Current Perspectives on Podiatric Practice Settings

Most of the panelists feel that residency prepared them well for their eventual job searches. One significant factor cited was exposure to a wide variety of specialties, disciplines and practice types. The podiatrists interviewed share that this breadth of experience helped them identify their areas of interest, including their preferred practice settings. Additionally, panelists who feel their residency experience provided them deep exposure to foot and ankle pathology say that their comfort treating patients contributed to a smoother interview and networking process, and possibly even contributed to early success in their chosen settings.

Another way residency prepares podiatrists for the next step, they say, is through mentoring and support.

“Having the ability to seek guidance from those who have been through the process and benefit from their knowledge and experience gave me confidence in maneuvering through the job search process,” says Ashley Dikis, DPM, FACFAS, who practices in Des Moines, IA. “I also leaned heavily on my senior residents, many of whom shared information and resources on job postings, contract negotiation, etc.”

One panelist did not feel ready to undertake the job search post-residency, and chose to pursue fellowship training instead to increase competitiveness as an applicant. From a different point of view, one panelist adds that perhaps it is not solely the responsibility of the program to prepare a new practitioner for the job search.

“My residency ensured I had the skills to complete my job and provided me with time to look for my job,” says Robert Greenhagen, DPM, who practices in Omaha, Nebraska. “I believe it is up to the resident to prepare himself or herself for the job search. I tell our students that if you cannot find a job you want, where you want it, make it. Knock on doors, email hospital presidents, or cold call private practices. If all else fails, start your own practice.”

What Else Could Residencies Do to Help With the Job Search?

Alissa Parker, DPM, FACFAS, practicing in Washington, PA, feels, and many of the panelists agree, that residencies could provide informational presentations or mentorship specifically on targeted topics such as: preparing CVs, contract negotiations and other job search-related activities. Andy Roussel, DPM, FACFAS, who practices in Lake Ridge and Stafford, VA, adds that other key topics could include the current employment climate, discussion of practice types, and starting options/tracks. He goes on to say that financial considerations are important to understand, and that residencies might connect their trainees with resources to learn more about base salaries, incentives, benefits, supplemental and continuing education.

Allowing residents to attend local and national events and conferences is another helpful tool, they say. Several panelists in the roundtable cited this as an opportunity to create professional relationships and network, leading to more employment opportunities. Learning opportunities, including practice management and business skills, is also among the “wish list” of some of the panelists to best prepare current and future trainees to select and succeed in a given practice setting. Many add that it is very important that directors and programs give residents time to interview and explore next steps in their careers.

Several panelists opine that either on a program or a larger organizational level, that residents would benefit from a centralized “job bank” or similar listing of practices and employers searching for new hires. Augusta D. Henderson, DPM advises that there are multiple platforms where residents can search for jobs, but it requires significant time investment to keep up with the various options.

“One consolidated and well-organized search site would be helpful,” she says. “One of the larger podiatric organizations hosting a yearly or quarterly job fair is also an attractive potential resource.”

How Does One’s Job After Residency Differ From That During Training?

The panelists share a variety of opinions on this question. Some feel their current practice is fairly similar to their training, while others feel it is drastically different. However, considering their answers as a whole, the differences are primarily in setting, valuable skill sets, and case distribution.

Many panelists note that the setting of their current practice differs from their training, mostly in the types of facilities they spend time in. Dr. Parker, who primarily works in a community-based hospital center, feels that some coordination of available patient care services proves challenging, such as with certain specialties not existing in-house. Other panelists say that they spend less time in the hospital, and more in the office or outpatient clinics. Rural versus urban locations and the number of DPMs in the area are other key differences mentioned.

Although professional transitions often necessitate building and growing one’s skills, the panelists add that they note specific differences from during their training. Tea Nguyen, DPM, practicing in Santa Cruz, CA, stresses how much business aptitude, patient relationships, and self-branding have become essential to her direct care private practice.

Dr. Roussel agrees that personal interactions with patients, along with staff, families and colleagues prove a crucial part of one’s professional endeavors.

“The other major difference is needing to quickly improve your time management,” he says. “This affects your practice as well as your personal life.”

Additionally, several panelists mentioned that the distribution and types of cases they see is significantly different than that from training. Some cite more or less trauma cases, differing numbers of inpatient consults, and/or less emergency add-on-type cases. Others feel their patient population is different, and therefore comes with different types of pathology.

Did You Stay With Your First Job?

Seven panelists are still practicing where they first began their careers after training and two are not. One of the seven, Dekarlos Dial, DPM, FACFAS did not personally change practice settings, per se, but notes his original job was with a large physician-owned multispecialty practice which a hospital system eventually purchased. He currently practices in this setting in High Point/Winston-Salem, NC.

Important Aspects of Various Practice Settings

Owner, Direct Care Private Practice. Dr. Nguyen says she enjoys setting the structure of the practice, including her schedule, which she adjusts per her needs. She adds that she chooses to not incorporate inpatient responsibilities or ER call, as she found it was not a good fit for herself or her goals.

“I have complete control over everything from the patients I see, how I want to get paid, the staff hiring process, financial decisions, and when protocols need to change,” she explains.

Dr. Nguyen notes few limitations to her practice type except perhaps a lack of coverage when she wants to be out of clinic.

“… my overhead is low, so it’s not as stressful in the cash practice as it used to be when I was insurance-based,” she says.

She goes on to say that the year she opened her practice, she had her daughter and brought her to the office until she was ready for daycare. Accordingly, when her staff is in a bind, she also allows them to bring their children to the office if necessary to support their needs as working parents.

Hospital-Affiliated Multispecialty Group. Dr. Parker splits her time between the office, wound care, inpatient work and the ER. She says she feels that administration is very receptive to her scheduling preferences and patient appointment types. She splits calls and rounding with two other doctors, which can be very time-consuming or more manageable at any given time. Add-on cases after hours do occur when on inpatient call, and she tries to otherwise tack infection cases onto her OR block day when possible.

“Because I work in a smaller community, I feel that many of my referrals come from former patients and their families, which is very rewarding,” she adds.

Dr. Parker relates that staffing can be a challenge in her setting, as the larger group is responsible for hiring support staff. She also notes that affiliation with a hospital, in her experience, demands greater availability of the provider than some other clinical settings.

Assistant Professor, Academic Practice. Dr. Dikis made the transition into academia four years after completing residency, a welcomed achievement of long-time goal. The 7 DPMs in her practice do have some input into patient distribution and as a result can build their clinics around their particular interests. Call rotates weekly, during which time the on-call provider tends to after-hours calls, inpatient consults and any add-on procedures. While she and her colleagues take call for their own patients that present to the ED, they do not take formal ED call.

“Every day is different,” she says. “Working in academia, my time is split between patient care, teaching, research, committee work, academic advising, service, and administrative duties. My schedule varies wildly, but I enjoy the variety. Working with students keeps you on your toes!”

She shares that in order to balance the variety of her duties, this naturally results in less clinic time and lower surgical volume.

“Less than 50 percent of my time is allocated toward direct patient care,” she adds. “It could be difficult for someone transitioning directly from residency to work in academia and obtain the case numbers they need to obtain surgical board certification in a timely manner. It is certainly possible, just potentially more challenging, which should be a consideration.”

The ability to perform some of her work remotely contributes to Dr. Dikis’ work-life balance. Although her academic schedule is more structured, she says she is usually able to adjust to attend to family obligations. Her overall workload may increase at certain times in the year, necessitating more hours or taking work home, but she relates that this does balance out.

Hospital-Based Practice and Residency Director. Dr. Dial covers inpatient cases at his level-1 academic training center, along with satellite hospitals. Podiatry is fully integrated into the call schedule with the hospital, mostly for trauma and diabetic foot infections, he says. Dr. Dial shares that a care setting such as his allows one to appreciate the privilege of caring for patients while maximizing growth potential.

“I have a passion for academia and the ability to teach and train residents,” he explains. “Working in academic leadership has given me the opportunity to deepen our involvement in our health care system.”

Dr. Dial feels his practicing setting has few, if any limits, including the ability to carve out the family and professional balance he desires.

“I have always been a family first individual,” he says. “You have to carve out quality time for your family and never deviate from this plan. In my opinion, work balance leads to a reduction in stress, less burnout and a happier life.”

Physician Owned/Directed Multispecialty Clinic Practice. Matthew J. Dzurik, DPM, FACFAS is the Chief of the Foot and Ankle Department in his organization in Wilmington, NC, and can manage the schedules and types of patients that both he and his partners see.

“We have found certain pathologies that we like and have tailored our practice around those patients,” he says. “We also try to achieve a work-life balance; so we all have different schedules that fit our families’ needs.”

Dr. Dzurik expresses appreciation for the relationships he has with other providers in the practice, leading to a wide variety of pathology and direct referrals from over 200 providers. He manages inpatient duties mostly for his own patients, and does not take ER call due to practicing in a smaller town and a varied educational background of the DPMs in his area.

One limitation of practicing in a multispecialty group is not being able to bring certain products and supplies into the practice in a timely manner, says Dr. Dzurik. Approval and ordering of such items must go through a predetermined process. But, he adds that a high point is the ability to balance work and family, as his organization allows him to tailor his practice to fit his needs, especially as his childrens’ needs grow or change.

Owner, Private Limited Multispecialty Practice. Dr. Greenhagen explains that his practice has four divisions: podiatry, vein and vascular surgery, physical therapy, and pedorthics. He notes that he has control of his schedule and patient types, but points out that this can be limiting if one narrows their preferences too much. He rounds on all hospital consults and post-surgical patients, and takes limited ER call. His practice has a hybrid model that also works within the Veteran’s Administation (VA) system, and he notes that his primary ER responsibilities are at the VA.

“I love that my success is mine,” he says. “I have been able to build an amazing practice with an amazing team. I go to work every day with my friends. We have been fortunate enough to grow our practice, and while other providers have found the model less satisfying, we continue to grow with new partners and associates.”

An important challenge Dr. Greenhagen shares is that business is earned and referrals are not automatic.

“Your reputation and outcomes determine your success,” he says. “You also are very vulnerable to insurance payment cuts and unpaid bills from your customers.”

He feels that his particular type of practice exhibits pros and cons when it comes to work-life balance. While he says some private practices choose to control practice demands to allow for more balance, others may demand more from the provider than other employment situations.

“The provider is responsible for the success and possibly failure of the practice, so it is tough to leave the job at work,” he shares.

Partner, Large Multi-Practice Group. Dr. Roussel began as an associate in a 2-office small group private practice run by 4 physicians, becoming a full partner in 4 years. His practice then joined a large multi-practice group, Foot and Ankle Specialists of the Mid-Atlantic, last year and still practices as 4 partners and an associate physician in 2 locations.  He has admitting and consulting privileges at a large trauma center and a smaller community hospital and rotates call coverage with other local physicians at both. Each of the DPMs in his portion of the practice also rotate office call duties. He shares that natural diversity in his patient flow and positive working relationships with this colleagues make scheduling micromanagement unnecessary.

“I enjoy the diversity of my practice,” he says. “I have a wide range of pathology, patient ages, activity levels, and backgrounds. This is a benefit of working in the suburbs of Washington, DC, but also close enough to more rural areas of Virginia, as well.”

Dr. Roussel says that due to many orthopedic specialists and large orthopedic groups in his area, there is some competition for acute trauma cases that present to the ED. However, he adds that his practice setting has always allowed for a balance of work and family. Sharing call and a positive working relationship with colleagues makes coverage and cooperative care a regular occurrence.

Partner, Private Orthopedic Practice. Spencer Monaco, DPM, FACFAS says he sees a diverse population of patients of many ages, with a high surgical volume in his area of West Chester, PA. He focuses his practice on trauma and reconstruction, along with sports medicine.

“Being in private practice allows me to be more selective of the types of patients I feel I can help the best,” he adds. “An orthopedic type of clinic will certainly have advantages, but also disadvantages on certain procedures commonly performed in a podiatry office.”

He says he typically sees inpatients as postsurgical cases, and less commonly consults following admission from the ED.

“The biggest limitation so far is being the first and only podiatrist within the group,” says Dr. Monaco. “Having a system that is built around podiatry has its advantages when it comes to having office supplies, practice protocol handouts and patient information already set in place.”

However, he cites autonomy as a significant advantage of partnership in such a practice, allowing him to enjoy the work he invests into training, duties and patients.

Associate, Large Podiatry Group Practice. Augusta Henderson, DPM, who practices in Nashville, TN, says that consistent office hours and OR block time, along with standardized maximum patient volumes contribute to a manageable schedule, in her experience. She says all providers in her practice accept the same insurances, and that colleagues often refer to each other after an initial patient visit to ensure that various pathology types end up with the providers that treat them the most.

“My days and my practice are predictable, and I have plenty of time left over in the day to pursue my other interests or spend time with my family,” she adds. “It is easy to finish all of my work at work and not have to bring it home with me.”

Dr. Henderson and her colleagues provide inpatient care to their existing patients as needed. However, she notes that in her area, outpatient referrals often occur early, resulting in less need for hospitalizations. She is also available for ER call, but typically only received requests to see established patients.

One challenge she feels her practice type experiences is the limitations of private practice electronic medical records (EMR). Having trained in an academic setting, she says that she must rely heavily on hospital and primary physicians sending their notes and testing results promptly, or patients bringing discs of imaging. Whereas, in a hospital-based EMR, these items are often immediately visible among all specialties.

Is There Room To Grow In Different Types of Practices?

The panelists’ descriptions of growth potential that they note in their practices are identifiable as either at the personal, group, or community levels. Additionally, all the panelists felt positively about growth options available. Personally, some panelists focus on growth opportunities, whether in skills and knowledge (inside and outside medicine), a more traditional promotion-type track or financial growth. In a more group-style focus on growth, panelists cited the possibilities of opening satellite offices, growing efficiency, adding providers, resources or revenue.

Other panelists focused on growth benefitting patients and the community. They cited goals of providing access to patients in rural areas, those with travel distance challenges, or expanding resources to be able to treat more patients and pathologies.

Key Aspects of Academics and Organizational Responsibilities

Six of the 9 panelists do have access to academic participation. Those that do not either do not have an academic institution in the area, or the teaching organization may not include podiatry or related specialties. Those that do participate do so at many levels. Some have affiliations with residency programs as attendings or Directors, others participate in institutional continuing education opportunities. Dr. Dikis, for example, has job duties that focus primarily on teaching and students, and others serve as adjunct faculty.

As a program Director, Dr. Dial participates in or helps coordinate weekly core conference, grand rounds, and radiology rounds, along with research meetings, journal clubs, morbidity-mortality conferences, fresh frozen surgical cadaver labs and collaborative meetings with vascular surgery.

Non-academic leadership and collaboration opportunities also exist among the different practice styles, although perhaps in different ways. Dr. Nguyen cites small, but growing networks of physicians with insurance-free practices as an important resource. Many practice settings hold regular meetings (monthly, quarterly) and encourage physician participation in committees. Some also participate in medical staff meetings and committees for their inpatient affiliations. Dr. Roussel notes his practice sends internal email and video updates. The scope of all of these meetings varied among practice types. Dr. Henderson specifically noted a twice weekly practice “huddle call” where everyone in the company can share goals and ask for assistance, in addition to monthly physician meetings. Overall, the panelists feel there are leadership opportunities when one wishes to pursue them.

Final Words of Wisdom

Weigh the Immediate and Long-Term Potential of a Contract. Dr. Henderson encourages job-seekers to evaluate a potential contract for what is means in the first year and what it could mean by the fifth year. She feels that prospective employers should be willing to openly discuss this concept.

Plan For Transitions. Dr. Roussel stresses that physicians need to plan for and expect to invest time for training and learning curves, whether during a transition to a new practice or group, or even to just a new EMR. He explains that the short-term inconvenience and daunting nature of such changes is challenging, but that adjustment does happen along with a return to a normal flow.

Time and Effort Pays Off. Dr. Greenhagen shares that a private practice appeals to competitive personalities and can be a difficult practice model. However, he shares that the work is very worthwhile. Other panelists agree that in their settings, persistence and dedication pay off.

Learn About New and Alternative Practice Options. Dr. Nguyen wishes she knew more about concierge and direct care medicine during her training years. She shares that in her experience, they offer significant freedom in the way one practices. Concierge medicine, she says, implies a retainer membership fee paid by the patient to the doctor in exchange for quicker access to the provider. For covered services, she adds, the doctor bills the insurance. Direct care is a movement towards no insurance, she says, either a low-cost membership or fee-for-service for episodic scenarios resolvable within a few visits. Hybrid versions also exist. She adds that she finds these models decrease a doctor’s patient load, provide patients autonomy of choice and support preventive care models.

Identify Your Priorities. Dr. Parker says, that when looking for jobs, she prioritized OR block time and the ability to secure trauma and infection cases. She also encourages those interested in education to prioritize that as well. Dr. Dikis agrees, stressing the level of enjoyment she gets from working with students.