Having a bad day? Read this post.

[PADPM]

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For those of you who may be frustrated with your daily activity, or believe that you've had a bad day, or for those of you who may believe it's always more glorious if you have that coveted "M.D." degree, please read this great post/thread.

http://forums.studentdoctor.net/showthread.php?t=796697

 

[347932]

Thanks for sharing. I have days something like that once in awhile. You really do see your soul floating away on those days. At least I do.

 

[Podfather]

For those of you who may be frustrated with your daily activity, or believe that you've had a bad day, or for those of you who may believe it's always more glorious if you have that coveted "M.D." degree, please read this great post/thread.

http://forums.studentdoctor.net/showthread.php?t=796697

Read it and have lived it. My favorite for our profession is the RFC patient who thinks that is all we do. I walk into the room 5 minutes late (I usually run close to time) and she/he is frowning and says "I almost left". When I explain I had to see an emergency, they usually say "emergency your a foot doctor". I die a little inside. LOL Fortunately I only have a handful of those. In my northeastern days it would be 30-50% of my schedule.

 

[that1guyfromFL]

In my northeastern days it would be 30-50% of my schedule.

I've heard this exact same thing from multiple pods.


I suppose scope laws and the resulting narrow perspective come into play, but there clearly is a difference between what people in NJ/NY think when you say "podiatrist" versus the southeast or west coast.

I've also noticed a tendency for some "born and bred" NE pods to be less than thrilled with the push for parity and expanded scope.

This seemed counter intuitive (shouldn't those in restrictive areas be more motivated?) until I thought about the fact that a pod who was trained and has practiced under restrictive scope laws probably wouldn't be in a position to personally take advantage of an expanded scope.

Lack of residency and post residency training in areas such as RRF can't be remedied in a few ACFAS CME's.

Thus, those pods are faced with pushing for progress that could potentially result in them measuring up less favorably with the "new kids on the block" that might move in once the scope was more in line with current training standards.

 

[dtrack22]

Lack of residency and post residency training in areas such as RRF can't be remedied in a few ACFAS CME's

Don't forget some of the History and Physical skills that some older pods never got.

A few are rather vocal about the rest of us not being qualified to perform an admitting H&P...even though we all get the skills in a Physical Diagnosis course and then again in non-pod residency rotations.

 

[janV88]

Personally I feel there is huge disconnect with some of the older pods who are practicing. Some these guys have to be oblivious to the current quality of training and education that podiatry students are receiving.

I agree completely. A lot of the negative things that disgruntled podiatrists write on some of the forums online and the most recent PM News discussion on H&Ps shows how little some of these Podiatrists know about the our current training.

 

[347932]

I would be ashamed of any podiatrist who outwardly spoke against students learning how to take a history of present illness or learning to conduct a thorough physical exam. These are skills that we def need to master for rotations or someone is going to chew our ass out badly.

It sure as hell not going to be me and I can't tell you how many times we've talked about taking historys, conducting physical exams, etc in our essentials of clinical reasoning course at Scholl. The lab experiences are probably the best thing about the course. Being to able to practice our communication and utilizing the H&P techniques we have been taught in front of current physicians and M4s has been a pretty valuable experience. The fact we are getting all of this in our first year is also a great opportunity. Some medical school students don't start working with standardized patients until their 2nd year.

Personally I feel there is huge disconnect with some of the older pods who are practicing. Some these guys have to be oblivious to the current quality of training and education that podiatry students are receiving. I concur with some of the above posted thoughts that they are probably threatened by our training.

My personal feelings may not be on target or "right" to some of the current practicing pods who are on these forums but that's how I feel. Everyone should be on board about trying to make the profession more mainstream and to ensure that new graduates are getting top notch education and training. But apparently that is not the case. That kind of makes everyone look bad in my opinion...

Firstly, there is a difference in learning to conduct a full H&P and then getting into practice and wanting to be the one to do this for surgical clearance. In our community, this is what is being pushed for and it makes me nervous, really. My malpractice insurance covers me for foot and ankle issues, but if I miss a gallop during a pre-operative H&P, and the patient strokes out on my table, how can I defend that? Especially once you've been in practice for awhile, it becomes harder and harder to be the "every man/woman" medical. Again, I'm all for learning these skills, but in practice I would personally rather have an experienced MD who does full body H&P's thirty times a day clearing my patients for me. Conversely, I would rather see their diabetic patients for partial nail avulsions, rather than see them after the fact, when all hell breaks lose with this patient's issues.

As far as the disconnect, let me put it this way. How much do you know about the trials and tribulations that these docs went through to pave the way for you? When I see bitterness from older docs about many of the practice issues it goes something like this "Kids these days, don't appreciate what was done for them by our generation. They have no idea what we went through so they can get all this fancy training and get hospital privileges to do these procedures." These docs feel just as much disconnect from the younger generation as you feel about the older generation. There will ALWAYS be naysayers. Brush them off and be thankful for those out there who made your future better.

How much has training really changed in the last 10 years? I can tell you with a reasonable amount of certainty that it hasn't changed much. Also, remember, as PADPM mentioned in another post, some of these older practitioners are still attendings out there and still have a lot of great things to teach you about surgery, practice and life in general. Find those practitioners and learn from them!

 

[PADPM]

I really believe that there may be a misconception regarding the routine foot care/palliative care issue and who is performing this service.

These services are needed across the country, and not just in the Northeast. Some doctors have simply chosen not to make it a part of their practice, and there is no right or wrong answer. However, like it or not, there will always be a percentage of the population such as those with diabetes or vascular disease who will require palliative care. If "we" don't do it, someone else will be happy to collect the money.

Our practice does treat a lot of patients for palliative care and that's our choosing. However, every doctor in our practice is also ABPS certified. And our practice does more surgery at the local hospitals than any other group(s) and we receive more consults for complicated cases than any other groups. As stated before, we have made the decision to treat ALL ailments, from the simple to the complex. That way our patients and our referring doctors don't have to filter what to send or what we see. Our office is "one stop shopping" and I have to believe that's part of our success.

We are not "old school" and technology has not passed us by, just ask Kidsfeet who has visited our office. We run a wound care center with hyperbaric oxygen, we are up to date on surgical techniques, AND we provide lots of palliative care. And we have lots of happy patients.

It just has worked out that I treat the least amount of palliative care patients in our practice, though my partners are very well trained. Today is a relatively short day for me and I will be done by 4 pm. I will see about 40 patients today and I'm scheduled to see only 3 "routine foot care patients". The remainder are coming in for a full spectrum of foot/ankle disorders. Some of my partners may be seeing 25 or 30 routine patients today, but I assure you that they are as well respected as I am by the patients and referring doctors.

Unfortunately, there are too many "urban legends" floating around podiatry. Most of those are simply based on lack of knowledge and experience or bitter doctors that have been unsuccessful.

Additionally, I am allowed to perform H&P's but have decided to have the patients have the H&P performed by their primary care physician. This helps maintain a relationship between the PCP and our office and keeps the PCP "in the loop". I'm also a firm believer in doing what I do best, and letting specialists do what they do best. Despite my ability to perform H&P's etc., I believe that others may be more adept at picking up a murmur or other pathology that I don't come in contact with as often.

I do what I believe is best for my patient, not necessarily my ego.

 

[shenanigans327]

As I'm just starting out in Podiatry, "in my other life"( I don't know if I'm giving too much away here as there are not that many RN's that go back to Podiatry School), I was a Circulator in the OR and it was always my responsibility to check the Pre-op paperwork for all cases booked in the room prior to going back. Having said that, 99.9% of Pre-op H&Ps were done by the patients' primary care docs, not the surgeon. So I completely agree with the attendings on the board about "doing what we (not me yet, someday though)do best". I just had a quick question, and forgive me if I'm overstepping, the day of surgery I usually see an H&P addendum attached to the chart saying that it's been updated and there are no changes...is that usually completed by you docs on the day of surgery? Thanks

 

[347932]

I just had a quick question, and forgive me if I'm overstepping, the day of surgery I usually see an H&P addendum attached to the chart saying that it's been updated and there are no changes...is that usually completed by you docs on the day of surgery? Thanks

I can only speak for myself, but yes I do do this before each case on each patient, the day of their surgery.

 

[Podfather]

Ay my hospital, Podiatrists are permitted to do pre-operative H&Ps. I do them on patient's without significant or unstable medical problems. Those unstable patients or those with significant medical problems are sent to PCPs and other specialists for surgical clearance. Our residents not only perform them for many DPMs but for MD/DOs in other specialties. If you are trained and have the experience, a DPM is qualified to perform them. Most DPMs are smart enough to determine who should have a more involved pre-op workup and clearance. Also, please remember, the anesthesiologists are the gate keepers. If they feel a patient needs a better work-up they will not permit anesthesia and cancel the case regardless of your degree. This does not mean, I manage their medical problems that may arise but do what my orthopedic colleagues do and consult for medical management.

If you sign an addendum saying there have been not changes, don't kid yourself; medicolegally and simply medically that is same as if you did the initial examination. Technically if you are not permitted to do the initial exam, how can you confirm that there has been " no changes" unless you re-examine them?

In regards to our referring MDs, they help pushed this through since they knew the training of our residents and to be frank often they were not paid for the service. Anesthesia will do them for all of the surgeons in some locations but prefer not to.

If you are not trained, do not have the experience, or are uncomfortable doing them then don't. That makes you an ethical doctor. However, just because someone doesn't want to or isn't trained to do something please do not hold back those who are and want to. Many years ago many DPMs told me I shouldn't do rearfoot or ankle surgery (heck some said any surgery). They claimed that orthopedists did that kind of work. Their reasoning was if I can't do it and I am a DPM why do you think you can?

 

[347932]

If you sign an addendum saying there have been not changes, don't kid yourself; medicolegally and simply medically that is same as if you did the initial examination. Technically if you are not permitted to do the initial exam, how can you confirm that there has been " no changes" unless you re-examine them?

Medicolegally what my lawyers tell me this means, which has held up in court, is that you asked the patient if they have had any changes since their H&P (like if any new meds were prescribed by an outpatient clinic) was done and that you have reviewed the results of the H&P that their doctor did and confirmed the lab results with the patient. Its no doubt that if they have a fatal event on the table during surgery, it won't really matter who did what. This has happened and you're on the hook regardless.

 

[Podfather]

Medicolegally what my lawyers tell me this means, which has held up in court, is that you asked the patient if they have had any changes since their H&P (like if any new meds were prescribed by an outpatient clinic) was done and that you have reviewed the results of the H&P that their doctor did and confirmed the lab results with the patient. Its no doubt that if they have a fatal event on the table during surgery, it won't really matter who did what. This has happened and you're on the hook regardless.

Our hospital attorneys said just the opposite. By signing that statement your are confirming that there have been no changes in both their history AND PHYSICAL. Now I think this requirement is a burden but a requirement I believe by JACHO and perhaps CMS.

In reality, few surgeons of any degree actually re-perform either but when you sign, you are saying you did both. The attorney also stated if you are not permitted to do an H&P (because your facility does not feel you are qualified) then how can you be qualified to update it?

 

[347932]

Our hospital attorneys said just the opposite. By signing that statement your are confirming that there have been no changes in both their history AND PHYSICAL. Now I think this requirement is a burden but a requirement I believe by JACHO and perhaps CMS.

In reality, few surgeons of any degree actually re-perform either but when you sign, you are saying you did both. The attorney also stated if you are not permitted to do an H&P (because your facility does not feel you are qualified) then how can you be qualified to update it?

Is it different by state you think?

 

[Podfather]

Is it different by state you think?

Not sure. But I believe these are JACHO and/or CMS requirements which would mean it's a requirement for every hospital. However, ask 3 attorneys a question typically you get 4 answers LOL.

I do know several hospitals interpret the issue differently. If your hospital says it's OK then you will be fine there. In malpractice issues I do not know.

 

[PADPM]

These are interesting points, since I do have to sign off on all H&Ps regardless of whether I've performed them or not.

I fully support our ability to perform H&P's, but choose not to do them the majority of the time for the reasons I've already mentioned. If I have a "healthy" patient who can't get to the PCP in time for surgery, I will take care of the H&P. If I have any questions, I will contact the PCP or appropriate specialist.

Interestingly, I was consulted for my opinion regarding a DPM who DID perform his own H&P's but for some "odd" reason, he only did a "complete", and I mean "complete" H&P on his young (18-35 years of age) female patients. Finally, a few of them found his exam a little creepy and a little too "touchy-feely" and reported him. It was hard to defend why it was so important to perform a breast exam on these patients, (every H&P I've ever received from a PCP had the breast and genital exam portion as "deferred" for podiatric surgical clearance), especially when he NEVER performed H&P's on male patients or older women. When looking at the stats of the female patients, he also never performed H&P's on overweight women, etc. He was rather picky. Needless to say, despite my decision to pass on the case, he was brought up on charges.

So if and when I do an H&P on a female patient, a female member of my staff is always present. And breast and genital exams are not part of my pre op clearance. If JACHO makes it mandatory, than I'll oblige

 

[347932]

I fully support our ability to perform H&P's, but choose not to do them the majority of the time for the reasons I've already mentioned. If I have a "healthy" patient who can't get to the PCP in time for surgery, I will take care of the H&P. If I have any questions, I will contact the PCP or appropriate specialist.

Does your state/community/hospital require that you take and pass a special course for that, "certifying" you to do this, or is it inherent in your license?

 

[Podfather]

These are interesting points, since I do have to sign off on all H&Ps regardless of whether I've performed them or not.

I fully support our ability to perform H&P's, but choose not to do them the majority of the time for the reasons I've already mentioned. If I have a "healthy" patient who can't get to the PCP in time for surgery, I will take care of the H&P. If I have any questions, I will contact the PCP or appropriate specialist.

Interestingly, I was consulted for my opinion regarding a DPM who DID perform his own H&P's but for some "odd" reason, he only did a "complete", and I mean "complete" H&P on his young (18-35 years of age) female patients. Finally, a few of them found his exam a little creepy and a little too "touchy-feely" and reported him. It was hard to defend why it was so important to perform a breast exam on these patients, (every H&P I've ever received from a PCP had the breast and genital exam portion as "deferred" for podiatric surgical clearance), especially when he NEVER performed H&P's on male patients or older women. When looking at the stats of the female patients, he also never performed H&P's on overweight women, etc. He was rather picky. Needless to say, despite my decision to pass on the case, he was brought up on charges.

So if and when I do an H&P on a female patient, a female member of my staff is always present. And breast and genital exams are not part of my pre op clearance. If JACHO makes it mandatory, than I'll oblige

That is a problem. And fortunately your "creepy foot doctor" (for those not aware of this term google Red Stripe beer creepy foot doctor) was dumb and outed himself on his issues. There are MDs/DOs that have those types of full exam criteria. I would say 99% of all pre-op H&Ps defer or write refused on those exams. The irony is that the powers who accredit hospitals technically require them. I do not perform them either. I have a female member there for an H&P on a female as well. Simple common sense. The residents do them in the pre-op holding area.

 

[Podfather]

Does your state/community/hospital require that you take and pass a special course for that, "certifying" you to do this, or is it inherent in your license?

The determination (assuming your state laws permit them) of who can do an H&P is purely a hospital decision. We simply used the same language the dentists used for the rule/bylaw change that was required. We did add to the "when qualified a podiatrist may perform the H&P" that for any medical problems that may arise during a patent's stay, the podiatrist must consult a physician on staff at the hospital. Although a given it was felt by those helping us to obtain the privilege several years ago (and a safeguard I wanted in case some DPM went all Marcus Welby on me) it would answer some questions a few on the medical staff may ask.

 

[PADPM]

Hey, I think we interviewed the guy in that video for a position in our practice but he didn't accept our offer!!

Actually, in my opinion he looks very much like a DPM who is pretty well known at one of the schools (in his younger days).

 

[Podfather]

Hey, I think we interviewed the guy in that video for a position in our practice but he didn't accept our offer!!

Actually, in my opinion he looks very much like a DPM who is pretty well known at one of the schools (in his younger days).

Yes he is a good editor too! LOL

 

[Podfather]

Yes he is a good editor too! LOL

OK could not resist. As weird as this is for us, still funny and better than the last video discussed for this site. LOL

http://www.youtube.com/watch?v=ELKZ-1yrDJI

 

[347932]

OK could not resist. As weird as this is for us, still funny and better than the last video discussed for this site. LOL

http://www.youtube.com/watch?v=ELKZ-1yrDJI

OMG I've never seen that before!! BWAHAHAHAHAHAHAHAHA!!

That is some funny stuff...

 

[jonwill]

This is my new favorite video of all time. I don't care if it makes pods look weird...it's hilarious.

That is awesome!

 

[Feli]

Hooray beer!

...Being at a pod residency hospital, I also thought this one was pretty funny for any of us residents (or attendings?) who routinely find ourselves playing tug-of-war with the MDA/CRNA for the pt's chart while trying to get our pre-op paperwork done each day.

*Disclaimer: the butt of the joke is DPM residents/surgeons, but if you can't have a laugh at your own expense, oh well...

[YOUTUBE]r6tJ9sUPCxg[/YOUTUBE]