primary care

[songaila]

I am a little troubled by some of the comments. If anyone can clearify for me, that would be great. Some of you are saying that people that "don't work hard" to get the "three year residency" are the ones that can not get the "good jobs." I just wonder what if a person goes into the podiatry profession "want" to do the primary care stuffs. Are they not going to have a future because of the saturated market. What if a person does a PSR-24, what is their outlook? Are "two-year residencies" that bad?

So, does a perspective student has to "want to be the surgeons of the feet" in order to succeed. I am asking because the podiatrist I shadowed do most "clip and chip" and that is the bulk of his practice. Also, what is the propect of working in nursing home?

Thank you very much

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[FALL06]

I've shadowed several podiatrists in the Austin area and have seen a variety of practices. One of the older doctors I shadowed graduated in the 70's before residency was required. He had a mainly routine care practice but still had numerous repeat patients. Largely, the procedures that bill the best are not necessarily the high profile surgeries when you consider time invested and post-op commitment. So one does not need to be board certified in rearfoot reconstructive surgery to be financially successful.

 

[Dr_Feelgood]

I am a little troubled by some of the comments. If anyone can clearify for me, that would be great. Some of you are saying that people that "don't work hard" to get the "three year residency" are the ones that can not get the "good jobs." I just wonder what if a person goes into the podiatry profession "want" to do the primary care stuffs. Are they not going to have a future because of the saturated market. What if a person does a PSR-24, what is their outlook? Are "two-year residencies" that bad?

So, does a perspective student has to "want to be the surgeons of the feet" in order to succeed. I am asking because the podiatrist I shadowed do most "clip and chip" and that is the bulk of his practice. Also, what is the propect of working in nursing home?

Thank you very much

Most of the time it is suggested to do a PM&S36 b/c if you want to do more than clip and chip and forefoot surgery you must have the extra year of training. If you do a PM&S 24 you will forever be limited.

If you were 100% sure that you don't care about the rear foot and ankle or limb salavage than do a PM&S 24.

 

[songaila]

Thank you for the reply. That is what the podiatrist told me too. So, if one goes to "primary care", the two year would make more sense right? Since there are a variety of different residencies. Are all the quotes of high salary the result of joinging "multi-specialty" groups. It seems like there is something missing here. Anyone recently graduate with only 2 year residency? And how does one fare in finding a job?

 

[Feli]

I agree that more training gives you options for income and flexibility, but a good podiatrist will succeed regardless. C&C is always going to be the bread and butter of the profession.

The main podiatrists I shadowed were in a large northern Minnesota hospital in the city where I did my undergrad. Due to scope of practice, they do little more then C&C, orthotics, and minor office procedures (nail avulsions, wart surgery, etc). They do help a ton of people, have plenty of patients, and make a fine living, though. Near the end of my undergrad, I searched that hospital's website for pod openings just for the heck of it. There was one position posting, and it read "non-surgical podiatrist at XXX clinic location."

One of the younger podiatrists up there had went to DMU (or whatever Des Moines pod college was called circa 1990), finished near the top of his class, and done a one year pod ortho residency which was pretty good for the time he graduated. He had taken over his father's private practice and did some OR procedures (I shadowed him on a digit amputation and a hammertoe correction). Still, C&C, orthotics, and minor office procedures were the bulk of his practice. He gave me some very good advice (paraphrased obviously because this was years ago): "Learn orthotics and primary foot care very well. Surgery is always there, but view the basics as your primary source income. The surgery is just an extra perk and periodic income bonus."

One thing which concerns me slightly in the profession is the apparent trend toward less attention to biomechanics and orthotics as newer pods are all looking for heavy surgical training. My biomechanics professor mentioned how "pedorthists" have begun to appear here in Florida to fill that gap. They undergo far far far less schooling than podiatrists yet can make basic orthotics. This program is only about a month long:
http://podiatry.temple.edu/pedorthics/pedorthics.html#online (click 'Pedorthics program on the right side)
Personally, I don't view the it as a major threat to new grads since their high training in surgery/wound care/etc will more than compensate, but pedorthists definetly could take a fairly significant chunk of business from current C&C and orthotics podiatrists.

I guess you could do a PMS-24 residency if you did really only ever want to do primary pod care or you were surely going to practice in a state with very limited scope of practice, but I wouldn't advise it and I will definetly be doing a PMS-36. Chances are that most graduates (25-30yrs old on graduation) may practice for 30-50 years in podiatry. That is a very long time, and scope of practice and innovations will greatly change the profession. More training, even if you don't use it right away, is never a bad thing. You don't want to limit yourself down the line just to get out into practice a year sooner...

Truthfully, from what I've heard, all pod residencies will probably convert to PMS-36 pretty soon anyways, so this might be a moot point by the time you graduate if you aren't even a pod student yet...

 

[songaila]

I saw that link from Temple too. I didn't know what that was. It is ironic that the podiatry school offers it.

 

[songaila]

From what I have heard Florida and New York(NYC) is full of podiatrists.(with the two podiatry school) Any states that is really short of podiatrists. Someone mentioned "idaho" once. The podiatrist I shadowed told me the same thing.(NYC) The bulk of practice would be C and C at least in NYC. He thnks that three year would just be too long since the debt piled up if one does not being able to practice the surgery. A reminder, NY state is not exactly podiatry friendly. That is why I was asking about all the surgical residencies. Thank you all for the reply.

 

[Dr_Feelgood]

I agree that more training gives you options, but a good podiatrist will succeed regardless. C&C is always going to be the bread and butter of the profession.

The main podiatrists I shadowed were in a large northern Minnesota hospital in the city where I did my undergrad. Due to scope of practice, they do little more then C&C, orthotics, and minor office procedures (nail avulsions, wart surgery, etc). They do help a ton of people, have plenty of patients, and make a fine living, though. Near the end of my undergrad, I searched that hospital's website for pod openings just for the heck of it. There was one position posting, and it read "non-surgical podiatrist at XXX clinic location."

One of the younger podiatrists up there had went to DMU (or whatever Des Moines pod college was called circa 1990), finished near the top of his class, and done a one year pod ortho residency. He was in private practice and did some OR procedures (I shadowed him on a digit amputation and a hammertoe correction). Still, C&C, orthotics, and minor office procedures were the bulk of his practice. He gave me some very good advice: "Learn orthotics and primary foot care very well. Surgery is always there, but view the basics as your primary source income and the surgery is just an extra perk."

One thing which concerns me slightly in the profession is the apparent trend toward less attention to biomechanics and orthotics as newer pods are all looking for heavy surgical training. My biomechanics professor mentioned how "pedorthists" have begun to appear here in Florida to fill that gap. They undergo far far far less schooling than podiatrists yet can make basic orthotics. This program is only about a month long:
http://podiatry.temple.edu/pedorthics/pedorthics.html#online
(click 'Pedorthics program on the right side)

Personally, I don't view the it as a major threat to new grads since their high training in surgery/wound care/etc will more than compensate, but pedorthists definetly could take a fairly significant chunk of business from current C&C and orthotics podiatrists.

I think that you a mistaken about the decrease in biomechanics. Biomechanics is the key to a successful surgery. If you read the pod journals they talk about how you choose the right procedure by evaluating planal deformities, i.e. you don't correct a flat foot in the calcaneus if the problem is in the ankle joint.

As for orthotics, I think that move to pedorthists is good. It is the hedgehog theory, be good at one thing and refer out the rest. If a pod was smart they would have a pedorthists on staff, which ensures patients get their needs met and the pod still has time to see more patients.

 

[Podman]

I think that you a mistaken about the decrease in biomechanics. Biomechanics is the key to a successful surgery. If you read the pod journals they talk about how you choose the right procedure by evaluating planal deformities, i.e. you don't correct a flat foot in the calcaneus if the problem is in the ankle joint.

As for orthotics, I think that move to pedorthists is good. It is the hedgehog theory, be good at one thing and refer out the rest. If a pod was smart they would have a pedorthists on staff, which ensures patients get their needs met and the pod still has time to see more patients.

I'm with feelgood on that one - biomechanics is an integral foundation in our profession - radiographs, surgery, and improving foot function (conservative treatments).

Though, I believe that orthotics will remain as an integral aspect of conservative treatments - not everyone will elect to undergo a foot surgery and not everyone is a candidate for a foot surgery as well. If I was a patient, I'd prefer my foot and ankle specialist handle my case from A to Z - so if orthotics were to be the solution, then I'd like to have the DPM prescribing them instead of any other professional - yes, i realize that other professionals like the ones mentioned above posess knowledge in biomechanics and are qualified to cast for the orthotics - but what if the patient has ulcerations or soft-tissue infections in addition to their Gait deformity - wouldn't it make more sense for the foot and ankle specialist to handle the entire course of the treatment in that case? Just a thought...

 

[Feli]

...As for orthotics, I think that move to pedorthists is good. It is the hedgehog theory, be good at one thing and refer out the rest. If a pod was smart they would have a pedorthists on staff, which ensures patients get their needs met and the pod still has time to see more patients.

I agree somewhat, but it's always good to have options and be at least well rounded. Especially if you are going to practice in a non-metro area, you are going to have to do basically everything related to the foot at least periodically.

Podiatry is already a specialty, and I feel some students get too carried way with sub-specializing. Even during the first semester, I had people asking me, "what kind of podiatrist do you want to be?" It was as if they though some podiatrists make orthotics, some do sports medicine, some see pediatric podiatry problems, etc.
I kinda laughed at the question and reply, "well, podiatry's already a specialty. I plan on doing at least a little bit of everything." It might be true that vascular and endocrinology physiology really interest me the most and I therefore may focus on diabetic limb salvage and ulcer healing, but I want to know how to do everything related to podiatric practice. I want to be a pretty complete practitioner even if I don't use some of the knowledge very often...

You are correct that pedorthists might be good for booming high volume pod practices in metro areas so that the DPMs can see more patients, but in smaller towns, losing some of the orthotics business may hurt some podiatrists with less training who derive a significant % of their income from orthotics. From my understanding, pedorthist is still a relatively new and changing profession, so I guess its effect on podiatry remains to fully be seen...

 

[Dr_Feelgood]

I agree somewhat, but it's always good to have options and be at least well rounded. Especially if you are going to practice in a non-metro area, you are going to have to do basically everything related to the foot at least periodically.

Podiatry is already a specialty, and I feel some students get too carried way with sub-specializing. Even during the first semester, I had people asking me, "what kind of podiatrist do you want to be?" It was as if they though some podiatrists make orthotics, some do sports medicine, some see pediatric podiatry problems, etc.
I kinda laughed at the question and reply, "well, podiatry's already a specialty. I plan on doing at least a little bit of everything." It might be true that vascular and endocrinology physiology really interest me the most and I therefore may focus on diabetic limb salvage and ulcer healing, but I want to know how to do everything related to podiatric practice. I want to be a pretty complete practitioner even if I don't use some of the knowledge very often...

You are correct that pedorthists might be good for booming high volume pod practices in metro areas so that the DPMs can see more patients, but in smaller towns, losing some of the orthotics business may hurt some podiatrists with less training who derive a significant % of their income from orthotics. From my understanding, pedorthist is still a relatively new and changing profession, so I guess its effect on podiatry remains to fully be seen...

I agree about smaller markets, but more than likely it would be important to know the principles of casting more than the creation of an orthotic. It would be easier and cheaper.

 

[KHep]

The pod that I shadowed did a residency when they weren't required and learned rear foot surgeries that he has never used. If you know that you don't have any interest in this, and hopefully we all will by the time we're looking for matches, then I see no point in doing the extra year. I personally hope to do a 3 yr, but I don't think that everyone should feel compelled to just to follow the trend. If you learn it in residency and don't keep up on it, your not going to being able to do it years later. Just my .02.

 

[krabmas]

I just talked to an attending today about this same topic. His view was that even if the pod never uses any of the surgery for the rearfoot or the forefoot , they solely did C and C and orthotics this pod would at least have the knowledge of the pathology and ways to treat it surgically so he would know when to refer and to whom.

I do not think the problem lies in what training people get whether it be 2 or 3 years, I think the problem lies in the person that does not know his limits. Some PM&S 36 grads should not be surgeons because even after 3 years of training they still cannot think and do not have manual dexterity.

Unfortunately for patients there are many people out there that are afraid to say "when". Either themselves or their residency directors.

 

[efs]

Dr Feelgood makes a key point, that really needs to be emphasized.

There seems to be a split between surgery and "primary care" (which often is though of as the non-surgery stuff, in particular orthotics and biomechanics.)

To me (and a lot of others) biomechanics is really the key to podiatry. Without a firm grasp on biomechanics you could really screw up a huge proportion of the surgery. Even the "simple" bunion problems are all really biomechanical issues. Without considering that you may not be selecting the appropriate procedures.

Biomechanics is really the bread and butter part of podiatry. But this applies to both the surgery part and the non-surgery stuff. If you have this part down, you will certainly have a better grasp on the pathology you see, why it happens and what you can do to make it better.

To some extent the "reconstuctive" procedures we do are making internal changes to the foot structure to affect the function in the same way that orthotics make an external change to the foots function.

Biomechanics is really a key to this. And it is something that we emphasize/teach/learn/do better than any of the other folks that also treat foot pathology.