Hey guys, Don here. Welcome to Podiatry Practice
Mastery where we're helping you get to the $1,000,000 mark and
beyond. So this is going to be the
$1,000,000 minute. This is going to be kind of a
different one because I don't usually talk about my my
surgical days because I don't have that many of them these
days. That's more by design than
anything else in order to kind of focus on optimization in my
schedule. So as I kind of I'm preparing a
couple of articles for new practitioners, I'm just going to
remind everyone, if you're trying to get to $1,000,000, you
need to kind of produce about $2000 a day if you're, if you're
working five days a week. So that's how you get to the
$1,000,000 mark in production. And I just find that sometimes
hard with, with surgical cases because of the time of the, the
recovery and also for the kind of the low paying aspect of the
surgical cases themselves and the kind of the not the most
efficient use of time. So a few ways we kind of try to
be more efficient would be putting more, more cases would
be one way. Another way is by doing DME, not
at the hospital, not giving them a Cam boot at the hospital, but
give them a Cam surgical shoot at the hospital and then give
them a Cam boot in our office at the 1st post op, you know, post
op bag. I guess that that is something,
but that's not. So they don't get their foot,
but that's not really a big revenue producer, but, and then
having shorter turn around time. So using more of a surgical
center where there can be a lot of quick turn around.
Unfortunately, I don't have that.
I, I work at a local hospital here and we have block time and
I usually do it every two to three months.
So I use one day every two to three months.
So I'm going to go over kind of my cases.
I, I work with residents as well.
And it's actually the same residency that I went to here at
Saint Vincent's here in, in Worcester.
And, and, and I'm going to kind of talk a little bit about what
I was talking with, with the residents as well, because I
think that's, you know, helpful kind of some ideas.
So the first case was a bilateral de rotational
arthroplasty of the 5th digit for a female.
She, she was, she's very simple. She was actually illiterate and
she need help like putting her name down and with medications
and everything. And she had some really bad
sleep apnea, obstructive sleep apnea during the procedure.
So the the nurse actually called her primary care to set up the
visits for them to look at that, but that that procedure went
well. Usually when I do these, I'll do
one side and the resident will do the other side.
This is a third year resident. She's going to be going doing a
fellowship afterwards and we had a little talk about fellowship.
So I think in terms of the training, if you don't get all
the training you need in residency, then I think a
fellowship is a good idea. I don't I didn't do a
fellowship, but I think I think it would have benefited me
because I feel like certain areas I'm not as comfortable
with like midfoot fusions, Lapidus as I didn't do a lot of
rear foot fusions and things like that.
I didn't do a lot of those. So I don't feel comfortable and
so I don't do them. I think that could be a benefit
though, because means less surgery for me and I think
probably more productivity in the office.
I know my colleague here that does do a lot of them.
He says, yeah, well, the rear foot surgery gets me all my
referrals from other other patients.
So he could be right in that case as well.
So it could be a lot more new patients if you're doing that
surgery for other patients coming in.
OK. The second patient of the day
was an older gentleman I had done a few years back, about
four years back I did on the left foot.
He had a very, very painful 3rd digit cows under the third met
head. I did a, an elevational
osteotomy like a one of those V elevational osteotomies and that
worked fine. And now he wanted the right foot
done and he had a bunion really bad hammer toe, rigid hammer toe
and on 2nd and 3rd and he had a kind of a plantar flexed
metatarsal, but I think it was more due to the hammer toe.
So we did a Austin bunionectomy. Those are the ones I'm most
comfortable with. Did a arthrodesis of the 2nd,
3rd digit with pinning. And, and you know, just to kind
of talk through this, this one, the, the toe went white
afterwards because I think it was so cocked up and it was
white for a long time. So I dropped the tourniquet
before I closed and it was still white.
And then finally in the recovery area, it, it got a little bit
purplish and with good OK cap fill time.
So I'm a little concerned about that one.
And then also with working with the resident, I think sometimes
at least the resident I was working with, they have a
confidence that without merit. So they they seem like they're
confident, but they don't really know what they're doing.
And I think this is an aspect of maybe some residents that I see.
And so she was like, oh, yeah, I can do this.
And he had a cord on top of the toe and he shooted in the lips
to take it out. And she took too much skin.
And so she had a hard time closing the skin on the top of
that second toe. And so I, I, you know, she was
making this huge ellipse and I'm like, you have to go closer to
that lesion, otherwise you're not going to be able to close.
So that was a kind of a struggle for, for her.
And I just, I just kind of let her wallow in, in the discomfort
and learn from it. But that was, that was what I
noticed with that second case. So this patient I'm going to
call and probably going to have him come in sooner and I may
pull that K wire sooner than than I would have normally when
I usually do it in the office. That was the second case.
The third case was a woman I did about because 10 years ago I
think I did her, she had some hammer toes 2-3 and four done.
Her 4th digit, she was walking on the side of it on the lateral
aspect. It kind of curled in and the
bone changed a little bit. So I took out a little bit of
the bone kind of an arthroplasty without shortening it just a
little bit on the lateral side of that bone.
And I did a de rotational arthroplasty as well for her.
And so her instead of her toenail being on the side
pointed laterally, it was pointed dorsally again.
So just correct kind of the toenail and it's going to feel
better for her. So that was the third one.
And then the I think there was the 4th 1 was a this was one
that I saw a week ago. She had a couple of amputations.
She had some osteo or her bone was sticking out in her second
digit where she had a previous amputation of the distal
phalanx. So that bone was sticking out.
It was all infected, the whole bone all the way down to the
base, not including the, the, the, the, the metatarsal looked
fine. So we took out that whole second
toe and then the third toe was there.
It was the only one hanging out forward because the 4th and 5th
were curved or hammered. And so I did a partial
amputation of the 3rd as well, just because otherwise I knew
that would, I knew that ulcer just due to the pressure on
that, on that area for that, for that patient.
So those were, those were kind of the, the surgeries and it
was, it was kind of neat working with the, the resident.
But once again, this, this confidence that they have, well,
that's kind of unmerited, can kind of be, can kind of be a
challenge. I tried to do the surgeries as,
as, how do you say it as efficient as possible.
And you know, we'll see kind of how they go.
I think there was one more. I'm just kind of looking for it
right now. It was that one.
Oh yeah. Then the last one was it was a
screw removal of a of a Austin that I did.
And so this one we that once again let the resident do it.
And she's oh, I can see the hole and she put the pin in as if she
found it. And once again, she had this
confidence that wasn't there because she didn't use the C arm
to find the one of the actual cannulated screw was once she
did find that, then she was able to pull it out pretty easily and
it was kind of extending a little bit once again into the
joint. And that's what was bothering
this patient. And then the other kind of mess
up, I was like to talk more about my mess ups and what goes
well was when we ordered the surgical implementation, I used
an osteomed screw, but they brought me a headed screw and I
usually use the headless, the headed one, when we put it in,
it didn't work. It didn't bite and so they had
to get a different set with the headless screws in there.
Usually they're in the same set, so the Rep was there, but it was
like a waste of a screw. And the reason once again,
because the resident just took the screw, put it on and didn't
think of doing that. So there's multiple issues of
this with teaching residents. I think it's something that just
comes with teaching and I kind of let them feel the pain, learn
from it, and I think they're going to be better afterwards.
So that's not something I usually talk too much about
because I don't do too much surgery, but I enjoy, I enjoy
being there with the residents. It's not the best use of the
time if we're talking get into the $1,000,000 mark and beyond,
but I think it's something also to to talk about.
I'm, I'm still would like input from those listeners that are
listening. I'm trying to do a series of, of
articles for new practitioners. So kind of like what are the
things that you wish you had known when you're starting out
to try to get your practice to the $1,000,000 mark?
I'm, I'm trying to talk about like initially just getting
patients right, getting patients in the dark.
So you have to be busy first before you can start being
profitable. And then once you are busy, then
you can switch that and be more profitable in your, in your
practice. I'm going to talk about that.
If you could e-mail me any of your kind of big ideas that you
wish you would have known or things that you find that the
residents that you work with lack or the maybe the associates
that you have are lacking in which you would wish you could
tell them. I will put this in these
articles. OK, OK guys, thank you.
Till next time.