What made the 3 year surgical residency a requirement?

[The Last Reclaimer]

Just hear me out. I've been looking into podiatric medicine for almost a month. It sounds like the surgical volume of practice for each podiatrist can vary greatly. Some do lots of surgery, some almost do none, some are in some variance in between the two polar sides of that spectrum. Why make the three-year surgical residency a requirement, why isn't it optional? Is the foot and ankle surgical needs of the US that high? I'm sorry if that sounds like a weird or foolish question, but I'm just curious. Thanks all!

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[Weirdy]

Just hear me out. I've been looking into podiatric medicine for almost a month. It sounds like the surgical volume of practice for each podiatrist can vary greatly. Some do lots of surgery, some almost do none, some are in some variance in between the two polar sides of that spectrum. Why make the three-year surgical residency a requirement, why isn't it optional? Is the foot and ankle surgical needs of the US that high? I'm sorry if that sounds like a weird or foolish question, but I'm just curious. Thanks all!

Are you content with clipping toenails or seeing nothing but wounds all day?

You might not do surgery after you get out. You may never use the full breath of your training when you get out. This is both by personal preference and by realizing where you stand in terms of being comfortable with the procedures you do.

But you WILL be judged on your training by hospitals and other physicians who send patients to you.

Don't limit an already limited profession. A DPM in the US is not like a DPM in other countries.

 

[Feli]

MDs and DOs all do 3yrs minimum... that is the structure DPMs chose also: 3 year residency which includes surgery.

Honestly, even before podiatry school is done, you already know skin and nail issues, ingrowns, injections, insoles, common Rx, wound care, etc pretty well. The residency is just to reinforce that stuff for anyone who wasn't paying good attention in school... and mainly to learn F&A surgery and hospital consults. Good students will already know most of the surgical indications and basics of procedure selection and execution (on paper), but you need to actually learn and hone the techniques with repetition and mentorship.
...if you ask me, it should be 2yrs for most (general podiatry) and 4yrs for some (podiatry surgery)... sorta like dentists. Is there that much surgery for everyone to be doing it? Well, it depends on your practice and referral base. The present thinking is that every podiatrist sees bunions, wounds, flat feet, etc... so they all need to know how to fix them (or at least how to recognize them and know when they need surgey to refer them out if they won't/can't fix it). As above, better to have it and not need it than need it and not have it. It is like in your other thread where different DPMs have different office/surgery ratio based on practice setup... just like Uro or ENT or GSurg or etc - but they nearly all do at least some surgery.

Regardless, it is what it is. If you wanted to be a non-surgical podiatrist, you'd still need 3yrs. We have a podiatry medicine board which most pass (ABPM) and a podiatry surgery board (ABFAS) which fewer pass... and both require 3yr residency completion for eligibility.

If you wanted to do podiatry with less than 3yrs PGY training in present day and beyond, then you could drop from residency after 1 or 2yrs and still get a state license in most places. You wouldn't be elgible for any recognized podiatry board. You could probably get "certified" by one of the fake boards, but you'd be relegated to house calls, office work, rural areas and non-surgical cases unless you found a place crazy enough to give you OR privileges. Not recommended.

...in the end, nobody is going to tell you (or care) if you do or do not go to podiatry school. It is a personal decision, and I'd suggest shadowing DPMs in your area. Try some in private office, some at a hospital clinic, ortho group DPM if available in your or nearby area, etc.

 

[deleted1066189]

Just hear me out. I've been looking into podiatric medicine for almost a month.

Did you end up taking the MCAT yet?

 

[The Last Reclaimer]

Did you end up taking the MCAT yet?

No.

 

[The Last Reclaimer]

Are you content with clipping toenails or seeing nothing but wounds all day?

You might not do surgery after you get out. You may never use the full breath of your training when you get out. This is both by personal preference and by realizing where you stand in terms of being comfortable with the procedures you do.

But you WILL be judged on your training by hospitals and other physicians who send patients to you.

Don't limit an already limited profession. A DPM in the US is not like a DPM in other countries.

Hi weirdy. Again thanks for your insight. Your answer confuses me a bit.

You’re saying that I might have no choice but to do nothing but clinic, and you’re also saying don’t limit a limited profession.

Sorry for my ignorance.

 

[The Last Reclaimer]

MDs and DOs all do 3yrs minimum... that is the structure DPMs chose also: 3 year residency which includes surgery.

Honestly, even before podiatry school is done, you already know skin and nail issues, ingrowns, injections, insoles, common Rx, wound care, etc pretty well. The residency is just to reinforce that stuff for anyone who wasn't paying good attention in school... and mainly to learn F&A surgery and hospital consults. Good students will already know most of the surgical indications and basics of procedure selection and execution (on paper), but you need to actually learn and hone the techniques with repetition and mentorship.
...if you ask me, it should be 2yrs for most (general podiatry) and 4yrs for some (podiatry surgery)... sorta like dentists. Is there that much surgery for everyone to be doing it? Well, it depends on your practice and referral base. The present thinking is that every podiatrist sees bunions, wounds, flat feet, etc... so they all need to know how to fix them (or at least how to recognize them and know when they need surgey to refer them out if they won't/can't fix it). As above, better to have it and not need it than need it and not have it. It is like in your other thread where different DPMs have different office/surgery ratio based on practice setup... just like Uro or ENT or GSurg or etc - but they nearly all do at least some surgery.

Regardless, it is what it is. If you wanted to be a non-surgical podiatrist, you'd still need 3yrs. We have a podiatry medicine board which most pass (ABPM) and a podiatry surgery board (ABFAS) which fewer pass... and both require 3yr residency completion for eligibility.

If you wanted to do podiatry with less than 3yrs PGY training in present day and beyond, then you could drop from residency after 1 or 2yrs and still get a state license in most places. You wouldn't be elgible for any recognized podiatry board. You could probably get "certified" by one of the fake boards, but you'd be relegated to house calls, office work, rural areas and non-surgical cases unless you found a place crazy enough to give you OR privileges. Not recommended.

...in the end, nobody is going to tell you (or care) if you do or do not go to podiatry school. It is a personal decision, and I'd suggest shadowing DPMs in your area. Try some in private office, some at a hospital clinic, ortho group DPM if available in your or nearby area, etc.

I understand what you’re saying. I am asking specifically about the surgical component of residency not being optional.
The overall vibe that I’m getting is that the amount of surgery you’re doing is going to be limited in quantity. That there is a surplus in podiatrists doing surgery, therefore you’ll end up doing a low amount overall, so why not make the surgical component optional. I should’ve clarified that in my post my apologies

 

[Weirdy]

Hi weirdy. Again thanks for your insight. Your answer confuses me a bit.

You’re saying that I might have no choice but to do nothing but clinic, and you’re also saying don’t limit a limited profession.

Sorry for my ignorance.

Making residency optional (which you are trained in both surgery and further medical management of foot/ankle pathology) limits this profession.

You are not learning just surgery during residency.

 

[The Last Reclaimer]

Chill out. It doesn't matter what I "like", but making a blanket statement that 99% of DPMs perform surgery is simply inaccurate.

There's also a misconception regarding those who are trained in surgery and those who actually perform surgery on a regular basis. Not everyone who has surgical training is competent to perform surgery, and they often learn that soon after starting practice. Having a patient who is 100% under your care, from start to finish is much different than performing cases as a resident. It doesn't take too many poor results in private practice, to make some people a little gun shy.

In my experience over many years of practice, is that realistically the vast majority of DPMs are spending most of their time in the office and not the OR.

And I believe that number will be even greater as health care changes are implemented. Any of you who are already in practice understand that many elective procedures now require pre authorization. With the exception of trauma or infection, the majority of foot and ankle surgery is elective. There will continue to be more scrutiny and more and more procedures will need pre authorization. Insurance companies will start (and many have already) requiring more non surgical care be attempted prior to approving elective cases.

I foresee the surgical volume of the average private practice DPM to actually decrease over the next few years due to cutting back on elective surgery. This is also happening with spine surgeries, arthroscopic procedures, physical therapy allowances, etc.

The insurance carriers are tighenting their belts and the end result will mean less elective surgery for all professions. It just so happens that a lot of what we bring to the OR is elective.

This right here is what convinced me the surgery Component should be optional.

Sorry for being a pain. I’m just trying to figure out the profession as best as possible the APMA is extremely vague about the surgical component.

 

[Feli]

... I’m just trying to figure out the profession as best as possible...

Shadow.

You can talk for 10 years about what deep sea fishing or picking up girls or playing lacrosse or whatever is like, but one day trying it with someone proficient in that skill is worth much more. Optho, ENT, Urology, OB, etc etc spend more avg time in clinic than surgery also... certainly doesn't mean they wasted their time learning procedures. Even most ortho and gen surg and plastics and vasc are roughly 50/50.

You seem caught up in the "is profession X worthy of me." In reality, a lot of students never get into professional school... many others drop out or flunk out. Others don't fully apply themselves. Every profession will have its leaders and its riders on the struggle bus. The correct question then becomes if you are worthy of the profession and if you will be motivated to succeed. Again, shadow and try to surround yourself with the best and brightest in podiatry or wherever you consider. If you can see yourself satisfied, get the training and apply yourself to the fullest extent possible. GL

 

[Weirdy]

What Feli said.

Stop asking. Start jumping.

Even if we tell you its all sunshine and rainbows and surgery is great blah blah blah, you will never want to commit to anything (yes or no) because you will always be asking "What if ?"

Stop being indecisive. Stop making life decisions based on what you read from an internet forum. Shadow multiple DPMs, study harder for your MCAT, and start thinking for yourself and formulating your own opinions about whatever profession you choose after SEEING and DOING as much as you can.

An internet forum will never give you the full picture.

 

[heybrother]

Forget about surgery for a second. Forget about what the right number of years is.

Podiatry school does not produce graduates who are ready to practice independently. PERIOD.

Even if we were talking practicing on some sort of European level - chip, clip, nail fungus, plantar fasciitis, orthotics - graduating students wouldn't be able to walk into a clinic and impress anyone. The schooling is designed to produce future residents, not future independent limited practitioners.

Sit in a corner as a 2nd/3rd year resident letting a student talk to the patient OR watching a student not know what to do when the patient doesn't get numb during a matrixectomy and you'll know this.

 

[The Last Reclaimer]

Forget about surgery for a second. Forget about what the right number of years is.

Podiatry school does not produce graduates who are ready to practice independently. PERIOD.

Even if we were talking practicing on some sort of European level - chip, clip, nail fungus, plantar fasciitis, orthotics - graduating students wouldn't be able to walk into a clinic and impress anyone. The schooling is designed to produce future residents, not future independent limited practitioners.

Sit in a corner as a 2nd/3rd year resident letting a student talk to the patient OR watching a student not know what to do when the patient doesn't get numb during a matrixectomy and you'll know this.

I understand what you’re saying and I worded my original post poorly. What I was trying to ask is why is the surgical component of residency not optional, not Podiatric residency itself.

 

[Weirdy]

I understand what you’re saying and I worded my original post poorly. What I was trying to ask is why is the surgical component of residency not optional, not Podiatric residency itself.

Why would it be? Not trying to come off aggressive, but I don't think you understand how limited this profession is.

Surgery is a tool, a treatment option to whip out and perform when circumstances call for it.

You are a foot and ankle doctor. You are already limited to that one area of the body. No one outside of your profession knows what you do or what you are capable of treating.

Why limit yourself further by making surgical training optional?

 

[The Last Reclaimer]

Why would it be? Not trying to come off aggressive, but I don't think you understand how limited this profession is.

Surgery is a tool, a treatment option to whip out and perform when circumstances call for it.

You are a foot and ankle doctor. You are already limited to that one area of the body. No one outside of your profession knows what you do or what you are capable of treating.

Why limit yourself further by making surgical training optional?

Im re-reading my original post and I really should've taken way more time explaining my reasoning for the question. You're not being aggressive, I screwed up my writing.

From both shadowing locally where I live and browsing on here, it seems like the demand for foot and ankle surgery is low for most podiatrists compared to that of foot and ankle care demands that can be dealt with in the clinic. So why not make the surgical component optional if the alleged surgical demand per podiatrist is so low. It would make the residency training shorter and podiatrists could start practicing sooner. And if a podiatrist wants to pursue further training, then it's their option to do so.




Then again I could be completely underestimating the demand/supply ratio for foot and ankle surgery from podiatrists.

 

[Weirdy]

Im re-reading my original post and I really should've taken way more time explaining my reasoning for the question. You're not being aggressive, I screwed up my writing.

From both shadowing locally where I live and browsing on here, it seems like the demand for foot and ankle surgery is low for most podiatrists compared to that of foot and ankle care demands that can be dealt with in the clinic. So why not make the surgical component optional if the alleged surgical demand per podiatrist is so low. It would make the residency training shorter and podiatrists could start practicing sooner. And if a podiatrist wants to pursue further training, then it's their option to do so.




Then again I could be completely underestimating the demand/supply ratio for foot and ankle surgery from podiatrists.

Further splitting an already small and divided profession does nothing to add value to our profession as a whole. Especially when we are fighting an uphill battle in terms of recognition and awareness among MD/DO colleagues.

Now you are starting to sound like you want to push an agenda a few other DPMs have wanted instead of asking legitimate questions as a pre-pod.

What good would it do to explain to MD/DO/hospitals "Yes I am a foot and ankle specialist. No I cannot operate, but I can do everything else. Yes we have a residency but it further divides into 2 tracks."

I don't think you've seen enough down river to understand how many people truly have no idea what we do and what we bring to the table in terms of both revenue and skillset.

 

[The Last Reclaimer]

Further splitting an already small and divided profession does nothing to add value to our profession as a whole. Especially when we are fighting an uphill battle in terms of recognition and awareness among MD/DO colleagues.

Now you are starting to sound like you want to push an agenda a few other DPMs have wanted instead of asking legitimate questions as a pre-pod.

What good would it do to explain to MD/DO/hospitals "Yes I am a foot and ankle specialist. No I cannot operate, but I can do everything else. Yes we have a residency but it further divides into 2 tracks."

I don't think you've seen enough down river to understand how many people truly have no idea what we do and what we bring to the table in terms of both revenue and skillset.

I understand you’re view point that does make sense.

Sorry about that. These were questions that popped up in my head while shadowing. The DPM I was with brought up his perspective that the surgical component is a rather small portion of the whole profession.

But what you’re saying makes perfect sense.

 

[PTPuser]

I understand you’re view point that does make sense.

Sorry about that. These were questions that popped up in my head while shadowing. The DPM I was with brought up his perspective that the surgical component is a rather small portion of the whole profession.

But what you’re saying makes perfect sense.

It could be a small component for that particular podiatrist...but truth is, it's nicely split based on what the physician is comfortable with treating, the demand and which modality is best for that patient.

Even though it's strictly foot and ankle, the pathology for that particular area is vast as hell. Like others have posted, there's no way in hell I am ready to practice on my own after pod school. I need that three years to learn and be able to manage my patients in all aspects including surgery.

I came into the profession for many of reasons but one of the biggest thing that drew me to the field is the fact that I have the ability to manage patients both medically and surgically.

And in PP, you loose money if you keep referring out to others for things that you should be able to do or is within your own scope of practice. But again, that comes down to what the physician is comfortable with.

 

[heybrother]

Its already been well stated mostly. Its a small body part. It has a minimal autonomic component. The majority of complaints are MSK in nature. The best way to understand when conservative treatment is necessary and appropriate is to understand when surgery is appropriate.

Now I'm going to ramble a little. The simple truth is - the majority of people don't require surgery. People routinely present with a problem and potentially even a deformity - and most of them get better without needing anything beyond conservative therapy. The goal most of the time is not to "fix" the patient's foot - its to return them to when they were pain-free.

Beyond true infection, trauma, etc - the number one way to generate surgery in my experience is to
(1) under treat the patient - you didn't get better because I didn't do anything and therefore now you have to have surgery
(2) scare tactic the patient - if you don't do this now you'll regret, won't be able to have it done later, it will cause arthritis!

Unfortunately even many traumas are overpronounced as MUST BE FIXED when many would heal with minimalist conservative interventions. I see things being fixed that healed with weight-bearing in a CAM boot. Sadly, since patients have no idea what requires surgery and what doesn't the patients afterwards will tell people "Dr. X fixed my foot" when what they should really say is - Dr. X cost me $5000 and exposed me to unnecessary risk.

The above are bread and better for a lot of "busy" surgeons.

Surgery is hands down the number one cause of insanity, infighting, problems and what not for this profession. It can be a wonderful thing for a patient or it can be a nightmare for all involved.

-Many patients who could theoretically benefit from surgery are too sick, stupid, crazy, unhealthy etc to benefit. I specifically recall driving through my residency town and seeing this guy walking on an unstable busted foot - hrm, that would be a great case - then I opened my eyes and saw the dull gaze, the fact that he was in his underwear and it was like 30 degrees and raining and he appeared to be covered in filth. Not a great candidate.

-People set patients up for things they can't handle or deal with or understand. I was looking at my residency surgery schedule several years ago when I saw a rearfoot fusion that was booked on a patient I hadn't met, heard about, etc. When residents booked a case - we talked. I look at the chart - brand new patient booked on first visit by attending with no resident present. Made a note to remind whoever pre-oped her the day of to talk to her about the recovery. I see her at like her 1st or 2nd post-op and she's busted the fusion to pieces. She tells me "I decided I needed to be brave and start walking on it". There's a bunch of different ways you could take this apart and look at it, but something went amiss and now you have a major awful complication.

-Surgery patients are needy. Demanding. Scared. They call lots. They want pain medication. They do stupid things - how did your bunion get stepped on by a football player when you were supposed to be non-weight bearing. Doc - I know you said I can't walk on it for 2 months but I have to go back to work! Doc I still have numbness over my ankle fracture incision. Doc - my toe doesn't move anymore. Doc - I'm still swollen 3 weeks out. My toe is swollen. I put this cream on my foot that you didn't prescribe me and my incision opened up. I got my splint wet 1 day after surgery and its Sunday morning at 3am, help! Doc I put preparation H on my incision and then I waited 5 days to call you and my foot is red all the way from the toe to the ankle.

-A lot of the surgery we do - DOESN'T WORK. I think there are a lot of depressed insane pods who've spent their life having to explain away their junk work. Fix bunion. Bunion immediately comes back. Fix toe - toe immediately drifts. Its what they were taught. Its all they know. But they have to be a surgeon! They have to be in the OR. Its part of their being. Part of their ego. Some old pod who was retiring recently told me he was in the OR every week for 40 years. He operated on the nurses! I see his long term outcomes - they are garbage.

-Some surgeons KNOW what's needed, but still refuse to do it. Its a bit of - when all you have is a hammer everything is a nail. I saw patients in residency with complicated deformities where my attending only wanted to fix the part they wanted to fix. They wanted to do some tendon work when it was clearly an osseous problem.

-Amusingly, all of the surgery worship is funny to me because as I am in private practice I see exactly what pays and what doesn't. There is no big magic mark-up for procedures associated with really long follow-up. Your best case osseous follow-up is ~3 visits + a long term. Perhaps an early visit to remove dressings. A second to remove sutures. A 3rd to transition to a shoe and a long term to release to running. 90 day globals are awful. My wife had a c-section and I think the OB saw her ONCE afterwards. Good luck doing that on a rearfoot fusion.

-Finally - infighting. Our certification is based on doing these cases which means we are very motivated and I don't think that serves patient's interests which is funny because the whole thing was invented to protect patients.

Anyway! Learn surgery. Try and put yourself in a position where you can grow and adapt. Realize that what a lot people have taught themself is garbage. You'll see this in residency when some attending shows you their 3rd attempt at a Reverdin Green on an arthritic joint and they ask you - what do you think? 4th year is regularly about buttering people up about their crap x-rays.

You can have a nice career and not be super surgical, but it will be a better career if you understand when surgery is truly warranted.

There are a handful of surgeries in my opinion that are more powerful and better than all the others. I personally get almost no trauma/ankle referrals. My 4 most powerful surgeries that I think you could build a perfect reconstructive practice on are (1) 1st MPJ fusion (2) Lapidus (3) Evans (4) Gastrocnemius recession. Skill at anything else is gravy. This paragraph is meant to be sort of tongue in cheek. Obviously there are other good surgeries out there and ultimately we need to do right by our patients. That said - for all the talk of total ankle and flatfeet and everything I think my town would be best served by someone with perfect understanding of the 1st ray and how it contributes to deformity and instability of the foot.

Last of all. I've joked that I recently did a brachymet cause basically for free. Healthy 30 something year old woman. Still managed to bang the damn thing a lot. Came in to tell me about it every time. Would I still do the case again even though it was basically free and less profitable than 2 flexor tenotomies? Of course. We need to do right by people.

Ramble complete.

 

[Feli]

...People routinely present with a problem and potentially even a deformity - and most of them get better without needing anything beyond conservative therapy. The goal most of the time is not to "fix" the patient's foot - its to return them to when they were pain-free.

Beyond true infection, trauma, etc - the number one way to generate surgery in my experience is to
(1) under treat the patient - you didn't get better because I didn't do anything and therefore now you have to have surgery
(2) scare tactic the patient - if you don't do this now you'll regret, won't be able to have it done later, it will cause arthritis!

Unfortunately even many traumas are overpronounced as MUST BE FIXED when many would heal with minimalist conservative interventions. I see things being fixed that healed with weight-bearing in a CAM boot. Sadly, since patients have no idea what requires surgery and what doesn't the patients afterwards will tell people "Dr. X fixed my foot" when what they should really say is - Dr. X cost me $5000 and exposed me to unnecessary risk.

The above are bread and better for a lot of "busy" surgeons...

Yes, these are subjects that can be debated until the cows come home.

Personally, I don't believe the deformities do "get better." Some will be tolerable to the patient for awhile or forever, but the patients also may eventually find their way elsewhere. If the Walgreens pads and insoles and creams or the Amazon heel cups or ankle braces or vitamins worked, then they wouldn't be in your office. Hammertoes, bunions, flat foot, cavus, arthritis, tendonitis (chronic), etc are progressive conditions... the progression rate and pain level will vary patient to patient. Some of them will be tolerable to the pt (or the pt not a surgical candidate), and other pts will elect for surgical care at some point. I view it as our job to simply outline the options for the patient, answer questions, and let them consider how much trouble with pain and shoe fit they have... at the beginning and again later at f/u visits after some conservative care.

Communication and rapport are the keys. We are basically health counselors... who can perform procedures if needed. If the patient is clearly there wanting bunion pads and shoe advice, give them that. If they have been to one or more other DPMs and are mad that nothing is better, discuss all options and ask questions to eval them as a surgical candidate. Wording and scripts can be very effective. For most elective deformity stuff, mine goes along with some variation of this:

"So, this won't get better on its own, and it might get more painful as the years go by, but we are talking about changes over years and decades - not overnight. You've probably already noticed those changes developing? It is ultimately up to you as to how much it bothers you and affects your daily life and life quality. You will know when it's time... if it ever is that time for you. Some patients come back in a month and want to schedule asap, some call years later if the injections and things aren't helping anymore, and some never need to. Luckily, this [condition] is not a broken ankle sticking through the skin or a bad infection that needs to be fixed tonight. It is entirely your choice as to if and when you want to learn more about surgery options, recovery, and such.

It's advisable to find a board certified surgeon if the pain is frustrating you and you need to get serious about having [condition] repaired at some point. Also bear in mind that you are a better surgical candidate for a good result and faster recovery in your 40s or 50s than your 70s or 80s... that's because we never know what meds or health issues you might have later on. That said, it's totally up to you. You may choose that the time is pretty soon or you may choose it's never, and we're here to support you either way. Today, you just want to know the options and gain information, so you can take your Xray copy, review this handout on [condition], try the pad and the insoles, and just let me know next time if the medicine was helpful and if you have any questions. Can you think of any right now?"

...Keep in mind that our patients who got "better" with conservative and disappear might just have gone somewhere else to have surgery or get a second opinion.
Likewise, some of our surgery patients "doing great" might have gone elsewhere for a revision due to our under-correction or non-union or re-ulceration or whatever.

There is also tremendous bias on the part of us as clinicians. I agree. We see what we know and are biased to offer the treatments we are proficient at

 

[heybrother]

I don't think I disagree with anything you said. As I indicated above, I just think there are people who can find a way to make that same set of words predatory. The simple truth is I'm already changing how I'm practicing. Where I came from - wounds were only seen by vascular surgery and podiatry. There was no dilly dallying. When I started in my town I played nice with the wound healing centers. I'm advancing the time table now. If they wait a year to refer to me - that's enough time. The next graft isn't going to change anything.

 

[Feli]

I don't think I disagree with anything you said. As I indicated above, I just think there are people who can find a way to make that same set of words predatory. The simple truth is I'm already changing how I'm practicing. Where I came from - wounds were only seen by vascular surgery and podiatry. There was no dilly dallying. When I started in my town I played nice with the wound healing centers. I'm advancing the time table now. If they wait a year to refer to me - that's enough time. The next graft isn't going to change anything.

For sure. Any professional - medical or otherwise - can use their powers for good or evil
Most patients will do pretty much whatever you recommend if you are a half decent salesman.

As I see it, there are a few ways to do a good amount of surgery as a DPM:
-do a lot of trauma/wound call and consults... not very good hours unless you have residents
-get referrals for surgery from medical community (DPMs and PCPs are best... lecture PTs on tendon/ankle, PCPs on everything, ER on foot fx, etc)
-market yourself and pimp your skills (in your facility and in the community)
-see a LOT of patients and play the numbers game... some % of them will require surgery depending on referral base
-DO THE SURGERY and get a rep for it... your post-op pts tell others, OR staff/anesth spreads word of who is good and they have lots of downtime to gab, etc
-talk patients "into" surgery... as you mentioned, pretty nefarious... and risky of malprac if you don't have a chart built yet

...Like you, I am extremely aggressive on wound and diabetic stuff also. It is a race between healing and infection... one or the other happens every time (consider death to be infection, lol). So, I consult vascular or get a MRI early... labs to see if they need nutrition consult. I debride for a bit and then reconstruct or amp deformities that stall or keep pre-ulcerating or ulcerating despite good DME... esp for the working age pts. I use basically nothing but real tissue (their graft or flap or another human live tissue product) if I need coverage.
I think the years of putzy wound care gives false hope and grinds the morale of most patients down and down while their health also tailspins from being in a chair or boot or cast frequently/permanently. Sure, the hospital loves those 2x weekly for years pts, but that is not my problem. I only do that "pallative care" type of wound care on pts who have so many comorbidities they can't do anesthesia, can't have any more vasular recon, and nothing will work (and I offer them BKA / AKA refer or second opinion at that point also... yet they keep coming back like a bad penny until their MI, sepsis, pneumonia, etc hospitalization coup de grace).

It blows my mind when I get patients who have had long term wound care and they end up sent to me for a "second opinion." I had a lady this year, middle aged DM, who had a hallux malleus ulcer on and off for 18mo give or take. She had decent DM shoes and custom accomodative insoles, so I suggested replacing those when it's time and advised she talk to her doc about surgery (IPJ fusion or Keller or Jones or whatever... I would probably do flexor tendon lengthen and IPJ desis on a pt of that age, but it was his pt). When he got my note with that and saw her, he flipped out. He had been expecting me to recommend some new graft or antibiotic or something... for a weightbearing ulcer due to progressive deformity. He told me, "I've already healed her four times... I will heal her again. Thanks for nothin." He told her that I was off base... that elective surgery isn't allowed with COVID anyways (not elective), surgery could cost her that toe (so could inevitable osteo), and other BS to keep her as a wound patient. The funny thing is that I would have obviously sent her back post-op for DM preventative care and RFC if he wanted me to do the surgery anyways.

^^It just shows how sensitive the egos can be, and how you see what you know. That guy just saw debridement and lotions and potions and shoes, and I saw clear need for limb salvage surgery asap. Regardless, if you want to get (and keep) the surgery referral sources, you have to make friends on both sides of the podiatry fence... surgery and minimal/no surgery training. I did what is right for the patient, but I doubt that guy will send me patients again... at least not for awhile.

...In my eyes, there already is a big divide in podiatry. Weirdy may be right that it might be better to work with the system we have and hope the bottom teir programs and students improve, but I am of the stance that it would be better to rip off that band aid and have general podiatrists and surgical podiatrists (like dentistry) where it is clear who is who. We need to put people in positions where they can succeed, not struggle. It already happens that divided way anyways in my estimation: roughly one half to one third get a poor residency and/or fail ABFAS qual... then, they probably don't join ACFAS, they likely do inferior CME and get further behind every year, and they struggle for privileges - esp if they can't pass ABPM either. Even some of the grads who get ABFAS qual can't pass the certification case review or never get enough cases to sit, and then they're in nearly the same boat (although nearly 100% of those will still pass ABPM and do ok if they know their limits).

We act like "that was then, this is now... everybody gets a residency now" or "ABFAS is just too hard," but in reality, we all know many classmates who aren't board cert for surgery or aren't doing any surgery at all (or shouldn't be and wouldn't have privi at any major hospital). It is what it is... everyone's residency says "surgery." Some know their limits, many do not. The DPM who I mentioned above referring me that wound patient is not a senior practitioner... he did a 3yr program that was supposed to lead to RRA and ABFAS cert in the largest population city (I usually check when refers come in... I honestly assumed he'd do the deformity surgery and was just CYA with the 2nd opinion for me to concur with him). The moral of the story is to work hard and apply yourself to the fullest extent possible... but, like you said, be ethical. Surgery is not joke... recognizing the need for it or executing it.

 

[Weirdy]

...In my eyes, there already is a big divide in podiatry. Weirdy may be right that it might be better to try to turn a blind eye and group hug and hope the bottom teir programs and students improve, but I am of the stance that it would be better to rip off that band aid and have general podiatrists and surgical podiatrists (like dentistry) where it is clear who is who. We need to put people in positions where they can succeed, not struggle. It already happens that divided way anyways in my estimation: roughly one half to one third get a poor residency and/or fail ABFAS qual... then, they probably don't join ACFAS, they likely do inferior CME and get further behind every year, and they struggle for privileges - esp if they can't pass ABPM either. Even some of the grads who get ABFAS qual can't pass the certification case review or never get enough cases to sit, and then they're in nearly the same boat (although nearly 100% of those will still pass ABPM and do ok if they know their limits).

With all due respect sir, I was not asking for people to turn a blind eye and sing kumbaya and magically the cesspool resolves itself.

My point was there are a**hat students out there who will continue to do surgery even if they do not have the skills for it.
There are also students who will go to brand name residencies and end up as horrible doctors upon graduation. No amount of "improvement" will change that.

Forcing a surgical/non surgical track will not keep these same students out of surgery. It will only damage the reputation of the profession as a whole.

MD/DO colleagues don't care about the intricacies of our profession. They judge us as a whole. We are as good as our worst podiatrist.

 

[PTPuser]

When he got my note with that and saw her, he flipped out. He had been expecting me to recommend some new graft or antibiotic or something... for a weightbearing ulcer due to progressive deformity. He told me, "I've already healed her four times... I will heal her again. Thanks for nothin."

I noticed this attitude more in podiatry than any other specialties I've ever worked with in my previous life.

There's this weird cut throat-ness in this profession and I'm having a hard time seeing where its stemming from.

 

[shezadeh]

I have actually been wondering this, and hopefully someone can correct me. Previously, weren't there both non-surgical and surgical podiatry residencies? I have seen profiles of podiatrists that indicate the training was less than three years, and possibly non-surgical (or not with a surgical emphasis at least).

 

[Bubuddy]

I have actually been wondering this, and hopefully someone can correct me. Previously, weren't there both non-surgical and surgical podiatry residencies? I have seen profiles of podiatrists that indicate the training was less than three years, and possibly non-surgical (or not with a surgical emphasis at least).

If I am not mistaken, podiatry being a surgically-based residency was made mandatory in ~2015(?), closing all non-surgical-based ones as a result. I think some of the current/past residents can chime in on this.

 

[DexterMorganSK]

Can read more on this by searching: American Podiatric Medical Association’s Vision 2015