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Help needed with general podiatry treatments

Discussion in 'General Issues and Discussion Forum' started by S. Edwards, May 22, 2013.

  1. S. Edwards

    S. Edwards Welcome New Poster

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    Hello Everyone,

    Long time reader, first (maybe second?) time poster.

    I thought that it may be a good idea to seek advice from the wider podiatric community in regards to assistance in developing satisfaction from my general podiatric patients. I have been practicing for approximately 2 years and have been exposed to the realization that patients often shop around between practitioners before they find a ‘good one’ – and then they can be exceedingly loyal to that podiatrist. I really want to be one of the ‘good ones’ that patients recommend their friends to come and see.

    I am in a very fortunate position, I have a fantastic job working for a podiatric surgeon here in Melbourne and I truly love my job as a podiatrist, especially the surgical side of things and orthotic therapy.

    One area of podiatric practice that I feel I struggle with is my performance with routine general podiatry patients. This isn’t through lack of effort, I always try hard – I just have much more interest in the world of podiatric surgery (which I intend to pursue) and to a lesser extent orthotics.

    I would like to proffer my general podiatry care protocol for critique, and would love if I could receive any pearls of wisdom and/or feedback that you have found increase patient satisfaction.

    My general podiatry treatment:
    - Greet the patient in the waiting room with a handshake and smile.
    - Seat the patient in the treatment chair and remove their shoes and socks if they have not already done so.
    - Begin with the nails, I cut the nails slightly into the sulci so the nail has a curved appearance. I was previously taught to cut right down into the sulci – do you agree with this?
    - Remove debris and file nail edges with Black’s file.
    - Debride hyperkeratotic lesions and enucleate heloma dura.
    - Burr nail edges smooth (and burr whole nail if onychauxic).
    - Moore’s disc entirety of foot, focusing on debridement areas and heels.
    - Chlorhexadine wash.
    - Emollient application.
    - Wipe clean and put shoes and socks back on.
    - Addendum: I leave notes in my files as to what we talked about so we can continue the conversation, eg ‘patient was about to go on holiday to x’
    - Walk out with the patient and tell reception that I ‘need to see mrs x in 8 weeks’ etc.

    Questions/ Things I struggle with:
    - I struggle to debride dry hyperkeratosis to an extent that the patient has ‘baby feet’. This especially occurs on heels and sometimes I find it difficult to get a perfectly smooth result.
    - Do you apply anything to the feet before debridement?
    - With severely onychauxic nails do you keep burring until the nail is of normal thickness? Do you have any tips on how to achieve this?
    - Do you always apply plantar padding?
    - Do you have any other pearls that improve patient satisfaction?

    I understand that a Podiatrist with 20+ years experience will be far superior than a practitioner of my own experience, however it can be disheartening when you are doing your upmost to ensure your patient is happy and they don’t return.
    Thanks for your time and input,

    Steve Edwards
  2. davidh

    davidh Podiatry Arena Veteran

    Hi Steve,

    If you are unsure about how effective your routine podiatry care treatment is you should seek out a refresher course. It's much easier for a tutor to see where your weaknesses lie, rather than us looking at a list.

    Not sure why you would include "putting shoes and socks back on"?
  3. mr2pod

    mr2pod Active Member

    Hi Steve

    Firstly, I congratulate you in your acknowledgement of an area of weakness, and your attempt to gain improvement. Although my areas of interest and possibly expertise is more biomechanics, I have always prided myself on my routine care over the past 15 years.

    - I use chlorhexadine to keep hyperkeratotic lesions "moist" before and during debridement. I find this provides a much easier surface and allows for, in your words "baby feet". A small trick I acquired from a tutor.
    - I attempt to burr onychauxic nails to a "normal thickness". I beleive the key is the quality and type of burr used - it should not take much to achieve this.

    Making a connection with the client is very important, and it sounds like you are attempting to do this.

    I wish you the best in your endeavours to improve.

    Scott Leslie
  4. Samuel Ong

    Samuel Ong Member

    Hi Steve,

    I am no expert but hope this helps.

    Firstly, it is important to ascertain the exact reason the patient is coming in to see you, and make sure you address that. They may be there to have their nails trimmed and calluses debrided, but they are also there because they:

    1. Can’t reach down to their feet. Don’t have the tool/time.
    2. Want some pampering.
    3. Want someone to talk to

    If it is 1, then they will tend to come back unless you unless you were very unfriendly or did a bad job. After all, they just want their nails trimmed and callus debrided.

    If it is 2, then they usually require something “extra”. Those are the patients that are not afraid to “shop around”. They are coming to you to get a general treatment, but what they really want is someone to care for them. Most of the times they are able to do those treatments themselves, but come to you as they want a professional to look after them. Some will even tell you that its their treat to come to the podiatrist. If they have been to a previous podiatrist, ask for the reason they never went back. Impress them with your knowledge. Show care by checking doing a brief neurovascular exam (palpating pulses & monofilament) the first time you see them, talk to them about their fungal nails, footwear, HAV etc.

    If it is 3, then you will need to be able to engage the patient in conversation. Obviously being a good conversationalist helps, but often just by asking the right open ended questions you can get them to talk with you just listening and giving the occasional response.

    Secondly, in psychology there is something called the “primacy-recency effect”. It means that we tend to remember the things at the start and at the end, but not so much in the middle. From what I can gather, you are already providing a good initial impression (not much more you can do other than greeting the patient warmly and smiling). What I do to improve the patient’s last impression of me is by spending 2-5 mins (depending on my timing) massaging some moisturiser into their feet. Often it would be their favourite part of the treatment as it is and only thing they actually enjoy. Although many would argue that there would be little clinical benefit, I personally think that anything that we can do to improve patient satisfaction should be carried out as long as it is not contraindicated. Its abit like a dentist giving a kid a lollipop so the kid would associate the dentist with the lollipop rather than the painful/negative experience. Improved patient satisfaction will lead to better patient compliance and loyalty.

    Don't beat yourself up :hammer: if you are trying your best but patients still decide to go elsewhere. Some patients can never be pleased.

    Just make sure you never give up on your quest for improvement! :drinks
  5. Deka08

    Deka08 Active Member

    2 questions (for your patients toward the end of the treatment).
    1) is there anything else I can do for you?
    2) are you happy with everything we've done today? I ask this of every new patient.

    If after this (and the other stuff mentioned here) the patient don't come back, then buddy you have given them every opportunity to provide feedback for you to make an adjustment to your treatment.
    Only other thing I would say is time and not rushing someone through.
    Good luck champ, honestly, probably took me several years and some beat downs to lift my game to what I, and my patients, are pretty happy with.
  6. Lorcan

    Lorcan Active Member

    Hi Steve

    Why do anything that's not medically necessary rather than cosmetically so? Your a highly qualified medical specialist in your field, not a pedicurist.
    Would you go to your dentist and expect him/her to brush your teeth?
  7. Lab Guy

    Lab Guy Well-Known Member

    When I was in practice, I trained my staff to deliver general Podiatric care. I would then enter the room to check the feet over, enucleate any IPKs or corns and see if there were any new problems developing. I would then mobilize there feet and ankles. I would distract their ankles and STJ as well as mobilize their lateral column. I would also distract their digits.

    Let me tell you, they always wanted to see me for their foot mobilization as it made them feel so good and none of their other Podiatrists ever performed foot mobilization. The foot mobilization would take me about 2 minutes and then my assistant would come in and apply foot cream and help them with their shoes and socks. Patients would walk out feeling lighter on their feet, their muscles more relaxed. If you can learn and implement foot mobilization, your patients will love you for it.

  8. normy

    normy Member

    I am long retired now but I recall reading this survey report somewhere, cannot remember where.
    Two dentists ,one was an all singing ,dancing top expert practitioner in every field ,but lacking in people skills.
    The second one was a very nice sociable person ,excellent at routine chiropody treatments ,listened to all that the patient said and showed a personal interest in the patient
    this was the one with the most successful practice.
    This can apply to Podiatrists also
  9. drdebrule

    drdebrule Active Member

    Your general podiatry treatments sound good to me. Perhaps a survey for your patients needs analysis would be helpful?

    Also, I think Lab Guy's point about adding mobilization is in the right direction because this adds value to your practice. Think about adding new things to your practice: yearly peripheral arterial screening ABI for 65 and older, gait or fall risk analysis, diabetic risk assessment, placing a pad in the shoe for a hammer toe etc. All of these things add more value in your patients eyes and maybe this will be helpful for you. Good luck to you!
  10. S. Edwards

    S. Edwards Welcome New Poster

    Thank you all for your informative feedback. Its great to hear input from others in the field. Im going to try to institute some of the recommendations stated above.

    With Kind Regards,

    Steve Edwards

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