Rearfoot only???

[347932]

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I had a very interesting discussion with a close colleague of mine recently that went something to the effect that residents were now going to go to the hospital that he goes to, but will only cover one surgeon there, and only do the rearfoot cases when they come up with this doctor. Even though my colleague is very busy at this hospital doing both OP surgery, inhouse care and diabetic limb salvage cases, apparently the residency director of this program doesn't think his senior residents should "bother" with these cases, or offer to help my colleague with his cases. It seems his residents are too busy. Forget about covering in house patients, which would offer a significant experience in the multi disciplinary approach to the diabetic foot. Do they get in somewhere else? Probably. Can you ever get enough of it? No way.

This scenario brings up some interesting issues in our education, as I've heard this type of attitude in many of the places I've visited, and from many of my colleagues who are involved with residencies.

First let me say, that I can't condone this from a residency director as it seems to perpetuate the whole "I'm a sexy RF surgeon and anything else is beneath me", type of attitude. I've visited certainly very busy RF oriented residencies and the one thing that many of the residents complain about is that they are not prepared for private practice as they barely get their FF numbers and can't remember the last time they cut on a bunion. Bad news all the way around. You MUST be extraordinarily proficient at the bread and butter if you want to survive. Few of you will have the luxury of being in a trauma based F&A Ortho practice.

Another issue I have is that I know this residency. I know that residents at this residency double scrub cases to make their numbers. There is no doubt in my mind that they are NOT too busy, but once again, have this air that FF cases are beneath them by the time they are in their senior year. Yes they get their numbers, but NO CASE is beneath any of us. Trust me on this one. Every case is a learning experience no matter how small.

As you all know I've recently transitioned to a large, very busy podiatry practice. Even though I am among the youngest practitioner in the group, even the oldest of the docs in the practice teach me something new everyday! I am extremely lucky in that regard. I am surrounded by highly intelligent, highly skilled Pods, who have the presence of mind to realize that there is always something to learn. I learn from them all the time. Hopefully, I have something to offer to them as well, and they sometimes learn from me as well. Learning is lifelong, and hopefully, you all realize this.

Do as many cases as you can from all parts of the foot. Don't limit your education, because a higher authority thinks you are above it. You aren't. The smart ones in that residency will make an effort to NOT double scrub and maintain an even mix of all cases throughout their residency time. Believe me, it'll come back in spades. Don't be afraid to speak up, and follow your instincts. By the time you're a senior resident, hopefully your director has enough respect for you to realize that he or she should let you decide what you still need to learn. Take control of your training and don't just do it because someone told you so.

 

[jonwill]

I agree. At my particular residency program, I had all of my numbers early into my second year. By the time I reached my third year, I had done a lot of everything. As tempting as it was to cover only the bigger cases, I still covered a lot of the basic stuff. What kept me going was the thought that in less than a year, I wouldn't have anyone looking over my shoulder and everything I did would be 100% on me. When you think of it that way, you suddenly want to do every procedure as much as you can no matter how many times you've done it!

 

[Feli]

I agree that a program should either have their residents cover every one of an attending's cases - or not cover him. Cherry picking really has no place in training, and I can tell you that my attendings would tell you to not show up for any cases if they didn't have at least a junior resident there for even nail or wart procedures in the OR. To them, a case is a case, and a dictation is a dictation... and they expect that as a tradeoff for the training opportunity.

"Common things occur commonly," and you had better be darn good at them when you're out in the real world as an attending. No matter how good you can fix a pilon or Charcot, patients are going to assume you're incompetent if you can't even handle an orthotic or a wound dressing with precision. We're specialists, and you need to be a master of all aspects of your craft.

...Few of you will have the luxury of being in a trauma based F&A Ortho practice...

It's neat how everyone has a different idea of luxury.

Give me an office full of BC/BS heel pain, HAV, and flatfeet all day long... I will gladly give up the night calls and no-pay comminuted fx in substance abusers 😎

 

[347932]

It's neat how everyone has a different idea of luxury.

Give me an office full of BC/BS heel pain, HAV, and flatfeet all day long... I will gladly give up the night calls and no-pay comminuted fx in substance abusers 😎

You are wiser than most. Some residents only see "the case", and not the life surrounding that case. Many residents won't even consider the financial disaster many of these cases are, but only how "cool" it is doing them.

One of the issues with my initial comment is just about that. Some residents feel all they need to do to is show up, get handed the knife, and bolt. That does very little to prepare them for actual practice. In my scenario, my feeling is that that is just as much about the attitude of the Director, and is no wonder to me how some residents have that attitude as well, as they progress through residency.

 

[Podfather]

You are wiser than most. Some residents only see "the case", and not the life surrounding that case. Many residents won't even consider the financial disaster many of these cases are, but only how "cool" it is doing them.

One of the issues with my initial comment is just about that. Some residents feel all they need to do to is show up, get handed the knife, and bolt. That does very little to prepare them for actual practice. In my scenario, my feeling is that that is just as much about the attitude of the Director, and is no wonder to me how some residents have that attitude as well, as they progress through residency.

I agree. It's a fine line between building confidence and creating a big ego. I find the director must always point out how their "cool" case may have been done differently, what the long term ramifications are, discuss the reimbursement and complications.

Most residents learn humility within in six months of graduating when all of a sudden it's their patients. One complication and they usually start to realize the didcatic parts of their training were as important as their time in the OR. Often, I will get numerous cases sent to me by certain residents. Many times it's surgical but sometimes it's eczema , a recurring verruca, or other simple/common conditions. With time the the consult requests diminish and the training wheels come off. Then you know the residency system worked.

 

[GSRaw]

.. residents were now going to go to the hospital that he goes to, but will only cover one surgeon there, and only do the rearfoot cases...

I'm not sure what program you're alluding to, so I'm going to generalize and play residents advocate for a minute. In my experience the above scenario is becoming more common, especially for senior residents hoping to be RF qualified. Personal opinions of your colleague aside, is it possible the program is simply short rearfoot numbers? Assuming this was in part the case, then it would be in the residents (and the programs) best interest to work with surgeons who do more of those types of procedures.

...my colleague is very busy at this hospital doing both OP surgery, inhouse care and diabetic limb salvage cases...

Coverage for traveling cases is a touchy issue, especially when residents are working with one doc in multi-discipline group. The fact that your colleague is busy and what cases senior residents perform are two different issues. At most programs the procedures are "tiered" by resident year in order to keep the numbers fair. FF/DFI/ID cases are typically first/second year cases and I've personally never seen a senior resident scrub those cases, unless to assist a junior resident.

If the were junior resident's helping senior residents with RF cases rather then primary scrubbing FF cases with another doc, that's an opportunity for your colleague to approach the residency director/residents about covering cases. However, without knowing more about the relationship between your colleague and the program, it's not clear whether or not his serviced are needed

Also keep in mind that there are other factors that dictate how involved residents are at other locations. These include how far they have to travel, if they have to cover multiple hospitals, how many cases are scheduled that day they travel, etc. No, it's not always convenient or necessary to make residents travel to cover a single case, in fact unless its a long case it might not be worth the time at all. These are sometimes practical decisions, all politics aside.

apparently the residency director of this program doesn't think his senior residents should "bother" with these cases, or offer to help my colleague with his cases.

Assuming the bolded statement is true and not just sour grapes from your colleague (who might feel shafted for not having resident coverage), that is unfortunate for both the residents and the program. Do you know if your colleague had a conversation with the director or residents or is he simply assuming that by not offering coverage for his cases that they do not value his work?

..It seems his residents are too busy. Forget about covering in house patients, which would offer a significant experience in the multi disciplinary approach to the diabetic foot. Do they get in somewhere else? Probably. Can you ever get enough of it? No way.

Everyone knows coverage of in-house patients is a very time consuming and a tedious job, which is why at most programs it's done by a first/second year resident. Furthermore if they are just sending seniors over to get RF numbers it might not be possible (policy wise or time wise) to cover those patients. It's certainly significant experience, which is why it's required during in your education. I'm not downplaying the value of the experience to senior residents, but it's usually not a senior resident doing the in-house work.

..There is no doubt in my mind that they are NOT too busy, but once again, have this air that FF cases are beneath them by the time they are in their senior year.

If the senior residents fulfilled their FF numbers then why would they take that opportunity from junior residents? Furthermore, if they do want to do more FR/trauma when they graduate who's to criticize that decision? That's what I would consider "taking control of their education", not scrubbing cases your junior residents could be doing. Without knowing more it's hard to have an opinion either way regarding your colleagues feelings. Considering the director sought out someone to get his senior residents more numbers it would make sense he would do the same for his junior residents, assuming there was the need. Just because they are not involving your colleague doesn't mean they don't value his work.

GSR

 

[347932]

I'm not sure what program you're alluding to, so I'm going to generalize and play residents advocate for a minute. In my experience the above scenario is becoming more common, especially for senior residents hoping to be RF qualified. Personal opinions of your colleague aside, is it possible the program is simply short rearfoot numbers? Assuming this was in part the case, then it would be in the residents (and the programs) best interest to work with surgeons who do more of those types of procedures.

My colleague does plenty of Rearfoot and this hospital. My take on it is that any resident should want to cover an excellent surgeon's cases (which this person is very much so). There is more to learn than just shear numbers.

Coverage for traveling cases is a touchy issue, especially when residents are working with one doc in multi-discipline group. The fact that your colleague is busy and what cases senior residents perform are two different issues. At most programs the procedures are "tiered" by resident year in order to keep the numbers fair. FF/DFI/ID cases are typically first/second year cases and I've personally never seen a senior resident scrub those cases, unless to assist a junior resident.

I don't think this is a very good way to make sure everyone gets trained well. All residents should cover all cases regardless of PGY status. If anything, complicated FF cases require more finesse and should be handled by a more senior.

If the were junior resident's helping senior residents with RF cases rather then primary scrubbing FF cases with another doc, that's an opportunity for your colleague to approach the residency director/residents about covering cases. However, without knowing more about the relationship between your colleague and the program, it's not clear whether or not his serviced are needed.

My close colleague was a residency director at one time (and a very good one I might add) and is known very well and very well respected in the community.

Also keep in mind that there are other factors that dictate how involved residents are at other locations. These include how far they have to travel, if they have to cover multiple hospitals, how many cases are scheduled that day they travel, etc. No, it's not always convenient or necessary to make residents travel to cover a single case, in fact unless its a long case it might not be worth the time at all. These are sometimes practical decisions, all politics aside.

I disagree. I would travel one hour each way if I knew I had a good learning opportunity when I was going through. AS a resident, you should be taking every opportunity. Sounds like laziness to me, sorry.

Assuming the bolded statement is true and not just sour grapes from your colleague (who might feel shafted for not having resident coverage), that is unfortunate for both the residents and the program. Do you know if your colleague had a conversation with the director or residents or is he simply assuming that by not offering coverage for his cases that they do not value his work?

This was heard from the mouth of the director on more than one occasion, by more than one person. I confirmed this myself. Not sour grapes. Just a sour Director.

Everyone knows coverage of in-house patients is a very time consuming and a tedious job, which is why at most programs it's done by a first/second year resident. Furthermore if they are just sending seniors over to get RF numbers it might not be possible (policy wise or time wise) to cover those patients. It's certainly significant experience, which is why it's required during in your education. I'm not downplaying the value of the experience to senior residents, but it's usually not a senior resident doing the in-house work.

Again, the "I'm a bigshot" mentality. It is the responsibility of all residents to learn what they need, to get into private practice. If they are lucky enough to be in a practice like I am, they will do FAR more inhouse work than those fancy RF cases they are running to do. It's simple math. Don't you want to the most of what you will actually be doing when you get into practice. If senior residents feel it's above them to do inhouse work, (which taxes the brain much more than a triple arthrodesis does) we are in a lot of trouble.

If the senior residents fulfilled their FF numbers then why would they take that opportunity from junior residents? Furthermore, if they do want to do more FR/trauma when they graduate who's to criticize that decision? That's what I would consider "taking control of their education", not scrubbing cases your junior residents could be doing. Without knowing more it's hard to have an opinion either way regarding your colleagues feelings. Considering the director sought out someone to get his senior residents more numbers it would make sense he would do the same for his junior residents, assuming there was the need. Just because they are not involving your colleague doesn't mean they don't value his work.

Any case is worth scrubbing. I've been in practice 10 years and learn something every single time I'm in the OR. You're right though. All the residents should cover all the attendings at that hospital. It is a university hospital which is affiliated with the residency and at least ten cases a week go off there. At least ten inhouse cases are going on throughout the week at this place. Intersting that no one considers covering this place, and just one doctor and just one class of surgeries. It just doesn't make sense to me

GSR

Thanks for the input. I'm not picking on you, I hope you realize, but just can't make heads or tails of the situation.

 

[PADPM]

This is a very interesting topic, and it also hits close to home. Because our group performs a fair amount of surgery, we do have the opportunity to have a resident scrub on our cases, but the residents said they will NOT cover our in-house patients. (they are coming from another facility)

Let me make something extremely clear. I'm not asking or expecting any resident to come to the hospital for a nail consult, or to change a dressing for me. However, if a patient is in-house for a complicated wound, etc., and that patient ends up in the O.R. and the resident scrubs, I ABSOLUTELY expect that resident to follow that patient on the floor. That doesn't mean I'm not going to visit the patient myself or that I'm asking the resident to cover for me. I'm simply expecting the resident to follow a patient he/she was involved with in the O.R.

Similarly, if a patient is sent to our service via the ER that also ends up in the O.R. and then back on the floor, I absolutely expect that resident to see the patient post op if he/she scrubbed on the case.

Isn't pre and post operative care a major part of the learning process??? Shouldn't a quality resident WANT to see the post op results??? I am quite confident in my abilities, and don't need a resident to scrub in on my cases for "help". If a resident scrubs on my case, it is for him/her, not for me. But I don't want or expect any resident to hit and run, I don't need that and won't accept that attitude. If he/she is too busy to follow up on these patients, I'll be happy to perform ALL care myself.

This problem goes relatively deep. I'm also confident this is a problem Podfather has witnessed. We are turning out some decent technical surgeons who don't always know how to handle post op problems or what normal or abnormal REALLY looks like following certain procedures.

The actual performance of the procedure is often the simplest part of the entire process. It's knowing how to handle a patient pre-operatively, peri-operatively and post-operatively that REALLY counts. And if you're too busy to participate in these critical components, than I have no interest in you scrubbing on my case.

 

[347932]

The actual performance of the procedure is often the simplest part of the entire process. It's knowing how to handle a patient pre-operatively, peri-operatively and post-operatively that REALLY counts. And if you're too busy to participate in these critical components, than I have no interest in you scrubbing on my case.

👍👍

Where I used to practice, the resident would always ask me if I "needed" him or her there.

The answer to that question is universally "No". The resident is not there to "help" me, in fact, having a resident there and teaching generally slows me down. The times I have had the biggest post operative disasters was when I allowed the resident to perform the procedure (cut the Sural nerve or the DP artery for example, transect the Tibial Nerve instead of dissecting it, getting into the Tarsal Tunnel when looking for the PTT...the list goes on and on), but it's a learning process and I personally enjoy teaching. I'm not saying all my cases come out perfectly, either, but the complications tend to be expected given the circumstances with the patient (banged their footand got a hematoma, non union due to ambulating AMA, splinting their incision and getting cellulitis or a post op wound...etc), and not because of a disastrous anatomic blunder.

Do we "need" you there. Of course not. Our training wheels came off years ago. Should you be there? That's up to you and your Residency Director, I guess. Realize that you are missing out every time there is a learning opportunity, and you miss it.

Yes, yes, I realize you can't be at every case, but if you elect to only participate in certain procedure only, you are short changing your education, whether your Director thinks that way or not.