What I would do differently

[Robin-jay]

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I’m still not sold on flatfoot recons as commonly as in residency, having been working in private practice. I see too many patients from other docs still in pain from recons years ago.

Orthotics and weight loss with good shoes could’ve been the fix for half of them honestly. There’s really bad flatfeet that could benefit from it sure but I think there are a lot of docs out there being more aggressive than they should be when it comes to flat feet.


There’s also way too many podiatrists cutting on flatfoot patients who don’t have pain.

Someone should really do a study on weight loss for pedal pain management.

 

[wakaflocka88]

These are the thoughts of many of us coming up who will be the associates and residents you have to train (assuming you are affiliated with such).

Then again, work as hard as you possibly can to not be in that situation stuck in a scummy PP job.

The best advice I listened to - hang out with the smart kids that don’t complain.

 

[Hybrocure]

Someone should really do a study on weight loss for pedal pain management.

I mean there’s a reason why most speedbridge patients are massive

 

[Forcewielder]

A few things I've thought of while reading this thread.

1) Podiatry is not competitive with ortho. The best pod students would have been able to get into medical school (maybe) but ortho takes their pick of the litter. The guys I know that went ortho are at another level. They also do 5yrs of residency and typically a fellowship and during each year do more surgeries than most residency programs do in a 3yr format. It just stands to reason that when the potential of a student is much higher and they keep much more intense and extended training then they'll nearly always be better than the lower potential, less trained person. There's nothing wrong with this. Just know your limits. If you went to a top tier program and want to do recons then go for it. Most should stick to the smaller stuff and focus on crushing clinic because that's where the money us made in PP.

2) As mentioned above, the money that hospitals pay their doctors isn't so much what the doctor makes personally but what they bring as a package. I make my hospital more with my imaging orders than most PP associates collect altogether. There's facility fees, labs, DME, referrals, and surgery. The surgery at a hospital can make them tens of thousands for a single case whereas in a surgery center your professional fee may only generate $300 personally. So all that is to say that PP owners don't necessarily have a lot to give their associates. Some are straight up crooks, but it's a tough job to turn a 6 digit profit in this current iteration of PP medicine.

3) Nothing is going to change any time soon. As the saying goes, "Those who don't do teach." The best and brightest often are too busy making money to slow down and help the profession. And the opening of the new schools is going to have decades of negative ramifications. There's no way to avoid it at this point. Personally, I'm a bit of a pessimist by nature, but I am trying to make what I can and get out of debt, pay off my house, and fund my retirement ASAP because there's a legitimate chance my job could be significantly less productive in a decade. Others have said it before, but the negativity here is more of a balance to the fluff pieces that the schools give out. No one can honestly say the profession will still be viable in a decade with how negatively things have gone this past decade. Add in the fact that many many rural hospitals are starting to close or are nearly there because of changes in reimbursements and the huge number of Medicaid patients now. Even the mega hospital chains are consolidating to improve their insurance rate negotiations. Mid levels are also increasingly creeping on physician duties. Imagine if NPs or even RNs can start doing RFC some day and 75% of what podiatry sees becomes obsolete.

So yeah, just my thoughts. Cheers!

 

[Hybrocure]

A few things I've thought of while reading this thread.

1) Podiatry is not competitive with ortho. The best pod students would have been able to get into medical school (maybe) but ortho takes their pick of the litter. The guys I know that went ortho are at another level. They also do 5yrs of residency and typically a fellowship and during each year do more surgeries than most residency programs do in a 3yr format. It just stands to reason that when the potential of a student is much higher and they keep much more intense and extended training then they'll nearly always be better than the lower potential, less trained person. There's nothing wrong with this. Just know your limits. If you went to a top tier program and want to do recons then go for it. Most should stick to the smaller stuff and focus on crushing clinic because that's where the money us made in PP.

2) As mentioned above, the money that hospitals pay their doctors isn't so much what the doctor makes personally but what they bring as a package. I make my hospital more with my imaging orders than most PP associates collect altogether. There's facility fees, labs, DME, referrals, and surgery. The surgery at a hospital can make them tens of thousands for a single case whereas in a surgery center your professional fee may only generate $300 personally. So all that is to say that PP owners don't necessarily have a lot to give their associates. Some are straight up crooks, but it's a tough job to turn a 6 digit profit in this current iteration of PP medicine.

3) Nothing is going to change any time soon. As the saying goes, "Those who don't do teach." The best and brightest often are too busy making money to slow down and help the profession. And the opening of the new schools is going to have decades of negative ramifications. There's no way to avoid it at this point. Personally, I'm a bit of a pessimist by nature, but I am trying to make what I can and get out of debt, pay off my house, and fund my retirement ASAP because there's a legitimate chance my job could be significantly less productive in a decade. Others have said it before, but the negativity here is more of a balance to the fluff pieces that the schools give out. No one can honestly say the profession will still be viable in a decade with how negatively things have gone this past decade. Add in the fact that many many rural hospitals are starting to close or are nearly there because of changes in reimbursements and the huge number of Medicaid patients now. Even the mega hospital chains are consolidating to improve their insurance rate negotiations. Mid levels are also increasingly creeping on physician duties. Imagine if NPs or even RNs can start doing RFC some day and 75% of what podiatry sees becomes obsolete.

So yeah, just my thoughts. Cheers!

Good post. But I’ll say it time and time again. Midlevels won’t ever deal with feet when they have their pick of the litter for the rest of the body.

Midlevels are our main referral sources because they don’t want to even look at the feet. They won’t be clipping nails anytime soon.

 

[Forcewielder]

Good post. But I’ll say it time and time again. Midlevels won’t ever deal with feet when they have their pick of the litter for the rest of the body.

Midlevels are our main referral sources because they don’t want to even look at the feet. They won’t be clipping nails anytime soon.

You're not wrong. But there's a real scenario where RNs under an NP could do RFC.

Adam Smasher says It best: Embrace Lobster medicine!

 

[Hybrocure]

You're not wrong. But there's a real scenario where RNs under an NP could do RFC.

Adam Smasher says It best: Embrace Lobster medicine!

Likewise, RNs also have their pick when it comes to patient care. Literally everything else in their options is better than busting crumblies

 

[Retrograde_Nail]

Lots of good thoughts and comments in this thread.

Podiatry school is a gross misinterpretation of what your professional career will be. Your sheltered and protected from the outside world. Taking classes along side MD/DO thinking you are one of them. Then you get to third and fourth year and instead of continuing your medical training doing rigorous medicine and surgical rotations with these MD/DO students you have to pay out of pocket to travel all around the country to do podiatry externships and suck up to residents and attendings hoping they will pick you to match at their program. Burning a lot of money and time when you should be training doing real rotations in other medical and surgical specialties before you enter residency. Then you come back from your podiatry externships to do some core rotations at local hospitals and realize how much medicine you don't know.

Then you get to residency. You do your non podiatry rotations and realize how much you don't know. You forget about that when you get back on podiatry rotations and you are doing big cases thinking you are really important. Then you do another off service rotation and realize you have no idea what you are doing when it comes to medical management or handling things on other surgical services because you were really never exposed to it as a student because you were laughing at that podiatry attendings jokes on your externship to make them like you.

During residency you start to pick up the differences in how other doctors and nurses talk to you when they realize you are not an MD/DO. Then you feel the underlying disrespect that is never blatant but subtle. The tone in how they talk to you. Almost like you are not a fellow attending but a student almost. It is hard to describe. We are just there but not really considered needed or important. We are a luxury for these other services who can just dump whatever they don't want to do on you. That is what podiatry is.

You graduate and think you will use all this high quality surgical training. For the 10% of graduates who get employed by a hospital you will use some of them. For those who work at major Level I and II trauma centers (which is an even smaller percentage) you will use all of those skills because you will actually get the diverse pathology and volume. Everyone else will work private practice and do toes and forefoot for the most part with some other elective recon if they feel comfortable with it. You will do toenails and diabetic limb salvage (if you are comfortable with offloading surgeries and charcot) and you will do basic wound care. That's about it.

What they sold you in school and what you get in reality statistically are two very different things. Anybody who is an attending on here and has been in practice for 5-10 years and disagrees with what I am saying please chime in.

Lastly, what makes it worse or harder to be a podiatrist is the saturation. You get a great hospital job you really never have the ability to stick up for yourself. As soon as you are deemed a problem for admin because an MD/DO complains about you then you become expendable. There will be 300 DPMs ready to apply for your job when it gets posted. This hurts us negotiating salaries on future contracts. It hurts careers. We have no leverage.

 

[wakaflocka88]

Lots of good thoughts and comments in this thread.

Podiatry school is a gross misinterpretation of what your professional career will be. Your sheltered and protected from the outside world. Taking classes along side MD/DO thinking you are one of them. Then you get to third and fourth year and instead of continuing your medical training doing rigorous medicine and surgical rotations with these MD/DO students you have to pay out of pocket to travel all around the country to do podiatry externships and suck up to residents and attendings hoping they will pick you to match at their program. Burning a lot of money and time when you should be training doing real rotations in other medical and surgical specialties before you enter residency. Then you come back from your podiatry externships to do some core rotations at local hospitals and realize how much medicine you don't know.

Then you get to residency. You do your non podiatry rotations and realize how much you don't know. You forget about that when you get back on podiatry rotations and you are doing big cases thinking you are really important. Then you do another off service rotation and realize you have no idea what you are doing when it comes to medical management or handling things on other surgical services because you were really never exposed to it as a student because you were laughing at that podiatry attendings jokes on your externship to make them like you.

During residency you start to pick up the differences in how other doctors and nurses talk to you when they realize you are not an MD/DO. Then you feel the underlying disrespect that is never blatant but subtle. The tone in how they talk to you. Almost like you are not a fellow attending but a student almost. It is hard to describe. We are just there but not really considered needed or important. We are a luxury for these other services who can just dump whatever they don't want to do on you. That is what podiatry is.

You graduate and think you will use all this high quality surgical training. For the 10% of graduates who get employed by a hospital you will use some of them. For those who work at major Level I and II trauma centers (which is an even smaller percentage) you will use all of those skills because you will actually get the diverse pathology and volume. Everyone else will work private practice and do toes and forefoot for the most part with some other elective recon if they feel comfortable with it. You will do toenails and diabetic limb salvage (if you are comfortable with offloading surgeries and charcot) and you will do basic wound care. That's about it.

What they sold you in school and what you get in reality statistically are two very different things. Anybody who is an attending on here and has been in practice for 5-10 years and disagrees with what I am saying please chime in.

Lastly, what makes it worse or harder to be a podiatrist is the saturation. You get a great hospital job you really never have the ability to stick up for yourself. As soon as you are deemed a problem for admin because an MD/DO complains about you then you become expendable. There will be 300 DPMs ready to apply for your job when it gets posted. This hurts us negotiating salaries on future contracts. It hurts careers. We have no leverage.

Current students - save this post, print it and read it again 5 years from now.

 

[Hybrocure]

Current students - save this post, print it and read it again 5 years from now.

Read it every day tbh

 

[HeySister]

The happiest people in this field in my age cohort (around 5 years out) either had no or minimal (75k or less) student loans at graduation, or married high earning partners. If you fall into those categories and like the job it's probably worth doing again. If you don't fall into those categories, could be rough. Make a good effort to go PLSF and it may even out. How things look over the next 20 years are more concerning to me than how things are now. Somebody posted above about 6 docs retiring in their community and 15 new docs coming in. You don't need to be an economist to figure out the problem. Of those 6 docs I bet 4-5 were mostly chip and clip and orthotics. The 15 new incoming docs are probably looking for something else.

I would do it again but if you can go to medical school or are close to being competitive, you are likely better served working on your app/mcat and applying until you get in rather than going podiatry.

 

[Dermato Fight Club]

The happiest people in this field in my age cohort (around 5 years out) either had no or minimal (75k or less) student loans at graduation, or married high earning partners. If you fall into those categories and like the job it's probably worth doing again. If you don't fall into those categories, could be rough. Make a good effort to go PLSF and it may even out. How things look over the next 20 years are more concerning to me than how things are now. Somebody posted above about 6 docs retiring in their community and 15 new docs coming in. You don't need to be an economist to figure out the problem. Of those 6 docs I bet 4-5 were mostly chip and clip and orthotics. The 15 new incoming docs are probably looking for something else.

I would do it again but if you can go to medical school or are close to being competitive, you are likely better served working on your app/mcat and applying until you get in rather than going podiatry.

Yes. Sorry If I didn't make that point but yes the new doctors are all 3 year trained vs. the older doctors who were likely just chip and clip.

So in my opinion patients in my area would be better served with 2-4 surgical pods doing 30+ cases per month vs. 20 surgical pods doing 1-8 cases per month.

The leaders 20 or so years ago wanted all podiatrist to do a three year residency. I can't fault them for that. They likely grew up with some people doing residencies (1 year) and others not doing any residencies. They had to prove themselves to the md/do communities of what they could do. They wanted it to be easier for the next generation to say hey our residency length is equivalent to yours. This was a great idea in theory.

The big problem is that residencies are so variable and probably 50% of them should be closed. If that happened though, there would be chaos as you would have all those students who had loans not be able to get a residency and therefore could not be licensed in most/all? states.

Again, I think the issue is saturation but I look at it from another standpoint. I just think there is not enough foot/ankle surgery numbers in the community to warrant all these foot/ankle surgeons. The real demand for us is the warts/ingrowns/plantar fasciitis/nails etc.

Maybe it is just me but I see maybe 1-5 true rearfoot cases a year. I see about 3-6 lis franc fusions. I used to do these cases but at this point, it is just easier/less stressful to send them out.

So with all that said, what is the solution?

That's easy (sarcasm). CPME should close all residencies that do not meet their own requirements. If they were to actually do this, about 50-75% or more would be canned. This will not happen because CPME has an incentive to have more podiatry students as there are deans of schools that sit on the committee.

Once those residencies are closed, then only the best students will get residencies. Those students without residencies would have a very tough time getting a license to practice and there would be chaos as we would have to likely change everything that was worked so hard for by the previous generation of requiring three year residencies to now doing a completely different type of model.

 

[Retrograde_Nail]

Yes. Sorry If I didn't make that point but yes the new doctors are all 3 year trained vs. the older doctors who were likely just chip and clip.

So in my opinion patients in my area would be better served with 2-4 surgical pods doing 30+ cases per month vs. 20 surgical pods doing 1-8 cases per month.

The leaders 20 or so years ago wanted all podiatrist to do a three year residency. I can't fault them for that. They likely grew up with some people doing residencies (1 year) and others not doing any residencies. They had to prove themselves to the md/do communities of what they could do. They wanted it to be easier for the next generation to say hey our residency length is equivalent to yours. This was a great idea in theory.

The big problem is that residencies are so variable and probably 50% of them should be closed. If that happened though, there would be chaos as you would have all those students who had loans not be able to get a residency and therefore could not be licensed in most/all? states.

Again, I think the issue is saturation but I look at it from another standpoint. I just think there is not enough foot/ankle surgery numbers in the community to warrant all these foot/ankle surgeons. The real demand for us is the warts/ingrowns/plantar fasciitis/nails etc.

Maybe it is just me but I see maybe 1-5 true rearfoot cases a year. I see about 3-6 lis franc fusions. I used to do these cases but at this point, it is just easier/less stressful to send them out.

So with all that said, what is the solution?

That's easy (sarcasm). CPME should close all residencies that do not meet their own requirements. If they were to actually do this, about 50-75% or more would be canned. This will not happen because CPME has an incentive to have more podiatry students as there are deans of schools that sit on the committee.

Once those residencies are closed, then only the best students will get residencies. Those students without residencies would have a very tough time getting a license to practice and there would be chaos as we would have to likely change everything that was worked so hard for by the previous generation of requiring three year residencies to now doing a completely different type of model.

Easiest thing to do is close down schools. Cut class sizes in half for the next 10 years. Problem solved. But that can't happen because then professors at these schools would be let go because there is no tuition dollars coming in to pay their salaries.

 

[Adam Smasher]

What they sold you in school and what you get in reality statistically are two very different things. Anybody who is an attending on here and has been in practice for 5-10 years and disagrees with what I am saying please chime in.

Great post. The only thing I disagree with is being disrespected, I've always been approached respectfully when asked foot questions by colleagues. But that could vary from community to community.

One phrase I (unsuccessfully) tried to popularize is "the podiatry bait and switch." In the early years of schooling, you learn the full gamut of basic science. If you don't see complex recon cases, you can at least read about it. But you get into practice and 75% of pts just want their nails trimmed and a pair of shoes each year. So from the CPME/APMA perspective, it doesn't matter if your residency is trash because you can always fall back on lobster work. And even if your residency was good, if you can't find work that draws on your good training, there's always lobster work to be found.

And that's their goal. The APMA doesn't want any toenail left behind. Build more schools, overtrain students, produce way more "foot and ankle surgeons" than needed, and then leave it to market forces to determine who's going to grind nails all day and who's going to render real patient care.🦞

 

[air bud]

You know if people just refused to do nail care except on truly at risk patients....

 

[Forcewielder]

You know if people just refused to do nail care except on truly at risk patients....

Isn't it odd that they leave q modifiers as predominantly subjective criteria? Who is to say I couldn't find that pulse in a morbidly obese cankle? Lol why not use an objective metric like ABIs or NCV results? I don't get why anyone wants to qualify the 40yo Medicaid DM2 who just can't reach their feet because they're a dicky-do. (For those not from the south that's where the belly sticks out further than the "dick"y do)

 

[air bud]

Isn't it odd that they leave q modifiers as predominantly subjective criteria? Who is to say I couldn't find that pulse in a morbidly obese cankle? Lol why not use an objective metric like ABIs or NCV results? I don't get why anyone wants to qualify the 40yo Medicaid DM2 who just can't reach their feet because they're a dicky-do. (For those not from the south that's where the belly sticks out further than the "dick"y do)

Don't get me started.... If you've had an amputation, if you've had a significant ulcer, if you've been revascularized then you need nail Care otherwise it's not medically necessary. I don't care if your diabetic. I don't care if you're diabetic and neuropathic. Blood flow problems then yes happy to do it and it's important.

Open a medi spa charge cash... If you're doing nail Care on these patients or anybody with fungal toenails you are just perpetuating the problem that the profession has.

 

[JewOnThis]

Op, great post. Now, get back to selling orthotics and amerigel.

 

[air bud]

Op, great post. Now, get back to selling orthotics and amerigel.

I missed you

 

[Feli]

You know if people just refused to do nail care except on truly at risk patients....

Many, many good points above.

Podiatry, as a profession overall, basically has two options to be legit and lucrative as a profession:

• #1: Have only about 6-8k podiatry docs practicing with midlevels/RN/assistants to do nail care and easy stuff and see post-ops (make it like ENT, urology, plastics, ophtho, derm, ortho, etc etc run an office)
• #2: Have maybe 10k-12k general podiatrists (office and wound stuff) and then 3k-5k or so surgical podiatrists who went on to longer training and who get funneled all of the real OR recon cases (dental type model)

I'd vote for #2 (mainly since you can't just suddenly eliminate two thirds of current pods).

In the real world we live in, with new podiatry schools opening and about 20k podiatrists and counting, you can bet that nearly all DPMs will do nail/callus care. 99% will. They need to eat. The group owner or VC or hospital or MSG demands RVUs and revenue. It's that simple. Sure, some podiatrists will do more or less nail routine foot care, but that stuff and ingrown or warts or wounds are how the bills get paid.

As it stands, you will have all of the DPMs averaging one or two OR surgery cases per week (average... some totally non-op and some hospital/ortho etc DPMs doing a bit heavier volume). However, we all know the demand for F&A surgery is far oversupplied.

It's plain to see that the vast majority of us are overtrained... and we're all undervalued due to saturation. The answers are not hard, but they're not palatable.

...Most residents will never receive the training expected in a 3 year foot and ankle surgery program because there just aren't enough cases to go around. Residency spots need to be significantly decreased (in order to maximize quality) which would also mean that school seats need to be decreased.

-The big issue is that we have all these 3 year trained foot and ankle surgeons coming out and yet their real benefit to society i.e how they make money is going to be cutting toenails, treating warts, wound debridement, and for the most part just telling people no, your foot pain is normal, buy a better shoe/insert

-In the 12 years I've been out 6 pods have retired/left and 15 have come to the area

-After 4-6 months of not doing a flatfoot recon/Achilles tendon rupture etc. You ask yourself if you should be doing them?
-I had a good/great residency. When I graduated, I just did not have the patient population in private practice demanding those procedures. My patient population essentially wanted injections for their end stage PTTD etc. ...

Yes, 100% agree. ^

My experience is completely similar (pretty good training, but use it fairly rarely as I don't push surgery on ppl, they typically don't need it). My volume - both clinic pts and surgery cases - is probably lower as I am solo as opposed to busier group office (although I don't have much ortho presence nearby).

Finishing residency, I was told by one podiatrist I liked and considered working with that, "to do a good amount of surgery as a podiatrist, you need to see a LOT of patients in the office. Most people do NOT need surgery."
As our training evolved, the option used to be that a podiatrist with solid surgical training could come out and his own group and those nearby would feed him because their training/pref was minimal surgery (the guy who said that was in that refer-to surgeon role). He got not only triples referred to him, but also bunions, met fx, and other basic stuff. There are still a few DPMs who function this way, and I thought I might also... but it's a dying breed. Now, most group owners are not C&C pods anymore... but ones who do surgery. It's the same with associates, most modern VA pods, etc. Nearly every DPM coming out of training thinks they are a bigtime recon surgeon... they refer out very little if any surgery.

The math and demand just doesn't support that with 20k podiatrists (and roughly 2.5k F&A orthos doing high volume, most gen orthos doing at least ankle fx and some F&A). There are absolutely not enough cases to go around - for podiatry training or for continued competence. PRR and PLS logs would confirm this. The fact that many pods don't even try for ABFAS confirms this.

I got a few recon and other refers from other DPMs in my early career. More recently, the only stuff I might get from other DPMs is from friendly ones IF they're out of town or OON for pt insurance... or I get pts from competition ones if they upset the pt so bad on outcome/bill that the pt finds me on their own. Every podiatrist is trying to do their own surgery - or at least keep it in their group - to get numbers or revenue or keep a full schedule. It's not sustainable, and it also causes 100% of us $50k or more of student loan interest to learn stuff most of us will very seldom use.

 

[heybrother]

Isn't it odd that they leave q modifiers as predominantly subjective criteria? Who is to say I couldn't find that pulse in a morbidly obese cankle? Lol why not use an objective metric like ABIs or NCV results? I don't get why anyone wants to qualify the 40yo Medicaid DM2 who just can't reach their feet because they're a dicky-do. (For those not from the south that's where the belly sticks out further than the "dick"y do)

The findings criteria were probably created in conjunction with an expert from the APMA forever ago ie. they wanted something "useable". Someone somewhere came up with them.

The class C findings to me are problematic ie. some are physical exam findings, some are things that require discussion - ie. I've never had a patient report "claudication" - that has to be teased out. Paresthesias is non-specific. Is it exam findings or patient reported? I suspect people use it whether the patient reports tingling or numbness or even if the physical exam shows loss of sensation. Amputations are specifically called out but nothing about past or current ulcerations or complications resulting from them. Should Charcot be a risk factor that would warrant more evaluation?

I'll put my own variation on airbud's comments. Revascularization, past / current ulceration should be "Class A" findings. I think a case could be made for Charcot even if all the Bs and Cs aren't there.

Theoretically "high risk" care is supposed to be about prevention. I had quite a few people who I thought were high risk go 1.5 years without a trim and that has shaped some of my consideration.

 

[dtrack22]

Indications for nail care should be narrowed to basically amps and objective vasculopaths (NIV study of your choice to confirm). Callus care should be allowed monthly but indications should be narrowed to amps, objective PAD, and LOPS. These visits should be treated like dental routine cleanings where an MA or Tech does all of them so the Dr can pop in and look and spend the rest of their day treating real problems. Reimbursements can drop even further since it’s going to be a $15-20 /hr employee doing them.

I have no problem with getting rid of 11720/1 and 1105X all together, but Podiatry as a profession would never let that happen. So narrower indications and a dental model in terms of who’s performing the care is the best compromise IMO.

 

[Adam Smasher]

It's adorable how naive you guys are being about this.

Firstly, no one wants to tell toenail pts to take a hike more than I do. I don't want to hear about "at-risk" pts. For all the toes I've amputated, I've yet to amputate one secondary to haphazard nail trimming. So don't talk to me about EBM. What's the NNT? No one knows. I bet it's huge. But there's no incentive for anyone in leadership to research that, because it would lead us to conclude we don't need as many schools as we have.

The laws/regs surrounding nailcare are NOT about medical evidence. This is about Medicare beneficiaries, aka voters.
1. They want their nails trimmed.
2. They want it done by a trained professional, ie someone making more than $20/h.
3. They want Medicare to pay for it.

So lawmakers collaborate with APMA to come up with rules for who's covered--which I follow to the letter--and the current state of podiatry is the result. An oversupply of overtrained surgeons cutting nails in response to the pitiless forces of supply and demand.

 

[Homo sapien]

Don't get me started.... If you've had an amputation, if you've had a significant ulcer, if you've been revascularized then you need nail Care otherwise it's not medically necessary. I don't care if your diabetic. I don't care if you're diabetic and neuropathic. Blood flow problems then yes happy to do it and it's important.

Open a medi spa charge cash... If you're doing nail Care on these patients or anybody with fungal toenails you are just perpetuating the problem that the profession has.

I 100% agree. Cutting nails on any old SOB doesn't do anything to increase reputation and skills.

 

[air bud]

It's adorable how naive you guys are being about this.

Firstly, no one wants to tell toenail pts to take a hike more than I do. I don't want to hear about "at-risk" pts. For all the toes I've amputated, I've yet to amputate one secondary to haphazard nail trimming. So don't talk to me about EBM. What's the NNT? No one knows. I bet it's huge. But there's no incentive for anyone in leadership to research that, because it would lead us to conclude we don't need as many schools as we have.

The laws/regs surrounding nailcare are NOT about medical evidence. This is about Medicare beneficiaries, aka voters.
1. They want their nails trimmed.
2. They want it done by a trained professional, ie someone making more than $20/h.
3. They want Medicare to pay for it.

So lawmakers collaborate with APMA to come up with rules for who's covered--which I follow to the letter--and the current state of podiatry is the result. An oversupply of overtrained surgeons cutting nails in response to the pitiless forces of supply and demand.

Easily the most real thing written on here...

 

[heybrother]

Since we're talking about being naive - I admit I'm naive in dreaming that CPME would force podiatry schools to raise their minimum MCAT to the 50th percentile. That would require an increasing from like 493 which is the 25th percentile (yeah) to 501-502 (49-51%).

A review of my in system collections (not cash) from insurance shows nail/callus codes make up 7% of my collections for this year. I thought it would be dramatically higher. The numbers themselves are not "wrong" though they are an understatement concerning the volume of patients who present to discuss a callus or want their nails cut.

I'm attempting to be quite a bit more aggressive about letting people at a first visit know that their nails and calluses are uncovered and it is improving my collections. You can't collect what you don't ask for. I've probably told this story on here before, but a long time (30+ year) staff member who has essentially only worked podiatry her whole career did tell me one time - "what about the people who can't pay? Is it just "f*** them". I didn't go into this to be Satan, but I also didn't agree to cut every nail and callus in the world. The original owner of the practice had all sorts of patients presenting with various cash pay prices where people were paying from $30-35-40-45-70 to come in and have nails or calluses trimmed. He also was a regular abuser of the 99212. I'm sure he felt he was doing the right thing and helping people but he also simultaneously complained that the office was being destroyed and no money was being made. I looked back as far as Athena would let me and the office really wasn't making any money until I arrived. For many of our fee schedule prices I have over the last few years increased them by 50% or greater. I'm mostly of the opinion that the prices for our services need to be increased within reason until I'm satisfied. A cash pay visit shouldn't be a bad encounter - it should cost what the value of our services are. That said, our uncovered prices have only gone up 20ish% and there is more pushback. Some of it is ability to pay. Some of it is just the old "Medicare should pay for this". I'm of the opinion it would be difficult to get patients to pay what CMS currently reimburses for nail/callus services when performed together, but you can't collect what you don't ask for.

 

[PTPuser]

Since we're talking about being naive

You mentioned something in the past about how podiatry should be like dentistry where majority of it can be done in clinic and I still think about that and how I can shape that vision for my future.

 

[Forcewielder]

It's adorable how naive you guys are being about this.

Firstly, no one wants to tell toenail pts to take a hike more than I do. I don't want to hear about "at-risk" pts. For all the toes I've amputated, I've yet to amputate one secondary to haphazard nail trimming. So don't talk to me about EBM. What's the NNT? No one knows. I bet it's huge. But there's no incentive for anyone in leadership to research that, because it would lead us to conclude we don't need as many schools as we have.

Honestly that's bizarre you've never seen that. I've amputated at least a half dozen in my short career. People often cut themselves, do Epsom salt soaks until the toe is blown up and it is probing to bone. Must have to do with patient population because mine are all do-it-yourself rural folk.

 

[Hybrocure]

Honestly that's bizarre you've never seen that. I've amputated at least a half dozen in my short career. People often cut themselves, do Epsom salt soaks until the toe is blown up and it is probing to bone. Must have to do with patient population because mine are all do-it-yourself rural folk.

The only ones I’ve had to amp were from other docs and mainly from nail procedures moreso than nail trimmings. I think some people either have poor patient selection for their matrixectomies or are too aggressive. Usually the former. I don’t use blades on my nail procedures which I think helps avoid that.


Oh god this is sounding like a PM News reply..

 

[heybrother]

You mentioned something in the past about how podiatry should be like dentistry where majority of it can be done in clinic and I still think about that and how I can shape that vision for my future.

I think sometimes we can get ourselves into trouble when we talk about other profession and don't necessarily understand the nitty gritty ie. I'm sort of under the impression that dentists do great but do have high overhead costs due the labs they use / supply costs. So I could be barking up the wrong tree praising them. That said, the idea of the doctor focusing on things that are worth $500-thousands of dollars while someone else grinds out the basics definitely has an appeal.

The problem though is the fee schedule game still works against us even in the office because of how the foot has been ground down. I did a 28113 / 5th metatarsal head resection on an older woman today. Watched a 1st year anesthesiology resident struggle to intubate (but he did learn by doing). If I did the procedure in the office with epi, which probably would not be the right thing to do, it would still only be worth $560. I'm sort of under the impression dentists got 2x that for a crown like ...15 years ago.

 

[heybrother]

The only ones I’ve had to amp were from other docs and mainly from nail procedures moreso than nail trimmings. I think some people either have poor patient selection for their matrixectomies or are too aggressive. Usually the former. I don’t use blades on my nail procedures which I think helps avoid that.


Oh god this is sounding like a PM News reply..

When you retire you can keep going to podiatry conferences and then walk up to the microphone at the end of every lecture to tell the story of that 1 time you saw something 30 years ago.

 

[Hybrocure]

When you retire you can keep going to podiatry conferences and then walk up to the microphone at the end of every lecture to tell the story of that 1 time you saw something 30 years ago.

And you can drop an obscure term that starts with Ony-

 

[heybrother]

I still remember my first (and only) cause of onychomycosis leading to osteomyelitis. I will submit the case and my stats to adamsmasher so he can calculate the NNT. It is obviously proof that nailcare is essential!

 

[Hybrocure]

I still remember my first (and only) cause of onychomycosis leading to osteomyelitis. I will submit the case and my stats to adamsmasher so he can calculate the NNT. It is obviously proof that nailcare is essential!

Are you sure it was onychomycosis?

Or was it onychogryphosis? Or Onychodystrophy?


Onychomyelitis?

 

[heybrother]

Are you sure it was onychomycosis?

Or was it onychogryphosis? Or Onychodystrophy?


Onychomyelitis?

I did not take biopsy so the world will never know. The patient had a swollen hallux IPJ. His PCP was treating it for gout. I removed part of the nail and pus came out from a sinus. X-ray shows bone dissolution. He had a history of vascular interventions. I told him we needed to let his vascular surgeon know. He told his PCP and they sent him to a WHC. He's probably still there having a curette stuck into that sinus. There is something very funny to me about billing a 99204 and a 11720.

 

[Adam Smasher]

Honestly that's bizarre you've never seen that. I've amputated at least a half dozen in my short career. People often cut themselves, do Epsom salt soaks until the toe is blown up and it is probing to bone. Must have to do with patient population because mine are all do-it-yourself rural folk.

Depending on how deep they cut themselves, I can see how this would be true. However I'll see your anecdote and raise you mine: I have patients who often cut themselves, and then they just heal. Remember your diabetic foot ulcer triad: neuropathy, deformity, and repetitive trauma. Cutting the skin while cutting the nail isn't repetitive trauma. It's barely trauma at all.

This is all confounded by PAD, which I take much more seriously. Even then, is the amputation due to PAD or is it due to cutting the nail too short? Was World War I a result of the rising tension due to nationalism and militarism amongst European nations? Or was it simply due to the assassination of Franz Ferdinand?

 

[Homo sapien]

Since we're talking about being naive - I admit I'm naive in dreaming that CPME would force podiatry schools to raise their minimum MCAT to the 50th percentile. That would require an increasing from like 493 which is the 25th percentile (yeah) to 501-502 (49-51%).

A review of my in system collections (not cash) from insurance shows nail/callus codes make up 7% of my collections for this year. I thought it would be dramatically higher. The numbers themselves are not "wrong" though they are an understatement concerning the volume of patients who present to discuss a callus or want their nails cut.

I'm attempting to be quite a bit more aggressive about letting people at a first visit know that their nails and calluses are uncovered and it is improving my collections. You can't collect what you don't ask for. I've probably told this story on here before, but a long time (30+ year) staff member who has essentially only worked podiatry her whole career did tell me one time - "what about the people who can't pay? Is it just "f*** them". I didn't go into this to be Satan, but I also didn't agree to cut every nail and callus in the world. The original owner of the practice had all sorts of patients presenting with various cash pay prices where people were paying from $30-35-40-45-70 to come in and have nails or calluses trimmed. He also was a regular abuser of the 99212. I'm sure he felt he was doing the right thing and helping people but he also simultaneously complained that the office was being destroyed and no money was being made. I looked back as far as Athena would let me and the office really wasn't making any money until I arrived. For many of our fee schedule prices I have over the last few years increased them by 50% or greater. I'm mostly of the opinion that the prices for our services need to be increased within reason until I'm satisfied. A cash pay visit shouldn't be a bad encounter - it should cost what the value of our services are. That said, our uncovered prices have only gone up 20ish% and there is more pushback. Some of it is ability to pay. Some of it is just the old "Medicare should pay for this". I'm of the opinion it would be difficult to get patients to pay what CMS currently reimburses for nail/callus services when performed together, but you can't collect what you don't ask for.

Yes indeed f them and their free nails. We can't do free labor for everyone. F them all

 

[Forcewielder]

Was World War I a result of the rising tension due to nationalism and militarism amongst European nations? Or was it simply due to the assassination of Franz Ferdinand?

Well clearly it was due to a secret oligarchy that was pushing for a world War that would allow for Scottish independence. Haven't you seen the documentary The King's Man?

 

[podwho]

Lots of good thoughts and comments in this thread.

Podiatry school is a gross misinterpretation of what your professional career will be. Your sheltered and protected from the outside world. Taking classes along side MD/DO thinking you are one of them. Then you get to third and fourth year and instead of continuing your medical training doing rigorous medicine and surgical rotations with these MD/DO students you have to pay out of pocket to travel all around the country to do podiatry externships and suck up to residents and attendings hoping they will pick you to match at their program. Burning a lot of money and time when you should be training doing real rotations in other medical and surgical specialties before you enter residency. Then you come back from your podiatry externships to do some core rotations at local hospitals and realize how much medicine you don't know.

Then you get to residency. You do your non podiatry rotations and realize how much you don't know. You forget about that when you get back on podiatry rotations and you are doing big cases thinking you are really important. Then you do another off service rotation and realize you have no idea what you are doing when it comes to medical management or handling things on other surgical services because you were really never exposed to it as a student because you were laughing at that podiatry attendings jokes on your externship to make them like you.

During residency you start to pick up the differences in how other doctors and nurses talk to you when they realize you are not an MD/DO. Then you feel the underlying disrespect that is never blatant but subtle. The tone in how they talk to you. Almost like you are not a fellow attending but a student almost. It is hard to describe. We are just there but not really considered needed or important. We are a luxury for these other services who can just dump whatever they don't want to do on you. That is what podiatry is.

You graduate and think you will use all this high quality surgical training. For the 10% of graduates who get employed by a hospital you will use some of them. For those who work at major Level I and II trauma centers (which is an even smaller percentage) you will use all of those skills because you will actually get the diverse pathology and volume. Everyone else will work private practice and do toes and forefoot for the most part with some other elective recon if they feel comfortable with it. You will do toenails and diabetic limb salvage (if you are comfortable with offloading surgeries and charcot) and you will do basic wound care. That's about it.

What they sold you in school and what you get in reality statistically are two very different things. Anybody who is an attending on here and has been in practice for 5-10 years and disagrees with what I am saying please chime in.

Lastly, what makes it worse or harder to be a podiatrist is the saturation. You get a great hospital job you really never have the ability to stick up for yourself. As soon as you are deemed a problem for admin because an MD/DO complains about you then you become expendable. There will be 300 DPMs ready to apply for your job when it gets posted. This hurts us negotiating salaries on future contracts. It hurts careers. We have no leverage.

Thats why you have to accept your role, or do what I did and go into it for the money, run your own practice and clear 250-400 doing boring ass work, occasional grafts, basic forefoot sx and enjoy your life outside of 9-5 because making money and spending it is way more fun then being a podiatrist.

 

[Retrograde_Nail]

Thats why you have to accept your role, or do what I did and go into it for the money, run your own practice and clear 250-400 doing boring ass work, occasional grafts, basic forefoot sx and enjoy your life outside of 9-5 because making money and spending it is way more fun then being a podiatrist.

Are you a solo practitioner or do have associates helping you make profit? I’d respect you more if you were solo. 250k was a lot of money 10 years ago.

 

[Feli]

Are you a solo practitioner or do have associates helping you make profit? I’d respect you more if you were solo. 250k was a lot of money 10 years ago.

Amen.

$250k ten years ago would get you a big pimpin Ferrari 458 Italia. Now, a Ferrari EV costs over twice that. So, even MD surgeons will be feeling the crunch of inflation.

I still lol at the pods coming out of residency who think $150k or $200k/yr is "enough"... if you're single and like 2br condo and barely ever eating out and paying for 20yrs on your loans. Cost of living and student loan interest rates have been a killer ever since Covid (but luckily the market has kept pace).

 

[deleted1162946]

Amen.

$250k ten years ago would get you a big pimpin Ferrari 458 Italia. Now, a Ferrari EV costs over twice that. So, even MD surgeons will be feeling the crunch of inflation.

I still lol at the pods coming out of residency who think $150k or $200k/yr is "enough"... if you're single and like 2br condo and barely ever eating out and paying for 20yrs on your loans. Cost of living and student loan interest rates have been a killer ever since Covid (but luckily the market has kept pace).

I’m starting out at $200k but want to make 300+ then I’ll likely be comfortable. $200k is hard to pay off loans for sure

 

[Feli]

And now we have psychiatrist making $400k+ routinely... awesome.
They don't even put on gloves or do procedures. Call zero to minimal.
I'd imagine their malpractice is pretty cheap (occasional bipolar ppl's family trying to blame you for a suicide?).
They can run a PP with just one scheduler... virtually no supplies or assistants or anything needed. A notepad and eRx.
Add that to CRNA and RN and 25 MD/DO specialties that are better job and ROI than DPM.

But DPMs have parity... APMA ftw there. Let's open some more podiatry schools. 🙂

 

[Retrograde_Nail]

I’m starting out at $200k but want to make 300+ then I’ll likely be comfortable. $200k is hard to pay off loans for sure

Private practice podiatry or hospital/MSG employed?

 

[podwho]

Are you a solo practitioner or do have associates helping you make profit? I’d respect you more if you were solo. 250k was a lot of money 10 years ago.

Yes. Less than 2 yrs out. On pace for 275 and with new ipa rates and growth I am aiming for 350 next yr. Depends how much I want to work honestly. Might hire an associate if it keeps growing. Let’s not forget business owner income is > w2.

I agree, 200 is nothing post covid inflation.

 

[deleted1162946]

Private practice podiatry or hospital/MSG employed?

MSG

 

[Feli]

Yes. Less than 2 yrs out. On pace for 275 and with new ipa rates and growth I am aiming for 350 next yr. Depends how much I want to work honestly. Might hire an associate if it keeps growing. Let’s not forget business owner income is > w2.

I agree, 200 is nothing post covid inflation.

Yes, this is the way to do it. That is good if you bought out a retire office... very good if that's a cold startup.

That's where I think the biggest frustration comes for employed PP associate and supergroup pods (so vast majority of DPMs): no choices. Even more than relatively low income for what they produce, they realize a couple years in they are trapped... usually no room for advancement, no ownership, little control of staff/supplies/marketing, no legit path to more income, and can't take more time off without losing income. If they get busy or get a good rep, owner usually just hires another associate. It's an endless career path as a worker bee.

 

[Retrograde_Nail]

MSG

That’s pretty low salary for MSG. You are worth more than that.

 

[deleted1162946]

That’s pretty low salary for MSG. You are worth more than that.

Best I could do out of residency. Hope to bonus and make more