Good point, and it's one that is tough for a lot of students/residents to realize and/or accept. There are clearly exceptions, but most jobs out there are vastly different from the residency experienceIf you go to a residency program that offers high quality training in trauma but very little or low quality in everything else I think you will find yourself disappointed with your career options. Because your expectations (from previous residency training and experiences) won't coincide with what's out there in reality.
why do you need to do a fellowship in order to perform procedures being done by a bunch of other non-fellowship trained podiatrists? How many TARs did Schuberth do in residency? And if he didn't do any TARs in residency and he didn't do a year long fellowship after residency, how on earth can he possibly do the procedure today? I get that if you have an interest (and lets pretend that interest won't change after residency) you would be wise to go to a program that has emphasis in said interest, but for some reason there is this pervasive thought amongst (especially) students and (to a lesser extent) residents that you need to do something in residency in order to do it in practice.There are very few programs that supply adequate training to be fully proficient in trauma and TAR. (Exceptions do exist) If these topics are your interest you are best served by going to a solid program and then follow up your three years with an exceptional fellowship
Exactly my point. You absolutely can go to a residency program that develops strong clinical and surgical skills/thought process and slap on a TAR. Graduates from our program (lots of trauma, few TARs) put TARs in patient's their first year out routinely. One of our recent graduates who's been practicing for a month has a TAR coming up in a few weeks, he only did one or two by himself in residency and he'll be using a different system this go around. I'm sure the same can be said for many other procedures by graduates from other programs.The people that do not go to an exception program who come out of training and think they can slap in a TAR or manage a calc fx are crazy.
This will be a good thread when someone starts it (job search tips/tricks/etc), but orthopedic groups who are ok hiring podiatrists absolutely do expect you to do foot and ankle trauma...that's why they hired you, so that they don't have to do calcs anymore. Hospitals are much more dependant on the system and can be anywhere from "anything foot and ankle from our other providers and our ED is yours" to "ortho gets ED trauma referrals and you take ingrown toenails and foot wounds."As someone looking at jobs now I can tell you most hospital systems and Orthopaedic groups don't see you as an entity that handles LE trauma. They see you as someone who can pump out elective recon procedures, bunions, hammertoes, wounds, orthotics, etc.
I may be taking this out of context but this is exactly right. You should be going to a program that provides you with good "skills." Someone with good hands and enough clinical experience to manage post-op problems can do any elective foot and ankle procedure that they want, TAR included.So choose wisely what you want out of your residency training. Those are the skills you will have for life.
I guess at the the end of the day either of our opinions is justified so long as individuals recognize their limits when they reach them and do what is best for the patient.I would tend to agree with dtrack on this coming from a similar program of a lot of trauma / rear foot ankle and low TAR. Go to a program with a solid and diverse surgical foundation. You don't need to perform every single foot and ankle surgery in residency to be able to perform them in practice. I have solid training in ankle fx, pilon fx, fusions, tendon- ligamentous balancing, osteotomes, etc but only 2 TARs. That won't stop me from doing them in the future. Just like I won't hesitate doing a opening or closing base bunion, even though I've only done 1 of each, if it's what's best for the patient.
This thinking makes much of residency unethical. At least if you are at a program where the resident is actually doing the cases...This experience can come by having scars on the street or by further training. Which is more ethical?
Completely missing my point re: trauma in residency. Maybe janv said something I missed. Trauma isn't beneficial in residency because you are going to a lot of it in practice. Trauma is beneficial because of soft tissue and dissection considerations. Because of reduction and fixation principles learned. Because it's not cookie cutter and you have to make more intra-operative decisions than you do in a huge majority of your elective cases. Because you are more likely to have post-operative complications compared to a case when you work on unswollen skin in a patient who you got to select, and you have to learn to deal with those complications if your program is set up to do so. Because trauma heavy programs tend to be at places where the residents have more autonomy than your average podiatry program. It has nothing to do with how many communited naviculars and open calcs and forefoot crush injuries you're gonna get in practice. And I've never said that it's better than recon, in fact my whole point was that it doesn't really matter what the programs emphasis is. Again, it's about skills and many programs with many different emphases can give you those skills. Go to the best one you can.And that's if you can even get your hands on those cases! If you are working for a podiatry group good luck getting those cases. Those fractures are going to the university hospital and getting fixed by the ortho traumatologist or foot and ankle fellowship trained ortho.
I'll preface this by saying that the only thing having good surgical AND clinical training without doing a ton of TARs is going to limit in my practice will be the the indications in which I put them in. Meaning, the folks mentioned who do a lot of these put them in people that don't meet the most rigid of criteria, they are pushing the boundaries, more power to em. I will still put them in, just with less frequency and tighter inclusion criteria in my patient selection...until the implants themselves improve.So let me get this straight...because you guys have great skills and technically can utilize those skills to put in a TAR...what happens when you run into complications? Who are you going to lean on for advice?
TAR is still unchartered territory in my book. There is a lot we don't know. Despite having great skills these leaders of our professions do revisions on their patients all the time. It is those experiences which make me feel more comfortable about attempting to perform this procedure during my career.
Ankle fusion.......what's that?
I know this comment is made somewhat tongue-in-cheek, but I would mostly agree with this. When treating end-stage ankle DJD in my practice (and I treat a lot of ankle DJD, relatively speaking), I have really transitioned to mostly TARs and very few ankle fusions. A patient must have a significant contraindication to not favor a TAR over an ankle fusion. If I'm being honest with myself, my TAR patients certainly do better than my ankle fusion patients. It's a much quicker recovery (barring any complications), and functionally they do better and are happier. It's not to say that an ankle fusion does poorly, but from a functional standpoint, the TAR does better. This is proven in the literature, and I can certainly attest to this with my firsthand experience in my own practice.
You are describing something outside of the constraints of the discussion, at least as far as my posts are concerned. Of course someone from a below average program (Joe's bunion shack) should not go out and slap TARs in their patients. But that person didn't get the clinical and surgical management experience of operative patients that I'm talking about. Which was really my original point, number of TARs or trauma your program does isn't as important as the clinical and surgical skills your program develops. I think there are plenty of programs across the country that do give you those experiences and skills. How many programs in our profession do that is certainly up for debate, and we could have that discussion (though we'd all just be guessing). While I do think my training is in the upper echelon within our profession, there are programs all over the country that are pumping out equally well trained/talented/etc podiatrists (or foot and ankle surgeons for all the acfas folks who may read this). Most of whom will do many a procedure that they got little exposure to in residency. They'll do it just like everyone did before us and most patients will be better for it.Also I think you make a good argument, but you are an exception, not the rule. Most graduates do not have the experience that you have. The point I think AnkleBreaker and myself are trying to make is that someone graduating from joe's bunion shack should not go out and think they can do TARs. They probably can figure their way through it, but there is going to be unneeded collateral damage.
It's just something to take down and put a TAR inAnkle fusion.......what's that?
We both know that this could happen with any type of complication regardless of the procedure. And I'm willing to bet it will be more common with a TAR than high energy trauma.Even if you did manage to get those high energy trauma cases. If one of your patients goes somewhere else and ends up in an anti-DPM ortho office you can bet your bottom dollar you are going to get sued.