Improving surgical skills post-graduation

[Mrbigshot95]

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It feels extremely crazy to be posting this after not being active for over 7 years. What a rollercoaster of a career this has been. I've visited here from time to time and it's nice to see those of you have been around for all that time and reading about some of the positive changes in your careers since then. without further ado...

I don't want to bore anyone with any details regarding my career and I will try to get straight to the point.

Due to a variety of factors, none of which I'll go into, I ended up at a terrible residency which had severely compromised surgical training. I know some people will already be thinking that I should have left, and though I agree (in hindsight), there were personal factors with family that tied me down to that location, as well as promises from the residency about upcoming changes. Ofcourse, none of these changes ever came, and despite us pleading with CPME about our situation from year 1, they did not care. I also know people will want me to disclose which residency program this is, but I will decline to do that at this time. I do believe that the residency has since changed for the better with some structural and management changes and I would not want any of my comments to reflect poorly on the progress that has been made. I feel as though I attended my residency program during the worst 3 years of it, when it had abysmal training, which is quite unfortunate.

Anyway, so I eventually graduated from the program feeling extremely unconfident in my surgical skill and have been working for a private practice as an associate over the past few years. My situation is not terrible financially (though it's not great), and I know that I'm probably getting mustached by the owner, but I feel like it can be much worse. My current boss is mostly aware of my situation and has been willing to mentor me in surgery, but he is quite limited in his scope and does not perform a lot of surgery, which limits my opportunity to learn. I have done a handful of cases over the past few years that have turned out okay, but I can't shake the feeling of anxiety I feel booking any case. Additionally, it feels terrible to feel compromised regarding how I can help my patients. For example, my residency barely showed me any tendon repairs (my boss doesn't do them either), and I want to be able to do tendon work on my patients without feeling that I don't have the skills for it. I'm not looking to do crazy ankle recons, just want to be able to offer what I feel is basic foot/rearfoot surgical services to my patients.

The purpose of this post is to ask what opportunities are available for me to improve my surgical skills. I don't know if this looks like finding the right mentorship situation, attending courses/conferences, doing a fellowship, going back into training (absolutely bonkers idea), or just learning on my own time using videos/books. Unfortunately, my life is busy and currently resolves around my very small children, so certain options are definitely more difficult to execute. I don't have a ton of free time but my family and I are willing to make adjustments if it benefits me and my career. My wife keeps telling me to go to a fellowship and says that we will figure it out. In hindsight, maybe I should have as "remedial/extra" training but I did not pursue that route post-graduation. I know they aren't popular in this forum but I'm really not sure what the best options are for me. It also feels that the problem with good fellowships is that they are pursued by residents who come from good programs (that don't need the additional training) and that has become the expectation by those fellowships. When I spoke with previous residents from my program who went to fellowship (most of which had some level of compromised training), they stated that they had to lie about the training they received and that you just have to "fake it till you make it". I know that this mentality applies to a lot of different career paths, but I just can't get behind that when it comes to real life consequences of operating on someone's body. This is the exact trouble I have today. Like sure, can I "wing" a tendon repair? Probably. And maybe that's the only way to improve? However, my morality prevents me from not sending a patient to go see someone more experienced and "better". Like wouldn't I want that for my own parents/spouse/children?

Ultimately, the reality of the situation might be me just having to make most of the career that I made. I understand very well that there were a lot of career decisions that were in my control and this mostly my fault. I'm willing to sleep in the bed that I made, but if there are any strategies/recommendations that any of you know that could help, I would greatly appreciate it. Or if any of you absolute bosses would be willing to take someone, who is truly willing to work hard and learn, under their wing, I would be forever grateful. I'm sure this post will be met some negativity but I'm willing to take online bashing for sake of improving myself for my children.

Holy **** this became a rant and was totally not "straight to the point". Sorry y'all.

TLDR: Poor surgical trained podiatrist wondering what avenues exist to improve his surgical skills. TIA.

 

[Sybly]

It feels extremely crazy to be posting this after not being active for over 7 years. What a rollercoaster of a career this has been. I've visited here from time to time and it's nice to see those of you have been around for all that time and reading about some of the positive changes in your careers since then. without further ado...

I don't want to bore anyone with any details regarding my career and I will try to get straight to the point.

Due to a variety of factors, none of which I'll go into, I ended up at a terrible residency which had severely compromised surgical training. I know some people will already be thinking that I should have left, and though I agree (in hindsight), there were personal factors with family that tied me down to that location, as well as promises from the residency about upcoming changes. Ofcourse, none of these changes ever came, and despite us pleading with CPME about our situation from year 1, they did not care. I also know people will want me to disclose which residency program this is, but I will decline to do that at this time. I do believe that the residency has since changed for the better with some structural and management changes and I would not want any of my comments to reflect poorly on the progress that has been made. I feel as though I attended my residency program during the worst 3 years of it, when it had abysmal training, which is quite unfortunate.

Anyway, so I eventually graduated from the program feeling extremely unconfident in my surgical skill and have been working for a private practice as an associate over the past few years. My situation is not terrible financially (though it's not great), and I know that I'm probably getting mustached by the owner, but I feel like it can be much worse. My current boss is mostly aware of my situation and has been willing to mentor me in surgery, but he is quite limited in his scope and does not perform a lot of surgery, which limits my opportunity to learn. I have done a handful of cases over the past few years that have turned out okay, but I can't shake the feeling of anxiety I feel booking any case. Additionally, it feels terrible to feel compromised regarding how I can help my patients. For example, my residency barely showed me any tendon repairs (my boss doesn't do them either), and I want to be able to do tendon work on my patients without feeling that I don't have the skills for it. I'm not looking to do crazy ankle recons, just want to be able to offer what I feel is basic foot/rearfoot surgical services to my patients.

The purpose of this post is to ask what opportunities are available for me to improve my surgical skills. I don't know if this looks like finding the right mentorship situation, attending courses/conferences, doing a fellowship, going back into training (absolutely bonkers idea), or just learning on my own time using videos/books. Unfortunately, my life is busy and currently resolves around my very small children, so certain options are definitely more difficult to execute. I don't have a ton of free time but my family and I are willing to make adjustments if it benefits me and my career. My wife keeps telling me to go to a fellowship and says that we will figure it out. In hindsight, maybe I should have as "remedial/extra" training but I did not pursue that route post-graduation. I know they aren't popular in this forum but I'm really not sure what the best options are for me. It also feels that the problem with good fellowships is that they are pursued by residents who come from good programs (that don't need the additional training) and that has become the expectation by those fellowships. When I spoke with previous residents from my program who went to fellowship (most of which had some level of compromised training), they stated that they had to lie about the training they received and that you just have to "fake it till you make it". I know that this mentality applies to a lot of different career paths, but I just can't get behind that when it comes to real life consequences of operating on someone's body. This is the exact trouble I have today. Like sure, can I "wing" a tendon repair? Probably. And maybe that's the only way to improve? However, my morality prevents me from not sending a patient to go see someone more experienced and "better". Like wouldn't I want that for my own parents/spouse/children?

Ultimately, the reality of the situation might be me just having to make most of the career that I made. I understand very well that there were a lot of career decisions that were in my control and this mostly my fault. I'm willing to sleep in the bed that I made, but if there are any strategies/recommendations that any of you know that could help, I would greatly appreciate it. Or if any of you absolute bosses would be willing to take someone, who is truly willing to work hard and learn, under their wing, I would be forever grateful. I'm sure this post will be met some negativity but I'm willing to take online bashing for sake of improving myself for my children.

Holy **** this became a rant and was totally not "straight to the point". Sorry y'all.

TLDR: Poor surgical trained podiatrist wondering what avenues exist to improve his surgical skills. TIA.

If s ok podiatry is f upped. I been in it 40 years or soon .. ugh

 

[Stormblest]

I have also been thinking about this. I did a decent residency and did a lot of diabetic foot cases and mostly more straightforward stuff.

Now when I have a more complex case such as severe, rigid deformities I know what to do it’s just that I haven’t done much of it and it seems like they don’t turn out exactly how I envisioned. Maybe that’s to be expected to an extent or maybe I should be referring those people out.

One thing I do pretty regularly though is ask reps to set up a cadaver lab so I can practice and refresh myself on whatever surgeries I have coming up and it definitely helps. I suspect at some point I will stop doing this but I’m still less than 2 years out from residency and feel like there is much still to learn.

 

[heybrother]

Help me understand something - you are 7 years out of training? How many cases have you done since leaving residency ie. you said a handful?

 

[air bud]

Operate more.

 

[deleted1235332]

Wow. Pretty sad to read OP. I want to first off congratulate you for at least giving a damn. A lot of our colleagues don’t feel comfortable/confident doing cases and proceed anyways which is obviously terrible for patients and outcomes. With that said, there is always some uncomfortableness with operating. That’s expected. Especially the fresher you are.

I’m unsure if even a fellowship would truly make you feel confident/comfortable though. I do think having someone scrub in on your cases would be beneficial. But ultimately if you’re starting to get far removed from training and don’t feel comfortable I think you should consider doing mostly nonop stuff. No shame in that.

Good luck

 

[Adam Smasher]

Operate more.

Second this. Ride the pus bus. You'll be surprised how much you figure out doing cases everyone expects are going to go badly no matter what you do.

 

[air bud]

But seriously. Acfas has labs, lots of things have paid labs. Rep cadaver labs.... It's more about being familiar with the anatomy. You need to see it.

 

[Adam Smasher]

Aso, Industry labs are useful within the narrow confines of what the reps want to sell you.

Some conferences have cadaver labs which is a less biased way to learn, since it's your own dime. Example: ACFAS usually has nice hands-on labs.

 

[Mrbigshot95]

Thanks for the responses so far everyone!
Based on what was said so far, its clear that it wasn't at all clear how long I've been working. Only been an attending for 1.5 years. the 7 years was from whenI was posting as a student! Also, I intentionally said handful to not be judged and I suppose that term can be extremely subjective. Its truthfully very little. averaging out to less than 1 per month.

 

[Mrbigshot95]

If s ok podiatry is f upped. I been in it 40 years or soon .. ugh

It definitely is. It's funny how I read some of my student posts and messages that have so much enthusiasm for the career. That has not aged well at all.

 

[Mrbigshot95]

I have also been thinking about this. I did a decent residency and did a lot of diabetic foot cases and mostly more straightforward stuff.

Now when I have a more complex case such as severe, rigid deformities I know what to do it’s just that I haven’t done much of it and it seems like they don’t turn out exactly how I envisioned. Maybe that’s to be expected to an extent or maybe I should be referring those people out.

One thing I do pretty regularly though is ask reps to set up a cadaver lab so I can practice and refresh myself on whatever surgeries I have coming up and it definitely helps. I suspect at some point I will stop doing this but I’m still less than 2 years out from residency and feel like there is much still to learn.

Kudos to you for trying those cases. As others have said, I guess more experience will hopefully result in better outcomes for you. Sometimes the idea of using a case as a good learning experience makes me feel unethical like I should send it out. Also my anxiety pushes me over the edge and I send it.

The rep suggestion is really helpful though. I will try doing that as often as I can!

 

[Mrbigshot95]

Help me understand something - you are 7 years out of training? How many cases have you done since leaving residency ie. you said a handful?

I've been out of training for 1.5 years now and have averaged out to less than 1 per month.

 

[Mrbigshot95]

Some of you have echoed operating more which I totally agree with. I have overcome a small percent of my anxiety just by having more experience. For the cases that I was trained in (nothing well unfortunately) I know that I'll continue to find increase in confidence and skill. I suppose this post was asking more about learning how to do the things I wasn't trained in, which feels like is a lot.

I do also understand that medicine is constantly changing and innovations come out frequently. I'm sure many of you are doing procedures and techniques that may not have even been out at the time of your training. Sometimes you just have to suck it up and try new things. In my case it's just many new things lol.

Appreciate the recommendations about attending conferences/labs. It feels tough to leave wife and very small children as we have no help where we live but I can't use that as an excuse all the time. I will try making more time for these things and will figure a way to make it happen in terms of the fam.

 

[heybrother]

I've been out of training for 1.5 years now and have averaged out to less than 1 per month.

You replied before I could post it - you're going to have to find a way to do more cases or you're never going to experience the slow methodical growth that comes with continuously operating. Skills are transferable.

 

[Mrbigshot95]

Wow. Pretty sad to read OP. I want to first off congratulate you for at least giving a damn. A lot of our colleagues don’t feel comfortable/confident doing cases and proceed anyways which is obviously terrible for patients and outcomes. With that said, there is always some uncomfortableness with operating. That’s expected. Especially the fresher you are.

I’m unsure if even a fellowship would truly make you feel confident/comfortable though. I do think having someone scrub in on your cases would be beneficial. But ultimately if you’re starting to get far removed from training and don’t feel comfortable I think you should consider doing mostly nonop stuff. No shame in that.

Good luck

Thanks. I often tell myself that nobody gives a crap about their patients more than me. I hope that I never have to compromise that for the rest of my career. Definitely agree with the uncomfortableness statement and I am quite fresh so there more of that right now for sure.

Thats fair, and my current boss is willing to do that from time to time which is helpful. That is basically what I currently do. Very little cases. Mostly RFC. Not bothered by it too much currently. Just want to be able to do more for people without feeling like I "can't". I felt so bad when finishing residency that I even considered full non op. But that felt like such a limiting move both personally, and professionally (as far as career opportunities are concerned).

 

[Feli]

Operate more.

Yep... this is about it. ^^

...I would say too little, too late. Sounds pessimistic, but it is about the surgical principles: muscle memory, familiarity with dissections, approaches, instruments and implants. There is a reason surgery training is years long and thousands of cases (hopefully). The reason MD/DO surgery residency is a lot better than nearly all podiatry residencies is that they are standardized to do much more overall imaging reps, academics, suture reps, dissection reps, implant reps, etc etc etc. They have the surgical principles down, they have done all the common stuff, they know the anatomy and have passed difficult tests on all of it.

It is fine to learn a similar procedure if you have the fundamentals down (eg, MIS bunion when you've done many open Austins... or Lapidus when you've done many Austins and first MPJ fusions... or peroneal repair when you've done lateral ankle stabs), but you can't re-invent the wheel. Can't make chicken salad out of chicken spit. If you are trying to learn Hagund or Achilles ruptures when you've hardly ever done Achilles surgery aside from watching a few percutaneous TALs with TMA in residency, then that will not go well. Same with triple arthrodesis when you've barely ever done a Kidner. You will frustrate yourself and likely have bad outcomes.

If you truly want to learn, do a fellowship. But honestly, that is a waste at this point. The ship has sailed. The weekend classes are expensive and just to reinforce or learn a new implant... but they are not residency in any way or shape or form. It is better to just stick to what you know and feel comfortable with. If that's just wound care and basic amps... ok. If it's forefoot elective and the wound/amp, ok also. If it's more, then sure. You can make a fine living just doing office procedures, referring out complicated surgery (to the between 10 and 100+ "Foot and Ankle Surgeon" associates in your area)... and you can make a good living even sending the basic surgery out also. There is no shortage of other podiatrists hungry for surgey in any corner of USA; that is 1000% iron clad truth. You can make a fine living with low stress just doing office dx, injects, DME, warts, nails, RFC, basic wounds, etc. Gotta swallow your ego when you have hundreds of thousands in student loans, and you won't hurt anyone by doing surgery you are not skilled at if you approach your practice that way.

Personally, I had hoped to learn Lapidus really well in training, but the switch from mostly DMO (Austin) to Lapidus was just starting, and there were only a handful of programs that would get residents a lot of first assist Lapidus. I graduated with maybe 10 Lapidus, 20 first MPJ fusions, 20 first MPJ implants, 20 base/shaft osteotomies, 100 Austins... and 1500 overall procedures on my logs. I did Lapidus for big or hypermobile or young bunions right from the start after graduation... and it was the other first ray stuff and overall volume of 2-5 cases and 5-10+ procedures scrubbed in each day of residency that gave me the confidence to do Lapidus pretty well (very well as I got some exp). I have probably done at least 100 Lapidus as an attending now (and about that many first MPJ fusion). Get it? It's the principles, overall skill set with the instruments, dissections. GL
[fyi, I am above average, for a DPM, at surgery and can also say that I can make fine income with little or no surgery and the 80 or 90% of the problematic stress, paperwork, and bad hours comes from surgery... so it will be very nice to do just that and eventually wind down being non-op last 6mo of my career]

 

[Mrbigshot95]

You replied before I could post it - you're going to have to find a way to do more cases or you're never going to experience the slow methodical growth that comes with continuously operating. Skills are transferable.

100%. and I think the operating rate will definitely increase. Increased confidence as well as increased schedule. Still building up rn.

 

[Mrbigshot95]

Yep... this is about it. ^^

...I would say too little, too late. Sounds pessimistic, but it is about the surgical principles: muscle memory, familiarity with dissections, approaches, instruments and implants. There is a reason surgery training is years long and thousands of cases (hopefully). The reason MD/DO surgery residency is a lot better than nearly all podiatry residencies is that they are standardized to do much more overall imaging reps, academics, suture reps, dissection reps, implant reps, etc etc etc. They have the surgical principles down, they have done all the common stuff, they know the anatomy and have passed difficult tests on all of it.

It is fine to learn a similar procedure if you have the fundamentals down (eg, MIS bunion when you've done many open Austins... or Lapidus when you've done many Austins and first MPJ fusions... or peroneal repair when you've done lateral ankle stabs), but you can't re-invent the wheel. Can't make chicken salad out of chicken spit. If you are trying to learn Hagund or Achilles ruptures when you've hardly ever done Achilles surgery aside from watching a few percutaneous TALs with TMA in residency, then that will not go well. Same with triple arthrodesis when you've barely ever done a Kidner. You will frustrate yourself and likely have bad outcomes.

If you truly want to learn, do a fellowship. But honestly, that is a waste at this point. The ship has sailed. The weekend classes are expensive and just to reinforce or learn a new implant... but they are not residency in any way or shape or form. It is better to just stick to what you know and feel comfortable with. If that's just wound care and basic amps... ok. If it's forefoot elective and the wound/amp, ok also. If it's more, then sure. You can make a fine living just doing office procedures, referring out complicated surgery (to the between 10 and 100+ "Foot and Ankle Surgeon" associates in your area)... and you can make a good living even sending the basic surgery out also. There is no shortage of other podiatrists hungry for surgey in any corner of USA; that is 1000% iron clad truth. You can make a fine living with low stress just doing office dx, injects, DME, warts, nails, RFC, basic wounds, etc. Gotta swallow your ego when you have hundreds of thousands in student loans, and you won't hurt anyone by doing surgery you are not skilled at if you approach your practice that way.

Personally, I had hoped to learn Lapidus really well in training, but the switch from mostly DMO (Austin) to Lapidus was just starting, and there were only a handful of programs that would get residents a lot of first assist Lapidus. I graduated with maybe 10 Lapidus, 20 first MPJ fusions, 20 first MPJ implants, 20 base/shaft osteotomies, 100 Austins... and 1500 overall procedures on my logs. I did Lapidus for big or hypermobile or young bunions right from the start after graduation... and it was the other first ray stuff and overall volume of 2-5 cases and 5-10+ procedures scrubbed in each day of residency that gave me the confidence to do Lapidus pretty well (very well as I got some exp). I have probably done at least 100 Lapidus as an attending now (and about that many first MPJ fusion). Get it? It's the principles, overall skill set with the instruments, dissections. GL
[fyi, I am above average, for a DPM, at surgery and can also say that I can make fine income with little or no surgery and the 80 or 90% of the problematic stress, paperwork, and bad hours comes from surgery... so it will be very nice to do just that and eventually wind down being non-op last 6mo of my career]

Thanks for the response and honesty. As I stated in my original post, I am okay with laying in the bed that I made. I just wanted to know if any actually viable avenues existed that felt like they may be good options for me. If there are none, I have no problem hearing that harsh reality from you all. I don't need fake optimism from anyone here. I wouldn't call your response pessimistic. Realistic is more accurate and it's appreciated.

 

[Retrograde_Nail]

Do as many courses possible

 

[eyeeye_captain]

I can make fine income with little or no surgery and the 80 or 90% of the problematic stress, paperwork, and bad hours comes from surgery...

Since you folks have given the OP good advice already (yeah, it really is just reps), I’ll just add some more commendation for being the doc who cares, wants to be able to offer what’s needed, and wants to make sure the patient gets appropriate care. Sorry your program failed you.

Trigger warning: I get the skepticism on fellowships here. If the wife is on board and you’re ok biting the bullet at a program you’ve vetted and will actually let you cut, then that’s going to be the fastest way to get closer to your goals. Cadavers are better than the pig eyes I used to practice on, but real patients are always better. In theory it would be easiest to get volume and mentorship, but I know the feelings here, and the other folks will have a better feeling for it that’s realistic.

While I continue to be flattered that Feli generally makes MD/DOs out to be bigger rock stars, you best believe I know folks out of good, name brand residencies who have done fellowships not for the extra breadth of skills but because of a lack of confidence. If you’re thinking about LASIK etc. and the doc advertises that they did a refractive fellowship, pretty decent chance they fall into this category. It’s kinda the unspoken reason for why general surgeons do MIS programs. It doesn’t make them bad surgeons, just usually tells you they were self aware enough to want more training.

 

[Mia McBhul]

The purpose of this post is to ask what opportunities are available for me to improve my surgical skills. I don't know if this looks like finding the right mentorship situation, attending courses/conferences, doing a fellowship, going back into training (absolutely bonkers idea), or just learning on my own time using videos/books.

Pursue a fellowship. You'd be surprised how many people do a fellowship few years out of residency. I personally did a fellowship and it advanced my skills significantly! Fellowship directors are also aware of the quality of training (or rather lack thereof) being given in todays podiatry residencies and the right director will certainly be sensitive to your situation.

You've spent so many years of your life into this already. Whats 1 more year?

 

[air bud]

Pursue a fellowship. You'd be surprised how many people do a fellowship few years out of residency. I personally did a fellowship and it advanced my skills significantly! Fellowship directors are also aware of the quality of training (or rather lack thereof) being given in todays podiatry residencies and the right director will certainly be sensitive to your situation.

You've spent so many years of your life into this already. Whats 1 more year?

Not trying to be a jerk....but you have documented your "situation"...what did a fellowship ultimately get you?

 

[Mia McBhul]

Not trying to be a jerk....but you have documented your "situation"...what did a fellowship ultimately get you?

surely it would've been a much worse "situation" if I wasn't capable of doing any surgery other then infections/amps...now I'm opening up my own practice in a few months. I wouldn't have the guts to do that if I didn't feel self confident about my surgical skills

 

[heybrother]

surely it would've been a much worse "situation" if I wasn't capable of doing any surgery other then infections/amps...now I'm opening up my own practice in a few months. I wouldn't have the guts to do that if I didn't feel self confident about my surgical skills

You don't need surgical skills to open a practice - you need cash money 🙂

I'm starting a practice currently - pleasant surprise. My hospitals credential "me" - not my practice. I wrote to them asking if I'd have to recredential again and they said - no, you just need to change your address with us. Such a relief.

 

[619]

I recommend you attend the Podiatry Institute Cadaver Course based in Atlanta. Very hands-on. Start with the fore-foot course. All the best OP

Cadaver Courses | The Podiatry Institute, Inc. | Decatur, GA

Enhance your surgical skills with our Cadaver Courses. Join us for hands-on training & expert instruction. Limited spots available!

www.podiatryinstitute.com

 

[air bud]

surely it would've been a much worse "situation" if I wasn't capable of doing any surgery other then infections/amps...now I'm opening up my own practice in a few months. I wouldn't have the guts to do that if I didn't feel self confident about my surgical skills

Awesome glad you are doing your own thing

 

[SouthPod7]

What did you spend those 3 years in residency doing then? Were you just a clinic slave? Was this a VA program?

 

[Mia McBhul]

You don't need surgical skills to open a practice - you need cash money 🙂

not really, including buying the xray machine my initial start up costs will be like ~40k..

 

[heybrother]

not really, including buying the xray machine my initial start up costs will be like ~40k..

It hasn't been as bad as I thought it would be, but I'm spending more than you because I bought the building I'm going to be in. My suspicion though is my true practice spend is super close to where you are at.

Buying stuff for your office is funny though. We bought some stuff on Wayfair ie. waiting rooms chairs. They were total crap and the screw holes didn't line up. Got our money back and they literally told us not to return them - just throw them away. Went to a used office furniture store and bought near pristine medical grade furniture for a song.

Have been knocking stuff out but realized I need to pay for VOIP phones. Spent the morning trying to see if there's a way not to pay ECW for Healow.

Trying to build it right to start with is interesting, but there will be something to be said for just falling back into seeing patients.

 

[Aresnebula]

not really, including buying the xray machine my initial start up costs will be like ~40k..

Do you own your office space?

 

[heybrother]

Do you own your office space?

At $40K - probably not.

I purchased a physician office building. The doctor had moved elsewhere in town to a newer nicer area. Here's how my commercial loan was structured. In residential - you buy a building and just pay it off over 30 years or whatever. For me - I put down 15% and then I pay each month as if its a 25 year mortgage but I owe a balloon payment at some version of 3/5/7 years where I either pay it off or refinance. The 3/5/7 year plans determined the interest rate though they were all pretty similar with about a 0.5% spread from top to bottom. Had to setup my business accounts with the bank.

 

[Hybrocure]

This is a good thread and I think has a lot of great advice that would help a lot of people in OPs situation who don’t post here and just lurk, because I feel this is a more common situation than many think.

Lots of crappy residencies out there. In my situation mine was decent but I am in PP for years now with just not the surgical volume I had back has a resident.

You get rusty if you don’t do certain cases often enough. Muscle memory does take hold at times but every now and again you get thrown a curveball with patients who have big ass feet and bleed like mfs, ****ty anatomy, etc.

As others have stated here - try courses and reach out to your reps for anatomy labs. For some reason I’ve found when I do a lab my skills from residency snap right back for whatever case I’m planning to do. Also, make connections with other pods in your area or at your hospital. You’d be surprised how many docs are willing to help you out and scrub in with you for cases.

There’s a lot of good people out there willing to help. If a pod in my area wanted me to help them out even though I’m technically “competition” I wouldn’t hesitate to do it. They would do the same for me. It’s just how it is. Every one of us no matter how well trained has felt uncomfortable at some point before with one case or another.

 

[Mia McBhul]

Do you own your office space?

No. I'll be renting...just a little concerned on how I'll be able to fill up the office for a good 5 days. will probably be doing nursing homes on the side while I build the practice.

The high horse I've been sitting on is actually a donkey!! worked too hard to achieve the numbers to get RRA certification, only to end up going after toenails aggressively. Ultimately, toenails are how a podiatry practice is built

 

[Stormblest]

No. I'll be renting...just a little concerned on how I'll be able to fill up the office for a good 5 days. will probably be doing nursing homes on the side while I build the practice.

The high horse I've been sitting on is actually a donkey!! worked too hard to achieve the numbers to get RRA certification, only to end up going after toenails aggressively. Ultimately, toenails are how a podiatry practice is built

Sounds like your skills would be much better used working at a hospital tbh. Crazy that some do a 3 year residency + fellowship to mostly do routine foot care. Need a 1 or 0 year option for people who have little interest in surgery.

 

[DogSnoot]

No. I'll be renting...just a little concerned on how I'll be able to fill up the office for a good 5 days. will probably be doing nursing homes on the side while I build the practice.

The high horse I've been sitting on is actually a donkey!! worked too hard to achieve the numbers to get RRA certification, only to end up going after toenails aggressively. Ultimately, toenails are how a podiatry practice is built

 

[Mia McBhul]

Sounds like your skills would be much better used working at a hospital tbh. Crazy that some do a 3 year residency + fellowship to mostly do routine foot care. Need a 1 or 0 year option for people who have little interest in surgery.

I don't disagree. But those hospital jobs are extremely rare to come by these days it seems...I am absolutely interested in surgery. But these are just the cards I've been dealt. Will build up the practice with the toenails and take lots of call at the hospital with hopes that I build up enough of a reputation that surgical consults eventually find their way to me. Thankfully I'm opening up in an area that is not oversaturated

 

[Adam Smasher]

Denial: I'm finishing up residency and all my attendings tell me what I great surgeon I'll be! I'm never going to trim toenails.
Bargaining: Well I need to trim some toenails to fill the empty slots on my schedule.
Anger: The only referrals I ever get are for toenails!!!
Depression: So this is my career, all the years of school, all the papers I wrote, the presentations I gave, all for toenails.
Acceptance: 🦞

 

[Boba Foot]

People just need to accept the fact that you're gonna have to deal with toenails if you're a podiatrist. Nail pathology is one of, if not the, most common reasons patients seek your services. You don't see plumbers refusing to deal with ****.

 

[Toenail]

The problem with podiatry is that we can’t open up new schools fast enough to keep up with the insane demand. I think the reason for this is that all of the GMO stuff in food causes toenails to grow faster and thicker and with the aging population, they don’t have the strength in their fingers to manage this serious medical condition. Literally millions of new toenails every year that are needing real medical care from a doctor.

 

[619]

Spent the morning trying to see if there's a way not to pay ECW for Healow.

If you don't want to pay Healow then what do you use for online booking? Zocdoc is more expensive and almost a ripoff when they started taking a piece of the pie for every appointment booking (even if the patient does not show up)


I am a big fan of Healow with ECW. Healow is $49 flat fee a month for unlimited booking. Here is my most recent invoice from eCW

 

[heybrother]

If you don't want to pay Healow then what do you use for online booking? Zocdoc is more expensive and almost a ripoff when they started taking a piece of the pie for every appointment booking (even if the patient does not show up)


I am a big fan of Healow with ECW. Healow is $49 flat fee a month for unlimited booking. Here is my most recent invoice from eCW
View attachment 418687

Hey - obviously appreciate your ECW perspective. I was referring to the Healow pay 3.49% credit card business. I was looking to see if I could find something cheaper. Honestly I didn't think there was a lot out there that was in some way dramatically cheaper and if you do something different you are likely going to have issues with posting and reconciliation.

 

[Feli]

Anyone thinking that they will never trim toenails at any point in their careers is a complete idiot.

We all do. And we always will. At this point, it's maybe 10% of what I do every week. And that's not much compared to most.

Agree 100% ... same with wounds. There is no getting around them as a DPM.
That is just what people, patients, nurses, other docs expect from podiatry.

...and personally, I'd always rather see RFC than wounds. No question. The nail pts have far fewer issues, admisions and bad hours, less clinic contamination, less grossed-out staff members.

The funny part is that most of the podiatrists who are too good to cut nails also do tons of wound care/consults/surgery. I don't get it.

 

[Boba Foot]

If you don't want to pay Healow then what do you use for online booking?

What's your experience with online booking? I've been intrigued with it because I've been working on online presence, search engine optimization, etc. and online booking is very low friction and theoretically leads to a higher conversion rate from leads. However I've always been skeptical of the no-show frequency of online booking. I'd think that unless there was a way to collect a deposit to hold an appointment, you'd end up with relatively high no shows. Sort of like how medicaid are notorious for no shows.

 

[Weirdy]

What's your experience with online booking? I've been intrigued with it because I've been working on online presence, search engine optimization, etc. and online booking is very low friction and theoretically leads to a higher conversion rate from leads. However I've always been skeptical of the no-show frequency of online booking. I'd think that unless there was a way to collect a deposit to hold an appointment, you'd end up with relatively high no shows. Sort of like how medicaid are notorious for no shows.

ZocDoc is around 50% no show rate. For some reason the patients that have been FMLA/pain seeker trouble makers always use ZocDoc and end up doctor shopping on there.

Healow phone app is clunky. Have to choose location you want then, doc you want, then available time slot. If you are double or triple booking- Healow still only considers that 1 time slot so your availability may seem artificially extremely scarce (no appts available when you're really only single booked entire day)
Make sure you config-> schedule -> working hours so the doc even pop up as available to schedule

Multispecialty Office here does get some Healow booking requests but they account for maybe 10-15% of total bookings split with ZocDoc.

Other 80-90% is from phone calls.

Google bookings are even fewer. 0-5% if any.

 

[diabeticfootdr]

It feels extremely crazy to be posting this after not being active for over 7 years. What a rollercoaster of a career this has been. I've visited here from time to time and it's nice to see those of you have been around for all that time and reading about some of the positive changes in your careers since then. without further ado...

I don't want to bore anyone with any details regarding my career and I will try to get straight to the point.

Due to a variety of factors, none of which I'll go into, I ended up at a terrible residency which had severely compromised surgical training. I know some people will already be thinking that I should have left, and though I agree (in hindsight), there were personal factors with family that tied me down to that location, as well as promises from the residency about upcoming changes. Ofcourse, none of these changes ever came, and despite us pleading with CPME about our situation from year 1, they did not care. I also know people will want me to disclose which residency program this is, but I will decline to do that at this time. I do believe that the residency has since changed for the better with some structural and management changes and I would not want any of my comments to reflect poorly on the progress that has been made. I feel as though I attended my residency program during the worst 3 years of it, when it had abysmal training, which is quite unfortunate.

Anyway, so I eventually graduated from the program feeling extremely unconfident in my surgical skill and have been working for a private practice as an associate over the past few years. My situation is not terrible financially (though it's not great), and I know that I'm probably getting mustached by the owner, but I feel like it can be much worse. My current boss is mostly aware of my situation and has been willing to mentor me in surgery, but he is quite limited in his scope and does not perform a lot of surgery, which limits my opportunity to learn. I have done a handful of cases over the past few years that have turned out okay, but I can't shake the feeling of anxiety I feel booking any case. Additionally, it feels terrible to feel compromised regarding how I can help my patients. For example, my residency barely showed me any tendon repairs (my boss doesn't do them either), and I want to be able to do tendon work on my patients without feeling that I don't have the skills for it. I'm not looking to do crazy ankle recons, just want to be able to offer what I feel is basic foot/rearfoot surgical services to my patients.

The purpose of this post is to ask what opportunities are available for me to improve my surgical skills. I don't know if this looks like finding the right mentorship situation, attending courses/conferences, doing a fellowship, going back into training (absolutely bonkers idea), or just learning on my own time using videos/books. Unfortunately, my life is busy and currently resolves around my very small children, so certain options are definitely more difficult to execute. I don't have a ton of free time but my family and I are willing to make adjustments if it benefits me and my career. My wife keeps telling me to go to a fellowship and says that we will figure it out. In hindsight, maybe I should have as "remedial/extra" training but I did not pursue that route post-graduation. I know they aren't popular in this forum but I'm really not sure what the best options are for me. It also feels that the problem with good fellowships is that they are pursued by residents who come from good programs (that don't need the additional training) and that has become the expectation by those fellowships. When I spoke with previous residents from my program who went to fellowship (most of which had some level of compromised training), they stated that they had to lie about the training they received and that you just have to "fake it till you make it". I know that this mentality applies to a lot of different career paths, but I just can't get behind that when it comes to real life consequences of operating on someone's body. This is the exact trouble I have today. Like sure, can I "wing" a tendon repair? Probably. And maybe that's the only way to improve? However, my morality prevents me from not sending a patient to go see someone more experienced and "better". Like wouldn't I want that for my own parents/spouse/children?

Ultimately, the reality of the situation might be me just having to make most of the career that I made. I understand very well that there were a lot of career decisions that were in my control and this mostly my fault. I'm willing to sleep in the bed that I made, but if there are any strategies/recommendations that any of you know that could help, I would greatly appreciate it. Or if any of you absolute bosses would be willing to take someone, who is truly willing to work hard and learn, under their wing, I would be forever grateful. I'm sure this post will be met some negativity but I'm willing to take online bashing for sake of improving myself for my children.

Holy **** this became a rant and was totally not "straight to the point". Sorry y'all.

TLDR: Poor surgical trained podiatrist wondering what avenues exist to improve his surgical skills. TIA.

Everyone improves their skills (and their judgement) post-training and for a long while after that. The steepest incline I had in both was for the first 5 years after training. As GI Joe said, knowing is half the battle ... recognizing your weaknesses through self-evaluation (as you are doing), indicates you are a conscientious surgeon. It's the practice of surgery that makes you better and more confident. I think your self-doubts, and subsequent actions to improve, are normal and healthy.

 

[diabeticfootdr]

Anyone thinking that they will never trim toenails at any point in their careers is a complete idiot.

We all do. And we always will. At this point, it's maybe 10% of what I do every week. And that's not much compared to most.

And in the patients who need it ... it's a vitally important treatment.

My ex wife's father lives in Palo Alto, CA and he's upper 80's with qualifying conditions and on anticoagulation, mycotic nails so thick he has difficulty fitting in shoes. He's called multiple podiatry offices in the area (and I did a few too), they all refuse to perform the treatment (despite it being a covered benefit in Medicare) and have told him to get a pedicure.

That's not good care.

I don't mind doing it for patients when it makes a difference.

 

[Toenail]

I cannot wait for the day that Medicare no longer reimburses these medical grade pedicures and strictly only covers foot care for folks where it actually prevents a serious
complication risk (ie ulcer/amputation). I have submitted letters several times to politicians that cutting toe nails for folks that don’t have LOPS is an utter waste of tax payer money. I hope that it will soon gain traction.

 

[Toenail]

So patient with PVD shouldn't have this service? Only people with LOPS should qualify? That's short sighted and rather...stupid.

You should know that I graduated towards the bottom of my class.

 

[DYK343]

I don't mind doing it for patients when it makes a difference.

My issue is for every 10 nail referrals I get 6-7 dont actually need it.
I have to bend rules to get them covered.
If i dont do it and tell them to get a pedicurist I get a bad review and PCPs stop referring to me.
Its a crap situation to be put in. Which is why I once again stopped accepting new nail care referrals (I self refer/keep my own diabetic limb salvage patients).