You are starting a residency...

[PeaJay]

Hint to students: if any program ever brags that its off-service aka non-pod months are their "biggest strength," that's a backup at best.

Agreed… I would encourage prospective residents to consider off service rotations as part of the whole package as you can be a great surgeon, but it you cannot manage your own patients in an hospital/msg setting you will look plain foolish.

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[Shiyuan]

Although I love dermatology, I will say the quality of dermatology rotations are pretty much a joke. You just watch a bunch of people going for skin checks and get carbuncles frozen off. I wish they let you do more - assist in Mohs, biopsy, debride, etc.

At least for me, there was not enough interesting pathology.

 

[Shiyuan]

Not to open this can of worms... but has anyone recently (i.e. within last 2-3 years) done the Bako Fellowship? Is it anymore improved? When I was there it was just hanging out with pathologists, eating free food and self-studying 🤷🏻‍♂️

EDIT: Bringing this up since some residencies require it.

 

[ExperiencedDPM]

Not to open this can of worms... but has anyone recently (i.e. within last 2-3 years) done the Bako Fellowship? Is it anymore improved? When I was there it was just hanging out with pathologists, eating free food and self-studying 🤷🏻‍♂️

EDIT: Bringing this up since some residencies require it.

Can anyone seriously call this a fellowship?

 

[Shiyuan]

Can anyone seriously call this a fellowship?

Good point... “Mini-Fellowship” rather 💪🏻

 

[dtrack22]

Good point... “Mini-Fellowship” rather 💪🏻

It’s a rotation. Nothing more.

 

[dtrack22]

but it you cannot manage your own patients in an hospital/msg setting you will look plain foolish.

This, in a nutshell is why we have such a bad name in the "real world".

Orthopedic surgeons would prove you both wrong. Zero inpatient management of patients being done by ortho. They would never think to admit the typical podiatry inpatient (DFU, uncontrolled DM, PAD, CKD, CHF…).

Nobody cares if you can medically manage your patients kidney disease in the real world. Even the rural critical access hospital I work at has 24/7 hospitalist coverage for inpatients.

 

[Shiyuan]

It’s a rotation. Nothing more.

When I was looking for jobs 5 or so yrs ago, I had an interview with a dermatology group. They were actually very impressed that I went through this “Dermatopathology Mini-Fellowship” (the actual course verbiage) even though it was only 2 weeks (and I told them this!!!).

Goes to show you that outside of the DPM world how certain silly courses actually “look good on paper” to others when they were not really a big deal.

 

[PeaJay]

Orthopedic surgeons would prove you both wrong. Zero inpatient management of patients being done by ortho. They would never think to admit the typical podiatry inpatient (DFU, uncontrolled DM, PAD, CKD, CHF…).

Nobody cares if you can medically manage your patients kidney disease in the real world. Even the rural critical access hospital I work at has 24/7 hospitalist coverage for inpatients.

I think you are missing the point.

I am not advocating that we need to medically manage (although this is often done in some systems). I am saying that you need to know proper vascular work-up (well not learn if you spend your 3 years in surgery centers), you need to know how to manage cancer (skin cancer of the foot is sent to podiatry in my system), you need to know infectious disease ( don’t want to miss the tte/tee with s. Aureus bacteremia or miss managing a clear fire engine red strep infection with anything other than a cephalosporin), you need to know how to manage poly trauma (miss a spine injury because all you know is ankles/fee) , ect… you need exposure to not be a fool that knows nothing but the foot

 

[PeaJay]

That’s not what your post said. At all. I can quote it again if you’d like.

ENTs, Ortho, any of surgical specialty not named General Surgery relies on internal medicine and Hospitalist services to medically manage their patients pre and post op. Period. Podiatry is no different in that regard.

Where I trained ortho managed about half of their own patients. Gen surg managed their own. Vasc managed their own. OMFS managed their own. podiatry managed medically simple and consulted hospitalist for more complex (still pod primary).

Per the other discussions in this thread, ortho doesn’t always manage, but they definitely are capable. I don’t advocate that pods should always admit primary, but you should be able to if needed.

I advocate for a balanced knowledge base (see last post). The high volume programs I rotated at we’re exposed to volumes of poorly performed cases. In situ stj fusions with no correction other than ablation of the joint, many fictional neuromas, fixing “hammer toes” where no hammertoe existed , ect. You can’t tell me that my procedure heavy off service education was a waste when compared to that trash.

 

[PeaJay]

I don’t advocate that pods should always admit primary, but you should be able to if needed.

Ideally we should be able to handle our own elective inpatient cases. There is no reason you can’t manage pain meds and some fluids. More complex patients…leave it to hospitalists.

Back to the crux of this thread…we need more than just case volume (volume is undoubtedly important), we need a balanced education.

 

[de Ribas]

I saw a guy on LinkedIn who did a very very well known fellowship who called himself an orthopedic podiatrist LOL

I have seen at least several advertise like that. They are so special.

 

[AttackNME]

don’t want to miss the tte/tee with s. Aureus bacteremia or miss managing a clear fire engine red strep infection with anything other than a cephalosporin

deally we should be able to handle our own elective inpatient cases. There is no reason you can’t manage pain meds and some fluids.

Even though I trained at a VA where we primarily managed this stuff, it was still a joke. The attendings didn’t make any real medical decisions or actually managed anything, that was all done by the intern who went off medicine consult recs. I mean it’s not hard to d/c nephrotoxic drugs and push fluids for AKI, go through the repeat culture and echo algorithm for bacteremia, order PICC line etc, but when something goes slightly awry we wouldn’t know what to do, and why should we be doing this stuff when there are hospitalists whose job is to do this?

Our time would be better spent being able to read an angiogram and understanding when there is still microvascular disease even after a revascularization.

Glad to see you embrace the limb salvage realm! I think the spy angio will have good relevance for these high risk amp closure cases. I dont think anyone uses it in my state so it'll be a battle to get one approved.

 

[AttackNME]

I don't see the point of spy angio. If the angio shows microvascular disease you are really better off wound vac the wound close, maybe adding some ACELL or doing Integra to give is a jump start. Sometimes that is not good enough and you just need to bring the amputation more proximal. But the point is you need to understand this before just doing a distal amp and telling the patient "I don't know". Setting patients expectations is critical. We do it for elective MSK cases I am unsure why it is not done for these amp cases. I feel like microvascular disease is not discussed enough with patients. They need to understand there is a chance things will not heal and in some cases a more proximal amp is necessary.

There are studies that show local tissue oxygenation plateaus at about 3-4 weeks after angio or 3-5 days after bypass, so the small vessel disease of the immediate post-intervention may not reflect the local tissue perfusion at your time of closure depending on the vascular intervention. The utility of the spy angio is you close the wound and use it the eval perfusion of the flap, if it has poor perfusion, then you resect and treat open.

 

[PeaJay]

mean it’s not hard to d/c nephrotoxic drugs and push fluids for AKI, go through the repeat culture and echo algorithm for bacteremia, order PICC line etc, but when something goes slightly awry we wouldn’t know what to do, and why should we be doing this stuff when there are hospitalists whose job is to do this?

Again I am not advocating that we take over those tasks, but how should at least know how to manage or at worst who to consult.

Let me give some recent examples…

I work in a rural area with vascular coverage only at the main campus (60 miles away). I have recently dealt with a young gentleman bounced around a couple ERs working up cards Issues. Everyone mentioned leg pain, but given negative US it was written off as msk pain. Feel a popliteal pulse… nope they didn’t complete that, handheld Doppler exam of dp/pt/pp… nope they didn’t do that, cft… they did do that…delayed. Guess what… asymmetrical pulses. Ordered sementals with wave forms and got the patient to vascular for an embolic arterial blockage. Did I manage… no. Did I know what it was and who to get it to… yes. I have full confidence that plenty of my colleagues would have clipped the nails and sent the patient on for the next missed diagnosis.

How about the one with “blue spots” that were chalked up to polycythemia. Well if you are well trained the you know where this is going…dry gangrene… did I manage the blueish coloration with paste and other podiatry stuff… nope ordered an ct angio and off to vasc.

What about the cellulitis that was blamed on the stable Charcot. Discharged before blood cultures finalized with only pod follow up. Yup saw the S. Aureus and got cards and ID consult…

 

[air bud]

Ideally we should be able to handle our own elective inpatient cases. There is no reason you can’t manage pain meds and some fluids. More complex patients…leave it to hospitalists.

Back to the crux of this thread…we need more than just case volume (volume is undoubtedly important), we need a balanced education.

Again you are an outlier 98 percent of podiatry residencies do not teach this. You are a better doctor for having this training. If you were able to get top notch podiatry training on top of this medical training then you weny to a great program.

 

[Weirdy]

Again I am not advocating that we take over those tasks, but how should at least know how to manage or at worst who to consult.

Let me give some recent examples…

I work in a rural area with vascular coverage only at the main campus (60 miles away). I have recently dealt with a young gentleman bounced around a couple ERs working up cards Issues. Everyone mentioned leg pain, but given negative US it was written off as msk pain. Feel a popliteal pulse… nope they didn’t complete that, handheld Doppler exam of dp/pt/pp… nope they didn’t do that, cft… they did do that…delayed. Guess what… asymmetrical pulses. Ordered sementals with wave forms and got the patient to vascular for an embolic arterial blockage. Did I manage… no. Did I know what it was and who to get it to… yes. I have full confidence that plenty of my colleagues would have clipped the nails and sent the patient on for the next missed diagnosis.

How about the one with “blue spots” that were chalked up to polycythemia. Well if you are well trained the you know where this is going…dry gangrene… did I manage the blueish coloration with paste and other podiatry stuff… nope ordered an ct angio and off to vasc.

What about the cellulitis that was blamed on the stable Charcot. Discharged before blood cultures finalized with only pod follow up. Yup saw the S. Aureus and got cards and ID consult…

I'm surprised there are residencies that don't train you to diagnose like this.

Its criminal not to have this knowledge coming out of residency.

 

[AttackNME]

Again I am not advocating that we take over those tasks, but how should at least know how to manage or at worst who to consult.

Let me give some recent examples…

I work in a rural area with vascular coverage only at the main campus (60 miles away). I have recently dealt with a young gentleman bounced around a couple ERs working up cards Issues. Everyone mentioned leg pain, but given negative US it was written off as msk pain. Feel a popliteal pulse… nope they didn’t complete that, handheld Doppler exam of dp/pt/pp… nope they didn’t do that, cft… they did do that…delayed. Guess what… asymmetrical pulses. Ordered sementals with wave forms and got the patient to vascular for an embolic arterial blockage. Did I manage… no. Did I know what it was and who to get it to… yes. I have full confidence that plenty of my colleagues would have clipped the nails and sent the patient on for the next missed diagnosis.

How about the one with “blue spots” that were chalked up to polycythemia. Well if you are well trained the you know where this is going…dry gangrene… did I manage the blueish coloration with paste and other podiatry stuff… nope ordered an ct angio and off to vasc.

What about the cellulitis that was blamed on the stable Charcot. Discharged before blood cultures finalized with only pod follow up. Yup saw the S. Aureus and got cards and ID consult…

Oh to me sounds like just being thorough and a good doctor to the basic stuff. But when you talk about knowing to manage medical issues I had a different idea in mind.

One time I had a patient admitted for over a week for nausea, in fact GI was consulted and patient was scheduled for an endoscopy. Finally the medicine resident decided to check the foot and found an abscess that was glaringly obvious and consulted podiatry. I told them I was gonna do surgery right away and they should cancel the endoscopy since I didn’t see any evidence of bleeding or other medical reason for the endoscopy.

In Texas they’re talking about hospitalist podiatrist or something, I see how hospitals overwhelmed with inpatients could benefit from a capable podiatrist in basic medical management for stable issues, not too hard to do a sliding scale, pain med regimen, continue home meds, AKI, push fluids for NPO patients who are not on dialysis or in heart failure. This is pgy1 medicine stuff that we could learn from an MD/DO attending who cared to teach and a podiatry resident willing to learn. Most podiatrists wouldn’t want to do it myself included even though I’ve learned it too.

 

[PeaJay]

Oh to me sounds like just being thorough and a good doctor to the basic stuff. But when you talk about knowing to manage medical issues I had a different idea in mind

If “just being thorough” is your thought then you are adequately trained. A lot of our colleagues would not know what to do…

 

[dtrack22]

But when you talk about knowing to manage medical issues I had a different idea in mind.

Correct. The first comment of “medically managing,” means treating these medical conditions. Not recognizing them and working them up or immediately referring them to the appropriate specialist. Sort of a total 180 from the original post/comment that started the discussion…

 

[619]

You can't make a living in podiatry without offering some sort of surgical service or option for certain pathologies. Trimming toenails and calluses and wounds only go so far.

This is the mindset of hospital employed folks vs PP employed folks. If you are hospital employed then taking patients to the OR generates the most wRVU. If you are PP employed it is the opposite. PP employed folks make more money in clinic.

We are both correct and both have the same goal. The goal is to make $$. Different ways to make the same $$. Pains me when I see folks in PP talking about the big cases they do in the OR when they get paid peanuts for it. Folks in PP don't see the actual EOB to see that surgery does not pay.

 

[diabeticfootdr]

I think the spy angio will have good relevance for these high risk amp closure cases. I dont think anyone uses it in my state so it'll be a battle to get one approved.

I find SPY enormously valuable. We use it intraoperatively as a qualitative tool to predict what tissue will survive or not. Every time I didn’t trust it intraoperatively, I was wrong.

 

[icebreaker32]

Doing what exactly in PP? Using PCR? Billing nail biopsies when its really nail debridement? Please explain to me what you are doing that is profitable in clinic if you are billing ethically and not abusing something?

Are you serious? You can't see the things that are done in clinic that are profitable without abusing something? I don't even know where to start from. General podiatry pathologies from heel pain, any tendonitis, any MSK pain, warts, ingrown, custom inserts etc all generate good revenue without having to bill anything shady. These are all straight forward Lev 3 OV, X-Ray, Inj and DME when indicated.

I don't even have a PCR and I only bill nail biopsy when I take a punch from the matrix. Another myth in this forum is that most pods in PP do PCR which is further from the real world. General office podiatry generates a lot of revenue especially when you have a good flow of new patients daily. As I said in my clinic on a typical day, about half my patients are new patients mostly coming in for procedures.

It is possible to do well without scammy things and lots of OR procedures…..it requires a certain volume, good insurance mix, ancillary services, DME and selling cash pay items like orthotics, lotions, topicals and laser for toenail fungus most often. Wound care can be profitable sometimes also if Medicare and a private secondary, but the insurance mix tends to be poor with wound care and often comes with inpatient work also which is more profitable for hospital employed podiatrists.

Podiatry is saturated most places……so the above is usually not possible unless already established. I have seen it time and time again. One lives like a resident a few years longer after finishing residency working for others and then themselves. The scammy factor increases some and suddenly they are now doing better than they would be working for someone else. The scammy factor increases much more and now they are making in the top 25 percent of the profession while not having an insurance mix, volume or pathology much different than a typical PP podiatrist. Their treatment protocols become totally based on the individual’s particular insurance carrier and also on only what they can get paid very well on.....any attempt to even consider EBM goes out the window completely.

 

[ExperiencedDPM]

It is possible to do well without scammy things and lots of OR procedures…..it requires a certain volume, good insurance mix, ancillary services, DME and selling cash pay items like orthotics, lotions, topicals and laser for toenail fungus most often. Wound care can be profitable sometimes also if Medicare and a private secondary, but the insurance mix tends to be poor with wound care and often comes with inpatient work also which is more profitable for hospital employed podiatrists.

Podiatry is saturated most places……so the above is usually not possible unless already established. I have seen it time and time again. One lives like a resident a few years longer after finishing residency working for others and then themselves. The scammy factor increases some and suddenly they are now doing better than they would be working for someone else. The scammy factor increases much more and now they are making in the top 25 percent of the profession while not having an insurance mix, volume or pathology much different than a typical PP podiatrist. Their treatment protocols become totally based on the individual’s particular insurance carrier and also on only what they can get paid very well on.....any attempt to even consider EBM goes out the window completely.

Very accurate. I’ve seen too many young doctors start making money with what I consider scammy things.

Laser for toenail fungus. That’s simply stealing money from patients. Balance braces pay well and have NO legitimate supporting studies and are not used by physical therapists, physiatrists or neurologists. Applying amniotic grafts weekly to pinpoint wounds is a money make and completely abused. Selling potions and lotions and nerve remedy pills is analogous to being a snake oil salesman.

I know this thread is how docs make money in the office vs OR, but I can’t help but add that a lot of doctors are making big money inappropriately billing surgical procedures and unbundling. Sometimes it’s caught by the insurance company and it’s computer systems and too often it gets paid.

 

[air bud]

This thread is actually supposed to be the how to start a residency thread and we were doing a good job on it....
That said I feel like DME can be scammy as well... And don't get me started on the unnecessary ordering of x-rays. Practice someplace where it's a pain in the ass to get an X-ray done and you will get good and realize how little you actually need them. One of my recent jobs it literally would take somebody a half hour to get an x-ray and they had to come see me first before I sent them up front to register on the hospital side of things go down the hallway wait get an x-ray walk across the hallway to my office which was on the medical group side of things amazingly inefficient I wasn't able to change it.....stopped ordering many x-rays

 

[Shiyuan]

How often would y’all do academics:

- journal club
- radiology / case reviews
- cadaver labs
- etc.?

Daily meetings of some sort perhaps? That’s how we did it at my program.... daily a.m. academics/radiology review with every other week journal clubs (usually concomitant rep dinners) and monthly cadaver labs.

 

[air bud]

Daily....seems like busy work. You should be out covering cases and no time to drive/inefficient use of time. Day hours are for surgery or clinic. If you have time for academics mid morning then not enough surgery. Surgery should be 630 to 2 or 3, then knock out 1 to 2 hours of clinic and go home.

Weekly academics is reasonable I think.

We had a few ASC that we were cutting at 5am. One was full of TFPs that let you fly as a 1st year. The other was a stud who did awesome cases. Both ASCs always had full coverage. And they were 30 mins away from where people lived.

 

[air bud]

This is how you set up sx schedule. Someone who is in house, usually a 2nd year is in charge of getting all the faxed/emailed/called in/ daily surgery schedules. They then put them in on a shared website. Has to be done by certain time each day usually 3pm.
Each month the pick schedule changes. 3rd years then 2 then first. Your order changes monthly, everything is fair. Person putting in the schedule texts 1st pick and tells them to select cases. 1st pick goes to website determines which cases they want (have to do whole lineup, can't cherry pick). Have to allow reasonable amount of time for delays/ transportation ie can't do a flat foot line up with 4 other cases and then sign up for a TAR that everyone knows will start before you are done with flat foot line up .

1st person picks cases puts name by them then texts next person to pick. And so on. Chiefs job is to mediate anybody being dumb trying to abuse schedule.

Someone assigning cases is a recipe for diaster and abuse.

 

[PeaJay]

Weekly rad/case review with quick lecture and coordinated cadaver work would be ideal. 3-4 hours tops. 3 hours or academic/cadaver work a week should be more than enough.