Charting a Course for Success in a Limb Salvage Private Practice: One Surgeon's Experience

Hi, my name's Haywan Chiu. I'm a surgical podiatrist practicing in Albuquerque, New Mexico. My expertise is diabetic limb salvage. That's all I do almost a hundred percent.

Yeah. In private practice, as you know, diabetic limb salvage, the patients stick with you once you inherit them, and the hard part is following them throughout the duration of their inpatient and outpatient course. During that outpatient setting, a lot of these high risk wounds can get infected and you send them to the hospital. The hard part for me was to send them to the hospital and have just whoever's on call take care of it. So I ended up taking a lot of personal time off in order to take care of these patients. And after two weeks of a heavy limb salvage call burden, that becomes unsustainable. I learned quickly that I needed to have a team of colleagues to take care of these things that have the same mindset and skillset as I do. So quickly, being in private practice, the cool part is you're able to hire one and whomever you want. I was able to bring on one of my earlier partners, to join me and help me in our mission to serve the community for diabetic limb salvage preventing major amputations.

We scrubbed a few cases together just so that we can learn each other's practice algorithms and skill sets, and having some discussions, we were able to have some more similar mindsets so that when we do patient handoffs, we can quickly communicate what's going on and what needs to be done. Now that I have two reliable partners with similar mindset as I do, it's made our ability to provide a good limb salvage service to our community has been tremendous.

Treatment algorithm, meaning that when you see something, you immediately know what to do. If you see something and you think about, oh, what should you do, that makes life so much harder. And that's why specializing is so key because you see a lot of the same situations, even though if you didn't specialize, it may be once a month or once every couple months. But when you specialize, I'm seeing certain cases monthly or weekly sometimes, and immediately you know what to do. Or if there's some kind of infection to a toe, you know exactly whether or not you can take care of it in the inpatient or outpatient setting and quickly decide what the next steps should be rather than spending time talking about all the options and thinking about what you need to do next.

I think when I say treatment algorithm... I mean that's for everybody. Plantar fasciitis, you should have a whole set of exactly all the things that you do based on the patient's severity of symptoms. Same with infections, severity of symptoms, and just whole set of treatment plans that you already know you can just plug them right into your treatment plan and go. That makes your limb salvage or whatever clinic that you have a lot more streamlined and thriving.

Traditionally, in residency we're rounding every single day, doing dressing changes every single day. I sometimes go into the hospital twice, and in private practice you know that this is all not covered. It's all part of your global. In my experience, patients don't really care if you round on and look at their foot every day. They just want to be out of the hospital and be better and be moving on with their lives.

I found that I've started to skip some rounding days. There are days where I don't round all together. I know that's sometimes controversial, but if I do a source control surgery and everything's left open, I know for sure there's a second surgery. I'll maybe round once to make sure that I didn't miss anything glaringly obvious enough to tell the patient like, "Hey, we might need to do a little bit more." But most of the time I've come to the point where after my initial source control surgery, I don't have any surprises anymore in the post-op rounding process. I'll round on them once, I'll talk about what the next step is to recovery and just provide education really. The rounding for me after the first surgery is more education. I'm not looking at the wound to figure out what I need to do. The second surgery's more about wound closure, steps to getting them back to recovery as soon as possible. Things that the patient can do to improve their chances of a better outcome postoperatively.

There are days when I am so slammed that I have no time to round and I'm approaching burnout, 20 consults, 20 surgeries in a week or so. What I'll do is, do the first surgery, whatever it is. I'll book the second surgery right away for three or four days, because now I know I'm going to bring them back. And that second surgery is either going to be some kind of repeat washout or a wound closure. I'll consent for both and I'll find out once I open the dressings when they're asleep on the table. That's the second surgery. Skipping some of that rounding process after you've gained a lot of experience to know and have predictable, reliable post-surgical outcomes of your source control surgery will really reduce your level of burden when you're in the hospital. If you know that this is going to be outcome it makes your life so much easier. In summary, that just means if you are honest with yourself about how good you can do source control the first time, your life gets so much easier after that.

I think diabetic limb salvage, when I first got into it, I didn't think that it is a doable thing in the private practice world, but I found that to be not true at all. I have had some stints at university and at the VA, and I know there's a lot of help there, but also obviously there's a bureaucracy too. In private practice, you have a lot of control over your schedule and scheduling and privileged in where you go do your limb salvage at which hospitals, and I've found that simple [inaudible 00:06:49], you don't need all the fancy stuff in your cart to apply on these wounds. Just good surgical debridement carries a long way. So in private practice, I find very possible to do a hundred percent diabetic limb salvage. I guess my message is just even if you're in private practice and you want to do this a hundred percent, don't shy away from it. You could totally do it. I'm doing it.