Wound care certification: Compensable or reprehensible?

by Michael S. Miller, CEO and Medical Director of The Miller Care Group

Universally, regardless of the area of expertise, employment, endeavor or action, there is always some sort of stratification. The best soccer players (that’s “football” for my colleagues across the pond) have the highest profiles and, of course, the highest subsequent annual salaries. They earn these unabashedly because their skills place them well above others. People with extraordinary managerial skills, computer skills, or any other abilities that elevate them to the highest echelons of their endeavor are rewarded based on the initial and ongoing demonstration of skill. 

While in many of these situations some sort of certification is achieved or obtained, it is unquestionably the skill level that they demonstrate ad infinitum that places them in the highest strata. Their real test is simply to do great work that is easily recognized as great.

What does ‘wound care certification’ mean?

Recently, one of the simplest and most basic human skills involving recognizing natural born leaders (such as people who possess superior intelligence or skills) has been obviated by contrived and far-too-often unrelated documentation purporting to prove expertise. For the sake of this diatribe, I am talking about wound care certification. I have previously blogged and spoken about the numerous issues involving the current state of so-called “wound care certification” and based on a series of recent events, the time has once again come to rattle the cages of comfort. Unlike TRUE board certification, which is unfortunately (but for many reasons) limited only to physicians, the zeal to create a “guarantee of expertise” hurdle for which those who can jump it are suddenly granted infinite omniscience and omnipotence has resulted in quite the opposite.

There are presently a myriad of organizations that offer some version of the epithet “Expert in Wound Care and Everything That's Related To It”. The overwhelming majority provide an educational course immediately prior to an examination, which for all but the most daft, virtually assures a passing grade. The driving force behind this mad dash has been that facilities and other entities actually believe that these tests not only confirm wound care knowledge, but directly relate to expertise. 

More intriguing, however, is the fact that with some subtle exceptions, the people taking these “guarantees of expertise” are coming from specialties that certainly are integrated, but overall completely unrelated. Nurses, physical therapists, dietitians, and physicians unquestionably need to have the same, most basic knowledge regarding the infinitely complex world of wounds. But to believe that each of them individually passing the same test means having the same knowledge is ludicrous.

I support those whose passion for wound care and careers have been based on attempting to adhere to Father Hippocrates’ admonition, Primum non nocere (“First, to do no harm”). Not surprisingly, encounters with those waving their wound care expert certificates in front of them (like a shopper during triple coupon value days) have been most unsatisfying. 

As will come as no surprise, my splenic venting is the result of recent verbal interactions with a local BIG hospital wound care therapist spouting wound care gibberish including twice a day dressing changes, “peanut butter and jelly sandwich dressings” (using three and four incompatible products), and advising me that foul odor unquestionably portends gangrene mandating consideration for amputation. 

Of course, the conclusion of the shocking, disgraceful, scandalous, atrocious, appalling, boring, monstrous, heinous but well-intentioned recommendations are always punctuated by their self-congratulatory “And I am certified” as to underpin the validity of their care of their most current sacrificial lamb. Of course, my questions to her regarding the illogic and what evidence she had only resulted in the well-worn "I've been doing this for a long time.” Not a single answer to my questions, but a lot of stuttering.

What is the value of wound care certification?

The question is, of what real value is wound care certification? For those seeking the sought-after economic benefits, then unquestionably having this piece of paper (regardless of what it does or does not portend) solves the problem. 

As a Board-Certified General Surgeon, I was tormented by three different board examinations: a written test, an oral examination of six hours, and lastly, having two surgeons observe me performing several major surgeries and reviewing case charts. While I am by no means recommending this version of the Spanish Inquisition for wound care expertise, there is no question in my mind that the ability to answer questions whose answers were presented mere hours before is highly problematic in terms of identifying true expertise. I recognize that certification must start somewhere and having been involved in test question creation, verification and more for numerous written certification examinations, I understand that the investment of time and energy is nothing to be taken lightly. However, since wound care is a “boots on the ground” practice, then those boots need to be examined.

I have proposed (with mixed reception) that an additional level of verification of expertise must be initiated. I recognize that economics play an important role in both ends of the quest for achieving a higher strata by paying for certification resulting in access to higher compensation. However, the investment to demonstrate expertise must be met with higher compensation only when this expertise is defined and unquestionably recognized and demonstrated. 

Insurance companies routinely request mandatory chart reviews to assure that standards of care are met and more, that the documentation exists so that compensation is commensurate with the documented care provided. 

Why should the certification of a wound care specialist be any different?

In the myriad of turn-key wound care operations in almost every hospital, they have a cookbook and quota system, so why even force certification on anyone since these wound care dabbling automatons simply follow the code written into their ports?

So, the time has come to take a critical look at how to create a hurdle and what it must be made of. What will it take for the wound care certifying bodies to recognize that it is the practice of wound care that demonstrates expertise, not the ability to answer a bland, factual conundrum? 

To create a new paradigm requires courage; but more, true altruism. I propose that so-called “wound care certifying entities” take their certification to the next level by mandating submission of redacted charts from candidates looking to truly demonstrate wound care expertise. A minimum number (3 or 4) redacted charts would be required from each of the major wound categories: pressure-based tissue injuries, Venous based, diabetic neuropathic (which arguably would include arterial/ischemic), and then an additional eight or so other wound or related cases for an approximate total of 20. I think this is a very reasonable number considering the myriad number of cases that a true wound care expert should be seeing and participating in over a defined period. 

Using specific criteria and a point system based on accepted for evidence-based or best practice criteria, a panel of three experts (yes, I know that this circles back but you have to start somewhere) would score these cases and then identify whether or not this particular candidate met the minimum standards to be truly called a certified wound specialist or whatever title that entity purports to proclaim. To paraphrase Associate Justice Potter Stewart of the United States Supreme Court, I cannot define great wound care, but I can recognize it when I see it. 

Compensation based on a spoon-fed examination, self-proclaimed expertise, and substandard care masquerading as the end result of certification have had their time in the sun. The new mandate is to do what the insurance companies and other bureaucratic oversight entities are unquestionably moving toward. Where I grew up, we call it “Put up or shut up.” If you want to get paid for providing true wound care expertise, then waving a printed e-mail from an organization stating: Veni didici, tradidi vobis praecepta mea (I came, I learned, I passed) may be a good start, but until you treat more than a piece of paper in that bed, it's not wound care – or at least not what I would want for myself, my family or my patients.