Thoughts on Fellowship given job market

[DMEpod]

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I’m busy as hell and do well financially and I don’t love podiatry at all. This is just a way to put food on the table for my wife and kids. If I lost my hospital job and couldn’t find work other than PP podiatry I’d quit the profession and get a job at UPS ASAP

Literally this except I have a cushy PP job not hospital. This is just a job to get by and thankfully it makes a relatively good living for me and my family. But you better believe every time I'm between pts and not scrolling SDN I'm looking for the next google or amazon to invest in and gtfo this job

 

[Feli]

... I'm looking for the next google or amazon to invest in and gtfo this job

Still plenty of rise left in GOOG... I have been buying it almost 10yrs now. It's my #1 holding, even more than index. Right now, Google's not even back to pre-Ukraine price, even despite massive inflation. Revenue and EPS is up up up since basically forever, so I'd say it's best share price value in awhile (but always good value due to all the useful/essential and profitable services they control).

If you you want other good gainers, try NVO and LLY... have gained a ton (both have already 2x or 3x since I got in a couple years ago when Wegovy was approved), but they will continue to profit even more. It seems Americans like to eat but don't like being fat. Crazy concept.

I never got into AMZN... saw too many fizzle out like jet.com and buy.com and overstock.com etc etc etc. Competition seems easy and profit margin is slim. I'm probably missing something, but there are always 100 invests to make $ if you're not solid on something.

 

[deleted1162946]

Still plenty of rise left in GOOG... I have been buying it almost 10yrs now. It's my #1 holding, even more than index. Right now, Google's not even back to pre-Ukraine price, even despite massive inflation. Revenue and EPS is up up up since basically forever, so I'd say it's best share price value in awhile (but always good value due to all the useful/essential and profitable services they control).

If you you want other good gainers, try NVO and LLY... have gained a ton (both have already 2x or 3x since I got in a couple years ago when Wegovy was approved), but they will continue to profit even more. It seems Americans like to eat but don't like being fat. Crazy concept.

I never got into AMZN... saw too many fizzle out like jet.com and buy.com and overstock.com etc etc etc. Competition seems easy and profit margin is slim. I'm probably missing something, but there are always 100 invests to make $ if you're not solid on something.

I have a lot of Google too but AI could significantly change the company. I love google because of YouTube even if it’s not such a big % of their business

 

[Feli]

I have a lot of Google too but AI could significantly change the company. I love google because of YouTube even if it’s not such a big % of their business

Well that would be fine.
More AI means fatter people, so more DM and weight loss Rx sold.
Either way.

In all seriousness, Google dominates AI. They have plenty of their own sauce there. Sure, ChatGPT is the trendy name this year and first mover, but Google is the definite favorite to win that overall space also... just like search, email, vids, maps, and whatever else. Even in stuff they don't win, they get close (phones, browser, cloud, home devices). If they get split off and spun to component part stocks at some point, cool... I can probably retire a year or two after that happens. But then the AI will kill us all, so that's kinda lame.

...We need a podiatry fellowship in AI related podiatry stuff. And a CAQ... definitely a CAQ in podiatric AI.

 

[deleted285117]

Well that would be fine.
More AI means fatter people, so more DM and weight loss Rx sold.
Either way.

In all seriousness, Google dominates AI. They have plenty of their own sauce there. Sure, ChatGPT is the trendy name this year and first mover, but Google is the definite favorite to win that overall space also... just like search, email, vids, maps, and whatever else. Even in stuff they don't win, they get close (phones, browser, cloud, home devices). If they get split off and spun to component part stocks at some point, cool... I can probably retire a year or two after that happens. But then the AI will kill us all, so that's kinda lame.

...We need a podiatry fellowship in AI related podiatry stuff.

 

[Hybrocure]

It would be nice if some fellowship trained lurkers could give their two cents about their experience (good or bad). I know everyone on here trashes fellowships but there are some really good ones out there that do turn out great podiatrists.

 

[Feli]

It would be nice if some fellowship trained lurkers could give their two cents about their experience (good or bad). I know everyone on here trashes fellowships but there are some really good ones out there that do turn out great podiatrists.

You can log in here or make free account to see the ACFAS fellowships, nearly all of them list their current and past fellows. Then, just like any doc, google the fellow names and see where they work now. The majority end up in private practice group associate gigs, like most DPM grads. Of course the top DPM fellowships (Hyer, CORE, Cottom, etc) tend to get ortho jobs or hospital jobs many times (a lot later start own practice or ortho partner also)... but even some of them are in PP associate after the additional year of elite fellowship. I was gonna link to a few, but that's kinda bad form... maybe they chose job based on location or family, dunno.

So, the results aren't amazing (more and more fellows to PP as saturation increases)... and that's even the avg-to-great ACFAS fellowships. Just imagine how bad the job placement is for the poor-to-average CPME fellowships or the unapproved ones out there. I don't think most of the CPME ones even list who their fellows are... many go unfilled, for obvious reasons (many VA sponsors, no name attendings, five count em 5 wound care fellow spots at the prestigious Wycoff NYC!).

I agree it'd be good to see what the placement and income rates are for:

• avg DPM 3yr residency
• high power residency 3yr
• ABFAS BQ
• non-ABFAS BQ
• avg residency + avg fellowship
• high power residency + avg fellowship
• high power residency + good fellowship
• [avg/poor residency + top fellowship doesn't really exist]

At the end of the day, we know it's basically better name residency/fellowship will tend to do more in terms of job options and BQ/BC, but that's partially the training program or alumni network as well as equal part just better DPM talents going in also.

 

[Hybrocure]

You can log in here or make free account to see the ACFAS fellowships, nearly all of them list their current and past fellows. Then, just like any doc, google the fellow names and see where they work now. The majority end up in private practice group associate gigs, like most DPM grads. Of course the top DPM fellowships (Hyer, CORE, Cottom, etc) tend to get ortho jobs or hospital jobs many times (a lot later start own practice or ortho partner also)... but even some of them are in PP associate after the additional year of elite fellowship. I was gonna link to a few, but that's kinda bad form... maybe they chose job based on location or family, dunno.

So, the results aren't amazing (more and more fellows to PP as saturation increases)... and that's even the avg-to-great ACFAS fellowships. Just imagine how bad the job placement is for the poor-to-average CPME fellowships or the unapproved ones out there. I don't think most of the CPME ones even list who their fellows are... many go unfilled, for obvious reasons (many VA sponsors, no name attendings, five count em 5 wound care fellow spots at the prestigious Wycoff NYC!).

I agree it'd be good to see what the placement and income rates are for:

• avg DPM 3yr residency
• high power residency 3yr
• ABFAS BQ
• non-ABFAS BQ
• avg residency + avg fellowship
• high power residency + avg fellowship
• high power residency + good fellowship
• [avg/poor residency + top fellowship doesn't really exist]

At the end of the day, we know it's basically better name residency/fellowship will tend to do more in terms of job options and BQ/BC, but that's partially the training program or alumni network as well as equal part just better DPM talents going in also.

I know quite a few of them (both as mentors and as colleagues) but they’ve all been practicing for a bit by now. Im more so mentioning it just for the sake of having more positive (or negative) voices here to contribute to the conversation. I’m curious to see the experiences new fellows are having these days.

 

[Retrograde_Nail]

I know quite a few of them (both as mentors and as colleagues) but they’ve all been practicing for a bit by now. Im more so mentioning it just for the sake of having more positive (or negative) voices here to contribute to the conversation. I’m curious to see the experiences new fellows are having these days.

The older fellows who graduated 10 years ago when there were a handful of fellowships don’t have the same perspective as new graduating fellows. They are out of touch with reality.

You need to talk to graduating fellows from 2020 on. See what they are doing. Guarantee majority are doing private practice jobs or just started their own practice.

 

[HalluxSlicer]

The older fellows who graduated 10 years ago when there were a handful of fellowships don’t have the same perspective as new graduating fellows. They are out of touch with reality.

You need to talk to graduating fellows from 2020 on. See what they are doing. Guarantee majority are doing private practice jobs or just started their own practice.

Like I said before, the recent Fellow grad (2022) from one of the competitive ACFAS fellowship is at a PP in high COL area making 160K starting; seeing about 30 patients mornings and afternoons with 1 OR day per week. Has privileges at few local community hospitals. From my POV he seems overworked and have been grinding which I respect but the compensation to debt ratio is insane... which begs the question; is fellowship even worth it...

I believe fellow grads from 10-20+ years ago are better off, to include all the seasoned podiatricians that is on here. For someone who is set to join the podiatry workforce in few years, seeing the current climate is just so daunting and make want to not even complete residency because it all does not seem WORTH IT. Can I just do 1 year of residency and pass Part 3 so I can be a licensed podiatrist / physician from the eyes of the State Government? Obviously without completing it, you won't get the Board qual / Cert from ABPM and ABFAS but I know there are DPMs out there practicing just with 1 year of residency. Thoughts on this?

 

[Adam Smasher]

The older fellows who graduated 10 years ago when there were a handful of fellowships don’t have the same perspective as new graduating fellows. They are out of touch with reality.

The problem with fellowships is that their purpose has evolved rapidly over the years. It really wasn't that long ago that you did a fellowship as remedial training after a sub-par residency. I can't say how I know this, but source: trust me, bro.

Then around the early 2010s there was a shift from remedial residency grads seeking fellowship to elite residency grads seeking fellowship. Not coincidentally, the 3-year surgical residency was standardized in 2009. So the mindset is still prevalent: I put in more years to differentiate myself better and rise to the top in the applicant pile.

I'm not in touch with any fellows of the 2020s but the proliferation of fellowships is surprising to me. We go from "fellowships are remedial" to "fellowships are for the elite" to "fellowships are fairly elite but common enough that they're not special." I'll quote my old prof in pod school who said "4 years of training is dumb, why not make it an even 5 years and become a general surgeon so you can operate on the entire body?"

 

[Adam Smasher]

Can I just do 1 year of residency and pass Part 3 so I can be a licensed podiatrist / physician from the eyes of the State Government? Obviously without completing it, you won't get the Board qual / Cert from ABPM and ABFAS but I know there are DPMs out there practicing just with 1 year of residency. Thoughts on this?

I agree 100%

But if you can't get board certified, you can't get hospital privileges and some insurances will have issues with you. The deck is stacked against new grads. And we wonder why applications are down.

 

[diabeticfootdr]

It would be nice if some fellowship trained lurkers could give their two cents about their experience (good or bad). I know everyone on here trashes fellowships but there are some really good ones out there that do turn out great podiatrists.

It would be nice … but people are reluctant to post because they get attacked by the same 10 regular keyboard warriors if they don’t share the worldview that podiatry sucks.

 

[Adam Smasher]

Yes, it is an entirely reasonable and logical supposition that fellowship trained foot and ankle surgeons with publications to their name who have endured the rigors of a lengthy training process are afraid of having their feelings hurt by anonymous commenters in an online forum.

 

[podwho]

It would be nice … but people are reluctant to post because they get attacked by the same 10 regular keyboard warriors if they don’t share the worldview that podiatry sucks.

The state of the profession and one’s individual situation can be two completely different things. If you have a good job and do well then who gives a **** about problems for new grads or those who got bad training. Keep your head down and grind. Podiatry only sucks for those whose 7 year 200k+ investment lead to a low paying job. If you’re making good money what’s there to complain about? The future of podiatry is irrelevant to most as long as they are getting $$$.

I’m just here for the entertainment.

 

[GreenHousePub]

For my anecdotes:

The Fellowship grads I know from 2015, 2018 and 2021 are all working standard private practice jobs alongside non-fellowship trained podiatrists.
The one I knew who graduated from 2010 also worked a private practice gig before starting at a hospital a few years later.
One I know from 2023 just started at a hospital after graduation.

 

[diabeticfootdr]

Yes, it is an entirely reasonable and logical supposition that fellowship trained foot and ankle surgeons with publications to their name who have endured the rigors of a lengthy training process are afraid of having their feelings hurt by anonymous commenters in an online forum.

Look what SDN did to Doug Richie. He came here to enlighten you and SDN regulars belittled him, calling him just a has-been peddling a brace.

He quickly stopped posting.

Who needs that disrespect and conflict in their life? Keyboard warriors feed off it. It is their life.

The whole profession knows SDN Podiatry forums are a toxic cesspool where opinions and anecdotes rule conversations. Where every thread is derailed by someone with an agenda to tear down the podiatry because professional jealousy convinced them they didn’t get what they deserved.

 

[FutureDPM323]

The problem is that there arent good jobs out there. A fellowship director can’t just create a new well paying long term job each year for their respective fellow especially when there are so many fellowships now.

Once you graduate fellowship youre still applying to the same jobs as everyone else. There isn’t a magic website that has jobs just for fellowship trained podiatrist.

 

[icebreaker32]

Look what SDN did to Doug Richie. He came here to enlighten you and SDN regulars belittled him, calling him just a has-been peddling a brace.

He quickly stopped posting.

Who needs that disrespect and conflict in their life? Keyboard warriors feed off it. It is their life.

The whole profession knows SDN Podiatry forums are a toxic cesspool where opinions and anecdotes rule conversations. Where every thread is derailed by someone with an agenda to tear down the podiatry because professional jealousy convinced them they didn’t get what they deserved.

I feel many on here were inappropriate with Dr. Richie.

There are some on here that are more sarcastic and confrontational than others.

I will disagree with you that things are wonderful in the real world and podiatry just has its problems like every profession does.

For the time and money involved with this profession the job market and saturation are shockingly bad.

Potential students need to be aware, current students and residents need to have realistic expectations and a plan to find/create a decent job. Our leaders need to address this over our board fighting and enrollment cris. Fix the saturation and everything else will fix it self.

 

[Adam Smasher]

Look what SDN did to Doug Richie. He came here to enlighten you and SDN regulars belittled him, calling him just a has-been peddling a brace.

He quickly stopped posting.

Who needs that disrespect and conflict in their life? Keyboard warriors feed off it. It is their life.

I can't comment on Doug Richie since I wasn't a part of that conversation. Obviously none of us should tolerate personal insults. But if anyone wants to come forward with a dissenting view, they're obligated to back their position up. This reflects on the sad state of online discourse today (not just SDN), where people are so sensitive that the sheer fact that you've been disagreed with is a traumatic experience. If that describes anyone lurking here, I have news for you: far greater challenges await you in this life

 

[DMEpod]

The problem is that there arent good jobs out there. A fellowship director can’t just create a new well paying long term job each year for their respective fellow especially when there are so many fellowships now.

Once you graduate fellowship youre still applying to the same jobs as everyone else. There isn’t a magic website that has jobs just for fellowship trained podiatrist.

This is true. People do fellowship then go on to do mobile podiatry lol. The job prospects out there are tough. Just talking to colleagues and former co-residents it's pretty sad that more often than not people are unhappy in their current position. Whether it's hours, pay, benefits, or location. Lot's of people taking jobs just to be a practice owners resident with slightly better pay. A bit demoralizing honestly.

 

[Sweatshirt]

I need to know what happened to Pronation. How are we going to get total toenail jokes anymore

 

[Susitna]

The problem is that there arent good jobs out there. A fellowship director can’t just create a new well paying long term job each year for their respective fellow especially when there are so many fellowships now.

Once you graduate fellowship youre still applying to the same jobs as everyone else. There isn’t a magic website that has jobs just for fellowship trained podiatrist.

You’ve drank the SDN Kool-aid on Fellowships. I’d defer to Dr. Rogers advice.

 

[deleted285117]

You’ve drank the SDN Kool-aid on Fellowships. I’d defer to Dr. Rogers advice.

Have you searched for jobs recently? Look at the available openings on LinkedIn, Indeed, PracticeLink, etc.

There are a *few* good jobs posted. Now imagine all the new grads (including fellowship grads) looking for a good job. Not enough. Fellowship might give you a “one-up” depending on the fellowship’s training (ex UMich helps prep you for academia/research gigs), but overall too many mouths to feed.

Not saying fellowship training is “bad”, per se, just may not be worth it in the long run.

 

[FutureDPM323]

You’ve drank the SDN Kool-aid on Fellowships. I’d defer to Dr. Rogers advice.

what kool aid? i personally haven’t made a decision yet as to whether I would like to do a fellowship or not as i am still looking into it but ive looked for jobs in the area I would like to work in and it does not look good.

And no i’m not willing to uproot my life once more like I did with residency for the sake of this profession just to try and find a somewhat decent job in the middle of no where which isn’t even guaranteed.

I would like to return home to practice to be closer to my family, core group of friends etc and should be able to do that without having to worry about the kind of salary and benefits I’m going to get you know like any other practicing physician but here we are because well podiatry

 

[diabeticfootdr]

Have you searched for jobs recently? Look at the available openings on LinkedIn, Indeed, PracticeLink, etc.

I just searched Indeed.

“Podiatrist” brought up 829 jobs.

Sorted by those requiring a Doctorate Degree: 239.

https://www.indeed.com/m/jobs?q=podiatrist&l=&sc=0kf%3Aattr%286QC5F%29occ%28CFV7X%29%3B&from=serpso

Of course, the quality of some of those job are less than desirable (almost criminal) and I’d never advise any of my trainees to take those, but there are many good ones.

 

[GreenHousePub]

what kool aid? i personally haven’t made a decision yet as to whether I would like to do a fellowship or not as i am still looking into it but ive looked for jobs in the area I would like to work in and it does not look good.

And no i’m not willing to uproot my life once more like I did with residency for the sake of this profession just to try and find a somewhat decent job in the middle of no where which isn’t even guaranteed.

I would like to return home to practice to be closer to my family, core group of friends etc and should be able to do that without having to worry about the kind of salary and benefits I’m going to get you know like any other practicing physician but here we are because well podiatry

If you are looking at a fellowship, look at the previous graduates first and see where they are working. Also see how many people they have on staff, more people means more networking opportunities.

 

[wakaflocka88]

I just searched Indeed.

“Podiatrist” brought up 829 jobs.

Sorted by those requiring a Doctorate Degree: 239.

https://www.indeed.com/m/jobs?q=podiatrist&l=&sc=0kf%3Aattr%286QC5F%29occ%28CFV7X%29%3B&from=serpso

Of course, the quality of some of those job are less than desirable (almost criminal) and I’d never advise any of my trainees to take those, but there are many good ones.

239 jobs for 500+ grads and not including current working pods that are also job hunting. The math does not add up. You are reinforcing what us regular posters have been saying for a very long time. Thank you.

 

[Boba Foot]

Sorted by those requiring a Doctorate Degree: 239.

Slightly more than 40% the amount of pod residents graduating in a given year. Was this meant as a good statistic?

 

[icebreaker32]

I just searched Indeed.

“Podiatrist” brought up 829 jobs.

Sorted by those requiring a Doctorate Degree: 239.

https://www.indeed.com/m/jobs?q=podiatrist&l=&sc=0kf%3Aattr%286QC5F%29occ%28CFV7X%29%3B&from=serpso

Of course, the quality of some of those job are less than desirable (almost criminal) and I’d never advise any of my trainees to take those, but there are many good ones

There are not many good jobs at all. Lots of mobile podiatry and typical associate jobs. Fellows and practicing podiatrists are also applying, not just 3rd year residents.

Also good jobs are inundated with applicants. They are able to filter applications, interview and fill podiatry positions faster than many other healthcare postings. So many job postings might have already selected their candidates to interview if looking at a posting over 30 day old. A mobile podiatry posting over 30 days old....sure that might be still be open.

I will agree with others your best bet is to see where the residents/fellow ended up the last couple of years as far as jobs. Even doing it this way it is hard to tell the good from the typical bad associate jobs.

 

[DMEpod]

I think the low number of jobs to graduate ratio is probably because this is just the best kept secret so jobs have be real secretive. It's kind of like the kgb or cia of medicine

 

[diabeticfootdr]

239 jobs for 500+ grads and not including current working pods that are also job hunting. The math does not add up. You are reinforcing what us regular posters have been saying for a very long time. Thank you.

The problem with your math is that this is post July when finishing residents already have jobs. There aren’t 500+ grads looking to apply for a job in September.

Look at the number in March. Better representation.

And this is only Indeed. Many jobs are posted in other platforms or not posted at all.

So the math actually adds up.

 

[deleted285117]

The problem with your math is that this is post July when finishing residents already have jobs. There aren’t 500+ grads looking to apply for a job in September.

Look at the number in March. Better representation.

And this is only Indeed. Many jobs are posted in other platforms or not posted at all.

So the math actually adds up.

I would say LinkedIn is the worst... I think the search algorithm is just plain dumb, because when you search “podiatrist” you’ll get jobs for CRNAs/OB docs/etc. and not much DPMs.

 

[dtrack22]

Sorted by those requiring a Doctorate Degree: 239.

No need to be disingenuous here. In the first three pages (at least on mobile) of your job search there are at least 6 jobs that are for Foot and Ankle Orthopedic Surgeons. That’s about 10% of the listings. Then at least 1/3 of the jobs on every page are SNF/mobile podiatry/assisted living jobs. The next most popular are IHS and FQHC positions which often times don’t offer any surgical opportunities outside of clinic procedures which means new grads are limited in board certification opportunities.

There aren’t 239 jobs for Podiatrists on indeed and I know you know that. And of the remaining jobs in that search that are actually seeking a DPM, a plurality of job listings are looking for someone to cut toenails in nursing homes.

I personally have no problems with any of the rah-rah podiatry types. I’m glad they post. But when those folks purposefully/knowingly pee down our legs and tell us it’s raining…well, the perceived negativity/attacks/whatever you want to call em, kinda make sense.

There aren’t “no good jobs” available. There aren’t “239 Podiatry jobs on indeed.com” either. Both groups could just stop lying…

There are “too few good jobs for the number of ‘surgically trained’ DPMs we graduate every year.” Or “Podiatry has one of the weakest job markets within the healthcare industry.” Those statements are accurate. I believe them to be true. I’m certainly not one of the “10 posters” who gang up on podiatry cheerleaders or new people. Though I’m certainly intelligent enough to realize what’s happening when APMA BOT friends and family sign up to post hit and runs, and I’m sure I called folks out when that happens.

Someone tell me anything I just said that they disagree with…I’ll wait. But I don’t anticipate any responses. They never do respond to my posts (hint: they know I’m right). They just go back and forth with the trolls like Pronation and then complain about how everyone here is mean to them.

 

[HalluxSlicer]

Podiatrist salaries on Indeed: From 80K-225K BUT majority of salaries be around $150K or less...

Internal Medicine salaries on Indeed: From 220K-350K

PA / NP Salaries: From 80K to 150K

 

[HalluxSlicer]

I think we need to advertise to pre-meds that Podiatry is a great field if you don't mind 7-8 years post-undergrad training to make just as much as your STEM friends who graduated way before you did. Oh and the surgeries Podiatric schools are glamorizing about actually doesn't make money so you resort to doing clinic which MD, DO, PA, NP, and even nail salon ladies can treat as well as diagnose! So what are you actually good for you may wonder? Great question. Just ask your local Podiatry Cheer Team!!

But wait, there's more! Job market is pretty crappy but don't fret as Nursing Homes and Wound Care centers would LOVE to have you look at fungal toenails and wounds ALL DAY LONG. If a geriatric, disabled patient ask for their finger nails to be trimmed, you just let them know that you'll send a referral for an MD/DO to take a look at it cuz DPMs got this detrimental thing called ~~~Out of Scope~~~

 

[FutureDPM323]

It’s not there are NO good jobs out there. It’s just that there aren’t many good jobs out there and especially good jobs in a particular area.

You’ll have a handful of good jobs all over the country but then only 1 or 2 in a certain area and suddenly you have dozens of applications for that 1-2 job posting in that one particular area.

when people typically apply to jobs, they don’t look all over the country. it’s usually regionally depending on where they’d like to work. So do that search again and localize it to SoCal, NorCal, DMV, South Florida, Detroit Metro, Philly metro etc etc and see what options people actually have if they’re looking for a particular area. Hint: it’s not much if anything.

 

[Hybrocure]

I’ve noticed a trend of more ortho places hiring FA orthos instead of podiatrists. There were a period of years where podiatrists were getting these jobs and I feel like since Covid there has been a shift. Schools should be gearing our education more towards what we will realistically be doing in practice not what maybe 5% of our profession does. Yet it seems every student goes into 3rd and 4th year talking about reconstructive surgery and ankles all the time lol.

 

[deleted285117]

I’ve noticed a trend of more ortho places hiring FA orthos instead of podiatrists. There were a period of years where podiatrists were getting these jobs and I feel like since Covid there has been a shift. Schools should be gearing our education more towards what we will realistically be doing in practice not what maybe 5% of our profession does. Yet it seems every student goes into 3rd and 4th year talking about reconstructive surgery and ankles all the time lol.

Haven’t you heard? We are “Foot and Ankle Surgeons” now, bro! 😂

 

[Hybrocure]

Haven’t you heard? We are “Foot and Ankle Surgeons” now, bro! 😂

Reconstructive rearfootandankle surgeon DPM, ABFAS, FACFAS, FACFOAM, FACMAN, EXFIX.

 

[Feli]

I’ve noticed a trend of more ortho places hiring FA orthos instead of podiatrists. There were a period of years where podiatrists were getting these jobs and I feel like since Covid there has been a shift. Schools should be gearing our education more towards what we will realistically be doing in practice not what maybe 5% of our profession does. Yet it seems every student goes into 3rd and 4th year talking about reconstructive surgery and ankles all the time lol.

Those jobs are just plain gone.
They have been taken. Podiatry has GREATLY outpaced any demand for those roles of DPM in ortho group. Again, 600+ "surgical" podiatrists and only ~75 ortho F&A come out of training annually. That's nuts... it'll demolish any ortho demand for DPMs very fast.

30 or 20 or 10yrs ago, being a well-trained DPM (3yr or even 2yr surgical before that), you could definitely call around to ortho groups or talk to ones you scrubbed during residency (assuming you got a high power DPM residency and had the skills, no given then - or now, sadly). Plenty of guys from my program did just that.... first bigger ortho groups and better cities/areas, then smaller ortho groups or more rural ones, then tiny ortho groups or undesired areas, finally that niche was cashed. A few of my classmates and tons of others from good programs did the same in their various target areas, but that was 10+ years ago. Those ortho group spots got taken one by one by one. It got increasing hard to find them.

Now, present day, those spots are 99.9% filled, and virtually none of the DPMs who have taken them have retired (or will anytime soon).
The only ortho jobs I see DPMs getting these days are non-op or maybe convincing one or two young orthos to hire them and let them start their own practice within the shared office. There is the rare networking masterwork of getting into a decent ortho group via a DPM retirement or adding surgical DPM, but that is <1% of new grads, usually elite fellowship or residency grads (and luck). Even many of those are small ortho groups or the DPM has to go cross-country from their choice location to get it.

Look at even podiatry golden boy Calvin Rushing DPM ortho group job as an example: tiny ortho group, very outer margins of a metro. Sure, still probably an good job and income better than two thirds or even job quality better than 3/4 of employed DPMs, but it's not a large group or popular location by any means... and that is one of the top DPM grads in the country (very good residency + our #1 fellowship with excellent training/connections). No matter who you are, there just aren't very many ortho jobs left anywhere (that will take a DPM). Other recent top residency or top residency + fellowship grads like him ton't get ortho group at all - and not for lack of trying. They try hard, but we're oversupplied... ortho group DPM positions are harder than ever to find. Even ACFAS presidents don't have much choice of location if they want to work ortho group. Another example: the only two ortho group DPMs I know of in my current practice state are same elite residency, same group (legit large ortho group in fairly desired area)... and one got the other in.

...Basically, you can still cold call ortho groups, but 2023+ chances are now exceedingly rare of finding an ortho group who doesn't have a DPM but wants one. The market is tapped out... tremendously oversupplied. It will continue to be. Meanwhile, 3yr DPM residencies and fellowship DPMs are everywhere. Even top fellowship DPM grads have trouble finding the ortho jobs with solid skill and networking. Those are basically extinct... and the DPMs who leave those ortho jobs or whose ortho group adds another podiatrist (rare) will pass the jobs along to a friend or whoever. They won't be posted widely - if at all. That ship has sailed. 🙂

 

[LordofWaffles]

I'm a resident, but I think a fellowship is a good opportunity to become better at limb salvage, if you really have passion for it. I think because we all do these surgical residencies now, we are really becoming known to all for wounds, amps and recons. With that, you'd have to work for a hospital, and a lot of time spent with no guarantee. You would make good money, and I'm finding those jobs are only going to come with luck or at least with 5 years of experience. You could base your practice around recons, wounds, arthrodesis, I'm sure you'd be plenty busy, but from what I am hearing the reimbursement just doesn't make it worthwhile.... could be wrong about that though.

I met an excellent fellowship trained podiatrist out on externship. Scrubbed a charcot recon with him and it was just so refreshing to be with someone that good. He went to a very good high volume fellowship where he did like 400 various recons that year. Today, he's part of a University hospital, teaches a lecture every now and then. He really enjoys the academics which you'll find is common among successful fellows. He's like 15 years out. He probably makes about 400k. He really loves what he does though and is easily one of the brightest podiatrists I have ever met...... yet he only makes about 400k, his value should be double that... Also, he had to relocate his entire family for his job, literally across the country, which he had to fight tooth and nail for after he was screwed out of the same position by his fellow colleagues in his home town. I really can't make this stuff up. His hometown had a University hospital too where he did the same.

I wouldn't do fellowship solely for ankle fracture/tar or ortho group in mind unless you know you have a spot waiting for you.... the majority of common folk are just always going to associate broken bones, or elective bone surgeries with ortho. They're just not going to sit there on their phone debating what a podiatrist can and can't do, especially while they're in pain. When I was a kid I broke my toe and went to an Ortho, I literally had no idea what a podiatrist was lol. It's why people label themselves as "the foot and ankle group" or surgeon or whatever. Look up the "the bunion king" you really gotta sift through that website deep to find the letters DPM haha. I don't know personally if it's good or bad for the field to ditch 'podiatrist'. Just feels dishonest, and you always should be honest when it comes to someone's health.... Again I'm just a resident, but this is how i personally feel.

We do have a thing going for us with the bunions, since a lot of people for some reason don't understand it's a bone problem or associate it with 'ewwww' lol

Podiatry really would be a hidden gem if the cost and time put into it were a little less. It's not that bad. The nails are the worst part ehh big deal, life could be worse. Actually a retired orthopedic surgeon came into our clinic the other day for nail care, and he was so appreciative of the service he received. Just remember you went to PODIATRY school, people actually love an excellent 'podiatrist' even if you don't.

It all really goes back to the schools, they're the ones increasing the cost and the time, because they think they should be getting paid what MD professors get... They're the ones trying to increase the prestige of the word 'podiatrist' with the extra training, yet more than half of the field ditches the label for F/A surgeon. The extra time, training and money have had no impact on salary for the majority of the profession... I guess the stigma of the dumb premed kids going to podiatry school must be true cause the ones who went 30 years ago are really effing up the field.... 🙂

 

[Hybrocure]

I'm a resident, but I think a fellowship is a good opportunity to become better at limb salvage, if you really have passion for it. I think because we all do these surgical residencies now, we are really becoming known to all for wounds, amps and recons. With that, you'd have to work for a hospital, and a lot of time spent with no guarantee. You would make good money, and I'm finding those jobs are only going to come with luck or at least with 5 years of experience. You could base your practice around recons, wounds, arthrodesis, I'm sure you'd be plenty busy, but from what I am hearing the reimbursement just doesn't make it worthwhile.... could be wrong about that though.

I met an excellent fellowship trained podiatrist out on externship. Scrubbed a charcot recon with him and it was just so refreshing to be with someone that good. He went to a very good high volume fellowship where he did like 400 various recons that year. Today, he's part of a University hospital, teaches a lecture every now and then. He really enjoys the academics which you'll find is common among successful fellows. He's like 15 years out. He probably makes about 400k. He really loves what he does though and is easily one of the brightest podiatrists I have ever met...... yet he only makes about 400k, his value should be double that... Also, he had to relocate his entire family for his job, literally across the country, which he had to fight tooth and nail for after he was screwed out of the same position by his fellow colleagues in his home town. I really can't make this stuff up. His hometown had a University hospital too where he did the same.

I wouldn't do fellowship solely for ankle fracture/tar or ortho group in mind unless you know you have a spot waiting for you.... the majority of common folk are just always going to associate broken bones, or elective bone surgeries with ortho. They're just not going to sit there on their phone debating what a podiatrist can and can't do, especially while they're in pain. When I was a kid I broke my toe and went to an Ortho, I literally had no idea what a podiatrist was lol. It's why people label themselves as "the foot and ankle group" or surgeon or whatever. Look up the "the bunion king" you really gotta sift through that website deep to find the letters DPM haha. I don't know personally if it's good or bad for the field to ditch 'podiatrist'. Just feels dishonest, and you always should be honest when it comes to someone's health.... Again I'm just a resident, but this is how i personally feel.

We do have a thing going for us with the bunions, since a lot of people for some reason don't understand it's a bone problem or associate it with 'ewwww' lol

Podiatry really would be a hidden gem if the cost and time put into it were a little less. It's not that bad. The nails are the worst part ehh big deal, life could be worse. Actually a retired orthopedic surgeon came into our clinic the other day for nail care, and he was so appreciative of the service he received. Just remember you went to PODIATRY school, people actually love an excellent 'podiatrist' even if you don't.

It all really goes back to the schools, they're the ones increasing the cost and the time, because they think they should be getting paid what MD professors get... They're the ones trying to increase the prestige of the word 'podiatrist' with the extra training, yet more than half of the field ditches the label for F/A surgeon, and the extra time, training and money have had no impact on salary for the majority of the profession... I guess the stigma of the dumb premed kids going to podiatry school must be true cause the ones who went 30 years ago are really effing up the field.... 🙂

Good post. But personally I think fellowship is more important for rearfoot elective or trauma cases. The stuff many residencies may not have the resident go skin to skin on.

I feel extremely competent at limb salvage after residency, so much so that it has caused my elective skills to suffer unfortunately.

However - limb salvage is a much more realistic and marketable trait for a podiatrist in todays climate there is no question about that. And I don’t necessarily mean ex fixes and Charcot recons. I’m talking about driving the pus bus. Hospitals want someone to amp toes and drain pus so the real surgeons can focus on their abdominal, polytrauma, or vascular call work. And that’s not a bad thing. It’s a super common issue that LOTS of people need help with and unfortunately it’s work that many frown on doing because they’ve been brainwashed into thinking they’re going to be trauma gods. And while you’re not necessarily saving lives, it can be rewarding to help prevent a BKA or sepsis with early intervention.

 

[LordofWaffles]

Good post. But personally I think fellowship is more important for rearfoot elective or trauma cases. The stuff many residencies may not have the resident go skin to skin on.

I feel extremely competent at limb salvage after residency, so much so that it has caused my elective skills to suffer unfortunately.

However - limb salvage is a much more realistic and marketable trait for a podiatrist in todays climate there is no question about that.

yeah I forgot to mention the trauma and rearfoot as part of the first part. good point. Anything that you'd imagine being called in for while on the pus bus haha.

 

[Feli]

I'm a resident, but I think a fellowship is a good opportunity to become better at limb salvage...

No, man... no. Limb salvage is a joke in difficulty terms... definitely don't need fellowships for it. You get plenty at any decent DPM residency. Wounds / amps / Charcot / etc DM surgery is honestly the easiest thing in podiatry scope (aside from maybe derm/nail office stuff). It is definitely the easiest of the three core F&A surgery types, and you are plenty competent in wound/amp after first and 2nd year at most programs.

Trauma = high difficulty, low patient expectations
Elective = moderate to high difficulty, high patient expectations
Limb salvage = low to moderate difficulty, low patient expectations

Wound and amp surgery is just incredibly easy because nobody else wants those patients (MDs, even most other DPMs who are busy avoid them).
Anyone who can do real trauma and elective F&A can always slop around with Charcot and amps and wound surgery. The converse is NOT true. Follow those Charcot recons until you graduate and see how they do... follow-up is the enemy of "good" surgery. Everything looks good in recovery room.

Also, with wound cases, you can always just blame the infection, comorbidities, diabetes, advanced age, etc for bad outcomes.
There is a reason most vasc surgeons and ortho and ortho F&A leaves limb salvage to podiatry... and that's not because they don't know how to do it. It's because they don't want it; it's fairly boring... and they have better paying stuff to do. 🙂

The "hardest" part of limb salvage is just saying "time for BK amputation" or "cast it until they get their amp" (Charcot)... because then the cash register shuts off. Wound wizards tend not to like that... they want more visits, more HBO, more RVU, wacky amps that are fraught with early failure in the EBM, Charcot cases that don't work, etc. That is the hard part of limb salvage: being ethical. Another hard part is not getting depressed with the sick pts, bad outcomes, generally poor insurances.

But to say limb salvage med/surg is hard or needs fellowships after 3yrs residency? No way.

 

[Retrograde_Nail]

It would be nice … but people are reluctant to post because they get attacked by the same 10 regular keyboard warriors if they don’t share the worldview that podiatry sucks.

This is getting very old.

We ask for your comments on certain topics and you refuse to respond. When do you respond is just as sarcastic and snide as some of the other posters on here. There is really no difference in tone and attitude between you and the rest of us.

 

[LordofWaffles]

Follow those Charcot recons until you graduate and see how they do...

O yeah believe me I've seen multiple fail already just as a student. I don't agree with it personally, I think its torture to put an ex fix on someone have them follow up for months, maybe years, see them break down again while they try and comply. I would never actually do that myself. I actually read an article not too long ago that even about 70% of TMAs will breakdown and need more proximal amp. I mean for sure there are patient's out there who want to be given the chance to keep their foot even if it's a very low chance and their foot is not really functional. Seen it first hand with a guy who's talus was completely gone from charcot, half the calc was gone, his foot flopped. The patient refused BKA over and over again. The doc did recon with femoral head allograft and Ex fix, patient was really happy when it was all said and done, I actually watched him take his first step in clinic.... BKA a year later... I literally just happened to be in the right place, right time every time that patient came. I really felt terrible for him, to go through all of that. There's docs out there who honestly want to give them the chance, theres docs who hear the cash register "cha ching" and theres docs out there who really don't want to do it have the training and get begged.

But to say limb salvage med/surg is hard or needs fellowships after 3yrs residency? No way.

I guess I meant it more in a way as If you wanted to try to base a practice around it and be ethical, but yeah you're right. You shouldn't need the fellowship for it. My overall point though was that we are getting well known for that discipline. I mean when you look at the big picture things are better for pods, but like everyone has said... the saturation is real.

 

[Hybrocure]

O yeah believe me I've seen multiple fail already just as a student. I don't agree with it personally, I think its torture to put an ex fix on someone have them follow up for months, maybe years, see them break down again while they try and comply. I would never actually do that myself. I actually read an article not too long ago that even about 70% of TMAs will breakdown and need more proximal amp. I mean for sure there are patient's out there who want to be given the chance to keep their foot even if it's a very low chance and their foot is not really functional. Seen it first hand with a guy who's talus was completely gone from charcot, half the calc was gone, his foot flopped. The patient refused BKA over and over again. The doc did recon with femoral head allograft and Ex fix, patient was really happy when it was all said and done, I actually watched him take his first step in clinic.... BKA a year later... I literally just happened to be in the right place, right time every time that patient came. I really felt terrible for him, to go through all of that. There's docs out there who honestly want to give them the chance, theres docs who hear the cash register "cha ching" and theres docs out there who really don't want to do it have the training and get begged.

I guess I meant it more in a way as If you wanted to try to base a practice around it and be ethical, but yeah you're right. You shouldn't need the fellowship for it. My overall point though was that we are getting well known for that discipline. I mean when you look at the big picture things are better for pods, but like everyone has said... the saturation is real.

And even then to base an outpatient practice around limb salvage is tough. Many limb salvage patients have poor or no insurance that a private practice can’t work with. Many of their insurances will fight you for home health dressing changes or require them to be seen at a wound facility for dressing changes (who will inevitably poach your patient).

It’s a nightmare to say the least. This is one of the reasons why limb salvage docs do well at hospital employed jobs that have the resources to get paid for this. I’m in PP and while limb salvage is my forte, outside of patients I bring directly to the OR or ones with tiny wounds, it is an absolute logistical headache taking care of them otherwise especially if they lack home/social support.

 

[Feli]

...I mean for sure there are patient's out there who want to be given the chance to keep their foot even if it's a very low chance and their foot is not really functional...

Yes, this is the bottom line.

Every patient wants to keep their toe or foot or whatever. All of them want that.
It is the job of a good and ethical doc to do functional salvage only... and to counsel the ones for whom that's not possible - or for whom that best chance is an amp, even a BKA. There always 1001 other podiatrists or wound RNs who will do nonsense "salvage" that will fail and waste the little time the patient has left with HBO or debrides and grafts or frivolous surgery despite underlying deformity or osteomyelitis. The road to amputation is littered with people who were bandaging the wound and thought they were healing the wound (or knew they were just cashing checks all along).

I was told something memorable by a senior resident at UPenn Presby when I was on the clerkship. He is a good doc, on the lecture circuit now. We were talking about implants with high fail rate or some dumb surgery things... and why patients would ever want that. He simply said: "patients will do whatever the f*** you tell them to do." He is not wrong. Docs have power. He was underscoring that power of communication - and the ethical responsibility that comes with it.. People can be talked into nearly anything, for better or worse.

In my office, I have now "lost" a couple patients this month:

• One DM pt had prior 2-5th ray nibble amps. I did Rx shoes and filler first visit, he was molded for them at Hanger store... but it was too late. He developed styloid ulcer, needs BKA due to 5th met base osteo (MRI confirmed, spread to cuboid). I had to hospitalize him for IV abx after failing PO just to stabilize him, and I set him up for BKA consult inpt and that f/u outpt... but he found another DPM who will "save the foot." This guy was a BKA and still will be... he will just waste time, have failed hindfoot "salvage" surgery, pointless hospital days and more abx and meds, still get BKA later. No drastic harm unless med/renal or sepsis. Whatever.
• The other is actually pretty tragic. He is a DM biz owner with hallux malleus distal phalanx osteo from wound care from his snowbird area podiatrist over the winter, and I did MRI to confirm osteo and put him on PO abx. I sent him for a revasc done early this week and had him boarded next week during my block for hallux amp (leave base of prox phalanx if possible). Well, he called today to cancel the surgery. He went for opinion at the nearby wound center, and of course they will HBO him and put goop and "grafts" on it and they told him foot osteomyelitis can heal without surgery. Yup, 0.0001% for that happening. I had told him this would happen with most wound centers/docs, but it's his toe and foot and leg. The guy is now almost certainly going to get a TMA or BKA later this year when he probably could have healed a hallux amp next week and gotten off abx and out of the wound care loop. He fell for their BS. I see that wound center's patients often in the ER or on the floor with abscess, gas, osteo, etc from failed wound care... that had likely become hopeless months ago. They just don't want to say amp. They want the money. Oh well. They have that same discussion power that I do, but happy rainbows sell better than functional amputations.

At the end of the day, I could not care less... frankly, I need the appt slots for new patients anyways. I will fix some tendon ruptures or ankle scopes for athletes or do some complex bunions or a flat foot surgery for better payers with that time instead. I consider the small % of my practice that is limb salvage to typically be charity (it sometimes literally is) which I do to keep the ER happy and to help the community. It is easy and boring work. I sure won't do dumb wound salvage stuff with high fail rate just because the patients are looking for that "keep the foot a little longer" or because they would go along with it and it'd make me money. They can find other people to do that... my competition, hospital FTE podiatrists, whoever.

I sure hope I don't see the 2nd guy with the hallux osteo at the grocery store in 2 months with a BKA or see him in the ER with gas to the Lisfranc level... that'd be frustrating and awkward. One thing to do, in any practice situation, is be sure to tell the PCP that the patient is choosing to leave your care AMA, and that's very unfortunate yet you respect that choice... so PCP knows when they see the BKA that the patient was duped and strung along by another surgeon, not you.

Regardless of outcomes, the limb salvage is very technically easy when compared with real surgery (elective recon, higher energy trauma, deformities, etc). It is communication skill over all else, but you can't save them all... some will fall for wound wizardry and stupid 'salvage' stuff. Amputation can be a tough sell, even to some otherwise intelligent people.

 

[LordofWaffles]

Definitely see your points clearly, and yeah hopefully you don't end up seeing that guy. Thanks for sharing your experiences and your advice! Appreciate the wisdom from both of you, Feli and Hybrocure. Always humbled by this forum and always learning. Excited to get out there and eventually start my own practice. Do or die! I'm fortunate that one of my best friends currently owns a few small businesses. He told me today he can't wait to help me out and give me advice when I finally get there. He just really enjoys it. To me it's been worth it, I really like the field, I have kept my expectations real though. I hope to one day achieve the moustache, even if I have to live like a schmuck for a while longer, might as well. When I'm not scrubbing or reading, I'm working on my ambidextrous nail nipping skills... those are sure to impress and get the referrals going.