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.

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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.

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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.

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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].

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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].

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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.

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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.

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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.

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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.