Info on Penn-Presby Residency

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johnfootdoc

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Can anyone tell me about the Penn-Presby residency (ie. what you see as a 1st,2nd,3rd,4th yr, your opinion on it being a 4yr program, attendings, resident relationships with one another, type of schedule they work, etc.) THANK YOU!:)

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The attendings are top notch. Many of them were my professors when I was at Temple (then PCPM), and I have nothing but admiration for Drs. Mlodzienski and Downey.

I'm not sure about the 4 year curriculum to be honest. I did three years and found it to be a very intense, so I'm not sure what their structure is and how the rotations work for it to be 4 years. Ask the current or previous residents. That's probably your best bet to get the information you need.
 
As per Kidsfeet's post, the only way to really get the inside accurate story on a residency program is to speak with present or past residents.

However, I personally know Michael Downey, and he is a great person, great surgeon and great teacher. They don't get better than Mike. Mike trained in Atlanta with Dr. McGlammary and his co-resident was Scott Malay, who is also involved with the Penn-Presby program and is Dr. Downey's partner in private practice with Dr. Mlodzienski and a few other docs.

Dr. Malay is also a very skilled surgeon and is briliant and is also the current editor of the Journal of Foot & Ankle Surgery. There are many other quality attendings such as Harold Schoenhaus, etc. I don't know the details of the actual residency progam, but I can guarantee you that any program associated with Drs. Downey and Malay will be academically challenging and will also provide excellent surgical training.

I don't know the diversity, types of cases, etc., but can absolutely attest to the quality of the attendings.
 
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If you want 4yrs of training, then you are probably better off doing any good 3yr program (basically any top 25-50 program depending on preference) and then a solid 1yr fellowship offering with an elite surgeon/group (Hyer, DiDominico, etc etc). You'd get more cases that way, you'd get more diversity of attendings/procedures/patients, and you could say on your CV that you're fellowship trained.

You could do a lot worse than Presby. It's a good program, but they spend a TON of time on non-pod rotations. I'd say the strengths would be medicine training, good and foolproof "classic" surgery training via Downey, a leg up on journal publishing since Malay is involved, a lot of teaching responsibility due to many junior residents and rotating students, and "cutting edge" surgery with Schoenhaus (this last aspect is either a strength or a big weakness depending on your personal views on foot surgery). Weaknesses would be weak F&A trauma exposure, bad hours, and living in Philly.
 
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Feli,

I was just curious whether or not you actually externed or rotated through Penn-Presby, and if you did, what YOUR opinion is/was of Dr. Schoenhaus? He's quite a character (I personally like him), though as you state, he is gutsy in the O.R. and has attempted some things I've never even considered.
 
I have worked with Dr. Schoenhaus and was always impressed with his skill. I would agree that he takes risks in the OR, but always had a firm knowledge of what he was doing and didn't, imo, go beyond his personal skill level.

He serves as one of the pillars of what podiatry was and can be with the right attitude and a little bit of moxy.
 
Thanks for all the info!

For any of you familiar with the Temple 4 yr residency program, does anyone have any thoughts on which program is stronger, presby or temple? i know they both have their own strengths and weakness but I'm talking about, on the whole, which program is better overall, in your opinion?

Ps. I had Schoenhaus as a professor recently and LOVED HIM - so knowledgeable but still entertaining to listen too! would love to see what he's like in the OR
 
You could do a lot worse than Presby. It's a good program

A great program. It's a top 10 program. Look at the roster of the attendings: Malay, Downey, Schoenhaus, Troiano, Mlodzienski

How many other programs offer that many attendings of that caliber? There are certainly programs that do but not that many.
 
I agree. Once again, I've stated many times how highly I think of Dr. Downey. Dr. Schoenhaus has been around a long time and his skill and knowledge has certainly withstood the test of time. There are very few docs around with his knowledge AND experience. He's got a wealth of information to teach.

You also can not discount the fact that the program is affilated with a world class institution. Even though they are at Presby and not at the U of P, it's still the same health system and they are exposed to excellent medical care and training.

I would be proud if I was an alumni of this program.
 
One thing that fails to register with many prospective residents is how they will interact and learn from a particular group of doctors.

A program may have the best attendings around according to others, but if you can't jibe with them, it will be a very long 3-4 years. That's why visiting and talking to residents is so important. Its in the attitude, not just the reputation of the program.

I went a very round about way to get my 3 years of residency in and people thought I was crazy with all the traveling I did, but I wouldn't do it any other way in retrospect. Give yourself the best opportunity by doing your own research and talking to as many residents/doctors as you can.
 
Feli,

I was just curious whether or not you actually externed or rotated through Penn-Presby, and if you did, what YOUR opinion is/was of Dr. Schoenhaus? He's quite a character (I personally like him), though as you state, he is gutsy in the O.R. and has attempted some things I've never even considered.
PM sent... since I try to keep everything on here pretty optimistic.
 
Kidsfeet - I completely agree with what you are saying - the relationships between you and your attendings, not to mention your co-residents, are imperative.

right now though, I am trying to find programs to extern at that all have great reputations, attendings, sx training etc....and then, once I've been exposed to them all, I will make a decision based upon where I fit in the most regarding personality, teaching style, etc.

other programs i'm looking into include Temple, UMDNJ, Inova....any opinions on any of those programs? (or if anyone wants to suggest any others, that would be more than welcomed)
 
I've been out of the loop for so long now...how many externships can you attend now?

Target the externships you are interested in as far as residency positions. If you go to school at Temple, I would not extern at the residencies with the School as you are already there and they most likely know you.

UMDNJ was a great residency when I was coming up 10 years ago. If its maintained its quality over the years, I would spearhead that one as well.

One thing to consider as well, is to go far and wide for your training. Your career will be based upon the training you receive. There are AMAZING programs all over the country. Don't limit yourself to East Coast, just because you're an East Coaster. Train where ever the training is great, than live where you'll be happy.

Good luck.
 
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UMDNJ is still great, lots of trauma, hospital based attendings dedicated to your training, lots of clinic, some elective, good hospital based rotations, lots of NY students to teach.

Inova (I am biased) is awesome. Definitely check it out. It was the right place for me and has its perks.
 
Weaknesses would be weak F&A trauma exposure, bad hours, and living in Philly.

"Weak F&A trauma exposure" ??? Are you serious? I got a HUGE LOL on that one!
 
newankle -

does that mean you feel presby gets significant F&A trauma? were u an extern/resident there?
 
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A great program. It's a top 10 program. Look at the roster of the attendings: Malay, Downey, Schoenhaus, Troiano, Mlodzienski

How many other programs offer that many attendings of that caliber? There are certainly programs that do but not that many.

These posts are pointless. A top 10 residency to one student, may not be a top 10 program to someone else. Many of the so called "top 10" programs are ranked that way soley on the attendings names as well, not the training you recieve.

An example. Program X pays +$50k every year and is a relatively low income area (for a bigger city). Program X also gets you your cases within 8 months of your first year (you spend most of your time in an OR). You are rarely double/triple scrubbed since there are only 3 residents in the entire program and you interact with a lot of ortho's. You also spend some time down at the UAB ortho trauma center, home of Dr. James Andrews. Academics are great with weekly lectures, and case presentations/journal clubs where attendings actually show up.

Program X is real and I have never seen it mentioned on this site. There are some downsides (lot of hours, lot of call, enough but not a lot of routine care, probably lacks in pre-op/post-op care in the first year or two) but if you are a student who is set on joining an ortho group and want a ton of sx exposure then this might be a great fit. Too bad you don't know about it because it doesn't have the "name" or the "attendings".
 
These posts are pointless. A top 10 residency to one student, may not be a top 10 program to someone else. Many of the so called "top 10" programs are ranked that way soley on the attendings names as well, not the training you recieve.

An example. Program X pays +$50k every year and is a relatively low income area (for a bigger city). Program X also gets you your cases within 8 months of your first year (you spend most of your time in an OR). You are rarely double/triple scrubbed since there are only 3 residents in the entire program and you interact with a lot of ortho's. You also spend some time down at the UAB ortho trauma center, home of Dr. James Andrews. Academics are great with weekly lectures, and case presentations/journal clubs where attendings actually show up.

Program X is real and I have never seen it mentioned on this site. There are some downsides (lot of hours, lot of call, enough but not a lot of routine care, probably lacks in pre-op/post-op care in the first year or two) but if you are a student who is set on joining an ortho group and want a ton of sx exposure then this might be a great fit. Too bad you don't know about it because it doesn't have the "name" or the "attendings".

I agree. My surgical training was in an area that had very famous residencies as well, with very well known attendings and no one ever heard of the program I did. 2000 procedure as the only resident scrubbing in 2 years was an unbelievable experience.

That's why its important to look around all over and not just in your backyard.
 
Program X is real and I have never seen it mentioned on this site

No one said you can't get great training at a program without big name attendings. But when a program has attendings such as Penn-Presby, guys are top dogs in the profession, you can't just dismiss it as a decent program.

There are lots of programs out there like you described. There are no sleeper programs. Just because a program isn't mentioned on a site full of DMU first and 2nd year students with a few kids sprinkled in from other schools and attendings who haven't been in the residency loop for awhile (no slight intended) doesn't mean its not a known program so if you think you are keeping a secret to yourself because you aren't sharing it on this site, you are sadly mistaken.

My surgical training was in an area that had very famous residencies as well, with very well known attendings and no one ever heard of the program I did.

Care to share?
 
"Weak F&A trauma exposure" ??? Are you serious? I got a HUGE LOL on that one!
Well, yes, that was my impression.

Presby seemed to get some ankle/met/digit/etc fx brought in to their ORs from attending clinics, but their ER barely called them for anything besides wound/infection patients. I think the only thing I saw or heard about while there for a month was a 5th met fx (which was uninsured, basically nondisplaced, and just got casted). During my two night calls, we got one ER call... for cellulitis. One 3rd year was grumbling that an ankle fracture which had come in a couple months earlier had required them to page the 4th year in for the reduction and splinting. When most other programs I visited had interns and maybe occasionally 2nd years taking care of the ER calls, that sorta told me something.

I was told that HUP sucks up nearly all of the area's good and high energy trauma in their hospital system, and with an ortho program there, they were very abrasive towards the pod program (refused to allow rotation, any form of shared call, etc). The seniors told me that although the gen surg at Presby backed them, ortho had been a brick wall. They had been offered gen surg trauma rotations, but ortho trauma, ortho F&A, etc was basically out of the question due to the HUP ortho dept prioritizing the training of their own residents/fellows (and rightly so, I guess).

I was told that Temple or the program where Justin Fleming brings cases (formerly Frank-something?) were much superior for acute and ER exposure to F&A trauma. Again, just my experience and what I heard from Temple students and alumni whom I have no reason not to trust. I think Presby residents see enough overall surgery that they would know most of the dissections + anatomy, fixation methods, medical issues, etc to handle most trauma well... but, yes, I'd say they're definitely on the low end in terms of how much acute F&A trauma they see in the ER (closed reductions, splinting, etc) when compared to other high level PM&S residency programs. When you compare their trauma experience to DMC, UMDNJ, Palmetto, Oakwood, etc... it's a cat vs a pit bull. That can be said for many decent PM&S programs, though. It doesn't necessarily mean it's not a good program, but trauma's certainly not the emphasis... medical mgmt, off svc rotations, and elective surgery would be the main strengths of Presby, IMO.
 
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Well, yes, that was my impression.

Presby seemed to get some ankle/met/digit/etc fx brought in to their ORs from attending clinics, but their ER barely called them for anything besides wound/infection patients. I think the only thing I saw or heard about while there for a month was a 5th met fx (which was uninsured, basically nondisplaced, and just got casted). During my two night calls, we got one ER call... for cellulitis. One 3rd year was grumbling that an ankle fracture which had come in a couple months earlier had required them to page the 4th year in for the reduction and splinting. When most other programs I visited had interns and maybe occasionally 2nd years taking care of the ER calls, that sorta told me something.

I was told that HUP sucks up nearly all of the area's good and high energy trauma in their hospital system, and with an ortho program there, they were very abrasive towards the pod program (refused to allow rotation, any form of shared call, etc). The seniors told me that although the gen surg at Presby backed them, ortho had been a brick wall. They had been offered gen surg trauma rotations, but ortho trauma, ortho F&A, etc was basically out of the question due to the HUP ortho dept prioritizing the training of their own residents/fellows (and rightly so, I guess).

I was told that Temple or the program where Justin Fleming brings cases (formerly Frank-something?) were much superior for acute and ER exposure to F&A trauma. Again, just my experience and what I heard from Temple students and alumni whom I have no reason not to trust. I think Presby residents see enough overall surgery that they would know most of the dissections + anatomy, fixation methods, medical issues, etc to handle most trauma well... but, yes, I'd say they're definitely on the low end in terms of how much acute F&A trauma they see in the ER (closed reductions, splinting, etc) when compared to other high level PM&S residency programs. When you compare their trauma experience to DMC, UMDNJ, Palmetto, Oakwood, etc... it's a cat vs a pit bull. That can be said for many decent PM&S programs, though. It doesn't necessarily mean it's not a good program, but trauma's certainly not the emphasis... medical mgmt, off svc rotations, and elective surgery would be the main strengths of Presby, IMO.

The way things are done at Presby follows a very specific order and that is for good reason. Treating the entire patient not just the foot/ankle/leg is important to some physicians. Knowing how to do things correctly is of utmost importance, not just doing a lot of cases. I know plenty of surgeons who do a lot of cases and badly at that. This is obvious at this residency when you see the long-term train wrecks that are sent from all over to Downey to fix other's mistakes. Why? Because some TFP who couldn't cut his way out of a paper bag ruined someone. As for your experience I would say I never saw any month like you describe - for 48 months. One of my best friends in school was a resident for Justin at Frankford and they did a lot of trauma - non F&A trauma! Justin is a great surgeon and teacher as well because of who trained him and he was trained in this same way I'm speaking of. Presby residents get all the F&A cases that come into that ER which includes all the cellulitis BS and ankle sprains up to major trauma. That means when F&A comes in, the ER calls the pod resident and they handle everything and it is out of the ER's hair. The ER loves that as opposed to when trauma comes into HUP or CHOP and the ER has to wait forever for an ortho resident to come in and see the patient which clogs up the ER. Podiatry is 1st call for F&A at Presby, not ortho. Ortho gets all their trauma via HUP. Presby is the only ER the pod residents take call at but that provides more than enough. Now of course if there are more pod residents, that has to be shared. At other programs the lower year residents get to do ankles and other cases earlier but at Presby the 3rd and 4th years get those cases so you have to wait. The residency is not meant for everyone and many are not cut out for it. It's a marathon and not a sprint and that's what makes it special. Now... Go out and look for a job outside the realm of the podiatry world like with an ortho practice like you all so desire. Ask your ortho employer-to-be whether he would give a interview to a pod who did a 4 year residency at the University of Pennsylvania or a pod who did a 3 year residency (with or without fellowship) at some of these programs that may be big podiatry names but don't mean a good s**t to anyone else in the real world.
 
Why is the program 4 years? What's the idea behind it? Is the 4th year kind of treated like a fellowship or something?
 
The way things are done at Presby follows a very specific order and that is for good reason. Treating the entire patient not just the foot/ankle/leg is important to some physicians. Knowing how to do things correctly is of utmost importance, not just doing a lot of cases. I know plenty of surgeons who do a lot of cases and badly at that. This is obvious at this residency when you see the long-term train wrecks that are sent from all over to Downey to fix other's mistakes. Why? Because some TFP who couldn't cut his way out of a paper bag ruined someone. As for your experience I would say I never saw any month like you describe - for 48 months. One of my best friends in school was a resident for Justin at Frankford and they did a lot of trauma - non F&A trauma! Justin is a great surgeon and teacher as well because of who trained him and he was trained in this same way I'm speaking of. Presby residents get all the F&A cases that come into that ER which includes all the cellulitis BS and ankle sprains up to major trauma. That means when F&A comes in, the ER calls the pod resident and they handle everything and it is out of the ER's hair. The ER loves that as opposed to when trauma comes into HUP or CHOP and the ER has to wait forever for an ortho resident to come in and see the patient which clogs up the ER. Podiatry is 1st call for F&A at Presby, not ortho. Ortho gets all their trauma via HUP. Presby is the only ER the pod residents take call at but that provides more than enough. Now of course if there are more pod residents, that has to be shared. At other programs the lower year residents get to do ankles and other cases earlier but at Presby the 3rd and 4th years get those cases so you have to wait. The residency is not meant for everyone and many are not cut out for it. It's a marathon and not a sprint and that's what makes it special. Now... Go out and look for a job outside the realm of the podiatry world like with an ortho practice like you all so desire. Ask your ortho employer-to-be whether he would give a interview to a pod who did a 4 year residency at the University of Pennsylvania or a pod who did a 3 year residency (with or without fellowship) at some of these programs that may be big podiatry names but don't mean a good s**t to anyone else in the real world.

Vision 2015 will hopefully encompass this kind of training for all Podiatric Graduate.

It has been my experience that orthopedic groups don't give a rip where you did your training, as long as you have the chops to keep up with the foot and ankle load they will provide, both trauma and otherwise. Most Ortho Surgeons don't have a clue about our residencies unless they were there. "UPenn Podiatry residency?? Huh??"

One thing to keep in mind is regardless of how well you are trained and how good of a surgeon you are or think you are, we ALL have train wrecks. It more depends on the cases you choose to do and your patient population, unless you are just a terrible surgeon who eventually will have his or her malpractice yanked due to the number of complaints/lawsuits. "Train Wrecks" is arbritrary.
 
I agree with a lot of the comments that are all over the place. A top residency is simply a program that will be YOUR perfect fit. There is no easy answer for that question.

In reality, many of you will never have the opportunity to treat significant trauma in your private practice despite your training. It depends on where you end up practicing and the bylaws or your hospital and the "turf" wars with the present staff.

Or, some of you may not want trauma exposure and may want more limb salvage exposure or more pediatric exposure, etc. A "top" program is dependent on your future plans.

You have to personally know Michael Downey and Justin Fleming to understand that their training is slightly different. Those that trained in Atlanta have a slightly different philosophy and in my opinion are slightly "old school" in their thoughts, though not in their skills or knowledge or technology. I believe Justin is slightly more aggressvie than Mike, but Mike performs a LOT of clean up work for others failed cases.

And Justin does get a lot of trauma from the ER and works long and hard. He has turned the program into a great program since he got on staff. I believe the hospital system was Frankford and is now known as Aria Health.
 
Those that trained in Atlanta have a slightly different philosophy and in my opinion are slightly "old school" in their thoughts, though not in their skills or knowledge or technology

Could you please elaborate on what you mean by a different philosophy and how it compares to others? I am just in the process of deciding what programs to extern with and would love to hear more about different philosophies that programs may have. Thank you.
 
Could you please elaborate on what you mean by a different philosophy and how it compares to others? I am just in the process of deciding what programs to extern with and would love to hear more about different philosophies that programs may have. Thank you.
Go to Atlanta for a month if you can get accepted for the rotation. It's probably the best training program in the country depending on what you're looking for... definitely top 5 training no matter whom you talk to. You might decide it's not for you, but like it or hate it, you will learn a ton. The resources they have there with the pod institute, slide library, textbook, seminars, surgical case diversity/volume, etc is fantastic. You will not find a better "depth chart" of attendings anywhere, and that's a fact.

Their philosophy is pretty much summed up as "technique over technology." They focus on anatomy, use basic AO with Synthes 95+% of the time, use time-tested procedures for the most part, and remain fairly cost concious. The vast majority of their alumni don't do fancy new procedures/fixation just for the sake of doing it. They believe in "anything when indicated" but just don't do many ankle implants, ex fix, etc based on principle. It's a bit "old school" and inbred since the majority of their attendings trained in Atlanta or "affiliate" residency programs (other parts of the country where director/attending are Atlanta alumni... Scripps, Presby, Gundersen, StVincent Charity, Mercy, etc) but that conservative surgical philosolphy keeps you out of trouble.

Their views are pretty much in line with my own, and I have a lot of respect for their attendings. I will be one of the first in line to apply if Camasta or the program in general ever starts a fellowship or mini-fellowship, but 3 residency years of those hours and intensity would've been a bit much IMO when other programs offer nearly that level of training without jeopardizing your marriage and sanity as much. Some of their senior attendings, namely Ruch and Banks, virtually walk on water, so you will see residents scrambling to prep for rounds, etc with them... but they are guys who were, and still are, cornerstones of our profession. I love their seminars and will continue to read their publications and attend lectures.

I was there slightly after the transition from Northlake ("Tucker") ortho specialty hospital to DeKalb. DeKalb's a nicer and larger hospital, but due to being newt there, they were still working their way into the ER and not getting as much ortho trauma as they were at the previous location. They have great attendings and surely got nearly instant respect and are getting good trauma calls at DeKalb now. They also have an attending, Dr. Shaheed, at DeKalb-Hillandale who trained at a top trauma program (Palmetto in Miami) and teaches the residents on a lot of good trauma cases.
 
Go to Atlanta for a month if you can get accepted for the rotation. It's probably the best training program in the country depending on what you're looking for... definitely top 5 training no matter whom you talk to. You might decide it's not for you, but like it or hate it, you will learn a ton. The resources they have there with the pod institute, slide library, textbook, seminars, surgical case diversity/volume, etc is fantastic. You will not find a better "depth chart" of attendings anywhere, and that's a fact.

Their philosophy is pretty much summed up as "technique over technology." They focus on anatomy, use basic AO with Synthes 95+% of the time, use time-tested procedures for the most part, and remain fairly cost concious. The vast majority of their alumni don't do fancy new procedures/fixation just for the sake of doing it. They believe in "anything when indicated" but just don't do many ankle implants, ex fix, etc based on principle. It's a bit "old school" and inbred since the majority of their attendings trained in Atlanta or "affiliate" residency programs (other parts of the country where director/attending are Atlanta alumni... Scripps, Presby, Gundersen, StVincent Charity, Mercy, etc) but that conservative surgical philosolphy keeps you out of trouble.

Their views are pretty much in line with my own, and I have a lot of respect for their attendings. I will be one of the first in line to apply if Camasta or the program in general ever starts a fellowship or mini-fellowship, but 3 residency years of those hours and intensity would've been a bit much IMO when other programs offer nearly that level of training without jeopardizing your marriage and sanity as much. Some of their senior attendings, namely Ruch and Banks, virtually walk on water, so you will see residents scrambling to prep for rounds, etc with them... but they are guys who were, and still are, cornerstones of our profession. I love their seminars and will continue to read their publications and attend lectures.

I was there slightly after the transition from Northlake ("Tucker") ortho specialty hospital to DeKalb. DeKalb's a nicer and larger hospital, but due to being newt there, they were still working their way into the ER and not getting as much ortho trauma as they were at the previous location. They have great attendings and surely got nearly instant respect and are getting good trauma calls at DeKalb now. They also have an attending, Dr. Shaheed, at DeKalb-Hillandale who trained at a top trauma program (Palmetto in Miami) and teaches the residents on a lot of good trauma cases.

I was always very interested in their philosophy as to why they don't seem to use the advanced technology/techniques and I have to disagree with you that the "old school" stuff can "keep you out of trouble". It really depends where you end up practicing. Also, its one thing not to be trained to use the latest technologies, but do the attendings there teach you to have the confidence in your surgical skills to attempt these new techniques when you're out in practice? I'm all for Synthes, but there are better fixation techniques out there now. Yes, a Synthes screw is inexpensive for the hospitals, but until the hospital I work in starts giving me a piece of their pie, I couldn't care less how much a screw costs them.

I also really have a hard time with this "walk on water" thing associated with any resident in any program in any specialty. These resident who are used to being on such high ground will have a very rude awakening when transitioning to the world of the practicing physician vs. the senior resident. This is a transition in humility. Do they teach this in that residency?

We need supremely trained young Podiatric Surgeons who will forge ahead and blaze new ground on behalf of our profession. Find a residency that will help accomplish this goal of excellence. I'm sure you'll be surprised where you'll find the programs that will help you in this regard.
 
The program I did way back when was in Houston, TX. It no longer exists, and it wasn't one run by brothers or the BIG program there that has taken over the area.


Yes those programs were high volume and I agree provided great training as does the BIG program you mentioned that actually absorbed residents and attendings from your program. It is still high volume with similar numbers you had and now covers 20+ facilities with decent faculty (DPM, MD, DO) and great academics. Although trauma numbers are decent the one weakness is consistent acute ER trauma by the DPMs because of ortho politics.

Houston has always had a sleeper residency reputation and has produced some very successful DPMs.
 
Yes those programs were high volume and I agree provided great training as does the BIG program you mentioned that actually absorbed residents and attendings from your program. It is still high volume with similar numbers you had and now covers 20+ facilities with decent faculty (DPM, MD, DO) and great academics. Although trauma numbers are decent the one weakness is consistent acute ER trauma by the DPMs because of ortho politics.

Houston has always had a sleeper residency reputation and has produced some very successful DPMs.

The biggest weakness I saw when I was there was also that there was very little in the way of hospital exposure. I was lucky as I had a full year of a PPMR at a Medical School before being accepted to this "Advanced" level program, so I didn't miss that aspect, but the other residents at the other programs sure did.

None of my attendings now work with the BIG program or the other program that was absorbed. My program was a whole different animal at the time. No one ever heard of my attendings down there and that's the way they liked it. The politics got in the way of that.

I sure did learn a lot about surgery, in office care and practice management though. Towards the end of my residency, I was running multiple attendings' offices while they were on vacation lol. Nice huh?
 
The biggest weakness I saw when I was there was also that there was very little in the way of hospital exposure. I was lucky as I had a full year of a PPMR at a Medical School before being accepted to this "Advanced" level program, so I didn't miss that aspect, but the other residents at the other programs sure did.

None of my attendings now work with the BIG program or the other program that was absorbed. My program was a whole different animal at the time. No one ever heard of my attendings down there and that's the way they liked it. The politics got in the way of that.

I sure did learn a lot about surgery, in office care and practice management though. Towards the end of my residency, I was running multiple attendings' offices while they were on vacation lol. Nice huh?

Nice exposure for the times. I work with the other two programs and now they have a ton of hospital work and real rotations. The volume is as high as ever and a decent academic schedule. They have their own dissection lab that is fully supplied with power, c-arm, and arthroscopy towers. Still a lot of driving to cover all of the facilities. Several of the attendings are tied in at the state and national levels
 
Nice exposure for the times. I work with the other two programs and now they have a ton of hospital work and real rotations. The volume is as high as ever and a decent academic schedule. They have their own dissection lab that is fully supplied with power, c-arm, and arthroscopy towers. Still a lot of driving to cover all of the facilities. Several of the attendings are tied in at the state and national levels

Wow awesome. Sounds good to me!

I know about driving. I put over 40 000 miles on my car in my two years in Houston during my residency.
 
...Yes, a Synthes screw is inexpensive for the hospitals, but until the hospital I work in starts giving me a piece of their pie, I couldn't care less how much a screw costs them...
This seems to be a common theme: forget cost of surg implants or biologics, go with the company that has neat toys or gives good kickbacks. I've heard attendings say "I'll quit using the fancy and expensive stuff when everyone else does. As long as they keep trying the new toys, I want to also." I wonder how long that will persist, and how long insurance plans will continue to put up with it. It's funny how surgeons might use cannulated screws + ex-fix + stem cells at the hospital... but the same procedure at a surgery center they own a share in will be done with basic 6.5mm screws, k-wires, and a cast. Hmm

I'm certainly not trying to speak for the PI guys, but that is basically what I found very refreshing about their philosophy. They are cost concious, and they focus on pre-op planning (cadaver dissection, discussing the operations, etc), anatomy, solid technique (joint resection, alignment, positioning, etc), and AO principles (compression, shielding, etc). When their grads are done, it's up to them if they want to use k-wires or a $3000 lock plate... but they know that any of that stuff is only the icing on the cake, while the planning and surgical technique is the flour and yeast.
 
...We need supremely trained young Podiatric Surgeons who will forge ahead and blaze new ground on behalf of our profession. Find a residency that will help accomplish this goal of excellence. I'm sure you'll be surprised where you'll find the programs that will help you in this regard.
This is your opinion.

Another take on the matter would be that the anatomy doesn't change, and we have devised reasonable, satisfactory, and proven procedures for nearly all and F&A pathology. Myerson's text forward contains his remarks on his suprise of how little F&A surgery has changed during his career. Ruch's chapters in McGlamry echo that the restoration of functional anatomy is the key to success. The "advanced technology/techniques" you mention are largely industry toys searching high and low for an indication in the foot and ankle. Do we really need $1k tightrope for bunions or are they just looking for another way to sell a shoulder anchor? Do we require $25k ankle implants, or does a good desis work very well? Is it your sharp debridement and compression or the $15k of Apligraf which really healed the venous ulcers? Look yourself in the mirror and answer honestly.

Yes, advances like cann screws, lock plating, ex fix, and biologics are advances, but they can still be used as our "ace in the hole" when they're truly indicated and required... not just when we want to try them - or want a rep kickback. If anything, I'd say that significant improvements in resolution and exposure in flouro alone give us all the advantage we need to have a much easier time in the OR than the previous generations. JMO
 
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This seems to be a common theme: forget cost of surg implants or biologics, go with the company that has neat toys or gives good kickbacks. I've heard attendings say "I'll quit using the fancy and expensive stuff when everyone else does. As long as they keep trying the new toys, I want to also." I wonder how long that will persist, and how long insurance plans will continue to put up with it. It's funny how surgeons might use cannulated screws + ex-fix + stem cells at the hospital... but the same procedure at a surgery center they own a share in will be done with basic 6.5mm screws, k-wires, and a cast. Hmm

I'm certainly not trying to speak for the PI guys, but that is basically what I found very refreshing about their philosophy. They are cost concious, and they focus on pre-op planning (cadaver dissection, discussing the operations, etc), anatomy, solid technique (joint resection, alignment, positioning, etc), and AO principles (compression, shielding, etc). When their grads are done, it's up to them if they want to use k-wires or a $3000 lock plate... but they know that any of that stuff is only the icing on the cake, while the planning and surgical technique is the flour and yeast.

Don't get me wrong Feli, I only use what is appropriate for the intended procedure and not every new technology is more expensive. Every resident MUST learn about AO fixation and how to put in a Synthes screw. However, there are technologies that exist that are better than the "old school" stuff.

About your bolding my quotation, I'm sorry for being cynical BUT, when the CEO of our hospital system gets a $50M bonus and the same hospital system owns the insurance company that just cut my fees 5%, I couldn't care less how much that new plate costs. In 2008 the CEO of BC/BC got a bonus check of $43M for keeping costs low. Sorry, but my heart does not bleed for these insurance companies. Not one bit. We as consumers pay good money for our health insurance, which is then invested by these companies, who then make a mint off our money. Capitalism to the core. The fact that the attendings at PI are sensitive to cost is astounding to me, unless they own the hospital and make a fiscal decision to keep costs low to support themselves, like many doctors do who own surgery centers.

When a new "toy" comes out, I want to get my hands on it. I go to sawbones and cadaver workshops to get a taste of the product and the technique and if I find that it is something I would like to try, I do. Sometimes it means costing the hospital more, sometimes it means costing the hospital less. If a hospital tries to stop me from using a product, I find a hospital that will let me try it. This happens enough that the main hospital doesn't stop me anymore. Why? Because if I try a product once and don't like it, I never use it again. If I try a product and it works great, and my patients do better long term with, I get in through the system because I believe that it is in my patient's best interest.

Also, please educate me on these "kickbacks" you are referring to. Kickbacks are illegal. If you mean companies that offer consulting agreements to better their products and provide a hourly rate for the work you do for them and then require you to disclose this relationship when using or teaching about their products, maybe then we'll be on the same page. No offense taken with the underlying implication you made, but some people may become easily offended by this allegation.
 
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This is your opinion.

Another take on the matter would be that the anatomy doesn't change, and we have devised reasonable, satisfactory, and proven procedures for nearly all and F&A pathology. Myerson's text forward contains his remarks on his suprise of how little F&A surgery has changed during his career. Ruch's chapters in McGlamry echo that the restoration of functional anatomy is the key to success. The "advanced technology/techniques" you mention are largely industry toys searching high and low for an indication in the foot and ankle. Do we really need $1k tightrope for bunions or are they just looking for another way to sell a shoulder anchor? Do we require $25k ankle implants, or does a good desis work very well? Is it your sharp debridement and compression or the $15k of Apligraf which really healed the venous ulcers? Look yourself in the mirror and answer honestly.

Yes, advances like cann screws, lock plating, ex fix, and biologics are advances, but they can still be used as our "ace in the hole" when they're truly indicated and required... not just when we want to try them - or want a rep kickback. If anything, I'd say that significant improvements in resolution and exposure in flouro alone give us all the advantage we need to have a much easier time in the OR than the previous generations. JMO

Feli,

You've now made a case for not advancing anything that works. Ever.

When the ankle implant technology really starts working properly and the implant does really do what its intended to do, it will certainly revolutionize ankle trauma. How will it do that? By working out the kinks in the current system. Sure a Desis works. But are you going to cripple a young man who got into a motorcycle wreck by fusing the joint or trying to give him functional motion back. I agree that the current state of ankle implantation is nowhere near doing this yet, but it will be because of trial and error.

I enjoy how you refer to textbooks as examples of what is current. You do realize that any textbook takes about 4 years to write and that many of the techniques that are presented in the texts are sometimes already behind the times.

If you read some wound care literature, you'll see that certain wounds are better healed with products like Apligraft. So if it will heal in 12 weeks, why use a product that might heal it in 6 weeks. No difference in patient quality of life or limb salvage at all now is there?

Sure you can fix an ATFL with an open repair using a Braumstrom or using a Peroneal Tendon. Patients love being NWB for 4-6 weeks and then needing rehab for 4-6 weeks until their ankle gets stiff and they are getting muscle atrophy from disuse. Or try a new innovation that may mean your patients are WB in a Boot for 2 weeks and then back to full activity with a brace and full ROM in less than a month. Why even go there if the "old school" stuff works so well?

Forefoot Charcot reconstructions work great with Ex-Fix Frames don't they? Never mind they can fall and fracture their Tibias. Get limb threatening pin tract infection. Take the frame off at home with pliers. Have their dog lick their pins and get a cellulitis so badly that not even ID can start their work because they can't figure out which organism to hit first. OR try a new intramedullary fixation that allows you to close the incisions and heals great and all your patient needs is a cam boot while they heal.

I could go on and on...Progress is made by forward thinkers who take risks. Next time you meet a Podiatrist who is over 60, tell him/her thank you for all the forward thinking they did that got our profession so far in such a short period of time. Then think about how YOU will impact this profession so profoundly.
 
...I could go on and on...Progress is made by forward thinkers who take risks. Next time you meet a Podiatrist who is over 60, tell him/her thank you for all the forward thinking they did that got our profession so far in such a short period of time. Then think about how YOU will impact this profession so profoundly.
This is just a fundamental difference in philosophy. There's no right or wrong answers here.

Personally, I just tend to subscribe to the cliche mindset that "you don't want to be the first or the last guy doing something." If something works well, it will catch on (VAC, lock plating, DBM, etc), and if it doesn't, then you will be glad you weren't the guy experimenting on patients in order to get money for a study and/or to stroke your ego by being "revolutionary." The way I see it, my **** is pretty big, my wife is pretty hot, my life is pretty good, and as surgeons, we are already blessed with the skill set to change human anatomy and improve function. I'm certainly content letting some other guy be "the first" when it comes to inventing new totally new procedures or putting new devices into the body. I'm also not a huge fan of raising taxes or insurance premiums any higher than they need to be by using toys just for the sake of using them... even if "everybody else is doing it."

If a new device or procedure comes along that makes intuitive sense to me, I will certainly employ it. However, if we already have similar options which work fine for the procedure/pathology (again, we pretty much do have that for every F&A pathology I can think of... besides maybe RSD lol), then I have no problem waiting for the industry companies to create copycat products and underbid one another. I think SmartToe (buried k-wire), syndesmosis tightrope (screw), mini locking plates (crossed screws), endoscopic gastroc (mini-open), DBM (calc autograft or marrow aspirate), etc make a lot of sense... but when the costs remain pretty outrageous and there are much cheaper satisfactory options (in parenthesis), I probably won't be jumping to use the high-cost toys.

...Again, there is no easy answer, and I'm sure there's a happy medium between "cowboy" and "stone age" F&A surgeon. As far as thanking previous DPMs, I certainly do. More than anything, I'll thank them for increasing post-grad training in order to give residents the opportunity to learn the anatomy, techniques, pathology, and medicine better. The rep "toys" are great, but they have nothing to do with what has really advanced our profession: better education, training, and knowledge of the anat/pathology/treatments. I think that some individuals get too focused on the toys as a magic bullet and way to potentially compensate for inferior surgical (and clinical) evaluation/planning/technique - as well as failing to realize the exponential cost they bring.

When I look at many of the guys whom I veiw as the best modern F&A surgeons, I see that they really haven't done a whole lot besides emphasize learning or provide slight modification/enhancements to previously existing tools or procedures. Shockingly, they've managed to make quite a mark in our field without ever even naming a screw, procedure, implant, etc after themselves:
-Schuberth, Malay, Kalish, Jacobs, etc encouraging us to be scientists and lifelong learners as well as just technicians
-Ruch et al advocating strong AO techniques for improved stability in F&A surgery
-Sanders pilon protocol of plate fib and ex-fix tib... or to consider primary STJ desis if severe calc fx
-Weinraub retractor to save time on proven desis or graft procedures
-Downey, Steinberg, Camasta, etc encouraging us to focus as much on patient selection and communication as surgery itself
-Hansen theory of essential and nonessential joints
-Yu [re]popularizing the time tested mpj1 desis after the implant craze swept through podiatry
-Northwest, inc emphasizing the power of equinus on foot deformities
-Myerson educating on many minimally invasive techniques of existing procedures for faster surg and faster healing
-Coetzee adding evidence that lisfrance desis off the bat may save cost+suffering
-Catz+Mendo popularizing Lapidus, allografts, etc, in podiatry

...Again, all just my (inexperienced) views. Maybe my opinions will change someday and I'll be gunning to throw a robotic STJ into all of my patients. Who knows lol...
 
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I do believe that despite your comment that "Shockingly, they've managed to make quite a mark in our field without ever even naming a screw, procedure, implant, etc after themselves", there is a procedure called the Kalish bunionectomy/osteotomy.

However, your points are well taken.

But I do believe you could have made your points just as well without reverting to comments like "my **** is pretty big, my wife is pretty hot". Sorry, but you lost a lot of points with me with that comment.
 
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Feli,

What interest me the most is that you mentioned in a previous post the term "kickbacks" and then go ahead and rattle off a bunch of big name podiatrists, who whether you realize or not were, at one time or still are paid consultants for certain company who help them "educate" the masses.

I'm on the lecture circuit and many of us who do this regularly are "subsidized" to speak at these conferences which is totally legal and encouraged. Why do you think its the same people lecturing at all these conferences? Yes they are bright and have something to offer, BUT they have the resources. You also have to take into account that some people make a career out of lecturing (which I don't), rather than in private practice. How much credibility do these people have when discussing these products or techniques?

There are many, many extremely talented Podiatric Surgeons out there that run circles around the "big names" in our profession. You will never hear about them, because they have no interest in lecturing, get nervous in crowds...etc, but are still the top of our field. I'm a guitar player, and used to play in a band. I'm a guitar junkie and listen to all kinds of guitar music. The best guitar player in the world is some kid sitting in his bedroom jamming to Hendrix, who may never play on a stage for me to hear for a huge number of reasons. Just because someone is in the spotlight, doesn't mean they are the best. That's what keeps me humble in my travels. There will always be someone out there better than me. I use that as motivation to continue to push forward with my education and skill set.

I'm with PADPM concerning your personal assessment of your personal life. I'm here to learn and interact with my colleagues. Stroke your ego elsewhere please.
 
I'm here to learn and interact with my colleagues.Stroke your ego elsewhere please.

Feli is by far the most informative and non-confrontational poster to this forum (more so than any "3 stooges" aka attendings who always bicker and ruin all hope of good conversation by tuning each thread into a pissing contest) so why don't you go take your attitude and stroke it elseware.
 
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Sorry, but you lost a lot of points with me with that comment.

It was a metaphor for the good life, so while Feli probably won't tell you what to do with your score card, I will. You and Kidsfoot are like the toughest guys at the gay bar..seriously, you make everything into an argument and ruin any hope at good discussion.

kidfoot said:
If you read some wound care literature...
I don't think you need to educate anyone on literature. Especially coming from someone who just posted in another thread that most podiatry literature is not worth reading.
 
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It was a metaphor for the good life.

:thumbup:


have a sense of humor you two! :)

(ps great thread. Thanks to all who are contributing!)
 
It was a metaphor for the good life, so while Feli probably won't tell you what to do with your score card, I will. You and Kidsfoot are like the toughest guys at the gay bar..seriously, you make everything into an argument and ruin any hope at good discussion.

I don't think you need to educate anyone on literature. Especially coming from someone who just posted in another thread that most podiatry literature is not worth reading.


Another tough guy. Read ALL of my posts. I don't get into "pissing matches" with Feli, and have consistently complimented Feli on his maturity and excellent posts. Yes, instead of simply shooting from the hip and taking one statement out of the hundreds that I've posted, why don't you go back and read ALL the posts.

Metaphor or not, I didn't think that Feli had to resort to those comments, and apparently the moderators agreed with me, and that's why the specific words were deleted.

There is nothing wrong with the ability to respect someone, while also letting that same person know when you don't agree with certain comments made.

I just love when "students" like you come on this site and have the wisdom to take comments out of context and twist words. After agreeing with just about every post Feli has written, you then write that I "make every into an argument and ruin any hope at good discussion".

Have you even read the MAJORITY of my posts, or do you simply concentrate on the few that you choose?
 
Feli is by far the most informative and non-confrontational poster to this forum (more so than any "3 stooges" aka attendings who always bicker and ruin all hope of good conversation by tuning each thread into a pissing contest) so why don't you go take your attitude and stroke it elseware.

I'm not disputing that he has much to offer. I don't need to hear about his size or the status of his wife's looks.

Its a matter of DECORUM and RESPECT. As a student, I would think you would realise that. Those 3 stooges attendings may end up being your attendings in residency my good man. Settle down.
 
I don't think you need to educate anyone on literature. Especially coming from someone who just posted in another thread that most podiatry literature is not worth reading.

LOL I said that I read wound care literature. You know the kind from people who specialize in wound care. Of the whole body. Also just for your edification, I was on a panel at the medical school where I am on faculty discussing evidence based medicine and research outcomes and incorporating literature into the classroom and the clinical setting. So actually, I can educate about literature. Particularly since I've been published and have done editing for content for some of our journals. I read tremendous amount in all fields that affect our specialty. What have you done?

As far as your comment about myself stemming any sort of discussion. Well, if the discussion is useful and intelligent, I'm interested. I don't come to this forum to read banter about body parts and to be lambasted by students who don't seem to realize that this is a forum for professionals to interact with other professional. You don't like what I have to say, move on and don't read it.
 
Wow... haven't been on in a few days due to a tough rotation. I'm doing vasc sx this month and was on gen surg ER trauma call the night of the Eminem/Jay-Z concert... as jon surely knows, "minding your own business" in Detroit tends to get you shot up, beat up, run over, etc.

The wife/etc comment I made was joking and meant to be taken with a sizable grain of salt. I was just trying to imply that we need to keep what we do in perspective. I don't feel that we should define our happiness, self worth, nobility etc by what we do at work. The Freudian superego has to do its job well: IMO, there's no reason to ever use "advanced" technologies in hopes of impressing patients or colleagues... or worse, just to make ourselves feel macho. We have skills that can help a lot of people, but at the end of the day, it's F&A surgery... not pediatric oncology or liver transplants. Even ortho hand or ortho F&A (which some DPMs and students strive so hard to be just like) is not so noble or grand when compared to ortho trauma, spine, etc.

Innovation and invention arrive out of necessity. They always will. There's no need to try and hasten evolution IMO. Sometimes ideas may come from other surgical arenas (DBM, scope, etc), and sometimes they may arrive from our own (Austin, Weil, etc). We know the anatomy and dissections, we know the biomechanics, we know the instruments, and we know the implants. If something doesn't work, then we will look for solutions. I just think we need to use common sense as opposed to blindly looking for the industry knocking on our office doors or showing up at the surgery center with doughnuts saying "here's your solutions." Besides having existing solutions that work, a lot of the new toys haven't proven to be cost effective. Many have even failed before... yet as long as the money's there, they'll keep coming back "new and improved." The word "old" will always have a less positive connotation than "new," so there are hundreds of implant companies out to capitalize on that by convincing surgeons that they need to push the envelope.

...I think that in addition to case volume/diversity, personalities, and level of resident "hands on," the individual program/attending philosophies in surgical evaluation and procedure selection should play a pretty big role in student's selection of residency. Yes, I said student's selection of residency - and not the opposite - since that's how CASPR match is structured and that is what it becomes for students who work hard and have applied themselves in pod school. They will have many good options, but they need to find the program they feel can foster the skills they want to end up with. There are certainly programs which are more/less agressive with elective surgery, trauma, diabetic recon/salvage surgery, etc. Likewise, there are programs and attendings which are more/less industry driven... "stick with what works" versus "totally cutting edge."

It's all about finding which the individual feels comfortable with. No resident wants to spend 3yrs at a program that is so "cutting edge" it makes them want to throw up in their mouth, but they probably also don't want to be somewhere they view as "stone age." The way I see it, conservative and classical training does show you the anatomy well, and it will show you what worked has for decaded and decades (and still does today). If you want to be "revolutionary," then you can always go find a fellowship for that. However, residency should be more about learning how to lay the foundation than how to build the space-age skylights. Even some of the authors like Myerson, RW Mendicino, or Mike Lee who write or lecture a fair amount on percutaneous, scope, or minimal incision mods of procedures always stress that those same procedures should be done in traditional open fashion to the level of high competency before the alternate techniques are undertaken... and that you should always be prepared to convert to the traditional, fully open method for doing the procedure.
 
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Well, yes, that was my impression.

Presby seemed to get some ankle/met/digit/etc fx brought in to their ORs from attending clinics, but their ER barely called them for anything besides wound/infection patients. I think the only thing I saw or heard about while there for a month was a 5th met fx (which was uninsured, basically nondisplaced, and just got casted). During my two night calls, we got one ER call... for cellulitis. One 3rd year was grumbling that an ankle fracture which had come in a couple months earlier had required them to page the 4th year in for the reduction and splinting. When most other programs I visited had interns and maybe occasionally 2nd years taking care of the ER calls, that sorta told me something.

I was told that HUP sucks up nearly all of the area's good and high energy trauma in their hospital system, and with an ortho program there, they were very abrasive towards the pod program (refused to allow rotation, any form of shared call, etc). The seniors told me that although the gen surg at Presby backed them, ortho had been a brick wall. They had been offered gen surg trauma rotations, but ortho trauma, ortho F&A, etc was basically out of the question due to the HUP ortho dept prioritizing the training of their own residents/fellows (and rightly so, I guess).

I was told that Temple or the program where Justin Fleming brings cases (formerly Frank-something?) were much superior for acute and ER exposure to F&A trauma. Again, just my experience and what I heard from Temple students and alumni whom I have no reason not to trust. I think Presby residents see enough overall surgery that they would know most of the dissections + anatomy, fixation methods, medical issues, etc to handle most trauma well... but, yes, I'd say they're definitely on the low end in terms of how much acute F&A trauma they see in the ER (closed reductions, splinting, etc) when compared to other high level PM&S residency programs. When you compare their trauma experience to DMC, UMDNJ, Palmetto, Oakwood, etc... it's a cat vs a pit bull. That can be said for many decent PM&S programs, though. It doesn't necessarily mean it's not a good program, but trauma's certainly not the emphasis... medical mgmt, off svc rotations, and elective surgery would be the main strengths of Presby, IMO.

Temple DPM residents do see a lot of F&A trauma because they alternate call (every other day) with Orthopedic residents for F&A trauma at Temple University Hospital Level 1 Trauma Center / ER. As PADPM already pointed out, Dr. Justin Fleming works out of the Aria Healthsystem (formerly Frankford Hospital System). Aria Healthsystem Torresdale Campus (where the residency program is based out of) is a Level 2 trauma center. So, the DPM residents are exposed to a great deal of F&A trauma. By the way, there are currently no Ortho residents at Aria - Torresdale. Hence, the DPM residents also serve as ortho residents as well. I believe that one of the Crozer system hospitals that Crozer DPM residents rotate through is also a level 2 trauma center.
 
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