In this episode of the Podiatry Legends Podcast, I speak with Dr. Patrick Agnew, a true pioneer in paediatric podiatry and an expert in managing complex connective tissue disorders such as Ehlers-Danlos Syndrome (EDS). When it comes to building a fulfilling and impactful podiatry career, finding your niche can be the difference between just showing up to work and loving what you do.
The “Best Kept Secret” in Medicine
Like many of us, Patrick didn’t start off knowing about podiatry. After exploring marine biology and working in emergency rooms during college, he found himself disillusioned with mainstream medical careers. That changed after a single day of shadowing a podiatrist. What he saw was a profession that blended medicine, surgery, dermatology, and biomechanics, with minimal burnout and a high quality of life.
That first-hand experience, coupled with a chance to work alongside Dr. James Ganley (a founding member of the American College of Foot and Ankle Pediatrics), launched Patrick into a career filled with impact, innovation, and mentorship.
Check out my – Upcoming Events
The Pediatric Podiatrist’s Perspective
Today, Dr. Agnew is on the board of the American College of Foot and Ankle Pediatrics. He continues to write, speak, and advocate for greater understanding in this often-overlooked niche. According to Patrick, pediatric podiatry is an area many practitioners fear unnecessarily, mainly because the stakes seem higher and the data are often sparse.
That fear is valid. After all, treating a child wrong can lead to decades of problems. But Patrick encourages curiosity over fear. “There’s no competition,” he says. In fact, many podiatrists shy away from treating children because of perceived risks, parent pressure, or financial concerns. But for Patrick, those young patients are the most rewarding part of his work.
He reminds us that 15–20% of your caseload in a focused niche is often enough to fuel professional satisfaction, without needing to overhaul your entire clinic.
The Complexity of Ehlers-Danlos Syndrome (EDS)
One of the most fascinating parts of the interview was our discussion around connective tissue disorders, particularly EDS. These patients, often misunderstood or misdiagnosed, present with complex symptoms that affect multiple organ systems, but nearly all of them have foot-related issues.
Patrick has been involved with Ehlers-Danlos organisations since their early days and continues to treat patients with custom surgical procedures. One innovation he’s known for is a technique to reconstruct the medial collateral ligament in bunion patients, particularly effective for those with ligament laxity from EDS.
And yet, what stands out is his humility. Patrick makes it clear: there’s no one-size-fits-all treatment. Every EDS patient is different, and real data is limited. “There aren’t enough facts to tell for sure what will happen,” he says. That’s why second opinions, open dialogue, and continual learning are so important.
The Role of Lifelong Learning
Beyond clinical skills, Patrick is deeply invested in education. As the founder of a podiatric residency at Eastern Virginia Medical School, he’s trained countless residents. But he admits: it’s the teaching that makes him sharper. “The students think I’m testing them,” he laughs. “I’m asking them to teach me.”
This outlook reinforces one of the big takeaways from the episode: stay humble, stay curious. Whether it’s writing papers, lecturing, or just answering a student’s question, the act of teaching pushes you to reassess your own assumptions.
Why Niche Practice Matters
If you’ve ever thought about leaning into a special interest, whether it’s pediatrics, sports, or biomechanics, this episode is a powerful reminder to take that leap. Niching down isn’t about exclusivity; it’s about passion. As Patrick says, “You don’t have to do it 90% of the time, 15% to 20% can still make a big difference.”
Whether you’re a new graduate unsure where to focus or an experienced podiatrist ready to reignite your love for the profession, there’s a lot to learn from Dr. Patrick Agnew.
If this conversation with Dr. Patrick Agnew sparked something in you, whether it’s a curiosity about pediatrics, an interest in connective tissue disorders, or simply the desire to grow your niche, don’t let it fade. Share this episode with a colleague, reflect on your own career path, and remember: if you ever want business mentoring or help narrowing your focus, I’m just an email away.
If you’re looking for a speaker for an upcoming event or a facilitator to run a pre-conference workshop, please visit my Speaker Page to see the range of topics I cover.
Are You Looking for A Little Business Guidance?
A podiatrist I spoke with in early 2024 earned an additional $40,000 by following my advice from a 30-minute free Zoom call. Think about it: you have everything to gain and nothing to lose, and it’s not a TRAP. I’m not out to get you; I’m here to help you.
Please follow the link below to my calendar and schedule a free 30-minute Zoom call.
I guarantee that after we talk, you will have far more clarity on what is best for you, your business and your career. ONLINE CALENDAR
Business Coaching
I offer three simple coaching options:
- Regular Monthly Calls (one or two calls per month).
- Hourly Sessions – Book them as you need them.
- On-Site Clinic Training Days – Your team will love it.
But let’s have a chat first to see what best suits you. ONLINE CALENDAR
Facebook Group: Podiatry Business Owners Club
Have you grabbed a copy of one of my books yet?
UN-EDITED PODCAST TRANSCRIPT
Tyson E Franklin: [00:00:00] Hi, I am Tyson Franklin, and welcome to this week’s episode of the Podiatry Legends Podcast. With me this week, I have another legend. It is Dr. Patrick Agnew. He is from Virginia Beach in Virginia, and we’re not gonna hold him up too long today because he’s going surfing this afternoon. May touch on that, but Patrick, if you recognise the name, he was on episode 3, 7 3 titled Podiatry Student Recruitment Research and Unity. And that was with Dr. Ben Pearl and Dr. Patrick DeHeer, who’s also was on the podcast a couple of weeks ago. So after talking with Patrick on that particular episode, I wanted to even come back on because he had a, I thought, a really interesting career from being involved in the early developments of Podiatry, pediatrics.
To his military service in the United States Navy, serving in Desert Storm and Desert Shield. And I could go on. But Patrick, I’m gonna let you tell your story. So welcome back to the Podiatry Legends Podcast.
Patrick Agnew: Ah, thanks for the [00:01:00] in invitation. I had a lot of fun last time. That, that was a remarkable group you put together for that conversation.
I did a whole lot more listening than talking. I guess it’s my turn to talk more.
Tyson E Franklin: And that’s why I got Patrick DeHeer back on as well, and Ben Pearl had been on before and he’d spoken about his career. And when you touched on a few things, there were so many, like we could probably do a whole episode on Podiatry, pediatrics.
We could probably do a whole episode on you being in the Navy. So it’s one of those things that your career’s been so interesting. I think it’s really interesting to go through it all. So my first question as I like to ask a lot of people, what got you interested in this crazy profession in the first place?
Patrick Agnew: Excellent question. And I get to answer that almost every day. I I was always interested in medicine. I thought it would be worth. I was an undergraduate. I actually was a marine [00:02:00] biology graduate. Okay. Undergraduate. And I did that for fun ’cause I knew I could take my biology, chemistry, math and physics and still drive a zodiac around the living even inlet and scuba dive and do fun stuff.
But I didn’t really know which sort of specialty in, in medicine I would want to do. I drove an ambulance all through college and I worked in the emergency room at a local hospital, and I got to see a lot of different professions and what they did, and I got a little scared. A lot of the guys, a lot of the doctors seem to be very unhappy, you know, it seemed like they were not only divorces, but a lot of drinking, maybe some other bad habits.
Tyson E Franklin: Yeah. And
Patrick Agnew: I got a little scared about medicine in general, and I was wondering, what’s wrong with this? Why does so many people seem to succumb to those sort of problems? And I realised it, it wasn’t the medicine itself. Some of the demands and the different specialties seemed to be really [00:03:00] unreasonable.
That it was just expected that you weren’t gonna get any sleep. You were gonna be called at the most inconvenient times. And I was talking to my college guidance counselor. Well, I found out later we were both competing for spots in the same medical school. He was he was a graduate student.
He was my guidance
counselor so he may have had some additional agenda in giving me advice, but he said, why don’t you look into dentistry?
And I said, that looks like it’s even worse? And he said, well, how about Podiatry? And I said, what’s that? And he arranged for a visit with a local Podiatry. And Dr. John Dilio, and I spent a day with him and he seemed like the happiest guy I’d ever met in medicine. And I saw all the different things he did through the course of that day.
And I realised, gosh, this is like a best kept secret in, in the four hours I was there, he was a doing orthopedics, he was doing dermatology. He was a [00:04:00] vascular specialist.
Tyson E Franklin: So many podiatrists that have come on this podcast mention how they went and saw a Podiatry, for example, or they shadowed a Podiatry and they could, then they said the same thing.
This is like the best kept secret they’d ever heard of. The person actually enjoyed the job, wasn’t being called out after hours, had a great relationship with their patients, and I think this is really important for anyone who has another person come into your room to learn about Podiatry.
If you are not giving ’em the most positive experience, please don’t take them into your room. If you are one of those miserable podiatrists, which I don’t assume they listen to this podcast anyway, if you are miserable, please do not let school students or anybody else who’s thinking about doing Podiatry in your clinic, just let them go and see somebody else.
But I think that also applies when people first graduate, if they end up working somewhere and that person is a little bit [00:05:00] miserable, I think in your first few years, it’s really important to make sure you have a positive experience in those first few years if you’ve got a really negative boss, change jobs before you change professions.
That’s what I reckon.
Patrick Agnew: That sounds like great advice. The uh, American Pediatric Medical Association Council on Podiatric Medicine, so they have a referral network where interested students can link up with. Doctors in their community and have experiences like coat tailing in an office. And I’ve met a lot of really neat kids like that.
One of our new interns that just started our residency a couple weeks ago actually came and visited with me early in her college career and decided to become a Podiatry. Now she’s, now, she’s a Podiatry and she’s one of our surgery residents.
Tyson E Franklin: Yeah I, when I was in the UK in Liverpool doing a talk at the [00:06:00] foot and ankle show and there was a young girl there who came up to me and she said, I just wanna let you know I used to live in Australia and I came and saw you when I was like 10 or 11 as a patient.
That visit and that whole experience I went through with all my treatment, she goes, it was so positive that I said, from that day, I wanna be a Podiatry. And that’s how she got into it.
Patrick Agnew: You did a good thing.
Tyson E Franklin: Yeah. It’s amazing the impact you can actually have on people with what we do.
Patrick Agnew: Well, I think physicians had an impact on my development. I’ve broken about 13 bones. I’ve had about a hundred stitches. Yeah. I was a reckless, wild kid. Surfing, biking, skating, playing hockey, everything. I got hurt a lot. I was too little probably, or just not talented enough for some of these things.
And usually I’d be laying there in the emergency room and then the doctor would come in as the hero that was gonna put a cast on my arm and let me go home. [00:07:00] And I think I don’t know how many, what percentage of doctors had medical experiences as a child, but I’m sure it’s formative.
Yeah. And I’ll tell you, I haven’t been disappointed at all.
Tyson E Franklin: Yeah. I never even thought about Podiatry or never even thought about anything in healthcare because I played tons of sport, never got hurt. I just never got hurt. I was like rubber, I just bounced.
So I never had to go to a doctor. I never had to see a physiotherapist. I never saw anything except the dentist. So my brother ended up becoming a dentist. And that was the first exposure that, oh, you could do something in healthcare. And then fortunately, a good friend of mine or a guy I went through school with from grade one all the way through the end of high school, he went off and did Podiatry.
And I went back repeated grade 12. ’cause I had no idea what I was gonna do. And that’s how I was exposed to it.
Patrick Agnew: Well, I’m guessing like me, you weren’t disappointed. I knew what I was gonna be when I started. You’re not up to the [00:08:00] vagaries of some kind of a match, and it might wind up in some specials you don’t really like.
I knew where I was going and it was pretty wide open field. I mean, podiatrists, I guess, are the last surgeons to leave the barbershop, and we still, when I graduated in 1986, it seemed a little wild west. Yeah. A lot of the things we were doing, we were learning through. Almost folklore.
We weren’t deep enough yet into evidence-based medicine and our curriculum was getting closer and closer to allopathic medical school, but it wasn’t quite there yet. But there, there was a lot of uncharted territory. So when I got out into practice, I had done my residency with Dr.
James Ganley, who was one of the founders of the American College of Foot and Ankle Pediatrics. He had learned pe, he had learned orthopedic surgery working next to a Dr. Abundance at the Naval Hospital in Philadelphia. He was an [00:09:00] enlisted man, and Dr. Abundance took him into his clinic and knowing that he was already a doctor Podiatry and there wasn’t really a an officer commissioning program for Doctors of Podiatry.
Yeah. So he went in enlisted and worked with Dr. Abundance and learned orthopedic surgery and. Then he took those skills, opened his own practice, and part of that practice was working at a state hospital, which used to be all over the United States. And these were hospitals where people with physical, with severe physical and mental disabilities would be intern.
They were, they would live their lives there and he would try to help, he’d try to take these. Very disabled children and get ’em to the point where they could walk or at least get ’em where they could sit in a wheelchair straight and
Tyson E Franklin: yeah,
Patrick Agnew: exercise these skills.
Tyson E Franklin: So was it that aspect of seeing that where you could take a child who couldn’t walk to being able to make such a life changing experience for them?[00:10:00]
Patrick Agnew: That had a huge effect on me. Working driving an ambulance, working in the emergency room, I witnessed a lot of heroics.
Tyson E Franklin: Yeah.
Patrick Agnew: My very first night on the job in the emergency room, I was the thumper on the code team. I was doing chest compressions on a, on an old farmer who had keeled over on his field, and.
They brought him to the hospital, although he was, I, he was dead. Yeah. He really didn’t have a chance of survival, but we went ahead and decompressions. I could still see that guy’s face in my mind, but just the watching the people working around me and the the real adventure of making huge changes in people’s lives was very exciting to me.
And to be able to do that, even just working on. A relatively humble organ like the foot was was something that I pursued. So yeah, I gravitated towards things like reconstructive surgery pediatric birth defects and things that I guess pushed the edge of the envelope in Podiatry.
[00:11:00] And I and I. Offered those opportunities. It seemed like there were no boundaries and it still seems that way
Tyson E Franklin: and there weren’t a lot of people doing it at the time.
Patrick Agnew: No, still, not still pediatrics is a small group. I am on the board of directors of the American College of Foot and Ankle Pediatrics, as has been Dr DeHeer
and we have our national meeting coming up in September, by the way and we always do it at a national park. This one will be at Estee National Park in Colorado. We’ve been to the Everglades, we’ve been to the Badlands in South Dakota. We’d go all around the country to these national parks.
We usually spend a day exploring, and then we spend two and a half days studying like crazy and spending 12 hours in a conference room. And it’s a great group of people, but a fairly small one still.
Tyson E Franklin: Yeah. And when you say a small group, how many people is it that you’re talking about?
Patrick Agnew: Yeah. So we’ll often at that meeting get anywhere from, a hundred to two, 300 people at the max I’ve ever seen is [00:12:00] pushing 300. Okay. And the number of members of the American College of Foot and Ankle Pediatrics kind of vacillates in that range out of the many podiatrists in the United States.
That’s, those are it is a relatively small group. We talk a lot about how, I think a lot of, a lot of podiatrists are intimidated by pediatrics and that, what do you think that is? Well, it might not be an unhealthy reaction. Yeah, I mean, the consequences of failure are pretty grave. You do have liability for 21 years, you.
And if at any time during childhood a problem is discovered that’s legally actionable all the way until the, into the child’s an adult unlike adult care. Also, who would wanna hurt a kid? I mean, Jesus said, as, as bad as we are, at least we’re good to our kids. I think immediately after that he said, but even a dog’s good.
His kids, it was left-handed compliment, but we we do, no one wants to hurt a child. So [00:13:00] people get intimidated by that. But there are opportunities for increasing knowledge, even past Podiatry school and past residency for those who are interested.
Tyson E Franklin: You traveled overseas doing this as well.
Patrick Agnew: We haven’t had an American College of Foot and Ankle pediatrics meeting overseas. But I’ve traveled overseas with the United States military and done medical care for all ages.
Tyson E Franklin: With the pediatrics, you’ll still heavily involved in that now, aren’t you?
Patrick Agnew: Yes. Yep. I I still write some things and lecture pretty regularly. I’ll be one of the speakers at the meeting in Colorado again. Of course. I think that’s the, that’s how they get a double deal out of me. I’ve gotta be there for the board meeting anyhow, so they say, well, you have to work also.
And I that’s fair enough. I enjoyed that. I love lecturing and writing because it, well, it challenges my premises. I have my opinions on things and sadly, a lot of pediatrics [00:14:00] is opinion. The amount of real evidence-based medicine in foot and ankle pediatrics is limited. You’re never gonna find a good control group.
No mother wants her child to be in the control group.
Tyson E Franklin: Yeah.
Patrick Agnew: Again, nobody wants to hurt a child. Our institutional review boards and our research designs have to be especially carefully crafted to protect the innocent. And so a lot of pediatric foot and ankle care is based more on opinion than real scientific fact.
Also, a lot of the things that we see in pediatrics may not. Be consequential until a patient is an adult. We wanna do the right things while the patient’s young. And our opportunity for excellence is there, but we may not know the fruits of our labor while still in practice or even while still alive.
The consequences may be 20, 30, 40 years down the road. But that also makes it [00:15:00] interesting, it’s again, a. A wide open field. There, there any new knowledge brought there is precious because there is so little already in existence. There are a lot of opinions out there.
Tyson E Franklin: And when someone
Patrick Agnew: forms an opinion about pediatrics, they’ll defend it like a jihad. They’re like, this is the law, but and I’ll say, well prove it. Show me the data that supports your opinion. The first thing I tell parents when I meet parents of a potential of a pediatric patient is that, look, I’ve read everything on pediatrics for 40 years in several different languages, and I don’t know the answers.
I know my opinions, I know the facts that are out there, and there are two. There aren’t enough facts to tell for sure what’s gonna happen with your child. Yeah, or whether or not treatment is indicated, what the consequences of those treatment are gonna be. But in my experience and from the amount of [00:16:00] data that is available, here’s my recommendation.
Now, and I also tell them, if you go to another provider, which I encourage second opinions always.
Tyson E Franklin: Yeah.
Patrick Agnew: If you go to another provider and they tell you they know what’s best for your child, you should run the other direction. You’re they’re telling you their opinion. That, but they’re selling it as fact.
Tyson E Franklin: And
Patrick Agnew: I think that’s wrong. I think we really need to be humble and honest with our patients about what we do and don’t know.
Tyson E Franklin: So many little nuggets that I could pull out from what you were just saying. Then one about yeah, we all have opinions and I say the same thing to patients.
When they say, what should I do? I go, well, from my experience and what I’ve worked out work, treating other patients, this is what I think will be best. And if they said to me, oh, can you guarantee that’ll work? I go, no . I can tell you what next week’s a lot of numbers are gonna be, but I can’t guarantee that’s what they’re gonna be.
This is just, like I said, it’s my opinion, but I like how you’ve been doing this most of your career [00:17:00] and how you get together at these meetings and you still openly just admit You don’t know everything. And I get really annoyed when I’ll see a Podiatry who will stand up and they try and pretend they’re the expert.
In a particular area, and they just with confidence, and I mean with a hell of a lot of confidence, they get and just blurt out their opinions on everything, but they say it in such a manner that they scare a lot of the new and younger graduates thinking, oh, that must be the right way to do it. Because they banged their chest when they did it and they were, they have a little bit of aggressive tone in their voice, so they must be right.
But that’s not always the case.
Patrick Agnew: That’s a big yellow, a big red white flag there. Big scary behavior. And it’s huberous and it can be dangerous.
Tyson E Franklin: Yeah. Well, you’ll see ’em on, you’ll see ’em on Facebook where somebody will post a comment and you might look and go, yeah, I don’t think that’s exactly right.
You’ll see these polite comments coming through and then you see these just twats just [00:18:00] all of a sudden. Nah. And they’ll post. Four different references of different articles and really just almost humiliate that person. And I’m thinking, yeah, you could’ve just sent them a private message to do that.
Didn’t have to be in a, in an open forum.
Patrick Agnew: I appreciate the passion, but I also admire humility. And
Tyson E Franklin: the other part I thought you said was really good is when you go to these events and you like talking and you like writing because it forces you outta your comfort zone a little bit.
Tell me if this happens with you, but when I wrote it’s no secret there’s money in Podiatry. And the funny part is that book’s not about making money, I said to this other author, can I ask you a question?
With all the time and effort and research I put into writing that book, I feel a lot smarter by doing that. And he went, yeah, you do. Because you can’t just say something without checking the facts. But I found the same thing. Every time I write a blog article. Anything. [00:19:00] I feel better for the process,
Patrick Agnew: just the process of trying to explain something to someone else. Deep into your understanding.
That might have been Ben Franklin. I, there’s a quote there I’ll have to look up, but I had the blessing of founding a residency program here at our medical school and 25 years ago. And. That was a relatively rare thing for a Podiatry residency to be in a big regional allopathic medical school like Eastern Virginia Medical School.
And I had, thank God, the initiative and the guidance of Dr. Kieran May, who was a professor of surgery. He was the chief of surgery at Temple University when I was a student, and he became aware of a grant program through the United States government to start new residencies. He called me up and he said, Patrick, would you like to start a residency?
I said, absolutely. Yeah, I can’t wait. And it was a lot of work. I remember faxing paperwork to the [00:20:00] council on Pediatric medical Education from the nursing station as my youngest son was being born down the hall of the of the hospital. So we had so much paperwork to do, but the, my residents and my students.
Think that I’m teaching them for their benefit.
Tyson E Franklin: Yeah.
Patrick Agnew: It’s a it’s a big charade. Okay. I’m teaching them to reinforce my knowledge and hang around these brilliant young people. These kids are so smart. I would not be able to get my own residency now. I wasn’t a smart enough student. To get my residency program that’s so competitive and we get a couple of hundred applicants for each spot.
And they’re top notch in their classes and these kid just being around these kids, I hope I absorb some of their knowledge and intelligence just through osmosis and being near them. But I, I practice, I guess a lot of Socratic teaching. I ask them a question and yeah, they think I’m asking the question ’cause I [00:21:00] wanna know if they know the answer.
I wanna know, I want them to give the answer, want them to teach me.
Tyson E Franklin: I’ll admit that. When, what, when having a clinic, and we’d always have at least one or two students come through every year who like in their final year and they’re thinking about what they’re gonna do. And our goal is always make sure they have a fantastic experience.
One, not just because were we looking to employ somebody, but I wanted them to say, this is what a really good clinic looks like. This is what, if you ever have your own clinic. Try and make it better than mine. ’cause then that is gonna be fantastic. But I would ask them a lot of questions and they would be answering stuff and I’m going, oh, I didn’t know that.
That’s actually really interesting. And that’s the thing. And that’s why I always think it’s great. You are always on that path of learning. Even though now I’m not in a clinical situation, I talk a lot more about business and marketing. I’d probably read more marketing books than anybody else, or business books, because every time I pick up a book and read it, I’m always [00:22:00] learning something new.
If I was still in a clinical situation, I’d be reading a lot more Podiatry stuff.
Because I think you’ve always gotta be just improving.
Patrick Agnew: Well, you can have all that Podiatry, all that medical knowledge, but if people aren’t coming in your door. They’re not benefiting from all your hard work.
So the marketing part’s irrefutably important.
Tyson E Franklin: My goal is if I can learn more about business, more about marketing, more about communicating with patients and being able to get your message across to them. If I spend my time doing that, then that saves the people that come along to my events.
You don’t have to spend the months of reading all these books. I’m just gonna give it all the information to you. In one day, and then you can go back and actually apply that.
Patrick Agnew: Excellent. You said something else that reminded me of a thing Dr. Ganley used to say frequently, which is if the student doesn’t surpass the teacher has failed.
So I don’t know if that was his quote, but it’s a great one. The I love [00:23:00] watching. My former residents go on to great things and I think it reflects very positively on our teaching program, but also on their their dedication and their drive and their initiative to go on to to make their own careers.
But yeah, it’s a. It’s like having having three new children every year.
Tyson E Franklin: I think that’s a really good point. Once didn’t
Patrick Agnew: grow up. Yeah,
Tyson E Franklin: I remember I’ve had a number of Podiatry that came and worked for me who went off and set up their own businesses and did other things, and they did far better and did a lot more than I ever did with my own practice, but even some of my coaching clients.
Then you did the right thing. Yeah. I look at some of my coaching clients who at the ages that they are, have. Doubled what I ever did in my practice at that same age. And I’m just like, it actually makes you feel really good.
Patrick Agnew: That’s irrefutable success. You did a good thing.
Tyson E Franklin: So, Back to you, back to your career , so is majority of your career [00:24:00] all based around pediatrics?
Patrick Agnew: No, it’s a significant part of my practice,
probably 15 to 20% is pediatric.
Tyson E Franklin: I’m so glad you said that is Uhhuh. I’m always a bang on the drum about find your niche, find something in Podiatry that you love doing, and the more you can entwine that into your day, the more you’re gonna just enjoy, gonna work each day.
But it doesn’t need to be 90% of what you do. It doesn’t, it’s probably not even gonna be 50%, but 15 to 20% is a great percentage.
Patrick Agnew: It’s that 80 20 rule. Dr. G to always mention said, 80% of your effort goes into 20% of your patients and vice versa. There’s 20% of your patients that are gonna require 80% of your efforts.
And that’s a, that’s just a way of things are. Now the, we were talking about the niche manship actually published a paper with Podiatry management or Podiatry today, one of those [00:25:00] two magazines on niche manship and specifically addressing pediatrics. And how there there’s no competition.
Dr. Ganley used to say children are loud, smelly, and wet, and their parents are usually poor. So it’s not like everybody wants pediatric patients.
Tyson E Franklin: That is so true. That is so true.
Patrick Agnew: But they’re my favorite patients. I know why they’re there. Yeah. Some of my adult patients want time off work. They wanna sue somebody they want.
They may not want to get better. Yeah. Every single one of my pediatric patients wants to get better and that’s very encouraging. Not always the case with adults. Yeah, that’s,
Tyson E Franklin: it’s true. I do recall you having a lot of children coming through the clinic.
I wanna get back and playing football. I wanna be playing soccer. They just wanted to be out pain because it was interfering with their life. And they give you honest answers. Had, you make some of them, how’d this go? It was horrible. [00:26:00] They don’t care about your feelings either. But it will admit some adults.
You question sometimes, especially if it was an insurance claim.
And you’d be saying to them, I don’t think what you’ve got here is related to what the injury you had. And I, that’s not the answer. That was the incorrect answer.
Patrick Agnew: Not what they wanted to hear. Yeah.
Tyson E Franklin: Yeah.
So I can understand your appeal in that area. But you did the article on niching, did you, about niching into that area?
Patrick Agnew: I said, look in your community there, there’s some service related to foot and ankle medicine that is underserved or neglected. At the time I started and up until just a year or two ago, I’ve been the only Podiatry at our children’s hospital on the children’s hospital medical staff.
I applied for privileges many decades ago. There was some. Questions. Yeah. About, why does a Podiatry [00:27:00] need privileges at a children’s hospital and does this exist anywhere else? And one of the only other children’s hospitals in the country that I could find that did have a Podiatry was Children’s Hospital in Cincinnati.
And the Podiatry there was kind enough to write a letter and say, yep, have privileges here. Here’s what I do with them. And I got my privileges and I do, little blocks of surgery there throughout the year. We’ll go months with no pediatric surgery cases, and then we’ll do five in a day. It’s it’s like an ice cream shop, yeah. They all come at once. But another niche that we haven’t talked about yet, and I wanted to touch on is these patients with connective tissue disorders.
That’s something I stumbled into. The second annual meeting of the Ehlers Danlos National Foundation was at a local hospital where I was on staff and a colleague, [00:28:00] Dr.
Pat Aino, who was a orthopedic hand surgeon, had also been a naval officer, and he put a actual three by five card. On a bulletin board at the hospital. That’s how we used to communicate. And it said there’s a meeting of the Aler de Los National Foundation at this hotel in Chesapeake, Virginia on Saturday.
And so I showed up and I sat in the back of the room and I was listening and everybody was complaining about foot problems.
Pat came up to me halfway through and he said, are you interested in this? And I said, yeah. I remember remembered hearing about it as a student. I assumed that they had foot problems.
I had been in practice for about five minutes, so I didn’t have anything to do. So said, yeah, I’m interested in, we actually went to a hotel room and did punch biopsies on the shoulders of these patients and sent their tissue off to a Dr. Bitten up in Seattle. [00:29:00] Was, and probably still is one of the world’s leading authorities on connective tissue in the ultra structure.
And he’s looking at these specimens under electron microscope and such.
Tyson E Franklin: Yeah.
Patrick Agnew: So I and, not probably the way research will be done today, 30 years later, but so is this
Tyson E Franklin: real, this is very early on in your career though, that you got involved in this. Yes, sir. Yeah. So this isn’t something that’s just more recent.
This is something you’ve done over the last 30 years as well.
Patrick Agnew: Yes, sir. I’ve been affiliated with Ehlers Danlos organisations since really the inception, like the, as I say, the second annual meeting of the EDNF. Now, the EDNF later morphed into the Ehlers Danlos society, currently based in London. And it’s an international, large international organisation now with some incredible.
Geneticists and rheumatologists and I sit in the corner of the room, intimidated by the brain power in the room.
And I’ll apologize for, Hey, I just take care of their feet. I, all this other [00:30:00] stuff’s fascinating, but, and they’ll say, no, no patients actually like you.
These guys. Poking and prodding and researching them, but I make their feet feel better. So they like coming to see me. And we do have people come to our private practice and our teaching program from all around the world for, we developed a couple of procedures that seem to help them.
Tyson E Franklin: Yeah.
Patrick Agnew: And we’ve learned a lot, mostly on the job. There isn’t, again, enough data in that area to know exactly what’s right to do. And we do consider the connected tissue disorders all to be on a spectrum where you might have the same chromosome as another patient, but your phenotype, your expression of that chromosome may be very different and but just almost a hundred percent have foot problems.
Tyson E Franklin: When you are talking about coming up with a procedure you would’ve done a number of procedures previously. So do you get together with other podiatrists who sit down and go. I was wondering if, and you take ’em [00:31:00] through a process and what you are thinking based on everything you’ve done in the past, and then they share, well, we’ve done something similar and modified it here, then you all agree that we’re going to try this.
Patrick Agnew: So that’s one method. Yeah. And we certainly have gone that direction. The procedure that is probably the most common one we use is a replacement of the medial collateral ligament of the first toe. You hear about bunion operations and the Yeah, relatively high failure rate. And it’s disconcerting and everybody’s always trying to find the best bunion operation.
I’d submit that there is no best bunion operation. There are several different things we might call a bunion at different levels on the first ray that might require different types of treatment, but one thing that happens all too often is the big token just flop back over.
Tyson E Franklin: And
Patrick Agnew: if you have incompetent ligaments, and this is an idea I got from Dr.
Ganley also, was that if a ligament is already stretched outta [00:32:00] shape like the medial collateral ligament of the first toe, why would you trust it to hold the toe straight? It’s already failed once. So a lot of bunion operations include a, a capor fee or a tightening of that medial capsule to hold the toe straight.
This is a ligament that’s already demon demonstrated itself to be incompetent. So we’ve been replacing the ligament with suture and bone anchor devices and we’ve experimented with different types to try to find the best fit. And we’ve been, we’ve done many of these over the last eight or nine years.
We published a number of posters at different national conferences. And we think we’ve got it pretty well refined now where it could augment just about any other bunion operation. And we’re, we’ve been using it in people who don’t have connective tissue disease. Yeah. More routinely now. And I think it’s a, I bet 3000 years from now, [00:33:00] archeologists gonna dig up a bunch of people around Virginia Beach and they’ll have perfectly straight toes.
Tyson E Franklin: Well, you’ve seen that thing. In Egypt, they found that toe prosthesis thousands and thousands of years ago.
And that, that did the rounds everywhere.
Patrick Agnew: How about that?
Tyson E Franklin: Somebody came up with that 3000 years ago and probably at the time went, Hey, what do you reckon about this? And they’ve gone, it’s not bad.
Patrick Agnew: The tricky thing about these niches is that in children and in people with connective tissue disorders, you have to learn a lot of internal medicine too.
Pediatricians are probably the most poorly paid and most sophisticated in internists in order to treat pediatric foot and ankle problems, I think you’re obliged to learn a lot about kids. You need to know about medications that may not be appropriate for children or appropriate doses.
How usual childhood diseases may impact foot and ankle problems.
Tyson E Franklin: And
Patrick Agnew: we had [00:34:00] one, one patient where a child had strep throat and developed erythema nodosum on the foot. No one could figure out why this child had these painful skin lesions on their foot, and it was an autoimmune response to their strep throat.
So something that you wouldn’t pick up on if you didn’t spend some time studying about children in general, not just their foot problems. And in the patients with connective tissue disease is, this is especially true, connective tissue connects every cell in your body to the next cell. So if you have hereditary or genetic flaw.
In your connective tissues, you can have dysfunction in every organ system.
Tyson E Franklin: Makes sense.
Patrick Agnew: So you need to know not only that these people are gonna have a special path of mechanical foot that doesn’t necessarily pronate, but it’s sags. But you also need to know that they might have postural orthostatic tachycardia syndrome.
If you’re trying to fix that flat foot or fix that bunion, you need to know that their blood [00:35:00] pressure may fluctuate. So you speak with the anesthesiologist about that. You need to know how careful we need to be moving the patient so we don’t dislocate their shoulder or something. They can have disautonomia and have their temperature suddenly change.
Have mast cell activation syndrome where there seem to be allergic to everything. Only one of, one of our former directors of our medical and scientific board of the Ehlers Danlos Society said to me that in order to take care of people with connective tissues, you just have to know everything about everything.
And I said, well, I’m a carpenter.
Tyson E Franklin: Yeah,
Patrick Agnew: maybe a cabinet maker on a good day. But I I don’t know everything about everything, but I endeavor to know enough about diseases of childhood diseases or comorbidities of connected tissue disorders to take proper care of these patients’ foot problems with a broader perspective on their general health.
Tyson E Franklin: [00:36:00] But I like what you said then just about, you being a carpenter for example. But I think even people in the trades they know their trade and they might have seen an electrician do enough work to figure out. There’s certain things I know I could probably do ’cause I’ve seen them do it 10, 15 times.
But I think the skill is when you know your limitations and you know when you need to bring in that expert to do the wiring, bring in that guy to do the plumbing. You might’ve seen him do the plumbing before. You could probably dig a couple of pipes, but you know, you’re a carpenter. Bring in the plumber when you need him.
And I think that’s in healthcare, it’s really important. We’re not that, I’m saying that we should just stay in a lane, but we know our lane really well. We should know what’s in the other lanes, be able to touch upon it, but then know when to draw those other specialties in to help us out. Don’t try and do everything yourself.
Patrick Agnew: Great wisdom there and certainly demonstrated best. The best demonstration of that in our [00:37:00] institution is our patients with diabetes. We have a multidisciplinary approach where every day I’m speaking with a vascular surgeon, often with a plastic surgeon, sometimes with an orthopedic surgeon, often with their endocrinologist.
Often with their infectious disease specialist, and we’re all working together to try to keep them from losing that leg. And we don’t just, we don’t call what we do wound care. Yeah. We have a wound care clinic and it’s certainly part of it, but that’s just one of the parts. We call it limb salvage, and we’re trying to prevent the, trying really hard to prevent limb loss.
The data is old, but I’ve heard that five year survival rates after diabetic limb amputation are only about 48%, which is worse than breast cancer, prostate cancer and lymphoma put together.
So we’re fighting a very important fight.
Tyson E Franklin: I think is really important. Everything you’ve said is you run your practice, [00:38:00] you are doing some teaching as well. And this is what I said to Patrick DeHeer, when I looked through his career, all the things he had done in his career, I was like, how did you fit this all in one lifetime?
And when I look at what you’ve done with everything you’ve done in pediatrics and all the other interests that you’ve had over that period of time, and you still surf, you still made time for surfing. I just think that’s incredible.
Patrick Agnew: Well, maybe I just have a DHD like a lot of Americans. I mean, we were kicked outta all the civilized countries, right?
You look at the founding Fathers of America. They were scientists, farmers. I know Warriors all at once. They couldn’t sit still
Tyson E Franklin: I know I look at, Ben Franklin and you see just all the different things that he did in his career. Just makes you wonder how they actually fit everything [00:39:00] in.
So I’m just gonna point out people, if you’ve been listening to this podcast all the way through up to here, that we have had a few internet problems. While we’ve been doing this, we’ve been dropping internet.
So if sometimes all of a sudden it’s gotta a point and it’s paused a little bit, that is the reason why. And plus something else I wanna point out is Patrick does need to go surfing this afternoon. And because of the interruptions with the internet, we’ve basically been talking a lot longer than what this recording will actually make it.
So Patrick, I wanna get you back so we can talk about your military service and what you do with the Navy so you’d be cool to do that.
Patrick Agnew: I would love to do that. I’m planning in retirement to write a book on the, on podiatrists, at least in the Navy and maybe in the military in general.
Tyson E Franklin: Yeah. There
Patrick Agnew: are some amazing stories of what people have done. Can’t wait that to do that. And I’m, I’ve been researching it all along and trying to I’m no professional historian.
Tyson E Franklin: Yeah. Mostly
Patrick Agnew: what I know is virtually folklore, [00:40:00] but I’m trying to get the references and the actual facts from the horse’s mouth.
I, while my memory still works and while these people are still alive and can tell their stories, ’cause there are some great ones out there
Tyson E Franklin: Certainly my
Patrick Agnew: military experience. I wouldn’t trade for anything. I saw things I never thought I would, I had opportunities I never thought I would have.
That’s definitely something I would love to talk about.
Tyson E Franklin: Yeah, I think it would be fantastic. As a separate thing, I thought we’d probably we’d work our way through it on this episode, but because of all the interruptions, but the pediatric stuff was too interesting to just brush over it.
And I know there’s a lot of pods who are interested in that area, and I think some of the things you’ve done or some of the things you’ve said are probably gonna inspire him to look into it a little bit more. And I must admit I had a fear of pediatrics. I don’t have kids come in and I’d treat the simple ones, and I really enjoyed doing that. But it, I did have a slight fear in that area. ’cause I thought, I don’t know enough. . But you’ve already pointed out after 30 years, you’re still learning about [00:41:00] that area of Podiatry. So I think if there’s anyone who’s had an interest in that area, just accept it that you’re not gonna know it all.
And it’s an ongoing process.
Patrick Agnew: Wise words. Yeah,
Tyson E Franklin: it’s,
Patrick Agnew: Yeah, don’t good. The good news is nobody knows enough, but and that there are ways to learn more. There are resources.
Tyson E Franklin: Yeah. And if anyone says they know everything, they’re lying.
Patrick Agnew: Absolutely
Tyson E Franklin: There is. Great. So Patrick, I wanna thank you for coming on Podiatry Legends Podcast.
I apologize for whatever’s gone on with the internet today, but you know what? That’s life and we still got through it and we’re still both smiling, so it doesn’t really matter.
Patrick Agnew: It’s been a privilege. Thank you.
Tyson E Franklin: Okay, and I’ll look forward to talking again very soon.
Patrick Agnew: Awesome.