Clinical Presentation Skills: How to be a Stand Out Applicant for Employment

PGY-3 Year…Freedom at Last! Right? 

How to be a stand out applicant for employment

By: Jonathan D. Rouse, DPM, DABPM

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Your phone goes off in the middle of the night. You pop up immediately because you are a PGY-3 and you’re used to this lifestyle now. You’re just happy it’s not a pager going off…until you see it’s your junior PGY-1 calling. You pick up and they ask you how to order a medication in the EMR. Of course you’re happy to help because you are nice and empathetic. You get it; you were once a PGY-1 trying to figure out how the heck to input orders in the system.

We’ve all been in the trenches. The first day of residency, wide-eyed, scared and asking ourselves, “What did I get myself into?!” Then second year comes and you’re so used to the smell of wounds that you can probably eat lunch while treating them, although unsanitary and not recommended. By the end of your PGY-2 year, your confidence level is usually beginning to peak. Your PGY-3 year starts, and the feeling of being near the top of the food chain is ephemeral as you realize that you soon need to find a real job while still completing your training. While nothing can replace great training and confidence, there are some preparations that can aid you in standing out against other applicants.

Curriculum Vitae (CV)

The CV is a living breathing document. I personally view it as a professional diary as it shows everything that you have done in relation to your professional life. It’s hard to fill up during residency because you are so busy training, but it should be updated at least quarterly. Once in your PGY-3 year, it should be updated monthly. I recommend keeping a list on your phone of information to add, then once the time comes, you aren’t struggling to remember information. Also, when saving the file, I recommend putting the date last updated on the file so you are aware of the last time you made updates. Everything you do, whether it be workshops, cadaver labs, research, specialized trainings, published journal articles, pending journal articles, poster presentations, etc., needs to be on your CV. The bullet points should be quick and to the point, however, elaborating on your residency training is a good idea so as to not undersell or oversell yourself when the time comes to apply for employment.

Your CV is also a reflection of your organizational skills. It should have a natural flow and be separated into different headings such as: Education, Professional Training, Work Experience, Research Experience, etc. It should also be chronological within each sub-heading. The job you’re applying for may have 30+ applicants depending on the position; if the reviewer has to jump all over your CV to try to figure it out, it’s going in the trash. Proofread, proofread, and then proofread again. Then have your parents, spouse, best friend, whomever proofread it again.

Your professional references are also very important, so ensure you are selecting people that can speak positively about your professional and clinical skills. The interviewer(s) will more than likely contact your references to learn more about you as they will only get to know a little bit about you in your interview.

Cover Letter / Letter of Intent

A Cover Letter or Letter of Intent should be supplied with every employment opportunity you apply for along with your CV. Before applying, do your research so you can explain why you think you would fit into that particular practice / hospital. Explain how you think you can help the practice / hospital become successful with your skill set. This is a chance for you to sell yourself, so make it count! Again, proofread, proofread, proofread.

One of your best resources is the product reps in the area you are looking to work. They will know about job openings, personalities or different doctors, which surgical centers have the best food in the doctor’s lounge, etc. They are at your disposal and are full of information that can aid you. Nothing will make you look better than going into an interview and knowing nearly everything about someone’s practice or hospital. Just act surprised when they tell you they have Surf and Turf daily in the Doctors’ Lounge! (Do these even exist anymore)?

Logs

Once you meet the minimum required number for surgical procedures, biomechanicals, H&Ps, etc., you should stop logging right? WRONG! I believe you should try to log all encounters in residency. Perform a nail avulsion? Debride and perform cryoablation on verrucae? Put on an Ex-Fix (This is not a stand-alone surgical procedure)? Debride a wound and place a bioalternative? These should all be logged as category 6, (Other Podiatric Procedures).

Put a detailed explanation in the Notes on PRR when logged and you have a diary from residency. Your numbers matter! Imagine the strength of a cover letter with sentences such as: “Extremely comfortable in the clinic setting as well as the Operating Room; 10,000+ patients seen in clinic while performing over 800 surgical cases in Residency.”

Or if you happen to be applying to a Wound Care Center part time: “5,000+ patients seen in residency with greater than 25% of them obtaining bioalternative products to aid in healing. Comfortable managing complicated wounds and extremely knowledgeable about the different treatment modalities.”  Statements such as these will set you apart from other candidates as they may not have the data to support why they should be hired over you.

It’s great to be able to have data when interviewing. What if a practice is looking to expand and needs a Podiatrist with RRA experience? You have all of your rearfoot cases, but if logged correctly, you can pull out how many External Fixators, Delta Frames, etc completed in residency. If you can send prospective employers your logs or be able to pull data from them when they inquire about certain skill sets, you will stand out as the numbers speak for themselves.

Be Realistic

Every Doc thinks they deserve to make $1 million per year out of residency. The dues have been paid and now it’s time to get paid the big bucks! But guess what? You will likely be offered a lower salary than you were hoping for, especially if you are entering a practice system versus a hospital system. The reason for the lower salary is that the owner is taking a chance on you. The practice cannot afford to pay you $175,000 guaranteed salary your first year out of residency because you don’t even have any established patients yet! What you should be hoping for is a decent base salary and a good performance based bonus structure. That means the more money you bring into the practice, the bigger bonus you get, which should make you work harder so you can get paid! Do that for a year or two, and now you have some leverage to renegotiate your contract for a larger base salary.

Another problem I see is that a lot of residents are applying for high-volume trauma positions or Orthopedic group positions when they did not receive this type of training during residency. Yes, it can pay more, but if you aren’t qualified for the job, you’re going to be wasting time and money interviewing once and possibly twice for the job. Instead, you could be interviewing for a perfect job elsewhere before someone else snatches it up. Be realistic and honest about your skill set and personality and you will be able to find the right fit.

“Do I Need a Fellowship?”

I get this question A LOT from both residents and students. My answer is always the same: If you’ve had a well-rounded residency experience, you likely don’t need a fellowship. If you feel like you need more confidence in the operating room, go do a fellowship. If you had a void in your residency training and you are uncomfortable with it, go do a fellowship. If you want to be seen as The Expert in a certain subspecialty, go do a fellowship with a targeted focus. It is all a personal choice that only you can answer as you are going through your training.

Remember the Podiatric Roots

80% – 90% of most Podiatrists’ time is spent in clinic. The best thing you can do in residency starting Day One is to learn how to perform a good clinical exam and treat patients conservatively when possible. If you didn’t and you’re at the beginning of your PGY-3 year, you have time left to polish your skills. Most patients don’t want to have surgery unless they absolutely need it. Yes, you may be able to put in a Total Ankle Replacement in 2 hours with no jig and no fluoro, but can you give a proper Hallux anesthetic injection for a nail avulsion without the patient screaming? Don’t overlook where Podiatry came from by focusing too much on surgery. You should be able to teach the PGY-1s & PGY-2s how to do almost everything in clinic during your PGY-3 year. That’s when you know you’re ready.

Board Certification

Getting board certified as fast as possible is the most important professional accomplishment a recent residency graduate can obtain. It allows you to get on insurance plans quicker, get hospital privileges quicker, you will likely get a bump in your salary for being board certified, and it looks professional. The great thing about the ABPM is that you are able to take the qualification exam during residency and the certification exam the Fall after, thus becoming board certified as soon as 4 months after completion of residency. I like to refer to the ABPM as the “Board of What We Do Everyday.” It truly is the only certifying board that recognizes what we do on a daily basis and is one of two Podiatric board certifications recognized by the JCRSB (the other being ABFAS – which can take 1-7 years to obtain). It is important to get board certification quickly and in my opinion, every graduating resident should be signing up for and taking the exam. Dual board certification is very important and I believe all practicing Podiatrists should obtain both ABPM and ABFAS.

My hope is that each resident gets at least one nugget of information out of this article. My advice, especially for those just starting residency, is to remember that this is your last chance before you enter the real world. Once you get that residency certificate, you are practicing under your own license on your own patients. Soak up everything in residency and it will pay dividends for your future. And never forget, “Treat every patient like they’re your mother.”

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Jonathan D. Rouse, DPM is a Diplomate of the American Board of Podiatric Medicine. He is the Chief of Podiatry at the Captain James A. Lovell Federal Health Care Center in North Chicago, IL where he also serves as the Residency Director. He is active on multiple national committees and is very passionate about the growth of the field while still staying true to its roots.
You can follow Dr. Rouse’s adventures on Instagram by following @docrousedpm

ABPM Exhibits at the American College of Physicians Internal Medicine Conference

Dr. Mitchell Shikoff at the ACP Internal Medicine Meeting

Dr. Mitchell Shikoff at the ACP Internal Medicine Meeting

By: Mitchell Shikoff, DPM

This past April I had the opportunity, along with our assistant Executive Director, Marc Benard, DPM, to exhibit at the American College of Physicians Internal Medicine Conference in Philadelphia, PA. This conference is the largest medical seminar in the country. It is attended by over 11,000 physicians yearly representing countries from around the globe. This was part of our outreach to medical specialties to showcase the ABPM and the benefits of incorporating ABPM diplomates into treatment plans for their patients with lower extremity pathologies. Our attendance was received enthusiastically by the conference organizers and the hundreds of physicians who came to our booth. We were told repeatedly about the value of podiatrists to the individual practitioners and their respective hospitals. Many contacts were made and referrals recommended for ABPM diplomates around the United States.

We also had the opportunity to monitor some of the lectures and clinical skills breakout sessions. I was able to make contacts with the organizers of the conference to investigate the inclusion of speakers from the ABPM in future seminars. Dr. Benard and I submitted a proposal for the ABPM to conduct clinical skills sessions to the conference organizing committee. I am happy to report that our proposal was accepted and, in fact, a request was made by the committee for an even larger role than our proposal.

It is our belief that this is the first time that podiatry has been represented at their conference and will be the first time that podiatry will become part of the faculty.

We are following up on this success with our attendance at the second largest medical seminar in the country at the end of this September. We will be exhibiting at the American College of Family Physicians conference in Philadelphia.

We see these outreach methods as a value added service to our diplomates and a grass roots effort at achieving parity in the medical community.

ABPM Board of Directors 2019-2020

We are pleased to announce the results for the 2019-2020 Election of Officers!
(L-R) Drs. Chagares, Geller, Rogers and DeLauro
(L-R) Drs. Chagares, Geller, Rogers and DeLauro
The following Diplomates make up the current ABPM Board of Directors:

W.E. Chagares, DPM, President
Stephen M. Geller, DPM, Vice President
Lee C. Rogers, DPM, Treasurer
Nicole M. DeLauro, DPM, Secretary
Gina M. Painter, DPM, Immediate Past President

Melissa J. Lockwood, DPM, Director
Coleen Napolitano, DPM, Director
Bryan J. Roth, DPM, Director

Marc A. Benard, DPM, Assistant Director
James W. Stavosky, DPM, Executive Director

We would also like to thank the following Directors who are leaving the Board for all of their dedicated service to the ABPM:

Steven L. Goldman, DPM
Mitchell D. Shikoff, DPM

ABPM Spotlight! Meet New Director, Bryan J. Roth, DPM

Bryan J. Roth, DPM

Bryan J. Roth, DPM

The ABPM welcomes Bryan J. Roth, DPM as the newest addition to the Board of Directors! Dr. Roth has been a Diplomate with the ABPM since 2015 and has since been actively involved in item writing and examination development for both the In-training and Qualification sub-committees. Currently, he is the subsection Chair for the ABPM Examination Committee’s Qualification Examination and serves the ABPM as a residency site evaluator for the Council on Podiatric Medical Education (CPME).

“Since becoming a Diplomate of the ABPM, my involvement on behalf of the organization has been challenging, engaging, and one I look forward to continue as a Director. I welcome the opportunity to serve as a Director of the ABPM to both shape the organization and, through it, to have a direct role in furthering the advancement of our future residents, physicians and profession.”

He received his Doctor of Podiatric Medicine (DPM) from the Ohio College of Podiatric Medicine, and completed a PM&S-36 residency at Maricopa Medical Center (MMC) in Phoenix, AZ. Outside of serving as an ABPM Director, Dr. Roth is active faculty at MMC within the Department of Surgery, where he serves as Chief of the Podiatry Service, as well as Director of the Creighton University-Arizona Health Education Alliance Podiatric Medicine and Surgery Residency Program.  Dr. Roth also serves both as a residency site evaluator and a surgical case reviewer for the ABFAS. He has authored multiple papers in both podiatric medicine and podiatric surgery.

Dr. Bryan Caldwell is named dean of Barry University’s School of Podiatric Medicine

Bryan Caldwell, DPM

Bryan Caldwell, DPM

Bryan Caldwell, DPM, from Kent State University has been named dean of Barry University’s School of Podiatric Medicine (BUSPM). Caldwell, who served as assistant dean, director of Clinical Education and Clinical Operations, and professor at the Kent State University School of Podiatric Medicine, assumed his role at Barry on Aug. 1.

He earned a Master of Science degree from the University of Notre Dame, and a Doctor of Podiatric Medicine from the former Ohio College of Podiatric Medicine. He completed a hospital residency at Florida Hospital in Orlando, FL.

Dr. Caldwell became certified by the American Board of Podiatric Medicine in 1997 and served as a Physician Executive Leadership Academy Fellow with Case Western Reserve University School of Medicine. Caldwell returned to medical school and earned a Doctor of Medicine degree in 2017 from the International University of Health Sciences, completing all his clinical clerkships in the University Hospitals Health System and Clinton Memorial Hospital.

Source: PM News, Online

ABPM Spotlight! Meet Director, Lee C. Rogers, DPM

Lee C. Rogers, DPM

Lee C. Rogers, DPM

Lee C. Rogers, DPM became a Diplomate of the ABPM in 2008. After serving several years on the ABPM Exam Committee, he was elected to the Board of Directors in 2015.

As a Director, Dr. Rogers led the initiative to start ABPM’s first Certificate of Added Qualification (CAQ), which was first offered in 2017, and is currently the sub-Chair of the CAQ in Amputation Prevention and Wound Care. He is also co-authored the ABPM’s document on Privileging and Credentialing Doctors of Podiatric Medicine which has been instrumental in helping ABPM Diplomates obtain and keep their hospital privileges.

“I have seen ABPM grow and it’s on the path to be the largest and most influential certifying board in podiatry within the next 5 years. As an ABPM Director, I will continue to be a leading force in efforts that will help to drive this change. I will also promote policies to help those podiatrists who are single-board-certified, by ABPM, like me.  I have been working to connect ABPM with the many international organizations of podiatrists.  We are now a very young organization, with 60% of our membership being less than 10 years out of residency.  I support getting our younger members involved in committees and nominating them for Board positions.  I advocate for improving processes in the Board Headquarters, including the adoption of new technology to make the busy lives of our Diplomates easier.”

Originally from Gallatin, Missouri, he completed his undergraduate education at Truman State University and received his Doctor of Podiatric Medicine (DPM) from Des Moines University in 2004. Following graduation, Dr. Rogers completed a PM&S-24 residency at Saint Vincent Catholic Medical Centers in New York in 2006, and a fellowship in diabetic limb salvage and wound care at Scholl College of Podiatric Medicine in 2007.  Since then, he has focused much of his practice and research on the diabetic foot and currently sits on several committees for many organizations around the world that promote podiatry or diabetic foot care.  He has authored over 150 papers or book chapters and delivered almost 500 lectures in all 50 states and more than 40 countries.

New Dean and ABPM Diplomate, Dr. Kathleen Satterfield, takes charge at critical time for WesternU’s College of Podiatric Medicine

ABPM Diplomate, V. Kathleen Satterfield, DPM, FACFAOM, MAPWCA

ABPM Diplomate, V. Kathleen Satterfield, DPM, FACFAOM, MAPWCA

Western University of Health Sciences’ College of Podiatric Medicine is trying something unprecedented in podiatric medicine – having its students sit for the same licensing exam as osteopathic (DO) and allopathic (MD) students.

To provide stability during this critical juncture, WesternU has tapped CPM Associate Dean and ABPM Diplomate, V. Kathleen Satterfield, DPM, FACFAOM, MAPWCA, as the College’s new dean, effective May 1, 2019.

“Dr. Satterfield has been an integral part of the College of Podiatric Medicine from its early days. She is uniquely qualified to lead the College as a seasoned academic podiatric physician and surgeon,” said Daniel R. Wilson, MD, PhD, President of Western University of Health Sciences. “She will ensure that the high standards of performance and accomplishment set by the College over the past decade will continue to be met, indeed, surpassed, even as our students enter a new era for podiatry at WesternU and beyond.”

Satterfield has worked at WesternU since September 2010 and provides leadership continuity as she succeeds Founding Dean Lawrence Harkless, DPM, who retired in June 2017, and Executive Associate Dean Lester J. Jones, DPM, MSEd, who has served as interim dean and retired at the end of April.

“Our college is going through some growing pains,” Satterfield said. “I was afraid if I stopped now maybe somebody with a different goal would come in. We’re trying something very ambitious here in California and that is a change in our license, in a way.”

Satterfield had planned to retire before being asked to consider becoming a candidate for dean.

“Dr. Satterfield brings a wealth of academic and personal experience to the position of dean. She was one of the founders of our pioneering curriculum, integrating podiatric education with that of the other health professions, and our outcomes demonstrate the correctness of our approach,” said WesternU Provost and Chief Operating Officer Gary M. Gugelchuk, PhD. “Now she brings that wealth of background to propel the College to even higher levels of achievement.”

The reason Dr. Satterfield decided to take on the task: CPM students

“I love our students,” she said. “We wouldn’t be here if it weren’t for our students, and they have the potential to treat so many more people than one person can.”

CPM students are now more than 90 percent embedded with College of Osteopathic Medicine of the Pacific students, taking much of the same curriculum and tests.

“Because we asked ourselves a few years ago, ‘When does an orthopedic surgeon become an orthopedic surgeon? In his or her residency,’” Satterfield said. “Why should it be any different for podiatric physicians and surgeons? We want our students to be excellent doctors first, and then trained to be podiatrists.”

CPM is moving toward having its students earn a Physicians and Surgeons Certificate, which will require approval from the Medical Board of California, the National Board of Medical Examiners, the American Medical Association, and the American Podiatric Medical Association.

In preparation, WesternU CPM students will sit for the Comprehensive Basic Science Examination beginning this year and for the next two years, as a preliminary testing process to identify readiness to sit for the United States Medical Licensing Examination (USMLE) steps 1, 2 and 3.

“Once we prove our students are passing the same tests that their DO and MD colleagues do with success, we have a good argument that we have reached parity,” Satterfield said.

One concern emanating from others in the profession is whether CPM students would concentrate on becoming physicians at the expense of becoming good podiatrists.

“Our students have proven that to not be the case,” Satterfield said. “They have the highest rate of residency placement of any school in America. Our students have a 100 percent pass rate on their clinical skills physical exam and ultimately on their boards part 2, which is all podiatry. I think we have proven that you can be a good physician first and then trained to be a podiatrist.”

Dr. Satterfield is the person best suited to take over the as the next CPM Dean, Jones said. She understands CPM’s highly comprehensive and rigorous curriculum, the complex nature of regional and professional accreditation standards and requirements, and has the highest degree of integrity, diligence, intellect and resilience to failure, which places the College in good hands.

“It is my belief that she possesses a feeling of a calling to maintain the highest standards that are the fundamental building blocks that gave rise to the Western University of Health Sciences College of Podiatric Medicine,” Jones said.

Career switch from a Journalist to a Doctor of Podiatric Medicine

Dr. Satterfield, who became a podiatrist as a second career, never imagined she would be dean one day. She first learned about podiatric medicine while working as an investigative journalist at the El Paso Times. She was investigating a medical doctor with questionable practices on the El Paso-Juarez border, and in the course of her undercover work met podiatrists who were in the same building as the subject of her investigation. They specialized in diabetic limb salvage and wound care, which she found interesting. She continued to visit them to learn more about their profession long after her investigative series was over.

“I had always been interested in the medical field,” Satterfield said. “In podiatry I saw that patients would come in with a problem and a procedure would be done for them, whether it was an injection or wound care, and they all seemed to be happy going out. I thought that would be really fulfilling and satisfying. You’re helping somebody and actually making a living doing it. It was so very different than investigative journalism work where I had to ask people questions they really did not want to answer and I had a lot of doors shut in my face.”

Satterfield earned her Doctor of Podiatric Medicine degree from the College of Podiatric Medicine and Surgery at Des Moines University, and completed her podiatric medicine and surgery residency at Yale University School of Medicine Clinical Campus/West Haven Veterans Administration Medical Center. She became Board Certified with the American Board of Podiatric Medicine (ABPM) in 1996.

She first met Harkless as a podiatry student, and he would have a tremendous influence on her career. He recruited her to work with him at the University of Texas Health Science Center at San Antonio, and then, after he came to WesternU, convinced her to come to Pomona during the College of Podiatric Medicine’s early years.

“He hired me first as a consultant, and then I came out as a faculty member and associate professor, and then rose through the ranks. It’s been a wonderful adventure,” Satterfield said. “I really have enjoyed it. I have a lot to thank Dr. Harkless for in my life.”

Now as dean she will focus the College’s recruitment on Pomona and the surrounding areas, which have a lot of top-quality students interested in a surgical career. A large number of CPM students come from UC Riverside and UC San Diego. CPM will increase recruiting at those schools and all University of California branches.

“If you go into medical school as an MD or DO student you’re not guaranteed that you will have a surgical career,” she said. “If you go into podiatric medicine and surgery, you are guaranteed you will come out as a surgeon (from) your training.”

She also wants to raise the profile of podiatric medicine as a whole.

“Our profession is one of the best-kept secrets in the world,” Satterfield said. “Once a student shadows a podiatrist at the hospital, or they go into the operating room, or they see patients in the clinic, they love it. They ask, ‘Why didn’t I know about this?’”

Podiatric medicine is a small profession, with about 15,000 practitioners in the U.S., far too few to take care of everyone with diabetic foot problems, sports injuries or other needs that podiatrists are trained to address.

“There is a great need, but we have difficulty filling our class with qualified students,” Satterfield said. “The University has been absolutely wonderful about not forcing us, as some institutions have, to fill a class with students that may not be able to make it. We fill our class with students we know can make it. That is my first goal — to get qualified people into the seats so we fill our classes.”

Dr. Kathleen Satterfield and Dr. Lawrence Harkless were honored as a master during the American Professional Wound Care Association (APWCA) Annual Meeting in Philadelphia, Pa. in April 2011. (Jeff Malet, WesternU)

Drs. Kathleen Satterfield and Lawrence Harkless were honored as a master during the American Professional Wound Care Association (APWCA) Annual Meeting in Philadelphia, PA. in April 2011. (Jeff Malet, WesternU)

Source: WesternU News, Western University of Health Sciences’ College of Podiatric Medicine

ABPM Spotlight! Meet Director, Mitchell Shikoff, DPM

Mitchell Shikoff, DPM

Dr. Mitchell Shikoff has been a Diplomate of the ABPM since 1989 and has served on the board since 2009. Dr. Shikoff has several roles as a Diplomate of ABPM; he is currently the Vice President, Chair of the Case Document Review Committee, Chair of the Credentials Committee, serves on the Speakers Bureau, and formed the Marketing Committee on which he is extensively involved. Dr. Shikoff is also the ABPM representative to the American Podiatric Medical Association (APMA), the American Board of Foot and Ankle Surgery (ABFAS) and the Joint Committee on the Recognition of Specialty Boards (JCRSB), where he has served as the Chair. He represents both the ABPM and the ABFAS as a residency program reviewer for the Council on Podiatric Medical Education (CPME).

“My time serving as a Director of the ABPM for the past ten years has been challenging and rewarding. I’ve been able to be part of a transformational process of the ABPM and witness astounding growth in membership and Diplomate value. I am proud of the significant changes and encourage all residents to attain certification promptly. Finally, get involved with the Board on one of the many committees and run for a position as a Director. It will keep you at the forefront of your chosen profession.”

Originally from Northeast Philadelphia, Pennsylvania, he completed his Bachelor of Science and Bachelor of Arts undergraduate degrees at the Pennsylvania State University in 1979. Dr. Shikoff received his Doctor of Podiatric Medicine in 1983 from the Dr. William M. Scholl College of Podiatric Medicine in the Rosalind Franklin University of Medicine and Science. He completed his post graduate surgical training in St. Louis, Missouri. Dr. Shikoff has offices in Bensalem, PA and Feasterville, PA since 1985 and continues to take advanced training in various aspects of Podiatric Medicine, Surgery, and Wound Care which most recently includes new biologic wound dressings and Hyperbaric Oxygen Therapy. Dr. Shikoff has served as a residency director of a three year PMSR program, and thoroughly enjoys training residents at the hospitals where he is an attending.

As a dedicated husband and father of two, Dr. Shikoff has many interests outside of Podiatry. He enjoys bicycling, skiing, scuba diving, fishing, traveling, and spending quality time with the family.

Outpatient vs. Inpatient Workup of Diabetic Foot Infections

By: Marisse Lardizabal, DPM,

Diabetic foot infections (DFI) are both challenging and common amongst all podiatrists. Treatment of DFI’s require a level of comfort and training as well as resources available to clinicians. ABPM has traditionally been a great source of information for podiatrists which makes the board certification by ABPM paramount.  Like many podiatrists, you may encounter these types of patients initially in the clinic/outpatient setting, where you can catch the potential signs and symptoms of a diabetic foot infection waiting to happen.

First, nothing can substitute a thorough History and Physical Exam on a patient.  A complete NLDOCAT will give one a lot of information as well as develop a story as to why the patient is presenting with a diabetic foot infection.  For example, time frame of the ulceration, how well the patient’s diabetes is controlled, and any prior and/or current ulcerations will help you formulate a treatment plan. This may also foreshadow how compliant a patient will be with their recovery.  A thorough physical exam is of significant value when looking for classic clinical signs of infection, as well as the status of the neurovascular structures. Does the patient have enough circulation to heal an ulcer? Is a referral to a vascular surgeon necessary? Obtaining radiographs and necessary labs (CBC, CMP, ESR, CRP) should be obtained for a complete work up.

The Infectious Disease Society of America Diagnosis and Treatment of DFI, also known as IDSA Classification, is one of the most helpful guidelines that should be utilized by clinicians who treat DFI routinely. This guideline classifies DFI based on severity of the infection, clinical signs, and constitutional symptoms presented. IDSA also makes recommendations of what the appropriate treatment course should be.  For example, consider a patient who presents with erythema <2 cm around the ulcer with 2+ signs of infection. According to the IDSA guidelines, the patient’s infection is classified as “uncomplicated soft tissue infection” or Mild DFI. Therefore one may feel comfortable sending the patient home with oral antibiotics, local wound care and offloading as well as a 3-5 day follow up to see if the signs of infection have resolved.

Moderate DFIs (erythema > 2cm with 2+ signs of infection present) are the most challenging to classify and treat. Without close observation, these patients can potentially get worse and can be very much considered as admitting criteria depending on presentation of the infection.  At times, these patients can benefit from a decompression of the infected foot in the clinic setting, while making sure wound cultures are obtained prior to discharge. If patients are discharged home, close follow up and monitoring is essential. If symptoms do not improve, the safest course of treatment may be hospital admission for IV antibiotics and possible surgical interventions.

 

Lastly, severe DFIs are complicated local infections in conjunction with the patient endorsing constitutional symptoms as well as presence of SIRS criteria. These are the patients that will be admitted to the hospital for surgical management of the infection due failure of conservative treatment.  The IDSA guidelines are key elements to be familiar with as they will guide your treatment and tell you which patient will need a higher level of care.

Once the patient is admitted to the hospital, inpatient work up of DFI is very much similar to the outpatient setting.  If admitting the patient under Internal Medicine, it is important to communicate necessary labs, imaging, choice of IV antibiotics, NPO status as well as plan for surgical intervention to the service for an efficient and effective hospital course.  One may consider advanced imaging, such as an MRI (preferably prior to surgical intervention), whether there is concern for osteomyelitis or abscess in the foot.  The advanced imaging should by no means delay surgical intervention if it is considered emergent.

This brief overview of triaging DFIs can hopefully streamline how DFIs are treated in one’s practice.  Effective treatment of DFIs is our expertise and it will benefit our patients to have a standard of how it is treated.  Being board certified by ABPM, I feel confident in treating DFIs with the knowledge and background that I continually use in my daily career as a Podiatrist.

 

References:

Clinical Infectious Diseases, Volume 54, Issue 12, 15 June 2012, Pages e132–e173, https://doi.org/10.1093/cid/cis346

Dr. Charles C. Southerland – In his own words: Why not Med School?

“During the first year of my fellowship, I encountered a patient, a beautiful young woman in her early 20’s with a burgeoning career as a model in Miami, who was experiencing intense heel pain.  She had been treated by other physicians for Plantar Fascitis and tendonitis without any resolution. I diagnosed her with Tarsal Tunnel syndrome and confirmed that with a neurology consultation for NCVS and EMG.  The patient was taken to surgery for a Tarsal Tunnel release.  During the course of the procedure, we encountered a tumor pressing on the posterior tibial nerve. The tumor was removed and the pathology report defined the tumor as a Synovial Sarcoma, Stage 4.

The patient was sent to Sloan Kettering Cancer institute in New York, along with lab results and 35mm slide photographs of the tumor. The Sloan Kettering team confirmed the diagnosis and recommended that the patient undergo a below the knee amputation with follow up chemotherapy.  During the chemotherapy, she lost her hair, and the surgical site on the stump of her leg dehicsed.  She dropped to about 60 pounds from an original weight of 120 lbs.  However, in the end, she survived both the chemotherapy and the cancer.  She kept in touch with me throughout the entire process. I developed a close relationship with the patient and her parents. After arriving back from New York, the patient related to me that the Sloan Kettering team had kept the 35 mm slides I had sent with her (in those days, it was not so easy to make photographic duplicates). When she explained that a podiatrist had made the diagnosis, they told her that podiatrists did not make diagnoses for cancer and that she should credit the neurologist who caught the abnormality on the nerve conduction study. The patient asserted to them that she credited the podiatrist with saving her life. The folks at Sloan Kettering told her that podiatrists were “not real doctors” and so had no real part in the process of treating her cancer. She later related to me that she found them to be arrogant and egotistical.

I remember being very much offended by what she told me, frustrated at being recognized as “only” a podiatrist. At the time, I was reading a book by Victor Frankl, “Man’s Search for Meaning”. Victor Frankl was an Austrian Neurologist and Psychiatrist during World War II.  He was Jewish and became a concentration camp prisoner by the Nazis during the war. He was tortured and emasculated by his captors. One day, as he hung helpless before his tormentors he came to an amazing realization. In order to do what they were doing to him, they could not help but to hate a fellow human being. In a moment of remarkable clarity, Victor Frankl realized that while they could not choose to not hate him, he could choose to NOT hate them back. In this seemingly small thing, he had power over them to determine how he would react to the terrible things they were inflicting upon him. They could not choose mercy, but he could.  In reviewing this, I came to a nexus moment question:  “If I could do it all over again, would I choose to have encountered this beautiful young woman as an MD or as a DPM?”  Two MD’s had treated her before  I saw her, one an orthopedist, the other a general surgeon, and both missed the diagnosis. IF I had chosen to attend St. Louis University School of Medicine, instead of podiatry school, and encountered this patient, would she have lived or died because of this tumor? I realized at that moment, that I was totally, completely, absolutely content to be a podiatrist. If the only thing I would ever accomplish as a podiatric physician was to catch this diagnosis and intervene in a way that saved this young woman’s life, it was all worth it – four years of college, four years of podiatry school, one year of residency training and two years of fellowship. What a wonderful lesson, one that has caused me to be very happy in the practice of Podiatric Medicine for over 30 years now. By the way, my patient returned to her modeling career as a poster model for lower limb amputee snow skiers. She could be found in a number of ads for outrigger ski poles and single limb skiers. To this day, she has lived a good life and remains a good friend.”

 

 

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