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Hey guys, Don here. 
Welcome to Podiatry Practice 

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Mastery where we're helping you 
get to the $1,000,000 mark and 

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beyond. 
So this is going to be the 

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$1,000,000 minute. 
This is going to be kind of a 

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different one because I don't 
usually talk about my my 

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surgical days because I don't 
have that many of them these 

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days. 
That's more by design than 

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anything else in order to kind 
of focus on optimization in my 

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schedule. 
So as I kind of I'm preparing a 

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couple of articles for new 
practitioners, I'm just going to

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remind everyone, if you're 
trying to get to $1,000,000, you

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need to kind of produce about 
$2000 a day if you're, if you're

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working five days a week. 
So that's how you get to the 

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$1,000,000 mark in production. 
And I just find that sometimes 

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hard with, with surgical cases 
because of the time of the, the 

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recovery and also for the kind 
of the low paying aspect of the 

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surgical cases themselves and 
the kind of the not the most 

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efficient use of time. 
So a few ways we kind of try to 

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be more efficient would be 
putting more, more cases would 

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be one way. 
Another way is by doing DME, not

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at the hospital, not giving them
a Cam boot at the hospital, but 

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give them a Cam surgical shoot 
at the hospital and then give 

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them a Cam boot in our office at
the 1st post op, you know, post 

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op bag. 
I guess that that is something, 

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but that's not. 
So they don't get their foot, 

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but that's not really a big 
revenue producer, but, and then 

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having shorter turn around time.
So using more of a surgical 

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center where there can be a lot 
of quick turn around. 

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Unfortunately, I don't have 
that. 

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I, I work at a local hospital 
here and we have block time and 

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I usually do it every two to 
three months. 

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So I use one day every two to 
three months. 

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So I'm going to go over kind of 
my cases. 

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I, I work with residents as 
well. 

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And it's actually the same 
residency that I went to here at

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Saint Vincent's here in, in 
Worcester. 

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And, and, and I'm going to kind 
of talk a little bit about what 

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I was talking with, with the 
residents as well, because I 

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think that's, you know, helpful 
kind of some ideas. 

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So the first case was a 
bilateral de rotational 

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arthroplasty of the 5th digit 
for a female. 

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She, she was, she's very simple.
She was actually illiterate and 

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she need help like putting her 
name down and with medications 

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and everything. 
And she had some really bad 

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sleep apnea, obstructive sleep 
apnea during the procedure. 

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So the the nurse actually called
her primary care to set up the 

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visits for them to look at that,
but that that procedure went 

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well. 
Usually when I do these, I'll do

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one side and the resident will 
do the other side. 

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This is a third year resident. 
She's going to be going doing a 

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fellowship afterwards and we had
a little talk about fellowship. 

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So I think in terms of the 
training, if you don't get all 

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the training you need in 
residency, then I think a 

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fellowship is a good idea. 
I don't I didn't do a 

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fellowship, but I think I think 
it would have benefited me 

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because I feel like certain 
areas I'm not as comfortable 

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with like midfoot fusions, 
Lapidus as I didn't do a lot of 

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rear foot fusions and things 
like that. 

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I didn't do a lot of those. 
So I don't feel comfortable and 

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so I don't do them. 
I think that could be a benefit 

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though, because means less 
surgery for me and I think 

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probably more productivity in 
the office. 

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I know my colleague here that 
does do a lot of them. 

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He says, yeah, well, the rear 
foot surgery gets me all my 

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referrals from other other 
patients. 

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So he could be right in that 
case as well. 

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So it could be a lot more new 
patients if you're doing that 

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surgery for other patients 
coming in. 

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OK. 
The second patient of the day 

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was an older gentleman I had 
done a few years back, about 

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four years back I did on the 
left foot. 

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He had a very, very painful 3rd 
digit cows under the third met 

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head. 
I did a, an elevational 

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osteotomy like a one of those V 
elevational osteotomies and that

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worked fine. 
And now he wanted the right foot

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done and he had a bunion really 
bad hammer toe, rigid hammer toe

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and on 2nd and 3rd and he had a 
kind of a plantar flexed 

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metatarsal, but I think it was 
more due to the hammer toe. 

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So we did a Austin bunionectomy.
Those are the ones I'm most 

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comfortable with. 
Did a arthrodesis of the 2nd, 

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3rd digit with pinning. 
And, and you know, just to kind 

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of talk through this, this one, 
the, the toe went white 

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afterwards because I think it 
was so cocked up and it was 

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white for a long time. 
So I dropped the tourniquet 

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before I closed and it was still
white. 

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And then finally in the recovery
area, it, it got a little bit 

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purplish and with good OK cap 
fill time. 

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So I'm a little concerned about 
that one. 

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And then also with working with 
the resident, I think sometimes 

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at least the resident I was 
working with, they have a 

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confidence that without merit. 
So they they seem like they're 

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confident, but they don't really
know what they're doing. 

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And I think this is an aspect of
maybe some residents that I see.

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And so she was like, oh, yeah, I
can do this. 

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And he had a cord on top of the 
toe and he shooted in the lips 

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to take it out. 
And she took too much skin. 

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And so she had a hard time 
closing the skin on the top of 

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that second toe. 
And so I, I, you know, she was 

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making this huge ellipse and I'm
like, you have to go closer to 

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that lesion, otherwise you're 
not going to be able to close. 

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So that was a kind of a struggle
for, for her. 

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And I just, I just kind of let 
her wallow in, in the discomfort

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and learn from it. 
But that was, that was what I 

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noticed with that second case. 
So this patient I'm going to 

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call and probably going to have 
him come in sooner and I may 

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pull that K wire sooner than 
than I would have normally when 

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I usually do it in the office. 
That was the second case. 

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The third case was a woman I did
about because 10 years ago I 

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think I did her, she had some 
hammer toes 2-3 and four done. 

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Her 4th digit, she was walking 
on the side of it on the lateral

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aspect. 
It kind of curled in and the 

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bone changed a little bit. 
So I took out a little bit of 

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the bone kind of an arthroplasty
without shortening it just a 

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little bit on the lateral side 
of that bone. 

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And I did a de rotational 
arthroplasty as well for her. 

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And so her instead of her 
toenail being on the side 

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pointed laterally, it was 
pointed dorsally again. 

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So just correct kind of the 
toenail and it's going to feel 

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better for her. 
So that was the third one. 

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And then the I think there was 
the 4th 1 was a this was one 

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that I saw a week ago. 
She had a couple of amputations.

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She had some osteo or her bone 
was sticking out in her second 

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digit where she had a previous 
amputation of the distal 

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phalanx. 
So that bone was sticking out. 

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It was all infected, the whole 
bone all the way down to the 

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base, not including the, the, 
the, the, the metatarsal looked 

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fine. 
So we took out that whole second

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toe and then the third toe was 
there. 

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It was the only one hanging out 
forward because the 4th and 5th 

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were curved or hammered. 
And so I did a partial 

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amputation of the 3rd as well, 
just because otherwise I knew 

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that would, I knew that ulcer 
just due to the pressure on 

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that, on that area for that, for
that patient. 

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So those were, those were kind 
of the, the surgeries and it 

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was, it was kind of neat working
with the, the resident. 

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But once again, this, this 
confidence that they have, well,

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that's kind of unmerited, can 
kind of be, can kind of be a 

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challenge. 
I tried to do the surgeries as, 

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as, how do you say it as 
efficient as possible. 

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And you know, we'll see kind of 
how they go. 

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I think there was one more. 
I'm just kind of looking for it 

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right now. 
It was that one. 

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Oh yeah. 
Then the last one was it was a 

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screw removal of a of a Austin 
that I did. 

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And so this one we that once 
again let the resident do it. 

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And she's oh, I can see the hole
and she put the pin in as if she

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found it. 
And once again, she had this 

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confidence that wasn't there 
because she didn't use the C arm

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to find the one of the actual 
cannulated screw was once she 

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did find that, then she was able
to pull it out pretty easily and

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it was kind of extending a 
little bit once again into the 

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joint. 
And that's what was bothering 

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this patient. 
And then the other kind of mess 

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up, I was like to talk more 
about my mess ups and what goes 

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well was when we ordered the 
surgical implementation, I used 

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an osteomed screw, but they 
brought me a headed screw and I 

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usually use the headless, the 
headed one, when we put it in, 

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it didn't work. 
It didn't bite and so they had 

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to get a different set with the 
headless screws in there. 

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Usually they're in the same set,
so the Rep was there, but it was

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like a waste of a screw. 
And the reason once again, 

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because the resident just took 
the screw, put it on and didn't 

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think of doing that. 
So there's multiple issues of 

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this with teaching residents. 
I think it's something that just

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comes with teaching and I kind 
of let them feel the pain, learn

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from it, and I think they're 
going to be better afterwards. 

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So that's not something I 
usually talk too much about 

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because I don't do too much 
surgery, but I enjoy, I enjoy 

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being there with the residents. 
It's not the best use of the 

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time if we're talking get into 
the $1,000,000 mark and beyond, 

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but I think it's something also 
to to talk about. 

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I'm, I'm still would like input 
from those listeners that are 

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listening. 
I'm trying to do a series of, of

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articles for new practitioners. 
So kind of like what are the 

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things that you wish you had 
known when you're starting out 

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to try to get your practice to 
the $1,000,000 mark? 

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I'm, I'm trying to talk about 
like initially just getting 

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patients right, getting patients
in the dark. 

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So you have to be busy first 
before you can start being 

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profitable. 
And then once you are busy, then

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you can switch that and be more 
profitable in your, in your 

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practice. 
I'm going to talk about that. 

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If you could e-mail me any of 
your kind of big ideas that you 

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wish you would have known or 
things that you find that the 

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residents that you work with 
lack or the maybe the associates

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that you have are lacking in 
which you would wish you could 

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tell them. 
I will put this in these 

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articles. 
OK, OK guys, thank you. 

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Till next time.