Surgery vs clinic heavy residency programs

[Pronation]

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?

I'll take the bait.

Because if you did 1 hindfoot/ankle fusion and the remainder was pus to hit that magic 50 cases for RRA, then you shouldn't be doing hindfoot/ankle fusions because you were a bad student, went to a garbage residency, and you'll argue that you can do these cases because you're "good with your hands".

We already know that the governing board for podiomotry is a joke.

---

Members don't see this ad.

 

[Feli]

I'll take the bait.

Because if you did 1 hindfoot/ankle fusion and the remainder was pus to hit that magic 50 cases for RRA, then you shouldn't be doing hindfoot/ankle fusions because you were a bad student, went to a garbage residency, and you'll argue that you can do these cases because you're "good with your hands".

We already know that the governing board for podiomotry is a joke.

You will never really go wrong just following the ACFAS Credentialing of Foot and Ankle Surgeons and Guidelines for Surgical Delineation of Privileges .

That is what I've found the vast majority of hospitals to do these days and what I've advised to any chief or doc who asks me my ideas on the subject. It takes the subjectivity largely out of it. Most important, the facility/chief can say they are following the outline from our national surgical organization, so it saves time and is protective against the type of applicant who insist ABLES is the same as ABFAS or starts talking lawsuits or discrimination unless you let them do Charcot recons.

Those ACFAS guidelines are pretty general and allow for wide privileges of core foot and RRA and special (TAA). That means nobody will lose Achilles rupture repair just because they haven't done one in 5 years... as long as they are doing de/reattach, TAL, etc similar stuff. The chief doesn't have to comb logs for 30 different procedure types (digit fusion, digit plasty, digit amp, digit tendonotomy, nail avulsion, digit neoplasm... lol) like many antiquated TFP hospital privi apps ask for. Also, there is room for slight subjectivity with case logs and proctoring... if the chief chooses (guy who has good training and RRA in remote past but did a VA job or limited-scope state and hasn't done much RRA in those years but wants to start again).

It is pretty unfortunate, but I have had to subtly or not so subtly recommend to the chief that certain doc privileges and on-call be examined for possible limitation or revocation (after first suggesting repeatedly to the docs themselves that they can refer complex stuff). I'm glad it's not my problem and I've done my due diligence after that suggestion, but there are some seriously dangerous docs out there... both in terms of operating with serious contra-indications (PAD, advanced age elective, etc), poor technique/outcomes (usually same procedure on basically everyone also), or mainly just issues of repeatedly neglecting bad infection/deformity/injury or grossly undertreating to the patient's serious detriment since the docs were scared or unable to recognize the magnitude or do the case properly (Austin for bad rheumatoid foot, 4th ray amp for midfoot gas, casted displaced Lisfranc, etc etc... pretty sad).

 

[air bud]

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.

Only thing you got wrong here....don't worry I am sure new students are only getting better at face to face communication with the help of TikTok, Snap, FB etc....crap now I sound like @NobodyDPM

 

[Pronation]

Back in my day we used an abacus!

 

[deleted1097413]

Go for the good surgical program. Very unlikely that a program will be poor in surgery but have some sort of amazing clinical experience. The good surgery programs will have good clinical experiences because you will be seeing good MSK pathology in the attendings clinics.

 

[NobodyDPM]

I'll take the bait.

Because if you did 1 hindfoot/ankle fusion and the remainder was pus to hit that magic 50 cases for RRA, then you shouldn't be doing hindfoot/ankle fusions because you were a bad student, went to a garbage residency, and you'll argue that you can do these cases because you're "good with your hands".

We already know that the governing board for podiomotry is a joke.

That's total BS. Orthopedists who do a General residency can do bunions in the OR if they chose.

Are you a foot and ankle surgeon or not? That's part what people who graduate from Podiatry residency are. It's not up to you to split hairs. And is why we have such a fractured profession.

You are continuing the joke that is our governing board by thinking you should be a gatekeeper. So again, why do you think or feel that this is your role? Because if not you, nobody else? Come on, man. That's just obtuse.

 

[Pronation]

That's total BS. Orthopedists who do a General residency can do bunions in the OR if they chose.

Are you a foot and ankle surgeon or not? That's part what people who graduate from Podiatry residency are. It's not up to you to split hairs. And is why we have such a fractured profession.

You are continuing the joke that is our governing board by thinking you should be a gatekeeper. So again, why do you think or feel that this is your role? Because if not you, nobody else? Come on, man. That's just obtuse.

Thank you for your input. While we’re on the topic of gatekeeping I’d also like to discuss highway travel. What I do is immediately make my way over to the left lane and set my cruise control to exactly the speed limit. This way I can help the police officers against people who commit crimes such as speeding.

 

[NobodyDPM]

Thank you for your input. While we’re on the topic of gatekeeping I’d also like to discuss highway travel. What I do is immediately make my way over to the left lane and set my cruise control to exactly the speed limit. This way I can help the police officers against people who commit crimes such as speeding.

Ahhhhh...you're one of those internet trolls...now I understand.

 

[Weirdy]

This is the internet.

Take it easy and please be respectful when you have the patience for it.

Trolling in good nature is OK.

 

[NobodyDPM]

This is the internet.

Take it easy and please be respectful when you have the patience for it.

Trolling in good nature is OK.

Understood.

Just as a side note, I asked him very pointed questions, which he didn't answer and then he got snarky. My patience had expired at that point. We don't need individual "gatekeeper" like that in our profession. That is the highest order of disrespect to ones' colleagues and one of the reasons we continue to be so fractured as a group.

 

[air bud]

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.

Did 3 things yesterday I haven't done in the 5 years I have been out, but did plenty of in residency - Medial mal takedown, static ex fix and TA transfer. I watched a few videos, read a few things and asked a few friends/attendings. Everything went well, pretty easy also. Because it was part of my training.

Edit - different patients for the record.

 

[NobodyDPM]

Did 3 things yesterday I haven't done in the 5 years I have been out, but did plenty of in residency - Medial mal takedown, static ex fix and TA transfer. I watched a few videos, read a few things and asked a few friends/attendings. Everything went well, pretty easy also. Because it was part of my training.

Edit - different patients for the record.

Exactly. I never understood this, "you haven't done 5 triples, so we won't give you the privileges for it". As I mentioned, for something like Ankle Implants, I get it. Then again, when you have people like @Pronation who feel they should be Gatekeepers, despite all of our other professional organizations already doing that, it's no wonder there are issues.

 

[Pronation]

"you haven't done 5 triples, so we won't give you the privileges for it".

This is the ole boomer approach to gatekeeping, so... At my hospital, where I am chief podometric sturgeon, we pretty much use the ACFAS gatekeeping guidelines. More specifically, we require that someone applying out of residency for hindfoot and ankle privileges to have performed at least 15 hindfoot or ankle fusions of ANY type. This is already a laughably low number.

 

[air bud]

This is the ole boomer approach to gatekeeping, so... At my hospital, where I am chief podometric sturgeon, we pretty much use the ACFAS gatekeeping guidelines. More specifically, we require that someone applying out of residency for hindfoot and ankle privileges to have performed at least 15 hindfoot or ankle fusions of ANY type. This is already a laughably low number.

Well wouldnt they need that anyways for whatever the acronym thing is for rearfoot residency program thing?

 

[med2345]

Sorry to butt in here… but for the attendings/residents on this forum:

How many cases/week would you consider a high/very high surgical load residency? 20? 40?

 

[heybrother]

Well wouldnt they need that anyways for whatever the acronym thing is for rearfoot residency program thing?

I haven't looked in awhile but its 50 cases divided up into essentially elective/non-elective and then soft tissue/osseous. You absolutely can graduate without 15 rearfoot/ankle fusions. Its part of why pronation has been going on about what I'll call "1 of each + pus". He's essentially saying people got 1 case of each category or whatever is needed and then lumped the rest under I guess amputation or something like that.

Everyone will have their cutoff for what they think is unimpressive or not good enough. There's was a story on Podiatry Today or whatever of a young podiatry graduate who bought his residency director's program. He asked for ankle priviledges at his own residency hospital and was denied because he only had 9-10 ankle fractures.

I literally drove 4 hours (2 there, 2 back) routinely to pick up extra surgery days during my residency because I thought - what if some place has some cutoff and my scopes or fractures or fusions number doesn't cross the line.

Interestingly, where I am the ortho hospital requires you to demonstrate every 2 years you are doing cases of similar difficulty/style to the scope you request.

.

 

[Pronation]

I haven't looked in awhile but its 50 cases divided up into essentially elective/non-elective and then soft tissue/osseous. You absolutely can graduate without 15 rearfoot/ankle fusions. Its part of why pronation has been going on about what I'll call "1 of each + pus". He's essentially saying people got 1 case of each category or whatever is needed and then lumped the rest under I guess amputation or something like that.

Everyone will have their cutoff for what they think is unimpressive or not good enough. There's was a story on Podiatry Today or whatever of a young podiatry graduate who bought his residency director's program. He asked for ankle priviledges at his own residency hospital and was denied because he only had 9-10 ankle fractures.

I literally drove 4 hours (2 there, 2 back) routinely to pick up extra surgery days during my residency because I thought - what if some place has some cutoff and my scopes or fractures or fusions number doesn't cross the line.

Interestingly, where I am the ortho hospital requires you to demonstrate every 2 years you are doing cases of similar difficulty/style to the scope you request.

.

Bingo. I just checked PRR. Only 4 “elective osseous” diversity cases are required. So that could be satisfied at some garbage program where the residents quintuple scrub with their “RRA guru” who puts an MBA and a gastroc for every flatfoot that comes through through the door.

My hospital actually had those silly rules that you had to do a certain amount of a specific type of procedure in a period of time to maintain those individual privileges. I whined to have that nonsense removed.

edit: Just to clarify, this example of a subpar resident at a garbage residency could get their RRA by tossing in a couple MBAs and finishing off the rest of the RRA requirement with pus - ie logging a calc osteotomy after they nibbled off some rotten infected bone sticking out the back of a bed bound patient's heel. Would you want someone like this doing your family member's ankle fusion? I sure wouldn't...

 

[air bud]

Sorry to butt in here… but for the attendings/residents on this forum:

How many cases/week would you consider a high/very high surgical load residency? 20? 40?

I think I did maybe 1200 pod cases? Around 1700 procedures. Mine was surgery heavy. Minimal clinic which was optional and not enforced...but unique program. I could go weeks without seeing another co resident as 3rd year. I could be at home in my underwear by 10am every day if I wanted to.

 

[air bud]

I was just asked to update privileges at my hospital, so what I said went. I said 50 rearfoot procedures every 2 years.

 

[air bud]

I thinking was if somebody else tried to come in for some reason which I don't see any way they could because I'm small enough that it can't support another person, I am going to do whatever I can to keep them out

So there you go, me being the gatekeeper.

 

[DYK343]

Sorry to butt in here… but for the attendings/residents on this forum:

How many cases/week would you consider a high/very high surgical load residency? 20? 40?

I did probably between 20-30 cases a week when on service from pus to ankle replacement. Operated pretty much the entire time minus some mandatory clinic hours and off service rotations. I was aggressive on my cases though. I grabbed every case I could. Finished somewhere around 2.5-3k procedures (I cant really rememer).

There was plenty to go around for all residents to hit that number so I took full advantage of it. I had a situation where I could have also been in my underwear at 10am after morning rounds but I took full advantage of the 3 years I had there. I also really respected my attendings. No bad blood between anyone and it was a very enjoyable part of my life.

I consider that a high volume residency. Probably one of the higher volume residencies in the country? Maybe not #1 but I would wager top 20% in terms of volume.

My clinical experience lacked in comparrison to most but I feel I am doing fine in clinic these days. First 6 months to a year was a bit rough but I figured it out without any major issues.

 

[air bud]

I did probably between 20-30 cases a week when on service from pus to ankle replacement. Operated pretty much the entire time minus some mandatory clinic hours and off service rotations. I was aggressive on my cases though. I grabbed every case I could. Finished somewhere around 2.5-3k procedures (I cant really rememer).

There was plenty to go around for all residents to hit that number so I took full advantage of it. I had a situation where I could have also been in my underwear at 10am after morning rounds but I took full advantage of the 3 years I had there. I also really respected my attendings. No bad blood between anyone and it was a very enjoyable part of my life.

I consider that a high volume residency. Probably one of the higher volume residencies in the country? Maybe not #1 but I would wager top 20% in terms of volume.

My clinical experience lacked in comparrison to most but I feel I am doing fine in clinic these days. First 6 months to a year was a bit rough but I figured it out without any major issues.

That is top 5 total I am sure. Crazy numbers. Clinic is easy. Inject this, immobilize that, stretch more. I was weak clinically for sure. But fortunately joined another pod (colleague not boss...) In a MSG that I could rely on to help.

 

[DYK343]

That is top 5 total I am sure. Crazy numbers. Clinic is easy. Inject this, immobilize that, stretch more. I was weak clinically for sure. But fortunately joined another pod (colleague not boss...) In a MSG that I could rely on to help.

I didnt do 500 ankle fusions. Its fairly easy to run a forefoot slam and get a lot of procedures. But it was a busy experience.

I didnt log it if I didnt do the case >80%. Most cases minus first 3-6 months I did >80% if not 100%. Attending would take the knife to teach a trick or something like that.

We only had 1-2 attendings who didnt let the resident do much. They did tend to be the DPM TAR guys which we scrubbed to be involved and learn. But overall it was a great experience.

The F&A orthos let us do almost everything and were more than happy to teach.

 

[Feli]

Sorry to butt in here… but for the attendings/residents on this forum:

How many cases/week would you consider a high/very high surgical load residency? 20? 40?

Around 10/wk is fine as primary assist. You should have another 10+ weekly cases available where you are second assist with another resident being primary.

I think we have some confusion of cases vs procedures. Austin, Akin, Weil 2nd, arthrodesis 2nd PIPJ = 1 case, 4 procedures.

That answer I gave is cases, not procedures. 10 cases/wk x 2 years (100wks) of podiatry (24mo pod, then 12mo off service) is 100 weeks on service... so multiply cases per week by 100 weeks. That 10 cases/wk means you graduate with 1000 cases and will be at least 1500-2000+ procedures with first assist level involvement. My grad log numbers were similar to airbud but with a bit more procedures since every damn bunion in Michigan gets an Akin also, lol. That is PLENTY of surgery.... we did higher end programs in terms of logs. I would assume any talk of averaging 15-20+ cases per week includes the second assist ones or is meaning to say procedures instead?

Who knows, but you have to consider what is even possible in a day. When you figure 40hrs per week of potential OR time (less at ASC, more at hospitals... but hospitals are much slower) and consider turnover times and consider some cases going for awhile and driving between facilities (you will drive a lot at 99% of high volume residencies) and also occasional clinic or meal breaks, 30 cases in a week is not really even possible (at least not where I trained). 30 procedures is doable, but consider the difference. If 20+ first assist cases happened in some weeks or even every week, that is certainly top 1% of all pod residencies in terms of overall volume.

Anyways, it was certainly not possible for me or any resident to get 30 or even 25 first assist F&A cases weekly where I trained since we had a dozen locations, we had limited volume on some days, and first years do the vast majority of the quicker cases like toes or I&Ds and amps while seniors took the recon stuff and trauma. I doubt I ever had a single week with even 20 cases in my whole 3yrs honestly. You don't need more than ~8/wk avg, though... 10 or 12+ weekly cases average and you are golden. You would have to divide the minimum requirements by 100wks to see what you need to "get your numbers," but it is not much at all... and make sure you match a place with at least 2x or 3x the minimums per resident with legit logging. At mine, we might go do a Lapidus/Weil/HT case, then Achilles case, then a Austin/Akin at the surgery center... and then you drive back to the main hospital and just read since by afternoon, there's nothing but I&D add on that you just let the on-call first year do. That would be a 3 case and 6 procedure day first assist... probably better than average day with that particular case complexity. A real busy day might be 5 cases as first assist (maybe 15 procedures if a couple were forefoot slams) and 15+ cases for the week, but you also have those slow months in winter that balance it out also... and you also tend to let your juniors do more and more first assist once you have your numbers and feel fine with certain dissections (at least I did that,,, and make those first years buy you Taco Bell for every Austin skin-to-skin you could've done but let them get!).

You would be surprised at even how many highly regarded programs only have about 5-8 legit first assist cases per resident per week. They still get their numbers, and they learn with very good surgeons and cool cases... but they do a lot of double/triple scrubbing. It is always better to have your cake (numbers) and eat it too (good attendings/teachers). But yeah, I would say 10 per week first assist (so roughly 1000 cases and 1500-2000 procedures) has you above 80% or more of residency programs (not including ones that log fraudulently with unbundling and bogus RRA logs). You are probably ahead of 90% nationwide with those same 10/wk numbers assuming your program does any appreciable amount of real RRA work (ankle fx, hindfoot fusions, flatfoot, etc... not just hindfoot I&D, partial calcanectomy, de/reattach, and Charcot "recon" that will get a BKA a couple months later). That is something you really have to pay attention to... is the "RRA" real recon stuff and trauma or just a bunch of diabetic nonsense? You want to see and learn it all... the recon stuff is much harder and patient expectations are much higher.

 

[NobodyDPM]

This is the ole boomer approach to gatekeeping, so... At my hospital, where I am chief podometric sturgeon, we pretty much use the ACFAS gatekeeping guidelines. More specifically, we require that someone applying out of residency for hindfoot and ankle privileges to have performed at least 15 hindfoot or ankle fusions of ANY type. This is already a laughably low number.

That's not what you wrote previously.

And my take is that if you satisfied the CPME's requirements for your program, you should not have to prove cases to get privileges. Just another podiatry BS tactic. And this RRA/Foot surgery thing in residency should go away. It just further stratifies the haves from the have nots. Again, barring things like ankle implants, there should be no restrictions. And none of this proctoring cases either. What a load of crap that is. Someone who has been doing surgery for 40 years proctoring someone fresh out of residency? Or someone not Board Certified proctoring someone who is? Come on now.

 

[NobodyDPM]

Sorry to butt in here… but for the attendings/residents on this forum:

How many cases/week would you consider a high/very high surgical load residency? 20? 40?

I did 2000 cases in 2 years in my Surgical Residency. I would say that was a pretty high surgical load.

That doesn't include the 200-300 cases I did in my first non surgical program.

 

[air bud]

I did 2000 cases in 2 years in my Surgical Residency. I would say that was a pretty high surgical load.

Operating in the dark and uphill both ways?

 

[NobodyDPM]

Operating in the dark and uphill both ways?

Man, how did you know!!!???

The surgery center where I did my surgical residency was owned by the Pods that ran the residency. 12-15 cases every Friday and the rest in between at other facilities with other attendings. It was glorious. I also didn't have any other rotations, as I did them all in my first residency. Oh, except Anesthesia, sorry. But then, once the patient was sedated or under general, I moved over and helped with the cases.

 

[Pronation]

And this RRA/Foot surgery thing in residency should go away. It just further stratifies the haves from the have nots.

I agree with you 100%. A good start would be to shut down the awful residency programs that cannot meet "RRA" requirements; or turn them into chiropody programs.

 

[NobodyDPM]

I agree with you 100%. A good start would be to shut down the awful residency programs that cannot meet "RRA" requirements; or turn them into chiropody programs.

Not sure if you're being sarcastic...

When the "three years or nothing" became mandated, I was not a fan. Not every person who gets into Podiatry school is meant to be a surgeon, so why treat the profession that way? Especially since, when this three years thing started, there weren't enough programs for everyone, and some people were left out in the cold. The vast majority of states require at least one year of post graduate training to be eligible for a license. So we had a handful of grads who were very limited as to where they could practice because Podiatry got high and mighty with itself.

I proposed to the APMA, to start a handful of 1 year programs to make sure everyone got a chance to practice where ever they wanted, and was laughed at. "That would mean taking a step backwards!!" I was told. My response was, "no, that means we take care of our own..." And laughed at again. That's about the same time I stopped being involved with our profession at the political level.

Now, it's not quite an issue, unless we do what you propose. Then what? We close those programs, and the pendulum will swing to not enough residencies again. Are you going to pick up the pieces and create those one year programs like we had back in the day when I was coming up? To make sure everyone gets a fair shot at a license anywhere they chose? Or will you be one of the ones telling those with no residency to suck it up and just practice in the States where one year of training is not required?

 

[Shiyuan]

In terms of clinic vs. surg... I can put on a mean low-dye strap 👍🏻😜

 

[Utvolsdpm]

In terms of clinic vs. surg... I can put on a mean low-dye strap 👍🏻😜

Dremmel skills can’t be learned in the OR either!

 

[Feli]

Operating in the dark and uphill both ways?

ABFAS exam was all PhD level math problems back then also....

Pi * square root of 10 * 5! / 0 = ???

 

[HardRoadPaved]

Pi * square root of 10 * 5! / 0 = ???

I feel like this is an equation from a facebook meme with the title "95% of people get this math question wrong" and the comments are littered with answers proving the point

 

[DYK343]

Around 10/wk is fine as primary assist. You should have another 10+ weekly cases available where you are second assist with another resident being primary.

I think we have some confusion of cases vs procedures. Austin, Akin, Weil 2nd, arthrodesis 2nd PIPJ = 1 case, 4 procedures.

That answer I gave is cases, not procedures. 10 cases/wk x 2 years (100wks) of podiatry (24mo pod, then 12mo off service) is 100 weeks on service... so multiply cases per week by 100 weeks. That 10 cases/wk means you graduate with 1000 cases and will be at least 1500-2000+ procedures with first assist level involvement. My grad log numbers were similar to airbud but with a bit more procedures since every damn bunion in Michigan gets an Akin also, lol. That is PLENTY of surgery.... we did higher end programs in terms of logs. I would assume any talk of averaging 15-20+ cases per week includes the second assist ones or is meaning to say procedures instead?

Who knows, but you have to consider what is even possible in a day. When you figure 40hrs per week of potential OR time (less at ASC, more at hospitals... but hospitals are much slower) and consider turnover times and consider some cases going for awhile and driving between facilities (you will drive a lot at 99% of high volume residencies) and also occasional clinic or meal breaks, 30 cases in a week is not really even possible (at least not where I trained). 30 procedures is doable, but consider the difference. If 20+ first assist cases happened in some weeks or even every week, that is certainly top 1% of all pod residencies in terms of overall volume.

Anyways, it was certainly not possible for me or any resident to get 30 or even 25 first assist F&A cases weekly where I trained since we had a dozen locations, we had limited volume on some days, and first years do the vast majority of the quicker cases like toes or I&Ds and amps while seniors took the recon stuff and trauma. I doubt I ever had a single week with even 20 cases in my whole 3yrs honestly. You don't need more than ~8/wk avg, though... 10 or 12+ weekly cases average and you are golden. You would have to divide the minimum requirements by 100wks to see what you need to "get your numbers," but it is not much at all... and make sure you match a place with at least 2x or 3x the minimums per resident with legit logging. At mine, we might go do a Lapidus/Weil/HT case, then Achilles case, then a Austin/Akin at the surgery center... and then you drive back to the main hospital and just read since by afternoon, there's nothing but I&D add on that you just let the on-call first year do. That would be a 3 case and 6 procedure day first assist... probably better than average day with that particular case complexity. A real busy day might be 5 cases as first assist (maybe 15 procedures if a couple were forefoot slams) and 15+ cases for the week, but you also have those slow months in winter that balance it out also... and you also tend to let your juniors do more and more first assist once you have your numbers and feel fine with certain dissections (at least I did that,,, and make those first years buy you Taco Bell for every Austin skin-to-skin you could've done but let them get!).

You would be surprised at even how many highly regarded programs only have about 5-8 legit first assist cases per resident per week. They still get their numbers, and they learn with very good surgeons and cool cases... but they do a lot of double/triple scrubbing. It is always better to have your cake (numbers) and eat it too (good attendings/teachers). But yeah, I would say 10 per week first assist (so roughly 1000 cases and 1500-2000 procedures) has you above 80% or more of residency programs (not including ones that log fraudulently with unbundling and bogus RRA logs). You are probably ahead of 90% nationwide with those same 10/wk numbers assuming your program does any appreciable amount of real RRA work (ankle fx, hindfoot fusions, flatfoot, etc... not just hindfoot I&D, partial calcanectomy, de/reattach, and Charcot "recon" that will get a BKA a couple months later). That is something you really have to pay attention to... is the "RRA" real recon stuff and trauma or just a bunch of diabetic nonsense? You want to see and learn it all... the recon stuff is much harder and patient expectations are much higher.

20 cases (not procedures) is 4 a day if only operating M-F. Count weekend trauma/pus and its not impossible to get 20+ a week - at least at the program I did.

We had 3 locations. All within 15min of each other. Attendings would line up 5-6 Austins (or equivalent) at the surgery center and I/we would get done sometimes before 1PM (depending on speed of resident). Then cover whatever is still running at the main hospital after surgery center.

Then when "done" for the day residents covered whatever came in through the ER, which was a busy ER. Every night 3-4 pus cases easy.

I did between 20-30 cases (not procedures) a week. It was a brutal 3 years but I grew exponentially and ill always miss my time there.

My procedure numbers definately favored forefoot over rearfoot. My 2nd year my procedure numbers exploded because I was doing the forefoot slams, 5 austin/akins, etc that gave me a lot of procedures. 3rd year the RRA cases were less procedures and took more time (obviously). 3rd year maybe 15-20 cases a week but I often still had to cover the forefoot stuff if there was no recon cases going.

We didnt have a lot of residents to go around at my program. Rarely double scrubbed unless it was something really interesting. We definately worked >80hrs a week but I never said anything. We had work to do!

 

[wakaflocka88]

20 cases (not procedures) is 4 a day if only operating M-F. Count weekend trauma/pus and its not impossible to get 20+ a week - at least at the program I did.

We had 3 locations. All within 15min of each other. Attendings would line up 5-6 Austins (or equivalent) at the surgery center and I/we would get done sometimes before 1PM (depending on speed of resident). Then cover whatever is still running at the main hospital after surgery center.

Then when "done" for the day residents covered whatever came in through the ER, which was a busy ER. Every night 3-4 pus cases easy.

I did between 20-30 cases (not procedures) a week. It was a brutal 3 years but I grew exponentially and ill always miss my time there.

My procedure numbers definately favored forefoot over rearfoot. My 2nd year my procedure numbers exploded because I was doing the forefoot slams, 5 austin/akins, etc that gave me a lot of procedures. 3rd year the RRA cases were less procedures and took more time (obviously). 3rd year maybe 15-20 cases a week but I often still had to cover the forefoot stuff if there was no recon cases going.

We didnt have a lot of residents to go around at my program. Rarely double scrubbed unless it was something really interesting. We definately worked >80hrs a week but I never said anything. We had work to do!

Ditto, agree with all the above insights. In my final year, definitely had weeks where 20+ cases was the norm and then there were quiet weeks with less than 10 cases. I still recall in one week - we had 20 operative ankle fractures, that was nuts. Even with all this experience in residency, I can say that practicing in the real world with an ankle fracture is still not a walk in the park.

 

[DYK343]

Ditto, agree with all the above insights. In my final year, definitely had weeks where 20+ cases was the norm and then there were quiet weeks with less than 10 cases. I still recall in one week - we had 20 operative ankle fractures, that was nuts. Even with all this experience in residency, I can say that practicing in the real world with an ankle fracture is still not a walk in the park.

Ankles are weird. They are either super easy and pop together with minimal effort or I'm in there for what feels like forever. I compare them to a lapidus. Its either 45min or 3hrs. No in between.

 

[Pronation]

I proposed to the APMA, to start a handful of 1 year programs to make sure everyone got a chance to practice where ever they wanted, and was laughed at. "That would mean taking a step backwards!!" I was told. My response was, "no, that means we take care of our own..." And laughed at again. That's about the same time I stopped being involved with our profession at the political level.

I agree with you 100%. We should convert the terrible residency programs into 1 year programs so that the students who barely graduated pod school can still get to practice - as chiropodists.

 

[Shiyuan]

I agree with you 100%. We should convert the terrible residency programs into 1 year programs so that the students who barely graduated pod school can still get to practice - as chiropodists.

Where’d my cordless Dremel go... time to bust dem crumblies

 

[NobodyDPM]

I agree with you 100%. We should convert the terrible residency programs into 1 year programs so that the students who barely graduated pod school can still get to practice - as chiropodists.

We are talking about being a doctor here. And some people, even bright ones, just don't want to be surgeons. And there are some that get through some residency now, and realize that surgery isn't for them. Having "good hands" has nothing to do with your intelligence level at all. And some of the smartest people don't have the hand skills. So who you would you prefer? The top of the class who can't cut their way out of a paper bag, or someone who is middle of the class (or lower) who is brilliant with their hands?

Btw, it takes a lot more brains to work up a patient medically, properly, then to do fix an ankle fracture.

 

[Feli]

We are talking about being a doctor here. And some people, even bright ones, just don't want to be surgeons. And there are some that get through some residency now, and realize that surgery isn't for them. Having "good hands" has nothing to do with your intelligence level at all. And some of the smartest people don't have the hand skills. So who you would you prefer? The top of the class who can't cut their way out of a paper bag, or someone who is middle of the class (or lower) who is brilliant with their hands?

Btw, it takes a lot more brains to work up a patient medically, properly, then to do fix an ankle fracture.

I don't even think it is necessarily this. It is more often just personal choice. The ones with truly bad hands or who take two hours to do an Austin will typically improve to mediocre after enough reps, and good students almost invariably get good/great training program match. I have yet to see the truly bad surgeon from a good program (since hundreds and thousands of reps tends to make them mediocre or good). Besides, you can't stop them anyways if they're decided on doing surgery and they passed all the qualifications. The only stop for them would be repeated malpractice causing insurance/hospital problems after years in practice... and that's a huge maybe that you much more typically see with surgeons with crap training and failed boards trying to do stuff they are in way over their head on. Those are the veeeery small minority who did good training and passed qual/cert and still suck, though. The goofballs who did a residency with just toe amps and bunions and neuromas... and now wants to do Charcot frames and flatfoot recon are thankfully also rare.

A significant amount of people (in any specialty) just don't want to work that hard. In podiatry, they might do surgery fine from a technique standpoint and they did a fair/good residency, passed ABFAS BQ... but then residency ends. They start to realize that simply showing up for the 3 scheduled cases with doc A one day and 4 with doc B the next day was a luxury that ends after training. As an attending yourself, they have to find the cases and manage the pre/post paperwork and conversations. They have to see a LOT of patients in the typical podiatry clinic to get any appreciable amount of surgery (find the sugery between the many many many nail/derm care, diab/wound, sports/ortho but doesn't want/need surgery, etc patients). I would estimate most DPMs see 25-50 office visits per single surgery case... so an average week might be 100+ patients and only 2-3 surgery cases - or less (depending on pt population and how the DPM talks/treats pathologies).

Also, they find that you have to take at least some eve/weekend call to do surgery (even if it is only calls on your own surgical patients going to ER for tight cast, infection, bandage wet, had a fall, etc). A lot of major hospitals require you to take general F&A call/consults rotation to even be on staff at all. Again, many DPMs don't want that... they want to work banker hours and be gone to Aspen or the coast every weekend carefree. That is why you see 3yr grads who did a decent training and passed ABFAS BQ still choosing to do nursing homes or cushy non-op VA jobs, minimal surgery in solo or group PP, etc.