Certification And Wound Care Expertise: Are They One And The Same?

First, I would like to thank the readers for taking the time to review the topics I have presented regarding the world of wound care.

If you read my blog, you are likely seeking some insight or clinical perspectives that may help you in managing patients with chronic wounds from a variety of etiologies.

This month, I would like to turn the tables and gain some knowledge from you, my respected colleagues, on your approach to things, specifically how you have attained your level of expertise.

I would also like to dedicate this month’s blog to anyone on the receiving end of wound care turf jobs. If you do not know what I am referring to, please consider the following scenario.

A nursing facility directs a patient with a deteriorating heel ulcer to you for a consult. In reviewing the patient’s history and the ulcer, you find an outside provider has performed serial debridement of an ischemic limb at bedside. In reality, this provider has no surgical training, no board certification and no hospital privileges. He or she comes to the facility every one to two weeks to perform debridement on the patients with wounds.

If you think this scenario is far-fetched, think again.

Wound care is an evolving multidisciplinary specialty with the podiatric profession at the forefront of its development. The past 15 to 20 years have been a remarkable and dynamic time in which breakthroughs in research and product development have positively impacted both providers and patients alike.

Persistent inconsistencies in the delivery of care have been a personal concern during this timeframe. I have dubbed this a widespread phenomenon of anecdotal chaos that continually undermines all emerging positives.

Addressing A Lack Of Standardization In Education

One of the issues wound care faces is the lack of standardization regarding educational level within the specialty. Part of the problem may stem from deciding who the providers are within the specialty. Are they surgeons in the twilight of their career who may be less likely to adopt new standards of care? Is it a nurse working for a home health agency that, over time, become the de facto wound expert within an agency, a designation based solely on the number of years of service?

It has been my observation that a number of providers who fall into the two examples mentioned also look to claim a level of expertise based on his or her total years in medicine, not necessarily in time dedicated to wound care. This phenomenon is certainly not limited to older surgeons and nurses.

As a result, many providers feel justified in portraying themselves as experts in wound care. They may stand behind their certifications, which they may have achieved through two-day courses or by joining an organization that included a designation implying competency in wound care as part of the benefit of paying dues.

I must disclose that I have served as a member on the Board of Directors of the American Board of Wound Management for the past several years. I have held the Certified Wound Specialist (CWS) designation for nearly 12 years.

That said, there is no shortcut when it comes to attaining a level of expertise, no matter what the discipline or craft. Years of study and an application of knowledge in the clinical setting are the ways to develop competency.

Showing your level of expertise by way of a valid credentialing board is one important way to raise the bar and to ultimately improve the quality of care that our patients need and deserve.

Where do you stand on this issue?

• Do you think certification in wound care is necessary?
• Do you see any problems with those who portray themselves to be proficient in any area, let alone wound care, based on a shortcut to certification?
• Do you think there is a lack of clarity regarding where to obtain certification (i.e., which is the best certification to attain) in wound care?

Before I conclude, I would again like to assert the important place in wound care that our colleagues hold. Do not take this lightly. Please continue to raise the bar for yourself and your patients.



Neil H Hecht DPMsays: May 10, 2012 at 3:05 pm

Dr. Bell,

Those of us that are board-certified in foot and ankle surgery and also in podiatric orthopedics with residency training, hospital affiliations and long-term experience with wound care probably DO NOT need certification in wound care.

I am the charter wound care podiatrist at one hospital wound center (x 18 years), work at another, and do regular wound/infection inpatient consultations at three hospitals almost daily. I have been a residency director as well as participating as an attending in other residency training programs over the years.

I have three fellowship designations, belong to our APMA and affiliated state/local assn's/societies, and keep up with various wound and other periodicals as well as CMEs. I enjoy wound care referrals from other doctors including podiatrists in the area.

The notion of going for another certification after 33 years in practice seems entirely unnecessary in my case. I am not alone. However, for newer and inexperienced doctors, certification does seem like a good idea.

I hope my comments are similar to others in my position and welcome your response.

Neil H Hecht, DPM, FACFAS,FACFAO, FAPWCA, DABPS, DABPO (etc)

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Desmond Bellsays: May 10, 2012 at 9:18 pm

Thank you for your comments, Dr. Hecht.

Your credentials and years of experience are certainly exemplary and I have no doubt that if you were to sit for a wound care board exam, you would pass quite handily.

I realize I am probably preaching to the choir in my latest blog. The issue I have is with those who may think they are at a higher level of wound care expertise than they truly are. It is still the "Wild West" in the wound care community due to the inconsistencies among providers. This poses a threat on multiple levels, ranging from safety of patients and economics to the future of wound care.

We need good people such as yourself to shine and help raise the bar. Wound care as a specialty is at a delicate time. The next two years will be of scrutiny by CMS and the Insurance companies that we have not seen to date. With these entities looking to marginalize wound care and limb preservation, it is imperative that those of us who advocate for our patients and specialty do so by demonstrating our expertise beyond the walls of the clinic or wound center.

Why not validate your level of expertise? I took my re-certification exam a little more than a year ago. Even though I have very little free time these days, I found that reviewing in preparation for the exam was quite beneficial and empowering as well!

I can say, as a member of the Board of the ABWM, the thought of NOT passing and the embarrassment that would ensue crossed my mind! I know that every board member who I serve with who has taken their re-certification exam in the past two years shared the same emotion!

Show what you know! One of the great things about medicine is that we can always continue learning and challenging ourselves, lest we run the risk of becoming irrelevant.

I hope you will reconsider your position and seek to earn the designation that is commensurate with your abilities and expertise.

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Ron Raducanu, DPMsays: May 11, 2012 at 8:40 am

I've only been involved in a wound care center for about seven months but have done my share of wound care over the last ten years.

What would a certification actually do for us? How would it separate those that have it versus those that don't? Will it be ANOTHER way our profession tends to try to segregate?

Let's keep doing what we do and avoid adding MORE letters after our names. I can't afford to keep up anymore.

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Desmond Bellsays: May 11, 2012 at 2:02 pm

It is not a question of what Wound Care certification will do for us. By "us," I assume you are referring to podiatrists as a group. A quick answer is that wound certification enhances your credibility among those who share your passion for wound care and limb preservation.

The issue here is not one of "ANOTHER" certification for podiatrists. it is the importance of quality of care delivery in the INTERDISCIPLINARY specialty of wound care.

There are far too many "dabblers" who do not appreciate the complexity of wound healing and frankly are not providing care that is acceptable (i.e., standard of care).

If that is not the case, then you have just illustrated part of the problem I refer to in my blog as well as in a previous blog. Again, I am likely preaching to the choir but it is the providers who know enough to be dangerous who are the ones marginalizing the importance and impact of wound care and limb preservation. This is not limited to podiatrists!

Ron, your expertise and passion seems to be in the area of Pediatrics and Ex-fix. I am certain colleagues refer to you due to your specialization and skill set, and that your contributions to limb preservation are real. Had you not attained your FACFAS status, do you think you would hold the same level of credibility among your peers or within your community? Where would podiatry be without the American College of Foot and Ankle Surgeons?

Patients do seek out certified wound specialists. People are savvy in their use of social media and they will look for the "best" via the web, whether it be doctors or plumbers.

Also, when you marginalize those among our profession who have attained wound certification status, you play right into the hands of CMS and the insurance companies.

Payors are looking to figure out ways to cut reimbursement in wound care. By reducing the value of the specialty of wound care by thinking that certification and a higher level of knowledge are not important, then you fall on the side of those who do not see the importance of wound care in general.

You may not perceive wound care to be anything other than a small or moderate part of your practice. As podiatrists, we are truly the leaders in wound care and limb preservation. Other professions look to us for help and wound certification has opened many doors for me within the interdisciplinary team. This has translated into better access and facilitation of care for my patients!

To think that we should "keep doing what we are doing" supports the status quo. I disagree with this sentiment. Avoid more letters after our names sounds as if gaining more knowledge is somehow a bad thing. We MUST DO BETTER and never become comfortable with our achievements.

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Ron Raducanu, D.P.M.says: May 16, 2012 at 11:44 am

I'm going to take issue with some of the comments you have made.

Firstly, those that "dabble" do so because they feel they have knowledge. Requiring board certification will thereby change the standard of care and may actually limit the access some of these patients have to wound care specialists who may have no interest in certification.

I'm all for education, which is a far different animal than what you are proposing. I recently joined a large group that does a fair amount of wound care and even though I had experience with wounds, they had the foresight to recommend that I attend a very intensive, full-week course to sharpen my knowledge and skills in that department. It was an awesome learning experience BUT the best experience so far for me has been working with an incredibly knowledge wound care expert in our practice who has been kind and patient enough to share his years of experience with me, and really advanced my knowledge. No certification in the world can replace that.

That being said, when you compared a potential certification with being involved with ACFAS, we need to clarify a couple of things. ACFAS is NOT a certification body. The ABPS is. I was invited to join the ACFAS as a Fellow based on my three years of residency and passing both a written and oral examination given by the ABPS. ABPS certification is becoming a requirement for privileging at hospitals and for acceptance onto insurance panels in many communities. This is exactly what I'm concerned about with your certification recommendation. I've been involved in wound care for 10 years and don't see myself getting ANOTHER certification because I don't feel I need it. BUT then someone shows up with less experience, but IS certified and now my position at the WCC is in jeopardy. You see where this is going?

You're right. I am very interested and have a passion for podopeds and ex-fix. I am currently the President of the American College of Foot and Ankle Pediatrics. In that position, I can probably start making moves toward a type of certification in podopediatrics, but to what end? Podopeds is just as specialized a population as our wound patients, but I want to be INCLUSIVE in this regard. I could probably start the process and then move toward excluding my colleagues from seeing the kids so that those of us who are certified get all the pie and not just a slice. That's not who I am so I don't.

Lastly, to be honest, I just don't want to spend the money anymore. Every new examination and certification process takes money and years, and I'm starting to find I would prefer to not spend more money on it, and have to comply with certain guidelines to just keep doing what I'm doing. That's just me. I pay enough dues. I don't need anymore. That may be shortsighted, but the thousands I spend on licenses, APMA, ABPS, ACFAS, ASPS, ACFAP...etc, is just getting a bit much.

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Desmond Bellsays: May 18, 2012 at 1:49 pm

Ron,
I truly appreciate your candid replies. Thank you most sincerely. They contain much value and your thoughts certainly reflect similar sentiments among many, not just our colleagues.

Nowhere have I stated that I am advocating for mandatory wound certification. I am simply pointing out the discrepancies in the levels of care within the wound care community and the potential dangers they pose.

I realize the decision to seek certification is an individual one and should remain so.
What I am hoping to do is raise awareness of the issues that wound care is facing. A number of these issues stem from a lack of consistency within the specialty.

Your work with podopediatrics is certainly important and I commend your leadership and passion. I am not aware, however, of any concerted efforts by payors to limit or cut reimbursement for services in this area. If there were, I am sure you would see the value of strength in numbers and being one voice for your patients. Credibility through validation, whether you like it or not, is a critical aspect in having that voice heard and this is one of the reasons for my opinions regarding the importance of wound care certification.

Cutting of our services will be the path to denial of access to care. Recommending that our colleagues become certified will help minimize the potential for such events from occurring. I cannot imagine certification ever being a causative factor that would reduce access to care!

I share your vision of the concept of INCLUSION, which is why I believe that our colleagues should seek to become certified. The fragmented levels of care and lack of standardization do potentially hurt us and our patients versus somehow blocking access to care. We need as many good people as possible from all disciplines to contribute to the effort. Anecdotal chaos serves no one.

If money is truly a concern, financial assistance is available. Compliance guidelines are minimal and include having to obtain a few continuing education credit hours wound care within each biennium, a way to keep your knowledge base current. You already have the years of knowledge. New practitioners cannot sit for a true credentialing exam in wound care so only someone with years of experience, like yourself, have earned the right to be considered for certification. Again, the point is not to exclude anyone, but to raise the bar for all and not lower it.

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