"Three Hands—A Specialty Without Specialists"

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By Thomas E. Serena MD, FACS, FACHM, FAPWCA

I had the honor of lecturing to an audience of mostly European physicians at the M.I.L.A.N. Diabetic Foot Conference this past February in Milan, Italy. My session this year focused on our current and ongoing research in point-of-care diagnostics. To date, we have enrolled more than a thousand patients in a dozen clinics across the United States. All of these trials led to the development of the first commercially available wound diagnostic, WOUNDCHEK (Systagenix, Gargarve, UK), approved in Europe last year (it has not yet received FDA clearance for use in the US). A revolutionary product, I imagined that it would have received rapid, wide-spread acceptance among my European colleagues. At the end of the presentation I asked for a show of hands: “How many of you are using the test in your clinics or hospitals.” In an audience of nearly one hundred, only three attendees raised their hands.

This raised another question: Why are wound care clinicians slow to adopt certain products or devices despite ample evidence that would support their incorporation into daily practice? On the other hand, the use of some products with little or no evidence is commonplace. We preach evidence-based medicine but an examination of practice patterns reveals little evidence that we practice what we preach. This phenomenon is not limited to novel products, such as diagnostics. Total contact casting (TCC) has long been the gold standard for offloading the diabetic foot, but it is still not offered as a treatment option in most wound clinics; electrical stimulation has robust evidence suggesting that it promotes wound healing while the e-stim machines gather dust in the back corner of the physical therapy department; there is still resistance to the use of hyperbaric oxygen therapy (HBOT) despite evidence that it prevents amputations in patients with diabetic foot ulcers and promotes healing in a variety of other diseases; Becaplermin underwent four randomized clinical trials which demonstrated efficacy in healing diabetic foot ulcers--it is rarely prescribed.

Better minds than I have proposed countless explanations to explain why evidence is less important than what dressing worked on the last patient or which pharmaceutical representative bought pizza for the clinic. I propose an obvious and perhaps uncomfortable explanation: We are a specialty without specialists. The most common physician staffing model for wound care centers is a panel in which multiple doctors take blocks of time as brief as 4 hours per week. These practitioners then return to their primary practice. They do not have time to evaluate new modalities or stay current with our rapidly advancing field. Large panels served their purpose but now they inhibit our development of a specialty that provides patients with the best possible care. Wound care as a specialty cannot advance without “woundologists” and “vulnolgists,” (a term my Italian colleagues have coined) whose sole focus is the care of patients with acute and chronic wounds. The wound care champion is the answer and the solution to making wound care an evidence-based specialty respected by the medical community.

About The Author
Dr. Thomas Serena has published more than 75 peer-reviewed papers and has made in excess of 200 presentations worldwide. He has been elected to the Board of Directors of both The Wound Healing Society and the American College of Hyperbaric Medicine (ACHM), the leading academic society in the field of Hyperbaric Medicine. In 2013 Dr. Serena was elected vice president of the American Professional Wound Care Association (APWCA). Dr. Serena has opened and operates Wound Care and hyperbaric oxygen treatment clinics across the United States.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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