Few questions about podiatry

[anon4895]

I've recently become very interested in podiatry and have been reading through the "true stories from podiatric residency" thread. I noticed a lot of stories about getting called to the er to respond to foot traumas; things like gsw's and fractures. These things are very cool to me and one of the reasons I think I would enjoy the work. However, those type of things seem to overlap a lot with orthopedic surgeons. What factors decide if podiatry or ortho get called to foot trauma? Is it possible/common to work in a hospital where these injuries are always left to ortho?

There seems to be an overlap in other areas too. Things like a rash on the feet (derm or pod) or a diabetic ulcer in need of debridement (gen surg or pod). So what sort of things fall specifically into the domain of podiatry? If there is overlap what factors determine who takes care of it?

Thanks guys

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[dtrack22]

What factors decide if podiatry or ortho get called to foot trauma? Is it possible/common to work in a hospital where these injuries are always left to ortho?

The answer to your first question is multi-factorial. But from my limited experience it boils down to hospital politics and subsequently how many of each specialty they have on staff. Right now, I would say it is more common for ortho to take F/A call at a majority of the hospitals across the country. You hear a lot about trauma from residents because that's part of the training. Many of those residents are on podiatry's services at the time but there are programs where your major rearfoot cases come while you are rotating with ortho. It is absolutely possible to work in an area where ortho is given everything. But it's also possible to be in an area where pods cover most if not all of the trauma cases.

Things like a rash on the feet (derm or pod) or a diabetic ulcer in need of debridement (gen surg or pod). So what sort of things fall specifically into the domain of podiatry? If there is overlap what factors determine who takes care of it?

Everything on the foot falls into the domain in podiatry. If you decide on podiatry school you'll quickly learn 2 things. The foot (especially with many derm pathologies) tends to present differently than the rest of the body. And the foot is also largely ignored by the rest of medicine. An example; ER's miss ~20% of lisfranc injuries...1 out of 5...that's a lot of people not receiving care for an injury that can have some debilitating consequences. If you are good at what you do, in any specialty, you will be asked to care for patients.

So who takes care of it? Again, IMO it depends mostly on the area and who they have available as well as how you've established yourself as a valuable referral resource to family practice docs, vascular surgeons, endocrinologists, etc.

The drawback to podiatry is that you are stuck with the foot for the rest of your life, but I'm convinced that you can mold your practice into whatever you'd like (as long as it falls within our scope). Love woundcare? you can spend all day debriding and ex fixating things. Don't want to touch nails or wounds? Don't. There is quite a bit of flexibility within the profession...as long as you're ok with feet.

 

[g squared 23]

Trauma mainly goes to ortho groups. If you happen to be the F/A guy for an ortho group, you'll get plenty just by default. Podiatry groups don't get called as often for trauma, unless ortho doesn't want it (probably an uninsured patient, which means podiatry doesn't want it either and it probably won't go to surgery anyway) or unless that podiatry group is well trained and very established at that particular hospital. But generally speaking, no, trauma is a very, very small part of most podiatrist's practice. GSWs and open fractures are uncommon during residency, and incredibly rare in actual practice. Overall, when ER docs think broken bones, they think ortho. They aren't going to differentiate a bad ankle fracture from a very distal tibia fracture in order to send it to us; they know it's a fracture and that ortho can take care of it. They'll also see the proximal fibular fracture in a PER and assume it's out of our scope. So it's not really bias against podiatry, it's that ER doctors don't really know any better, most of the time.

Foot ulcers are treated by any specialty that wants to deal with them, and that most commonly happens to be podiatry. Although I've seen general surgeons, orthopods, and infectious disease doctors all treat them as well.

 

[Feli]

...It is absolutely possible to work in an area where ortho is given everything...

Can you please PM me about some of these wonderful practice opportunity areas? I am a very giving person, and I'd be kind enough to always donate ortho all of the midnight uninsured ankle fractures and also won't even mind if vasc or gen surg stole all of the MedicAid foot infections.

As more DPMs (and MDs, and DOs) are taking employment with multispec, hospitals, ortho groups, etc... it really is getting harder and harder to get away from the call, the inpatient consulting and surgeries, the medically complicated and brittle patients, and the hospitals in general. The hospital systems realize that well trained DPMs do much, much more than just cutting toenails, injecting heel spurs, and occasional bunion surgery. Those large group or hospital employers didn't give you a high base salary and recruitment/relocation package since you're such a nice, swell guy who got mostly A's in pod school. They hired you to make them money... end of story. You will usually be expected to do wound care, take trauma call, see inpatients with foot issues, and do after-hours surgeries. Those things are needed for the patients, and since barely anybody wants to do them, so they'll make it part of your job (hopefully you can split up call schedule with other DPMs employed in the group).

Even a lot of guys in private pod practice are doing mergers (or even buyouts) with larger physician groups or hospital systems. Since those big groups can negotiate with insurances easier, they get the private practice guys to fear having no business and/or low low reimbursement rates if they stay alone as a private small business. Once they're on the hook with the big system, then they are essentially employees, and their "job" may change in less than desirable ways. It also might not... totally depends on the situation (and maybe they got such profit in the buyout they will just retire soon after if the hospital starts making them do call, rounds, excessive wound/amp work, etc).

In the end, it's going to get harder and harder to have the "good life" 9-4 M-Th office practice with well insured, ambulatory, and pretty healthy patients who are nearly all there for elective complaints. I'm fortunate (or unfortunate, depending on how you look at life) to be in a situation where my practice is 95+% outpatient right now: a tiny bit of basic wound care in the office and the rare inpatient consult for a patient that we had previously seen in the office is as "rough" as it gets. That means no morning rounding, no night or weekend call, and aside from the occasional low energy F&A trauma that one of our patients or their family suffers, my surgery is scheduled weeks ahead so that I can start my cases early (and therefore on time... with the right equipment arranged... with a good OR team that has experience in pod/ortho, not just whoever's on call).

In the end, it all comes down to what you want. If you love trauma so much that family and sleep and things like that take a back seat, then go be a trauma surgeon or an ortho trauma guy. If you greatly enjoy trauma but want more balance, I'd say be an ortho. If you simply enjoy procedures and would like making a very good living while having personal time, I'd suggest ENT, plastics, podiatry, derm, optho, or dentistry (do a fellowship, though). ER and some of the medicine specialties like neuro or rheum or endocrine would be up there too, but there's less top end income (ER) and less procedures in the int med specialty ones. To each their own. They're all "the best job in the world" for the right individual. GL

 

[dtrack22]

I will admit that part of my post (actually several of my posts in different forums/threads) was nothing more than the proverbial carrot dangling there to draw out some of you guys that are much more knowledgeable Maybe I shouldn't admit it, but I have no problem being wrong and/or argumentative for the sole purpose of baiting attendings, residents, and students from other schools into posting...

But there are several hospitals/hospital systems (between Iowa and the west coast) that either don't have the pods to take call or don't let them. I know of at least 1 residency program where you get nearly all of your trauma and rra numbers w/ortho because of hospital politics. It's rare, but they exist.

 

[Feli]

... I know of at least 1 residency program where you get nearly all of your trauma and rra numbers w/ortho because of hospital politics. It's rare, but they exist.

There are a fair amount of programs like that, unfortunately. And, with few exceptions, private orthopedists generally don't let the DPM residents participate much in the cases (partially since you're a DPM, partially because they're not used to training). If it's a teaching program and the orthos do let residents participate, then the problem becomes that the DPM trainees will almost invariably take a backseat to ortho residents, especially for the "good cases" or most popular attending surgeons.

That tends to create a bit of a dilemma for some students' residency search... myself included:
Do you want to go to a program that scrubs with ortho a lot and has good case numbers and trauma volume on paper (despite the fact that you may have had little hands-on besides retracting and maybe suturing/splinting in many of those cases)? A lot of people will say "numbers are numbers," and when it comes to some of the hospitals, that certainly is the case. Your CV and case logs will look good with all those "first assist" logs on complex cases and trauma. However, you have to be honest with yourself: should you be doing complex level cases you just scrubbed into and basically watched? A lot depends on the person and their confidence and skill level, I guess.
...or would you rather go to a program where you are trained in the OR mostly by DPMs? The fact that you're the same profession, degree, training model, etc usually means DPMs tend to allow residents more active involvement in the OR with the technically hard parts of the procedures (osteotomies, fixations, reductions, etc). However, based on typical podiatry office referrals and patient population, your case logs will be more filled with forefoot/midfoot procedures and not necessarily a ton of rearfoot and ankle cases (although you will likely get to actually DO a lot in most of them). Your end result might be that you are an awesome surgeon with great skills, but your logs might be borderline inadequate for full scope RRA privileges in some areas... depending on how hospital politics are.

There's really no right or wrong answer. I chose all clerkships (and then residency) knowing I wanted to be trained by DPMs. I figured that I'd gone to podiatry school, learned the biomechanics and clinical medicine from DPMs, read the DPM textbooks... why change now and try just chase surgical log numbers to backdoor my way into effectively being a F&A ortho? I decided early on that I wanted to train with a high volume residency program where most of the surgeons were podiatrists doing the RRA work. However, that's just a personal choice. I did scrub with some orthos (private practice) during residency on the rare days we didn't have a lot of pod cases on the schedule, and it was fun to see their techniques on fractures, flat foot, post trauma arthrodesis, etc... but I mised well have been watching a video of the techniques most times. I feel my training overall was great, but those ortho experiences contributed minimally since the docs just didn't have an interest to teach much... and general orthos, while typically adequate, don't always put a ton of planning and prep into F&A cases. Now, especially with the new logging, I sure hope there aren't too many programs out there that "get their numbers" that way.

 

[JewOnThis]

There are a fair amount of programs like that, unfortunately. And, with few exceptions, private orthopedists generally don't let the DPM residents participate much in the cases (partially since you're a DPM, partially because they're not used to training). If it's a teaching program and the orthos do let residents participate, then the problem becomes that the DPM trainees will almost invariably take a backseat to ortho residents, especially for the "good cases" or most popular attending surgeons.

That tends to create a bit of a dilemma for some students' residency search... myself included:
Do you want to go to a program that scrubs with ortho a lot and has good case numbers and trauma volume on paper (despite the fact that you may have had little hands-on besides retracting and maybe suturing/splinting in many of those cases)? A lot of people will say "numbers are numbers," and when it comes to some of the hospitals, that certainly is the case. Your CV and case logs will look good with all those "first assist" logs on complex cases and trauma. However, you have to be honest with yourself: should you be doing complex level cases you just scrubbed into and basically watched? A lot depends on the person and their confidence and skill level, I guess.
...or would you rather go to a program where you are trained in the OR mostly by DPMs? The fact that you're the same profession, degree, training model, etc usually means DPMs tend to allow residents more active involvement in the OR with the technically hard parts of the procedures (osteotomies, fixations, reductions, etc). However, based on typical podiatry office referrals and patient population, your case logs will be more filled with forefoot/midfoot procedures and not necessarily a ton of rearfoot and ankle cases (although you will likely get to actually DO a lot in most of them). Your end result might be that you are an awesome surgeon with great skills, but your logs might be borderline inadequate for full scope RRA privileges in some areas... depending on how hospital politics are.

There's really no right or wrong answer. I chose all clerkships (and then residency) knowing I wanted to be trained by DPMs. I figured that I'd gone to podiatry school, learned the biomechanics and clinical medicine from DPMs, read the DPM textbooks... why change now and try just chase surgical log numbers to backdoor my way into effectively being a F&A ortho? I decided early on that I wanted to train with a high volume residency program where most of the surgeons were podiatrists doing the RRA work. However, that's just a personal choice. I did scrub with some orthos (private practice) during residency on the rare days we didn't have a lot of pod cases on the schedule, and it was fun to see their techniques on fractures, flat foot, post trauma arthrodesis, etc... but I mised well have been watching a video of the techniques most times. I feel my training overall was great, but those ortho experiences contributed minimally since the docs just didn't have an interest to teach much... and general orthos, while typically adequate, don't always put a ton of planning and prep into F&A cases. Now, especially with the new logging, I sure hope there aren't too many programs out there that "get their numbers" that way.

I know way too many programs that dont let residents do any rearfoot cases, and these are programs with DPM attendings in the OR.

 

[g squared 23]

I know way too many programs that dont let residents do any rearfoot cases, and these are programs with DPM attendings in the OR.

I saw this as well at several places.

I think it has to do with how comfortable the attending is with the bigger cases. If they are sweating bullets and not sure exactly what they are doing, they're less likely to let the residents do any work because they don't have the skill or confidence to bail them out in the event something goes wrong or the resident messes up.

 

[g squared 23]

Are we talking about programs that have the PMSR/RRA (formerly the PMSR-Cert) classification here or non-RRA programs?

They were supposed RRA programs. It's tough, because even some of the programs with decent reputations could be relatively rearfoot deficient. As a student you'll quickly realize which places let their residents work and have enough rearfoot cases to go around. Most people suggest checking the residents' numbers (esp rearfoot), but these can get artificially inflated when they cheat and "unbundle" procedures.

 

[g squared 23]

I was afraid you were going to say that. It's really an uphill battle when trying to target programs as a student. I'll stick to "word of mouth".

That's your best bet. Good luck.

Another bet would be to go to a program that doesn't have astounding numbers, but focuses heavily on surgical principles. If you can dissect really cleanly and develop solid fundamentals, you can rely on those more than learning specific individual procedures. If you learn a sloppy 1st ray dissection, then your triple AD dissection will be sloppy and overly traumatic as well, no matter how many of them you get to do.

Just something to consider.

 

[ldsrmdude]

They were supposed RRA programs. It's tough, because even some of the programs with decent reputations could be relatively rearfoot deficient. As a student you'll quickly realize which places let their residents work and have enough rearfoot cases to go around. Most people suggest checking the residents' numbers (esp rearfoot), but these can get artificially inflated when they cheat and "unbundle" procedures.

This is one of the harder parts of choosing a program to do a clerkship at, and eventually do residency at, in my opinion. I tried to look at the 3rd year residents and see how comfortable they were at the rearfoot/more complex cases. If the 3rd years (and to an extent the 2nd years) were comfortable with challenging cases, then they were taught good surgical principles and have been allowed to do the challenging parts of the case, as Feli and g squared 23 alluded to. I've been places where the senior residents looked uncomfortable with all but the most basic procedures. Blame it on the attending or on the resident, but either way, it makes me put surgical numbers in a frame of reference. Just my 2 cents.

Edit: While I am thinking about it, let me just add that I think we've compounded onto the problem of making it tough to adequately judge residents numbers with the change a few years ago of not requiring a certain level of participation to count a case as a "First-Assist" case. When it was a "C" case, it was supposed to require >50% participation, but the way I read things, all I need to do to count a case as a First Assist is to scrub in (anyone can feel free to correct me if I am wrong).

 

[dyk343]

Getting ready to start this clerkship process. This thread has been very helpful, but also caused a lot of confusion on what to focus on in terms of choosing programs.

Ive read the CASPR/CRIP pages and emailed all the residencies I am interested in. But they all seem to act like their residency is the greatest pod residency out there. I wish there was a book with reviews of the programs written by residents/students.

 

[ldsrmdude]

Getting ready to start this clerkship process. This thread has been very helpful, but also caused a lot of confusion on what to focus on in terms of choosing programs.

Ive read the CASPR/CRIP pages and emailed all the residencies I am interested in. But they all seem to act like their residency is the greatest pod residency out there. I wish there was a book with reviews of the programs written by residents/students.

There is, or was, a book that came out every year from the APMSA (I think) where residents would fill out a page about their program and it would get compiled into a book. It was anonymous to encourage residents to be honest. I assume they still put this book together. At the least, each school should have the books from a year or two ago.

And I agree, choosing programs to clerk at sometimes ends up being a crap shoot. As mentioned above, word of mouth (from a reliable source) is sometimes a very good way to go.

 

[dtrack22]

The Residency survey is still published and sent to the 2nd year APMSA delegate at every school (along with the Asics order forms/catalogs). I have no idea where each school traditionally paces it though. We put one copy in the library and another in the clinic. Probably good places to check regardless of which programs you are at.

Depending on the program, many of the reviews are really poorly done and don't give you a lot of info. I gave it a once over and haven't opened it back up again since. Maybe it was just the programs I was looking at?

 

[air bud]

Those residency surveys are in my opinion wildly inaccurate. I was amazed at the discrepancy even within the book between 2 evaluations of the same program. I get what you 3rd years are struggling with, I am seeing it firsthand right now as a 4th year. As a student you want to get every program right, but I think the reality is that you win some and you lose some in your picks. This is why going to places like Scholl or DMU are so important in that they allow you visit more programs than other schools. You are not going to like all the programs you go to. This is why I encourage 3rd years to visit as many programs as you can. I have gone to 1 program that I only needed to meet the director for 1 day to know that I would never want to do residency there. I ended up wasting a month. Also, when relying on firsthand information from students and their personal opinion of the program, take into consideration the personality of that student.

 

[g squared 23]

Those residency surveys are in my opinion wildly inaccurate. I was amazed at the discrepancy even within the book between 2 evaluations of the same program. I get what you 3rd years are struggling with, I am seeing it firsthand right now as a 4th year. As a student you want to get every program right, but I think the reality is that you win some and you lose some in your picks. This is why going to places like Scholl or DMU are so important in that they allow you visit more programs than other schools. You are not going to like all the programs you go to. This is why I encourage 3rd years to visit as many programs as you can. I have gone to 1 program that I only needed to meet the director for 1 day to know that I would never want to do residency there. I ended up wasting a month. Also, when relying on firsthand information from students and their personal opinion of the program, take into consideration the personality of that student.

^^Good point as well about taking other students' opinions in the context of their personality: some people want a more laid back program and would trash talk an intense one that may be your cup of tea.


I wish I had visited more programs during 1st and 2nd year, if only for a day, because in reality, I usually knew that first day whether I was interested in that program and could see myself there as a resident. I did visit one program during 2nd year, spent half a day with the director and knew that program wasn't for me, even though I really liked the location. I'm really glad I didn't waste a month there as an extern. The more programs you can cross off your list with your own firsthand experience, the easier scheduling your rotations will be.

I ended up legitimately considering 3 programs for residency out of 7 total externships, which wasn't a terrible ratio I suppose. I'm still appreciative of the training I received at the other programs, but I would not have enjoyed spending 3 years there and it makes me wonder if I could have chosen my rotations a bit more carefully, and not just relied on reputation.

 

[dyk343]

Thanks for the responses. Ill look for those APMSA books.

 

[Feli]

... If you can dissect really cleanly and develop solid fundamentals, you can rely on those more than learning specific individual procedures. If you learn a sloppy 1st ray dissection, then your triple AD dissection will be sloppy and overly traumatic as well, no matter how many of them you get to do...

Dissection is over-rated, man. At the conferences, case round tables, and on the board exams, all you want is goooood lookin xrays.

In all honestly, though, a lot of podiatry residents (and attendings) have a tendency to over-dissect in my opinion, especially when it's a procedure they don't do a lot of. The more chicken scratch short knife strokes, the more scissor spreads, the longer the tourniquet's up, and the more the retractors are tugging on the skin, the more vascular damage to the tissues and bone you will cause. You will also see more edema, bruising, and pain post-op when you do excess trauma to the structures. "Pretty" surgery = wasted time and more trauma more often than not. I remember some cases where people didn't want to advance to bone until they'd found all of the area nerve(s) to carefully retract them (med dors cut for lapidus, sural for evans or calc fx, etc). Maybe it's just my opinion, but I plan my incision based on the local anatomy, and I make each deepening of the incision with a single stroke and a careful eye for the structures. I sure don't go out of my way looking for them, though. I'd be very happy to never see the major nerves or vessels... that means they stayed safe and protected in the skin flap edge or Camper fascia and they're safe away from retractors, pin drivers, rasp etc bruising them (or worse) during the osseous work. Know where the nerves are, do your best not to hit them, but you're trying to do a procedure, not free up and dissect out and visualize everything like it's anatomy class all over again

A real good book on the subject is 'Surgical Exposures in Orthopaedics: The Anatomic Approach." Only the last 20% or so pertain to foot and ankle cases, but even the intro and stuff do a quality job of explaining how less dissection, less periosteal stripping, etc have become the new ideal.

 

[Feli]

There is, or was, a book that came out every year from the APMSA (I think) where residents would fill out a page about their program and it would get compiled into a book. It was anonymous to encourage residents to be honest. I assume they still put this book together. At the least, each school should have the books from a year or two ago.

And I agree, choosing programs to clerk at sometimes ends up being a crap shoot. As mentioned above, word of mouth (from a reliable source) is sometimes a very good way to go.

Yes, the APMSA book has reviews of the programs, and each pod school should have it on file... talk to your APMSA rep or your school's clerkship coordinator.

Barry Univ also does internal reviews of clerkships their students choose (mostly southern programs... use the picklist at the top):
http://www.barry.edu/podiatry/podiatry-medicine-school/clerkship-post-grad-training/student-survey.html
I think all the schools should do something like this. Again, just like the APMSA book, online reviews, rumors about residencies, take the opinions with a sizable grain of salt. They are just one person's experience and impression of the program. Nonetheless, it does help a bit when narrowing down your list of places to apply for potential clerkship months.

 

[dyk343]

http://www.barry.edu/podiatry/podiatry-medicine-school/clerkship-post-grad-training/student-survey.html

Very helpful. Thank you.