Same/Not the Same

John Fuller Beckwith6/8/2026

In a recent discussion with a patient about the various treatments she has received for her complicated lymphedema presentation, she said this phrase: “Same/not the same.” This pithy statement encapsulates so much about the state of lymphedema treatment. This patient’s case deals with challenging chronic wounds, so in her case the phrase was a response to how other treatments had worked for her, both wound care with wound compression and with other lymphedema therapists. The context was: the treatments seem essentially the same, and yet they are not at all the same. Superficially they seem the same yet some were essentially ineffective while others are demonstrably effective. The point is that lymphedema treatment when done right, with fidelity to the principles of CDT, with a view to applying interventions in a way to leverage an optimal outcome rather than just applying an intervention that can be billed, with the patient truly at the center of the process, is the intervention that has a decisive impact. It is not just a facsimile of the treatment, it seems the same, and yet it is completely different. And patients know that difference.

I have thought on this for a while in our field of lymphedema after hearing or reading some, ‘expert,’ commentary on lymphedema. A marketing presentation for a large health system advertising its lymphedema surgery program interviews the surgeon. The surgeon comments on the various surgical options and the advanced techniques involved, but when speaking of non-surgical/conservative options, just mentions that also the patient can do ‘compression.’ The implication is the highly skilled surgeon sees conservative treatment as just some sort of compression. As though all compression is the same. As though conservative treatment is limited to compression and not full CDT. There was no distinction made regarding options for high-level flat-knit custom-fit compression or that the skilled CLT could provide a highly specialized bandage compression that is very effective. Let alone MLD. To the reader, the surgeon groups all compression as the same. Yet those of us who follow CDT principles know all compression is not the same. And that comprehensive conservative treatment involves so much more. Same, yet not at all the same.

Along these lines I listened to a blog with a ‘wound and lymphedema expert’ talking about managing wound care with significant edema. Yet this, ‘expert’ kept repeating that after the wound care, ‘compression’ should be applied, never differentiating the various levels and types of compression or even the skills involved in applying the gold-standard lymphedema compression. The implication was that compression is compression is compression. Nothing could be further from the truth. Wound specialists apply compression daily, and in various forms from 3-layer to 4-layer to cohesive bandages to the ubiquitous Unna’s boot, yet they don’t do lymphedema compression. Then I can see a patient who has been in wound care compression for months and in two visits reduce the supposedly well-compressed leg dramatically (and also, btw, heal the non-healing wound). Same/not the same.

For my private clinic I tried to get on the panel of one of the better-paying insurances in my area. In making the application I was told the panel was full for lymphedema specialists. There are literally only a handful of certified lymphedema specialists in my region, so I knew who these people might be. I knew they provide substandard lymphedema care and do not adhere to full dosing of CDT. So I called to personally challenge this insurance company, making the argument that the members of this insurance were not receiving the full benefit of skilled lymphedema care. The medical director for this insurance told me that the company seeks the certification and assumes that is enough to ensure quality care. When I said I would provide a higher level of care that reasoning was dismissed because the certification is as far as they vet the level of care. As though the mere certification ensures a high standard of care. Nothing is further from the truth. Again, same, but not at all the same.

As a final example, a patient was referred to me by the local DME garment fitter. This patient had been seeing another local lymphedema ‘expert’ for their breast cancer-related lymphedema, their lymphedema was significant after months of progression. With this other ‘expert’ there was no in-clinic MLD, there was no education and guidance to a compression sleeve and no exposure to the skilled short-stretch lymphedema compression bandage. The DME provider knows the work done in my clinic and recommended contacting me. Ultimately seen, bandaged, MLD daily and reduced the arm by half after no reduction with the other ‘expert.’ We are both ‘lymphedema experts,’ yet still: Same/Not the same.

If you are a patient and you read this, please know there are some ‘experts’ out there who actually do the work, that you should see improvement, that therapy should be daily, that it should be hands-on. Seek them out. If you are a CLT ‘expert’ and you don’t provide the full CDT as instructed in your certification class, know that your patients can and will find a CLT who does, and they will know the difference. Same/Not at all the same.