in the province and new projects such as this school are on hold. Building new hospitals also on hold. Building subways and LRT are on hold. All construction is on hold. Will they build the school? Yes. Timeline? Start of construction to begin after 2020 (must get funding in the next oil boom).

And even if the province did go ahead with the school (higher ups in the Health Service have stated that the school is on hold) there are no province wide hospital privileges for DPMs. Only in Calgary can you have access to a hospital OR. And in Calgary, only 5 out of 45 DPMs have privileges. And there are no plans to add anymore. Why? No funding. So why would the province build a school for students when they do not allow hospital based surgery for podiatry. And soon office based surgery will be decreased.

Well you might read this and say, hey if I can do surgery in my own clinic and charge $1000 per bunion then I am cruising. This may happen today, but it is predicted that within 2-5 years in office surgery will be stopped. Why? Due to serious lapses in infection protocols, the entire province mandated a new sterizliation procedure which has ended up costing doctors extra expense. Well you can pass the expense on to the patients right? Yes, up to a limit. You cannot charge $5000 for bunion. Also the College of physicians have mandated a new surgery centre policy that has requirements for electric, ventilation, size, shape etc for surgical areas. The cost to build up to this code is immense and one DPM (or even 2 DPMs) cannot afford this. So in-office surgery will be coming to slow stop shortly. And remember, even if you do surgery in your office, you cannot even prescribe any narcotic at all for postop pain.

What would I recommend? Well come to Canada, if your dream is to do so. There is no barrier to DPMs (except in Ontario but you could get around that by being a chiropodist). In fact, the new labour mobility laws will soon mean that chiropodists with basic foot traininig will soon be able to practice foot care in BC and Alberta, so even the basic foot care will soon be more competitive. Again, please come to Canada if that is your wish, this post is not to discourage you but rather to give you some clear flat out info that has not been very well disseminated to date.

If I were a Canadian who was a DPM in a US residency today, what would I do? I would sit for US boards and try my best for a US job and licensure before trying Canada. Why? Better scope of practice in US, more opportunity and from what I can see, Pod and Ortho groups are ready to hire you and teach you the ropes and you can do quite well. Also houses are cheaper in the US, taxes are lower and the dollar is at par.

If I were a Canadian DPM student in a US pod school today or on externships today what would I do? I would study like crazy and score as high as possible. Why? Because the number of residency spots is on the decline and the number of DPM students is increasing. Simple supply and demand. Add to this the fact that at least 25% (more like 50%) of US pod residencies do not accept Non-US citizens and therefore your pool of possible spots just decreased.

I had a Canadian student contact me recently asking for a job in Canada in case he did not get a residency spot in the US. He is a 4th year DPM student. Well, I would hire him. I may not be able to pay him much, but he can learn a bit and make a bit of money whilst waiting for a spot to open next year. But he is stuck in where he can work and what he can do. In BC he may be able to do basic work without residency. In Alberta, no such luck, you need a 2 year residency. In Ontario no luck, you need to sit for the chiropody exam and have that license. So after 4 years of gruelling DPM studies and work, he finds out that his top 3 choices in the match wanted him, but could not accept him because he was not a US citizen. Luckily he got the next one and is in a great program. Remember, podiatry residencies are not like medical residencies, if you do not match in podiatry (and do not match in the scramble) then you do not get a back up program. You are done. You get to wait until next year. If you are Canadian what will you do? Your US visa does not allow you to sit in the US and do nothing. And in order to work in the US for the one year, you need a new visa (working visa not study visa) and you need a sponsor, some employer who will go through the entire employment process for immigrants and also you need to ensure that there is no other US citizen better or equally qualified for the temporary one year position. Therefore after 4 years of schooling, even if you wanted to cut toe nails for one dollar, you could not do it in Ontario, Alberta, and most likely the entire US. So study hard, because if you do not match in a podiatry residency and you happen to be Canadian, I don’t know how many of you I can hire (joke).

If I were a Canadian pre-pod student looking at podiatry today what would I do? I would not say stay away, but rather consider podiatry if you have ties to the US and you can get a green card, or you are quite smart and can out-compete your colleagues and secure a US residency and then perhaps live and work in the US (by the way, some Canadian students think they are much smarter than Americans. This is absolutely not true. You may rank high, but Americans are as smart as Canadians and the numbers are against you, play the statistics and you will see that there will always be more Americans smarter than you because of the fewer number of Canadians in a class. My advice, don’t be arrogant).

Would I go to DPM school to come back to Canada to practice as a pod? Probably not, the chances to be successful are very very slim in comparison to the US. Also you need a lot of money to pull this off and with interest rates going up and no loan deferment or forgiveness by Canadian banks and educational institutions the costs are quite high. To start in most towns that already have a DPM its hard, but now there chiropodists coming in.

Again, I am not trying to be negative, although it probably looks like it. Please check and double check your facts about practicing podiatry in Canada. Not is all that it appears here. If you feel for any reason that what I have written is not the truth, or if you have any questions or concerns, please please send me a PM or post to the board and I will try my best to answer. I do not wish to hide anything at all and will answer to the best of my abilities.

Good luck to all, whether you be Canadian, American, or other. We are all in this ship of podiatry together.

@dtrack22:
Thanks for reading. You are correct that American Healthcare is changing and it has a possibility of looking a bit like the Canadian system. Take advantage of the upcoming changes, from what I hear, 32 million more people will now have insurance....you should be up to your eyeballs in foot consults.

@pieds:
thank you for reading my post. you are part of my target audience. please feel free to ask as many questions as you can think of. I hope I can answer all of them.
Lets see...
The year 2020 is an approximation that I put together myself. I was repetitively told by various persons the same two statements every time I enquired regarding the situation in Canada for pods: Since 1994 every year I was told that next year is the year that ontario opens up again to podiatrists. Never happened. I was also told every year that next year is the year that we get narcotic privileges. Also has not happened.

What did happen was an unexpected piece of legislation, the Labour Mobility Act (not sure of exact name of act). There are a couple of conditions for chiropody/podiatry and so these professions are still not included.

So when you are hoping that a certain piece of legislation gets passed, whether it be in ontario or nationwide in Canada, expect it to take a long long time. And it takes longer when it is for a profession which is already represented in the province by another group (see chiropodists).

But getting back to your first question, the reason i chose 2020 is because I think that the Labour Act is supposed to take effect quite soon (if it hasnt already) for all trades that it covers, lets say for the sake of argument that it is supposed to be law in 2010.

They (government) put a couple of clauses before podiatry and chiropody can take effect (not sure of the exact nature of the clauses) and the government decided that we (the pods and the chiropodists) need time to sort things out, so lets add 2 years to do this, after that it will take 2 years (or more) to form the college of podiatric physicians (this is not our association, this is the college to which we all must belong, like the OMA ontario medical association versus the college of physicians) for ontario and a year to get into the health act (separate from the labour act) so now we are at 2015, plus you have to add 1 year for government delays and what not, and then even if the dpms are legislated to work in ontario again, the private insurances have to change to accept them (they already pay out for pod billing, but now with more pods billing they will have to restructure their charges to the employers to cover more orthotics, more nail care, etc causing a possible rate increase, etc). so although you may be able to work in ontario, there may be trouble with insurance companies who did not realize that you were coming. And ofcourse add to all this that at some point in time there will be a provincial election, or two, and in an election year nothing really gets done, especially if the current provincial government may be defeated over its healthcare cuts (see pharmacies and generic drugs in ontario) and over the new HST tax in ontario. So I came up with a nice round number of 2020 or thereabouts. Sure I am off in the number of years, they are after all guesses on how long it takes to get things done, but really there is no school in Canada to push podiatry and anyone who does have a DPM degree from ontario goes elsewhere (anywhere but ON) so where is the push going to come from.
You stated that you have US PR. You still want to come back to Ontario? I spoke to a couple of Canadian pods about working in the US...we all joked that we had cried that we did not have PR or green cards because life would be so much easier with such a document. some dpms on this forum indicate that the average US DPM salary is approx $150,000 per year. With a good business sense, an excellent location in a less saturated area, your earnings increase to 200 or even 350K per year. And you are quite well respected amongst the other docs, you do surgery or you can specialize in things like infectious disease like doctor warren joseph, you can be in limb salvage like armstrong or rogers, you can do plastic surgery, wound care, etc. you can never do anything like this anywhere in canada.
By the way, you mentioned that you are from Markham, ON. did you ever count how many chiropractors are doing orthotics there? I just googled orthotics and markham and not only are there chiropractors and chiropodists and one podiatrist, there is also a franchise called bio ped which eats, sleeps and breathes shoes and orthotics. That level of saturation is brutal when people do not even know what a podiatrist is and then they have to pay to see one. I might sound harsh, but better i tell you now than you go set up there and get hurt.
I think you are quite smart, I really liked the line about flying and using your training. If I were you, I would practice in Miami and commute from the Bahamas. Seriously, it can be done. My friend went to university in Miami and one of the profs would leave miami on thursday for bahamas and come back on Monday. Sure miami is saturated, but so is Markham ontario.
As for the ontario website, they can do surgery such as bunions and hammertoes. They can inject local anesthetic. But this is how that website applies to you: (and they really should have told you this because you are eager and want to learn more, not sure if they did tell you but I will.)
1. None of the things listed can be done by any DPM after 1993. So if you graduate today or in 2018 (unless the law changes), you are a chiropodist not a foot surgeon or podiatric surgeon. Dont even think about this again.
2. Lets say you do surgery in Ontario, even though you cannot, but lets just say you do, you can anesthetize the area with local, you can cut soft tissue and bone, and you can suture. Now surgery is done, what can you prescribe for post op pain? Nothing more then regular tylenol or ibuprofen. No morphine derivatives, no percocet, no oxycontin, no way no how. So what kind of post op pain management do you have? not much. you have to rely on the primary care physician for post op management. this applies even to DPMs who got in before 1993. They cant prescribe pain meds either.
As an aside, even if you want to do a post op xray, you will have to charge the patient. Trust me, they do spend money but after a while patients hate spending, they reach a limit.
Can you prescibe any non foot related meds? No. Things like lipitor you may prescribe in the US during residency but not as a practicing pod, and not in Ontario either. Lets say your patient has poor circulation and you are sending them to vascular but this being canada the wait time to see vascular is 6months, can you prescribe plavixx? nope. you send them to their family doc who will have to do this. Will he/she do this? Most likely not, because they want vascular to diagnose the vascular disease and give guidance on limb ischemia and meds and possible surgeries, not DPMs. This is definitely the situation in Markham.
I know you will miss Ontario, its your home, but think smart. I could easily make florida or california or texas my home. I wouldnt think twice about that. But still I chose Canada, I think I want to fight it out. Lets see what happens. I promise to keep you posted if I hear anything about Ontario opening up.

Hi Heeltoe

Thanks for your comments.

I will try to write better. Usually I am writing here after long day at work and looking after kids too. So just trying to pump out info to you guys but not proofreading or spacing out well then paragraphs. My apologies.

DPMs in Ontario have wonderful practices to sell. I have seen 4 of them. They all do well (the ones from before 1993). I have not seen a DPM office after 1993, mostly because these are chiropody offices and I was not interested. Yes a few of the pre-1993 did try to sell me their office, either straight out or thru partnership buy-in, but unless the law changed to allow me to be a dpm, i could not do what they did and therefore could not earn the income that they did.

By not earning their income, I mean for example they did bunion surgery and charged $1000 per bunion and if i took over i could not.

OHIP will not cover you if you go to Ontario now.

So no coverage by ohip for you, and no ability to bunion surgery. These two facts I can tell you are FIRM. This applies to Ontario. What else the pre-1993 DPMs are doing is tough to figure out because they are a small group and dont talk much.

So yes they do well, but you techinically cannot achieve the same because the laws that apply to them do not apply to you and vice versa.

If you really want to know how much you will earn in Toronto or Markham or anywhere in metro ontario, take into account what you will be able to offer and factor in all your competition and then you will have a rough estimate. For example, i think, that if you graduate in 2012 from residency, assuming that no law change, then you will have to sit for another exam after residency for the chiropody college. Then assuming you pass (and trust me, their exam is different then our NBPME I, II, III.), you will have a chiropody license that allows less then what you are used to as a DPM with 3 year residency. You will NOT be doing bunion corrections and putting in pins and screws with a chiropody license. You will be debriding nails, corns, callus, prescribing and fabricating orthoses, assessing gait. There is nothing wrong with conservative care, I do a lot and it pays the bills. But keep in mind that other caregivers like chiropractors, massage therapy and physio and OTs do all the same.

Also, in Ontario there are foot care nurses. If you think you will make ends meet in the beginning by doing nail care in a nursing home, well, you have some competition there too. The visiting nurses are a small group, getting stronger everyday in numbers and politics. They currently do most nursing home foot care. Why are they getting stronger? Because for one thing there is a push in Canada to hire more LPNs, licensed practical nurses, and these are less expensive in terms of salary then RNs, registered nurses. So the outgoing RNs get picked up by their RN mates in nursing homes to do foot care because the hospital based or clinic based jobs are going to LPNs.

So your nail care is even competitive.

Now please, dont get me wrong, you can definitely do all of this and make good money in ontario. When I do orthotics, my charges are $525. But I dont do 100 per month, more like half that if I have a good month. I cover 2 nursing homes also. At each nursing home, I wanted to charge $25 per patient to debride nails. No corns, no biomech exams, just basic nail care. I had to drop my price to 15 to stay competitive, now that my competitor is gone, I will raise to 20. I see 15 nursing home patients per day, more than that and your hand really hurts in the long term and you cant handle it. My overhead for nursing homes is cheap. so I keep what I kill basically.

Why should I have to do that, and a person who graduated and came to ontario before 1993 get to do surgery? Doesnt make sense to me. And i am not angry with those pre1993, they are our forefathers, but really this double standard gets to you some days. If it doesnt then I dont belive you.

So can you make a decent living in Ontario. Yes. Will it be similar to what pre 1993 earns, no.

I dont know about all of the other provinces, especially maritimes, but I am pretty sure that you can practice in MB with DPM, and as for SK, I am 75%sure. But can you do surgery like bunion correction with screw, I do not know. For the most part, it is biomechanical in those provinces.

Yes you are correct for BC MSP. Only minimal payment by MSP, $23 per person, and only if they are low income earner, like welfare type thing.

Yes private surgery in BC is suitable to earn good income. But you have six problems to private surgery. This applies to BC and AB.

1. You are going to have a harder time trying to defend yourself in court against negligence when you get an infection from putting in any implantable device such as MBA implant, Hypocure, screws, staples, k-wires when you did the procedure in your office where the local health board has limited access and no one can verify your infection protocols.

2. There is no IV sedation or general anesthesia in your office. And the law indicates that where dentists and MDs can give this anesthesia, pods can only give local. therefore can you really comfortably in saying with a clear conscience to a patient that they can under go an ankle block or mayo block with no pain? Sure you can give valium...trust me, this is not the same as IV sedation. So right off the bat, you are starting your surgery with pain. This is true, ever inject the PT nerve behind the malleolus with no IV sedation. When you bury the hub of the needle it kills!!!

3. Do you inject epi with your local block? If you do, then this does not appy to you. If you dont, then you need a tourniquet. How will you inflate a tourniquet for 60 minutes to 250mmHG without causing discomfort to your patient if they do not have IV sedation or general anesthesia?

4. In BC and parts of AB like Calgary, some pods who are in the hospital system are booking patients that do not have to pay any money for surgery. Remember, foot surgery is still fully covered by Alberta Health and BC MSP for certain surgeons. You will not be covered. Plus, in BC and parts of AB, the orthos are getting faster at doing foot cases as surgery wait times decrease. Why will someone pay you $2000 for a bunion correction when if they wait 1 year they will get it free.

5. Also in BC and AB, there are numerous surgery centres and private orthos are available. So in terms of competition for private bunions, you have not only your fellow pods to outcompete, but now ortho as well. Why would ortho sit and watch you charge $2000 for a bunion and they get nothing. Of course now they are in on it too. And if they (ortho ) is ready to do it, then a family doctor MD who has a choice between you and ortho will tend to refer to ortho.

6. Lastly, lets say you are very cautious, you dont do surgery in your clinic, you go to a local surgery centre. And lets say you have an MD that refers lots and lots of surgery to you, so you have lots of surgeries booked. How much will you have to charge the patient? You will have to charge what the surgery centre charges you, plus factor in follow up care, your time pre and post op, your dressing changes post op, your liability, etc. You could easily get to over $3000. Not many people will agree to this. You will have to be in a great area with a very strong referral base to get this.

Again, please do not think I am doom and gloom. But look at points 1-6 and tell me honestly what you think are your chances of success.

As for private surgery being cancelled. I am sorry if you misunderstood me. Private surgery will NOT be cancelled. It is the ability to do it in your office that may be cancelled. Why would it be cancelled, because the local health authority cannot regulate your office easily, for example your doorways must be certain width, your preop area must be certain size, how you use screws and describe their sterilization will be very strict. So in order to comply, you will need to make lots of changes and this construction will be expensive. I do not think that the number of surgeries is more than the cost of the construction. So you will be forced to go to a surgery centre.

Now you can still do surgery in the office, provided you comply with all inspections and leasehold improvements. Then you should be ok. But this is expensive to do.

You must have heard about pharmacy in ontario and the generic cutbacks. From ontario, this will spread to quebec and BC and so on across the nation.

the same way, changes regarding infection protocols, private surgery centres, standards, etc will spread from AB to BC to ON, etc. So if this happens for example in AB today, you wont have much time before it happens in BC, maybe a few years. Also why would you do surgery with wrong protocols in place, because if anything goes wrong, and it goes to court and the other side finds out you had incorrect protocols, yyou will have a tough time to defend yourself.

For you question regarding Edmonton, this is the basic info that I have. There is NO access to public or hospital ORs. So you do not work at a hospital or do surgery there. For now all surgery is done in your clinic. The new infection standards are just rolling out by health ministry, how they will affect DPMs I dont know. Even if you only use nail cutters to go to the nursing home, you will need a new autoclave and new system to disinfect.

Who is doing well in Edmonton? Well the older groups do quite well from what I hear. Who does not do well? no one really says, but from what I have seen and heard, all the new people are having a tough time with surgery. For orthotics, in Ontario welfare patients and government assistance patients and seniors can get orthotics from DPMs (prescription and dispensed). In Alberta the government assistance program for welfare, plus the seniors programs, plus the injured workers assistance programs all pay for orthotics and orthopedic shoes but not to DPMs. That is a huge gap!!!! Can you imagine the amount they are missing in payments!!!! These people: seniors, welfare low income, and workers can all get orthotics from physio and pedorthists and orthotists.

So now based on this scenario, Edmonton is ok only if you have a stong referral base and you are in a high income area.

As for the count of DPMs, sorry for any incorrect info. The number I got (45) was based on office count, not the actual number of DPMs. Also I included Canmore, Lethbridge, Oktoks, Airdrie in my count.

The number of DPMs only, not including office count or surrounding areas is more like 30.

Yes ofcourse you can build a surgery centre with other surgical specialities. First off, they have to agree to accept a DPM. If you are good, they will. But its easier to join them if you are an MD. Next, how many bunions can you do in a day, week, month , year, and what are your charges. Remember, you are talking about doing cases with the big guys, plastics, opthalmology, they do cataracts, lasic, breast aug/reduc like crazy. And they are quite busy. I dont think your numbers will match theirs. But the key thing is that your numbers dont have to match theirs, you can just do what you can and that is all. So you dont buy in a big share, you just get a small share. You can finance this thru the bank and you should be ok. But, I am not sure that it isnt better to just rent the space from them. They will most likely rather rent to you than take you as a partner because your numbers are too small. If you wish to rent, see my paragraphs above regarding the costs. The amazing surgery centres are always ready to rent to you, but can you afford to pass on their costs and factor in your costs and present your patient with a final bill? All the while competing with orthos who have their own centre or comepeting with the local hospital that does surgery for free?

I think your ideas are fantastic, but you are not looking at this as a businessperson. you need to do more investigation. And you need to do projections of costs.

There are restrictions on narcs. Call the pod association of the province you want, they will confirm.

The DPMs you shadowed, please provide a bit more info. Were they in a major metro? Did they do surgery? What year did you shadow? How long were they practicing? All these are factors to take into account. Every year the number of chiropractors and chiropodists is increasing, there is a school for each of these in Canada, both in Toronto. If they each pump out 200 students (not sure of exact graduating class), the first thing they are taught is orthotics and how to capitalize on them. If you read chiropractic economic mags and practice building mags, they all, each and everyone I have read, teach them how to do more and more orthotics.

I have patients telling me that the footmax or TOG scanner is so great. Why dont I have one? Means that I am poorer or worse doctor than their chiro or physio. The truth is that 2-D scanning is incorrect for casting for orthotics. I do not believe in it. But TOG is huge and they take on more chiropractors every year and they all offer shoes and orthotics and now that summer is here, sandals. how can you compete unless you become one of them. My chiros around me, are doing well, amazing. They are probably at $350,000. They ask me to come to their offices to do nail care for some of their patients, or to help out on tough biomechanical cases. They send me surgical referrals. Not all chiros are like this.

When I visit their offices to chat, they have a staff member scanning patients, and each patient gets a little talk about the scan, then gets an orthotic and a shoe. this goes on from 1pm to 8pm every wednesday. They cycle thru 40 patients on average. I get a 10% referral rate from these 40 for nail or hammertoe stuff.

I too have shadowed about 25 DPMs across the country, ON, BC, AB and none was able to pull this off.

You will do well, but how do you compete against this?

No need to apologize to me, infact I should apologize to you, one, for not being clear enuff, two for being doom and gloom.

Trust me you will do well, you can probably have a decent income, nice house and a couple of nice cars. Also you will fill your pension plan nicely.

I only wrote what I did mainly for one student, he knows who he is. He came to visit me and almost did not match this year. He got tearful in my office. He had no idea about anything regarding Canada and podiatry and he was Canadian and he was going to come back here. And he almost came back with no residency.

How can I justify to him, or to you or more importantly to myself to sit quiet on info that I have and not share it? I only got thru school because my friends shared all their school work and past exams with me.

So you can shadow other DPMs, but now i hope you have a bit of an inside track as to what really goes on.

Next time you see a DPM do office surgery in Canada, dont ask him/her how much they got for the bunion, ask instead to see the infection protocol paperwork and check to see when was the last time they were inspected by board of health. If you can do this and feel satisfied that they are up to the standard required, then this is better knowledge then basic prices. Prices you can call and enquire about any time. Its the inside stuff that counts.

Good luck and ask me more questions, I hope I can help answer them and not guide you wrong.

And oh yes, come back to Canada, but still try your luck in US first, you might get a better offer there.

Hi Heeltoe,

I just re-read my post and it only makes sense if you read it with yours. My post is all answers to your questions.

Sorry if I make it more confusing. Just tried to answer all your questions, thats all.

also dont forget that DPMs can charge for xrays in BC, AB, and pre1993 in ON, but patient can get free xrays done by radiology in same places. How can you justify to patient to charge them for xrays?

Most new DPMs not charging for xrays because that charge is just cash grab. Plain and simple.

And, if case goes to court, you have to be perfect in your xray review, same as a radiologist. If you miss something and the radiologist sees it, you are in big trouble.

take care
👍

Hi again Heeltoe,

I find this back and forth discussion very interesting and have to admit i have been logging in to see what your next questions will be. keep it up, you seem very informed and I am very happy to see this in a student.

From your last response:

1. Yes there is a major problem in Ontario. Even though you are technically a DPM, you are not recognized as one by the province if you enter ontario to practice after 1993. I do not forsee this changing anytime soon.

2. Doing surgery within the office. Yes while you are correct that surgery is done in the office today, I have a strong feeling this will change tomorrow, ie the near future.

Let us first determine who does surgery in the office. Putting aside suturing of lacerations and digging out basic foreign bodies, which is done in urgent care walk in clinics, surgery for the most part done in the office is by plastics, derm, and pod. Ortho as far as I know does not do any surgery in office. Do not misunderstand this as doing surgery in a surgery centre, that is totally different. I am talking about a room in your office, where instead of examination you do procedures.

Now the procedures done by plastics and derm are very very basic. There is no significant opening of soft tissue and no cutting of bone. This deeper surgery is reserved for the surgery centre.

Pods are cutting bone, inserting hardware and basically doing ortho procedures of the foot, in the office. It is these procedures that I know are going to be stopped. You can still do a flexor tenotomy in the office, you can still do a partial nail avulsion or even matrixectomy, and you can do verruca debridement. What the college of physicians and surgeons is upset about with podiatry is that we open joints and bones in our offices. It is this latter group of ortho procedures that will be shifted to surgery centres or the hospitals.

You may think that numerous MDs are doing procedures in their offices, and maybe they are, but what are the procedures and also are you sure they are not doing it in a certified surgery centre of their own. For a dermatologist, or plastic surgeon, to build out a surgery centre to the specifications of the local health authority can be done because they have lots of procedures to do all over the body and they are very busy too. I spoke to a dermatologist who told me that when he started he was 80% medical derm and 20% cosmetic, after 5 years he was 60% medical derm and 40% cosmetic and now after 10 years he is earning income from 60% cosmetic and only limits his medical practice to 40%. His income is close to one million including private cosmetic procedures.

The plastic surgeons and other surgeons such as general surgery, derm, etc use podiatry as an example when they speak to their college stating why should DPMs be so invasive as to do bone work in the office setting and they cant do more invasive procedures. The college does not give any formal direction but from what I hear the feeling is that either the MDs will be able to do more procedures, (less likely) or the DPMs will be doing less in the office (highly likely). Where this will end up, I dont know, but rest assured that if you are doing a bunion in the office, you are probably doing the most invasive thing a surgeon can do in the office and the college of physicians is frowning on this. No other physician is cutting bone in the office. I am 99% sure on this but I could be wrong.

So what to do? Well you kind of answered this already, you need to take your cases to a surgery centre, or build your own.

But remember, you can build your own provided you have enough inflow of patients coming in wanting surgery.

Do I think you will have enough inflow, yes. But going back to my comment that others are doing private surgery such as orthos, and they will probably get more referrals, this is true. I think you agree that all things being equal, a family doc will refer to ortho, its a fact of life in the jungle we live in. Now what I was trying to say but did not in my earlier post was that when ortho does a private surgery in a surgery centre, they more likely than not, own part of the centre. Usually the centre is owned by ortho or by whatever specialty and anesthesia is provided by an outside group of anesthesiologists.

Because ortho owns the centre, they can drop prices or have lower prices because either way, they make money. The will either make money on the facility or they will make money on the surgical case. That is why if you state that your bunion correction is $3000 to the patient, they may be able to get it done for $2000 elsewhere. Because the surgeon is the owner of the facility, he/she can compete on price. Because you are given a set rate by the facility, your costs are usually higher because the facility wants to make money.

Now when you graduate, lets assume 2012, what will you do? I dont think you will be busy enough to build out a surgery centre. You may want to try surgery in office if the law hasnt changed on that, but personally I wouldnt because of pain to the patient, risk of infection, etc. So I agree with you that you will go to a surgery centre to do cases. This will solve many birds with one stone, your anesthesia for injection of local, your tourniquet pain, the infection protocols, etc. But, now you are paying someone to do this (paying for anesthesia). The anesthesiologist wants a cut of the bunion payment, the surgery centre with all its nurses wants a cut, and so on and so on. So when you start in 2012, you will be competing on price with DPMs who still do office surgery (assuming the law hasnt changed forcing a closure to office surgery) and you will compete with foot and ankle orthos who are performing private surgery but at a possibly lower rate than you.

However, as you mention, there is plenty to go around in terms of patients, and I agree with this. Therefore the private orthos will be busy with public and private surgery, and they cant do everone's feet, so you will still get surgical patients.

Now also take into consideration outside factors. Because you are just not a podiatrist. You are a business person also. As you know, interest rates are going up in Canada and the costs associated with buying a home in Vancouver are up and prices are up. A single family home is $950K. so now your pool of potential patients decreases as disposable income decreases due to the cost of borrowing increasing and basic necessities like shelter increasing.

But so far I am only talking about surgery as this seems to be the way our discussion is going. If you were to ask about biomechanical stuff and other non-surgical patients, then yes there is plenty to go around.

I dont doubt that you will do surgery when you come to BC or AB or maybe by the time you graduate, even ON. But if as you stated that you dont want to go to school for so long just to be a chiropodist, then you need to re-assess. Because what I am trying to convey to you is that every scenario you have given me about DPMs doing well does not apply to you (atleast I dont think it does) because you will be starting at a time when surgery in office will most likely be reduced and surgery centre procedures will be more common and ortho will be waking up to the fact that they can do surgery too (privately).

How much surgery do you think you will do (percent)? I think conservative care to surgery your ratio would be 80-85% to 15-20%.

My belief is that all the DPMs that you shadowed or spoke to were definitely supplementing their income with conservative care such as orthotics, etc and their surgical loads were either low, (if they were hospital based then different situation) and if they were busy surgically then they must have been practicing a long time to achieve such high demand surgically.

So again going back to your business acumen, you will increase other treatments will trying to increase surgery. When you start, and your income is mostly from orthotics and basic care, you will have to compete against the other health professionals who now do orthotics and basic foot care.

Therefore, if you are doing your business projections for a loan for your podiatry office corporation then you will have to put in a lot of research into figuring out just how many orthotics you can do in a month or a year and also how much foot surgery can you really get in a month or a year.

Just to give you a quick example, lets talk ganglion cysts. I thought I would to a lot because they are easy to do and lots of people seem to have them and ortho doesnt have time to do them when they are busy with hips and knees and stuff. So I spoke to family docs to get referrals and this time I concentrated on cysts. I got the referrals but once the patient found out they had to pay for surgery, they hesitated and mention this to the family doc. Now these docs are nice and they said to the patients listen, he is a foot doctor so he can do it better than anyone, the only other person who can take this out is general surgery. The patients chose gen surg. And you know how long the wait time was? 3 months for each one. They (gen surg) calls this lump and bump sugery and they love to bang out 5 in a day just to supplement income. And so the general surgeons who love to take these out have already established referrals patterns with the family docs.

so now I ask you, how would you compete against this? It is very difficult to state that you will get referrals in a health system where other providers do the exact same thing as you.

Perhaps you could do some awesome marketing and get the word out that you are the best for foot and the patient does not need a referral to see you. That might work and I think you should try it. But keep in mind that we are all doing the same. Your success will be based on geographic location, local income of the patient population, and existing referral patterns.

As you had mentioned, you can try for the 5 spots on the hospital based group of surgeons. This is an awesome group I think because they are all well educated, and they do all the surgical procedures we were taught in residency and pod school. They will not be expanding due to funding. Atleast I dont think they are to expand. Also most of the 5 are fairly young so I dont see any retirements coming up. Lastly, they did have a vacancy about 2 years ago. The competition for just one spot was intense. Keep in mind that you, me and every other Canadian DPM wants this job. The person they chose not only had a residency completed but also had significant work experience as an attending with lots of cases done. In order to match his work experience, you would need (i am guessing) 5 years post residency surgical experience.

So lets review for a second.

Trying to get hospital based in Calgary, almost impossible.

Opening your own surgery centre, possible, but expensive.

Doing surgery in your own office, possible, but my guess soon to be stopped or reduced in the types of procedures you can do (eg only soft tissue, no bone work). Also the least expensive option and best if you are short of funds. Also have to think ethically about infection protocols, etc.

Getting busy surgically. Possible, but getting harder due to increasing competition not only from number of providers increasing, but also those providers that own centres can offer it cheaper. Also existing referral patterns may inhibit you from getting the cases that you deserve, see my example of the ganglion cyst and general surgery.

Trying to make expenses meet and make a profit from orthotics and nail care. Out of all the scenarios, this is most likely a winner. This you can do easily, has little expense and gives great returns. The downside, competition increasing. Just google vancouver orthotics and see that the number one link is for a chiropractor. And the majority of links are chiro and physios. very few do plaster casts so that may be an advantage for you. But then again when I have to compete against them, I have to compete against orthotic shoes and sandals and so on. I have to take time off of my surgical track and start to focus more on business moves like introducing shoes and sandals. And you know what is the problem with shoes? Besides the fact that you are a surgeon selling shoes...that you are now a shoe salesman. Now nothing wrong with being a shoe salesman, but patients can be picky or fussy, especially if they have foot pain, they have issues with size, shape, color, etc. You have to do returns and exchanges and what not. Are you going to do all this?

Nonetheless, orthotics and nail care are your winning strategies. And with these you can set up anywhere in Canada.

So to summarize, yes you can do surgery, certain drugs you cannot prescribe, no I dont think you will be busy surgically despite what other DPMs may have told you (this is for metro areas, I dont really know about communities less than 750,000 pop). And my guess is that if you come back, you will be relying a lot more on nails and orthotics than surgery...considerably more than you can currently imagine. Again, I cannot emphasize enough that there is nothing wrong with this scenario of less surgery more orthotics, provided that you can mentally accept the fact that you will be doing a lot of non-surgical treatment.

Well I hope this answers in greater detail your concerns. As I mentioned in previous posts, you will be successful in the sense that you will get a house, couple of cars, have money for retirement, but its not going to be a huge windfall like certain MDs. Also in comparison to the US, if you do it right and are lucky you can earn more, but from what I understand, with the newly insured people coming with obamacare, you will be busier surgically and it will be easier to make more in the US, you wont need luck like you do here.

Best of luck

Family docs that know you and work with you will refer to you. My example was of a family doc who doesnt know you. In that case, they will most likely refer to ortho.

Keep in mind that most DPM practices do not rely on referrals as the main source. There is also word of mouth and general walk-ins from advertising. So not getting too many referrals is not always a sign of poor patient statistics in Canada.

You are correct in stating that most rearfoot is ortho, most forefoot is a mix between ortho and pods.

The numbers I quoted for surgery between ortho and pods are not exact, just keep that in mind. There will be price differentials, but once you arrive its up to you to decide what the market will bear. For example north vancouver can charge more for a bunion than White Rock. The exact differences in price I dont know. I know even between pods there are large price differences. I have seen $1500 for bunion and $3000 for the same. I have seen $200 for orthotics and I have heard of $650. So not sure of the exact differences but some do exist.

Yes I agree surgery would be 15-20% and a lot would revolve around nail care and orthotics. Perhaps you dont mind doing this, but being trained for ankle and calcaneal fractures or limb salvage and then never seeing it in practice is a difficult pill for some to swallow.

I have a question for you. Why would you join a practice? In Canada, any province, unlike the US there are no hospital or insurance plans to join, so you can start anywhere. You have to factor in a lack of patients in the beginning but really I dont think it would be a problem if you can budget properly.

I think that joining a practice in a free market such as Canada would mean that you get paid a percentage for patients that can go anywhere. So patient X can see you at your own place, or they can see you in the associate position you are in, it doesnt matter to the insurance at all. I fail to see the benefit of joining a group in such an environment.

Joining a group to simply have a patient base is incorrect.

In fact, I think the senior partners of any group you join would take a cut (?30-50%) of your earnings. It would be cheaper to start on your own. The instant patient base that comes with an existing practice is not worth it in my opinion. The same would go for buying a practice in Canada. You dont need to buy one, you can just as easily start one, albeit slow in the initial phases.

Most DPMs I know started their own. And those who joined a group left the group within 1-2 years and started their own.

You could initially start with a group and then move on your own, but if there is a non-compete clause you may have to move very very far.

Also if you join a group, they will most definitely take a cut from your earnings and chances are have you do the stuff they dont want to (which is expected but does not make me feel good), but when you want to advance, you will have to buy into the practice. So when said and done, not only would you have been giving a cut of your earnings, but you would then have to buy in. This totally does not make sense to me and this last part is not directed to you heeltoe but to anyone who wishes to buy a practice in Canada, there really is no need to go through the expense of that. If you are buying, then it is based on a misunderstanding and insecurity and not a prudent financial move. But again, these are just my thoughts. When I speak to guys who are in practice and who plan to bring in associates or sell to juniors, all I see is a golden parachute or exit strategy for the senior and shackles and chains for the junior. This is much different than the US I am sure.

Take care👍

Hi again,

If you go back to my earlier posts you will see that I had mentioned that infection protocols were increasing and becoming more stringent. This is happening based on increasing infection outbreaks and risks.

An example in Alberta was in a town near Edmonton where colonoscopes were not sterilized properly. As a result, according to some friends who told me, Alberta Health Ministry totally changed and re-wrote infection protocols just this past year. This will affect all doctors who do procedures. Most doctors have stopped procedures or had to change to disposable instruments. The affect on podiatry will be quite large because new autoclaves will be needed and more instruments because from what I understand, it will take 48 hours before a newly autoclaved instrument can be used again.

Now the exact same problem has occurred in BC. This just in:

500 Patients Potentially Exposed to Contaminated Scope at Victoria Hospital Investigation discovers traces of blood on endoscope used for ERCP.


An improperly cleaned endoscope at Victoria General Hospital may have exposed 500 patients to infection, Vancouver health officials announced last week.
During a recent review of endoscope cleaning processes at the hospital, the Vancouver Island Health Authority discovered traces of blood inside one of 4 endoscopes used there, Martin Wale, MD, VIHA's executive medical director for quality, patient safety and infection control, told reporters. While investigators found "residual biological material on one scope," they "did not find any visible materials on any of our endoscopes."
Doctors were able to link the contaminated scope to a bacterial infection contracted by a terminally ill patient who had undergone a pancreatic endoscopy at the hospital, CTV reports. The patient later died, but VIHA officials say it was his existing illness, not the infection, that caused his death.
VIHA has notified 500 other patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) between June 2008 and January 2010 of the contamination risk, offering them free testing for infections. "The risk [of infection] is less than one in 30 million," says Dr. Wale, "but we are taking a precautionary approach by notifying patients, because the infections are treatable."

Bonjour, mon frère lespieds!

merci pour ce que vous avez écrit.

Si vous étudiez à l'UQTR pour la podiatrie, vous ne pouvez pas obtenir une résidence en chirurgie. Si vous n'avez pas de résidence en chirurgie, alors vous ne pouvez pas travailler en Colombie-Britannique ou en Alberta.

Pour commencer votre recherche, vous devez vérifier les lois de podologie dans les autres provinces. La première chose à vérifier la formation nécessaire pour travailler dans les autres provinces. Si vous étudiez à l'UQTR, vous serez limité au Québec, je pense.

Restez en contact avec moi frère

a la prochain👍