What is the NORM of what we do?

[malleolusman]

After having been in school and meeting lots of podiatrists and so forth, it seems there is big difference between what some proclaim it is "what we do".

For one thing, some podiatrists i've spoken with say things like "well, the reality is SX doesn't pay that well . . the bread and butter is in the conservative care. thats where you make a living" I am wary of that statement after reading/hearing others experiences, if the SX doesn't pay, then why do we have podiatrists signing with ortho groups?

Others here, who are employed by Temple, are STRICTLY surgical podiatrists, who perform phenomenally complex (at least to me right now!) procedures. This makes sense, since they are employed by the university, so therefore their sub- speciality I guess is strictly podiatric surgery. Then there are others working specifically in hospital based settings doing team-limb salvage. Then back home, I shadowed a podiatrist who does SX three times a week, at the same time does basic clinical care as well 5 days a week. Then, I hear of the podiatrists who do a little bit of everything: wound care, c&c, sx. Then I read/hear about the podiatrists coming fresh out of residency to sign with ortho groups, and I imagine they would not being doing ANY conservative care. Nothing but SX?

What is the norm here? What is the reality upon graduating from residency and moving into a practice setting & is our profession trying to head for SX only or are the discrepancies just a result of truly widely ranging residency education??

experienced pods/residents your input would be appreciated

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[PADPM]

I don't really think there is a "norm". As you've already observed, there are many types of practice models. However, this is true in many specialties. There are ob-gyn's that only do gyn and no longer do any ob. There are orthopedic groups in my area that have some orthopods that are actually no longer performing surgical procedures due to malpractice premiums. They do workmen's comp exams, evaluations, non-operative fracture care, etc.

There are opthamologists that only perform cataract surgery and others that specialize in retina, Lasik surgery, etc.

There are dermatologists that are now opening "skin care" cosmetic center and are performing Botox treatments, Sculptra injections, Restlyene injections, etc., and there are those that have "traditional" dermatology practices treating acne, psoriasis, skin lesions, etc.

If you have a surgical practice, it can "pay", if you utilize your O.R. time efficiently and have decent insurance coverage. If there is a lot of managed care in your area and you are running to the hospital and your case is "bumped" and are spending 3 hours of your day to perform a 45 minute case that pays $400, it's not exactly "cost effective". But if your patient needs surgery, your patient needs surgery.

In my particular area, I probably make more money in the office than the O.R., no matter how complex the case. More complexes cases usually take more time, and also require more post op follow up. The majority of insurance companies have a "global" fee which encompasses post op visits, which means you don't get paid for post op care for 30, 60 or 90 days depending on the procedure.

If you are efficient, and have several cases lined up at a time, surgery can be financially rewarding, not to mention rewarding to you and your patient.

Most orthopedic practices that hire DPM's can do so because they are already so busy and overloaded. I know of very few if any orthopedic practices that are "hurting for patients". Orthopedic surgeons have no bias against them from the medical community and receive referrals for every possible ache, pain and injury. They also receive referrals from the E.R., etc. Many orthopods I know are HAPPY to not touch feet, so when a DPM walks in they are busy from day one, and these orthopedic groups don't get referrals for corns, ingrown nails and calluses. It's just the nature of their business.

Our practice has over a dozen doctors, and some are more surgically oriented than others. I've actually cut back on my surgical load in an efforrt to let some of our younger associates obtain their cases for board certification.

Since that time, my "production" income has not dropped. Additionally, one of our doctors who performs the least surgery in our practice is one of our highest income producers.

So there really is no "norm". It depends on your training, your geographic area, your referral base and your eventual own decisions. If you open your own practice and decide to only perform surgery, you must decide what to do when a patient with a non surgical problem calls you.

My philosophy was to never turn down a patient no matter how trivial the problem, and I built a pretty large practice. That's not to say I didn't "turn down" patients. I refused to accept certain insurance carriers because I couldn't work for free, and I would not perform surgery on patients if I "got that feeling" (podfather knows "that feeling"). But I built my practice by providing the full scope of care. When I got "big enough", I was able to pick and choose and have my associates see patients IF I didn't want to.......but that still hasn't happened.

After ALL these years, if one of my "original" patients can't make it to the office, I will actually make a house call, because I'm loyal to those that came to me when I was starting out and was seeing 10 patients a week.

I will never forget those patients and now that they're getting up in years, I won't send one of my associates. I go to his/her home and I'm happy to help. And after all these years, they still bake me cookies.

 

[malleolusman]

great insight. thanks

 

[newankle]

There really is no "norm". Most podiatrists do a little of everything. I do no wound care and no diabetic primary care (checkups, nails, calluses). We have cast techs that do all our casting and bracing and our PT's do my orthotics. I do all surgical and non surgical care of the foot and ankle otherwise but I'm in an orthopaedic practice and that's where the interest lies.

 

[Podfather]

couldn't work for free, and I would not perform surgery on patients if I "got that feeling" (podfather knows "that feeling").

Amen. It's nice to have another "old bull" on this site.

 

[Feli]

...I read/hear about the podiatrists coming fresh out of residency to sign with ortho groups, and I imagine they would not being doing ANY conservative care. Nothing but SX?...

That sounds like a great way to lose your license.^

Every surgeon does some amount of conservative care since every elective surgery patient needs to fail that route before surgery is indicated as a treatment. Any F&A surgery text - pod or ortho - will also have plenty of info on the non-operative treatments that should be tried for deformities before surgery enters the treatment plan. It might not always be the surgeon themself making the orthotic/brace, showing the patient stretching excercises, giving the injections, providing diabetic education, etc. That stuff might have been done by the PCP, another community pod, another specialist, or a PA or PT. Who knows? The point is that the conservative care has to get done somewhere (and it needs to be documented)... if it didn't get done and documented, then the surgeon is essentially scheduling the patient for elective surgery that's not indicated. Not wise.

Besides just the chance that good quality conservative care will make a deformity or ailment syptoms improve to the point that surgery can be delayed or avoided altogether, it's just a good way to build a patient relationship. You are well trained to provide conservative care, and the patient is paying you to apply all of your skill and knowledge - not just the surgical portion. Should you reach the point of surgery and then get a less than optimal result (infection, nonunion, persistent pain, recurrence, etc etc), I will bet you dollars to doughnuts that the time you spent gaining the patient's trust and trying to avoid the surgery becomes solid gold. The doc-patient relationships is the factor that is far and away the most likely to save your skin when you need to have that frank discussion with the patient that the operation failed, they need revisional surgery, they need amp, etc. However, if you are the simple technician who barely gives lip service to conservative care before promptly scheduling each bunion patient for anesthesia and an osteotomy, then not only are you missing out on a chance to conservatively help the patient and gain their trust, but you're also missing a lot of money.

When all else fails, just think about what you'd want if you were the patient. If a doc A wanted you to "sign here" for him to cut on your foot right off the bat yet doc B explained your condition, formulated a conservative care plan, made your symptoms nearly disappear without surgery, you'd tell your friends and family to avoid doc A yet be singing the praises of doc B to anyone who you ran across. If you ever got to the point where you needed surgery, who would you go to: the guy who offered you nothing but surgery (since that's "what he does") or the doc who took time to educate you and gave you all your viable options?

A foot and ankle ortho or a well trained DPM who is working in an ortho group almost certainly does more surgery than the avg DPM working solo or in a pod group, but the patients still all get conservative care for their deformity in one form or another. The ortho group is obviously viewed by referring docs as the surgical solution, so more of their patients will be just pre/post op. The pod groups will be viewed more as a comprehensive foot care provider, so they will have more non-operative patients and also be relied on for the whole spectrum from initial visit to surgery to long term follow up.

As was stated, there is really is no "norm" for a DPM. Every training program has its emphasis, and every individual has their interests. It all depends on what you want to focus on and how much you value money, family/free time, interesting cases (and what you consider interesting), etc.
DPM1 might do office 2d per week, rounds/consults 1d per week, wound care 1d per week, and surgery 1d per week.
DPM2 might do office 3d per week, nursing home 1d per week, refer out his surgery, and take 3 day weekends - every weekend.
DPM3 might do office 2d per week, surgery 2d per week, and rounds 0.5d per week, and sport team exams 0.5d per week.

I would guess that for recent grads, the initial average is roughly 3d office, 0.5d surgery, 0.5d wound care, and 0.5d rounds/consults. You might get heavier on surgery if you work in an ortho/multispec group or just more surg cases as you gain more overall patients. It varies a lot, though. A lot of wiser pod groups tip the scales and make themselves more efficient by having one partner or associate heavy on office, one or two heavy on surgery, one heavy on rounds/consults, one heavy on wound care, etc. That maximizes everyone's efficiency and productivity since it optimizes billing/competency in that area and cuts down on commute time. Medicine is always becoming more and more specializes... jack of all trades is a master of none.

 

[NatCh]

Amen. It's nice to have another "old bull" on this site.

I guess we could say this forum is "full of bull."

Ha ha.