Why This Woundologist Transitioned From Hospital-Based to Office-Based Wound Care

I had the opportunity to meet Andy Rohrer quite by chance on the phone when I was asked to connect with him about a challenging patient. As it turned out, I had no advice for him—but he had a lot of wisdom for me. I was intrigued by his office-based wound care practice in rural Arkansas where he was providing the highest quality of care possible anywhere, despite many challenges and barriers to access. I was inspired by his commitment and his creativity. At the end of our conversation, he said, “There are people who will die without every finding their purpose in life. I am one of the lucky ones, because I found the thing I was born to do.” I was inspired and I knew you would be, too, so I’ve asked him to write this month’s editorial.

—Caroline Fife, MD

I practice in West Memphis, Arkansas, about 15 miles from the city of Memphis, Tennessee. The location is suburban but the culture is rural. My people in Arkansas primarily work in farming and “blue collar” industries. West Memphis, Arkansas is separated from Memphis, Tennessee by the Mississippi River. We find that many Arkansans are simply intimidated by even the thought of crossing the bridge to go into Memphis (population about 650,000).

I am fiercely protective of my patients and our way of life here in Arkansas. I know they are hard-working, independent people who often try to fix things themselves; unfortunately, they show up for medical care only when things have progressed to dire circumstances. The drive time for patients to reach me varies from a few minutes to more than 2 hours. Our payer mix is increasingly Medicare Advantage plans (which is causing huge frustration) with a fair amount of private insurance. The “Medicaid-only” population is around 10%. There are some patients with no insurance.

I took a leap of faith in 2019. I went from working in a hospital-based outpatient wound management center to a private-practice office setting. Working in a hospital-based wound center wasn’t all bad. In fact, much of it was great. The comfort of being backed by a health care system is reason enough to just stay put in the hospital. Having access to emergency services provided an added level of comfort. Resources were readily available along with many integrated services, and the overall financial accounting was not any of my business (or so I thought).

But within the first days of the COVID pandemic, those advantages became liabilities. Resources disappeared. Emergency services became taxed to a level that was unprecedented. Services like hyperbaric oxygen therapy collapsed, often taking the hospital-based outpatient department with it if the department’s finances were dependent on that service line. While there might have been some creative ways to adapt, hospitals are not known for their creativity and they certainly don’t support “out of the box” thinking by nurse practitioners.

The Advantages and Challenges of Private Practice

I saw the writing on the wall and I transitioned to a private practice setting. I do not have access to hyperbaric oxygen, but in my private practice, I am able to offer many other advanced therapeutics that were unavailable in the hospital setting. I also shed the defeating bureaucracy of a hospital system. My clinic is not subject to intrusive inspections from Voldemort—sorry, I mean the Joint Commission—the preparations for which took hours away from patient care and did nothing to improve quality.

The private practice setting does have challenges. I do not have access to certain types of expertise like infectious disease (ID) specialists. There are few ID physicians in my area and since the pandemic they are overwhelmed. That means I have become quite skilled at managing my own antibiotics. We place PICC lines right here in the office. Since the hospitals can’t keep the operating rooms staffed, procedures have to be done in the office if at all possible.

However, if there is a therapeutic product that I want to try, I try it. If there is a different service that I want to offer, I offer it. I don’t have to ask for permission to do good work. If there is a patient who has trouble paying their bill, I make the decision about how best to help them. I use novel custom-compounded topical antimicrobials formulated from culture results.

I have a unique relationship with home health because they are my primary source of patient referral. I invest a lot of time training and helping the local home health nurses. This allows me to see patients less frequently but still ensure good care. In return, they refer patients to me and essentially do my marketing for my clinic. Even though I treat mostly rural patients, the result is one of the most robust and complete wound management programs within the Memphis area. We offer a complete array of cellular- and/or tissue-based products, in-house prosthetics and orthotics, diabetes education, and the only integrated lymphedema massage therapy programs in the region. Because we are associated with a vascular practice, we have managed to build a complete program capable of treating significantly wounded patients.

The Woundologist

People are not in wound centers because of what they have, they are there because of who they are. Our patients have highly complex medical problems that have to be tackled at the level of the patient, not the wound. That’s why I detest the phrase “wound care,” because this is not what I do. I practice advanced wound management. I consider myself a Woundologist. We Woundologists heal wounds they said could not be healed. We preserve limbs they said could not be preserved. We treat patients who thought they could not be helped. No matter what setting you practice in, what we do matters.
 
I would be lying if I said that I haven’t struggled with discouragement in the past two years—but when a patient, family member, or primary care practitioner tells me how much my team means to them, it re-invigorates me to carry on. The challenges of the COVID-19 pandemic required me to move my practice out of the hospital setting and to optimize care in my office in order to keep patients from requiring hospitalization. The result is that I get to practice at the height of what a clinician in this field is capable of doing. I am the Woundologist.

Stephen “Andy” Rohrer, MSN, RN, APRN, AGACNP-BC, FNP-BC, CWS, is in practice in West Memphis, Ark.

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