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Importance: Encouraging primary care patients to address depression symptoms and care with clinicians could improve outcomes but may also result in unnecessary treatment.Objective: To determine whether a depression engagement video (DEV) or a tailored interactive multimedia computer program (IMCP) improves initial depression care compared with a control without increasing unnecessary antidepressant prescribing.Design, Setting, and Participants: Randomized clinical trial comparing DEV, IMCP, and control among 925 adult patients treated by 135 primary care clinicians (603 patients with depression and 322 patients without depression, defined by Patient Health Questionnaire-9 [PHQ-9] score) conducted from June 2010 through March 2012 at 7 primary care clinical sites in California.Interventions: DEV targeted to sex and income, an IMCP tailored to individual patient characteristics, and a sleep hygiene video (control).Main Outcomes and Measures: Among depressed patients, superiority assessment of the composite measure of patient-reported antidepressant drug recommendation, mental health referral, or both (primary outcome); depression at 12-week follow-up, measured by the PHQ-8 (secondary outcome). Among nondepressed patients, noninferiority assessment of clinician- and patient-reported antidepressant drug recommendation (primary outcomes) with a noninferiority margin of 3.5%. Analyses were cluster adjusted.Results: Of the 925 eligible patients, 867 were included in the primary analysis (depressed, 559; nondepressed, 308). Among depressed patients, rates of achieving the primary outcome were 17.5% for DEV, 26% for IMCP, and 16.3% for control (DEV vs control, 1.1 [95% CI, -6.7 to 8.9], P = .79; IMCP vs control, 9.9 [95% CI, 1.6 to 18.2], P = .02). There were no effects on PHQ-8 measured depression score at the 12-week follow-up: DEV vs control, -0.2 (95% CI, -1.2 to 0.8); IMCP vs control,  0.9 (95% CI, -0.1 to 1.9). Among nondepressed patients, clinician-reported antidepressant prescribing in the DEV and IMCP groups was noninferior to control (mean percentage point difference [PPD]: DEV vs control, -2.2 [90% CI, -8.0 to 3.49], P = .0499 for noninferiority; IMCP vs control, -3.3 [90% CI, -9.1 to 2.4], P = .02 for noninferiority); patient-reported antidepressant recommendation did not achieve noninferiority (mean PPD: DEV vs control,  0.9 [90% CI, -4.9 to 6.7], P = .23 for noninferiority; IMCP vs control,  0.3 [90% CI, -5.1 to 5.7], P = .16 for noninferiority).Conclusions and Relevance: A tailored IMCP increased clinician recommendations for antidepressant drugs, a mental health referral, or both among depressed patients but had no effect on mental health at the 12-week follow-up. The possibility that the IMCP and DEV increased patient-reported clinician recommendations for an antidepressant drug among nondepressed patients could not be excluded.Trial Registration: clinicaltrials.gov Identifier: NCT01144104. [ABSTRACT FROM AUTHOR]

The article focuses on a study which investigated if an intensive educational program in mindfulness, communication and self-awareness is linked with improvement in the well-being, psychological distress and the capacity to relate to patients of primary care physicians. The study included 70 primary care physicians in Rochester, New York who were enrolled in continuing medical education (CME) course in 2007-2008. It found that physicians who enrolled in the CME course showed improvements in mindfulness, burnout and depersonalization. Study authors concluded that mindful communication program is associated with improvements in well-being and attitudes associated with patient-centered care.

Context: Direct-to-consumer (DTC) advertising of prescription drugs in the United States is both ubiquitous and controversial. Critics charge that it leads to overprescribing, while proponents counter that it helps avert underuse of effective treatments, especially for conditions that are poorly recognized or stigmatized. Objective: To ascertain the effects of patients’ DTC-related requests on physicians’ initial treatment decisions in patients with depressive symptoms. Design: Randomized trial using standardized patients (SPs). Six SP roles were created by crossing 2 conditions (major depression or adjustment disorder with depressed mood) with 3 request types (brand-specific, general, or none). Setting: Offices of primary care physicians in Sacramento, Calif; San Francisco, Calif; and Rochester, NY, between May 2003 and May 2004. Participants: One hundred fifty-two family physicians and general internists recruited from solo and group practices and health maintenance organizations; cooperation rates ranged from 53% to 61%. Interventions: The SPs were randomly assigned to make 298 unannounced visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder. The SPs made a brand-specific drug request, a general drug request, or no request (control condition) in approximately one third of visits. Main Outcome Measures: Data on prescribing, mental health referral, and primary care follow-up obtained from SP written reports, visit audiorecordings, chart review, and analysis of written prescriptions and drug samples. The effects of request type on prescribing were evaluated using contingency tables and confirmed in generalized linear mixed models that accounted for clustering and adjusted for site, physician, and visit characteristics. Results: Standardized patient role fidelity was excellent, and the suspicion rate that physicians had seen an SP was 13%. In major depression, rates of antidepressant prescribing were 53%, 76%, and 31% for SPs making brand-specific, general, and no requests, respectively (P<.001). In adjustment disorder, antidepressant prescribing rates were 55%, 39%, and 10%, respectively (P<.001). The results were confirmed in multivariate models. Minimally acceptable initial care (any combination of an antidepressant, mental health referral, or follow-up within 2 weeks) was offered to 98% of SPs in the major depression role making a general request, 90% of those making a brand-specific request, and 56% of those making no request (P<.001). Conclusions: Patients’ requests have a profound effect on physician prescribing in major depression and adjustment disorder. Direct-to-consumer advertising may have competing effects on quality, potentially both averting underuse and promoting overuse. [ABSTRACT FROM AUTHOR]

Context Informed patients are more likely to actively participate in their care, make wiser decisions, come to a common understanding with their physicians, and adhere more fully to treatment; however, currently there are no evidence-based guidelines for discussing clinical evidence with patients in the process of making medical decisions. Objective To identify ways to communicate evidence that improve patient understanding, involvement in decisions, and outcomes. Data Sources and Study Selection Systematic review of MEDLINE for the period 1966-2003 and review of reference lists of retrieved articles to identify original research dealing with communication between clinicians and patients and directly addressing methods of presenting clinical evidence to patients. Data Extraction Two investigators and a research assistant screened 367 abstracts and 2 investigators reviewed 51 full-text articles, yielding 8 potentially relevant articles. Data Synthesis Methods for communicating clinical evidence to patients include nonquantitative general terms, numerical translation of clinical evidence, graphical representations, and decision aids. Focus-group data suggest presenting options and/or equipoise before asking patients about preferred decision-making roles or formats for presenting details. Relative risk reductions may be misleading; absolute risk is preferred. Order of information presented and time-frame of outcomes can bias patient understanding. Limited evidence supports use of human stick figure graphics or faces for single probabilities and vertical bar graphs for comparative information. Less-educated and older patients preferred proportions to percentages and did not appreciate confidence intervals. Studies of decision aids rarely addressed patient-physician communication directly. No studies addressed clinical outcomes of discussions of clinical evidence. Conclusions There is a paucity of evidence to guide how physicians can most effectively share clinical ev... [ABSTRACT FROM AUTHOR]

Presents letters to the editor as of April 3, 2002. Drug therapy for patients with type-2 diabetes; Treatment decisions for type-2 diabetes; Costs of making practice more cost-effective; Poliomyelitis and Parkinson Disease.

Proposes a definition of professional competence in physicians, reviews current means for assessing it, and suggests new approaches to assessment. Data sources, study selection, data extraction, and data synthesis; Conclusion that institutional support, reflection, and mentoring should accompany multidimensional assessment programs for developing basic skills, clinical reasoning, teamwork, time management, and learning strategies.

Mindful practitioners attend in a nonjudgmental way to their own physical and mental processes during ordinary, everyday tasks. This critical self-reflection enables physicians to listen attentively to patients' distress, recognize their own errors, refine their technical skills, make evidence-based decisions, and clarify their values so that they can act with compassion, technical competence, presence, and insight. Mindfulness informs all types of professionally relevant knowledge, including propositional facts, personal experiences, processes, and know-how, each of which may be tacit or explicit. Explicit knowledge is readily taught, accessible to awareness, quantifiable and easily translated into evidence-based guidelines. Tacit knowledge is usually learned during observation and practice, includes prior experiences, theories-in-action, and deeply held values, and is usually applied more inductively. Mindful practitioners use a variety of means to enhance their ability to engage in moment-to-moment self-monitoring, bring to consciousness their tacit personal knowledge and deeply held values, use peripheral vision and subsidiary awareness to become aware of new information and perspectives, and adopt curiosity in both ordinary and novel situations. In contrast, mindlessness may account for some deviations from professionalism and errors in judgment and technique. Although mindfulness cannot be taught explicitly, it can be modeled by mentors and cultivated in learners. As a link between relationship-centered care and evidence-based medicine, mindfulness should be considered a characteristic of good clinical practice. [ABSTRACT FROM AUTHOR]

Presents a study to examine the extent to which experienced family physicians in various practice settings elicit the agenda of concerns patients bring to the office. Design; Setting and participants; Main outcome measures; Results; Conclusions.

The author explores how physicians might reconcile the imperative to provide patient-centered care with the complex ways in which clinicians and patients construct preferences. Patient-centered communication promotes healing relationships which elicit and consider patients' perspectives. Construct preferences are affected by cognitive, emotional and relationship factors. According to reason-based choice theories, good decisions require logical consideration of options without emotional interference. However, the importance of emotions has been highlighted in neurocognitival research. Libertarian paternalism also indicates that leaders should influence patients' preferences to achieve desired goals while leaving the choice to the individual.

The article presents the authors' views on diagnosis and treatment of people suffering from chronic pain, and presents a case of a patient who went years with out a diagnosis, and no one understood why she seemed to get every possible complication from her treatments. It is opined that such cases illustrates how suffering can persist in patients who live with chronic illnesses and how persistent suffering can make physicians feel helpless.

A letter to the editor and a response are presented regarding the article "Association of an Education Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians," by M. S. Krasner and colleagues published in a 2009 issue.

Presents a letter to the editor in reply to readers' criticism of the authors' research methods.