The Evolution of Wound Care and Woundology Protection Status
Evolution of the wound care specialist

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

"The average isn't average because its average. The average is average because its best." – J.B.S. Haldane

In 1972, Stephen J. Gould, the renowned paleontologist and masterful essayist, published the theory of punctuated equilibrium in which he challenged the long held belief that evolution occurred gradually over time. He knew that the creation of new species occurred when isolated populations of individuals faced environmental challenges to which they either adapted or perished. Gould asserted that this change happened rapidly when conditions favored it. Interspersed between the spikes in speciation are prolonged periods without change (equilibrium). In the case of the human species, globalization and a fairly stable environment have resulted in negligible change in our evolutionary history: we are enjoying equilibrium.

I must first apologize to the evolutionary biologists for hijacking their nomenclature, but the burgeoning specialty of wound care, or woundology as I like to refer to it, needs an expanded lexicon. Over a thousand wound and hyperbaric centers have emerged from the primordial swamp in the last decade; however, these centers are not staffed by a single cohesive species. Far from it! The genetic makeup of the current woundologist is derived from every medical specialty. As a result, many of the wound center inhabitants fail to view themselves as being part of a new species. They are all too often maladapted to the wound center environment. The centers themselves are often silos isolated from their own medical community. I am astonished at how many wound centers are not part of a hospital department. They exist in an outpatient backwater. In addition, the minimal attendance at wound healing meetings is evidence that most clinicians operating in a wound center are isolated from the evolutionary thrust. These conditions are ideal for the birth of wound care practices that are neither evidence-based nor logical.

Preparedness as a Woundologist

The majority of my time is spent in wound clinics evaluating the quality of care delivered. The variation in the practice of wound care is unparalleled in medicine. I have termed the cause for this phenomenon, "practice drift." Physicians who gravitate into the practice of wound care are often ill-prepared, poorly educated and frankly, uninterested. First of all, chronic wound care receives cursory coverage in medical school and residency training. Most physicians sit in on a weekend course in preparation for their career in wound care with little or no follow-up or on-going education. In the current panel model for staffing wound care centers, physicians see patients in blocks of four hours per week – as opposed to a dedicated woundologist working daily in the center. As a result, their focus remains on their primary practice and continuing education does not include wound healing.

More troubling is the attendance at wound healing meetings and membership in wound healing societies. The majority of clinicians working in wound centers do not attend wound-specific conferences, join the societies or even read the literature. The consequences of this isolation is the development of wound care practice patterns that are at best ineffective and at worst potentially harmful and often downright bizarre. I have witnessed compression wraps deliberately placed upside down, mixtures of numerous products with opposing mechanisms of action pasted into ulcers, betadine poultices, packaging used as a secondary dressing, and hyperbaric oxygen applied in an indiscriminate manner. The wound societies have spent long hours drafting practice guidelines which few physicians read and which even fewer follow.

Evolving the Species of Wound Care Specialists

The list of issues surrounding the speciation of woundologists is endless. The answer is education. But how do we educate clinicians if we cannot reach them? I am afraid the time has come to mandate education or face extinction. I suggest a minimum number of wound and hyperbaric-specific CME/CEUs be required in order to maintain privileges in the wound and hyperbaric center. Physicians practicing in the wound center should be required to follow maintenance of certification regulations as they do in other specialties. There is a strong movement afoot to develop fellowships and board certification in wound care. I support it. Finally, accreditation of wound centers through one or more wound healing societies is needed.

We find ourselves in the midst of chaotic evolutionary change in the development of our woundology species. We must all strive to select the best practice for our own survival.

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 2014 Dr. Serena was elected 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.


Thomas - As a fellowship trained and full-time practicing wound care physician for the past thirteen years, I am sad to say that I too have witnessed what you have described. Although education and monitoring of CME activity, etc. is important and needed, I do not think it strikes at the core issue. You said it well, "uninterested". The education in my opinion needs to be directed at the hospital administrators who overall tend to see their wound care centers as sources of revenue and therefore as long as that is happening, they could care less about the level of training and motivation their part-time providers possess. This in large part is precisely why I opened my own private clinic on the hospital campus (without HBOT), to attempt to maintain quality and excellence that is not governed and diluted by others who are primarily focused on revenue. I too have fallen into the silky web of isolation in this setting as financial and manpower support have not been there for the annual pilgrimage to the wound care meetings I long to attend. It is a bit of a Catch-22 and I feel the frustrations of so much of what you describe. Thank you for being a "voice in the wilderness".

Thank you Dr. Serena for your comments. As I have also reflected in some of my blogs, the variability [and as you have pointed out -- inconsistency, lack of education, paucity of interest] of our care will only continue to force the insurers, including CMS, to restrict remuneration for all. Why would any insurer put up with the variability of outcomes and cost? Our wound care specialty needs to quickly embrace some standards.

Dr. Serena,

I thoroughly enjoyed you blog! I leaped into the Woundcare space from a vascular surgical fellowship in the pursuit of happiness and I FOUND IT!!! Now I am slowly SNF by SNF building my own practice in Denver. I call myself Woundcare Initiatives & Specialty Health aka tag is healing one WOUND, one WISH at a time.

Might I be able to speak with you but for a few short moments at SAWC? I am seeking some advice about a few business development ideas I have that include telemedicine, laser therapy and antisepsis in the post acute Longterm care setting.

Look me up on LinkedIn and Facebook.

Thank you very much.

Dr Serena,

Thank you for your insight. As a CWOCN practicing in an acute care hospital, I see many patients being treated at our local wound care centers and so want to scream at the crazy wound care orders the patients show me that have been prescribed by the physician at the wound care center. The lack of knowledge of the properties and indications of the products that they are using and combining is astounding. Such a disservice to our patients!

Dr. Serena, "unfortunately" I have to agree with you about the many physicians we work side by side at wound care centers. As a dedicated full time wound care practitioner for the last 6 years I am sick of seeing physicians does not care about the quality of management but the bill they collect at the end of the day and the administration is ok with that.
My few comments: about the woundology: if you check the meaning of woundology you would be surprised that it may have been used in English literature for totally different meaning and purpose. Please google it.
About becoming member of societies: I am actively looking for a Wound Care Society that has clear goals to better the specialty and I am not yet convinced that most of the societies in this field are truly have goals and credentials to prove that. I am planning to become a member of American Collage of Wound Healing and Tissue Repair. I think as wound care specialists we need to gain academic support to improve the quality of care to be distributed evenly for the population -not only patients but referring physicians- in need and bring some quality check for the practices in wound care.
Thank you for your blog and facilitating the discussion.

Dr. Serena,

Thank you for confirming what I have been observing in my studies of the wound care ecosystem. I enjoyed your article enormously and am now determined to learn more about your company.

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