TURNING LEMONS INTO LEMONADE THREE: GET A BETTER LEMON (PART ONE)
by John L. Trench III, DPM (no login)

Welcome back my friends, to the show that never ends....
                                         (With a nod and a "Thanks" to Emerson, Lake and Palmer).

When last we saw our heroes--that's you, the boys and girls who are thinking about entering podiatry, who are already in podiatry school, who are currently in residency, as well as you who have come out into practice as a new or recent (past 10+ years) graduate--they were engaged in a mighty struggle with that gigantic fire-breathing, man- (and woman-) eating dragon, Debt! Holding high their [Direct Loan Program/income-contingent repayment option] shields and wielding their razor-sharp [accelerated debt repayment system] swords, they yet stand, bruised, bloodied, but unbowed on the field of battle!

(>Sheesh!< Did I write that crap up there?)

Now that you have had the chance to get your loan situation under control and get started retiring your debts early--if you haven't bothered to do this yet, you have no one to blame but yourself when you flush down the toilet, kiddies, so get off your a*ses and get moving, okay?--it is time to examine the subject of how you get the training you have been denied (if you are an RPR, PPMR, or POR graduate, that is).

This is a vital subject. Not having full-scope training--i.e., having been denied surgical or surgical and biomechanics/non-surgical orthopedics training--is not an inconsequential thing. Your prospects for surviving long enough to build a viable, income-producing, bill-paying practice will depend upon being able to offer the broadest possible range of services to your patients. During the first year of your practice, patients are going to be coming to you in dribbles and drips, presenting a mix of palliative, minor medical, biomechanical, and surgical work. With each subsequent year, your patient load will slowly--and I do mean slowly--grow larger, still presenting a mix of patients, with perhaps 90% to 95% +/- presenting various nail pathologies, painful corns and calluses, symptomatic hammer toes, symptomatic bunions/HAV, and heel pain (most commonly plantar fasciitis)--these, I believe, still represent the top five conditions that will present to the average podiatrist's office on a daily basis--with all other pathologies combined comprising the remaining 5% to 10% of patients coming to you. The more you are trained to do, the more of that work you will keep--and the income it generates. Conversely, the more limited and circumscribed your training and skills base, the more of that work you will be forced to send right back out your door and down the street to the more fully trained podiatrists--along with the income that work can generate.

When you are starting up and building your practice, you cannot afford to allow any income to walk out your door. As an ethical podiatrist who has, say, completed a "true" Podiatric Primary Medicine Residency, you will be forced to refer out all significant surgical and biomechanics work the same moment it comes into your office, sending it to the appropriate specialist. On many days that may account for anywhere from 30% to 100% of the patients consulting you. That's an awful lot of money that you are forced to not only leave on the table, but actually shift into somebody else's pocket. In exchange you will receive...nothing.

The blunt fact is that the better-trained POR graduates can do everything that the best of the PPMR graduates can do, plus the biomechanics/non-surgical orthopedics work that the PPMR graduates are (in theory, anyway) denied training for and thus are not qualified to do. The better-trained PSR graduates, meanwhile, can do everything the best of the PPMR graduates are trained to do, as well as everything the POR graduates are trained to do, plus all of the surgical procedures that the PPMR and POR graduates are (in theory, anyway) denied training for and thus are not qualified to do. In these wonderful days of Medicare, Medicaid, and the whole big HMO/PPO/MCO alphabet soup, guess which one(s) are going to be the most competitive, and thus the most likely to survive and prosper?

(HINT: Managed care organizations that know anything at all about our so-called "specialties" know bullsh*t when they see and smell it. They know that it is not in their interests to allow three doctors on their provider panels to do work that only really takes one podiatrist. And since one podiatrist--the PSR-trained podiatrist--is qualified to do everything the other two can do, plus surgery, their choice is...well, you figure it out.)

None of these more fully trained men and women are going to refer anything with any significant level of income attached to it out of their offices and into yours. And when you get right down to it, why should they? After all, the situation as it exists today is very much to their advantage--lacking the training and skills to treat the more complex and interesting conditions, you podiatric primary medicine "specialists" have no choice but to refer all those patients out. Why should they reduce their advantage on your behalf? Out of charity? A sense of pity for you?

Give me a break.

Nope, the referral flow is going to be almost exclusively one-way: from you to them. Admittedly, you will get some patients from them from time to time: all the time-consuming $16.52 covered-service toenail trims, for example, along with every crazed loon, lawsuit-happy parasite, and money-losing malingerer they come across from time to time. Yup, just makes your mouth water and your body tingle with pleasant anticipation, doesn't it?

End of tirade--time I was getting back to the central point: 

As a new DPM struggling to establish a practice today, you need every penny of income you can possibly generate in order to survive and keep your doors open long enough to build that practice to a self-sustaining level. The more work you have to send out, the less income you will earn. That substantially diminishes your probability of survival. In my considered opinion, for the overwhelming majority of RPR and PPMR graduates, as well as a great many POR graduates, it effectively reduces the probability of survival to zero. YOU CANNOT AFFORD TO LET ANY OF THOSE PATIENTS WALK OUT OF YOUR DOOR BECAUSE OF EXCESSIVELY [AND ARBITRARILY] LIMITED TRAINING AND SKILLS! Unless you aggressively act to rectify the critical deficiencies in your training, most of you are doomed.

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A QUICK SIDE NOTE:

Yes, I know, some of you had exceptional PPMR or POR programs that gave you the same level of surgical training that a lot of official PSR program residents get. That is not, however, consistent. Some of you received really good training in surgery, some of you merely adequate training, and many of you didn't get diddly squat. The residency programs are not standardized. (What a surprise.) 

What is becoming standardized is the way you are treated after entering practice: systematic denial of access to managed care panels and payment for the surgical work you are trained to do, denial of meaningful hospital privileges for the surgical work you are trained to do, denial of access to meaningful board certification covering the surgical work you are trained to do, etc.

If anybody out there thinks this is accidental, or that it derives from well-intentioned and benevolent opinions and actions on the part of our "leadership" rather than simple greed and the desire to carve out the lion's share of financial opportunity and the most profitable (as well as the most technically interesting) professional turf for themselves and exclude everybody else from it, please get your head out of your [obvious anatomical reference] and face reality!

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So what do you do about this miserable and destructive state of affairs? Well, now, lemmesee....

Hey, I know--you COULD go back and do another two-year residency, this time getting a surgical one. After all, with the declining enrollment levels, more residencies are going to be up for grabs with less competition, right? That would do the trick, right?

Wrong--at least I firmly believe it's wrong, and I think I can put forth a strong argument supporting this belief:

First of all, it is unlikely that you would be able to GET a surgical residency as a returning already-been-residency-trained-once candidate. Whether officially acknowledged or not, there is and will continue to be a strong tendency to favor new graduates fresh from school over returnees from the less-desirable side of the professional "tracks"--you had your chance. Judging by a post or two on this forum, there would also seem to be at least some possibility of funding problems attendant to accepting a person into a surgical residency who has already been trained in a different type of residency--problems which, if they in fact exist, would effectively eliminate any possibility of you getting into a PSR.

Second, surgical residencies make up approximately one-half of the available residency positions--less than half, actually, last time I looked. Do you suppose that a whole bunch of the students graduating at the time you are seeking a surgical slot are going to be all hot-and-heavy to get a NON-SURGICAL residency, leaving the PSRs open for you? Do you think for one minute that large numbers of students are at this very moment actually plotting and scheming and developing their strategy so that they can land that exciting Podiatric Primary Medicine Residency, eschewing those nasty, time-wasting surgical residencies? [If you DO think this--what kind of major mind-altering drugs are you doing, Spanky? Please contact me, 'cause I've got some really prime ocean front property for you up in Montana, that you just gotta buy! Right now! As is! For cash!]

Nope, every one of those PSR slots is going to be hotly contested, while the overwhelming majority of those non-surgical POR and PPMR slots --possibly ALL of them, if the entering class size is small enough--will go begging. You will be competing with virtually every graduating student, plus a respectable number of returnees just like yourself who did non-surgical residencies and now want that all-important surgical training.

Third, you probably can't AFFORD to do it. Take a look at your student loan promissory notes, and see how long you are allowed to defer your loans for residency training. Unless they've changed a lot from my student days, they probably only give you about two years. Pretty much used it all up already, right? Now remember at how much you got paid as a resident--or, if that was a long time ago, take a look at the current pay levels. Not exactly lavish, are they? Now, MD and DO residents can get hit with student loan bills while still in residency, too--but most of them attended the government-subsidized schools in their home states, and paid really low tuition as a result, so their monthly bills are a lot lower than yours. Also, those MD and DO residents get paid a lot more than you do, so they are in a better position to afford those monthly student loan bills when they finally start to come in. And, as the icing on the cake, a lot of them can take advantage of various loan repayment and forgiveness options that will pay off their debts in return for service in specified underserved areas. Those options will become available to us podiatrists, too. When Hell freezes over and Jerry Falwell gets a sex change.

Of course, there's always forebearance for the loans--that way, while you're getting re-abused for two more years, your loans can grow into an even BIGGER burden! Hey--bonus!

Who said this profession doesn't know how to treat its young right?

Okay, so much for going back into residency--for most of you, it just isn't a realistic option. So what's a struggling young podiatrist to do? Or a struggling OLDER podiatrist, for that matter!

Well, what say we all get together and:

REFUSE TO ACCEPT OR ABIDE BY THE ARBITRARY LIMITATIONS!

Oooooooh! Could I possibly be so treasonous as to suggest bucking the status quo being pushed off on us by the
APMA, the ABPS, and the [board-in-search-of-a-legitimate-reason-for-existing] ABPOPPM? You bet your
debt-riddled a-double-s I am!

That really is all we have to do, when you come right down to it. Just refuse to cooperate. Refuse to accept the
non-surgical limitations, the denial of training and skills, the denial of access to surgical hospital privileges and
managed care provider panels, the denial of access to meaningful board certification--or the relegation to second-
or even third-class status by unreasonable and arbitrary "alternate pathway" certification limitations and
"grandfathering" clauses. Refuse to support the "Fearless Leaders" and their pet organizations in this effort of
theirs. Refuse to allow them to push this destructive crap off onto you, or onto your classmates, your residency
mates, and your similarly-situated colleagues. That's what you have to do to put an end to this mess. It's ALL you
have to do.

Well, not QUITE all....

Here's the stuff you have to do be willing to do, in order to secure for yourselves and your posterity the fruits of
true liberty and professional equality:

STEP ONE: STICK TOGETHER AND SUPPORT EACH OTHER

We're striking out into uncharted territory here. Supporting colleagues is not something for which the podiatric
profession is noted. Nepotism and cronyism: yes. Greed, crass self-interest, and blatantly exclusionary and
discriminatory professional turf-grabbing: yes. Fraternal behavior in keeping with the best of the Hippocratic
Tradition: no. This profession is and has always been plagued by the turf-grabbing, back-stabbing,
underhanded-dealing, cheating, lying, etc., etc., etc., that you see today. It's just that now, with the ABPS so
entrenched and marketing its propaganda so aggressively to hospitals and third party payors, the APMA so
intractable in its refusal to reign in the ABPS and require it to be responsive to the will of the majority (which, by
the way, favors fair and open access to board certification in all areas by all podiatrists on the basis of skill,
knowledge and judgment rather than the initials of one's residency program), and the aggressive growth of
managed care into every market, these typical podiatry profession traits have been magnified from the merely
irritating, frustrating and inconvenient to the dangerously destructive. Look to thy back, lest thine own friend
plunge a knife into it. Welcome to the podiatry of old. Ask Brian Gale what its like--he's been experiencing the
joys and warm-fuzzies of traditional podiatry brotherhood for the past 8 years and $250,000-plus. Similar joyous
experiences await you all out here.

There are individuals who represent notable and refreshing exceptions, however, and you will find some of them
posting on this board. Dr. Richard Willner, Dr. Brian Gale, Dr. Neal Frankel, and Dr. Dranon are examples,
although certainly not the only ones. I've come across others elsewhere on this forum, through Podiatry Online,
through PM News, and through contact with colleagues at various seminars. The problem is, such exceptions are
just that: exceptions. These people are not representative of the profession as a whole. Of the podiatrists today
who take any public action--and like any organization, it's a minority who actually take action--a dismayingly
significant percentage are in the "flaming a-hole" category and will be acting to advantage themselves by
disadvantaging you. Meanwhile the overwhelming majority of podiatrists, while generally decent and nice men
and women, display an alarming level of apathy to issues of importance to this profession, save only those that
affect them personally and directly--they may be sympathetic to the plight of new and recent practitioners (and
indeed, most ARE sympathetic), however, they just don't get involved. And don't particularly want to.

Brian Gale-type situations are a direct consequence of this attitude. As Benjamin Franklin so aptly observed
during deliberations over the drafting and signing of the Declaration of Independence, if we do not all hang
together, we will most assuredly all hang separately!

If you are going to survive, you will have to stand together, providing each other with unwavering support in the
face of all opposition. I therefore propose that you gather your groups together and hammer out a pact agreeing
to precisely such a support network. Pledge yourselves to one another--and really mean it!

You should stick together and stand up for one another as a class at your school. You should form the same
support network between the individual classes at your school--and between all the classes at all of the other
schools. You should expand that support network to include the disenfranchised of the ten or twelve graduating
classes that came before you. And you should keep that network open to the young men and women who will
follow us into podiatry in the future. We are all in the same boat--and if that boat continues as it is now, it will sink
and we will all drown, regardless of the residency we boast. It is terribly unfair and unjust that some should get
full scope training while others should be consigned to limited and inadequate training that excludes them from
important, profitable, and technically satisfying areas of practice. This is an extremely small profession, not just in
terms of practitioner numbers, but in terms of scope of practice. The knowledge and skills base needed to
practice the full scope of this profession is finite, and can be mastered by every individual. We do not have so
broad a scope or so massive a knowledge base in any area that specialization is necessary to ensure quality of
care delivered. Nor is there any apparent widespread interest in our profession to focus practice in any one of the
three areas, with the single notable exception of surgery--witness the fact that the overwhelming majority of
practices include ALL phases of podiatric medicine and surgery, and not just non-surgical medical or
non-surgical orthopedics/biomechanics. 

(There ARE a bunch of elitist monkey-doots out there who hanker to practice only surgery, however--please
note that this is a primary driving force behind the discriminatory specialization and board certification structures
we are currently afflicted with, as they understand that they must cut the rest of us out of surgery completely--pun
intended--in order to reserve all the surgical work, and the surgical fees that work generates, to themselves and
allow them to enjoy the purely surgical practices of their dreams. That you and I and so many like us must be
sacrificed in order for that to happen is a small price to pay, in their view.)

And it is not merely a matter of : "Oh well, life's unfair, and there's nothing I can do about it!"--for while it is true
that life is indeed unfair sometimes [most of the time?], it is ALSO true that you possess both the ability AND the
moral obligation to take effective action to redress those inequities.

You OWE it to each other to provide unfailing, unwavering, unending support to all of your colleagues. And by
"support" I do NOT mean that you will see to it that if you get a PSR, the poor schmucks who get PPMRs will
get all your cheaply-reimbursed and mind-numbingly dull toenail trimming and callus paring work while you suck
all the interesting and profitable surgical cases out of their practices! That is not support--that is parasitic, sucking
the life's blood out of them the way a tick or a leach sucks blood from its victims.

By support, I mean that each and every one of you will share with everyone else the skills and knowledge you
acquire from your residency training--and share it with the generations to come, as well as with the many
"have-nots" of the generations of podiatrists that have preceded you. And that each and every one of you will
stand up and demand fair, open, impartial access to training and board certification in all areas of podiatric
medicine and surgery, for all practitioners both now and in the future.

STEP TWO: GETTING YOUR TRAINING AND SKILLS THE OLD-FASHIONED WAY

Do not let ANYBODY in your class go untrained in surgery, or non-surgical orthopedics, or anything else that
makes up the work to be found in a well-rounded, full-scope practice of podiatric medicine and surgery.

Every one of you must pledge to share anything and everything you learn, with everyone else. No matter how big
or how seemingly small and insignificant, everything any of you learn, share with everyone. See to it that ALL of
you are equally well trained in the full scope of practice.

Make this pledge to everyone in your class, as well as to the classes ahead of and behind yours, across all the
schools. But do not limit it there. Extend that pledge to include all of the future classes, the young men and women
yet to matriculate to podiatric medical school. And to all of the past classes, to those of us trapped in the
"have-not" trash heap and already suffering the destructive effects we are attempting to warn you against and to
help you avoid. Let NO ONE fall through the cracks.

This means setting up your own training and mentoring systems, connecting people together in every area of the
country in a rotating system that will enable EVERYONE to become fully trained in every aspect of this
profession. Some of you will secure residencies where you will be trained in reconstructive forefoot and
non-reconstructive rearfoot surgery. Some of you will be trained to perform forefoot, rearfoot, and ankle--and a
few will wind up in states where they can get surgical experience all the way up to the tibial tuberosity. Some of
you will have extensive training and experience in non-surgical orthopedics and biomechanics. Some of you will
have extensive experience in treating and preserving compromised limbs in diabetic, neuropathic, and dysvascular
patients. ALL OF YOU will have something valuable to share, and ALL OF YOU will find you have much of
value to learn from even the most limited and inadequately trained (ie, PPMR or RPR) among you.

Hold back nothing. Share everything. Learn everything--we are a limited profession focusing upon a limited
anatomical area presenting a limited set of conditions, treatments/procedures, and skills, that can in fact be
mastered and practiced to a high level of quality by every individual practitioner. Refuse to accede to the
arbitrary, exclusionary, discriminatory limitations the self-serving hacks of the "Old Boy Network" are attempting
to enforce upon us--and refuse to allow those limitations to be imposed upon anyone else.

Will this be difficult and complicated? Not really. Actually, the major difficulty you will run into is dealing with the
amoral bottom-feeders among you. You'll recognize them right after residency matches are announced: they're
the ones who get PSRs and suddenly see the "wisdom" of these discriminatory and segregationist training and
board certification policies--policies many of them will have been extremely vocal in rejecting PRIOR TO getting
a PSR slot. They are the minority, thankfully. We'll discuss ways to rid our profession of these human lice in a
future post.

Actually, the way I am suggesting that you share your skills and training is precisely how many [if not, in fact,
most] of the podiatrists in previous generations got their training--and how we "have-nots" struggle to get our
skills today. The problem is, such an approach tends to be rather "hit-or-miss", resulting in an uneven acquisition
of skills. I am proposing that you create a structured, systematic approach in order to ensure that everyone gets
uniform training in the full scope of podiatric medical and surgical practice, in a rational and effective manner. By
doing so, there is far less struggle, and no one is left out.

I propose the development of advanced training programs that will serve as a combination of preceptorship and
fellowship. These programs will be set up in such a manner as to enable them to be tailored to address to the
unique needs and training deficiencies presented by each preceptor/fellow, while at the same time honing the
many skills and enhancing the knowledge base in the areas they have already mastered. In addition, they can be
set up to permit the preceptor/fellow to actively pursue his or her private practice concurrently with the training
program. There is no inherent conflict--practice and training need not be mutually exclusive. It will merely require
some coordination and careful structuring. In this way, each doctor can continue to build and advance his or her
practice, incorporating the new skills being learned into that practice along the way.

(If anybody out there knows of some quirk in the law that does make them mutually exclusive, please let us all know here. Okay?) 

The instructors in this system will initially be drawn from the many surgically trained and qualified experienced
practitioners out there who are sympathetic to the plight of the new and recent graduates, who recognize that it is
in both their personal best interest as well as in the best interest of the profession as a whole to see to it that every
podiatrist is fully trained and qualified to practice the full scope of podiatric medicine and surgery. If you have
paid much attention to certain of the letters to PM News and Podiatry Online, as well as to some of the posts to
this forum in the past, then you already know that there are a fair number of doctors out there willing to take
new-comers "under their wing" and teach them the surgical skills (and medical, and orthopedic/biomechanical)
they lack. This retraining system can be centered around them, allowing preceptor/fellows to rotate with various
teachers across the country in order to ensure the widest possible exposure to the full range of skills offered by
this profession.

Ultimately, all of us would become part of the teaching network in this system after completing our training,
sharing with others in need the same skills and knowledge that has been shared with us. Fair is fair, after all--no
freeloading, no parasitic blood-sucking allowed. You benefit, you share. Period. That, by the way, is exactly how
a profession is SUPPOSED to act!

This system need not be a loose and unofficial assemblage, either. Indeed, if it is to be meaningful, I assert that it
must conform to specific rules and guidelines, and be recognized and controlled by an official national body. To
this end, I submit that we create a Podiatric Preceptorship/Fellowship Certification Council, which will be
responsible for developing the preceptorship/fellowship program and administering it. This council would itself
seek independent accreditation in exactly the same manner and from exactly the same body as the American
Podiatric Medical Specialties Board has done: from the National Commission for Certifying Agencies (NCCA) of the National Organization for Competency Assurance (NOCA).

Such recognition is essential for several reasons. First, by meeting the requirements necessary to achieve NCCA
accreditation, the program would simultaneously achieve a significant level of objective credibility. Second,
obtaining independent and objective accreditation would go a long way toward lessening or eliminating potential
medico-legal concerns one might face should a claim ever be filed against one at some point during one's
career--one's training is routinely subject to investigation, and merely saying "I learned surgery by asking my
buddy to teach me," is not a big credibility-builder. Being able to say, however, that "I received my surgical
training in the preceptorship/fellowship program in podiatric medicine and surgery accredited by the
nationally-recognized National Commission for Certifying Agencies, following completion of my
APMA-approved [insert designation of program here] residency, giving me [4/5] years of post-graduate
training," would offer significantly enhanced credibility.

This post is waaaaay too long as it is, and there's a little bit more to go. I'll put the rest into the fourth "Lemons"
post--for now, let's close this one.

John L. Trench III, DPM
jltrench@gte.net

Posted on Aug 28 2000, 11:47 PM
from IP address 63.27.95.186