Do you feel overtrained?

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Just curious in this question. For those who have graduated residency within the last 20 years, how would you rate your training based on the bottom 95% (easiest pathology) of patients?

 

[DarkPathMedicine]

We are definitely overtrained for the work that we do on a daily basis. From the diagnosis to treatment of common foot problems the patients have, we are confident and sufficient enough. Now, depending on the residency that we did individually, there will always be variability in the training and confidence level. I'd say for the DPMs that had a good/excellent residency training, they are overtrained and under utilized because there's not enough of complicated cases or surgeries to do.

 

[Hybrocure]

I think it depends on the person. You can be adequately trained and still feel anxiety over certain cases. Just like how gunners and super smarties think they failed every test they take when they pass w flying colors.

The largest change I’ve noticed is that my job post residency didn’t keep up with the case variety and surgical volume that I had during residency. When you aren’t cutting enough or cutting enough on certain cases over time your skills will suffer

 

[Homo sapien]

Oh

Clinical- overtrained
Surgically- adequate-to-undertrained

 

[Sweatshirt]

Podiatry - Overtrained (this profession is not hard at all)
Medicine - Undertrained (what is Sodium?)

 

[air bud]

Insert Feli rant about oversaturation. It's this simple. If you don't operate enough your skills and confidence suffer. Now that I am back to a busy job and operating 1-2 a week my confidence and ultimately outcomes continue to improve.

 

[footpainhealer]

Just graduated and we rotate with a few private practices as 3rd year residents in a variety of socioeconomic settings.
I would estimate that about 85 to 90% of a 30 day period has been clinical stuff that we are certainly overtrained for. I personally felt like I could run an entire clinic on my own by the end of first year of my training since we have a good clinic at our hospital where we do everything from every injection to every in office procedure like toe amps, tenotomies, etc.

The other 10 to 15% of these private practices were the surgeries and I would say about 80% of those surgeries are your bread and butter, podiatry stuff like bunions, hammer toes, EPF, etc. The remaining 20% of the surgeries would be more involved, but still relatively simple if you had decent training like lateral ankle ligament reconstruction, flat foot reconstructions, the occasional IM nail for end stage arthritis. During my private practice rotations, we only had two more-complicated full Charcot recons that I can think of where we had to do a closing wedge ostomy through the entire tarsal bones and beam everything as well as fuse the hind foot. Now at our actual hospital, the Charcot recons are a little bit more common where it would be probably two - three every few months vs in private practice where the doc told me he probably does that once a year to two years and sometimes longer.

So overall, from a surgical standpoint, in my opinion, in private practice we can range from overtrained (since the majority of the time we're not gonna be doing anything more invasive than a flat foot recon or an ankle fusion) to undertrained if you had subpar training where even 4 foot stuff is questionable for you.

If I were a hospital employed podiatrist that's not associated with a residency program, I would probably feel over trained since it seems like most of them only get consults for infections and wounds, which we should all be pretty darn good at at this point. I know there are some hospital employ docs that get the ankle fracture and Achilles rupture consults, which I also feel comfortable with, but it seems in the real world that that stuff usually doesn't get consulted to us so in that regard, we would be over trained.

 

[Weirdy]

Skill atrophy very, very real without proper reps after residency.

 

[Adam Smasher]

3 years ago, I wrote:

the path to licensure is needlessly long for what I am doing right now. I think the UK/Canada/Australia do it right, podiatrists have bachelor’s degrees and basically do chiropody procedures only. Instead of a doctorate + 3 year residency, we could have a “Master’s of Chiropody” or something, so you can learn pharmacology and prescribe Lamisil/antibiotics and not cut deeper than the subcutaneous tissue and still do 90% of everything I’m already doing.

4th year of podiatry school is pointless, clerkships are basically job interviews for residency. After interviews in January of 4th year, everyone mentally checks out and isn’t really learning anything anyway. Residency training was a speed bump for me on the way to licensure. If we MUST be surgeons, 2 years is enough to figure out hallux valgus and diabetic foot infections. My director did it in 1.

As it stands, 100% of podiatrists undertake a course of training that is for the benefit of 10-20% who will actually use it.

For perspective, I met a nurse practitioner recently who was certified in wound care as well as foot care. She started her private practice focused on wound care and visits nursing homes to trim toenails on the side. Not bad for a zero-year residency.

 

[MicroPod]

To be fair, I think doctors who spend most of their time in clinic probably feel over trained with 90% or more of their patients. Its the 10% of the time where you need that extra training/education to recognize what is going on and provide appropriate treatment. I think the surgery part is different and should be separate part of discussion.

 

[Feli]

...Charcot recons are a little bit more common ....
...So overall, from a surgical standpoint, in my opinion, in private practice we can range from overtrained (since the majority of the time we're not gonna be doing anything more invasive than a flat foot recon or an ankle fusion) to undertrained if you had subpar training where even 4 foot stuff is questionable for you. ...

Yeah, we have a wide variation in training.

You can always go from calc fractures and flat foot to just bunions and Haglunds... but you can't do the reverse.

Charcot [major recon types, not just planing or TAL/tendonot]... don't even get me started on that.
Charcot is the epitome of podiatry not having enough surgery and work to do. You can talk patients into anything.
There are the very rare centers that do it well and often (usually teaching), but it's still mostly a fool's errand that ends BKA.
I've done maybe two or three actual RRA type Charcot recon since residency... and not because I don't know how. They are just so futile. The patients are so unhealthy. Just CROW/cast until they can get into DM custom insole shoes... or until they get their amp. You have to move on the the patients who can actually be fixed. It's great to understand Charcot dx and educate patients, but I always find the Charcot recon lectures a very good stretch and phone call break at any CME meeting. It cracks me up when the limb salvage guys drone on "surgery #5 was a nail at the start of this year, then 6th was a tendonotomy for forefoot re-ulcer, 7th surgery was I&D VAC for heel ulcer, and 8th for skin graft last month... they're doing well." 🙂

 

[msion]

For pure musculoskeletal stuff no, I don't feel we are overtrained and definitely have a place in the healthcare system. I enjoy treating these pathologies. It's all about biomechanics and respect the science of tissue healing. Can make a big difference in their lives.

But... at least for me private practice has somewhat turned into a chronic pain management clinic. Heel pain, sure can treat that. But wait, they got lower back pain, fibromyalgia and throw some connective tissue disorders on top of it then this becomes a nightmare. They never get better. They should really see pain management. But pain management doesn't want to see them.
My worst fear is walking into the room and they start telling me that intense burning radiating pain on their legs.

 

[air bud]

For pure musculoskeletal stuff no, I don't feel we are overtrained and definitely have a place in the healthcare system. I enjoy treating these pathologies. It's all about biomechanics and respect the science of tissue healing. Can make a big difference in their lives.

But... at least for me private practice has somewhat turned into a chronic pain management clinic. Heel pain, sure can treat that. But wait, they got lower back pain, fibromyalgia and throw some connective tissue disorders on top of it then this becomes a nightmare. They never get better. They should really see pain management. But pain management doesn't want to see them.
My worst fear is walking into the room and they start telling me that intense burning radiating pain on their legs.

ALL biomechanics. When you figure out how to explain this to patients in layman's terms your practice explodes. And not Dennis Shavelson biomechanics

And to reiterate what I often say ...all the talk about wounds being 1st year simple stuff....this is BS. Wound care is surgery. It is biomechanics, anatomy, physiology etc. it is very rewarding. Healing an ulcer that has been recurrent and mistreated for years is awesome. It's surgical reconstruction. Gastroc/TAL, TA tendon transfers, hindfoot nails, PL/PB transfers, floating osteotomy, Keller etc. And I am not talking Charcot. These patients love you. They have wasted months of their lives in wound care centers. You walk in, explain this is why the ulcer is there (not because you wore the wrong shoes), this is how we will heal it..they love you.

 

[Adam Smasher]

But how are we supposed to keep 600 new DPMs per year busy without their panel of weekly 11042s?

 

[AttackNME]

But how are we supposed to keep 600 new DPMs per year busy without their panel of weekly 11042s?

You think every new grad actually wants to do wound care? Not even majority want to do it

 

[Adam Smasher]

You think every new grad actually wants to do wound care? Not even majority want to do it

You're right. To offset for this, we will need more schools.

 

[Bluecollarmed]

I think it depends on your residency and what you see mostly in practice. I'm rural so pretty broad scope that comes through clinic but mainly UC/ER follow ups for fractures and ingrowns etc. I have done more nail avulsions as a student and in the first year of practice than all of residency which equated to about 3. Luckily they are easy and don't require a ton of brain power. My residency clinics were almost purely orthopedic so anything from an MSK standpoint is cake. I do some wound care and really didn't enjoy it at first but when you understand and see it from the perspective of biomechanics it makes it more enjoyable than just scrape this dead tissue weekly and as airbud has said, can produce more surgery and RVUs than most elective stuff.

 

[Retrograde_Nail]

This is an interesting thread. Thanks for creating it. Very important conversation to have.

Depends on your practice situations. If you end up in private practice you are over trained. Private practice will NEVER offer the complex cases and the volume you wound see in ortho, MSG or hospital employed positions.

If you end up in ortho group, MSG or hospital employed your residency/fellowship training dictates whether you are under/over trained. Lots of podiatrists end up in hospital positions and they still stink and can't handle everything thrown at them. It is a fact.

Your residency training dictates your success. The problem with fellowship training is that residents who do weak programs are now getting into fellowship programs since there are so many of them. The end result is still a bad podiatrist. This is why fellowship training in podiatry means nothing now. In a short period of time podiatry has completely blown this to smithereens. It means nothing.

I did a high powered residency program. No fellowship. On paper I am just ok compared to all these "foot and ankle surgeons but really podiatrists on LinkedIn". But I landed a hospital job straight out of residency which I built from the ground up and turned into a 10,000 RVU per year gig. I was able to do that because I had solid core training from residency and did some courses in things I was not comfortable with and continued to expand my skills so I saw everything and was able to treat everything. With experience your confidence increases to take on bigger cases. If you are still unsure then have your rep put you in courses. It benefits you and your rep's company. Never stop doing courses.

I left that gig due to hospital politics and constant in fighting with orthopedics. I left and went to a bigger hospital with two other surgical podiatrists already on staff. In a short period of time I am now doing close to 13,000 RVUs per year. Taking on big complicated cases on a weekly basis. I have ancillary staff consisting of two nurses and an NP. I am now doing total ankle replacements as well along with everything else I was doing before. This is a tertiary referral center. You have to be able to handle the complexity of cases that come your way. In this scenario you can still be under trained if your residency training was poor. You can still be under trained if you did a bad residency program and then did fellowship. You are still a bad podiatrist who can't handle this scenario.

This is why podiatry is stupid and complicated for MD/DO to comprehend. There is still no consistency with training. They are highly unsure what one podiatrist can do compared to the next.

I can do any case thrown at me. Any case. But on paper I am just a 3 year trained podiatrist. No fellowship training. You have never heard of me. In the last 8 years (since I became an attending) I am willing to bet a lot of money I've done more cases (total number of cases) than majority of people who lecture nationally for this profession.

 

[Feli]

I think it depends on your residency and what you see mostly in practice...

... podiatry is stupid and complicated for MD/DO to comprehend. There is still no consistency with training. They are highly unsure what one podiatrist can do compared to the next. ...

Yep, the residencies we have are still all over the board. Some do 15 cavus foot recon, some do 3, many do none. Same for TAR. Same for pilon fx. Same for Charcot. Same even for midfoot fusions and Lapidus. But they're all the same podiatry surgery residency credential on paper.

This is just not the case for MD residencies (any ortho knows and does huge volume of fx/recon stuff, any gen surg sees many hernia/app/chole/etc, any plastics knows flaps/implants/wounds). They have achieved a consistent product, consistent board pass rate, etc. Fellowships are just to add in one area or another - and makes them a specialty surgeon.

In addition to having the training, the MD/DO surgeons have jobs and volume out there. In podiatry, it's our job to go find it at rare jobs or within the mainly wound and nail care need.

 

[Robin-jay]

Grossly overtrained.

Don't understand the point of learning complex surgeries when I likely won't pursue that level of surgery.

 

[Feli]

...But... at least for me private practice has somewhat turned into a chronic pain management clinic. Heel pain, sure can treat that. But wait, they got lower back pain, fibromyalgia and throw some connective tissue disorders on top of it then this becomes a nightmare. They never get better. They should really see pain management. But pain management doesn't want to see them.
My worst fear is walking into the room and they start telling me that intense burning radiating pain on their legs.

Yep, I train and re-train my MAs on this. I just tell them patients with fibro, many past foot surgeries, wide as they are tall, crps, etc are 90% people we can't help - but we also shouldn't spend a ton of time on them (or we can't help the many other ones who will get better). Many of the complex and chronic pain and back injury/surgery and psych pts will take a ton of our time if we let them, trying to do real workup and/or inadvertently just wanting to vent... so she knows to pretty much just do 1min HPI and get me in the room.
Otherwise, if she treats them like a normal pt, it takes her 5mins to do HPI and then hits me with doom-n-gloom presentation "in room 2, your A and B didn't help her much, C made the pain worse, she didn't set up do the PT yet, new pain issue at XYZ, says she's sad she hasn't worked in 5 years now and her cat is sick." 😵

It's sad, and I think a lot of the pain is legit, but it also seem to link to the fact that so many people get paid to sit at home and watch Netflix and talk shows. The amount of teens (mostly females, but both genders) not finishing high school due to social anxiety or various other mental health issues is staggering. Those are also scary patients and pretty much no procedures or surgery if at all possible. It will all surely get MUCH worse with AI and much more unemployment and free time. I feel bad with the next generation of podiatry having even more MCA, more unemployed, more fibro, all that. 😕

For me, most of those people get topical crm (otc, diclof, lido, capsaic, whatever), PT, and maybe custom Rx DME as appropriate. I don't even like to do injections for them or sell them anything OTC (often makes them same/worse or wanting to come back more often). I mostly Rx it all just so it's not my office's customer service issue and I can push their f/u date out "so you have time to get that Rx." It's sad.

Heaven help the new associate or new hospitals DPMs who operate on these pts or do a bunch of inject$ on them or make/$ell custom DME to them. The same goes for most drug addict pts. 💣

 

[heybrother]