This is a thought-provoking post and there's definitely a lot of treatments and strategies I've adopted and rejected.
The single biggest change happened to me after about 6 months of practice. When I finished residency, I was full of book knowledge and was keenly interested in academics. Very rapidly, that gave way to focusing on billing and optimizing my own productivity. This his particularly hard as my student loans entered repayment, and the cold hard reality sunk in about how little money I'm actually earning.
When I started I thought retail was bogus. I thought it was the sort of thing scummy doctors do to squeeze money out of patients. I'm warming up to it now. I think if it's a legitimate product that you personally or someone you know uses, like urea cream, it's an easy sell. Remember, retail is not just the cost of goods sold but also the service of matching customer to product. So my 300% markups are entirely justified.
I'm on the MIS bandwagon. Calling MIS a fad is like calling laparoscopy a fad.
I originally wanted to market myself as a sports medicine guy, but now do a lot with wound care. Wound care is labor intensive and will upend your schedule if you aren't careful, but it reimburses well. Better than nail care. Also the market for "sports medicine specialists" is much more saturated than for "wound care specialists."
I used to do a lot of total contact casting. I figured out how to source the components and trained my assistants on how to assemble them into boxes, and I thought I'd decoded the matrix, because I could net $200/visit from some payers. I stopped doing it because it always backed up my schedule and patients were just as likely to ulcerate on the back of their heel or at the rim of the cast as they were to heal the wound I was trying to heal. Not that I'll never do it again.
For recalcitrant heel pain not responsive to stretching/orthotics/PT/night splint/etc, I used to do Topaz. That worked about 50% of the time. Then I started doing EPF. That was less effective than Topaz, I found. Plus for the reimbursement, doing an EPF in the OR is dumb. Then I started doing EGR + EPF. That's a great operation, really slick. 20 min and it reimburses better than a bunion. I dunno what the RVU crowd will say about that. Of course now I bought a shockwave unit and patients have been
very happy with that modality.
The COVID pandemic came with a mandated postponement of all elective surgery. I had a lot of time on my hands in the office and a small group of patients who were clamoring for pain meds because of their heel pain or heloma molle hammertoes that I couldn't do anything about. So I decided may as well try it in office under local. I had long conversations about the risks of surgery with them and blocked out expansive periods on my schedule. It was basically empty anyway because everyone was on lockdown. The cases all went brilliantly. Plantar fasciotomies, hammertoe arthroplasties, ganlgion cyst excisions. You can do a lot in a regular office exam room. And office surgeries reimburse super good. Patients are extremely happy not to have anesthesia/hospital bills too. This was the most important clinical lesson to me from the pandemic.
When I make custom foot orthotics, I still do a full biomechanical exam. I started out doing it because I wanted to be the sports medicine guy and I was seeing 10 pts a day so I had time to do it, so I felt like it made me look like an expert. But you do it enough and it takes you 5 min plus you learn things about why the person is having the pain they're having. If your posting instructions are "post to cast" they always do 3 degrees RF varus and nothing more. So I came up with this formula:
RF posting = (tibia varus + STJ neutral)/2
FF posting = FF netural postion*2/3
If the forefoot posting is > 7 degrees, I post extrinsic. This way the foot is maintained in supination during the toe-off phase of gait. If the patient's max dorsiflexion is <0, I add 3mm heel lift. If the patient's first ray is plantarflexed, I do a first ray cutout AND dancer's pad.
Does this make me a lunatic or a visionary? You decide.
I used to use a lot of cantharidin for warts.
@Feli is right, debride q2weeks + salicylic acid works great, and I've had zero phonecalls about pain. I'll use AgNO3 swab to cauterize them each visit.
Likewise for intractable plantar keratosis or corns or whatever we're calling them, I went from
1) debride with 64 blade, 11055 or tell pt it's not covered and prepare for an argument
2) to debriding with 64blade + AgNO3, 17110, which has worked pretty well for lesions < 1mm
3) to excisional biopsy under local anesthetic 1142x. needs a stitch, and somehow the legion still recurs
4) to XR, w/u for some kind of offloading surgery. This is necessary for 5th toe pipj lesions but most people who get these are smokers so you're rolling the dice. I've personally had a high rate of nonunion with floating MIS metatarsal osteotomies and I can't recommend them. A lot of people don't want to go through all of this for what they regard as just a little callus.
5) now I'm back to debriding with 64 blade + AgNO3 swab to cauterize the base. I give 1-2 cc lidocaine which allows for a more aggressive debridement. I'm sure I'll end up doing something else.
As for the question about being less likely or more likely to suggest surgery, the biggest red flag for me is not smoking or obesity but
is the patient being argumentative before surgery. Not just with the doctor but with your support staff. If they are nasty before surgery, they will be ungrateful and unappreciative afterwards and I simply do not have the customer service acumen to handle that. So I am not the right surgeon for anyone who wants to be disagreeable with me.
I'm more likely to offer surgery to ulcer patients than I used to be, and others on here have reached this same conclusion.
I wrote a lengthy post about why I think diabetic shoes are hogwash. Hallux IPJ ulcers need a Keller bunionectomy to mobilize the mpj. I literally told a guy that if he doesn't want to do this, he needs to go to the wound clinic for his care because all I'm doing is waiting for his toe to need amputation. There are other examples of procedures to offload wounds, and I'll leave it to the other commenters here who operate more than I do to describe them.
Sorry this was a random/disorganized post.
