Life Skills Life Skills

How and When to Decide Where to Practice

Jeffrey Robbins, DPM

**** This lecture is not available for CME ****

  • Author
  • Jeffrey Robbins, DPM

    Director, Podiatry Services
    VA Central Office
    Louis Stokes Cleveland VAMC
    Cleveland, OH

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    Jeffrey Robbins has nothing to disclose

  • Lecture Transcript
  • So there is going to be a couple of lectures back to back and then we will go back into academics, and the first speaker is going to be Dr. Jeff Robbins who is the Director of the VA in Louis Stokes Cleveland VA Medical Center. He has been on the platform very, very frequently. He is an eloquent speaker, he has some excellent thoughts to share with you and he is going to tell you how and when to decide where to practice, just don’t do it in Philadelphia [Indiscernible] [0:00:30].

    Jeffrey Robbins: And I want to take this opportunity to thank the present folks for putting on the program for residents, residency directors. As you know we have a COTH program next door for residency directors. I wanted to start up and before I got into my topic, I wanted to start off with a bit of news that even some of the elder statesman in the back of the room may not be aware of. The latest journal of the – Journal of the Bone & Joint Surgery, the Orthopedic Journal had an editorial and the editorial was an orthopedic form, the Projected Shortage of Orthopaedists May Be Our Fault. And in that rather lengthy treatise, there was a paragraph that I would like to read to you.

    Osteopathic physicians and surgeons have accomplished an enormous expansion of the provision of healthcare in the past years. Likewise podiatrists who for generations have limited their work to minor surgeries of the toes, managed over a very short period of time to become doctors/surgeons who currently care for patients with all types of musculoskeletal conditions below the knee. They treat traumatic injuries as well as degenerative infections and congenital diseases with clinical and surgical means. They perform internal fixation of fractures of the tibia, ankle, os calcis, hindfoot, and forefoot. In addition, they perform total ankle arthroplasties and tendon transfers. In the process, they have become experts in the field to the point that it is ludicrous to argue that their qualifications do not allow them to cover such a wide territory.

    One can safely predict that, in the not too distant future, they will request official authorization to perform total knee replacements as well as other complicated procedures. Likewise, it is quite possible that others, including chiropractors, nurse practitioners, physical and occupational therapists, and orthopedic technicians, will attempt to expand their practices in the same manner as the podiatrists.

    I thought that was information that you should know and I thought that was wonderful news. Now there are some people back there who are making the statement right now, I have lived long enough. That was written by, his name is Augusto Sarmiento, MD, he is an orthopedic surgeon, I am not sure where he practices, I just got a copy of the note. So if you want me to, forward you a copy that just let – the people who are present now and I will be happy do that. So I have been asked to talk about why and when to decide where to practice. And it is an interesting question and of course I am going to use my past experiences personally as well as the experiences I have had as a residency director, chief of podiatry and then of course the National Program Director for the VA.

    But before you answer the question, you need to and before you look for a place, you need to answer some questions. The first and the most important question is you need to ask your spouse or significant other, where they want to live. And if you think I am joking, try to do without them. It is so important that you are on the same page about where you're going to spend the rest of your lives, decide what kind of life he wants, not just about what you do for a living. When I gave a graduation speech, when my daughter graduated from podiatry school and I did the commencement address and one of the things I talked about is that I have 8 favorite jobs. My favorite job is parent, my second favorite job is husband, but please don’t tell my wife.

    My third is son and I am still fortunate to have a mother, my fourth is friend, my fifth is musician, my sixth is teacher, my seventh is musician and my eight is podiatrist. So you are more than what you do for a living and if you are only what you do for a living, you are not living a complete life. So it is vitally important that you define yourself in those terms. And so when you're making this decision, you need to remember how you define yourself in that entire complexity. Decide whether you want a rural or suburban or an urban practice, whether you want cultural diversity or a homogenous culture. I am not saying you are xenophobes, but homogenous culture for some people is much more comfortable than a cultural diverse neighborhood for some folks and that’s perfect fine.

    A fast-paced lifestyle versus Mayberry, a place to raise children or a place that’s close or close enough to family, now I see some of you snickering about close enough to family and that’s, that some of that is true. Weather, sports entertainment, green space, climate, whether those things are important to you, these are really, really important before you make the commitment about going to some place to practice. So what kind of practice do you want, that’s another important decision. Solo practice, a solo practice is going to give you by and large the most autonomy, you are the boss. You decide what's done, when it’s done, how it's done and by whom, you are the boss. You're also the business person, you're also responsible for paying for the lights, the carpet, the equipment, the supplies, the office staff, the government, the accountant, the lawyer and so on.

    So you have to be both the doctor and the businessman, but it does give you also the most potential income. Do you want to work in a group practice, there is less autonomy, less income potential and usually you are contracted and that contract may be tied to productivity. So i.e., if you produce this much, you get that much upto a certain level. You also get however a regular paycheck and that certainly has its benefits and you may also get benefits in a private institution or private practice, a solo practice, you are responsible for the benefits, for you and all your employees, in a group practice, less so. Institutional practice, whether it’s a VA, DOD, a University, an HMO you have even less autonomy and less potential income.

    And again a contract that may or may not be tied to productivity, but again you get a regular paycheck with benefits and some of those benefits are travel to meetings, you get an allowance for books in some cases, CME, those kinds of things. But again, in that type of practice, you are – you have less autonomy and you're responsible for, to a boss and sometimes your boss doesn't have the vision that you have and sometimes it's hard to get that boss to see your vision, especially when you think it's a really good idea.

    So you really need to think about that. So when should you look for a practice or a place to practice and for a type of practice and so on. And once you have made all those decisions and you come to at least a general conclusion about where you want to practice, how you want to practice and those kinds of things, then you to decide when you should look and it’s a little less obvious. Now if you know that you want to go back to your hometown, you know you want to go back and that’s the place you came from, that’s the place you want to go back to, your family is there, your friends are there, some thing is therefore, you want to go back there.

    Then you can start when you are still in school, every time you come home, visit a podiatrist who are, you know obviously too late for you guys, because you guys are already residents. But some of you may have already done this, go back to the place that you come from, visit the local podiatrist, see what's going on, get your pulse on the community, find out if there are opportunities, either in private practice as an associate or opening up a solo practice and sometimes in some rural areas, there is actually support dollars for opening up a private practice. They are not as often as, not as generous as they used to be, but that still exists in some very rural areas.

    I usually recommend however that if short of that, if you don't have a place to go back to, I usually recommend that in the fall of your third year, you begin the formal search. So once you determine again, where you want to go, go there and familiarize yourself with the community, especially if it’s a place that you've never lived before or you are only superficially familiar with. Go there and spend a few days there if you can, see what's going on, try to get invited to someone's home for a dinner, so you can get sort of a pulse on what's going on in the community. Meet some podiatrists if you can arrange that as well, not all podiatrists, see if they are young, many and most are very, very happy to have you come into their office except for Harold who doesn’t want you to be in Philadelphia.

    But the rest of us are kind of cool, no and he is just joking, because the more people that are in a community, the more they get the reputation of being the center for podiatry and so more patients will be coming there because it’s a center of excellence. I've never been afraid of that and I was always that, that didn’t make sense to me and that the more outstanding people that you had in an area, the more patients that will come to them. Send letters out indicating your desire to locate in that community and request any information and opportunities to practice, you can do that to individual podiatrists, you can do that to state associations, the local associations. Don't be afraid to do that, I just got through talking about the CVs, don’t lie in your CVs and don’t embellish them, because they can just, they just come back and bite you.

    Be honest with your CVs, if you did work with research, identify that research and if it results in a publication, that's great, if it didn't, identify why it didn’t. If you truly do not know where you want to go, watch the practices available, the associate wanted ads in the various podiatry websites and blogs. That’s a terrific place to you know to do that. I generally don't recommend that process, I think that it’s much more important for your long-term success and your overall happiness, that you're comfortable with the place you are going to go, and then you are not just going someplace for a job, but that you have people there or you have a connection there or you have a sport or a passion or something else that’s there that makes for that complete life.

    Podiatry is a phenomenal profession, I love it, but it's not what defines me. All those things define me and they should define you as well and most importantly, don't be afraid to network with people you meet. Some of you have residency directors that are nationally renowned and don't be afraid to ask them, do you have any connections in Rhode Island, in Wisconsin, in Washington state. Don't be afraid to utilize the resources that you have, recognize the networking opportunities you have and take advantage of them. And it says zero here, so I guess I am done. Anyone have any questions? If not, I'll be here this afternoon and I thank you for your attention.