Guest Editorial

Fact vs. Fiction in being a
‘Rearfoot and Ankle Surgeon’

by Glenn M. Weinraub, DPM

gweinraub@faiv.com
Kaiser Permanente
San Francisco, California

‘Certainly by doing a three year surgical residency I will be at the top of my game once entering into practice…certainly I will make more money, do more interesting cases, be better respected by my MD peers, have better surgical results and be thought of as an overall great guy by the O.R. staff.’

They say that nothing ruins good operative results like follow-up. Well, having graduated from a fairly high volume, well regarded residency about nine years ago, I am here to give you the results of my “Residency Follow-up”.

Unfortunately, the “certainties” of the first paragraph are simply not true. While I do have a practice that requires me to perform reconstructive surgery of the rearfoot and ankle, I still believe that the true test of a foot surgeon is in his / her ability to obtain consistently good results in forefoot reconstructive procedures. I once overheard a well respected orthopaedic surgeon tell his resident that it is much more difficult to fix an unstable 2nd digit hammertoe than it is to fix a hip fracture…he is right! Striving for and obtaining good surgical outcomes will garner more respect from your MD colleagues than pointing out that you are a rearfoot and ankle surgeon.

Fortunately or unfortunately, having a practice devoted to the rearfoot and ankle is not the smartest way to build ones nest egg. Take for example the Charcot pantalar fusion with the external fixator...this type of case may take up to 6 hours to complete, and then there are the weekly post-op visits (which can take up to 40 minutes given the external fixation). The economic benefit of performing this type of work is minimal, but you do this type of work because you love doing it!

As for doing more interesting cases, I still believe that the forefoot provides a more consistent source of technically challenging surgical opportunities than the rearfoot and ankle. During my training, the best technically skilled surgical whom I had the pleasure of working with was almost exclusively a forefoot surgeon.

One observation I have noted over the years is that surgeons are very pre-occupied with being highly regarded by the OR staff in the hospital / surgery center. For good or bad, the folks in the OR always believe that the doctor who gets done the fastest is the best surgeon, they simply will not be impressed by your 5 hour triple arthrodesis.

So, what have I learned in the last 9 years since residency? First and foremost is to be humble and honest, both with your patients and yourself. Second is that we are neither forefoot surgeons nor rearfoot surgeons, rather we are Podiatric Surgeons. And finally remember (somewhat tongue in cheek) the following from Campbell’s text…”good surgical judgment comes from experience, and experience comes from poor surgical judgment”.  Huh ?