Wound work

by

Clinical practice

In 2011, I unexpectedly had to shift my career, forced to leave my radiology group to remake myself and my practice. Although maintaining my privileges at the local hospital was a challenge because of my former partners’ exclusivity contract (more on that, perhaps, in a future article), I managed to carve out the ability to do hospital-based cases if the need arose. I also had help from radiology friends in a neighboring state and joined their group with plans to start a varicose vein practice where I lived.

While the vein practice was ramping up, I had extra time on my hands. A plastic surgeon from the local wound healing center was sending me a wide variety of patients with ulcerations and I became intrigued. I had no idea what these patients needed to heal aside from the standard IR “fix the veins and artery” piece. That is, I didn’t know what kind of dressings to put on their wounds nor what recommendations to make.

After looking into opportunities at the local wound healing center, I was pleased to learn that they were looking for physicians to staff the practice—and would provide the requisite training. I figured this would open doors to more referrals and would allow me to be seen in the medical communities’ eyes as a fellow provider and not just a “privileged radiologist.” Wound care is often seen as an undesirable part of practice, and I thought that if I were seen pitching in and doing wound care, I would be seen more as one of the clinical doctors.

Because my former radiology group tried to block this effort, again citing their exclusivity contract with the hospital, It was important for me to point out to potential referrers that I am a physician first and a radiologist second and that the DR group did not own the privileging rights of a person based solely on their original training as a radiologist. It also took the support of the medical director of the wound care clinic, a cardiothoracic surgeon with whom I had started the aortic stent graft program many years before. He and I had worked closely together in the OR on many occasions, and without his support my wound care career might have ended before it ever began.

Eventually, I went off for training: a week-long, 45-hour intensive training program that was mostly focused on hyperbaric medicine and dive tables. I have never had to use a dive table since this training, so don’t let that part scare you off.

I found wound care to be a fantastic way to get more involved in the medical community, to have a steady referral base and to contribute to the well-being of patients.

When I started in the clinic, I was paired with an experienced nurse who helped me tremendously. Initially, wound care can seem overwhelming with a wide variety of dressing materials available and the need to debride almost every single wound. However, after several months it became clear that dressings boil down to the adage “If it is wet dry it out, and if it is dry make it wet.” The difference between an Unna boot and a multilayer compression wrap became clearer and I got comfortable with a curette and scalpel. To this day I still don’t care for wounds with exposed bone and tendon, but most wounds are not that deep and not that hard to treat.

There turned out to be several benefits to working in a wound care center: Referrals to my vein practice increased. I was the first person to diagnose these patients with arterial ulcers and the angiograms/interventions were mine if I wished to do them. I ordered labs and imaging on a regular basis, which makes you desirable to the administration. When you handle the wound care, you direct the care of your patients, not just waiting around for referrals.

In addition, I found that I truly enjoyed wound care. I worked with a great team and was seeing my patients every week until they healed or moved on to something else. You can’t heal every single patient, but over 92% will heal if they are compliant. Along the way you really get to know and develop a personal relationship with your patients. They hug you when they are healed and sing your praises. I have occasionally been mentioned in obituaries as having played an important role in that person’s life. In short, wound care has been one of the most rewarding areas of medicine that I have ever participated in.

Earlier this year I said goodbye to my wound healing practice after more than 7 years. To continue, I would have had to form an LLC, hire a billing office and negotiate insurance contracts for a half-day of wound care per week. Wound care for me was a fun thing, not a requirement to make a living. When I first started in wound care there was only one hospital-employed physician in Montana's wound care space, and everyone else was independent. As of 2019, there is only one independent podiatrist and everyone else is a hospital employee. The dissolution of small practices is real.

I do love my new job and the freedom it allows me to pursue other interests, and in any case I am running for the state legislature in 2020, which will take all of my spare time. However, I found wound care to be a fantastic way to get more involved in the medical community, to have a steady referral base and to contribute to the well-being of patients. It is an excellent relationship-building opportunity. I formed stronger bonds with our diabetes physicians, vascular surgeons and primary care doctors. Based on my experiences, I would strongly recommend getting involved in your local wound healing center as a wound care physician.