“Our community of reflective practitioners will continue its quest informed.…”
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* Kurt C. Stange

The online discussion of the November/December 2004 issue of the *Annals* demonstrates the variety of comments that lend richness and texture to the peer-reviewed research studies. The discussion contains a number of short reactions and author responses that inform reflective practice1 and further inquiry. These serve a “letter to the editor” function, but with greater immediacy. In addition, the thoughtfulness of many of the online commentaries approaches the depth of an editorial. These analyses challenge, interpret, put into context, and often go beyond the insights accessible in the original research article. These varied comments—from short reactions to more detailed commentaries—are both interesting and provocative. Here are excerpts from some of the recent online comments. Although admittedly out of context, I hope the words of your colleagues will pique your interest and draw you into reading the deeper insights of their authors. Both the online comment and the article to which it refers are referenced.

“Patients present with something that is a problem for them, they ask the clinician to participate in its identification and resolution.…”2,3

“Once we are aware of the individual’s hopes and dreams we can no longer see him/her as a ‘crock,’ a ‘sure loser,’ a ‘dead ender’ or whatever dismissive epithet we might have assigned them.”2,3

“In this research, we have tried to give these patients a voice.”4,5

“[A]ll family physicians should be encouraged to form personal and confidential relationships with their adolescent patients in order to address unmet reproductive health needs.”6,7

“[D]epression is often under-recognized in primary care settings, not because primary care clinicians lack the knowledge or feel that it is unimportant, but because multiple competing demands during the primary care encounter often overwhelm the clinician.”8,9

“I have come to think of comorbid psychiatric illness (particularly depression) and other chronic medical illness … as the ‘Dual Diagnosis’ of the 21st century.”10,9

“… investigat[e] the two unexpected findings.”11,9

“If this direction of causality is true, then … our description of common negative symptoms experienced by elderly patients is called depression and … depression is a symptom of reduced quality of life. Therefore, we should focus our attention directly on improving physical and mental functioning and improving quality of life.”12,9

[For feedback] “[t]o be influential, a number of prerequisites have to be met.…”13,14

“A successful, but single intervention generally does not last a long time.”13,14

“Theory: the challenge for translating evidence into practice.”15,14

“A Dutch study in primary care found that diagnostic testing, labeled as superfluous by a panel of experts, had no negative effect on health status and that medical consumption was not higher in patients that underwent excessive testing.”16,14

“Our research and clinical patients have suggested numerous inputs and components for … how individuals understand and respond to their family history of chronic disease.”17,18

“I think that to date the best—maybe the only—tool [for implementing the biopsychosocial model] is the updated problem-oriented problem list.”19,3

“I believe that a new model of family medicine can be much more biopsychosocial and relationship centered when we provide continuous care not dependent on visits.”20,3

“Their paper lends a panoramic view, almost breathtaking, while integrating new and deep approaches that have emerged since Engel.”1,3

“… Engel’s biopsychosocial model ‘is both a philosophy of clinical care and a practical clinical guide.’”21,3

“George Engel’s teachings … are not dogma, they were based on insight and an empirical analysis and understanding of what is happening in the therapeutic doctor-patient relationship.”2,3

“The whole is greater than the sum of the parts.”2,3

“Clinical practice is an ongoing study (? research) in the evolution of health and illness in individuals, families and communities. The science of medical practice is dependent upon doing what all clinicians must do when patients present with a story or problem.… Every family chart is the ‘laboratory notebook’ on the evolution of health and disease.…”2,3

Please join these and other writers in adding your insights at [http://www.annfammed.org](http://www.annfammed.org), or by following the links for the comments or the article to which they refer.

*   © 2005 Annals of Family Medicine, Inc.

## REFERENCES

1.  Reis S. Welcome contribution [eletter]. [http://www.annfammed.org/cgi/eletters/2/6/576#1335](http://www.annfammed.org/cgi/eletters/2/6/576#1335), 6 December 2004.
    
    

2.  Farley ES. Perambulations on: “The Biopsychosocial Model 25 Years Later” [eletter]. [http://www.annfammed.org/cgi/eletters/2/6/576#1295](http://www.annfammed.org/cgi/eletters/2/6/576#1295), 3 December 2004.
    
    

3.  Borrell-Carrió F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Ann Fam Med. 2004;2:576–582.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMi82LzU3NiI7czo0OiJhdG9tIjtzOjIxOiIvYW5uYWxzZm0vMy8xLzg2LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

4.  Paulman A. Delay [eletter]. [http://www.annfammed.org/cgi/eletters/2/6/541#1362](http://www.annfammed.org/cgi/eletters/2/6/541#1362), 10 December 2004.
    
    

5.  Lacy NL, Paulman A, Reuter MD, Lovejoy B. Why we don’t come: patient perceptions on no-shows. Ann Fam Med. 2004;2:541–545.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMi82LzU0MSI7czo0OiJhdG9tIjtzOjIxOiIvYW5uYWxzZm0vMy8xLzg2LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

6.  Baker NJ. Accessing quality information regarding reproductive health [eletter]. [http://www.annfammed.org/cgi/eletters/2/6/549#1307](http://www.annfammed.org/cgi/eletters/2/6/549#1307), 3 December 2004.
    
    

7.  McKee DM, Karasz A, Weber CM. Health care seeking among urban minority adolescent girls: the crisis at sexual debut. Ann Fam Med. 2004;2:549–554.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMi82LzU0OSI7czo0OiJhdG9tIjtzOjIxOiIvYW5uYWxzZm0vMy8xLzg2LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

8.  Parchman ML. Depression, competing demands and new models of care [eletter]. [http://www.annfammed.org/cgi/eletters/2/6/555#1340](http://www.annfammed.org/cgi/eletters/2/6/555#1340), 6 December 2004.
    
    

9.  Noël PH, Williams JW Jr, Unützer J, et al. Depression and comorbid illness in elderly primary care patients: impact on multiple domains of health status and well-being. Ann Fam Med. 2004;2:555–562.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMi82LzU1NSI7czo0OiJhdG9tIjtzOjIxOiIvYW5uYWxzZm0vMy8xLzg2LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

10. Lawson PHI. A chronic disease needs to be treated as such [eletter]. [http://www.annfammed.org/cgi/eletters/2/6/555#1310](http://www.annfammed.org/cgi/eletters/2/6/555#1310), 3 December 2004.
    
    

11. Silverberg LI. A beginning [eletter]. [http://www.annfammed.org/cgi/eletters/2/6/555#1299](http://www.annfammed.org/cgi/eletters/2/6/555#1299), 3 December 2004.
    
    

12. Guthmann RA. A question of causality [eletter]. [http://www.annfammed.org/cgi/eletters/2/6/555#1297](http://www.annfammed.org/cgi/eletters/2/6/555#1297), 3 December 2004.
    
    

13. Buntinx F. Feedback plus and quality improvement in general practice [eletter]. [http://www.annfammed.org/cgi/eletters/2/6/569#1373](http://www.annfammed.org/cgi/eletters/2/6/569#1373), 13 December 2004.
    
    

14. Verstappen WHJM, van der Weijden T, Dubois WI, et al. Improving test ordering in primary care: the added value of a small-group quality improvement strategy compared with classic feedback only. Ann Fam Med. 2004;2:569–575.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMi82LzU2OSI7czo0OiJhdG9tIjtzOjIxOiIvYW5uYWxzZm0vMy8xLzg2LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

15. Légaré F. Theory: the challenge for translating evidence into practice [eletter]. [http://www.annfammed.org/cgi/eletters/2/6/569#1352](http://www.annfammed.org/cgi/eletters/2/6/569#1352), 7 December 2004.
    
    

16. Meijer LJ, et al. Diagnostic tests only diagnostic? [eletter]. [http://www.annfammed.org/cgi/eletters/2/6/569#1350](http://www.annfammed.org/cgi/eletters/2/6/569#1350), 7 December 2004.
    
    

17. Crouch MA, et al. Decision making implications [eletter]. [http://www.annfammed.org/cgi/eletters/2/6/583#1323](http://www.annfammed.org/cgi/eletters/2/6/583#1323), 3 December 2004.
    
    

18. Walter FM, Emery J, Braithwaite D, Marteau TM. Lay understanding of familial risk of common chronic diseases: a systematic review and synthesis of qualitative research. Ann Fam Med. 2004;2:583–594.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiMi82LzU4MyI7czo0OiJhdG9tIjtzOjIxOiIvYW5uYWxzZm0vMy8xLzg2LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

19. Spenser T. Tools for the job [eletter]. [http://www.annfammed.org/cgi/eletters/2/6/576#1364](http://www.annfammed.org/cgi/eletters/2/6/576#1364), 11 December 2004.
    
    

20. Scherger JE. A New model of family medicine is needed to reactivate the biopsychosocial model [eletter]. [http://www.annfammed.org/cgi/eletters/2/6/576#1347](http://www.annfammed.org/cgi/eletters/2/6/576#1347), 7 December 2004.
    
    

21. Gracia D. Engel’s legacy [eletter]. [http://www.annfammed.org/cgi/eletters/2/6/576#1327](http://www.annfammed.org/cgi/eletters/2/6/576#1327), 5 December 2004.