The "old" salary question

[347932]

"Although you're comment is dripping with sarcasm, which I usually appreciate, in this situation it is not only misplaced, but rather offensive to me..."

I know plenty from working for a billing company. Of course, we worked with NW groups and hospitals. I know how busy a typical multi-specialty, ortho, or pod group is back home and what they are able to collect. Of course, I'm not you so my experience doesn't mean anything.

This is just like every other thread you post in. You are always right. Students can't publish research, ortho's would willingly start at 150k, all reps have malpractice, etc. It's always fun to see someone prove you wrong and then watch you backtrack and say "well, where I practice that's not how it is". It's getting old.

Kettle black much?

What a practice COLLECTS may have little to do with what the doctors in said practice actually takes home. I guess they didn't teach you that at the billing company you worked for did they? Did you know that multi-specialty practices sometimes have to pay a percentage of their collections to the parent company? How does that figure into how much the doctors take home?

"It's getting old"? If you don't like what I have to say, no one is forcing you to read my posts buddy. Skip them. I couldn't care less.

I'm still waiting for the links and data. I told you that when you provide them, I will shut up. So shut me up already.

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[dtrack22]

What a practice COLLECTS may have little to do with what the doctors in said practice actually takes home.

And this whole time I though they were keeping every penny that came into their office. Silly me.

 

[347932]

And this whole time I though they were keeping every penny that came into their office. Silly me.

Once again, YOU brought this up without qualifying how this factors into this thread and then come up with a snide remark when someone calls you out on it. Stay on TRACK (haha see what I did there??).

 

[that1guyfromFL]

To the young and recently trained 100,000 base minimum with bonuses is not unreasonable and within a few years (if you work hard) 200-300,000 obtainable. That is assuming you join a busy practice with overflow, hustle, and are in the right region.

I'm going to immediately repost this quote when someone decides to start yet another salary thread.

Oh and

 

[javajava]

So whats the lowest and highest paid region on average

 

[Feli]

...Yes, there is a higher risk of complications with the bigger cases, but they bring a litle more sense of accomplishment too.

I would not necessarily say there's a higher risk of complications with RRA (but each procedure is different, so read the lit on any specific comparison). However, the complications are more devastating... and the malpractice settlements are therefore MUCH bigger.

Basically, as I see it, a lot of stuff looks good on the table. Follow-up for residents is often "sutures are in, bandage it up," and then the patient is basically never seen again unless there's a return to the OR. When it's actually your patients who end up with ankle nonunions, hardware infections, Achilles dehiscenses, DVT/PE, opoid addictions, or RSD, then your views may change. Just food for thought.

Again, when patients require it, I will fuse ankles, do complex recon, and fix nasty fractures (but sure won't be happy about it unless I am paid to take call or it's a reasonably well insured ER). However, if I have a equally well-trained partner who is highly gung-ho about that stuff (esp unpaid ER call nights), then more power to him. I will be happy to park my Caddy along side his used Civic... and I won't mind sending him postcards from my European vacations to cheer him up while he's in the ER at 1am and then the OR at 3am. Heck, if his malpractice carriers are making his rates unreal, then I can probably give up some "boring" heel pain, onycho, or DM forefoot ulcer patients so that he can still feed his family.

 

[PADPM]

I would not necessarily say there's a higher risk of complications with RRA (but each procedure is different, so read the lit on any specific comparison). However, the complications are more devastating... and the malpractice settlements are therefore MUCH bigger.

Basically, as I see it, a lot of stuff looks good on the table. Follow-up for residents is often "sutures are in, bandage it up," and then the patient is basically never seen again unless there's a return to the OR. When it's actually your patients who end up with ankle nonunions, hardware infections, Achilles dehiscenses, DVT/PE, opoid addictions, or RSD, then your views may change. Just food for thought.

Again, when patients require it, I will fuse ankles, do complex recon, and fix nasty fractures (but sure won't be happy about it unless I am paid to take call or it's a reasonably well insured ER). However, if I have a equally well-trained partner who is highly gung-ho about that stuff (esp unpaid ER call nights), then more power to him. I will be happy to park my Caddy along side his used Civic... and I won't mind sending him postcards from my European vacations to cheer him up while he's in the ER at 1am and then the OR at 3am. Heck, if his malpractice carriers are making his rates unreal, then I can probably give up some "boring" heel pain, onycho, or DM forefoot ulcer patients so that he can still feed his family.

Feli,

You are wise beyond your years. Although I'm confident someone will twist your words and/or take them out of context, I certainly understand the underlying message.

Although most of us who have the ability enjoy the challenge of performing complicated cases, they unfortunately are not without complication and also unfortunately don't always pay the bills. Even Podfather who performs a lot of complicated surgical procedures has confirmed the fact that the surgical procedures aren't always or usually the procedures that pay the bills.

I've discovered that you can't attempt to convince many that even with high level surgical training, many may not choose to perform surgery all the time or may realistically have the opportunity when in "real" practice. Not every patient enters your office wanting or needing surgical correction. You're often a better doctor if you can manage a patient without taking him/her to the O.R.

But the bottom line is that many of the doctors in training on this site really don't have a concept of what that reality is until they are actually there, and will then have to make that decision when the time arrives.

What I've attempted to state is that IF you choose not to perform surgery all day, or if that opportunity doesn't present itself despite excellent training, you can STILL earn an excellent living.

Our group practice is very diversified. I've stated over and over again that I perform very little routine palliative care, and perform about 50% of the surgery in our practice. However, I am NOT the biggest producer in our practice and some of the docs that do more palliative care and the "smaller" things in practice produce more for the practice than I do.

I have a pretty good balance in my practice, though at times it's a little busier or more hectic than I'd like. However, many of the docs in training may disagree with you now, but may agree with you later when they have more experience. That's why they make chocolate and vanilla.

When you begin you're third year I believe I'm going to PM you and "reveal" my identity to see if you may be interested in a position with our group. I like the way you think.

 

[newankle]

I would not necessarily say there's a higher risk of complications with RRA (but each procedure is different, so read the lit on any specific comparison). However, the complications are more devastating... and the malpractice settlements are therefore MUCH bigger.

Basically, as I see it, a lot of stuff looks good on the table. Follow-up for residents is often "sutures are in, bandage it up," and then the patient is basically never seen again unless there's a return to the OR. When it's actually your patients who end up with ankle nonunions, hardware infections, Achilles dehiscenses, DVT/PE, opoid addictions, or RSD, then your views may change. Just food for thought.

I pesonally don't let fear of complications effect my decision to perform surgery. I don't think it should effect how much surgery you do or choose to do in any way.

 

[PADPM]

I pesonally don't let fear of complications effect my decision to perform surgery. I don't think it should effect how much surgery you do or choose to do in any way.

Agree 100%. I can't speak for Feli, but my take on what he is saying is that it's a little easier to be brave, etc., when you are a resident and don't ultimately have the responsibility for following through with the patient as a private patient. Bandaging up the patient and watching the patient get wheeled out is often the last contact for the resident.

In "real" practice, many considerations have to be factored into the equation, such as the patient's lifestyle, work restrictions, method of getting to and from your office, who is available to assist the patient at home, whether the patient has to climb 3 flights of stairs to get to his/her apartment, etc., etc., etc. There is a human attached to the foot/ankle that adds a little to the equation that is often forgotten about when a resident is performing surgery on your patient.

Complications can certainly make you gun shy, but it's also the other little everyday things as I've mentioned above that aren't always considered during training.

 

[Feli]

I pesonally don't let fear of complications effect my decision to perform surgery. I don't think it should effect how much surgery you do or choose to do in any way.

Well, I don't disagree, but the bolded part bugs me.^

The only real factors that should contradict elective surgery (IMO) are:
1) likely patient noncompliance (crazy pts, hist of litigous behavior + "bad doctors," uneducated pts, social/transport issues, etc)
2) Lack of vascularity to heal the surgery
3) Medical comorbidities making anesthesia or surgical healing very difficult or impossible (recent MI, morbid obesity, immunosupressed, malnourished, heavy smoker, etc etc)
4) Lack of surgeon skill set / preparation / confidence /experience for the procedure
5) Lack of insurance (this is debatable)

For major trauma surgery or bad infection/abscess/osteo, then you have to take the smokers, questionable nutrition, questionable sanity/complance patients. It's not ideal, but you can't refuse to do a gas gangrene amp or open fracture washout + stabilization. You can't. Still, if you're a good surgeon, you can make even urgent and emergent trauma or infection surgery more or less agressive based on the candidate.

...but look, we ALL know of the *****s throwing Taylor Spatial Ilizarovs on patients who are color blind diabetics with HbA1c of 10, poor hygene, no transportation for follow up, and no idea of how to do pin care + adjustments, etc. We know of surgeons who will talk patient who need a simple ankle scope or arthrotomy cleanup - maybe even just an Arizona brace - into a total ankle implant. We know of guys who will do a forefoot slam of Lapidus, AD234, Tailors bunionectomy and AP5th on a 65yo obese diabetic woman when a simple Keller or Silastic and some comfort shoes+insoles is what the patient could reasonably get by with. Those guys trained in residency for that stuff, and they're gonna find patients to cut on and do those procedures... by any means possible. That is just not good practice, though (review the Hippocratic Oath if necessary).

There is confidence, and there is just plain stupidity (aka selfishness, ego trip, and "creating" indications for surgery the surgeon wants to try). A very famous DPM trauma surgeon joked in a recent lecture that podiatrists are "eager pioneers" with regard to new procedures, new implants, etc. A lot of us have little man complex. While that drives us to keep training, reading, and learning more, it also has a downside that some DPMs (and MDs.. and DOs) will push overly agressive, and even unecessary, surgery on patients. You went to Presby, and there's a good example of an attending there I respect, but think is waaay over-agressive... often trying crazy stuff for the sake of trying crazy stuff (and because he's in the last stages of his career and won't have to face the amps and foot surg cripples he may create in the process).

There is a happy middle ground between being a timid, under agressive surgical pod... and being a cut-on-everyone hack who will hurt people and do surgery on bad candidates. That middle ground is honestly where I hope to land... God willing. Just my 2c

 

[jonwill]

I pesonally don't let fear of complications effect my decision to perform surgery. I don't think it should effect how much surgery you do or choose to do in any way.

I personally think fear is a good thing as a surgeon. I've got a couple pediatric recons coming up next week. I've definitely got that "pit" in my stomach. But that's what will make me careful, thorough, and focused. I think it's more often when you aren't worried about a surgery that things go wrong.

 

[that1guyfromFL]

There is a happy middle ground between being a timid, under agressive surgical pod... and being a cut-on-everyone hack who will hurt people and do surgery on bad candidates. That middle ground is honestly where I hope to land... God willing. Just my 2c

Very well put IMO.

It's very easy to lose nuance in a casual written word venue like SDN.
I really appreciate the time you took to explain your perspective in more detail.

 

[that1guyfromFL]

I personally think fear is a good thing as a surgeon. I've got a couple pediatric recons coming up next week. I've definitely got that "pit" in my stomach. But that's what will make me careful, thorough, and focused. I think it's more often when you aren't worried about a surgery that things go wrong.

Once you make the decision to perform a procedure, would you consider the healthy fear you are talking about to be analogous to how any performer (athletes, TV hosts, etc) feel before going on stage?

What came to my mind is the big difference between feeling anxious/excited to get a big game underway and wanting to do well VS worrying about making an error to lose the game or not coming through in a clutch situation before the game has even started.

Maybe the analogy isn't perfect, but what I'm getting at is this: at what point do you stop worrying about the outcome and focus on performing in the moment? Do you ever?

Other residents/attendings please chime in as well!

 

[PADPM]

Well, I don't disagree, but the bolded part bugs me.^

The only real factors that should contradict elective surgery (IMO) are:
1) likely patient noncompliance (crazy pts, hist of litigous behavior + "bad doctors," uneducated pts, social/transport issues, etc)
2) Lack of vascularity to heal the surgery
3) Medical comorbidities making anesthesia or surgical healing very difficult or impossible (recent MI, morbid obesity, immunosupressed, malnourished, heavy smoker, etc etc)
4) Lack of surgeon skill set / preparation / confidence /experience for the procedure
5) Lack of insurance (this is debatable)

For major trauma surgery or bad infection/abscess/osteo, then you have to take the smokers, questionable nutrition, questionable sanity/complance patients. It's not ideal, but you can't refuse to do a gas gangrene amp or open fracture washout + stabilization. You can't. Still, if you're a good surgeon, you can make even urgent and emergent trauma or infection surgery more or less agressive based on the candidate.

...but look, we ALL know of the *****s throwing Taylor Spatial Ilizarovs on patients who are color blind diabetics with HbA1c of 10, poor hygene, no transportation for follow up, and no idea of how to do pin care + adjustments, etc. We know of surgeons who will talk patient who need a simple ankle scope or arthrotomy cleanup - maybe even just an Arizona brace - into a total ankle implant. We know of guys who will do a forefoot slam of Lapidus, AD234, Tailors bunionectomy and AP5th on a 65yo obese diabetic woman when a simple Keller or Silastic and some comfort shoes+insoles is what the patient could reasonably get by with. Those guys trained in residency for that stuff, and they're gonna find patients to cut on and do those procedures... by any means possible. That is just not good practice, though (review the Hippocratic Oath if necessary).

There is confidence, and there is just plain stupidity (aka selfishness, ego trip, and "creating" indications for surgery the surgeon wants to try). A very famous DPM trauma surgeon joked in a recent lecture that podiatrists are "eager pioneers" with regard to new procedures, new implants, etc. A lot of us have little man complex. While that drives us to keep training, reading, and learning more, it also has a downside that some DPMs (and MDs.. and DOs) will push overly agressive, and even unecessary, surgery on patients. You went to Presby, and there's a good example of an attending there I respect, but think is waaay over-agressive... often trying crazy stuff for the sake of trying crazy stuff (and because he's in the last stages of his career and won't have to face the amps and foot surg cripples he may create in the process).

There is a happy middle ground between being a timid, under agressive surgical pod... and being a cut-on-everyone hack who will hurt people and do surgery on bad candidates. That middle ground is honestly where I hope to land... God willing. Just my 2c

Great post. I had a high risk diabetic patient with PVD come in with a fibular fracture. Ideally, she needed an ORIF, but she had so many comorbidities I opted for a Cam Walker and a wheelchair. She refused a rigid cast.

She had an unrelated problem, was admitted to a hospital where I'm not on staff and a BIG name DPM was consulted. He took her to the O.R., put her in all kinds of hardware, she broke down and then he put her in a frame. It was a matter of weeks before she ended up with an amputation.

So Feli hit the nail right on the head, that some of our colleagues let their ego get in the way of simple good judgement.

 

[dtrack22]

PADPM,

Do you treat, let's call them complicated, patients (diabetes, tons of comorbitities, poor ambulation/mobility, etc.) like you would a geriatric patient more often than not?

What I mean by that is you are more concerned with function and independence in these patients (like you would an older adult) as opposed to a healthy individual where the chance of "curing" the problem is much more realistic?

I ask because we took our Geriatrics course recently and I feel like there are a lot of similarities between many of the poorly controlled diabetics and the older population when it comes to intervention.

I would assume you are always making sure the benefits of surgery outweigh the risks, but it seems that in patients like the one described above QOL would rarely be improved with aggressive tx.

 

[NatCh]

Once you make the decision to perform a procedure, would you consider the healthy fear you are talking about to be analogous to how any performer (athletes, TV hosts, etc) feel before going on stage?

What came to my mind is the big difference between feeling anxious/excited to get a big game underway and wanting to do well VS worrying about making an error to lose the game or not coming through in a clutch situation before the game has even started.

Maybe the analogy isn't perfect, but what I'm getting at is this: at what point do you stop worrying about the outcome and focus on performing in the moment? Do you ever?

Other residents/attendings please chime in as well!

You might enjoy reading this book:
http://sianbeilock.com/choke-book.html

 

[that1guyfromFL]

You might enjoy reading this book:
http://sianbeilock.com/choke-book.html

Thank you NatCh!

I'm fascinated by the relationship between mindset and performance, even chose it as a senior research project topic in undergrad. I will definitely pick this book up!

 

[NatCh]

Thank you NatCh!

I'm fascinated by the relationship between mindset and performance, even chose it as a senior research project topic in undergrad. I will definitely pick this book up!

You're welcome. I just might have to re-read it (then we can form our own SDN book club -- wheeee!).

 

[Feli]

Thank you NatCh!

I'm fascinated by the relationship between mindset and performance, even chose it as a senior research project topic in undergrad. I will definitely pick this book up!

In purely practice management and business terms, everyone who wants to perform at his highest level needs a good attorney as well as an excellent accountant... and probably a smart finance planner/manager. (source citation = NatCh)
...Of course, there's also books on the subjects; I'm reading The Art of the Deal by Donald Trump as I head towards formal interviews, contract negotiations, maybe even starting my own practice, etc later this training year.


Additionally, in terms of personal growth and development, every successful person usually benefits from a good counselor (psychologist, psychiatrist, clergy, books, etc) and a good primary care doctor (and specialists if need be)... all used as consultants on an as-needed basis for individual issues/screenings.
(source citation = my lawyer)

So, there's your core 5 (or more?) people who you hire. As for the relationships you just create, it also goes without saying that strong social support of family, friends, co-workers, church or spirituality, etc are valuable to most people who are at the top of their field (or even anywhere near that). And of course, everyone also tends to do better with hobbies, vacations, a good spouse, etc. It's really up to you, and you alone, to take your life seriously... in pod school, residency, and beyond.

...Yep, I officially became "old" a couple months ago, and I can already tell I'm gonna enjoy my 30s even more than my 20s

 

[newankle]

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