What does your ideal residency look like?

[ldsrmdude]

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Let's theoretically say you could design your own residency program. What would it look like?

How many other residents per year?

How many active attendings?

What percentage of time would be spent in the OR? Clinic? Wound center? Dedicated research time?

Mix of pathology (inpatient vs outpatient and forefoot vs rearfoot vs ankle).

Anything else that you would find important in designing your ideal program, assuming you couldn't choose the hospital or the location?

 

[CATSandKILOS]

Curious first year...
How many other residents per year? Can I hear some pro vs cons of programs with large numbers (I saw some NYC programs have like 8 residents!) vs smaller programs. Does that end up becoming like a Grey's Anatomy** situation where people are fighting to scrub in?

Slash what about going to a residency program that has many other programs (ortho, peds, obgyn, etc) vs strictly podiatry?

**Just started watching this show and I'm officially obsessed.

 

[dyk343]

Ideal? Good mix of hands on (not retracting your whole residency) elective, reconstructive, and trauma. Good relationship with Ortho. Worthwhile clinic where you see and evaluate preoperative, devise a plan, and post op. Good exposure to common podiatry as well.... but not a free nail tech. Wound clinic a half day a week.

70% OR, 30% clinic

1/1/1 or 2/2/2 unless there are a lot of attendings doing (good) cases. Too many residents tends to have too many personalities. I witnessed a lot of drama at high resident programs. I feel 3-5 attendings per resident is the minimum number... 3 if the attendings are very surgically active 5 if not as active. Numbers should be met by halfway through residency (or sooner).

No whiners for coresidents or attendings.

 

[ldsrmdude]

Ideal? Good mix of hands on (not retracting your whole residency) elective, reconstructive, and trauma. Good relationship with Ortho. Worthwhile clinic where you see and evaluate preoperative, devise a plan, and post op. Good exposure to common podiatry as well.... but not a free nail tech. Wound clinic a half day a week.

70% OR, 30% clinic

1/1/1 or 2/2/2 unless there are a lot of attendings doing (good) cases. Too many residents tends to have too many personalities. I witnessed a lot of drama at high resident programs. I feel 3-5 attendings per resident is the minimum number... 3 if the attendings are very surgically active 5 if not as active. Numbers should be met by halfway through residency (or sooner).

No whiners for coresidents or attendings.

How much focus on inpatient versus outpatient?

 

[heybrother]

I like what Dyk said. I like the idea that your clinic is directly tied to the surgeries you are doing. I've been to some programs where I spent a lot of time in clinic and day after day clinic generated no surgery. Your core attendings are ideally full scope surgically so that you see full scope coming in during clinic. I don't want to be dependent on one person for something that should be "common" place. One person bringing in ankle replacements? Ok. Only one person for rearfoot or ankle? Probably not ideal.

Ideally podiatry doesn't "need" ortho. If they are the only place you can get rearfoot/ankle, not ideal.

Inpatient/hospital call - getting called in for consults to cut nails in hospital, ...never. Consult service only. If they don't want what we are offering - sign off. Other staff onboard with how we keep things moving. Inpatient wound care potentially directed to wound-care nurses. Trauma not pre-filtered by ortho.

"Diabetic focused" - pass. Everywhere I've been has generated more than enough wound care, prevention, and amps. It doesn't require a special focus.

I've been or heard of a few places where podiatry residents slip away from off-service rotations for our surgeries.

 

[dyk343]

Inpatient/hospital call - getting called in for consults to cut nails in hospital, ...never. .

I have been to programs where every night there were 15 nail consults to see. Ideally a resident should be seeing surgical/emergency consults, studying for the upcoming cases, and reading literature at the end of the day.. Not nails and calluses. My director has specifically instructed us to deny every nail consult, unless there is need for nail avulsion/onychocryptosis. Not because we are too good for that type of work... But because our time should be spent on more educational and emergent matters. Nails are not-emergent and can be seen as outpatient. Plenty of clinics that will gladly take them.

Inpatient management is important. Residents should round on most of their inpatients daily or every other unless there is literally nothing to do for them. I want to see my post ops and how they are progressing. This makes the hospital doctors see you more and give more consults as well.

Also, strong medicine rotations should be mandatory. Not hide in the back type of rotation. The more and more I go through residency the more thankful I am that I busted it on my medicine rotations. Very helpful for the whole picture of the patient as well as networking for the residency program.

I do think a strong relationship with ortho is important. We work with ortho a fair amout. We get a lot of "extra" cases through them and they are great trauma surgeons. They love having us because we round on their patients, do op reports, etc, etc so its mutual benefit. The same goes for vascular and general surgery.

Are you thinking about opening a new program ldsrmdude?

 

[PeaJay]

What would it look like?
Personally, I would like a hospital based system where the podiatry department/group acts as an admitting service with full scope as dictated by training. There should be some semblance of symbiosis between ortho and podiatry.

How many other residents per year?
Tw0 to Three a year. There needs to be a group that can foster learning and push each other to get better and hold each other accountable. Truly there needs to be at least one person to bounce ideas off and get reassurance when needed.

How many active attendings?
A gaggle? This is variable. There needs to be a fair amount such that if one attending takes a vacation the program does not suffer. Ideally the number should not be so large as to hinder the development close ties and a functioning relationship.

What percentage of time would be spent in the OR? Clinic? Wound center? Dedicated research time?
There should be a mix of all of the above. I prefer and would be willing to argue this to the death. I feel that there needs to be a large volume of high quality clinic. As residents we should be exposed to volumes of true pathology, not just onychomycosis. There is much to be learned from clinic. This is not to say there should be a lack of surgical volume. There needs to be a balance. A lack of clinic to bolster numbers is a disservice to an appropriate education and training.

Mix of pathology (inpatient vs outpatient and forefoot vs rearfoot vs ankle).
Ideally there should be a mixed bag of attendings that function to bring a well rounded program together. There should be some turn and burn guys who do forefoot work. On the other hand there should be methodical and deliberate rearfoot clinicians to drive home the required rearfoot concepts (I am not talking about cowboys, There is no place for people doing procedures because they can). The others should be somewhere in between.

I think if possible the service should be an admitting service. This allows you to function at your true capacity and learn to manage the individual as a whole. (this does not mean you should start managing all medical ailments, that is what a med consult is for, but you should be able to captain the ship)

Anything else that you would find important in designing your ideal program, assuming you couldn't choose the hospital or the location?
An environment that is accepting of teaching.

 

[ldsrmdude]

Are you thinking about opening a new program ldsrmdude?

That's actually where this whole thought process started for me. I like education and teaching. Right now, the only thing that I really don't like about my practice situation is that there are no residents that we work with. One of the hospitals I work at has family medicine and internal medicine residents and we're talking about setting up a rotation through our office for them. A podiatry residency would be great, but I'm trying to get a better idea of what the ideal residency would be so I could see if it would be possible where I'm at. That and I thought it would spark some good discussion 🙂

 

[josebiwasabi]

What would it look like?
Primarily based in 1-2 hospitals including a level 1 trauma center

How many other residents per year?
I've seen both small and large programs, both work well if you choose residents based on personality as well as academics.

How many active attendings?
I think you need a core of attendings equal to the number of residents per year, and then of course you would have the 20+ attendings you work with less frequently at various surgicenters.

What percentage of time would be spent in the OR? Clinic? Wound center? Dedicated research time?
50% OR, 25% clinic, 25% inpatient management. Wound stuff would be included in both the clinic and inpatient management. It's critical that the focus of the clinic is procedural and also geared towards booking cases. Seeing nails/calluses q3months is great for private practice if your model is based off of that but a resident run clinic shouldn't have that be the majority of the pathology. I don't think dedicated research time is a necessity.

Mix of pathology (inpatient vs outpatient and forefoot vs rearfoot vs ankle).
I like having a large inpatient census. Right now I'm on a rotation where my census is 31 with approximately 20 being primary. I would have balked at that back in July but now it's completely manageable. I think ideally during your 1st year you would do a lot of the "dirty" inpatient cases, do a mix of inpatient/outpatient as a 2, and then primarily outpatient as a 3. I think that rearfoot/ankle cases shouldn't be limited to PGY3s and that PGY1s should get exposure to them.

Anything else that you would find important in designing your ideal program, assuming you couldn't choose the hospital or the location?
Strong, youngish leadership that is able to forge and maintain good relationships with the rest of the hospital. Real offservice rotations. Only take well qualified applicants ie top 50% or top 33% but also place a heavy emphasis on personality. Listen to resident feedback when evaluating students, we work with them the most. Greatest amount of call as a 1, with less as a 2, and minimal to no call as a 3.

 

[dyk343]

That's actually where this whole thought process started for me. I like education and teaching. Right now, the only thing that I really don't like about my practice situation is that there are no residents that we work with. One of the hospitals I work at has family medicine and internal medicine residents and we're talking about setting up a rotation through our office for them. A podiatry residency would be great, but I'm trying to get a better idea of what the ideal residency would be so I could see if it would be possible where I'm at. That and I thought it would spark some good discussion 🙂

👍 Do it!

 

[ldsrmdude]

👍 Do it!

One attending does not a residency make. 🙂 There are some definite hurdles that would need to be overcome in order for it to happen. It's just a thought at the moment, we'll see if there is some buy-in from other attendings and the hospital if things progress that far.

To all who have posted, these are great insights!

 

[janV88]

I'll speak from my experience as a 2nd yr.

How many residents per year?
This will depend on how many active attendings there are as well as how the program is structured. You want enough cases where residents are kept busy most of the time but not sitting around doing nothing during slow weeks. At my program, we have the ability to pull residents from off service rotations during busy weeks. Podiatry comes first.

How many active attendings?
Depends on how active. My program has 8 core attendings who practice full scope Podiatry. Some operate 2 times per week. We have 2 residents each month available for cases. Each day should have atleast as many attendings operating as residents. Obviously I'm talking about active attendings with 3-5 cases per day.

What percentage of time would be spent in the OR? Clinic? Wound center? Dedicated research time?
PGY-1 should be in OR as much as possible. They should be exposed to all aspects of Podiatry from hammertoes to pilons. Obviously start off with simpler cases then by the end of the year should have performed or actively assisted (not just retracting or closing) in all types of cases. This will prepare them for PGY-2.

PGY-2 should be the work horse of the program. Performing almost all cases skin to skin from recon to trauma to elective cases. This leaves PGY-3 residents available for rare or complex cases of their choosing.

PGY-3 should be able to cherry pick the rare and complex as they choose. TARs, rare trauma, complex recon, etc. They should also be available for clinic. I have no experience with resident run clinics but visions of county type hospital clinics come to mind and IMO that would not be ideal. Clinic experience is meant to prepare for "real life" practice. Obviously full scope podiatry would be ideal. Clinic is where residents learn how to talk to patients, perform office procedures, and learn how to run an office, billing, etc.

Mix of pathology (inpatient vs outpatient and forefoot vs rearfoot vs ankle).
Like Anklebreaker mentioned above, Rearfoot/Ankle should be about 70%. If you make a list of all procedures in the foot and ankle, I would guess percentages in each anatomical region would be close to 30% forefoot: 70% rearfoot/ankle. Your educations and experience should reflect that.

Anything else that you would find important in designing your ideal program, assuming you couldn't choose the hospital or the location?
Hospital based for sure. No running around to different surgery centers. A couple are probably fine but like Anklebreaker said, driving all day is a waste of time. For podiatry, I think community hospitals are typically better than university. This way you aren't competing for foot and ankle cases. As a student I rotated at programs with ortho and podiatry programs. Terrible for podiatry. Typically ortho gets called 1st and podiatry gets dumped on. I once met an ortho resident that bragged about stealing cases from podiatry. Another program I met an ortho attending that was speaking on the phone saying "All extremity cases should go to ortho, not podiatry. My residents are just being lazy giving it to podiatry." All in front of me, a student, and the podiatry resident on his service.

My program is a community hospital and all foot and ankle goes to podiatry, not ortho. The hospital also has 1 ortho foot and ankle on staff and he has recently been able to take call with Podiatry. Another plus is no ortho residents. So when the ortho attendings do get the random ankle fracture, they welcome the podiatry residents to help out. Being the only residents does wonders for the Ortho relationship. They see the cases we are doing, they see our training, they see our work. For example, 2 weeks ago I did a skin to skin pilon with one of the ortho attendings...I've worked with him only once previously.

ldsrmdude, good luck with opening a program. I hope you are successful. Podiatry needs more quality programs.

 

[ldsrmdude]

@janV88 Thanks for the encouragement. Like I said, it's just a thought right now, maybe even some wishful thinking. As you said, podiatry needs more good programs. The only way that will happen is for doctors who potentially are in a situation to help, go out of their way to put a program together. There are a lot places where programs could exist, but don't simply because no one has put forth the effort to do it.

Maybe I'll convince SDN to co-sponsor the program and we'll have rotations in social media and online forum management 😀

 

[jmarshall20]

Love all the great info and would love to hear which programs out there you feel encompass the "ideal" situation/setup? Which programs do you feel are closest to your best case scenario?

I know every program has their strengths and weaknesses and I've read through all the residency reviews and have that second hand information rolling around in my head.

I'm along way from residency decision making time, but like to have a solid game plan in place and vision of my goals. During school classes are the clear cut focus, but in the end residency is the goal. I'd love to hear from the more seasoned vets out there and I'm sure I'm not alone.

PS. hope this a valid place to post this question.

 

[ldsrmdude]

During school classes are the clear cut focus, but in the end residency is the goal.

Let me just say that although residency is the next step after school, it's really not the "goal." The reason that I say that is because being a practicing physician should be the end goal and the question of what residency is the best really depends a lot on what your "goal" is, i.e. what type of practice you want to have in the end. If you want a large surgical volume with complex trauma as an attending, going to a small community program with an emphasis on diabetic wounds is probably not the best pathway.

 

[jmarshall20]

Let me just say that although residency is the next step after school, it's really not the "goal." The reason that I say that is because being a practicing physician should be the end goal and the question of what residency is the best really depends a lot on what your "goal" is, i.e. what type of practice you want to have in the end. If you want a large surgical volume with complex trauma as an attending, going to a small community program with an emphasis on diabetic wounds is probably not the best pathway.

I completely agree with your sentiment. We often compartmentalize things into nice little boxes and things to check off a list instead of taking the big picture into consideration. I have my inexperienced, and most likely naive, thoughts on how I would like to practice as a physician. Right now most of that circles the realm of what I find interesting. I know this will change as after 100's and thousands of procedures interesting can become mundane.

My question was just general in nature regarding what those already practicing or in residency think are the programs out there that meet what they feel is an ideal program. One size does not fit all, and as you mentioned, "best" really means nothing as different goals and personal preferences will dictate what is more appropriate for each individuals education and training.

I'm just open minded and love discussing other's views and gaining as much knowledge as possible. In short I'd love to hear the opinions of those who know more than me, and find it very interesting reading everyone's thoughts on an ideal program.

Cheers.