Surgery vs clinic heavy residency programs

[miamifeat]

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In retrospect, does a surgery heavy or clinic heavy program best prepare you for post residency?

What’s the magic ratio between the two?

 

[deleted285117]

I found having multiple off-service rotations was hugely beneficial... PM&R, ortho, derm, ID, etc...

 

[PeaJay]

I found having multiple off-service rotations was hugely beneficial... PM&R, ortho, derm, ID, etc...

I would agree with a large caveat and that would be the affiliation of the residency.

My experience is that mostly residents from large tertiary teaching hospitals have this view. I trained at a tertiary referral center with a multitude of training programs. Being treated as any other intern on vasc/ID/IM/trauma/ortho/hand/plastics/rheum was very eye opening and prepared me for the “real world”.

In a perfect residency you would cut all morning, grind out a clinic or do floor work and then cut all night. Rinse then repeat. Getting abused (within limits) will prepare you.

 

[dtrack22]

Clinic can be a much smaller % than surgery but it needs to be valuable clinic. You need to work up complicated patients, treat common conditions yourself with injections, in office procedures, etc., you should be coding visits, and you need to see post-op patients that you operated on or assisted with.

Driving around covering cases and then only having some resident run indigent clinic where the pathology is crap or you have a limited ability to treat, is pointless. Having VA clinic where there are a ton of patients but the pathology is crap, is also pointless.

Typically residency programs at larger academic institutions with other residency programs are going to do a much better job of this. Community based programs (cut and run) where you are covering local private practice docs’ cases and spend some time in their clinics tend to be worse. Well, worse in how they prepare you to run and manage a 30 patient clinic. But from a lifestyle standpoint I imagine they are probably pretty awesome.

 

[air bud]

Clinic can be a much smaller % than surgery but it needs to be valuable clinic. You need to work up complicated patients, treat common conditions yourself with injections, in office procedures, etc., you should be coding visits, and you need to see post-op patients that you operated on or assisted with.

Driving around covering cases and then only having some resident run indigent clinic where the pathology is crap or you have a limited ability to treat, is pointless. Having VA clinic where there are a ton of patients but the pathology is crap, is also pointless.

Typically residency programs at larger academic institutions with other residency programs are going to do a much better job of this. Community based programs (cut and run) where you are covering local private practice docs’ cases and spend some time in their clinics tend to be worse. Well, worse in how they prepare you to run and manage a 30 patient clinic. But from a lifestyle standpoint I imagine they are probably pretty awesome.

Graduated from a community based program as described above...accurate.

Dtrack tires of me texting him with questions since he did a program with legit clinic and big time surgery.

 

[DYK343]

Clinic can be a much smaller % than surgery but it needs to be valuable clinic. You need to work up complicated patients, treat common conditions yourself with injections, in office procedures, etc., you should be coding visits, and you need to see post-op patients that you operated on or assisted with.

I think you nailed it right here. Clinic is worthless if you're a resident and doing preventative care so your attending can sit with his/her feet kicked back - which is sadly common in podiatry.

Clinic should be more focused on pathology and pre/post surgical. Not always easy to do as not every attending will be slammed with cool pathology. But its the way it should be in a teaching environment.

1/2 to 1 day a week in wound healing center would also be beneficial IMO.

Were not all the exact same in how we learn. DPM schools are not equal and provide different education to students. I felt pretty good about clinic after getting my degree. On the converse I felt weak in surgery after getting my DPM degree.

IMO as long as you have the clinical foundations clinic is something you can improve on along the way.

Surgery is not easy to teach youreself. Beyond the simple stuff we do surgery requires a lot of confidence, repetition, and experience - at least for me.

With that said I'm biased as I went to a strong surgical program with mild/moderate clinical volume. I was way more nervous for my first day of "real" clinic than I was for my first solo surgery which was a lapidus.

4.5 years after residency graduation I still struggle with derm.

 

[air bud]

Surgery surgery surgery. You can learn clinic. You will text your buddies and say hey when are you bringing your plantar fascia patients back for a 2nd injection? You can look online and see some big sports med MD's post op Achilles recovery protocol. You can text an attending a pic of an xray and ask how you would salvage this forefoot that was operated on 20 years ago. But you need the reps in the OR to feel confident in surgery, have seen things go wrong, and be able to make gametime intraop changes.

And screw derm. If you are worried about derm GTFO. Know what melanoma looks like and be able to bust some crumblies. A little clotrimazole here, a lot of terbinafine there and boom. Doesn't respond to those hey go see this person.

A resident run clinic sounds worthless.unless.it is JPS. Sounds like free labor.

 

[NobodyDPM]

My take is that residents do not spend enough time, not even close, in a private office setting. Residency "clinics" are valuable, but generally the patient demographics are not what you are likely to see in a private office setting when out of residency.

Being a physician of any kind is being an educator. You have to know how to talk to your patients. You have to be able to discuss what you know at their level so they understand what they are dealing with and can make informed decisions about their care. Then you need to be able to provide the care effectively, and get paid for what you've done. I find many new practitioners are terrible at this. They lack the experience and sometimes even the knowledge to do this properly.

And this is partially by design. I don't think the CPME allows enough office time. As far as surgery goes, most programs worth their salt far exceed the numbers required by the CPME. Is that enough? It depends on the individual. I've trained residents that have great hands and will make excellent surgeons with just a little real world experience. Than again, I've also seen the reverse. People who have no business doing surgery at all. Ever.

Our residents know I have an open door policy. They are welcomed to come to my office anytime, and some take me up on it. They come mostly to learn about billing, but some some stay to learn my speeches and schtick with my patients, because they realize that you have to know how to talk to someone, if they are to trust you with their care. YMMV.

 

[NobodyDPM]

Surgery surgery surgery. You can learn clinic. You will text your buddies and say hey when are you bringing your plantar fascia patients back for a 2nd injection? You can look online and see some big sports med MD's post op Achilles recovery protocol. You can text an attending a pic of an xray and ask how you would salvage this forefoot that was operated on 20 years ago. But you need the reps in the OR to feel confident in surgery, have seen things go wrong, and be able to make gametime intraop changes.

And screw derm. If you are worried about derm GTFO. Know what melanoma looks like and be able to bust some crumblies. A little clotrimazole here, a lot of terbinafine there and boom. Doesn't respond to those hey go see this person.

A resident run clinic sounds worthless.unless.it is JPS. Sounds like free labor.

I kinda sorta hope you're kidding. Would you trust a doctor that had to "look up" how to care for their patient?

Screw Derm? I see a lot of Derm that shows more serious medical conditions and requires further work up. Not just Tinea.

Are you doctor or a technician?

 

[air bud]

I kinda sorta hope you're kidding. Would you trust a doctor that had to "look up" how to care for their patient?

Screw Derm? I see a lot of Derm that shows more serious medical conditions and requires further work up. Not just Tinea.

Are you doctor or a technician?

100 percent not kidding. I look stuff up all the time mid clinic. I take a pic, send it some buddies and find a reason to stall...

Yes screw Derm. That is what dermatologists are for. Skin just covers bones and muslces. I offload and move bones around when the skin breaks down.

 

[NobodyDPM]

100 percent not kidding. I look stuff up all the time mid clinic. I take a pic, send it some buddies and find a reason to stall...

Yes screw Derm. That is what dermatologists are for. Skin just covers bones and muslces. I offload and move bones around when the skin breaks down.

So you're a technician. Got it.

 

[Pronation]

Screw Derm? I see a lot of Derm that shows more serious medical conditions and requires further work up. Not just Tinea.

Some of us have a busy enough practice where we can choose what we don't want to do.

I refer most of this skin stuff to my group's dermatologist as well.

 

[Scrantonicity]

I kinda sorta hope you're kidding. Would you trust a doctor that had to "look up" how to care for their patient?

Screw Derm? I see a lot of Derm that shows more serious medical conditions and requires further work up. Not just Tinea.

Are you doctor or a technician?

Yeah but how much of that derm did you actually see or understand in residency?? I have gotten pretty good at dermatology after years of seeing the same stuff over and over again out in practice. Some of it has been trial and error. And yes, a lot of it has been "looking things up"--especially in the early years of practice. What is wrong with that? The patient doesn't know. I'd rather have a doctor look something up than rely on a lay-person's google search. Now that I've been out for 10 years, I rarely have to look anything up--but so what if I did? I'm a tech?

Dermatologists do a full derm residency for a reason. I feel like in podiatry we are kinda winging it until we see the patterns in our practice--our training is so focused on what's UNDER the skin.

 

[air bud]

My take is that residents do not spend enough time, not even close, in a private office setting. Residency "clinics" are valuable, but generally the patient demographics are not what you are likely to see in a private office setting when out of residency.

Being a physician of any kind is being an educator. You have to know how to talk to your patients. You have to be able to discuss what you know at their level so they understand what they are dealing with and can make informed decisions about their care. Then you need to be able to provide the care effectively, and get paid for what you've done. I find many new practitioners are terrible at this. They lack the experience and sometimes even the knowledge to do this properly.

And this is partially by design. I don't think the CPME allows enough office time. As far as surgery goes, most programs worth their salt far exceed the numbers required by the CPME. Is that enough? It depends on the individual. I've trained residents that have great hands and will make excellent surgeons with just a little real world experience. Than again, I've also seen the reverse. People who have no business doing surgery at all. Ever.

Our residents know I have an open door policy. They are welcomed to come to my office anytime, and some take me up on it. They come mostly to learn about billing, but some some stay to learn my speeches and schtick with my patients, because they realize that you have to know how to talk to someone, if they are to trust you with their care. YMMV.

You are 1 million percent correct on this. Your ability to teach and and explain in simpler terms the etiology of whatever pathology the patient presents with is key to your success. So to clarify some previous statements...resident run clinics are still a joke. I would want to do clinic with that super busy surgeon. He/She doesn't just have people sign up for surgery for no reason. They have the ability to demonstrate knowledge, compassion, and confidence. Be around that person. But unfortunately that person often times is so busy they prefer not to have residents in their clinic so they can be more efficient. At least in my experience.

 

[air bud]

So you're a technician. Got it.

a well trained, well compensated technician who gets good technical results? yes.

 

[NobodyDPM]

Yeah but how much of that derm did you actually see or understand in residency?? I have gotten pretty good at dermatology after years of seeing the same stuff over and over again out in practice. Some of it has been trial and error. And yes, a lot of it has been "looking things up"--especially in the early years of practice. What is wrong with that? The patient doesn't know. I'd rather have a doctor look something up than rely on a lay-person's google search. Now that I've been out for 10 years, I rarely have to look anything up--but so what if I did? I'm a tech?

Dermatologists do a full derm residency for a reason. I feel like in podiatry we are kinda winging it until we see the patterns in our practice--our training is so focused on what's UNDER the skin.

I saw a lot of Derm in residency. Mostly because after my non-surgical residency, I was able to spend a lot of time in the office of my attendings during my surgical residency. The residencies set up for "advanced training" were set up that way. These were programs that only accepted residents who had had a year of training already. And were excellent since all the necessary rotations were already done in the first non-surgical year. And there are certain things in derm, you should be able to easily discern. Not just Tinea.

I'm sorry, but did you really have to "look up" a lot during your first years in practice? Once again, that means that you did not have sufficient in office training during your residency.

 

[NobodyDPM]

a well trained, well compensated technician who gets good technical results? yes.

Bravo. A technician, none the less. And then we wonder why we have to fight for equality in the medical realm. We should strive to be physicians before we are surgeons/technicians.

If you are happy with your practice, I have nothing to comment about to you specifically, really. I would just hope that others reading this aspire to more.

Has it ever occurred to you that one day, you may not be able to be technically proficient anymore? Then what?

 

[Scrantonicity]

I saw a lot of Derm in residency. Mostly because after my non-surgical residency, I was able to spend a lot of time in the office of my attendings during my surgical residency. The residencies set up for "advanced training" were set up that way. These were programs that only accepted residents who had had a year of training already. And were excellent since all the necessary rotations were already done in the first non-surgical year. And there are certain things in derm, you should be able to easily discern. Not just Tinea.

I'm sorry, but did you really have to "look up" a lot during your first years in practice? Once again, that means that you did not have sufficient in office training during your residency.

Yeah, I'm one of those techs that keeps a Fitzpatrick's derm book in my office. I'm really happy for you that you knew it all when you started--after your two residencies and all.

 

[NobodyDPM]

Yeah, I'm one of those techs that keeps a Fitzpatrick's derm book in my office. I'm really happy for you that you knew it all when you started--after your two residencies and all.

LMAO....back in my day, only half the class got surgical residencies after the first go around. Then only about 20% got surgical residencies after that. Not this everyone gets 3 years regardless of whether they should ever set foot in an OR.

I am no Derm master. But I don't discard it either. And neither should anyone else.

Sarcasm duly noted, but altogether unnecessary.

 

[air bud]

Bravo. A technician, none the less. And then we wonder why we have to fight for equality in the medical realm. We should strive to be physicians before we are surgeons/technicians.

If you are happy with your practice, I have nothing to comment about to you specifically, really. I would just hope that others reading this aspire to more.

Has it ever occurred to you that one day, you may not be able to be technically proficient anymore? Then what?

I maintain my technical proficiency by doing surgery...you can't be technically proficient by not doing technical stuff. Is anyone else confused here?

 

[air bud]

LMAO....back in my day, only half the class got surgical residencies after the first go around. Then only about 20% got surgical residencies after that. Not this everyone gets 3 years regardless of whether they should ever set foot in an OR.

I am no Derm master. But I don't discard it either. And neither should anyone else.

Sarcasm duly noted, but altogether unnecessary.

There is no doubt that there is a different basis for training between grads 5-10 years out/today and those 20 years out. We all have our value and purpose. And yes, I would not have gotten the training I got had it not been for the sacrifices made and challengesfaced from those before me.

 

[Scrantonicity]

LMAO....back in my day, only half the class got surgical residencies after the first go around. Then only about 20% got surgical residencies after that. Not this everyone gets 3 years regardless of whether they should ever set foot in an OR.

I am no Derm master. But I don't discard it either. And neither should anyone else.

Sarcasm duly noted, but altogether unnecessary.

Sure, the residency system has definitely devolved in some ways...it's not equal, and I agree they shouldn't ALL be surgical, especially for many of my classmates I remember that couldn't even apply tape correctly to a big toe--I guess that's the gist of this entire thread.

But, for those of us peons that did a 3 year surgical residency--sorry, I mean training to be a pod tech--I guess we just had to grow as clinicians and physicians while we practiced medicine in the real world. Some of that includes calling classmates, friends from residency, and looking things up. Guess we missed the boat back in "your" day when we all could have come out as all knowing pod gods.

Glad the sarcasm is noted--it's just so hard not to lol

BTW, I came out of residency feeling VERY confident in both my surgical and clinical skills, but I didn't know HALF of what I know now after 10 years of experience. Does this not make sense??

 

[NobodyDPM]

I maintain my technical proficiency by doing surgery...you can't be technically proficient by not doing technical stuff. Is anyone else confused here?

I would venture to say you are what? In your mid 30s? No matter how much "technical stuff" you do, your technical skills will start to deteriorate at a certain point. It's not a matter of "if" but "when".

 

[dtrack22]

And then we wonder why we have to fight for equality in the medical realm. We should strive to be physicians before we are surgeons/technicians.

Nothing wrong with this thought, I just disagree. I don’t think parity has anything to do with being a “physician” vs a “technician.” Most of medicine is going towards the latter and has been for some time now.

The only reason we have to fight for parity is because our applicant pool, education and training are seen as “different” and ultimately “inferior” to the allopathic and osteopathic models. We could do 5 yr residencies at large academic centers exclusively, doing nothing but foot and ankle (with all the clinic you could want), only to have the same issues because of DPM at the end of the name. Those who are skeptical or adversarial to Podiatry in general don’t care and would not be swayed just because you know which steroid cream to put on a rash vs the guy who sends it to Derm and admits he’s not the best person to treat it because he only fixes bunions. In office. Cash pay.

 

[NobodyDPM]

Sure, the residency system has definitely devolved in some ways...it's not equal, and I agree they shouldn't ALL be surgical, especially for many of my classmates I remember that couldn't even apply tape correctly to a big toe--I guess that's the gist of this entire thread.

But, for those of us peons that did a 3 year surgical residency--sorry, I mean training to be a pod tech--I guess we just had to grow as clinicians and physicians while we practiced medicine in the real world. Some of that includes calling classmates, friends from residency, and looking things up. Guess we missed the boat back in "your" day when we all could have come out as all knowing pod gods.

Glad the sarcasm is noted--it's just so hard not to lol

BTW, I came out of residency feeling VERY confident in both my surgical and clinical skills, but I didn't know HALF of what I know now after 10 years of experience. Does this not make sense??

Here's what's funny.

I never said I was some master out of residency. I was responding to the "GTFO" comment made about Derm and how you should be able to be able to identify more than just Tinea. And that was responded with "I like to move bones around and stuff", to which I replied that this was more of a technician thing than a physician thing. Which it is. if you discount a whole aspect of private practice because you'd rather "move bones around and stuff" then yes, you are mostly a technician.

Any doctor that thinks they have nothing left to learn and improve upon should retire. Period. I still don't "know it all" and likely never will with how medicine evolves. Btw, the practice of actual medicine evolves much more so than in the surgical realm. Case in point, there are some podiatrists, young and old, that still fixate bunions with K-Wires. Did they evolve? No, they didn't. Which makes them technicians, not physicians. If you go to a Podiatry conference, surgically, they are talking about the same thing they've been talking about for 20 years.

Yes, that makes sense. And it should be that way. But I akin that more to EXPERIENCE than ACADEMICS. The academics were there in your head. You just had to experience it to solidify it.

 

[NobodyDPM]

Nothing wrong with this thought, I just disagree. I don’t think parity has anything to do with being a “physician” vs a “technician.” Most of medicine is going towards the latter and has been for some time now.

The only reason we have to fight for parity is because our applicant pool, education and training are seen as “different” and ultimately “inferior” to the allopathic and osteopathic models. We could do 5 yr residencies at large academic centers exclusively, doing nothing but foot and ankle (with all the clinic you could want), only to have the same issues because of DPM at the end of the name. Those who are skeptical or adversarial to Podiatry in general don’t care and would not be swayed just because you know which steroid cream to put on a rash vs the guy who sends it to Derm and admits he’s not the best person to treat it because he only fixes bunions. In office. Cash pay.

As much as I understand what you're saying, let me throw this in.

The first part of my career was as Community faculty at a major Medical School, where I was very involved in not only the Podiatry residency, but in all residencies there. I was on multiple committees within the Medical School, blah, blah, blah, When I got there, the over all feeling of Podiatry was exactly that Podiatrists were technicians. Both because of cutting toenails, but also because we only did "simple" surgery. We were looked down upon by the General Surgery and Orthopedic surgery departments.

As I became more involved and the faculty and residents at the school started interacting with me more, it became clear to them that I had the knowledge to participate with them equally with patients on the floor and the OR. Some of the General Surgery residents would come scrub with me on these "simple" cases and realized they weren't so simple. I became the impetus for the school to integrate Podiatry into the mutli-specialty world of teaching in a Medical School. And I ended up teaching classes to Med and Nursing School students concerning the Lower Extremity.

I'm not writing this to boost myself up, because all that was a lifetime ago. I'm writing this because, to me, it's important that we are more than just technicians in the OR. And that sentiment is being lost every year.

 

[josebiwasabi]

Here's my 2 cents as someone who is a recent grad who now trains residents and students.

An ideal residency would produce graduates that are proficient in ALL aspects of podiatric medicine and surgery.

This includes but is not limited to:
-bread and butter surgery
-complex and revisional surgery
-trauma
-basic and complex limb salvage
-biomechanics
-bread and butter clinic pathology
-conservative care for MSK pathology
-wound care
-podopediatrics
-dermatology
-inpatient management and how to communicate with other services
-research (broad category but includes designing studies, writing papers, and critical analysis of literature)
-billing and coding
-soft skills including how to explain medical conditions to patients, difficult conversations, etc

In reality, most residency programs will be strong in certain areas and weak in others.

The difference, in my opinion, is that some skills can be significantly improved after training while others cannot. This is why if I had to choose a program, I would choose one that is heavier on surgery. If you don't feel comfortable with orthotics modifications, you can do some CME and talk to other practitioners and 5 years into your career you will probably be pretty decent at it. If you don't feel comfortable with anything more than a lapidus at the end of residency, chances are that you will not be doing flatfoot recons, triples, TARs etc 5 years into your career, regardless of how many CMEs and courses you attended that cover that stuff.

The question to ask is, what type of training will allow me to have the type of practice that I want 5-10 years after I finish residency? After seeing and treating the non-surgical stuff in clinic for 3-4 days per week in clinic for 5-10 years, most people will be proficient in both the medical and business aspects of running a successful clinic, even the ones that are all about surgery, surgery, and more surgery.

 

[Scrantonicity]

Here's what's funny.

I never said I was some master out of residency. I was responding to the "GTFO" comment made about Derm and how you should be able to be able to identify more than just Tinea. And that was responded with "I like to move bones around and stuff", to which I replied that this was more of a technician thing than a physician thing. Which it is. if you discount a whole aspect of private practice because you'd rather "move bones around and stuff" then yes, you are mostly a technician.

Any doctor that thinks they have nothing left to learn and improve upon should retire. Period. I still don't "know it all" and likely never will with how medicine evolves. Btw, the practice of actual medicine evolves much more so than in the surgical realm. Case in point, there are some podiatrists, young and old, that still fixate bunions with K-Wires. Did they evolve? No, they didn't. Which makes them technicians, not physicians. If you go to a Podiatry conference, surgically, they are talking about the same thing they've been talking about for 20 years.

Yes, that makes sense. And it should be that way. But I akin that more to EXPERIENCE than ACADEMICS. The academics were there in your head. You just had to experience it to solidify it.

"I'm sorry, but did you really have to "look up" a lot during your first years in practice?" That's what you said...which implies that you never had to enlist any kind of outside help after your training...guess it triggered me lol. I can't be the only one.

I do understand and agree with what you say about being a technician...but in the end, we just do what works (which can be different for every single one of us). Unfortunately, we often have to make mistakes and/or check ourselves along the way figuring out exactly what that is. Is that the fault of our training? I don't think so. I think it's just part of the experience...that's why we call it practice, right? I have no doubt that the people posting on this board are more than just "technicians"--but it probably took some time in the real world (outside of residency) to become more. Even the simple things like bedside manner--you don't exactly train for that...just happens and gets better over time (unless you're some gifted extrovert).

 

[NobodyDPM]

"I'm sorry, but did you really have to "look up" a lot during your first years in practice?" That's what you said...which implies that you never had to enlist any kind of outside help after your training...guess it triggered me lol. I can't be the only one.

I said "a lot"...that means "often" in my book.

So how does that imply that I "never had to enlist any kind of outside help..."?

I am not responsible for your reading comprehension nor how you interpret what I write. Words have specific meaning. If you chose to interpret them a certain way, by all means, ask for clarification before coming to erroneous conclusions.

There's a big difference between "a lot" and "sometimes", or "once in awhile". If you have to look up "a lot" of stuff when first coming out, your training was sub par.

 

[Scrantonicity]

Look, Dr Nobody, I appreciate your vocabulary lesson. I wish I could retract my statement that a lot of what helped me in my early years was looking things up. Maybe if I had said "some" of what helped me, you would think I'm a good doctor 🙂

 

[NobodyDPM]

Look, Dr Nobody, I appreciate your vocabulary lesson. I wish I could retract my statement that a lot of what helped me in my early years was looking things up. Maybe if I had said "some" of what helped me, you would think I'm a good doctor 🙂

I have no idea what kind of doctor you are. And glad to help! 😛

 

[Scrantonicity]

I have no idea what kind of doctor you are. And glad to help! 😛

I'm just glad I somehow overcame my sub-par training and my terrible reading comprehension. Now excuse me while I go look up why my patient is complaining of pain in their heel.

 

[NobodyDPM]

I'm just glad I somehow overcame my sub-par training and my terrible reading comprehension. Now excuse me while I go look up why my patient is complaining of pain in their heel.

Just know...you aren't alone in that...😈

 

[shadesofgrey]

I will echo what others have said, you should focus on surgical exposure. Ideally with a small portion of clinic that is largely post/pre op and wound care.
If you are learning how to run a clinic on the fly the damage you can do is likely limited and many times you can ease into it as the clinic volume builds. This is not possible with surgery, and that jump to a surgery you aren't 100% comfortable with, is scary for you and sometimes dangerous for the patient. Get the most surgical training you can while someone else is there to guide you.

 

[NobodyDPM]

Let's ask a different question.

How many times do you have to do a surgery before you are comfortable doing that surgery? And how many surgeries do you have to do to become comfortable with something entirely new? For example, let's say you never did a Kidner in residency, but are very comfortable, as a whole, in the OR. Do you think you're qualified to do that Kidner or not?

 

[air bud]

Honestly not many t

Let's ask a different question.

How many times do you have to do a surgery before you are comfortable doing that surgery? And how many surgeries do you have to do to become comfortable with something entirely new? For example, let's say you never did a Kidner in residency, but are very comfortable, as a whole, in the OR. Do you think you're qualified to do that Kidner or not?

Honestly not many times. If you did 200 ankle surgeries in residency and its your first time doing something new...has the anatomy changed? no. has the dissection changed? no. You can open a book, go to a course and ask some buddies when it comes to figuring out the exact biomechanical etiology and how to properly address it. But if you have that experience making that midline ankle incision...then you can do most anything. Just new type of plate/screw/bone cut. Anatomy doesn't change. How we address it does.

I did maybe 25 ex fix in my last year of residency. legit teacher, consultant for Orthofix now. None since I have been out in 5 years. Honestly haven't had the patients that needed one except for maybe a handful. But now I am someplace where I will see a lot more legit candidates. So now it is time to do them. Static frame this week, hexapod next week. Nervous, sure. But I have gone to courses, talked to friends and have the reps as a resident to be comfortable with putting a frame on. Talk to this guy extensively.

 

[NobodyDPM]

Honestly not many t

Honestly not many times. If you did 200 ankle surgeries in residency and its your first time doing something new...has the anatomy changed? no. has the dissection changed? no. You can open a book, go to a course and ask some buddies when it comes to figuring out the exact biomechanical etiology and how to properly address it. But if you have that experience making that midline ankle incision...then you can do most anything. Just new type of plate/screw/bone cut. Anatomy doesn't change. How we address it does.

I did maybe 25 ex fix in my last year of residency. legit teacher, consultant for Orthofix now. None since I have been out in 5 years. Honestly haven't had the patients that needed one except for maybe a handful. But now I am someplace where I will see a lot more legit candidates. So now it is time to do them. Static frame this week, hexapod next week. Nervous, sure. But I have gone to courses, talked to friends and have the reps as a resident to be comfortable with putting a frame on. Talk to this guy extensively.

Excellent. So how much surgery does one really need to see in residency to become proficient?

And why do we still have to prove we've done a procedure when applying for hospital privileges? Especially once Board Certified? I ask this rhetorically and hope the younger generation fixes this.

 

[Scrantonicity]

Let's ask a different question.

How many times do you have to do a surgery before you are comfortable doing that surgery? And how many surgeries do you have to do to become comfortable with something entirely new? For example, let's say you never did a Kidner in residency, but are very comfortable, as a whole, in the OR. Do you think you're qualified to do that Kidner or not?

I do like that question. I've asked myself that a couple times over the years. Every time, I have said yes. The foot is the foot--if you're a skilled surgeon with good hands and you know the anatomy/biomechanics--it's pretty hard to mess anything up. I have zero qualms doing a surgery I haven't done before.

As far as having to prove it before applying for hospital privileges--I don't know how we could change that...there just isn't any other reliable "measuring stick" (besides certifications I guess) to show that you're a skilled surgeon with good hands and you know the anatomy/biomechanics, is there?

 

[NobodyDPM]

As far as having to prove it before applying for hospital privileges--I don't know how we could change that...there just isn't any other reliable "measuring stick" (besides certifications I guess) to show that you're a skilled surgeon with good hands and you know the anatomy/biomechanics, is there?

Well, I don't think that any other specialty requires a list of procedures to perform like we do. Which means it comes from us. Podiatry. Which has to change.

I could be wrong, but when a Vascular Surgeon asks for privileges, do they have to show a list of procedures they did in Fellowship? Or an Ortho for that matter? I know for sure that Orthos don't need a Foot and Ankle Fellowship to do Foot and Ankle Surgery in the hospitals I've been on staff at. This has been a bone of contention for me for my whole career. Certain specialty surgeries I get. Especially back in my day. Like for Ankle Implants. I do think you need some more specialty training to be able to perform those properly. Training I didn't get, so no thanks.

Does anyone have any knowledge about this? I haven't done credential checks for hospitals in about a decade so things may have changed.

 

[air bud]

Well, I don't think that any other specialty requires a list of procedures to perform like we do. Which means it comes from us. Podiatry. Which has to change.

I could be wrong, but when a Vascular Surgeon asks for privileges, do they have to show a list of procedures they did in Fellowship? Or an Ortho for that matter? I know for sure that Orthos don't need a Foot and Ankle Fellowship to do Foot and Ankle Surgery in the hospitals I've been on staff at. This has been a bone of contention for me for my whole career. Certain specialty surgeries I get. Especially back in my day. Like for Ankle Implants. I do think you need some more specialty training to be able to perform those properly. Training I didn't get, so no thanks.

Does anyone have any knowledge about this? I haven't done credential checks for hospitals in about a decade so things may have changed.

agree totally about it being a podiatrist keeping a podiatrist out...@cutswithfury will attest to that all day long.

So to tie this all back in....do all these surgeries in residency to cut this discussion off before it starts.

My first job out, a MSG, ortho wouldn't let me doing achilles or ankle fx (they wanted fx, they though achilles too hard for them so had to be too hard for me). My second job new state new MSG/hospital let me do whatever I want. More rural than the first. No ortho presence. My third job, ortho group where ortho rules the privileging dept,..can do whatever I want. They trust me. They do them I do me.

At some point though, can't count on residency numbers forever, so board cert probably kicks in and supercedes. Each situation different. And VERY fluid unfortuantely.

 

[Pronation]

Well, I don't think that any other specialty requires a list of procedures to perform like we do. Which means it comes from us. Podiatry. Which has to change.

I could be wrong, but when a Vascular Surgeon asks for privileges, do they have to show a list of procedures they did in Fellowship? Or an Ortho for that matter? I know for sure that Orthos don't need a Foot and Ankle Fellowship to do Foot and Ankle Surgery in the hospitals I've been on staff at. This has been a bone of contention for me for my whole career. Certain specialty surgeries I get. Especially back in my day. Like for Ankle Implants. I do think you need some more specialty training to be able to perform those properly. Training I didn't get, so no thanks.

Does anyone have any knowledge about this? I haven't done credential checks for hospitals in about a decade so things may have changed.

This is an interesting subject because I don’t think any of these other professions have some of these residency programs floating around like unflushable turds. You know the ones that I am talking about, where residents quadruple scrub a toe chop that takes the attending an hour to do just so that they can barely me the already hilariously low minimal competency numbers.

HOT TAKE

So yes, I am one of those gatekeeping DPMs because I don’t want one of these losers coming to my hospital, trying to do a procedure that they have no business doing, maiming the patient, and ultimately giving me and the profession in the area a bad rep.

 

[NobodyDPM]

So yes, I am one of those gatekeeping DPMs because I don’t want one of these losers coming to my hospital, trying to do a procedure that they have no business doing, maiming the patient, and ultimately giving me and the profession in the area a bad rep.

Why do you feel you are the one to do this? I've seen hospitals get into serious hot water for things like this. If the State laws allows Podiatrists to perform certain procedures, who are you do deny them that right, if they have the training? Why do you get to say what procedure a Podiatrist has business doing or not? "Me and the profession in the area a bad rep"? More so than the many other issues that give us a bad reputation?

It isn't your hospital.

We have state boards of medicine and malpractice insurance to handle when doctors have the issues you claim are yours to oversee.

Come on, man. How do you know you aren't one of the ones giving Podiatry a bad name in your community?

 

[Scrantonicity]

This is an interesting subject because I don’t think any of these other professions have some of these residency programs floating around like unflushable turds. You know the ones that I am talking about, where residents quadruple scrub a toe chop that takes the attending an hour to do just so that they can barely me the already hilariously low minimal competency numbers.

HOT TAKE

So yes, I am one of those gatekeeping DPMs because I don’t want one of these losers coming to my hospital, trying to do a procedure that they have no business doing, maiming the patient, and ultimately giving me and the profession in the area a bad rep.

True...and you'd hope that it would be self-limiting...that those that just didn't train enough would stay out of the OR. Unfortunately, our profession has been constantly pushing for surgery, surgery, surgery to get these hospital doors open wider--but it comes at a cost. The duds will always keep trying to do more than they are qualified for, and it will always be a thorn in our side.

 

[NobodyDPM]

At some point though, can't count on residency numbers forever, so board cert probably kicks in and supercedes. Each situation different. And VERY fluid unfortuantely.

Yep, this is the issue I'm speaking of precisely. I ran into this recently when applying for RF privileges. Hadn't done a triple in awhile. Done plenty of Kidners, Retros, Tendon repairs, Lapidus Procedures, etc. They wouldn't give me triples or subtalar fusions. Had to get another Pod that knew me well involved and they finally caved. Sheer stupidity.

 

[NobodyDPM]

True...and you'd hope that it would be self-limiting...that those that just didn't train enough would stay out of the OR. Unfortunately, our profession has been constantly pushing for surgery, surgery, surgery to get these hospital doors open wider--but it comes at a cost. The duds will always keep trying to do more than they are qualified for, and it will always be a thorn in our side.

Not just our profession. Believe me, there are plenty of "trained" surgeons out there who have no business whatsoever being in the OR. There are duds in just about every surgical profession, and they all try to push the envelope of what they should be doing. I've seen this first hand with General, Vascular and Orthopedic surgeons. Some sued hospitals to get to do what they wanted, even after they botched a few cases. They then ultimately only had to stop when they couldn't get malpractice any longer. Guess why.

 

[Scrantonicity]

Not just our profession. Believe me, there are plenty of "trained" surgeons out there who have no business whatsoever being in the OR. There are duds in just about every surgical profession, and they all try to push the envelope of what they should be doing. I've seen this first hand with General, Vascular and Orthopedic surgeons. Some sued hospitals to get to do what they wanted, even after they botched a few cases. They then ultimately only had to stop when they couldn't get malpractice any longer. Guess why.

Yeah I'm sure that's true, and we see evidence of that all the time. I just wonder if it's proportionally worse in our profession. Most of those other specialties are strictly surgical, where podiatry is kind of a hybrid--so it seems we would have a larger percentage of non-surgically inclined people in our profession trying to operate because they were forced to do a 3 year surgical residency.

 

[NobodyDPM]

Yeah I'm sure that's true, and we see evidence of that all the time. I just wonder if it's proportionally worse in our profession. Most of those other specialties are strictly surgical, where podiatry is kind of a hybrid--so it seems we would have a larger percentage of non-surgically inclined people in our profession trying to operate because they were forced to do a 3 year surgical residency.

It's not. If anything, I find it to be worse. When matching for surgical specialties in allopathic and DO medicine, most applicants have never done any manual medical work. Maybe a few hand ties here or there, but they don't quite have "externships" like we do, and they rotations in school are hardly hands on, in most settings. Don't forget how few actually get surgical specialties in medicine. Great surgeons are a needle in a haystack.

 

[air bud]

Why do you feel you are the one to do this? I've seen hospitals get into serious hot water for things like this. If the State laws allows Podiatrists to perform certain procedures, who are you do deny them that right, if they have the training? Why do you get to say what procedure a Podiatrist has business doing or not? "Me and the profession in the area a bad rep"? More so than the many other issues that give us a bad reputation?

It isn't your hospital.

We have state boards of medicine and malpractice insurance to handle when doctors have the issues you claim are yours to oversee.

Come on, man. How do you know you aren't one of the ones giving Podiatry a bad name in your community?

legit complaint here. everyone has a motive...

 

[Scrantonicity]

It's not. If anything, I find it to be worse. When matching for surgical specialties in allopathic and DO medicine, most applicants have never done any manual medical work. Maybe a few hand ties here or there, but they don't quite have "externships" like we do, and they rotations in school are hardly hands on, in most settings. Don't forget how few actually get surgical specialties in medicine. Great surgeons are a needle in a haystack.

Pretty scary thought...

 

[Feli]

You want max surgery. No question. That's the hard part. That is what a hospital-based residency is for.

Yes, you need to see some pre- and post-op patients, listen to attendings and senior residents talk to the patients about their deformities and their XRs to help develop your scripts, etc. You need to see some suture line infections and some non-unions. You will do plenty of that in the inpatient rooms, ER, and clinic at any residency with a lot of surgery cases. It helps to go out to the offices of good attendings in your 3rd year once you are sick of cutting (assuming good surgery volume program). You have been a human communicator since before kindergarten, though... if you aren't fairly good already, it's a bit late.

...You should already know "clinic" from podiatry school. If you can't do a nail avulsion or H&P or heel inject or SOAP note or don't know how to treat verruca or etc before residency... well then you should send a letter to your pod school dean telling him to improve rotations. Those are core competencies. Billing? Yeah, that is useful, but you should get at least some exposure in residency, you need to learn mostly on your own no matter where you train, you will learn more at your first PP/MSG/ortho job than any residency (since it actually matters to you then), and you can always learn more coding later (lifelong task for 99% of DPMs, no matter how much they saw in residency).

Finally, it is eeeeeeasy to improve clinic stuff after graduation by talking to friends and doing meetings or articles about coding, procedures, practice mgmt, etc. I can text my buddy right now and ask how he treats tough tinea cases or how he bills a night splint or a shave biopsy. He can reply in 5 or 10 words. Easy.
Surgery improvements later once you're in practice? No, not so much. You usually can't just do a FDL transfer when you haven't done any midfoot/PT procedures in training. You can take a cadaver class or find out about a new implant, but if you don't already have the suture, anatomy, AO, etc principles rock solid from residency... then just refer out the cases you are uncomfortable with. It's irresponsible and frustrating to 'learn' surgery on patients. You should be bored with surgery (but still trying to improve or see unique cases or best techniques) halfway through any decent residency.