A Country Doctor Reads: September 20, 2019 – Full Circle With Sertraline, Airmanship and Mastery in Medicine, EMR Notes Exaggerate Comprehensiveness

Full Circle With SertralineAntidepressant that Treats Anxiety or Anxiety Medication that Only Sometimes Helps Depression?

Yesterday’s buzz about sertraline brought a sad smile of recognition to my face. The research, done in British General practice settings was first published by The Lancet Psychiatry, which costs money. I read it on BBC. Sertraline: Antidepressant works ‘by reducing anxiety symptoms first’ was the headline and the study showed that sertraline had almost twice as much effect on anxiety as it did on depressive symptoms, and the effect on anxiety came much quicker:

“After six weeks, the patients taking sertraline reported a 21% greater improvement in anxiety symptoms – such as feeling worried, nervous and irritable – compared to the control group taking a dummy pill. After 12 weeks, the gap was 23%.

But there was little evidence of the drug reducing depressive symptoms, such as poor concentration, low mood and lack of enjoyment after six weeks – and only marginal improvements (13%) after 12 weeks.

Nonetheless, the group taking antidepressants were twice as likely as the other trial participants to say their mental health felt better overall.

“It appears that people taking the drug are feeling less anxious, so they feel better overall, even if their depressive symptoms were less affected,” said lead study author Dr Gemma Lewis, from UCL.”

Back when SSRIs were brand new, they were only indicated for treating depression. I still remember the mental acrobatics doctors went through as we prescribed it for anxiety. The thinking then was that the anxiety we so successfully treated with sertraline was in fact a manifestation of less-than-obvious depression. And here we are, with the opposite being touted as the real scoop on how this now 28 year old drug works.

Does anyone believe we have precision in psychiatric diagnosis? Or even in describing or naming symptoms?

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AIRMANSHIP – Mastery in Aviation, Seamanship on the Ocean. How About Mastery in Medicine?

The New York Times ran a piece about the relative inexperience of pilots involved in a Boeing 737 Max crash. Even with many years of experience, commercial pilots don’t really gain the experience flying under extreme conditions, like fighter pilots. This article certainly made me think of a new dimension to the typical comparisons between the airline industry and healthcare: There’s all this talk about predictability and checklists, but what about getting some practice flying upside down – or in medicine, practicing under adverse conditions as part of your training?

“Airmanship” is an anachronistic word, but it is applied without prejudice to women as well as men. Its full meaning is difficult to convey. It includes a visceral sense of navigation, an operational understanding of weather and weather information, the ability to form mental maps of traffic flows, fluency in the nuance of radio communications and, especially, a deep appreciation for the interplay between energy, inertia and wings. Airplanes are living things. The best pilots do not sit in cockpits so much as strap them on. The United States Navy manages to instill a sense of this in its fledgling fighter pilots by ramming them through rigorous classroom instruction and then requiring them to fly at bank angles without limits, including upside down. The same cannot be expected of airline pilots who never fly solo and whose entire experience consists of catering to passengers who flinch in mild turbulence, refer to “air pockets” in cocktail conversation and think they are near death if bank angles exceed 30 degrees. The problem exists for many American and European pilots, too. Unless they make extraordinary efforts — for instance, going out to fly aerobatics, fly sailplanes or wander among the airstrips of backcountry Idaho — they may never develop true airmanship no matter the length of their careers. The worst of them are intimidated by their airplanes and remain so until they retire or die. It is unfortunate that those who die in cockpits tend to take their passengers with them.

www.nytimes.com/2019/09/18/magazine/boeing-737-max-crashes.html

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BREAKING NEWS: Doctors’ EMR Notes Overstate Comprehensiveness of History and Physical Exam – JAMA

Question  How closely does documentation in electronic health records match the review of systems and physical examination performed by emergency physicians?

Findings  In this case series of 9 licensed emergency physician trainees and 12 observers of 180 patient encounters, 38.5% of the review of systems groups and 53.2% of the physical examination systems documented in the electronic health record were corroborated by direct audiovisual or reviewed audio observation.

Meaning  These findings raise the possibility that some physician documentation may not accurately represent actions taken, but further research is needed to assess this in more detail.

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2751388

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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