Interview Questions for Preventive Foot Care for Diabetics

Diabetic foot ulcers are a serious complication of diabetes, arising from a combination of factors. Think of it like this: diabetes damages blood vessels and nerves, creating a perfect storm for foot problems. The most common risk factors fall into these categories:

• Neuropathy: Nerve damage reduces sensation in the feet, meaning you might not notice injuries like cuts or blisters. This is like walking around with numb feet – you won’t feel a pebble in your shoe until it causes significant damage.
• Peripheral Arterial Disease (PAD): Reduced blood flow to the feet slows healing and increases the risk of infection. Imagine trying to mend a broken pipe with a weak water supply – the repair is much slower and less effective.
• Foot Deformities: Conditions like hammertoes, bunions, and Charcot foot make the feet more susceptible to pressure points and injuries. These deformities are like cracks in a foundation that make it unstable.
• Poor Foot Hygiene: Improper cleaning and drying can lead to infections. This is like creating a breeding ground for bacteria.
• Smoking: Smoking further restricts blood flow, worsening PAD and hindering healing.
• High Blood Glucose Levels: Poorly controlled blood sugar damages blood vessels and nerves more quickly. This is like constantly adding fuel to the fire.

Managing these risk factors is crucial in preventing diabetic foot ulcers.

Regular foot self-exams are incredibly important for diabetics because they are your first line of defense against serious foot complications. Early detection of even minor problems can prevent them from turning into ulcers or infections. Think of it as a preventative maintenance check-up for your feet.

A daily self-exam allows you to identify issues such as:

• Cuts, blisters, or sores: These may go unnoticed due to neuropathy.
• Redness, swelling, or warmth: Signs of infection.
• Changes in skin color or texture: Indication of poor circulation or nerve damage.
• Ingrown toenails: Can lead to infection.
• Calluses or corns: Can become painful and infected.

By catching problems early, you can take prompt action and prevent serious complications, such as amputation. Making this a daily routine is a small investment with potentially enormous returns.

A comprehensive diabetic foot exam goes beyond a simple visual inspection. It’s a systematic assessment encompassing several key elements:

• Visual Inspection: Examining the feet for cuts, blisters, redness, swelling, deformities, and calluses.
• Palpation: Feeling the skin temperature to assess circulation and checking for any areas of tenderness or pain.
• Neurological Examination: Assessing sensation using a monofilament test (a thin, flexible wire that measures the lightest touch a person can feel) and checking reflexes. This helps detect peripheral neuropathy.
• Vascular Examination: Assessing pulses in the feet and ankles to check for PAD. A Doppler ultrasound may be used to measure blood flow more accurately.
• Foot Structure Assessment: Checking for deformities like hammertoes or bunions.
• Skin Integrity Assessment: Checking for dryness, cracking, or other skin issues.

These elements combined provide a complete picture of the patient’s foot health and help identify areas requiring intervention.

Assessing for peripheral neuropathy involves testing both sensation and reflexes. The most common method is the monofilament test. This involves lightly touching various points on the foot with a calibrated monofilament. The patient indicates whether they feel the touch. Inability to feel the monofilament at certain pressure points suggests reduced sensation. The test is simple, but very effective in picking up early signs of nerve damage.

Beyond the monofilament test, a neurological examination should also include:

• Vibration sense testing: Using a tuning fork to assess the ability to feel vibrations.
• Reflex testing: Checking ankle reflexes to assess nerve function.
• Temperature sensation testing: Testing the ability to discriminate between warm and cold.

These combined assessments provide a thorough understanding of the patient’s nerve function in their feet.

Assessing for Peripheral Arterial Disease (PAD) involves checking the blood flow to the feet and ankles. This typically starts with a physical examination to check the pulses in the feet and ankles. Weak or absent pulses indicate reduced blood flow.

Further assessment may involve:

• Ankle-Brachial Index (ABI): This non-invasive test compares blood pressure in the ankle to blood pressure in the arm. A low ABI indicates PAD.
• Doppler ultrasound: This uses sound waves to measure blood flow in the arteries of the legs and feet, providing a more detailed assessment of blood flow.
• Angiography: In some cases, a more invasive procedure like angiography may be needed to visualize the arteries and identify blockages.

The combination of these methods provides a comprehensive evaluation of arterial health in the lower extremities.

Diabetic foot infections can be subtle initially, often presenting with non-specific symptoms. It’s crucial to be vigilant for any changes in the foot. The signs and symptoms can include:

• Increased pain or tenderness: Even a minor injury can become severely painful with infection.
• Redness, swelling, and warmth around a wound: These are classic signs of local infection.
• Pus or drainage from a wound: A clear indication of infection.
• Fever or chills: Signs of a systemic infection (infection spread beyond the foot).
• Increased warmth in the affected area: Indicates increased blood flow due to infection.
• Changes in skin color: Darkening or discoloration of the skin.

Any of these symptoms warrant immediate medical attention. Diabetic foot infections can rapidly escalate, leading to severe complications.

Appropriate wound care for diabetic foot ulcers is crucial for healing and preventing complications. The key principles are:

• Debridement: Removing dead or infected tissue from the ulcer. This promotes healing and reduces infection risk.
• Wound cleansing: Gently cleaning the wound with sterile saline solution. Avoid harsh antiseptic solutions that can delay healing.
• Appropriate dressings: Using dressings that promote a moist wound environment. The type of dressing depends on the specific wound characteristics.
• Offloading: Reducing pressure on the ulcer to promote healing. This can involve using special shoes, braces, or crutches.
• Infection control: Treating any infection promptly with antibiotics. This requires appropriate culture and sensitivity testing to identify the causative organism.
• Regular monitoring: Closely monitoring the wound for any signs of infection or changes in healing.

Wound care should be performed by a healthcare professional experienced in managing diabetic foot ulcers. Improper wound care can worsen the condition and increase the risk of complications.

Diabetic foot ulcers are wounds that develop on the feet of people with diabetes. They occur because of nerve damage (neuropathy) and poor blood circulation (peripheral artery disease), both common complications of diabetes. These complications make it harder for the body to heal injuries, even minor ones. We categorize ulcers based on their location and depth:

• Neuropathic ulcers: These are the most common type. They typically occur on the bottom of the foot, especially over pressure points like the ball of the foot or heel, due to decreased sensation. Imagine a small stone in your shoe; someone with neuropathy might not feel it, leading to repeated pressure and eventual ulceration.
• Ischemic ulcers: These are caused by reduced blood flow to the foot. They often appear on the toes or the outside of the foot, and tend to be deep and slow to heal. Think of it like a plant not receiving enough water; without adequate blood supply, the tissue dies.
• Neuroischemic ulcers: These are a combination of neuropathic and ischemic ulcers. They share characteristics of both, being painful and slow to heal.
• Infected ulcers: Any of the above ulcers can become infected, presenting with increased pain, swelling, redness, and pus. This is a serious complication requiring immediate medical attention.

Understanding the type of ulcer is crucial for targeted treatment. For example, ischemic ulcers require improving blood flow, while neuropathic ulcers focus on pressure relief.

Offloading is absolutely critical in diabetic foot ulcer treatment. It means removing or reducing pressure on the affected area to promote healing. Without offloading, the ulcer will likely remain open, increasing the risk of infection, amputation, and other complications. Imagine trying to heal a paper cut while constantly pressing on it – it won’t close. Similarly, continued pressure on a diabetic foot ulcer prevents healing. The goal of offloading is to allow the ulcer to heal by giving the tissues a chance to regenerate.

Successful offloading significantly improves healing rates and reduces the risk of amputation. It’s a cornerstone of our treatment strategy, and we often explain this to patients using the analogy of giving the wound a ‘rest’ to allow it to heal properly.

We have a range of offloading options, tailored to the individual patient’s needs and the severity of the ulcer:

• Total contact casts (TCCs): These provide complete pressure relief by distributing weight evenly across the entire foot. They’re often used for severe ulcers.
• Custom-molded shoes and inserts: These provide individualized pressure relief, accommodating unique foot shapes and deformities. They are often more comfortable for long-term use.
• Removable cast walkers (RCWs): These offer a balance of support and mobility, allowing for partial weight bearing.
• Special therapeutic shoes: These are designed with features like extra depth and cushioning to reduce pressure.
• Crutches or walkers: For severe cases, complete offloading might require the patient to avoid weight bearing altogether.

The choice of offloading method depends on factors like the size and location of the ulcer, the presence of infection, the patient’s mobility, and overall health.

Patient education is key to preventing and managing diabetic foot ulcers. We emphasize the importance of daily foot care, explaining each step clearly and demonstrating the proper techniques:

• Daily inspection: Encourage patients to examine their feet daily, looking for any cuts, blisters, redness, or swelling. Using a mirror to check the soles is vital.
• Washing: Gentle washing with lukewarm water and mild soap. Avoid harsh chemicals or scrubbing, which can damage the skin.
• Drying: Thorough drying, especially between the toes, is essential to prevent fungal infections. Patting, not rubbing, is important.
• Moisturizing: Applying moisturizer to the feet, avoiding the area between the toes to prevent moisture buildup.
• Nail care: Trimming toenails straight across and avoiding cutting into the corners to prevent ingrown toenails.
• Regular professional foot care: Schedule regular checkups with a podiatrist for professional assessment and care.

We often use visual aids like diagrams and videos to make the instructions clear and easy to follow. We also provide written materials reinforcing the key points.

Footwear choice is crucial for preventing and managing diabetic foot problems. We recommend shoes that are:

• Well-fitting: Shoes should be the right size and shape, allowing enough room for the toes to move freely. Avoid shoes that are too tight or too loose.
• Supportive: Shoes with good arch support and cushioning help to distribute weight evenly and reduce pressure points.
• Seamless construction: Seamless shoes minimize friction and the risk of blisters and skin irritation.
• Made of breathable materials: Breathable materials help to keep the feet dry and prevent excessive sweating.
• Closed-toe design: Closed-toe shoes protect the toes and feet from injury.

We advise patients to avoid high heels, flip-flops, and pointed-toe shoes, as these can increase pressure on the toes and feet. Custom-made shoes or orthotics are frequently recommended, particularly for patients with deformities or high risk of ulceration.

Specialized footwear and orthotics play a vital role in preventing and treating diabetic foot problems. They provide crucial support, cushioning, and pressure relief, significantly reducing the risk of ulcer development and promoting healing.

Specialized footwear, such as therapeutic shoes, is designed with extra depth and width to accommodate custom-made inserts and provide ample space for swollen feet or deformities. They often feature supportive soles and seamless interiors to minimize friction.

Orthotics are custom-made inserts designed to correct foot deformities, improve weight distribution, and reduce pressure on specific areas. They are particularly helpful for patients with plantar fasciitis, metatarsalgia, or other foot conditions that increase the risk of ulceration.

The combined use of appropriate footwear and orthotics can significantly enhance the effectiveness of other treatment modalities, resulting in improved ulcer healing and reduced risk of recurrence. We often involve a certified pedorthist in the process to ensure that the orthotics perfectly fit the patient’s feet and effectively address their specific needs.

Pain management in patients with diabetic foot ulcers is a multifaceted approach, combining several strategies:

• Analgesics: Over-the-counter pain relievers like acetaminophen or ibuprofen can help manage mild to moderate pain. For more severe pain, stronger prescription medications, such as opioids, may be necessary, carefully managing the risks associated with opioid use.
• Topical treatments: Topical anesthetics or creams can provide localized pain relief, targeting the ulcer site directly.
• Neuropathic pain management: If nerve pain is a significant component, medications specifically designed to treat neuropathic pain, like gabapentin or pregabalin, might be prescribed.
• Wound care: Proper wound care, including debridement (removal of dead tissue) and infection control, is crucial for pain management as it addresses the underlying cause of the pain.
• Offloading: As discussed earlier, pressure relief is paramount not only for healing but also for reducing pain.
• Physical therapy: Physical therapy can help improve range of motion, strength, and overall function, potentially alleviating pain and improving mobility.

Pain management should be individualized based on the patient’s specific needs and pain levels. We regularly assess the patient’s pain using validated pain scales and adjust treatment accordingly. A holistic approach involving medication, wound care, and physical therapy, provides the best chance of controlling pain and promoting healing.

A patient with a diabetic foot ulcer should be referred to a specialist, such as a podiatrist, wound care specialist, or vascular surgeon, immediately if there are signs of infection (increased pain, swelling, redness, warmth, pus), deep or rapidly progressing ulceration, bone involvement (osteomyelitis), or if conservative management has failed to show improvement within a reasonable timeframe (typically 2-4 weeks). Early specialist referral is crucial for optimal wound healing and preventing serious complications.

Think of it like this: a small cut you can manage at home is different from a deep wound that needs a professional’s expertise. Similarly, a minor diabetic foot ulcer may respond to basic care, but more serious cases require specialized intervention.

Diabetic foot ulcers can lead to a cascade of devastating complications. These include:

• Infection: Bacteria easily invade the ulcer, potentially spreading to the bone (osteomyelitis) or bloodstream (sepsis), leading to life-threatening situations.
• Gangrene: Severe infection and lack of blood flow can cause tissue death, requiring amputation.
• Osteomyelitis: Bone infection is a severe complication requiring prolonged antibiotic treatment and potentially surgery.
• Amputation: In advanced cases, amputation of the affected toe, foot, or even leg may be necessary to save the patient’s life.
• Chronic pain: Even after healing, chronic pain can significantly impact quality of life.
• Reduced mobility: Ulcers and subsequent complications can severely restrict mobility, leading to decreased independence.

The severity of complications depends on factors like the depth and size of the ulcer, the presence of infection, and the patient’s overall health.

Tight blood glucose control is paramount in preventing diabetic foot ulcers. High blood sugar levels damage nerves (neuropathy) and blood vessels (angiopathy) in the feet. Neuropathy reduces sensation, leading to unnoticed injuries. Angiopathy restricts blood flow, impairing the healing process and increasing susceptibility to infection.

Imagine your blood vessels as highways transporting essential resources to repair tissues. High blood sugar damages these highways, creating traffic jams and limiting the delivery of building materials needed for healing. Maintaining good blood glucose control keeps these highways open and efficient, promoting healthy foot tissue and reducing the risk of ulcers.

Charcot foot is a serious complication of diabetes characterized by bone destruction and deformity in the foot. Common signs include:

• Swelling: Often significant and painless swelling of the affected foot and ankle.
• Redness and warmth: Increased temperature and redness in the affected area.
• Deformity: Progressive foot deformity, with the foot appearing rocker-bottom shaped, dislocated joints or prominent bones.
• Pain (variable): Pain may be present, but often surprisingly absent due to neuropathy.
• Loss of normal foot arch: A flattening of the arch of the foot.

The onset is often insidious, with the patient noticing progressive swelling and deformity over time. It’s critical to differentiate Charcot foot from infection, as treatment differs significantly.

Management of suspected Charcot foot requires immediate specialist consultation. The primary goals are to protect the foot from further injury, reduce inflammation, and promote healing. This typically involves:

• Non-weight-bearing: Using crutches, a wheelchair, or a total contact cast to eliminate weight-bearing on the affected foot is crucial to prevent further damage.
• Immobilization: A total contact cast or specialized offloading footwear is used to protect the foot.
• Pain management: Medications like analgesics and anti-inflammatory drugs may be used for pain relief.
• Blood glucose control: Strict blood sugar control is vital to improve healing and reduce inflammation.
• Infection management: Treatment of any infection present is paramount using antibiotics.
• Surgical intervention: In severe cases, surgery may be needed to correct deformities or treat fractures.

The treatment plan is highly individualized and depends on the severity of the condition and the patient’s overall health.

Antibiotics play a critical role in managing diabetic foot infections. They are essential in combating bacteria, preventing the spread of infection, and promoting wound healing. The choice of antibiotic depends on the type and severity of the infection, as determined by culture and sensitivity testing. Broad-spectrum antibiotics are often used initially while waiting for culture results.

It’s crucial to emphasize that antibiotics should be prescribed and monitored by a healthcare professional. Improper use can lead to antibiotic resistance, making future infections harder to treat. The duration of antibiotic therapy is guided by clinical response and culture results.

Various wound dressings are used in diabetic foot ulcer management, each with its own properties and benefits. The choice of dressing depends on the type and severity of the ulcer, the amount of exudate (wound drainage), and the presence of infection. Some common types include:

• Alginate dressings: Highly absorbent dressings suitable for heavily exuding wounds.
• Hydrocolloid dressings: Self-adhesive dressings that create a moist wound environment, promoting healing.
• Foam dressings: Absorb exudate and provide cushioning for painful wounds.
• Hydrogel dressings: Hydrating dressings that are suitable for dry or necrotic wounds.
• Transparent film dressings: Impermeable dressings that provide a moist environment and allow for wound visualization.

The goal is to create an optimal wound environment that supports healing. Regular assessment and dressing changes are essential to ensure proper wound management.

Surgical intervention for diabetic foot ulcers is a last resort, considered only when conservative treatments fail to achieve adequate healing. The indications are complex and depend on several factors, including the ulcer’s depth, presence of infection, bone involvement (osteomyelitis), and the patient’s overall health.

• Severe Infection: If the ulcer is severely infected, despite aggressive antibiotic therapy, surgery might be necessary to debride (remove) infected tissue and prevent sepsis. This could involve procedures like incision and drainage or extensive debridement.
• Osteomyelitis: Infection spreading to the bone requires surgical intervention. This often involves surgical debridement of infected bone and potentially bone grafts or amputation in severe cases.
• Ischemic Ulcers: Ulcers that fail to heal due to inadequate blood supply (ischemia) might necessitate surgical revascularization (procedures to improve blood flow) or, unfortunately, amputation if revascularization isn’t feasible.
• Non-healing Ulcers: Despite optimal wound care and treatment, some ulcers simply don’t heal. In such scenarios, surgery may be considered to remove necrotic tissue and promote healing. This could involve procedures like skin grafting or local flaps.
• Gangrene: The presence of gangrene (tissue death) is a clear indication for surgical intervention, often requiring amputation to prevent life-threatening complications.

The decision to proceed with surgery is always made on a case-by-case basis after a thorough assessment of the patient’s condition and the ulcer’s characteristics. A multidisciplinary team, including podiatrists, vascular surgeons, and infectious disease specialists, is often involved in the decision-making process.

Monitoring the healing progress of a diabetic foot ulcer is crucial to ensure timely intervention and prevent complications. This involves a combination of clinical assessment and potentially advanced imaging.

• Visual Assessment: Regularly assessing the ulcer’s size (length, width, depth), exudate (wound drainage), and surrounding skin condition is fundamental. We use standardized tools like wound photography and planimetry to track changes accurately.
• Wound Bed Assessment: Evaluating the wound bed’s characteristics – such as the presence of granulation tissue (healthy tissue formation), necrotic tissue (dead tissue), or eschar (dried, black crust) – is essential. This informs our treatment strategy.
• Infection Assessment: Monitoring for signs of infection, such as increased pain, swelling, redness, warmth, or purulent discharge, is vital. We may use swabs to culture the wound and guide antibiotic therapy.
• Clinical Measures: Tracking parameters like blood glucose levels, HbA1c, and white blood cell count helps assess the overall metabolic control and the presence of infection.
• Imaging Studies: In complex cases, imaging techniques like X-rays, ultrasound, or MRI may be used to assess the depth of the ulcer, the presence of bone infection (osteomyelitis), or vascular compromise.

We use a combination of these methods to create a comprehensive picture of the healing process. A decline in healing or the emergence of new complications warrants prompt adjustments to the treatment plan. For instance, a sudden increase in wound size or signs of infection might require a change in dressings, antibiotics, or even surgical intervention.

Preventing diabetic foot amputations is a primary goal in diabetic foot care. It involves a multi-pronged approach focusing on risk factor modification and meticulous foot care.

• Blood Glucose Control: Maintaining optimal blood glucose levels is paramount. Poorly controlled diabetes significantly increases the risk of complications, including foot ulcers.
• Regular Foot Examinations: Patients should examine their feet daily for any cuts, blisters, redness, or swelling. Regular professional foot exams by a podiatrist are equally important.
• Proper Footwear: Wearing well-fitting shoes that protect the feet from injury is crucial. Avoid going barefoot, wearing flip-flops or high heels. Custom-made orthotics can often be beneficial.
• Skin and Nail Care: Maintaining proper hygiene and diligently caring for toenails (avoiding ingrown toenails) are critical to preventing infections.
• Smoking Cessation: Smoking dramatically impairs blood flow to the extremities, increasing the risk of ulcers and delayed healing. Quitting smoking is therefore vital.
• Regular Vascular Assessments: People with diabetes should undergo regular assessments of their peripheral arterial circulation to identify and manage peripheral arterial disease (PAD).
• Neuropathy Management: Diabetic neuropathy (nerve damage) reduces sensation, increasing the risk of injury unnoticed. Managing neuropathy often involves medication and patient education.

Implementing these preventive measures significantly reduces the likelihood of developing diabetic foot ulcers and the need for amputation. Education is key: empowering patients to take an active role in their foot care is crucial for success.

Patient education and counseling form the cornerstone of effective diabetic foot care. My approach is to provide clear, concise information tailored to each patient’s individual needs and literacy level. I use a variety of teaching methods, including visual aids, demonstrations, and interactive sessions.

• Initial Assessment: I start by understanding the patient’s current knowledge and practices regarding foot care. This allows me to target the educational materials to their specific needs.
• Demonstrations: I demonstrate proper foot examination techniques, nail care, and the application of moisturizing creams. Hands-on practice often improves retention.
• Visual Aids: Brochures, diagrams, and videos illustrating proper foot care practices are effective tools. These visuals complement verbal instructions.
• Personalized Plans: I create personalized foot care plans that outline daily routines, including foot examination, cleaning, moisturizing, and nail care.
• Follow-up: Regular follow-up appointments are crucial to reinforce learning, address any questions or concerns, and monitor adherence to the care plan.
• Community Resources: Connecting patients with local resources like support groups and diabetes educators extends the educational reach.

For instance, I might work with a patient who has limited vision to develop a tactile method of foot examination, focusing on touch rather than sight. The key is adaptation and personalization to meet individual needs and preferences.

Effective communication with patients and their families is crucial in managing diabetic foot problems. I utilize a patient-centered approach, ensuring clear and empathetic communication.

• Active Listening: I prioritize active listening to understand their concerns, fears, and misconceptions regarding their condition.
• Plain Language: I avoid medical jargon and use simple, straightforward language, ensuring they understand the information provided.
• Visual Aids: Diagrams, pictures, and videos can effectively communicate complex information, particularly for those with low health literacy.
• Involving Families: I involve family members in the educational process, as they often play a vital role in supporting the patient’s care.
• Repeat and Summarize: I frequently repeat and summarize key information to ensure comprehension and address any questions or misunderstandings.
• Empathy and Patience: I maintain a patient and empathetic demeanor, acknowledging the emotional burden associated with diabetes and foot complications.

For example, I’ve found it helpful to use a shared decision-making approach, involving the patient and their family in making treatment choices. This empowers them and improves adherence to the treatment plan.

One challenging case involved a 72-year-old male with poorly controlled type 2 diabetes, peripheral neuropathy, and a deep, infected ulcer on his heel. He presented with severe pain, swelling, and signs of systemic infection. Initial conservative treatment with antibiotics and wound care showed minimal improvement after several weeks.

The challenge lay in balancing aggressive management of the infection with the patient’s age and comorbidities. We needed to avoid unnecessary surgical intervention, which carries risks in older patients, while preventing the spread of infection. We carefully monitored his clinical markers, including inflammatory markers and blood cultures. We also used advanced imaging (ultrasound) to assess the depth of infection and exclude osteomyelitis.

We opted for a staged approach, initially focusing on intensive wound debridement and local antibiotic therapy. We employed a negative pressure wound therapy system to improve tissue perfusion and promote healing. With close monitoring and adjustments to the treatment plan based on regular assessments, the infection gradually subsided. The ulcer eventually healed completely, avoiding the need for amputation. This case highlighted the importance of a multidisciplinary team approach, regular monitoring, and flexible treatment strategies tailored to the individual patient’s needs.

Staying current with advancements in diabetic foot care requires a multifaceted approach.

• Professional Organizations: I actively participate in professional organizations like the American Diabetes Association (ADA) and the American College of Foot and Ankle Surgeons (ACFAS), attending conferences and accessing their resources.
• Peer-Reviewed Journals: I regularly review peer-reviewed journals such as the Diabetes Care and Journal of the American Podiatric Medical Association to stay updated on the latest research findings.
• Continuing Medical Education (CME): I participate in CME activities, including online courses and workshops, to enhance my knowledge and skills in diabetic foot care.
• Collaboration with Colleagues: I actively engage in discussions and collaborations with colleagues, sharing experiences and insights on challenging cases.
• Technological Advancements: I stay informed about new technologies used in diabetic foot care, including advanced wound dressings and imaging techniques.

By constantly seeking knowledge and integrating the latest evidence into my practice, I ensure I provide the best possible care to my patients.