Guido LaPorta, DPM, MS
Director Podiatric Medical Education
Community Medical Center
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Okay, let�s start the remainder of the afternoon, and I�m going to give a life skill talk on fellowships. And the question is, do I need a fellowship? And the residents here, how many of you are considering a fellowship? Okay. A few hands go up. And you know, based on that, I think we need to ask a few questions, and the reason is that a fellowship in podiatry � podiatric surgery � or one of its sub-specialties � is a little different than an orthopedic foot and ankle fellowship. And I think you�ll appreciate the fact that an orthopedic foot and ankle fellow has developed an interest in foot and ankle surgery having seen some of it in his or her residency, and now wishes to train in that particular sub-specialty. And quite frankly, and orthopedist will not be hired as a foot and ankle surgeon without a fellowship in that particular area. So the stakes are a little bit different.
So what does it mean to us? Well, basically, you finish your podiatric medical school, you finish your residency, and then you decide, well, I want to spend an additional year or two in sub-specialty training. And I think that�s what it should be. The sub-specialty may be either medical or surgical. And it can be made necessary by a number of reasons: the increasing body of knowledge, or you want to use new and innovative methods. You may have had areas where you just didn�t have exposure in your residency and you really wish to learn those particular techniques and/or approaches. Fellowships in podiatry are still somewhat controversial. There are those who feel that they�re unnecessary; there are those who feel that they�re redundant, and I would be honest with you and tell you that when fellowships first started, many of them were redundant. They turned out to be a fourth year of residency. That�s no longer the case. And consequently I think fellowships that are available now are in fact true definitional fellowships as medicine defines it.
Many thought it marginalized the residency program, and in fact, you know, nothing could be further from the truth. No profession ever prospered by lessening its educational requirements, and consequently the more that can be gotten the better. The biggest problem is that there�s a limited number, and consequently you�ll be vying with a host of people for the few positions that exist. So you have to look at fellowships as a continuation or a continuum of the educational process providing you with advanced knowledge, ability to do research, and collaborative scholarly activities � unlike and at a different level than the residency experience. So the continuum is podiatric medical school, residency, fellowship, and then continuing medical education which basically never ends.
Podiatry fellowships � the APMA authorize the council to approve fellowships, and if you want to read more about approved fellowships, get the council document 820 which lists the requirements for a fellowship, so you can gauge, you can protect yourself. You can gauge and see whether or not the fellowship that you might be interested in actually meets those requirements. Just as if not more important than in my mind are the ACFAS approved fellowships, which don�t necessarily have council approval, but at this particular point in time, that really is a moot point � it really doesn�t matter.
So what are the pros and cons of doing a fellowship? Well, there are many pros. Extra training in a specialized field, you may have better research opportunities than you had as a resident, possible higher income (underline �possible�) � if you go and work for a healthcare system and/or a hospital, you may in fact demand a higher salary; if you go and work for a multi-podiatry group, don�t count on it. But the possibility always exists. Connections, professional advancement, recognition � you may get a competitive advantage. Certainly you will get increased skills and exposure to other medical fields � again, on a level different than as a resident. And hopefully you would have a wider scope.
What are the cons? Well, the cons are the time investment. You know, most fellowships are one or two years. You�re going to lose a little income, or your ability to start earning an income. And as I mentioned before, it doesn�t necessarily guarantee increased income if you do a fellowship.
There are many fellowships that are available. Scanning the list just this past week under surgical, there�s arthroscopy, reconstructive surgery, trauma, total ankle replacement, plastic surgery, minimally invasive surgery. And there are a number of non-surgical fellowships available � dermatology, biomechanics, sports medicine, wound healing, arthritis and infectious disease. You may very well do, and I�ve had a number of residents complete our surgical fellowship, our surgical residency and do a non-surgical fellowship, because they had an interest in dermatology, they had an interest in sports medicine which we don�t do a lot of, or infectious disease. So it really depends. So you need to ask yourself a few questions I think. Do you need additional training? Where do you want to practice? Who�s going to be your competition? Can you command a higher salary? Should you do the fellowship now or later? But most importantly, what�s your passion? I�ll tell you that 15 years ago I got very interested in � actually longer, 20 years ago � I got very interested in external fixation. I did not attend a podiatry seminar for seven years! I spent all my time going to five or six Ilizarov seminars, visiting people, spending time with them in their operating rooms to learn how to do external fixation. Now, if that�s your interest, you can accomplish that in one year; and although not get paid well, get paid for doing it. So follow your passion � whatever it is you want to do, whatever it is you want to learn, now may be the time to do that.
Additional training � why might you need it? Well, unfortunately, you may have been or might be in an assist-me residency. Very little hands on. Lot of work, but very little hands-on. That may be a reason for additional training. You may have had a residency that�s operating room only � no pre or post-operative exposure. And that�s great while you're a resident, �cause you�re getting all those numbers, but it�s not great when you open up practice, because you don�t necessarily know how to follow these patients or what to expect. You may be in a one-track residency � what do I mean by that? I mean that there�s a ton of work but it�s all the same thing. You know, how many of you are in residencies where you basically see only one or two bunion procedures or one or two flatfoot approaches, all three years you�re there? You know, that, that may strike you as not being the best way to attack these particular problems. You may have a self-confidence issue. There�s nothing wrong with that � a lot of people do. And if you do, and have the ability to get a fellowship, there�s one way to build your self-confidence, because you�re seeing the full spectrum of patient � pre, operating room, post. And consequently, it helps round out not only your confidence and your skills but also your decision-making process, which many of you may not have during the residency, �cause everything you do has already been decided. All right? So that�s another way of looking at it.
What�s your passion? Do you want to go into academics or teaching? Do you want to start a residency or be a fellowship director yourself? You want to do research? Do you want to go into a surgical sub-specialty? Is there someone you wish to work with? I know if I were graduating right now and Ted Hanson weren�t retired, that I�d want to work under him regardless of what he was doing. I could care less. But I have so much respect for that man that I would do a fellowship with him for a year just because he�s Ten Hanson. So you know, that person may exist for you, and that�s a very good way of deciding whether or not you want to do a fellowship.
You also have to assess the need. Is there a demand for what you want to do? Are you going to practice in a rural or in a densely populated area? What about hospital credentialing? Do you want to merely compete with podiatrists in your community, or do you want to try in some way to stand out? Depends on where you�re going to practice. And it may actually get you a better job. You know, you could probably practice where I do in Pennsylvania and get your degree from Sears and it wouldn�t matter, right? You�re not going to be up against high-powered podiatric practices. But if you go to an urban area, if you decide you want to practice in San Francisco, you want to practice in Washington DC, Baltimore, Chicago, where a high percentage of practitioners are fellowship trained, then it may be necessary to be fellowship trained. I know when I returned home to Scranton, Pennsylvania, what I did at that time was, I wouldn�t return home until I was board certified. That was the fellowship of the day. And the reason I made that decision was, that there were no surgical privileges for podiatrists in my area. I had to be the one to do that and to do that I had to be board certified. I was told that by the hospitals, so that was my decision at that time. It delayed my opening practice three or four years, but it was the best move that I made.
How about hospital credentialing? You know, depending on the facility you want to work at, depending on what you want to do, you may have to be fellowship trained to do total ankle replacements, to do external fixation. If that�s what you wish to do. But you need to find that out. So I guess the first thing you have to decide is where you want to practice, okay? Because the demands made of practitioners may be different in different areas of the country. Should you do it now or wait? And if you wait, what might be some reasons that you might want to do it later? It�s not unheard-of to practice for a few years and then go into residency. I have three fellowship trained spine surgeons in my area. All three of them practiced general orthopedics for a good amount of time before they decided they wanted to go back and do spine surgery. So they left their practice for a year and went and did a fellowship. There�s nothing wrong with that. In fact there may be some advantages. Whatever weaknesses you have as a practitioner may become very apparent after a few years in practice.
Science changes. You�ll go into a fellowship with a stronger skill set, more experience. The fellowship may actually mean more to you at that time. And there are other reasons why you may want to wait. You may not want to pass up a great job opportunity, and it�s opportunity where you want to live, it�s a great opportunity, you might want to take it. You may even be able to negotiate the fact that you want to go back for a fellowship at a later date. You may want to start a family, start a home. You may want to pay off student loans. You know that BMW you leased, you know, it�s coming back to roost now, you know? You gotta start paying that back, sooner or later. And quite frankly, what�s going to happen? Hopefully this happens during your residency, but it may not, but some event or circumstance may occur that�s going to change your focus. You may start out doing a certain type of practice and something happens that�s going to change your opinion of what you want to do. And that may get you to go back for a residency and get additional training.
So I�m not saying you should all run in and do a fellowship. It may be beneficial to wait just because five years from now there are going to be far more fellowships available, and I�m sure the quality of them is going to be that much more improved. It may be to your advantage to actually wait. So take all those things into consideration. It�s a very important decision; you should make it wisely; and the two biggest hints that I have for you is, what�s
your passion, and where do you want to practice. Because that�s going to determine, for the most part, whether or not you should do a fellowship.