Are Podiatry Fellowships Necessary?

[CutsWithFury]

Now that I've been in practice for two years and have gained some perspective on what real world podiatry is and where I think my practice is going I wanted start a new thread to open the conversation up to graduated fellows, current fellows, current residents and practicing podiatrists to get some viewpoints from individuals from all different training backgrounds.

I am a hospital employed DPM. I work in a multi-specialty group. I am very productive based on MGMA RVU thresholds. I have a busy practice and do everything from diabetic at risk footcare, wound care to complex foot and ankle recon. I get foot and ankle trauma from our hospital ED (share ankle trauma call with ortho). I've literally done every foot and ankle procedure in my first two years of practice with exception to total ankle replacement and deformity correction using an external fixator. Overall I am quite happy with the diversity and volume of cases I am doing.

I did not do a fellowship but I did graduate from a historically strong residency program that provided me exposure to all kinds of procedures, including total ankle replacement.

So are podiatry fellowships necessary? For me, personally, no. Because I feel like I am practicing full scope podiatry and I've been very successful building a good reputation in the community and thus my practice volume has grown steadily.

Did I look at podiatry fellowships when I was in residency? Yes I did. I even interviewed for several but did not get one. I looked into fellowships because I do believe they have a role of increasing surgical competency and efficiency. Do I think I would be a better surgeon than I am today if I did a fellowship? If you asked me this question in residency I would say yes but after practicing for two years and doing cases on my own I would now say no.

Are podiatry fellowships necessary to ultimately be successful in podiatry? No I do not think so. After two years of being in practice I have gained the confidence to do any procedure I would like. It took time but I now personally believe I am where I would be if I had completed a fellowship. So now I personally believe I did not lose anything NOT doing a fellowship.

Fellowship for me would have given me more reps with certain cases making me a quicker surgeon and more prepared to come out and practice. That is what I was looking for. My residency training had given me exposure to everything you could possibly see. I was looking for more reps before going into practice. It did not work out for me that way but I was fortunate to land a very good hospital employed position coming out of residency and the rest is history.

I don't think all fellowships are the same. There are some fellowships which are historically strong and are the way fellowships should be which is the fellow doing the surgery while the attending watches. We all know that is not the case. In some fellowships the fellow is still holding retractors and seeing the fellowship directors post-ops in clinic.

What exactly is podiatry trying to accomplish with fellowship training? "Parity" the ACFAS will tell you. If you do a fellowship you are achieving parity with foot and ankle ortho. I personally believe nothing could be further from the truth. Do you think the AAOS and AOFAS are going to bow down to the fellowship trained podiatrist? I can ensure they will not. Every time it looks like the APMA makes some positive strides working with the AAOS and AOFAS ortho comes back and puts us back in our place. These two ridiculous articles published by members of the AOFAS come to mind:

Study Asserts Higher Costs And Longer Hospital Stays When DPMs Perform Ankle Arthroplasty And Ankle Arthrodesis Procedures

A controversial study maintains that when podiatrists perform ankle arthroplasties and ankle arthrodeses, patients experience longer hospitalization and higher costs in comparison to when the surgeries are performed by orthopedic surgeons.

www.podiatrytoday.com

Lower Complication Rate Following Ankle Fracture Fixation by Orthopaedic Surgeons Versus Podiatrists. - PubMed - NCBI

Two completely poorly written and biased studies which sole purpose is to make DPMs look bad. Anybody in healthcare could look/dissect the methods/ data and can conclude that these are low power studies with a lot of flaws. But it didn't stop JBJS and FAI from pushing it through to achieve its purpose which is to make DPMs look bad in the public eye. The general public has no idea that these studies are completely trash. This is what the AOFAS and AAOS truly think about us. So how does podiatry fellowship training achieve parity when AAOS and AOFAS continue to publish defamatory articles with no push back from the ACFAS and APMA?

There are fellowships in infectious disease/ wound care. Does that mean that graduates of these fellowships know more about infectious disease pathology than 3 year trained internal medicine physicians with fellowship training in infectious disease? What's the point of this podiatry fellowship? There are fellowships in podiatric dermatology. Does this mean we know more about dermatology in the foot compared to board certified dermatologists? Will that hold up in the court of law? Very debatable.

There are fellowships in orthoplastics, muscle flaps, and complex deformity correction with external fixators. Yes, these are EXCELLENT training programs which offer excellent exposure to significant deformities. But these training programs are based out of large university hospital settings with ample resources and organization. If you are resident graduate or fellowship graduate who gets a job with a podiatry group, orthopedic group or a hospital group in an area that is either rural or based out of a small community hospital do you really think this kind of pathology will be coming through your door in high enough volume to justify the need for your fellowship training in the first place? Could your practice setting even support dealing with these patients and giving them the care that they need? I think these are important questions to ask ourselves moving forward. Does the profession REALLY need "x" number of podiatry fellowship graduates each year with training in very complex limb salvage roaming around the USA with no place to actually utilize their training? What does that accomplish in terms of achieving parity?

Not all podiatry fellowship graduates even land ortho or hospital jobs anymore. They are joining podiatry groups. Which again asks the question...did they really need the fellowship training in the first place when they are stuck in a podiatry associate job starting off at 75-100K clipping toenails for starters while they start building their practice? I think these are honest questions to ask ourselves instead of following the herd or what the ACFAS is telling young graduates to do.

On top of all of this there are new fellowship training programs opening each year. How many fellowship programs do we actually need in our profession? Are all fellowship graduates on the same level of training graduating from the fellowship training programs? No they are not. So then what is the point? This fellowship training discrepancy is the same training discrepancy we are seeing in our residency training programs. Does this do anything towards solidifying parity? No it just continues to add to the vagueness of our training in the public eye. In the eye of MD/DO. I can assure you there will always be questions/reservations from ortho and general surgery when the new hot shot fellowship podiatrist comes to their hospital wanting to do a TAR, muscle flap, ex-fix. There will be political road blocks. They may even say no right off the bat because they need to protect quality of care at their facility. They won't care you did a podiatry fellowship. You didn't take the USMLE, you didn't graduate from an orthopedic residency, you didn't graduate from a foot and ankle orthopedic fellowship, you didn't sit and pass the ABOS which is regulated by the ABMS. In the end that is what matters.

Not trying to get people triggered here. Asking honest questions. I think we really need to take a hard look at podiatry fellowship training and its role. Because I personally think it has done nothing to achieve parity based on my experiences dealing with orthopedics at my current job, dealing with the surgical committee and fighting to do certain procedures at my hospital and from what I have seen from looking at the AAOS and AOFAS actions (publishing crappy scientific articles in the name of making podiatry look bad).

Looking forward to a positive and constructive conversation with my peers on these matters.

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[Homo sapien]

I concur with most of this. I am about to be PGY2 in the Midwest and I don't think I'd need a fellowship at all. It seems like another year of residency for no goddamn reason. All that crazy recon trauma stuff just probably (at least initially) won't be coming through a fresh grad's door so much that that extra training is necessary. Plus, most of us won't be working for some massive academic center with all these resources and things. And considering podiatry is much more than complex recon and plastic surgeries, a lot of us don't even want to do that type of work. and we don't need it for certification either (like IM docs need fellowship to do cards, or ortho docs do fellowships in knees or hands or something)

I think instead of chasing after what MDs/DOs do, podiatry should focus more on being good at what they do and showing and proving it.

 

[DYK343]

My fellowship trained friends ALL have great jobs.
Most fellowship trained pods get good jobs. Maybe some join low ball offer podiatry groups but most fellowships market their grads.
Your statement makes it seem all get low paying jobs. That's not true at all. Most come out with better jobs.
Most fellowship trained pods are doing big cases.
Fellowship pods usually or will eventually train residents.
Better trained/more experienced residents only help the profession.

Fellowships are not bad for the profession. Some are going to be better than others. Not everyone needs one and I did not do one but I am pro fellowship. They open a lot of doors and promote the profession for years to come.

 

[CutsWithFury]

My fellowship trained friends ALL have great jobs.
Most fellowship trained pods get good jobs. Maybe some join low ball offer podiatry groups but most fellowships market their grads.
Your statement makes it seem all get low paying jobs. That's not true at all. Most come out with better jobs.
Most fellowship trained pods are doing big cases.
Fellowship pods usually or will eventually train residents.
Better trained/more experienced residents only help the profession.

Fellowships are not bad for the profession. Some are going to be better than others. Not everyone needs one and I did not do one but I am pro fellowship. They open a lot of doors and promote the profession for years to come.

I didn’t insinuate that all fellowship trained DPMs get poor jobs I am just stating a fact that not everyone getting a fellowship is going to land a good job. Especially with the increasingly number of new fellowship programs being started.

Do you have any comments on the need for more fellowships or on the quality of training of these new fellowships? Do you have any comments on how all these fellowship programs with specific advanced training help our profession when most podiatry fellowship graduates don’t end up in large academic centers where they would most likely come across this advanced pathology?

 

[AttackNME]

Now that I've been in practice for two years and have gained some perspective on what real world podiatry is and where I think my practice is going I wanted start a new thread to open the conversation up to graduated fellows, current fellows, current residents and practicing podiatrists to get some viewpoints from individuals from all different training backgrounds.

I am a hospital employed DPM. I work in a multi-specialty group. I am very productive based on MGMA RVU thresholds. I have a busy practice and do everything from diabetic at risk footcare, wound care to complex foot and ankle recon. I get foot and ankle trauma from our hospital ED (share ankle trauma call with ortho). I've literally done every foot and ankle procedure in my first two years of practice with exception to total ankle replacement and deformity correction using an external fixator. Overall I am quite happy with the diversity and volume of cases I am doing.

I did not do a fellowship but I did graduate from a historically strong residency program that provided me exposure to all kinds of procedures, including total ankle replacement.

So are podiatry fellowships necessary? For me, personally, no. Because I feel like I am practicing full scope podiatry and I've been very successful building a good reputation in the community and thus my practice volume has grown steadily.

Did I look at podiatry fellowships when I was in residency? Yes I did. I even interviewed for several but did not get one. I looked into fellowships because I do believe they have a role of increasing surgical competency and efficiency. Do I think I would be a better surgeon than I am today if I did a fellowship? If you asked me this question in residency I would say yes but after practicing for two years and doing cases on my own I would now say no.

Are podiatry fellowships necessary to ultimately be successful in podiatry? No I do not think so. After two years of being in practice I have gained the confidence to do any procedure I would like. It took time but I now personally believe I am where I would be if I had completed a fellowship. So now I personally believe I did not lose anything NOT doing a fellowship.

Fellowship for me would have given me more reps with certain cases making me a quicker surgeon and more prepared to come out and practice. That is what I was looking for. My residency training had given me exposure to everything you could possibly see. I was looking for more reps before going into practice. It did not work out for me that way but I was fortunate to land a very good hospital employed position coming out of residency and the rest is history.

I don't think all fellowships are the same. There are some fellowships which are historically strong and are the way fellowships should be which is the fellow doing the surgery while the attending watches. We all know that is not the case. In some fellowships the fellow is still holding retractors and seeing the fellowship directors post-ops in clinic.

What exactly is podiatry trying to accomplish with fellowship training? "Parity" the ACFAS will tell you. If you do a fellowship you are achieving parity with foot and ankle ortho. I personally believe nothing could be further from the truth. Do you think the AAOS and AOFAS are going to bow down to the fellowship trained podiatrist? I can ensure they will not. Every time it looks like the APMA makes some positive strides working with the AAOS and AOFAS ortho comes back and puts us back in our place. These two ridiculous articles published by members of the AOFAS come to mind:

Study Asserts Higher Costs And Longer Hospital Stays When DPMs Perform Ankle Arthroplasty And Ankle Arthrodesis Procedures

A controversial study maintains that when podiatrists perform ankle arthroplasties and ankle arthrodeses, patients experience longer hospitalization and higher costs in comparison to when the surgeries are performed by orthopedic surgeons.

www.podiatrytoday.com

Lower Complication Rate Following Ankle Fracture Fixation by Orthopaedic Surgeons Versus Podiatrists. - PubMed - NCBI

Two completely poorly written and biased studies which sole purpose is to make DPMs look bad. Anybody in healthcare could look/dissect the methods/ data and can conclude that these are low power studies with a lot of flaws. But it didn't stop JBJS and FAI from pushing it through to achieve its purpose which is to make DPMs look bad in the public eye. The general public has no idea that these studies are completely trash. This is what the AOFAS and AAOS truly think about us. So how does podiatry fellowship training achieve parity when AAOS and AOFAS continue to publish defamatory articles with no push back from the ACFAS and APMA?

There are fellowships in infectious disease/ wound care. Does that mean that graduates of these fellowships know more about infectious disease pathology than 3 year trained internal medicine physicians with fellowship training in infectious disease? What's the point of this podiatry fellowship? There are fellowships in podiatric dermatology. Does this mean we know more about dermatology in the foot compared to board certified dermatologists? Will that hold up in the court of law? Very debatable.

There are fellowships in orthoplastics, muscle flaps, and complex deformity correction with external fixators. Yes, these are EXCELLENT training programs which offer excellent exposure to significant deformities. But these training programs are based out of large university hospital settings with ample resources and organization. If you are resident graduate or fellowship graduate who gets a job with a podiatry group, orthopedic group or a hospital group in an area that is either rural or based out of a small community hospital do you really think this kind of pathology will be coming through your door in high enough volume to justify the need for your fellowship training in the first place? Could your practice setting even support dealing with these patients and giving them the care that they need? I think these are important questions to ask ourselves moving forward. Does the profession REALLY need "x" number of podiatry fellowship graduates each year with training in very complex limb salvage roaming around the USA with no place to actually utilize their training? What does that accomplish in terms of achieving parity?

Not all podiatry fellowship graduates even land ortho or hospital jobs anymore. They are joining podiatry groups. Which again asks the question...did they really need the fellowship training in the first place when they are stuck in a podiatry associate job starting off at 75-100K clipping toenails for starters while they start building their practice? I think these are honest questions to ask ourselves instead of following the herd or what the ACFAS is telling young graduates to do.

On top of all of this there are new fellowship training programs opening each year. How many fellowship programs do we actually need in our profession? Are all fellowship graduates on the same level of training graduating from the fellowship training programs? No they are not. So then what is the point? This fellowship training discrepancy is the same training discrepancy we are seeing in our residency training programs. Does this do anything towards solidifying parity? No it just continues to add to the vagueness of our training in the public eye. In the eye of MD/DO. I can assure you there will always be questions/reservations from ortho and general surgery when the new hot shot fellowship podiatrist comes to their hospital wanting to do a TAR, muscle flap, ex-fix. There will be political road blocks. They may even say no right off the bat because they need to protect quality of care at their facility. They won't care you did a podiatry fellowship. You didn't take the USMLE, you didn't graduate from an orthopedic residency, you didn't graduate from a foot and ankle orthopedic fellowship, you didn't sit and pass the ABOS which is regulated by the ABMS. In the end that is what matters.

Not trying to get people triggered here. Asking honest questions. I think we really need to take a hard look at podiatry fellowship training and its role. Because I personally think it has done nothing to achieve parity based on my experiences dealing with orthopedics at my current job, dealing with the surgical committee and fighting to do certain procedures at my hospital and from what I have seen from looking at the AAOS and AOFAS actions (publishing crappy scientific articles in the name of making podiatry look bad).

Looking forward to a positive and constructive conversation with my peers on these matters.

Many excellent points and I agree. The role of all these new types of fellowships popping up is questionable. The following statement might not sit well with many of our colleagues but I think the only role of TODAY’s podiatrist in a major university is limb salvage, not trauma/recon. The reason being is that one of the many foot and ankle ortho responsibilities is to train their ortho residents to pass the foot and ankle portion of the OITE. Podiatrists don’t take the OITE, so we can’t help them pass a test we don’t have any experience with. The way I think we can best achieve parity is to have fellowships require a USMLE score and passing the foot and ankle portion of the OITE.

Another question is whether or not it is appropriate to have podiatry residencies the way it is, where your only option is a 3 year program with the expectation to be completely foot and ankle trained. I think this is unrealistic, and does not reflect the workload required of us in the real world. I’m not gonna pretend to know the answer, but here is my current opinion/suggestion:

How about we make all podiatry residencies 2 years with focus on forefoot, maybe scrub some rear foot just for experience and education, and you graduate and can practice forefoot surgery, or non-surgical if you wish. For those that want to do rearfoot, they will have applied for a 1 year elective rearfoot residency (or call it fellowship). Or if you want to do limb salvage, you can apply for a limb salvage fellowship instead of doing the rearfoot program. And then those that want to do total ankles will apply for a total ankle fellowship only after they’ve completed a rearfoot program. So it’ll be almost a-la-carte. This isn’t that ridiculous because allopathic medical training includes internship years, transitional years, and residencies, sometimes each are done in different states, followed by a fellowship, or even two fellowships. I think this will make it easier for programs to focus their training efforts. Programs that have total ankle training should try to have their fellows take the foot and ankle portion of the OITE to see how they do because it’ll be a pretty big deal if all those graduates can pass it. Fellowships should require USMLE scores and use it as a way to evaluate their applicants. The USMLE score is just another way used to differentiate medical students apart from each other aside from their GPA and MCAT. Our average MCAT is always going to be lower, but podiatry students gunning for total ankle fellowship may be better represented with a USMLE score that could potentially be comparable to medical students gunning for ortho residency.

 

[AttackNME]

I didn’t insinuate that all fellowship trained DPMs get poor jobs I am just stating a fact that not everyone getting a fellowship is going to land a good job. Especially with the increasingly number of new fellowship programs being started.

Do you have any comments on the need for more fellowships or on the quality of training of these new fellowships? Do you have any comments on how all these fellowship programs with specific advanced training help our profession when most podiatry fellowship graduates don’t end up in large academic centers where they would most likely come across this advanced pathology?

There are studies showing the big learning curve to doing total ankles, which tells me that there is definitely a need for a recon fellowship that has a focus on total ankles. I think there is also a benefit to a limb salvage fellowship, because limb salvage podiatry should belong in every major university and there is a trend for those universities to be seeking out fellowship trained limb salvage podiatrists. The reason I think a separate year is beneficial is for doing research. Major universities like and support research, and usually you get a bonus in your salary for doing research, so learning how to do it is beneficial. There is a recent article that looked at what podiatric topics are most published outside of podiatry journals, and the most common topic is diabetic foot ulcers, meaning the medical research community as a whole is more interested in DFUs.

 

[air bud]

The idea of doing a fellowship and giving up a year of income earning just for total ankles is a poor decision in my opinion. First of all, how many total ankles are done each year by podiatry vs ortho? As we all know, there are only more and more well trained F & A orthos. They aren't wasting their time doing hammertoes...I have a friend who did the top 1-3 fellowship in terms of TAR - guess how many that person put in their first 2 years out? Less than 2. Amazing person, I assume a very good surgeon - those people just are there for pods.
Then in terms of finances.

An extra year at 6.8% interest of 300k loans - 20k in interest
A lost year of compounding interest of at least 30k (you and spouse back door roth IRA & 401k max) and up to 56k ( if right set up - IRAx2, 401k 403b HSA) - Those are tax deferred buckets that are open only for that year that you can't make up in the future. That 30k you didn't invest first year out is worth 129k in 30 years at 5.5 return and that 56k is worth 242k. You going to do that many TARs to make that up?

I understand those aren't perfect arguments. But here is one:

YOU ARE A PODIATRIST. YOU ARE NOT SMART (trying to put nicely) IF YOU ARE DOING A WOUND CARE FELLOWSHIP OR A RESEARCH FELLOWSHIP OR A INFECTIOUS DISEASE FELLOWSHIP.

 

[AttackNME]

The idea of doing a fellowship and giving up a year of income earning just for total ankles is a poor decision in my opinion. First of all, how many total ankles are done each year by podiatry vs ortho? As we all know, there are only more and more well trained F & A orthos. They aren't wasting their time doing hammertoes...I have a friend who did the top 1-3 fellowship in terms of TAR - guess how many that person put in their first 2 years out? Less than 2. Amazing person, I assume a very good surgeon - those people just are there for pods.
Then in terms of finances.

An extra year at 6.8% interest of 300k loans - 20k in interest
A lost year of compounding interest of at least 30k (you and spouse back door roth IRA & 401k max) and up to 56k ( if right set up - IRAx2, 401k 403b HSA) - Those are tax deferred buckets that are open only for that year that you can't make up in the future. That 30k you didn't invest first year out is worth 129k in 30 years at 5.5 return and that 56k is worth 242k. You going to do that many TARs to make that up?

I understand those aren't perfect arguments. But here is one:

YOU ARE A PODIATRIST. YOU ARE NOT SMART (trying to put nicely) IF YOU ARE DOING A WOUND CARE FELLOWSHIP OR A RESEARCH FELLOWSHIP OR A INFECTIOUS DISEASE FELLOWSHIP.

The people I know that do TARs don’t do it for the money, if you check the Medicare reimbursements of that CPT code and compare it to say a TMA, you’d be surprised. They do it to provide a valuable service to the community, and it usually takes a few years in practice to build your patient base, which is probably why your friend did two so far. That’s actually pretty good in the first year out. Someone who didn’t have TAR training that wants to do it should probably practice for several years before they attempt their first TAR. With that said, if you are truly good enough to be doing TARs, that is a quick way to differentiate yourself from your peers in your community, and you will get a lot of referrals. Those referrals will then refer their friends, etc, which is difficult to measure in cash value but that’s a way to market yourself to get more patients.

To produce a good research manuscript requires a lot of time and energy with the study design and carrying out the study. Anyone can put together a case report pretty easily, but a research fellowship that pays somebody to learn and do the study is very much needed. Why? Because doing research doesn’t pay well, infact if you want to do research in private practice you’re gonna need somebody to sponsor your project unless you want to front over a grand in your own money to pay for an IRB. On top of that, the time you spent doing it, writing it up, doing revisions and resubmission to journals is free labor. The work of research shouldn’t be undermined, it’s an under-appreciated need. To demand evidence based medicine when the process to obtain this “evidence” is under-appreciated and not compensated (or poorly compensated for if you’re in a university) is baffling to me. Not saying that people doing research all day should be paid more than someone busting their ass doing cases and taking call, but at least respect the work they do for the little or no pay they receive for it. If your priority is to make money to pay back student loans and support your family, then research obviously is a bad choice for you.

 

[CutsWithFury]

The people I know that do TARs don’t do it for the money, if you check the Medicare reimbursements of that CPT code and compare it to say a TMA, you’d be surprised. They do it to provide a valuable service to the community, and it usually takes a few years in practice to build your patient base, which is probably why your friend did two so far. That’s actually pretty good in the first year out. Someone who didn’t have TAR training that wants to do it should probably practice for several years before they attempt their first TAR. With that said, if you are truly good enough to be doing TARs, that is a quick way to differentiate yourself from your peers in your community, and you will get a lot of referrals. Those referrals will then refer their friends, etc, which is difficult to measure in cash value but that’s a way to market yourself to get more patients.

To produce a good research manuscript requires a lot of time and energy with the study design and carrying out the study. Anyone can put together a case report pretty easily, but a research fellowship that pays somebody to learn and do the study is very much needed. Why? Because doing research doesn’t pay well, infact if you want to do research in private practice you’re gonna need somebody to sponsor your project unless you want to front over a grand in your own money to pay for an IRB. On top of that, the time you spent doing it, writing it up, doing revisions and resubmission to journals is free labor. The work of research shouldn’t be undermined, it’s an under-appreciated need. To demand evidence based medicine when the process to obtain this “evidence” is under-appreciated and not compensated (or poorly compensated for if you’re in a university) is baffling to me. Not saying that people doing research all day should be paid more than someone busting their ass doing cases and taking call, but at least respect the work they do for the little or no pay they receive for it. If your priority is to make money to pay back student loans and support your family, then research obviously is a bad choice for you.

Research was never a highly paid position in any field. It never will be. People who do research are people who take great pride in finding answers, publishing and presenting in front of their peers at scientific conferences. Only few people make actually money doing research. It is most likely the physicians who get paid by companies as research consultants or are paid to run an actual department of research at a university or large hospital system, etc.

Getting back on point...

I find your comments about TAR interesting. Just because a podiatrist offers a particular procedure that no other podiatrist does doesn't mean other specialties can't do it. Therefore they aren't really differentiating themselves from the community. I would say most foot and ankle orthopedists I've worked with or known are doing TAR in their practices. They are doing them much more readily than podiatrists because they are apart of large orthopedic groups which are well oiled machines that pump out and see a lot more MSK pathology involving the foot and ankle.

Building a TAR practice out of a podiatry practice is incredibly difficult. Probably more difficult now than it was 20 years ago. I think it would be easier to accomplish in a rural area but then again...should you be actually doing it? Does the rural hospital have the resources to handle complications involving complex foot and ankle procedures?

 

[AttackNME]

Research was never a highly paid position in any field. It never will be. People who do research are people who take great pride in finding answers, publishing and presenting in front of their peers at scientific conferences. Only few people make actually money doing research. It is most likely the physicians who get paid by companies as research consultants or are paid to run an actual department of research at a university or large hospital system, etc.

Getting back on point...

I find your comments about TAR interesting. Just because a podiatrist offers a particular procedure that no other podiatrist does doesn't mean other specialties can't do it. Therefore they aren't really differentiating themselves from the community. I would say most foot and ankle orthopedists I've worked with or known are doing TAR in their practices. They are doing them much more readily than podiatrists because they are apart of large orthopedic groups which are well oiled machines that pump out and see a lot more MSK pathology involving the foot and ankle.

Building a TAR practice out of a podiatry practice is incredibly difficult. Probably more difficult now than it was 20 years ago. I think it would be easier to accomplish in a rural area but then again...should you be actually doing it? Does the rural hospital have the resources to handle complications involving complex foot and ankle procedures?

While a greater percentage of graduating foot and ankle ortho docs are more likely to perform the procedure than podiatry graduates, I think the bigger picture is that there aren’t enough total ankle docs to cover the United States. Big cities and rural towns are the “extremes” that we think of, and are not the only places that exist. There are large communities and less popular states where there are few foot and ankle docs, and the podiatrists in those communities are taking on big cases. I live in one of those states where there is only one foot and ankle MD doc, and he isn’t replacing the ankles of everyone in this state, podiatrists are. Without podiatrists here, the patients will have an incredibly long wait, or have to drive out of state, let alone get a second opinion.

 

[CutsWithFury]

While a greater percentage of graduating foot and ankle ortho docs are more likely to perform the procedure than podiatry graduates, I think the bigger picture is that there aren’t enough total ankle docs to cover the United States. Big cities and rural towns are the “extremes” that we think of, and are not the only places that exist. There are large communities and less popular states where there are few foot and ankle docs, and the podiatrists in those communities are taking on big cases. I live in one of those states where there is only one foot and ankle MD doc, and he isn’t replacing the ankles of everyone in this state, podiatrists are. Without podiatrists here, the patients will have an incredibly long wait, or have to drive out of state, let alone get a second opinion.

I think you make some good points. TARs are not as reliable as knees and hip replacements though. The nature of knee and hip OA is mostly from primary osteoarthritis (wear and tear). These are straightforward joints to work with.

Ankle arthritis is mostly post-traumatic in nature with associated deformities (i.e. hx of ankle trauma). Making joint replacements with a less reliable implant (compared to knees and hips) in more complicated joints (associated ankle joint deformity) lead to more complications. There is a reason it takes about 50 TARs before complications go down dramatically. Thats been defined in the literature. Despite this complications can still occur...then you need to know how to deal with the complications.

Now...do we really need a bunch of podiatrists running around doing TARs? The simple straightforward ankle joints are long gone. When somebody gets a TAR these days it most likely requires a staged approach. Addressing the underlying ankle joint deformity prior to placing the TAR. It can be a lot of work. And it is not straightforward. You need to know what you are doing.

Very few podiatry residency programs offer the TAR volume to become competent. If any. Fellowship training is helpful for more exposure to TAR but how many TARs are you actually doing as a fellow? Just like TAR competency/exposure in residency the TAR exposure in fellowship is HIGHLY VARIABLE. Not all fellows are getting equal exposure to TAR.

 

[AttackNME]

I think you make some good points. TARs are not as reliable as knees and hip replacements though. The nature of knee and hip OA is mostly from primary osteoarthritis (wear and tear). These are straightforward joints to work with.

Ankle arthritis is mostly post-traumatic in nature with associated deformities (i.e. hx of ankle trauma). Making joint replacements with a less reliable implant (compared to knees and hips) in more complicated joints (associated ankle joint deformity) lead to more complications. There is a reason it takes about 50 TARs before complications go down dramatically. Thats been defined in the literature. Despite this complications can still occur...then you need to know how to deal with the complications.

Now...do we really need a bunch of podiatrists running around doing TARs? The simple straightforward ankle joints are long gone. When somebody gets a TAR these days it most likely requires a staged approach. Addressing the underlying ankle joint deformity prior to placing the TAR. It can be a lot of work. And it is not straightforward. You need to know what you are doing.

Very few podiatry residency programs offer the TAR volume to become competent. If any. Fellowship training is helpful for more exposure to TAR but how many TARs are you actually doing as a fellow? Just like TAR competency/exposure in residency the TAR exposure in fellowship is HIGHLY VARIABLE. Not all fellows are getting equal exposure to TAR.

I think we all want more regulations for fellowships, I'm sure it'll happen, just takes time. We're still evolving pretty rapidly

 

[CutsWithFury]

I think we all want more regulations for fellowships, I'm sure it'll happen, just takes time. We're still evolving pretty rapidly

With the rate they are being created I doubt we will see any regulation outside of what the ACFAS standards/stipulations are

 

[GreenHousePub]

Fellowships are definitely necessary to keep the supply of associates who are willing to work for 60k for 1-2 years going. It's saving a lot of people a lot of money.

I know a few people who did fellowships, some got great jobs, others accepted the same associate jobs everywhere else.

 

[Scrantonicity]

Yeah...I think the only benefit I would have had if I had done a fellowship would have been a little more time to find that "perfect" job. Seems like I was pretty rushed during my 3rd year, and ended up getting a pretty crappy job because of it. During this "fellowship" I would have kept close tabs on my co-residents and learned from their experiences before taking the plunge. Of course, just like GreenHousePub said above there's not a guarantee that this would have worked out for my benefit. You can still wind up with that crappy job. So other than that, total waste of time (and money).

 

[CutsWithFury]

An ortho group with foot and ankle ortho already on staff wants a fellowship trained DPM to do at risk diabetic foot care, wounds and amputations....

Parity?

 

[josebiwasabi]

Is a fellowship necessary for all graduates? Absolutely not.
Do I regret doing one? Nope, I am without a doubt a better surgeon and clinician after this year.

A fellowship is not, and should not, be an extra year of residency. I think the biggest differences between this year and my PGY3 experience would be a) having my own independent clinic schedule, b) seeing all of my postops (and non-op care!) longitudinally, c) doing complex cases with minimal help/input from the attending.

I am joining a private practice this fall. They offered me a significantly higher base salary and a more advantageous bonus structure compared to the other associates.

If we're going to say an extra year of training is a negative thing, let's focus on eliminating 4 year residency programs.

That being said, I do agree that not all fellowships are equal. Some of them are of questionable quality.

 

[dtrack22]

a) having my own independent clinic schedule, b) seeing all of my postops (and non-op care!) longitudinally, c) doing complex cases with minimal help/input from the attending.

This should be a standard experience in residency. It was in the program I trained at. The fact that it isn’t is exhibit A as to why the focus should be improving residency training as opposed to creating new (mostly pointless) fellowships.

 

[josebiwasabi]

This should be a standard experience in residency. It was in the program I trained at. The fact that it isn’t is exhibit A as to why the focus should be improving residency training as opposed to creating new (mostly pointless) fellowships.

How did you have your own clinic as a resident?

 

[dtrack22]

How did you have your own clinic as a resident?

Hospital/academic center based program where all of the patients funneled through one clinic/office and attendings were either not present or let you do your thing when they were there. It was more of a collective, in terms of the residents (plural) had their own clinic, but you could see whoever you wanted and follow any patient from start to finish and without interruption of your treatment plan by an attending.

 

[josebiwasabi]

Hospital/academic center based program where all of the patients funneled through one clinic/office and attendings were either not present or let you do your thing when they were there. It was more of a collective, in terms of the residents (plural) had their own clinic, but you could see whoever you wanted and follow any patient from start to finish and without interruption of your treatment plan by an attending.

I also attended a residency program based out of a large academic/teaching hospital and we had a similar setup for resident clinic. I really do not think it is anywhere near the same clinic experience as what I've had this year where I function as an attending in an orthopedic practice.

 

[CutsWithFury]

I also attended a residency program based out of a large academic/teaching hospital and we had a similar setup for resident clinic. I really do not think it is anywhere near the same clinic experience as what I've had this year where I function as an attending in an orthopedic practice.

Why? Were you trimming toenails in resident clinic during your residency?

You should be following post ops in resident clinic and learning how to manage patients following particular post op protocols.

 

[josebiwasabi]

Why? Were you trimming toenails in resident clinic during your residency?

Not sure how you got that from my post. I probably trimmed a toenail every 6 months in residency. I went to a strong surgical program.

You should be following post ops in resident clinic and learning how to manage patients following particular post op protocols.

Yes, and if someone isn't doing that in residency they are probably at a crappy VA chip and clip program.

The clinic experience in residency versus fellowship is different, that is all I am trying to say. In fellowship I function as an attending and have the ability to create and adjust my own post op protocols. I am practicing under my own full state license. I have my own dedicated MA and ortho tech. I do not present patients to anyone, no one co-signs my notes. I have a 2 full days of clinic per week where the patients are specifically scheduled to see me, not my attending, and not a random resident covering clinic that day.

If you got the experience in residency that I am getting in fellowship then everyone should sign up for your program because it would clearly be the best program in the country.

 

[CutsWithFury]

Not sure how you got that from my post. I probably trimmed a toenail every 6 months in residency. I went to a strong surgical program.

Yes, and if someone isn't doing that in residency they are probably at a crappy VA chip and clip program.

The clinic experience in residency versus fellowship is different, that is all I am trying to say. In fellowship I function as an attending and have the ability to create and adjust my own post op protocols. I am practicing under my own full state license. I have my own dedicated MA and ortho tech. I do not present patients to anyone, no one co-signs my notes. I have a 2 full days of clinic per week where the patients are specifically scheduled to see me, not my attending, and not a random resident covering clinic that day.

If you got the experience in residency that I am getting in fellowship then everyone should sign up for your program because it would clearly be the best program in the country.

How is that different from a good residency clinic? I went to a program where attendings were there for the sake of just being there but we did our own post-op protocols for the surgical patients who followed up with us. The only difference between a solid residency clinic and a fellowship clinic you are describing is that you are no longer presenting. Big deal.

Your fellowship clinic is no different than your colleagues who chose to practice out of residency. Everyone is seeing their own surgical patients and making decisions and dictating orders to ancillary staff.

If you needed a fellowship year to learn how to treat surgical patients in the clinic then you have to question the quality of the residency program. Residency training is suppose to train you to get ready to practice.

 

[dtrack22]

In fellowship I function as an attending and have the ability to create and adjust my own post op protocols. I am practicing under my own full state license. I have my own dedicated MA and ortho tech. I do not present patients to anyone, no one co-signs my notes. I have a 2 full days of clinic per week where the patients are specifically scheduled to see me, not my attending, and not a random resident covering clinic that day.

In residency I functioned as an attending and had the ability to create and adjust my own post-op protocols. The clinic had 2 MAs dedicated to my service. I did not present patients to anyone as a 3rd year and most of 2nd year. I had 2-2.5 days of clinic every week I was on service (which was all but maybe 5-6 months over 3 years). The only difference between what you typed and my residency experience is that I did not have an unrestricted license, someone cosigned my notes (whether or not they saw or gave input on the patient), and the patient wasn't assigned to me but I was in the same clinic and could chose to follow or not follow any single patient I wanted to. Which means if I did a big recon, or if I was just playing around with how I wanted to treat plantar fasciitis or neuromas, I could see that patient every time they came in.

We would have 100-120 patients scheduled in clinic as well. You could end up seeing 30-40 patients by yourself as a resident. I have yet to work in a podiatry office where I've had to see a higher volume of patients or more complicated pathology than I did in residency. My residency clinic experience was overkill for what has been asked of me in the real world to this point. I can't imagine fellowship being significantly different or superior other than more MSK pathology in one of those fellowships where you work with a ortho group or within orthopedic dept of a hospital or MSG.

The only difference between a solid residency clinic and a fellowship clinic you are describing is that you are no longer presenting. Big deal.

And I didn't even have to do that throughout most of residency...we did it in a very informal way sometimes during and often times outside of clinic hours just to go over the pathology, case, etc.

 

[pod18]

I agree a lot with the sentiment in the original post about fellowships and "parity". I was at a weekend course recently where the one of the ACFAS lecture circuit/fellowship trained podiatrists had a 10 minute spiel about how fellowship training is the future of podiatry and the ultimate way to achieve parity. It's incredibly frustrating to see the supposed leaders of our profession tout these fellowships as the way to achieve parity with MD/DO. It literally makes zero sense. Fellowship training in the MD/DO world is transformative. An internal medicine doctor can become a cardiologist, infectious disease, endocrinologist, rheumatologist, etc. A general surgeon can be come a vascular surgeon, CT surgeon, colorectal, etc. Their fellowship training quite literally dictates their career path and job options. A fellowship trained podiatrist is .. a podiatrist.

To pretend that fellowship training is the way to achieve parity is short sighted and ignorant. The way to achieve parity is blatantly obvious but the profession refuses to do it because it will require a lot of hard decisions/work. Schools would have be to closed/merged and literally 80-90% of residency programs would be shuttered because they would be nowhere near ACGME standards. Our profession has already been told how to achieve parity. Instead we are trying to do it our own roundabout way.

 

[AttackNME]

I agree a lot with the sentiment in the original post about fellowships and "parity". I was at a weekend course recently where the one of the ACFAS lecture circuit/fellowship trained podiatrists had a 10 minute spiel about how fellowship training is the future of podiatry and the ultimate way to achieve parity. It's incredibly frustrating to see the supposed leaders of our profession tout these fellowships as the way to achieve parity with MD/DO. It literally makes zero sense. Fellowship training in the MD/DO world is transformative. An internal medicine doctor can become a cardiologist, infectious disease, endocrinologist, rheumatologist, etc. A general surgeon can be come a vascular surgeon, CT surgeon, colorectal, etc. Their fellowship training quite literally dictates their career path and job options. A fellowship trained podiatrist is .. a podiatrist.

To pretend that fellowship training is the way to achieve parity is short sided and ignorant. The way to achieve parity is blatantly obvious but the profession refuses to do it because it will require a lot of hard decisions/work. Schools would have be to closed/merged and literally 80-90% of residency programs would be shuttered because they would be nowhere near ACGME standards. Our profession has already been told how to achieve parity. Instead we are trying to do it our own roundabout way.

Thinking about how dentists can practice right out of school with training to do basic procedures and those that want special training do a fellowship or advanced training, maybe that's what we should do. How would you feel about pod residencies going back to the way it was (whatever that means whether it be nonsurgical or forefoot surgery focused) and fellowships be where everything else is learned. That will make it more true to the sense of a transformative program. I agree that would require a lot of restructuring of existing residency programs

 

[CutsWithFury]

I agree a lot with the sentiment in the original post about fellowships and "parity". I was at a weekend course recently where the one of the ACFAS lecture circuit/fellowship trained podiatrists had a 10 minute spiel about how fellowship training is the future of podiatry and the ultimate way to achieve parity. It's incredibly frustrating to see the supposed leaders of our profession tout these fellowships as the way to achieve parity with MD/DO. It literally makes zero sense. Fellowship training in the MD/DO world is transformative. An internal medicine doctor can become a cardiologist, infectious disease, endocrinologist, rheumatologist, etc. A general surgeon can be come a vascular surgeon, CT surgeon, colorectal, etc. Their fellowship training quite literally dictates their career path and job options. A fellowship trained podiatrist is .. a podiatrist.

To pretend that fellowship training is the way to achieve parity is short sighted and ignorant. The way to achieve parity is blatantly obvious but the profession refuses to do it because it will require a lot of hard decisions/work. Schools would have be to closed/merged and literally 80-90% of residency programs would be shuttered because they would be nowhere near ACGME standards. Our profession has already been told how to achieve parity. Instead we are trying to do it our own roundabout way.

This is an outstanding post. I can bet I know the DPM who was saying fellowship training equals parity. Nothing could be further from the truth. Ortho does not care

 

[Feli]

Fellowships are not necessary in podiatry. I'm not against them, but they just aren't needed. It's a personal decision. I never considered doing one for one minute. As was mentioned, the pod fellowships don't change your career path or lead to a sub-specialty board certification, as they do for MDs. In podiatry, you are going to be a foot and ankle specialist/surgeon with or without one.

A good residency is helpful for surgical volume, diversity, networking. That is main key... and it's usually achieved by working hard in podiatry school. Certainly not all are residencies are created equal, but they are getting better on average. I put a ton of time and work into finding the right fit for me. At the program I'd trained at, we had over 3 decades where nobody did a fellowship when I left, but now, a few have started to do fellowships since then. I hope their reasoning was to learn billing or to network or something (and I'm sure it was)... because if they don't know surgery inside out and have surgical confidence after doing a very good program, they probably never will.

There are hundreds of excellent F&A podiatry surgeons (and ortho) who never did a fellowship... residency directors, private practice millionaires, famous authors and lecturers, etc. There are podiatrists who did 2yr or occasionally even 1yr residency training awhile ago who are excellent. A lot of them are doing and teaching procedures they never learned in residency (usually since those implants or ideas didn't exist at the time)... they simply know the anatomy, know the instruments, know the pathology, and keep up with CME and techniques by reading and talking with colleagues at meetings.

Also, there are also co-residents from the exact same programs where some flounder or just do basic stuff and some have rock star careers or do advanced pathology and procedures. The same would go for fellows from the same program. A lot of it is personal motivation, confidence, and coordination.... and just personal preference. Not everyone has the same personality, priorities, or goals. No matter what, your education will become outdated, so no matter how many PGY years you do, it's up to you to keep up on reading and current standards of care. Some do, some don't.

That said, I'm glad people do podiatry fellowships! Whether they think they were lacking surgical volume, lacking research, lacking networking,, lacking clinic/billing, lacking confidence in some area, wanting to learn patient relations better from top attendings, etc... good for them. More training and better skill and knowledge can make us all look better. I think that is where ACFAS is coming from. Another year of cases and clinic won't turn a timid Tommy into confident Chris, though. You have to take the training wheels off sometime... might as well be paid decent for it, have your student loan balance go down and not up, and start accumulating cases for board cert if that's your goal. Even with MD fellowships that actually do lead to sub-spec and usually increased income, it is hard to make up for that extra training year(s) and the income and opportunity loss it causes. That is why so many go unfilled.

In podiatry, it is a serious dice roll if you are undertaking a fellowship just to beef the resume, network, and hope for a better quality and/or paying job. Like the 7 Habits book says, it always helps to begin with the end in mind; it is a risk to do fellowship just because you reach your last year of residency and don't know what that end is. I think that is the main reason most people do them (unsure of career path or hoping for ortho job or better job options), but that is like counting on an Ivy league or private university name on your resume to open doors or tap you into an alumni network. Maybe it will work, maybe it won't... but it will definitely cost you money, and most good residencies and personal networking skill can do basically the same thing. Again, personal decision.

..."Good judgement comes from experience, and experience comes from bad judgement." Or, if you prefer "There are two ways to learn: your mistakes or the mistakes of others. One is quicker, one is cheaper... and they're the same one." The second quote implies that paying for mentorship is efficient, and I would agree for some things. I would have loved to do a fellowship and learned with elite surgeons and thinkers for another year, but again, for podiatry, you did that for 3 years in residency and 1000 or more procedures already (assuming decent program). You have seen and assisted in more foot procedures and office patients than most F&A fellowship trained ortho, esp if you count student experience also. Hopefully most of the bad judgment and mistakes you see are during residency and at conferences and grand rounds, but nobody bats 1.000. Fellowship or not, you will ultimately have your own continued learning via your personal struggles and complications no matter what. "If you aren't having complications, you aren't doing surgery." You are going to have sub-optimal results and you are going to fail, especially with surgery. It's a fact. FEAR = fail early and responsibly.

The ultimate hope of any resident or fellow's teacher is that the student will eventually not need them. "Experience is the only teacher, and we get his lesson indifferently at any school." Ultimately, it is up to you to develop your own communication and patient relations style in the office; it is much more key to overall success to diagnose, assess patients, build trust, and set them up for success... than knowing any certain surgical move. Again, you have to take the training wheels off sometime. I could have probably just said that

 

[Scrantonicity]

Fellowships are not necessary in podiatry. I'm not against them, but they just aren't needed. It's a personal decision. I never considered doing one for one minute. As was mentioned, the pod fellowships don't change your career path or lead to a sub-specialty board certification, as they do for MDs. In podiatry, you are going to be a foot and ankle specialist/surgeon with or without one.
A good residency is helpful for surgical volume, diversity, networking. That is main key... and it's usually achieved by working hard in podiatry school. Certainly not all are residencies are created equal, but they are getting better on average. At the program I'd trained at, we had over 3 decades where nobody did a fellowship when I left, but now a few have started to do fellowships since then. I hope their reasoning was to learn billing or to network or something... because if they don't know surgery inside out and have surgical confidence after doing a very good program, they probably never will.
There are hundreds of excellent F&A podiatry surgeons (and ortho) who never did a fellowship... residency directors, private practice millionaires, famous authors and lecturers, etc. There are podiatrists who did 2yr or occasionally even 1yr residency training awhile ago who are excellent. A lot of them are doing and teaching procedures they never learned in residency (usually since those implants or ideas didn't exist at the time)... they simply know the anatomy, know the instruments, know the pathology, and keep up with CME and techniques by reading and talking with colleagues at meetings.
Also, there are also co-residents from the exact same programs where some flounder or just do basic stuff and some have rock star careers or do advanced pathology and procedures. The same would go for fellows from the same program. A lot of it is personal motivation, confidence, and coordination.... and just personal preference. Not everyone has the same personality, priorities, or goals. No matter what, your education will become outdated, so no matter how many PGY years you do, it's up to you to keep up on reading and current standards of care. Some do, some don't.
That said, I'm glad people do podiatry fellowships! Whether they think they were lacking surgical volume, lacking research, lacking networking,, lacking clinic/billing, lacking confidence in some area, wanting to learn patient relations better from top attendings, etc... good for them. More training and better skill and knowledge can make us all look better. I think that is where ACFAS is coming from. Another year of cases and clinic won't turn a timid Tommy into confident Chris, though. You have to take the training wheels off sometime... might as well be paid decent for it, have your student loan balance go down and not up, and start accumulating cases for board cert if that's your goal. Even with MD fellowships that actually do lead to sub-spec and usually increased income, it is hard to make up for that extra training year(s).
In podiatry, it is a serious dice roll if you are undertaking a fellowship just to beef the resume, network, and hope for a better quality and/or paying job. I think that is the main reason most people do them (hoping for ortho job or better job options), but that is like counting on an Ivy league or private university name on your resume to open doors or tap you into an alumni network. Maybe it will, maybe it won't... but most good residencies and personal networking skill can do basically the same thing. Again, personal decision.
..."Good judgement comes from experience, and experience comes from bad judgement." Or, if you prefer "There are two ways to learn: your mistakes or the mistakes of others. One is quicker, one is cheaper... and they're the same one." The second quote implies that paying for mentorship is efficient, and I would agree for some things. I would have loved to do a fellowship and learned with elite surgeons and thinkers for another year, but again, for podiatry, you did that for 3 years in residency and 1000 or more procedures already (assuming decent program). You have seen and assisted in more foot procedures and office patients than most F&A fellowship trained ortho, esp if you count student experience also. Hopefully most of the bad judgment and mistakes you see are during residency and at conferences and grand rounds, but nobody bats 1.000.
Fellowship or not, you will ultimately have struggles and complications no matter what. The ultimate hope of any resident or fellow's teacher is that the student will eventually not need them. "Experience is the only teacher, and we get his lesson indifferently at any school." Ultimately, it is up to you to develop your own communication and patient relations style in the office (much more key to overall success to diagnose, assess patients, set them up for success... than any certain surgical move). Again, you have to take the training wheels off sometime. I could probably just say that

I really liked what you posted...but dang man, use bullet points or something My eyes are bleeding lol.

 

[dtrack22]

I really liked what you posted...but dang man, use bullet points or something My eyes are bleeding lol.

If you say anything to scare Feli back into hiding...

 

[CutsWithFury]

Fellowships are not necessary in podiatry. I'm not against them, but they just aren't needed. It's a personal decision. I never considered doing one for one minute. As was mentioned, the pod fellowships don't change your career path or lead to a sub-specialty board certification, as they do for MDs. In podiatry, you are going to be a foot and ankle specialist/surgeon with or without one.

A good residency is helpful for surgical volume, diversity, networking. That is main key... and it's usually achieved by working hard in podiatry school. Certainly not all are residencies are created equal, but they are getting better on average. I put a ton of time and work into finding the right fit for me. At the program I'd trained at, we had over 3 decades where nobody did a fellowship when I left, but now, a few have started to do fellowships since then. I hope their reasoning was to learn billing or to network or something (and I'm sure it was)... because if they don't know surgery inside out and have surgical confidence after doing a very good program, they probably never will.

There are hundreds of excellent F&A podiatry surgeons (and ortho) who never did a fellowship... residency directors, private practice millionaires, famous authors and lecturers, etc. There are podiatrists who did 2yr or occasionally even 1yr residency training awhile ago who are excellent. A lot of them are doing and teaching procedures they never learned in residency (usually since those implants or ideas didn't exist at the time)... they simply know the anatomy, know the instruments, know the pathology, and keep up with CME and techniques by reading and talking with colleagues at meetings.

Also, there are also co-residents from the exact same programs where some flounder or just do basic stuff and some have rock star careers or do advanced pathology and procedures. The same would go for fellows from the same program. A lot of it is personal motivation, confidence, and coordination.... and just personal preference. Not everyone has the same personality, priorities, or goals. No matter what, your education will become outdated, so no matter how many PGY years you do, it's up to you to keep up on reading and current standards of care. Some do, some don't.

That said, I'm glad people do podiatry fellowships! Whether they think they were lacking surgical volume, lacking research, lacking networking,, lacking clinic/billing, lacking confidence in some area, wanting to learn patient relations better from top attendings, etc... good for them. More training and better skill and knowledge can make us all look better. I think that is where ACFAS is coming from. Another year of cases and clinic won't turn a timid Tommy into confident Chris, though. You have to take the training wheels off sometime... might as well be paid decent for it, have your student loan balance go down and not up, and start accumulating cases for board cert if that's your goal. Even with MD fellowships that actually do lead to sub-spec and usually increased income, it is hard to make up for that extra training year(s) and the income and opportunity loss it causes. That is why so many go unfilled.

In podiatry, it is a serious dice roll if you are undertaking a fellowship just to beef the resume, network, and hope for a better quality and/or paying job. Like the 7 Habits book says, it always helps to begin with the end in mind; it is a risk to do fellowship just because you reach your last year of residency and don't know what that end is. I think that is the main reason most people do them (unsure of career path or hoping for ortho job or better job options), but that is like counting on an Ivy league or private university name on your resume to open doors or tap you into an alumni network. Maybe it will work, maybe it won't... but it will definitely cost you money, and most good residencies and personal networking skill can do basically the same thing. Again, personal decision.

..."Good judgement comes from experience, and experience comes from bad judgement." Or, if you prefer "There are two ways to learn: your mistakes or the mistakes of others. One is quicker, one is cheaper... and they're the same one." The second quote implies that paying for mentorship is efficient, and I would agree for some things. I would have loved to do a fellowship and learned with elite surgeons and thinkers for another year, but again, for podiatry, you did that for 3 years in residency and 1000 or more procedures already (assuming decent program). You have seen and assisted in more foot procedures and office patients than most F&A fellowship trained ortho, esp if you count student experience also. Hopefully most of the bad judgment and mistakes you see are during residency and at conferences and grand rounds, but nobody bats 1.000. Fellowship or not, you will ultimately have your own continued learning via your personal struggles and complications no matter what. "If you aren't having complications, you aren't doing surgery." You are going to have sub-optimal results and you are going to fail, especially with surgery. It's a fact. FEAR = fail early and responsibly.

The ultimate hope of any resident or fellow's teacher is that the student will eventually not need them. "Experience is the only teacher, and we get his lesson indifferently at any school." Ultimately, it is up to you to develop your own communication and patient relations style in the office; it is much more key to overall success to diagnose, assess patients, build trust, and set them up for success... than knowing any certain surgical move. Again, you have to take the training wheels off sometime. I could have probably just said that

Good to see you again. Your wisdom is missed on these forums

 

[CutsWithFury]

Would love to hear more from the fellowship trained DPMs. I know they are watching...

 

[Scrantonicity]

If you say anything to scare Feli back into hiding...

LOL I know, I know I shouldn't have said anything--I always enjoyed his posts back in the day.

 

[air bud]

Not sure how you got that from my post. I probably trimmed a toenail every 6 months in residency. I went to a strong surgical program.

Yes, and if someone isn't doing that in residency they are probably at a crappy VA chip and clip program.

The clinic experience in residency versus fellowship is different, that is all I am trying to say. In fellowship I function as an attending and have the ability to create and adjust my own post op protocols. I am practicing under my own full state license. I have my own dedicated MA and ortho tech. I do not present patients to anyone, no one co-signs my notes. I have a 2 full days of clinic per week where the patients are specifically scheduled to see me, not my attending, and not a random resident covering clinic that day.

If you got the experience in residency that I am getting in fellowship then everyone should sign up for your program because it would clearly be the best program in the country.

I got that experience as a first year attending making 225k, putting 40k plus into tax protected accounts.
One of my arguments against fellowships is the financial impact. Another year of loans, another year of lost tax deferred income.

 

[air bud]

Man what blast from the past. Here's to more Feli - Dilly Dilly

 

[JewOnThis]

My fellowship trained friends ALL have great jobs.
Most fellowship trained pods get good jobs. Maybe some join low ball offer podiatry groups but most fellowships market their grads.
Your statement makes it seem all get low paying jobs. That's not true at all. Most come out with better jobs.
Most fellowship trained pods are doing big cases.
Fellowship pods usually or will eventually train residents.
Better trained/more experienced residents only help the profession.

Fellowships are not bad for the profession. Some are going to be better than others. Not everyone needs one and I did not do one but I am pro fellowship. They open a lot of doors and promote the profession for years to come.

There is some truth to what DYK has posted. I definitely agree on fellowship trained pods getting better jobs, but in terms of doing more 'BIG' cases, not really.

 

[CutsWithFury]

There is some truth to what DYK has posted. I definitely agree on fellowship trained pods getting better jobs, but in terms of doing more 'BIG' cases, not really.

I agree. SOME truth. Fellowships are becoming too many. They are not all of the same quality. Producing fellows who theoretically could still be pretty terrible surgeons (especially if they went to a weak residency). What does that accomplish?

Fellowship did lead to better jobs. I know several fellowship trained colleagues who had inside information on really good jobs across the USA because the ACFAS had job recruiters helping them.

But that is not always the case anymore because of the volume of fellows being pumped out each year. There are fellows accepting private podiatry practice jobs which really defeats the purpose of being fellowship trained in my opinion.

If you are going to be fellowship trained it should be multi-specialty group employed, ortho group employed, university/academic hospital employed or bust.

 

[air bud]

I am not sure people realize the amount of BS fellowships out there. Apparently everyone thinks of fellows of Hyer, Cottom, Fleming, brigido etc...

 

[G0dFather]

They won't care you did a podiatry fellowship. You didn't take the USMLE, you didn't graduate from an orthopedic residency, you didn't graduate from a foot and ankle orthopedic fellowship, you didn't sit and pass the ABOS which is regulated by the ABMS. In the end that is what matters.

YOU ARE A PODIATRIST. YOU ARE NOT SMART (trying to put nicely) IF YOU ARE DOING A WOUND CARE FELLOWSHIP OR A RESEARCH FELLOWSHIP OR A INFECTIOUS DISEASE FELLOWSHIP.

This should be a standard experience in residency. It was in the program I trained at. The fact that it isn’t is exhibit A as to why the focus should be improving residency training as opposed to creating new (mostly pointless) fellowships.

Some of the best quotes that summarize everything that is wrong these days with what is a fabulous profession !!

 

[CutsWithFury]

Some of the best quotes that summarize everything that is wrong these days with what is a fabulous profession !!

Just some OGs speaking truth. Thank you for the kind words sir.

I am shocked this thread has not gotten some ACFAS fellowship trained DPMs to create accounts and put their two cents in. I think it would be vital to understand their experiences (positive and negative) with fellowship training and how it shaped their careers.

 

[Sartorius P.O.D.]

I have enjoyed the comments

I recently had the privilege of enjoying a cocktail with a past President of ACFAS and the subject of fellowships was brought up. He had some cool insights (very much off the record haha). On of the more interesting ones was was that he wasn't really sure if the fellowships were helping forward the profession all that much in way of parity as they were mostly going to people from high powered residencies that probably didn't learn much of anything new in their year of training. If we really wanted to increase parity we should be giving advanced training to the people who didn't get it in residency, therefore increasing the net number of podiatrists with advanced training. Now it is kind of a rich getting richer scenario. I think it is impossible to actually change this, but it's interesting idea and I don't disagree with the reasoning.

How about we make all podiatry residencies 2 years with focus on forefoot, maybe scrub some rear foot just for experience and education, and you graduate and can practice forefoot surgery, or non-surgical if you wish. For those that want to do rearfoot, they will have applied for a 1 year elective rearfoot residency (or call it fellowship).

I feel like this idea has been getting a lot of traction lately and I couldn't disagree more. I am lucky to train in area where there are a lot of podiatrists who practice the full scope and are credentialed to do anything below the knee including pilons, TAR, frames etc. In fact, there are no FA orthopods in our system so virtually all the elective work and >50% of the foot & ankle trauma is being done by DPMs. However there have been multiple occasions as a resident when our service was consulted and a non-rearfoot trained podiatrist was on call or was just given the consult or referral. This lead to some awkward conversations with the consulting MD or ED doc about why the doctor who is on call for "foot & ankle" or the guy to whom they like to send patients can't fix the ankle fracture or consult on the really bad flat foot when the other podiatrist can.

Yeah ,not everyone wants to do trauma and RRA but I feel like one our biggest issues in this profession is that there is a huge disparity between what a podiatrist is and is what they are CAPABLE of doing. At least having a system where everyone is minimally trained in the same way might change that a little over the next decade or two. If you have the 1-2, 2+1, 3 year residency model it just makes it harder for other medical community to understand who we are and what we are about. Are we going to start designating people as "surgical podiatrists, DPM-s" or "limb salvage specialists, DPM-ls", "Nailcare Guru, DPM-tfp? Where does it end?

 

[air bud]

I have enjoyed the comments

I recently had the privilege of enjoying a cocktail with a past President of ACFAS and the subject of fellowships was brought up. He had some cool insights (very much off the record haha). On of the more interesting ones was was that he wasn't really sure if the fellowships were helping forward the profession all that much in way of parity as they were mostly going to people from high powered residencies that probably didn't learn much of anything new in their year of training. If we really wanted to increase parity we should be giving advanced training to the people who didn't get it in residency, therefore increasing the net number of podiatrists with advanced training. Now it is kind of a rich getting richer scenario. I think it is impossible to actually change this, but it's interesting idea and I don't disagree with the reasoning.



I feel like this idea has been getting a lot of traction lately and I couldn't disagree more. I am lucky to train in area where there are a lot of podiatrists who practice the full scope and are credentialed to do anything below the knee including pilons, TAR, frames etc. In fact, there are no FA orthopods in our system so virtually all the elective work and >50% of the foot & ankle trauma is being done by DPMs. However there have been multiple occasions as a resident when our service was consulted and a non-rearfoot trained podiatrist was on call or was just given the consult or referral. This lead to some awkward conversations with the consulting MD or ED doc about why the doctor who is on call for "foot & ankle" or the guy to whom they like to send patients can't fix the ankle fracture or consult on the really bad flat foot when the other podiatrist can.

Yeah ,not everyone wants to do trauma and RRA but I feel like one our biggest issues in this profession is that there is a huge disparity between what a podiatrist is and is what they are CAPABLE of doing. At least having a system where everyone is minimally trained in the same way might change that a little over the next decade or two. If you have the 1-2, 2+1, 3 year residency model it just makes it harder for other medical community to understand who we are and what we are about. Are we going to start designating people as "surgical podiatrists, DPM-s" or "limb salvage specialists, DPM-ls", "Nailcare Guru, DPM-tfp? Where does it end?

Picking up steam....my director (former higher up in ABFAS) has been yelling about this for literally decades. Good luck. But yeah its the answer.

And 1 million percent right about the rich getting richer. I know lots of guys who went to Rush, Hyer, Brigido, Cottom etc. They went to places like West Penn, DMC, PSL, Orlando etc, not some VA in arkansas.

 

[AttackNME]

I have enjoyed the comments

I recently had the privilege of enjoying a cocktail with a past President of ACFAS and the subject of fellowships was brought up. He had some cool insights (very much off the record haha). On of the more interesting ones was was that he wasn't really sure if the fellowships were helping forward the profession all that much in way of parity as they were mostly going to people from high powered residencies that probably didn't learn much of anything new in their year of training. If we really wanted to increase parity we should be giving advanced training to the people who didn't get it in residency, therefore increasing the net number of podiatrists with advanced training. Now it is kind of a rich getting richer scenario. I think it is impossible to actually change this, but it's interesting idea and I don't disagree with the reasoning.



I feel like this idea has been getting a lot of traction lately and I couldn't disagree more. I am lucky to train in area where there are a lot of podiatrists who practice the full scope and are credentialed to do anything below the knee including pilons, TAR, frames etc. In fact, there are no FA orthopods in our system so virtually all the elective work and >50% of the foot & ankle trauma is being done by DPMs. However there have been multiple occasions as a resident when our service was consulted and a non-rearfoot trained podiatrist was on call or was just given the consult or referral. This lead to some awkward conversations with the consulting MD or ED doc about why the doctor who is on call for "foot & ankle" or the guy to whom they like to send patients can't fix the ankle fracture or consult on the really bad flat foot when the other podiatrist can.

Yeah ,not everyone wants to do trauma and RRA but I feel like one our biggest issues in this profession is that there is a huge disparity between what a podiatrist is and is what they are CAPABLE of doing. At least having a system where everyone is minimally trained in the same way might change that a little over the next decade or two. If you have the 1-2, 2+1, 3 year residency model it just makes it harder for other medical community to understand who we are and what we are about. Are we going to start designating people as "surgical podiatrists, DPM-s" or "limb salvage specialists, DPM-ls", "Nailcare Guru, DPM-tfp? Where does it end?

I think we should organize our training based on what's best for our patients, not based on what's easiest for the medical community to understand. Do you believe every one of your classmates want to and will be doing flat foot and trauma? The disparity is reflective of work we do, which we need to constantly reevaluate given the growing diabetic population.

 

[CutsWithFury]

I think we should organize our training based on what's best for our patients, not based on what's easiest for the medical community to understand. Do you believe every one of your classmates want to and will be doing flat foot and trauma? The disparity is reflective of work we do, which we need to constantly reevaluate given the growing diabetic population.

WTF?!?!

Hello? You play to win the game!

Podiatry residency training needs to be universally regulated and SIMILAR so every MD/DO knows what we can do. The medical community needs to understand our training. Right now they have no idea what we can and can’t do because their experiences with podiatrists are so variable.

Universally similar training throughout all podiatry residencies will never happen so our professions troubles will continue.

Fellowship training is not the answer. It just adds to the vagueness of our training.

I’m a better surgeon than some of my colleagues who did fellowship. Why? Because they spent three years of their residency training getting crappy training. One year of fellowship doesn’t change anything. BUT now these fellowship trained DPMs can possibly get better jobs because they are “fellowship” trained when in reality they still are not very good. Now the MD/DOs on staff sees the quality of their work and now thinks fellowship trained DPM is not very good either. Again this adds to the vagueness of our training. The vicious cycle continues.

Things have to change at the residency training level for our profession to move forward.

 

[AttackNME]

WTF?!?!

Hello? You play to win the game!

Podiatry residency training needs to be universally regulated and SIMILAR so every MD/DO knows what we can do. The medical community needs to understand our training. Right now they have no idea what we can and can’t do because their experiences with podiatrists are so variable.

Universally similar training throughout all podiatry residencies will never happen so our professions troubles will continue.

Fellowship training is not the answer. It just adds to the vagueness of our training.

I’m a better surgeon than some of my colleagues who did fellowship. Why? Because they spent three years of their residency training getting crappy training. One year of fellowship doesn’t change anything. BUT now these fellowship trained DPMs can possibly get better jobs because they are “fellowship” trained when in reality they still are not very good. Now the MD/DOs on staff sees the quality of their work and now thinks fellowship trained DPM is not very good either. Again this adds to the vagueness of our training. The vicious cycle continues.

Things have to change at the residency training level for our profession to move forward.

I don't care what the MD/DO community thinks of our training, I only care that we prepare the future generation to do the work that they want to do, and to do it well, and I strongly believe separate training tracks are the way to do that.

I know of people that don't really want to do rearfoot or ankle stuff, but they fear what their colleagues will think about them so they go for fellowship to get more training just to catch up. They're probably not going to post on here to tell us how they really feel but there's a lot of people in that boat. Rather than ****ting on fellowships or talking **** about people that do limited surgery or want to pursue nonsurgical podiatry, we should support them and respect them, and offer a fast track to training, much like dentists and cardiologists are separate to oral surgeons and ct surgeons.

 

[CutsWithFury]

Nobody is talking crap on fellowships. Nobody is talking crap on DPMs who just want to cut toenails.

Residency training needs to be similar and better regulated. Because it’s not.

Fellowship doesn’t do anything except add to the vagueness of our training.

 

[AttackNME]

Nobody is talking crap on fellowships. Nobody is talking crap on DPMs who just want to cut toenails.

Residency training needs to be similar and better regulated. Because it’s not.

Fellowship doesn’t do anything except add to the vagueness of our training.

Not saying you specifically but there is a very derogatory term floating around describing podiatrists that do surgery with limited/no training, or podiatrists that don’t do surgery. I’m sure people on here will have comments describing the finer details of the definition of said acronym, but anyway that’s besides the point... In the end, you and I have a mutual goal which is to improve residency training. You started this forum asking for how to do that, well what’s your idea? You think we should just shut down all the “bad” programs?

I’ve said it over and over, I like the idea of having people that want to pursue non surgical or forefoot surgical careers have an option for such training that is separated from rearfoot/ankle training. There is then less dilution of surgical numbers, plain and simple. Imagine a life where you as a resident got to scrub double the amount of rearfoot cases you had in your residency because half of your coresidents don’t want to do it and are focusing on forefoot and clinic procedures.

I always will remember my experience when I first met a cardiothoracic surgeon in my cardiology rotation at a hospital as a third year student. I was in awe to see the CT surgeon speak to the cardiologist to get suggestions on meds to manage his postoperative CABG. If I was to go all soap-boxy I will say this, I dream that one day the foot and ankle podiatrists will one day routinely consult their forefoot or non surgical compadres on orthotic management of their postoperative midfoot reconstruction because those forefoot/non surgical focused people will be very good at what they do.

 

[Sartorius P.O.D.]

I think we should organize our training based on what's best for our patients, not based on what's easiest for the medical community to understand. Do you believe every one of your classmates want to and will be doing flat foot and trauma? The disparity is reflective of work we do, which we need to constantly reevaluate given the growing diabetic population.

No I don't think everyone needs to be doing RRA in practice. The guys I know making the most money in this profession don't touch that stuff. I think everyone needs to be trained to do it and make an informed decision. I'm not sure that this diabetic gravy train that podiatrists have been riding is sustainable. We don't have the numbers to meet the exponential increase in demand for palliative diabetic foot care that is coming down the pipeline so that will probably transition to being a thing that can be offered by a non-physician provider that is cheaper. You don't need 4 years of medical education and a 1y residency to cut nails and shave calluses. An orthotist can dispense shoes and make insoles. If/when we go to a managed care or universal system, you can bet your bacon podiatrists are going to be the first on the chopping block and the ones only doing stuff that doesn't really need to be done by a doctor will be hurting. Making a decision to not practice is different than not knowing how to practice.

I dream that one day the foot and ankle podiatrists will one day routinely consult their forefoot or non surgical compadres on orthotic management of their postoperative midfoot reconstruction because those forefoot/non surgical focused people will be very good at what they do.

Your dream came true. that one day was in 1982. And why would someone send $200-500 cash out of their own practice? Are you suggesting that a person who does "extra" training (as per your proposed model) would forget how to cast STJ neural and post rearfoot/forefoot once they learned how to do a triple?

 

[AttackNME]

No I don't think everyone needs to be doing RRA in practice. The guys I know making the most money in this profession don't touch that stuff. I think everyone needs to be trained to do it and make an informed decision. I'm not sure that this diabetic gravy train that podiatrists have been riding is sustainable. We don't have the numbers to meet the exponential increase in demand for palliative diabetic foot care that is coming down the pipeline so that will probably transition to being a thing that can be offered by a non-physician provider that is cheaper. You don't need 4 years of medical education and a 1y residency to cut nails and shave calluses. An orthotist can dispense shoes and make insoles. If/when we go to a managed care or universal system, you can bet your bacon podiatrists are going to be the first on the chopping block and the ones only doing stuff that doesn't really need to be done by a doctor will be hurting. Making a decision to not practice is different than not knowing how to practice.


Your dream came true. that one day was in 1982. And why would someone send $200-500 cash out of their own practice? Are you suggesting that a person who does "extra" training (as per your proposed model) would forget how to cast STJ neural and post rearfoot/forefoot once they learned how to do a triple?

I prefer stj nc fusions for my flatfoot, and I've noticed that people with severe flat feet can't handle a rigid orthotic, so I usually cast for an accommodative orthotic rather than doing any significant correction with my cast in my experience. But there's something to be learned and advanced from classic root biomechanics, we need smart and dedicated nonsurgical podiatrists to take the time to modify, better understand what durometer and type of material are better for what type of situation/pathology, and to publish their results.