Surgery in Podiatry

[DYK343]

The friends of mine that did one of the few quality fellowships out there all got great jobs.

The friends of mine that did middle of the road (or less) fellowships all got great jobs too.

My n is low but from what I see doing fellowship did them well in job markets.

It really helps to get a good residency program then evaluate towards the end if you think you need another year. I didnt do a fellowship. I didnt need to do one and I got a great job fresh out of residency. I also went to a very strong surgical residency. I didnt need more numbers. I was ready for the real world.

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[Shiyuan]

For my MSG, they just wanted BQ/BC. They couldnt care less about fellowship training. I find most non-pod physicians know/care little about DPM fellowship training. They all feel we are physicians and surgeons, end of discussion...

Or, at least the impression i’ve gotten in my community (Central FL).

 

[CutsWithFury]

The friends of mine that did one of the few quality fellowships out there all got great jobs.

The friends of mine that did middle of the road (or less) fellowships all got great jobs too.

My n is low but from what I see doing fellowship did them well in job markets.

It really helps to get a good residency program then evaluate towards the end if you think you need another year. I didnt do a fellowship. I didnt need to do one and I got a great job fresh out of residency. I also went to a very strong surgical residency. I didnt need more numbers. I was ready for the real world.

How many people do you personally know that did fellowship training?

 

[air bud]

are we doing the fellowship thing again? I might have an interesting related datapoint about this soon...

 

[DYK343]

How many people do you personally know that did fellowship training?

6 that I know of
edit 7 but that was a wound fellowship and probably not the best choice.

 

[air bud]

6 that I know of
edit 7 but that was a wound fellowship and probably not the best choice.

But would these people have still gotten good jobs without it? These were all smart people with good training. I am in a similar boat. I have 4 or 5 friends that did fellowship. All got great jobs. But i have 5 friends all of graduated at top of class, good training and also have great jobs and killing it. So what did they miss out on?

That's the problem with fellowships. They don't get you jobs that other people CANT get. The legit ones select the people who don't need the training but just want it. These people would be successful on their own. Now if they selected middle tier and made them great then something there. But that's not what is happening. So then all the non elite fellowships select middle tier and maybe maybe not make people better. But hey free labor.

 

[Feli]

The friends of mine that did one of the few quality fellowships out there all got great jobs.

The friends of mine that did middle of the road (or less) fellowships all got great jobs too.

My n is low but from what I see doing fellowship did them well in job markets.

It really helps to get a good residency program then evaluate towards the end if you think you need another year. I didnt do a fellowship. I didnt need to do one and I got a great job fresh out of residency. I also went to a very strong surgical residency. I didnt need more numbers. I was ready for the real world.

This is about my exp also... fellowship tends to have more ppl in good PP groups, MSG, hospital, etc. But they were go-getters in the first place.

Fellowships are good for some people depending on their goals and confidence by 3rd year residency. It might be a help to get some jobs, but if we still have all of these top teir program directors (fellowships and residencies both) and many national speakers, book authors, and etc who did 2yr decent training, then how is 3yrs of better training not good enough? We know the anatomy, we know the instruments. The training wheels will always have to come off sometime. How many cases and simples and horizontals and overdrills and I&D and BK casts and does it really take???

The time and $ expense of an additional year is crazy to me when you already have the skills at a good residency, though. Personally, I'd like to retire at 50 or 55, and there is no reason that's not totally possible. Adding another year of training which is not needed, racks up debt/interest, won't lead to any additional certs, doesn't change your specialty... nuts. Sure, fellowship could increase the chances of MSG or ortho or hospital jobs, but there is absolutely no guarantee of getting such - or that you can't get them with just good logs/residency/skill. Many of the 'great jobs' a fellowship - even a top one - may have opened up are actually burnout jobs (call, ortho group, travel, teaching, publishing, working for the fellowship group, etc).

And I'm sure Rodriguez does good work (some ppl just have an interest), but the guy's not even ABFAS cert, very mediocre residency, no fellowship (mini euro short one like tons of ppl did). Gumann would be another... ho-hum training but had cojones, passion and dedication to his work. The list is long of residency directors who are similar story. That right there shows you can help a lot of ppl and make a lot of money without necessarily even doing a high power program - much less another fellow year after. Will a high power residency give you a better shot? Yeah. Fellowship? Superfluous for good/great residency grads imo.... and the people who need the good fellowships (mediocre/crap residency) won't get the spots.

 

[Shiyuan]

IMO DPM Fellowship only helps you land “better” (oxymoron there) podiatry jobs.

 

[air bud]

Getting back to the original topic....how many of us experienced/board cert pods want a complicated revision cavus recon.....vs a forefoot slam? The former walks in my office? Buh bye. I can think of 1 of 10 well trained friends that might be willing to take that one on. Complicated is cool to residents and students. Not to real life practicing people.

 

[CutsWithFury]

Getting back to the original topic....how many of us experienced/board cert pods want a complicated revision cavus recon.....vs a forefoot slam? The former walks in my office? Buh bye. I can think of 1 of 10 well trained friends that might be willing to take that one on. Complicated is cool to residents and students. Not to real life practicing people.

I'll bite

A cavus recon is not that hard. This is the difference between maxing out your training and experience vs being a forefoot guy. The former makes a lot more money than the latter.

If you aren't doing full on foot and ankle surgery then I don't really understand why you became a podiatrist in the first place. You want to sub specialize further in a small part of the body. Sounds stupid. Kind of like podiatry.

 

[air bud]

I'll bite

A cavus recon is not that hard. This is the difference between maxing out your training and experience vs being a forefoot guy. The former makes a lot more money than the latter.

If you aren't doing full on foot and ankle surgery then I don't really understand why you became a podiatrist in the first place. You want to sub specialize further in a small part of the body. Sounds stupid. Kind of like podiatry.

Maxing out my training? Or mininalizing my stress?

 

[Pronation]

I’ll bite too. I love cavus recons and find it less tedious than a forefoot slam. Not so sure about it from a reimbursement standpoint though

 

[CutsWithFury]

I’ll bite too. I love cavus recons and find it less tedious than a forefoot slam. Not so sure about it from a reimbursement standpoint though

Justiable procedures for cavus recon include lateralizing calcaneal osteotomy, dorsiflexory first met osteotomy, PL to PB transfer, gastroc recession, and most likely hammer toe repair of toes 2-5 as this is typically seen in bad cavus feet.

 

[DYK343]

But would these people have still gotten good jobs without it? These were all smart people with good training. I am in a similar boat. I have 4 or 5 friends that did fellowship. All got great jobs. But i have 5 friends all of graduated at top of class, good training and also have great jobs and killing it. So what did they miss out on?

That's the problem with fellowships. They don't get you jobs that other people CANT get. The legit ones select the people who don't need the training but just want it. These people would be successful on their own. Now if they selected middle tier and made them great then something there. But that's not what is happening. So then all the non elite fellowships select middle tier and maybe maybe not make people better. But hey free labor.

Never know. But I bet they still would have done well knowing those people. As Feli pointed out - go getters.

 

[DYK343]

Justiable procedures for cavus recon include lateralizing calcaneal osteotomy, dorsiflexory first met osteotomy, PL to PB transfer, gastroc recession, and most likely hammer toe repair of toes 2-5 as this is typically seen in bad cavus feet.

Its the rigid midfoot cavus that I shy from.
I've done a heavy handfull of the procedure you described above.
Some with PT tendon transfer out of phase.
Most of them did really well but I do have some problems (mostly sural nerve - my least favorite and always a problem).

 

[Pronation]

Justiable procedures for cavus recon include lateralizing calcaneal osteotomy, dorsiflexory first met osteotomy, PL to PB transfer, gastroc recession, and most likely hammer toe repair of toes 2-5 as this is typically seen in bad cavus feet.

Indeed, I find that just doing tenotomies is sufficient for the hammertoes.

 

[air bud]

Justiable procedures for cavus recon include lateralizing calcaneal osteotomy, dorsiflexory first met osteotomy, PL to PB transfer, gastroc recession, and most likely hammer toe repair of toes 2-5 as this is typically seen in bad cavus feet.

ok none of those are hard. I am talking crazy cavus recons...whatever dudes

 

[air bud]

Its the rigid midfoot cavus that I shy from.
I've done a heavy handfull of the procedure you described above.
Some with PT tendon transfer out of phase.
Most of them did really well but I do have some problems (mostly sural nerve - my least favorite and always a problem).

this is what i am referring to. None of those procedures cutswithhate said are hard.

 

[air bud]

Its the rigid midfoot cavus that I shy from.
I've done a heavy handfull of the procedure you described above.
Some with PT tendon transfer out of phase.
Most of them did really well but I do have some problems (mostly sural nerve - my least favorite and always a problem).

Fellowship and Bitcoin fix this.

 

[CutsWithFury]

this is what i am referring to. None of those procedures cutswithhate said are hard.

Emotional damage

Air Bud you have become more fragile with age

 

[Pronation]

this is what i am referring to. None of those procedures cutswithhate said are hard.

Oh yea, I see what you’re saying. The arthritic cavovarus foot with 70 degrees met adductus. Those aren’t so fun

 

[wakaflocka88]

Getting back to the original topic....how many of us experienced/board cert pods want a complicated revision cavus recon.....vs a forefoot slam? The former walks in my office? Buh bye. I can think of 1 of 10 well trained friends that might be willing to take that one on. Complicated is cool to residents and students. Not to real life practicing people.

Recently referred out a cavus. Not touching it. I also refer out complex charcot that may need IF + frame. I’m not ballsy enough and not good enough to do it. Period. I choose to minimize stress as my current load is enough already. A fellowship may have provided me more reps in the above - but it would not have guaranteed me a job out of fellowship doing the same stuff. I got my job with networking, connections and work experience in my first job. I would have lost out on this if I did another year of training.

 

[DYK343]

Recently referred out a cavus. Not touching it. I also refer out complex charcot that may need IF + frame. I’m not ballsy enough and not good enough to do it. Period. I choose to minimize stress as my current load is enough already. A fellowship may have provided me more reps in the above - but it would not have guaranteed me a job out of fellowship doing the same stuff. I got my job with networking, connections and work experience in my first job. I would have lost out on this if I did another year of training.

There is nothing more un-glorifying than putting a charcot foot back together to quickly watch it re-charcot.
No thanks. Glady refer them out too.

 

[CutsWithFury]

You guys hate money. This is very un American. I’m disgusted

 

[PeaJay]

I actually find cavus more straightforward. There is a set formula. Flatfoot has so many things contingent on surgeon preferences/comfort.

For boards I would rather follow a cook book and avoid being penalized for doing a joint sparing when they prefer fusion.

 

[zircushio]

Recently referred out a cavus. Not touching it. I also refer out complex charcot that may need IF + frame. I’m not ballsy enough and not good enough to do it. Period. I choose to minimize stress as my current load is enough already. A fellowship may have provided me more reps in the above - but it would not have guaranteed me a job out of fellowship doing the same stuff. I got my job with networking, connections and work experience in my first job. I would have lost out on this if I did another year of training.

I think we have the same set up (as I transition into that set up soon). I have great surgical training from my residency, I just don't prefer to touch cavus foot, flatfoot, or charcot recon. When asked if I am qualified to do everything, the answer is yes. But I don't think that reimbursements are reflective of the time, energy, and f/u required with these patients. There is an orthopod that does FF all the time, but I am sure he gets paid by the boatload that warrants it. I agree with the sentiment shared above, complex cases are cool in residency, but I don't see how you can justify doing them when they don't pay. My ego won't be bruised that I pass along a cavus recon.

 

[wakaflocka88]

I think we have the same set up (as I transition into that set up soon). I have great surgical training from my residency, I just don't prefer to touch cavus foot, flatfoot, or charcot recon. When asked if I am qualified to do everything, the answer is yes. But I don't think that reimbursements are reflective of the time, energy, and f/u required with these patients. There is an orthopod that does FF all the time, but I am sure he gets paid by the boatload that warrants it. I agree with the sentiment shared above, complex cases are cool in residency, but I don't see how you can justify doing them when they don't pay. My ego won't be bruised that I pass along a cavus recon.

I agree on your views. However, for me, if a case such as Peroneal/lateral ankle is done, that’s actually multiple procedures and worth a lot of wRVU for me. In PP - not so much.

 

[air bud]

I actually find cavus more straightforward. There is a set formula. Flatfoot has so many things contingent on surgeon preferences/comfort.

For boards I would rather follow a cook book and avoid being penalized for doing a joint sparing when they prefer fusion.

Interesting take. You can take over Derner's annual cavus recon lecture at acfas when he retires.

 

[DYK343]

I agree on your views. However, for me, if a case such as Peroneal/lateral ankle is done, that’s actually multiple procedures and worth a lot of wRVU for me. In PP - not so much.

Exactly this. If you get 100% RVU for each procedure you do in a cavus recon thats a slam dunk.
PP the reimbursements tank with each procedure you do and its just not worth it.

 

[zircushio]

I agree on your views. However, for me, if a case such as Peroneal/lateral ankle is done, that’s actually multiple procedures and worth a lot of wRVU for me. In PP - not so much.

Ah yes, I forgot you were on the wRVU boat. Your job sounds awesome! I don't mind peroneal/lateral ankle, to me that is much more straight forward and enjoyable to do. Does anyone have any experience as an out-of-network provider? Haven't found much along that route.

 

[air bud]

Ah yes, I forgot you were on the wRVU boat. Your job sounds awesome! I don't mind peroneal/lateral ankle, to me that is much more straight forward and enjoyable to do. Does anyone have any experience as an out-of-network provider? Haven't found much along that route.

Peroneals and LCDO are fine. Midfoot cavus is not. Will never do a Dwyer. Love flatfoot. Evans gastroc almost always FDL MCDO. Fast to fuse NC. Sometimes cotton. Would rather plantar translate a 1st TMT. Any questions? Fuse it.

 

[DYK343]

Peroneals and LCDO are fine. Midfoot cavus is not. Will never do a Dwyer. Love flatfoot. Evans gastroc almost always FDL MCDO. Fast to fuse NC. Sometimes cotton. Would rather plantar translate a 1st TMT. Any questions? Fuse it.

Dwyers are ineffective. If its done at least lateralize it.

Closing Z osteotomies is where its at over Dwyer.

 

[air bud]

Dwyers are ineffective. If its done at least lateralize it.

Closing Z osteotomies is where its at over Dwyer.

Never even seen one of those. I forget who were the people that were big proponents of those? Wasnt Weil?

 

[GreenHousePub]

Getting back to the original topic....how many of us experienced/board cert pods want a complicated revision cavus recon.....vs a forefoot slam? The former walks in my office? Buh bye. I can think of 1 of 10 well trained friends that might be willing to take that one on. Complicated is cool to residents and students. Not to real life practicing people.

I want neither. Nothing sounds more miserable than a bunion and 4 hammertoes clogging up an OR day.

 

[DYK343]

Never even seen one of those. I forget who were the people that were big proponents of those? Wasnt Weil?

I dont think they started the closing Z osteotomy for cavus. Articles from Weils about scarf osteotomy of the calcaneus for flatfoot.

Pretty sure closing Z osteotomy is out of ortho literature.

 

[CutsWithFury]

A z osteotomy for the Calc sounds not fun.

Doing an MIS Calc slide resects enough bone for you to freely move the tuber wherever you want it.

 

[DYK343]

A z osteotomy for the Calc sounds not fun.

Doing an MIS Calc slide resects enough bone for you to freely move the tuber wherever you want it.

I have done all mine open. Any issues with medial neurovascular structures doing it minimally invasive?

Edit: One of my attendings used to have me do them with a gigli saw in percutaneous fashion. I was always paranoid I had the medial vascular bundle trapped (or one of the tendons) but they always worked out fine.

I might retry the gigli. I hate sural nerve complications with open. OK. Im convinced its better now.

 

[CutsWithFury]

I have done all mine open. Any issues with medial neurovascular structures doing it minimally invasive?

Edit: One of my attendings used to have me do them with a gigli saw in percutaneous fashion. I was always paranoid I had the medial vascular bundle trapped (or one of the tendons) but they always worked out fine.

I might retry the gigli. I hate sural nerve complications with open. OK. Im convinced its better now.

The burr is very forgiving on the neurovascular structures. I once cut a Charcot foot fixed/fused in Varus at the midfoot by another surgeon in half through one stab incision both medial and lateral using the MIS burr.

 

[air bud]

Oh man the Gigli saw. The guy who taught me Charcot LOVED that thing for midfoot osteotomies. You just gotta get those hips moving and get the motion started and keep going.

Gigli

 

[Feli]

Recently referred out a cavus. Not touching it. I also refer out complex charcot that may need IF + frame. I’m not ballsy enough and not good enough to do it. Period. I choose to minimize stress as my current load is enough already. A fellowship may have provided me more reps in the above - but it would not have guaranteed me a job out of fellowship doing the same stuff. I got my job with networking, connections and work experience in my first job. I would have lost out on this if I did another year of training.

Yeah, in the end, you need to make your own luck in the job hunt and in the OR once the time-out is done.

Imagine the poor ppl who took a fellowship to start 2020, got very few cases from it with covid shutdowns, then had an even worse job market after. Uffffff!

 

[DYK343]

Oh man the Gigli saw. The guy who taught me Charcot LOVED that thing for midfoot osteotomies. You just gotta get those hips moving and get the motion started and keep going.

Gigli

I did so many BKAs with gigli saws. I tried to cut thru the tibia as a first year with a sagittal saw and it bounced right off the tibia. Epic failure. Gen surg laughed at me and handed me a gigli saw and thats all I got going forward LOL.

 

[CutsWithFury]

Yeah, in the end, you need to make your own luck in the job hunt and in the OR once the time-out is done.

Imagine the poor ppl who took a fellowship to start 2020, got very few cases from it with covid shutdowns, then had an even worse job market after. Uffffff!

I would demand another year of fellowship. They got totally screwed.

 

[air bud]

I would demand another year of fellowship. They got totally screwed.

unpaid of course. yes, it is available.

 

[heybrother]

If you do the Michigan fellowship and your 2 years are bad do you do another 2

 

[CutsWithFury]

If you do the Michigan fellowship and your 2 years are bad do you do another 2

These research/academic fellowships are pointless. All they accomplish is that you become the chosen ones for the APMA to tout. But you’re not a better surgeon or doctor for it. You won’t make more money in your career from it.

Looking forward to a DPM who did an academic fellowship and is one year out in practice talk about physician burnout. So podiatry….