- Email: [email protected]
TREATING DEFECTIVE BABIES
1334 LESSONS FOR GENERAL PRACTICE
SIR,—The tragic personal paper published on April 23 (p 921) under the title Failure to Examine the Patient must cost any general practitioner reader a moment’s pause. Every day we see patients with minor symptoms, most of which will not prove serious. The challenge is to spot the more serious case early, and yet we can all remember instances when we failed in this and offered false reassurance to patients who afterwards deteriorated and even died. What is to be done? One approach is to frighten us with horror stories with guilt inducing titles (an enduring myth is that a general practitioner should always make a full examination and that anything less is cutting corners). The effect may be that we examine our patients more fully for some days or weeks before the next period of pressure brings other priorities to the fore. Your title is misleading. An examination might have revealed nothing. The main mistakes appear to have been excessive delegation of clinical responsibility to a receptionist and, presumably, failure to listen to the patient sufficiently to make a proper decision about subsequent examination or, more important, investigation. Experienced clinicians try to use their time to get the maximum "pay-off" in terms of problem identification. We contend that in general practice, as in hospital,I,2 most of this time should be devoted to "history" rather than examination. The other lesson here is about attitudes and caring. The poor patient and his relatives had a negative encounter with a receptionist and then a brief, unsatisfactory consultation. Later’the doctor was apparently reluctant to discuss the case. All these factors tend to lead to bitterness and recrimination and it may be significant that more than half the paper is devoted to the unsatisfactory complaints
procedure. In summary, therefore, we feel the lessons to be learned here are about listening, history taking, and about caring in general. Necessary examination and investigation will follow. Perhaps your title should have been "A tragic diagnostic error". Primary Medical Care Group, Faculty of Medicine, Southampton University,
GEORGE FREEMAN
Aldermoor Health Centre, Southampton SO 16ST
DAVID JEWELL
TREATING DEFECTIVE BABIES
SIR,-Dr Silverman (April 30, p 989), in his letter on nonof defective babies, labels those who hold opposite views
treatment
his as "self-righteous", "busybodies", and "self-appointed moralists". As one who supports the notion that an employee may remain anonymous in reporting what heor she views as gross neglect of a patient, I believe Silverman’s name-calling is an emotional appeal to generate support for his position. I have often discussed with paediatricians, neurologists, surgeons, and fellow nurses the plan of care for a defective baby. By opposing a physician’s or a parent’s decision I am not expressing a "selfrighteous" attitude. Rather, I am obligated by profession and conscience to serve as the patient’s advocate, particularly when the life of a helpless baby is at stake. Although parental considerations are significant, my first obligation is the welfare of patients under my care. If Silverman believes such conduct warrants the label "busybody", then so be it but if he believes my standing as an advocate for the patient is an "obnoxious intrusion into decisions about medical care", then he is sorely mistaken. Silverman writes of "agony-stricken parents". What of the to
following case? "An infant with Down’s
publicised
one at
syndrome and
intestinal
Johns Hopkins Hospital,
atresia, like the much-
was not
treated because his
was wrong for their baby and themselves. He
parents thought that surgery died seven days after birth."3 1.
2.
Hampton JR, Harrison MJE, Mitchell JRA. et al. Relative contributions of historytaking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J 1975; ii: 486-89 Platt R Two essays on the practice of medicine. Manchester Univ Med School Gaz 1947; 27: 139-45.
Campbell AGM Moral and ethical dilemmas in special care nursery. N Engl J Med 1973; 289: 890-94.
3. Duff RF,
Does any parent experience this degree of "agony"? In the Johns Hopkins case referred to the baby felt fifteen days of unimaginable agony. These are only two of many children who would have greatly appreciated a "self-appointed moralist" to speak and act on their behalf. Yet this did not happen, and two children are dead. Such examples of gross neglect on the part of care givers
demonstrates the need for government action. I am committed to assisting a parent in any way possible through the excruclating ordeal of accepting a child less than perfect by society’s standards. If this is not possible, other options must then be pursued.But I will not passively observe the death of a defective, yet salvageable child. If accusations and name-calling are an inevitable result of such a position, then I accept these labels for what they are worth. Neonatal Intensive Care, Saint Francis Hospital and Medical Hartford, Connecticut, USA
Center,
PAUL KAPUSTINSKI
TREATMENT OF TESTICULAR TUMOURS
SIR.—We agree with Dr Newlands and colleagues (April 30, p 948) that the treatment of metastatic malignant teratoma with a fixed number of cycles of chemotherapy is inappropriate. Recognising that it is important to titrate treatment against the extent of disease, we have for some years had a policy of reassessment after four cycles of chemotherapy, deciding then whether to discontinue treatment, continue with chemotherapy, or proceed to surgery.The range of biological problems in testicular cancer is wide, extending from the patient with one or two small lung metastases seen on computerised tomographic scanning to the patient with massive abdominal or lung disease. These extremes of the clinical spectrum have profound prognostic significance, and treatment needs to be adjusted, not only in terms of the duration and number of cycles of chemotherapy but also in terms of the number and nature of the drugs used, bearing in mind the clinical requirement and the risks of immediate or long term toxicity. The problem in assessing multidrug treatment schedules is to be sure that each drug contributes to the outcome of therapy and that the results represent an improvement over those achieved on regimens with fewer drugs. Excellent results can be obtained with combinations of a very few drugs of proven efficacy. Since 1979 we have investigated bleomycin, etoposide, and cisplatin (BEP) in metastatic testicular teratoma. Data on 36 patients treated between 1979 and 1981 show BEP to be highly effective, with 33 (92%) of men alive and 30 (83%) disease-free.6 If etoposide 120 mg/m2 is used on the first three days of each cycle (rather than five days) haematological toxicity is mild and not associated with serious infective complications. 74% of patients received four or fewer cycles of BEP. Our latest results are, for 49 patients with a follow-up of 13-49 months (median 26), 43 (88%) alive, 41 (84%) without evidence of disease. Our intention was to devise a lower toxicity regimen for patients with limited volume disease, but it is also clear that BEP is active in patients with bulky tumour. Thus, in the published study,6 of 19 men with large volume disease, 17 are alive, 15 without evidence of tumour. In the bigger series currently 15/16 (94%) of patients with limited volume tumour and 26/33 (79%) of patients with advanced bulky disease are disease-free. Vinblastine was added to BEP m selected patients considered to be at high risk (liver involvement. combination of bulky lung and abdominal disease). This experience suggests that reduction of toxicity and enhancement of therapeutic efficacy are not necessarily mutually exclusive. When comparing recent results with, for example, the early experience of Einhorn and his colleaguesthe contribution of Adoption: an option for the imperfect child. Pediatrics 1983, 71: 664-65 MJ, McElwain TJ, Barrett A, Hendry WF Combined management of malignant teratoma of the testis. Lancet 1979, ii 267-70. Peckham MJ, Barrett A, Lieu KH, et al The treatment of metastatic germ-cell testicular tumours with bleomycin, etoposide and cis-platin (BEP) Br J Cancer
4. Hill RM. 5. Peckham 6.
1983; 47: 613-19. 7. Einhorn LH, Donohue J. Cis-diamminedichloroplatinum, vinblastine and bleomycin combination chemotherapy in disseminated testicular cancer Ann Intern Med 1977. 87: 293-98.
SIR,—The tragic personal paper published on April 23 (p 921) under the title Failure to Examine the Patient must cost any general practitioner reader a moment’s pause. Every day we see patients with minor symptoms, most of which will not prove serious. The challenge is to spot the more serious case early, and yet we can all remember instances when we failed in this and offered false reassurance to patients who afterwards deteriorated and even died. What is to be done? One approach is to frighten us with horror stories with guilt inducing titles (an enduring myth is that a general practitioner should always make a full examination and that anything less is cutting corners). The effect may be that we examine our patients more fully for some days or weeks before the next period of pressure brings other priorities to the fore. Your title is misleading. An examination might have revealed nothing. The main mistakes appear to have been excessive delegation of clinical responsibility to a receptionist and, presumably, failure to listen to the patient sufficiently to make a proper decision about subsequent examination or, more important, investigation. Experienced clinicians try to use their time to get the maximum "pay-off" in terms of problem identification. We contend that in general practice, as in hospital,I,2 most of this time should be devoted to "history" rather than examination. The other lesson here is about attitudes and caring. The poor patient and his relatives had a negative encounter with a receptionist and then a brief, unsatisfactory consultation. Later’the doctor was apparently reluctant to discuss the case. All these factors tend to lead to bitterness and recrimination and it may be significant that more than half the paper is devoted to the unsatisfactory complaints
procedure. In summary, therefore, we feel the lessons to be learned here are about listening, history taking, and about caring in general. Necessary examination and investigation will follow. Perhaps your title should have been "A tragic diagnostic error". Primary Medical Care Group, Faculty of Medicine, Southampton University,
GEORGE FREEMAN
Aldermoor Health Centre, Southampton SO 16ST
DAVID JEWELL
TREATING DEFECTIVE BABIES
SIR,-Dr Silverman (April 30, p 989), in his letter on nonof defective babies, labels those who hold opposite views
treatment
his as "self-righteous", "busybodies", and "self-appointed moralists". As one who supports the notion that an employee may remain anonymous in reporting what heor she views as gross neglect of a patient, I believe Silverman’s name-calling is an emotional appeal to generate support for his position. I have often discussed with paediatricians, neurologists, surgeons, and fellow nurses the plan of care for a defective baby. By opposing a physician’s or a parent’s decision I am not expressing a "selfrighteous" attitude. Rather, I am obligated by profession and conscience to serve as the patient’s advocate, particularly when the life of a helpless baby is at stake. Although parental considerations are significant, my first obligation is the welfare of patients under my care. If Silverman believes such conduct warrants the label "busybody", then so be it but if he believes my standing as an advocate for the patient is an "obnoxious intrusion into decisions about medical care", then he is sorely mistaken. Silverman writes of "agony-stricken parents". What of the to
following case? "An infant with Down’s
publicised
one at
syndrome and
intestinal
Johns Hopkins Hospital,
atresia, like the much-
was not
treated because his
was wrong for their baby and themselves. He
parents thought that surgery died seven days after birth."3 1.
2.
Hampton JR, Harrison MJE, Mitchell JRA. et al. Relative contributions of historytaking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J 1975; ii: 486-89 Platt R Two essays on the practice of medicine. Manchester Univ Med School Gaz 1947; 27: 139-45.
Campbell AGM Moral and ethical dilemmas in special care nursery. N Engl J Med 1973; 289: 890-94.
3. Duff RF,
Does any parent experience this degree of "agony"? In the Johns Hopkins case referred to the baby felt fifteen days of unimaginable agony. These are only two of many children who would have greatly appreciated a "self-appointed moralist" to speak and act on their behalf. Yet this did not happen, and two children are dead. Such examples of gross neglect on the part of care givers
demonstrates the need for government action. I am committed to assisting a parent in any way possible through the excruclating ordeal of accepting a child less than perfect by society’s standards. If this is not possible, other options must then be pursued.But I will not passively observe the death of a defective, yet salvageable child. If accusations and name-calling are an inevitable result of such a position, then I accept these labels for what they are worth. Neonatal Intensive Care, Saint Francis Hospital and Medical Hartford, Connecticut, USA
Center,
PAUL KAPUSTINSKI
TREATMENT OF TESTICULAR TUMOURS
SIR.—We agree with Dr Newlands and colleagues (April 30, p 948) that the treatment of metastatic malignant teratoma with a fixed number of cycles of chemotherapy is inappropriate. Recognising that it is important to titrate treatment against the extent of disease, we have for some years had a policy of reassessment after four cycles of chemotherapy, deciding then whether to discontinue treatment, continue with chemotherapy, or proceed to surgery.The range of biological problems in testicular cancer is wide, extending from the patient with one or two small lung metastases seen on computerised tomographic scanning to the patient with massive abdominal or lung disease. These extremes of the clinical spectrum have profound prognostic significance, and treatment needs to be adjusted, not only in terms of the duration and number of cycles of chemotherapy but also in terms of the number and nature of the drugs used, bearing in mind the clinical requirement and the risks of immediate or long term toxicity. The problem in assessing multidrug treatment schedules is to be sure that each drug contributes to the outcome of therapy and that the results represent an improvement over those achieved on regimens with fewer drugs. Excellent results can be obtained with combinations of a very few drugs of proven efficacy. Since 1979 we have investigated bleomycin, etoposide, and cisplatin (BEP) in metastatic testicular teratoma. Data on 36 patients treated between 1979 and 1981 show BEP to be highly effective, with 33 (92%) of men alive and 30 (83%) disease-free.6 If etoposide 120 mg/m2 is used on the first three days of each cycle (rather than five days) haematological toxicity is mild and not associated with serious infective complications. 74% of patients received four or fewer cycles of BEP. Our latest results are, for 49 patients with a follow-up of 13-49 months (median 26), 43 (88%) alive, 41 (84%) without evidence of disease. Our intention was to devise a lower toxicity regimen for patients with limited volume disease, but it is also clear that BEP is active in patients with bulky tumour. Thus, in the published study,6 of 19 men with large volume disease, 17 are alive, 15 without evidence of tumour. In the bigger series currently 15/16 (94%) of patients with limited volume tumour and 26/33 (79%) of patients with advanced bulky disease are disease-free. Vinblastine was added to BEP m selected patients considered to be at high risk (liver involvement. combination of bulky lung and abdominal disease). This experience suggests that reduction of toxicity and enhancement of therapeutic efficacy are not necessarily mutually exclusive. When comparing recent results with, for example, the early experience of Einhorn and his colleaguesthe contribution of Adoption: an option for the imperfect child. Pediatrics 1983, 71: 664-65 MJ, McElwain TJ, Barrett A, Hendry WF Combined management of malignant teratoma of the testis. Lancet 1979, ii 267-70. Peckham MJ, Barrett A, Lieu KH, et al The treatment of metastatic germ-cell testicular tumours with bleomycin, etoposide and cis-platin (BEP) Br J Cancer
4. Hill RM. 5. Peckham 6.
1983; 47: 613-19. 7. Einhorn LH, Donohue J. Cis-diamminedichloroplatinum, vinblastine and bleomycin combination chemotherapy in disseminated testicular cancer Ann Intern Med 1977. 87: 293-98.