Transcript:
SAWC Difference Makers Podcast — Episode 12
Dot Weir, RN, CWON, CWS:
Welcome to the SAWC Difference Makers Podcast, where breakthroughs meet the bedside.
I’m your host, Dot Weir. Let’s dive into today’s conversation.
Well, hello, everyone, and thanks for joining us today. It’s my extreme pleasure to be chatting today with not only a colleague, but a very dear friend of—we’ve decided—a little over 30 years, Dr. Robert Snyder.
Rob is not the kind of person who’s going to brag about himself, so let me do a little bit of that for him because he’s had such an amazing career.
Dr. Snyder is a podiatrist by his original training, a DPM. He also has a master’s in business administration and a master’s in science in wound healing, which he earned in Cardiff, Wales. I’m going to ask him to tell us a little bit about that. He is a Certified Wound Specialist Physician, and he gives us credit for taking our prep course for that. He’s done a lot of work with Barry University, which we’ll get into, and he’s also a visiting professor in Cardiff.
That’s just scratching the surface of what Dr. Snyder has accomplished in his career. And, just like me, we’re both still working.
First, welcome, Rob.
Robert Snyder, DPM, MBA, MSc, CWSP, FFPM RCPS (Glasgow):
Thank you very much. It’s really my pleasure and honor to be here with you, especially you, and I’m looking forward to an interesting dialogue.
Weir:
Absolutely. So let’s start. How long have you been in practice, if that’s okay to ask?
Snyder:
I’ve been in practice 40 years—a very long time.
I’ve had multiple careers throughout that 40-year period, starting, of course, with private practice after residency.
I transitioned, and I’ll tell you a very quick story about how that happened. I was doing a lot of elective surgery—bunion surgery, hammertoe surgery, those kinds of things. I remember walking into a room where I thought I had done a fantastic job on a patient’s bunion, and she was not happy. She had her arms folded, she was scowling, and she said, “My toe isn’t straight enough. I don’t think I’m very happy about this.”
So I went into the next room, and I had performed an open transmetatarsal amputation. The area was still open, but the foot was saved. The woman started crying when I walked into the room, and she grabbed my hands and said, “Thank you for saving my leg and my life.”
At that moment, it was really an epiphany. I said, “This is really what I want to do.”
My partner and I sold our practice, and I was thinking about how I would proceed. I took whatever money I had earned from the practice and started going to meetings all over the United States. I would approach individuals who I thought could be mentors for me.
I think mentoring is such an important aspect, not only for me, but for everyone.
I went around the country visiting these folks, and they were very generous and very kind. No one said no, and I learned a tremendous amount. I also started writing. I started reading. Of course, I would read all the references and all the articles. I really wanted to become very knowledgeable in this area.
When I came back to my original location, I contacted all of my physician friends and said, “I’m really not practicing podiatry anymore. I’m going to be a woundologist or a wound management specialist. This is really what I want to do.”
They told me I was crazy. They said, “You’ll never make a living.”
Well, the rest is history.
I would walk through the halls and have people running after me with photos of wounds, asking, “What do I do here?” It really changed my life.
It gave me a significant amount of exposure. I started getting involved with industry, and I started to get a lot of calls about how I could help them with lecturing and consulting. I did a lot of work with Johnson & Johnson at the time, probably for 10 years, and I think you were very instrumental in that.
I also want to say that Dot has been a cheerleader of mine for as long as I’ve known her, and I’m eternally grateful.
When the assets from Johnson & Johnson were sold to Cystogenics, I was asked to consider being a chief medical officer for that company. Even though it was a company that had well-established products, it really was a brand-new company.
That gave me an opportunity to travel all over the world and lecture everywhere. I went to Japan. I went to all the meetings. It was really a wonderful experience for me.
In the interim, of course, I’m a lifelong learner, so I continued to take courses.
I did the master’s in Cardiff. That was very interesting. At that time, we didn’t have a significant online platform, so I had to go there a few times. I got to meet a lot of wonderful people, and Sam Holloway and I still keep in contact.
Through the years, I went from being a lecturer all the way up to a visiting professor there.
In the interim, I also decided that if I was going to move in another direction, I probably should have some business experience. So I completed a master’s of business administration at George Washington University. I took most of it online, but I had to go to the school as well.
After that—actually, I didn’t tell you this—but I also went to Harvard Medical School and completed the Global Clinical Scholars Research Training program because I knew that training in research was extremely important.
Mentoring—I want to reiterate—is extremely important. Jason Haft, who was in research for many years, took me under his wing and said, “I’m going to show you how this works, how the budgeting works,” and so forth. I spent quite a bit of time with him and also Robert Warner, who had a very significant impact on my life.
I started doing research. Over time, because of my connections with industry, I was able to get a significant number of requests to conduct clinical research.
I wound up doing more than 75 randomized controlled trials during my career, first in my office setting and then ultimately at Barry University, where I started the clinical research division, which at that point really didn’t exist.
From there, I decided that I wanted to consider academia.
Jeff Jensen had just been hired as the dean. He and I were doing a course with Robert Warner every month for National Healing at the time, and Jeff approached me and said, “Would you consider being on the faculty?”
Initially, it was part-time. He said, “I won’t let you take this job unless I can get you a full professorship,” which he ultimately did through the provost and so forth. I worked for 6 months part-time and then transitioned to full-time.
I opened the clinical research division. We started a course on wound healing and limb preservation, which was really unheard of before that time. We did an entire course on that, which is still in place today.
I taught a lot and mentored a lot of students and trained residents. It was a very exciting time in my life.
Ultimately, the dean who was in place left, and they needed a new dean. I was asked to be interim dean, and then ultimately I was asked to be dean.
I was at Barry for 15 years. I was the dean for 5 of those years. It was a very interesting transition for me. I was still teaching, but not as much. I wasn’t with the students as much, which was kind of frustrating for me, but I thought it was a position where I really could make a difference.
I still had a practice, and I had transitioned one of my partners, whom I had trained, to join me at Barry. One of my partners unfortunately passed away at a very early age. So we had this office, and I said, “Well, I certainly could sell it, but why don’t I just donate it to the school?”
I donated my practice and my goodwill to the university so that the students could have another clinic. I thought that was important.
Then my wife and I established an endowment at the school for students who couldn’t afford to go to meetings. If there was a meeting in California, for example, it would be very expensive for them to go there. So we set up an endowment that would allow those students to go to these meetings, stay at a hotel, and not have to worry about the cost so they could get that opportunity firsthand.
The caveat was that they had to be wound-related meetings. It had to be SAWC, it had to be DFCon, it had to be Diabetic Limb Salvage, and so forth, because I always instilled in them the fact that podiatry really has a significant place on the wound healing team.
That’s probably one of the only places where there’s no redundancy in what it is we do.
I’m pleased to tell you that the residents I trained and a significant number of students whom I had an opportunity to interface with ultimately went into wound management and limb preservation. They’re doing that as a full-time profession, so I’m very happy about that.
For a number of reasons, I decided to leave the university, even though I was a tenured professor. I just felt I had done all I could do.
So I started working with industry again. I affiliated with 2 Israeli companies, both of which I’m still affiliated with.
But my love really is designing and carrying out clinical trials. What I’ve become expert at, I think, is designing clinical trials. I think that is a very valuable skill because it allows pharmaceutical companies to feel more comfortable that they are moving in the right direction.
I’m also on the executive board of the WCCC. Vicki Driver has also been a mentor of mine, and I’ve been very pleased to serve with her. That’s also been a very important current aspect of my life.
I’m just moving and continuing to learn.
Actually, I’m taking another course at Harvard on global health care. I think that’s kind of the next step. We’re moving into a value-based model, so I really think I need to have a better understanding of what that means and how it functions in other countries throughout the world.
That should be very interesting, and I’m looking forward to it. It actually starts this month.
Weir:
Wow. That’s all I can say right now—wow.
You have brought back so many memories of things that you and I have been able to experience together over the years. Cystogenics—I had totally forgotten about that. I went to a meeting. Where were they, Gargrave?
Snyder:
Gargrave, which, by the way, has closed.
Weir:
Yeah. It was a wonderful place.
You and I have had this relationship, but we’ve also been able to interact professionally. I’ve seen this exquisitely professional side that you have and the things that you’ve done and contributed.
I think you made such an important point. You and I are not spring chickens—no offense—but we have to be mentoring people.
I know you get this question: “How do I get into this? How do I do this?”
So let’s start with somebody saying, “Dr. Snyder, I really want to learn how to do research. How do I even get my first clinical trial?”
What would your answer be?
Snyder:
Number 1, you really have to have a significant interest and the will to want to do this because it’s not for the faint of heart.
Clinical trials are not only difficult to design, particularly in this day and age, but they’re very difficult to carry out in many respects because of the very narrow inclusion and exclusion criteria.
I’ll give you an example. I had many students contact me when I was dean and say, “Gee, I’d love to get involved in clinical trials.” But they really weren’t interested. It was more, “Well, I want it on my CV.”
Then there were a couple of students, usually 1 every year, who would come to me, and I would see something in them that was just a spark. Then I knew that these were people whom I could really make an impact with.
I didn’t mentor hundreds of students. I usually had 1 student, maybe 2 every year. Several of them have gone out to do just amazing things.
I also felt that students should play an integral role in publishing. I’ve published close to 300 peer-reviewed journal articles, and sometimes it’s very intimidating.
What I would do is take a student under my wing who I felt was really interested and had enough bandwidth to be able to do this. I would have them help me do the research and find the articles and so forth.
Once that was done, I didn’t make them a footnote. I actually put them on the byline. Yes, I was the primary author in most cases, but even with book chapters, I had residents working with me, and I gave them full credit for doing a very significant job in getting those chapters done.
It raises their sense of confidence. It allows them to see how the process works because writing an article is not that difficult—unless, of course, you’re looking at analysis with a significant statistical bent. That’s not for everyone, including me.
That’s one of the reasons I took the global research program at Harvard, because I realized that was not a flaw, but something I didn’t know enough about. So I wanted to learn more.
I felt it would let them go through the process with me.
I think what really startled them was when we submitted to a peer-reviewed journal and started to get feedback, and the feedback very often wasn’t that great: “You did this wrong. We didn’t like this.”
Sometimes there were 15 or 20 queries, and they would get very upset.
I would say, “No, this is how it works. Once you correct all these, if you feel they’re appropriate, you’re going to see that your manuscript will be better, not worse.”
I think that was an important experience for them because when they go out into the cold, cruel world and start submitting publications themselves, they have to be prepared for that.
I have to share one other thing with you. I had trained a resident, and he was very good, very talented. We kept in touch for a while and then lost touch.
About a year ago, I got a call from him, and he said, “Dr. Snyder, you were in the operating room with me today.”
I said, “What do you mean?”
He said, “We had this very difficult case once that you and I had to deal with. You walked me through it, and I was able to save the patient’s limb. I had almost exactly the same case, and I was thinking back to what you had told me when we were doing the case together.”
That really meant so much to me.
I’m only looking for some signal that the contribution I made for these people is long-lasting. That’s really my entire goal at this point in my life—to share what I have, to share my knowledge, to keep learning, and to do what I can to carry the torch.
We both know that we stand on the shoulders of the people who came before us.
I don’t think a lot of students today really understand that.
They don’t understand, particularly with podiatry, how difficult it was to get into a hospital in 1975 or 1977 and how now they have 3-year residency programs. Very often, they’re welcomed with open arms. They work in orthopedic groups.
All of that was a pipe dream when I graduated.
I’m very pleased that it has happened, and I hope that I played a small role in allowing that to go forward.
Weir:
I don’t think there’s any question about that.
That brings up such a good point about where podiatry has grown and gone.
When I was a baby nurse, back in the 1970s, podiatrists were office-based folks who did nail care and took calluses down, compared with the role podiatry plays today as foot and ankle surgeons and in limb salvage.
I guess you can choose which direction you’re going to go within podiatry. But I had forgotten that, in the past, sometimes it was hard to even get credentialed into a hospital.
Now podiatry is such a vital part of our collaboration. I’ve been in wound care centers for 25 or 26 years, and you have to have podiatry involved.
You have absolutely contributed to that growth. I think you’re one of the icons in the podiatry world.
You mentioned the WCCC. I think there are so many behind-the-scenes things going on right now, especially with some of the advanced modalities that are used. There’s so much controversy around skin—I still want to fall back and call them skin substitutes.
But I want everybody to know about the WCCC and what that group is working toward with the FDA. Could you give us a little information on that?
Snyder:
The WCCC is sanctioned by the FDA. I think Vicki had a significant role in making that happen.
What we’ve done is create a significant number of committees—the GAPS group, the Real-World Evidence group, and others.
It actually started with looking at end points because the end points in most trials are not appropriate. The wound does not have to be completely healed—completely reepithelialized, with no drainage and no dressing.
Many products and therapies that we use are not meant to heal wounds. They’re meant to improve them so you can move to the next step.
That’s really where it started, but it has grown into a tremendous organization.
We have contact, through Vicki and others, with very significant individuals in government, the FDA, and CMS. We’re now looking at patient-focused care as well, which is extremely important.
Another thing to keep in mind is what advanced therapies, as an example, are appropriate to use in clinical trials.
Again, I could talk for an hour on the WCCC, but there really is nothing significant out there that tells us what we should be including or not including. So we’re kind of shooting in the dark in that regard, and we’re using therapies that may or may not be validated by the FDA.
That’s another thing we’re working on.
Many publications have already come out on various aspects. It’s a totally volunteer organization, but you have very hardworking, very smart people on all of these committees.
I think—and I know—that over time we’re going to make a significant impact on how trials are done and how patients are treated.
Weir:
First, let’s define it. It’s the Wound Care Collaborative—
Snyder:
Community.
Weir:
Right, the Wound Care Collaborative Community.
Snyder:
Yes. It’s the only wound collaborative community that’s sanctioned by the FDA. You have cardiology, you have others. We’re probably, believe it or not, the most active collaborative community they have within their stable of collaborative communities.
There’s so much work being done.
Again, I have to give credit to Vicki for really starting this. She spends what is really a full-time job doing this, raising funds, and so forth.
I think that over time we will make a significant impact. I think we’ve already made a significant impact.
We also have, of course, an innovations project that we do at SAWC, either before or during SAWC. This coming one is going to be, I believe, before the SAWC meeting so people aren’t distracted and moving in and out.
We have some very formidable people on various committees who are putting in work at no cost because they realize the importance of what this could mean to researchers and to patients in the future.
Weir:
I want to put a point on the end point piece because I don’t know that it might resonate with everyone, depending on their background and how long they’ve been in practice.
Looking at trials—and I did maybe 5 in my whole life—it was always complete, skin-to-skin healing. That was the end point, meaning that was the success of the product.
I remember with some of the Regranex trials, they did it in some wounds that weren’t diabetic foot ulcers. The wounds would completely fill in with granulation tissue, but if they didn’t then go on to complete healing, it was considered a failure—which obviously was not a failure.
The issue with the WCCC is huge because, again, how often do we use something from start to finish? We change our treatment plan along the way, and that’s good wound care.
But the clinical trials made it so that you had to have the same thing for 20 weeks, or whatever the duration of the trial was.
So this is critically important work.
I wanted people to know what the WCCC was. And you all meet at each SAWC, right? Spring and fall?
Snyder:
The WCCC Summit will be held at the SAWC Spring meeting, which is going to be held in Philadelphia.
Again, Vicki has a cohort of people who help her with this. Joe Rolley is a very critical piece as well. I don’t know if you know Joe, but he’s an incredibly gifted man and has given a tremendous amount of time, along with many others whom I certainly could name.
People are really invested in this organization, and I think we’re starting to see some movement.
Again, we’ve been looking at end points—primary, secondary, and tertiary end points—for decades, and we’ve never been able to move the needle.
I did a study a number of years ago based on Peter Sheehan’s work on the 50% in 4-week healing model. I remember meeting with the FDA, and this particular product had not reached the primary end point.
I started to talk about 50% in 4 weeks, which was a study that I had done, and they put their hand up and said, “No, no. We don’t want to discuss this because we don’t think it’s relevant.”
I think for that reason, a lot of products and therapies don’t have a lot of evidence, particularly dressings. Silver dressings are an example.
There’s very little work done on dressings that contain silver, and because of that, silver got a black eye, particularly in the United Kingdom and in other places.
We had to create a committee to counteract that—to show that there is a place for it and that there is some importance.
I think we’re beginning to move the needle. I think it’s accelerating a bit now that these meetings have occurred.
We have some very important people who are going to be speaking at our meeting, and I think that will be very helpful because we believe now that they finally get it.
They finally understand, particularly with patients being interviewed and showing how wounds have affected their lives.
There were patients who said, “I had cancer and I had a wound, but the wound was the element in my life that was destroying it because I was so focused on the wound and the doctor’s visits and the hyperbarics that I couldn’t live my life.”
They were less concerned about their cancers and more concerned about their wounds.
I think we have a ways to go, but I think we’re moving the needle.
Weir:
That is so awesome.
You brought up names, and for anybody listening who hasn’t been in wound care for years and years and years—I mean, you and I have been practicing longer than a lot of people have been walking around.
Samantha Holloway, Jason Haft—I mean, George Cherry was another.
Snyder:
I spent time with George Cherry.
Comité had this award called the Wound Care Ambassador Award. I don’t know if you remember it.
Weir:
I do, yeah.
Snyder:
I happened to win it, along with 2 others, to go to the Oxford Wound Healing Meeting and had an opportunity to spend time there.
That’s where I met Marco Romanelli, actually. We’ve remained friends for years since.
George Cherry was doing clinical research. He wasn’t a physician; he was a PhD. But he was very smart, very engaged, and very interesting to speak with.
Unfortunately, he passed away a couple of years ago.
Again, these are people who have made profound impacts whom nobody knows about. You talked about behind the scenes. There are so many people who are not prominent but are doing tremendous things for the profession.
We just have to find those people, and we have to recognize them in some way.
You asked another question about how someone would get involved.
I think, first, you have to have an interest. Because I only do wound care research, obviously I’m limited in how I can discuss the importance of research more broadly.
But they need to find a mentor, whether it’s me or somebody else who does clinical research. That’s going to be critically important.
I think they have to study. They have to take courses. They have to make sure that what they’re doing is relevant.
Certainly, you can start with a proof-of-concept study. You can publish it in a poster.
Again, that can be very intimidating, particularly for a younger person the first time. So you need to have someone who can guide you through that process—even how to create a poster and have it submitted.
That’s why there is a lot of very interesting material out there that we never see. People may think they’re too busy, but I don’t think that’s really the reason. I think they’re intimidated by the process.
It’s not that difficult to understand, but you need someone to walk you through those elements so that you know you’re doing something that can make an impact.
Many posters that we have at SAWC, as an example, are extraordinarily meaningful. It’s just a matter of getting the work out there.
Weir:
Absolutely.
Well, you are definitely the shoulders of—what was the phrase that you used?
Snyder:
We stand on the shoulders of the people who came before us.
Weir:
Right. I’ve got to tell you, you’ve got some of the biggest shoulders of anyone I know.
Snyder:
Well, that’s very kind. And so do you, obviously. Look where you’ve come. Unbelievable where you are today.
Weir:
Well, I have so loved talking to you.
We’ll wrap this up for now. But you all have had the opportunity to listen to Dr. Robert Snyder.
First of all, he is a gem of a person. You’re so sincerely caring about anyone who is standing in front of you and whatever issues they may have.
It has just been a pleasure to be your friend. I think we’re more friends than colleagues—but both.
Snyder:
I feel exactly the same way. Thank you.
Weir:
That’s a wrap for this Difference Makers. I appreciate you all joining us.
Rob, again, thank you for your time, and we’ll see you next time.
Snyder:
My pleasure.
Outro:
The SAWC Difference Makers Podcast is brought to you by the Symposium on Advanced Wound Care, one of the leading forums for advancing wound care education, research, and collaboration, and Wounds, the official journal of SAWC.