Do We Shortchange Simple Clinical Solutions In Residency Programs?

A topic that has been recurring in residency program circles and in practice rears its head even now. That topic revolves around our advancing techniques and technologies, and how we approach podiatric surgery.

During residency, doctors approached many of the patients I saw in clinics and in private practices from an academic standpoint. Physicians analyzed their foot types based on their chief complaint. Then we, as residents, would discuss the possible treatments with our attendings. Treatments ranged from the most conservative treatment to the simplest surgical intervention through to the most complex foot and ankle reconstructions to relieve these issues.

If a patient came in for basic, run of the mill heel pain, we treated the heel pain but then also looked at their radiographs (if we took them). We once again reviewed their foot types and how we could potentially prevent their feet from experiencing similar symptoms with a foot reconstruction. This academic exercise certainly was very important in our growth as podiatric physicians and surgeons, but seemed a little extreme in certain situations. This was especially the case when some of us came to realize that for some of our attendings, this was not an exercise at all but a way to prepare their “talk” with their patients.

What I mean is that some of my attendings would take a simple situation, which seemed to warrant a simple solution, and use it to hone their most complex of surgical skills. Who was I to say whether this was warranted or not at the time, but in my mind, I function at the “keep it simple” mindset. I find that this has kept me out of trouble more times than not.

In my mind, sure, you have to have these complex procedures in your arsenal. However, the true measure of a great physician/surgeon is really the thought process behind the treatment protocol and being able to differentiate between the need for the complex and the need for the simple.

This comes up in my travels as a lecturer and as an educator within the residency program. If you can treat heel pain with strapping, an injection and subsequent custom orthotics down the road to control the foot type, should you really be investigating a complex rearfoot procedure and midfoot realignment to correct a seemingly simple problem? That being said, certainly if the patient presents with painful issues in these foot structures, that is one thing, but the example of simple heel pain is the one that seems to crop up the most.

Shouldn’t we be approaching these issues with a diagnostician’s mentality? Diagnose the presenting complaint first, address it and see if any further steps are needed. Why devise the complex approach first before attempting the most simple and even possibly the most effective solution?

I find that there is a gap between residency and private practice in this regard. Residents love to do those big, complex procedures. Those are the “flex my muscles, hear my roar” surgeries everyone loves as a resident. I know I did. However, this does not transfer to private practice very well.

We all hear the stories of the young associates who somehow only want to do the complex rearfoot stuff without realizing the impact this can have in general. The patient will be yours forever and the time involved both in the office postoperatively and in the OR is something that is not very well compensated. (Got to pay back those loans.) We also need to consider the long-term effect on this patient’s foot and the outcome of the surgery.

This makes it really hard for me to justify not giving this patient the option of a low Dye foot strapping and long term control with custom orthotics versus a tendo-Achilles lengthening, Maxwell-Brancheau arthroereisis (MBA) implant, Kouts procedure, midfoot fusion and the various other “fixes” I hear so much about.

Keep it simple, folks.



DC STRANsays: August 16, 2011 at 12:35 am

Well Ron, you never mentioned this to me or any of your attendings during your time in Houston.

I was Ron's residency director and to my knowledge, he obtained an excellent education. He was exposed to every aspect of podiatry including heavy pediatrics, which he lectures about now.

I find it insulting to read about those surgeons who would hone their surgical skills. I would ask everyone to request Dr. Raducanu's surgical log and see all of these crazy procedures he is speaking of.

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Dr. Ron Raducanusays: August 16, 2011 at 2:12 pm

I received excellent training. No doubt about that. I also spent a year somewhere else before coming to your program.

I meant no insult to you personally Dr. Stran nor was this a criticism of the excellence you instilled in me as a resident. There were SOME attendings (of the forty or so I worked with over the course of my three years of residency) that I found a little overzealous. Residency is just as much about learning what NOT to do as it is learning what do. I think you were the one that may have pointed that out to me.

If you want specific examples of these, I can provide them but that wasn't the point of the article. Also, as you know, I've continued in the academic world and have encountered many, both in residency and in private practice, who felt the same way about SOME of their attendings. This doesn't discount the training they received but is simply a matter of fact.

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Allen Mark Jacobssays: August 17, 2011 at 6:12 pm

Well Ron, you've just learned that the truth does hurt. Your comments regarding academic medicine vs. reality are absolutely correct. Everyone knows that to be true. The current epidemic of arthroereisis procedures for everything from hammertoes to back pain to diabetes is proof enough. TALs for heel pain and so on all have "theoretical academic justification". I call it surgeons' logic, which can justify surgery for anything.

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