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Posted to Family-L recently:

 NWAHEC – Herbs&Dietary Supplements is a very well done online curriculum on herbs and dietary supplements.

The program includes:

Baseline assessment of participant's knowledge, attitudes and clinical communication practices with regard to herbs and dietary supplements.

Answers on this assessment are for curriculum evaluation only. The answers on this questionnaire do not affect educational credit.

The curriculum. 40 1-page, self-instructional modules on commonly used herbs and supplements (sample module). Access to evidence-based information from reliable Internet sites from academic centers and the US government (links and resources). Access to a moderated Listserv (discussion group) with your colleagues who are interested in herbs and supplements. The Listserv will have a maximum of two postings per week. There will NOT be any advertising in these postings, and participants may choose to un-enroll in the ListServ. Post-course assessment and evaluation. Participants must get 70% correct on 10 knowledge questions to obtain continuing education credit.

Updates – back from vacation

Dave has a fishtank, Elyse ponders security, and (I missed this one) .. hospitals are using SMS to remind patients of their appointments, and Enoch had a baby

Dodgeit is a cool, free receive-only e-mail thingy that will do RSS.

Dave (the other one) is planning bloggercon III.      I can't make it as I'll be in Boston celebrating the World Series win, and .. oh yeah .. I'll be at the AAMC meeting.

Clinical notes:

Moderate wine drinkers have lower hypertension-related mortality: a prospective cohort study in French men

American Family Physician has a nice review of emergency contraception

Effect of a topical diclofenac solution for relieving symptoms of primary osteoarthritis of the knee: a randomized controlled trial

There's a great review on the treatment of acne in JAMA.

Physician Suicide

A colleague passed away this week:

Albany, N.Y. : Timesunion.com : Obituaries

He was the victim of a terrible disease called depression, and I didn't know it – nor did most of his colleagues. He was a wonderful physician – and was adored by his patients, medical students, residents and colleagues.   A careful, thoughful physician, I always found him easy to speak with – and (unlike some specialists) he valued the opinions and contributions of primary care physicians.

Some would say that health care providers make terrible patients.

They're missing the point. It's very hard for physicians to reach out to other physicians in a trusting way. It's common for physicians to hesitate seeking treatment for psychiatric illness due to a misperception that such treatment will become public knowledge or will impact their status on hospital staffs. Last week, I was asked by a patient not to enter the Zoloft prescription I was writing into her chart. I told her that I couldn't do what she was asking, and I addressed her concerns that the entry in her medication list would make her "look crazy" to anyone looking at the record.

Yet it's been hard for me to address similar concerns from physicians in such a convincing way.  They must respond to annual questionnaires from the hospitals where they admit patients, and they must list all medcations and medical problems they are being treated for. While such information is strictly confidential, many physicians know that their peers who sit on the credentialing committee will see this information.  One physician patient told me that – while he would like to be treated for a given problem – he would prefer I NOT treat him for his – as he wold have to report this treatment.

Something is wrong when the people who are supposed to care for everyone else cannot get care for themselves because of such fears. Could our colleage have been helped? I wish I knew. Here's a little news blurb on the topic of physician suicide.  It's the leading cause of "early death" in our profession.

Psychiatry in Primary Care

Today – like many days – was psychiatry day.  Here's a nice set of algorithms from Primary Care Psychiatry. 

Anxiety and depression are commonly encountered in primary care – and while I am certain that we underdiagnose these problems, i'll bet we overdiagnose them too – especially when we don't connect well with our patients.  It's not uncommon for me to meet a new patient with a longstanding health problem who has been (unsuccessfully)  treated with an SSRI by their previous physician for somatic complants with no clear cause.

I'll admit that sometimes the actions of the previous physician make sense to me – the patient with an anxiety disorder or depression who has persistent somatic complaints may very well be depressed or anxious – which is more likely the root cause of the fatigue or muscle pain than some rare biochemical disorder.  Yet it's a tough line to walk – and sometimes people see a physician's attempt to treat depression as a cop-out in the context of a persistent somatic problem that feels (and is) very real. 

There's no easy answer here.  Depression is not a wastebasket diagnosis that we should throw at our patients when the TSH turns out to be nornal.  Then again – we should not ignore it.    Building an alliance with our patients to build a good understanding and shared decisionmaking can avoid such either-or dillemas. 

I won't say I'm always successful at this  .but I do try my best to walk this line in a respectful, caring manner.


Have been experimenting with Dragon NaturallySpeaking voice-recognition, in a few weeks and today I was able to complete all of my progress notes with a combination of which recognition and templating using electronic medical record.

It certainly easier than just typing the rhythm is something that will take some getting used to.  Certainly, I can't do the voice-recognition in the office with my patients.

I bought an array microphone to experiment with that in the office.  It seems to work OK the headset works a little bit better I think.

The most recent investment was in a good medical dictionary.  It certainly does make a difference.

For example, I'm using a right now (and have been using it for all of this post).  Here's a fake patient dictation:

Best BETs

New find:

Best BETs (Best Evidence Topics)

Physicians need rapid access to the best current evidence on a wide range of clinical topics. But where to find it? Textbooks are frequently out-of-date, and we don't have the time to perform literature reviews while the patient is waiting. 

BETs were developed in the Emergency Department of Manchester Royal Infirmary, UK, to provide rapid evidence-based answers to real-life clinical questions, using a systematic approach to reviewing the literature. BETs take into account the shortcomings of much current evidence, allowing physicians to make the best of what there is. Although BETs initially had an emergency medicine focus, there are a significant number of BETs covering cardiothoracics, nursing, primary care and paediatrics.

It's an excellent site and the content is top-notch.


Lyme disease

Lyme disease is .. as they say .. overdiagnosed and underdiagnoed.  I've certainly missed it.   I've also ordered more Lyme antibody tests than I would like.  In this region, Lyme disease is very common.  This article – based on a study of data from Wisconsin – determines that Lyme testing is ordered far more frequently than necessary.  I would agree.  Yet the regional variation in the incidence of Lyme disease is significant.  Your mileage may therefore vary.

Feeling Important

Well, it's been about 10 days since my last post – so I'll get rolling again with a "Doogie Howser" philosophical entry.

Meeting with a medical student about her career choices last week, I was reminded once again that making a decision about what to do for the rest of our lives is no easy task.   I'm not sure when I decided to be a family physician, but I think it was before medical school.    In my student's case, I was struck by how she had so much insight into her need to "feel important."

Rounding on the nephrology service, she felt important because she was "the expert."  Other physicians asked for help .. which made the nephrologists important.  The same thing happened on Surgery, Infectious Disease, etc.

Yet this student does so well listening to (and really hearing) her patients that she has also been drawn toward primary care and psychiatry.  Yet these specialties don't feel so important to her .. she doesn't see the primary care physician as the expert.

I was struck by how clearly and honestly she could express this to me.  Many other students struggle with this .. and I often find the ones who can express this need to be important and be the expert are the ones who need it the least.

Removing a wayward q-tip from a patient's ear this morning … I felt less important than simply helpful.    Yet this is what our work is about .. and indeed, we must maintain our humility.    I counseled the medical student that the initial thrill of feeling important wanes as time marches on.