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Fellowship: a good idea or not?

by Ryan Kemp, BA,BS,DPM,

I am a second year podiatry resident looking for some good advice. I feel I have been fortunate to have been exposed to some excellent training both surgically and clinically in my podiatry residency program, but wonder if the decision to continue my education as a fellow would be beneficial? Does it make you more marketable? Is there any evidence suggesting that you receive more money starting out? Does it affect your hospital privileges?

If you have any comments regarding podiatric fellowship training, please respond?

Would you consider a podiatry fellowship a good career decision?
YES (8 votes)
88.888888888889%
NO (1 votes)
11.111111111111%
  • Comments17 Comment(s)
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  • Dan Chaskin, DPM,

    Any idea that keeps a podiatrist employed even as a resident for a hospital may be a good idea in this current healthcare economic climate. To net more than a current residents salary after all practice expenses. With some practices closing down why not consider the option of approaching the hospital and requesting permanent employment? I am not just talking about podiatry but all of medicine and hospital based medical care. One possible reason for reimburstment cuts may be that professions are publically adversising how financially successful the "average practitioner is". If you were a politician why would you protect against reimburstment cuts if a profession is advertising the average practitioner is doing so well. Thus I believe more cuts in reimbursment are coming.   I am not addressing this question just for podiatry but for any field in the health care profession. I believe one possible answer is for every profession to stop advertising how "good" the average salary is for providers on the outside.

    Daniel

    class 84

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  • Alexander Estrada, BS,DPM,FACFAS,MS,

    My advice is to do whatever it takes to get ABPS certification. I'm not "knocking" the other boards, but ABPS is pretty much the most recognisable and marketable certification to have. If you can get ABPS AND ABOPPM (or whatever it's called now), even better, but ABPS is the bare minimum.  If you can get the raerfoot certification, that's a plus, but the "Foot Surgery" certification is essential. Certainly aboard certified podiatrist is more marketable and most places are asking (if you are seeking employment as a staff Podiatrist or as an associate) for the rear-foot certificate. If the fellowship "interests" you, then by all means pursue it, but I don't think it'll really make a difference as far as securing a job or marketing yourself. I know of people who have done the AO fellowship & what landed them a job was the fact that they were ABPS certified & the AO certificate was simply gravy / extra brownie points.

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  • Marc Garfield,

    You will have to follow your own instincts and desires.  You should read the posts of those who opine here to understand the vantage point from which the opinions are based.  My biases are as follows:  We educate too long, incurring too much debt and defer our careers too long.  Recent grads will have a very hard time paying off their debts.  The coveted rearfoot surgeries, charcot reconstructions and skin grafts involved in fellowships are not going to make you more profitable than someone who does alot of bunions and ingrown toenails.  But it will give you a potential marketplace niche or keep you on par with other advanced trained DPMs. So consider where you want to practice, what that market is likely to bring to the table.  If you are going to practice in a state that is going to limit your scope of practice or you have little likelihood of garnering the referrals necessary to do the work you are training for then do not bother wastin time in a fellowship. If you are going to move to an area where there are a lot of well trained DPMs then make sure you can compete.

    If you are going to a city you are already familiar with, make sure that it is realistic to get the referrals and hospital privileges necessary to utilize the training that you are considering, otherwise get out and go make a living.

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  • H David Gottlieb, DPM,

    Both Alex and Marc offer good advice.

    I'd like to add that Fellowship is helpful if you want to be able to specialize in the area that the Fellowship focuses on and you feel you need more training.

    There are two types of Fellowship in podiatry: CPME approved and non-CPME approved. At this stage of development in podiatry training I'm not really sure what this distinction means to the graduate. I don't believe that either one helps to become ABPS Board Certified but you need to check that yourself. Requirements change frequently.

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  • Jeffrey Kass, DPM,
    Ryan - Marc has good advice above. I would add we don;t know you. We don't know the amount of loans you have and how much the fellowship would pay. Leaving that aside for a second. One must keep in mind there are different types of fellowships. If they offer no further education (which some do) then do not bother. There are some BS Fellowships,,,not Bachelor of Science...but rather Bull---- that are a complete waste of time where you are used for slave labor., and do not learn much of anything. There are others where the experience can be very worthwhile. This is where you have to weigh the pluses and minuses. I will tell you that one can never go back in time and I do believe this is the time to get the BEST EDUCATION that you can, yet heeding the advice given by Marc. I think some of these Surgical Fellowships are awesome and can put you a notch above your colleagues in terms of things you will be trained to do. I do think you will be more marketable as you can get picked up by an Orthopedic group. Again, it would depend on where you want to end up practicing as state laws vary etc, If you desire to do surgery though....get the best exposure you can. I don't think you will ever regret knowing more...but, you have to take a program that will offer you that. Not all do.
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  • Dan Chaskin, DPM,

    My advice is to do whatever it takes to get ABPS certification. I'm not "knocking" the other boards, but ABPS is pretty much the most recognisable and marketable certification to have.

    In NYS if you want to be licensed to do ankle surgery a non surgical board will not allow you to medically treat infections of the leg unless contiguous foot ulcers are present. You probably cannot even take a skin biopsy of the ankle unless a contiguous foot ulcer is present. But then again if you took a PSR 24 or any residency training that was not "approved" as a MEDICAL AND SURGICAL program you probably won't meet the criteria for the "medical training" required to be licensed to medically treat the ankle in NYS. I guess this state is the first to apply "current training models" and not accept training modes that may have been taken many years ago. If current training is being used as criteria and if current training relates to current competence is the public benefited? If possibly outdated training is used as minimal screening criteria how is the public benefited? Bottom line again why not approach the hospital and ask if there are openings for permanent employment?


    Daniel

    class 84

    Reply
  • Marc Garfield,

    The bottleneck for ABPS certification has more to due with your caseload AFTER residency.  Any legitimate residency should get you where you need to be upon certificate completion.  Most people that cannot certify have a problem because they come out with grand plans of a cold startup practice or take a job covering nursing homes to get started and then cannot build the case load before the time limits expire.  Make sure that you position yourself to have a surgical practice upon leaving the training phase of your career.  Do not confuse "paying your dues" with deferring the surgical component of your career until you have "proven yourself".  This would never be acceptable to any other surgical specialist and it should not be acceptable to podiatrist with surgical aspirations.  You do not have to do surgery.  But if you want to you need ABPS and you should plan accordingly.  But again, I cannot imagine that you would be short on cases upon leaving residency.

    Student loans are not the only reason to start your career.  It sounds crazy, but if you do the math a mailman makes about the same money over a lifetime as the average podiatrist considering that they can start working at age 18 and retire at 55 at about $65k/year then receive enough pension money and health care benefits to live into their 90's.  The more time you defer, the less you are borrowing and putting off investing in your real estate, one less year to contribute to you IRA, kids college funds etc.  If I bought a house anywhere near high school graduation, I would have paid about $120k in the neighborhood I grew up.  When I came out of school those houses where $500K.  Yes, there was a real estate bubble along the way.  But those houses after the bubble pop are now $375k. 

    I am no oracle but anyone that does not think that we are facing a dollar devaluation in coming years, which translates into massive inflation is optimistic at best, but probably insane.  Moreover, physician reimbursement is facing a top down reorganization in coming years that will likely prove damaging to physicians that rely on procedures in a fee for service environment.  Please read Dr Borreggine's post on PMNews this week for ONE opinion on the future of medicine in general.

    No point in getting scared, you are in the club now.  Jump in an pull your weight the best way you know how. If you need another year of training after the 10 years of post grad education you just went through then take it now.  If not ...get to work. 

    Again. you should review where you want to practice and talk to some PCPs and some DPMs to best consider a realistic picture of the referral side(what the PCPs want from podiatry) and some DPMs (what podiatrist are really seeing and working with between the referral and direct patient markets). Then consider how you want to fit in either by directly competing or addressing a niche of unmet needs.

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  • Alexander Estrada, BS,DPM,FACFAS,MS,

    Some real valid points were brought up above. It really does make sense to look into where you want to live and where you want to be "professionally" in 10 years. If you want to let's say work in New York & have a New York based practice or career, then it wouldn't be worth it to do a big "surgical " fellowship since the scope of practice is more limited in that state. If you are the type of person that wants to make money & are more entrepreneurial, then maybe a surgical fellowship may not be worth it. Many of the most successful Podiatrists I know aren't ABPS certified & if they are, really don't do any rear-foot / ankle / charcot type of work. A mentor of mine once told me "there's a million dollars in the forefoot" and I don't think that's far from the truth. There are guys out there that make TONS of money on braces, orthotics, DME work & barely go into the OR. Let's face it, in today's day & age, it doesn't pay to be in the OR when you can be in your office & generate thousands of dollars in revenue for a days work.

    As far as finaces & geting case volume for your boards numbers, a common avenue to look into is going in as an employee / associate. That way you'd be getting into an established practice (you don't have to worry about establishing one yourself) and will have access to large volumes of patients and get your numbers faster for the boards all the while generating some steady income for you. Many people then either choose to go off on their own or get offered a partnership position after that milestone is achieved (takes 2-3 years from what I've seen).

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  • Dan Chaskin, DPM,

    Any legitimate residency should get you where you need to be upon certificate completion.

     

    What is the definition of a legitimate residency program? For what legitimate purpose regarding licensure is the program being completed for? For licensure of the foot? For licensure of the ankle and foot?

    If a New York podiatrist wishes to treat the ankle in New York should they give up their practice and complete and approved residency program in podiatric medicine and surgery? Is there some sort of a way for residency equivilancy to be offered by the colleges of podiatric medicine?

    If NYS began requiring a residency program that is "approved" in medicine and sugery could other states begin following NYS policy? Bottom line is if training was performed many years ago and such training may possibly be unrelated to current competence or may be a different type of approved training model, a podiatrist may be currently competent yet not meet a states requirements. This puts all the podiatrists that completed some sort of residency program that is not approved in the same boat as podiatrists that did not complete any residency at all. I guess states have requirements to protect the public. I guess states feel that current training models perhaps may best protect the public so such requirements possibly may be developed by other states. The moment that states require minimal screening residency requirements for podiatrists that did not complete any residency program this then sets the precedent for states not to accept programs that possibly may be outdated or possibly not related to current competence. After all aren't requirements set to protect the public?

    Bottom line is a fellowship I feel is a wonderful idea if you first obtain the state requirements for licensure regarding the state you wish to practice in. After all if you complete a fellowship and wish to treat the ankle and you do not meet the minimum state requirement to treat the ankle then what is the purpose of completing the fellowship?

     

    Daniel

     

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  • Jeffrey Kass, DPM,

    Ryan - I am not sure if you read barry Block's PM NEWS online or not. But, I would suggest you simply look at the classified adds at the end of the NEWS of the day....There are Docs looking for people to join their practice...for the most part it appears surgically skilled is what is being sought...

    You don't see anyone looking for a "general podiatrist".... I think that speaks volumes. Your current traiing may indeed be enough. I don;t know what you are capable or comfortable doing...that is somehing you have to decide. If you have the capability of doing a solid fellowship...and the financial means to not enter practice yet, I, personally would grab it.

    Had, I had such an oppurtunity 16 years ago - I know without a shadow of a doubt my income would be higher.

    Its much harder to try and learn things through weekend seminars and the likes compared with getting in the trenches of a Fellowship. In the grand scheme of things a year is not very long.  

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  • H David Gottlieb, DPM,

    Ryan,

    There is lots of very good advice for you here.

    It all depends on you, what you want in your future, and how much flexibility you want in your future professional career. If your Fellowship is in an area you love and want more training in then go for it. One never goes wrong doing what they love.

    You do have to get Board Certified and the sooner the better. The clock on that starts tickikng as soon as you pass the Qualifying exam. Your residency cases no longer count toward Certification so try and get cases soon. I do not know if Fellowship cases count towards Certification so you have to check with ABPS to find out.

    One thing to remember is that not all Fellowships are CPME approved. It may or may not matter.

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  • Jeffrey Kass, DPM,

    Dr. Gottleib - I don't really think it matters if it is certified or not. another words if the training is there it is there. I am not sure the piece of paper itself matters. There is a wound care fellowship that is certified in New York and I will tell you - is the biggest joke. I do not believe the Fellows learn anything in the program. I think it is a way of the hospital to make money off of them - end of story.

    The surgical training in the residency is the piece of paper you need. If Ryan is looking to do a surgical fellowship he will be that much better trained and his numbers should be able to be more easily achieved. If the clock starts ticking once the written test is passed then he sits ofr the test when he is finishing or towards the end of the Fellowship....

    If someone would offer me today a Surgical Fellowship, where I would be able to somehow condense my practice hours, so that I would not have to give it up (since, my family relies on the income) I would clean toilet bowls to get it.

     

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  • Ryan Kemp, BA,BS,DPM,

    Thank you all for the solid advice. Just to make my situation a little more clear, let me explain. I am in a residency program that is a young program, virtually unknown, but in my humble opinion very good. Does that matter that it is not a well known program? I hope that it doesn't, but my gut tells me it does matter a little.  The program is a PMSR/RRA three year program, which means I will be able to sit for both forefoot and rear-foot ABPS certification. Currently I already have the number of surgical cases to graduate a three year program. I enjoy the surgical aspect of podiatry and the mental and technical challenges it puts into the day to day.  The program I'm in is in the Midwest, but I'm looking for positions from Colorado westward (I'm an Idaho guy) but don't want a tiny town (at least 50,000 population).  I do have a family and living on resident salary isn't easy. Like a lot of almost new medical professionals, I'm nervous about the future of healthcare...i.e. making enough money to support my family and paying off my student loans. Hospitals are buying up private practices and multi-specialty physician groups like Willy Wonka bars with golden tickets. I feel like I'm going to have to work for someone even though I never really pictured that as my future of choice.  I don't know if private practice is a good physician model anymore, and even if it is, I don't think I would qualify for the business loans that I would need to start up. So if I need to work for someone, is that quality fellowship or extra training or extra certificate worth one more year at a resident salary? If considering a fellowship, I'm only looking at ACFAS approved programs. Another great point that was brought up was about the compiling of cases during a fellowship year that count toward my ABPS credentialing, I don't know if that's the case. But I will definitely look into it. Let me know if this changes the advice you all have graciously provided.

    Ryan

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  • Jeffrey Kass, DPM,
    It does not matter the name of the program,it is the quality of the training you are getting. I think for the most part surgical fellowships would of augmented training for guys like me who did what was known way back when as a PSR-12. But, Ryan, if you have enough cases and are in a 3 year program....from what you describe, I will change my advice and tell you to start job hunting. It sounds like you should be capable to do what you need to. The exposure one should get in a rearfoot certified program should allow you a comfort level to do just about anything you will likely encounter. On that note, I wish you all the best with whatever you decide.
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  • Guido Laporta, DPM,

    If you are considering a Fellowship because you will be more marketable or command a higher salary, forget it.

    If on the other hand, regardless of how good your training is, you want additional training in a subspecialty area, I would suggest you strongly consider a Fellowship.

    That would be the proper motivation for a Fellowship.  Additionally, you will get one additional year of nurturing which can only make you a better clinician

    Reply
  • Dan Chaskin, DPM,

    Just because one is board certified in podiatric surgery what is to prevnet a plaintiff attorney from having experts that are board certified in podiatric medicine? Why can't the plaintiff attorney can argue "well you are not even board certified in podiatric medicine so if you performed wound care did you refer the patient to a podiatrist who is board certified in the conservative procedure of propperly "offloading the foot" before you went in and possibly surgically removed that metatarsal head that may have possibly resulted in further complications? Also if bunion surgery was performed and a bad result was obtained what is to stop the plaintiff attorney from asking did you refer the patient to a podiatrist that is board certified in podiatric medicine regarding conservative care? If the public may place so much emphasis on board certification any plaintiff attorney can possibly allege if there was the availability of podiatrists who are board certified in podiatric medicine or conservative care why wasn't a referral made to such a podiatrist so that the patient could be treated by a podiatrist that was board certified in conservative care before proceding with the surgery? Similarly if a podiatrist is board certifed in podiatric medicine and not board certified in surgery what is to stop a plaintiff attorney from alleging why wasn't the referral made to a podiatrist that is board certified in surgery? Well the answer may be that the patient wanted a non board certified podiatrist who wasn't certified in podiatric surgery and this was fully explained to the patient. What is the plaintiff attorney argues "The problem is that if a podiatrist is not board certified in podiatric medicine and only board certified in surgery shouldn't this also be disclosed to the patient before the patient decides conservative care should not be attempted?" Why shouldn't the patient at least be afforded the knowledge that there are podiatrists board certified in podiatric medicine who can consider their individual situation before deciding to forgoe conservative attempts? What is to stop a plaintiff attorney from asking these questions to any jury in any podiatric medical malpractice proceedings? Shouldn't all patients benefit from the knowlege that there are podiatrists who are board certified in different fields of podiatry that are available to treat or give second opinions? Personally the individual podiatrists current competence at performing the given procedure is isn't this what is most important? Do plaintiffs attorneys place too much emphasis on board certification? Lastly aren't there too many lawsuits without any merit? If a plaintiff attorney loses the case shouldn't the plaintiff attorney be responsible to pay court costs?

     

    Daniel

     

    class 84

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  • H David Gottlieb, DPM,
    Quote:

    If someone would offer me today a Surgical Fellowship, where I would be able to somehow condense my practice hours, so that I would not have to give it up (since, my family relies on the income) I would clean toilet bowls to get it.

     


    Jeff,

    It was literally that attitude and phrase "I would clean toilet bowls to get it" that convinced the program I was applying to to hire me. This kind of a 'can do' attitude makes all the difference.

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