Skip the Maggots, Doc: Study Shows They’re Not Better for Wound Cleaning

Strange as it may sound, maggots have recently been in vogue in medical circles. In increasing numbers, doctors have been placing live maggots on patients’ wounds to clean out decaying tissue; because the maggots eat only dead tissue and leave healthy tissue untouched, they’ve been seen as an efficient way to clean the wound. But now researchers have announced the results of the first large clinical trial comparing maggots to traditional therapies, and found that maggots don’t have a clear advantage.

Maggots did clear away the dead tissue faster, but that’s where their superiority ended. “Maggots, although they sped the cleaning, didn’t speed the healing of the wound,” [lead researcher Nicky] Cullum said in an interview. “Both treatments had a similar cost, but the maggots led to more pain.” The researchers found no evidence that maggot therapy should be recommended for routine use on leg ulcers [Bloomberg].

People with poor circulation in their legs often develop difficult-to-treat leg ulcers. Standard treatments for these ulcers employs various kinds of hydrogels — wet dressings that pull dead tissue from the ulcers. With hydrogels, but not with maggot therapy, a compression dressing can be used to cover the wound and ease patients’ pain [WebMD].

In the study, published in the British Medical Journal, 270 patients with leg ulcers were treated either with larvae of the green blowfly or hydrogel and followed for up to a year. Cullum says the test subjects were game for the experiment: “Surprisingly, people were disappointed when they were allocated to hydrogel” [Bloomberg]. Researchers found that both sets of patients healed at the same rate, but those treated with maggots reported twice as much pain.

The researchers didn’t write off the wriggly therapy entirely. They say that maggots may yet have advantages in some specialized areas, such as preparing patients for skin grafts, where faster wound cleaning means patients can be moved into surgery more swiftly. But establishing this will require further clinical studies [Reuters].

Related Content:80beats: Calling Forth the Body’s Own Stem Cells Could Speed Tissue RepairDISCOVER: The Healing Power of Maggots DISCOVER: Bloodsuckers explores the use of leaches in modern medicine

Yes, We Do Give Frequent Flyer (S)Miles: Virtual Mentor

Chris Brooks, MD

I can recall writing a note in Walter’s chart like it was yesterday [1]. It began, “This is the 200th emergency department visit for Walter this year,” and it was only mid-summer. Less than 6 months later accounts of this infamous patient’s last days circulated though the hospital. In a strange way, I felt as though a family member had died.

LEARNING OBJECTIVERecognize that a biopsychosocial understanding of frequent emergency department users can improve their care, reduce use of medical resources, and prove rewarding to physicians.

Walter had been a fixture in our department for many years. Every physician in the emergency department knew him well, as did many of the internal medicine physicians. Nurses and technicians were on a first-name basis with Walter, who was renowned not only in our department but in most emergency departments in the city.

Encounters with Walter were always difficult at best. He would wander in at random times with vague or chronic complaints. With his head down, he would shuffle into the waiting room mumbling complaints in a monotone, high-pitched voice to the triage nurse. Refusal to cooperate with care was his custom. He would be found sitting in his assigned room, nearly every square inch of his body covered with ragged, unwashed clothing. A sweatshirt hood (or two) often covered his head. Taking of vital signs was usually refused, as was most diagnostic testing. House staff were often surprised to learn that Walter was neither uneducated nor homeless. In fact, he held an advanced engineering degree and, despite roaming the hospital campus at all hours of the day, owned his own home.

In spite of his usual vague and chronic complaints, Walter had advanced congestive heart failure. He was one of those patients always ill enough to be admitted to the hospital, even on his best days. He had chronic hypoxia, severe edema of his lower extremities, and chronic renal insufficiency. Discussions about administering furosemide were usually met with arguments by Walter about how it would affect his renal function coupled with refusal of a lab test for a serum creatinine. Walter firmly resisted any suggestion for hospital admission but was often so ill that he lacked the energy to refuse. These times offered a respite for the emergency department. It was easy to tell when Walter was in the hospital; those were the days when he wasn’t in our emergency department.

The crux of the matter was Walter’s underlying paranoid schizophrenia, which he refused to acknowledge. In fact, the one sure way to get him to leave the emergency department was to threaten to consult psychiatry. Mere mention of the service would result in cries of anguish, and his elopement from the department would soon follow. Surprisingly, this strategy was seldom used. Perhaps the staff realized that efforts to address his underlying psychiatric illness would be futile. Walter was never a threat to others or to himself, except for his medical noncompliance.

Descriptions circulating through the hospital surrounding the circumstances of Walter’s death were troubling. He had been admitted for worsening dyspnea and, as usual, had refused most interventions. His status declined, prompting his transfer to the intensive care unit where psychiatry was consulted. Numerous therapeutic modalities were then imposed, but Walter’s condition continued to worsen, and he eventually succumbed to his illness. One can only imagine the anguish resulting from his loss of autonomy during his final days.

Discussion

Patients who are regulars in emergency departments have been given many titles including “frequent flyers.” The “problem” is not unique to the United States. English-language literature describing the characteristics of these patients and the issues surrounding their emergency department care comes from many countries [2-9]. The implication is usually that patients are somehow using the emergency department in an inappropriate manner. Studies have clearly shown, however, that about half have chronic medical conditions, and for a variety of reasons most are not able to be seen in the offices of primary care physicians [2, 4-6, 8, 10-12]. Furthermore, these patients comprise a complex group that is in constant flux. The majority frequent the emergency department for a short period of time, usually less than 1 year, but there is a small minority that visits the emergency department over a long period of time, often many years [11]. This subgroup is studied little but is often the source of emergency department lore [13].

Walter is one of the few who maintained his familiarity with the emergency department staff over time. Like many patients in this subgroup, he was labeled “difficult,” a label that is fraught with problems. Descriptions and categorizations of so-called difficult patients have been in existence for many years, the modern classic being Groves’s article, “Taking Care of the Hateful Patient” [14]. The term is used to indicate that such patients are noncompliant, manipulative, and self-destructive. Differing expectations on the part of patient and physician can produce mutually negative outcomes in the medical encounter. Two traditional physician views present barriers to an ideal patient-physician relationship: the concept itself of the difficult patient and a biomedical view of medicine that tends to exclude social conditions. Patients like Walter are perceived by medical caregivers as “at fault” for poor medical outcomes. In many of these cases, unaddressed psychosocial issues are the root of the patients’ repeat visits, but attempts to manage those issues don’t necessarily reduce the number of emergency department encounters [15]. Phillips et al., for example, found that case-management strategies increase emergency department utilization, even while having a positive effect on some psychosocial factors for frequent users [3].

There are common factors among the frequent user group. Those with poor health, low income, psychiatric illness, substance misuse, and public insurance are more likely to be frequent users [8, 12, 16, 17]. Health insurance seems to otherwise not matter, nor does access to care [18].

Few studies have examined the underlying reasons that patients frequent the emergency department. Examining the issue from the patient’s perspective, Olsson and Hansagi found that frequent emergency department visitors perceive pain or other symptoms as a threat to their life or personal autonomy [9]. Overwhelming anxiety compels them to seek urgent help. Satisfaction with care becomes adversely affected when the patients sense that the emergency department staff classifies their frequent visits as inappropriate or when their symptoms are belittled.

In our case, Walter developed long-term relationships with various members of our emergency department staff. Many suspected that, like the ultimate frequent flyer, Walter had a social, albeit dysfunctional, relationship with them [13]. It is interesting that resources tend to be used in a more efficient manner on the long-term subgroup of frequent users than on the short-term group. Perhaps emergency department providers streamline the evaluation process due to familiarity with the patient, or they come to terms with the conflicting goals of therapy that are so troubling in encounters with difficult patients. My last few encounters with Walter were cordial and, in fact, quite rewarding. Accepting the limitations on care imposed by the patient, being willing to deviate from what most physicians would label “standard of care,” and patience were universally rewarded. Here, respect for patient autonomy was all that was demanded and took priority over other values. Not all of our colleagues agreed with this approach, but expanding care to include psychosocial as well as medical needs led to a rewarding patient-physician relationship.

Many do not consider the emergency department to be a place where long-term relationships are typically built. Cases like Walter’s, however, illustrate that the potential for them exists here. Emergency department physicians do, on occasion, form deep, meaningful relationships with their patients. Today, other patients have taken Walter’s place in our department. Some of them are quite objectionable, but all seem to have unique psychosocial needs that present an almost daily challenge. Meeting these needs and improving their lives continues to be a rewarding experience.

---

Notes and References

1. Pseudonym used.
2. Kennedy D, Ardagh M. Frequent attenders at Christchurch Hospital’s Emergency Department: a 4-year study of attendance patterns. N Z Med J.2004;117(1193):U871.
3. Phillips GA, Brophy DS, Weiland TJ, Chenhall AJ, Dent AW. The effect of multidisciplinary case management on selected outcomes for frequent attenders at an emergency department. Med J Aust. 2006;184(12):602-606.
4. Byrne M, Murphy AW, Plunkett PK, McGee HM, Murray A, Bury G. Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics. Ann Emerg Med. 2003;41(3):309-318.
5. Salazar A, Bardes I, Juan A, Olona N, Sabido M, Corbella X. High mortality rates from medical problems of frequent emergency department users at a university hospital tertiary care centre. Eur J Emerg Med. 2005;12(1):2-5.
6. Dent AW, Phillips GA, Chenhall AJ, McGregor LR. The heaviest repeat users of an inner city emergency department are not general practice patients. Emerg Med (Fremantle). 2003;15(4):322-329.
7. Fulde GW, Duffy M. Emergency department frequent flyers: unnecessary load or a lifeline? Med J Aust. 2006;184(12):595.
8. Williams ER, Guthrie E, Mackway-Jones K, et al. Psychiatric status, somatisation, and health care utilization of frequent attenders at the emergency department: a comparison with routine attenders. J Psychosom Res. 2001;50(3):161-167.
9. Olsson M, Hansagi H. Repeated use of the emergency department: qualitative study of the patient’s perspective. Emerg Med J. 2001;18(6):430-434.
10. Kne T, Young R, Spillane L. Frequent ED users: patterns of use over time.Am J Emerg Med. 1998;16(7):648-652.
11. Ruger JP, Richter CJ, Spitznagel EL, Lewis LM. Analysis of costs, length of stay, and utilization of emergency department services by frequent users: implications for health policy. Acad Emerg Med. 2004;11(12):1311-1317.
12. Zuckerman S, Shen YC. Characteristics of occasional and frequent emergency department users: do insurance coverage and access to care matter? Med Care. 2004;42(2):176-182.
13. Schaulis MD, Snoey ER. Three years, a thousand visits: a case study of the ultimate frequent flyer. Ann Emerg Med. 2001;38(1):87-89.
14. Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298(16):883-887.
15. Malone RE. Whither the almshouse? Overutilization and the role of the emergency department. J Health Polit Policy Law. 1998;23(5):795-832.
16. Hunt KA, Weber EJ, Showstack JA, Colby DC, Callaham ML. Characteristics of frequent users of emergency departments. Ann Emerg Med. 2006;48(1):1-8.
17. Mandelberg JH, Kuhn RE, Kohn MA. Epidemiologic analysis of an urban, public emergency department’s frequent users. Acad Emerg Med. 2000;7(6):637-646.
18. Blank FS, Li H, Henneman PL, et al. A descriptive study of heavy emergency department users at an academic emergency department reveals heavy ED users have better access to care than average users. J Emerg Nurs. 2005;31(2):139-144.

---

Chris Brooks, MD, is an associate professor of emergency medicine at the Washington University School of Medicine in St. Louis, and an assistant director for the emergency medicine residency program at that institution. He serves on the hospital ethics committee, ethics consultation subcommittee, and the Society of Academic Emergency Medicine’s ethics committee. His area of interest is clinical ethics and professionalism for emergency-medicine trainees.

Related in VM

Hospital Resources: A Practical Treatment Plan for Homeless Patients, January 2009

AMA ANNOUNCES PHYSICIAN CLASS ACTION AGAINST WELLPOINT

Lawsuit expands effort to halt insurer scheme that shifts medical costs to physicians and patients

 LOS ANGELES – In an expansion of its ongoing effort to expose and prohibit an industry-wide health insurance scheme to defraud patients and physicians of proper reimbursement, the American Medical Association (AMA) today announced it is among several medical societies that filed a class action lawsuit against WellPoint, Inc., the largest health insurer in the U.S.

 The lawsuit, filed today in Los Angeles federal court, alleges that WellPoint colluded with others to underpay physicians for out-of-network medical services, resulting in patients paying an excessive portion of the medical bill.  The AMA filed similar class action lawsuits last month against Aetna Health, Inc. and CIGNA Corporation.

 “Physicians will not tolerate an apparent conspiracy that allows health insurers to play by their own rules without regard to patients, or the legitimate costs required to care for them,” said AMA President Nancy H. Nielsen, M.D.

 The three AMA lawsuits claim that each insurance company conspired with Ingenix, a unit of United Health Group, on a price fixing scheme that relied on an obscure database to set artificially low reimbursement rates for out-of-network care. A year-long investigation by the New York attorney general confirmed that the Ingenix database is intentionally rigged to allow insurers to shortchange reimbursements.

 “The AMA’s work to remove the cloak of secrecy from the Ingenix database promises to benefit patients and physicians by reforming the corrupt system for paying out-of-network medical bills,” said Dr. Nielsen. “Now that the underlying scheme has been exposed, health insurers are doing the right thing by cutting their ties with the flawed Ingenix database. However, serious damages resulting from prior use of the Ingenix database still need to be addressed.”

 In addition to seeking reforms for the invalid payment systems used by Aetna, CIGNA and WellPoint, the AMA and partnered medical societies also seek relief for physicians who were seriously harmed by the insurers’ long-term use of the flawed Ingenix database.

 The Litigation Center of the AMA and State Medical Societies is supporting the WellPoint lawsuit in partnership with the California Medical Association, Connecticut State Medical Society, Medical Association of Georgia and North Carolina Medical Society.

 To view the individual legal complaints filed against Aetna, CIGNA or WellPoint, please visit the AMA Litigation Center website.

Taming Parkinson’s With Electric Pulses Through the Spine

Parkinson’s patients could one day find relief from their symptoms by wearing a device on the backs of their necks that sends steady pulses of electricity up their spinal cords and into their brains, according to a new study. Researchers tested the technology on lab rats and mice that were nearly immobilized with Parkinson’s-like symptoms, and saw an immediate and dramatic effect. As long as a mild current flows up their spines and into their brains, the animals regain the ability to scamper around their cages, as if they were normal…. [Lead researcher Miguel] Nicolelis added that the procedure was now being tested on monkeys, and “if it succeeds, human clinical trials could begin in the next few years” [The New York Times].

Some Parkinson’s patients have already found relief from their symptoms with deep brain stimulation, in which tiny electrodes are surgically implanted in their brains to make a “brain pacemaker,” but this new experiment was the first to try a less invasive form of neural stimulation. If the findings are confirmed in humans, scientists say, the procedure could dramatically improve treatment for the disease by making electrical therapies safer and more broadly available [Technology Review].

Parkinson’s progressively kills brain cells that produce dopamine, a message-carrying chemical associated with movement. Dopamine replacement drugs can delay symptoms for a while but there is no good treatment and no cure…. In healthy people, neurons fire at different rates as information is sent between the brain and the body to initiate motion. Nicolelis said the problem in Parkinson’s disease is that neurons become scrambled and begin firing all at once [Reuters].
Deep brain stimulation is believed to work by interrupting that synchronized firing and restoring normal neural rhythms. In the new study, published in Science, researchers found that tiny, paper-thin electrodes that are implanted in the spine and touch the outside of the spinal cord have a similar effect. A video of an experiment shows that when the current is switched on, the rat immediately begins to move freely around its cage.

Spinal cord stimulation has previously been used to treat such medical conditions as chronic pain, spasticity, and strokes. But although the technology has been well tested on humans, its benefits for Parkinson’s remain to be seen. An expert on stimulation theories who was not involved in the research, Dr. Rodolfo Llinás, said the treatment “makes good sense,” but he added: “How successfully it will translate to humans is an important issue. The human spinal cord is much more complex than the rodent counterpart, and long-term stimulation might result in nasty secondary effects” [The New York Times].

Related Content:80beats: Obsessive Compulsive Sufferers May Find Relief With a “Brain Pacemaker”80beats: For Treating Parkinson’s, A “Brain Pacemaker” Beats Out Medication

UK Aims to Create “Unlimited” Supply of Synthetic Blood from Stem Cells

A high-powered consortium in the United Kingdom has declared a push to create synthetic blood from embryonic stem cells over the next decade. “In principle, we could provide an unlimited supply of blood in this way” [BBC News], says researcher Marc Turner. Synthetic blood would be guaranteed to be free of viruses like HIV, and could also prevent shortages at blood banks, emergency rooms, and battlefield operations.

While the American biotech company Advanced Cell Technology (ACT) announced last August that they had developed a technique of creating blood from embryonic stem cells, the new UK effort has more significant institutional backing. The multimillion-pound deal involving NHS [National Health Service] Blood and Transplant, the Scottish National Blood Transfusion Service and the Wellcome Trust, the world’s biggest medical research charity, means Britain will take centre stage in the global race to develop blood made from embryonic stem cells [The Independent].

Researchers will test human embryos left over from in vitro fertilization treatment to find those destined to develop into the universal “O-negative” blood donor group. O-negative blood can be transfused into anyone without fear of tissue rejection and is the only safe option when a patient’s blood group is unknown or not immediately available. This precious blood is in limited supply because only 7% of the population belongs to this blood group [BBC News]. However, embryonic stem cells can multiply indefinitely in the lab, so one O-negative embryo could theoretically supply blood for an entire nation.

Researchers say that red blood cells have good potential as a synthetic product because they have no nucleus, an adaptation that enables the haemoglobin protein at the centre of the cells to carry oxygen. This means that these synthetic red blood cells cannot develop into cancerous cells because they contain no DNA from a nucleus [The Independent]. The team hopes to have “proof of principle” in the next three years, and a marketable product in five to ten years.
But once they’ve mastered the technique of transforming stem cells into blood cells, a bigger hurdle may be scaling up the procedure to produce industrial amounts of blood. The ACT scientists demonstrated that it is possible to make up to 100 billion red blood cells, an unprecedented number, but a litre of donated blood contains about 5 trillion cells – more than 5,000 times the number of synthetic cells made by ACT [The Independent].

Related Content:80beats: Obama to Lift Bush’s Restrictions on Stem Cell Research Today 80beats: Lab-Grown Red Blood Cells Could Allow for “Blood Farms”DISCOVER: Sliced: Building a Better Blood BankDISCOVER: The Future of Blood

New Forces Shaping the Patient-Physician Relationship: Virtual Mentor

Howard A. Brody, MD, PhD

Dr. Burke, a primary care physician, is seeing Mrs. Carter during a return visit to evaluate a new medication and exercise regimen she has recommended for Mrs. Carter’s osteoarthritis of the knee. Mrs. Carter is very pleased and mentions that she is now able to work in her garden again.

LEARNING OBJECTIVEUnderstand how the essential elements of the traditional patient-physician relationship can be preserved and perhaps enhanced even as the one-to-one nature of the relationship changes.

Dr. Burke uses a version of the electronic medical record (EMR) that facilitates narrative notes in addition to check-off options. She adds the comment, “Able to work in garden again,” to her progress note for the visit.

On the next visit, Dr. Burke reviews her previous note and asks Mrs. Carter at the beginning of the session, “And how is your garden coming along?” Mrs. Carter is pleased that the doctor remembered her favorite hobby.

Dr. Gold, another primary care physician, has an identical encounter with his own osteoarthritis patient, Mrs. Carter. The form of EMR he uses makes it very complicated to add narrative notes and favors check-off boxes. He clicks on the box, “Joint function: improved.”

During the next follow-up visit, Dr. Gold cannot remember whether it was Mrs. Carter or one of his other patients who liked to garden. He decides to play safe and not bring up the subject.

EMR’s Impact

Most experts are enthusiastic about the potential of the EMR to improve quality of care and reduce costs. What impact will the EMR have on the patient-physician relationship? As the above hypothetical and anecdotal cases study suggest, that depends.

I am simplifying greatly in suggesting that there is such a thing as thepatient-physician relationship that might be altered by new developments. Different models for the relationship have been proposed and debated [1]. For this discussion I am assuming that the “traditional” relationship has three important elements—first, the patient’s awareness of the physician’s fiduciary duty to serve the patient’s health-related interests; second, the patient’s sense of being treated as a unique person and not simply as a case of medical disease; and finally, an openness to active give-and-take, with patients participating in therapeutic decisions to the extent that they wish.

The EMR is only one of a series of innovations that promise to affect the patient-physician relationship in ways that may be without precedent. The field of bioethics has always shown a great interest in anticipating the ethical consequences of new medical technologies—from organ transplantation and mechanical ventilation, to stem cells and nanoparticles. The field has shown less proclivity for investigating new forms of personal and social relationships [2].

Bioethics’ neglect of relationships may mirror its lack of interest in primary-care issues. Subspecialty practice often defines itself in terms of its technological tools. Primary-care practice defines itself in terms of the relationship, with the patient at its core. Thus, continuity of care and personalized care are definitive features of primary care.

It is past time to be exploring the impact recent innovations are likely to have on the relationship. One way of focusing the discussion is to look at the idea of the “medical home” and pay-for-performance (P4P).

The Medical Home

Developed in pediatrics as a model for caring for special-needs children, the medical-home concept has now been embraced in family medicine and general internal medicine and has caught the interest of health policy analysts [3]. The enthusiasm is driven by the realization that most patients suffer from one or more chronic illnesses, and the U.S. system does a poor job of managing those patients and their illnesses. The medical home promises a number of features that could help the system do a better job.

• Patient-centered care, such as same-day scheduling and ease of access by telephone, e-mail, and Internet.
• EMR and aggressive quality monitoring.
• Interdisciplinary team care.
• Coordination of care, whether delivered on-site or referred outside.
• Focus on prevention and health education, including group visits.

These components should not obscure the basic idea of the medicalhome. Home is a place in which we feel welcomed. If patients do not experience a welcoming environment when they arrive, the other features, however impressive, will not accomplish what is needed.

If the medical-home concept develops as now envisioned, patients will find themselves experiencing an ongoing personal relationship with, not one individual, but a facility and team of individuals. Because coordinated team care seems to offer so many advantages for dealing effectively with the demands of preventive medicine for chronic illnesses, we hope that this transition will be a net plus for the patient. Whether it will or not, and what the specific gains and losses might be, will require careful study and monitoring. We can readily imagine how transferring allegiance from a primary physician to a care team and clinic facility could lead to a diminished sense of a personal relationship. There are, however, important opportunities for expanding the notion of relationship that also ought to be factored in and studied.

Consider the idea of group visits—a group of patients with diabetes meet monthly to discuss topics like diet, exercise, and foot care with the physician, nurse, or nutritionist. These patients supplement the relationship with their physicians and other team members with the interactions among a group of other patients suffering from the same condition. At group visit meetings, they share tips that each has learned about self-management of diabetes and provide mutual emotional support and encouragement. Social support of this kind can itself be a factor in improving health outcomes, along with advice and encouragement the patient receives regarding diabetes.

Finally, the ideal medical home will exist in a relationship with the community in addition to its individual relationships with patients. If the medical home follows the model of one of the most successful types of primary care facility—the federally qualified community health center—it will have a community advisory board to help ensure that the voice of community representatives is heard and the health needs of the community are understood, through the eyes of its members. The medical home that pursues this model will be a public health facility as well as an individual-care facility, responsive to its patients’ needs at all levels.

In sum, the medical home threatens the traditional patient-physician relationship in some ways but also offers to deepen and expand it. What about another policy innovation—pay-for-performance (P4P)?

Pay-for-Performance

It has been difficult to find any policymaker willing to say anything bad about P4P because at first blush it sounds like the ideal solution to the age-old problem—how can I pay my physician when, and only when, he or she does something that benefits my health? The advent of so-called evidence-based practice guidelines holds out the promise that we can measure quality care precisely. If we then tie reimbursement to guideline adherence, perhaps we have finally reached the economic nirvana.

Sadly, the reality falls rather short of the ideal. The actual evidence regarding P4P, and the degree to which practice guidelines actually reflect the best available evidence, is rather discouraging [4].

It is relatively easy to measure the percentage of diabetic patients for whom the physician has ordered a glycohemoglobin level test in the last 12 months. It is much more difficult to measure the components of the patient-physician encounter that go toward creating and sustaining a personal relationship. In all such cases, the measurable usually drives out the important. When physicians are paid a lot for doing discrete, technical procedures and very little for spending time with and talking to patients, we have the sort of health system we have today, which is long on procedures and short on meaningful relationships.

Society values both the appropriate use of new technological and management innovations and the maintenance of a strong personal and therapeutic relationship between patients and physicians. My recommendations are to embrace the medical-home model but be wary of P4P [2]. In each case much more evidence will be required to determine real outcomes and discover whether either the promise or the peril has been realized in practice.

---

References

1. Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship.JAMA. 1992:267(16):2221-2226.
2. Brody HA. The Future of Bioethics. New York, NY: Oxford University Press; 2009.
3. Martin JC, Avant RF, Bowman MA, et al. The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;(2 Suppl 1):S3-S32.
4. Auerbach AD, Landefeld CS, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med. 2007;357(6):608-613.

---

Howard A. Brody, MD, PhD, is director of the Institute for the Medical Humanities and the John P. McGovern Centennial Chair in Family Medicine at the University of Texas Medical Branch in Galveston. He is author of The Future of Bioethics.

Related in VM

Responsibility and Collaboration in Health Team Care, March 2009

Are There Blueprints for Building a Strong Patient-Physician Relationship?March 2009

Med Students Lobby Congress for Tuition Breaks

WASHINGTON, March 12 -- Medical students from across the country took time out of their hectic schedules this week to talk to legislators -- and MedPage Today -- about top issues facing medical students.

About 300 student members of the American Medical Association were on Capitol Hill as a kick-off to the AMA's advocacy meeting.

In this video report, Emily Walker, MedPage Today's Washington correspondent, talks with three of them about the staggering debt new doctors face, and how that specter and the high costs of malpractice insurance can dictate choice of specialty.

Low-Tech Solution to a High-Tech Problem: Virtual Mentor

Commentary by David Anthony, MD, MSc

Mr. Jones visited Dr. Green because he had developed an infection on the bottom of his right foot. Before his appointment, Mr. Jones looked up his symptoms on the Internet and found that they could be indicative of type 2 diabetes. After examining Mr. Jones, Dr. Green ordered a fasting glucose test.

LEARNING OBJECTIVEUnderstand how physicians can use the knowledge and interest that web-savvy patients bring to the clinical encounter to improve disease management and the therapeutic relationship.

The test results showed a glucose level of 250 mg/dL, which indicated that Mr. Jones did indeed have type 2 diabetes. Dr. Green informed Mr. Jones of the results by telephone and asked him to come in to discuss treatment options and lifestyle changes that would help him get control of his diabetes.

“I have read about diet and exercise options for diabetic patients on the Internet, but I don’t think that I can make that sort of change,” Mr. Jones said. “I would prefer to start on medication right away.”

During the next visit, Dr. Green agreed that if Mr. Jones was not willing to make lifestyle changes he should start medication. He wrote a prescription for metformin, a first-line treatment for type 2 diabetes. When Mr. Jones looked at it, he said to Dr. Green, “I have also researched treatments for type 2 diabetes and would prefer to have the newest and best treatment. I can’t remember the name but it is a combination of two drugs.” While Dr. Green knew that this treatment was often an effective option, he was also concerned about using a more potent and expensive treatment before he had seen the effects that metformin had on Mr. Jones’s glucose levels.

Commentary

This scenario is becoming increasingly common as more patients access web-based health information prior to and after visiting a physician. The case displays the potential advantages and pitfalls of this new dynamic in medicine. Mr. Jones’s preparations for his second visit with Dr. Green have allowed him to make an informed choice about pursuing diet (or not, in his case), which most likely abbreviated Dr. Green’s efforts. Mr. Jones was also led to ask for a medication that, in Dr. Green’s judgment, might possibly harm him. The knowledge imbalance between patients and physicians has changed, producing situations in which physicians must learn to communicate with web-savvy patients and harness the power of the most potent source of information in history [1].

In 2005, an estimated 117 million Americans searched for health information on the web, a number that has increased dramatically over the past 10 years [2]. Approximately half of these individuals report discussing the results of their web-surfing with their doctors [2]. Another study found that 80 percent of adult Internet users reported searching for information about their own health [3]. The percentage of each age group that uses the Internet to access health information decreases as age increases [4]. Such individuals also tend to be from more affluent communities and are predominantly women [4-7].

A New Dynamic in the Office

The rise of web-savvy patients alters the power dynamic in the patient-doctor relationship. In the older model of care, physicians served as unchallenged content experts who were called upon to lay out therapeutic plans for patients. Patients were expected to trust their physicians and comply with the prescribed plans. This marked asymmetry simplified communication in the office (inasmuch as it was almost uniformly one-way), but it also led to misunderstandings and paternalistic patient-doctor relationships. Even before the Internet became such a tool, physicians and researchers recognized the challenges in the uneven relationship and began to develop a more patient-centered model of care.

Patient-centered medicine aims to level the playing field in the office so that the patient and his or her caregivers have an active role in the development of a treatment plan. The movement emphasizes understanding a patient’s cultural background, lifestyle, health beliefs, and personal preferences as essential to successfully negotiating a plan. Once a patient’s concerns and beliefs are understood, a physician can find common ground with the patient and settle upon mutual goals and plans. The rise of patient-centered medicine, which grew in part out of research conducted by family physician Ian McWinney and colleagues, is detailed in Patient-Centered Medicine: Transforming the Clinical Method[8]. Physicians who maintain more patient-centered relationships gain higher levels of trust and adherence to therapy from their patients [9-11]. The Institute of Medicine now considers patient-centered care one of the six domains of quality health care.

Patients with Information

The patient-centered model of care offers Dr. Green solutions in treating Mr. Jones. Patients have always come to physicians’ offices with varying levels of knowledge of allopathic medicine. Along with cultural background, personal preferences, and prior experiences, a patient’s understanding of medical information contributes to his or her health beliefs and expectations for treatment. Before the rise of the Internet, people obtained information from their family members, colleagues, books, newspapers, magazines, and television and tended to trust these sources, despite the fact that they could be remarkably misleading. The Internet simply ups the ante by providing access to a dramatically increased amount of medical information in an easily searchable format.

Patients’ ability to become well-informed about their health conditions through the Internet has potential advantages. Greater patient understanding can close the knowledge gap between patients and physicians slightly and thus ease physicians’ efforts to achieve common ground. Particularly in cases of chronic disease such as diabetes, where successful treatment requires patients to take an active role in understanding and applying their treatment plans (e.g., diet, exercise, glucose testing), quality information can improve patients’ ability to care for themselves. Unfortunately, physicians often make the mistake of reacting negatively to an assertive, informed patient, taking it as an affront to their authority and expertise. Such responses handicap the physician’s ability to establish a connection with a patient and can inhibit trust and adherence.

Solutions

In responding to Mr. Jones’s statements, Dr. Green should seek further understanding of his patient’s beliefs, by saying, for example, “I’m interested by your comment about metformin; can you explain why you believe newer medicines are better for you?” Or asking, “What have you read that led you to say that you cannot make dietary changes?”  Dr. Green should ask Mr. Jones where he found the information on which he is basing his beliefs; blogs and Internet forums are far less reliable sources than sites devoted to patient education. Upon hearing about his patient’s beliefs, an affirming statement can help generate trust without placing undue support on those beliefs: “I can understand how reading that could lead you to say you do not want to take metformin.”

Dr. Green should then share his own beliefs with Mr. Jones, formulating his comments to respond to his patient’s specific concerns and needs. If Mr. Jones thinks he will need two medications to control his sugar because his mother is diabetic and she takes two, Dr. Green can describe the natural history of diabetes and its tendency to worsen with time. Alternately, if Mr. Jones wants the newer combination pill because “the latest advances are always better,” Dr. Green can explain his concerns about the safety record of new medications, perhaps citing the recent association of rosiglitazone (a compound in the newer drug) with incidence of heart disease in the management of diabetes. Finally, before settling upon a plan, Dr. Green can seek common ground by clarifying their shared goals, “I am impressed by your concern about your new diagnosis, and I assure you that I will strive to help you achieve excellent control of your sugar.”

The skills described above are basic communication tools that can help resolve most perceived disagreements between patients and physicians. There is one important skill, however, that is specific to working with web-savvy patients: physicians should become familiar with trustworthy web resources and be able to guide their patients’ web surfing. There are many excellent patient-education web sites. With regard to diabetes, for example, Dr. Green could direct Mr. Jones to the National Diabetes Clearinghouse for current information in English and Spanish from the National Institutes of Health.

The rise of the Internet has exponentially increased patients’ access to health information, potentially altering the patient-physician relationship by raising the level of patients’ medical knowledge (and perhaps their level of misunderstanding). While the Internet is a high-tech tool, the key to communicating with web-savvy patients is remarkably low-tech. A patient-centered approach emphasizes understanding patients’ concerns, beliefs, and goals, as well as establishing common ground in the development of a mutually understood plan. Physicians who successfully negotiate treatment plans with their patients will achieve higher levels of trust and adherence in return and increase the likelihood that patients will log onto recommended sites, further improving their understanding and treatment.

---

References

1. Wald HS, Dube CE, Anthony DC. Untangling the web—the impact of Internet use on healthcare and the physician-patient relationship. Patient Edu Couns. 2007;68(3):218-224.
2. Krane D. Number of cyberchondriacs—U.S. adults who go online for health information—increases to estimated 117 million. Healthcare News. 2005;5(8):1-7. http://www.harrisinteractive.com/ news/newsletters/healthnews/HI_HealthCareNews2005Vol5_Iss08.pdf.
3. Fox S. Online health search 2006. Pew Internet & American Life Project. http://www.pewinternet.org/pdfs/PIP_Online_Health_2006.pdf. Accessed January 30, 2009.
4. Taylor H. Cyberchondriac update. 2002. http://www.harrisinteractive.com/harris_poll/index.asp?PID=299. Accessed January 30, 2009.
5. Campbell RJ, Nolfi DA. Teaching elderly adults to use the internet to access health care information: before-after study. J Med Internet Res. 2005;7(2):e19.
6. Ferguson T. Online patient-helpers and physicians working together: a new partnership for high quality health care. BMJ. 2000;321(7269):1129-1132.
7. Robinson C, Flowers CW, Alperson BL, Norris KC. Internet access and use among disadvantaged inner-city patients. JAMA. 1999;281(11):988-989.
8. Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam C, Freeman TR. Patient-Centered Medicine: Transforming the Clinical Method. Thousand Oaks, California: Sage Publications; 1995.
9. Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49(9):796-804.
10. Fiscella K, Meldrum S, Franks P, et al. Patient trust: is it related to patient-centered behavior of primary care physicians? Med Care. 2004;42(11):1049-1055.
11. Mauksch LB, Dugdale DC, Dodson S, Epstein R. Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. Arch Intern Med. 2008;168(13):1387-1395.

---

David Anthony, MD, MSc, is an assistant professor of family medicine and the director of the Family Medicine Clerkship at the Warren Alpert School of Medicine at Brown University in Providence, Rhode Island. His interests include quality of care at hospital discharge, statistics in primary care, and electronic solutions to the model family practice.

Related in VM

Type 2 Diabetes: Lifestyle Changes and Drug Treatment, March 2009

Through the Physician's Eyes: The Patient (Internet)-Physician Relationship, November 2001

AMA Supports President's Decision to Fund Stem Cell Research

For immediate release

March 9, 2009

Statement attributable to:
Joseph Heyman, MD
Board Chair, American Medical Association

"The American Medical Association supports President Obama's decision to lift the ban on federal funding of stem cell research. Stem cell research holds great promise to treat diseases that science has so far been unable to cure, and this change in policy will allow researchers to accelerate their efforts by applying for federal research funds.

"The AMA supports biomedical research on stem cells and has encouraged strong public support of federal funding for this research. Today's action by President Obama will help scientists realize the potential of stem cell research to benefit the many Americans living with diseases such as diabetes, Parkinson's and Alzheimer's."

The script for getting fit: Help your patients move off the couch

Sometimes getting patients to exercise takes more than just talk. It requires giving specific tips for starting a fitness program and sticking with it injury-free.

By Geri Aston , AMNews correspondent. Posted March 2, 2009.

By now, physicians are familiar with the push to treat patients' physical activity level like any other vital sign measured at each visit. The idea is to encourage people to exercise to improve their health status.

But talking about the importance of exercise and getting a patient to exercise are two different things. The latter can be difficult. "The biggest thing that we've recognized is that most patients hate exercise," says American Medical Association President-elect J. James Rohack, MD, a cardiologist from Bryan, Texas.

So what can doctors do to get patients off the couch? And once they do, how can physicians help patients avoid injuring themselves?

One way to motivate patients is to discuss the benefits of activity, says Robert S. Gotlin, DO, director of the orthopedics and sports rehabilitation program at Beth Israel Medical Center in New York. "There are definitive correlations with healthy living and longevity." Centers for Disease Control and Prevention data show that regular exercise can decrease the risk of cardiovascular disease, diabetes and certain cancers, while improving mental and bone health.

Once that message has sunk in, it's time to work with the patient to set goals and discuss what activities he or she likes. If the patient enjoys the exercise, he or she is more likely to stick with it, Dr. Gotlin says.

But how much exercise is enough? The Dept. of Health and Human Services in October 2008 issued its Physical Activity Guidelines for Americans. They recommend that adults get 2½ hours of moderate-intensity aerobic activity or 1¼ hours of vigorous activity weekly.

People can determine whether they're exercising hard enough by keeping tabs on their heart rates, which during moderate exercise should be 50% to 75% of their optimal maximums. The maximum heart rate can be calculated by subtracting one's age from 220. Multiplying that figure by 0.5 and by 0.75 will give the beats-per-minute range for moderate activity.

But that can be confusing, says Robert E. Sallis, MD, immediate past president of the American College of Sports Medicine and chair of Exercise is Medicine, an initiative founded by the ACSM and the AMA. An easier technique to share with patients is the sing/talk test, he says. "You should exercise at an intensity level high enough that you couldn't sing, but not so intense that you couldn't talk."

Although getting aerobic exercise to maintain cardiovascular health is the most important component of a regimen, activities that promote muscle strength also are necessary, Dr. Sallis says. HHS recommends that adults work muscle-strengthening exercises into their routine at least two days a week.

Working out for 30 minutes five times a week might seem like too much for some people. In this case, doctors can suggest that patients break it into three 10-minute bouts of activity. The benefits from these bursts are indistinguishable from those derived from a half-hour of sustained exercise, Dr. Sallis notes.

For particularly resistant patients, Dr. Rohack doesn't even talk about exercise. Instead, he promotes "quality movement." He discusses how patients can work it into their daily lives. For example, they can park farther from the store, take the stairs instead of the elevator, walk in the mall, or garden.

The HHS recommendations are a good standard to have in mind, says Brian Halpern, MD, a primary care sports medicine specialist who serves as assistant attending physician at the Hospital for Special Surgery in New York. If some patients won't buy into the five-days-a-week plan, it's OK, as long as they start doing something. "A little bit of exercise is better than none," he says. After time, the physician can try to escalate the patient's program.

Safety first

So once patients get on board with the concept of regular exercise, how can physicians help them proceed safely? One of the first issues to consider is whether a physical exam is necessary. Doctors disagree slightly on this point. Some always recommend that patients get a physical before starting an exercise program. Others say patients who see their physicians regularly and are otherwise healthy can get started without one. Doctors do agree that patients with a personal or family history of certain conditions, such as cardiovascular disease or high blood pressure, should get checked out first.

Physicians also should be on the lookout for medical red flags, Dr. Rohack says. For example, if a person in his 40s or 50s says he needs to start exercising because he's so out of shape that he gets winded easily, the physician should screen the patient for heart disease or other problems.

Doctors should go over warning signs with patients who have a known condition, Dr. Gotlin says. A patient "may be taking their blood pressure medication and thinking they're immune to anything going wrong. No. You've got to be aware of chest pain, shortness of breath, arm pain, tingling in the hand."

But having a chronic disease does not rule out exercise in most cases, and indeed physical activity helps control several conditions, such as diabetes, high blood pressure and heart disease. These patients just have to be more prepared. "If you're a diabetic, make sure you have something sweet with you," Dr. Gotlin says. "If you're an asthmatic, make sure you have your inhaler."

Osteoarthritis of the knee or hips also can complicate exercise. The easiest activity to prescribe -- walking -- can be too hard for arthritic patients. Swimming and water aerobics, which take weight off the joints, are good alternatives.

Doctors have to give special consideration to heavy patients, Dr. Rohack notes. They get hot faster, and their weight puts more stress on their joints. Water activities are a good option for these patients.

Starting at square one

Once the patient starts being active, the risk of injury is always present. Dr. Halpern frequently sees people who have hurt themselves exercising. Common problems include knee pain, arthritis flare-ups, sciatica, neck strain, tendonitis in the elbow and rotator cuff injuries.

Most often, the injured patient is someone who tried to go from zero to 60 when they first started exercising or is a weekend warrior who hasn't conditioned properly.

"Somebody says, 'I'm going to start a running program,' and they start running every day for a mile or two," Dr. Halpern says. They end up developing a stress fracture or some other type of overuse injury. "The bad part of that is it can turn a person off to exercise permanently."

For the patient starting out, the best advice is to begin slowly. Patients who decide their exercise goal is to return to a sport after years of hiatus will need help working up to a safe participation level.

Basketball is an example of a wonderful aerobic sport, Dr. Rohack says. "But if you haven't played in a while and you say, 'I'm going to go start doing the stuff I did 10 years ago,' sorry, but the body, the hand-eye coordination and the endurance isn't going to be there." The sport requires a lot of stamina, so the patient should start out walking, and work up to a fitness level at which he or she can jog for 45 minutes, he recommends.

Weekend warriors are prone to making the same mistake as exercise newbies. "On the weekend, suddenly they're going to weight lift, they're going to jog, they're going to bike, and they're not used to that high intensity," says Kevin Plancher, MD, associate clinical professor in orthopedic surgery at Albert Einstein College of Medicine in New York. These patients, too, need to condition properly to avoid injury.

People also get hurt when they haven't warmed up before exercise, Dr. Rohack says. He advises patients to do simple stretching for a couple of minutes to get the blood flowing and the joints limber.

Another valuable bit of counsel doctors can give patients is to cross train to avoid overuse injuries. "Don't put all your eggs in one basket," Dr. Gotlin says. Patients should vary their activities so that different muscle groups are targeted on different days.

Dangers lurk at the gym, too. The most common mistake is improper use of weights. Some people lift heavy weights and do few repetitions, Dr. Plancher says, when they should be using lighter weights and doing more repetitions. People also use bad form. When lifting weights on a machine, patients' hands should be in their peripheral vision to avoid shoulder injury, he says.

Leg extensions are another frequent misstep because they put too much strain on the patella tendon, Dr. Plancher cautions. People also err by doing deep squats and knee bends instead of simply doing one-third squats and bends, which are safer and work the quadriceps just as well.

At the gym, patients also should take the same precautions to avoid catching communicable diseases -- from coughs and colds to methicillin-resistant Staphylococcus aureus -- as they use everywhere else. People should wipe equipment with an alcohol-based product before using it, wash their hands after working out, and avoid touching their eyes or mouth, Dr. Halpern says.

How a person exercises isn't the only factor in injury prevention. Personal equipment is important as well. For most people, all that's required is a pair of good shoes with ample arch support and padding. This is especially important for patients with plantar fasciitis or arthritis, doctors say. Patients with orthopedic problems might need a referral to a specialist to make sure they have the right shoes and inserts. Other advice is common sense -- wear a helmet when cycling and layer clothing in cold weather.

Once patients are active, doctors may want to check periodically on their progress. The conversation could alert the physician to a problem resulting from exercise, says Matthew J. Matava, MD, associate professor of orthopedic surgery at Washington University School of Medicine in St. Louis. Asking a patient how his or her golf game is going could lead to a discussion about how the patient has back pain on the course, he says.

Some physicians might not be comfortable taking on exercise counseling in the first place, Dr. Rohack notes. For these doctors, referrals are always an option. Most communities have choices -- exercise physiologists, physical therapists or athletic trainers. In this circumstance, the doctor can make a "fitness prescription," noting any underlying conditions or necessary limitations, and let the exercise professional develop the program.

Patient-Physician Relationships: Gone or Evolving?

Encounters between individuals are as an essential part of medicine as they are of life. The cases in this issue of Virtual Mentor describe challenging encounters in clinical medicine, and their commentaries share an emphasis on the importance of communication between a patient and physician. The articles that fill out the issue explain the importance of the patient-physician relationship and the factors that are shaping it, examine connections between poor communication and risk of litigation, recount an unlikely situation in which a relationship between a “frequent flyer” and physician developed, and introduce a program designed to help medical students build relationships with patients. Patient-physician relationships, as well as encounters between professionals, are often difficult, complicated by both internal and external factors. Yet there are ways that we, as physicians, residents, and medical students, can improve our ability to develop and nurture these relationships.

In the first case, a web-savvy patient researches his symptoms and treatment options on the Internet and relays what he thinks his treatment should be to the physician. David Anthony describes how the rise of accessible medical web resources has slightly changed the patient-physician balance of information in a way some physicians view as a challenge to their authority and expertise. But, he suggests, physicians can use the knowledge of their patients to improve patient care and develop patient-centered relationships that further enhance shared decision making. He also challenges physicians to become familiar with trustworthy web resources so they can guide their patients to reliable online sources.

The physician in case two is contemplating whether or not to offer participation in a phase I trial to the parents of a teenager who has aggressive terminal cancer. Thomas W. LeBlanc and Philip M. Rosoff explain how the mere offer of trial participation can create a therapeutic misconception in the patient and his parents—to the extent that they believe the trial has a real chance of providing therapeutic benefit, when in reality the chance of benefit is virtually nonexistent. The commentators examine the physician’s duty to act in the patient’s best interest versus his or her duty to inform patients of all options and the broader topic of the importance of phase I oncology trials for the advancement of medicine. In their commentary, Courtenay R. Bruce and Anne Lederman Flamm focus on the duty of physicians to inform patients and allow for autonomous decisions. While they acknowledge the reality of the therapeutic misconception, they argue that full disclosure in the informed-consent process provides patients (and parents, in this case) with the information they need to make a decision, thereby respecting their autonomy. They also discuss the concept of assent in situations in which the patient is not legally competent to give consent.

The third case presents a mother who takes her 4-year-old daughter to several pediatricians, and ultimately settles on one who is willing to prescribe antibiotics for her daughter. The case also includes a disagreement between two physicians in the same office over the child’s treatment. D. Micah Hester views the case as a series of missed opportunities for good communication, not only between the physician and the parent, but also between the two physicians who treat the child. Benjamin Levi speaks to miscommunication in the scenario, but also comments on problematic aspects of the second physician’s clinical judgment in prescribing treatment that was not medically indicated.

In the clinical pearl, Natalie A. Brooks outlines management strategies for type 2 diabetes, the chronic condition that is the basis for the first clinical case. She emphasizes that treatment decisions must be tailored to individual patients.

One question that is central to this issue is whether or not a good patient-physician relationship even matters. In the journal discussion, Scott B. Grant addresses the questions not only of whether or not the patient-physician relationship is important, but what factors improve or stress it. He explains and critiques two models that the journal article authors propose as blueprints for a good relationship.

Kelly Dineen tells a compelling story in the policy forum of the importance of professional caregivers’ adherence to their scope of practice. In the new model of comprehensive patient care, physicians alone cannot meet the full range of the patients’ medical and health-promotion needs, and because of this, physician assistants and advanced practice registered nurses are included in health care delivery. She identifies physicians’ responsibilities for overseeing and collaborating with them.

In the medicine and society article, Howard A. Brody describes two forces that are shaping the patient-physician relationship: the medical home and pay-for-performance. He argues that, while the idea of the medical home threatens the one-on-one nature of the traditional patient-physician relationship, it broadens and enhances the relationship in ways that are, on balance, more significant. On the other hand, he believes that pay-for-performance will not improve relationships between patients and physicians and recommends approaching this concept with wariness. As technology progresses, physicians have the ability to treat patients more competently. These advances do not necessarily have to replace the relationships between patients and physicians that are the core of medical practice.

At a time when many physicians are lamenting changes in medicine that have significantly diminished their ability to develop relationships with patients (e.g., increased amounts of paperwork, shorter office visits), Chris Brooks relates the story of patient-physician relationships in an unlikely setting—the emergency room. He describes a “frequent flyer” patient who visited the emergency room on an almost daily basis and developed relationships with staff members that allowed them to care for him more compassionately and in a resource-conscious way.

As medicine has become more technical, medical education has increasingly focused on the knowledge of disease processes, often squeezing out time for considering the important relationships between patients and physicians. In light of this, some medical schools have attempted to renew the emphasis on relationships in medicine. Arno K. Kumagai discusses the 2-year Family Centered Experience at the University of Michigan, which pairs medical students with community members who have chronic or serious diseases. He describes the goals, benefits, and challenges of this program.

Kristin E. Schleiter, in the health law piece, explores the subject of medical malpractice litigation. According to documented studies, patients who have good relationships with their physicians are less likely to file complaints in the event of an adverse medical outcome.

Relationships in medicine are as important now as they were in the past. Today’s technology allows physicians to do much more to treat diseases, but this enhanced ability need not replace physicians’ communication and ability to empathize with patients. In other words, the ability to treat the disease must not undermine the ability to treat the patient with the disease. As the articles in this issue demonstrate, relationships are still, and will continue to be, an essential element of medicine. With so many factors competing for the physician’s time and energy, we must not lose sight of the importance of communication, empathy, and knowledge of the patient as a person.

---

Anji WallMD/PhD studentSaint Louis University