In a thought provoking Special Communication published in this issue (see page 161), David Armstrong and Joseph Mills, from the limb salvage unit at the University of Arizona, suggest a potential change in language when treating diabetic patients with neuroischemic ulcerations of the lower extremity. Once an ulceration is closed, they recommend referring to the patient as being “in remission” as opposed to being “cured.” Their justification for this change is prior comparisons in complexity and mortality that have been made between patients with aggressive cancers, where the term is routinely applied, and those with diabetic foot complications. Using the term remission instead of cure implies a more urgent need for close follow-up to prevent a recurrence of the condition. Why limit this nomenclature to only those complications in patients with diabetes? Couldn’t the same be said about many of the conditions we treat in the lower extremity?
According to the Merriam-Webster online dictionary, cure can be defined as “a complete or permanent solution or remedy,” whereas remission is defined as “a state or period during which the symptoms of a disease are abated.” How often are we certain that we have, in fact, achieved a complete or permanent remedy? Is it always necessary to have a “permanent remedy”? An example that comes immediately to mind was the resistance of many clinicians to use oral or topical antifungal agents in the treatment of onychomycosis. An oft-heard refrain was, “Why should I bother to treat this patient when it will just come back anyway?” As with any infection, onychomycosis can recur. The organism is ubiquitous in the environment and many patients are genetically predisposed to the infection. That doesn’t obviate the need for treatment, even if it is just putting the patient into remission. By treating the patient, they obtain symptomatic, and yes, cosmetic, relief. Informing patients that they are not cured—but in remission—stresses to them the importance of routine maintenance treatments and visits.
One of the most common presenting patient complaints is heel pain. Injections can be given, biomechanical interventions attempted, and even the occasional surgical procedure performed. Certainly, the patient can be made comfortable or even totally pain free. But, what happens if patients stop wearing their orthotic devices, don’t lose weight, continue at the same job wearing the same shoes, or continue with any of the other risk factors that may have led to the heel pain in the beginning? Were these patients ever really cured or just in remission? By altering the simple words, patient expectations might be better managed. Readers can come up with multiple other examples in their own minds.
All of this may seem like little more than trivial wordsmithery, if not a bit unsettling. Clinicians pride themselves on being able to cure patients—to make them permanently better. It is disconcerting to realize that this might not always be the case. Can a simple modification in habit by altering a few words change the entire health-care paradigm, as often discussed in public health circles, from one of disease management to one of health maintenance?
