My Scope of Practice: Championing the Podiatrist`s Role in Wound Care

    Propelled in large part by the increasing number of people with diabetes who have subsequent foot problems, podiatry is moving into the mainstream of medicine.

Because of their knowledge of biomechanics, offloading, and debridement, podiatrists can provide the prophylactic and emergent foot wound care that physicians in other specialties may not have the training or inclination to offer. Most surgical specialties deal with acute pathologies; however, podiatrists often treat chronic conditions, thus setting the stage for care of chronic wounds. Their recognition as important members of multidisciplinary wound care teams is growing, largely due to clinicians like Rob Snyder, who have championed the role of the podiatrist as the "hub of the wheel" in lower extremity wound care.

    Robert J. Snyder, DPM, FACFAS, CWS, a diplomat of the American Board of Podiatric Surgery and a podiatric physician for almost 30 years, spent the first 18 years successfully practicing general podiatric surgery in southern Florida. Over time, he developed a keen interest in wound healing but realized he needed additional education. He sold his practice and with the resources from the sale created his own "mini-fellowship" in wound management through a personal course of study with several components. He attended numerous meetings and seminars and cultivated relationships with wound care experts around the country who could teach him new techniques. Eventually, he aligned with a local wound care center, continuing to nurture his skills with the help of his mentors and continuing education programs.

    He learned a few training tricks along the way. "When I decided to pursue wound management on a full time basis, I found that doing hospital rounds at the same time of the day allowed me to see only a few physicians," Dr. Snyder says. "So I rotated the time I did rounds and had the opportunity to meet people I otherwise wound not have met, which was good for my education and for building my wound care practice." He acknowledges that states vary on how far up the leg a podiatric surgeon can practice. "In some states, podiatrists can provide care up to the ankle. In Florida, however, we function under a 'leg law'." He feels it is most advantageous to practice where the law is most favorable because "dealing with more of the leg provides diversity in wound conditions." In addition to diabetic foot wounds, people with venous and decubitus ulcers are now a large segment of his practice.

   Dr. Snyder found that writing - something he enjoys and has a flair for - is a good way to stay current with the literature and best practices. He has authored recurring columns in Podiatry Today and Podiatry Management, as well as many articles for Ostomy/Wound Management (he is a member of the Editorial Advisory Board) and other peer reviewed journals. He received the Duoderm Research Award from ConvaTec, a Bristol-Myers Squibb Company, and attended the Wound Healing Summer School at Oxford University, UK. "Visiting England, immersing myself in the culture and observing their wound healing practices, was a highlight in my professional career," he says.

   For Dr. Snyder, a collaborative approach to wound healing is a major priority, and understanding wound etiologies and science is key to healing recalcitrant wounds. He says, "Our ability to understand the science behind manipulating micro-environment and altering wound bioburden will lead to appropriate therapies and dressing choices." His practice is devoted to wound management, limb salvage, and education. He has found that most general physicians don't have the interest or expertise to deal with wounds and are willing to turn that aspect of care over to another clinician. However, in doing so, they expect the same level of expertise that any other specialist would offer. "You have to do it better with evidence-based protocols," says Dr. Snyder. "You cannot focus just on the area you treat - you have to broaden your educational scope. To increase your credibility among other physician specialties, you need a broad range of knowledge and the expertise to manage wounds in the complex patient. This creates a wider net of experiences and is usually labor-intensive, time-consuming work. However, a well-trained podiatric wound care physician who is visible and available to the medical community he/she serves can enjoy a fulfilling, dynamic, rewarding practice.

    "From another perspective, the podiatrist may see a patient who needs medical care and generate referrals to other physicians and specialists, thus creating new alliances," Dr. Snyder explains. "Ultimately, the goal is for the general physician to see a challenging wound and think 'podiatrist'. Maintaining a presence in the hospital helps facilitate that goal."

   For almost 8 years, Dr. Snyder has served as a faculty physician at the Wound Care Center at Northwest Medical Center, Margate, Fla., and as Director of Wound Management Education at that institution. Dr. Snyder facilitates the teaching of wound science and management to interested staff physicians and nurses. Topics range from staging wounds to medical and surgical management and to complex wounds such as Pyoderma gangrenosum (PG) and malignancies, which may be underdiagnosed. "Wounds have a tremendous impact and potential liability in the hospital setting," he says. "We often utilize a network of inpatient and outpatient nurses and physician instructors from our wound care center program to address these issues. We emphasize wound pathology and educate about prevention, nutrition, and offloading. A subtle balance between medical and surgical treatment in a collaborative model is the key to healing recalcitrant wounds."

   Dr. Snyder often teaches about new wound care technologies as adjuncts to good wound care practices. The hospital recently awarded him the Nova Award for his professionalism, his abilities to motivate staff, and his commitment as a patient advocate. "We share evolving care options," he says. "For instance, when new advances in endovascular surgery have the potential to reduce morbidity, we secure a physician to address groups on the topic." Dr. Snyder is also actively involved in teaching wound management to podiatry residents and lectures extensively around the country on topics relating to wound management and limb salvage.

    Dr. Snyder is also the Director of the Wound Care Center at University Hospital, Tamarac, Fla., in operation for 3 years. "I was appointed to the Directorship because the institutional administration recognized the role of podiatrists as gatekeepers for wound care. Podiatrists are proving they are uniquely qualified to take the lead in wound care." In addition, Dr. Snyder chairs the Skin and Wound committee that influences product selection (including support surfaces) and chairs the CME Committee that facilitates educational programs.

    "Clinicians new to wound care can start with what I call 'scratch-and-dent' wounds- wounds that improve with appropriate care as long as adequate circulation is present - and then gain experience treating more complicated lesions," he says. "They also need to develop an appreciation for the patient perspective. Because patients have comorbidities and may be seeing two or three other physicians, the wound care specialist also must be reasonable, fair, and honest - avoiding 'sugar-coating' the patient's condition - and set realistic goals. The wound care clinician also should work closely with the patient's other specialists as part of a team effort to coordinate care, review test results and consultations, and decide how they fit into the treatment plan.

    "In a perfect world, the patient would be admitted to the hospital so that the blood tests, scans, angiograms, MRI, and Doppler studies could be performed within 1 to 2 days. However, due to DRGs, hospitals tend to resist this notion unless there is evidence of infection or an ischemic limb. I think if a study were conducted, the results would show that patients admitted for 24 to 36 hours for essential testing and consultations would be better served. Specialists could work quickly in a collaborative model and a treatment plan could be adapted in short order."

    Dr. Snyder acknowledges that coordinating care among specialists is dependent on mutual respect. An infectious disease specialist, for example, can suggest a new antibiotic, perhaps with input from other clinicians working on the case; the vascular surgeon may work in tandem with an endovascular radiologist with fellowship training; a physical therapist might offer alternative adjunctive therapies. "We need cohesiveness among interdisciplinary providers," Dr. Snyder says. "And we need to constantly re-evaluate how we approach and provide care. On-going dialogue among disciplines is the most important part of the wound care model."

    As podiatrists gain steadier footing as active participants and leaders in wound care protocols, their role in research also will evolve, from participating in something as rudimentary as trying a new dressing on a patient to conducting double-blind studies. "As wound care clinicians, we must demonstrate that we can utilize products in unique ways and in combinations to create potential synergy," Dr. Snyder says. "We can influence the economic direction of practice and products, improving on old uses as we improve care. Research has become an integral part of my practice and evidence-based medicine remains paramount. Podiatrists have a key role in the future of wound care in my scope of practice."