For better or for worse, we live in an “As Seen on TV” culture. Often, our patients come to us with their own thoughts and ideas based on a commercial that they saw on late night television, an advertisement from the magazine on an airplane or something that they have “researched” on the Internet.
We would venture to guess that a week does not go by when a patient comes into your office with a specific question about a newspaper clipping or something that he or she has printed off the World Wide Web.
In some ways, this vast amount of information readily available to our patients is a blessing. It allows them to become actively involved in their own care with the freedom to ask their own questions on their own time. Of course, it can be a curse in many other ways. Daniel Boorstin noted that “The fog of information can drive out knowledge.” Unfortunately, the quality of the information often does not match its quantity.
As physicians, we feel it is our duty to provide an assessment of all available information in order to recommend what we feel is the best option for our patients. This has become increasingly difficult as the amount of “available information” expands exponentially. For example, we recently did a Google search on “Diabetic Foot Ulcer Cure” and came up with 437,000 results in 0.22 seconds. The following sites represent a small sample of what we found.
Diabetic_foot. For those unfamiliar, Wikipedia brands itself as a free online “encyclopedia” in which anyone can log on and edit an entry. It is often the first Internet stop for people with a general question about a specific topic. Wikipedia does have a “Diabetic Foot” page that emphasizes prevention and treatment. Prevention is by “frequent chiropody review” in addition to injury avoidance and good lower extremity hygiene. The antibiotic regimen proposed in the treatment section consists of the combination of flucloxacillin, amoxicillin and metronidazole. In regard to advanced therapies, Wikipedia only references nitric oxide, light therapy and hyperbaric oxygen therapy. 
http://portal.acm.org/citation.cfm?id=1361226. This Web site provides a link to an article published in the International Journal of Telemedicine and Applications.1 It describes outcomes following a pilot program in Denmark to provide expert consultation and evaluation of diabetic foot ulcerations through telemedicine as opposed to direct patient-physician contact.
According to the article, video consultation occurred between a patient and a visiting nurse at one site, and a diabetic foot expert at a separate site. All parties (physician, visiting nurse, and patient) reported satisfaction with the process and indicated that it was a viable way of performing treatment.
www.reversegangrene.com. This is a Canadian-based Web site for a company dedicated to “the who, why, when and how of reversing gangrene naturally” through the use of nutrition. This Web site recommends two primary interventions to prevent amputation from gangrene.
The first is Gangrene Clear-G Formula, which can reportedly help save limbs by: “increasing peripheral nutrient-dense, oxygen-rich and germ-fighting blood flow; providing nourishment; accelerating the inner self-healing effect; and repairing the tissues affected by an insufficient blood supply.” It is a powdered blend of 80 vitamins, minerals, nutrients and phytonutrients mixed into a solution and taken orally two to five times daily.
The second intervention is Y-DAN, which is described as a “gentle, slow-motion exercise,” similar to tai chi, that can reportedly help improve blood flow to the affected extremity.
http://www.presstv.ir/detail.aspx?id=41449§ionid=3510210. This Web site provides preliminary information on “a new anti-diabetes herbal medication, which can effectively treat diabetic foot ulcers.” Angipars™ is a new medication being “mass produced” in Iran and is reportedly available orally, topically or intravenously.
We tried to dig a little deeper on this one but we could only find an article describing Angipars™ as some form of herbal extract known as semelil in a pharmacologic journal published by the Tehran University of Medical Sciences.2
http://foothealth.about.com/od/diabetesfeet/a/compairfootmass.htm. This site describes the use of compressed air massage in the treatment for diabetic foot ulcerations. “Compressed air massage works similar to filling a car tire with air, except that the air goes on your skin and not in a tire.” It reportedly facilitates a temporary increase in the local vascular supply.
http://www.sarkaritel.com/news_and_features/health/diabeticfoot.htm. This Web site provides a link to an article written by Sunita Govind, a health reporter in India, who offers important and much needed information about diabetic foot disease in that country. However, we did have one question when Govind reported that “a diabetic foot can lead to frog foot, ulcers, gangrene and ultimately amputation.” Despite our research, we were unable to determine the exact nature of what constitutes a “frog foot.”
While it is impossible to control all of the information that will reach our patients, it is our duty and responsibility to educate them and ourselves with regard to the questions that they bring us. Instead of laughing off these Web sites and not giving them a second thought, active physicians will take a step back and see what they can learn from the situation.
For example, Wikipedia is probably not the best place for patients to look for answers to their questions about the diabetic foot. However, after reviewing the page, we went on an active search for better sources. We now refer patients with general questions to several Web sites including the American Diabetes Association (www.diabetes.org/type-1-diabetes.jsp ), the American Podiatric Medical Association (www.apma.org/s_apma/sec.asp?CID=371&DID=17520 ), and the American Medical Association (http://jama.ama-assn.org/cgi/reprint/293/2/260.pdf ).
We took a second look at our most commonly utilized antibiotic regimens and decided to continue to follow the recommendations established by the Infectious Diseases Society of America with respect to diabetic foot infections.3 We then reviewed the recent peer-reviewed publications regarding nitric oxide, light therapy and hyperbaric oxygen treatments, so we could make up-to-date and evidence-based recommendations to our patients.4-22
As another example, before visiting reversegangrene.com, we would have been unable to tell you that phytonutrients are compounds derived from plants that are thought to have health-protective effects.23-25 Although we cannot specifically comment on the Gangrene Clear-G Formula, one should not underappreciate the impact of nutrition on diabetes and wound healing.26-30 In regard to this Web site page, you would probably be surprised at the documented impact of tai chi exercises on diabetes.31-34
We can probably all agree that telemedicine means are not the ideal way to evaluate our patients with diabetes but it is probably better than nothing. Would you rather not evaluate a patient with a diabetic foot ulceration at all or have some form of evaluation, no matter how limited?
In the United States and throughout the world, the rate of diabetes and lower extremity amputations as a result of diabetes have steadily increased and increased at a rate that exceeds our ability to produce diabetic foot “experts.” As a profession, we should be exploring different ways for a limited amount of specialists to evaluate a growing number of patients effectively.
In many situations, we are teaching ourselves in addition to our patients. Each and every situation presents a unique opportunity for self-education and self-improvement so we are better able and more prepared to help the next patient we encounter.
Dr. Meyr is a third-year resident within the podiatric surgical residency program at the INOVA Fairfax Hospital in Falls Church, Va.
Dr. Steinberg is an Assistant Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C. He is a Fellow of the American College of Foot and Ankle Surgeons.
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2. Larijani B, Heshmat R, Bahrami A, Delshad H, Ranjbar Omrani G, et al. Effects of intravenous Semelil (ANGIPARSTM) on diabetic foot ulcers healing: a multicenter clinical trial. DARU Vol 16, Suppl. 2008.
3. Lipsky BA, Berendt AT, Deery HG, et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2004 Oct 1; 39(7): 885-910.
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18. Strauss MB. Hyperbaric oxygen as an intervention for managing wound hypoxia: its role and usefulness in diabetic foot wounds. Foot Ankle Int. 2005 Jan; 26(1): 15-8.
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