Oral Histories of Podiatry, the Diabetic Foot, and Wound Care Research

Robert Frykberg

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Zweli: [: 00:00:00

Dr. Freyberg has an encyclopedic knowledge of the research, in his field. And, he's also a member of Open Wound Research as our chief research officer. So I get to enjoy, having this library of Alexandra, on our meetings. And I think you guys will enjoy, the insight he gives about the history of wound care.

hanged or not changed. And I [: 00:01:00

Apple Music and other podcast, avenues. So hope you enjoy it. Leave any comments, suggestions, et cetera. They're always greatly appreciated. Thank you. ​

Hello, welcome to the Open Wound Research Podcast. This is episode number two, and our guest today is Dr. Robert Frykberg, a respected wound care clinician and researcher. We're really excited to have Dr. Frykberg with us today, and welcome to the podcast, Dr. Frykberg.

Thank you. It's really good to be here.

an and researcher with about [: 00:02:00

He also has written more than 150 publications. So with that impromptu and wide ranging introduction, I think we've captured just a part of what, uh, Dr. Frykberg has done in the community. So, perhaps, Dr. Frykberg, to start, we can go back in time to when you chose to go to podiatric school.

What kind of drove that decision to go into medicine, uh, as a Jersey boy?

y in this, in this field for [: 00:03:00

And then I was discouraged from that. They said, well, you'll never get into the graduate school if you go to undergraduate school here. So I said, well, Okay. Okay. I guess I'm going to change, you know, cause I always love the, the water. I guess that's, that always raises the question. Well, how did I end up in Phoenix, Arizona?

e very advanced in their, in [: 00:04:00

People don't realize it now because there's so many medical schools, both DO and allopathic medicine, uh, back in the early and mid seventies, there were not as many medical schools. Uh, and the competition was very, very intense. Uh, because there were so few slots and, um, uh, I guess I didn't have, uh, enough, uh, wherewithal to really try to push to apply to 50 schools.

ace to go to school than San [: 00:05:00

So I went to school in San Francisco. And, uh, the bonus was that in, in the mid seventies, early to mid seventies, there was a new experiment in medical education where they were compressing four years into three years. And that didn't last long. I don't know why, because it was fine for me. And I was the first class to go in to the accelerated three year program, which just meant we had fewer vacations and we concentrated, uh, more into the time that we had.

ed ourselves and enjoyed the [: 00:06:00

And so, so I, uh, I completed studies there. The interesting thing is that I really only wanted to go to certain few places for residencies. And residency programs back then, as people wouldn't realize now, were very, very difficult to obtain in podiatry because there weren't enough slots. for all the graduates that we had.

I mean, there were fewer schools. I think we had four or five schools back then, but there were not enough residency slots. Uh, and most slots that were available were just one year slots. And there were only a handful of places with two year and there were really no three year residency slots. So I was just very selective because I thought, well, I did pretty good in school, so I'm going to be selective and just apply to the ones that I wanted.

erful match day came around, [: 00:07:00

And Lo and behold, in about a month of really depression and wondering what I was going to do after a month, um, I got a call from the program that I most wanted, which was my number one choice, my number one choice. And he says, uh, I hope you're still available because we had to pull out of the match because of internal problems or funding problems or something.

first choice, which was very [: 00:08:00

And that's how I went to Boston. And then from there, uh, my career developed. So that's, that's it in a nutshell, but it was interesting how it all, how it all worked out. And, and really for viewers who can't realize it now, it is really difficult getting into schools, uh, back in the early and mid seventies.

There just weren't enough slots. Even New Jersey where I grew up, uh, did not have its own medical school. Now it's got two or three schools. But back then there was there was nothing. My brother, much smarter than I, much more accomplished. He was a serious student in high school, or I can't say I was really serious student.

iam Mary and, uh, he, he was [: 00:09:00

Zweli: That's a very interesting. I didn't know that history, uh, but it makes sense. There was a lot of investment in higher education, I guess, to build out those professional schools.

Bob: Oh, yeah. Oh, yeah. You know, I think it's easier now, to be quite honest with you, to get into a medical school and, and pedi or, and podiatry school.

nstructor, who was fabulous. [: 00:10:00

You know, if you did get a residency, cause some of my, some of my students, my fellow students actually went right into practice cause you were not even required to have a residency in podiatry to get a license back then. In fact, most practicing podiatrists back in the seventies did not have, uh, residencies cause there just hadn't been those available.

inic with other, uh, Harvard [: 00:11:00

And I just dealt right in. I mean, I was very serious about it at that point. I know you don't believe that now, but I was really serious about things back then because I said, I'm going to do as best I can and I'm going to make sure that they know that podiatrists, uh, are, are here for a reason and that we can, um, We have our role in this big medical complex and I was going to do my very best and, uh, things just went on from there.

, um, in the hospital in New [: 00:12:00

an expert in diabetic foot. [: 00:13:00

Um, I was just fortunate that I was surrounded by really high level people. In my, in my early years and then meeting other high level people, and that kind of pushes you in the right direction. Whereas I think if I was in a small community hospital, With less academic people surrounding me, um, I wouldn't have kind of taken the path that I took, you know, and that's, so it really, really is important that who you associate with, who you're influenced by.

r surgery. And we're talking [: 00:14:00

Who was really the head vascular surgeon, Carl Hoare, who was a, another vascular surgeon. And these, these guys were really, really top of their field and really pioneers. And people might know the name Gary Gibbons. Gary Gibbons was a resident, just a, uh, I think he, he finished six months after I started as his chief surgery resident.

years ago. So, uh, [: 00:15:00

I'm trying to make your job easier as well. So you don't have to think of quite, okay. Cause I know your limitations as, as far as that goes.

Zweli: This is great because I think, you know, when I came into wound care, Uh, I like history. I like to understand the past and I think that's, uh, it, it doesn't, the future doesn't mirror the past, but it sure rhymes.

And so, uh, it's always interesting to see where this, this, this field progressed from and the learnings that we've kind of built upon. And it's, it's interesting for me to hear that, diabetic foot ulcer wasn't particularly an interesting part of podiatry medicine at that time. Or..

atry school in California, I [: 00:16:00

either. I just interviewed there and the Joslin clinic. And I knew there was a specialty in diabetes there. But then I got there and I started to become a little bit more scholarly, if you would, because I wasn't scholarly at all. in podiatry school for the most part. Neither, neither were my professors for that matter.

Um, but, but if you think about, as I was saying, where you train and who you train with, uh, you might be well aware of the multidisciplinary concept that you hear all the time, you know, multidisciplinary management of the diabetic foot. And again, diabetic foot, it was always my, my forte and interest. So, and I kept saying, oh gee, you know, they've been having multidisciplinary diabetic foot.

es, long before I was there. [: 00:17:00

The problems of gangrene, how they're, they're increasing in his patients, how patients are suffering needlessly, that patients need to be checking their feet. They need to have proper footwear. They need to be, have cleanliness of their feet. They need to see their doctor for good diabetes control.

ry well respected podiatrist [: 00:18:00

So he had his team. He had his specialized foot care nurses. He had his, uh, internist, as well as himself, uh, Dr. Bailey. I think there was a Dr. Root, too, but there was a Dr. Bailey, and he had his surgeons, the McKittrick brothers, and several others, and his podiatrists. And that was the nucleus of the multidisciplinary clinic, including education for the patients, and having foot rounds.

e was presented. This is the [: 00:19:00

ys say, no, he didn't look at: 1934

I'm not saying all of them, [: 00:20:00

So that's enough for that historical perspective, but I always find it very interesting when you go back into the old literature and you really read what was, what was present a century ago or so, you know, or longer.

Zweli: Speaking about the old literature. By our count, uh, my assistant looked at how many articles you've written and the count came to about 150 articles.

lishing before I was born. In: 1977

I know you, [: 00:21:00

Bob: Very interesting, because I don't, I don't think it's that prevalent. Certainly not in our profession. And I'm talking podiatry.

So I can be somewhat critical, but yet I've seen a great evolution in it. Go back to the seventies, you know, podiatry was, uh, not a new profession. It was certainly evolving from the old carapity to more of a surgical and more medical management, but surgery was new. Back, back in the fifties and sixties and that, but academics was not, you know, I, I just this past week, I, I recall telling somebody, you know, my, my degree is a DPM doctor of podiatric medicine.

And I always kidded [: 00:22:00

All right. Um, but again, my first publication, actually, I started to write when I was a senior in podiatry school because one of my early mentors, Ray Locke, from Englewood, New Jersey, who my mother had worked with, he was at the hospital where my mother, my mother had worked, was really, was really a pioneer and very, very, very thoughtful about many things.

, my first. Two publications [: 00:23:00

So it was mentorships. But I also remember something that always stuck with me. We had a, uh, a journal editor of that podiatry journal. And of course, as a podiatrist, I didn't really read too many other journals, but I remember an editorial that he wrote, and this was Dalton McLamory, who many of your listeners would, would know of, who is from Atlanta, Georgia.

ety or, or the key to making [: 00:24:00

And that always stuck with me. So I always, was thinking about, well, you know, we need to be publishing more, you know, obviously people, people publish, but most of the publications back then did not come out of the podiatry school. So I know I'm kind of critical here, but it's absolutely true. You know, most publications come from residency programs or people out in the field who just have an interesting case or something else.

But back in the late seventies, you know, there were, it wasn't a lot of good mentorship. in, in the podiatry schools and programs. But luckily, as I said, I was surrounded even in my residency by really good people who are really top, top of their game. And they kind of pushed me towards this. And, and, um, one of the best earliest publications was with, God bless him, George Kozak, who was a, uh, physician at the Joslin Clinic, who I became very friendly with.

e seventies. There were very [: 00:25:00

But again, we have to go back 40 something years, uh, when, when the study of diabetes and complications was really starting to come into fruition, certainly lower extremity complications. Okay. Sorry. I've said enough. I've said plenty. No,

Zweli: no, no apologies. I, you know, what we, what I really like about this format is where.

of um, I know personally in [: 00:26:00

But I think a lot of times, you know, when people come with new technologies, they're not to your point that new, you know, it's usually a change in technology in the underlying delivery method. Or, uh, in the worst case, it's, it's, it's writing, uh, a paper that perhaps spins things a little bit too far, which we've seen as well.

Um, so, uh, again, uh, uh, please take your time. This is, um, fascinating to me personally, but also fascinating to the audience, I think, that, uh, wants to kind of delve into this. So, can you talk a little bit about, uh, Uh, more, uh, to me about the Charcot foot because I see it everywhere. Everyone writes about it.

[: 00:27:00

point as well. Going back to: 1978

to now from Harrison brand in: 1966

But I had the interest in, in Charcot Foot. And, uh, Uh, started to see more and more publications in it. And I think the first publication, the first textbook that I saw that really had anything about it was, was really, um, um, Marv Levin's book, which I studied and used in my podiatry training too. And he had the, the diabetic foot medical surgical management of diabetic foot.

Foot, which published also in: 1966

lly, my first one was back in: 1991

h it. And so we published the: 2010

But if you really go back in history, you know, we know we have the French theory of pathogenesis, the neuro, what we call the neurovascular theory. Then we have the neurotraumatic theory of Charcot patho, uh, pathophysiology, if you will, by, uh, Volkman and Verkow, who are almost contemporaries of Charcot.

rouwer and Allman, I think in: 1981

se. And then Steve Edelman in: 1988

put forth a paper, that kind of combined thing, a modern theory, which was a combined pathogenesis of both the neurovascular and the neurotraumatic theories. Uh, so what I'm getting at is, I don't think our pathogenesis really has changed much, our understanding. Except, this is always interesting, and I tell this a lot, and if I'm getting too far down in the weeds, just tell me, Zweli.

the Deaconess, talking with [: 00:32:00

on co fields, I think it was: 1984

r, like a stress fracture or [: 00:33:00

But yet, in some people, a small twist or a sprain of the ankle can lead to this aggressive inflammatory response that results in this full manifestation of osteoarthropathy or the Charcot foot. What is the missing link? And this is what I was discussing with my friend, Skip Vignotti. I said, what is it?

his paper. And I think it was: 2006

philis? Charcot himself first: 1983

, uh, Paul Brand published in: 1966

So you're seeing the same process develop through all these different disease states, all who have a neuropathy, but not everybody who has those neuropathies are going to develop Charcot Foot. So there's got to be some trigger or some predisposing trigger or predisposing, I should say, factor. That, that allows for an unregulated, uh, osteoclastogenesis, which leads to unregulated inflammatory response and unregulated, uh, response to injury.

is with bisphosphonates, uh, [: 00:36:00

I'm getting at, Even since in: 2010

gain, the way back machine to: 1967

But you can't just go in willy nilly and operate on these acutely inflamed feet. So, so back to your, your question, really, is there anything radically new? No, because I think we're going back. We understand you it's acutely inflamed. You have to rest that foot. to get it to calm down, and it's going to take a long time to calm it down.

Now, I think more people are comfortable doing surgery on it, but hopefully recognize that surgery itself can be an exciting event for reactivation. Okay, and maybe external fixation and percutaneous pinning and stabilization, that might be something, something with promise for the future, but we need larger studies.

ich, which patients are best [: 00:38:00

We realized Charcot ankles always do bad and they rarely will fuse and stabilize. So on these, these, uh, deformities, these joints, your best option is early surgical stabilization. Okay. And that I think still holds the same now, except now we realize any ankle fracture and neuropathic patient needs to be treated as Charcot because those are the ones that are going to go bad as quickly as they'll go.

urgery on Charcot feet, but, [: 00:39:00

e's early papers in, I think,: 2003

in a new new papers, but is [: 00:40:00

No, but I think people need to realize these are really complicated people and that we really need to treat them as, as JTH Johnson said, don't treat them with dread, but treat them with a respect for the magnitude of the underlying disease. And that still holds true. Um, what 50, 50 some odd years later.

So again, nothing new to the sun. It's all back there. If you care to look for

d this is from my background [: 00:41:00

There's a genetic component to these patients. That is implicit or, uh, unobserved and we don't quite understand yet, and that big, that plays a big role in, in, in the manifestation of pressure ulcers and with pressure ulcers. As I learned from you, I include, patients who have, ulcerations of the foot on boney prominences.

in. In the world of diabetes [: 00:42:00

Bob: Now, can I give you my exposition or my disquisition on pressure ulcers, pressure wounds?

I, I have, I have been, as I've said, a diabetic foot person all of my career. But through you and, Working with Ryan from, Ryan Dirks from United Wound Healing and us working together on open wound research, I've realized several things. Pressure ulcers far supersede diabetic foot ulcers in numbers. As you well know, Zwali, I mean, you've got a great experience in this area.

type of chronic wound. Okay. [: 00:43:00

Any brick and mortar center might have, what, a thousand, several hundred unique patients per year. Whereas, as you well know, you know, we, we can have 30, 000 in a large wound care facility. Uh, group and in our own work that you're doing so much work for on our, our, our pressure registry, you know, five to 4, unique pressure injury patients in a year, just pressure injuries.

c foot ulcer here, but let's [: 00:44:00

And certainly our other, your other, our other colleagues and Ryan and his group. But I think it's because it's been understudied because sponsors or the medical device industries. And that includes advanced therapies for wound care that we're very familiar with. They shied away from it because they thought, well, we can't really do anything there.

We can't get good results there. I said, well, that doesn't make sense. Of course you can. If you follow all the basics of offloading and proper patient assessment, looking for infection and treating infection when it's present, proper classifying wound, proper turning, et cetera, et cetera. And I, I think. And you could disagree if I'm wrong.

hat misconception in the old [: 00:45:00

And so maybe the results weren't as good as we would want to or expect now. However, as I see it, especially since the pandemic where I've seen the practice of mobile wound care exploding, certainly in our country. Uh, because patients don't want to go to a hospital or a clinic. They want the clinic to come to them.

groups, they have protocols, [: 00:46:00

And so that's why I like to bring our results to the sponsor as we're doing with, with our liftoff registry and saying. Look at the results that we're getting. This is our standard of care. Our standard of care is far better than what you ever thought before. What would happen if we use advanced therapies or your advanced products or devices on these wounds and get that increased enhanced level of healing?

to be quite honest with you, [: 00:47:00

re, which can identify these [: 00:48:00

complete evolution prior to their clinical identification. So there's some really interesting things that I'm really just learning about on, on pressure ulcers that I don't think we've really appreciated before. And like, like for identification of skin moisture or sub epidermal moisture, I think it should be a no brainer.

Any patient admitted to a facility should have these measurements done to make sure that they're not going to get hit with a, a pressure, a new pressure ulcer that was evolving. Prior to that patient ever arriving in that facility, and they're the ones that take the hit for it, you know, so I think there's probably underlying nutritional factors Including anemia.

moisture associated, device [: 00:49:00

Prevent it just by focusing on prevention, which is my next big thing, even diabetic foot, you know, as you said, I, I do a lot of speaking around, around the world, probably more than I even do around the country now, not as much as some of our colleagues who we well know, but I think we need to focus on prevention, prevention of all wounds, because for the last 25, about 30 years, we've been focusing on advanced therapies, but with the influx of people into war, country who are all at high risk, you know, third world countries, uh, are at higher risk for diabetic foot ulcers.

from some parts of the world [: 00:50:00

We're never going to be able to address the tsunami of, of problems that are going to come into our country unless we focus on prevention far more seriously than we did before. And prevention can be simple by screening everybody, you know, if we're talking pressure again, screen everybody for, uh, skin moisture content, however you, you want to do it, look, look at, look at them, look at their footwear, uh, uh, do a good clinical skin assessment, look at the sub epidermal moisture content, uh, make sure everybody is offloaded, which you expect to be by now.

ust under a pillow under the [: 00:51:00

Yeah. We're, we've been talking about end of life, skin changes. I think that's different. And you, you know more about that than I do. And Pamela, who will be on your next podcast knows far more about that than I do, but we have to focus on prevention. You know, we have to, and we haven't focused on it enough, and I think if we do, and I'm talking about from the home to the hospital when that is the case, and into the nursing home.

our patients while they were [: 00:52:00

How do we intervene early? Before, is there a genetic component to it, like Charcot, and, and, and if we can identify those risk factors before the problem occurs, we're going to be much better at preventing the problem, okay, by adding it to what we already know.

Zweli: And, and, you know, I think one of the things that, uh, we've, we spent a fair amount of time at Open Wound Research and, uh, just to correct one thing, I was the nursing home administrator, I was a partner in a group that serviced nursing homes, just for correction for the audience.

ons that, um, the prevention [: 00:53:00

And so talking to domain experts such as yourself and other members of our group and people in the community and saying okay You know, what is our belief at the this Implicit rate that should occur versus what does occur and then saying okay Can we risk stratify and create models that can look at a patient's factors and give us an estimate of a probability of a wound developing.

cing nursing homes was that, [: 00:54:00

Bob: early attention, early intervention.

Zweli: Exactly, but there's 20 percent of people that despite that there's something, some factor that we can't observe directly that's blocking them from healing, you know. And so I think I'm, I'm excited about prevention. I'm excited about the idea of secondary prevention. So once you heal that wound, making sure that it does not, occur again, uh, and, and in our data, we've seen that if they occur again, that tail gets dragged out.

In terms of cost time to heal, et cetera

have enough data pretty soon [: 00:55:00

That's what's so exciting. It's the numbers. It's always a numbers game. You know, wound care research is still in its infancy, really, and it's not sophisticated. And the biggest, biggest issue The biggest lacking is numbers. Okay. Cause all the studies are, Oh, we got, we've had 50 patients. We have a hundred.

Oh, we got 300 patients. What? Darn it. Now we have 10, 000 patients in a couple of years. We're going to have 20, 000 patients that gets into the range of drug studies, pharma, pharmacology, pharmacological studies, where they have these huge numbers. That's what's exciting because we're going to be able to identify the very things that you're asking about.

r diabetic foot and probably [: 00:56:00

Well, what level of PAD, or is it a, or is it an interaction term? It's a PAD times A1C or, or PAD. PAD times neuropathy times anemia, you know, that's what we'll be able to do. And I see the smile on your face. You're as excited about this as I am. My job with, with open wound research is just to ask the stupid clinician questions, because I don't know these answers.

s always the wise guy in the [: 00:57:00

Why this? Why that? Why didn't you mention this? And I, I'm just so excited about this in, in an area, pressure ulcer research, that is, it's, it's really virgin territory for the most part. Not, not, not really, but it's really unstudied territory. That's why a year ago we started talking about doing the open wound research registry because it's going to be in five years.

bless them, who, who are so [: 00:58:00

You know, I ask him, can you do this? Can you do that? Because I have to make it very simple so I can see how our dashboards work. And it just gets more and more and more exciting to think about what we're going to be able to do. Yeah. With our, our lift off pressure registry, you know, 10, 000 patients is pretty exciting for any wound care thing.

And we have the, the, um, resource documentation, the original source documents that we can always go back to, which is, which is more beneficial than these. Nationwide registration, like the Medicare database, the Pearl Diver database, which are limited, but they have outcomes, but we can get right down to the source, right down to the source document, because these are all our own patients.

iable, and that one, looking [: 00:59:00

I'll get it. And it's just extracted right from the .. The EHR into our registry, uh, I'm sure other people who might, might listen to this can be equally excited down the road. It's just fascinating because we're on untraded territory, you know, and I think, I think, uh, I, I look at the smile on your face because you're as excited as I am about what kind of things we could do, not just modeling, but as we said, what was it yesterday's really, I want to see the modeling and how the modeling is validated by the actual, events by the crude events that we're going to have.

hat very closely. It's just, [: 01:00:00

So, and I'm not a, I'm not a numbers guy. Yeah. I've got a degree in quantitative methods, but I told that person, I'm no, I'm no math person. You don't want me in quantitative methods. And they said, yeah, this is what you wanted to, but the number, the numbers, what the numbers can tell us is just so exciting.

You know, and, but let's mirror the large data set, actual numbers and outcomes and percentages healings with what you can do with your predictive models. And boy, when those two merge or coalesce or become, let's use a statistical model. statistical term, when they become coaxial, that's when we really get excited.

You know, and I'm looking at the smile on your face because you're as excited about that as I am. And we can only do that with numbers.

g, uh, for, for me, for you, [: 01:01:00

S. gets older, it's only going to get worse. It's not going to get better, uh, unless we can, we can do things at scale that make sense. So, to me, uh, I lived in, in that world for 12 years where I saw it every day. And it's something that, uh, Just spoke to me when we started, we started open wound research and we looked at the lift off registry.

We've got about 60 to 120 seconds to go. I want to ask you a question to close out this interview, and it's been fantastic. I appreciate the history, I appreciate the exposition, and I appreciate the passion that you brought to diabetic foot ulcers, and as my face lit up, your face lit up about pressure ulcers.

e following question. If, if [: 01:02:00

Something that my

Bob: name is trademarked. So be careful. There's there's something in my mind that there is a wound genie Trademark out.

Zweli: All right a generic fantastical non commercial

Bob: wound genie A real live

Zweli: fantastical wound genie from the arabian nights. Um, What would what would you wish for if there was one thing you could wish for

Bob: Okay, because I did think about this.

t's see. This wound has this [: 01:03:00

This one has this elevation of proteases. I think I'd like to, to wave a magic wand over a wound and say, what is deficient in this wound that I need to address? Is there too much excess or too little of this, whether it be minerals, Whether it be nutrients, whether it be MMPs or tissue inhibitors of MMPs, or blood flow, or this or that.

Wave a wand over it and tell me what I need. And I think we're coming to that area now. You know, when you look at moleculite, uh, if I'm allowed to use those terms for, um, um, for, for fluorescent imaging, looking for bacterial burden, when we're looking at the dipstick for, uh, elevated levels of proteases, even those are on 100%.

hing like that. That'll tell [: 01:04:00

But if I had one thing, it would be Tell me exactly what I need to do or what I must take away from this wound to get it to heal on its own.

Zweli: That's a brilliant. That's brilliant. Like a wound phaser. Hopefully that's not trademarked either. Well, listen, it's been fantastic. I, I again appreciate your time. I appreciate you sharing with the audience.

And again, what we're trying to do with this podcast is to do long form discussions with experts where They share about their career, they share about the science and they share about where they see the wound care world going. And I just think you've done that fantastically. So I appreciate your time and thank you again for being our second

Bob: guest.

[: 01:05:00

Zweli: purpose. So that's a little bit of animus. Uh, just to keep things

Bob: interesting. No, not animus at all. No, I missed it. very much. It was a pleasure. Appreciate it. Thank you. Bye bye. Thanks a lot. Bye bye.