Surgical Number/Case Load

[DogSnoot]

Hi, SDN can we talk about a hot topic which is residency surgical case number. Can someone give incoming resident and student, what makes a good program surgical number wise ?

1) how many dirty cases should a program offer to to a student/resident as first assist to be considered a “good” value?
2) how many rear foot number should a program offer as first assist to be considered “value” ?
3) what real work rearfoot procedures are being billed for the most and we should focus on being proficient/learning ?
4) is learning inpatient care vs clinic care important? What’s the value of each in the real world?
4) how do you know if upper resident are screwing logged number ?

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[edog10]

1) You will get as many dirty cases as you can handle in every residency. Hopefully you are not assisting anyone but doing them yourself.
2) 300-500 your last 2 years?
3) doubles, triples, lump n'bump achilles work; some flatfoot procedures. trauma is cool but very few people, er PAWDs get enough to focus your practice on
4) depends, if you have no desire to work for a hospital I would focus on billing and how to run an office efficiently. stuff you can't learn reading books. But if you take a hospital job, being able to round, navigate the OR/ED and communicate with other specialties is golden. Plus, being on the RVU circuit, all that matters is adding as many codes as possible - let your coders figure it out
4) No clue

 

[Adam Smasher]

1) how many dirty cases should a program offer to to a student/resident as first assist to be considered a “good” value?
2) how many rear foot number should a program offer as first assist to be considered “value” ?
3) what real work rearfoot procedures are being billed for the most and we should focus on being proficient/learning ?

I'll defer to others. There was talk at one point about switching numbers for benchmarks, in other words some people can figure out metatarsal osteotomies in 5 cases, others need 20, what matters is that you've reached your proficiency. We tend to talk down dirty cases here ("riding the pus bus") but I personally find them interesting. It's worth your time to go out of your way to see them so you can appreciate the visual of diseased/healthy tissue. I had attendings in residency who mismanaged even those cases. Most programs have no shortage of dirty cases, however.

4) is learning inpatient care vs clinic care important? What’s the value of each in the real world?

Learn enough inpatient care so you can communicate intelligently with Medicine, Anesthesia, Cardiology, etc. In practice, you have better uses for your time than to get involved in admissions--and its corollary, dispo.

The most important thing about podiatry clinic in residency is learning how to talk to patients. The actual medical decision making for outpatient podiatry is very straightforward, which is why it was once upon a time possible to practice outpatient podiatry without residency training at all, and that's the way it's still done outside the U.S.

4) how do you know if upper resident are screwing logged number ?

same way CPME knows...we don't.

 

[Hybrocure]

People are rarely ever honest about their surgical numbers. Numbers don’t mean much if you weren’t actually the one operating. This is the most important thing.

Some stuff like total ankles, I don’t think there’s a single program out there that’s having residents do them skin to skin. Hence why many people who do them in practice take additional training or fellowship, or will double scrub as an attending for them.

For realistic resident cases though, I would take 10 skin to skin bunions over retracting for 100 lapidus any day. People like to assume retracting helps you learn but it’s bs. The day you become an attending you never hold a senn for the rest of your life. Knowing how to assist does NOT make you a better surgeon. Hot take I know.

 

[Hybrocure]

As for dirty cases..scrub as many as you can. It’ll make you good with using a blade and learning to control bleeding. I’ve been baffled how some docs out there will do an IM nail or triple but struggle to do a toe amp.

It’s still a fun feeling to scrub in, disarticulate a hallux in 20 seconds and scrub out while the OR staff is like wtf that was fast. Ultimately this will be podiatry’s future anyhow better learn how to be the best you can be at debridement and amps. Your ability to do these cases well will make you look much better to MDs/DOs than messing around with a 2-3 hour fusion case.

 

[Pronation]

I’ve been baffled how some docs out there will do an IM nail or triple but struggle to do a toe amp.

I don’t believe you.

 

[Retrograde_Nail]

Hi, SDN can we talk about a hot topic which is residency surgical case number. Can someone give incoming resident and student, what makes a good program surgical number wise ?

1) how many dirty cases should a program offer to to a student/resident as first assist to be considered a “good” value?
2) how many rear foot number should a program offer as first assist to be considered “value” ?
3) what real work rearfoot procedures are being billed for the most and we should focus on being proficient/learning ?
4) is learning inpatient care vs clinic care important? What’s the value of each in the real world?
4) how do you know if upper resident are screwing logged number ?

I think you ask important questions but you are not going to get a real accurate answer because unfortunately the training in podiatry is really just so VARIABLE.

On top of this everyone has different skills in the OR. Everyone has different abilities. So with experience comes different needs to master certain procedures. It really is as simple as that.

Rather than focusing on numbers I would focus on the quality of training. How do we define quality?

My interpretation:

1) Active teaching from attending during every case whether you are doing the case or just retracting
2) Pre surgery discussions about the case and pathology. Are attendings having phone conversations with residents the night before the case or are they sitting reviewing the big cases before they do them in the morning?
3) Are residents seeing these surgical patient's in the clinic to manage?
4) Are senior residents actively teaching junior residents?

These four are the biggest things you need to become competent.

If you never review cases before you do them with the attendings you LOSE out on learning experiences. If your attending doesn't even talk to you during the case or is unwilling to answer questions during the case then you LOSE out on learning experiences. If you never see these surgical patients again then you never know if the surgery even worked, how do you manage complications, how do you even deal with the patient after surgery. You need to learn clinical management of surgical pathology as much as you need to learn how to do the surgery.

Is there a culture of teaching within the program? Are senior residents taking the time to teach junior residents cases? If not it is because they have nothing to teach because they still LACK experience. This is not a good sign. It means the senior residents are NOT CONFIDENT.

This is why your rotations as a student are vital. You need to remember these four things. Pay close observation to what the residents at every program are doing. Play close attention to what the attendings are doing. Are the attendings just using the residents for slave labor or are the attendings there to teach? Are the senior residents doing majority of the cases skin to skin? If they still are not even late into their third year that is a problem.

Podiatry residency programs are essentially overall not very good. Hardly any have all 4 of these things. Very few do. It is probably less than we like to admit as a profession. Majority of residencies have major holes in their training and education. Many programs state they do high volume but the quality of these cases are not very good because the attendings do not care and bust out cases and do not teach the residents because teaching slows them down.

If residencies were as complete as we brag about then why are so many people seeking fellowship training? I laugh because I have been out long enough that I have seen DPMs who were students when I was resident who went on to do bad residency programs and then went on to do mediocre fellowships who now think they have more experience than most.

This is what our profession is turning into. Mix this dynamic with job saturation and it will implode sooner than later. We are already seeing it with decreased admissions to podiatry schools. When you add it all together it does not look very stable and it is a very risky investment.

 

[PeaJay]

I think you ask important questions but you are not going to get a real accurate answer because unfortunately the training in podiatry is really just so VARIABLE.

On top of this everyone has different skills in the OR. Everyone has different abilities. So with experience comes different needs to master certain procedures. It really is as simple as that.

Rather than focusing on numbers I would focus on the quality of training. How do we define quality?

My interpretation:

1) Active teaching from attending during every case whether you are doing the case or just retracting
2) Pre surgery discussions about the case and pathology. Are attendings having phone conversations with residents the night before the case or are they sitting reviewing the big cases before they do them in the morning?
3) Are residents seeing these surgical patient's in the clinic to manage?
4) Are senior residents actively teaching junior residents?

These four are the biggest things you need to become competent.

If you never review cases before you do them with the attendings you LOSE out on learning experiences. If your attending doesn't even talk to you during the case or is unwilling to answer questions during the case then you LOSE out on learning experiences. If you never see these surgical patients again then you never know if the surgery even worked, how do you manage complications, how do you even deal with the patient after surgery. You need to learn clinical management of surgical pathology as much as you need to learn how to do the surgery.

Is there a culture of teaching within the program? Are senior residents taking the time to teach junior residents cases? If not it is because they have nothing to teach because they still LACK experience. This is not a good sign. It means the senior residents are NOT CONFIDENT.

This is why your rotations as a student are vital. You need to remember these four things. Pay close observation to what the residents at every program are doing. Play close attention to what the attendings are doing. Are the attendings just using the residents for slave labor or are the attendings there to teach? Are the senior residents doing majority of the cases skin to skin? If they still are not even late into their third year that is a problem.

Podiatry residency programs are essentially overall not very good. Hardly any have all 4 of these things. Very few do. It is probably less than we like to admit as a profession. Majority of residencies have major holes in their training and education. Many programs state they do high volume but the quality of these cases are not very good because the attendings do not care and bust out cases and do not teach the residents because teaching slows them down.

If residencies were as complete as we brag about then why are so many people seeking fellowship training? I laugh because I have been out long enough that I have seen DPMs who were students when I was resident who went on to do bad residency programs and then went on to do mediocre fellowships who now think they have more experience than most.

This is what our profession is turning into. Mix this dynamic with job saturation and it will implode sooner than later. We are already seeing it with decreased admissions to podiatry schools. When you add it all together it does not look very stable and it is a very risky investment.

Pure GOLD… couldn’t have said it better.

 

[diabeticfootdr]

The number of cases to be comfortable with a procedure varies between trainee. That is why MAVs are a less desirable way to judge competence. ACGME uses milestones and I (on behalf of ABPM) as well as the APMA advocated for this in public comments to the CPME 320 rewrite. CPME didn't adopt parity on this.

 

[MortonExtension]

The number of cases to be comfortable with a procedure varies between trainee. That is why MAVs are a less desirable way to judge competence. ACGME uses milestones and I (on behalf of ABPM) as well as the APMA advocated for this in public comments to the CPME 320 rewrite. CPME didn't adopt parity on this.

So how would milestones be judged? By faculty of the program?

 

[Pronation]

So how would milestones be judged? By faculty of the program?

By how many resident spots aren't filled the following year to figure out which ones need to be held back to keep the labor force strong.

 

[diabeticfootdr]

So how would milestones be judged? By faculty of the program?

Yes, that's how it works for ACGME.

 

[FutureDPM323]

I think you ask important questions but you are not going to get a real accurate answer because unfortunately the training in podiatry is really just so VARIABLE.

On top of this everyone has different skills in the OR. Everyone has different abilities. So with experience comes different needs to master certain procedures. It really is as simple as that.

Rather than focusing on numbers I would focus on the quality of training. How do we define quality?

My interpretation:

1) Active teaching from attending during every case whether you are doing the case or just retracting
2) Pre surgery discussions about the case and pathology. Are attendings having phone conversations with residents the night before the case or are they sitting reviewing the big cases before they do them in the morning?
3) Are residents seeing these surgical patient's in the clinic to manage?
4) Are senior residents actively teaching junior residents?

These four are the biggest things you need to become competent.

If you never review cases before you do them with the attendings you LOSE out on learning experiences. If your attending doesn't even talk to you during the case or is unwilling to answer questions during the case then you LOSE out on learning experiences. If you never see these surgical patients again then you never know if the surgery even worked, how do you manage complications, how do you even deal with the patient after surgery. You need to learn clinical management of surgical pathology as much as you need to learn how to do the surgery.

Is there a culture of teaching within the program? Are senior residents taking the time to teach junior residents cases? If not it is because they have nothing to teach because they still LACK experience. This is not a good sign. It means the senior residents are NOT CONFIDENT.

This is why your rotations as a student are vital. You need to remember these four things. Pay close observation to what the residents at every program are doing. Play close attention to what the attendings are doing. Are the attendings just using the residents for slave labor or are the attendings there to teach? Are the senior residents doing majority of the cases skin to skin? If they still are not even late into their third year that is a problem.

Podiatry residency programs are essentially overall not very good. Hardly any have all 4 of these things. Very few do. It is probably less than we like to admit as a profession. Majority of residencies have major holes in their training and education. Many programs state they do high volume but the quality of these cases are not very good because the attendings do not care and bust out cases and do not teach the residents because teaching slows them down.

If residencies were as complete as we brag about then why are so many people seeking fellowship training? I laugh because I have been out long enough that I have seen DPMs who were students when I was resident who went on to do bad residency programs and then went on to do mediocre fellowships who now think they have more experience than most.

This is what our profession is turning into. Mix this dynamic with job saturation and it will implode sooner than later. We are already seeing it with decreased admissions to podiatry schools. When you add it all together it does not look very stable and it is a very risky investment.

100% agree to all of this. there’s so much more to residency than just the numbers. you really want to find a program with a good balance of surgery AND clinic…I know some people will tell you clinic is dumb and it’s all about the surgery but honestly I really disagree. Clinic is your chance to ask any and all questions but also an opportunity to work up patients, speak to them about their options and really get used to what it’ll be like to be a practicing podiatrist.

Honestly as a student and even now as a resident I feel like the best residents I speak to are the ones who are at programs that have high surgical volume but also good clinics ie not nail jail clinics

 

[Feli]

It is a bit of a pointless discussion. Nearly all programs fudge their logs. Think past logs.

Programs that get their numbers tend to log accurate... but there is always the temptation to embellish. Most will (to hope for even better privileges or job).
Programs that do not get numbers obviously fudge their logs (or they'd risk not graduating).
A lot of places/directors/residents also just don't fully understand logging... they unbundle the procedures/case intentionally... or from ignorance.
CPME does not care and cannot close/reduce programs/spots with the upcoming residency shortage of new schools. Sad but true.

...so, as a student/clerk, the best thing you can do is look at the surgery schedule and talk to the residents. Look at the academics and obviously attend them... pay attention particularly to the 3rd year residents and any young attendings who are alumni. That WILL be you if you go there. Attendings matter too; there's fair diff between good ones who teach well and do good work... and just cases with putzers.

Logs are unfortunately a bit pointless as they have a veeery high chance to be fluff or embellished. The program's daily schedule and overall program quality are what matters. Ask to be on the email list or get a look every day brah. As said, prep and academics help to get the most of procedures... and they help you pass boards. The important thing to see is that their is real RRA surgery going on nearly every day for at least the 3rd years and hopefully some of the 2nd years (ankle fx, lisfranc, calc, etc... or elective osteotomies, fusions, flat foot, cavus, etc etc). Most of the lower programs have very little real RRA and try to use easy diabetic junk (TAL, amps, Charcot) to get RRA logs. As said, you will get some of that anywhere, and it's not hard... but if that's almost all they have, it's not a good program.

Programs that are plating SER-2 minimal displaced basic ankle fractures on older ppl are usually crap.
Programs that are "ORIF" fifth met shaft or avulsion fractures, basic hallux fx, or most central met fx are nonsense. If they're clearly fishing for surgery, they don't have enough.
Programs that "RRA numbers" mainly from Charcot recons that will be a leg that's in a Vasc Surg bag and a box a few months later are generally not good ones.
Programs logging numbers with the fellow(s) doing the case ... complete joke, wtf.
Programs where the residents are clearly just showing up unprepared (XR, fixation, steps, etc) because the attending does the case and won't pass the knife much/any are questionable.
Programs that "get most of our rearfoot with ortho" are often cringe-worthy and simply claiming retract-a-thons first assist.
Programs that never have RRA on the schedule are obviously junk.

The most common RRA in regular practice is ankle fx, Achilles de/reattach, gastroc, soft tissue mass... stuff like that. The hard stuff is NOT common in PP unless you seek it out or you're in an area without ortho. It is always good to know it all, though... can always decline to do some of it later on. Flat foot, cavus, bad RRA arthrosis will come in once in awhile. I will say there is a BIG difference in high energy vs low energy trauma... both the OR skill and the med mgmt skills/timing around the injury and complications afterward. Anyone can plate a SER-2 without syndesmotic injury (since the correct answer is often just CAM boot) or a 2nd met diaphysis fx (also seldom needs more than CAM or pin)... much fewer can do a dislocated PER-4 or pilon or intra-artic calc fx well.

Inpatient care is pretty much junk if you're in PP (which most DPMs are). It's crap that leads to early/late days and even eve or weekends. It is lower pay per hour. Most avoid it as best they can (only do it until office fills up or they get associate to dump it onto). You'd always rather have the better payer pts and have them come to you (clinic, ASC) versus go chase down mediocre/poor insurance pts (hospital, ER, WCC). There is a reason solo PP docs dodge consults and group/supergroup PP have their junior associates chasing down any consults and going to the wound center and inpt nonsense or even ECF/house call nonesense while senior/owner docs never touch that stuff ("too busy in the office").
Hospital employ DPMs is another story... almost all are required to do call and significant inpt work. Either way, you will learn more than enough of it in any decent residency (teach hospital, non-teach but arranged teach rotations, etc). You will probably learn more than enough of it by the end of pgy1. No joke.

So...
1) how many dirty cases... easiest thing ever, doesn't matter, pgy1 stuff
2) how many rear foot number... judge by quality/diversity
3) what real work rearfoot procedures are being billed for the most... easy elective ones above
4) is learning inpatient care vs clinic care important? ... learn it, yes. Value? No, you won't want to do it in PP, most dodge it after residency.
5) how do you know if upper resident are screwing logged number ? ... you don't, go by surg schedule and academics and resident/alumni quality 🙂

 

[Feli]

So how would milestones be judged? By faculty of the program?

This is what I do... or recommend be done (for staff apps and privileging).
It's pretty much talk to director and ABFAS BQ for newer-grad DPMs... or after-residency logs and ABFAS BQ/BC for more exp.
It is all you really can do. As Retro said, some programs suck. Many of them.
You can look at the made-up logs or the CV with a program you've never heard of, or you can pick up the phone and talk to the director (or chief of surg at past hospital if an exp DPM), ask them what kind of cases they get, how the hospital applicant did, etc. There is no saying the director isn't going to pimp their grads, but the picture usually clears up at least a bit.

 

[Hybrocure]

Agree 100% w Feli. I’ve been on externships where they were ORIF every fifth met fx and many other met fractures or hallux fractures. Many of these patients are already walking into the office in sandals and the accident occurred a couple weeks ago and it doesn’t hurt that bad.

In practice you may only need to orif a handful out of every hundred. Even minor open fractures - irrigate and clean in clinic, repair lac in office just like the ED. Done.

In outpatient trauma clinics orthos will get some foot GSWs and send them home with abx and wound care. Same stuff gets sent to a pod all of a sudden it’s a STAT OR case at 2am bumping a testicular torsion case to do the same thing you could’ve done in office but in the OR lol. Sometimes it’s just silly.

 

[air bud]

I don’t believe you.

I assume by IM nail he is referring to a k wire for a hammertoe and a triple as 3 hammertoes. Yes?

 

[MidnightSun32]

Rather than focusing on numbers I would focus on the quality of training. How do we define quality?

My interpretation:

1) Active teaching from attending during every case whether you are doing the case or just retracting
2) Pre surgery discussions about the case and pathology. Are attendings having phone conversations with residents the night before the case or are they sitting reviewing the big cases before they do them in the morning?
3) Are residents seeing these surgical patient's in the clinic to manage?
4) Are senior residents actively teaching junior residents?

These four are the biggest things you need to become competent.

Could not be any more accurate. I think some already know who I am, but I'll reply even though it might make it more obvious amongst residents.

I transferred from a subpar program to a very good program my first year. Because of that, I can emphasize how important the quoted message is. Previous program really didn't teach, lots of retracting, lots of dirty cases for the most part. The program I am at now is very focused on teaching residents. I was handed a blade right away. The attendings are very patient as they teach. We talk about cases beforehand. Discuss pathology. Follow up of patients, post op course. My seniors are supportive and teach. I stopped focusing on what I was logging and just trying to get numbers vs now focusing on how am I doing these surgeries. Taking notes before and after. Actively learning. Granted, I finished the majority of my numbers (damn biomechanicals I haven't been focused on) first year, I just don't think the number requirement is high enough. You need to perform these surgeries to know how to do them. Not just retracting and then logging (I know that happens with quite a few programs).

You are going to do dirty cases everywhere, probably more first year because most first years manage floors or take a lot of call, but you should be doing other cases too. I was shocked when my program told me ankle fractures were cases first years do a lot of. Very big contrast to where I came from. Look for programs where you actually get the blade, you are taught, and where you will learn as much as you can. I did not truly start learning how to think through surgeries/clinic diagnoses/pages I'm called about, until I switched programs... because now I have to do these things vs just watch my attending do them. I still have a lot to learn, but I know that I will be competent when I graduate. I am no longer frantically worried about finding a good fellowship in order to feel good about my training. I will not be doing a fellowship.

TLDR: Go to a program where they will teach you to operate, to treat people in clinic, to do the things you want to do after residency. If you are already at a program where the training is less than desired, make the most of it- work hard and take advantage of all of the opportunities you have access to..... or transfer to a better program. But this is just the rambling of a tired resident. 🙂

 

[GreenHousePub]

Could not be any more accurate. I think some already know who I am, but I'll reply even though it might make it more obvious amongst residents.

I transferred from a subpar program to a very good program my first year. Because of that, I can emphasize how important the quoted message is. Previous program really didn't teach, lots of retracting, lots of dirty cases for the most part. The program I am at now is very focused on teaching residents. I was handed a blade right away. The attendings are very patient as they teach. We talk about cases beforehand. Discuss pathology. Follow up of patients, post op course. My seniors are supportive and teach. I stopped focusing on what I was logging and just trying to get numbers vs now focusing on how am I doing these surgeries. Taking notes before and after. Actively learning. Granted, I finished the majority of my numbers (damn biomechanicals I haven't been focused on) first year, I just don't think the number requirement is high enough. You need to perform these surgeries to know how to do them. Not just retracting and then logging (I know that happens with quite a few programs).

You are going to do dirty cases everywhere, probably more first year because most first years manage floors or take a lot of call, but you should be doing other cases too. I was shocked when my program told me ankle fractures were cases first years do a lot of. Very big contrast to where I came from. Look for programs where you actually get the blade, you are taught, and where you will learn as much as you can. I did not truly start learning how to think through surgeries/clinic diagnoses/pages I'm called about, until I switched programs... because now I have to do these things vs just watch my attending do them. I still have a lot to learn, but I know that I will be competent when I graduate. I am no longer frantically worried about finding a good fellowship in order to feel good about my training. I will not be doing a fellowship.

TLDR: Go to a program where they will teach you to operate, to treat people in clinic, to do the things you want to do after residency. If you are already at a program where the training is less than desired, make the most of it- work hard and take advantage of all of the opportunities you have access to..... or transfer to a better program. But this is just the rambling of a tired resident. 🙂

Glad to hear you got a good program. It will be hard, and you will work long hours, but it will be worth it when you are working the same jobs as everyone else lol

 

[HardRoadPaved]

I assume by IM nail he is referring to a k wire for a hammertoe and a triple as 3 hammertoes. Yes?

Don't laugh as the later pays about the same in private practice

 

[MidnightSun32]

Glad to hear you got a good program. It will be hard, and you will work long hours, but it will be worth it when you are working the same jobs as everyone else lol

I am pretty satisfied with the job I lined up for after graduation; was easier with the reputation of the program 🙂, particularly where I'm going. Not saying I couldn't have done it with the previous program, but I would have needed the fellowship.

Edited bc I sounded like a pretentious tool unintentionally- I have a specific area I wanted to end up. The future job is very familiar with the hospital/residency program I'm currently at, which helped.

 

[MortonExtension]

I am pretty satisfied with the job I lined up for after graduation; was easier with the reputation of the program 🙂, particularly where I'm going. Not saying I couldn't have done it with the previous program, but I would have needed the fellowship.

Edited bc I sounded like a pretentious tool unintentionally- I have a specific area I wanted to end up. The future job is very familiar with the hospital/residency program I'm currently at, which helped.

I know a wyckoff grad when I see one

 

[MidnightSun32]

I know a wyckoff grad when I see one

Whatever makes your day better 🤣