Improving surgical skills post-graduation

[Adam Smasher]

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This is an old argument with new participants. Here are some talking points:

-yes all patients need their nails trimmed, the same way teeth need to be brushed and faces need to be washed
-no, the person trimming those nails doesn't need a doctorate + 3 year residency
-it's not the PCP's job to know if a patient has "trophic skin changes" or whatever we use to get their nail care covered
-Medicare is never taking nail care away, they're just going to reduce reimbursement little by little over time so C&C podiatrists need to trim more nails in order to sustain their cashflows. In other words, the less they pay, the more nails get trimmed.
-For decades now, DPMs have talked about the dental training model which is a good concept and will also NEVER happen, not that we'll ever stop bringing it up.

 

[Feli]

....-For decades now, DPMs have talked about the dental training model which is a good concept and will also NEVER happen, not that we'll ever stop bringing it up.

 

[DYK343]

It's not necessary for PCPs to know if their patients have PVD or Neuropathy? Geez, and here I thought MDs and DOs were supposed to be smarter than the average Lobster. And rather than a blanket garbage statement, let's make an effort to educate them, huh? Nah...it's easier to just complain online. Pffft...

I dont want to signle any specific group out... but... Its more PAs and NPs than MD/DOs that send innappropriate referrals.

And yes I have reached out. Only to incite anger and loss of referral source.

Its better to say "we are full for that diagnosis and can not accept anymore" than to try to chase PCPs down and cause problems.

Im way too busy for that.

So you're lying to make $35?

Maybe educate the PCPs that refer to you about the rules of the game?

Funny how people here talk about being lobsters, but don't seem to elevate the game by being honest with their patients and referral base.

No lying. I just stopped accepting new referrals. Its not worth it to me.

My wRVU reimbursement rate is heavily affected by patient satisfaction scores.

Once my scores started dropping I had management look into where the negative referrals were coming from. Almost every single negative review I got was related to toenails that I had told wasnt covered by insurance/cash pay.

So I stopped accepting any and all nail referrals a couple months ago. My satisfaction scores went right back up.

 

[Sweatshirt]

No exaggeration at all, I had a 65 year old guy come in today saying the only reason why he was here is because he just turned 65 and his friends said the best part of turning 65 was getting on Medicare and seeing a podiatrist to cut your nails

 

[Sybly]

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 ****.

You’re right! Surveys show most podiatrist do this make to help make living

 

[Boba Foot]

ZocDoc is around 50% no show rate.

I wouldn't mess with ZocDoc. Paying for no shows is a hard non-starter for me. I'm shocked they actually find physicians willing to do that.

It's not necessary for PCPs to know if their patients have PVD or Neuropathy? Geez, and here I thought MDs and DOs were supposed to be smarter than the average Lobster. And rather than a blanket garbage statement, let's make an effort to educate them, huh? Nah...it's easier to just complain online. Pffft...

If you're a PCP seeing a patient with 4 or 5 chronic illnesses that you're managing, trying to keep them compliant, etc. I would imagine the last thing you'd care about is what kind of class finding they may have to get their nails cut. Quite simply, it's not their problem, it's ours. They want the patient out of the office and on to the next one. Expecting them to keep up with all the arbitrary nail coverage guidelines is expecting a lot.

No exaggeration at all, I had a 65 year old guy come in today saying the only reason why he was here is because he just turned 65 and his friends said the best part of turning 65 was getting on Medicare and seeing a podiatrist to cut your nails

The circle of life: turning 21 and buying your first legal beer and turning 65 and having some poor sucker $350k in debt cut your toenails because they've got bills to pay.

 

[Stormblest]

I got lucky that my hospital has a LEAP program where they have nurses that do DM nail care. So I rarely have to trim nails.

I still get dumb referrals for nail fungus though mostly from PA/NP, half of them it’s not actually fungus so I guess it’s a good thing they sent to me instead of having them take more rounds of terbinafine - legit have seen patients who they kept them on it for over a year with no change on a thickened nail due to micro trauma over the years. I am a highly trained fungal nail expert in their eyes I guess.

 

[619]

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.

I use square for card payment. Not sure anymore how much they charge but if most mom&pop shops use square then I figure it is good enough. This is my last report from yesterday. It automatically deposits into bank account next day. I looked at several reports and the effective fee rate changes almost daily. I think it depends on which card patient use (Visa vs MC vs Amex) and the fees they charge for processing. But it usually averages around 2.7% to 3.0% effective rate.

 

[619]

This day had an effective rate fee of 3.32%. No idea why

 

[Sybly]

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.

Turn on fellow podiatrist?!!

 

[Weirdy]

This day had an effective rate fee of 3.32%. No idea why

View attachment 418773

Does day of the week matter?

 

[619]

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.

I like that patients have the option for online booking. Its a good feeling showing up on Monday morning and there are a few online requests to be seen on Monday so we make sure to get them in. A lot of things happens over the weekend so patients are looking for who is available to see them Monday morning. In my experience, Folks who book online over the weekend or overnight are at my office door first in the morning begging and ready to be seen.
For online presence, I will say google is also huge in getting new patients. We all google for where to eat and read reviews to decide. Same habit when picking a doc to see. Google reviews are close to gospel.

 

[619]

Does day of the week matter?

Honestly I have no idea.

I am thinking I should make a spread sheet, plot a graph, Venn diagram, bar charts and see if there are any patterns but I have toenails to clip so no time for that.

 

[Bored Snorlax]

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

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: 🦞

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.

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 ****.

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.

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.

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.

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).

Honestly I have no idea.

I am thinking I should make a spread sheet, plot a graph, Venn diagram, bar charts and see if there are any patterns but I have toenails to clip so no time for that.

No exaggeration at all, I had a 65 year old guy come in today saying the only reason why he was here is because he just turned 65 and his friends said the best part of turning 65 was getting on Medicare and seeing a podiatrist to cut your nails

I’m just here to confirm Adam “AO Fellowship Director” Smasher’s Law has survived peer review. The data are becoming impossible to ignore. Given enough replies, toenails will emerge. Statistically terrifying. This should immediately be published in JFAS, JAPMA, PM News, and Podiatry Today as a landmark paper titled “Inevitable Onychomycosis: The Natural History of Every Podiatry Discussion.”

Truly outstanding work @Adam Smasher

 

[air bud]

I got lucky that my hospital has a LEAP program where they have nurses that do DM nail care. So I rarely have to trim nails.

I still get dumb referrals for nail fungus though mostly from PA/NP, half of them it’s not actually fungus so I guess it’s a good thing they sent to me instead of having them take more rounds of terbinafine - legit have seen patients who they kept them on it for over a year with no change on a thickened nail due to micro trauma over the years. I am a highly trained fungal nail expert in their eyes I guess.

How does the leap program play into this?

 

[air bud]

Honestly I have no idea.

I am thinking I should make a spread sheet, plot a graph, Venn diagram, bar charts and see if there are any patterns but I have toenails to clip so no time for that.

Isn't this literally what AI is for?

 

[Adam Smasher]

@Bored Snorlax

I'm happy you enjoy my repurposed memes from the 00s. Also, all your metatarsal base are belong to us

 

[Bored Snorlax]

@Bored Snorlax

I'm happy you enjoy my repurposed memes from the 00s. Also, all your metatarsal base are belong to us

Metatarsal bases have fallen. Lisfranc is compromised. Toenail involvement is now inevitable. I’ll notify JFAS/JAPMA immediately.

 

[Stormblest]

How does the leap program play into this?

Lower Extremity Amputation Prevention (LEAP) was started before I even started here. It is run by the hospital system's diabetes program because we have a high amputation rate compared to national average. They have a nurse at each facility/clinic (I think 6 or 7 total) who does diabetic foot exam and DM nail care. Occasionally they will come get me if the patient develops a wound and then they will follow up with me.

 

[Sole Badguy]

Yes you should operate more to build confidence. But that's like telling somebody in the desert to drink more water. We got too many podiatrists, cases are going to be hard to come by unless you're in the right work environment that feeds them to you.

Also...these discussions about toenails really just emphasize the gap between hospital and PP pods. Since most pods are in PP, a lot of what the hospital pods are advocating for - RFC by nurses in particular - are podiatric blasphemy. Very "let them eat cake" of them, but maybe they'd change their tune if they get replaced by F&A ortho and have to swim with the lobsters. Come on in, water's fine:

 

[air bud]

Yes you should operate more to build confidence. But that's like telling somebody in the desert to drink more water. We got too many podiatrists, cases are going to be hard to come by unless you're in the right work environment that feeds them to you.

Also...these discussions about toenails really just emphasize the gap between hospital and PP pods. Since most pods are in PP, a lot of what the hospital pods are advocating for - RFC by nurses in particular - are podiatric blasphemy. Very "let them eat cake" of them, but maybe they'd change their tune if they get replaced by F&A ortho and have to swim with the lobsters. Come on in, water's fine:

Literally every word you said here is correct

 

[diabeticfootdr]

Don't misunderstand me. Nail debridement should be reclassified as a delegated procedure. As a technical skill, it can be learned in a short period of time and it doesn't require a 4-4-3 trained medical specialist to do it. However, it does take a physician to diagnose, risk classify, and provide other appropriate treatment. A podiatrist should provide that risk assessment and supervise a technician performing the debridement, treat any complications, and then CMS should reimburse less as a delegated procedure.

 

[Feli]

Don't misunderstand me. Nail debridement should be reclassified as a delegated procedure. As a technical skill, it can be learned in a short period of time and it doesn't require a 4-4-3 trained medical specialist to do it...

Cool, because podiaty's moving past 4-4-3 trained with $300k debt ...
... more to 4-4-3-1 trained with $400k debt now.

 

[heybrother]

I charge patients $90 for uncovered nails. Almost no one fights it.

I don't want to supervise/delegate for less money. These patients are often a huge drain on staff. No one else in medicine is routinely offering a $30 service.

 

[Boba Foot]

No one else in medicine is routinely offering a $30 service.

Every PCP goes diagnosis fishing to turn a routine physical into a level 4.

 

[air bud]

Every PCP goes diagnosis fishing to turn a routine physical into a level 4.

It's hard to not build a level 4 in a hospital setting... There's so many images, testing, other people's notes, chronic issues to review. To be clear things that are relevant to your diagnosis. Throw in a little bit of ruralness and social determinants of health.... Level 4 is pretty much the baseline

 

[Weirdy]

Every PCP goes diagnosis fishing to turn a routine physical into a level 4.

Depends on the area and age.

Healthy 20-30yo in for a physical? Takes the medicine guys 3 minutes and out the door.

50yo with abd pain, HLD, DMII- you're already at a level 4 with chart review + meds + imaging.

My area has train wrecks.
At baseline, all of the older patients are level 4s easily- and this is strictly outpatient clinic.

 

[Adam Smasher]

Don't misunderstand me. Nail debridement should be reclassified as a delegated procedure. As a technical skill, it can be learned in a short period of time and it doesn't require a 4-4-3 trained medical specialist to do it. However, it does take a physician to diagnose, risk classify, and provide other appropriate treatment. A podiatrist should provide that risk assessment and supervise a technician performing the debridement, treat any complications, and then CMS should reimburse less as a delegated procedure.

As long as we're in fantasy land, I'd like to take it a step further. Imagine the podiatry equivalent of a dental hygienist. Someone who can diagnose, risk classify, and treat thickened toenails without physician supervision. I would hire three of them.

 

[diabeticfootdr]

As long as we're in fantasy land, I'd like to take it a step further. Imagine the podiatry equivalent of a dental hygienist. Someone who can diagnose, risk classify, and treat thickened toenails without physician supervision. I would hire three of them.

This is actually currently being discussed by APMA. A resolution passed the HOD to explore these models and take control of it as a profession before someone else does.

But they won't be able to diagnose. Even a dental hygienist requires supervision (of some level) in most states. Only a physician or independent practitioner can legally diagnose.

 

[heybrother]

Got it. Why mess with your RVUs, eh?

Is this how Podiatrists make $300K a year? Suits run the show and tell you who is better to see?

Yes, all that, but they make $400K a year. They aggressively push E&M and higher RVU procedures. Almost all podiatry clinic procedures pay less than 99213 - so they don't do them. And they aggressively dump their post-ops / globals on WHCs or NPs. Meanwhile, over in private practice the APMA wants us to supervise a grand carousel of the elderly and demented having their nails cut for $20 a pop.

 

[Boba Foot]

Who said anything about "class findings"?

It IS their problem if a patient has PVD or LOPS and they don't know it. They are the first line of defense.

You quoted Smasher's post about "trophic changes" which is literally a class finding...

 

[Toenail]

Do you read? Try again.

I ain’t too good at it. That probably contributed to me graduating at the bottom of my class. Thank goodness my patients don’t know this when I’m booking their trimal open malreduction and internal underfixation.

 

[dtrack22]

Do you read? Try again.

 

[air bud]

View attachment 418915

It's a matter of time....