Letters to the Editor
Additional Letters to the Editor Available Online:
Alternative to the Traditional Bilateral Neck Exploration Richard Lopchinsky, M.D., and Abigail Love
Hemolytic Anemia Manifesting as Improved A1C Values Kai Ming Chow, M.D.
Patient Autonomy: Reflections from a Developing Country
to the editor: Family medicine is a discipline that has always supported a patient's right to medical care. Family physicians are advocates for their patients and consider them as equal partners in their health care. Our primary focus as family physicians is on the development and maintenance of a trusting relationship with our patients.1,2
It is interesting that in the developed world an autonomy-based model of medical practice exists that has evolved from a more paternalistic model.3 In parts of the developing world, there is still a paternalistic model of medical practice that is now reported to be in transition toward a model based more on patient autonomy.4
The traditional paternalistic model of medical practice assumes that the physician knows what is best for the patient.4 The patient in such a model is a passive recipient of the medical care, which violates fundamental patient rights and therefore cannot be supported. However, the good aspect of such a model is the trust that a patient has in his or her physician,5 which unfortunately can be violated.
The patient autonomy model of medical practice protects patient rights, gives them partnership status in their health care, and involves them in the decision-making process. However, this can sometimes have detrimental consequences for the trusting relationship that existed between the physician and the patient. The focus is on providing care to the patient while safeguarding against a possible lawsuit. This can seriously erode the trust between physician and patient.
We, in the developing world, are perhaps witnessing the gradual demise of the strong paternalistic model of medical practice; this is a welcome happening, but at the same time we are wary of the possible advent of a strong patient-autonomy-based model, whereby the trusting relationship is likely to be eroded.
There are good aspects in both of these models of medical practice. Physicians should ensure to keep them in order to guarantee patient rights and maintain the trust in the physician-patient relationship.
We, as primary care physicians, are in an ideal situation to ensure medical practice that is ethical and based on dignity and respect for physicians and patients.
REFERENCES
1. Fugelli P. James Mackenzie Lecture. Trust - in general practice. Br J Gen Pract 2001;51:575-9.
2. Parchman ML, Burge SK. The patient-physician relationship, primary care attributes, and preventive services. Fam Med 2004;36:22-7.
3. Shelstad K. Landmark United States biomedical ethics cases: a selected bibliography. Med Ref Serv Q 1999; 18:27-53.
4. Qidwai W. Paternalistic model of medical practice. J Coll Physicians Surg Pak 2003;13:296.
5. Rachagan SS, Sharon K. The patient's view. Med J Malaysia 2003;58(suppl A):86-101.
Defending the Use of EBM and Shared Decision Making
to the editor: Evidence-based medicine (EBM) was considered a "dirty word” in a malpractice trial reported in 2004 in JAMA.1 Dr. Daniel Merenstein, a family physician, related his experience where he appropriately used EBM and shared decision making regarding prostate cancer screening. Unfortunately, this was followed by a court trial after the patient was later diagnosed with prostate cancer. The plaintiff's counsel argued that EBM and shared decision making were not "standard of care” and won the case. Four physicians testified to this effect as expert witnesses for the plaintiff.
This disheartening report1 has stirred much discussion in the medical community. Numerous professional organizations and scientific groups recommend care consistent with Dr. Merenstein's approach, acknowledging the uncertainty in our current understanding of prostate cancer screening, and promoting patient autonomy with informed decision making.
To put this malpractice trial in perspective, the outcome does not redress substandard medical care or malpractice, but rather demonstrates a failure of our legal system.
To teachers of EBM: Do not consider this single case report1 evidence that practicing EBM leads to malpractice claims. What is not reported is how many malpractice cases are prevented by approaches using EBM and shared decision making.
To the medical community: EBM and shared decision making is standard of care if defined as being supported by most professional organizations, medical license boards, educators, and other groups of patients and physicians, or by using the accepted definition of EBM as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”2 However, EBM and shared decision making is not standard of care if it is defined as "how most physicians practice.” This is a tragedy and one that requires action. All physicians should have training in the skills of EBM and shared decision making, and our clinical systems must be modified to support these practices.
To the American public: Our tort system greatly needs reform. The courts are meant to provide justice, not compensation for life's harsh realities. Justice is best served by determining the truth. EBM teaches us to systematically and critically appraise information, separating fact from bias. Legal combatants start with the desired testimony, and then find willing "experts.” Bias (from the legal consultant's desired outcome and the expert witness's financial gain) determines the information presented. To provide justice based on truth, we need a different selection process for expert witnesses. Why shouldn't our legal system be based on the conscientious, explicit, and judicious use of current best evidence in making decisions about individual cases?
REFERENCES
1. Merenstein D. A piece of my mind. Winners and losers. JAMA 2004;291:15-6.
2. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't [Editorial]. BMJ 1996;312:71-2.
Case Report:
Insect Bite Reveals Botfly
Myiasis in an Older Woman
to the editor:
A 64-year-old woman presented to our Urgent Care center for evaluation
of an itchy lesion on her right medial lower leg, which had lasted for 15 days.
She reported having an insect bite on this area of her leg while in El
Salvador. Physical examination revealed a 2-cm violaceous nodule with
"pinpoint” central opening and serosanguineous discharge. She was treated
for an infected insect bite with cephalexin, 500 mg
three times daily.
After three days, she showed no improvement. This examination revealed a tiny
dark object protruding from the central punctum. With careful lateral pressure
and traction, a 2-cm-long botfly (Dermatobia
hominis) larva was removed.
The botfly is found in the forests of Mexico, Central America, and South America. The gravid female fly usually captures a mosquito and sticks a packet of eggs into its abdomen. When the carrier insect feeds on a warm-blooded animal, the eggs hatch and the larva penetrates the skin. It feeds on host tissue and maintains a breathing pore in the skin.1 The larva then goes through the second and third stages of maturation. A third-stage larva measures 2 to 3 cm and has rows of spines around its abdomen.2 Between 27 and 128 days, the third-stage larva exits through the entrance wound and pupates in the soil for another 27 to 78 days. At that time, an adult fly emerges and lives two to 19 days without feeding. The entire life cycle lasts three to four months.3
Persons with botfly myiasis have a history of travel and an insect bite, and symptoms include itching or pain, and/or a feeling of movement in the skin. The typical lesion is a subcutaneous nodule with central pore and serosanguineous discharge. This lesion may be mistaken for an infected insect bite, boil, or inflamed epidermal inclusion cyst.
Attempts to suffocate and force extrusion of the larva with paraffin oil, petroleum jelly, bacon, chewing gum, beeswax, or polymyxin B ointment have been made with variable success. Gentle traction reinforced with lateral pressure also may be effective, as with our patient. Some physicians have used local lidocaine, chloroform, or a venom extractor.4 Physicians must be careful not to leave behind parts of larva. Surgery allows complete removal of larva and debridement of the cavity. Secondary infection is rare because of the bacteriostatic nature of the intestinal secretions of the larva. Using protective clothing and insect repellents should help prevent this and similar infections.5
NAEEM SAJJAD, M.D.
GREGORY BIEDERMAN, M.D.
REFERENCES
1. Bravo F, Sanchez MR. New and re-emerging cutaneous infectious diseases in Latin America and other geographic areas. Dermatol Clin 2003;21:655-68.
2. Sampson CE, MaGuire J, Eriksson E. Botfly myiasis: case report and brief review. Ann Plast Surg 2001;46:150-2.
3. Powers NR, Yorgensen ML, Rumm PD, Souffront W. Myiasis in humans: an overview and a report of two cases in the Republic of Panama. Mil Med 1996;161:495-7.
4. Boggild AK, Keystone JS, Kain KC. Furuncular myiasis: a simple and rapid method for extraction of intact Dermatobia hominis larvae. Clin Infect Dis 2002;35:336-8.
5. Robert L, Yelton J. Imported furuncular myiasis in Germany. Mil Med 2002;167:990-3.
Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org.
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