Variability is the Swimmer’s Itch of Wound Care

It is not that we do not try to address the situation: we are just not trying hard enough.

We have several wonderful professional associations like the Association for the Advancement of Wound Care (, the American Professional Wound Care Association (, Wound Healing Society (, the Wound Ostomy and Continence Nurses Society™ (, and the American College of Wound Care Specialists ( ; we have academic-oriented groups like the National Pressure Ulcer Advisory Panel ( ; we have several organizations that have created certification programs for wound care as with the American Board of Wound Management (, The American Board of Wound Healing (, the Wound Ostomy Continence Certification Board ( , the Wound Care Education Institute®(

At some point though, you have to take a step back and say to yourself why do we have ALL of these organizations (and I acknowledge that I missed several)? I am working in this field of wound care now for twenty years and until I had to put together that list, I did not know there were so many. Which to join? What certification do I get [the most frequent question asked of me by physicians at conferences]? Are all of these certifications real? What do these certifications do for you?

Even within the physician group you have multiple specialists bringing their expertise [and prejudices of training] to the bedside of the patient: internists, family practice, general surgeons, vascular surgeons, podiatrists, plastic surgeons all bring unique knowledge to the bedside — and variability.

Through no fault of any society or organization, we have dozens of guidelines, best practices, and protocols for the same condition creating an overlapping collage of acceptable practices. Each group claiming that their own is the one to follow, each referencing the same general group of studies, few of which meet the criteria of randomized, double-blinded studies that if they had enough patients in the study who fit a well-defined clinical group could actually help us. That is why many of those same guidelines, in a show of academic honesty, have to rate the suggestions, with a majority of recommendations relegated to consensus of the experts. Of course, each group of professionals has their own experts that do not necessarily agree on specific recommendations.

When you turn to the academic review organizations like Cochrane or the published meta-analysis studies looking at ‘dressing x’ for ‘condition y’, you gain a strong understanding of how little we really can rely upon as fact. And at the same time, you could easily find some study, somewhere that justifies anything that you may offer to a patient; as in, “According to the Journal of Medicine of Upper Volta”…

For the patient that has been treated by multiple doctors before you see them or the patient that is receiving treatment in multiple places (for example, the patient with a wound who was in the hospital, is sent to the nursing home, comes to the wound center, and is being transitioned to home health), the opportunities for variability in what the patient was told, the products that were recommended, and the information on the wound that was documented is at the least, frustrating to the patient, costly, confusing, and not something that any of us would want our parents to experience [The Parent Rule].

We have over four thousand products to choose from in our armamentarium to place on a wound and like witches creating a cauldron of a secret potion, we witness sandwiches of dressings for wounds that include layers of products that are costly and often unnecessary. You sometimes listen to what a patient was told to do by someone and wonder why they didn’t use peanut butter and jelly as part of the multiple layers of stuff. For many patients, the dressings become the focus rather than correcting the underlying pathophysiology of the wound; and we know so, because even when you spend ten minutes with a patient explaining in the detail why compression is the most important aspect of the care of their venous insufficiency ulcer, you will still be questioned on why you changed the type of absorptive dressing on top of the wound.

This variability results in delayed care, costly care, prolonged healing, and missed opportunities to save portions of the human body. It also creates a lot of finger pointing that is neither useful for the care of the patient or to our profession.

It is time that we create a movement to collaborate across our specialty.

© Scott Matthew Bolhack MD, MBA, CWS, CMD, FACP, FAAP

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