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I received an e-mail several weeks back from ABPM saying that I should go onto the student doctor network to write nice things about podiatry to gin up some positive sentiment about this field to prospective applicants to podiatry school. But embellishment isn’t my thing. I don’t sell snake-oil to my patients. When patients ask me if an injection is going to hurt, I tell them without hesitation, “Yes, it is going to hurt, but only for 10 seconds.” My patients appreciate that I play things straight with them, so I’m going to play things straight for any podiatry students and pre-health students out there, because ultimately that’s what will be most useful to you.
About me: I finished residency 5 years ago, carpet bombed the USA with my CV, found a private practice in a location that was ok with a salary that was also ok, bought in as partner 3 years ago. Some things worked out for me, some things didn’t. I don’t do trauma, I’ve dabbled in flat-foot surgery, I operate about 3 days/month not counting evening/weekend add-ons. I’m facing enormous demand for non-operative care. I don’t do lasers or shockwave or swift wart treatments or kerryflex or other magic cure-alls. The only thing I dispense is a certain brand of premolded orthotics, and if the company wants me to mention their name they can pay me to do so. My personal take-home gross was around 300k in 2021, so after taxes, retirement contributions, and debt service I can still live decently comfortable though it’s definitely not champagne and caviar. I put in about 50-55 hours a week, rarely more.
Also I haven’t posted on SDN for years. For some people podiatry is their passion, their mission in life. Sorry, but podiatry is just work for me. So when I’m not working, I avoid reading/watching anything about podiatry or feet or medicine in general.
Before I get into this, bear in mind some of this is only particular to my situation and 100% of this is my opinion, and my opinion along with $3 will get you on the subway, so YMMV.
Things I like about (private practice) podiatry:
1. I’m the boss. I call the shots. This is not an insignificant thing. I can tailor my practice to my needs. For now I’m hustling pretty hard, but I can easily scale this down. If you’re employed by a MSG or a hospital you have to fall in line with their culture. But I’ve got the leeway to delineate what I do and don’t do. A lot of internists/NPs/PAs don’t have that.
When I started off, there was a nursing home that I would visit every couple of months and trim toenails for a couple of hours. But they were being obnoxious about the way I did it. Plus they were giving my biller the runaround about demographic/insurance info. So we told em to take a hike.
In residency, my director was adamant that we address every toenail consult promptly. I guess he figured we’d impress the MDs or something. Reality is hospitalists have better things to worry about than if patients get their nails trimmed or not. So when hospitals consult me to trim someone’s toenails, I don’t even respond. Terrible lighting, uncomfortable working conditions, and I’ve got to carry my dirty nail nippers home with me afterwards. Plus patients are always anticoagulated AF so if I cut them, they’ll bleed buckets. So I’m not doing it. Your inpatient, your problem. Discharge the patient and send em to my office for treatment. Public aid pays for patient transport, and there’s a bus stop in front of my office if that’s not an option.
So private practice gives you enormous autonomy. Yes there are exploitative positions out there in private practice. If someone is making you a bad offer, do not be shy about hopping on the next airplane onto the next town/state and you will eventually find a position that will work for you.
2. As a podiatrist, you have the opportunity to make a big impact on patients’ lives. I’ve done some really cool things both in and out of the OR. There are people with crippling heel pain, on the verge of disability, that is beneath ortho’s dignity to treat. Curing their mycosis or ingrown is boring to many of us who’ve been doing this for years but to the patient, it’s huge. I take on a wide range of problems, some challenging, many not, and that leads to generally interesting and diverse work day.
3. I don’t hate trimming toenails. Yeah it’s icky, but like changing your children’s diapers, you start to bond with the person you’re treating and the act itself isn’t so terrible. The initial charting can be tedious, but afterwards it’s mostly a copy-paste template. If you can learn Lauge-Hansen, you can learn Q modifiers. Besides, some insurances will pay me $125 for 5-10 min of nail/callus care, brainless work, negligible liability, no global. Plus these patients are always super nice and super grateful afterwards. Meanwhile my bunion patients regard me like a car mechanic. Why did we ever get involved in bunion surgery?
4. The Grass Is Always Greener mindset is pervasive in medicine. I had an anesthesiologist tell me he wanted to steer his son towards a career in podiatry because podiatrists always seemed so much happier than the other surgeons. Meanwhile he was earning $1mil/year and was unhappy. Baffling. Anyway, since there’s no shortage of posts about how good everyone else has it, I’m going to be petty about other health professions. Here we go, enjoy some empty calorie negativity:
6. Personally, I enjoy diabetic wound care. It’s a lot of work, and many patients are challenging, and you will get same-day arrivals and evening/weekend calls for urgent issues. But it’s also very interesting, and frankly I find it breathtaking when you find the modality that works and a longstanding ulcer utterly disappears. Sometimes it’s as simple as gluing plastizote to the underside of the patient’s insole. Total contact casting is severely underutilized. It pays decently well, and if you are smart about where you source your supplies you don’t need that super expensive derma-sciences kit.
A lot of doctors don’t like treating ulcers because they re-ulcerate. The way I look at it is none of us is immortal, our bodies always break down and deteriorate no matter what we do. It’s the human condition. Some patients need surgery to get their ulcers healed for good, some patients need amputations no matter what you do. You just try your best and your patients appreciate it.
7. Ultimately podiatry has been fairly good, I’ll never go hungry, the work is interesting, the people are interesting. Happiness is a mindset, you have to be grateful for what you have no matter what you have.
Things I Don’t Like So Much about (Private Practice) Podiatry
1. By far, number 1, the path to licensure is needlessly long for what I am doing right now. I think the UK/Canada/Australia do it right, podiatrists have bachelor’s degrees and basically do chiropody procedures only. Instead of a doctorate + 3 year residency, we could have a “Master’s of Chiropody” or something, so you can learn pharmacology and prescribe Lamisil/antibiotics and not cut deeper than the subcutaneous tissue and still do 90% of everything I’m already doing.
4th year of podiatry school is pointless, clerkships are basically job interviews for residency. After interviews in January of 4th year, everyone mentally checks out and isn’t really learning anything anyway. Residency training was a speed bump for me on the way to licensure. If we MUST be surgeons, 2 years is enough to figure out hallux valgus and diabetic foot infections. My director did it in 1.
As it stands, 100% of podiatrists undertake a course of training that is for the benefit of 10-20% who will actually use it. We have an ongoing credentialing “Arms Race” where now fellowships are becoming more and more sought-out. My professor at podiatry school used to say, if you’re going to do 4 years, why not make post graduate training an even 5 years and you can become a general surgeon and operate on the entire body?
And since the ABPM wants to initiate this good will movement to promote podiatry on SDN, I’m going to call out these CAQs. They are all RIDICULOUS.
It’s not enough to get your degree.
It’s not enough to finish 3 years of residency.
It’s not enough to get licensed
It’s not enough to get certified
It’s not enough to do annual MOC activities
We’re being offered CAQs? All you have to do is compile an application, take a test, and pay a fee. I pray that every doctor here sees this for the naked cash grab that it is. Purchasing a CAQ is no greater testament to my competency than my hat that says “#1 Dad” is a testament to my parenting. But the sad reality is a lot of us feel inadequate and have to apply for the next latest greatest credential.
This more than anything else is why applications are down—the return on investment of 7 years isn’t here. The people in leadership (including ABPM) create more steps on the back end to make it harder for us working in the trenches, and then wonders where are the applicants on the front end.
2. The petty egotism of other podiatrists. The fact that we’re afraid to speak openly (not anonymously) and frankly of our profession’s shortcomings in a public forum for fear of repercussions.
3. As noted above, I don’t hate trimming toenails. But I do hate the way many people automatically make that association when they hear I’m a podiatrist. I hate that you can perform a limb-saving surgery and then visit the patient the next day in the hospital and all they or the family members care about is getting their nails trimmed. As though I carry my nail nippers in my pocket at all times “just in case.”
4. This is particular to private practice and to my situation, but if you buy into a partnership, make sure the contract stipulates how the pie is going to be split up. After my buy-in, some of my partners quietly started reducing their clinic hours. When I brought it to their attention that they were working less, and consequently generating less, and consequently should be taking a smaller slice of the pie, they were utterly insulted at the suggestion. We ultimately worked out an agreement, but I would have preferred to sort it out ahead of time. I’m still glad I bought in, because the alternative is starting from the ground up. That requires a skill set we just don’t get in residency or school. But I’ll always be salty over the 10s of thousands of dollars I’ve been putting into my partners pockets over the past few years.
5. Not so much a dislike but more of an idiosyncrasy of private practice. You will spend a bit of time doing managerial tasks. Yes, I have an office manager who handles a lot of it, but at the end of the day it’s my business and I have to be cognizant of what’s going on and how things are operating. For example I had a day where two of my medical assistants started bickering and I had to basically be their dad just so everyone could coexist peacefully.
6. Unpopular opinion: routine foot screenings for every patient with diabetes are a waste of time. I get patients on my schedule with uncomplicated diabetes who are perfectly capable of trimming their own toenails. They have no complaint other than their PCP told them to see me. So I do a neurovascular check and give a canned speech about checking their feet. I’ll pay lip service to glycemic control, but ultimately I’m not licensed to manage this and if anyone is going to convince this person to eat right, it won’t be their podiatrist. And then prn. Sorry, my schedule is too full to be scheduling you for an annual 99212 just to make sure your feet are still securely connected to your legs.
“But what if you miss something?” there is a sub-population of patients with diabetes who truly are an ulcer risk can and will go from intact epidermis to osteomyelitis in a matter of weeks. These are the people I can recognize and I keep them on a short leash. This does not equate to the broad brush recommendation that EVERYONE with diabetes needs to see me just for the sake of seeing me.
7. Finally, and most importantly, as a podiatrist, my recommendations will often be viewed with a certain degree of suspicion. Most of my patients have full confidence in me. But their doctors do not. I had a patient with Achilles tendonitis that I was getting queued up for surgery until his friend told him I as a podiatrist shouldn’t be treating this. PCPs regularly refer my ulcer patients to the wound clinic, for no other reason than because the wound clinic is called a wound clinic. I once had a PCP dc the Lamisil I prescribed over concern for the patient’s kidneys—seriously. I told the patient fine, your PCP can manage your mycosis then. I could and probably should do a little outreach, but I gave up a long time ago on winning hearts and minds. The old biases will always be there.
8. EDIT/BONUS/ADDENDUM: In line with #7, I hate the podiatry bait and switch. I hate that you can start school under the impression that you can be a big-shot surgeon and be an integral member of the medical community. For a lot of us this won't pan out, certainly not for me. I never wanted to be a small-business owner, but that's what I am, luckily I've got a good head for it. And, as stated above, I don't hate routine foot care. But anyone can do it, which means I'm hardly irreplaceable. And no undergraduate pre-health student undertakes their course of study with that as their end goal. In the heirarchy of needs, self-actualization lies at the top. All of us in this forum had enormous potential. Are you reaching it as a podiatrist?
So there you have it, my unvarnished opinion. The good and the bad, warts and all (lol). Podiatry ain’t a bad gig. Problem is it’s not the best move you’ll ever make either. It can be a good fit for the right person and only you know if that’s you. As for me, do I have regrets? Yeah a few. Anyway I’ve spent enough of my Saturday on podiatry.
About me: I finished residency 5 years ago, carpet bombed the USA with my CV, found a private practice in a location that was ok with a salary that was also ok, bought in as partner 3 years ago. Some things worked out for me, some things didn’t. I don’t do trauma, I’ve dabbled in flat-foot surgery, I operate about 3 days/month not counting evening/weekend add-ons. I’m facing enormous demand for non-operative care. I don’t do lasers or shockwave or swift wart treatments or kerryflex or other magic cure-alls. The only thing I dispense is a certain brand of premolded orthotics, and if the company wants me to mention their name they can pay me to do so. My personal take-home gross was around 300k in 2021, so after taxes, retirement contributions, and debt service I can still live decently comfortable though it’s definitely not champagne and caviar. I put in about 50-55 hours a week, rarely more.
Also I haven’t posted on SDN for years. For some people podiatry is their passion, their mission in life. Sorry, but podiatry is just work for me. So when I’m not working, I avoid reading/watching anything about podiatry or feet or medicine in general.
Before I get into this, bear in mind some of this is only particular to my situation and 100% of this is my opinion, and my opinion along with $3 will get you on the subway, so YMMV.
Things I like about (private practice) podiatry:
1. I’m the boss. I call the shots. This is not an insignificant thing. I can tailor my practice to my needs. For now I’m hustling pretty hard, but I can easily scale this down. If you’re employed by a MSG or a hospital you have to fall in line with their culture. But I’ve got the leeway to delineate what I do and don’t do. A lot of internists/NPs/PAs don’t have that.
When I started off, there was a nursing home that I would visit every couple of months and trim toenails for a couple of hours. But they were being obnoxious about the way I did it. Plus they were giving my biller the runaround about demographic/insurance info. So we told em to take a hike.
In residency, my director was adamant that we address every toenail consult promptly. I guess he figured we’d impress the MDs or something. Reality is hospitalists have better things to worry about than if patients get their nails trimmed or not. So when hospitals consult me to trim someone’s toenails, I don’t even respond. Terrible lighting, uncomfortable working conditions, and I’ve got to carry my dirty nail nippers home with me afterwards. Plus patients are always anticoagulated AF so if I cut them, they’ll bleed buckets. So I’m not doing it. Your inpatient, your problem. Discharge the patient and send em to my office for treatment. Public aid pays for patient transport, and there’s a bus stop in front of my office if that’s not an option.
So private practice gives you enormous autonomy. Yes there are exploitative positions out there in private practice. If someone is making you a bad offer, do not be shy about hopping on the next airplane onto the next town/state and you will eventually find a position that will work for you.
2. As a podiatrist, you have the opportunity to make a big impact on patients’ lives. I’ve done some really cool things both in and out of the OR. There are people with crippling heel pain, on the verge of disability, that is beneath ortho’s dignity to treat. Curing their mycosis or ingrown is boring to many of us who’ve been doing this for years but to the patient, it’s huge. I take on a wide range of problems, some challenging, many not, and that leads to generally interesting and diverse work day.
3. I don’t hate trimming toenails. Yeah it’s icky, but like changing your children’s diapers, you start to bond with the person you’re treating and the act itself isn’t so terrible. The initial charting can be tedious, but afterwards it’s mostly a copy-paste template. If you can learn Lauge-Hansen, you can learn Q modifiers. Besides, some insurances will pay me $125 for 5-10 min of nail/callus care, brainless work, negligible liability, no global. Plus these patients are always super nice and super grateful afterwards. Meanwhile my bunion patients regard me like a car mechanic. Why did we ever get involved in bunion surgery?
4. The Grass Is Always Greener mindset is pervasive in medicine. I had an anesthesiologist tell me he wanted to steer his son towards a career in podiatry because podiatrists always seemed so much happier than the other surgeons. Meanwhile he was earning $1mil/year and was unhappy. Baffling. Anyway, since there’s no shortage of posts about how good everyone else has it, I’m going to be petty about other health professions. Here we go, enjoy some empty calorie negativity:
- Chiropractic. We criticize our profession for opening up needless schools (justifiably so) but at the end of the day they’re teaching real medicine. Not so for chiropractic. These need to be in the dictionary next to charlatan. Vertebral subluxation is not a thing. One of the founding chiros claimed to cure someone’s deafness through spinal manipulation. Fun fact, the auditory nerve is a cranial nerve, its root doesn’t originate in the spinal cord.
- Pharmacy. Terrible
- Optometry. I hate selling people overpriced garbage, and that would include eyeglass frames.
- Physical Therapy. I feel bad for PT, they help so many of my patients, their work is truly important. But there’s a REALLY low ceiling on your income, and if you’re after a 3 year doctorate you may as well go to law school. (Actually don’t, lawyers are generally miserable)
- PA. This is personal for me. When I was in residency there were some PAs on other services to fill in for residents who were post-call and do floor work. Some were cool and I got along ok with them. A lot of them were patronizing and treated me like a simpleton because I was a DPM. I co-scrubbed with a PA on my ortho rotation for a hip arthroplasty and I asked her if she wouldn’t mind doing the admission medication reconciliation, because our EHR was always fastidious like that especially with asthma meds. She says to me “oh right you probably didn’t learn about those drugs.” And in my mind I was thinking “no, I understand beta-agonists, it’s that this is tedious busy work and you’re a hospital employee so do your job.” And there’s the rub. PA is a great move if you’re chasing the bag. The ROI is better than most other health degrees. But make no mistake you will be a scut-puppy for life. You’ll treat drug-seekers and STI exposures in the ER. You’ll water-ski in the OR. You’ll shoot botox in the derm clinic. You’ll face patient disappointment when they were hoping to see the doctor and not you.
- NP/CRNA: I’m lumping them together, I’ve got no ill will towards them, just because they’re not as stuck up as a lot of PAs. I suppose you put in your years as a RN doing floor work, facing disrespect from admins, doctors, patients, other nurses, it gives you some perspective. Sure the ROI is great, you can earn while you learn, but anesthesia seems like a boring job. And NPs tend to get funneled into primary care which also is not my cup of tea. See also what I said at the top about my opinion.
6. Personally, I enjoy diabetic wound care. It’s a lot of work, and many patients are challenging, and you will get same-day arrivals and evening/weekend calls for urgent issues. But it’s also very interesting, and frankly I find it breathtaking when you find the modality that works and a longstanding ulcer utterly disappears. Sometimes it’s as simple as gluing plastizote to the underside of the patient’s insole. Total contact casting is severely underutilized. It pays decently well, and if you are smart about where you source your supplies you don’t need that super expensive derma-sciences kit.
A lot of doctors don’t like treating ulcers because they re-ulcerate. The way I look at it is none of us is immortal, our bodies always break down and deteriorate no matter what we do. It’s the human condition. Some patients need surgery to get their ulcers healed for good, some patients need amputations no matter what you do. You just try your best and your patients appreciate it.
7. Ultimately podiatry has been fairly good, I’ll never go hungry, the work is interesting, the people are interesting. Happiness is a mindset, you have to be grateful for what you have no matter what you have.
Things I Don’t Like So Much about (Private Practice) Podiatry
1. By far, number 1, the path to licensure is needlessly long for what I am doing right now. I think the UK/Canada/Australia do it right, podiatrists have bachelor’s degrees and basically do chiropody procedures only. Instead of a doctorate + 3 year residency, we could have a “Master’s of Chiropody” or something, so you can learn pharmacology and prescribe Lamisil/antibiotics and not cut deeper than the subcutaneous tissue and still do 90% of everything I’m already doing.
4th year of podiatry school is pointless, clerkships are basically job interviews for residency. After interviews in January of 4th year, everyone mentally checks out and isn’t really learning anything anyway. Residency training was a speed bump for me on the way to licensure. If we MUST be surgeons, 2 years is enough to figure out hallux valgus and diabetic foot infections. My director did it in 1.
As it stands, 100% of podiatrists undertake a course of training that is for the benefit of 10-20% who will actually use it. We have an ongoing credentialing “Arms Race” where now fellowships are becoming more and more sought-out. My professor at podiatry school used to say, if you’re going to do 4 years, why not make post graduate training an even 5 years and you can become a general surgeon and operate on the entire body?
And since the ABPM wants to initiate this good will movement to promote podiatry on SDN, I’m going to call out these CAQs. They are all RIDICULOUS.
It’s not enough to get your degree.
It’s not enough to finish 3 years of residency.
It’s not enough to get licensed
It’s not enough to get certified
It’s not enough to do annual MOC activities
We’re being offered CAQs? All you have to do is compile an application, take a test, and pay a fee. I pray that every doctor here sees this for the naked cash grab that it is. Purchasing a CAQ is no greater testament to my competency than my hat that says “#1 Dad” is a testament to my parenting. But the sad reality is a lot of us feel inadequate and have to apply for the next latest greatest credential.
This more than anything else is why applications are down—the return on investment of 7 years isn’t here. The people in leadership (including ABPM) create more steps on the back end to make it harder for us working in the trenches, and then wonders where are the applicants on the front end.
2. The petty egotism of other podiatrists. The fact that we’re afraid to speak openly (not anonymously) and frankly of our profession’s shortcomings in a public forum for fear of repercussions.
3. As noted above, I don’t hate trimming toenails. But I do hate the way many people automatically make that association when they hear I’m a podiatrist. I hate that you can perform a limb-saving surgery and then visit the patient the next day in the hospital and all they or the family members care about is getting their nails trimmed. As though I carry my nail nippers in my pocket at all times “just in case.”
4. This is particular to private practice and to my situation, but if you buy into a partnership, make sure the contract stipulates how the pie is going to be split up. After my buy-in, some of my partners quietly started reducing their clinic hours. When I brought it to their attention that they were working less, and consequently generating less, and consequently should be taking a smaller slice of the pie, they were utterly insulted at the suggestion. We ultimately worked out an agreement, but I would have preferred to sort it out ahead of time. I’m still glad I bought in, because the alternative is starting from the ground up. That requires a skill set we just don’t get in residency or school. But I’ll always be salty over the 10s of thousands of dollars I’ve been putting into my partners pockets over the past few years.
5. Not so much a dislike but more of an idiosyncrasy of private practice. You will spend a bit of time doing managerial tasks. Yes, I have an office manager who handles a lot of it, but at the end of the day it’s my business and I have to be cognizant of what’s going on and how things are operating. For example I had a day where two of my medical assistants started bickering and I had to basically be their dad just so everyone could coexist peacefully.
6. Unpopular opinion: routine foot screenings for every patient with diabetes are a waste of time. I get patients on my schedule with uncomplicated diabetes who are perfectly capable of trimming their own toenails. They have no complaint other than their PCP told them to see me. So I do a neurovascular check and give a canned speech about checking their feet. I’ll pay lip service to glycemic control, but ultimately I’m not licensed to manage this and if anyone is going to convince this person to eat right, it won’t be their podiatrist. And then prn. Sorry, my schedule is too full to be scheduling you for an annual 99212 just to make sure your feet are still securely connected to your legs.
“But what if you miss something?” there is a sub-population of patients with diabetes who truly are an ulcer risk can and will go from intact epidermis to osteomyelitis in a matter of weeks. These are the people I can recognize and I keep them on a short leash. This does not equate to the broad brush recommendation that EVERYONE with diabetes needs to see me just for the sake of seeing me.
7. Finally, and most importantly, as a podiatrist, my recommendations will often be viewed with a certain degree of suspicion. Most of my patients have full confidence in me. But their doctors do not. I had a patient with Achilles tendonitis that I was getting queued up for surgery until his friend told him I as a podiatrist shouldn’t be treating this. PCPs regularly refer my ulcer patients to the wound clinic, for no other reason than because the wound clinic is called a wound clinic. I once had a PCP dc the Lamisil I prescribed over concern for the patient’s kidneys—seriously. I told the patient fine, your PCP can manage your mycosis then. I could and probably should do a little outreach, but I gave up a long time ago on winning hearts and minds. The old biases will always be there.
8. EDIT/BONUS/ADDENDUM: In line with #7, I hate the podiatry bait and switch. I hate that you can start school under the impression that you can be a big-shot surgeon and be an integral member of the medical community. For a lot of us this won't pan out, certainly not for me. I never wanted to be a small-business owner, but that's what I am, luckily I've got a good head for it. And, as stated above, I don't hate routine foot care. But anyone can do it, which means I'm hardly irreplaceable. And no undergraduate pre-health student undertakes their course of study with that as their end goal. In the heirarchy of needs, self-actualization lies at the top. All of us in this forum had enormous potential. Are you reaching it as a podiatrist?
So there you have it, my unvarnished opinion. The good and the bad, warts and all (lol). Podiatry ain’t a bad gig. Problem is it’s not the best move you’ll ever make either. It can be a good fit for the right person and only you know if that’s you. As for me, do I have regrets? Yeah a few. Anyway I’ve spent enough of my Saturday on podiatry.
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