Pros and Cons On A Career in Podiatry IMO

[Adam Smasher]

I received an e-mail several weeks back from ABPM saying that I should go onto the student doctor network to write nice things about podiatry to gin up some positive sentiment about this field to prospective applicants to podiatry school. But embellishment isn’t my thing. I don’t sell snake-oil to my patients. When patients ask me if an injection is going to hurt, I tell them without hesitation, “Yes, it is going to hurt, but only for 10 seconds.” My patients appreciate that I play things straight with them, so I’m going to play things straight for any podiatry students and pre-health students out there, because ultimately that’s what will be most useful to you.

About me: I finished residency 5 years ago, carpet bombed the USA with my CV, found a private practice in a location that was ok with a salary that was also ok, bought in as partner 3 years ago. Some things worked out for me, some things didn’t. I don’t do trauma, I’ve dabbled in flat-foot surgery, I operate about 3 days/month not counting evening/weekend add-ons. I’m facing enormous demand for non-operative care. I don’t do lasers or shockwave or swift wart treatments or kerryflex or other magic cure-alls. The only thing I dispense is a certain brand of premolded orthotics, and if the company wants me to mention their name they can pay me to do so. My personal take-home gross was around 300k in 2021, so after taxes, retirement contributions, and debt service I can still live decently comfortable though it’s definitely not champagne and caviar. I put in about 50-55 hours a week, rarely more.

Also I haven’t posted on SDN for years. For some people podiatry is their passion, their mission in life. Sorry, but podiatry is just work for me. So when I’m not working, I avoid reading/watching anything about podiatry or feet or medicine in general.

Before I get into this, bear in mind some of this is only particular to my situation and 100% of this is my opinion, and my opinion along with $3 will get you on the subway, so YMMV.

Things I like about (private practice) podiatry:

1. I’m the boss. I call the shots. This is not an insignificant thing. I can tailor my practice to my needs. For now I’m hustling pretty hard, but I can easily scale this down. If you’re employed by a MSG or a hospital you have to fall in line with their culture. But I’ve got the leeway to delineate what I do and don’t do. A lot of internists/NPs/PAs don’t have that.

When I started off, there was a nursing home that I would visit every couple of months and trim toenails for a couple of hours. But they were being obnoxious about the way I did it. Plus they were giving my biller the runaround about demographic/insurance info. So we told em to take a hike.

In residency, my director was adamant that we address every toenail consult promptly. I guess he figured we’d impress the MDs or something. Reality is hospitalists have better things to worry about than if patients get their nails trimmed or not. So when hospitals consult me to trim someone’s toenails, I don’t even respond. Terrible lighting, uncomfortable working conditions, and I’ve got to carry my dirty nail nippers home with me afterwards. Plus patients are always anticoagulated AF so if I cut them, they’ll bleed buckets. So I’m not doing it. Your inpatient, your problem. Discharge the patient and send em to my office for treatment. Public aid pays for patient transport, and there’s a bus stop in front of my office if that’s not an option.

So private practice gives you enormous autonomy. Yes there are exploitative positions out there in private practice. If someone is making you a bad offer, do not be shy about hopping on the next airplane onto the next town/state and you will eventually find a position that will work for you.

2. As a podiatrist, you have the opportunity to make a big impact on patients’ lives. I’ve done some really cool things both in and out of the OR. There are people with crippling heel pain, on the verge of disability, that is beneath ortho’s dignity to treat. Curing their mycosis or ingrown is boring to many of us who’ve been doing this for years but to the patient, it’s huge. I take on a wide range of problems, some challenging, many not, and that leads to generally interesting and diverse work day.

3. I don’t hate trimming toenails. Yeah it’s icky, but like changing your children’s diapers, you start to bond with the person you’re treating and the act itself isn’t so terrible. The initial charting can be tedious, but afterwards it’s mostly a copy-paste template. If you can learn Lauge-Hansen, you can learn Q modifiers. Besides, some insurances will pay me $125 for 5-10 min of nail/callus care, brainless work, negligible liability, no global. Plus these patients are always super nice and super grateful afterwards. Meanwhile my bunion patients regard me like a car mechanic. Why did we ever get involved in bunion surgery?

4. The Grass Is Always Greener mindset is pervasive in medicine. I had an anesthesiologist tell me he wanted to steer his son towards a career in podiatry because podiatrists always seemed so much happier than the other surgeons. Meanwhile he was earning $1mil/year and was unhappy. Baffling. Anyway, since there’s no shortage of posts about how good everyone else has it, I’m going to be petty about other health professions. Here we go, enjoy some empty calorie negativity:

• Chiropractic. We criticize our profession for opening up needless schools (justifiably so) but at the end of the day they’re teaching real medicine. Not so for chiropractic. These need to be in the dictionary next to charlatan. Vertebral subluxation is not a thing. One of the founding chiros claimed to cure someone’s deafness through spinal manipulation. Fun fact, the auditory nerve is a cranial nerve, its root doesn’t originate in the spinal cord.
• Pharmacy. Terrible
• Optometry. I hate selling people overpriced garbage, and that would include eyeglass frames.
• Physical Therapy. I feel bad for PT, they help so many of my patients, their work is truly important. But there’s a REALLY low ceiling on your income, and if you’re after a 3 year doctorate you may as well go to law school. (Actually don’t, lawyers are generally miserable)
• PA. This is personal for me. When I was in residency there were some PAs on other services to fill in for residents who were post-call and do floor work. Some were cool and I got along ok with them. A lot of them were patronizing and treated me like a simpleton because I was a DPM. I co-scrubbed with a PA on my ortho rotation for a hip arthroplasty and I asked her if she wouldn’t mind doing the admission medication reconciliation, because our EHR was always fastidious like that especially with asthma meds. She says to me “oh right you probably didn’t learn about those drugs.” And in my mind I was thinking “no, I understand beta-agonists, it’s that this is tedious busy work and you’re a hospital employee so do your job.” And there’s the rub. PA is a great move if you’re chasing the bag. The ROI is better than most other health degrees. But make no mistake you will be a scut-puppy for life. You’ll treat drug-seekers and STI exposures in the ER. You’ll water-ski in the OR. You’ll shoot botox in the derm clinic. You’ll face patient disappointment when they were hoping to see the doctor and not you.
• NP/CRNA: I’m lumping them together, I’ve got no ill will towards them, just because they’re not as stuck up as a lot of PAs. I suppose you put in your years as a RN doing floor work, facing disrespect from admins, doctors, patients, other nurses, it gives you some perspective. Sure the ROI is great, you can earn while you learn, but anesthesia seems like a boring job. And NPs tend to get funneled into primary care which also is not my cup of tea. See also what I said at the top about my opinion.

5. Even though surgery is a small part of my practice, I have found my aptitude for surgery to be useful in the clinic. There are DPMs out there who get all flustered about the idea of percutaneous tenotomies or excisional skin biopsies. Reality is if you keep your cool and get yourself set up, you can bang these out in the space of a 15 min office visit. Yes it’s a little barbaric doing these in the clinic and the injection is painful for the patient. You know what else is painful? Anesthesia/OR copays.

6. Personally, I enjoy diabetic wound care. It’s a lot of work, and many patients are challenging, and you will get same-day arrivals and evening/weekend calls for urgent issues. But it’s also very interesting, and frankly I find it breathtaking when you find the modality that works and a longstanding ulcer utterly disappears. Sometimes it’s as simple as gluing plastizote to the underside of the patient’s insole. Total contact casting is severely underutilized. It pays decently well, and if you are smart about where you source your supplies you don’t need that super expensive derma-sciences kit.

A lot of doctors don’t like treating ulcers because they re-ulcerate. The way I look at it is none of us is immortal, our bodies always break down and deteriorate no matter what we do. It’s the human condition. Some patients need surgery to get their ulcers healed for good, some patients need amputations no matter what you do. You just try your best and your patients appreciate it.

7. Ultimately podiatry has been fairly good, I’ll never go hungry, the work is interesting, the people are interesting. Happiness is a mindset, you have to be grateful for what you have no matter what you have.

Things I Don’t Like So Much about (Private Practice) Podiatry

1. By far, number 1, the path to licensure is needlessly long for what I am doing right now. I think the UK/Canada/Australia do it right, podiatrists have bachelor’s degrees and basically do chiropody procedures only. Instead of a doctorate + 3 year residency, we could have a “Master’s of Chiropody” or something, so you can learn pharmacology and prescribe Lamisil/antibiotics and not cut deeper than the subcutaneous tissue and still do 90% of everything I’m already doing.

4th year of podiatry school is pointless, clerkships are basically job interviews for residency. After interviews in January of 4th year, everyone mentally checks out and isn’t really learning anything anyway. Residency training was a speed bump for me on the way to licensure. If we MUST be surgeons, 2 years is enough to figure out hallux valgus and diabetic foot infections. My director did it in 1.

As it stands, 100% of podiatrists undertake a course of training that is for the benefit of 10-20% who will actually use it. We have an ongoing credentialing “Arms Race” where now fellowships are becoming more and more sought-out. My professor at podiatry school used to say, if you’re going to do 4 years, why not make post graduate training an even 5 years and you can become a general surgeon and operate on the entire body?

And since the ABPM wants to initiate this good will movement to promote podiatry on SDN, I’m going to call out these CAQs. They are all RIDICULOUS.

It’s not enough to get your degree.
It’s not enough to finish 3 years of residency.
It’s not enough to get licensed
It’s not enough to get certified
It’s not enough to do annual MOC activities

We’re being offered CAQs? All you have to do is compile an application, take a test, and pay a fee. I pray that every doctor here sees this for the naked cash grab that it is. Purchasing a CAQ is no greater testament to my competency than my hat that says “#1 Dad” is a testament to my parenting. But the sad reality is a lot of us feel inadequate and have to apply for the next latest greatest credential.

This more than anything else is why applications are down—the return on investment of 7 years isn’t here. The people in leadership (including ABPM) create more steps on the back end to make it harder for us working in the trenches, and then wonders where are the applicants on the front end.

2. The petty egotism of other podiatrists. The fact that we’re afraid to speak openly (not anonymously) and frankly of our profession’s shortcomings in a public forum for fear of repercussions.

3. As noted above, I don’t hate trimming toenails. But I do hate the way many people automatically make that association when they hear I’m a podiatrist. I hate that you can perform a limb-saving surgery and then visit the patient the next day in the hospital and all they or the family members care about is getting their nails trimmed. As though I carry my nail nippers in my pocket at all times “just in case.”

4. This is particular to private practice and to my situation, but if you buy into a partnership, make sure the contract stipulates how the pie is going to be split up. After my buy-in, some of my partners quietly started reducing their clinic hours. When I brought it to their attention that they were working less, and consequently generating less, and consequently should be taking a smaller slice of the pie, they were utterly insulted at the suggestion. We ultimately worked out an agreement, but I would have preferred to sort it out ahead of time. I’m still glad I bought in, because the alternative is starting from the ground up. That requires a skill set we just don’t get in residency or school. But I’ll always be salty over the 10s of thousands of dollars I’ve been putting into my partners pockets over the past few years.

5. Not so much a dislike but more of an idiosyncrasy of private practice. You will spend a bit of time doing managerial tasks. Yes, I have an office manager who handles a lot of it, but at the end of the day it’s my business and I have to be cognizant of what’s going on and how things are operating. For example I had a day where two of my medical assistants started bickering and I had to basically be their dad just so everyone could coexist peacefully.

6. Unpopular opinion: routine foot screenings for every patient with diabetes are a waste of time. I get patients on my schedule with uncomplicated diabetes who are perfectly capable of trimming their own toenails. They have no complaint other than their PCP told them to see me. So I do a neurovascular check and give a canned speech about checking their feet. I’ll pay lip service to glycemic control, but ultimately I’m not licensed to manage this and if anyone is going to convince this person to eat right, it won’t be their podiatrist. And then prn. Sorry, my schedule is too full to be scheduling you for an annual 99212 just to make sure your feet are still securely connected to your legs.
“But what if you miss something?” there is a sub-population of patients with diabetes who truly are an ulcer risk can and will go from intact epidermis to osteomyelitis in a matter of weeks. These are the people I can recognize and I keep them on a short leash. This does not equate to the broad brush recommendation that EVERYONE with diabetes needs to see me just for the sake of seeing me.

7. Finally, and most importantly, as a podiatrist, my recommendations will often be viewed with a certain degree of suspicion. Most of my patients have full confidence in me. But their doctors do not. I had a patient with Achilles tendonitis that I was getting queued up for surgery until his friend told him I as a podiatrist shouldn’t be treating this. PCPs regularly refer my ulcer patients to the wound clinic, for no other reason than because the wound clinic is called a wound clinic. I once had a PCP dc the Lamisil I prescribed over concern for the patient’s kidneys—seriously. I told the patient fine, your PCP can manage your mycosis then. I could and probably should do a little outreach, but I gave up a long time ago on winning hearts and minds. The old biases will always be there.

8. EDIT/BONUS/ADDENDUM: In line with #7, I hate the podiatry bait and switch. I hate that you can start school under the impression that you can be a big-shot surgeon and be an integral member of the medical community. For a lot of us this won't pan out, certainly not for me. I never wanted to be a small-business owner, but that's what I am, luckily I've got a good head for it. And, as stated above, I don't hate routine foot care. But anyone can do it, which means I'm hardly irreplaceable. And no undergraduate pre-health student undertakes their course of study with that as their end goal. In the heirarchy of needs, self-actualization lies at the top. All of us in this forum had enormous potential. Are you reaching it as a podiatrist?

So there you have it, my unvarnished opinion. The good and the bad, warts and all (lol). Podiatry ain’t a bad gig. Problem is it’s not the best move you’ll ever make either. It can be a good fit for the right person and only you know if that’s you. As for me, do I have regrets? Yeah a few. Anyway I’ve spent enough of my Saturday on podiatry.

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[Feli]

This gets venerated along with his how to study / take ABFAS post.

 

[icebreaker32]

A good example of what PP is when it works out and you have a reasonable buy in for partnership.

 

[air bud]

I talked to a guy yesterday who is about 4 years out did a fellowship. Doing a thousand RVs a month consistently. Has three total ankles coming up next week. Frames nails total ankles does it all. On top of that is getting paid like 500 bucks a day for call probably bringing in 6 to 700,000 as an employed podiatrist. Has a partner in the same system doing the same amount.

I know we like to get super negative on this forum but I continue to meet and know of a ton of people that are killing it. Don't get me wrong this guy making six or seven there's no way I would want that at this point with my family.

Talk to another friend the other day in private practice. Did a fellowship worked for another podiatrist for about a year and a half two years hated it. Decided to move to a really cool City close to family with a bunch of other podiatrists in town. Through hard work and just being a good person in about 3 years of owning his own thing is bringing home 6 to 700,000 with no PCR machine. Has a boat and a lake house.

I stated many times on here I can think of 15 people that I went to school with residency etc and that I keep in touch with 15 of 15 are all killing it making 300 plus.

I can't speak to people who went to other schools and other regions I feel like a lot of this is dmu related and Midwest related.

Adam smasher make some good points about how you don't have to be super surgically trained and do big complicated stuff or do all this fancy stuff that increase risks of audit and questionable billing etc. Show up see patients be good at your job keep expenses low.

For people getting a late start on life, even 5 to 10 years Podiatry is a terrible choice I think you are much better off just getting into the market immediately with a two-year degree. You need as much time in the market as possible and be making money instead of trying to catch up when you are 40.. for somebody coming straight out of college yes it certainly is a more reasonable option.

 

[deleted1138023]

Podiatry is a risk. If you bet on yourself, and work hard it can turn good. It's just not a guarantee like all other MD/DO specialties. I would advise against podiatry. Just not worth the risk. 7 years after undergrad (with 300k in loans) to just *potentially* barely make 100k is not worth it.

 

[air bud]

Would love to have more people who view this forum but don't post, contribute their opinions on this topic

 

[NatCh]

Nice write-up. It took a lot of time and effort and I agree with much of it. Well done.

As you said, it's Saturday and I have stuff to do otherwise I could comment on every paragraph but that would take too long.

One thing that you noted was the thing about Internists calling stat toenail trimming consults on their patients just before discharge. WTH? They must picture podiatrists waiting down the hallway with nail nippers in hand ready to come-a-runnin' or something. My Residency Director also wanted us to hustle down there and trim their toenails before discharge. The heck with that. Schedule them as a normal appointment like everyone else.

Also agree on the grass-is-greener syndrome in medicine. Everyone else must have it better, right? Working in a medical field is just hard, regardless of specialty.

 

[PeaJay]

Definitely agree with the posts above.

All of my podiatry school friends are doing very well. I only keep in close contact with a few people and we have all found our niche. Some are ortho guys doin huge volume and earning accordingly and then myself doing more of an Adam smasher practice in an hospital/msg.

This profession is not bad, but could be better.

 

[NatCh]

I talked to a guy yesterday who is about 4 years out did a fellowship. Doing a thousand RVs a month consistently. Has three total ankles coming up next week. Frames nails total ankles does it all. On top of that is getting paid like 500 bucks a day for call probably bringing in 6 to 700,000 as an employed podiatrist. Has a partner in the same system doing the same amount.

I know we like to get super negative on this forum but I continue to meet and know of a ton of people that are killing it. Don't get me wrong this guy making six or seven there's no way I would want that at this point with my family.

Talk to another friend the other day in private practice. Did a fellowship worked for another podiatrist for about a year and a half two years hated it. Decided to move to a really cool City close to family with a bunch of other podiatrists in town. Through hard work and just being a good person in about 3 years of owning his own thing is bringing home 6 to 700,000 with no PCR machine. Has a boat and a lake house.

I stated many times on here I can think of 15 people that I went to school with residency etc and that I keep in touch with 15 of 15 are all killing it making 300 plus.

I can't speak to people who went to other schools and other regions I feel like a lot of this is dmu related and Midwest related.

Adam smasher make some good points about how you don't have to be super surgically trained and do big complicated stuff or do all this fancy stuff that increase risks of audit and questionable billing etc. Show up see patients be good at your job keep expenses low.

For people getting a late start on life, even 5 to 10 years Podiatry is a terrible choice I think you are much better off just getting into the market immediately with a two-year degree. You need as much time in the market as possible and be making money instead of trying to catch up when you are 40.. for somebody coming straight out of college yes it certainly is a more reasonable option.

Just about every DPM I know in real life is doing well. This forum is just extra-bitchy.

 

[icebreaker32]

75 percent I know are doing well. Most had to open their own solo practice. Too many are coding in a way that is probably fraudulent or in a questionable kick back arrangement. Some of those doing questionable things have made ludicrous amounts of money and have had board action taken but are still practicing.

Most jobs are in PP for new grads. What percentage of those lead to a fair buy in is a concern.

You have to separate yourself from others for good jobs or be very geographically open. If not you might have to open up your own practice. If you are willing to be a small business owner with its pros/cons and element of risk then podiatry is a reasonable career choice.

Most do well in podiatry, but you are guaranteed less and have to be much more proactive than many fields.

 

[air bud]

I saw a post on Twitter the other day. It was from a tech guy and lots of tech guy responses...and its the internet....but the question was if you lost your job today, how long would it take you to find a similar job with similar responsibilities/pay/lifestyle. The large majority of responses were 1-7 days. I "stopped working" in July. It will have taken me 5 months to find a similar job by the time I start in a few weeks. I have moved 1/3 of the way across the country to get this job. It easily could have taken me 9-12 months. Still paying on a house that hasn't sold yet and not sure if it will any time soon. MD/DO would likely have taken 1-2 weeks as well doing locums as a stop gap if they wanted to.

 

[PeaJay]

I saw a post on Twitter the other day. It was from a tech guy and lots of tech guy responses...and its the internet....but the question was if you lost your job today, how long would it take you to find a similar job with similar responsibilities/pay/lifestyle. The large majority of responses were 1-7 days. I "stopped working" in July. It will have taken me 5 months to find a similar job by the time I start in a few weeks. I have moved 1/3 of the way across the country to get this job. It easily could have taken me 9-12 months. Still paying on a house that hasn't sold yet and not sure if it will any time soon. MD/DO would likely have taken 1-7 days as well doing locums as a stop gap if they wanted to.

Exactly…everyone I know/keep in touch with is doing well. However, one wrong move and we could be unemployed having to start over across the state or across the country. All due to an inconsistent job market.

 

[Boba Foot]

Smart take. Thanks for the well-rounded post and not just being bitter like most of us.

 

[Boba Foot]

For people getting a late start on life, even 5 to 10 years Podiatry is a terrible choice I think you are much better off just getting into the market immediately with a two-year degree. You need as much time in the market as possible and be making money instead of trying to catch up when you are 40.

I feel seen.

 

[air bud]

I feel seen.

This includes myself.

 

[CutsWithFury]

I received an e-mail several weeks back from ABPM saying that I should go onto the student doctor network to write nice things about podiatry to gin up some positive sentiment about this field to prospective applicants to podiatry school. But embellishment isn’t my thing. I don’t sell snake-oil to my patients. When patients ask me if an injection is going to hurt, I tell them without hesitation, “Yes, it is going to hurt, but only for 10 seconds.” My patients appreciate that I play things straight with them, so I’m going to play things straight for any podiatry students and pre-health students out there, because ultimately that’s what will be most useful to you.

About me: I finished residency 5 years ago, carpet bombed the USA with my CV, found a private practice in a location that was ok with a salary that was also ok, bought in as partner 3 years ago. Some things worked out for me, some things didn’t. I don’t do trauma, I’ve dabbled in flat-foot surgery, I operate about 3 days/month not counting evening/weekend add-ons. I’m facing enormous demand for non-operative care. I don’t do lasers or shockwave or swift wart treatments or kerryflex or other magic cure-alls. The only thing I dispense is a certain brand of premolded orthotics, and if the company wants me to mention their name they can pay me to do so. My personal take-home gross was around 300k in 2021, so after taxes, retirement contributions, and debt service I can still live decently comfortable though it’s definitely not champagne and caviar. I put in about 50-55 hours a week, rarely more.

Also I haven’t posted on SDN for years. For some people podiatry is their passion, their mission in life. Sorry, but podiatry is just work for me. So when I’m not working, I avoid reading/watching anything about podiatry or feet or medicine in general.

Before I get into this, bear in mind some of this is only particular to my situation and 100% of this is my opinion, and my opinion along with $3 will get you on the subway, so YMMV.

Things I like about (private practice) podiatry:

1. I’m the boss. I call the shots. This is not an insignificant thing. I can tailor my practice to my needs. For now I’m hustling pretty hard, but I can easily scale this down. If you’re employed by a MSG or a hospital you have to fall in line with their culture. But I’ve got the leeway to delineate what I do and don’t do. A lot of internists/NPs/PAs don’t have that.

When I started off, there was a nursing home that I would visit every couple of months and trim toenails for a couple of hours. But they were being obnoxious about the way I did it. Plus they were giving my biller the runaround about demographic/insurance info. So we told em to take a hike.

In residency, my director was adamant that we address every toenail consult promptly. I guess he figured we’d impress the MDs or something. Reality is hospitalists have better things to worry about than if patients get their nails trimmed or not. So when hospitals consult me to trim someone’s toenails, I don’t even respond. Terrible lighting, uncomfortable working conditions, and I’ve got to carry my dirty nail nippers home with me afterwards. Plus patients are always anticoagulated AF so if I cut them, they’ll bleed buckets. So I’m not doing it. Your inpatient, your problem. Discharge the patient and send em to my office for treatment. Public aid pays for patient transport, and there’s a bus stop in front of my office if that’s not an option.

So private practice gives you enormous autonomy. Yes there are exploitative positions out there in private practice. If someone is making you a bad offer, do not be shy about hopping on the next airplane onto the next town/state and you will eventually find a position that will work for you.

2. As a podiatrist, you have the opportunity to make a big impact on patients’ lives. I’ve done some really cool things both in and out of the OR. There are people with crippling heel pain, on the verge of disability, that is beneath ortho’s dignity to treat. Curing their mycosis or ingrown is boring to many of us who’ve been doing this for years but to the patient, it’s huge. I take on a wide range of problems, some challenging, many not, and that leads to generally interesting and diverse work day.

3. I don’t hate trimming toenails. Yeah it’s icky, but like changing your children’s diapers, you start to bond with the person you’re treating and the act itself isn’t so terrible. The initial charting can be tedious, but afterwards it’s mostly a copy-paste template. If you can learn Lauge-Hansen, you can learn Q modifiers. Besides, some insurances will pay me $125 for 5-10 min of nail/callus care, brainless work, negligible liability, no global. Plus these patients are always super nice and super grateful afterwards. Meanwhile my bunion patients regard me like a car mechanic. Why did we ever get involved in bunion surgery?

4. The Grass Is Always Greener mindset is pervasive in medicine. I had an anesthesiologist tell me he wanted to steer his son towards a career in podiatry because podiatrists always seemed so much happier than the other surgeons. Meanwhile he was earning $1mil/year and was unhappy. Baffling. Anyway, since there’s no shortage of posts about how good everyone else has it, I’m going to be petty about other health professions. Here we go, enjoy some empty calorie negativity:

• Chiropractic. We criticize our profession for opening up needless schools (justifiably so) but at the end of the day they’re teaching real medicine. Not so for chiropractic. These need to be in the dictionary next to charlatan. Vertebral subluxation is not a thing. One of the founding chiros claimed to cure someone’s deafness through spinal manipulation. Fun fact, the auditory nerve is a cranial nerve, its root doesn’t originate in the spinal cord.
• Pharmacy. Terrible
• Optometry. I hate selling people overpriced garbage, and that would include eyeglass frames.
• Physical Therapy. I feel bad for PT, they help so many of my patients, their work is truly important. But there’s a REALLY low ceiling on your income, and if you’re after a 3 year doctorate you may as well go to law school. (Actually don’t, lawyers are generally miserable)
• PA. This is personal for me. When I was in residency there were some PAs on other services to fill in for residents who were post-call and do floor work. Some were cool and I got along ok with them. A lot of them were patronizing and treated me like a simpleton because I was a DPM. I co-scrubbed with a PA on my ortho rotation for a hip arthroplasty and I asked her if she wouldn’t mind doing the admission medication reconciliation, because our EHR was always fastidious like that especially with asthma meds. She says to me “oh right you probably didn’t learn about those drugs.” And in my mind I was thinking “no, I understand beta-agonists, it’s that this is tedious busy work and you’re a hospital employee so do your job.” And there’s the rub. PA is a great move if you’re chasing the bag. The ROI is better than most other health degrees. But make no mistake you will be a scut-puppy for life. You’ll treat drug-seekers and STI exposures in the ER. You’ll water-ski in the OR. You’ll shoot botox in the derm clinic. You’ll face patient disappointment when they were hoping to see the doctor and not you.
• NP/CRNA: I’m lumping them together, I’ve got no ill will towards them, just because they’re not as stuck up as a lot of PAs. I suppose you put in your years as a RN doing floor work, facing disrespect from admins, doctors, patients, other nurses, it gives you some perspective. Sure the ROI is great, you can earn while you learn, but anesthesia seems like a boring job. And NPs tend to get funneled into primary care which also is not my cup of tea. See also what I said at the top about my opinion.

5. Even though surgery is a small part of my practice, I have found my aptitude for surgery to be useful in the clinic. There are DPMs out there who get all flustered about the idea of percutaneous tenotomies or excisional skin biopsies. Reality is if you keep your cool and get yourself set up, you can bang these out in the space of a 15 min office visit. Yes it’s a little barbaric doing these in the clinic and the injection is painful for the patient. You know what else is painful? Anesthesia/OR copays.

6. Personally, I enjoy diabetic wound care. It’s a lot of work, and many patients are challenging, and you will get same-day arrivals and evening/weekend calls for urgent issues. But it’s also very interesting, and frankly I find it breathtaking when you find the modality that works and a longstanding ulcer utterly disappears. Sometimes it’s as simple as gluing plastizote to the underside of the patient’s insole. Total contact casting is severely underutilized. It pays decently well, and if you are smart about where you source your supplies you don’t need that super expensive derma-sciences kit.

A lot of doctors don’t like treating ulcers because they re-ulcerate. The way I look at it is none of us is immortal, our bodies always break down and deteriorate no matter what we do. It’s the human condition. Some patients need surgery to get their ulcers healed for good, some patients need amputations no matter what you do. You just try your best and your patients appreciate it.

7. Ultimately podiatry has been fairly good, I’ll never go hungry, the work is interesting, the people are interesting. Happiness is a mindset, you have to be grateful for what you have no matter what you have.

Things I Don’t Like So Much about (Private Practice) Podiatry

1. By far, number 1, the path to licensure is needlessly long for what I am doing right now. I think the UK/Canada/Australia do it right, podiatrists have bachelor’s degrees and basically do chiropody procedures only. Instead of a doctorate + 3 year residency, we could have a “Master’s of Chiropody” or something, so you can learn pharmacology and prescribe Lamisil/antibiotics and not cut deeper than the subcutaneous tissue and still do 90% of everything I’m already doing.

4th year of podiatry school is pointless, clerkships are basically job interviews for residency. After interviews in January of 4th year, everyone mentally checks out and isn’t really learning anything anyway. Residency training was a speed bump for me on the way to licensure. If we MUST be surgeons, 2 years is enough to figure out hallux valgus and diabetic foot infections. My director did it in 1.

As it stands, 100% of podiatrists undertake a course of training that is for the benefit of 10-20% who will actually use it. We have an ongoing credentialing “Arms Race” where now fellowships are becoming more and more sought-out. My professor at podiatry school used to say, if you’re going to do 4 years, why not make post graduate training an even 5 years and you can become a general surgeon and operate on the entire body?

And since the ABPM wants to initiate this good will movement to promote podiatry on SDN, I’m going to call out these CAQs. They are all RIDICULOUS.

It’s not enough to get your degree.
It’s not enough to finish 3 years of residency.
It’s not enough to get licensed
It’s not enough to get certified
It’s not enough to do annual MOC activities

We’re being offered CAQs? All you have to do is compile an application, take a test, and pay a fee. I pray that every doctor here sees this for the naked cash grab that it is. Purchasing a CAQ is no greater testament to my competency than my hat that says “#1 Dad” is a testament to my parenting. But the sad reality is a lot of us feel inadequate and have to apply for the next latest greatest credential.

This more than anything else is why applications are down—the return on investment of 7 years isn’t here. The people in leadership (including ABPM) create more steps on the back end to make it harder for us working in the trenches, and then wonders where are the applicants on the front end.

2. The petty egotism of other podiatrists. The fact that we’re afraid to speak openly (not anonymously) and frankly of our profession’s shortcomings in a public forum for fear of repercussions.

3. As noted above, I don’t hate trimming toenails. But I do hate the way many people automatically make that association when they hear I’m a podiatrist. I hate that you can perform a limb-saving surgery and then visit the patient the next day in the hospital and all they or the family members care about is getting their nails trimmed. As though I carry my nail nippers in my pocket at all times “just in case.”

4. This is particular to private practice and to my situation, but if you buy into a partnership, make sure the contract stipulates how the pie is going to be split up. After my buy-in, some of my partners quietly started reducing their clinic hours. When I brought it to their attention that they were working less, and consequently generating less, and consequently should be taking a smaller slice of the pie, they were utterly insulted at the suggestion. We ultimately worked out an agreement, but I would have preferred to sort it out ahead of time. I’m still glad I bought in, because the alternative is starting from the ground up. That requires a skill set we just don’t get in residency or school. But I’ll always be salty over the 10s of thousands of dollars I’ve been putting into my partners pockets over the past few years.

5. Not so much a dislike but more of an idiosyncrasy of private practice. You will spend a bit of time doing managerial tasks. Yes, I have an office manager who handles a lot of it, but at the end of the day it’s my business and I have to be cognizant of what’s going on and how things are operating. For example I had a day where two of my medical assistants started bickering and I had to basically be their dad just so everyone could coexist peacefully.

6. Unpopular opinion: routine foot screenings for every patient with diabetes are a waste of time. I get patients on my schedule with uncomplicated diabetes who are perfectly capable of trimming their own toenails. They have no complaint other than their PCP told them to see me. So I do a neurovascular check and give a canned speech about checking their feet. I’ll pay lip service to glycemic control, but ultimately I’m not licensed to manage this and if anyone is going to convince this person to eat right, it won’t be their podiatrist. And then prn. Sorry, my schedule is too full to be scheduling you for an annual 99212 just to make sure your feet are still securely connected to your legs.
“But what if you miss something?” there is a sub-population of patients with diabetes who truly are an ulcer risk can and will go from intact epidermis to osteomyelitis in a matter of weeks. These are the people I can recognize and I keep them on a short leash. This does not equate to the broad brush recommendation that EVERYONE with diabetes needs to see me just for the sake of seeing me.

7. Finally, and most importantly, as a podiatrist, my recommendations will often be viewed with a certain degree of suspicion. Most of my patients have full confidence in me. But their doctors do not. I had a patient with Achilles tendonitis that I was getting queued up for surgery until his friend told him I as a podiatrist shouldn’t be treating this. PCPs regularly refer my ulcer patients to the wound clinic, for no other reason than because the wound clinic is called a wound clinic. I once had a PCP dc the Lamisil I prescribed over concern for the patient’s kidneys—seriously. I told the patient fine, your PCP can manage your mycosis then. I could and probably should do a little outreach, but I gave up a long time ago on winning hearts and minds. The old biases will always be there.

So there you have it, my unvarnished opinion. The good and the bad, warts and all (lol). Podiatry ain’t a bad gig. Problem is it’s not the best move you’ll ever make either. It can be a good fit for the right person and only you know if that’s you. As for me, do I have regrets? Yeah a few. Anyway I’ve spent enough of my Saturday on podiatry.

Good post but being the negative Nancy I always am I need to clarify for anyone reading this.

Private practice people need to STOP saying that employed podiatrists have no say over their practice. They absolutely do. At my first job I was being over run with routine diabetic foot care and the hospital told me to do their nursing homes which I refused to do. After several years I told them to get me a non surgical podiatrist which they did. I punted conservative care to this DPM and they did nursing homes too. Problem solved.

At my new hospital job I do a ton of out reach so I have to do conservative care but when I come back to our largest and main clinic in town I told them I am only seeing MSK since I am there only a few times a month. Hospital admin had no problem with that either.

Employed docs have a say they just might need to fight for it a little but we eventually get our way.

There's a lot of stupid untrue rhetoric online from the PP crowd when it comes to employed podiatrists. I don't know maybe they are just jelly. The Facebook thread about the fraudulent soon to be investigated practice in Virginia was a great example of that. A bunch of PP owners and PP employees saying how employed podiatrists limit their earning potential because the hospital makes the lion share of profits.

That is true in some sense because they do absorb facility fees and down stream revenue from referrals, advanced imaging studies, EMGs, labwork, etc etc etc. But hospitals offer podiatrists amazing benefits, sign on bonuses, moving stipends, retention bonuses, 5% match for 403B, paid malpractice, etc. These are things no private practice can match or would want to match.

Hospital employment provides a CONSISTENT VOLUME of pathology that PP podiatrist could only dream about too. My hospital has a treatment radius of 1 million people since its the main tertiary referral center. We have several ortho traumatologists yet podiatry still gets its fair share of foot and ankle trauma. There is no shortage of wounds, charcot and other limb salvage opportunities and of course people coming in for bread and butter podiatry complaints who are typically good surgical candidates.

The post above clearly shows what it is like to be a private practice pod. Mostly wounds and routine care. Three days a month of surgery? I do surgery every week. I just started my new gig and my day for operating each week has had 2-5 cases per week so far. When I am on call I could be doing add ons almost everyday. Employed podiatrists are going to eat at the table and get their fill. Their bank accounts will be looking good too. You don't know unless you know.

 

[619]

I appreciate the post from OP as it is truthful and well written however I agree with the above post from @CutsWithFury . I am in solo practice and doing very very well for myself. However a new grad will and should never turn down a hospital/MSG job for a PP and think everything will be rosy like OP. OP is a case study of n=1. For every associate like OP making $300k in PP, there are hundreds of fellow pod associates making $120k to $150k with no chance of buy in after over 5 years working as an associate.

It is the norm to work for a hospital/MSG making $300k plus with solid benefits however it is wayyy far from the norm to work in PP making anything close to $300k starting out or even after 5 years.

 

[NatCh]

Good post but being the negative Nancy I always am I need to clarify for anyone reading this.

Private practice people need to STOP saying that employed podiatrists have no say over their practice. They absolutely do. At my first job I was being over run with routine diabetic foot care and the hospital told me to do their nursing homes which I refused to do. After several years I told them to get me a non surgical podiatrist which they did. I punted conservative care to this DPM and they did nursing homes too. Problem solved.

At my new hospital job I do a ton of out reach so I have to do conservative care but when I come back to our largest and main clinic in town I told them I am only seeing MSK since I am there only a few times a month. Hospital admin had no problem with that either.

Employed docs have a say they just might need to fight for it a little but we eventually get our way.

There's a lot of stupid untrue rhetoric online from the PP crowd when it comes to employed podiatrists. I don't know maybe they are just jelly. The Facebook thread about the fraudulent soon to be investigated practice in Virginia was a great example of that. A bunch of PP owners and PP employees saying how employed podiatrists limit their earning potential because the hospital makes the lion share of profits.

That is true in some sense because they do absorb facility fees and down stream revenue from referrals, advanced imaging studies, EMGs, labwork, etc etc etc. But hospitals offer podiatrists amazing benefits, sign on bonuses, moving stipends, retention bonuses, 5% match for 403B, paid malpractice, etc. These are things no private practice can match or would want to match.

Hospital employment provides a CONSISTENT VOLUME of pathology that PP podiatrist could only dream about too. My hospital has a treatment radius of 1 million people since its the main tertiary referral center. We have several ortho traumatologists yet podiatry still gets its fair share of foot and ankle trauma. There is no shortage of wounds, charcot and other limb salvage opportunities and of course people coming in for bread and butter podiatry complaints who are typically good surgical candidates.

The post above clearly shows what it is like to be a private practice pod. Mostly wounds and routine care. Three days a month of surgery? I do surgery every week. I just started my new gig and my day for operating each week has had 2-5 cases per week so far. When I am on call I could be doing add ons almost everyday. Employed podiatrists are going to eat at the table and get their fill. Their bank accounts will be looking good too. You don't know unless you know.

Why, that all sounds really good. Are you done being miserable yet?

 

[icebreaker32]

If you look at all this objectively and remove yourself a bit it is so obvious.

The most likely way to guarantee a good job with great benefits immediately is to work for a hospital (or maybe Ortho/MSG with ownership potential.) The best, brightest, and most driven seek out these jobs……not just to do more surgery, but because they are better jobs.

Are there enough of these jobs for all? Not even close. Connections aside (which in many cases will all but guarantee a job) to get these jobs one needs to separate themselves. How can a new residency graduate do that…..it is hard. That is why so many are doing fellowships. The only other way is to be willing to go to the Dakotas, try to create your own job, or pure luck.

If one is board certified in RRA with a few years experience and has ties to an area and the hospital thinks you will stay longerm you wil be an excellent candidate. New residency graduates can not immediately be board certified.

Back to PP. Many that eventually do well in PP as owners are making around the same as those that start off in hospital jobs. There are still more outliers in PP making over a million dollars a year.

One can do very well or at least well enough usually in PP as an owner. Some will fail. It is not guaranteed you will do well. Running a small business is not for everyone.

My largest complaint with PP is 3 things.

1. Most of the associate jobs are not good and do not offer a fair buy in if they offfer one at all. Yes there are some good PP jobs out there, but they are the minority. There are not enough jobs outside of PP for most.

2. Running a small business sucks in many ways to put it nicely, especially in medicine. Some do really enjoy it and it can provide job stability and a sense of self fulfillment if run well.

3. There is just too much shady stuff going on in PP. Too many in PP could not make it at all, let alone make some of the crazy salaries they do without jumping on whatever the next cash cow is they over utilize: nail biopsies for all, sclerosing injections for all, braces for all, grafts for all wounds, compounding meds for all, PCR for all, other unnecessary labs for all, hardware kickbacks, out of network scams etc. This stuff goes on in other specialties to an extent, but they have lots of lawyers to pick and choose wisely what they get involved with and they internally audit to make sure they are following guidelines…..in podiatry if something new pays well it spreads faster than Covid. It will be worked into the treatment protocols immediately based solely on insurance coverage.

Some private practices can do very well by only accepting good insurance and having ownership in an ASC……but our profession is way too saturated for that to be the norm. I wish this was more the norm in PP.

 

[air bud]

I appreciate the post from OP as it is truthful and well written however I agree with the above post from @CutsWithFury . I am in solo practice and doing very very well for myself. However a new grad will and should never turn down a hospital/MSG job for a PP and think everything will be rosy like OP. OP is a case study of n=1. For every associate like OP making $300k in PP, there are hundreds of fellow pod associates making $120k to $150k with no chance of buy in after over 5 years working as an associate.

It is the norm to work for a hospital/MSG making $300k plus with solid benefits however it is wayyy far from the norm to work in PP making anything close to $300k starting out or even after 5 years.

OP said he bought in so not Associate.

 

[CutsWithFury]

OP said he bought in so not Associate.

Still doesn’t sound that great. They even admitted as soon as they bought in the other “partners” started working less (probably on purpose) while collecting monies off the new partners hard work.

Very podiatry

 

[air bud]

If you look at all this objectively and remove yourself a bit it is so obvious.

The most likely way to guarantee a good job with great benefits immediately is to work for a hospital (or maybe Ortho/MSG with ownership potential.) The best, brightest, and most driven seek out these jobs……not just to do more surgery, but because they are better jobs.

Are there enough of these jobs for all? Not even close. Connections aside (which in many cases will all but guarantee a job) to get these jobs one needs to separate themselves. How can a new residency graduate do that…..it is hard. That is why so many are doing fellowships. The only other way is to be willing to go to the Dakotas, try to create your own job, or pure luck.

If one is board certified in RRA with a few years experience and has ties to an area and the hospital thinks you will stay longerm you wil be an excellent candidate. New residency graduates can not immediately be board certified.

Back to PP. Many that eventually do well in PP as owners are making around the same as those that start off in hospital jobs. There are still more outliers in PP making over a million dollars a year.

One can do very well or at least well enough usually in PP as an owner. Some will fail. It is not guaranteed you will do well. Running a small business is not for everyone.

My largest complaint with PP is 3 things.

1. Most of the associate jobs are not good and do not offer a fair buy in if they offfer one at all. Yes there are some good PP jobs out there, but they are the minority. There are not enough jobs outside of PP for most.

2. Running a small business sucks in many ways to put it nicely, especially in medicine. Some do really enjoy it and it can provide job stability and a sense of self fulfillment if run well.

3. There is just too much shady stuff going on in PP. Too many in PP could not make it at all, let alone make some of the crazy salaries they do without jumping on whatever the next cash cow is they over utilize: nail biopsies for all, sclerosing injections for all, braces for all, grafts for all wounds, compounding meds for all, PCR for all, other unnecessary labs for all, hardware kickbacks, out of network scams etc. This stuff goes on in other specialties to an extent, but they have lots of lawyers to pick and choose closely what they get involved with and they internally audit to make sure they are following guidelines…..in podiatry if something new pays well it spreads faster than Covid. It will be worked into the treatment protocols immediately based solely on insurance coverage.

Some private practices can do very well by only accepting good insurance and having ownership in an ASC……but our profession is way too saturated for that to be the norm. I wish this was more the norm in PP.

Trying to remember, what is your setup?

Agree with @CutsWithFury about having considerable control in an employed position. If it's a new service line like my previous and new gig, then create what you want they don't know any better. If joining at some point talent and hard work ends up winning out. Or more simply not being lazy like other people. Produce and you get to call the shots. Don't produce and you are a member of the herd or eventually standing outside.

 

[air bud]

Still encouraging other Private Practice people to chime in here

 

[air bud]

Why, that all sounds really good. Are you done being miserable yet?

No.

 

[CutsWithFury]

Why, that all sounds really good. Are you done being miserable yet?

Go scope a 1st MTP joint or obsess over 2nd MTP joint plantar plate tears and cross over toes or whatever you sports med freaks are into these days.

 

[icebreaker32]

Trying to remember, what is your setup?

Agree with @CutsWithFury about having considerable control in an employed position. If it's a new service line like my previous and new gig, then create what you want they don't know any better. If joining at some point talent and hard work ends up winning out. Or more simply not being lazy like other people. Produce and you get to call the shots. Don't produce and you are a member of the herd or eventually standing outside.

Currently at a VA

Have been in other settings also.

 

[air bud]

Go scope a 1st MTP joint or obsess over 2nd MTP joint plantar plate tears and cross over toes or whatever you sports med freaks are into these days.

So much anger.

 

[NatCh]

Go scope a 1st MTP joint or obsess over 2nd MTP joint plantar plate tears and cross over toes or whatever you sports med freaks are into these days.

Dude are you okay? I’m concerned you’re going to have a heart attack.

 

[CutsWithFury]

Dude are you okay? I’m concerned you’re going to have a heart attack.

Death by podiatry

 

[NatCh]

Death by podiatry

May that never happen.

 

[HardRoadPaved]

Go scope a 1st MTP joint or obsess over 2nd MTP joint plantar plate tears and cross over toes or whatever you sports med freaks are into these days.

Saints WR Michael Thomas is getting his plantar plate tear fixed. Out for the season

 

[LadyPod]

Background: I am in my last year of residency and will be joining a private practice after graduation with a great offer. I have been stalking SDN since my pre-pod days. My opinion isn’t about life after residency, I’m not on my own yet, but more of the profession in general. I have my numbers, will be trained well surgically, and published. I’m slightly jaded from residency, but hoping my optimistic and young opinion can help others.

Pros:
- Our profession can provided a comfortable lifestyle. IMO you can pay off your loans, provide for your family/save, and have $$ leftover for that Disney vacation. ** Ignoring the 80k salary PP positions, but that is not the focus of my vent.
- “Podiatry residents are always so happy compared to other surgical specialties”. We don’t treat life or death patients. That takes a tremendous load off you. Imagine telling a family their grandma died because of your mistake. Yeah, I don’t want that. On that note, I say we are a quality of life specialty. A patient tell you, "I know I have this wound that I'm NWB with to heal, I want to be able to walk on the beach with my grandson. Help me".
- I enjoy the diversity of our care. Diabetic limb salvage IMO is an art. Looking at a wound, strategizing my flap and how I can make this filet of toe cover the wound. You can have clinic one day then be in the OR the next. You really can craft your schedule and how you want to practice. Don’t forget, clinic can pay very well and most of the time better than surgery
- I know for me and my slightly undiagnosed ADHD, I always need to be doing something. I know I will be working when I’m in my 60-70s because I just can’t sit still. Our profession can allow you to work a few days a week and still get your ‘feet wet’.
- I don’t want my patient base to be mostly nails. HOWEVER, I have been told by my surgery heavy attending that it’s nice having an “easy” patient once in a while in clinic. I also enjoy the ability to create close relationships with these patients. I want a patient I am able to talk to them about say my future children and they remember.
- I do genuinely feel our patients value and are thankful for our work.

Cons:
- Not everyone should be doing surgery. Think of the worst student in your class. Now think of them operating on your parent, partner, or child. Scary right? I wish our profession still offered an option for non-surgical pathway.
- Our profession as a whole does not have BDE (Big D*** Energy). We have an ego and hate admitting we’re not MDs. Look at our colleagues who only say they are foot and ankle surgeons. Yes, you are a foot and ankle surgeon, but you’re also a podiatrist. I like and will call myself a surgical podiatrist or podiatrist who specializes in surgery.
- Fellowships. IMO a fellowship should only be pursued if you want specialized training i.e. TARS, charcot, rearfoot deformity correction, or more advanced trauma. There is a big difference between bad and good programs. You would think training for 3 years on the foot and ankle alone would be enough. For the bad programs, it’s not. IMO if you have good foundation in surgical principles, confidence, and hands you can figure it out.
- Our board certification SUCKS. I just took my ITE last month and honestly the didactic portion was ridiculous. I'm not dumb, trust me, but even studying another month wouldn't have helped. Again, IMO, podiatrist out there with an ego trying to make themselves feel better.
- More of a personal vent - I hate suturing or putting a wound vac between toes.

My advice to future podiatry students:
- You can read everything you want on here, but my best advice is to shadow! Pick up the phone and call a practice near you. Feel free to PM me too. There are pros and cons to everything in life and it’s up to you to do the research.

My advice to podiatry students:
- I hate hearing students say “I want an easy or “country club” residency” or “I don't want to do X,Y,Z surgery”. I will be frank - you have no idea what you want to do as a student. You do not know enough. Do not let your training dictate what you can and can’t do surgically. Pick a program that trains you well and YOU can decide what you want to do.
- Do well on your off-service rotations. Remember, the IM, Gen Surg, and Ortho residents etc are making their opinions about our profession right now in training. Don’t be “that” podiatry resident. Learn and ask questions. It goes a long way. Pay attention on externships how other services treat the podiatry team. It will say a lot.
- START THE JOB SEARCH EARLY. Good jobs are swiped early. Good jobs (even PP *triggered SDN docs*) are out there.

Conclusion: I am happy with my decision to become a podiatrist. Sure there are cons, but I’m overall an optimistic and happy person so I find the positives in life. I love what I do, treating and getting to know my patients, and I’m looking forward to being out on my own.

 

[LadyPod]

I received an e-mail several weeks back from ABPM saying that I should go onto the student doctor network to write nice things about podiatry to gin up some positive sentiment about this field to prospective applicants to podiatry school. But embellishment isn’t my thing. I don’t sell snake-oil to my patients. When patients ask me if an injection is going to hurt, I tell them without hesitation, “Yes, it is going to hurt, but only for 10 seconds.” My patients appreciate that I play things straight with them, so I’m going to play things straight for any podiatry students and pre-health students out there, because ultimately that’s what will be most useful to you.

About me: I finished residency 5 years ago, carpet bombed the USA with my CV, found a private practice in a location that was ok with a salary that was also ok, bought in as partner 3 years ago. Some things worked out for me, some things didn’t. I don’t do trauma, I’ve dabbled in flat-foot surgery, I operate about 3 days/month not counting evening/weekend add-ons. I’m facing enormous demand for non-operative care. I don’t do lasers or shockwave or swift wart treatments or kerryflex or other magic cure-alls. The only thing I dispense is a certain brand of premolded orthotics, and if the company wants me to mention their name they can pay me to do so. My personal take-home gross was around 300k in 2021, so after taxes, retirement contributions, and debt service I can still live decently comfortable though it’s definitely not champagne and caviar. I put in about 50-55 hours a week, rarely more.

Also I haven’t posted on SDN for years. For some people podiatry is their passion, their mission in life. Sorry, but podiatry is just work for me. So when I’m not working, I avoid reading/watching anything about podiatry or feet or medicine in general.

Before I get into this, bear in mind some of this is only particular to my situation and 100% of this is my opinion, and my opinion along with $3 will get you on the subway, so YMMV.

Things I like about (private practice) podiatry:

1. I’m the boss. I call the shots. This is not an insignificant thing. I can tailor my practice to my needs. For now I’m hustling pretty hard, but I can easily scale this down. If you’re employed by a MSG or a hospital you have to fall in line with their culture. But I’ve got the leeway to delineate what I do and don’t do. A lot of internists/NPs/PAs don’t have that.

When I started off, there was a nursing home that I would visit every couple of months and trim toenails for a couple of hours. But they were being obnoxious about the way I did it. Plus they were giving my biller the runaround about demographic/insurance info. So we told em to take a hike.

In residency, my director was adamant that we address every toenail consult promptly. I guess he figured we’d impress the MDs or something. Reality is hospitalists have better things to worry about than if patients get their nails trimmed or not. So when hospitals consult me to trim someone’s toenails, I don’t even respond. Terrible lighting, uncomfortable working conditions, and I’ve got to carry my dirty nail nippers home with me afterwards. Plus patients are always anticoagulated AF so if I cut them, they’ll bleed buckets. So I’m not doing it. Your inpatient, your problem. Discharge the patient and send em to my office for treatment. Public aid pays for patient transport, and there’s a bus stop in front of my office if that’s not an option.

So private practice gives you enormous autonomy. Yes there are exploitative positions out there in private practice. If someone is making you a bad offer, do not be shy about hopping on the next airplane onto the next town/state and you will eventually find a position that will work for you.

2. As a podiatrist, you have the opportunity to make a big impact on patients’ lives. I’ve done some really cool things both in and out of the OR. There are people with crippling heel pain, on the verge of disability, that is beneath ortho’s dignity to treat. Curing their mycosis or ingrown is boring to many of us who’ve been doing this for years but to the patient, it’s huge. I take on a wide range of problems, some challenging, many not, and that leads to generally interesting and diverse work day.

3. I don’t hate trimming toenails. Yeah it’s icky, but like changing your children’s diapers, you start to bond with the person you’re treating and the act itself isn’t so terrible. The initial charting can be tedious, but afterwards it’s mostly a copy-paste template. If you can learn Lauge-Hansen, you can learn Q modifiers. Besides, some insurances will pay me $125 for 5-10 min of nail/callus care, brainless work, negligible liability, no global. Plus these patients are always super nice and super grateful afterwards. Meanwhile my bunion patients regard me like a car mechanic. Why did we ever get involved in bunion surgery?

4. The Grass Is Always Greener mindset is pervasive in medicine. I had an anesthesiologist tell me he wanted to steer his son towards a career in podiatry because podiatrists always seemed so much happier than the other surgeons. Meanwhile he was earning $1mil/year and was unhappy. Baffling. Anyway, since there’s no shortage of posts about how good everyone else has it, I’m going to be petty about other health professions. Here we go, enjoy some empty calorie negativity:

• Chiropractic. We criticize our profession for opening up needless schools (justifiably so) but at the end of the day they’re teaching real medicine. Not so for chiropractic. These need to be in the dictionary next to charlatan. Vertebral subluxation is not a thing. One of the founding chiros claimed to cure someone’s deafness through spinal manipulation. Fun fact, the auditory nerve is a cranial nerve, its root doesn’t originate in the spinal cord.
• Pharmacy. Terrible
• Optometry. I hate selling people overpriced garbage, and that would include eyeglass frames.
• Physical Therapy. I feel bad for PT, they help so many of my patients, their work is truly important. But there’s a REALLY low ceiling on your income, and if you’re after a 3 year doctorate you may as well go to law school. (Actually don’t, lawyers are generally miserable)
• PA. This is personal for me. When I was in residency there were some PAs on other services to fill in for residents who were post-call and do floor work. Some were cool and I got along ok with them. A lot of them were patronizing and treated me like a simpleton because I was a DPM. I co-scrubbed with a PA on my ortho rotation for a hip arthroplasty and I asked her if she wouldn’t mind doing the admission medication reconciliation, because our EHR was always fastidious like that especially with asthma meds. She says to me “oh right you probably didn’t learn about those drugs.” And in my mind I was thinking “no, I understand beta-agonists, it’s that this is tedious busy work and you’re a hospital employee so do your job.” And there’s the rub. PA is a great move if you’re chasing the bag. The ROI is better than most other health degrees. But make no mistake you will be a scut-puppy for life. You’ll treat drug-seekers and STI exposures in the ER. You’ll water-ski in the OR. You’ll shoot botox in the derm clinic. You’ll face patient disappointment when they were hoping to see the doctor and not you.
• NP/CRNA: I’m lumping them together, I’ve got no ill will towards them, just because they’re not as stuck up as a lot of PAs. I suppose you put in your years as a RN doing floor work, facing disrespect from admins, doctors, patients, other nurses, it gives you some perspective. Sure the ROI is great, you can earn while you learn, but anesthesia seems like a boring job. And NPs tend to get funneled into primary care which also is not my cup of tea. See also what I said at the top about my opinion.

5. Even though surgery is a small part of my practice, I have found my aptitude for surgery to be useful in the clinic. There are DPMs out there who get all flustered about the idea of percutaneous tenotomies or excisional skin biopsies. Reality is if you keep your cool and get yourself set up, you can bang these out in the space of a 15 min office visit. Yes it’s a little barbaric doing these in the clinic and the injection is painful for the patient. You know what else is painful? Anesthesia/OR copays.

6. Personally, I enjoy diabetic wound care. It’s a lot of work, and many patients are challenging, and you will get same-day arrivals and evening/weekend calls for urgent issues. But it’s also very interesting, and frankly I find it breathtaking when you find the modality that works and a longstanding ulcer utterly disappears. Sometimes it’s as simple as gluing plastizote to the underside of the patient’s insole. Total contact casting is severely underutilized. It pays decently well, and if you are smart about where you source your supplies you don’t need that super expensive derma-sciences kit.

A lot of doctors don’t like treating ulcers because they re-ulcerate. The way I look at it is none of us is immortal, our bodies always break down and deteriorate no matter what we do. It’s the human condition. Some patients need surgery to get their ulcers healed for good, some patients need amputations no matter what you do. You just try your best and your patients appreciate it.

7. Ultimately podiatry has been fairly good, I’ll never go hungry, the work is interesting, the people are interesting. Happiness is a mindset, you have to be grateful for what you have no matter what you have.

Things I Don’t Like So Much about (Private Practice) Podiatry

1. By far, number 1, the path to licensure is needlessly long for what I am doing right now. I think the UK/Canada/Australia do it right, podiatrists have bachelor’s degrees and basically do chiropody procedures only. Instead of a doctorate + 3 year residency, we could have a “Master’s of Chiropody” or something, so you can learn pharmacology and prescribe Lamisil/antibiotics and not cut deeper than the subcutaneous tissue and still do 90% of everything I’m already doing.

4th year of podiatry school is pointless, clerkships are basically job interviews for residency. After interviews in January of 4th year, everyone mentally checks out and isn’t really learning anything anyway. Residency training was a speed bump for me on the way to licensure. If we MUST be surgeons, 2 years is enough to figure out hallux valgus and diabetic foot infections. My director did it in 1.

As it stands, 100% of podiatrists undertake a course of training that is for the benefit of 10-20% who will actually use it. We have an ongoing credentialing “Arms Race” where now fellowships are becoming more and more sought-out. My professor at podiatry school used to say, if you’re going to do 4 years, why not make post graduate training an even 5 years and you can become a general surgeon and operate on the entire body?

And since the ABPM wants to initiate this good will movement to promote podiatry on SDN, I’m going to call out these CAQs. They are all RIDICULOUS.

It’s not enough to get your degree.
It’s not enough to finish 3 years of residency.
It’s not enough to get licensed
It’s not enough to get certified
It’s not enough to do annual MOC activities

We’re being offered CAQs? All you have to do is compile an application, take a test, and pay a fee. I pray that every doctor here sees this for the naked cash grab that it is. Purchasing a CAQ is no greater testament to my competency than my hat that says “#1 Dad” is a testament to my parenting. But the sad reality is a lot of us feel inadequate and have to apply for the next latest greatest credential.

This more than anything else is why applications are down—the return on investment of 7 years isn’t here. The people in leadership (including ABPM) create more steps on the back end to make it harder for us working in the trenches, and then wonders where are the applicants on the front end.

2. The petty egotism of other podiatrists. The fact that we’re afraid to speak openly (not anonymously) and frankly of our profession’s shortcomings in a public forum for fear of repercussions.

3. As noted above, I don’t hate trimming toenails. But I do hate the way many people automatically make that association when they hear I’m a podiatrist. I hate that you can perform a limb-saving surgery and then visit the patient the next day in the hospital and all they or the family members care about is getting their nails trimmed. As though I carry my nail nippers in my pocket at all times “just in case.”

4. This is particular to private practice and to my situation, but if you buy into a partnership, make sure the contract stipulates how the pie is going to be split up. After my buy-in, some of my partners quietly started reducing their clinic hours. When I brought it to their attention that they were working less, and consequently generating less, and consequently should be taking a smaller slice of the pie, they were utterly insulted at the suggestion. We ultimately worked out an agreement, but I would have preferred to sort it out ahead of time. I’m still glad I bought in, because the alternative is starting from the ground up. That requires a skill set we just don’t get in residency or school. But I’ll always be salty over the 10s of thousands of dollars I’ve been putting into my partners pockets over the past few years.

5. Not so much a dislike but more of an idiosyncrasy of private practice. You will spend a bit of time doing managerial tasks. Yes, I have an office manager who handles a lot of it, but at the end of the day it’s my business and I have to be cognizant of what’s going on and how things are operating. For example I had a day where two of my medical assistants started bickering and I had to basically be their dad just so everyone could coexist peacefully.

6. Unpopular opinion: routine foot screenings for every patient with diabetes are a waste of time. I get patients on my schedule with uncomplicated diabetes who are perfectly capable of trimming their own toenails. They have no complaint other than their PCP told them to see me. So I do a neurovascular check and give a canned speech about checking their feet. I’ll pay lip service to glycemic control, but ultimately I’m not licensed to manage this and if anyone is going to convince this person to eat right, it won’t be their podiatrist. And then prn. Sorry, my schedule is too full to be scheduling you for an annual 99212 just to make sure your feet are still securely connected to your legs.
“But what if you miss something?” there is a sub-population of patients with diabetes who truly are an ulcer risk can and will go from intact epidermis to osteomyelitis in a matter of weeks. These are the people I can recognize and I keep them on a short leash. This does not equate to the broad brush recommendation that EVERYONE with diabetes needs to see me just for the sake of seeing me.

7. Finally, and most importantly, as a podiatrist, my recommendations will often be viewed with a certain degree of suspicion. Most of my patients have full confidence in me. But their doctors do not. I had a patient with Achilles tendonitis that I was getting queued up for surgery until his friend told him I as a podiatrist shouldn’t be treating this. PCPs regularly refer my ulcer patients to the wound clinic, for no other reason than because the wound clinic is called a wound clinic. I once had a PCP dc the Lamisil I prescribed over concern for the patient’s kidneys—seriously. I told the patient fine, your PCP can manage your mycosis then. I could and probably should do a little outreach, but I gave up a long time ago on winning hearts and minds. The old biases will always be there.

So there you have it, my unvarnished opinion. The good and the bad, warts and all (lol). Podiatry ain’t a bad gig. Problem is it’s not the best move you’ll ever make either. It can be a good fit for the right person and only you know if that’s you. As for me, do I have regrets? Yeah a few. Anyway I’ve spent enough of my Saturday on podiatry.

Also, I have had the same experiences with PAs. They are a hit or miss miserable bunch. Feels like they have something to prove, kinda like podiatry, but much worse.

 

[heybrother]

I think the OPs post is reasonably fair. The problem with being "established" is we can forget that:

1. Pre-partner is full of land mines.

*Money to move? Money for a house?
*Benefits? Health insurance? Malpractice
*Quitting? Money for tail? <-----Seriously. If you end up paying tail you'll never forget that.
*Moving a lot? Will you have cases for board certification?

2. The quality of the partnership sets your path forward.

*The simple truth is most people should be eat what you kill / keep the majority of your work efforts and yet partnership doesn't always assure that. Additionally, we talk about partner money but we don't talk about what it cost to acquire it or how the payback/buy-in occurs.

3. Other people never become truly established.

4. There are far too many people on here who had to do nursing home work not for hustle money but to survive.

5. This profession was marketed to us as a path to surgery.

A small thing on money and organizations.

1. Hospitals pay well but obviously they do keep more money than they give out.

2. In a large enough group or organization there is likely more money to be made concentrating ancillaries within your group.
ie. orthopedists who own their own MRI and surgery center have something wonderful.

3. Podiatry ancillaries tend to be scammy.
ie. a diabetic shoe van? Seriously. There's a reason CMS put all sorts of rules on DM shoes and require a DO/MD to be involved.
ie. PCR on all open wounds - tha's what he said and its garbage.

Hard not to disagree with icebreaker. A lot of podiatrists are very dependent on finding billing opportunities that pay too much. The axe is probably coming within the next year or 2 for the graft game. Medicare pays $500 for an Austin but will reimburse you $1000 for a $200 graft that you just pocket the difference on - that can't be right.

 

[air bud]

Saints WR Michael Thomas is getting his plantar plate tear fixed. Out for the season

Definitely a podiatrist it's going to fix it.

 

[CutsWithFury]

Background: I am in my last year of residency and will be joining a private practice after graduation with a great offer. I have been stalking SDN since my pre-pod days. My opinion isn’t about life after residency, I’m not on my own yet, but more of the profession in general. I have my numbers, will be trained well surgically, and published. I’m slightly jaded from residency, but hoping my optimistic and young opinion can help others.

Pros:
- Our profession can provided a comfortable lifestyle. IMO you can pay off your loans, provide for your family/save, and have $$ leftover for that Disney vacation. ** Ignoring the 80k salary PP positions, but that is not the focus of my vent.
- “Podiatry residents are always so happy compared to other surgical specialties”. We don’t treat life or death patients. That takes a tremendous load off you. Imagine telling a family their grandma died because of your mistake. Yeah, I don’t want that. On that note, I say we are a quality of life specialty. A patient tell you, "I know I have this wound that I'm NWB with to heal, I want to be able to walk on the beach with my grandson. Help me".
- I enjoy the diversity of our care. Diabetic limb salvage IMO is an art. Looking at a wound, strategizing my flap and how I can make this filet of toe cover the wound. You can have clinic one day then be in the OR the next. You really can craft your schedule and how you want to practice. Don’t forget, clinic can pay very well and most of the time better than surgery
- I know for me and my slightly undiagnosed ADHD, I always need to be doing something. I know I will be working when I’m in my 60-70s because I just can’t sit still. Our profession can allow you to work a few days a week and still get your ‘feet wet’.
- I don’t want my patient base to be mostly nails. HOWEVER, I have been told by my surgery heavy attending that it’s nice having an “easy” patient once in a while in clinic. I also enjoy the ability to create close relationships with these patients. I want a patient I am able to talk to them about say my future children and they remember.
- I do genuinely feel our patients value and are thankful for our work.

Cons:
- Not everyone should be doing surgery. Think of the worst student in your class. Now think of them operating on your parent, partner, or child. Scary right? I wish our profession still offered an option for non-surgical pathway.
- Our profession as a whole does not have BDE (Big D*** Energy). We have an ego and hate admitting we’re not MDs. Look at our colleagues who only say they are foot and ankle surgeons. Yes, you are a foot and ankle surgeon, but you’re also a podiatrist. I like and will call myself a surgical podiatrist or podiatrist who specializes in surgery.
- Fellowships. IMO a fellowship should only be pursued if you want specialized training i.e. TARS, charcot, rearfoot deformity correction, or more advanced trauma. There is a big difference between bad and good programs. You would think training for 3 years on the foot and ankle alone would be enough. For the bad programs, it’s not. IMO if you have good foundation in surgical principles, confidence, and hands you can figure it out.
- Our board certification SUCKS. I just took my ITE last month and honestly the didactic portion was ridiculous. I'm not dumb, trust me, but even studying another month wouldn't have helped. Again, IMO, podiatrist out there with an ego trying to make themselves feel better.
- More of a personal vent - I hate suturing or putting a wound vac between toes.

My advice to future podiatry students:
- You can read everything you want on here, but my best advice is to shadow! Pick up the phone and call a practice near you. Feel free to PM me too. There are pros and cons to everything in life and it’s up to you to do the research.

My advice to podiatry students:
- I hate hearing students say “I want an easy or “country club” residency” or “I don't want to do X,Y,Z surgery”. I will be frank - you have no idea what you want to do as a student. You do not know enough. Do not let your training dictate what you can and can’t do surgically. Pick a program that trains you well and YOU can decide what you want to do.
- Do well on your off-service rotations. Remember, the IM, Gen Surg, and Ortho residents etc are making their opinions about our profession right now in training. Don’t be “that” podiatry resident. Learn and ask questions. It goes a long way. Pay attention on externships how other services treat the podiatry team. It will say a lot.
- START THE JOB SEARCH EARLY. Good jobs are swiped early. Good jobs (even PP *triggered SDN docs*) are out there.

Conclusion: I am happy with my decision to become a podiatrist. Sure there are cons, but I’m overall an optimistic and happy person so I find the positives in life. I love what I do, treating and getting to know my patients, and I’m looking forward to being out on my own.

Why do you need a fellowship to do any of the things you listed? It’s called get a good residency.

 

[Adam Smasher]

I edited in reason #8 under dislikes, since I thought the tone of my original post was perhaps too positive.

I hate to be negative about my life when I know about kids in Africa who are conscripted into military service. But if your mantra becomes "Podiatry: at least you're not a child soldier" it kind of says everything you need to know.

 

[619]

Hard not to disagree with icebreaker. A lot of podiatrists are very dependent on finding billing opportunities that pay too much. The axe is probably coming within the next year or 2 for the graft game. Medicare pays $500 for an Austin but will reimburse you $1000 for a $200 graft that you just pocket the difference on - that can't be right.

$500 for an Austin is not right either when some private insurance reimburses about the same for an ingrown nail that takes less than 10 mins. And I am sure you heard about the proposed 4% cut in medicare rate that will soon be going into effect. At the end, doctors are getting screwed big time.

 

[Boba Foot]

And I am sure you heard about the proposed 4% cut in medicare rate that will soon be going into effect. At the end, doctors are getting screwed big time.

I'm not sure the feasibility of it, but can doctors unionize and push back against Medicare and private insurance rate cuts? Might be more effective than lamenting it every year.

 

[LadyPod]

Why do you need a fellowship to do any of the things you listed? It’s called get a good residency.

I don't disagree.

I do think a good fellowships can provide you extra training in those procedures if you want more practice before you're out on your own.
But to your point and what I said in my post, if you go to a good residency and have the correct surgical foundation, confidence, and hands you don't need a fellowship.

 

[air bud]

I edited in reason #8 under dislikes, since I thought the tone of my original post was perhaps too positive.

I hate to be negative about my life when I know about kids in Africa who are conscripted into military service. But if your mantra becomes "Podiatry: at least you're not a child soldier" it kind of says everything you need to know.

Just read your update. Totally true. I have never thought of it this way. This is totally a failure on the schools and should be a major talking point. If this significant of a portion of your grads are going to become small business owners there should be much more focus on it. I understand MD/DO have the same possibility and they don't cover that but I feel theirs is much less.

Would like to see a significant change in the schools. Quit wasting our 3rd and 4th years. 3rd year is a waste of time doing nails in the schools clinics. 4th year is free labor on 1 month interviews. Add in some business development/personal finance/accounting type classes. At least make an optional rotation.

Edit - Failure may be a strong word....let's just say it's a way that our education could be improved. And we already know it is not in the new Texas schools mission statement...see that thread for details....and of course the school will say it is their job to prepare you for residency....but should there be more emphasis at admissions that there is a very high likelihood you will one day be a small business owner...yes.

And I just thought of a reason why it should be discussed more and taught. MD/DO can choose to work in PP and learn how to run a business. DPM is basically forced to work in/run a SMB due to the lack of hospital jobs. No lack of hospital jobs for MD/DO

 

[GreenHousePub]

$500 for an Austin is not right either when some private insurance reimburses about the same for an ingrown nail that takes less than 10 mins. And I am sure you heard about the proposed 4% cut in medicare rate that will soon be going into effect. At the end, doctors are getting screwed big time.

Definitely not right. We get about 900 for an Austin. 1500 for a double and 1600 for a lapidus. I actually switched over to doing all my bunions MIS just because the recovery time is quicker, I only have to see them at most 3x in the global period and they do very well.

 

[Weirdy]

I actually switched over to doing all my bunions MIS just because the recovery time is quicker, I only have to see them at most 3x in the global period and they do very well.

Which system?
How long did it take you to master the burr?

 

[air bud]

Which system?
How long did it take you to master the burr?

@dtrack22

 

[GreenHousePub]

Which system?
How long did it take you to master the burr?

I used stryker/wright medical.
I was such a fan I scheduled 2 more for the end of this month. Went from a 20+ IM angle to parallel. Super impressed.
Took me about 1 cadaver and I felt very comfortable with the burr. I guess burring all those nails really did help after all these years....

 

[heybrother]

I used stryker/wright medical.
I was such a fan I scheduled 2 more for the end of this month. Went from a 20+ IM angle to parallel. Super impressed.
Took me about 1 cadaver and I felt very comfortable with the burr. I guess burring all those nails really did help after all these years....

The last thread on this has won me over. I picked the Arthrex rep as an arbitrary starting point for trying to do MIS. The hurricane seems to have slowed the process. I told them I had 2 cases in December that I think are perfect for MIS. Find myself wishing I'd asked Stryker cause I don't think the training is going to happen before then.

 

[PatchAdamsFan]

While we're on the topic of staying off-topic (great post @Adam Smasher), I use both Arthrex and Stryker MIS burrs for bunions and prep of almost any joint in the right patient. Took me 2 cadaver labs personally, and my first bunion/hammertoe case took almost 2 hours. My most recent bunion one last week took 18 minutes. They're walking in sneakers at 3-4 weeks, without pain or stiffness - it's pretty neat to see. Almost forgetting how to suture using all these stab incisions.

 

[DexterMorganSK]

This is an excellent thread by @Adam Smasher
Please try to stay on topic or make another thread on the topics y'all are interested in.

 

[air bud]

More PP people who don't regular post please

 

[Weirdy]

Thank you for the replies.

Apologies for getting off topic.

May start an MIS thread in future.