Every Patient Tells A Story Part 12

7 In one study, over half of the patients interviewed: In one study, over half of the patients interviewed: Baker LH, O'Connell D, Platt FW. What else? Setting the agenda for the clinical interview. Baker LH, O'Connell D, Platt FW. What else? Setting the agenda for the clinical interview. Annals Annals Int Med Int Med. 2005;143(10):776771.

7 In other studies doctor and patient disagreed: In other studies doctor and patient disagreed: Starfield B, Wray C, et al. The influence of patient-pract.i.tioner agreement on outcome of care. Starfield B, Wray C, et al. The influence of patient-pract.i.tioner agreement on outcome of care. Am J Public Health Am J Public Health. 1981;71:127131. Burack RC, Carpenter RR. The predictive value of the presenting complaint. J Fam Pract J Fam Pract. 1983;16:749754.

7 "If you ask questions": "If you ask questions": Epstein RM, Street RL. Patient centered care for the 21st century: physicians' roles, health systems and patients' preferences. Epstein RM, Street RL. Patient centered care for the 21st century: physicians' roles, health systems and patients' preferences. ABIM ABIM. 2008 Summer Forum, "From Rhetoric to Reality: Achieving Patient Centered Care."

7 "you can never foretell": "you can never foretell": Doyle AC. "The Sign of Four," Doyle AC. "The Sign of Four," Sherlock Holmes: Sherlock Holmes: The Complete Novels and Stories The Complete Novels and Stories, vol. 1. NY: Bantam, 1986, p. 175.

7 differences between the average and the individual: differences between the average and the individual: Fosarelli P. Medicine, spirituality and patient care. Fosarelli P. Medicine, spirituality and patient care. JAMA JAMA. 2008;300(7):836838.

8 "What the patient brings to the process": "What the patient brings to the process": Platt F. Two collaborating artists produce a work of art: the medical interview. Platt F. Two collaborating artists produce a work of art: the medical interview. Arch Int Med Arch Int Med. 2003;163:11311132.

8 A visit to a doctor's office: A visit to a doctor's office: Forem J. Make the most of a doctor's visit. Forem J. Make the most of a doctor's visit. Boston Globe Boston Globe, September 19, 2005.

8 In 1989, the average doctor's appointment: In 1989, the average doctor's appointment: Mechanic D, et al. Are patient office visits with physicians getting shorter? Mechanic D, et al. Are patient office visits with physicians getting shorter? N Engl J Med N Engl J Med. 2001;344(3):198204.

8 Studies suggest that getting a good history: Studies suggest that getting a good history: Stewart M, et al. The impact of patient-centered care on outcomes. Stewart M, et al. The impact of patient-centered care on outcomes. J Fam Pract J Fam Pract. 2000;49(9):796804. Levinson W, et al. A study of patient clues and physician responses in primary care and surgical settings. JAMA JAMA. 2000;284:10211027.

8 can even reduce visit time: can even reduce visit time: Mauksch LB, et al. Relationship, communication and efficiency in the medical encounter. Mauksch LB, et al. Relationship, communication and efficiency in the medical encounter. Arch Int Med Arch Int Med. 2008;168(13):13871395.

8 patient satisfaction is higher: patient satisfaction is higher: Stewart M, et al. The impact of patient-centered care on outcomes. Stewart M, et al. The impact of patient-centered care on outcomes. J Fam Pract J Fam Pract. 2000;49(9):796804. 12 similar patterns in other patients: similar patterns in other patients: Allen JH, et al. Cannabinoid hyperemesis: cyclical hyperemesis in a.s.sociation with chronic cannabis abuse. Allen JH, et al. Cannabinoid hyperemesis: cyclical hyperemesis in a.s.sociation with chronic cannabis abuse. Gut Gut. 2004;52:15661570.

12 Other case reports followed: Other case reports followed: Allen JH, de Moore GM, et al. Cannabinoid hyperemesis: cyclical hyperemesis in a.s.sociation with chronic cannabis abuse. Allen JH, de Moore GM, et al. Cannabinoid hyperemesis: cyclical hyperemesis in a.s.sociation with chronic cannabis abuse. Gut Gut. 2004;52;15661570. De Moore GM, Baker J, et al. Psychogenic vomiting complicated by marijuana abuse and spontaneous pneumonmediastinum. Aust NZJ Psychiatry Aust NZJ Psychiatry. 1996;30:290294. Roche E, Foster PN. Cannabinoid hyperemesis: not just a problem in Adelaide Hills. Gut Gut. 2005;54:731.

14 Studies have repeatedly shown: Studies have repeatedly shown: Hill J. Effect of patient education on adherence to drug treatment for rheumatoid arthristis. Hill J. Effect of patient education on adherence to drug treatment for rheumatoid arthristis. Ann Rheumatic Dis Ann Rheumatic Dis. 2001;60:869875. Kripalani S, et al. Interventions to enhance medication adherence in chronic disease. Arch Int Med Arch Int Med. 2007;167(6):540549.

14 Patients who understand their illness: Patients who understand their illness: Lin E HB, et al. Working with patients to enhance medication adherence. Lin E HB, et al. Working with patients to enhance medication adherence. Clin Diabetes Clin Diabetes. 2008;26:1719.

16 A diagnosis of terminal cancer: A diagnosis of terminal cancer: Ca.s.sell EJ. Diagnosing suffering: a perspective. Ca.s.sell EJ. Diagnosing suffering: a perspective. Annal Int Med Annal Int Med. 1999;131:531534.

Chapter 2: The Stories They Tell.

28 Current thinking focuses on stories as the key: Current thinking focuses on stories as the key: Lucey CR. From problem lists to illness scripts: a new strategy to learn and teach professional thinking in small groups, a lecture given 1/14/03. Hunter KM. Lucey CR. From problem lists to illness scripts: a new strategy to learn and teach professional thinking in small groups, a lecture given 1/14/03. Hunter KM. Doctors' Stories: The Narrative Structure of Medical Knowledge Doctors' Stories: The Narrative Structure of Medical Knowledge. Princeton, NJ: Princeton University Press, 1991, p. 17. Montgomery K. How Doctors Think: Clinical Judgment and the Practice of Medicine How Doctors Think: Clinical Judgment and the Practice of Medicine. New York: Oxford University Press 2006;4553. Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med N Engl J Med. 2006;355:221725.

28 These stories, what researchers now call illness scripts: These stories, what researchers now call illness scripts: Schmidt HG, Rikers RMJP. How expertise develops in medicine: knowledge encapsulation and illness script formation. Schmidt HG, Rikers RMJP. How expertise develops in medicine: knowledge encapsulation and illness script formation. Med Ed Med Ed. 2007;41:113339, Charlin B, et al. Scripts and clinical reasoning. Med Ed Med Ed. 2007;41:117884.

29 One of the ways doctors are taught to think about disease: One of the ways doctors are taught to think about disease: Mangruikar RS, et al. What is the role of the clinical "pearl." Mangruikar RS, et al. What is the role of the clinical "pearl." Am J Med Am J Med. 2002; 113(7):61724. Ioannidis JPA, Lau J. Uncontrolled pearls, controlled evidence, meta-a.n.a.lysis and the individual patient. J Clin Epidemiolo J Clin Epidemiolo. 1998;51(8):70911.

31 Dr. Andre Lemierre, a physician in Paris, first described this disease in 1936: Dr. Andre Lemierre, a physician in Paris, first described this disease in 1936: Lemierre A. On certain septicemias due to anaerobic organisms. Lemierre A. On certain septicemias due to anaerobic organisms. Lancet Lancet. 1936;1:7013. Centor RM. Should Lemierre's syndrome re-emergence change pharyngitis guidelines? Ma.n.u.script from author. Singhal A, Kerstein MD. Lemierre's syndrome. Medscape Medscape. 2001;94(9):88687. http://www.medscape.com/viewarticle/410830.

32 Like those presented to Fitzgerald: Like those presented to Fitzgerald: Hunter KM. Hunter KM. Doctors' Stories: The Narrative Structure of Medical Knowledge Doctors' Stories: The Narrative Structure of Medical Knowledge. Princeton, NJ: Princeton University Press, 1991.

34 Anderson spent a year interviewing patients about their experiences in the health care setting: Anderson spent a year interviewing patients about their experiences in the health care setting: Anderson A. Anderson A. On the Other Side: African Americans Tell of Healing On the Other Side: African Americans Tell of Healing. Louisville, KY: Westminster John Knox Press, 2001.

Chapter 3: A Vanishing Art.

39 A man in his fifties comes to an emergency room: A man in his fifties comes to an emergency room: Jauhar S. The demise of the physical exam. Jauhar S. The demise of the physical exam. N Engl J Med N Engl J Med. 2006;354:548551. 42 most of the doctors holding a post-residency fellowship: most of the doctors holding a post-residency fellowship: Mangione M, Nieman LZ, Kaye D, Gracely E. The teaching and practice of cardiac auscultation during internal medicine and cardiology training: a nationwide survey. Mangione M, Nieman LZ, Kaye D, Gracely E. The teaching and practice of cardiac auscultation during internal medicine and cardiology training: a nationwide survey. Annal Int Med Annal Int Med. 1993;119(1):4654.

42 If letter grades were being handed out: If letter grades were being handed out: Mangione S, Nieman LZ. Pulmonary auscultatory skills during training in internal medicine and family practice. Mangione S, Nieman LZ. Pulmonary auscultatory skills during training in internal medicine and family practice. Am J Resp & Crit Care Med Am J Resp & Crit Care Med. 1999;159(4 pt 1):11191124.

43 Residents, their teacher-physicians: Residents, their teacher-physicians: Vukanovic-Criley JM, Criley S, et al. Competency in cardiac examination skills in medical students, trainees, physicians and faculty. Vukanovic-Criley JM, Criley S, et al. Competency in cardiac examination skills in medical students, trainees, physicians and faculty. Arch Int Med Arch Int Med. 2006;166:610616.

43 Perhaps, Mangione suggests: Perhaps, Mangione suggests: Mangione S. Teaching and practice of cardiac auscultation during internal medicine and cardiology training. Mangione S. Teaching and practice of cardiac auscultation during internal medicine and cardiology training. Ann Int Med Ann Int Med. 1993;119(1):4754. Mangione S, Nieman L. Pulmonary auscultatory skills during training in internal medicine and family practice. Am J Am J Resp Crit Care Resp Crit Care. 1999;159:11191124. Mangione S, Duffy FD. The teaching of chest auscultation in primary care training: has anything changed in the 1990's. Chest Chest. 2003;124(4):14301436.

44 In 1980 the average length of stay: In 1980 the average length of stay: Cha.s.sin MR. Variations in length of stay: their relationship to health outcomes. Report for the Office of Technical a.s.sessment, U.S. Congress, Washington, D.C., 1983. Cha.s.sin MR. Variations in length of stay: their relationship to health outcomes. Report for the Office of Technical a.s.sessment, U.S. Congress, Washington, D.C., 1983.

44 In a recent study done at Yale: In a recent study done at Yale: Private communication, John Moriarty, a.s.sociate Program Director, Yale Tradition, Internal Medicine Residency Program. Private communication, John Moriarty, a.s.sociate Program Director, Yale Tradition, Internal Medicine Residency Program.

45 In 1950 approximately 15,000 people died of rheumatic heart disease: In 1950 approximately 15,000 people died of rheumatic heart disease: http://www.americanheart.org/presenter.jhtml?identifier=4712.

52 In a study published in 2002: In a study published in 2002: McGreevy KM, et al. Clinical breast examination-practices among women undergoing screening mammography. McGreevy KM, et al. Clinical breast examination-practices among women undergoing screening mammography. Radiology Radiology. 2002;24:555559.

Chapter 4: What Only the Exam Can Show.

56 The patient's story contained the diagnostic tip-off: The patient's story contained the diagnostic tip-off: Hampton JR, et al. Contribution of history-taking, physical examination and laboratory evaluation to diagnosis and management of medical outpatients. Hampton JR, et al. Contribution of history-taking, physical examination and laboratory evaluation to diagnosis and management of medical outpatients. BMJ BMJ. 1975;2(5969):486489. Sandler G. The importance of the history in the medical clinic and the cost of unnecessary tests. Am Heart J Am Heart J. 1980;100(pt 1):928931.

56 When he couldn't find a good answer: When he couldn't find a good answer: Reilly BM. Physical examination in the care of medical inpatients: an observational study. Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet Lancet. 2003;362:11001105.

Chapter 5: Seeing Is Believing.

84 "If the patient's normal appearance is preserved": "If the patient's normal appearance is preserved": From "Prognosis" in From "Prognosis" in Hippocratic Writings Hippocratic Writings. NY: Penguin Books, 1983, p. 171.

84 "By realizing and announcing beforehand": "By realizing and announcing beforehand": Ibid., p. 170. Ibid., p. 170.

88 The decision to either admit the patient: The decision to either admit the patient: Mellors JW, Horwitz RI, et al. A simple index to identify occult bacterial infection in adults with acute unexplained fever. Mellors JW, Horwitz RI, et al. A simple index to identify occult bacterial infection in adults with acute unexplained fever. Arch Int Med Arch Int Med. 1987;147(4):666671.

90 "I have trained myself": "I have trained myself": Doyle AC. "The Adventure of the Blanched Soldier," Doyle AC. "The Adventure of the Blanched Soldier," Sherlock Holmes: The Complete Novels and Stories Sherlock Holmes: The Complete Novels and Stories, vol. 1. NY: Bantam, 1986.

91 But the most important trait they shared: But the most important trait they shared: Several sources were used in researching this: Klauder JV. Sherlock Holmes as a dermatologist. Several sources were used in researching this: Klauder JV. Sherlock Holmes as a dermatologist. Arch Derm Syphilology Arch Derm Syphilology. 1953;68(4):363377. Reed J. A medical perspective on the adventures of Sherlock Holmes. Med Humanit Med Humanit. 2001;27:7681. Ma.s.sey EW. Joseph Bell MD-Mr. Sherlock Holmes? South Med J South Med J. 1980;73(12):16351636. Scarlett E P. The old original: notes on Dr. Joseph Bell whose personality and peculiar abilities suggested the creation of Sherlock Holmes. Arch Int Med Arch Int Med. 1964;114:696701. Conan Doyle dead from heart attack. New York Times New York Times, July 8, 1930. Wisser KM. The creation, reception and perpetuation of the Sherlock Holmes phenomenon 18871930. Master's thesis, University of North Carolina, Chapel Hill, 2000. Leibow E. Dr Joe Bell: Model for Sherlock Holmes Dr Joe Bell: Model for Sherlock Holmes. Bowling Green, OH: Bowling Green University Popular Press, 1982.

92 "From close observation and deduction": "From close observation and deduction": Leibow E. Leibow E. Dr Joe Bell: Model for Sherlock Holmes Dr Joe Bell: Model for Sherlock Holmes. Bowling Green, Ohio: Bowling Green University Popular Press, 1982.

94 These students also improved: These students also improved: Dolev JC, Friedlaender LK, Braverman IM. Use of fine art to enhance visual diagnostic skills. Dolev JC, Friedlaender LK, Braverman IM. Use of fine art to enhance visual diagnostic skills. JAMA JAMA. 2001;286 (9):10201021.

95 On a monitor I see six adults: On a monitor I see six adults: This video was conceived and produced by Daniel J. Simons, a.s.sociate Professor, University of Illinois, Visual Cognition Lab. Screen it for your friends by going to This video was conceived and produced by Daniel J. Simons, a.s.sociate Professor, University of Illinois, Visual Cognition Lab. Screen it for your friends by going to http://viscog.beckman.uivc.edu/djs_lab/index.html.

96 So did more than half: So did more than half: Simons DJ, Chabris CF. Gorillas in our midst: sustained inattention blindness for dynamic events. Simons DJ, Chabris CF. Gorillas in our midst: sustained inattention blindness for dynamic events. Perception Perception. 1999;28:10591074.

97 Researchers call this phenomenon: Researchers call this phenomenon: Chun MM, Marois R. The dark side of visual attention. Chun MM, Marois R. The dark side of visual attention. Curr Op Neurobio Curr Op Neurobio. 2002;12:184189. Most SB, Scholl BJ, Clifford ER, Simons DJ. What you see is what you set: sustained inattentional blindness and the capture of awareness. Psych Rev Psych Rev. 2005;112(1):217242.

106 Partic.i.p.ants in the study were shown two pictures: Partic.i.p.ants in the study were shown two pictures: Kelley TA, et al. Effect of scene inversion on change detection of targets matched for visual salience. Kelley TA, et al. Effect of scene inversion on change detection of targets matched for visual salience. Journal of Vision Journal of Vision. 2003;2:15.

Chapter 6: The Healing Touch.

109 "It is the business of the physician": "It is the business of the physician": Adams CD, ed. Adams CD, ed. The Genuine The Genuine Works of Hippocrates Works of Hippocrates. NY: Dover, 1868, from The Digital Hippocrates The Digital Hippocrates, http://www.chlt.org/sandbox/dh/Adams/page.160.a.php.

112 The third that didn't have the CT scan: The third that didn't have the CT scan: Musunuru S, Chen H, et al. Computed tomography in the diagnosis of acute appendicitis: definitive or detrimental Musunuru S, Chen H, et al. Computed tomography in the diagnosis of acute appendicitis: definitive or detrimental. J Gastrointest Surg. 2007;11:14171422.

125 Mammographers agreed with one another: Mammographers agreed with one another: Elmore JG, Wells CK, et al. Variations in radiologists' interpretation of mammograms. Elmore JG, Wells CK, et al. Variations in radiologists' interpretation of mammograms. N Engl J Med N Engl J Med. 1994;331:14931499.

Chapter 7: The Heart of the Matter.

133 "tip of the iceberg": "tip of the iceberg": Salvatore Mangione, personal communication. Salvatore Mangione, personal communication.

136 "on account of the great degree of fatness": "on account of the great degree of fatness": Nuland SB. Nuland SB. Doctors: The Biography of Medicine Doctors: The Biography of Medicine. NY: Vintage Books, 1995, p. 220.

136 "I recalled a well known acoustic phenomenon": "I recalled a well known acoustic phenomenon": Duffin J. Duffin J. To See with a Better Eye: The Life of RTH Laennec To See with a Better Eye: The Life of RTH Laennec. Princeton, NJ: Princeton University Press, 1998, p. 122.

137 They argued that diseases could be cla.s.sified: They argued that diseases could be cla.s.sified: Ibid., p. 26. Ibid., p. 26.

139 It was usually attributed to heart failure: It was usually attributed to heart failure: I usually explain heart failure to my patients using a scene from I usually explain heart failure to my patients using a scene from I Love Lucy I Love Lucy. In this episode, Lucy and her friend Ethel take jobs in a candy factory, wrapping candies as they move by on a conveyer belt. Initially they are able to keep up and all the candies end up neatly wrapped. As the conveyer belt picks up speed, more candies are delivered, and it becomes harder and harder to keep up. Before long the two are overwhelmed and candies end up everywhere-in their pockets, in their blouses, on the floor. What happens to Ethel and Lucy is a.n.a.logous to what happens to the heart-with even the slightest physical stress, the weakened organ is overwhelmed by the amount of blood being brought in and, like the overflowing candies, the extra fluid backs up, ending up just about everywhere.

139 the now cla.s.sic finding of emphysema: the now cla.s.sic finding of emphysema: Duffin J. Duffin J. To See with a Better Eye: The Life of RTH Laennec To See with a Better Eye: The Life of RTH Laennec. Princeton, NJ: Princeton University Press, 1998, pp. 15758.

139 "oppression and palpitations": "oppression and palpitations": Major RH. Major RH. Cla.s.sic Descriptions of Disease Cla.s.sic Descriptions of Disease. Springfield, IL: Charles C Thomas Publisher, 1932, pp. 371372.

145 In one large multispecialty group in Boston: In one large multispecialty group in Boston: Blanchard G P. Is listening through a stethoscope a dying art? Blanchard G P. Is listening through a stethoscope a dying art? Boston Globe Boston Globe, May 25, 2004.

146 five cardiologists were pitted against echocardiography: five cardiologists were pitted against echocardiography: Jaffe WM, et al. Clinical evaluation versus Doppler echocardiogram in the quant.i.tative a.s.sessment of valvular heart disease. Jaffe WM, et al. Clinical evaluation versus Doppler echocardiogram in the quant.i.tative a.s.sessment of valvular heart disease. Circulation Circulation. 1988;78:267275. 146 In a study done by Christine Attenhofer: In a study done by Christine Attenhofer: Attenhofer Jost CH, Turina J, Mayer K, Seifert B, Amann FW, Buechi M, et al. Echocardiography in the evaluation of systolic murmurs of unknown cause. Attenhofer Jost CH, Turina J, Mayer K, Seifert B, Amann FW, Buechi M, et al. Echocardiography in the evaluation of systolic murmurs of unknown cause. Am J Med Am J Med. 2000;108:614620.

146 One study done of emergency room physicians: One study done of emergency room physicians: Reichlin S, et al. Initial clinical evaluation of cardiac systolic murmurs in the ED by noncardiologist. Reichlin S, et al. Initial clinical evaluation of cardiac systolic murmurs in the ED by noncardiologist. Am J Emerg Med Am J Emerg Med. 2004;22:7175.

147 Several studies have been done evaluating programs: Several studies have been done evaluating programs: Smith CA, et al. Teaching cardiac examination skills: a controlled trial of two methods. Smith CA, et al. Teaching cardiac examination skills: a controlled trial of two methods. J Gen Int Med J Gen Int Med. 2006;21(1):16. Barrett MJ. Mastering cardiac murmurs: the power of repet.i.tion. Chest Chest. 2004;126:470475. Favrat B, et al. Teaching cardiac auscultation to trainees in internal medicine and family practice: does it work? BMC Med Ed BMC Med Ed. 2004;4:5. http://www.biomedcentral.com/1472-6920/4/5.

161 "Direct observation of trainees": "Direct observation of trainees": Holmboe ES, Hawkins RE. Evaluating the clinical competence of residents in internal medicine: a review. Holmboe ES, Hawkins RE. Evaluating the clinical competence of residents in internal medicine: a review. Ann Int Med Ann Int Med. 1998;129:4248.

162 A study published recently shows how inadequate: A study published recently shows how inadequate: Hicks CM, et al. Procedural experience and comfort level in internal medicine trainees. Hicks CM, et al. Procedural experience and comfort level in internal medicine trainees. J Gen Intern Med J Gen Intern Med. 2000;15:716722.

Chapter 8: Testing Troubles.

171 Furthermore, there is plenty of solid evidence: Furthermore, there is plenty of solid evidence: Klempner MS, et al. Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of Lyme disease. Klempner MS, et al. Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of Lyme disease. N Engl J Med N Engl J Med. 2001;345:8592.

172 Finally, in October 1975: Finally, in October 1975: Clark E. Lyme disease: one woman's journey into tick country. Clark E. Lyme disease: one woman's journey into tick country. http://www.yankeemagazine.com/issues/2007-07/features/lymecountry.

173 Comparing the location of Steere's mystery cases: Comparing the location of Steere's mystery cases: Steere AC. David France, scientist at work. Steere AC. David France, scientist at work. New York Times New York Times, May 4, 1999.

173 In order to transmit the infection: In order to transmit the infection: Steere AC, et al. The emergence of Lyme disease. Steere AC, et al. The emergence of Lyme disease. J Clin Invest J Clin Invest. 2004;113(8):10931101.

173 some studies suggest that the most common presentation: some studies suggest that the most common presentation: Tibbles CD, et al. Does this patient have erythema migrans. Tibbles CD, et al. Does this patient have erythema migrans. JAMA JAMA. 2007;297:26172627.

178 PostLyme Disease syndrome: PostLyme Disease syndrome: Steere AC, et al. a.s.sociation of chronic Lyme arthritis with HLA-DR4 and HLA-DR2 alleles. Steere AC, et al. a.s.sociation of chronic Lyme arthritis with HLA-DR4 and HLA-DR2 alleles. N Engl J Med N Engl J Med. 1990;323:219223.

178 They recruited one hundred residents: They recruited one hundred residents: Shad.i.c.k NA, Phillips CB, Logigian EL, Steere AC, Kaplan RF, Berardi VP, et al. The long-term clinical outcomes of Lyme disease. A population-based retrospective cohort study. Shad.i.c.k NA, Phillips CB, Logigian EL, Steere AC, Kaplan RF, Berardi VP, et al. The long-term clinical outcomes of Lyme disease. A population-based retrospective cohort study. Ann Int Med Ann Int Med. 1994;121:560567.

178 Other studies too have found: Other studies too have found: Cairn V, G.o.dwin J. Post-Lyme borreliosis syndrome: a meta-a.n.a.lysis of reported symptoms. Cairn V, G.o.dwin J. Post-Lyme borreliosis syndrome: a meta-a.n.a.lysis of reported symptoms. Int J Epi Int J Epi. 2005;34:13401345.

179 Researchers at Tufts Medical Center: Researchers at Tufts Medical Center: Klempner MS, et al. Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of Lyme disease. Klempner MS, et al. Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of Lyme disease. N Engl J Med N Engl J Med. 2001;345:8592.

179 Two other rigorous trials: Two other rigorous trials: Krupps LB, et al. Study and treatment of post Lyme disease. Krupps LB, et al. Study and treatment of post Lyme disease. Neurology Neurology. 2003;60:19231930. Fallon BA. A randomized, placebo-controlled trial of repeated IV antibiotic therapy for Lyme encephalopathy. Neurology Neurology. 2008;70:9921003.

181 They don't trust either physical exams: They don't trust either physical exams: The International Lyme and a.s.sociated Diseases Society Evidence-based guidelines for the management of Lyme disease, published November 2006, p. 7, The International Lyme and a.s.sociated Diseases Society Evidence-based guidelines for the management of Lyme disease, published November 2006, p. 7, http://www.ilads.org/guidelines.html, accessed December 31, 2007.

181 In fact, when used as recommended: In fact, when used as recommended: Tugwell P, et al. Laboratory evaluation in the diagnosis of Lyme disease. Tugwell P, et al. Laboratory evaluation in the diagnosis of Lyme disease. Ann Int Med Ann Int Med. 1997;127(12):11091123.

181 These are some of the most common symptoms: These are some of the most common symptoms: Fletcher K. Ten most common health complaints. Fletcher K. Ten most common health complaints. Forbes Forbes, July 15, 2003. http://www.forbes.com/2003/07/15/cx_kf_0715health.html.