The Confident Clinician Podcast

In this episode, our founder, Dr. Jordan Robertson ND, shares a key paper in the nutritional management of Graves' disease that explains why patients experience rapid weight gain after treatment.  She discusses the metabolic rate changes that happen at diagnosis, 1 and 6 months after treatment, and how patients can be euthyroid but experience weight gain after ADT.  This episode is a snapshot of our full Graves' medical topic that supports clinicians with decision-making around supplementation, exercise and conventional treatments.  The Confident Clinician membership supports hundreds of practitioners every day in practice through our integrative medicine database and standards of care. Our membership opens twice per year, with July 2024 being our next enrolment opportunity for Naturopathic Doctors, Medical Doctors and Nurse Practitioners who practice evidence-based Integrative Medicine.    Hayashi, A. et al. Short-term Change in Resting Energy Expenditure and Body Compositions in Therapeutic Process for Graves' Disease. Intern. Med. 59, 1827–1833 (2020).

In this episode, Dr. Stephanie Bayliss, a Naturopathic Doctor based in British Columbia, reviews how we assess and manage sexual side effects from SSRI's. Up to 80% of SSRI treated patients can experience sexual side effects. This may include changes to desire, arousal or satisfaction. Dr. Bayliss explores both the conventional care guidelines on managing these sexual side effects, and promising up and coming integrative solutions, including Saffron and Probiotics.    References: Hashemi-Mohammadabad, N., Taghavi, S.-A., Lambert, N., Moshtaghi, R., Bazarganipour, F. & Sharifi, M. (2024). Adjuvant administration of probiotic effects on sexual function in depressant women undergoing SSRIs treatment: a double-blinded randomized controlled trial. BMC Psychiatry, 24(1), 44. https://doi.org/10.1186/s12888-023-05429-w  Izadi, S., Mohammad-Alizadeh-Charandabi, S., Yadollahi, P., & Mirghafourvand, M. (2024). Effect of vitamin E with and without saffron on the sexual function in women of reproductive age with sexual dysfunction: a randomized controlled trial. BMC women's health, 24(1), 143. https://doi.org/10.1186/s12905-024-02980-w  Kashani, L., Raisi, F., Saroukhani, S., Sohrabi, H., Modabbernia, A., Nasehi, A. A., Jamshidi, A., Ashrafi, M., Mansouri, P., Ghaeli, P., & Akhondzadeh, S. (2013). Saffron for treatment of fluoxetine-induced sexual dysfunction in women: randomized double-blind placebo-controlled study. Human psychopharmacology, 28(1), 54–60. https://doi.org/10.1002/hup.2282 Modabbernia, A., Sohrabi, H., Nasehi, A. A., Raisi, F., Saroukhani, S., Jamshidi, A., Tabrizi, M., Ashrafi, M., & Akhondzadeh, S. (2012). Effect of saffron on fluoxetine-induced sexual impairment in men: randomized double-blind placebo-controlled trial. Psychopharmacology, 223(4), 381–388. https://doi.org/10.1007/s00213-012-2729-6  Perlis, R. H., Laje, G., Smoller, J. W., Fava, M., Rush, A. J., & McMahon, F. J. (2009). Genetic and clinical predictors of sexual dysfunction in citalopram-treated depressed patients. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology, 34(7), 1819–1828. https://doi.org/10.1038/npp.2009.4   

In this episode, Dr. Sylvi Martin, a naturopathic doctor and registered nurse psychotherapist based in Ontario, delves into the often overlooked realm of body image and eating disorders in men. Despite common misconceptions, a significant portion of individuals affected by eating disorders are men, comprising 10 to 25% of those affected. Dr. Martin highlights the challenges in identifying and addressing eating disorders in men, citing gaps in research and diagnostic tools that fail to capture the unique experiences and concerns of male individuals. Drawing from a qualitative study, Dr. Martin explores themes such as critical self-perception, societal influences, and the impact of media representations on men's body image. She emphasizes the importance of understanding men's experiences with body image and eating disorders to ensure proper assessment and support, calling for greater awareness and research in this often neglected area of healthcare. Dr. Martin will be one of the speakers at The Confident Clinician's Men's Health Grand Rounds happening May 02-May 03. Learn more here.   Be sure to check out Dr. Sylvi Martin, ND Eating Behaviour Workshop, from DSM to Diet Culture here   Reference: Paphiti, A., Newman, E., & Collin, P. (2024). “It's a Lot Deeper than the Way It Looks”: An Interpretative Phenomenological Analysis of Body Image for Men With Eating Disorders. The Journal of Men's Studies. doi: 10.1177/10608265231225400  

In this podcast, Antonella Aguilera-Ruiz, ND discusses the most evidence based way to talk about depression with our patients. And what can be the implications of attributing causation to the chemical imbalance theory. We take a look at two trials that give insight on why complexity is likely the name of the game and how causal attribution affects patient outcomes.  References:  Kemp, J. J., Lickel, J. J., & Deacon, B. J. (2014). Effects of a chemical imbalance causal explanation on individuals' perceptions of their depressive symptoms. Behaviour Research and Therapy, 56, 47–52. https://doi.org/10.1016/j.brat.2014.02.009 Nolan, A., & O'Connor, C. (2019). The effect of causal attributions for depression on help-seeking and treatment preferences. Journal of Affective Disorders, 257, 477–485. https://doi.org/10.1016/j.jad.2019.07.017 Zimmermann, M., & Papa, A. (2020). Causal explanations of depression and treatment credibility in adults with untreated depression: Examining attribution theory. Psychology and Psychotherapy: Theory, Research and Practice, 93(3), 537–554. https://doi.org/10.1111/papt.12247

In this episode, our founder, Dr. Jordan Robertson, uses chronic pancreatitis as an example to show why we need to read standards of care with a critical eye, especially when they make nutrition recommendations.  Nutrition recommendations in SOC guidelines are often aged (old studies), small studies or singular studies, or studies that look at an adjacent audience, not the audience in question.  We discuss the single study that has been the reference for not using a "high fibre" diet in patients with chronic pancreatitis and why we need to be critical of this recommendation, given that many patients with CP have a significant diabetes risk.  The study in question is this one:  Dutta, S. & Hlasko, J. Dietary fiber in pancreatic disease: Effect of high fiber diet on fat malabsorption in pancreatic insufficiency and in vitro study of the interaction of dietary fiber with pancreatic enzymes. Am. J. Clin. Nutr. 41, 517–525 (1985).  

The episode featuring Dr. Kara Dionisio, ND,faculty member at the Confident Clinician Club and facilitator of the Menopause Fellowship, discusses the role of naturopathic doctors in menopause care and explores potential for interdisciplinary collaboration in treatment. Key discussions included analyzing menopause healthcare delivery through naturopathic and conventional means, the increasing openness of conventional doctors to hormone therapy, and the unique value naturopathic practitioners bring through their holistic approach and time investment in patient education. Emphasis was placed on the importance of lifestyle changes, patient education, and nuanced treatment plans beyond hormone therapy, with the future of menopause care envisioned as systematic and collaborative, akin to pregnancy care models. Acknowledging both the possibilities and the complexities within current and future practices, the podcast encourages clinicians to consider their roles and foster partnerships in menopause management. Action Points  Recognize the role of naturopathic doctors in menopause care and strengthen interdisciplinary collaboration.  Understand the evolving acceptance of hormone therapy among conventional practitioners and leverage it to enhance patient care.  Emphasize the significance of comprehensive patient education on lifestyle changes, health screenings, and non-hormonal treatment options.  Promote the benefits of naturopathic care, such as personalized attention and education, for midlife women.  Encourage collaboration with conventional doctors to facilitate access to a full spectrum of healthcare services, including diagnostics and prescriptions.  Explore innovative approaches and research in menopause management, especially concerning lifestyle interventions and patient-specific care models.  Enhance communication with other healthcare professionals to create a unified, patient-centered approach to menopause care.     After a productive year inside the Confident Clinician Menopause Fellowship, with 14 standout naturopathic doctors, we held rich discussions on menopause, critically appraised research, and also engaged in broader deliberations on menopause healthcare advancement. An upcoming menopause practicum, April 11-13 will feature a comprehensive update on menopausal hormone therapy. Here, we're delving into our ongoing role in menopause care, exploring our impact amid the evolving healthcare landscape.   Interested in the Menopause Practicum? This limited capacity opportunity happening Apirl 11-13, 2024 is for practitioners who have purchased and completed the MHT Advanced Practice Training with Dr. Kara Dionisio, ND with the Confident Clinician. You can learn more about the pre-requisite here, or if you have already completed it, be sure to check you inbox for exclusive invite to the practicum!   

In today's podcast, we have Dr. Kim Bretz, ND, our GI fellowship facilitator, joining us to share the significant updates in the field of SIBO testing that will shape how we diagnose patients with this condition in the future.  She calls out one particular paper (referenced below) that calls into question many of the standard SIBO tests that practitioners use and explains where we go from here as practitioners who have relied on these outdated forms of testing in their practices.  Dr. Bretz is running a 1-day Advanced Training, SIBO Demystified, which is an essential training for practitioners who test and treat for SIBO in their practices. You can register for the course here to gain access to the live session, the recordings and the practice resources you need to be an up to date practitioner.  Join here.    Dervin H, Zarate-Lopez N, Sweis R,et al. Low prevalence of positive hydrogen breath tests inpatients with functional gastrointestinal conditions andhypermobile Ehlers–Danlos syndrome. Neurogastroenterology& Motility. 2023;35:e14570. doi:10.1111/nmo.14570

We don't want your patients to be satisfied. What do your patients expect when they see you? Do they expect a diet plan and a supplement? Probably. When people see a Naturopathic Doctor or an Integrative Doctor they expect to leave with a nutrition plan and a supplement. So when they get that, they are satisfied.  But satisfied people rarely refer, rarely come back and rarely write reviews. We want your patients to be ecstatic.  In today's special podcast episode, our founder, Dr. Jordan Robertson shows you 3 ways to stop meeting patient's expectations, and how to start exceeding them. We've built our entire framework for The Confident Clinician around exceeding expectations.  You can do this too.  By leveraging our resources (which based on our membership rate is about $1 each) you can be exceptional in your work every day.  Join now. 

Today's podcast episode is broadcast on both of our podcast platforms, Women's Health Unplugged, which is our public-facing podcast. It has over 500,000 downloads and has covered many women's health topics over the last few years.  Our clinician-facing podcast, The Confident Clinician Podcast, focuses on clinical topics and studies that are changing our practices in integrative care.  Today's topic is for everyone. We're talking about the term "hormone imbalance" and how damaging this term can actually be. We cover concepts such as Why accurate diagnosis is the first step towards getting treatment.  Why universal language is an important bridge to connect practitioners.  Why using vague terms (like your 'private parts') does a disservice to patients.  Which "buckets" of hormone concerns you might fall into, and why we need to accurately label you.  Where we go from here.   If you're a practitioner, be sure to get on the wait list for The Confident Clinician at www.confidentclinicianclub.com to ensure you're the first to access our hormone assessment module in 2024 when our doors open. 

In today's podcast, we cover a brand new study by Dev (2023) on using low-dose thyroid hormone in patients with subclinical hypothyroidism (TSH between 4.5-10 mIU/L).  We've seen the connection between slightly elevated TSH and migraine in a few populations, but this is the first clinical trial that attempts to lower headache frequency, intensity and duration with thyroid hormone replacement.  Have a listen to the episode, and be sure to subscribe to The Stacks, our new integrative medicine magazine that's free for subscribers. We'll help you stay up to date, without having to do the research yourself.    References:  1.Bhattacharjee, M. et al. Association of Low Thyroid Hormone with Migraine Headache. Mymensingh Méd. J. : MMJ 30, 43–47 (2021).   2.Dev, P. et al. The effect of low dose thyroid replacement therapy in patients with episodic migraine and subclinical hypothyroidism: A randomised placebo-controlled trial. Cephalalgia 43, 03331024231182684 (2023).   3.Hassan, M. A. E. et al. Potential Association between Subclinical Hypothyroidism and Childhood Migraine. Medicina 58, 1346 (2022).

In this episode we cover a recent study by Carrick (2023) and the effect of various claims on the beliefs and purchasing by fertility patients.  The patients in the study were presented with a fake supplement that made claims about surrogate markers with or without additional warnings about risks and/or live birth rate. The findings are incredibly important for integrative clinicians or clinicians who work in fertility and struggle with their patients navigating the online space.  One of the goals of our mentorship with clinicians inside the Confident Clinician is to help build bridges with conventional practitioners and the standards of care. When clinicians are clear about what the evidence actually says, it increases confidence in both patients and practitioners alike.  Enjoy the episode!  Be sure to subscribe to The Stacks, our free integrative medicine magazine for clinicians. You can get your first free copy here.      Carrick, M., Wilkinson, J., Polyakov, A., Kirkham, J. & Lensen, S. How do IVF patients interpret claims about fertility treatments? A randomised survey experiment. Hum. Fertil. 26, 347–354 (2023).

Decreasing night time water as a solution for nocturia is a common self-managing strategy that patients use and a common recommendation clinicians use to reduce the number of night time wakings.  The connection between sodium, fluid balance, urine production and nocturia has been well studied and presents a possible dietary solution to reduce the number of night time wakings your patinets with overactive bladder experience.  Have a listen to the episode to hear how much sodium you need to cut, and the bigger discussion on sodium, heart disease, sleep apnea, nocturia and metabolic syndrome.      Matsuo, T. et al. Efficacy of salt reduction for managing overactive bladder symptoms: a prospective study in patients with excessive daily salt intake. Sci. Rep. 11, 4046 (2021).

Today's podcast shares the literature on PCOS and exercise, and whether we're causing harm or doing good in our patients when we recommend HIIT. If you're online, you've likely seen mention of “exercise increasing stress” or “exercise worsening cortisol” in patients with PCOS and the suggestion that perhaps these patients shouldn't do hard exercise because they might “get worse”  In this episode, we cover the literature on HIIT and PCOS that has been published in the last 18 months, as well as a particular study by Mohammadi (2023) that specifically looks at cortisol in patients with PCOS when they do HIIT (run/walk intervals).  We also talk about the “forest for the trees” concept of prescribing exercise to our patients and how we can't get swept away with online trends - especially when there isn't research to support it.  Have a listen to the episode and we hope you join us in September for the Integrative Medicine Grand Rounds weekend where we are spending 3 days covering a Women's Health Update.    Mohammadi, S., Monazzami, A. & alavimilani, S. Effects of eight-week high-intensity interval training on some metabolic, hormonal and cardiovascular indices in women with PCOS: a randomized controlled trail. BMC Sports Sci., Med. Rehabilitation 15, 47 (2023).  

In today's episode we share the link between prostate cancer and alcohol, but more importantly, discuss the key thing to think about when looking at older literature on a topic.  As integrative clinicians, we are often excited about innovation in testing and assessment. We enjoy being the "health detective" that uses the latest technology to help patients be "found" or accurately diagnosed.  If we want to be innovative with assessment, we also have to apply a particular thought process to the way we read older literature. Are older studies conducted on who we think they are? Or did we change our diagnostic criteria enough that a study published in the 80s is no longer studying who we think we are studying? We use the conversation about PSA as a screening tool and alcohol intake as a good example of this.  Your opportunity to join The Confident Clinician is almost here. You can join the wait list here http://www.confidentclinicianclub.com  You can also test-drive our resources for only $37 (our IBD module) here or in USD here   Macke, A. J. & Petrosyan, A. Alcohol and Prostate Cancer: Time to Draw Conclusions. Biomolecules 12, 375 (2022).  

We know that we don't make promises in medicine. But what we should be able to do, is explain when a patient may expect results, what we expect to change, and which parts of their condition won't be improved by our treatment plans.    Can you do that?    In today's podcast, we announce our unbelievable offer to get access to our IBD medical topic, downloads, videos and evidence tables for just $37. You can get your access here (CAD, USD).    We use IBD as an illustration of how we often expect our patients to “get better”, we tell them they will “get better” but the reality of the research is that they might get “partially better on these few well researched parameters of their condition.”     In our IBD evidence tables, we show you which interventions induce remission versus maintain it, which interventions should change inflammation on colonoscopy (and which don't) and what to expect from diet change.    The confidence building that this learning module will give you is worth the $37, even if you don't routinely see patients with IBD.    You should be able to communicate to your patients how long it will take to improve, what to expect and what the long game is. This is exactly the kind of confidence-building content we provide our clinicians with every single month inside the Confident Clinician Club.

In this episode, we dive into Relative Energy Deficiency in Sport. You might be missing information when it comes to diagnosing oligomenorrhea, recurrent injuries or illnesses if you're not evaluating your patients for their energy availability. We'll review tools to evaluate your patient for RED-S and you'll learn about energy availability and how even recreational athletes may be at risk for RED-S.  If you want to dig deeper into treatment, you're invited to join Dr. Briana and fellow practitioners in June for the Sports Medicine Update Course. You can learn more here      References Ackerman, K. E., Holtzman, B., Cooper, K. M., Flynn, E. F., Bruinvels, G., Tenforde, A. S., Popp, K. L., Simpkin, A. J. & Parziale, A. L. (2019). Low energy availability surrogates correlate with health and performance consequences of Relative Energy Deficiency in Sport. British Journal of Sports Medicine, 53(10), 628. https://doi.org/10.1136/bjsports-2017-098958 Dave, S. C. & Fisher, M. (2022). Relative energy deficiency in sport (RED – S). Current Problems in Pediatric and Adolescent Health Care, 52(8), 101242. https://doi.org/10.1016/j.cppeds.2022.101242 Dipla, K., Kraemer, R. R., Constantini, N. W. & Hackney, A. C. (2021). Relative energy deficiency in sports (RED-S): elucidation of endocrine changes affecting the health of males and females. Hormones, 20(1), 35–47. https://doi.org/10.1007/s42000-020-00214-w FINN, E. E., TENFORDE, A. S., FREDERICSON, M., GOLDEN, N. H., CARSON, T. L., KARVONEN-GUTIERREZ, C. A. & CARLSON, J. L. (2021). Markers of Low-Iron Status Are Associated with Female Athlete Triad Risk Factors. Medicine & Science in Sports & Exercise, 53(9), 1969–1974. https://doi.org/10.1249/mss.0000000000002660 Gordon, C. M., Ackerman, K. E., Berga, S. L., Kaplan, J. R., Mastorakos, G., Misra, M., Murad, M. H., Santoro, N. F. & Warren, M. P. (2017). Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 102(5), 1413–1439. https://doi.org/10.1210/jc.2017-00131 Keay, N. & Francis, G. (2019). Infographic. Energy availability: concept, control and consequences in relative energy deficiency in sport (RED-S). British Journal of Sports Medicine, 53(20), bjsports-2019-100611. https://doi.org/10.1136/bjsports-2019-100611 Koltun, K. J., Williams, N. I., Scheid, J. L. & Souza, M. J. D. (2020). Discriminating hypothalamic oligomenorrhea/amenorrhea from hyperandrogenic oligomenorrhea/amenorrhea in exercising women. Applied Physiology, Nutrition, and Metabolism, 45(7), 707–714. https://doi.org/10.1139/apnm-2019-0640 Logue, D. M., Madigan, S. M., Heinen, M., McDonnell, S.-J., Delahunt, E. & Corish, C. A. (2018a). Screening for risk of low energy availability in athletic and recreationally active females in Ireland. European Journal of Sport Science, 19(1), 1–11. https://doi.org/10.1080/17461391.2018.1526973 Logue, D. M., Madigan, S. M., Heinen, M., McDonnell, S.-J., Delahunt, E. & Corish, C. A. (2018b). Screening for risk of low energy availability in athletic and recreationally active females in Ireland. European Journal of Sport Science, 19(1), 1–11. https://doi.org/10.1080/17461391.2018.1526973 Logue, D. M., Madigan, S. M., Melin, A., Delahunt, E., Heinen, M., Donnell, S.-J. M. & Corish, C. A. (2020). Low Energy Availability in Athletes 2020: An Updated Narrative Review of Prevalence, Risk, Within-Day Energy Balance, Knowledge, and Impact on Sports Performance. Nutrients, 12(3), 835. https://doi.org/10.3390/nu12030835 Loucks, A. B. & Thuma, J. R. (2003). Luteinizing Hormone Pulsatility Is Disrupted at a Threshold of Energy Availability in Regularly Menstruating Women. The Journal of Clinical Endocrinology & Metabolism, 88(1), 297–311. https://doi.org/10.1210/jc.2002-020369 Melin, A., Tornberg, Å. B., Skouby, S., Faber, J., Ritz, C., Sjödin, A. & Sundgot-Borgen, J. (2014a). The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad. British Journal of Sports Medicine, 48(7), 540. https://doi.org/10.1136/bjsports-2013-093240 Melin, A., Tornberg, Å. B., Skouby, S., Faber, J., Ritz, C., Sjödin, A. & Sundgot-Borgen, J. (2014b). The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad. British Journal of Sports Medicine, 48(7), 540. https://doi.org/10.1136/bjsports-2013-093240 Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., Meyer, N., Sherman, R., Steffen, K., Budgett, R. & Ljungqvist, A. (2014). The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine, 48(7), 491–497. https://doi.org/10.1136/bjsports-2014-093502 Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., Meyer, N., Sherman, R., Steffen, K., Budgett, R., Ljungqvist, A. & Ackerman, K. (2015). Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine, 49(7), 421. https://doi.org/10.1136/bjsports-2014-094559 Mountjoy, M., Sundgot-Borgen, J. K., Burke, L. M., Ackerman, K. E., Blauwet, C., Constantini, N., Lebrun, C., Lundy, B., Melin, A. K., Meyer, N. L., Sherman, R. T., Tenforde, A. S., Torstveit, M. K. & Budgett, R. (2018). IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. British Journal of Sports Medicine, 52(11), 687. https://doi.org/10.1136/bjsports-2018-099193 Schofield, K. L., Thorpe, H. & Sims, S. T. (2019). Resting metabolic rate prediction equations and the validity to assess energy deficiency in the athlete population. Experimental Physiology, 104(4), 469–475. https://doi.org/10.1113/ep087512 Sim, A. & Burns, S. F. (2021). Review: questionnaires as measures for low energy availability (LEA) and relative energy deficiency in sport (RED-S) in athletes. Journal of Eating Disorders, 9(1), 41. https://doi.org/10.1186/s40337-021-00396-7 Slater, J., McLay-Cooke, R., Brown, R. & Black, K. (2016). Female Recreational Exercisers at Risk for Low Energy Availability. International Journal of Sport Nutrition and Exercise Metabolism, 26(5), 421–427. https://doi.org/10.1123/ijsnem.2015-0245 Souza, M. J. D., Williams, N. I., Nattiv, A., Joy, E., Misra, M., Loucks, A. B., Matheson, G., Olmsted, M. P., Barrack, M., Mallinson, R. J., Gibbs, J. C., Goolsby, M., Nichols, J. F., Drinkwater, B., Sanborn, C. (Barney), Agostini, R., Otis, C. L., Johnson, M. D., Hoch, A. Z., … McComb, J. (2014). Misunderstanding the Female Athlete Triad: Refuting the IOC Consensus Statement on Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine, 48(20), 1461. https://doi.org/10.1136/bjsports-2014-093958

This past month in The Confident Clinician we offered a 2-day advanced training course on insulin resistance and diabetes. We offer these courses twice per year for our members and it's one of the best-rated member offers we provide our clinicians.  In today's episode we examine a recent study that examined the impact of a cheat day on nutrition and whether a "self selected meal" improved satiety, reduced food boredom and helped patients stay on their treatment plan.  Have a listen to the episode where we cover the study and give you some food-for-thought about how we prescribe nutrition plans to patients to support their metabolic health and weight loss.    Horgan, A. M. et al. Self-selected meal composition alters the relationship between same-day caloric intake and appetite scores in humans during a long-term ad-libitum feeding study. Eur J Nutr 62, 1003–1009 (2023).

How long did it take for you to decide to prescribe zinc to your patient?  In this solo episode, our founder, Dr. Jordan Robertson exposes an industry myth and gives you permission to do things in an easier way.  We've been told the definition of individualized medicine means practitioners spending hours (and going to the ends of the earth) to find a solution for one person. Not only does this lead to practitioner burnout (and not being properly compensated for their time) but it also means that patients aren't always being given the best treatment option possible.  The Confident Clinician membership and advanced training courses hand practitioners the answers to "what to prescribe" so they can focus on "how to prescribe" instead.  That, is the real definition of individualized medicine.  If you're not a member of The Confident Clinician, head to our website at http://www.confidentclinicianclub.com to get on the wait list or to use one of our on demand courses to up your clinical game. 

This month inside the Confident Clinician we expanded our database to include content on eye health. We provided our members with content on cataracts, dry dye, glaucoma, AMD and conjunctivitis, and included practice resources such as nutrition protocols, patient handouts and referral letters.  We also called out in this episode a free webinar we are offering our community (including you) on clinical burnout. We're providing registrants a self assessment (or the tools to assess your patients properly) and 3 key takeaways to improve your own burnout in your practice. You can register for the event here.  This podcast on fish oil and dry eye called out a specific challenge we have in research on integrative medicine, and highlights why the INQUIRY method of research actually gives us the most accurate translation from research to practice.  We highlight that if fish oil is added to standard care (eye drops) we may not fully understand the impact and that there are specific populations that are going to benefit from fish oil based on the underlying cause of their dry eye. We give you guidelines of how to use fish oil for your dry eye patients, and where we hope the research is going on this topic!      Chi, S.-C., Tuan, H.-I. & Kang, Y.-N. Effects of Polyunsaturated Fatty Acids on Nonspecific Typical Dry Eye Disease: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Nutrients 11, 942 (2019).   Molina‐Leyva, I., Molina‐Leyva, A. & Bueno‐Cavanillas, A. Efficacy of nutritional supplementation with omega‐3 and omega‐6 fatty acids in dry eye syndrome: a systematic review of randomized clinical trials. Acta Ophthalmol 95, e677–e685 (2017).

Infant Vitamin D requirements of 400 IU are only being met a fraction of the time, as compliance postpartum remains an issue with this busy and challenging phase of life.  In this podcast, we discuss the most recent systematic review by Coresello (2022) discussing various Vitamin D supplementation strategies postpartum, and potential alternatives to infant dosing strategies. We take a deep dive into two of the studies discussed that provide different maternal Vitamin D dosing strategies, one that includes daily dosing (Hollis 2015) and the other that utilizes monthly dosing (Chandy 2016). We also discuss the Cochrane Review on this topic (Tan 2020) which covers their review of Vitamin D dosing in exclusively breastfed infants.    References:  Chandy, D. D., Kare, J., Singh, S. N., Agarwal, A., Das, V., Singh, U., Ramesh, V., & Bhatia, V. (2016). Effect of vitamin D supplementation, directly or via breast milk for term infants, on serum 25 hydroxyvitamin D and related biochemistry, and propensity to infection: A randomised placebo-controlled trial. The British Journal of Nutrition, 116(1), 52–58. https://doi.org/10.1017/S0007114516001756   Corsello, A., Milani, G. P., Giannì, M. L., Dipasquale, V., Romano, C., & Agostoni, C. (2022). Different Vitamin D Supplementation Strategies in the First Years of Life: A Systematic Review. Healthcare (Basel, Switzerland), 10(6), 1023. https://doi.org/10.3390/healthcare10061023   Hollis, B. W., Wagner, C. L., Howard, C. R., Ebeling, M., Shary, J. R., Smith, P. G., Taylor, S. N., Morella, K., Lawrence, R. A., & Hulsey, T. C. (2015). Maternal Versus Infant Vitamin D Supplementation During Lactation: A Randomized Controlled Trial. Pediatrics, 136(4), 625–634. https://doi.org/10.1542/peds.2015-1669 Tan, M. L., Abrams, S. A., & Osborn, D. A. (2020). Vitamin D supplementation for term breastfed infants to prevent vitamin D deficiency and improve bone health. The Cochrane Database of Systematic Reviews, 12(12), CD013046. https://doi.org/10.1002/14651858.CD013046.pub2

Whey protein and dairy products tend to get negative press from integrative practitioners because of the "insulin-promoting" effects of whey. Interestingly, it is exactly this "insulin promoting" effect that creates positive post-parandial glucose changes in diabetic patients and likely contributes to the preservation of lean tissue in diabetic patients during dieting.  In this podcast we discuss an article by Memelink (2020) on the use of a Whey protein drink daily and after exercise in patients with type 2 diabetes and the impact the intervention had on HOMA-IR scores and lean tissue.  We also discuss an article by Smith (2020) and Miller (2021) and how these three articles contribute to our current understanding of using Whey protein in diabetic patients.  Memelink, R. G. et al. Effect of an Enriched Protein Drink on Muscle Mass and Glycemic Control during Combined Lifestyle Intervention in Older Adults with Obesity and Type 2 Diabetes: A Double-Blind RCT. Nutrients 13, 64 (2020).   Miller, E. G. et al. Effects of whey protein plus vitamin D supplementation combined with progressive resistance training on glycaemic control, body composition, muscle function and cardiometabolic risk factors in middle‐aged and older overweight/obese adults with type 2 diabetes: A 24‐week randomized controlled trial. Diabetes Obes Metabolism 23, 938–949 (2021).   Smith, K., Davies, K. A. B., Stevenson, E. J. & West, D. J. The Clinical Application of Mealtime Whey Protein for the Treatment of Postprandial Hyperglycaemia for People With Type 2 Diabetes: A Long Whey to Go. Frontiers Nutrition 7, 587843 (2020).

Integrative practitioners are in a unique position to help patients make decisions about medications such as Semaglutide (Ozempic). It's important that we deeply understand the data on medications so we can support patients (and not misinform them).   In this podcast we cover the STEP 1 Extension trial by Wilding. (**Note that I misquote in the recording and call it the STEP 5 extension trial).   We discuss topic such as   The morality of obesity medication and ridding yourself of bias. Cohort data - what they give us and what they don't. The STEP 1 extension trial that examines weight regain, cholesterol and blood pressure 1 year after discontinuing Semaglutide. Our possible future role in supporting these patients, but where we need more information.     Our members will be receiving a full intensive program on Insulin resistance and diabetes (including discussion on medication) in the spring of 2023. If you are not a member of The Confident Clinician, you can join the wait list to learn when our membership is available in the future.       DeSouza, C. et al. Efficacy and safety of semaglutide for type 2 diabetes by race and ethnicity: a post hoc analysis of the SUSTAIN trials. J Clin Endocrinol Metabolism 105, 543–556 (2019).   Wilding, J. P. H. et al. Weight regain and cardiometabolic effects after withdrawal of semaglutide: The STEP 1 trial extension. Diabetes Obes Metabolism 24, 1553–1564 (2022).

Everybody eats, but when is it concerning? How do we define “healthy eating behaviour”? What's the opposite of disordered eating? This episode with Dr. Sylvi Martin RN & ND opens up the conversation about the landscape of eating behaviour in general, exploring eating disorders, disordered eating behaviour, “normal” eating and introduces evidence-based intuitive eating and mindful eating.   Dr. Sylvi Martin, ND is offering an Eating Behaviours Workshop on February 10, 2023, inside the Confident Clinician. Make sure you are on our mailing list to be the first to know when registration opens at the end of January.    Dr. Sylvi Martin BScN RN ND (she/her) Sylvi is a naturopathic doctor, registered nurse psychotherapist, Certified Intuitive Eating Counsellor and Mindfulness Based Eating Awareness Training (MB-EAT) facilitator based in Toronto. Sylvi applies a weight-inclusive approach to helping individuals experiencing mental health related challenges and disordered eating behaviour.  Sylvi maintains dual practises in nursing and naturopathic medicine. After completing her Bachelor of Science in Nursing at Laurentian University in 2004, she practised acute care psychiatric nursing at St. Michael's Hospital in Toronto where she also completed a nursing research fellowship. She went on to graduate from the Canadian College of Naturopathic Medicine in 2009 after which she began her private naturopathic practice in Toronto. In addition to her naturopathic practise, Sylvi maintained her nursing practise by working on a mental health team for an Ontario health regulator where she was also part of a mental health response team for individuals in crisis. She has also completed additional training in Cognitive Behavioural Therapy for Eating Disorders. When she's not furthering her training or working on her latest workshop or course, she can be found perfecting her chocolate-savouring skills, feeding her “trust fund squirrels” at the cottage in between dips in the lake, or on the hunt for more scarves in some corner of the world with her partner Dave.   References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 Bergner, L., Himmerich, H., Kirkby, K. C., & Steinberg, H. (2021). Descriptions of Disordered Eating in German Psychiatric Textbooks, 1803–2017. Frontiers in Psychiatry, 11, 504157. Retrieved from https://doi.org/10.3389/fpsyt.2020.504157 Kristeller, J. L., & Hallett, C. B. (1999). An Exploratory Study of a Meditation-based Intervention for Binge Eating Disorder. Journal of Health Psychology, 4(3), 357–363. Retrieved from https://doi.org/10.1177/135910539900400305 Mason, A. E., Epel, E. S., Kristeller, J., Moran, P. J., Dallman, M., Lustig, R. H., … Daubenmier, J. (2016). Effects of a mindfulness-based intervention on mindful eating, sweets consumption, and fasting glucose levels in obese adults: data from the SHINE randomized controlled trial. Journal of Behavioral Medicine, 39(2), 201–213. Retrieved from https://doi.org/10.1007/s10865-015-9692-8 Ralph, A. F., Brennan, L., Byrne, S., Caldwell, B., Farmer, J., Hart, L. M., … Hay, P. (2022). Management of eating disorders for people with higher weight: clinical practice guideline. Journal of Eating Disorders, 10(1), 121. Retrieved from https://doi.org/10.1186/s40337-022-00622-w Satter, E. (2021). Normal Eating. Available at: https://www.ellynsatterinstitute.org/wp-content/uploads/2021/01/Normal-Eating-1-up-with-EC-2021-secure.pdf Tribole, E. & Resch, E. (2020). Intuitive Eating, 4th Edition. St. Martin's. Tylka, T. L., & Diest, A. M. K. V. (2013). The Intuitive Eating Scale–2: Item Refinement and Psychometric Evaluation With College Women and Men. Journal of Counseling Psychology, 60(1), 137–153. Retrieved from https://doi.org/10.1037/a0030893  

This past month inside The Confident Clinician, we covered the assessment, nutrition and supplements to support patients with IBD.  In today's episode we share with you the most compelling supplement to use in patients with IBD that hits the most number of treatment targets, some of the other supplements we studied and why most patients have dissatisfaction with their care for their IBD.  The Confident Clinician membership is opening January 17, 2023 for only 2 weeks until we close off membership access until July. You can learn more about our practice support, database and live ongoing trainings for Naturopathic Doctors here.  This was the article discussed in the podcast:  Sun, H. et al. Modulation of Macrophages Using Nanoformulations with Curcumin to Treat Inflammatory Diseases: A Concise Review. Pharm 14, 2239 (2022).  

In this episode, Dr. Jordan Robertson shares the content we covered this month inside The Confident Clinician Club IBD module. She shares a new study published in 2022 on the Low FODMAP diet, and the impact that what patients "expect" their diet to do on their subjective symptoms.  Melgaard et al exposed patients to a FODMAP or placebo provocation after improving patients symptoms with a low-FODMAP diet and showed the impact of how patients expected themselves to feel after a food exposure and their symptoms.  We also covered Why medical doctors are concerned about patients working with integrative practitioners and changing their diet.  The limitations of the nutrition research on IBD and where we may want to borrow from IBS literature.  The impact of the placebo/nocebo effect on patients with IBD.  If you're a member of our listener community, we want to invite you to join our free maternal mental health event happening in January. You can sign up for the workshop with our expert cilnicians here. 

Today's podcast is a fun cognitive gymnastics opportunity for you to think about the influence of bias in your clinical decision making with Dr. Jordan Robertson ND Fun. We promise.  Bias is rampant in clinical decision making and it's important that we break open the conversation by both identifying the types of bias that exist, and thinking about possible examples where this may show up in our clinical lives.  In this episode, we cover anchoring bias, the availability heuristic, the halo effect, confirmation bias, the framing effect, publication bias and a few others.  Clinicians need to rebuild their knowledge on an ongoing basis, which is hard for humans to do in general - and really hard as a clinician. We'll give you some new ways to think about your clinical decision-making and give you a safe space to deconstruct your own ideas to be better in practice.  Enjoy! We referred to a few courses that we've offered in the Confident Clinician that you can connect with here: www.confidentclinicianclub.com

Certain intervention trials studying nutrition and depression have intentionally included recommendations to include animal protein. In turn, this leads to the question about the particular role of animal protein on mood. In particular, if there is an association between diets that exclude animal protein and depressive symptoms? In this podcast, I dive into a large cohort study that was looking at this question and discuss the interesting findings they (didn't) find around the vegan diet and what they did find around food exclusion as a variable.    Matta, J., Czernichow, S., Kesse-Guyot, E., Hoertel, N., Limosin, F., Goldberg, M., … Lemogne, C. (2018). Depressive Symptoms and Vegetarian Diets: Results from the Constances Cohort. Nutrients, 10(11), 1695. https://doi.org/10.3390/nu10111695   Are you a practitioner and are you interested in Dr. Antonella's Mediterranean Diet Workshop? Registration is open now! Grab your spot here 

A recent meta-analysis (Bytyçi 2022) determined that the prevalence of statin intolerance is around 9%. Given the high rate of statin discontinuation in this group, intolerance should be identified and addressed to better support those who require lipid-lowering to reduce their cardiovascular risk.   Today's podcast will touch on this recent meta-analysis before focusing on the National Lipid Association's new scientific statement on statin intolerance outlining key considerations and practical tips to systematically approach your suspected intolerant patients.    References discussed in this episode: Bytyçi, I. et al. Prevalence of statin intolerance: a meta-analysis. Eur Heart J (2022) doi:10.1093/eurheartj/ehac015 Cheeley, M. K. et al. NLA scientific statement on statin intolerance: a new definition and key considerations for ASCVD risk reduction in the statin intolerant patient. J Clin Lipidol 16, 361–375 Jacobson, T. A. et al. The STatin Adverse Treatment Experience Survey: Experience of patients reporting side effects of statin therapy. J Clin Lipidol 13, 415–424 (2019)  

We hosted 500 practitioners at our Menopause Advanced Training course at the beginning of October and covered cognitive health and nutrition as part of that program.    We looked at the impact of the MIND diet on future cognitive function and whether or not we can influence cognitive decline in patients by changing their nutrition. One particular study, although small, pointed out the possible unintended consequences of caloric restriction without educating our patients about nutrition for their brain.    The study by Arjmand (2022) was the deep dive focus of the podcast today and gave some food for thought about how we educate our patients who are dieting about cognitive health. You'll be surprised at what happened to the group that wasn't given education on nutrition for brain health and will give you some clinical ideas for how to talk to your patients about MIND diet principles.    If you're hoping to join The Confident Clinician you can join our wait list at www.confidentclinicianclub.com to get notice when our membership opens in November.    References discussed in this episode:  Arjmand, G., Abbas-Zadeh, M. & Eftekhari, M. H. Effect of MIND diet intervention on cognitive performance and brain structure in healthy obese women: a randomized controlled trial. Sci Rep-uk 12, 2871 (2022). Morris, M. C. et al. MIND diet slows cognitive decline with aging. Alzheimer's Dementia 11, 1015–1022 (2015).

Recently a review article from 2020 caught my eye; Reconsidering the Role of Melatonin in Rheumatoid Arthritis. Sleep is a major issue for RA, and many patients and clinicians are turning to melatonin to aid with sleep issues, are we causing more harm than good? Melatonin has been known:  as a powerful antioxidant and anti-inflammatory properties to help with regulating T cell responses, T helper (Th)1, Th17, and regulatory T cells (Tregs). to help modulate the circadian rhythm and enhance sleep On the flip side, there is evidence from animal studies showing there are receptors for melatonin on synovial macrophages which promote the release of some Th-1-type proinflammatory cytokines. It has also been pointed out that the higher blood concentrations of melatonin in arthritic patients, especially in the early morning, might explain the morning stiffness and joint swelling experienced by patients - but does that mean that melatonin should be completely avoided? So far most of that evidence is coming from animal studies but are they translating with similar outcomes in human RCT? Let's dive into 2  human trials to see how melatonin impacts your RA clients. Save the Date! Dr. Alison Danby, ND will be running a 1-day Autoimmune 101 Workshop for clinicians on Friday, October 21, 2022. Registration opens September 21st. Join our mailing list to make sure you are in the know to grab those Early Bird Savings.  References: https://confident-clinician-club.s3.ca-central-1.amazonaws.com/The+Expert+Clinician/Autoimmune+101/TCC+Podcast/RA+%26+Melatonin+2007++(1).pdf https://confident-clinician-club.s3.ca-central-1.amazonaws.com/The+Expert+Clinician/Autoimmune+101/TCC+Podcast/RA+and+melatonin+-+2020+RCT+(1).pdf

This fall we are offering a menopause Advanced Training Course for our members of the Confident Clinician Club. Our focus is on cardiovascular disease, bone and mental health and will support non-prescribers to support patients beyond HRT. We are limiting our seats to 40 nonmembers to join our 500-member community for this live workshop. You can learn more about it here. [https://discover.theconfidentclinicianclub.com/menopause-intensive-1] This podcast is about the (lack of) research on Vitamin K for osteoporosis and why we have a difficult time recommending this solution for our patients based on the current literature.  Have a listen, and here are the references shared:  Salma et al. Effect of Vitamin K on Bone Mineral Density and Fracture Risk in Adults: Systematic Review and Meta-Analysis. Biomed 10, 1048 (2022).   Shiraki, M., Shiraki, Y., Aoki, C. & Miura, M. Vitamin K2 (Menatetrenone) Effectively Prevents Fractures and Sustains Lumbar Bone Mineral Density in Osteoporosis. J Bone Miner Res 15, 515–521 (2000).   Rønn, S. H., Harsløf, T., Oei, L., Pedersen, S. B. & Langdahl, B. L. The effect of vitamin MK-7 on bone mineral density and microarchitecture in postmenopausal women with osteopenia, a 3-year randomized, placebo-controlled clinical trial. Osteoporosis Int 32, 185–191 (2021).  

This past month we covered hair loss inside the Confident Clincian Club.    If you are not on our email list. You can sign up for the wait list for future membership opportunities here: https://confidentclinicianclub.com/   This podcast covered the importance of universal screening for iron deficiency (not iron deficiency anemia) in patients with hair loss, and how a ferritin reading might influence what diagnosis we assign a patient with presenting with hair loss.   Cheng, T. et al. The Diagnostic Value of Serum Ferritin for Telogen Effluvium: A Cross-Sectional Comparative Study. Clin Cosmet Investigational Dermatology 14, 137–141 (2021).   Salinas, M., Leiva-Salinas, M., Flores, E., López-Garrigós, M. & Leiva-Salinas, C. Alopecia and Iron Deficiency: An Interventional Pilot Study in Primary Care to Improve the Request of Ferritin. Adv Hematology 2020, 7341018 (2020).

This month's clinical podcast focus on studies looking at the impact of dietary patterns on the pain in arthritis. It's difficult to separate the research on weight loss (which is the dominant standpoint currently) and diet quality (executed through the Med diet) in any topic and arthritis is no different.  We also talked about why the integrative medicine space makes mistakes applying the theories of biological plausibility to arthritis, and why the research on lectins, the keto diet and nightshades are either non existent or not a useful way of supporting patients.  If you missed our enrollment for practitioners in July, you'll want to get on the waitlist for The Confident Clinician Club when we reopen in the winter of 2023. Our mailing list gets alerts about podcasts and other free offerings, as well as early bird pricing on our courses. You can join the wait list and download our free resources here www.confidentclinicianclub.com  1.Sadeghi, A., Zarrinjooiee, G., Mousavi, S. N., Sabet, S. A. & Jalili, N. Effects of a Mediterranean Diet Compared with the Low-Fat Diet on Patients with Knee Osteoarthritis: A Randomized Feeding Trial. Int J Clin Pract 2022, 7275192 (2022).

In November 2022 we tackled Hashimoto's Thyroiditis and looked deeply at how to interpret thyroid lab work from an evidence-based perspective.  In my lecture (we had an amazing guest expert speak on prescribing for thyroid in the second webinar of the month) I reviewed studies that look at the relationship between hypothyroidism and obesity.  Have a listen. You can join the membership twice per year, and the doors are open right now for July 2022 enrolment.  The club is the most economical way to support your practice this year, with our members paying under $15 per hour or resource for the year (we give you a TON of resources for your practice!).  Enjoy the podcast. It's about 12 minutes long. A quickie to help you think more critically about your thyroid patients.  Learn more here: www.confidentclinicianclub.com  

I this podcast episode, we welcome one of our educators, Dr. Kara Dinisio ND. Dr. Dinisio is one of the facilitators of our menopause hormone therapy course (which can be accessed here). When asked what she wanted to share with our audience, she chose a study by the Mayo Clinic published in Maturitas in 2016 that explores the knowledge base, attitudes and beliefs of practitioners about hormone therapy. Kara admitted she was nervous about choosing this paper, it is certainly not a type of study high on the hierarchy of evidence. However, she wanted to explore if it could serve as fodder for clinical self-assessment.  Can we use these studies to self-audit our knowledge, both as evidence-based practitioners and as a profession?  Can they help us identify our blind spots? Have a listen.      REFERENCES 1.  Files JA, Kransdorf LN, Ko M, et al. Bioidentical hormone therapy: An assessment of provider knowledge. Maturitas. 2016;94:46-51. doi:10.1016/j.maturitas.2016.08.014 2.  Yu Q, Lin L. The promotion of menopausal hormone therapy might be determined by the attitude of health-care professionals. Climacteric. 2022;25(3):213-214. doi:10.1080/13697137.2022.2057038

Is it the ED that kills patients or their low testosterone? This month's module of The Confident Clinician covered sexual health and libido, including a 90 minute lecture on treating erectile dysfunction.  The 90 minute webinar we shared with our community covered the nutrition and nutraceuticals that are effecacious for erectile dysfunction and how to assess ED as a marker for cardiovascular disease.  A 2022 study by Antonio (2022) stratified men by number of sexual symptoms, hormone levels and age to try and answer the age-old question about which is the chicken and which is the egg in our male patients.  Is it low testosterone that is the main issue? Or is ED an independent predictor of early death? This podcast reviews what was found in this study and how to think about the stratification of evidence to help us understand where to place focus.    Enjoy the episode!    Erectile dysfunction predicts mortality in middle-aged and older men independent of their sex steroid status Leen Antonio  PMID: 35429269 DOI: 10.1093/ageing/afac094 Abstract Background: erectile dysfunction is associated with mortality, whereas the association between low testosterone (T) and higher mortality remains controversial. Sexual dysfunction and low T often coexist, but the relative importance of sexual symptoms versus low T in predicting mortality is not known. We studied the interrelationships between sex steroids and sexual symptoms with all-cause mortality in a large prospective cohort of European men. Design: survival status was assessed in 1,788 community-dwelling men, aged 40-79, who participated in the European Male Ageing Study (EMAS). Sexual symptoms were evaluated via a validated questionnaire (EMAS-SFQ). Sex steroids were measured by mass spectrometry. Cox proportional hazard models were used to study the association between hormones, sexual symptoms and mortality. Results: about 420 (25.3%) men died during a mean follow-up of 12.6 ± 3.1 years. Total T levels were similar in both groups, but free T was lower in those who died. Men with three sexual symptoms (erectile dysfunction, reduced morning erections and lower libido) had a higher mortality risk compared with men with none of these symptoms (adjusted hazard ratio (HR) and 95% confidence intervals: 1.75 (1.28-2.40, P = 0.001)). Particularly, erectile dysfunction and poor morning erections, but not lower libido, were associated with increased mortality (HR 1.40 (1.13-1.74, P = 0.002), 1.28 (1.04-1.59, P = 0.023) and 1.12 (0.90-1.39, P = 0.312), respectively). Further adjusting for total T, free T or oestradiol did not influence the observed risk. Conclusions: sexual symptoms, in particular erectile dysfunction, predict all-cause mortality independently of sex steroids and can be an early warning sign of a poor health status.

In this short introductory episode, Dr Jordan Robertson, Naturopathic Doctor and the CEO of The Confident Clinician shares what our mission, vision and values are and how we'll be using our podcast platform to share evidence based information with clinicians every month.  The Confident Clinician Club for Naturopathic Doctors opens the doors twice per year, with our next enrollment happening July 2022. Learn more at www.confidentclinician.com