Physicians in wound clinics carry the responsibility of caring for millions of patients with wounds. Can concierge medicine physicians, who have a smaller patient population, help relieve the burden and provide personalized care? This author offers case studies and examples of the benefits of concierge medicine.
Chronic wounds are a symptom of disease and sometimes many diseases. In most cases, it isn’t really possible to heal the wound(s) unless you correctly diagnose and manage the underlying disease(s) that contribute to it. The average patient in my practice has 10 comorbid diseases and is on 12 medications. Despite the fact that they are invariably seeing excellent physicians, they often have more than 4 specialists involved in their care. The fortunate patients have family members who bring notebooks filled with medical records, labs and physician’s notes. In other words, a few patients are fortunate enough to have a family member or caregiver who is sophisticated enough and organized enough to coordinate their care. It takes an incredible amount of time and medical knowledge to do this well and the typical primary care physician simply does not have the time. Often, I end up being the one who coordinates the patient’s care, even though as the wound care physician, I am probably not the logical choice.
In the past year, two of my very complicated patients were serendipitously being seen by the same concierge physician. In both cases, the diagnosis was in question and possibly life threatening. By working with the concierge physician, we were able to get the patients the right care in a timely way, and get all the other needed specialists on board. Since then, I have recommended that complex patients with the resources to do so use a concierge physician to coordinate their complex patient care. They make house calls when needed, are available evenings and weekends, patients usually have a cell phone for them, they can help with pain management, and they can even go with patients to doctor’s appointments. Most importantly, they can keep up with the phone calls required to get all the specialists on the same page. Dr. Amy Mynderse is a master at this and I thought it might be useful to see “wound management” through her eyes.
—Caroline E. Fife, MD
Wound care physicians are undoubtedly some of the most unsung heroes in the medical community. At last count there are somewhere around 10,000 wound care physicians attempting to care for almost 7 million patients who are faced with chronic wounds.1
This silent epidemic only continues to worsen as our population continues to live longer, and comorbidities such as diabetes mellitus and obesity continue to increase. Patients with chronic wounds often need to be seen at least once, if not multiple times a week, to follow their progress and achieve the desired results. Oftentimes, it is not reasonable for us as a medical community to expect a wound care physician to be able to see patients as frequently as needed, when visits often take an hour or more depending on the amount of dressing changes, blunt debridement, and patient discussion required. As the problem of chronic wounds continues to grow, this seems to be an essentially non-sustainable situation for these physicians.
Primary care is another field that sees physicians struggling to keep up with the demands of the current healthcare system. With increasing demands about Relative Value Units (RVUs) and decreasing reimbursements from insurance companies, the burnout rate is high and many highly trained and well-respected physicians have chosen an alternative way to practice: concierge medicine. As of 2019 there were approximately 12,000 concierge medicine doctors and this number is expected to grow significantly over the next 5 years.2
Although there are many different ways to actually practice concierge medicine, universally, concierge physicians have a much lower patient volume to allow them to give the personalized care these patients are seeking. Whereas an average primary care doctor has 3,000 to 4,000 patients in their patient panel, a concierge physician generally has between 200 and 600.2
How Concierge Medicine Could Help Your Wound Clinic
This brings us to the question at hand: how can I, as a concierge doctor, be helpful to you, a wound care doctor?
The rare commodity that concierge physicians have at their fingertips is time. Time to have extended visits with patients. Time to see a patient daily or do home visits if necessary. Time to speak with multiple consultants on a patient’s behalf. Most importantly in this setting, time to look at wounds as frequently as needed. We have the time and ability to be your eyes and ears as often as you need.
When a patient calls with an increasingly painful wound, instead of the wound care doctor squeezing the patient into an already booked clinic, the concierge physician can see the patient within 24 hours, and often the same day. Afterward, a conversation and possible exchange of pictures between physicians can accomplish a tremendous amount, with minimal inconvenience to the patient, and without significantly increasing the burden for the wound care physician.
Case Studies in Concierge Medicine
Let me give you 2 examples of how this sort of partnership worked beautifully for 2 patients in my practice.
The first patient is a beautiful 21-year-old woman, who in the fall of 2019 was a senior in college with her whole life ahead of her. This all changed very abruptly when she developed a massive pulmonary embolism and had a prolonged hospital stay that was complicated by necrotizing fasciitis. Due to her severe infection, she ended up having a right sided above knee amputation (AKA) and extensive debridement of her stump all the way to her groin. The end result of her debridement was essentially a stump of what looked like raw meat. Hip disarticulation and flaps were considered but opted against due to the desire of the patient to eventually be able to use a prosthetic.
At this point her long journey of wound healing began. Her dressing changes were extensive. Her father did them 1–2 times a day. However, when she went to see her wound care physician she was so anxious and frightened, the doctor could barely touch her. Her doctor knew she had a concierge primary care physician (PCP) and the two of us worked together endlessly to get her on a medication regimen so she could tolerate these visits. Once that was accomplished, the patient began to heal better than anyone could have expected.
Despite this, there were some stubborn areas on her stump that just weren’t healing like the rest. Given her history of ulcerative colitis, her very astute wound care doctor thought about the possibility of pyoderma gangrenosum. She brought this to my attention and after reaching out to her gastroenterologist, we opted to try a course of steroids.
These areas responded well to this treatment, to the point that this amazing young lady is now walking on her prosthetic (and finishing her senior year of college) without difficulty. I truly believe it was the ability of her wound care doctor and I to work together seamlessly, with innumerable text and phone conversations regarding this young lady’s care, that allowed her to get to the place she is today.
The second patient is a woman in her 60s with Sjogren’s syndrome. She had been a dancer and she still practiced ballet 4 times a week. Eighteen months ago she began to develop pain and swelling in her feet. This was followed by small ulcers on the lateral malleoli, first on the left, then on the right. She had sought consultation with multiple doctors about this issue. Over a 6-month period she had multiple vascular studies and lab work, all of which were normal. She had home health come to her house and dress her wounds daily, yet they continued to worsen. She had seen her rheumatologist, who felt the wounds were not related to her underlying rheumatologic disease based on her unrevealing lab studies.
By the time I was involved in her care, she was in severe pain, and could not even wear shoes on her feet. After reviewing her studies, I felt this was very likely to be vasculitis, although her rheumatologist did not. I set her up with a new wound care physician, who called me immediately and had the same thought I did: regardless of what the labs said, this was untreated vasculitis. She could not get back into her rheumatologist for almost a month so after multiple discussions and seeing her wounds worsen very rapidly, we opted to try a course of steroids.
I saw this patient at her home 3 times a week for the first couple of weeks. I would be there at the time of her dressing change, send pictures to her wound care doctor, and we would decide together whether to change her steroid dose. Her wound care doctor would make alterations to the dressing change regimen and what we were putting on the wounds, and I was able to be there, to give her real time feedback and images of the effects of her changes. Eventually, she did get back into her rheumatologist, had a biopsy of the lesions, and was diagnosed with leukocytoclastic vasculitis.
The patient is now getting Rituxan every 3 months, is weaned off steroids, and though she hasn’t put her ballet slippers back on yet, her wounds have significantly improved and she is doing much better.
In both of these cases, I feel the partnership I was able to form with the wound care doctor had a significant impact on the patient’s outcome. I had the time to do the legwork that traditional PCPs just don’t have. I was able to see the patients as frequently as needed to achieve a positive outcome.
I truly believe the majority of primary care physicians would do this for their patients if they only had the time. Unfortunately, traditional PCPs are trying to function in a completely broken system, and time is one thing that is in short supply. I encourage you all to consider looking to a concierge physician model for your patients with complex wound issues. We would love to ease your burden and be your partners in healing.
Amy Mynderse, MD, practices at River Oaks Doctors Group in Houston.
1. Jarbrink K, Ni G, Sonnergren H, Schmidtchen A, Pang C, Bajpai R, Car J. Prevalence and incidence of chronic wounds and related complications: a protocol for a systematic review. Syst Rev. 2016; 5(1):152.
2. Daily L. Before you pay extra to join a concierge medical practice, consider these questions. Washington Post. Published Oct. 22, 2019.