Editorial: Predictably Unpredictable

It’s something unpredictable but in the end it’s right… — Billie Joe Armstrong, Frank E. Wright III, and Michael Pritchard for Green Day (from the song “Good Riddance")

  The complexity of humans continues to confound, perplex, amaze, and keep researchers on their toes. Case in point: In this issue of Ostomy Wound Management, Gabriel and colleagues discuss the use of the art and science of wound healing, as well as a considerable dose of creativity, to devise a strategy for reducing the number of surgical procedures needed to close soft tissue defects. Controlling for wound size and certain comorbidities aside, the results of this case series are a testament to human ingenuity. Further comparative studies are warranted to test this approach in different wound types and more diverse populations. But often, study population heterogeneity can confound predictability. We continue to search for go-to protocols for healing that work in as many situations as possible.   The study results reported by Kirsner et al in this issue are an important reminder that there may be more to a refractory wound than meets the eye. Just because a considerable number of our patients may not heal because offloading is less-than-optimal or their use of compression bandages may leave a lot to be desired doesn’t mean nonhealing is a factor of nonadherence to protocol. Or, just because there are dozens of treatment options doesn’t mean we should try them all before checking to make sure the initial diagnosis was correct. In this (first ever) report detailing the results of 350 ulcer biopsies submitted to the University of Miami Wound Pathology Service, almost 30% of the samples were found to have an atypical etiology. Of those, 23% were malignancies. Although, as the authors state, this is not a representative sample of all patients with refractory ulcers, the numbers are worrying and beg the questions, “How often are we missing important diagnoses?” and “How long should we keep treating before obtaining a biopsy?” Our ability to predict successful treatment is as much dependent on what we don’t see as what we do see.

  With physicians growing increasingly interested in wound care as a specialty, a new option for a related credential has been created. Special to OWM describes the birth of the American Board of Wound Medicine and Surgery (ABWMS), which aims to provide a new certification that will follow American Board of Medical Specialty (ABMS) guidelines with additional recognition from the American Osteopathic Association. In compliance with the ABMS and AOA, training programs have been initiated across the US; the first examination was administered in June, and the ABWMS has already certified qualified MDs and DOs in wound care.

  Also to consider: Healthcare providers, like the patients in their care, are human. Researchers recently examined the outcome of telehome care communication and self-care in patients with chronic conditions.¹ The results showed the telehome care nurses believed patients were integrating the support and advice received into daily self-care behavior. But they were not. The researchers concluded the influence on the nurses of the halo effect — ie, seeing what they want to see — may cloud their perception of what actually is occurring.

  Also of note: To keep pace with changing times and better facilitate the research-to-publication process, OWM is moving to an online manuscript submission program. Authors will be asked to submit their materials via Rapid Review (www.rapidreview.com). Our Instructions for Authors (in this issue, and always available online at www.o-wm.com) explain the manuscript preparation and submission guidelines to follow.

  In taking care of wounds, we need to be mindful of how capricious humans — whether on the giving or receiving end of care — can be. We cannot assume our instructions are followed. We cannot cavalierly write-off nonhealing to nonadherence in a stubborn wound. We should constantly test the status quo to find better ways to provide care. We need to quantify the wound really is doing as well as we would like. Only carefully conducted studies can provide the benchmarks — the predictability — of outcomes we must use to consider the effect of our efforts. Through such research, we might dispel what is preconceived and expected. Predictably, we will have to work harder to ensure hope and optimism prevail.

1. Shea K, Chamoff B. Telehomecare communication and self-care in chronic conditions: moving toward a shared understanding. Worldviews on Evidence-based Nursing. 2012;9(2):109–116.