Robert D. Sheeler

Considerations on Safety Concerns About Citalopram Prescribing

Citalopram (Celexa, Forest Laboratories, New York, NY) is one of the most widely prescribed selective serotonin reuptake inhibitors (SSRIs) in our practice. It has had good tolerability and low discontinuation rates in practice and in clinical trials.1-3 The recent US Food and Drug Administration (FDA) recommendation to not use doses higher than 40 mg/d because of potential QTc prolongation has been causing various difficulties.4 This warning has raised concerns from both psychiatrists and generalists at our institution both in regard to continuation of therapy that has been effective for patients that have responded to doses over 40 mg/d and in regard to the potential to use this medication above that dose range in future patients. Specifically, in our practices, there are patients who are doing well on higher doses. These patients are predominantly in our general and subspecialty psychiatry practices. Further, in our primary care practices, large numbers of patients take citalopram, and drug-drug interactions with agents such as proton pump inhibitors (PPIs), which can increase blood levels in patients taking 40 mg/d or less of citalopram, have also caused substantial prescribing problems. Members of the Mayo Clinic Neurology/Psychiatry Task Force as well as selected members from the Heart Rhythm Services group reviewed factors that should be communicated to prescribers in relation to citalopram prescribing in light of these new warnings regarding QTc prolongation and the risk for potential morbidity and mortality from drug-induced arrhythmias including torsades de pointes and sudden cardiac arrest.

Controlling health costs: Physician responses to patient expectations for medical care

ABSTRACTBACKGROUNDPhysicians have dual responsibilities to make medical decisions that serve their patients’ best interests but also utilize health care resources wisely. Their ability to practice cost-consciously is particularly challenged when faced with patient expectations or requests for medical services that may be unnecessary.OBJECTIVETo understand how physicians consider health care resources and the strategies they use to exercise cost-consciousness in response to patient expectations and requests for medical care.DESIGNExploratory, qualitative focus groups of practicing physicians were conducted. Participants were encouraged to discuss their perceptions of resource constraints, and experiences with redundant, unnecessary and marginally beneficial services, and were asked about patient requests or expectations for particular services.PARTICIPANTSSixty-two physicians representing a variety of specialties and practice types participated in nine focus groups in Michigan, Ohio, and Minnesota in 2012MEASUREMENTSIterative thematic content analysis of focus group transcriptsPRINCIPAL FINDINGSPhysicians reported making trade-offs between a variety of financial and nonfinancial resources, considering not only the relative cost of medical decisions and alternative services, but the time and convenience of patients, their own time constraints, as well as the logistics of maintaining a successful practice. They described strategies and techniques to educate patients, build trust, or substitute less costly alternatives when appropriate, often adapting their management to the individual patient and clinical environment.CONCLUSIONSPhysicians often make nuanced trade-offs in clinical practice aimed at efficient resource use within a complex flow of clinical work and patient expectations. Understanding the challenges faced by physicians and the strategies they use to exercise cost-consciousness provides insight into policy measures that will address physician’s roles in health care resource use.

Predictors of medical school clerkship performance: a multispecialty longitudinal analysis of standardized examination scores and clinical assessments

BackgroundEvidence suggests that poor performance on standardized tests before and early in medical school is associated with poor performance on standardized tests later in medical school and beyond. This study aimed to explore relationships between standardized examination scores (before and during medical school) with test and clinical performance across all core clinical clerkships.MethodsWe evaluated characteristics of 435 students at Mayo Medical School (MMS) who matriculated 2000–2009 and for whom undergraduate grade point average, medical college aptitude test (MCAT), medical school standardized tests (United States Medical Licensing Examination [USMLE] 1 and 2; National Board of Medical Examiners [NBME] subject examination), and faculty assessments were available. We assessed the correlation between scores and assessments and determined USMLE 1 cutoffs predictive of poor performance (≤10th percentile) on the NBME examinations. We also compared the mean faculty assessment scores of MMS students vs visiting students, and for the NBME, we determined the percentage of MMS students who scored at or below the tenth percentile of first-time national examinees.ResultsMCAT scores correlated robustly with USMLE 1 and 2, and USMLE 1 and 2 independently predicted NBME scores in all clerkships. USMLE 1 cutoffs corresponding to poor NBME performance ranged from 220 to 223. USMLE 1 scores were similar among MMS and visiting students. For most academic years and clerkships, NBME scores were similar for MMS students vs all first-time examinees.ConclusionsMCAT, USMLE 1 and 2, and subsequent clinical performance parameters were correlated with NBME scores across all core clerkships. Even more interestingly, faculty assessments correlated with NBME scores, affirming patient care as examination preparation. USMLE 1 scores identified students at risk of poor performance on NBME subject examinations, facilitating and supporting implementation of remediation before the clinical years. MMS students were representative of medical students across the nation.

Naming Migraine and Those Who Have It

Medical language has implications for both public perception of and institutional responses to illness. A consensus panel of physicians, academics, advocates, and patients with diverse experiences and knowledge about migraine considered 3 questions: (1) What is migraine: an illness, disease, syndrome, condition, disorder, or susceptibility? (2) What ought we call someone with migraine? (3) What should we not call someone with migraine? Although consensus was not reached, theresponses were summarized and analyzed quantitatively and qualitatively. Panelists participated in writing and editing the paper. The panelists agreed that “migraine,” not “migraine headache,” was generally preferable, that migraine met the dictionary definition for each candidate moniker, terms with psychiatric valence should be avoided, and “sufferer” should be avoided except in very limited circumstances. Overall, while there was no consensus, “disease” was the preferred term in the most situations, and illness the least preferred. Panelists disagreed strongly whether one ought to use the term “migraineur” at all or if “person with migraine” was preferable. Panelists drew upon a variety of principles when considering language choices, including the extent to which candidate monikers could be defended using biomedical evidence, the cultural meaning of the proposed term, and the context within which the term would be used. Panelists strove to balance the need for terms to describe the best science on migraine, with the desire to choose language that would emphasize the credibility of migraine. The wide range of symptoms of migraine and its diverse effects may require considerable elasticity of language.

Shared decision-making as a cost-containment strategy: US physician reactions from a cross-sectional survey

Objective To assess US physicians’ attitudes towards using shared decision-making (SDM) to achieve cost containment. Design Cross-sectional mailed survey. Setting US medical practice. Participants 3897 physicians were randomly selected from the AMA Physician Masterfile. Of these, 2556 completed the survey. Main outcome measures Level of enthusiasm for “Promoting better conversations with patients as a means of lowering healthcare costs”; degree of agreement with “Decision support tools that show costs would be helpful in my practice” and agreement with “should promoting SDM be legislated to control overall healthcare costs”. Results Of 2556 respondents (response rate (RR) 65%), two-thirds (67%) were ‘very enthusiastic’ about promoting SDM as a means of reducing healthcare costs. Most (70%) agreed decision support tools that show costs would be helpful in their practice, but only 24% agreed with legislating SDM to control costs. Compared with physicians with billing-only compensation, respondents with salary compensation were more likely to strongly agree that decision support tools showing costs would be helpful (OR 1.4; 95% CI 1.1 to 1.7). Primary care physicians (vs surgeons, OR 1.4; 95% CI 1.0 to 1.6) expressed more enthusiasm for SDM being legislated as a means to address healthcare costs. Conclusions Most US physicians express enthusiasm about using SDM to help contain costs. They believe decision support tools that show costs would be useful. Few agree that SDM should be legislated as a means to control healthcare costs.