Understanding Wound Care’s Psychology

  “Thank you for letting me take care of you today.”

  Those were the words spoken to her patients, after each encounter, years ago by one of my very important mentors. These few short words cemented her relationship with those patients and let them know they were a valued part of that doctor-patient relationship.

  To be sure, in the days that I spent in mentorship in her clinic just 10 years ago, I learned countless and valuable clinical pearls. The most indelible take-home message for me, however, was the visible impact those words had on the patients toward whom they were directed. I saw smiles and even looks of bewilderment as if to say, “What? The doctor is thanking me?” In these days of incredible demands on our time and the constant pressure to meet volume and scheduling requirements, it is easy to allow ourselves to become so focused on the tasks at hand that we lose sight of the most important person in the room … the patient. Over the years I have had the opportunity to share this concept with countless residents and medical students in the hope that they, too, will carry this simple yet elegant concept into their relationships and practices. And who was that brilliant and thoughtful mentor, you might ask? None other than the editor of this journal, Dr. Caroline Fife.

Understanding Wound Care’s Psychology

  The wound care visit, or any medical visit for that matter, is, under the best of circumstances, a daunting experience for our patients. They come to us with a myriad of emotions and feelings including concern, fear, misunderstanding, anger, and sadness. How we recognize, address, and manage those feelings is what establishes trust and adherence and what sets the stage for our future visits. The ultimate outcome of our wound healing efforts depends upon our knowledge and skill as providers as well as the ability and willingness of the patient to adhere to our recommendations. That ability and willingness, in turn, depends upon patient understanding and trust.

  In order for our patients to understand their problems and our recommendations for treatment, we must take the time to explain things in a manner understandable to them. In the case of the diabetic foot ulcer (DFU), patients must understand the role of neuropathy and the critical importance of strict offloading in addition to tight glycemic control. Simply giving a script for an uncomfortable and often unfashionable shoe, crutches, or wheelchair without that explanation is likely to result in low levels of trust and adherence. In the case of the venous leg ulcer, it is vital for patients to understand, in lay terms, the pathophysiology of venous hypertension, reflux, and edema before it will be possible for them to understand why they need to go home with a tight, possibly warm and uncomfortable compression wrap and elevate their leg above the level of the heart.

  As in the case of the DFU above, treatment plans without explanation and understanding of the reasons for them will likely result in poor trust and adherence. Patients are far more savvy consumers than in years past and have probably consulted “Dr. Google” before seeing us. Gone are the days when physicians could expect blind and unfailing patient adherence with only cursory instructions.

Breaking Down Patient Visits

  Let’s take a look at that patient encounter — which I believe we can separate into three distinct but overlapping phases: the introduction, the problem-solving/planning stage, and the closing. There will be variances according to whether patients are new or established as well as the complexity of their wound problem and comorbidities.

  The introduction phase should include establishing the identity of the provider as well as the patient with a clear introduction, a thorough history of the present wounding problem, an inquiry into coexisting med/surg problems, and a review of all medications presently being taken. It is poor form indeed to discover two months into treatment of a recalcitrant wound that the patient is also being treated with hydroxyurea for polycythemia vera or bevacizumab for a concurrent malignancy.

  The problem-solving/planning stage should include the differential diagnosis for the wound and any in-clinic diagnostic and therapeutic procedures as well as the plans for testing, treatment, and follow up. This phase should also include the explanation of the condition in words and terms that the patient and/or family are able to understand. An example would be the explanation of venous insufficiency in the context of a home plumbing system with supply lines, return lines, check valves, and a pump.

  Explaining the problem in these terms will help the patient to understand the need for compression as well as for elevation above the level of the heart to allow gravity to assist with edema reduction. The closing phase then is simply an opportunity to wrap things up, ask if there are remaining questions, establish a follow-up appointment, and to thank the patients for entrusting their care to you. Do this in whatever language you are comfortable with ... but do it.

The “Triple Aim”

  Hopefully this provides a loose framework for the construction of an effective and communicative provider-patient encounter, one that will establish trust early in the relationship and lead to improved and more expedient outcomes due to improved patient understanding and adherence to treatment recommendations. We must remind ourselves frequently that it is a privilege to be able to care for our patients. They have many options to obtain their wound care elsewhere. We are also wise to understand that as we move into accountable care organizations we will be expected to accomplish (and reimbursement will be tied to) the “triple aim.” This refers to the delivery of quality healthcare in a cost-effective manner while maintaining the highest levels of patient satisfaction.

  While we strive daily to practice according to the highest and most scientific standards of care, let us not forget the art of medicine and the importance of the provider-patient relationship. Developing trust, understanding, and partnership with our patients through effective and respectful communication will ultimately help to satisfy all three tenets of the triple aim.

  Lee C. Ruotsi, MD, CWS, UHM, medical director, Catholic Health Advanced Wound Healing Program, Buffalo, NY.