By Michael Miller DO, FACOS, FAPWCA
RAMBLINGS OF AN ITINERANT WOUND CARE GUY PT. 3
I just had the most amazing thing happen: I received a letter from my hospital informing me that they were considering creating an Open-Heart Surgery Center. Other than myself, there will be Radiologists, Family Practitioners, and Pathologists all participating in the program. In an effort to share the proceeds from participating in this venture, all participants will be offered four hour time periods throughout the week in which to practice this new specialty. Recognizing that we are not experts in this area of medicine, each of us will be required to take a one-week course in open-heart surgery before being able to hang our shingles outside the clinic.
I can't imagine that it will be too hard to make this a successful venture. I mean, we all learned how to suture, how to use a knife, and hopefully can recall the anatomy and physiology of the heart. How hard can it be? I suppose that there will be a learning curve, and so probably the first hundred or so cases won't come out perfectly. After a while I bet that I can do this as well as any heart surgeon who has been operating for many years, even if I am only able to do it 4-8 hours per week. The nurses and technicians at the clinic who will be there full-time will be able to help me out with any questions, right? To make sure that the program has good, authoritative oversight, it will be led by an ear, nose, and throat surgeon who watched two heart surgeries during her residency.
The hospital is negotiating with four companies, each of whom has promised to make us the “Best Open-Heart Surgery Center” in our area. They have policies and protocols that elucidate exactly what to do whenever whatever happens, kind of a coronary FAQ. Of course, I don't know how I will be able to keep up with the reading but, after all, it's only heart surgery. How much more is there to learn, other than what I get from the one-week course and what I learned in medical school 26 years ago? Besides, I’m too busy practicing my own specialty for the other 50+ hours a week to spend any time reading those journals.
Frankly, I don't think we have much of a choice as to whether or not to commence this venture, since almost every other hospital in the area is opening an identical open-heart surgery center. However, the potential for the hospital and the doctors to make money is fantastic, especially if we can get patients on that machine thing (which has great reimbursement). Of course, not everybody with a heart problem is a candidate, but I figure if we put enough people on it, some of them will have it paid for, and a few of them might even get better!
Those corporations said that demographics indicate that we will be able to generate enough patients to assure a great profit for all involved. They also promised that their corporate credo is that great outcomes are more important than “churn and burn,” and that a quota system for compensation “absolutely does not exist” (just like the State Police at the beginning and end of each month).
In the grand scheme of things, I am a physician specializing full-time in wound care and so… how difficult can the transition to open-heart surgery be?
While I am pulling my tongue out of my cheek, I ask you if this scenario sounds vaguely familiar? To those of you who, like me, have spent a considerable amount of time and energy learning the Art and Science of Wound Care, the earlier scenario is one that is all too often repeated - much to our chagrin. Of course, what makes this an even more bitter pill to swallow is the numerous so-called certifications in wound care that tout their ability to increase pay and or prestige.
How safe should the public feel in the expertise of someone who started wound care from Square Zero, then takes a one-week course, only to exit at the end ready to take (and pass) a test that establishes him or her as an expert? Remember that the vast majority of medical residencies have little to no modern wound care training. Of course, there are additional requirements, but none so stringent that a part-time conference-goer with a few cases seen and participated in couldn’t conceivably meet the minimum standards.
Yes, there needs to be some minimum way to establish general competency. What we currently have in place tends to assure access for the masses to jump the bar, pay the dues, and join the organization, more than to assure that those who are certified actually do quality wound care, not merely add to the roles of those who say “I do wound care.” Far too many “certified” wound care specialists know no more and have no better outcomes than before they gained pseudo-expertise.
And so, I offer my term and defining characteristics for those who purport to be wound care specialists without a real basis for their use of that term: “Wound Care Dabbler.”
Any health care professional who cannot spell NPUAP, uses Dakin's Solution or Acetic Acid as a wound dressing, thinks DTI is an insecticide, does not debride wounds until they bleed over 100% of the surface, treats venous insufficiency ulcers with anything other than some form of compression (or uses the term stasis ulcers), diagnoses all swelling as lymphedema regardless of the history, location, type or amount of swelling, mixes more than one wound care product in a wound at a given time (not counting the topper), routinely adds a topical antibiotic to their dressings, and finally, practices any medical specialty other than true wound care for the majority of their income (or less than 4 hours or one shift in a wound care center). You are invited to add your own peccadillos to this potentially exhaustive list.
Wound Care Specialists base our success on establishing a definitive diagnosis and assessing related factors, such as nutrition, circulation, and social/economic factors, among others, before we initiate treatment. Wound Care Dabblers have a “Ready, Fire, Aim” mentality, usually accompanied by the “antibiotic du jour.”
The good news for those of you who detest the Dabbler (imagine that as a T-shirt slogan) is that there is a strong, high-level push to look at outcomes. At first blush, this may seem draconian: if patients fail to improve or “heal,” then your compensation is affected. For those of you who are truly confident and competent in your selected vocations, this type of oversight, much of which is already in place in some form or another, is a welcome one.
Wound care is more than a medical specialty. It has become a game of ego. Regardless of the lack of progress (or unquestionable worsening) of a patient after multiple courses of antibiotics, and use of the latest Rep-lunch fueled dressing, the consideration of sending a patient who is clearly not improving to a competitor who is a real, bona fide, honest to goodness, Wound Care Specialist (certification optional) is paramount to admitting that you (actually the patient) need(s) help, and that as an ethical, responsible health care professional, the needs of that patient come before those of your auto finance company. Unfortunately, quashing any smidgeon of guilt is the simplistic rationale of, “how many reasons can there be for a wound to develop?” and more, “how many different kinds of wounds can there be?”
Any Dabbler will tell you that if you use the right antibiotic and the right dressing(s), then the wound should heal. Of course, if the wound fails to heal, the most likely reasons are that the patient (or nurses) put on too much of the dressing, or too little, or changed it too frequently, or not frequently enough. That buys you at least eight more weeks of visits. If you can debride the wound weekly, this scam can be perpetuated and perpetrated for a considerable time, ethically, professionally, and according to those non-quota based corporate guidelines, of course. Just ask the ER doctor I opposed on a legal case, who had “Over 30 years of wound care expertise,”; who was in charge of his hospital’s wound care program, and was primary teacher to the residents; who admitted to not reading a wound care journal for “years” and thought the Braden Scale was used to assess the amount of drainage in chronic wounds (congratulations to my colleague Dr. Barbara Braden on the newly expanded use of her ingenious tool).
But why pick on these Wound Care Dabblers? After all, they simply want to join our ranks, but not have to suffer through the tedious reading, the repetitive patient visits, without any expertise, any real knowledge, and a cavalier attitude about what we do.
Cases in point:
One of my favorites to see in clinic is the patient whose previous wound care “expert” exemplified the perpetual wound care brain-teaser: whether any and all open wounds in a diabetic are due to the effects of the diabetes (nevermind that pesky word “neuropathy”). This has led to interesting diagnoses, such as the patient (a poorly controlled diabetic) who developed an open wound of the ischium, which was documented by the successfully post-certification test Dabbler as a “diabetic buttock ulcer.” (Where do you find offloading shoes for that?) Having learned in the weeklong course of the imperative need for debridement of diabetic wounds, the Dabbler proceeded to debride the wound weekly to promote healing.
Lest the buttocks be the only site so misunderstood, I personally saw a case from a local “Best Outcomes” wound care center that had a long history of multiple open ulcers on both legs, associated with heavy drainage, frequent periods of “cellulitis,” and diabetes. The resident (under the auspices of yet another wound certified attending) proceeded to sharply debride the wounds, using only topically applied anesthesia spray, WEEKLY FOR A PERIOD OF TWO YEARS (YES, I AM SHOUTING!) with the repeatedly written diagnoses of Diabetic Leg Ulcers and Venous Stasis Cellulitis.
Or consider this case: a diabetic patient with recurrent Pyoderma Gangrenosum (PG) who, having been successfully healed on two previous occasions with great care and delicate treatment, went to a local wound care center where he was met by the esteemed clinic director. The patient was told that even though he had a history of PG in the exact same place, and the wounds looked and behaved exactly as his previous episodes, that these particular wounds were in fact “unquestionably Diabetic Leg Ulcers” requiring frequent and aggressive debridement…can you say “Pathergenic Nuclear Catastrophe?” When I asked the patient (who fled to my clinic after receiving eight weeks of this “care”), “After two previous episodes of PG, and the pain and my repeated admonishments to never let anyone cut or debride these, how could you let someone debride these, week after week, especially after they got worse and worse and you knew that the PG had recurred?” His answer was, “I went to the closer, local hospital wound care center, and the doctor said he was certified in wound care. Why would he lie to me?”
I wind down this month’s edition of “Ramblings of an Itinerant Wound Care Guy” with the recognition that there does need to be some means of identifying those who have achieved special knowledge and skills in their areas of expertise. Recognizing that physicians, nurses, therapists, and others have different training and responsibilities in the care of patients afflicted with wounds and related conditions, certifications need to be able to differentiate between the minimum accepted levels of expertise for each profession.
I look forward to the insurance companies and other oversight entities tracking outcomes for wound care centers and penalizing those severe outliers with highest costs and poorest outcomes. For now, the most immediate questions are:
- Is it better to have a lot of “less than ideal” wound care practitioners and facilities available, or fewer high-quality ones?
- Is the public’s safety at risk with more and more “part-time” wound care specialists providing care and controlling the economics of wound care?
- How do we educate the public in identifying evidence-based or expert consensus approved practices?
- How can we assure that when someone identifies themselves as a wound care specialist, that they truly have the minimal expertise to back it up?
- Is there a way for wound care specialists to cull out those who repeatedly perpetrate poor, costly, sophomoric, cost ineffective, high risk wound care on the unsuspecting public?
Perhaps certification needs to have multiple hurdles to jump. Taking a written test is one. Providing copies of several different examples of one’s wound charts (personal information redacted) to be reviewed by a panel of true experts might be a second hurdle to assure that they not only know the information, but have actually put it into practice. Lastly, perhaps a case-based oral examination to allow the opportunity to assess true understanding of all pertinent aspects of wound care. Arduous? Yes, but is the current solo written test assessment enough to assure minimum competency in wound care? Would you trust your grandmother’s open-heart surgery to someone with a one-week training program and a few hours per week of “expertise?”
As I work day after day in my clinics, the hospital, nursing homes, and on house calls treating patients with wounds and related conditions, I dream of the opportunity to take a one-week course, pass a test, and magically become an expert in another medical specialty I previously knew very little about. It’s as easy as saying “Abra-ca-Dabbler.”
Until next month…
About The Author
Michael Miller DO, FACOS, FAPWCA is the Founder and Medical Director of The Wound Healing Centers of Indiana and IndyLymphedema, as well as a clinical consultant, teacher, inventor, and published author.
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.