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The Best Kept Secret In Health Care: Or, Doctor Doesn't Always Know Best

A personal essay that lays bare the deficiencies in doctors' knowledge and experience in surprising ways. (Bennie J. Davis III/ flickr)closemore
A personal essay that lays bare the deficiencies in doctors' knowledge and experience in surprising ways. (Bennie J. Davis III/ flickr)

Every doctor knows that bedsores, especially the complicated ones, are nursing territory. Until I started making house calls, I hadn’t really thought much about bedsores at all. In the hospital, in the clinic, there were always nurses around. But in patients’ homes, it was a different story. If a nurse had checked on a home-bound patient’s bedsore the day before, or was going to visit the following day, I didn’t bother. It seemed wiser not to mess around with a complicated-looking dressing, one of those impossibly tidy collages of gauze and adhesive tape topped with a clear sticky square that neatly held everything together. Better to leave it than to apply a haphazard mess of bandages that might not prevent feces or urine from seeping into the wound.

One rainy March day, I’d driven to a patient’s house to do a routine checkup. The visiting nurse, who assessed my patient’s year-old bedsore twice a week, arrived a couple minutes later. The timing couldn’t have been better. I’d be able to sneak a peek at the bedsore without having to lay a hand on the area in question, and leave the tidying up to the experts.

...much of the practical, day-to-day, hands-on aspects of patient care is foreign to doctors.

An aide in bright pink scrubs led us to the small bedroom where the old man lay on an air mattress attached to a pump. He stared straight ahead, eyes half-closed, a navy baseball cap slipping to one side of his shiny scalp, gangly legs stretching beyond the edge of the bed. He was thin but still had some meat on his bones, and despite the thickening haze of dementia, I could sometimes detect a faint sense of who he was.

I did my exam. The nurse flicked off the mattress pump and she and the aide propped the man on his side. The aide stroked the man’s head while the nurse peeled off the bandages to expose the bedsore. Bedsores, also called pressure ulcers or decubitus ulcers, result from prolonged pressure on a body part. They usually develop in older people with limited mobility and poor nutrition, but any patient who can’t easily change his position is at risk. With unrelieved pressure on tailbone, hips, heels or any other bony area, a seemingly innocuous reddening of the skin can open into a shallow ulcer and morph disturbingly quickly into a deep hole that can take months or longer to heal. This is what I was looking at, a plum-sized hollow, a scooped-out area so deep you could almost see bone. Inside, the tissue looked like ground beef. The nurse soaked a piece of gauze with saline, pushed it into the hole without hesitation, expertly wiped away some creamy yellow discharge. One, two, three. All done. The patient barely cringed.

Because the wound was so big, a surgeon had recommended a wound vacuum, a device that constantly suctioned out pus and discharge to speed the healing process. The nurse tore open a couple packets of gauze, uncapped a bottle of saline, and unwrapped a thin foam disk the size of a sand dollar that could be connected to a negative pressure pump. Even though I’d signed a form approving the device the week before, I’d actually never seen someone use one.

I wondered at that moment whether the nurse and aide were puzzled by my lingering presence. I imagined a quick glance between them, a silent questioning why this peculiar doctor was just standing there and watching. Didn’t she have somewhere to rush off to? Why was she staying to watch the dressing of a wound? Weren’t doctors, by definition, experts in all matters medical, including wound care and everything else nurses and nurses’ aides did? Or perhaps they thought I’d switched into critical observer mode, that I was taking mental notes on their performance technique that I’d report back to some authority.

The truth? I was embarrassed. I’d been an attending physician for years. By sticking around, I was revealing a secret of my profession, after all, that much of the practical, day-to-day, hands-on aspects of patient care is foreign to doctors.

It’s easy for doctors to do what doctors always do ... while remaining oblivious to this alternate but equally important universe of caregiving...

Think of the most basic medical procedures — like starting an intravenous line. I hadn’t put in an IV since residency, back in the 1990s, and now I’d surely make a mess of it. And forget about hooking up the IV bag — I’d probably get air bubbles in it. Turning a patient in bed? You’d think it would be straightforward, but I’d never learned how to handle the inevitable tangle of limbs. In the hospital, none of this mattered: There was always other staff around, doctors simply didn’t do these things, and nobody was the wiser. But in a nurse-less setting, these lapses in doctors’ education glared in plain view.

The nurse expertly secured the wound vac into place, and I asked a couple of questions about her technique. But for the most part — it took about 10 minutes — I watched in humbled silence.

It’s easy for doctors to do what doctors always do — interpret test results, discover subtle exam findings, clinch an elusive diagnosis — while remaining oblivious to this alternate but equally important universe of caregiving: the languid, unrushed, down-to-earth, sometimes grubby, unglamorously practical, taken-for-granted heart of truly helping a patient in need.

Anna Reisman Cognoscenti contributor
Anna Reisman, MD, is an associate professor at Yale School of Medicine.

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