Physician burnout appears to be extremely pervasive in podiatric medicine.
In a recent Podiatry Today online poll, which asked the question “How has physician burnout affected you?,” 35 percent related suffering significant mental health issues due to burnout. An additional 28 percent have either changed jobs, left practice or plan to do so, and 17 percent of those polled have witnessed a colleague struggle significantly with burnout. According to the poll, which had 280 respondents, 21 percent say they have not been affected by burnout-related issues.
In regard to nearly 80 percent of podiatrists reporting some type of impact from physician burnout, Desmond Bell, DPM, CWS believes these results are accurate. Dyane Tower, DPM, MPH, MS, FACFAS agrees. While this sounds like a large percentage, Dr. Tower feels it makes sense in the context of the current health care climate.
Dr. Bell relates a moment when he realized how demoralized physicians have become.
“(At a) general meeting for staff physicians … the administrator focused on finances and productivity without one mention regarding patient care,” says Dr. Bell, the founder of the Save A Leg, Save A Life Foundation. “I looked around the room to see the reactions of my colleagues. Not one person was looking at the speaker. Every single physician had his or her head down. At that moment, I realized the extent to which medical professionals have become commodities.”
Pressure to advance in the field, patient expectations, reimbursement changes, never-ending paperwork and lack of administrative support are among the factors that may contribute to burnout in our field, shares Dr. Tower, the Director of Clinical Affairs for the American Podiatric Medical Association (APMA). Dr. Bell also feels multiple sources contribute to this phenomenon and adds that lack of training in social skills and interpersonal relationships, the demand to be more productive with fewer resources, and constantly being in “fight or flight” mode can also be contributing factors in the physician experience.
Both physicians agree that the podiatric profession must recognize that burnout or moral injury exists, and address it accordingly. Dr. Tower cites resources offered by the APMA (www.apma.org/wellbeing) and recognizes the APMA’s involvement in commenting on regulations and legislation that impact the way podiatrists practice. Peer-to-peer mentoring and coaching can provide short-term solutions as well, according to Dr. Bell, who is an Executive Physician Coach with MD Coaches, LLC.
Looking toward the future, Dr. Tower encourages podiatrists to be true to themselves and not hesitate to talk to someone when experiencing feelings of burnout or moral injury. She directs DPMs to www.fixmoralinjury.org for more information and emphasizing the importance of taking the blame off of physicians.
“Burnout, by definition, may suggest the physician is at fault and failed at resiliency and recovery from the circumstances. Moral injury, however, suggests that larger factors exist,” explains Dr. Tower.
Dr. Bell suggests physicians try to stay in the moment and remain positive when possible. However, he agrees that external circumstances need to change for the current trends with physician burnout to reverse.
“Learned helplessness refers to behavior after one endures repeated aversive stimuli beyond his or her control and can lead to clinical depression,” states Dr. Bell. “Having one’s medical judgement and decision making repeatedly (compromised) marginalizes the role of physicians.”
Do Diabetic Foot Ulcers Metastasize?
By Jennifer Spector, DPM, FACFAS, Associate Editor
Employing a “cancer analogy” in reference to diabetic foot ulcer (DFU) recurrence, authors of a recent study found that nearly half of patients “in remission” from previous DFUs had a DFU recurrence to the contralateral foot regardless of the location of the original ulcer.
The study, which was published in the Journal of Foot and Ankle Research, involved 129 patients. While 48 percent of the study participants experienced DFU recurrence to the contralateral foot, only 17 percent had a recurrence to the same anatomic location. Additionally, more than 60 percent of participants had multiple plantar wounds by the end of the study. Researchers reportedly followed patients for 34 weeks or until the withdrawal of consent. On average, patients had wounds in 2.2 distinct anatomical locations, according to the study.
Study authors relate the use of the cancer analogy is a powerful tool in expressing risk levels to patients and in organizing patient care. David G. Armstrong, DPM, MD, PhD, one of the authors of this research, acknowledges the provocative nature of the specific terminology.
“These terms intend to compare, with humility, the idea of diabetic foot complications to cancer,” explains Dr. Armstrong. “The idea is that a DFU recurrence more frequently occurs in another anatomic location, ‘metastasizing’ if you will.”
A study like this one makes an impact by encouraging providers to remember to check the rest of the affected foot or even the other foot, says Dr. Armstrong, a Professor of Surgery with the Keck School of Medicine at the University of Southern California. He relates that close attention to biomechanics, gait, shoe gear and disease management could benefit these patients with respect to minimizing DFU risk in any area of the lower extremity.
Additionally, Dr. Armstrong points out that more studies are necessary to expand on the current evidence. Prior to this research, he says most of the literature only addressed first wound recurrence and did not evaluate the location of that recurrence. Ulcer recidivism, as stated in the study, can carry a significant burden when it comes to cost of care, morbidity, mortality and resource use. Dr. Armstrong agrees and emphasizes that high-quality, comprehensive preventive care is vital to decreasing this burden.
Could An Additional Fixation Construct Prevent Recurrence With Lapidus Bunionectomies?
By Jennifer Spector, DPM, FACFAS, Associate Editor
How can surgeons address the risk of deformity recurrence after a Lapidus bunionectomy? A recent study in Foot and Ankle International evaluates a procedure modification that may help remedy this concern.
Surgeons treated a total of 62 hallux valgus patients with a Lapidus bunionectomy and added further fixation from the plantar medial first metatarsal to the intermediate cuneiform via a cross-screw technique. The researchers evaluated patients via multiple pre- and post-operative X-rays for the intermetatarsal angle, hallux valgus angle and tibial sesamoid position along with evidence of healed arthrodesis.
The study authors observed bony union in all but two cases, as those two patients required revision surgery for recurrence of deformity. In the study, the researchers noted angular and positional improvement over an average of 9.3 months for all angles measured, and these findings significantly outweighed the mean loss of correction across all parameters. The authors concluded that this modification showed good union rates, low complications and maintenance of correction.
Roberto Brandão, DPM, a co-author on this study, relates that this modified construct is meant to reproducibly increase stability and maintain long-term correction through increased surface area contact. This additional cross-screw fixation is in lieu of a traditional “home run” screw from the first metatarsal base to the medial cuneiform. The thought is that this construct could decrease sagittal plane motion with the additional point of fixation as researchers have shown in cadaver studies.
“This study sought to expand upon the cadaveric model, noting that with this increased stability, the construct could ideally lead to improved union rates and maintained correction,” notes Dr. Brandão, a fellowship-trained foot and ankle surgeon practicing in central Maryland.
There are some important pearls to keep in mind regarding this technique, according to Dr. Brandão.
“The guidewire for the screw must have a slight dorsal trajectory as the intermediate cuneiform has a unique triangular shape with more surface area dorsally,” points out Dr. Brandão. “(Be sure to also) avoid neurovascular injury and take care to avoid the second tarsometatarsal joint. Intraoperative fluoroscopy is very useful in successful placement of this screw.”
He also explains that a large reduction clamp around the first and second metatarsal necks can allow the surgeon to maintain reduction with minimal assistance. Soft tissue balancing and additional rotational correction are also possible with this technique, according to Dr. Brandão.
Overall, Dr. Brandão stresses that surgeons may choose to incorporate this construct for almost any bunion deformity they are treating with a first tarsometatarsal joint arthrodesis, and that one can address adjunctive procedures as necessary.
“We found that addition of this screw allows for greater intermetatarsal angle correction as well as maintained correction in short to mid-term follow up,” says Dr. Brandão.