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Let's Be Frank

What’s the Best Source for Evidence-Based Medicine?

Clinicians today may be quicker to look to the Internet for wound healing advice than they are to conduct clinical research. Boundaries must be set here.

At the time any healthcare provider enters the field, the greatest challenge we face is often our own naïve belief that we can help everybody. In wound care specifically, we want to heal not only every patient, but every chronic ulcer. The truth, however, remains that many factors interfere with this goal and that some patients will not progress as we want them to, despite our best efforts. This is when having the ability to properly determine the true underlying cause of the wound, and the willingness to take the time and effort to do so, may be what leads to successful wound management. 

Research indicates that 70% of lower-extremity wounds are venous, 10% are arterial, and 15% are of mixed etiologies.1 That leaves 5% of wounds that are atypical and that much more difficult to diagnose and treat. It is estimated that approximately 10% of the 500,000 chronic ulcers identified in the United States may be challenging and occurring in unusual presentations.2 The overall concern for the wounds that we treat may ultimately be related to not being able to determine the true causative factor, and the ramifications include increasing medical costs, delayed healing, increased likelihood of infection and amputations, and increased hospitalizations. According to the National Center for Policy Analysis, an estimated 10–20 percent of medical cases are misdiagnosed.3 

When faced with these challenges, what should our next steps be? 

Unfortunately, for many clinicians today a reliance on crowdsourcing, or seeking “consultation” online, particularly through social media, is replacing the practice of conducting actual medical research. It’s a predictably dangerous pattern that we need to be aware of due to the informal nature of these outlets. Yes, it’s also true that having the level of interconnectedness that we have today can be advantageous to our practice and our patients, simply because of the sheer ability to share and gather information. We need to ensure we are balancing the pros with the cons.

Research Vs. Crowdsourcing

If you’re like me, society’s increased use of and reliance on technology in the general sense has changed your perspective on social media. It took me a very long time to embrace platforms such as Facebook, LinkedIn, and others, but the potential to connect with countless wound care clinicians and experts around the world became too tough to resist. 

I am thrilled to have this type of access to my peers, but at the same time I am also concerned about the opinions that stretch the boundaries of diagnoses that some providers seem to be making in response to conversations and photographs that are shared online with limited knowledge of the patients’ healthcare history, circumstances, or plan of care. We’re suggesting dressings, modalities, treatment strategies, and the list goes on. Some advice and photo sharing could be in violation of the Health Insurance Portability and Accountability Act (HIPAA). Or, worse, it could simply be wrong, unprofessional, and/or not have a basis of evidence-based research. Yes, some professionals and various legitimate organizations will present case studies that constitute actual learning opportunities, but where do we draw the line on research and informality? 

My colleague, Caroline Fife, MD, once offered me an interesting (and scary) perspective that helps me to calm my concerns: that there are in fact patients everywhere who are being treated by licensed healthcare professionals in wound centers incorrectly who might benefit from even a casual exposure of their wound online. While this further complicates the nature of how we should treat our relationship with the internet, I believe it further emphasizes our need as a healthcare community to commit to evidence-based care and turn to research prior to turning to social media—even if that feels like the more delayed, less “human” course. 

Crowdsourcing refers to the practice of obtaining needed services, ideas, or content by soliciting contributions from a large group of people and especially from the online community rather than from traditional employees or suppliers.

Legally Speaking

Lisa Sanders, MD, FACP, utilizes crowdsourcing to help difficult-to-diagnose patients consider healthcare options from around the world through her column in the New York Times Magazine and now the Netflix program Diagnosis. There are numerous websites that exist today where patients, physicians, and health practitioners share ideas on difficult cases such as Figure 1, SERMO, CrowdMed and others. One company reported solving over 1,000 cases in which the average patient had been sick for 7 years, running up medical costs astronomically.3 

But some clinicians still question whether this type of educational/investigational media is acceptable. What’s more, Fife recently wrote a blog titled “Them That’s Been Sued and Them That’s Going to Be” about the concept of clinicians potentially being sued for malpractice when no doctor–patient relationship existed and for “curbside” consultation, where advice to colleagues is given in a casual encounter.4 The Supreme Court has already had something to say that would lead us to believe this type of litigious action isn’t reality but nobody truly knows what the future will hold in this regard.5 That said, it will remain imperative for us to understand that crowdsourcing should not serve as medical advice in the place of actual research. Crowdsourcing also does not allow us to develop the patient–provider relationship and should not replace any treatment plan based on evidence-based care. 

In an effort to combine the advantages that research and appropriate crowdsourcing have to offer when it comes to educational opportunities for Today’s Wound Clinic readers, we are planning to launch an educational wound care platform in 2020 that will allow clinicians to submit examples of difficult or interesting patient cases for others to provide their opinions, share similar experiences, and use their skills/expertise to help others that may have similar cases. Stay tuned. n

Frank Aviles Jr. is wound care service line director at Natchitoches (LA) Regional Medical Center; wound care and lymphedema instructor at the Academy of Lymphatic Studies, Sebastian, FL; physical therapy (PT)/wound care consultant at Louisiana Extended Care Hospital, Natchitoches; and PT/wound care consultant at Cane River Therapy Services LLC, Natchitoches.

Let's Be Frank
Frank Aviles Jr., PT, CWS, FACCWS, CLT-ALM, AWC

1. Kisner R, Casey G. Causes and management of leg and foot ulcers. Nursing Standard. 2004;18(45):57–8.

2. Gottrup F, Karlsmark T. Leg ulcers: uncommon presentations. Clinics Derm. 2005;23(6):601–11. 

3. Stretch R. How medical crowdsourcing empowers patients & doctors. Rendia. Available at . Published Aug. 2, 2016. 

4. Fife CE. Them that’s been sued and them that’s going to be. Available at Published July 8, 2019. 

5. Howatt G. Minnesota Supreme Court ruling on malpractice causes stir in medical community. Minnesota Star Tribune. Available at Published May 27, 2019. 

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