Editor`s Opinion: Sweat the Small Stuff: Patients Do!

    Familiarity breeds contempt. — Aesop, The Fox and the Lion Fables

    In the Hmong tradition, a person does not choose to become a shaman — rather, it is a vocation to which some are called. Specifically, persons who have been ill are frequently called to the required training because “their intuitive sympathy for suffering of others lends them emotional credibility as healers.”¹ By contrast, a history of illness is not a prerequisite for the education and training of Western healthcare providers. While many may consider healthcare a calling, they also have to make a career choice and only after many years of education and even more years of practice is an expert “born.”

    Many of our readers are experts. They see patients with wounds, ostomies, incontinence, or skin conditions everyday and provide expedient care with (generally) excellent clinical outcomes. In Western medicine, when we study the effects of expert care on outcomes, expert status generally is defined by cumulative years of practice, number of procedures performed per year, earned accreditation, and the like. Studies using these measures and definitions have shown that expert providers have better patient outcomes than those with limited experience. But how do years of experience and familiarity with conditions encountered every day affect our emotional credibility as healers? Is there a dark side to familiarity? Does familiarity, as recorded in Aesop’s fables, breed contempt?

    Fortunately for all of us, most experts do not “despise” the familiar. However, for better and for worse, familiarity takes the edge off. Trepidations are replaced with confidence, fear with certainty (most of the time anyway), awe with familiarity, and details with rote. The latter, I’m afraid, is what may cause us to lose our emotional credibility as healers. For us, many procedures become routine; patients, however, rarely approach their ailments as mundane. Yet chances are that a general “How are you?” asked of a patient during a follow-up visit will be answered with a reassuring, “Fine.” During a routine podiatry visit, one of my patients, a widow who lives alone, was told that she had a lesion on her foot that should be excised for further examination. Without further ado, the lesion was removed and she was homebound for 2 weeks, scrambling to get some help from friends and neighbors. She was furious because had she known in advance she would be unable to walk on sutures she would have filled her refrigerator and arranged for help. Did she talk about the stress of this unexpected immobility when she went for her follow-up visit? Of course not. The test results were good, the sutures were removed, and she simply started going to another podiatrist. The expert podiatrist had made a sound clinical judgment but a poor total patient care decision with regard to details.

    How many patients have returned for a follow-up visit to your office and told you how much that first dressing change hurt because the tape was securely applied to the hair on his arm? How many have told you that they didn’t really change their dressing twice a day because they had trouble reaching the wound or it made them queasy? Probably very few. Unless a complication develops or you ask very specific questions, chances are you’ll never hear about the “small stuff” that the patient may consider too embarrassing or too personal to share.

    The following are some observations/recommendations for clinicians based on my own experiences.

    First, and foremost, please prescribe dressings that do not require frequent changes. Few people want to clean and dress a wound on a daily (or, heaven forbid, twice-daily) basis. We all know that moisture-retentive dressings help wounds heal and reduce pain — remember they also help patients take showers without fiddling with plastic bags, Saran™ Wrap, and other moisture-defying Rube Goldbergs. Invest in some quality dressings and you will earn the respect and adoration (and most importantly, cooperation) of your patients.

    General advice is generally useless. For example, what does “Stay off that leg” really mean — staying in bed? Sitting in a chair 24 hours a day? Offer care admonishments within defined, realistic time frames.
Explain “normal” and “abnormal” pain — preferably in writing. If a procedure requires anesthesia, patients will experience little immediate discomfort when leaving your office or clinic; verbal instructions will probably be forgotten by the time they get to the car. Later, when they are in agony in the middle of the night, they have no idea what happened (or what to do). Having written directions and assurances assuages the psyche as well as the pain.

    Regardless of the adhesive used, remind patients not to pull the dressing during dressing change. Pushing the skin away from the adhesive or stretching the dressing to break the skin/adhesive bond is far less painful. Also, anyone who has ever had a wound knows that movement hurts. Thus, always prescribe a dressing that immobilizes the wound edges and, for some anatomical areas, a supporting bandage as well. A good self-adherent wrap is a god-send to patients with wounds in high mobility anatomical areas — it also doesn’t hurt, not to make a pun, that using the appropriate wrap to prevent edema and wound movement facilitates healing.

    Last but not least, ask specific questions to increase your expertise and improve your emotional credibility as a healer. Patients faced with managing the “small stuff” of living with a body that is less than whole are quite resourceful. Learn from them. Share their experience with others.

    Thankfully, my experiences do not come close to qualifying me for shaman-hood. I also am grateful for all of us that a history of illness is not a prerequisite for becoming a healthcare professional. However, remember that what has become your second-nature routine is a series of sometimes difficult and painful details for your patients. While you focus on overall outcomes, they are managing the minutia. An expert, emotionally credible healer considers both.