Solo Practice with Wound Care Focus

[Jummy Biffett]

Has anyone had any success/know of anyone successful in starting a solo private practice that focuses almost exclusively on limb salvage and wound care? I don't mean as part of a hospital or wound care center. I know it's probably very tough to pull off on your own given the nature of the work, but the need is certainly there and wound care seems to be the one area that other DPMs don't mind referring out to other pods. Feel free to call me crazy...

---

Members don't see this ad.

 

[heybrother]

Has anyone had any success/know of anyone successful in starting a solo private practice that focuses almost exclusively on limb salvage and wound care? I don't mean as part of a hospital or wound care center. I know it's probably very tough to pull off on your own given the nature of the work, but the need is certainly there and wound care seems to be the one area that other DPMs don't mind referring out to other pods. Feel free to call me crazy...

#1 - Are you going to be in a town with a Wound Healing Center
#2 - Will you take call?
#3 - Will you round / admit?

The problem with wound care is that a lot of the people who offer it do so without any intention of actually providing definitive surgical treatment that will resolve the problem. There are people out there who will 11042 a distal tip toe ulcer 52 times and try to qualify it for HBO before they'll do a flexor tenotomy or just amputate the toe.

I'm not bothered in the least bit by people who try to offer definitive surgical reconstruction to alleviate deformity and resolve the cause and I wish you luck if that's what you are after.

 

[PatchAdamsFan]

The problem with wound care is that a lot of the people who offer it do so without any intention of actually providing definitive surgical treatment that will resolve the problem

That's because they only had the ABPM Wound Care CAQ. If they also had the Surgery CAQ, then you know they're the pod for the job.

To the OP, I echo the same thoughts above. You will have a heck of a time with call and dealing with complications if you're not associated with hospitals or wound centers. I have some colleagues that are more wound focused, and they would never manage without multiple docs covering call and the availability of quality teams in wound centers.

 

[Jummy Biffett]

1. No wound care centers within 40 minutes of the town
2. Maybe at first to get busy
3. Assuming yes, my fear is being solo this would be an everyday requirement for quite a long time until can hire other docs/mid-levels

 

[Feli]

It is very possible.
Whether it is advisable is the question to ask yourself.

There are two major issues:
1: A lot of wound care patients are ppl who don't take very good care of themselves. Active and educated working age people with good payers don't typically get chronic wounds. So, the wounds tend to have poor payers... DM bigguns, EtOH, low education, etc... MCA often as they are unemployed or disabled... usually MCR at *best* if they are simply older ppl. There are the rare wound pts with good payers, but don't count on it. You also have maaany wound "emergencies" (a few being actual emergencies that can't just cook on abx until the next day), but either way, ER/inpt calls are incessant since the pts miss appts and are often just plain sick ppl. Roughest when starting out, you'd have seriously expensive office overhead with bariatric power chairs + wide halls + instruments + wrap/cast supplies + staff to help transfer the pts, etc. Wound appointments are typically NOT fast ones. Rx'ing custom DME or "educating" people who have eaten poorly for decades doesn't pay much. That's usually better to dump all of that on the hospital. This is technically manageable solo PP, but it's a tough and expensive road. You'd need to make up the equipment overhead and much inpt time and mediocre payers with all of the fake grafts that don't work or trying to be a consultant for said grafts or PD for low quality residency or something? Not ideal... but possible.
2: Wound care is very narrow. You would be almost 100% hosed if the hospital started a wound center and brought in a wound care doc (pod, GP, "semi-retired" gen or vasc, etc). You'd need to stay VERY friendly with the nearby hospital so that if they ever brought in an employed wound wizard, it'd be you. As was mentioned, a lot of wound docs and WCCs cling onto patients and dink them around for the (short) rest of their life when they should just heal or amp them.

If you are going to do it, your best bet would be in a large metro and near hospital(s) that don't have a wound center. You could also try a smaller town with no other DPMs, but that'd be game over if they brought one in as above. I have seen many of my Detroit attendings do a lot of wounds, consults, amps, etc in a PP setting (esp when starting up... difficult to get a lot of pts in PP in saturated areas without doing consult/wound/amp), but they still had to be somewhat diverse to fill out the schedule (bunions, minor trauma, basic derm stuff, geriatric nail care, etc). That is a fine plan: full scope but do mostly wounds to get off the ground and gain pts... or even stay wound-heavy if that's what you like or have best training for. It's fine to focus on one aspect, but you usually don't want to limit an already limited scope.

...In the end, there is a reason that most wound wizards are hospital employ or do those pts in the hospitals. When I was in an area where I had a fair lot of ulcer pts, I'd do a few easy and/or good payer ones in the office and send most of the bigger ppl, wheelchair, poor payers, etc to my wound care center day at the hospital a mile or two down the road. If I had had more wounds (def not my thing) than a half day or full day at WCC could fit, I would have sent them to hospital FTE to do them (and free my time for other new pts). It just makes more sense with the payers to do the lion's share of wounds in a hospital setting. YMMV

 

[icebreaker32]

It is very possible. Is it advisable is the question to ask yourself.

There are two major issues:
1: A lot of wound care patients are ppl who don't take very good care of themselves (poor payers MCA often as they are unemployed or disabled and usually MCR at *best* if they are simply older, many wound "emergencies" and ER/inpt calls since they miss appts and are just plain sick ppl, expensive office overhead with power chairs + wide halls + instruments + wrap supplies etc). This is manageable solo, but it's tough and expensive. You'd need to make up the overhead and much inpt time and mediocre payers with all of the fake grafts that don't work.
2: Wound care is very narrow. You would be almost 100% hosed if the hospital started a wound center and brought in a wound care doc (pod, GP, "semi-retired" gen or vasc, etc). You'd need to stay VERY friendly with the nearby hospital so that if they ever brought in an employed wound wizard, it'd be you.

If you are going to do it, your best bet would be in a large metro and near hospital(s) that don't have a wound center. You could also try a smaller town with no other DPMs, but that'd be game over if they brought one in as above. I have seen many of my Detroit attendings do a lot of wounds, consults, amps, etc in a PP setting (esp when starting up... difficult to get a lot of pts in PP in saturated areas without doing consult/wound/amp), but they still had to be somewhat diverse to fill out the schedule (bunions, minor trauma, basic derm stuff, geriatric nail care, etc). It's fine to focus on one aspect, but you usually don't want to limit an already limited scope.

...In the end, there is a reason that most wound wizards are hospital employ or do those pts in the hospitals. When I was in an area where I had a lot of them, I'd do a few in the office and send most of the bigger ppl, wheelchair, poor payers, etc to my wound care center day at the hospital. YMMV

Could not have said it better myself ^^^^^^^^

Also it is hard enough finding another podiatrist to cover for you as a solo practitioner. Insurances and hospitals require you to have someone who covers for you whenever you are not available......vacations, funerals, personal injury it really does not matter your excuse. If this is your exclusive patient population you will ALWAYS have multiple patients in the hospital making it that much harder for anyone else to want to cover for you. The local podiatrist covering for you will soon no longer be available to help you out after they realize this is your patient population and if there is no other podiatrist on staff or there are but they are not friendly and view you as competition......what is your solution?

Do not do it. Solo practice with even a little diabetic foot mixed in is hard enough. Doing diabetic foot exclusively as a solo doctor is possible in theory, but realistically a very bad idea.

 

[de Ribas]

Could not have said it better myself ^^^^^^^^

Also it is hard enough finding another podiatrist to cover for you as a solo practitioner. Insurances and hospitals require you to have someone who covers for you whenever you are not available......vacations, funerals, personal injury it really does not matter your excuse. If this is your exclusive patient population you will ALWAYS have multiple patients in the hospital making it that much harder for anyone else to want to cover for you. The local podiatrist covering for you will soon no longer be available to help you out after they realize this is your patient population and if there is no other podiatrist on staff or there are but they are not friendly and view you as competition......what is your solution?

Do not do it. Solo practice with even a little diabetic foot mixed in is hard enough. Doing diabetic foot exclusively as a solo doctor is possible in theory, but realistically a very bad idea.

Does any of it change if you are hospital employed? Hospital owns a wound care center and wants you to spend 1 day a week there.

 

[HardRoadPaved]

3. Your nasty a** wound care patients will stink up your waiting room and drive away patients looking for a nice experience. If you don't want an adult diaper thrown in your trash cans, then send them to a wound care center

 

[heybrother]

Small weird comment. Maybe some truth to it?

There may be weird geographic issues at play based on patient population. A friend of mine did the St. Louis residency. Some of the pictures and things he sent me were ...worse than anything I saw during residency. Similarly, I could not live in San Antonio. During my month there I saw 2 different people under the age of 30 who had already had revasc/BKA etc. Sadly just a very sick population.

Awhile back I was at my big hospital talking to the late night crew. I said to them I'd been at the hospital enough to see the boards and I didn't feel like there was that much pus on it. It also all seemed to be spread very light across ortho, general, vascular etc. I said when I visited JPS/San Antonio etc there were doctors doing 7+ amputations in a row. The hospital I was at is the dumping ground for the area and they basically said - yeah, we just don't get that much here. Must be a different patient population (though smaller size too).

 

[heybrother]

3. Your nasty a** wound care patients will stink up your waiting room and drive away patients looking for a nice experience. If you don't want an adult diaper thrown in your trash cans, then send them to a wound care center

So - this guy shows up with a rotting foot. Clearly needs a BKA. I see him walking down the hallway crying and screaming and I intercept the nurse to get an x-ray. I walk into the next room to make some progress while that happens and its this very nicely dressed college girl working on a masters etc. She looks at me and says to the affect of "I'm concerned that your patient who was in the waiting room with me is dying. He smells like rotting death".

Anyway. Begged the guy to go to the ED. He told me he wouldn't. Called his wife and begged her to talk to him. She said she'd make him. Then the next day she called back and told me that he'd accidentally left the strap on his post-op shoe behind and she wondered if we'd saved it.

 

[icebreaker32]

Does any of it change if you are hospital employed? Hospital owns a wound care center and wants you to spend 1 day a week there.

Hopefully if you are hospital employed, their employed general surgeon can cover your foot pus when you are gone regardless of if you work at a wound care center or not.

If you work at the wound care center one day a week and only see your diabetic foot there and are in private practice and have surgical privileges at the hospital, this is a bit more complex. The after hour outpatient calls would go to the wound care center, but the hospital might consult you if the patient ends up in the hospital and the bylaws might require you are available at all times or have coverage if consulted.

 

[diabeticfootdr]

Has anyone had any success/know of anyone successful in starting a solo private practice that focuses almost exclusively on limb salvage and wound care? I don't mean as part of a hospital or wound care center. I know it's probably very tough to pull off on your own given the nature of the work, but the need is certainly there and wound care seems to be the one area that other DPMs don't mind referring out to other pods. Feel free to call me crazy...

In brief, I think the overhead of doing good limb salvage/wound care is high if you’re in private practice. They’re time-consuming, nursing-intensive patients. That’s why these “stand-alone” wound centers (which don’t qualify for facility fee billing) often have financial difficulty.

 

[icebreaker32]

Small weird comment. Maybe some truth to it?

There may be weird geographic issues at play based on patient population. A friend of mine did the St. Louis residency. Some of the pictures and things he sent me were ...worse than anything I saw during residency. Similarly, I could not live in San Antonio. During my month there I saw 2 different people under the age of 30 who had already had revasc/BKA etc. Sadly just a very sick population.

Awhile back I was at my big hospital talking to the late night crew. I said to them I'd been at the hospital enough to see the boards and I didn't feel like there was that much pus on it. It also all seemed to be spread very light across ortho, general, vascular etc. I said when I visited JPS/San Antonio etc there were doctors doing 7+ amputations in a row. The hospital I was at is the dumping ground for the area and they basically said - yeah, we just don't get that much here. Must be a different patient population (though smaller size too).

If you live in an area with a higher percentage of diabetes and a higher percentage of poverty that is all it takes. If you add to this a very large population it will seem like an epidemic (not arguing it is not) in the community hospitals or to an extent any hospital located close to the poorer parts of the metro.... typically in the city. If you work at a hospital in these areas you will see the textbook black gangrene feet present even with all the treatment now available for PAD ( not saying it will always be successful even if treated earlier). You will also see the 30 year olds with BKAs who have many relatives that suffered the same fate at a similar age. Many of these patients do not live longer than their early 50s. There will also be lots of dialysis centers in these areas. The victims of genetics combined with poor lifestyle and poverty….obesity, poor medical care, not being able afford insulin, untreated severe HTN, poor diet etc.

If you work PP in the suburbs of the same metro and have a good insurance mix you will see much, much less and can always refer out the complex ones that do present as it will not be a large part of your practice.

 

[Adam Smasher]

I do a lot of wound care in my practice. Off the top of my head, some things that have made it work for me:

1. I only do foot wounds, venous leg ulcers get sent to the wound clinic. Leg ulcers never heal (at least never pemanently) and they mainly need a nurse to change their Unna Boots.
2. As noted above, it is labor intensive. You need help from either associates/partners as well as smart staff. I disagree with everyone saying you need to be on call always for pus bucket cases--this happens much of the time but not all of the time. I work in a community hospital setting where I can almost always let patients receive IV antibiotics and stack up 2-3 amps in one go. Obviously if its gas that's a different story.
3. As @Feli and @heybrother have noted, wound clinics are jokes. They're debriding away until they can cash in off the hyperbaric chamber, not addressing the underlying biomechanical problem.
4. Wound care is mostly time management and resource management. Time management not only in terms of what you're doing in the exam room but also in terms of charting burden (use your macros). Resource management in terms of figuring out how to source materials (A TCC can cost you $20 to $200 depending on what you use).
5. You need to know your payers, what they will cover and what won't they cover.
6. Be prepared for surprises, and be prepared to neatly document those surprises, because very often these are significant and separately identifiable evaluation and management services. Example: debride ulcer 11042, prescribe antibiotics for cellulitis 99214 (acute exacerbation of chronic problem + prescription drug management). This is a bigger bonanza than the shoe deregulation of the 1980s, lol.
7. If stinky wounds are smelling up your waiting room, your patients have an infection, they need surgery
8. Yes it's not a great population. But it can still be done profitably, and it's a better use of your time and training than grinding keratin. If all this is not your cup of tea, buy a shockwave machine and hand out business cards at your local gyms.

 

[air bud]

Let's be real here. You are doing wound care in the office to be able to put on 8k amniotic grafts. This won't last long. Current proposed legislation already targeting this. After that is passed wound care is not effective in the office. The only reason anyone currently does it is because they are hoping for Medicare & a secondary.

 

[Adam Smasher]

Skin subs are very profitable--for the companies pushing them. For us, it's a crap shoot, will you get paid, how quickly will you get paid, will you get audited, will your payment be retracted. For this reason, I only use them for patients who really need them, which is a pretty narrow sub-population.

And even if you can make a good money, so what? Are we only supposed to employ modalities that are unprofitable?

 

[Jummy Biffett]

Let's be real here. You are doing wound care in the office to be able to put on 8k amniotic grafts. This won't last long. Current proposed legislation already targeting this. After that is passed wound care is not effective in the office. The only reason anyone currently does it is because they are hoping for Medicare & a secondary.

I have no interest in pushing overpriced skin substitutes and I agree with you that they will soon be a thing of the past due to legislation. I'm talking about doing good, honest work and hoping to be reasonably successful with it. I know I'm sounding 'pie in the sky' here...but I picture seeing 20-30 patients per day (probably all 11042s) 3-4 days a week and then 1-2 days for OR/inpatient mgmt. Wouldn't that be enough to pay the bills?

 

[Feli]

Let's be real here. You are doing wound care in the office to be able to put on 8k amniotic grafts. This won't last long. Current proposed legislation already targeting this. After that is passed wound care is not effective in the office. The only reason anyone currently does it is because they are hoping for Medicare & a secondary.

I am doing 99203s in office to be able to put in $35-50 mini and small frag screws.

But yeah, air budordan is 100% right. Financially, you'd be hitching to a wagon with no EBM and destined to fail soon. It'd be like starting a flat foot clinic to dispense "custom" braces. Might be viable for a year or two but highly shaky long term.

I have no interest in pushing overpriced skin substitutes and I agree with you that they will soon be a thing of the past due to legislation. I'm talking about doing good, honest work and hoping to be reasonably successful with it. I know I'm sounding 'pie in the sky' here...but I picture seeing 20-30 patients per day (probably all 11042s) 3-4 days a week and then 1-2 days for OR/inpatient mgmt. Wouldn't that be enough to pay the bills?

There is no way to do that in a solo office... just far too many big patients, sick patients, wheelchair, need wraps, poor payers, etc. You will run into big problems that will take a lot of time and legwork to admit, set up surgery add-ons, PICC, urgent consults for Vasc or ID, etc etc etc.

It would pay the bills in theory, but it's just not possible. You need ingrowns, injects, insoles, good payer surgery/injuries... fast easy stuff for PP. Good payer is key. You can realistically see half that many per day in a bona fide wound center with multiple RNs doing wraps/measure/etc and MAs flipping rooms (which would be massive overhead expense in PP).

Nobody is trying to snuff out your thinking, but you are best off working hospital FTE if you want to do a lot of wound care or if that's your main skill set. Solo wound care has a ton of pitfalls. In PP, the only viable option is to maybe be in a medium/big group and be "the wound guy." You'd still have the issues of coverage, equipment, inpts, etc mentioned above, but the financial detriment of much equipment + avg/low payers can be mitigated to some point.

 

[Adam Smasher]

But yeah, air budordan is 100% right. Financially, you'd be hitching to a wagon with no EBM and destined to fail soon. It'd be like starting a flat foot clinic to dispense "custom" braces. Might be viable for a year or two but highly shaky long term.

What you do is you prescribe a custom molded AFO to offload the ulcer in preparation for application of skin subs for maximum scamming

 

[Jummy Biffett]

Nobody is trying to snuff out your thinking, but you are best off working hospital FTE

Point taken, my dreams have been sufficiently crushed (again). Time to sharpen the nail nippers I guess lol

 

[icebreaker32]

Point taken, my dreams have been sufficiently crushed (again). Time to sharpen the nail nippers I guess lol

You can certainly have some diabetic foot in you practice.....many, many podiatrists do diabetic wound care and surgery on diabetic patients (some more than others) in addition to everything else they treat. Some also work at a wound care center one or two half days per week.

 

[GreenHousePub]

They’re time-consuming, nursing-intensive patients.

Exactly. As well as patients way more likely to encounter complications and thus sue.
I try and offload as many of them as possible to "wound-centers" for this reason.

 

[Feli]

Point taken, my dreams have been sufficiently crushed (again). Time to sharpen the nail nippers I guess lol

You can do fine with hospital jobs if you want to do wound care. There are a good amount of those positions already... or more such gigs able to be created. Many, many.

The truly hard jobs are hospital or any generally well paid ones where you get refers for and do a lot of ortho/deformity/trauma surgery (MSG, ortho, go-to surgery guy in a DPM group, etc).

The funny thing is, at the end of the day, a lot of DPMs who want the ortho/deformity surgery jobs can't find those... they take the hospital jobs that are largely wounds/amps... and try to morph them into what they want. They don't want the wounds/amps, but that's what they can find that pays good. Conversely, the people who did more wound-heavy residency and are probably well-trained for wounds and interested in wounds often don't have the logs/board/CV chops to get the wound hospital jobs they'd love from the start. Welcome to podiatry

...as said, don't worry. You are a DPM. The wounds will find you.
The calluses. The Charcot. The gas gangrene. The amps. The diabetic shoe Rx. I avoid that stuff like the plague. I know I'm good at it, and I know it makes money... but I just don't want the bad hours or bad payers that come with most of it. It is boring to me. Same with the geriatric nails. I sure don't market to it or encourage refer docs to send it. It still finds me... almost every day. I can't seem to just get patients like Tom Brady new girlfriend for ankle sprain and Scar Jo for bunion every appt slot

 

[Jummy Biffett]

You can do fine with hospital jobs if you want to do wound care. There are a good amount of those positions already... or more such gigs able to be created.

Ah yes, I'll just go to the hospital job store and pick one up

 

[air bud]

I have no interest in pushing overpriced skin substitutes and I agree with you that they will soon be a thing of the past due to legislation. I'm talking about doing good, honest work and hoping to be reasonably successful with it. I know I'm sounding 'pie in the sky' here...but I picture seeing 20-30 patients per day (probably all 11042s) 3-4 days a week and then 1-2 days for OR/inpatient mgmt. Wouldn't that be enough to pay the bills?

Clearly you don't know how much they reimburse....I don't know how on earth you could do this on your own. I would recommend figuring out some type of hybrid model where maybe you do some independent contracting if you can't figure out a way to be employed by a hospital to share some of the costs with. And yes you are sounding pie in the sky. I know rural medicine and underserved areas. I can't imagine any scenario where there is that many patients that do not have access to wound care. And if you are talking that volume then the only conceivable way is a significant staff....this a wound care center.

 

[air bud]

Point taken, my dreams have been sufficiently crushed (again). Time to sharpen the nail nippers I guess lol

 

[619]

Has anyone had any success/know of anyone successful in starting a solo private practice that focuses almost exclusively on limb salvage and wound care? I don't mean as part of a hospital or wound care center. I know it's probably very tough to pull off on your own given the nature of the work, but the need is certainly there and wound care seems to be the one area that other DPMs don't mind referring out to other pods. Feel free to call me crazy...

I agree with what everyone has said and I will add my 2 cents.

Why will you open a practice just to box yourself to one thing (wound care). Choosing podiatry is already a box by itself but why make the box even smaller by doing just wound care. So let's pretend you open an exclusively limb salvage and wound care practice and you have patients coming in for ingrown nail, heel pain, warts, MSK pathologies etc. Will you turn those away?

My point is to build a practice and do general podiatry. See everything that walks through the door and then when you build your practice, if you love wound care so much you can turn away the ingrown nail and the heel pain and refer them to me. I will happily trade you wound patients for ingrown nail and heel pain. Joking aside, open your practice and treat everything foot and ankle. Don't box yourself from the begining.

 

[DYK343]

Call up wound healing centers associated with hospitals in the south or midwest where diabetes is rampant.

Guarentee you will get a WHC looking for a DPM and that may lead to hospital employment.

A lot of hospitals are looking for DPMs to cover inpatient management which is all diabetes.

You can make this work for yourself. Maybe not as easy in a super healthy part of the country with minimal diabetes but there are plenty of places you can make this work.

Reach out to diabeticfootdr for more advice.

 

[PTPuser]

...as said, don't worry. You are a DPM. The wounds will find you.

I'm adding this to my signature.

 

[air bud]

...as said, don't worry. You are a DPM. The wounds will find you.

let me fix it for you....as said, don't worry. You are a DPM. The nails will find you.

 

[heybrother]

#1 - This thread reminds me of airbud's joke about a podiatrist's favorite thing being "Medicare+ secondary". Its sort of an overly technical joke, but its really well done. Forget grafting for a second. These patients essentially don't experience the financial ramifications of their care. They aren't the highest paying patients, but they come back weekly and while they aren't happy the wound is open - they aren't directly paying for debridement, care etc,.

#2 - BCBS is the most common commercial insurance and "generally" the highest reimbursing other than local boutique varieties. I've touched on this elsewhere recently but plans that list themselves as "BCBS PPO" which is also called Blue Choice really run the gamut. The spectrum of patient responsibility runs from "Platinum" to "Bronze" and can literally run from zero deductible to thousands of dollars deductible. Patients with this insurance in general - are working. Some industries will pay for platinum plans for their employess but Walmart and grocery stories in my area buy BCBS PPO too. I've routinely met patients who told me they owe a WHC $3000-5000 and that they were dinged for $300-400 a visit. Running up the bill on patients with commercial insurance is real. It happens at hospitals, WHCs, etc. I won't make up statistics but every few years someone does an article where they asked people "could you afford a $400 surprise expense". The answer is usually a sad no.

Where I'm going with this is the reimbursement from patients with commercial insurance can be excellent, but the likelihood the patient can afford to pay will always be an issue and if the patient needs surgery its going to be time off work. The unfortunate truth is doctors' and patients' interests aren't always aligned. We need these $300 encounters to stay in business but insurance often isn't paying for the visits. The greatest thing you can do for these patients is permanently resolve their wounds and that can be tough. I routinely see deformities that could be addressed but he patient's DM is completely uncontrolled.

#3 A few morbid thoughts on wounds in private practice.

-You don't want dysvascular wounds

-The more complicated, deep, etc the wound is the worst for you because the products and dressings and what not are likely included within the reimbursement for the debridement.

-You want the patient to be sick, but not too sick ie. ie. 20cm^2 pays the same as 1.0 x 1.0 x 0.2cm.

-I personally don't enjoy maintaining those wounds that are exactly on the line between a callus and an ulcer. The care is easy. The documentation sends shivers down my spine.

The perfect private practice wound in short is on an ambulatory middle age diabetic with neuropathy but no angiopathy and located on the tip of a toe or under the 5th metatarsal head. It can be covered easily with a bandaid.

#4 - Free standing WHCs are a thing, and they incorporate all of the services / money makers etc. PCR, infusion, HBO, grafting etc. One of the WHCs in my towns has the internist (yeah) that runs it doing NC and vascular testing. He also has this "special formulation abx" topical that he sells. He's got some pod in his blood if you ask me.

#5 - We touched on it above, but the "health" of your local population really can determine how frustrating or not the wound population is to treat.

#6 - I'm sort of skeptical you can build a "stable" of wounds if you are doing the right thing. When I first came to my town I thought I would be considered "over aggressive" if I offered surgical offloading of wounds at the 1st visit. I'd bring people back, talk about the future, debride awhile. Now, I offer surgery on the first visit - especially if its a rapidly resolving surgery that allows immediate weight-bearing. I have no toe ulcers that I'm seeing weekly trimming on. I have no 5th metatarsal head ulcers. They come, I knock 'em out.

 

[wakaflocka88]

#1 - This thread reminds me of airbud's joke about a podiatrist's favorite thing being "Medicare+ secondary". Its sort of an overly technical joke, but its really well done. Forget grafting for a second. These patients essentially don't experience the financial ramifications of their care. They aren't the highest paying patients, but they come back weekly and while they aren't happy the wound is open - they aren't directly paying for debridement, care etc,.

#2 - BCBS is the most common commercial insurance and "generally" the highest reimbursing other than local boutique varieties. I've touched on this elsewhere recently but plans that list themselves as "BCBS PPO" which is also called Blue Choice really run the gamut. The spectrum of patient responsibility runs from "Platinum" to "Bronze" and can literally run from zero deductible to thousands of dollars deductible. Patients with this insurance in general - are working. Some industries will pay for platinum plans for their employess but Walmart and grocery stories in my area buy BCBS PPO too. I've routinely met patients who told me they owe a WHC $3000-5000 and that they were dinged for $300-400 a visit. Running up the bill on patients with commercial insurance is real. It happens at hospitals, WHCs, etc. I won't make up statistics but every few years someone does an article where they asked people "could you afford a $400 surprise expense". The answer is usually a sad no.

Where I'm going with this is the reimbursement from patients with commercial insurance can be excellent, but the likelihood the patient can afford to pay will always be an issue and if the patient needs surgery its going to be time off work. The unfortunate truth is doctors' and patients' interests aren't always aligned. We need these $300 encounters to stay in business but insurance often isn't paying for the visits. The greatest thing you can do for these patients is permanently resolve their wounds and that can be tough. I routinely see deformities that could be addressed but he patient's DM is completely uncontrolled.

#3 A few morbid thoughts on wounds in private practice.

-You don't want dysvascular wounds

-The more complicated, deep, etc the wound is the worst for you because the products and dressings and what not are likely included within the reimbursement for the debridement.

-You want the patient to be sick, but not too sick ie. ie. 20cm^2 pays the same as 1.0 x 1.0 x 0.2cm.

-I personally don't enjoy maintaining those wounds that are exactly on the line between a callus and an ulcer. The care is easy. The documentation sends shivers down my spine.

The perfect private practice wound in short is on an ambulatory middle age diabetic with neuropathy but no angiopathy and located on the tip of a toe or under the 5th metatarsal head. It can be covered easily with a bandaid.

#4 - Free standing WHCs are a thing, and they incorporate all of the services / money makers etc. PCR, infusion, HBO, grafting etc. One of the WHCs in my towns has the internist (yeah) that runs it doing NC and vascular testing. He also has this "special formulation abx" topical that he sells. He's got some pod in his blood if you ask me.

#5 - We touched on it above, but the "health" of your local population really can determine how frustrating or not the wound population is to treat.

#6 - I'm sort of skeptical you can build a "stable" of wounds if you are doing the right thing. When I first came to my town I thought I would be considered "over aggressive" if I offered surgical offloading of wounds at the 1st visit. I'd bring people back, talk about the future, debride awhile. Now, I offer surgery on the first visit - especially if its a rapidly resolving surgery that allows immediate weight-bearing. I have no toe ulcers that I'm seeing weekly trimming on. I have no 5th metatarsal head ulcers. They come, I knock 'em out.

Great talking points.

I’m a big fan of floating metatarsal osteotomies plus/minus a gastroc for forefoot wounds. Walk on a post op shoe day 1 and it’s life changing. Unfortunately these old crummy pods have no clue on this.

I mean the “surgical” options from day 1 are endless. Flexor tenotomies. PL/PB tenotomies. Medial band perc release. Gastroc recessions. Floating MIS style osteotomies.

Try bringing this up to the pod across the street hacking away at wounds for years and watch their reaction.

 

[DYK343]

As HeyBrother said there are tons of fairly easy straightforward things we can do to surgically offload wounds but these patients are usually medical nightmares with heart disease, CKD, fibrous ischemic appearing skin, and A1c >10.

I am not going to medically clear a trainwreck patient for surgery and neither is the PCP in my experience.

Even if its MAC, anesthesia gets nervous because they are concerned about unexpected consequence to convert mid case to general. I once had an anesthesia doc go off on me because the PCP note said "clear only for MAC anesthesia" - and I dont blame the guy for being mad at me and the clearing PCP. THat put all the risk on him.

These patients are sick. IMO its not as easy as "Just lengthen the P longus for a sub 1st met ulcer". There are more moving parts than that.

Do you guys run into pushback from PCP/anesthesia?

 

[icebreaker32]

Call up wound healing centers associated with hospitals in the south or midwest where diabetes is rampant.

Guarentee you will get a WHC looking for a DPM and that may lead to hospital employment.

A lot of hospitals are looking for DPMs to cover inpatient management which is all diabetes.

You can make this work for yourself. Maybe not as easy in a super healthy part of the country with minimal diabetes but there are plenty of places you can make this work.

Reach out to diabeticfootdr for more advice.

While I don't completely disagree with this, I feel nothing is guaranteed with podiatry and if something was offered from a hospital using this approach it might end up being an income guarantee in a rural area and not true hospital employment.

One really needs to understand exactly what an income guarantee is before cold calling hospitals and decide if it is something they would even consider. Most strongly prefer hospital employment over income guarantees.

 

[air bud]

While I don't completely disagree with this, I feel nothing is guaranteed with podiatry and if something was offered from a hospital using this approach it might end up being an income guarantee in a rural area and not true hospital employment.

One really needs to understand exactly what an income guarantee is before cold calling hospitals and decide if it is something they would even consider. Most strongly prefer hospital employment over income guarantees.

I have had multiple rural employed jobs and looked into many more. While I know income guarantees exist I don't think they are common.

 

[icebreaker32]

I have had multiple rural employed jobs and looked into many more. While I know income guarantees exist I don't think they are common.

Come to think of it the last podiatrist I know of that was proactively contacting hospitals not advertising and was offered/accepted one was about 8 years ago. Hospitals might have just given up on them as a way to save money since MDs only want employment these days.

 

[DYK343]

While I don't completely disagree with this, I feel nothing is guaranteed with podiatry and if something was offered from a hospital using this approach it might end up being an income guarantee in a rural area and not true hospital employment.

One really needs to understand exactly what an income guarantee is before cold calling hospitals and decide if it is something they would even consider. Most strongly prefer hospital employment over income guarantees.

I was recently in the hospital job market and my experience was they all really want someone to help with DM care.
Could just be the region/area I was applying to

Having 5 years experience and ABFAS made the job search much much easier than fresh out of residency.

 

[Feli]

Come to think of it the last podiatrist I know of that was proactively contacting hospitals not advertising and was offered/accepted one was about 8 years ago. Hospitals might have just given up on them as a way to save money since MDs only want employment these days.

It depends on the area for the MDs. A lot of MDs still won't touch hospital employment if they have a choice. They want PP solo, owner, or % worker. They realize the call and the committees BS and the politics hospital jobs come with... some have done those after residency and want out. Mainly, MDs just have quite a bit better PP jobs (base, %, partner path, etc) available on average than DPMs do.

Ortho, vasc, gen, and most surgical specialties strongly prefer PP/MSG with arrangement with the hospitals for call. They get the perks and relative security of hospital FTE without the BS. The exception is rural (esp rural + avg/poor payers), where hospital employ typically makes more sense.

It basically goes like this in most specialties:
Bad payers = try to be hosp employed
Ok payers = coin flip... maybe PP in metro
Good payers = strong pref towards PP

I agree primary care has gone largely to employ situations (mostly org, some supergroup or small/med group)... but even they prefer PP in good payer areas. It's still about 55 emply / 45 PP overall for MDs, though... just varies widely based on area and payers. I'm sure MD specialists, esp surgeons and procedure specialists, are still majority PP or large group.

...for podiatry, it's easy to sell oneself on the diab/wound/ulcer stuff and how that's profitable and makes PICC lines and MRIs and admits and basic amp/wound "surgery" to try to create hospital FTE jobs. That can work in a lot of places, but it takes a lot of cold calls and/or networking and casting a very wide net. They don't typically care much if you can do ankle fractures or even Charcot and that bone/joint stuff... they just want pus bus driver who generates $ flow and does stuff the other med staff (gen surg, ER, etc) don't want.

The truly harder DPM employ situ is the ortho/trauma/deformity hospital jobs... those will typically be from an outgoing F&A Ortho or DPM, and they are much rarer and less likely to ever be widely advertised. Some are PD jobs. They might be very mediocre pay in some govt and univ and even private hospitals/systems (ie Kaiser) and jobs kinda need to be subsidized with consultant work to make it good. I honestly think that is main the "strength" of doing a fellowship year sometimes (at the elite/name ones): trying to wiggle into those few job spots. A name residency program can also help, but they're just the toughest jobs to find - even if you have solid training and ABFAS. Kinda sad, but that's the state of podiatry

I was recently in the hospital job market and my experience was they all really want someone to help with DM care.
Could just be the region/area I was applying to

Having 5 years experience and ABFAS made the job search much much easier than fresh out of residency.

100%^^^

 

[air bud]

I was recently in the hospital job market and my experience was they all really want someone to help with DM care.
Could just be the region/area I was applying to

Having 5 years experience and ABFAS made the job search much much easier than fresh out of residency.

Hey bub stick to the narrative. Terrible job market and impossible to find hospital jobs.

 

[Feli]

Hey bub stick to the narrative. Terrible job market and impossible to find hospital jobs.

Typical DPM job search:

Low training, no ABFAS: hospitals are dream land > try MSGs > try large/medium pod groups > typical small/solo moustache PP group associate jobs* > "helloooo HealthDrive"?

Mediocre training, no ABFAS qual: hospitals won't give you time of day > beg for "limb salvage" hospital or MSG jobs with your six different CAQs > try large pod groups* > typical small PP gigs* > "I heard C&C solo office or a house call biz can work out ok"

Good training + ABFAS qual/cert: try hospital ortho-type jobs and ortho group apps > try VA or hospital "limb salvage" jobs* > try good large or small PPs > delve into lesser quality PP jobs if married to certain city/area > solo if desired

Elite residency or Good training + top fellowship + ABFAS +/- exp: get a couple of hospital ortho-type or ortho group job offers via the in-club (little/no choice of locations)* > burn out on "that life" and go solo or PP job in area of choice

*denotes typical end point(s)

 

[diabeticfootdr]

I am not going to medically clear a trainwreck patient for surgery and neither is the PCP in my experience.

Even if its MAC, anesthesia gets nervous because they are concerned about unexpected consequence to convert mid case to general. I once had an anesthesia doc go off on me because the PCP note said "clear only for MAC anesthesia" - and I dont blame the guy for being mad at me and the clearing PCP. THat put all the risk on him.

Do you guys run into pushback from PCP/anesthesia?

Do you/your PCPs still use the term medical clearance and actually “clear” patients for surgery?

The modern approach is a risk assessment and optimization.

Every surgery comes with risks. And even high risk patients deserve a surgical approach to wound healing as that is the fastest and sometimes only way the wound will heal.

Many patients with advanced neuropathy can be done under local-only. Anesthesia is still surprised by the anesthetic effect of profound neuropathy when the see they extent of surgery you can do even without local.

So, I have a consent discussion with high risk patients about risks/benefits/alternatives and they pretty much always accept the risk of moving forward with surgery. Then make sure the conversation is well-documented.

And you’re the surgeon. Only you can cancel the case. Remember, wound surgery is never elective. It is sometimes urgent, and occasionally emergent.

 

[diabeticfootdr]

Typical DPM job search:

Low training, no ABFAS: hospitals are dream land > try MSGs > try large/medium pod groups > typical small/solo moustache PP group associate jobs* > "helloooo HealthDrive"?

Mediocre training, no ABFAS qual: hospitals won't give you time of day > beg for "limb salvage" hospital or MSG jobs with your six different CAQs > try large pod groups* > typical small PP gigs* > "I heard C&C solo office or a house call biz can work out ok"

Good training + ABFAS qual/cert: try hospital ortho-type jobs and ortho group apps > try VA or hospital "limb salvage" jobs* > try good large or small PPs > delve into lesser quality PP jobs if married to certain city/area > solo if desired

Elite residency or Good training + top fellowship + ABFAS +/- exp: get a couple of hospital ortho-type or ortho group job offers via the in-club (little/no choice of locations)* > burn out on "that life" and go solo or PP job in area of choice

*denotes typical end point(s)

Just …

Disagree.

 

[Pronation]

And you’re the surgeon. Only you can cancel the case.

This is a great attitude to have to get thrown under the bus and sued into oblivion.

 

[Feli]

This is a great attitude to have to get thrown under the bus and sued into oblivion.

Yes, this idea of forcing surgery cases without clearance and agreement of anesthesia and support staff would have fit in great with the days when surgeons would throw hammers into the walls and call the circulators "tootsie."

It'd be an awesome way to quickly meet the director of surgery or the CMO of the hospital if one hasn't already.

 

[air bud]

Do you/your PCPs still use the term medical clearance and actually “clear” patients for surgery?

The modern approach is a risk assessment and optimization.

Every surgery comes with risks. And even high risk patients deserve a surgical approach to wound healing as that is the fastest and sometimes only way the wound will heal.

Many patients with advanced neuropathy can be done under local-only. Anesthesia is still surprised by the anesthetic effect of profound neuropathy when the see they extent of surgery you can do even without local.

So, I have a consent discussion with high risk patients about risks/benefits/alternatives and they pretty much always accept the risk of moving forward with surgery. Then make sure the conversation is well-documented.

And you’re the surgeon. Only you can cancel the case. Remember, wound surgery is never elective. It is sometimes urgent, and occasionally emergent.

yeah, I am certainly getting questions from people when I am like local only, trust me they won't feel anything. If its a fast case and they also have neuropathy of the brain....then local only.

And yes, I do not use the term clearance, risk assesment and optimization is correct. Also, hey Doc can you please clear this patient for surgery friday?

 

[Adam Smasher]

@diabeticfootdr is right for the most part. Yes no one is ever truly cleared for surgery, you just risk stratify. But preoperative nurses always use the old terms.

And yes you as surgeon are the only one who can cancel a case. Anesthesia has generally been on my side unless someone is overdue for a stress test. This is where I prefer to involve PCPs for chasing down all these issues, otherwise I'm "playing doctor."

A lot of stuff gets decided by committee, too. At one point we had a rule that you couldn't book anyone with hga1c over 8.5 because they didn't have enough inpatient beds for all the covid pts and didn't want us doing elective cases on anyone who was too sick, otherwise they might get admitted and take up a bed. I had a guy in the 9s (down from 16!) I wanted to do a exostectomy on, and he got canceled 2 days before surgery, and I'm like "the whole point of the surgery is to prevent a hospitalization! If I do it inpatient it defeats your objective"

 

[heybrother]

Anyone ever heard the anesthesia threat - we recommend you cancel the case. If you do not we will not help you and you can just have a nurse at the head of the bed?

 

[dtrack22]

without clearance

 

[DYK343]

I feel like I sparked a good discussion here. Once again hijacked a thread. Sorry OP.

At my last position I ran into TONS of pushback from anesthesia. They absolutely cancelled cases for further cardiac workup and quite regularly

Where I am now its much less but there are also sicker people here than where I was before. They are likely accustomed to it.

Medically optimized is a better term than cleared. Many PCPs will document that for medical legal reasons. There is no true clearance. But trainwrecks are trainwrecks and usually the ones who need a rebalance procedure to heal a wound are not very healthy.

My first cast I did in my new job was on an uncontrolled diabetic. Completely dehisced. Looked awful. Tried to do some rebalancing magic for a wound open ~2 years and while the surgery went well the surgical healing not so well. That plantar foot wound did heal though so I guess mission accomplished.

 

[DYK343]

yeah, I am certainly getting questions from people when I am like local only, trust me they won't feel anything. If its a fast case and they also have neuropathy of the brain....then local only.

And yes, I do not use the term clearance, risk assesment and optimization is correct. Also, hey Doc can you please clear this patient for surgery friday?

I agree. Anesthesia tends to not understand the power of pedal neuropathy.