Throughout the program you may notice there are a number of designated topics which we refer to as life skill talks, and it's kind of a brainchild of Alan Sherman, who thought that not only should we be providing academic information to residents, but maybe some insight as to where you want to go in life ' what opportunities exist for you, in practice, in academia, etc. So there are a number of talks ' I think it's about six ' that will be given by experienced foot and ankle surgeons who just want to share with you what their life has been about and what you can consider for your future.

Certainly you're going to be well-trained foot and ankle surgeons, but you still have a personal life, a wife, children, a place to live, and opportunities that you have to consider. And before you know it, the three-year programs come and go, and you're in your last year and you go, 'I don't really know what I want to do.' So we're going to have a number of talks given by a number of different people, and I'm going to kick it off by talking about options of practice post-residency. And I sat down and I started thinking about this and I said, Wow! There's been so many questions asked of me by my residents ' and I'm involved at the Penn Presbyterian Medical Center program in Philadelphia ' and have been in resident education for well over 40 years. So I think I've heard just about every question that can be asked as to what opportunities exist, etc. So I put a few things down to share with you. So I hope I don't bore you too much with this kind of talk.

So types of practice that one can look at. Certainly private, which solo practice is an option. I think a lot of people question, is that going to be viable in the future? Certainly with healthcare reform and what's going on in this government. Private, meaning a group type of practice where you're going to be with a number of podiatric physicians and surgeons, which I think is an advantage. Joint multidisciplinary group ' a joint multidisciplinary group. So we have multiple types of physicians in different specialties, and you are going to provide foot and ankle care. You could joint an orthopedic group. There have been a good number of our residents who have become the foot and ankle specialist, if you will, orthopod, in the orthopedic group. Even if they have other foot and ankle trained orthopedic surgeons working there, because quite frankly, the numbers of board certified foot and ankle surgeons that we provide from podiatric medicine and surgery far exceeds what's available for them in the orthopedic world. So that's an excellent option.

You could go into the colleges with a clinical practice plan, so you become part of a faculty and start either a private practice or a clinical plan that you're going to be seeing private patients. Hospital base practice. There are hospitals that are interested in having you as part of their faculty at their facility, or just opening solo but being in a medical arch building associated with a hospital. VA hospital ' there's certainly an opportunity for many people, and you can see the amount of people that are actually practicing in the VA. Indian reservation. Any combination of these things can be done ' nothing has to be exclusive. I think the more diversified you can be, may be an advantage, and then isolate or identify where you ultimately want to go.

And certainly you can purchase an existing practice ' certainly takes a little financial


capability to do it, whether you're going to borrow money or whether you're going to pay out a doctor who's there, but an existing practice in a good location is something to be considered. Let's take a look at some of these. Private, solo ' you go out on your own. What are the risks? Financial. You're going to make a big commitment and hope you're a success. You have responsibility to running an office. You have marketing considerations. You need a business sense to do this. Management skills. Layout an office. Hiring, billing, hospital insurance panels that you're going to need to get onto, and limited time off because of the need for coverage. So solo sounds good ' you're your own boss ' but these are some of the things that you'd better consider before you do it. So let's look at private group practice. You join a podiatric group. It's an established practice. Guaranteed income. They're going to provide you with a certain amount of dollars. That's nice. Management is controlled ' you don't have to even worry about it. It's time tested ' it's been around for a long time. The referral sources have been established. Affiliations are established with hospitals' insurance plans. Recognized reputation ' you're not just coming out of cold, you're in a group that people are being referred to. You have vacation weekend coverage. Residency participation we hope, so you're part of that component. Equipment is established. Everything is there waiting for you. It's a turnkey operation that you walk into. You have a system of EMR if they've had that added to their practice, and a professional camaraderie. So there's a lot of advantages in private group.

Let's look at the multidisciplinary group. You have a source of referrals. Insurance panels. No overhead concerns. Salary is relatively stable. Again, reputation established. Hospital affiliations. Insurance coverage. Health insurance coverage for yourself. And sharing other sources of income. Of course these multidisciplinary groups will often have MRI, physical therapy, DME providers, surgicenters. So each one of these overlaps somewhat. There are advantages that are consistent, but then there are certain things that are additive to it.

Let's look at the orthopedic group, with or without a foot or ankle surgeon there. You may be the only one. One of the disadvantages is they're always telling you that you can't take call for the general body in orthopedics, so you're somewhat limited in a sense to them, which could interfere with your ability to be a partner or buy into a group like that. You certainly have instant referrals, and these are good referrals. You're in an orthopedic group. You bet they're sending you patients for reconstructive foot and ankle surgery ' unless you're just going to be a generalist type of podiatrist, which is fine, in an orthopedic group. ER call, trauma, certainly if that's an interest, they will be able to open that door for you. Hospital affiliations, scope of practice, salary and benefits, coverage, share in the surgicenter, MRI, DMEs. These type of groups are entrepreneurial in nature. They have an established reputation. You have less autonomy, recognizing you're the foot and ankle guy in the group, not being able to provide all of the coverage that everybody else does, so sometimes you may be looked upon a little differently.

You can do tag team surgery. I talked about it this morning ' I'm doing an implant, getting my friendly orthopod to harvest bone. Fabulous. OATS procedure ' I used to


get the guy, used to harvest bone cartilage from the knee for me to do procedure. So scope of practice may be influenced by the state you select. If you're going to put a frame on somebody and your scope doesn't allow going into the leg, one of the orthopedic guys comes in and helps you do that.

Overhead is established, billing, personnel, ancillary personnel. These groups often have PAs and fellows. Make your life easier. I don't want to take a cast off; I don't want to put a cast on. The PAs are there to assist, evaluate, and make your life easy. You're there to diagnose and treat. And then certainly a percentage of the profits.

Let's look at a college practice plan. I used to participate in that at one point. You have an appointment at the college. That's nice. Faculty appointments are credentials that you will live with and have for the rest of your life. You have no overhead concerns. Billing is provided. College is doing all of it for you. Instant referrals again. Insurance panels. You're on immediately. Established podiatric reputation, nationally. Here's an opportunity that you're going to go above and beyond just being a standard practitioner in a solo practice. Speaking opportunities, research opportunities. You will have coverage in certainly the are of wound care. So once again there are some additional things that you could have if you belonged to the college environment.

Go into a hospital, open a practice right there - whether you're going to be hired by the hospital or whether you're on the campus, so to speak, so you have referral source is right there. Overhead is assisted by the hospital. Hospitals often encourage you to be there. Now, there are some questions about some of these Stark laws and what they can do in the way of kickbacks, but there is ways that they can help you in your overhead.

Privileges - scope of practice. They're going to do everything to help you get what you need to be able to provide the services that you wish to in an operating environment. Immediate status and recognition - it's nice to walk around a hospital with your name on the coat and the hospital's logo, and people recognize, "Oh, you're on that hospital." With a good reputation that helps who you are.

Residency potential. If they don't have residents there, that's the place that you want to start a residency, and they will be able to assist you in that capacity.

Salary - some hospitals pay you direct. You're an employee of the hospital. Or you could maintain a private practice.

Space available with build-outs by the hospital. They'll provide a space, they'll get it all ready for you. They want you to be in their environment.

Block time ' we take for granted, I'm here! I just finished a three-year program, I can do all of these surgical cases, but I need to get on an OR schedule, and I want it every week at a certain time. Being with that hospital, that's something that you need to deal with and negotiate right from the beginning.


Exposure to patients ' consultations in-house. You're the man or the woman, the foot and ankle designated surgeon for that environment.

ER call ' autonomy if desired, and certain you could sublease space.

When you go to the VA in Indian reservation, this is a different approach. Now you're looking at no overhead. You do have immediate status. The benefits are provided. You have diversity of exposure to pathology ' certainly the VA has got a ton of pathology. Possible residents' assistance. Interdisciplinary participation. You will have a nice salary that's provided. Location is variable ' VAs are all over the place. Indian reservations are pretty pervasive as well. Recognize, however, your scope of practice may be variable depending upon which facility you go to.

Let's look at the last guy. Let's say purchasing an existing practice. Well, you have an instant patient base. Certainly you're going to think there's a certain amount of attrition that will take place along with that base, because patients loved the doctor that was there, so when you purchase a practice, be sure that the doctor's going to stay there for at least three months, maybe six, to introduce you to the patients. And be sure the patients are aware that he is comfortable with you as the new doctor in the office. And it may not be bad to keep that doctor on for a while.

Support personnel in place. This office has been established. You have your office manager. The people know what to do with the patients. The patients are often comfortable with your personnel, let alone comfortable with the doctor.

All your equipment is included ' it's there. Usually your hospital affiliations are. You have a predictable overhead. You know pretty much what this practice is generating, what it's costing you and what you can net from a practice like this.

You have the insurance panels that you usually can get on pretty quickly. You have a referral source. Predetermined turnover. You know how much, how many patients you're going to lose, how many patients you're going to get, and how many new patients are coming into this practice. You have a history of accounts receivable, and certainly you have the option of lease-rent purchase in associated with the building.

So the purchase component, and the one thing I left out is dollars. You go to a bank to borrow money ' are you independently wealthy to buy it, or do you have a plan that you will establish with the doctor who's leaving that you will buy out the entire practice over a period of time? Which is always nice because you're doing it with accounts receivable and money that has been coming in.

Combination ' as I mentioned, all the above or any of the above. Autonomy along with income, security along with potential of conversion to sale of practice. You build equity, you develop own direction of practice, and if solo, along with other options, have the caution of overhead.



So what I try to do is break down and just share with you some thoughts, that each of these opportunities provides.

I thank you for the time.