A Conversation with Ajay Ghai, DPM

AJAY GHAI, DPM

FELLOW AT RECONSTRUCTIVE REARFOOT AND ANKLE SURGICAL FELLOWSHIP AT ANKLE & FOOT CARE CENTERS IN YOUNGSTOWN, OHIO

Q&A

Q1: Where did you go to podiatry school and where did you train during residency?
A: I went to school at Western University College of Podiatric Medicine in Southern California and I went to residency at Carilion Clinic in Roanoke, Virginia

Q2: At what point in your education or training did you begin thinking about pursuing a fellowship, was it during school or residency?
A: I don’t think I really started thinking about it until the first year of residency. There weren’t really as many as there are now so we didn’t really know much about it while in school. Basically, in the first year of residency, you end up going to all these conferences and meeting people and you start hearing about fellowships as additional training following residency. For me, I believe education can never hurt you, it can only help you. They can’t take away what you learn and it helps you hit the ground running. During my second year of residency, the program hired a doctor named Cory Fidler, who is one of Dr. Christopher Hyer’s old fellows in Columbus, Ohio, who told me more about fellowships and got me more interested.

Q3: Since there are different types of fellowships (limb salvage, reconstructive surgery, trauma, research-based, sports medicine, etc.), what were you specifically looking for when trying to pick a fellowship?
A: So my residency is very good at infection control and diabetes and very heavy on trauma. We did a good amount of reconstruction and total ankle replacements but not as much as I would like. So when I was looking for a fellowship, I was looking at hindfoot and ankle reconstruction with emphasis on total ankle replacement. When you look for a fellowship, you want to choose something that may be a weak point in your training or to pick up a new skill. Also, where our program was at, our institution didn’t expose us too much to billing and coding, how to manage private practice clinic, so I kind of wanted to see that aspect as well. Obviously, if you don’t know how to bill and code, you can’t make money when you get out so it’s very important and is something that is just not taught in school. Also, I wanted exposure and experience operating on revisional cases. The great thing about this fellowship is that Dr. DiDomenico gets a lot of referrals from other foot and ankle surgeons who performed procedures that didn’t quite turn out right and it’s our job to assess and come up with a plan to make the best out of that situation. In addition, he does a lot of flaps and tissue transfers, something I did not get too much experience in during residency, so this is another new skill that I was eager to acquire by completing this fellowship.

“I would say if you are looking for a fellowship, most of them nowadays since the candidate pool is so strong, research is definitely something that can set yourself apart.”

Q4: I noticed that for your specific fellowship, there are two research publications that are mandatory for fellows. Prior to coming into the Fellowship, was research something that you conducted during residency and school that you believe set yourself apart from other applicants?
A: I would say if you are looking for a fellowship, most of them nowadays since the candidate pool is so strong, research is definitely something that can set yourself apart. The more you can show the fellowship director that you can publish, the more they would be inclined to wanting to have you. I have an article coming out in JFAS sometime this year and I had a poster made that I presented at ACFAS during residency.

Q5: Since fellowships are generally only 1 year, are the research projects that you are expected to produce more of a retrospective study or case series type of publication?
A: Yeah, that’s the difficult thing as you are only there for 1 year. Sometimes the old fellows will have projects that they have started already and you can just try to finish them. The other way to publish is by working on a chapter for a textbook, which is what we are doing currently. There are ways to publish within a year, you just have to decide if you want to go for a study that is more difficult to produce or finish something that has already been started.

Q6: What would you say is a ‘typical day’ during fellowship if such a thing exists, or does it pretty much vary day by day? Do you have clinic for certain days? Are you in the OR all day? How does that work?
A: It’s a mix, day by day. I would say it’s about 2-2.5 days of surgery and 2.5-3 days of clinic. Since there is a residency associated with the fellowship, I do teach the residents one morning a week for radiology conference. Aside from that, it’s just hospital rounding and consults and managing inpatients.

Q7: Since your fellowship is directly associated with a residency program, how is that dynamic with residents as I know some residents/students do view programs that are associated with fellowships as a negative because they may think that the fellows take away cases from them. How is your relationship with the residents at your program?
A: It is a double-edged sword; it kind of depends on the specific residents and the specific fellow as to how that relationship can turn out. If there is a fellow that wants to take all the cases, then obviously it can create a negative dynamic with residents, and if you have residents wanting to take cases from the fellow, it has the potential for poor relationships. Here, however, we have a pretty good hierarchy. There are about 20 attendings that the residents work with> I mainly only work with 2-3 of the attendings so there is still plenty to go around with the other attendings so the residents have no issues getting their numbers. If residents are with me, anything that I am already comfortable on, I let them do. For example, I am pretty comfortable with trauma so we had an ankle fracture last week that I let one of the 2nd year’s do. If there is anything more complicated like a total ankle replacement or Charcot reconstruction or cavus/flatfoot recon, I take the lead and the residents will learn and assist. What they get out of it is that I teach them and I bring my experience from my residency program so they get basically another attending that teaches them.

Q8: In terms of the patients that you see, do you get to see your own patients and follow up on them (pre-op, post-op), or are you seeing mostly post-ops from other attendings?
A: Every fellowship is different. For me, I only manage Dr. DiDomenico’s clinic so I basically see all of his patients. Some weeks, he’s out of town at conferences or he’s at other meetings that he has to go to, so I cover his clinic those days. Whenever he’s out of town, I’ll handle whatever surgeries come in, like I had a case today that I had to do at the hospital. In addition, every other Saturday, I have a half day of clinic in which I am there on my own and see my own patients.

Q9: Is pursuing fellowship training common among residents that graduated from your program?
A: At my residency, I was the first resident to go into a fellowship, however, it is a relatively new program.

Q10: At your residency program, were the attendings encouraging of your desire to go into a fellowship?
A: Most of the attendings didn’t talk too much about it. The only attending that I had who knew a lot about fellowships was Dr. Fidler, who did Dr. Hyer’s fellowship, which is probably one of the best fellowship’s in the country. He was the one who guided me towards choosing a fellowship. It is so competitive now that it is challenging to get a fellowship; I applied for jobs and fellowships at the same time. I felt that my training was adequate that I could have gone out and practiced without a fellowship. A fellowship should not be something that you absolutely have to do, it should just be icing on the cake. You should already have solid fundamentals and know what to do. You should only do a fellowship to take you to that next level in order to get a new viewpoint on how to do things. If you train with someone who does things differently from how you did things in residency, you have a more complete toolkit. Another reason to do a fellowship is to add a new skill to your skillset, such as billing/coding, practice management, Charcot reconstruction, total ankle replacements, sports medicine, etc.

Q11: Did you visit fellowship programs before going through the application process? Is the process similar to residency, as how students visit residency programs beforehand prior to applying?
A: There is no centralized process (like CRIP), which makes fellowship applications more difficult. Every program has a different process. Basically, programs start choosing from June to December of your 3rd year of Residency. You have to go on their website and research and talk to people who have visited different fellowships, figure out which ones you are interested in, and then narrow that down to which ones you want to visit. Then, you have to call them to figure out when they select their fellow by and visit before that date. Unfortunately, there are not a whole lot of resources online to research fellowships. One of the only resources is probably the Student Doctor Network (SDN), which I don’t know if I’d actually recommend. Other than that, it’s mostly word of mouth. ACFAS has a fellowship fair every year on the Saturday of their annual conference in the morning, where Directors and fellows of programs are there, to whom you can ask questions to try to get to know the program a bit better.

Q12: When you apply to fellowships, do you apply during the beginning of 3rd year of residency, or does it depend on the specific program?
A: I would recommend visiting during January to June of the end of your 2nd year as most programs are starting to select by June/July/August. If you wait too long, you’ll be left out of the cycle.

About the Program

Q1: For your specific fellowship program, how many cases are you expected to do during the fellowship year? Are you essentially picking and choosing the cases that you want to see? For example, I know you said you wanted to become more proficient in total ankle replacements during this year.
A: I am in on pretty much every single case Dr. DiDomenico does. The only cases of his I may not cover is like an add-on I&D at night, as you don’t really need to do smaller type cases like that. The minimum amount of cases to be ACFAS accredited is 300. Every fellowship will be in the range of 300-1000, depending on the type of program. Some fellowships you are in the OR 4-5 times a week, some fellowships you are in the OR 1-2 days a week, it just depends.

Q2: In terms of job prospects after fellowship, is there a certain type of job setting that you would like to go into since you have done a fellowship (hospital system, multi-specialty group, orthopedic group, academic institution)?
A: I got offered a position and took a job in California in a large multi-specialty group.

Q3: Do you believe that your fellowship training helped you attain that job?
A: I can’t say for sure but I imagine it sets me apart from the large group of applicants that applied. I think if you are applying for a job in a more competitive area such a big metro (NYC, Chicago, LA, San Francisco, etc.), the fellowship training may be the thing that sets you apart from everyone else and helps you secure the position over someone else who may not be fellowship-trained. In addition, a lot of these fellowship Directors are very well connected in the field, so they may be able to make phone calls to help you out so it definitely grows your resource and networking base to give you more options, especially if you do a fellowship in a different location than you did your residency. Because of that, you may be able to branch out easier and wind up where you ultimately want to be.

Q4: Did you have a mentor to whom you asked questions to about fellowships, I know you mentioned Dr. Fidler, was he your personal go-to person for information regarding fellowships?
A: Pretty much, I used him a lot because he visited and knew about a lot of the fellowships that I applied to and I also had friends in the year above me that got fellowships at different places and I was able to ask them about their time there, what they liked, what they didn’t like, what types of cases they were doing, etc. I would use your upperclassmen and anyone else who has completed the fellowship as people to help you out navigating the process. You can also contact the program and ask for the contact information of previous fellows to ask them directly about the program. I did that with a couple of people and asked them about their experiences at their programs.

“However, you have to make sure that you’re not doing a fellowship just to do a fellowship. If you’re going to do a fellowship, do it in something that you are really interested in and you have a specific goal in mind or a new skillset you want to acquire.”

Q5: Did you apply pretty broadly to fellowships or did you have it narrowed down to just a few?
A: That’s the thing that I believe is evolving and changing nowadays as the applicant pool is growing every year, applicants are getting stronger, this is what I’ve been hearing from everyone that I’ve talked to that’s associated with a fellowship. Before, people would say apply narrow and only ones that you are really interested in. However, because of the competition lately, it’s harder to apply narrow and be confident that you will get a spot. I would say you would need to apply to around 10 to give yourself more of a chance. Certain years may be more competitive than others. Some programs are getting 70-80 applications for 1 spot, and you may be #2 at a couple programs and end up not getting a fellowship because you applied to only 3-4 programs so you would need to apply to a higher number to probably secure one. However, you have to make sure that you’re not doing a fellowship just to do a fellowship. If you’re going to do a fellowship, do it in something that you are really interested in and you have a specific goal in mind or a new skill set you want to acquire. For me, it was hindfoot reconstruction, flatfoot reconstruction, total ankle replacement, ankle fusion, and cavus foot reconstruction. Therefore, all the programs that I applied to deal with that and I was sure that I would get excellent exposure to those cases. Any programs that did not do total ankle replacements, I did not apply to, as that was one of the specific things I was looking to get out of a fellowship.

“As we move forward, I think you will see more and more podiatrists specializing in certain aspects of foot and ankle surgery.”

Q6: For someone who eventually wants to end up in a hospital setting, multi-specialty group, orthopedic group, etc., do you think the profession as a whole is moving towards fellowship training being the norm in the future?
A: Moving forward, possibly. Right now, definitely not. However, it basically puts you on par with your orthopedic colleagues as all of them have “fellowship-trained orthopedic foot and ankle surgeon” on their advertisements/signs so we can have “fellowship-trained podiatric foot and ankle surgeon” if we are fellowship-trained and gives us a marketability boost. I think the future is heading that way as things are becoming much more of a niche. As we move forward, I think you will see more and more podiatrists specializing in certain aspects of foot and ankle surgery.

Q7: In conclusion, do you have any general advice for current residents and students who may be thinking to apply to fellowships down the line, aside from all the valuable information that you have already shared?
A: To students, your job right now is to get a well-rounded residency… that should be your #1 concern. Don’t worry about fellowships until you get to residency. Once you get to residency, figure out what your program is lacking. No residency is perfect, they’re always going to be lacking in something. Figure out something specific that you want or are interested in gaining further expertise in that you want to do when you get out, and then start looking at fellowships that are related to that during your first year. Go to ACFAS, start networking with people, try to find a mentor who has done a fellowship or been through the process, and that will help you out greatly. Also, don’t bank on fellowships 100%, apply to jobs at the same time as well. It’s so competitive that you may not get one even though you may be an excellent candidate. During your first year of residency, figure out what skill you want to enhance or acquire, look for fellowships that specifically will give you exposure to that, narrow your list to ~10, visit as many as you can and keep in touch with the program and past fellows of those programs, and then apply. In the meantime, research is definitely something I would recommend if you want to do a fellowship. The rest is just your personality and you meshing with the program. Also, when applying to fellowships and jobs at the same time, if you come across a dream job that offers you everything that you are looking for (location, practice setting, caseload, lifestyle), take the job because they can be hard to come by and it may not be there after you complete your fellowship.

By Rafay Qureshi

Temple University School of Podiatric Medicine
Date/time of interview: 02/24/2019 at 6:15PM over the phone

the fellows

Special edition
Vol 1.

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