Questions for Podiatry's Leaders

[Bored Snorlax]

You are rehashing things we have repeated over and over again already.
Its reasonable to voice concerns and opinions.

But don't rehash the same problem just to sound eloquent.

Boards pass rates are a responsibility of the schools and students themselves. Superstar students will pass all their boards no matter what school they are at. Could there be curriculum/staffing changes to make it harder so that only superstar students are getting admitted >> higher pass rates? Yes. But that is more in the realm of what the school can do, not the current podiatry leadership.

edit; looking back i did nothing to contribute. Here are ways schools can increase their board pass rates and attrition

1) More rigorous gatekeeping. Increase admission scoring and standards. Stop scraping for bottom of the barrel. As much as I disagree with new schools opening in general, the Texas school, per their own horn tooting, seems to have taken this into consideration and recruited those with high stats. Higher stats = higher chance of passing boards and graduating. Can't speak to their soft skills.

2) Limit seats at each school. Lower quantity and focus on quality. This is impossible for some programs who already have small class sizes as they will cease to exist. The larger programs are more likely to be able to limit seats, but they do so at the risk of their bottom line and operating expenses.

3) Curriculum changes. This feels at times like a double edge sword. If you switch strictly to boards related teaching, they will be stellar in their board pass rates, but their actual experience and critical thinking skills take a hit. As a resident, you use the knowledge you have to think for yourself and the patient. The board answers may have jack all to do with the real world results. Do you want an army of 4th year students who can only recite board answers when in 1 year, they will be taking care of real patients that come with real consequences? You need a balance of both. The MD/DO curriculum/boards/correlation to how well they do in clinic is apples to oranges- they manage more complex pathologies and need to cover a much broader scope in detail. I disagree with your opinion of"If they all pass their boards and do well, how come podiatry is not the same?".

Thank you for your valuable input. I agree with all your points with the exception of #3.

The main reason is that everyone must pass boards or they will be unable to finish their program.

The board exams assess minimum competency required to practice podiatric medicine, and plays a big role in obtaining your desired residency if you pass the first time. Yes, there is more to podiatry than just the board exam, but realistically speaking this exam determines your career. I agree that there should be a balance of both increasing the competency of podiatric student clinically while simultaneously increasing board performance outcome. More people will apply to podiatry when there is a higher chance of success, which means potential for superstars to enter the field of podiatry and advance our profession.

I apologize if I was repeating some topics, I have genuine concerns not just for myself but also my friends going through the same program. I want all of us to succeed because everyone invests a lot of time, money, and sacrifice into pursuing this career.

It is also not comforting learning about the residency shortage that occurred with the previous school opening, but I hope the pod leaders will take action and not let history repeats itself.

P.S. I will continue to work hard in silence and get along with everyone I appreciate your advice.

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[HardRoadPaved]

2) Be normal.

Have you met everyone in your class? Holy moly we pick a lot of losers to get a degree.

I cant imagine what other ancillary med programs like Chiro are like.

 

[Weirdy]

Have you met everyone in your class? Holy moly we pick a lot of losers to get a degree.

I cant imagine what other ancillary med programs like Chiro are like.

I have. My statement was to reinforce what you are saying. I found it insane that just being a normal person could get you so far while looking at some of these students from all over clerk at our program.

There are tons of toxic people ---> who end up as DPMs --> maybe even gain leadership positions where they can make real change, but blatantly choose to self serve whether this be at the local, state, or national level.

 

[AttackNME]

I’d like to remind everyone that our podiatry problems aren’t very unique, there are loads of problems in medical education. Just take a look at the case of Dr Duntsch (aka Dr Death)

TLDR: he’s a neurosurgeon who was so bad in surgery that he killed people with complications thats been never heard of, he was so bad that he was the first doctor to go to jail. Btw he also got a phd, started a company with his attendings in residency that failed, forcing him to operate to make a living. He had very positive reviews from his residency attendings allowed him to get priviledges. How was he even allowed to graduate residency? Why did his attendings write him a positive review? How was he allowed to hop from hospital to hospital killing people along the way? It’s a systemic issue. Back to your question about passing part 1 @Bored Snorlax just study hard and pass it. Yes there are lots of problems with low boards pass rates that schools should address, but there are way bigger problems that needs to be solved before boards pass rates are deemed high priority

 

[icebreaker32]

I’d like to remind everyone that our podiatry problems aren’t very unique, there are loads of problems in medical education. Just take a look at the case of Dr Duntsch (aka Dr Death)

TLDR: he’s a neurosurgeon who was so bad in surgery that he killed people with complications thats been never heard of, he was so bad that he was the first doctor to go to jail. Btw he also got a phd, started a company with his attendings in residency that failed, forcing him to operate to make a living. He had very positive reviews from his residency attendings allowed him to get priviledges. How was he even allowed to graduate residency? Why did his attendings write him a positive review? How was he allowed to hop from hospital to hospital killing people along the way? It’s a systemic issue. Back to your question about passing part 1 @Bored Snorlax just study hard and pass it. Yes there are lots of problems with low boards pass rates that schools should address, but there are way bigger problems that needs to be solved before boards pass rates are deemed high priority

I do think we are too hard sometimes on our own profession in some ways. Plenty of MDs do not know their own limitations, are mentally unstable and addicted to drugs. Too many podiatrists act like all MDs are somehow perfect and only some podiatrists are incompetent. We still do have more inconsistent training, but less so than in the past.

Does podiatry as a profession have a lot of issues and the worst job market by far for a doctorate profession in healthcare care that requires 7 or more years of training after college?.....certainly.

 

[iridocyclitiss]

Thank you for your valuable input. I agree with all your points with the exception of #3.

The main reason is that everyone must pass boards or they will be unable to finish their program.

The board exams assess minimum competency required to practice podiatric medicine, and plays a big role in obtaining your desired residency if you pass the first time. Yes, there is more to podiatry than just the board exam, but realistically speaking this exam determines your career. I agree that there should be a balance of both increasing the competency of podiatric student clinically while simultaneously increasing board performance outcome. More people will apply to podiatry when there is a higher chance of success, which means potential for superstars to enter the field of podiatry and advance our profession.

I apologize if I was repeating some topics, I have genuine concerns not just for myself but also my friends going through the same program. I want all of us to succeed because everyone invests a lot of time, money, and sacrifice into pursuing this career.

It is also not comforting learning about the residency shortage that occurred with the previous school opening, but I hope the pod leaders will take action and not let history repeats itself.

P.S. I will continue to work hard in silence and get along with everyone I appreciate your advice.

realistically our leaders are not going to address the shortage of residency spots. They'll all just blame each other for why there is a residency shortage. That being said, I think the best thing you can do is just put your head down and work. I honestly don't think my school did a great job at preparing us for boards (inflated the crap out of our GPA's) or for fourth year (just worked us in their free labor clinics lol). that being said I feel like a ton of my classmates made this excuse that the school didn't prepare them for boards or fourth year blah blah blah and they failed boards and sucked at fourth year. Don't fall into this trap. You are responsible for your future. You are in the driver's seat. and by recognizing that and giving yourself that power you can get good grades, pass boards the first time, and do well in 4th year.

 

[diabeticfootdr]

View attachment 363984


@diabeticfootdr

1. Why are new schools being opened instead of focusing on improving the performance of existing schools and allocating them resources?

2. What steps are being taken to increase board performance and standardization of training/competency to promote the field of podiatry in a positive manner?
- MD/DO schools have a 1st time pass rate of 97-98%, but some podiatry schools have a 3yr avg. pass rate of 69-75%. This is an alarming figure and must be addressed immediately. There is a lot of financial risk involved with those statistics.

3. What assurance will new students like me have that there will be adequate and high quality residency slots when I graduate in 3.5 years? You mentioned there is no shortage currently, but situation changes each year.

Looking forward to your response and thank you for your time.

First, thanks for posting the graphic. I hadn't seen that before.

Second, while you addressed the questions to me, please don't assume I represent the entire profession of podiatry on any grand scale. There are about 70 organizations (if you include all the State Component societies) that are running the profession. Nor do I have all the answers. I have my own opinions on many issues, which I'm happy to share (and I have shared previously).

1. Why are new schools being opened? The profession can't regulate the number of schools. It's a free country and that would probably be found to be restraint of trade. If an eligible institution submits an application to CPME for accreditation and they meet the standards, then they must be accredited. And I actually approve of that over a good ol' boys club that could act anti-competitively.

2. What steps are being taken to increase board performance? I interpret that as "licensing" board (AMPLE) exam. That is in the realm of the schools. Probably specifically listed in CPME 120 (you can look it up). Use that as an indicator of the quality of the school's program and choose a school that has a good board performance. (On a side note, if you think the licensing board exam pass rate disparity with MD/DO is bad, wait until you read about the board certification pass rate disparity)

3. There is no shortage predicted for 3.5 years from now. Even with TX 27 students added in. But that doesn't mean you shouldn't work hard and try to get the best residency for you. The profession is small, which you can use to your advantage. Networking early really makes a difference. Start communicating with residency directors now.

 

[diabeticfootdr]

The podiatry leaders constantly peach about increasing quality of residencies and standards, but how will diluting the profession before increasing standards, producing better outcome, and securing better job opportunities help with any of that?

Oh yes, they preech about improving the quality of residencies, but what did they actually do? Pretty much nothing. That is the CPME and the Ad Hoc 320 Rewrite Committee which I served as a member for 1 meeting. As ABPM president I can appoint 1 representative. And I appointed myself for the last meeting after I was disappointed at the lack of progress. We publicly advocated for the following items in multiple communications with the CPME other organizations.

Big picture:
I advocated for scrapping 320 and adopting ACGME Common Program Requirements, then having a separate Specialty Standards document, just like all MD/DO programs have. If you want parity, why not follow the Common Program Requirements, especially since a tiny percent of podiatry residencies are in hospitals with no other ACGME residency. Of course that is a vision not shared by CPME, who may in fact have a conflict of interest with adopting ACGME standards (because then what are they needed for?)

Focused items:
We advocated to have a mandatory rotations in vascular surgery (achieved), pain management (denied), wound care (denied), dermatology (denied), rheumatology (denied). We advocated to change the comprehensive biomechanical exams to problem focused exams (achieved).

We also advocated to use the same methodology the ACGME uses to weed out poor performing programs. Essentially, they look at a rolling average of the former residents board scores and if the program is in the bottom 20%, it is automatically on probation. You can guess how that sat given the current pass rates for one of the boards.

But, don't just get mad and make a fuss on SDN. Get in a leadership position and make a difference!

 

[diabeticfootdr]

realistically our leaders are not going to address the shortage of residency spots. They'll all just blame each other for why there is a residency shortage.

Well, here everyone can be a leader. The best leadership one can offer is starting a program and becoming a residency director. Some people are actually in a position to do that, but all they do is gripe about why others aren't doing it.

States and the new schools are recruiting people to be residency directors at academic health centers.

If you're a student, become a student leader and hold the others in the profession accountable.

 

[DYK343]

3. There is no shortage predicted for 3.5 years from now. Even with TX 27 students added in.

Great! But seems to be a specific number. How about in 5 years when Tx has increased enrollment and LECOM is graduating students?

 

[DYK343]

Focused items:
We advocated to have a mandatory rotations in vascular surgery (achieved), pain management (denied), wound care (denied), dermatology (denied), rheumatology (denied). We advocated to change the comprehensive biomechanical exams to problem focused exams (achieved).

I think this would be good for the profession. Escieically time in derm, pain, and rheum (even if just 2 weeks).
But in reality it would cause a lot of programs to close - including good programs.
Unless at a very large or university hospital. A lot of hospitals dont have a derm/rheum/pain department. These are typically private practice.
Could try to set up rotations with outside private offices but thats always going to create problems.

THe program I graduated from in my opinion was top notch for DPM and general medicine training. But it may have to close if mandatory derm/rheum rotation.

 

[Shiyuan]

They denied rheum? 1 word: mor0ns.

 

[Bored Snorlax]

First, thanks for posting the graphic. I hadn't seen that before.

Second, while you addressed the questions to me, please don't assume I represent the entire profession of podiatry on any grand scale. There are about 70 organizations (if you include all the State Component societies) that are running the profession. Nor do I have all the answers. I have my own opinions on many issues, which I'm happy to share (and I have shared previously).

1. Why are new schools being opened? The profession can't regulate the number of schools. It's a free country and that would probably be found to be restraint of trade. If an eligible institution submits an application to CPME for accreditation and they meet the standards, then they must be accredited. And I actually approve of that over a good ol' boys club that could act anti-competitively.

2. What steps are being taken to increase board performance? I interpret that as "licensing" board (AMPLE) exam. That is in the realm of the schools. Probably specifically listed in CPME 120 (you can look it up). Use that as an indicator of the quality of the school's program and choose a school that has a good board performance. (On a side note, if you think the licensing board exam pass rate disparity with MD/DO is bad, wait until you read about the board certification pass rate disparity)

3. There is no shortage predicted for 3.5 years from now. Even with TX 27 students added in. But that doesn't mean you shouldn't work hard and try to get the best residency for you. The profession is small, which you can use to your advantage. Networking early really makes a difference. Start communicating with residency directors now.

I appreciate your response and transparency. You may not represent the entire profession, but you care enough about it to open a dialogue on SDN so others may freely express their opinion to help identify issues and make improvements.

1. I agree that competition is important to encourage schools to improve, but there should also be an equal amount of oversight to ensure that our profession does not become overly saturated and that every graduate is eligible for a high-quality residency.

I believe podiatry has a bright future ahead if:

A. The 11 schools can maintain high standards and pragmatic outcomes such as academics, boards pass rate, clinical exposure and training etc. comparable to our MD/DO colleagues. These schools should collaborate by sharing good ideas to help each other improve for the sake of their students and the future of podiatry.

B. The pod leaders actively create high quality residency programs so that any qualified graduate can get a spot. Pod leaders should also make it easier for residents to find jobs that compensate them fairly such as an alumni network/website. This is important to attract highly qualified applicants to podiatry.

2. Yes, I was referring to APMLE. I was not aware of the board certification pass rate disparity, but I will certainly do my research on it. In terms of APMLE, there is a significant amount of difference between podiatry and MD/DO pertaining to pass rate. I have little faith in the CPME considering they recently extended accreditation for a school, despite <70% 3-year avg. first time pass rate, through the end of 2027. This will undoubtedly result in many students being financially screwed and generate dissatisfaction for the field. CPME should make schools be more accountable for their students' success if they want to improve standards and outcomes.

3. TX 27 appears to be a manageable number, and the class of 2026 may have dodged a bullet. However, there is also LECOM in 2027 so I hope whoever is sitting at the high table of podiatry (can't wait for John Wick 4) will take that in HEAVY consideration.

 

[iridocyclitiss]

Well, here everyone can be a leader. The best leadership one can offer is starting a program and becoming a residency director. Some people are actually in a position to do that, but all they do is gripe about why others aren't doing it.

States and the new schools are recruiting people to be residency directors at academic health centers.

If you're a student, become a student leader and hold the others in the profession accountable.

I was a student leader, and I can't wait to be in a better position to help the profession.

 

[Feli]

...The pod leaders actively create high quality residency programs so that any qualified graduate can get a spot. Pod leaders should also make it easier for residents to find jobs that compensate them fairly such as an alumni network/website. ...

Tale as old as time, eh?

Training: I wish there was a "where are they now" for DPM grads who failed to match in the shortage years when Western began graduating. That would be enlightening, no doubt. The older residency shortages or years when people had to cobble a 1yr here + 1yr there to make a surgical residency were suboptimal... now, with much higher student loans and 3yrs standard for board exams, it's crippling to not get adequate training.

Compensation: It's a fact of the matter - in any profession - that you're worth as much as what it'd take the employer to replace you with a comparable producer in that locality. Either that, or you're an entrepreneur. That's the case for electricians, attorneys, taxi drivers, podiatrists, ortho surgeons, chiros, RNs, restaurant waiters, and anything else. It's very hard for a DPM to ask for $300k when others will happily do the work for under $200k. I have been the one weeding out dozens of MSG position applications within a few days of posting jobs (would have been hundreds of apps if we didn't take the ads down). I had people who knew me or were able to find my number through mutual contacts leaving voicemails and asking if I could help get their CV looked at. What one produces in collection $$$ or RVUs is only semi-relevant when their many area peers or MANY will-come-to-the-area peers will produce the same for less. It is all about cost of replacement, supply and demand, saturation... whatever you prefer to call it.

 

[Bored Snorlax]

Well, here everyone can be a leader. The best leadership one can offer is starting a program and becoming a residency director. Some people are actually in a position to do that, but all they do is gripe about why others aren't doing it.

States and the new schools are recruiting people to be residency directors at academic health centers.

If you're a student, become a student leader and hold the others in the profession accountable.

Hope I don't offend anyone with this comment, but I'd like to keep it real.

Students:

President = provide free food, put on resume
Member (me) = pay $10 a year and eat free food

There are some positions at school where people can represent the school at the national level, but that will depend on the individual if they want to use their influence to make an impact in podiatry. These positions are limited and typically ends up a popularity contest.

If you have any ideas let me know, for now I'll stick to being the quiet guy at the back of the library.

 

[pod squad]

Question for Podiatry's Leaders: What can be done to combat the encroachment of PA/NP/RNs into our territory? In my geographical area there are 3 full time job postings for 'Podiatry PA/NP' at well-regarded organizations and zero full-time DPM opportunities.

 

[HardRoadPaved]

Is the fear that you'll lose routine foot care? PA/NP/RN cannot do surgery. I thought the goal of three year residencies was for us all to become 'foot and ankle surgeons'

 

[GreenHousePub]

Is the fear that you'll lose routine foot care? PA/NP/RN cannot do surgery. I thought the goal of three year residencies was for us all to become 'foot and ankle surgeons'

I'm by no means a leader but from what I've experienced none of them want to do it. They view it as "beneath their level of education" lol.

 

[pod squad]

Is the fear that you'll lose routine foot care? PA/NP/RN cannot do surgery. I thought the goal of three year residencies was for us all to become 'foot and ankle surgeons'

Fair point, I guess I'd even rather see the job posted as 'non-surgical' DPM instead of PA/NP/RN

 

[Feli]

Fair point, I guess I'd even rather see the job posted as 'non-surgical' DPM instead of PA/NP/RN

We've priced ourselves out of it. ^^
Plenty of those "ortho group job" (with F&A Ortho in place) and many "non-op DPM" jobs that want C&C, maybe orthotics and wounds were done by historically DPMs... some still are, typically DPMs working for PA wage. Recently, newer younger DPMs became too expensive for those, though. Some of them still cave and have to take those positions, but most have to find something that'll pay their debt burden.

The cost of the education is HIGH. The average 4yrs pod debt burden has roughly doubled since I graduated <15yr ago.
People wild enough to do 4th year of residency (aka "fellowship") get another $25-50k+ loan interest and lost $50-100k+ in salary during that extra year. That is not to account for the poor 5+ years of school grads remedially strung along and paying and accumulating.... and they're unlikely to match well or sometimes at all. Try asking any pod school what % of their grads needed over 4 years to finish or what % of students left with no degree (we all know it's substantial), and you have a snowball's chance to get a straight answer.

There is obviously HIGH variability among DPMs in terms of training and capability/competence.
Board results and case volumes from residencies and practice situations and competence show that.
There are some DPM new resident grads who I'd hire to $400k if I were a hospital admin... others sadly aren't worth $100k/yr.

The core problem was and is (even with "all residencies are 3 years") that some residencies are junk, others are awesome, and most of all, that most pod schools aren't selective and accept too many students.
...100% of the things podiatrists complain of: the pay, the job offers, the saturation, the in-fighting and limiting of one another in practice or hospitals, the ABFAS fail rates of basically 100% at some residencies and almost 0% at other ones, the way associates are often treated, the fact that fellowship must be considered for competence after many "accredited" residencies, seeing people with 7yrs post-college working at nursing home companies, the overall rep of the podiatry profession... it all goes back to variability of training and overall saturation.

...and do MDs have these problems? Yes, a bit... nowhere near the scale of DPMs.
It's because they are selective on the front end (~90% matriculant-to-graduation rates in 4yrs speak to this), residencies are uniformly pretty good (uniformly board pass rates, large teaching hospitals), they quickly correct any over-saturation specialties (average specialty incomes, job postings).

Ergo, the DPM fix is clearly to pump the brakes with residencies being the limitation; MDs have done this in various specialties with success. For podiatry, we missed that boat... we made a lot of crap programs into "3 year programs" just to say we are all 3 year trained (instead of looking at actual capability and demand). Now, not even close to recovered from that year ~2000 blunder, we open 25% more schools and residency programs to hopefully fit those grads as fast as possible? Hmmm.

 

[PeaJay]

Question for Podiatry's Leaders: What can be done to combat the encroachment of PA/NP/RNs into our territory? In my geographical area there are 3 full time job postings for 'Podiatry PA/NP' at well-regarded organizations and zero full-time DPM opportunities.

Just hired an NP instead of another DPM.

Just a few thoughts
1. Applicants for the non-surgical positions can be “hit or miss” in quality.
2. I want some that can be “molded” to use my algorithms
3. Don’t you hate when you get a second opinion from a partner/outside provider and they have already said “you need surgery” or “you could benefit from xyz”? A good portion of the time they are not surgical candidates or the proposed diagnosis or plan is…well questionable. You won’t get that from an NP…you will get let’s get you to Dr. xyz for his/her opinion.
4. MSG/Hospital pods are usually paid well and an NP is cheaper. This helps the productivity numbers of the group/department.

 

[bloxxeeey]

Question for Podiatry's Leaders: What can be done to combat the encroachment of PA/NP/RNs into our territory? In my geographical area there are 3 full time job postings for 'Podiatry PA/NP' at well-regarded organizations and zero full-time DPM opportunities.

We have such a high demand we need PA/NP/RN to add to our job market.

 

[Pronation]

Is the fear that you'll lose routine foot care? PA/NP/RN cannot do surgery. I thought the goal of three year residencies was for us all to become 'foot and ankle surgeons'

News flash, they will refuse foot care crap. They have too many good jobs available to them. They are being hired to manage inpatient consults, simple office stuff, and post-ops for half the salary of a DPM. I predict that this will ultimately obliterate organizational job available for podiatrists. This is our leadership’s (old scummy mustache pods) wet dream. This means new grads will be mostly forced into slave labor PP associate positions where these old turds can continue to take advantage of them. Bravo podiatry.

 

[GreenHousePub]

2. I want some that can be “molded” to use my algorithms

Algorithm:
Is the patient breathing? (yes) --> Sell them formula 3 --> (patient refuses) --> give a free sample of formula 3 --> (patient refuses) --> begin foot soaks with vancomycin and lotrimin powder --> bill insurance 99205

 

[AttackNME]

Serious question. Do our leaders feel that the podiatry profession should eventually not do routine foot care?

 

[diabeticfootdr]

Serious question. Do our leaders feel that the podiatry profession should eventually not do routine foot care?

I think there is a difference between;
A. performing a comprehensive diabetic foot exam and making diagnoses and a risk assessment, that should be a podiatrist
and
B. the procedural act of routine foot care, that can be performed by a trained technician

 

[HardRoadPaved]

Serious question. Do our leaders feel that the podiatry profession should eventually not do routine foot care?

In all fairness look at CMS. The rules and regs are asinine to run a business only on RFC: supporting diagnosis, class findings, date of last service with PCP/managing specialist, time limits for reupping care, ABNs. Reimbursement for 99213 and 11056 are roughly the same. Nails... forget about it. The pathway to viability is being able to diversify past routine foot care.

To do that you need to convince the public we are a foot and ankle AUTHORITY. Forget parity, just get public to take us seriously. When person thinks my foot hurts they should think podiatry.

Vision 21st Century (didnt get there with Vision 2020)... too bad we'll all be gone by the end of the century. Vision 21st Century | APMA

 

[Shiyuan]

In all fairness look at CMS. The rules and regs are asinine to run a business only on RFC: supporting diagnosis, class findings, date of last service with PCP/managing specialist, time limits for reupping care, ABNs. Reimbursement for 99213 and 11056 are roughly the same. Nails... forget about it. The pathway to viability is being able to diversify past routine foot care.

To do that you need to convince the public we are a foot and ankle AUTHORITY. Forget parity, just get public to take us seriously. When person thinks my foot hurts they should think podiatry.

Vision 21st Century (didnt get there with Vision 2020)... too bad we'll all be gone by the end of the century. Vision 21st Century | APMA

I LOL’d when you said vision 21st century... but then I realized you weren’t joking.

I was in the era of Vision 2015. The goalpost keeps moving. I definitely think podiatry is moving forward, but unfortunately in a much slower pace than our “mid-level” colleagues.

 

[Adam Smasher]

In all fairness look at CMS. The rules and regs are asinine to run a business only on RFC: supporting diagnosis, class findings, date of last service with PCP/managing specialist, time limits for reupping care, ABNs. Reimbursement for 99213 and 11056 are roughly the same. Nails... forget about it. The pathway to viability is being able to diversify past routine foot care.

I think it's entirely viable to still build a practice around C&C. Yes the LCDs are convoluted but you can figure them out, they haven't changed dramatically in the past few decades. You need to run a really lean business, though. If you're 100% C&C, you don't need a lot of staff or even an XR unit. Just refer out anyone with actual problems. You have a low ceiling on your income potential, but it's low risk, there will never not be demand.

The hardship comes in when you go 50% C&C/50% real care. Now you need tech and inventory and auxiliary staff. Now your overhead is on the rise. If you can go 100% real care, the overhead is worth it, but otherwise you're not getting full return on your business assets.

 

[Feli]

Serious question. Do our leaders feel that the podiatry profession should eventually not do routine foot care?

The fact that an increasing % of hospitals, PPs, etc don't have docs do RFC would say no (med assists, nail nurse for hospitals, etc). Podiatry will do nail care, but the docs themselves? Less and less likely.

It'd be like dentists doing all of the routine cleanings. It'd be technically viable and not wrong... but very, very low income (without fraud).

I think it's entirely viable to still build a practice around C&C. Yes the LCDs are convoluted but you can figure them out, they haven't changed dramatically in the past few decades. You need to run a really lean business, though. If you're 100% C&C, you don't need a lot of staff or even an XR unit. Just refer out anyone with actual problems. You have a low ceiling on your income potential, but it's low risk, there will never not be demand.

The hardship comes in when you go 50% C&C/50% real care. Now you need tech and inventory and auxiliary staff. Now your overhead is on the rise. If you can go 100% real care, the overhead is worth it, but otherwise you're not getting full return on your business assets.

Correct... RFC practices with the DPMs themselves doing basically glorified "medical" pedicures all day have been around awhile. They are financially viable with very low overhead (although many of them still resort to nail path "biopsy" sampling, billing avulsions on routine nail trims, selling lotions and potions and soaks, etc).

Now, the days of more pod schools, much higher loan debt, $20+ per hour office staff, competing DPM offices who do nail care and also ankle fusions, RNs and midlevels doing nail care make it a lot harder. Plus, you know... there is that whole idea of the "fellowship trained DPM foot and ankle surgeon" and the ego bruise of doing mostly just C&C.

...since podiatry's already a specialty, the smart answer is usually to just do whatever walks in the door, unless it's a pure salary hospital job where you're paid regardless (VA and similar). There are more schools and DPMs than ever coming out of training now, and it's generally foolish to pass on anything you're trained for (hire help to do it if you won't or can't). Even assuming one has a serious surplus of the subset of payers/pathology they want, things ebb and flow... hire help and keep it all. Any high school kid could cut nails, but it's still money and patients missed to rebuff them.

 

[DYK343]

Just hired an NP instead of another DPM.

We are going to hire an NP at our hospital to help with non op stuff, wounds, post op, etc. Its the most economical way. Its not like general surgery, OBGYN, or any surgical profession doesnt have NPs and PAs working under them. Not sure why you got downvoted or why some are so protective.

News flash, they will refuse foot care crap.

Office visits:
99203 pays 1.6wRVU
99213 pays 1.3 wRVU.
99204 pays 2.6 wRVU
99214 pays 1.92 wRVU

Nail care (11721) pays 0.54 wRVU.
Debridement callus 11056 pays 0.5 wRVU
Wound debridement (11042) pays 1.01 (obvioulsy more if deeper but this is my most common wound code).

Cant blame NP/PA for not wanting to do nails that pay less than half of a regular office visit. If I saw 8 nail care patients an hour I still wouldnt break even compared to four easy 15min office visit encounters.

I really dont understand the DPM obsession with holding onto low paying nail care. At least on wRVU system which is really my only experience. Never worked private. Might pay more there? I lose money doing nailcare. I dont want to do nail care. To add to it 1/2 of my nail care consults are technically medicare fraud unless I "chart some things".

Wounds can be a mixed bag on reimbursement. If its just a weekly debridement then only 11042 really isnt paying well.


For any prepods/students reading a wRVU is "work relative value units" and each is worth approximately $50. Sometimes less. Sometimes more depending on the contract/location. Most hospitals and many MSG groups reimburse based on wRVU method. If the patient is there for a procedure then you cant bill an office visit. So a patient who comes back every 2 months for nail care you can only bill a 11721 and make 0.54 wRVU.

 

[Adam Smasher]

@Feli , I was not suggesting it's a desirable career goal for any DPM to end up in a C&C biz. Nor is it a proper use of their time and talents. Just saying it can work from a business perspective. Your biggest outlays are your chairs and your dremel. You wouldn't even need a DEA license. Malpractice premiums go way down. Sure you paid a lot in terms of years and loan debt, but those are sunk costs. @HardRoadPaved already noted a 11056 pays as well as a 99213. C&C patients don't give a damn if you can fuse ankles or not, they don't even really care that we do our magical "comprehensive diabetic foot examination." They just want their nails clipped. Structure the business efficiently and you could enjoy modest success, with very little stress. You don't have to be Morton's Steakhouse if you can be McDonald's.

To be clear, if I ended up doing something like this, I would drink myself to death.

I really dont understand the DPM obsession with holding onto low paying nail care.

Funny how all the problems in podiatry lead to the same conclusion. Let's all say it again, on 3.

1.

2.

3.

Because we're saturated!!!

Because you have the time and the office space and you need the income so may as well do it. Because there's a 100 other people in town who can do it just as good so you're not special, you're just a laborer. This is how asinine it is to say, "No profession shrinks itself into prosperity." This is not a profound insight from a great thinker, and should not be quoted as such in ABPM missives.

 

[PeaJay]

I think there is a difference between;
A. performing a comprehensive diabetic foot exam and making diagnoses and a risk assessment, that should be a podiatrist
and
B. the procedural act of routine foot care, that can be performed by a trained technician

This would be optimal if one was going to address nails.

The lawyers for the large organization I work for claim that we have to physically do the nail care (cannot be delegated). This is based off the exact phrasing in the statues per my understanding.

 

[PeaJay]

You need to run a really lean business, though. If you're 100% C&C, you don't need a lot of staff or even an XR unit. Just refer out anyone with actual problems. You have a low ceiling on your income potential, but it's low risk, there will never not be demand.

Running a nail are based nail care practice as a podiatrist is a poor business model. “Debridement” of nails will get you like 30 dollars. My local salons charge 35 for a trim. They have limited regulations and do not risk going to jail should they document wrong. Oh wait they don’t even have to document.

 

[Feli]

We are going to hire an NP at our hospital to help with non op stuff, wounds, post op, etc. Its the most economical way....

For podiatry in most hospitals, yeah. No doubt.
For podiatry PPs, an associate is usually same/cheaper. Doubly so in areas that are saturated and have large supply of associates.

It's too bad, but for hospitals, benefits are one of the biggest costs (PTO, med/dent/etc insurances, retire match, CME), and most don't realize how cheap they could get a podiatrist for. For the hospitals that understand podiatry pay/saturation, most still can't or don't want to pay a DPM a ton less than most other physicians - or typically, if they know our pay and job market, they know enough that they just want a real good one. The biggest diff is hospitals need the podiatrist freed up for wide RVU generation from surgery, ordering tests, inpatient work, keeping tough ER cases from leaving the facility, etc... things a typical PP can't really capitalize off to such an extent.

...I really dont understand the DPM obsession with holding onto low paying nail care. At least on wRVU system which is really my only experience. Never worked private. Might pay more there? I lose money doing nailcare. I dont want to do nail care. To add to it 1/2 of my nail care consults are technically medicare fraud unless I "chart some things".

Wounds can be a mixed bag on reimbursement. If its just a weekly debridement then only 11042 really isnt paying well....

In private, nail care patients are they key to ordering ABI, doing "nail biopsy" (and associated path lab if the group owns that), doing tendonotomies, wraps, doing DM shoes, possible OR elective on some RFC pts, they refer new pts, etc. Those are your 'big ticket' things in many PP... minor in-office tests and procedures, new pts. Those RFC patients are gold; they're an annuity. 💰

For hospitals, yeah... nail care makes no sense. I concur completely. You want to dump that on a tech, RN, etc... probably not even worth the time of midlevels, definitely not a doc. The overhead and the ancillary income from tests and surgery is just so much different (PP = inefficient time and risk by doing surgery on bad insurance, complicated pre or post op, wheelchair patients, rounding, etc... while hospitals = $$$ from the associated OR time, MRI, micro and path, etc the surgery or admit brought with it, and the surgery is not so inconvenient as DPM is in same building anyways).

 

[heybrother]

Yes, for anyone wondering. If you take 2 different groups of people who are paid in two completely different ways even though both do the exact same job they will both come to completely different conclusions.

In my world, Medicare 11056 + 11720 pays better than real BCBS 99214. What a world.

 

[DYK343]

Yes, for anyone wondering. If you take 2 different groups of people who are paid in two completely different ways even though both do the exact same job they will both come to completely different conclusions.

In my world, Medicare 11056 + 11720 pays better than real BCBS 99214. What a world.

11720 pays me 0.32 wRVU. 11056 pays me 0.5 wRVU.

I get about $41 for this 15min encounter.

If you dont mind me asking what does BCBS Medicare pay for your 11720/11056?

 

[Feli]

@Feli , I was not suggesting it's a desirable career goal for any DPM to end up in a C&C biz. Nor is it a proper use of their time and talents. Just saying it can work from a business perspective...


...To be clear, if I ended up doing something like this, I would drink myself to death.


Funny how all the problems in podiatry lead to the same conclusion. Let's all say it again, on 3.

1.

2.

3.

Because we're saturated!!!...

Yes, 100% correct.

Ditto for me on the nail care (office or NH).
I don't turn it away, but I sure don't encourage referrals for it or spend much time on it if there are few or no other issues (MA does 90% of it).

Saturation is the start and the end.
When I was in NC about 10 years ago out of residency for their state board (pretty hard... not quite ABFAS but much harder than NBPME type... written whole day and then orals... fairly high fail rate), there were 15-20 other DPMs there that year. Most were full-scope ABFAS qual or cert, a couple were even real exp surgeons or residency-director types doing TAA and pubs and such, and half I didn't know. We were all basically in the same building taking tests and interviews and presentations for two whole days. I found out three were working with a mobile podiatry company and loved it ("pays a lot better than the crummy office job I had prior, especially if we can pass this test and work here in NC"). I'm all for people doing whatever they like and whatever makes a living, but there are more and more hoops to jump through than ever to do even RFC nails. The saturation and debt and the overhead for even RFC practice (office or mopbile) force a lot of people to end up with something and say they wanted that or they enjoy that... or getting "creative" coding.

It is truly good that there are so many avenues one can do to make ends meet as a DPM (RFC, derm, wounds, full scope, basically only ortho part, teach, etc). I just hope that most pre- and current pod students shadow and read enough to realize that, even with decent training, the bigtime surgery/ortho part is getting more and more competitive and more replaceable and little bargaining that MDs would have (call, pay, location, etc). Those can definitely still be done, and some programs are great to set one up for it, but organizational jobs are sure not the role of the average DPM in the way the profession sells it. Even half of DPMs in those hospital FTE jobs are in constant concern of getting underbid for their job and/or they cold-called extensively and went to a random location to get those sort of jobs.

 

[Feli]

11720 pays me 0.32 wRVU. 11056 pays me 0.5 wRVU.

I get about $41 for this 15min encounter.

If you dont mind me asking what does BCBS pay for your 11720/11056?

That'd be around $100 with MCR+private secondary or 80% that with MCR or 50% with MCA. MCR adv plans can be problematic but theoretically similar to MCR. Any of it can obviously be a goose egg if you hit unpaid deductible, billers bumble it, etc.

Most BCBS (as primary) or other privats don't cover RFC. A few do. PPs hang onto those like gold.
If the private is secondary, they typically copycat primary (has to be MCR for RFC... MCA won't have secondary bcuz, yeah).

And I don't know exact on 11720, I do maybe one 11720 per week and rest 11721 (11720 are usually ppl with a BKA, for me)...
RFC is not enough of my practice that I usually have to get into counting or documenting 4/10 versus 7/10 mycotic-looking nails. Jmo.

...So, solo/owner would obviously get about 50% of that (overhead)... associate 30-35% or whatever they get in contract.
That's not bad for a visit the MA basically does (3mins to do the calluses and exam and chat).
And don't forget the nail biopsy or toeselyn or foot soaks or stuff, if you're into that kinda stuff

 

[DYK343]

That'd be around $100 with MCR+private secondary or 80% that with MCR or 50% with MCA. MCR adv plans can be problematic but theoretically similar to MCR.

Most BCBS (as primary) or other privats don't cover RFC. A few do. PPs hang onto those like gold.
If the private is secondary, they typically copycat primary (has to be MCR for RFC... MCA won't have secondary bcuz, yeah).

And I don't know exact on 11720, I do maybe one 11720 per week and rest 11721 (11720 are usually ppl with a BKA, for me)...
RFC is not enough of my practice that I usually have to get into counting 4/10 versus 7/10 mycotic-looking nails. Jmo.

So, solo/owner would obviously get about 50% of that... associate 30-35% or whatever they get.
That's not bad for a visit the MA basically does (3mins to do the calluses and exam and chat).
And don't forget the nail biopsy or toeselyn or foot soaks or stuff, if you're into that kinda stuff

What are the laws around a MA doing nail care under a DPM license?
Is that state to state? I remember looking into it and suggesting it but was shut down by the MSG attorneys I worked under.

 

[heybrother]

11720 pays me 0.32 wRVU. 11056 pays me 0.5 wRVU.

I get about $41 for this 15min encounter.

If you dont mind me asking what does BCBS pay for your 11720/11056?

1. Good BCBS usually pays a multiplier for procedures (not E&M) over Medicare. Something like 1.5x Medicare rate
2. Even good BCBS is still sub-Medicare for E&M. The 2021 RVU re-evaluation did not impact us.
3. Medicare in my area pays like just under $90 for 11056. BCBS pays like $105 for 11056 which is obviously not 1.5X.
4. Medicare doesn't reduce the value of 1172x when paid with 1105x. You get "full" value for both.
5. BCBS will in general deny the 1172x and say its bundled with the callus code. If they pay the nails they perform 50% reduction. I haven't looked in awhile (or been paid on it in awhile) but you get maybe $25-27 for the nails so the visit is worth somewhere between $105 and $130.
6. Medicare 11056 + 11720 is consistently $110 or something like that.
7. Real BCBS 99213 is less than $80.
8. Real BCBS 20550 is less than $85.

Compensation is often artificial. Why does commercial insurance pay 1/2 for a second procedure but Medicare pays full value for the nails after calluses. Why does BCBS pay sub-Medicare for visits but a positive multiplier against procedures etc.

People say we need to "diversify past routine foot care", but for PP people the only good Medicare code is 99213 (or - the E&M series in general). If you diversify past routine care you should just diversify past Medicare itself in general.

Doing surgery on Medicare patients unless you receive facility side money very possibly negatively affects your bottom line. I found myself the other day thinking about the guy who claimed "25 a day, $100 an encounter, etc". The other day I had 2 unhealthy patients who I took to the big hospital. A 1st MPJ Fusion and a osteomyelitis resection that I admitted afterwards. I don't think I broke $1100 total compensation on that day and I sat around for 3 hours waiting to get to operate. I did the cases quickly and efficiently. I only had to round once.

Anyway. Money and effort do not necessarily line-up.

The perfect private practice encounters are BCBS (a) new patient + 11750 or (b) new patient + x-rays + injection. The more of those on my schedule the less time I'll spend thinking about inconsistencies in compensation or that the DPM next door might be doing ankle fusions. I'll dab a tear from my eye with a $100 bill, light it on fire, and continue about my day.

 

[Feli]

What are the laws around a MA doing nail care under a DPM license?
Is that state to state? I remember looking into it and suggesting it but was shut down by the MSG attorneys I worked under.

Good question.... clear as mud.
Most places don't have any specifics. MA, like a baby version of RN, is a supervised position of largely undefined scope. The doing of those services is a gray area. It varies, though.

Same for disp DME, cast orthotics, take XR, etc that has codes associated... "under supervision of X." Basically all ortho clinics in PP or facility have a casting tech with only on-the-job training, and casting application bills a lot more than nail care and can have much bigger complications (ulcer, DVT, amp, etc etc). It's just a huge gray area for MAs, degree certificate or not... hospital or office. It's obviously a gray/black hole of ambiguity for PAs, RNs, etc of any "specialty" (which they almost invariably acquire simply by working a type of job or with that type of doc).

Attorneys will nearly always take the easy answer "that'd be risky" rather than look it up. APMA moustaches and Formula-18 obviously "fight for you" to make it a "qualification" thing... but we obviously know that many medical and non-medical people other than DPM can physically and legally cut toenails and fingernails since pedicure shops and medical pedi services and mobile nail care businesses exist in all states (as cash services, for relatives or friends, etc though).

Plenty of MAs (or DPMs who do most/all RFC themself) will say it's not allowed for MAs to cut nails because the MAs simply don't want to do it and some DPMs don't want to lose it... not actual legality. That "don't let the MAs cut nails... it requires a podiatrist or at least a student/resident. You can get in trouble" has been around forever. I heard it in school like everyone does. Definite misconceptions and vested interest and bias exist.

Just like a dental office routine cleaning and mouth XRs done by assist/tech on a new patient before the doc has even laid eyes on them, you obviously can't legally bill for those things if the doc's not even in the office or doesn't see the pt or finish and touch-up the care as needed (or you'd definitely be taking a huge risk of blowback). That's not to say it isn't done that way plenty in St Elsewhere with patients coming in and going without the doc ever laying hands on them or even eyes on them... or even being in the office. That is obviously not wise.

Plenty of DPMs even have MAs do lido for ingrowns, do calluses, apply billable wound graft/dressings, remove sutures, apply wart tx (or even debride and apply), etc. I think that's crazy to delegate out anything invasive or semi-invasive to someone who's not at least on RN level, but wat do I know?"

...Where is it? Where is it? Ah, here ( @heybrother has a 2022 meme awards finalist here)...

 

[Feeter]

For podiatry in most hospitals, yeah. No doubt.
For podiatry PPs, an associate is usually same/cheaper. Doubly so in areas that are saturated and have large supply of associates.

It's too bad, but for hospitals, benefits are one of the biggest costs (PTO, med/dent/etc insurances, retire match, CME), and most don't realize how cheap they could get a podiatrist for. For the hospitals that understand podiatry pay/saturation, most still can't or don't want to pay a DPM a ton less than most other physicians - or typically, if they know our pay and job market, they know enough that they just want a real good one. The biggest diff is hospitals need the podiatrist freed up for wide RVU generation from surgery, ordering tests, inpatient work, keeping tough ER cases from leaving the facility, etc... things a typical PP can't really capitalize off to such an extent.


In private, nail care patients are they key to ordering ABI, doing "nail biopsy" (and associated path lab if the group owns that), doing tendonotomies, wraps, doing DM shoes, possible OR elective on some RFC pts, they refer new pts, etc. Those are your 'big ticket' things in many PP... minor in-office tests and procedures, new pts. Those RFC patients are gold; they're an annuity. 💰

For hospitals, yeah... nail care makes no sense. I concur completely. You want to dump that on a tech, RN, etc... probably not even worth the time of midlevels, definitely not a doc. The overhead and the ancillary income from tests and surgery is just so much different (PP = inefficient time and risk by doing surgery on bad insurance, complicated pre or post op, wheelchair patients, rounding, etc... while hospitals = $$$ from the associated OR time, MRI, micro and path, etc the surgery or admit brought with it, and the surgery is not so inconvenient as DPM is in same building anyways).

Can an RN do nail debridements and still bill for it? Even with supervision by a podiatrist I am not sure how to bill it. Even for NP to do 12 nail care pts a day makes no fiscal sense in a hospital at this rates.

 

[Feeter]

Just hired an NP instead of another DPM.

Just a few thoughts
1. Applicants for the non-surgical positions can be “hit or miss” in quality.
2. I want some that can be “molded” to use my algorithms
3. Don’t you hate when you get a second opinion from a partner/outside provider and they have already said “you need surgery” or “you could benefit from xyz”? A good portion of the time they are not surgical candidates or the proposed diagnosis or plan is…well questionable. You won’t get that from an NP…you will get let’s get you to Dr. xyz for his/her opinion.
4. MSG/Hospital pods are usually paid well and an NP is cheaper. This helps the productivity numbers of the group/department.

Yeah at my new job I am told to send all wound care pts to our PA. I see all new DFUs and determine if they need surgery. If they just need wound care or offloading then they are referred to wound care PA. This allows me to just see mostly new pts and some follow ups. Post ops are seen by PAs as well. So most of the new pts are level 4 specially as most of them need surgery. That means 20 ptsa day will yield you almost 7k annually in wRVUs. Great way to maximize your yield imo and still provide good care. But this pretty much cuts out a need for non surgical podiatrist

 

[619]

Can an RN do nail debridements and still bill for it? Even with supervision by a podiatrist I am not sure how to bill it. Even for NP to do 12 nail care pts a day makes no fiscal sense in a hospital at this rates.

Depends on your state if podiatrist can supervise mid levels. There are over a 100 better use of an RN skills and training rather than doing nail debridements. RN don't even want to draw blood at a clinic let alone clip toenails. Phlebotomist exist because RNs no longer want to be drawing blood in clinic or the hospital. I think this is why RNs are able to expand their scope because they let go of some procedures that can be delegated. Same reason we have medical assistants and LPNs. The nursing association let these happen so they can focus on expanding their scope.

Dentists did the same with dental hygienists working under them. Podiatry needs similar if we want to expand our scope and focus on surgery and high skilled office procedures.

 

[Pronation]

high skilled office procedures

Do you even know anything about being the top total toenail replacement surgeon in your entire county?

 

[619]

Do you even know anything about being the top total toenail replacement surgeon in your entire county?

A fellowship in total toenail replacement is 100 times more useful in everyday podiatry practice than nerve repair, flaps or limb lengthening fellowships.
I love me some ingrown nails. One of my fav highly skilled procedures.

 

[DYK343]

A fellowship in total toenail replacement is 100 times more useful in everyday podiatry practice than nerve repair, flaps or limb lengthening fellowships.
I love me some ingrown nails. One of my fav highly skilled procedures.

Unless youre wRVU based then it pays less than a 99203.

11720 1.05 wRVU
99203 1.6 wRVU
If I do a nail avulsion and talk about options, post op care, Rx topical antibiotic, etc etc my billers will not let me bill an office visit. Only a 11720.

I had a meeting with management today. Starting this Friday all nail care referrals will go elsewhere. Its just not worth it to me on a wRVU system.

 

[air bud]

This was a defining conversation at ACFAS. Every busy hospital based pod I knew and talked to had a PA/NP. Even in states that didn't allow direct supervision. They just had an Ortho in their department sign off on everything instead. This is the future. Some were using PA/NP as a true extender with them seeing post-op etc but most had them practicing independently. Some only clinic based some surgery. But mostly clinic based. All of these additional hospital jobs out there, I am telling you they are filling up fast. The future is NP/PA, not non surgical pods. Until the surgery is overwhelming there is not a need for another pod. Heel pain? NP. Non op 5th met Fx? NP. Painful bunion? Surgery for the pod. I am telling you this is the very near future.

Any when they do bring in another surgical pod.....it is not to do the flatfoots and ankle fx....

Yeah at my new job I am told to send all wound care pts to our PA. I see all new DFUs and determine if they need surgery. If they just need wound care or offloading then they are referred to wound care PA. This allows me to just see mostly new pts and some follow ups. Post ops are seen by PAs as well. So most of the new pts are level 4 specially as most of them need surgery. That means 20 ptsa day will yield you almost 7k annually in wRVUs. Great way to maximize your yield imo and still provide good care. But this pretty much cuts out a need for non surgical podiatrist