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This is exactly why I have touted the dental model. I believe that the "podiatrist is a podiatrist" mantra touted by many at the top is impossible to do and the wrong direction.
Dr. Ritchie's observations if correct should not be unexpected. How can we ask students with huge student loans to then perform three years of hospital based/ advanced training in all aspects of lower extremity care that naturally will have a surgical emphasis not to expect a career with trauma and complex reconstruction? It would be like asking an maxillofacial surgeon to apply for jobs and expect them to clean teeth or fill cavities.
I have always agreed that wound care, biomechanics, sports based care, etc. are as equally important as complex reconstruction, TARs, trauma, frames, etc. But even with the requirements of the CPME to increase nonsurgical care, most of the departments within the hospital setting are surgically based. Even the medical care is complex and procedurally based: endovascular work, central lines, lumbar punctures, chest tubes are just a few examples. Residents now run codes, help in deliveries, and participate in complex decision making. So I agree that some residents develop a "God" complex and they act like they are the only ones who were ever trained but there are senior DPMs who have no idea what the typical resident does for three years of residency.
Imagine senior doc X who has built a successful practice over 30 years. They worked incredible hours, fought to open hospitals, faced discrimination by MDs, and yes were trained to do all surgery. But because of the slow evolution and the nature of our profession they have a mixed practice. Everything from RFC to complex reconstruction is included. Since there were no jobs when they came out they borrowed money to open cold or buy a practice. In the early days they hustled to pay the bills doing house calls, nursing homes, and other things that allowed them to have a practice that did ankle fusions, triples, and other reconstructive care. They stay current and do ex-fixes, TARs, and the latest techniques. Yet their practice can not suddenly discharge all of the RFC nor tell their referral sources that they are above nursing home care now. They have gone through lean times and now are financially successful. They are wanting to slow down and bring in their replacements.
They meet junior doc Y. They went to podiatric medical school and sat next to DO or MD students. They were told they were being mainstreamed. Suddenly, basic podiatry concepts were lost and more emphasis placed upon integration. Even wound care became more research and science driven. They then enter a 3 year residency described above in a larger teaching hospital versus the smaller community hospital where the senior doc trained. Some of their classmates are being offered incomes to start at a level that the senior doc took 5-10 years to reach. When interviewed the junior doc touts their training (BTW what the senior doc did about their own training 30 years earlier), their salary demands are at a level many of their friends have achieved, and they have never been exposed to old school podiatry (RFC, nursing homes). Add some generational differences in lifestyle goals and communication and no one should be surprised of the comments from both sides.
Solution: Guarantee all DPMs a 2year residency with the required medical and surgical rotations mandated by the CPME. Teach them the care they will see in a typical office based practice. Nail procedures, orthotics/bracing, basic peds, and the diagnosis and office based treatment of all lower extremity conditions. Sprinkle in exposure to advanced wound care and surgery (this would help them determine referral cases). Next, those with an interest in certain areas such as advanced wound care, sports medicine, surgery, possible peds would then apply for additional 2-4 year residencies (or fellowships). If you are one that thinks we need an MD/DO perhaps these can be part of those programs like the maxillofacial residents. After several years, the profession and the public would have a way of defining what DPMs do both as a profession and each individual.
I say to embrace diversity rather than kill it.
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Hear, hear.^^
Like Podfather, I've always thought the dental model was the way to go (however, I suggested only 1yr for basic pod and 3yr for surg):
http://forums.studentdoctor.net/showthread.php?p=7934055#post7934055
http://forums.studentdoctor.net/showthread.php?p=8974913#post8974913
...but we kinda missed the boat on that with the decisions made over the last few years by APMA, CPME, COTH, etc.
My only minor disagreement with Podfather is that I think that 3 good years is quite a bit for F&A surgery, though. Is that arrogant? Yeah. Is it true? Well, it depends how driven the resident is... and where you train and what the case volume/diversity and academics schedule is. Some guys try to make pod surg into some big, crazy, complicated stuff, but at the end of the day, it's the foot and ankle. Does what we do help a lot of people? Yes. Is it a pediatric heart transplant or resecting liver cancer or doing an abdominal aneurysm? Not exactly.
(OMFS are usually 4-6yrs post-grad simply because the first residency yr of that is basic and clinical science H&P and path classes... aka 3rd yr of MD school, and the second residency yr is general ER/med/surg/trauma rotations they didn't have in dent school... aka 4th yr of MD school)
In our profession, if you pick a good 3yr pod surg program, you will usually get more F&A procedures than a fellowship trained F&A ortho completes during residency + fellowship. We already did those gen surg, ER, med, etc rotations and classes in pod school. Therefore, I'm not sure how much more you'd really need or what the additional fellowship or residency years after 3yrs could offer... research maybe? I could see podiatric surgery being a 4+ year residency if it were an MD specialty where the intern residents show up with little but a very basic understanding of their specialty's specific anat/path/surg... or very green on general anat/path and med/surg like dental grads do. However, we learn so so much about F&A anatomy and pathology and surgery in pod school that (assuming you did well in your DPM program), you are very well set from the start of residency. Just look at how many very strong DPM surgeons (ACFAS leaders and similar) that we have out there who trained 2yrs - even 1yr - after their DPM. In the end, a lot comes down to the individual: you're still going to need to have the confidence and to board the cases yourself and get the procedures done. The training wheels have to come off sometime. JMO
At this point, we are pretty locked into having every DPM (who passes minimum boards) do a 3yr residency, though. I guess that's ok, but I agree fully that some people are going to have to suffer through a lot of surgery they will never have the confidence or desire to do... while not gettin enough reps on the basic care, non-surg treatments, and practice management that would actually help them more. Also, longer training for pods who will end up non-surg (either due to lack of interest or not passing appropriate boards) means more student loan interest they might be better off without. Then again, nobody forced them to apply to pod school, so I guess you sleep in the bed you make for yourself? Everything has a way of working itself out, and it's just good that DPMs have the post-grad options they do today. 👍
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Podfather, you hit the nail right on the head and I couldn't have written it better myself. However, the only thing I may change is that in many instances it took a lot longer than 5-10 years for many docs to earn what some of these young docs are asking for upon graduation.
Dr. Ritchie really was "spot on". A lot of the young grads come out and expect to enter many older existing practices thinking they are going to save the day with their amazing skills, not understanding that a LOT of existing practices are already performing the majority of these surgical procedures. However, the difference is that these practices are also providing the full spectrum of care, something many of these young docs have no experience with and no interest in learning. And the bottom line is that not every patient walks in the door wanting or more importantly NEEDING reconstructive foot/ankle surgery.
I've said it before and I'll say it again. There was a time when the very well trained foot/ankle surgeon was unique, but now it's "not so much" and as a result a saturation point develops. Therefore, those with the skills to treat patients surgically and non surgically will prosper the greatest.
For Feli:
The length of any of these additional residencies/fellowships would be dependent upon the goals. If all of the rotations and exposure to non-operative care was accomplished within the entry programs then perhaps 2 additional years are all we need. One could argue enhanced surgical rotations in other specialties for surgical programs, expansion of pediatric orthopedics, plastics techniques, etc. could easily require more time. In wound care programs, research, HBO, etc could be added.
Also we as DPMs have decided to use the knowledge and skills of many different specialties to treat the lower extremity. Ortho for example rarely address dermatological, plastic surgical, biomechanical aspects,neurological, and even wounds. Since we claim to be the best in treating the foot and ankle, philosophically does that include cancers, burns, etc.? I don't know. So it doesn't surprise me that someone with an entry program and then additional training may be longer in training than say some fields of medicine.
If one wishes to add a DO/MD degree then of course additional time in school and possibly a year of internship may increase the time further.
The length of any of these additional residencies/fellowships would be dependent upon the goals. If all of the rotations and exposure to non-operative care was accomplished within the entry programs then perhaps 2 additional years are all we need. One could argue enhanced surgical rotations in other specialties for surgical programs, expansion of pediatric orthopedics, plastics techniques, etc. could easily require more time. In wound care programs, research, HBO, etc could be added.
Also we as DPMs have decided to use the knowledge and skills of many different specialties to treat the lower extremity. Ortho for example rarely address dermatological, plastic surgical, biomechanical aspects,neurological, and even wounds. Since we claim to be the best in treating the foot and ankle, philosophically does that include cancers, burns, etc.? I don't know. So it doesn't surprise me that someone with an entry program and then additional training may be longer in training than say some fields of medicine.
If one wishes to add a DO/MD degree then of course additional time in school and possibly a year of internship may increase the time further.
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I know I do not have the experience some of you have with the profession, but even as a student I see this disparity happening. I have even heard some APMA members and attendings go so far as to blame organizations like ACFAS for the high surgical emphasis being pushed to our students and residents.
Personally, I care more for biomechanics, sports med, wound care, and general medicine than I do surgery. That is not to say that I do not want to be trained in rearfoot recon surgery but I do not wish to spend most of my career doing those procedures. I realize in my class I am in the minority by saying that and many of my classmates are pumped about all these intense surgical procedures. It's sad that I see so many programs do not cater much to biomechanics.
Personally, I care more for biomechanics, sports med, wound care, and general medicine than I do surgery. That is not to say that I do not want to be trained in rearfoot recon surgery but I do not wish to spend most of my career doing those procedures. I realize in my class I am in the minority by saying that and many of my classmates are pumped about all these intense surgical procedures. It's sad that I see so many programs do not cater much to biomechanics.
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So what can a podiatry student do if he/she wants to be well rounded like this? Can you choose a residency that emphasizes biomechanics? Or do you need to do a fellowship to attain this?
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My advice would be to be actively involved in your residency and with your attendings. There are countless opportunities for residents to participate with patient care over and above "the big cases", but this would demand initiative and a bigger commitment from the residents. More than just showing up to cut so to speak.
Many people I run across in my travels complain that all the residents want to do is "show up", cut and bolt. Very little in house care (over and above just doing the amputation), no office followup, no spending some of their off time in the office learning practice management skills and shadowing their attendings to find out how to talk to patients and teach them. Please don't tell me "but we don't have time!", because you do.
Yes, we are surgeons, but there is so much more to what we do than simply showing up to cut. There is so much opportunity during residency than OR time. MOST of what we do ISN'T in the OR. Make the most of it!
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I have a question/observation that I would like someone in the private sector to address. After reading the article and talking with people in my class, what happens when this becomes the norm. What happens to the private practice as an entity when a disparity of pay between hospital groups, ortho groups and private practice push new grads to not seek a private practice position. If say only ten percent (as an example) of the graduating class choose to pursue this route wouldn't this eventually put a huge strain on private practices looking for associates. Many in my class do not want to pursue a private practice and of those that do it's usually a family member or close friend they are looking to join in the future. Is ten percent a year (70-100) newly minted DPM's that are looking enough to sustain all the private practices across the nation? Does that raise a giant red flag for the owners of these practices or is this a non sequitur? I realize that ten percent is probably really low, but as acceptance in to ortho groups and hospital positions rise, isn't there a distinct possibility that the numbers may drop to that level in the future?
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This is an excellent question, but in MY opinion is not realisitcially going to be an issue.
I've actually addressed this issue (not directly) many times in the past. And please remember, this is my opinion. When Podfather and I graduated, only about 45% of our class at that time obtained residency positions. Yes, some of the best and brightest did NOT obtain a residency program, and the vast majority were one year programs. There were some 2 year programs and I believe a handful of 3 year programs (the only one's I can recall were Atlanta with McGlammary, University of Chicago with Gudas and St. Joseph in Philly with Vogler and Buckholz).
That means a LOT of excellent docs did not get programs, and docs like me and Podfather were very fortunate.
That also means that for many years, the really well trained podiatric surgeon was a unique resource. That doctor often received referrals from local DPM's who could not perform those procedures, did not have hospital privileges, etc. These doctors were a relatively rare commodity.
At that same time, the orthopedic community wasn't so friendly to the DPM community since performing these procedures was still in it's "relative" infancy.
Now move ahead to today. Almost every graduate, regardless of class rank will obtain a 3 year residency. Yes, there are obviously many programs with better quality training, but the vast majority of those passing their boards will obtain 3 year programs where they will graduate with significant foot, ankle and RF exposure.
And of course those grads will seek the "prestige" of the orthopod jobs, hospital jobs, multispecialty jobs, etc. HOWEVER, since the well trained DPM will no longer be so "unique" it's not going to be very long before all those prestigious jobs are all taken or are highly competitive. There is a saturation point.
There are only a finite number of those positions available, and certainly no where NEAR enough to accommodate anywhere near the number of grads seeking those positions yearly.
So, in summary, as the well trained DPM becomes less "unique" and those prestigious jobs reach the saturation point, the great majority will really have no choice other than to enter private practice IN MY OPINION.
I already see it happening.
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Amen. I am on staff at several hospitals (too many). At the hospital where one of my partners and I perform the majority of our cases, there is podiatric staff of about 20 docs. However, there is one other DPM and my partner and I who perform 99% of the cases (the other doc is a great guy and excellent).
Because between us, we are performing about 10-12 cases each week, a very well known and respected residency program contacted us to have the residents "scrub" with us. However, our group often has several in-house pts. for infections/diabetics, wounds, etc., that end up in the O.R. and then back on the floor. We asked if the resident would follow these patients or see these patients pre-operatively or post-operatively and we were told "NO".
We were NOT requesting the residents perform our consults. We were NOT requesting the residents do our scut work. However, as part of the education process, we thought prior to an I/D, amputation, Charcot reconstruction, etc., the resident should actually see the patient at bedside, look over the chart to evaluate the medical status, look at pre-op radiological studies, vascular studies, etc. We also thought part of the educational process included seeing the patient in-house post operatively to see what normal healing looks like and what complications look like.
But we were told "NO", they only wanted to scrub with us. Sorry to break the news to you, but none of us need the assistance of a resident and you learn NOTHING by walking into an O.R., cutting and going home. So we nixed the idea and now the residents will miss out on some nice numbers and great cases.
Additionally, I have an open door policy allowing residents to visit our office to see pathology. I DO NOT ask them to do ANYTHING. I have office assistants for those tasks. But they have to get their hair cut, go to the gym, or all kinds of B.S.
And no, it's not because I'm not well liked. I've got plaques on my wall from residents thanking me. It's simply a new breed that wants to "cut" and forgets about everything else. These docs are in for a VERY rude awakening.
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That's unfortunate, but I suppose it's inevitable when the profession is really shifting emphasis towards more advanced training in surgery.
Reminds me of the Harvey Cushing quote: "I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work. "
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Thank you for the replies, they are a welcome insight.
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Yes and no. "Seek" or "pursue" does NOT equal "getting" and "signing." Every pod grad could seek a hospital employee job, but they certainly wouldn't all get one. There's a finite number of hospitals who understand what DPMs can do and will let you practice full scope. Only a % of those are then looking to employee DPMs (and an even more finite number of those who will pay you anywhere near what you'd make in a well run private office ownership/partnership situation). The ortho groups are the same way: most would rather have a F&A ortho for various reasons (ego of the all might MD, to share gen ortho call, etc). Also, even a DPM grad is offered one of those jobs, do they want to be flexible on location to get a hospital ortho job that they managed to find wanted a DPM... and wanted to pay decent... and picked them over the other candidates? It's not really a slam dunk after all, is it? So, it really doesn't matter who wants what kind of job... many who go for the ortho or hospital jobs and have no luck will end up in pod private practice.
Yeah, a lot of residency grads want hospital jobs or ortho jobs. The pay up front is good, they are generally better about paying for your interview travel, and the surg volume is usually at least moderate - often fairly high. However, once a hospital has a doc "on the hook," it can get more complex. How will you get pay raises, incentives, etc? Is your job secure, or will they replace you if a younger doc will work harder for less $... or if the hospital admins/politics change? For grads looking long term, then private practice (ortho, pod, or multi-spec) usually does offer the best income, autonomy, and job security + satisfaction. When you own your own business (or a sizable piece of a small business), it just does tend to turn out that way. Who doesn't want to "be your own boss?" 😉
Overall, it's just the state of medicine in general. I think more and more DPMs finishing residency will end up in large groups - either physician groups or medical corporations that own hospital systems and employ various specialists. That's just the way medicine in general (MDs, DOs, and DPMs of all specialties) is trending with the reforms in EMR, govt insurance reimbursements, etc. The EMR and billing reqs are getting more costly and stressful, payments are dwindling, and a lot of private practitioners are getting tired of chasing their tails... many will sell out to large hospitals or groups - or even give up all together and just retire or become employees of the hospital systems.
http://www.acfas.org/ThisWeek/ThisWeek_09072011.html#538834
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Mods, clean up on isle 3.
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doctazero/caddypod/Traum/etc. created another s/n and swept across the forums with some unproductive banter again. FiveO was just replying to his latest post which has obviously been deleted by the moderators. Funny, how after doctazero was asked to follow the rules about multiple accounts, the others seemed to disappear.
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