Practice Perfect 790
Wound Care: The Psychiatry of Podiatry

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Chandler Hubbard, DPM, FACPM, CWSP

Practice Perfect December 28, 2021

It’s always fun to read the perspectives of others rather than simply that of your intrepid Practice Perfect blogger. It then brings me much pleasure to publish a piece from a young podiatric writer, Chandler Hubbard, DPM. Dr Hubbard is a recent graduate of the Chino Valley Medical Center residency and is in private practice in Upland, California where she is also an assistant professor at the WesternU College of Podiatric Medicine. Dr Hubbard has a deep and consistent interest in limb preservation and has promise to be a future leader in this subspeciality of podiatry. She also has a unique viewpoint resulting from her strong medical background as you’ll notice in her piece.
Best wishes.

Wound care is a lot like a game of chess; many pieces on a board that must be controlled, players needing to think ahead to anticipate the next move or step, and the challenge in that no game is the same.

Like chess, the pieces on the board represent the comorbidities that each patient presents with. It is our job in wound care to aid in controlling where those pieces move – are they tightly controlled like the sugars of a compliant diabetic, or are they fought across the board like peripheral arterial disease that strangles the tissue it crosses? As a podiatrist, I am a player in the game, and the wound is my opponent. I must anticipate the complications and outcomes the wound may take. Just as each game of chess can be played differently, so too is every wound different from the last.

Advances in Wound Care and Off Loading With Total Contact Casting

Christopher K Bromley, DPM, FACFAS

Delray Beach, Florida

Christopher K Bromley, DPM, FACFAS discusses risk factors that contribute to the development of wounds and the role of diabetes in foot wounds. Dr Bromley also differentiates different types of wounds, current wound care principles, as well as the role of total contact casts in the treatment of foot wounds.

Available Credits: CPME 0.75

Honestly, I am not a good chess player, but I am someone who accepts a challenge and, to me, the most difficult challenge in medicine is wound care. Fractures and reconstructions, while difficult, can be planned and reduced, while wounds have a mind of their own. Just when you think that wound is about to close, it reopens, enlarges, or a new problem arises. 

Over the last few years, I have committed myself to the art of wound care. I call it an art because sometimes science isn’t enough to explain and control a wound. My goal as a podiatrist is to prevent the formation of wounds and aid in healing wounds that cannot be prevented, all while simultaneously caring for a patient both physically, mentally, and emotionally.

I compare wound care lightly to a game of chess, but wounds are no game. They affect the lives of not only the patient but also the lives of their families. Treating a wound is not unlike treating cancer: it sometimes develops aggressively, takes its toll on the body and does not truly heal but simply goes into remission, leaving the patient changed. While dealing with a lower extremity wound, a patient and their family often go through the stages of grief. In no particular order, they deny, bargain, become angry and depressed and only sometimes find acceptance of their pathology. In fact, studies have shown that the stages of grief are often seen in the response to diabetic limb loss and amputation.¹ As podiatrists, our goals are not only to heal a wound but heal the hole (pun intended) it has left in a patient emotionally. We see our wound care patients on a more regular basis than the average patient, and we begin to know them better than we may know or understand other patients. We become intertwined in their lives, hearing about births, deaths, fights, triumphs, and tribulations. We meet spouses, friends, and caregivers and see the emotional response to victories in wound healing and losses in worsening of infections, ulceration, or loss of limb. Within those countless hours we spend debriding wounds or applying negative pressure therapy, we also counsel and guide patients to not only heal their wounds but also provide the support in assessing both the mental and physical aspects of psychological problems they face.

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These visits mirror therapists as they evaluate and treat in the cognitive behavioral therapy (CBT) fashion. In the psychiatric world, CBT is a short-term form of psychotherapy based on the concept that the way we think about things affects how we feel emotionally.² Cognitive therapy focuses on present thinking, behavior, and communication rather than on past experiences and is oriented toward problem solving. In this way, we give our patients hope and the tools to deal with their wounds and the problems that surround them. We have seen that podiatric pathologies are associated with worse health status in persons with severe mental illness.³ Some providers are more adept at approaching these subjects, while others prefer to be the patient’s mechanic and let others handle the emotional side of things. Regardless of your approach, it is absolutely necessary that we are aware of signs and symptoms of psychiatric pathology and provide the support our patients need; in the end it only benefits the success of the wound care. 

Now, I do not claim to be a psychiatrist, and in fact I went into podiatry to do the opposite of what my father did as a neuropsychiatrist. But I do follow a mantra he instilled in me: I will never heal a patient’s wound, but I will give my patient the tools and knowledge to heal themselves. It is in this way that I say wound care is the psychiatry of podiatry.

I will never heal a patient’s wound, but I will give my patient the tools and knowledge to heal themselves.

So, the next time you’re debriding that wound or applying that graft, truly ask that patient “how are you?” and be the psychiatric podiatrist. Checkmate.

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