1. Salcido, Richard MD

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"Patient-centered care," as an expression, is beyond a fad and a term du jour. I believe that it has crept into our professional lexicon, but what is its precise meaning? The term patient-centered care (PCC) has also made its way into the taxonomy of wound care. A recent Internet search using Google reveals a significant number of citations and Web sites defining and espousing the patient-centered approach in numerous settings, including patient-centered wound care (PCWC). In fact, few wound care books even include the term patient-centered care as a subtitle. However, a more rigorous search of the PubMed index came up with 1 article with the PCWC term related to wound care.1 When the key words "pressure ulcer" were used in combination with PCWC, no specific articles were found, and those that were identified used vague references to PCWC, such as palliative care, terminal care, pain management, and holistic care.

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What then is the precise definition of PCWC? As stated by Stewart,2 it may be easier to agree on what PCC is not; it is not about healthcare providers, board certifications, hospitals, insurers, and payers. In wound care, a good example may be the fact that sometimes (at least during lecture presentations) we focus on the wound rather that the patient with a wound, hence the need for a more "holistic" approach, which is mentioned as a frequent and regular modifier to explain the concept of PCC and PCWC.


To understand the term, we must quantify PCWC, and to obtain a rudimentary understanding of the term, the value of the term, and what it means to the patient (the target of the care), we should consider the intersection between the qualitative and the quantitative facets of the term. The final task will be to operationalize the concept of PCWC.


In our attempt to define PCWC, we should consider Occam's (or Ockham's) razor or the law of parsimony. William of Occam (1284-1347) was an English philosopher and theologian. His work on knowledge, logic, and scientific inquiry played a major role in the transition from medieval to modern thought. He based scientific knowledge on experience and self-evident truths and on logical propositions resulting from those 2 sources. In his writings, Occam stressed the Aristotelian principle that entities must not be multiplied beyond what is necessary. A problem should be stated in its basic and simplest terms. In science, the simplest theory that fits the facts of a problem is the one that should be selected. This rule is interpreted to mean that the simplest of 2 or more competing theories is preferable and that an explanation for unknown phenomena should first be attempted in terms of what is already known. Therefore, using Occam's razor (shaving down to the core principle), we can simplify the principle and/or the definition of PCWC (what does the patient want?).


Stewart2 states that the best way to measure patient "centeredness" is an assessment made by the patients themselves. In wound care, the patients need to be part of the wound care team. Instead of "empowering" patients to become active participants in their wound care, many patients will want to take a proactive leadership role in their care and correspondingly will empower healthcare providers to be on their team, as they direct the process and outcome centered on their goals and objectives.


Some organizations are addressing fundamental posits related to the concept of PCC in general. For example, the Institute for Healthcare Improvement (IHI) is an independent, not-for-profit organization helping to lead the improvement of healthcare throughout the world. IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping healthcare systems put those ideas into action. IHI is focusing on 3 areas that we believe will contribute to a complete framework for a PCC healthcare system.3 Specifically, IHI will work to articulate changes that


* enable healthcare providers to reliably meet the needs and preferences of patients.


* enable fully informed, shared decision making.


* include patients and their loved ones on healthcare improvement and design teams.



After considerable review about the concept of PCWC, I have concluded that this term serves as a philosophical anchor to remind us that the patient comes first as they should. As my wife, a coronary intensive care nurse, reminds me when I'm heading out the door worrying about organizational policies, procedures, and politics related to patient care of the day, she reassures me with the following phrase: "Remember take good care of the patient and all of that other stuff will be all right." However, in the real world, other factors sometimes cause us to focus just on the wound or systems-based minutiae related to patient care that directs our attention away from the patient. As we look for the simplicity espoused by Occam's razor, we may want to consider Albert Einstein's theory "Everything should be made as simple as possible, but not simpler."


Richard "Sal" Salcido, MD

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1. Dowsett C. Exudate management: a patient-centred approach. J Wound Care 2008; 17:249-52. [Context Link]


2. Stewart M. Towards a global definition of patient centred care. BMJ 2001;322:444-5. [Context Link]


3. Patient centered care: general. Last accessed December 22, 2009. [Context Link]