My perspective as a residency director, attending, etc.

[PADPM]

With over 20 years practice experience, and having served as a surgical residency director and an examiner for the oral portion of the ABPS certification examination, I believe I have some observations that may be of some value to residents and students.

During the exam process, I've noticed that many "well trained" candidates are not passing the exams. My feelings are that it is because the doctors are very well versed in the actual MECHANICS of the surgical procedures, but aren't always well trained in the pre operative and/or post operative assessment of the patient, including pre operative criteria and post operative complications or the post operative course.

In residency, we all want to "cut". It's simply what we like to do. However, there is also a patient attached to that foot, ankle or leg, and that patient has other considerations that are often not discussed in many residency programs. The resident simply walks into the OR, performs the case, and goes into the next room, etc., etc.

How often do you actually have the opportunity to follow a patient through to discharge? Many programs no longer have clinics, and residents often do not go to the attendings office to follow up on post op patients. And THIS is where the problem begins.

The decision process regarding which procedure to perform is not always easy. In many residency programs, that decision is made for you. The attending books a case and you simply walk into the OR. When you enter practice, there is no one there to make that decision for you. You must realize that Mrs. Smith has arthritis in her hands, therefore can not use crutches. Mr. Jones lives on the second floor with no elevator, therefore will have trouble when you put him in a non weightbearing cast.

These are all problems that arise in daily practice, but you often forget about in residency training. So what's my point???

Take advantage of offers that are made to you by generous attendings.

If they offer you time to spend in their offices, TAKE advantage of the offer. It will be nice to see a patient PRE OPERATIVELY to see exactly how a decision is made to book the case. It's even nice to learn the business aspect of how you tell a "soccer mom" that she can't drive for 3 weeks. It's also nice to see how a patient's post operative foot/ankle actually looks following surgery.

How much edema is normal? How much ecchymosis is normal? How long will it take for the ecchmyosis to resolve? Why is there bruising in an area that is no where near the surgical site? How long will the incision site be "numb"? How long will I have to be in a cast? When can I start going to the gym again?

These are all questions that you will eventually be faced with in practice, but are often oblivious to in residency, since many of you don't have clinics or private practice rotations. So, ask attendings if you can spend time in their offices. Don't be lazy.

The EASIEST part of surgery is the actual mechanics. The hardest part is understanding WHY you are cutting and understanding what you are attempting to accomplish. You must also completely understand the post operative course and expectations, and then you will be a complete surgeon. Until that point, you will simply be a mechanic.

And that's why I've seen too many candidates fail the exam. They're excellent mechanics, but not good doctors.

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[iceman69]

These concerns are often voiced in a similar but slightly different vein for many other types of surgeons. However, what you have described is a little frightening in that a DPM may well learn how to put humpty dumpty's foot and ankle and distal leg back together but fail to learn how to utilize different modalities do so. As a residency director can you name some programs that still have periooparative managment and clinics associated with them? Thanks.

 

[cool_vkb]

With over 20 years practice experience, and having served as a surgical residency director and an examiner for the oral portion of the ABPS certification examination, I believe I have some observations that may be of some value to residents and students.

During the exam process, I've noticed that many "well trained" candidates are not passing the exams. My feelings are that it is because the doctors are very well versed in the actual MECHANICS of the surgical procedures, but aren't always well trained in the pre operative and/or post operative assessment of the patient, including pre operative criteria and post operative complications or the post operative course.

In residency, we all want to "cut". It's simply what we like to do. However, there is also a patient attached to that foot, ankle or leg, and that patient has other considerations that are often not discussed in many residency programs. The resident simply walks into the OR, performs the case, and goes into the next room, etc., etc.

How often do you actually have the opportunity to follow a patient through to discharge? Many programs no longer have clinics, and residents often do not go to the attendings office to follow up on post op patients. And THIS is where the problem begins.

The decision process regarding which procedure to perform is not always easy. In many residency programs, that decision is made for you. The attending books a case and you simply walk into the OR. When you enter practice, there is no one there to make that decision for you. You must realize that Mrs. Smith has arthritis in her hands, therefore can not use crutches. Mr. Jones lives on the second floor with no elevator, therefore will have trouble when you put him in a non weightbearing cast.

These are all problems that arise in daily practice, but you often forget about in residency training. So what's my point???

Take advantage of offers that are made to you by generous attendings.

If they offer you time to spend in their offices, TAKE advantage of the offer. It will be nice to see a patient PRE OPERATIVELY to see exactly how a decision is made to book the case. It's even nice to learn the business aspect of how you tell a "soccer mom" that she can't drive for 3 weeks. It's also nice to see how a patient's post operative foot/ankle actually looks following surgery.

How much edema is normal? How much ecchymosis is normal? How long will it take for the ecchmyosis to resolve? Why is there bruising in an area that is no where near the surgical site? How long will the incision site be "numb"? How long will I have to be in a cast? When can I start going to the gym again?

These are all questions that you will eventually be faced with in practice, but are often oblivious to in residency, since many of you don't have clinics or private practice rotations. So, ask attendings if you can spend time in their offices. Don't be lazy.

The EASIEST part of surgery is the actual mechanics. The hardest part is understanding WHY you are cutting and understanding what you are attempting to accomplish. You must also completely understand the post operative course and expectations, and then you will be a complete surgeon. Until that point, you will simply be a mechanic.

And that's why I've seen too many candidates fail the exam. They're excellent mechanics, but not good doctors.

beautiful article ! im ending my 2nd yr and whenever i have vacation i make sure i shadow atleast 1 podiatrist (everytime a different doc) and observe his practice and learn from him. And all of them say the same thing as you mention. Please keep on posting, we can learn a lot of things from experienced attendings.

 

[PADPM]

iceman99,

I don't know the specifics of all residency programs, and that's some homework you'll have to do on your own. Regardless of whether or not the program has a clinic, etc., YOU personally can always take the initiative and be motivated.

If you see a case on the O.R. schedule, you can always contact the attending and ask to come to his/her office to review the pre operative films or to review the chart. Similarly, you can always ask an attending if you can follow up in his/her office with a patient post operative to see the results of the surgery you assisted (make sure you say you ASSISTED).

Some surgeons are private and don't want residents in the office, and some will welcome your initiative. When residents come to my office, it is a PRIVATE office, NOT a clinic, therefore the residents are not my "slave". They are there to observe and not to be my free worker bees. My patients are paying me for my services, not for my residents. Therefore, I do the work, not the resident.

I have the resident there to learn, not for free labor. However, this will differ from attending to attending. Some attendings will see you as a free worker in the office, and if that's the case....so be it. Regardless, it's a great opportunity for you, IF the attending is comfortable with you in his/her office.

By the way, as "stupid" as this sounds, PLEASE be careful with what you say in front of a patient. I actually had a student that never saw a post op patient in his life, and didn't realize that it's "normal" for there to be swelling, ecchymosis, etc., following major reconstructive surgery. So, this genius was in my office, watching me unwrap an ankle 6 days post op. After removing the post op splint and dressings, this genius bursts out "WOW, look at all that swelling and black and blue....that looks gross!!!"

In actuality, there was minimal edema and bruising, but he was inexperienced and didn't know better. So don't say ANYTHING, unless the attending asks you to comment!!!!

On a second note, IF you do take this initiative and start spending time with attendings, and your fellow residents do NOT, expect some harrassing and/or ridicule. They will tell you that you are kissing A_ _, but that's their problem, not yours.

You are NOT kissing butt, you are advancing your education and making yourself a better doctor. They have the same opportunity as you, and simply are not smart enough to see the big picture.

Utilize all your resources and you'll be a great practitioner and that will allow you to provide the best care for your patients. Then, when YOU are in practice, give the same back to the residents you train.

 

[SportPOD]

As someone who teaches podiatry students, the advice given by PADPM is very valuable. I always tell the 3rd and 4th years to look for a residency where the residents get a balance of clinic AND surgery. Yes, you need the numbers so that you're comfortable performing the surgery, but you also want to see how that foot looked before AND after, not just an hour before the surgery to do the H & P. This is where a resident's clinic comes in to play. Thanks for your insight PADPM.

 

[PMSIII]

Excellent insight by the attendings. As a future resident, I really appreciate this advise and couldn't agree more. I had just recently completed my private practice rotation and I benefited a great deal by working with my attending's patients pre-operatively, and post-operatively as well. I saw complications with their management, surgical consultations that included in-depth conversations about all that is to be involved with the procedure, the actual procedure in the OR, post-op course/management, and practice management with billing. That experience alone motivated me to make sure that I make every effort to spend time at doctor's offices, and certainly your opinions further reaffirmed my point of view.

 

[Feli]

This is great advice.

A lot of why I picked the program I did was the structure of the resident clinic structure where residents follow "their" patients...
If you see a patient in clinic/ER the day the procedure is booked, then you get first dibs on scrubbing that case as the primary assist. This is the way it's done even if it's a RF case and a junior resident, so it gives the first years a very good chance at getting in the RF mix early since they take most of the call and resident clinic coverage while senior residents are mostly at other hospitals and surg centers doing cases. Likewise, any OR case where that pt will then following up in resident clinic, it's the C person's job to be there at the time/date of any follow-ups. I thought that was a good way to get the total picture.

 

[dpmgrad]

Well said PADPM. Where abouts are you in Philly area?

 

[malleolusman]

Great insight PADPM

 

[krabmas]

This is great advice.

A lot of why I picked the program I did was the structure of the resident clinic structure where residents follow "their" patients...
If you see a patient in clinic/ER the day the procedure is booked, then you get first dibs on scrubbing that case as the primary assist. This is the way it's done even if it's a RF case and a junior resident, so it gives the first years a very good chance at getting in the RF mix early since they take most of the call and resident clinic coverage while senior residents are mostly at other hospitals and surg centers doing cases. Likewise, any OR case where that pt will then following up in resident clinic, it's the C person's job to be there at the time/date of any follow-ups. I thought that was a good way to get the total picture.

Saw your poster at ACFAS!

Where did you match?

 

[215512]

Saw your poster at ACFAS!

Where did you match?

I searched

http://forums.studentdoctor.net/showthread.php?t=608993

Bahaa and the rest of the search function police would be proud

 

[Feli]

Saw your poster at ACFAS!

Where did you match?

Oh, cool... I didn't know you were at the conference... I definitely would've made a point to say hello. I really enjoyed the lectures from Inova faculty at the meeting... great cases and videos of and some rare, interesting pathology.

I matched my top choice, St John North Shores on the east side of Detroit... can't wait to head up and begin.

 

[TacomaPod]

The residency program that I went to, Multicare foot and ankle residency in Tacoma Washington had plenty of patient interaction. We have a residency run clinic where the residents have their own patients and follow through from start to finish with patient. Every medical decision from surgery and non-surgical treatments are decided by the residents with the help of attendings.

Great training and it helped me be prepared when I got out. You are also exposed to the billing and coding aspects since you have to learn how to properly code and charge for patient visits and procedures. All surgical procedures you plan yourself on your own patients which makes you know what instruments and options you need for each type of case. If anyone has any questions they can feel free to contact me about the program.

And Surgical numbers are not a problem. I finished all my numbers by the end of my first year and those are numbers for a 3 year program.