How Much is Surgery Worth to You?

[NatCh]

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[air bud]

I’m in a predicament, I’ve been offered a fairly good salary by an ortho/msg but they wouldn’t want me to do any rearfoot. I guess it’s less headache and I don’t enjoy those procedures that much anyways but it does suck to know I’ll never get abfas certified in rra

Who cares take it.

 

[NatCh]

I’m in a predicament, I’ve been offered a fairly good salary by an ortho/msg but they wouldn’t want me to do any rearfoot. I guess it’s less headache and I don’t enjoy those procedures that much anyways but it does suck to know I’ll never get abfas certified in rra

Take it

 

[dtrack22]

I’m in a predicament, I’ve been offered a fairly good salary by an ortho/msg but they wouldn’t want me to do any rearfoot. I guess it’s less headache and I don’t enjoy those procedures that much anyways but it does suck to know I’ll never get abfas certified in rra

And here’s a big problem with ABFAS. Let’s take a few very technically easy “ankle” procedures as an example.

You take this job, and it is a good gig but you don’t get numbers for RRA. You work here for 5-6 years and then a better opportunity comes along. The new opportunity does give you the opportunity to fix fibula fractures and Achilles ruptures (for example). If ABFAS and their Diplomates had their way, you would never be able to perform any ankle surgery at your new job because you didn’t get the RRA certificate. Even though most hospitals without any ABFAS involvement/requirements would allow you to be proctored and gain those privileges. And an orthopedic surgeon who didn’t do an ankle fracture for 5-6 years would always be allowed to still fix ankle fractures if they so choose. But you can’t. Ever. At least not in a world where ABFAS RRA is mandated in order to do a gastroc recession.

The whole ABFAS “protecting the public” line is laughable. Just go on any social media platform and find accounts that belong to ABFAS certified podiatrists. They do dumb stuff all the time.

Here’s a $3000 fibula nail for a Weber A fracture with no medial instability.

And the justification for fixing it was a stress radiograph in which they noted fracture gapping when they recreated the deforming force/injury mechanism. Well yeah, of course the fracture gapped.

I get it, we did not all train at level 1 trauma and academic centers…but ABFAS doesn’t protect anyone. Certainly didn’t protect the patient above, who got a completely unnecessary surgery. And even if you think surgery was indicated (you’re wrong but I’ll play along), the construct itself is wrong/unnecessary. ABFAS is just a way for guys and gals who really want to be orthopedic surgeons (but are still just Podiatrists), feel more important/better than some of their peers.

Rant over. Take the MSG/Ortho forefoot job assuming the other options end up being working for another Podiatrist.

 

[Feli]

I’m in a predicament, I’ve been offered a fairly good salary by an ortho/msg but they wouldn’t want me to do any rearfoot. I guess it’s less headache and I don’t enjoy those procedures that much anyways but it does suck to know I’ll never get abfas certified in rra

I agree. You can take it if basically all else is right... money, location you like, well-run clinics, little/no call, no better options, youre ok with that, etc.

The are really not a ton of DPM jobs that do much true rearfoot (recon and trauma) anyways. Many do none at all.

Nearly all DPMs do basic podiatry derm/nail/wounds/non-op. Most do forefoot and the wound/amp. Fewer do diabetic charcot/wound surgery and call that 'rearfoot.' The smallest minority of pods do real RRA (fracture, Achilles, recon elective in non-DM pts) on a regular basis; those cases and referrals are hard to get as a DPM... and frankly, a small % of us have truly good training for that.

Personally, I do basically everything (few/none of the charcot recons... just not effective or logical). That's more because I'm in a smaller area with nobody else doing that stuff well. In the past, in metro areas, I'm fine giving the 'big' cases to ortho or even another DPM in my group who likes doing them... and I usually wouldn't get those refers in those places to begin with. I had one PP boss who told the office schedulers to put everything "ankle" on with him. In IHS, I would get most/all of the calc and Lisfranc (both harder than most anklr fx imo), but ortho got the ankles unless he was out of town.

At the end of the day, there are too many podiatrists.
There are way too many foreoot surgeons.
There are way way WAY too many foot and ankle surgeons these days.

Definitely get a setup leading to cases for ABFAS Foot, but there is a reason RRA cert is pretty rare: the training (actual skill set - not just 'PMSR RRA' on paper), the jobs, and mainly the RRA refers are hard to get.

 

[Feli]

....Just go on any social media platform and find accounts that belong to ABFAS certified podiatrists. They do dumb stuff all the time.

...Here’s a $3000 fibula nail for a Weber A fracture with no medial instability...
... ABFAS doesn’t protect anyone. Certainly didn’t protect the patient above, who got a completely unnecessary surgery. And even if you think surgery was indicated (you’re wrong but I’ll play along), the construct itself is wrong/unnecessary. ...

I would still say ABFAS is the best we have (do we want standards or no standards?), but i definitely believe the case you point out (and many I see also) are just testament to how rediculously overpopulated 'foot and ankle surgeons' are:

The fact that so many DPMs "fix" 5th met avulsions, 5th met shaft fx, central met shaft or neck fx, hallux extra articular fx, Weber A fx, SER2 minimal displaced without instability in low activity ppl, extra articular calc and tarsal fx, acute lat or high ankle sprain surgery in ppl FAR from being legit athletes, etc is kinda sad to see. I am embarassed to that on the board at the big hospitals or ASCs or in social media, podiatry throwaway journals, etc.

Many DPMs also do flap and fusions and grafts for hopeless Charcot midfoot or ankle that just ends up in a bucket soon after. That is a sadly common career path 'specialty' for DPMs, but it's easy to get away with since MDs don't want those consults or cases. We ride that 'limb salvage surgery' ticket to university hospital work. It is basically the podiatry equivalent of the general surgeons who will repeatedly try bariatric cases on poor candidates destined for complications, failure, or even death.

And don't get me started on the excess forefoot slams or mpj implant stuff on older folks that are fine with just wider shoes, pads, or a simple first mpj fusion or keller.

... To me, it's much more a function of scarcity than boards. The docs boarding this nonsense just don't have anything else legit to do, we have far too many 'foot and ankle surgeons,' and they want to do surgery. Sure, cases for ABFAS boards may play a role in aggressively looking for surgery pts while BQ, but I would think ORIF-ing most of the trauma that basically any text says should be non-op might actually work against them on case reviews.

 

[dtrack22]

I would still say ABFAS is the best we have (do we want standards or no standards?)

It’s not hard. We should have board standards that mimic any other surgical specialty. Our “best” board does not. And the most onerous requirements were put into place by leadership who generally received far less/worse training than current grads, and they also didn’t jump through any of the hoops they put in front of the new grads to get their own certification.

So far 100% of the malpractice cases I’ve reviewed are from ABFAS certified podiatrists. One is an attending at a residency program. ABFAS may actually be more of a danger to the public than the alternative…

 

[Shiyuan]

Take it. Who cares if no ABFAS RRA? Dumb reason not to take a great offer IMO.


….


Go ABPM. 💪🏻

 

[Hybrocure]

The fact that so many DPMs "fix" 5th met avulsions, 5th met shaft fx, central met shaft or neck fx, hallux extra articular fx, Weber A fx, SER2 minimal displaced without instability in low activity ppl, extra articular calc and tarsal fx, acute lat or high ankle sprain surgery in ppl FAR from being legit athletes, etc is kinda sad to see that on the board at the big hospitals or ASCs.

Nailed it. Unfortunately residents and new docs are being told by ABFAS lecturers, surgical reps, and podiatrists sponsored by surgical companies who help design these systems to throw a nail in every fibular fracture or up every 5th met shaft.

I’ve never had to take a hallux fracture to the OR. I’ve yet to have to operate on a fifth met and I see them often. Haven’t operated a central met. 95% of my lateral ankle sprains heal fine non op long term. Operable ankle fractures usually land in an ortho office or at the ED w an ortho referral before they have a chance to be scheduled in a private practice. Every fib fx I’ve seen in office has healed fine nonop.

I remember fresh out of residency I thought I had to operate on all these things my attendings operated on, then over time I just watched all those things heal without the need for surgery in my practice and it really changes your perspective.

I’ve given up on RRA cert. I’ll pursue Foot cert. Much easier to have a good relationship with the local recon/RRA guy in town you can send these rare complex cases to and theyll send you the TFP stuff they don’t want crowding their clinic.

Of course, every case ABFAS reviews to certify a podiatrist requires hardware to be placed so it can be judged. So you’ll have every new doc throwing every piece of metal they can into everything that comes their way.

 

[icebreaker32]

Take the job.

You know firsthand the job market is horrible. The only saving grace is that it only takes one good opportunity. Unless you are well above average in your networking and/or your CV really standouts this might be your one chance.

 

[wakaflocka88]

I’m in a predicament, I’ve been offered a fairly good salary by an ortho/msg but they wouldn’t want me to do any rearfoot. I guess it’s less headache and I don’t enjoy those procedures that much anyways but it does suck to know I’ll never get abfas certified in rra

100% take it. Make the money and go enjoy life and forget about podiatry politics forever.

I wonder if someone is going to rally in ABFAS posters to flood this section of how negatively we speak of them……

 

[AttackNME]

Honestly we can use good people in advancing non-surgical podiatry, it makes us the most money

 

[Hybrocure]

Honestly we can use good people in advancing non-surgical podiatry, it makes us the most money

I agree. Patients inherently want to avoid surgery. I operate, but when someone comes in and their first words are “I need surgery” 9 times out of 10 they’re not the type of person you want to cut on.

I wish there were more non op presentations at our lecture circuits that’s for sure. Unfortunately unless you’re slinging graft pics or hardware X-rays to show off you won’t be getting that rep $$

 

[Retrograde_Nail]

It’s not hard. We should have board standards that mimic any other surgical specialty. Our “best” board does not. And the most onerous requirements were put into place by leadership who generally received far less/worse training than current grads, and they also didn’t jump through any of the hoops they put in front of the new grads to get their own certification.

So far 100% of the malpractice cases I’ve reviewed are from ABFAS certified podiatrists. One is an attending at a residency program. ABFAS may actually be more of a danger to the public than the alternative…

Yeah they are all ABFAS certified because anyone who only has ABPM is prob not operating a lot. I don’t know many pods doing pilons, TARs, Charcot etc with only an ABPM cert…

 

[GreenHousePub]

I agree. Patients inherently want to avoid surgery. I operate, but when someone comes in and their first words are “I need surgery” 9 times out of 10 they’re not the type of person you want to cut on.

I wish there were more non op presentations at our lecture circuits that’s for sure. Unfortunately unless you’re slinging graft pics or hardware X-rays to show off you won’t be getting that rep $$

Onychomycosis Update 2024

 

[dtrack22]

Yeah they are all ABFAS certified because anyone who only has ABPM is prob not operating a lot. I don’t know many pods doing pilons, TARs, Charcot etc with only an ABPM cert…

So then why the push to limit privileging for ABPM folks who are clearly already self selecting to more general podiatry and forefoot or wound related cases?

If ABPM certifying people is a danger to the public, then I should have at least been sent one case where the DPM in question didn’t have ABFAS. Probably because they are staying in their wheelhouse and are getting privileges based on training/logs. As opposed to ABFAS folks who want so bad to be real surgeons that they seemingly put blinders on when it comes to self assessment of their own training and skills.

 

[Retrograde_Nail]

So then why the push to limit privileging for ABPM folks who are clearly already self selecting to more general podiatry and forefoot or wound related cases?

If ABPM certifying people is a danger to the public, then I should have at least been sent one case where the DPM in question didn’t have ABFAS. Probably because they are staying in their wheelhouse and are getting privileges based on training/logs. As opposed to ABFAS folks who want so bad to be real surgeons that they seemingly put blinders on when it comes to self assessment of their own training and skills.

I think you over simplify things and think podiatry should just follow standards of other professions.

How can you expect that when everything about this profession makes zero sense?

Education is a joke, clinical rotations are a joke, residency training is variable and mostly a joke, the abundance of fellowships make no sense.

Podiatry has no direction. Zero. We can't even get universal scope. Nurses have more scope than us despite us doing residency training. Nurses can do online classes and do some bogus clinical rotations and get more scope than we have now. A complete joke.

Everyone oversells their training and education to sound more important. The fact is none of us have gone through the same standards as MD/DO orthopedics. No matter how many times you redefine yourself you silly surgical podiatrist, foot and ankle surgeon, orthoplastic surgeon, podioplastic surgeon you.

I think this entire discussion about boards is ridiculous because of all of the above. There will never be a clear answer as there are too many podiatrists with different agendas and different points of view based on their own education and training who continue to meddle. We just waste time.

I remember when some people thought rebranding ABPS to ABFAS would be better for the profession because it would mean people would recognize our training better since it said foot and ankle surgery in it now. That is how delusional everyone is.

 

[Feli]

...residency training is variable and mostly a joke, the abundance of fellowships make no sense...

 

[NatCh]

Patients inherently want to avoid surgery.

This wasn't really the point you were trying to make but I'm good at going off on tangents, so....

When I hear a patient say, "I don't want surgery" I take it as, "I don't want surgery unless I need it." If surgery is the best treatment then I'll gladly tell them so. Most of the time they've already considered that surgery might be in the cards before they made the appointment, and they just want to make sure they're making the right decision.

If they're looking for advice on ways to "work through the problem" (e.g., where they should stick their yoga toes and K-T tape to fix their grade 3 hallux rigidus so they can keep running 50 miles per week) then I'll send them to P.T. or whatever and tell them to come back if (i.e., when) it doesn't work. I've wasted too many hours in my career trying to "work with the patient" doing Mickey Mouse, which just leads to frustration on all sides.

The end.

 

[dtrack22]

I think you over simplify things and think podiatry should just follow standards of other professions.

How can you expect that when everything about this profession makes zero sense?

Education is a joke, clinical rotations are a joke, residency training is variable and mostly a joke, the abundance of fellowships make no sense.

Podiatry has no direction. Zero. We can't even get universal scope. Nurses have more scope than us despite us doing residency training. Nurses can do online classes and do some bogus clinical rotations and get more scope than we have now. A complete joke.

Everyone oversells their training and education to sound more important. The fact is none of us have gone through the same standards as MD/DO orthopedics. No matter how many times you redefine yourself you silly surgical podiatrist, foot and ankle surgeon, orthoplastic surgeon, podioplastic surgeon you.

I think this entire discussion about boards is ridiculous because of all of the above. There will never be a clear answer as there are too many podiatrists with different agendas and different points of view based on their own education and training who continue to meddle. We just waste time.

I remember when some people thought rebranding ABPS to ABFAS would be better for the profession because it would mean people would recognize our training better since it said foot and ankle surgery in it now. That is how delusional everyone is.

This is just all over the place and has nothing to do with the premise of the post you quoted. Pop a Xanny or two, watch some football, take a break from the internet…

 

[Retrograde_Nail]

This is just all over the place and has nothing to do with the premise of the post you quoted. Pop a Xanny or two, watch some football, take a break from the internet…

It has everything to with what you posted. You like to crap on ABFAS because you are not ABFAS certified and you practice in a state where ABPM allows you do surgery in the ankle etc. Lucky you.

If you got your cases right away at a better job and got ABFAS certified you wouldn't bother with these posts. You got an agenda.

Doesn't mean ABFAS pathway to certification is legit. I agree its a terrible unfair process and no other specialty has to deal with it but what else would you expect from podiatry?

 

[dtrack22]

It has everything to with what you posted. You like to crap on ABFAS because you are not ABFAS certified

That’s not at all why I crap on ABFAS. I crap on board certification in general. I crap on MOC processes regardless of which board they are a part of. I crap on stupid regulatory hurdles that are falsely or unscientifically tied to “patient safety” and “expertise.”

you practice in a state where ABPM allows you do surgery in the ankle etc. Lucky you.

Yeah, that’s nearly all states. It’s not lucky when you’re in the overwhelming majority.

If you got your cases right away at a better job and got ABFAS certified you wouldn't bother with these posts. You got an agenda.

I have cases for ABFAS. I simply don’t need ABFAS and got tired of logging everything I did and paying an organization I don’t agree with more money for no reason. I don’t pay money to my state or the APMA for the same reason. I am principled. I would make the exact same posts about the flaws within their process regardless of my certification status. It’s not as if something I say here will change anything within the various organizations that don’t really serve our best interests. It’s an “anonymous” Internet forum. If I had an agenda I would probably put myself in a position to do something about those things I don’t agree with. But I don’t care at all what other podiatrists do. It no longer affects me. I’m free from the 🍆 measuring contests our various boards and professional organizations continue to engage in. I don’t need to nor do I want to be involved in any of it. I’m perfectly content doing my job, collecting my paycheck, and enjoying my relatively stress free life outside of work.

 

[Shiyuan]

I don’t care at all what other podiatrists do. It no longer affects me. I’m free from the 🍆 measuring contests our various boards and professional organizations continue to engage in. I don’t need to nor do I want to be involved in any of it. I’m perfectly content doing my job, collecting my paycheck, and enjoying my relatively stress free life outside of work.

100% this. I just want to serve my community to the best of my ability, go home, throw a Star Wars shirt on and be myself.

 

[Feli]

...There will never be a clear answer as there are too many podiatrists with different agendas and different points of view based on their own education and training who continue to meddle. ....

..It has everything to with what you posted. You like to crap on ABFAS because you are not ABFAS certified and you practice in a state where ABPM allows you do surgery in the ankle etc. Lucky you.

If you got your cases right away at a better job and got ABFAS certified you wouldn't bother with these posts. You got an agenda.

Doesn't mean ABFAS pathway to certification is legit. I agree its a terrible unfair process and no other specialty has to deal with it but what else would you expect from podiatry?

Yes, this is pretty much the way it is in all the world.
People try to discredit or de-value what they don't have... and venerate what they do happen to have.

It's just like MDs were saying CRNAs were marginally qualified... now CRNAs are that way with AAs.
A bit is insecurity, but mainly, people are going to protect where and how they eat.

In podiatry, that might be promoting fellowship, ABPM, ABFAS, a certain type of job - or whatever else - while down-talking others.
It will only get worse as podiatry gets more and more saturated... crazier and more aggressive marketing and competition and deprecation of colleagues/certs.

 

[Boba Foot]

I’m in a predicament, I’ve been offered a fairly good salary by an ortho/msg but they wouldn’t want me to do any rearfoot. I guess it’s less headache and I don’t enjoy those procedures that much anyways but it does suck to know I’ll never get abfas certified in rra

Take it. RRA cases are overrated. Bigger cases, same noncompliant patients, more problems.

 

[Hungry_Anxiety8703]

I often wonder why people seem so attached to surgery in this profession. It’s not like other surgical specialties where you get handsomely rewarded for your efforts. Quite often if you have no involvement in a surgical center or have full ownership you are giving away the bulk of the reimbursement back to your employer anyway. You are agreeing to see this patient for an extended amount of time for minimal compensation in comparison to simple in office procedures. Unless you have some undying passion for foot surgery I don’t see why it would influence your job selection decision much.

Hell even in ortho you will see people who decide to go F&A get poked fun at because it’s the lowest paying speciality

 

[Feli]

I often wonder why people seem so attached to surgery in this profession. It’s not like other surgical specialties where you get handsomely rewarded for your efforts...

I think part of it is just offering the whole skill set. It is illogical not to do as much as you learned and can offer.

For the guys who push surgery and are trying to operate on every patient, that's ego. Sure.

But for most, it's just having more services to offer, be referred, and get paid for. Self-limiting (not seeking board cert and continued competence) for foot surgery, even just RRA, is roughly as dumb as those DPMs who refuse to cut nails or refuse to do wound care or similar.

I do get not doing RRA since those refers/cases are hard to get in many DPM situations. They're hard, complications much more devastating, and many DPMs get very little training for them. However, basic foot pathology surgery is needed just to be competitive in nearly any DPM job - or owner - situation these days.

There are 600+ podiatrist grads coming out every year now. Over six hundred. All-time highs from here on out.
There will be even more grads as new schools expand class sizes.
That is more than orthopedics (all specialties, head to toe) graduate pretty soon.
The USA population is not growing.
That means more DPM apps for jobs and more offices, more options for patients.
Perhaps more pod schools will be added. Who knows. I though they were absolutely done after AZ. Western was wtf... they both grew since inception. And now, two more schools.

Podiatry is relegated to a very small chunk of human anatomy and has limited scope. I think it's very shortsighted to voluntarily limit oneself from any aspect of podiatry that your peers will nearly all be doing. Why offer 60 or 80% of what you trained for and could be referred when many others offer 95% or 100%? It makes no sense. This not only limits patients for PP, it limits job options for hospitals and MSGs.

Well, ok... sure, maybe it makes sense for some rare niche DPM who has convinced a university to pay him to be a "pediatric clubfoot and vertical talus guru" or "molecular foot wound statistician" or perhaps "forensic podiatry fellowship director" to see six or eight patients per day and do that self-limitation... but that is well under 1% and not typically viable without a cush 'academic' situation, and we all know this. That is not to mention how low the transfer options would be for such a doc. It is a risk play to limit and sub-specialize without doubt, particularly early in one's career.

What have we seen in medicine overall in the past when times got tough? Specialists turned to general exams to make ends meet. Podiatry doesn't have this option, due to scope. It is not wise to limit an already highly limited specialty of podiatry / F&A. Nobody logs ABFAS cases or takes the exams for fun; they do it so that their application doesn't get thrown out at most decent jobs... and so that they will be BC in their primary specialty (podiatric surgery) for any current or future hospital privileges and bylaws.

...Surgery is the most crippling thing in podiatry to limit; one's logs or lack of board cert can't really be recovered from. It would be different to say no wound care or no pediatric patients or something easy to start again later on, but surgery is the hardest part of podiatry to get hospital privileges for. To toss that away basically relegates a DPM to where we were 20+ years ago: limited pay to do PPMR office wounds and nails and insoles and injects, limited to non-op jobs, or doing PP competing with DPMs all around you for jobs and patients who can do everything you do - plus a lot more.

 

[dtrack22]

I often wonder why people seem so attached to surgery in this profession. It’s not like other surgical specialties where you get handsomely rewarded for your efforts. Quite often if you have no involvement in a surgical center or have full ownership you are giving away the bulk of the reimbursement back to your employer anyway. You are agreeing to see this patient for an extended amount of time for minimal compensation in comparison to simple in office procedures. Unless you have some undying passion for foot surgery I don’t see why it would influence your job selection decision much.

Hell even in ortho you will see people who decide to go F&A get poked fun at because it’s the lowest paying speciality

Because podiatry is a back door to become a pseudo-orthopod. I would venture to guess a large number of applicants go into podiatry to become “surgeons” when they otherwise would never have been able to do so given the fact that they couldn’t even get an interview at your average MD or DO school. They then go through a “surgical residency” and either feel the need to utilize the training or they have an inferiority complex when they find out that there is still plenty of disrespect towards them from some real doctors and a larger than expected number of their fellow podiatrists. That fuels the surgical desire even more. Some want to separate themselves from their peers who they see as less than competent and so striving to become an elite (Podiatric) Foot & Ankle Surgeon becomes the goal.

Some of us aren’t necessarily “attached to surgery,” but do it because it is indicated and we have the skills to provide the care. But those are the types of Podiatrists who would be happy to do less surgery or give up certain procedures so long as the income stayed the same. Employed, wRVU based DPMs might not be able to do that. Many of us get compensated reasonably well for surgery in that payment model. A secondary wound closure over lunch at the hospital you are employed at pays more than an hours worth of new patient office visits.