Non surgical podiatry

[hawaiinchick]

I have undergone extensive training in rearfoot forefoot and am even fellowship trained. unfortunately I have come to realize I actually really dislike surgery. i don’t enjoy it, I don’t care to include it in my practice, and I don’t feel I have the personality for it (I know, I didn’t realize this overnight for those asking why im in podiatry in the first place. it has been a process).

I do have an interest in wound care and other non operative components of the field. i don’t mind research and academics but dont have leads in this area. i am starting the job search process but I feel I don’t have a good chance with most practices if I truthfully say I want to be non surgical? I feel I will be turned down immediately and am embarrassed to even say I don’t want to do surgery as a recent grad from a good program. But I dont want to tell a practice i will do surgery and then not end up doing any?

Do I have chances as a hospital podiatrists? Is that even a real thing? Who at the hospital do I even reach out to? Some have told me to still reach out to ortho groups or PP who may look for a nonoperative person. How do I best market myself in this way? I feel pretty discouraged and am just feeling like I need to leave podiatry

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[Weirdy]

I feel you'd have a better shot advertising yourself as non surgical than surgical. Everyone in the job market is trying to do surgery to gain enough cases to submit for board certification- or they just genuinely like to do it and will do anything and everything. I havn't met a lot of people who will admit they don't want to do surgery.

Go to an ortho group who has an F&A and tell them straight up- hey, I don't want to do any surgery. Send me all your non surgical foot and ankle stuff- the stuff you don't want. Wounds, toes, diabetic foot care, ankle sprains or sports med that don't need surgery. Ortho wants to operate. They will push everything else that doesn't need cutting to you. Sounds like a win win.

Once you get your own established patient base, you can then start referring all surgical stuff to their F&A guy. Same thing applies to MSGs or hospitals where ortho already has a big presence and doesn't want podiatry cutting. Same thing also applies to podiatry groups if you end up going that route. Everyone graduating and entering a podiatry group will be hungry to cut for the same reasons above- boards case accumulation, experience, ego, whatever it may be. You will have an advantage because you are not taking cases away from them. They can dump everything else to you.

You advertise yourself the same way regardless of what setting you're in. "I want non surgical only. I do not want to deal with any of that. Any patients I see who need surgery will be sent to whoever does them in your group."

 

[MicroPod]

It may be a good idea to at least keep amps and I&Ds as part of your practice since no one else wants to do it. I’m with you though on a bunch of the rear foot and ankle stuff - have seen way too many complications and unhappy patients after.

 

[Feli]

You won't stand a chance at 95% of hospital openings (there are simply too many other DPMs who will do basics + surgery for the same/less pay), but you can definitely take the non-op route in an ortho group or large DPM group where you just send the surgery to other group docs. You answered your own question on the last part. Call up some ortho groups or medium/large DPM groups and tell them you will do insoles, injects, wounds... but not surgery. They will likely pay you less than other associates, but you can do ok. GL

This happens... we have had one or two over the years at the program I went to (high volume of surgery in training, most alums do medium/big surgery, many become PDs or ortho group, etc). I know that one of them eventually left podiatry entirely (usually only an option if you have a partner who does well financially). It's your career; do what make you fairly satisfied... go where you're treated best.

 

[Hybrocure]

There’s definitely a niche for non op. Some of the most profitable docs in areas I’ve trained or practiced have specialized in being non op. There are a lot of patients out there who will do everything they can to try and avoid surgery and will pay to do that. This usually does entail marketing and cash pay services though which may have questionable success rates.

I really wish there were more CMEs and lectures for non-op treatment protocols and ways to run a practice non op, unfortunately it’s hard to get hardware sponsor money for lectures when you’re not operating…

 

[heybrother]

Question for you - if you continued to do surgery but
(a) only did what you wanted
(b) only did it the way you wanted
(c) only did it on who you wanted
(d) declined, referred, etc everyone else

would you be more satisfied or inclined to continue operating?

Training sometimes has a way of making surgery more miserable than it needs to be. I found myself the other day doing a case I didn't really want to do and it reinforced for me the fact that I need to work harder on referring out the cases I don't want to deal with.

That said. Here's the hilarious part of podiatry. Theoretically the hardest part is getting the job. For most people, the job is like 80-95% non-operative. Going non-operative is basically saying you want to drop 0.5-1.0 days of inefficient work and probably replace it with a whole day of efficient work.

I won't tell you that surgery doesn't pay. Sometimes it does. It obviously allows you a pathway to resolve more issues. And obviously there are problems that are kind of surgical only - bunions somewhat come to mind.

You will also likely be doing a lot more diabetic foot care - that may or may not bother you.

My suspicion is many people have been in your shoes before and most simply chose to focus their surgical practice on the things they want to do and then ultimately moved towards non-op by saying no or decreasing their availability ie. they do 2 cases, twice a month and they fill them with plantar fascial releases or hammertoes or whatever.

A classmate of mine went to a program that I'm told had a lot of rearfoot. I asked them how much rearfoot they were doing after the pandemic and they basically wrote back "lol, f&*# rearfoot, we hired a superstar and I dump it all them".

 

[619]

You won't stand a chance at 95% of hospital openings (there are simply too many other DPMs who will do basics + surgery for the same/less pay), but you can definitely take the non-op route in an ortho group or large DPM group where you just send the surgery to other group docs. You answered your own question on the last part. Call up some ortho groups or medium/large DPM groups and tell them you will do insoles, injects, wounds... but not surgery.

They will likely pay you less than other associates, but you can do ok. GL

This is right and wrong at the same time. Only when you are employed in a hospital setting will they pay non-op less because in the hospital setting, you generate more wRVU in surgery.

However in a typical private practice, the non-op can and will earn more than the surgical pod. Nothing beats a full day of clinic doing general podiatry such as ingrown, corns/fungus, warts, heel pain, tendonitis, sprains, casting, dispensing DME etc. A non-op pod can work 8 or 9-5, no nights, no weekends, no calls, low risk and most important is less burn out and easily clear $200K as an associate. This can happen if you have a good contract (35%-40% collections), good patient volume and you know how to properly bill. If anyone says I am wrong then ask yourself why older/more experienced pods and owners will rather just chill in clinic all day seeing patients and maybe do a few simple surgery cases here and there but no big cases? Because clinic pays more and less headache and less stress and less burn out.

If OP goes to an owner pod looking for a job, OP will not get hired because the owner pod does not want anyone diluting his/her clinic volume. Owner pod wants a younger "naive" pod who wants to do surgery. That way owner pod can dumb surgical stuff on the new grad and owner pod can focus more on clinic.

If you notice I said owner pod (not young or old). I am about 5 years out and own my practice. I am far from old and I am already no longer interested in surgery especially big long cases. I have a good steady clinic volume but nothing busy or crazy. I enjoy my clinic days and not really hot about surgery anymore. If I decide to hire, I am not going to hire anyone who wants to hangout in clinic and not do surgery.

The biggest secret in private practice podiatry is surgery does not pay. But don't tell that to new or recent grads. Let them have all the surgeries.

OP biggest bet is maybe find a hospital job at a wound care center looking for non-op. A hospital that already has surgical pods will rather hire a PA/NP than hire another pod because they will be afraid if OP changes his mind and now wants to do surgery then OP dilute the surgical volume for the existing pods. Everyone wants to protect their turf. Few will believe that a young fellowship trained surgical pod wants to do only clinic.

I have seen some opening I think with Bristol Health looking for non-op pod but it's very rare. Either way the job market is bad for both op and non-op pods. You can't "standout" in podiatry by being non-op. Even ABFAS cert folks are applying for non-op podiatry jobs. The Irony. GL OP

 

[619]

I won't tell you that surgery doesn't pay. Sometimes it does. It obviously allows you a pathway to resolve more issues. And obviously there are problems that are kind of surgical only - bunions somewhat come to mind.

You have never treated a bunion non-op with custom inserts? lol The custom inserts pays more than the common bunion surgery (except if you Lapidus everyone regardless of IM angle) with zero global.

 

[LossToFollowUp]

Your situation is very location dependent. When I was searching for jobs, many private offices preferred someone more so non-op. Majority of private offices are profitable through clinical work. Funny enough, you might have better luck in saturated markets where there are plenty of other pods willing to take on the surgeries. If you can at least stomach doing amputations, I think you will do just fine.

I believe if you were aiming to work for a hospital, that would be very hard. Hospitals expect you to work to your full licensure especially so in more rural locations.

 

[air bud]

You have never treated a bunion non-op with custom inserts? lol The custom inserts pays more than the common bunion surgery (except if you Lapidus everyone regardless of IM angle) with zero global.

No since a custom insert doesn't do crap for a bunion other than you making money

 

[Adam Smasher]

The holy grail of PP podiatry profitability: L4361

🦞

 

[Feli]

This is right and wrong at the same time. Only when you are employed in a hospital setting will they pay non-op less because in the hospital setting, you generate more wRVU in surgery.

However in a typical private practice, the non-op can and will earn more than the surgical pod. Nothing beats a full day of clinic doing general podiatry such as ingrown, corns/fungus, warts, heel pain, tendonitis, sprains, casting, dispensing DME etc. ...

It all depends on the mindset of the owner of the PP, I suppose.
100% of any apps they get can do non-op.
Probably 80% can do non-op... plus hospital consults or wound center.
Maybe 50% can do non-op... plus hospital and WCC... plus forefoot/amp surgery.
Maybe 20% can do that above stuff... plus RRA cases.

In private, any owner wants the office to offer as many services as possible. A non-op is only attractive if they have multiple full scope docs already... and they can get the non-op fairly cheap (PA/NP money, or less). I get calls frequently from PCPs... "hey, can you do an Achilles rupture if I send you one"... "hi, do you do ankle fractures"... "can I send you a kid with flat feet"... etc. I tell them I do it all. It is easy for them to send and send. It doesn't matter who in the group does that stuff, but it's optimal to offer it all. Pods who can do triple arthrodesis still know how to do BCBS ingrowns too. Having an associate/partner who did limited DPM scope would be crippling to me. I would have to educate my staff on what complaints go to which doc. I would have to explain to refer sources that they can only consult or send X,Y,Z to me and tell the ER or inpt docs that they can call me but not associate/partner for same things if I'm on vacation.

That offering services is why it's definitely not worth paying more to hire a limited scope person in PP setting (hence why nearly any MSG, DPM, ortho group does not pay a non/minimal surgery DPM as much as a full scope one). It's simply supply and demand. It's about bringing services and offerings to the group. That is not to say a non-op DPM could not bonus fairly well from collections, but it is crazy to guarantee them more salary to attract one. The non-op DPM applying PP jobs will universally be offered less base than surgical DPM - occasionally same money. There is much more supply of the limited scope podiatrists available, and the pay is lower.

...For OP, go ahead and inquire on podiatry group associate jobs that sound like good area and docs to work with... but fully expect a possible 20-40% reduction of the advertised base guaranteed salary when you tell them that you are non-surgical (you should expect the same production %, however).

 

[Hybrocure]

Have any of you met an NP or PA who can do non op pod work better than an actual podiatrist? I sure haven’t. A majority of our 4 years of school has very little to do with surgery.

Literally every single NP and PA I’ve met and I have met many can’t wait to hand off any podiatry pathology over to a podiatrist.

There’s still a demand for non op or minimal op. Maybe even moreso now that every graduating pod is obsessing over surgery and fighting each other while simple but good paying clinic pathology goes unnoticed. Including routine care which can pay.

 

[Feli]

Have any of you met an NP or PA who can do non op pod work better than an actual podiatrist? I sure haven’t. A majority of our 4 years of school has very little to do with surgery.

Literally every single NP and PA I’ve met and I have met many can’t wait to hand off any podiatry pathology over to a podiatrist.

No, the pods are almost always better. Typically, the PA/NP might also be same price or even higher.
It is just really easy for the midlevels to learn, though.
I have NPs in my area (primary care or MSGs) who do 3+ heel injects, countless verruca tx, abx or ingrown proc, etc etc before sending to me. I encourage it. I give them tips if they ask (PT for ankle sprain hx, inject for OA, etc). They have unlimited scope. It's all a function of how they are paid and how busy they are as to whether they just send it versus they treat F&A a little - or a lot.

The primary and STRONG lure of the midlevel hire (or non-op DPM hire) is just that they aren't ambitious and won't take surgical volume or "good stuff" from surgical DPM (or ortho, etc... depending on the group). This is especially true for hospital DPMs... the PP can always fire/restrict the other DPM(s) hired. The PP will tend to hire a non-op or minimal trained DPM for same/cheaper than midlevel (and because they're same/better skill and more autonomous for billing), and the hospital DPMs will tend to strongly push for midlevel hire to see the dept's RFC and post-op visit and etc to protect cases/income/etc from another DPM hire's ambition.

The common hospital jobs are wounds and amps and DM stuff... possibly "general podiatry" (aka forefoot).
Hospital non-op DPM jobs are very rare, and basically any FTE hospital DPM will be mistrustful of another DPM. The non-op DPM applicant's best phone/interview move is to say they have not done surgery in a long time, GAVE IT UP, aren't board cert for it, etc. The hospital DPM doing surgery will probably still decline to hire them or ask the hospital to hire a midlevel.

 

[icebreaker32]

Agree with Feli that non operative hospital podiatrists are becoming less common, especially in desirable locations. There are still jobs posted occasionally, but the trend is definitely moving towards hiring midlevels.

Large podiatry groups will sometimes hire a non operative podiatrist, but the salary is usually not that high. This might be OK if you are living where you want and you have a partner/spouse that also has a good job…..if not then living an upper middle class lifestyle might be difficult, especially if you have children. Longterm job stability is unpredictable.

The VA is hiring less non operative podiatrists.

Being a solo non operative podiatrist is not impossible, but as mentioned at least doing some elective and non elective surgery and referring out the rest is a more realistic business model for most. Just because someone else has a niche boutique non operative practice with lots of cash pay doing very well does not mean this is an easy business model to replicate.

FQHCs are an option. Sometimes they want a surgical podiatrist, but often they have no preference if you if you do surgery or not. Benefits are usually good, but salaries can vary widely from one FQHC to another.

Ortho groups usually have a couple ways of looking at non operative podiatrists.

1. In addition to seeing whatever they don’t want to see they actually expect you make a nice profit for the group.

2. They look at you more like a PA to do everything they don’t want to see but are actually willing to take a slight loss on you because they realize you are not able to generate that much revenue with nails and post ops etc.

The longterm job stability at an ortho group is unpredictable. Some can work 25 years for the same group as a non operative podiatrist and other times you might be let go in less than 3 years even though you were a good employee. The reality is partners have periodic meetings and are constantly discussing how they feel they can increase revenue or cut costs, especially if they see their income dipping. You know they need to make that new boat payment in addition to the house, condo, car and private school payments for their kids etc. It is possible a few years earlier the partners collectively felt a non surgical podiatrist made economic sense for the group and a few years later they don’t.

Longterm job stability when one is not an owner or partner is not a problem unique to podiatry. The ability to find another good job quickly without moving though is more difficult in our profession. This is definitely one advantage to being an owner and not an employee, especially in a private practice setting.

 

[Feli]

...The VA is hiring less non operative podiatrists. ...

Absolutely.

The VA and IHS have some non-operative DPMs, but they're obsolete... they will be replaced with surgical pods when the retire.

The reason is more services offered by the surgical DPM, ability to take call... but also that surgical DPMs are in abundant supply and same or similar cost to non-op anyways (DPMs in general are at bottom of pay scale).

 

[hawaiinchick]

Thank you all for your help and comments. What about wound care centers? Can you independently contract with WCC? Do you operate on your patients when working in WCC or refer out / send them to the hospital?

 

[Retrograde_Nail]

Thank you all for your help and comments. What about wound care centers? Can you independently contract with WCC? Do you operate on your patients when working in WCC or refer out / send them to the hospital?

Very rare for a wound care center to want to contract with a individual private practice podiatrist when they can make a deal with an MSG or hospital who have podiatrists employed there who can work the wound care clinics for free.

 

[Feli]

Thank you all for your help and comments. What about wound care centers? Can you independently contract with WCC? Do you operate on your patients when working in WCC or refer out / send them to the hospital?

Agree with above... wound care centers typically don't employ pods (associated hospital may). They're typically just a place for pods to bring their own pts (like ASC or hospital ORs).

Just like ER call, there are too many area podiatrists who'd do it free to gain patients or a space to work.

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