• LecturehallLIFE SKILLS: Podiatric Fellowships - What You Need to Know
  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Male Speaker: Our next speaker is Dr. Alton Johnson, Jr. He is actually a research fellow at the hospital that I'm primarily working out of Penn Presbyterian Medical Center. He works with Dr. Malay. He received his BS in biology from Barry University in 2012 and Kent State College Of Podiatric Medicine. He is a KSU CPM recipient of the Segal AmeriCorps Educational Award scholarship. He is exciting on the forefront of podiatric medicine surgery and somebody who is going to come and talk to us about fellowship. Obviously, he has been able to attain one of the most sought-after fellowships in our profession at University of Pennsylvania with Dr. Malay. So welcome Alton Johnson.


    Dr. Alton Johnson: Good morning everybody. Thank you for introduction, Dr. Troiano. We work at the same hospital. Awesome doc. And great job in that presentation. I've learned every time you speak as well. So today my presentation is on podiatric fellowship, what you need to know. Disclaimer is, my opinions and advice don't represent Penn Medicine, Penn Medicine GME, University of Pennsylvania Hospital, AACFAS or the Present lecture series. Disclosure, I'm currently a consultant for Integral Life Sciences but doesn't really have much to do with this lecture, just a brief biography. So basically, I trained under Dr. Marie Williams for residency who is also one of the faculty members of Present and also currently doing a fellowship with Dr. Scot Malay who is the editor of Journal Foot and Ankle Surgery and pretty prominent guy in our field. I'm learning so much just in the first two or three months that I've been there so far and it's very challenging program. Here is my objective, just briefly look at them.

    And we will get to the crust of the lecture here. So why consider podiatric fellowship? It's not mandatory one to two years training, helps the fellow focus on his or her areas of interest and unique opportunity to train with some of the best foot and ankle, leg physicians and surgeons in our respective fields. It makes the fellow more competitive candidate for the real world market, a chance to integrate in the life as attending status. So basically, I want to race that up before I start my talk because basically this is the real reason why you should consider podiatric fellowship if you're interested because none of those things are technically guaranteed or promised to you. But because you have a strong interest in the respective field that you choose when you choose the fellowship such as mine which is clinical research. Kind of have to have a passion for it. There is not a guarantee that there will be a huge credit at the end of training that you will complete as a fellow in our field and I will get in more detail in it in later slides. Here is a little outline of the topics I will go over throughout the lecture. What you need to know about podiatric fellowship, the fellowship type, the accredited fellowship versus nonaccredited fellowship, applying to fellowship, the deadlines, preparation, interviews, prefilled shift transition, life as a fellow, life after fellowship and the pros and cons of fellowship. These are the types of podiatric fellowship that are currently available on the market for our field. It's trauma fellowship, reconstructive fellowship, general practice, prior practice which is I called bread and butter fellowship, plastic surgery, microsurgery, sports medicine, infectious disease, wound care. Infectious disease and wound care fellowship kind of overlap because typically those curriculums are about the same and those curriculums combine themselves most times at certain fellowship. In clinical research fellowship which I'm doing a two-year clinical research fellowship with Dr. Malay, usually those are two years, some of them are one year as well. Pediatric fellowship, dermatologic fellowship and nerve surgery fellowship. So basically, we all kind of have familiarity with the trauma reconstructive fellowship and this is what they typically majority of them kind of outline that they go by, is acute evaluation of management of foot ankle and leg injuries plainly state that you should choose to do fellowship and evaluation and treatment of post traumatic deformities and nonunions, kind of go through reconstructive aspect and offers exposures to both acute foot ankle and leg injuries and referral to practice based for complex post traumatic condition. Typically, an extensive amount of arthroscopy as well. And general for prior practice fellowship get you balance of pretty much your regular podiatric practice criteria and those fellowships are typically one year as well. Then you have your plastic, orthoplastic and aesthetic fellowships that are now kind of gaining more popularity and with a lot of microsurgery aspects as well in cosmetic and cosmesis type of fellowship such as fat pad injections and doing those nerve transposition type of surgeries. And typically, these fellowships want you to know that typically you're working with MD and DOs as well because those guys are typically the plastic surgeons that are affiliated with those institutions that you work with and trying to do the proper flaps and nerve transpositions as well. [Indecipherable] [0:05:32] arthroscopic surgery, open intervention which he mentioned in the slide previously and prevention, rehabilitation, daily management of athletic injuries and lot of people think it's like when you do the sports medicine fellowship, you're just doing surgeries all day but majority if you have athletes that want to be competitive, they don't want to get surgery because it's too much downtime. So actually majority of those fellowships and 90% are nonsurgical and they are working on a lot of nonsurgical interventions to get their athletes back on the field whether amateur or professional athletes safely.

    Next one is infectious disease fellowship. Has extensive training in antibiotic stewardship, management of diabetic foot infection, limb salvage, microbiology background. Like I said, it overlaps the wound care because typically those wounds come in effect at sometimes as well. Then you have clinical responsibilities of wound care fellowship, teaching, identifying research projects, regular exposure to surgeries, biomechanics, multi-disability specialty at wound care and limb preservation which I've been to once or twice a week as well in my fellowship. And then you have my type of fellowship that I'm currently doing, clinical research academic medicine which is typically is affiliated with a large teaching institution, sometimes with a program that has a residency program as well because of the size and volume that the patients that you're seeing to actually complete the research studies. And they see a lot of patient oriented research. Typically, these fellowships are two years like I mentioned and there is a pretty lump sum amount of research fellowship that are currently being developed and it's just -- I want to belabor it while reading them all. Then you have pediatric fellowship with reconstructive foot and ankle surgery of the leg as well including complex soft tissue derangements and complex fixation techniques, usually flatfoot recons, claw foot treatments, correction of congenital deformities as well. You have dermatological fellowship which also overlaps a little bit with plastic surgery dermal pathology and general podiatry, all similar to that plastic fellowship as well. And you have the cosmetic dermatological aspect of it, procedural dermatology and also these are typically affiliated with the MD or DO as well in the respective field. So you get a little bit more in-depth on the training.

    Then you have neurosurgery fellowship which is lower extremity peripheral nerve surgery. They teach you microsurgery as well with nerve repairs, atraumatic nerve manipulation, neurolysis, end-to-end anastomosis, end-to-end nerve coaptation and application of nerve conduits and allografts. So we move out to the next portion of the lecture. We have the categories of the accreditations and fellowship. So these are the types of accreditations that we have in podiatric medicine fellowship and surgery fellowship. We have the AACFAS which stands for the American College of Foot And Ankle Surgeon and you have the CPME accreditation body which is the Council of Podiatric Medical Education. Then you have nonpodiatric specific accreditation which in our field the only one that's currently outside of the podiatry accreditation is the Association of Extremity Nerve Surgeon. We had a gentleman speaking yesterday who was actually accredited by that body. He does nerve surgery. He is a podiatrist. Then you have nonaccredited fellowship which doesn't necessarily mean like they are good or bad or whatever but they are just not accredited by any of our governing bodies and typically they are either physician sponsored or voluntary sponsorship type of podiatric fellowships which typically means that podiatrist or MD or DO was actually providing the funding for that particular fellowship. And also, I will get in more detail on it but the Duke fellowship which is pretty good fellowship is not nonaccredited. So kind of let you know that there is good fellowships that's no accredited. So AACFAS, most people not familiar with AACFAS -- everyone is familiar with AACFAS but those who are not familiar with AACFAS, it's the governing body for podiatric medicine and surgery accreditation. And basically, these are the governing body for the surgery boards and those surgical board entities are the ones that manage the AACFAS accreditation which is AACFAS and there is the different types of accreditation you can have as a fellowship under the AACFAS accreditation which is recognized foot and ankle surgery reconstruction fellowship which means full accreditation and those categories of sports medicine wound care and pediatric.


    Then you have recognized research fellowship which my fellowship has been and that's a different category. Then you have foot and ankle reconstructive fellowship that have conditional status. All of the AACFAS fellowship has to start off as a conditional status fellowship before they can get full recognition, so just doesn't necessarily mean anything on a particular program. And then you have foot ankle surgery reconstructive fellowship that have probationary conditional status, meaning that either they didn't meet the minimum numbers for that year and you're placed on the conditional probation for that particular year until they get their numbers up and they could lose their accreditation and all those programs have to be open about that prior to the interviewing or sending application in and this information is all just updated the numbers. So just in the last year, they've added almost a dozen fellowships which is good. They are showing that there is a lot of interest in the fellowship and I will talk more about it towards the end of the lecture about why. Then these are the minimum criteria that the AACFAS has for their recognition of full accreditation for the fellowship. It has to be 12 months sub-specialty training and should be hands-on involving direct patient care, not mere observation, so meaning you actually are participating in the patient's care, surgery, both bedside and in the OR. Then you have fellowship directed that must be AACFAS fellow which means full accreditation with the AACFAS Boards. And if the director is the MD or DO, they have to have full accreditation with their respective board as well which is a good thing. So you're getting training by well-vetted professional. Then you have 50% or more of the ABFS qualified faculty on your staff that you're being trained by. So basically everyone knows that's training this fellow has to be AACFAS accredited.

    So the surgical program must be performed at a minimum of 300 surgical cases per the fellowship year and it goes back to mentioning that that's kind of what separates the AACFAS accreditation from these other accrediting bodies that they have that surgical criteria minimum of 300 cases and if you don't meet those for that particular academic year, your program will be in probationary status. And you also have to have full financial support of the fellow and also allow them within the AACFAS conference and you also have to be active member of AACFAS to be in this to be a fully accredited fellowship. My program is AACFAS accredited and CPME. Now, we will go to CPME. CPME is the council that governs basically our entire education for both the schools and for the residency as well and they are associated with APMA. And they have their own fellowship as well but they don't have a surgical criteria minimum which is a little different but still good. Also shows that if they are accredited by this institution that they get site visits and everything as well. Here is the minimum criteria. You get a program that's at least 12 months. Cannot be in the apprenticeship to also another -- clarity that fellow actually has to be participating in the patient's care and it's not like preceptorship or apprenticeship. There must be salary and benefits, dedicated time for conference and travel, access to medical library in the institution nearby. And these are lot smaller amounts with the CPME which is okay and there is sports medicine, wound care, dermatology and research fellowship which includes mine and then limb preservation as well.

    And you have your nonpodiatric specific accreditation what I kind of mentioned earlier. Like I said, the only one that's currently outside of the governing bodies of podiatry is the nerve fellowship and this one is accredited by the Association of Extremity Nerve Surgeon which is good, which is awesome. And they are nonaccredited -- I kind of hit on that as well but just getting in little bit more detail. So you have podiatric research and surgical fellowship at Duke that I mentioned and this is one of the reasons why I wanted to do this lecture is just to let people know like if you're interested in certain fellowship and wants to apply a year and year and half if you're interested in the Duke fellowship. So you have to apply like your second year and get your board and everything from the North Carolina Boards Association, Podiatric Board Association and everything. And for nonaccredited, some of these orthopedic groups or podiatry groups create their fellowship starting off nonaccredited, then apply for CPME or AACFAS status which doesn't mean that you're not getting good training, just maybe it's a new program to consider and there is actually some pretty good program that are nonaccredited that I know about around the country and outside of the country as well which I mentioned. Typically, these programs are spread word of mouth. Now you're applying to fellowship, this is the criteria that you need to get ready. So visit programs of interest throughout PG1 to 3. Some people actually started visiting as a student, fourth year student already visited our program because they have a strong interest in clinical research. People are kind of figuring out what they wanted to do early on which is good or just filling out the specialties. So the early bird catches the worm, kind of mentioned that, and then application process should start at least a year before the deadline and LOIs, letter recommendation, references, personal statement, CV, compilation of your posters and presentation.

    So start getting those posters in at AACFAS or local conferences to show that you're kind of interested in research or if you're interested in surgery on the respective field that you're in and you present to those and then also have your podiatry RN logs with the NAB diversities, your clinical logs summary and your clinical reports showing these programs which you are interested. Then you also have to know your why. So that's, I will get to that one when I get more about the interview but you kind of have to know why you're going to fellowship because it's the time commitment and it's also a financial commitment. I already mentioned, participating in research projects and then have all the boards for those respective programs that you're interested in, like the surgical board, medicine boards if you're interested in wound care like me, wound care boards as well and start saving for travel since PG1 because it gets very costly visiting programs and getting ready for interviews. So application deadline, typically in the fall, the previous academic year that you applied for and the deadlines range from July of that academic year March 1st and so this is we're like right in the amidst of the high season of application for these fellowships right now. I personally interviewed the entire year before selecting UPIN just to show strong interest in my clinical research background and everything. You must watch for the deadline because every program has a different deadline which may be something that we can work on at AACFAS to kind of standardize it but they all have rolling deadlines which is kind of -- if you find a program like -- there was -- for example, I was at the course one time and I worked with a doctor and she was at one other program in California. She was awesome, she taught me everything. I was like, oh, can I apply your fellowship? She was like we already knew what we wanted like a year ago. So I was not even can be a candidate for it. So just things like that, little nuances that you don't really realize are the one teaches you about. And so application followup. After sending your application, you call or email.

    If you do not hear back from the program in five business days after submission of these programs, the directors and if the director doesn't have a coordinator, they are pretty busy. It's kind of way it goes because if they are fellowship director, they are seeing a lot of patients to keep those surgical volumes up and so things that I did, I add the current fellows and social media such as Facebook or LinkedIn on the professional side. We started them for site visit and let them know, oh, I submitted my application, things like that, little nuances that you don't really find out about until you're in them and you miss to comply, you don't realize that. These doctors aren't just sitting on the desk waiting on the application unless they have a coordinator that usually takes care of that. So for preparation interviews, prepare for interviews and similar fashion as residency as in getting ready to know your classification system and your anatomy. There will be those type of question a lot but goes back to where I mentioned know your why because a lot wanted to know why you want this particular fellowship. There is like 50, 60 fellowships around the nations. Usually, we graduate about 550 residents, I'd say maybe a quarter of those residents may be interested in fellowship, but it's only a 50 slots, so half the people don't get fellowship they wanted. Something like that. So you have to know why you want that particular fellowship and don't just blindly just send out application and not know about the faculty on staff or know what they do or know what the current fellows are doing or know who the current fellows are going to be graduates of those programs or currently doing. That's one of the biggest things. So it's basically saying remember fellowship is optional unlike residency. So this is not something you have to do in our profession. Just still do those things. Things that I did have a former or current fellow from that program, give you a mock interview prior to the formal interview and have the current or former fellow from another program interview you as well because they kind of give an idea of the type of questions they are asked.

    Couple of my interviews were around where I've been 5, 6 doctors in the room and just kind of go at it and then you do presentation. Some of them were more laid back and you just meet and have a dinner and kind of talk and get to know you. So there is all varieties or types of interviews, little bit different than residency. So acing the interview, be engaged, ask questions, know the interviewer, practice, practice, like I mentioned, with mock interviews. Be prepared to talk about yourself, personal interest, longterm career goals. Every program asked me what was my five to ten year career goal, so why I even want to be in that particular respective field, why am I interested in clinical research in particular, why am I interested in interviewing at the program. And challenging patient interactions, they will ask you about. So that was like the most challenging patient or the most interesting case you had and why and your favorite type of cases as well or your particular research interest. And after you're interviewed, definitely send your thank you notes. Either send it via the traditional mail route or emails to the attending or the career fellow that interviewed you. And then post interview communications, just keep a line of communication if you're really interested in that program, even just the fact that they gave you interview, I'd definitely say, follow up with that. So other topics that I didn't really know until I got into the missed the fellowship is attaining licensure. PA, it takes like three to four months. So once you get that fellowship and is accredited, you need to start getting ready and geared up to have your medical licensure in that respective field. Getting your DEA number, things like that takes a little while. Obtaining malpractice if it's not via the fellowship, especially if you had a nonaccredited fellowship. Relocation expenses like I mentioned in the previous slides, definitely start saving, look at zero-interest credit cards if you have to do that, pull out debt to get it or healthcare professional loans or start moonlighting just to start getting ready for that transition.

    Some programs do have moving stipend as well. Usually, I get $1000 or $2000 for relocation, some of them, not all of them. Typically, the ones that are affiliated with the practice, private practice. So life as a fellow, it varies from program to program just like residency for our profession. You have clinical duties, surgical duties, clerical duties, research duties and teaching duties as well. Typically, if you're at the large institution, you want to clinical faculty at that institution as well teaching the medical students and/or residents. Conferences, CMEs, all came here at the conference as well. And then you do your boards credentialing, Medicare number, get a nonprofit insurances and malpractice, especially if you had those private practice fellowships, little nuances that you don't realize until you start. And also make sure you have time for vacation and have a work life balance. So this particular slide was actually given to me by one of my colleagues Dr. Calvin Rushing. He is actually a fellow at Dr. Hyer's program. He is a surgical fellow there. They have a two-year program, some type of training MDs or Dos. They do DPMs two years. They are pretty heavy in research. They actually release this information [indecipherable] [0:23:16] I knew they are doing this particular study, I will get into it but basically it's the study that sends out survey to graduate fellows of the foot and ankle full accredited fellowships and they sent out a survey and they got back a response I think about 10% to 15% because I think just for the hit, its statistical significance [indecipherable] [0:23:36] was very, very responsive about 10% to 15% of the surveys that you send it out to. This is the survey response they got from the graduate fellows of those particular programs. This does not include, like I said this is only from fully recognized AACFAS accredited fellowship. Basically, it's looking at where those fellows were after they graduated from the fellowship.


    So 46% of fellows that graduated from a fully accredited recognized surgical training fellowship end up going in to orthopedic practice, 28% of them end up in the group practice, 13% end up in the multispecialty group and 13% of them end up at university setting. So that's something just to think about as well when it comes to choosing your fellowship. On average, fellowship trained podiatrist are 4.2 million compared to non-fellowship trained podiatrist are only 3.03 million in the 30-year career. It's based on their statistical analysis and if you compare the net value versus accumulative net value, the difference of 30 years was 1.2 million versus 2.5 million for non-fellowship podiatrist versus fellowship podiatrist respectively. So the income breakdown on how they did it is basically the difference from the non-fellowship trained podiatrist versus fellowship trained podiatrist and clinical aspect. Typically, these guys make 70,000 more. In the clinical aspect, generally they make 20,000 more. In research aspect, they make about 2000 more. You have to combine research and associated research according to their study. They are going to present in this AACFAS coming February but they allow me to do it for this particular lecture. So shout out to Dr. Rushing and Dr. Hyer for allowing this. I'm presenting their research before they can present to anybody. So there is the pros and cons. So just trying to like embellish fellowship. So I'm going to start off with the cons of fellowship as to why you maybe shouldn't consider fellowship or why you should risk that you will be taking to the fellowship is. So I lost a one to two year attending salary which can be a big deal, especially with student loan interest that's recurring and depending on your life style and expectations, not all fellowships are accredited and prior fellowships tend to vary. So just because you went to this fellowship versus another fellowship, you get a totally different experience. So that's one of the things, they are not truly like that standardized which is something we can work on as the fellowships kind of develop more in that field.


    Then there is typically no further board examination for the subspecialty with the exception of like the nerve surgery and the infectious disease board. So that's the reason why majority of nonpodiatric doctors or physicians or surgeons usually do a specialty is because they can take board and say, I'm specializing this. But just because you did a fellowship doesn't mean you can take an additional work because the person that didn't do a fellowship can also take the wound care board or something like that. So it's one of those things you consider if you're not truly passionate about why you wanted to do a fellowship. And also you can lose your one to two years of surgical accreditation time. If you graduated from residency, you're already took your board -- clock starts ticking for the seven years to get your board certification after you do the qualification and it's typically right now AACFAS is pretty lenient about it, especially if you end up doing AACFAS accredited fellowship and they find out that you were in that accredited fellowship, the clock kind of stops, but they can always change that rule. I mean seven years from now, they can change the rule. So you can be in like, I missed two years because I was in my fellowship and they cannot give you that extension to get your qualification for surgery. And the pros is healthcare is involving. Patients want when doctors who have intense training and knowing their subspecialty. So it's always good to have someone that does this day in and day out. Then referring to Dr. Rushing and Dr. Hyer's slide, in the long run from the financial perspective, podiatrist who elect for fellowship training typically are in $1.2 million more than the non-fellowship trained podiatrist in their 30-year career. And typically your niche, so actually this is your specialty and people have to kind of respect that, especially the patient population and your colleagues will refer you if you're doing something like nerve surgery, dermatology. Then as a fellow, you also have access to fellowship only trained surgeries courses and educational opportunities, basically also networking, so you get to get networking opportunities as well and you do it because you want to do it. So going back to knowing your why, that's why you should do. You've chosen to do that fellowship. It's not a podiatry joke of the day. It's contact information. Any questions for the audience and that's the end of my talk. Hope everyone learned something new, even the attending. This is my references here.

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