This child is experiencing simple breath holding spells, a relatively common and benign condition that usually begins in children between the ages of 6 months and 6 years. The cause is uncertain but seems to be related to overactivity of the autonomic nervous system in association with emotions such as fear, anger, and frustration. The episodes are self limited and may be associated with pallor, cyanosis, and loss of conciousness if prolonged. There may be an association with iron deficiency anemia, but this child had a recent normal hemoglobin level.
These events are not volitional, so disciplinary methods are neither effective nor warranted. While children may experience a loss of consciousness and even exhibit some twitching behavior, the episodes are not seizures so neither EEG evaluation nor anticonvulsant therapy is indicated. No additional laboratory studies are indicated. Parents should be reassured that the episodes are benign and will resolve without treatment.

Ref: Rudolph CD, Rudolph AM, Lister G, et al (eds): Rudolph's Pediatrics, ed 22. McGraw Hill, 2011, p 2223.

https://www.theabfm.org/

http://www.healthisprimary.org/make-health-primary

Lets start with smoking .....

Tobacco use is a major preventable cause of premature death and disease worldwide. Approximately 6 million deaths related to tobacco use occur each year, including 600,000 from secondhand smoke. In the United States, an estimated 45.3 million people – about one in five adults – currently smoke, and an estimated 443,000 people die prematurely from diseases caused by smoking or secondhand smoke exposure. 

CDC has identified reducing tobacco use as a Winnable Battle. With additional effort and support for evidence-based, cost-effective strategies that we can implement now, we will have a significant impact on our nation's health.

http://www.cdc.gov/WinnableBattles/Tobacco/index.html

There is some evidence, at least anecdotally, that smoking is related to an increased risk in suicide... (those old "coffin nails"... but no one disagrees smoking is bad for you...not really.....

http://www.cbsnews.com/news/smoking-and-suicide-risk-may-be-closely-linked/

How about alcohol?.... of course, more serious impact with over-drinking, but even..."moderate alcohol intake ...is associated with increased risk of breast cancer, violence, drowning, and injuries from falls and motor vehicle crashes."

http://www.cdc.gov/alcohol/faqs.htm

and alcohol has been linked, at least anecdotally (? sp), to depression and suicide...

" Alcohol and drug abuse are second

only to depression and other mood disorders as

the most frequent risk factors for suicidal behavior

(2, 3). Alcohol and some drugs can result in a loss

of inhibition, may increase impulsive behavior,

can lead to changes in the brain that result in

depression over time, and can be disruptive to

relationships—resulting in alienation and a loss

of social connection (4). Furthermore, excessive

acute drug and/or alcohol ingestion could result in

death. According to data from a recent National

Violent Death Reporting System (NVDRS) report,

in 2007 alcohol was a factor in approximately onethird

of the reported suicides, and 62% of these

decedents had a Blood Alcohol Content (BAC) of

>0.08 g/dL at the time of death (5). 

http://www.cdc.gov/ViolencePrevention/pdf/NVDRS_Data_Brief-a.pdf

how about nutrition?  (namely Over-nutrition, given the obesity stats...)

bullying, obesity, and suicide

http://www.obesityaction.org/educational-resources/resource-articles-2/childhood-obesity-resource-articles/bullying-bullycide-and-childhood-obesity

 even just believing you are overweight...

http://www.sciencedaily.com/releases/2009/05/090520064349.htm

bullying also has immediate and long-term health impacts...

http://www.sciencedaily.com/releases/2014/05/140516202703.htm

cuts across social class

http://www.sciencedaily.com/releases/2014/05/140521133607.htm

increases with age,

http://www.sciencedaily.com/releases/2014/09/140910132530.htm

(you get the idea...)

and obese adults aren't spared, even the ones who have surgery....

obesity and suicide

http://www.psychweekly.com/aspx/article/articledetail.aspx?articleid=1573

so there are no quick fixes there, either....

suicide (n.) 

"deliberate killing of oneself," 1650s, from Modern Latin suicidium "suicide," from Latin sui "of oneself" (genitive of se "self"), from PIE *s(u)w-o- "one's own," from root *s(w)e- (see idiom) + -cidium "a killing" (see -cide). Probably an English coinage; much maligned by Latin purists because it "may as well seem to participate ofsus, a sow, as of the pronoun sui" [Phillips]. The meaning "person who kills himself deliberately" is from 1728. In Anglo-Latin, the term for "one who commits suicide" was felo-de-se, literally "one guilty concerning himself."

http://www.etymonline.com/index.php?term=suicide

So where is all this coming from?

(my background makes me familiar with it.... but recent series of events are as follows:)

---------- recently sent me this article, asking if I had read it:

http://www.kevinmd.com/blog/2014/11/physician-suicide-101-secrets-lies-solutions.html

I hadn't read kevin md's post, but had been aware of the physician suicides, though not the exact numbers...

Following up on this, I gathered a huge pile of materials, research, programs, etc...

 (Dr. Wible's work is fascinating--I also found some good information about programs addressing burnout in residents, including one at UNC: 

http://www.med.unc.edu/psych/education/taking-care-of-our-own

 Motivational Interviewing--(which I do, have read some books, been to some workshops, and essentially espouse the philosophy in my dealings with people, including clients--namely, people do what they are doing because it works for them, and until they decide it isn't, there is no changing their mind, let alone their behavior. 

I think it also applies to MOC, CME, etc.... anything like this where you get so much push-back.

Until someone recognizes something as a problem, and is willing to address it, nothing changes...

So, suicide is a huge problem in the general population...

http://www.cdc.gov/violenceprevention/suicide/who-report.html

and also in physicians. 

 If physicians don't acknowledge suicide in their own community (http://www.washingtonpost.com/national/health-science/when-doctors-commit-suicide-its-often-hushed-up/2014/07/14/d8f6eda8-e0fb-11e3-9743-bb9b59cde7b9_story.html, http://www.phfl.org/news-mainmenu-2/1-latest/1-versatility-3-intro, http://emedicine.medscape.com/article/806779-overview,

physicians certainly won't get help...

If physicians don't ask their patients, http://www.ncbi.nlm.nih.gov/pubmed/17893382, 

even if there are models:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146379/

Who will intervene?

Primary care is certainly positioned for intervention, whether they like it or not...

Primary Care:  A Crucial Setting for Suicide Prevention

Jerry Reed, PhD, MSW, Director, Suicide Prevention Resource Center

Up to 45% of individuals who die by suicide have visited their primary care physician within a month of their death; additional research suggests that up to 67% of those who attempt suicide receive medical attention as a result of their attempt. Given these statistics, primary care has enormous potential to prevent suicides and connect people to needed specialty care — especially when they collaborate or formally partner with behavioral healthcare providers.

http://www.integration.samhsa.gov/about-us/esolutions-newsletter/suicide-prevention-in-primary-care

but a good share of what you read about physicians and suicide is not about suicide per se, or suicide by physicians, but just what the role of physician's should be in supporting/aiding people who approach their physician about suicide....

This bit is meant to address the issue of physician assisted suicide.....

What are physician's responsibilities when it comes to garden-variety suicide?

Don't these patients (colleagues, students, family members, etc...) deserve every bit as much?

Is it less understandable, or less tragic, somehow?

(emphasis above and below, mine)...

Opinion 2.211 - Physician-Assisted Suicide

Physician-assisted suicide occurs when a physician facilitates a patient’s death by providing the necessary means and/or information to enable the patient to perform the life-ending act (eg, the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide).

It is understandable, though tragic, that some patients in extreme duress--such as those suffering from a terminal, painful, debilitating illness--may come to decide that death is preferable to life. However, allowing physicians to participate in assisted suicide would cause more harm than good. Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.

Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life. Patients should not be abandoned once it is determined that cure is impossible. Multidisciplinary interventions should be sought including specialty consultation, hospice care, pastoral support, family counseling, and other modalities. Patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication. (I, IV)

Issued June 1994 based on the reports "Decisions Near the End of Life," adopted June 1991, and "Physician-Assisted Suicide," adopted December 1993 (JAMA. 1992; 267: 2229-33); Updated June 1996.

So anyway.....

How are physicians to help themselves and each other, let alone their patients, if no one will own the situation?

I thought, maybe a Quality Improvement effort on the education of and screening for depression/suicidal ideation in our community might really be a good starting place....

Back to KevinMD... this article was published on 1-9-2015...

MOC is medicine’s self-inflicted wound

http://www.kevinmd.com/blog/2015/01/moc-medicines-self-inflicted-wound.html

Again, the imagery is vivid enough, and the message pretty clear:

"Really? Of all the issues we face in health care, this is the one where we collectively draw a line in the sand?

Pardon me, but that’s just stupid.

While it’s encouraging that professional organizations like the ACP are actively responding to the concerns of their members, it’s also taking away from efforts that matter more in the long-term.

We’ve taken our eyes off the ball.  Fighting among ourselves on MOC means that more concerning problems that threaten our profession are left unchecked."

http://www.kevinmd.com/blog/2015/01/moc-medicines-self-inflicted-wound.html

“A person in difficulties wants in the first place the help of another person on

whom he can rely as a friend—someone with knowledge of what is feasible but

also with good judgment on what is desirable in the particular circumstances, and

an understanding of what the circumstances are. The more complex medicine

becomes, the stronger are the reasons why everyone should have a personal doctor

who will take continuous responsibility for him, and, knowing how he lives, will

keep things in proportion…”1,p752

--TF Fox, 1960 in The Lancet

anyway...

there are obviously lots of resources....

some incredibly simple and user friendly (there is a mental health "first aid" model called QPR--Question, Persuade, and Refer... essentially you ask if someone is thinking about killing themself, persuade them to get help, and refer them to an appropriate source...

http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=299

It should really be taught like self-defense, or first aid... because it isn't dangerous, and really gives people a format to intervene when they are concerned about someone.

but why do physicians need to train on this?

physician personality can impact ability to assess depression

http://www.eurekalert.org/pub_releases/2008-09/uorm-pch092408.php

http://www.healthcentral.com/depression/c/4182/42398/personality/?ap=2007

so knowing that, instruments are even more important....

analyzing clinic notes...

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0085733

The military thinks it is a good idea...

http://www.eurekalert.org/pub_releases/2012-09/mc-mcs091012.php#.VJYH48iiCzw.facebook

and even a virtual patient, denise, to help train physicians!

http://www.eurekalert.org/pub_releases/2013-01/ghsu-vpm010313.php#.VJYH0accjIo.facebook

anyway....lots of random stuff...

http://www.mhacentralcarolinas.org/communityoutreach.cfm

http://www.sprc.org/

http://link.springer.com/article/10.1007%2Fs40596-014-0185-9

http://www.sciencedirect.com/science/article/pii/S1532046412001062

http://www.suicideassessment.com/pdfs/PsychiatricClinicsRole-playingPDF.pdf

http://csclv.nevada.edu/tasks/sites/csclv/assets/File/ijnes-2013-0075.pdf

An Online Spaced-Education Game Among Clinicians Improves Their Patients’ Time to Blood Pressure Control A Randomized Controlled Trial

That's the gist of an online game tested at eight Boston-area hospitals to see if it could improve treatment of high blood pressure by getting practitioners to follow recommended treatment guidelines.

Patients of the doctors and nurses who played the game over the course of a year got their blood pressure under control faster than those whose primary care providers were told to read educational materials instead, a "modest but significant" improvement, the researchers say. The results were published Tuesday in the journal Circulation.

when-doctors-play-this-game-you-get-better-medical-care

An Online Spaced-Education Game Among Clinicians 

Improves Their Patients’ Time to Blood Pressure Control

A Randomized Controlled Trial

http://circoutcomes.ahajournals.org/content/7/3/468.full.pdf+html

http://cherrylemonbear.tumblr.com/

http://cherrylemonbear.tumblr.com/

http://www.ibrarian.net/navon/
http://www.ibrarian.net/navon/ibrapedia_frames.jsp?phrase=medical+librarians
http://www.healthsciences.okstate.edu/medlibrary/ebm.cfm

This is a review of the master’s-level
curricula of the fifty-eight America Library
Association–accredited library and information
science programs and iSchools for evidence of
coursework and content related to library instruction.
Special emphasis is placed on the schools and
programs that also offer coursework in medical or
health sciences librarianship.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3484960/pdf/mlab-100-04-244.pdf
Informationists
http://www.mlanet.org/research/informationist/
Lancaster E prints
http://eprints.lancs.ac.uk/view/year/2008.type.html

ways to ace medical school
http://blogs.einstein.yu.edu/5-ways-to-ace-medical-school-exams-by-maximizing-study-time/

med student research posters
http://einstein.yu.edu/features/around-campus/310/einsteins-main-street-lined-with-research-posters/

daily writing tips
http://www.dailywritingtips.com/forgo-vs-forego/



Data sharing
http://www.nsf.gov/bfa/dias/policy/dmpfaqs.jsp

The Purpose Driven Life: What on Earth Am I Here For?
Author: Rick Warren

Publisher: Zondervan; 1st edition (October 1, 2002)

Review:

An interesting read--Warren's work is accessible, applicable to a wide audience.  Familiarity with Christian doctrine is helpful, but not necessary, as the author interlaces scripture passages with illustrative quotations ("God doesn't play dice"-- Albert Einstein.)  Religious anecdotes are appropriate and explanatory in context.  "Nearly a thousand" scripture quotations from documented translations of the Bible exemplify Warren's goal to "guide you through a personal 40-day spiritual journey that will transform your answer to life's most important question:  what on earth am I here for?"

Warren correctly and cleverly identifies the power of the "40 days"--a period of time God considers "spiritually significant."  There is implicit power in beginning this ritual journey--signified with a "covenant."
 
Dictionary.com defines a covenant as "A binding agreement; a compact.  See synonyms at bargain, law.  A formal sealed agreement or contract.  A suit to recover damages for violation of such a contract.  In the Bible, God's promise to the human race.
         
Warren encourages involving others, building a spiritual team--with Warren's signature the reader has the requisite number to begin the program.

     "Wherever two or more are gathered in My name, there I am with them, also."  Matthew 18:20.

Warren's book is well-written, process-oriented, designed for individual study and small group work, and apparently identified with a larger church movement (Saddleback Churches) and publication (The Purpose Driven Church.)  As a self-identified skeptic with regards to organized religion I was intrigued by the acceptance and apparent success of Warren's work.  Warren states, "A great commitment to the Great Commandment and the Great Commission will make you a Great Christian." (pg. 306.)  (So, who wouldn't want to be a great Christian, right?)

Warren explains complex subjects--Life's "Five Greatest Questions" (and answers), God's purpose(s) for our lives--in seemingly simplistic language given that these topics have baffled scholars, philosophers, and lay people alike for centuries.  Quoting Buddha, "When the student is ready, the teacher will appear."  The source of this critical awareness?  Dissatisfaction, disbelief, disenchantment, disenfranchisement, despair, depression, (we skeptics can alliterate as well...:o)
Self-selection is evident here--as with most self-help literature these resources are most often chosen by people looking for answers, solutions.  Most of us don't read diet books for the recipes--we want an answer to weight loss.  Perhaps the "purpose" we seek is a "spiritual Atkinism" of sorts--we read the book, follow the program, because we are looking for a purpose for our life, a reason for our existence. 

Warren establishes connection with the reader immediately--stating that God planned "this moment," and "longs" for you to discover the life he created you to live.  Warren lays open the path--God has been waiting for your attention, in His infinite wisdom and patience.  Any experience up to this point--positive, negative, generative, destructive--all are part of the plan.  God, if sought, will provide the map for the rest of our journey--sort of the AAA of spiritual guidance, complete with roadside assistance--He comes to us.

(tbc)