Family physician commentary
This case highlights several functions of the family physician and illustrates some of the challenges faced by primary caregivers. The dilemma in this scenario is that the patient ignored medical advice from specialists who had been consulted because of his worsening condition. What is a family physician’s responsibility in this circumstance? If you place yourself in this physician’s situation, you may experience a variety of emotions and thoughts, including frustration. How do you to provide a high standard of care for a patient who will not accept your recommendations?
Patient autonomy is paramount
As physicians we always need to respect patient autonomy. Though we may need to perform many roles, we always are the patient’s advocate. This can be difficult when a patient deviates from what we consider appropriate medical care. We may fear complications arising from lack of cooperation with advised treatment. In this case, the physician was legitimately concerned about worsening bone and skin breakdown, which could ultimately lead to foot or limb loss.
We are trained to evaluate and treat patients within our scope of knowledge and then incorporate the help of specialists as necessary. We are less well trained to deal with patients who refuse recommended medical treatments. In these situations, we must first thoroughly review with patients their options and the risks and benefits of each. We must also assess whether patients are competent to make decisions. If they are competent, then we must allow our patients to choose to do nothing, though it may not be what we would choose. The physician must make a choice of continuing to care for the patient, or begin the process of transferring care. If the patient-physician relationship continues, physician and patient should negotiate responsibility for outcomes and document the patient’s understanding.
In the case presented here, the patient continued seeing his physician for follow-up of his ulcer, though he had not followed the physician’s treatment recommendation. This required the physician to continue his relationship with the patient despite a major difference of opinion. This is an example of respecting a patient’s autonomy while continuing a therapeutic relationship. This case demonstrates several family physician functions in addition to patient advocate:
Family physician as coordinator… The physician obtained appropriate specialty consultations, and facilitated the patient’s visits to the podiatrist, orthopedist, wound care specialist, and plastic surgeon. He remained the central point of contact for the patient and assured that the patient received adequate follow-up.
…as comprehensive caregiver… This patient required management of several chronic diseases, including diabetes, hypertension, and obesity. He also needed health care maintenance. To give good care, the physician had to understand the patient’s background, work situation, and personal values. To appropriately treat the patient’s foot ulcer, the physician needed to know the patient, his work situation, and his medical history. As family physicians, we are able to build relationships with our patients that allow them to communicate their values, their history, and their wishes to us.
…and as educator. M.N. needed adequate and accurate information to make a final, informed decision concerning the care of his foot ulcer and osteomyelitis. As family physicians, we should be able to summarize for our patients their medical problem and present them with an overall picture of the problem and recommended treatment. This relationship allows the patient to make educated choices with a trusted healthcare provider.
–Jessica Farnsworth, MD
Antibiotic choice should be based on bone culture, as soft-tissue or sinus tract cultures do not accurately predict bone pathogens. When empiric therapy is necessary, coverage should always include S aureus. Cure of osteomyelitis has traditionally been thought to require removal of infected bone, but studies are showing that antibiotics may be adequate in two thirds of cases, especially those with good bioavailability. When bone is removed, shorter antibiotic therapy may be sufficient.2
Additional treatment options may include revascularization in an ischemic foot, which has been shown to salvage up to 98% of limbs. Hyperbaric oxygen may provide benefit, but data are insufficient to document this measure. Edema control may be beneficial for wound healing. Promising adjuvant therapies include granulocyte colony-stimulating factor (G-CSF), antibiotic-impregnated beads or orthopedic implants, and “biosurgery” with fly larvae.2
TABLE 2
Clinical characteristics of a severe infection
| Acute or rapidly progressive |
| Penetrating to subcutaneous tissues or involving fascia, muscle, joint, bone |
| Extensive cellulitis (>2 cm around ulcer rim) |
| Signs of inflammation, crepitus, bullae, necrosis, gangrene |
| Systemic signs: fever, chills, hypotension, confusion, volume depletion, leukocytosis |
| Metabolic abnormalities: severe hyperglycemia, acidosis, azotemia, electrolyte abnormalities |
| Absent pulses |
TABLE 3
Wagner ulcer grading system
| WOUND GRADE | WOUND DEPTH |
|---|---|
| Grade 0 | Intact skin |
| Grade 1 | Superficial ulcer |
| Grade 2 | Deep ulcer to tendon, bone, or joint |
| Grade 3 | Deep ulcer with abscess or osteomyelitis |
| Grade 4 | Forefoot gangrene |
| Grade 5 | Whole foot gangrene |
| The Wagner ulcer grading system does not identify infectious processes except in Grade 3. Erythema, edema, and pain may be present in foot infections, and may manifest as paronychia, cellulitis, or superficial skin infection. | |