Implementing a Chronic Wound Care Curriculum for Internal Medicine Residents

Objective. The objective of this study was to determine if participation in a practice-based learning session would change the residents’ reported wound care practice. Methods. A 90-minute didactic and skills workshop in chronic wound care was provided to 89 internal medicine (IM) residents divided into 4 groups, who were asked to complete an anonymous clinical vignette survey prior to the session and again 3 months after the practice-based learning session. Results. Comparisons of the pretest and posttest scores (Mann-Whitney U Test) showed only ordering moisture-retentive dressing changed significantly. Residents reported likelihood of preventing/managing wounds in their future career on a 10-point Likert scale (mean 4.92). Conclusion. Future directions aimed at assessing the wound care needs/resources of the IM outpatient clinics, the comfort of the supervising clinicians and residents, and targeting the curriculum to those most likely to benefit should be addressed before further refining the curriculum.

Internal medicine (IM) residencies often lack formal curricula in chronic wound care. Chronic wounds disproportionally afflict older adults, and future clinicians need to diagnose and treat a wide variety. Clinical vignettes have been shown to be an accurate surrogate of physician practice over chart review.¹ The objective of this study was to determine if participation in a practice-based learning session would change the residents’ reported wound care practice.

This prospective study was declared exempt by the Oregon Health & Science University Institutional Review Board. A 90-minute didactic and skills workshop in chronic wound care was given to 89 IM residents divided into 4 groups as part of their longitudinal outpatient curriculum. Residents were invited to complete an anonymous clinical vignette survey prior to the start of the workshop. The piloted survey addressed practices in assessment, documentation, debridement, and treatment. A pocket card with wound assessment and dressing selection was also provided. During each session, the same 3 cases of typical chronic wounds were presented (venous leg ulcer, pressure injury, and neuropathic foot ulcer); wound description, etiology, and treatment were also discussed. The case-based and hands-on skills portion allowed residents to practice conservative sharp debridement and wound dressing. Three months after the session, the residents were sent the same clinical vignette along with questions on changes and barriers to change in their practice. 

The curriculum was modified after each session, where the last session was the most refined for future use. Sixty-three residents (70%) and 19 residents (21%) completed a preclinical and postclinical survey, respectively. Ten (52%) of the postsurvey respondents stated they had made changes in their wound care practice. Changes included addressing underlying issues (2), improving wound descriptions (5) and dressing choices (1), and addressing pain management (1). Reported barriers to change included a supervising clinician not comfortable with wound care (6), resources (wound products/tools) not available in the clinic (10), and lack of confidence even after the session (8). Residents reported likelihood of preventing/managing wounds in their future career on a 10-point Likert scale (mean 4.92) (Tables 1, 2). 

The authors demonstrated that this wound curriculum led to resident-reported practice changes despite nonsignificant changes in vignette scores. They also found that residents encountered clinic-specific barriers to change in wound care practice. 

The low response rate for the posttest, inability to show individual changes by linking pretests and posttests, and refinement of practice-based learning sessions over the 4 weeks (variability in sessions) were the limitations of this study as well as it being conducted at a single institution.

Because this practice-based learning session will be repeated every 3 years in the IM residency, there are opportunities for improvement. Prior to the next session, the authors plan to train supervising clinicians in basic wound care, address wound care products/resources in the clinic, and possibly expand to other primary care provider training tracks, such as family medicine.

Integrating a chronic wound care practice-based learning session into IM outpatient care poses many challenges. Future directions aimed at assessing the wound care needs/resources of the IM outpatient clinics, the comfort of the supervising clinicians and residents, and targeting the curriculum to those most likely to benefit should be addressed before further refining the curriculum.

From the Oregon Health & Science University, Portland, OR

Address correspondence to:
Elizabeth Foy White-Chu, MD, CWSP
OHSU/Portland VA Health Care System
Medicine
6306 SE 45th Ave
Portland, OR 97206
whitechu@ohsu.edu

Disclosure: The authors disclose no financial or other conflicts of interest. This paper was presented as a poster at the Symposium on Advanced Wound Care Spring 2017.