Our History
Background
The incidence of non-healing cutaneous wounds is 5 to 7 million per year in the United States. It is estimated that this clinical volume results in over a 20 billion dollar cost to the healthcare system. Wound healing is a complex process that involves a coordinated integration of numerous clinical and biochemical pathways. The replacement of injured or damaged tissue can be compromised by multiple factors including but not limited to: obesity, diabetes, smoking, vascular disease, infection, renal failure, cancer, and malnutrition.
A classic example of a non-healing wound is a diabetic foot ulceration. With decreased sensation and frequently concomitant peripheral vascular disease, chronic ulcers can easily form in this ever-growing population. With an estimated 366 million diabetic patients by 2030, we can expect an increasing number of patients with chronic non-healing wounds in the future. With an aging society, it is also expected that there will be an increase in the number of surgical wounds, venous leg ulcerations, and traumatic wounds that will be at risk for non-healing. Further complicating the situation is the lack of formal education for physicians, nurses, therapists, and all ancillary health care providers on the science and treatment of non-healing wounds.
A paper by Patel and Granick in the Annals of Plastic Surgery in 2007 reported that a total of only 9.2 hours of formal didactic training related to wound healing was found in the average four-year medical school curriculum.
These factors all support the need to establish a formal wound care specialty. Although wound care has been practiced for hundreds of years, it has only been during the past 45 years that the age of modern wound care has flourished. British researcher George D. Winter’s 1962 seminal paper in Nature on moist healing catalyzed a radical shift from the passive gauze therapy that was promoted at the time.
However, the fear of promoting wound infections through the use of occlusive dressings delayed the emergence of commercially available wound products (dressings) until the late 1970s. Hydrocolloid dressings were released in 1982, and nurses became early adopters of the treatment. Physical therapists (PTs) provided a slightly different approach to wound healing through the use of energy-based modalities such as ultrasound, electrical stimulation, ultraviolet light, compression therapy, and manual lymphedema treatments. Virtually all wound care products and technologies lacked substantive evidence of efficacy from well-designed, carefully conducted randomized clinical trials, with many products developed under 510K regulatory status that allowed marketing without rigorous evidence or clinical trials.
The first recombinant growth factor (Becaplermin) for chronic wounds along with bioengineered tissues (Apligraf, Dermagraft) brought biotechnology to the field of wound care and stimulated physician interest in the field. Modern wound care centers were established and provided a disease-focused, central location for the diagnosis and management of complex wound care patients.
As the field of wound care matures, there is a critical need for rigorous training, research, evidence development, and advocacy to improve outcomes of patients with non-healing wounds. As mentioned, presently physicians receive only limited formal education concerning the diagnosis and treatment of wounds in either their pre or postgraduate medical education.
Many physicians, depending on residency training, will not receive any further information about wound care throughout their career. When a wound care center opens in a hospital, members of the existing medical staff are invited to participate and often receive less than one week of didactic training before working in the center. While this training is a considerable improvement in the current conditions, it is still considerably less rigorous than participating in a formal residency and fellowship-based medical education.
The path to specialization will need to not only provide for formal fellowship training at the graduate medical education level of accredited university centers but will also need to address the needs of those physicians currently practicing in the field who could benefit from the didactic content and are mid-career and cannot take a year off to pursue formal training. In addition, education for patients must not be underestimated or left off the agenda. Not only are patient-centered outcomes finally achieving their place in guideline development, but the voice of the patient at all levels of the education, research, and advocacy process must be incorporated.