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.