In past Practice Perfect editorials, I’ve pushed research as an important — perhaps fundamental — way to advance our profession. I still believe this is true, but I’d like to discuss a different facet of this issue, which may have a controversial side. I’m speaking here of the concept of Centers of Excellence.

What is a Center of Excellence?

Until relatively recently, I was ignorant of this idea until I read a fascinating piece by general surgeon Atul Gawande, MD in his book Better: A Surgeon’s Notes on Performance. If you haven’t read this book, I strongly recommend it. While discussing ways in which various folks in medicine are striving to improve patient outcomes, he reviews the idea of a center of excellence. It sounds pretty self-explanatory: a medical center in which excellent patient care is carried out. But it’s a bit more than this. Essentially, this is a tertiary care center that focuses on one principle disease process, handling the most complex cases in a manner superior to that available in the regular community.

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Lee Rogers, et al. develop this concept rather clearly in their recent article in JAPMA (Rogers, et al. 2010) as it relates to lower extremity amputation prevention. They summarize the three different levels of care for the diabetic foot (basic, intermediate, and center of excellence).

A modified list of the characteristics of the center of excellence model is as follows
(last three bullets are my additions):

• Prevention and care of complex cases.
• Regional, national, or international referral base.
• Set in a large teaching hospital or university.
• A broad team of health care providers delivering comprehensive care.
• Advancement of knowledge, including of other centers.
• Organizing educational meetings on multiple levels.
• An evidence-based approach to complex medical care.
• Pushing the envelope of innovative care beyond what is currently available.
• Continuous high quality basic and clinical research with an international presence in
  the scientific community.

Dr. Rogers and colleagues discuss this ideal in reference to the “toe and flow” model of limb preservation, which has yielded great success.  My congratulations go out to the wonderful work of not only Dr. Rogers, but Drs. Armstrong, Frykberg, Lavery, Lipsky, Harkless, Andros, Steinberg, and countless others (too many to name here – my apologies) who have brought podiatry to the forefront of diabetic limb salvage. 

I find one fact amazing in light of the history of medicine in the United States.  The bullets I’ve list above almost completely describe what was created at Johns Hopkins Hospital (JHH) in the early 1900’s.  The JHH, led by such famous names as William Welch, William Osler, William Stewart Halstead, and Harvey Cushing was an international center of excellence – without the formal designation.  It excites me to know this tradition is being revived throughout medicine today.

Please share your thoughts about how Centers of Excellence can be incorporated into our specialty on etAlk and in next week’s Practice Perfect, we’ll discuss how to both improve our care of the lower extremity and move podiatry into the forefront of medical care.

Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum. Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

References:

Rogers, et al. Toe and Flow: Essential Components and Structure of the Amputation Prevention Team. JAPMA, Sep 2010; 100 (5): 342-348.

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