Podiatry Surgery Volume

[footpainhealer]

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During your call weeks, you need to engage in weaponized incompetence. Next time you are consulted for a gangrene toe, advise the hospitalist that the patient is too medically complex to be within your comfort zone of management and that they need a second opinion or, preferably, transfer to a different hospital.

The funny part is, the reason our call is so busy is because other podiatrists from around our region are likely doing the exact same thing you're recommending. Weaponized incompetence. We're getting patients from several different hospitals (that have podiatrists on their websites) that apparently don't take call or don't want to operate on people, So they get sent to the hospital we cover.

My guy, those are CRAZY hours. Those are close to my residency hours but even then, I could come home in between for an hour to decompress because I lived right there. This practice is a recipe for burnout. When I was interviewing I was VERY strict about work/life balance and if it didn't mesh with the interviewer, I didn't proceed with the next steps. My family is extremely important to me, way more than patients (sorry to say). i guess it depends what your goals are, some people love the hustle but I hate it. I am an 8 hours per day kinda person. I am not gonna work beyond that for someone else. Now if it is my practice, I will gladly put in 100 hours a week.

Like I mentioned previously, residency was better than this in terms of hours. That's the benefit of being able to split clinics and cases between multiple residents vs having to do all of it on your own as an attending.

I don't love the hustle lol.
Only reason I am still here is because both of the owners are nice and really good mentors (both very well-trained too). They both will shift their clinics/cases if any of us younger docs/associates would like them in our cases. Both are available at any time, day, night, or weekend for anything we need. I'm definitely getting taken advantage of from a salary perspective, but I'm also still making a good chunk more than a lot of PP associates I know (including ones that have been out for multiple years already). But, I will admit, that it's becoming to be not worth it, in my opinion, because I don't really have time to see my family or enjoy the money I make.

 

[Hybrocure]

Proper pay (or just getting paid in general) for being on call prevents weaponized incompetence. Until then, I have no problem with turfing to higher care facilities. If a personal patient ends up at a hospital im on staff at, I take care of them. But I’m over doing free work for patients not established with my clinic. If a hospital is paying you to be on call though, you probably should do your job lol. But in podiatry that’s a bit rare for PP.

I’ve seen weaponzied incompetence happen when patients of mine go to hospitals or EDs I’m not on staff at. I read their pod consult notes at those hospitals, usually it’s a random area podiatrist consulted for free, they blame the impending amp on bad blood flow and escalate it to a level 1 hospital where vascular or ortho residents find out flow is fine but amp it anyways because it’s an infection that the other pod just didn’t want to deal with.


It’s not a podiatry specific thing either. EDs at prestigious hospitals employ weaponzied incompetence every day to turf out admits to other area hospitals that just don’t vibe with what their docs want to see.

 

[heybrother]

The funny part is, the reason our call is so busy is because other podiatrists from around our region are likely doing the exact same thing you're recommending. Weaponized incompetence. We're getting patients from several different hospitals (that have podiatrists on their websites) that apparently don't take call or don't want to operate on people, So they get sent to the hospital we cover.


Like I mentioned previously, residency was better than this in terms of hours. That's the benefit of being able to split clinics and cases between multiple residents vs having to do all of it on your own as an attending.

I don't love the hustle lol.
Only reason I am still here is because both of the owners are nice and really good mentors (both very well-trained too). They both will shift their clinics/cases if any of us younger docs/associates would like them in our cases. Both are available at any time, day, night, or weekend for anything we need. I'm definitely getting taken advantage of from a salary perspective, but I'm also still making a good chunk more than a lot of PP associates I know (including ones that have been out for multiple years already). But, I will admit, that it's becoming to be not worth it, in my opinion, because I don't really have time to see my family or enjoy the money I make.

You need a new job. Its not even a question.

Let's be real. Your best case scenario is that at some point they offer you a partnership deal that will be TERRIBLE. You'll take it hoping and believing your pay day has come, but you'll have to keep working at this terrible pace to try and make money and pay-off your terrible buy in. While all this is going on - CMS will be worsening the terms of Medicare reimbursement every single year.

But here's my joke for you - you're in "good company" doing the foolish thing and sticking around. I did it too, but I never worked as hard as you did. My EHR once told me the most patients I ever saw in a day was 26. I did spent my weekends reviewing claims, constantly writing/appealing, asking for payment fixes etc. While all this was going on my former business partner was off playing gold and traveling. He went to Europe for a 2 week golf vacation while I was working. I thought I had a ..fair / "ok" buy in at sub-$100K. But I'd find myself driving to work wondering why I was so miserable from a business/partner relationship experience when I theoretically had "made it".

Some day a switch will flip and you'll realize you have to go. In December of this past year I realized I'd brought in more money then I'd ever brought in and I would be receiving a trivial increase in pay for it. I reviewed my contract and in the course of it realized my partner had defrauded me.

And it was all avoidable. Both Dtrack and airbud told me to quit during Covid. That was years ago. I learned a lot in that time and I'd say I was incredibly prepared for starting my own business. But here's my final thing. Your situation is terrible, terrible, terrible. Its worse than mine ever was because I never actually worked that hard. I never truly took call. Saw like 3 inpatients in 7 years. Took a lot of Mondays off. Took every 1/2 Friday.

 

[heybrother]

Final thing - on the spectrums of <----------------------------> "old school doctor who works themself to death and lives for it" and "gen WTF who derives no satisfaction/avocado toast, whatever" - there are perfectly fine places in the middle where you do good work, have good encounters, get satisfaction from the pleasure of doing good work, while still prioritizing your life and loving your family.

 

[Hybrocure]

We should make a new thread on how to navigate switching jobs. I feel it’s something that is easy to say but harder to do logistically for a lot of people. Particularly with non competes, when and how to do it while still working, etc.

Moves are expensive. Having a family on top of that also and spouses with their own jobs, etc.

Would be nice to see how others navigated doing it.

 

[footpainhealer]

You need a new job. Its not even a question.

Let's be real. Your best case scenario is that at some point they offer you a partnership deal that will be TERRIBLE. You'll take it hoping and believing your pay day has come, but you'll have to keep working at this terrible pace to try and make money and pay-off your terrible buy in. While all this is going on - CMS will be worsening the terms of Medicare reimbursement every single year.

But here's my joke for you - you're in "good company" doing the foolish thing and sticking around. I did it too, but I never worked as hard as you did. My EHR once told me the most patients I ever saw in a day was 26. I did spent my weekends reviewing claims, constantly writing/appealing, asking for payment fixes etc. While all this was going on my former business partner was off playing gold and traveling. He went to Europe for a 2 week golf vacation while I was working. I thought I had a ..fair / "ok" buy in at sub-$100K. But I'd find myself driving to work wondering why I was so miserable from a business/partner relationship experience when I theoretically had "made it".

Some day a switch will flip and you'll realize you have to go. In December of this past year I realized I'd brought in more money then I'd ever brought in and I would be receiving a trivial increase in pay for it. I reviewed my contract and in the course of it realized my partner had defrauded me.

And it was all avoidable. Both Dtrack and airbud told me to quit during Covid. That was years ago. I learned a lot in that time and I'd say I was incredibly prepared for starting my own business. But here's my final thing. Your situation is terrible, terrible, terrible. Its worse than mine ever was because I never actually worked that hard. I never truly took call. Saw like 3 inpatients in 7 years. Took a lot of Mondays off. Took every 1/2 Friday.

I appreciate you being blunt about it. I don't think I'll be happy here long term, even if they offer partnership. The reality is, I would rather start my own practice. Even with all the administrative and business startup and billing and coding things I'm going to have to learn on my own as a startup practice, it would probably still be the same amount of hours I'm already putting in here working for someone else.

I don't wanna work for anyone ever again. I am perfectly happy just seeing 20 to 25 a day for 4 days, making 200 to 250. I feel like that's very doable as a solo private practice doc doing bread and butter stuff with no call and no rear foot reconstruction and all that stuff I'm currently doing.

 

[Hybrocure]

I appreciate you being blunt about it. I don't think I'll be happy here long term, even if they offer partnership. The reality is, I would rather start my own practice. Even with all the administrative and business startup and billing and coding things I'm going to have to learn on my own as a startup practice, it would probably still be the same amount of hours I'm already putting in here working for someone else.

I don't wanna work for anyone ever again. I am perfectly happy just seeing 20 to 25 a day for 4 days, making 200 to 250. I feel like that's very doable as a solo private practice doc doing bread and butter stuff with no call and no rear foot reconstruction and all that stuff I'm currently doing.

It is easier said than done though. It can take time to work up to that volume depending on where you live. A patient volume like that does not fall into your lap unless you buy out an existing practice unfortunately and even then if you do that, a lot of people leave because they aren’t seeing their old doc.

That’s at least the case where I am which is a big metro.

 

[footpainhealer]

It is easier said than done though. It can take time to work up to that volume depending on where you live. A patient volume like that does not fall into your lap unless you buy out an existing practice unfortunately and even then if you do that, a lot of people leave because they aren’t seeing their old doc.

That’s at least the case where I am which is a big metro.

Yep. Therein lies the dilemma. Before I graduated residency, I spent tons of time looking up metros and suburbs to look for places that aren't completely saturated. Purposely avoided all the common ones like LA, Miami, New York, Chicago, Dallas, Atlanta, etc., because I knew they were gonna be oversaturated for sure.
But even smaller cities that I looked into (like in flyover states) also had several practices with several doctors each. Where I work now is not even considered a metropolitan area, and there's already 4 foot and ankle ortho here, plus 12 podiatrists between the 3 different groups here. If we follow the 1:20,000 ratio that people throw out for podiatry practices, we are oversaturated by a multitude of factors. Yet, however, everyone in my group still gets at least 30 to 40 patients per day. So the volume must be there, and these people are coming from somewhere. I just don't get where and how they're getting here. lol

I don't know. Some part of me also thinks the money that I'd invest into starting a podiatry practice might be better put into something else entirely. Something completely unrelated to health care, like commercial real estate or a smoothie shop lol. And then I can do podiatry as a 1099 contractor for nursing homes and assisted living facilities in the meantime to make some money.

 

[Hybrocure]

Yep. Therein lies the dilemma. Before I graduated residency, I spent tons of time looking up metros and suburbs to look for places that aren't completely saturated. Purposely avoided all the common ones like LA, Miami, New York, Chicago, Dallas, Atlanta, etc., because I knew they were gonna be oversaturated for sure.
But even smaller cities that I looked into (like in flyover states) also had several practices with several doctors each. Where I work now is not even considered a metropolitan area, and there's already 4 foot and ankle ortho here, plus 12 podiatrists between the 3 different groups here. If we follow the 1:20,000 ratio that people throw out for podiatry practices, we are oversaturated by a multitude of factors. Yet, however, everyone in my group still gets at least 30 to 40 patients per day. So the volume must be there, and these people are coming from somewhere. I just don't get where and how they're getting here. lol

I don't know. Some part of me also thinks the money that I'd invest into starting a podiatry practice might be better put into something else entirely. Something completely unrelated to health care, like commercial real estate or a smoothie shop lol. And then I can do podiatry as a 1099 contractor for nursing homes and assisted living facilities in the meantime to make some money.

In my case - new patient flow is determined by PCP referral sources for the bulk of it. Sometimes this is done through hospital systems too. You can be credentialed at a hospital but part of their outpatient network and you get referrals from their outpatient clinics. A small percentage is from online/word of mouth.

A lot of PCPs have no idea who you are but their referral coordinators do and that’s who you want to know.

I would not advise quitting podiatry for a new field. We sometimes forget people doing well in non med fields now in their 30s have already been working at that 10 years already before we even got out of residency.

 

[heybrother]

You can still do rearfoot work as an owner if you want. It will often be under reimbursed (because of the Medicare "anchor" component to contract), but you'll keep all the money for the work you actually do.

I went to a conference recently and spoke to several associates - none of them were aware what their owner was being reimbursed for their cases. Not all of these cases are free. Efficient surgeons will still generate revenue from surgery cases. Yes, you might make more money seeing clinics patients. But you may also negatively impact your referral base if you don't see some of these cases through.

I keep saying this, but yes - I've had surgeries days where I waste a day to make less than a grand. I've also had surgery days where I made plural thousands of dollars and was done by 1pm.

When you own your own practice you'll have to ask yourself at the end of the year - would you rather have thousands fewer dollars? I've had plenty of cases I'd take back and I've had plenty of smooth sailing satisfied discharges where I'm seeing their family.

Plenty of doctors have made the transition into things like real estate, but most of them probably did so by using the seed money from medicine. Without beating people up - there's a measure of inconsistency on here where people want to "live their life and don't save" and then don't have the money that will allow them to break through to the next level. I'm trying to be very gentle in my language and not straw man because everyone on here signed a different contract and started from a different position. I know I was born on 3rd base in a lot of ways. The problem in podiatry is that the "next step" up in income isn't about being busy or being a better surgeon. Its either the jump to an institution or the jump to ownership. The 2nd of those requires money. The 2nd is also drmastically improved by having the money to buy the real estate that goes with the practice.

 

[Toenail]

If we follow the 1:20,000 ratio that people throw out for podiatry practices, we are oversaturated by a multitude of factors. Yet, however, everyone in my group still gets at least 30 to 40 patients per day. So the volume must be there, and these people are coming from somewhere. I just don't get where and how they're getting here. lol

I’m having a difficult time understanding how you are seeing 30-40 patients per day. What proportion of those patients are just coming for a toenail clipping?

 

[footpainhealer]

I’m having a difficult time understanding how you are seeing 30-40 patients per day. What proportion of those patients are just coming for a toenail clipping?

RFC is about 25-30%. I would say 10% is derm stuff like fungal nails/warts/ipk (not RFC patients, but younger ones), 20% wounds, and the rest MSK.

I ask myself that question everyday. We must have some sort of contract with the big local PCP groups because if anything foot related is even mentioned, they just send to us. Some of the referrals are so dumb, but it still takes up time.

 

[Homo sapien]

not that it's a 1 size fits all solution, but TTC nailing with MIS flipper foot has been pretty successful at our institution. relatively small incisions, less hardware, shorter OR times.

What's MIS flipper foot

 

[Feli]

What happens when the patient wants to “talk to the doctor” in PP I feel this is 90% of my patients calls to the office. Always feel like I gotta do it or get a bad review or lawsuit.

Yeah, it's lame. All of the "wants to discuss test/Rx/whatever."
Personally, I do this:

1. Call them back later that day or later in the week (even if you could call right away, don't reward this behaviour... but don't ignore them).
2. Start the convo with "hello, is Becky available?" ... "Hi Becky, this is Dr. XYZ. I'm just between appointments, but I heard you had a quick question?" They will get the hint, usually... the majority apologize and get quickly to the point.

...this is the absolute backbreaker in medicine as a whole: we don't have economic freedom to set our rates or charge hourly. For attorneys, the people who waste time or ask questions just get billed more fractional hours. They get billed 0.1 hours for an email or maybe 0.2 for a phone call, etc. Simple.

If docs billed per hour (at a rate of their own choosing), it'd be so much better. The better docs and ones in HCOL areas would charge more, and we'd all be busy. People would go where they found value. We wouldn't have to hope for MCR increases or locality adjusts in fee schedules for expensive areas.

 

[heybrother]

In the spirit of the above - train your staff. Never, ever take a note from your receptionist that says "John Joe wants to talks. 867-5309."

You don't want patient phonecalls and you certaintly don't want going in blind phonecalls. These phonecalls are almost always the exact sort of calls that you train your receptionist / MA to solve.

 

[Adam Smasher]

So as long as we're once again in fantasy land, if you could bill for calls, what payment model would you prefer?

1) It's a noncovered service and you bill the patient directly, which is basically what we have now. How much would you charge? Would it be a flat fee for the call or would you charge per minute? In increments of 10 min? Or would you bill by the complexity of the decision making (i.e. antibiotic request charges higher than discussing lab results)

2) It's covered fully by insurance. However, medicare and other payers invariably reimburse a pittance, because they will argue there's no office overhead costs associated with a phone call compared to an in-person encounter, and the lower reimbursement is a reflection of the efficiency of handling the matter over the phone. Also, because the patient's out-of-pocket is $0, you are now inundated with nuisance calls that you are contractually obligated to address as part of your participation in insurance plans.

3) It's covered by insurance but subject to copays and deductibles. The copay creates a barrier for unserious patients, so the call volume is less. But you need to chase down copays from everyone else because they're not physically present in your office. Medicare and the rest of the insurance companies still reimburse a pittance over the perceived efficiency they argue you are able to take advantage of. As a result, the reimbursement is not much more than the copay, and you're back to scenario #1, but with a ceiling on what you can charge set by the payers' contracted rate.

4) Subscription plan. Charge X dollars per month to have unlimited phone calls during set hours, say M-F 8am-6pm. Or fiddle with the variables to find something you like. It's the planet fitness model, charge a low membership fee with the expectation that many will subscribe but few will actually use it. Could be a deal with the devil, because some patients will call just to discuss the weather. Also what do you do when an non-subscriber calls with a problem you actually need to handle over the phone?

 

[Toenail]

RFC is about 25-30%. I would say 10% is derm stuff like fungal nails/warts/ipk (not RFC patients, but younger ones), 20% wounds, and the rest MSK.

I ask myself that question everyday. We must have some sort of contract with the big local PCP groups because if anything foot related is even mentioned, they just send to us. Some of the referrals are so dumb, but it still takes up time.

I think I understand now why you feel like there isn’t massive over saturation. Almost half of your day involves toenails, calluses, and warts. There is very minimal competition for this stuff. At least for now, give it another 5 years.

 

[Stormblest]

If doctors charged for phone calls all the sudden they would stop happening very often

 

[Bored Snorlax]

Believe it or not, the 2025 APMA Marit survey of 1,300+ DPMs found 55% take call, only 12% get paid for it, and median call pay is $350/night.

 

[air bud]

What's MIS flipper foot

For midfoot Charcot, just throw a nail. Lock up hindfoot/ankle, that's where deforming forces are coming from. Who cares about the hypermobility of the Charcot, that's the new "ankle" in terms of dorsiflexion of the foot.

 

[NTT123]

Believe it or not, the 2025 APMA Marit survey of 1,300+ DPMs found 55% take call, only 12% get paid for it, and median call pay is $350/night.

APMA: this reason we need more schools and fellowship! So residents and fellows can take unpaid call.

 

[footpainhealer]

APMA: this reason we need more schools and fellowship! So residents and fellows can take unpaid call.

If only all attendings are so lucky to have residents and fellows. The majority of attendings are taking unpaid call with no resident or fellow coverage.

 

[Bluecollarmed]

Some hospitals build your expected call contributions into your contract compensation which can get a little messy and never actually benefits you. This is how mine works since my call is "available" and no set dates/times I have to be around. wRVU hospital pods get production even if the patient doesn't have insurance so it's extra work but also extra pay. Not the same as being paid to be on call and also getting that production but it's something. PP docs I don't know why you're taking call unless it's a requirement for surgical privileges or it actually works out to be a steady influx of refers. If you haven't had the discussion with the hospitals though, your practice manager/docs need to sit down and say they want a call stipend or limit your availability to one that benefits the group (ie weekdays 8-6, no weekends or holidays)

 

[BeaverBlade]

your practice manager/docs need to sit down and say they want a call stipend or limit your availability to one that benefits the group (ie weekdays 8-6, no weekends or holidays)

this doesn’t work in reality. No one follows these rules. Whoever picks up the patient when it’s not your responsibility or groups responsibility will just wait until it is. If you’re on call…. You’re on call. It sounds good just doesn’t work.

My suggestion is if you don’t get paid, don’t do it. Just like any other job in the world

 

[NTT123]

Other specialties, aka the real surgeons, are in high demand. That’s why ortho and general surgery can get $1,000–$2,000 or more per day just for being on call.

There’s an oversupply of podiatrists. If one podiatrist chooses not to take call, there are another 10 pods willing to take it for free.

The best part? Some hospital unpaid call rotations are set up by the old pods. So if you don’t please them, you’ll quickly find out why you’re always on call during the worst days and times.

 

[Adam Smasher]

Plot twist:

No one at my hospital wants to take call, and the hospital doesn't want to admit diabetic foot infections either, so they use lack of surgical podiatrist coverage as a justification to transfer them out. Weaponized incompetence always prevails!

 

[footpainhealer]

There’s an oversupply of podiatrists. If one podiatrist chooses not to take call, there are another 10 pods willing to take it for free.

I hate to break it to you, but the latest Dean's Chat video and ACFAS instagram post says we're facing a podiatry shortage!
hahahahha

I just don't get it. To me, it is so blatantly obvious that we are oversaturated. I don't need data and studies to show me that proof. I can tell it's oversaturated just from contracts that people get, the amount of jobs that are out there, the pay scale of these jobs that are out there, go on Google Maps of any metro and just search podiatrists and see how many dozens and dozens and dozens of them there are.

These people are honestly starting to piss me off.

 

[NTT123]

I hate to break it to you, but the latest Dean's Chat video and ACFAS instagram post says we're facing a podiatry shortage!
hahahahha

I just don't get it. To me, it is so blatantly obvious that we are oversaturated. I don't need data and studies to show me that proof. I can tell it's oversaturated just from contracts that people get, the amount of jobs that are out there, the pay scale of these jobs that are out there, go on Google Maps of any metro and just search podiatrists and see how many dozens and dozens and dozens of them there are.

These people are honestly starting to piss me off.

BLS already told us there is not enough jobs for podiatrists. They don’t care.

 

[Boba Foot]

I hate to break it to you, but the latest Dean's Chat video and ACFAS instagram post says we're facing a podiatry shortage!
hahahahha

I just don't get it. To me, it is so blatantly obvious that we are oversaturated. I don't need data and studies to show me that proof. I can tell it's oversaturated just from contracts that people get, the amount of jobs that are out there, the pay scale of these jobs that are out there, go on Google Maps of any metro and just search podiatrists and see how many dozens and dozens and dozens of them there are.

These people are honestly starting to piss me off.

Unfortunately those in positions of authority often use that position to control the narrative that best suits their interests, regardless of whether it's accurate or not.

 

[Homo sapien]

I hate to break it to you, but the latest Dean's Chat video and ACFAS instagram post says we're facing a podiatry shortage!
hahahahha

I just don't get it. To me, it is so blatantly obvious that we are oversaturated. I don't need data and studies to show me that proof. I can tell it's oversaturated just from contracts that people get, the amount of jobs that are out there, the pay scale of these jobs that are out there, go on Google Maps of any metro and just search podiatrists and see how many dozens and dozens and dozens of them there are.

These people are honestly starting to piss me off.

They're a bunch of ****ing drifters. Keep student loan money and board fees coming in and **** the rest

 

[Toenail]

You can smell the desperation.

 

[Hybrocure]

Other specialties, aka the real surgeons, are in high demand. That’s why ortho and general surgery can get $1,000–$2,000 or more per day just for being on call.

There’s an oversupply of podiatrists. If one podiatrist chooses not to take call, there are another 10 pods willing to take it for free.

The best part? Some hospital unpaid call rotations are set up by the old pods. So if you don’t please them, you’ll quickly find out why you’re always on call during the worst days and times.

I know the holidays, it’s always the holidays