Doug Brunk

SAN DIEGO – Phase I results from the Clinical Antipsychotic Trial of International Effectiveness-Alzheimer's Disease (CATIE-AD) unveiled for the first time at the annual meeting of the American Association for Geriatric Psychiatry are so new that the presenting investigators emphasized that they're still trying to make sense of it all.

“The data we're presenting today are preliminary. We've barely gotten to understand them ourselves,” said Lon Schneider, M.D., professor of psychiatry, neurology, and gerontology at the University of Southern California, Los Angeles, who is one of the study's lead investigators. “We first saw them Feb. 4. The data should be considered preliminary until the full report is evaluated by peer review for scientific validity and clinical importance. I hope you'll keep that in mind.”

The main goal of the trial is to compare the efficacy and effectiveness of risperidone, olanzapine, and quetiapine, and examine treatment algorithms over the course of 36 weeks in treating psychosis and severe agitation in community-dwelling patients with Alzheimer's disease. The trial design has been previously described in medical literature (Am. J. Geriatr. Psychiatry 2001;9:346–60).

“This is not your pharmaceutical company's clinical trial,” Dr. Schneider remarked. “This is not a simple randomization of drug or placebo and 10 weeks later declare victory for one or another. It's also not FDA's idea of an efficacy trial. The FDA needs trials from which they can generate labeling about a drug's use. We're trying to generate information to inform clinicians on the subtleties of using medication.”

Investigators enrolled 421 Alzheimer's disease patients with a median age of 78 years in the trial from 10 private clinic sites, 25 university sites, and 2 Veterans Affairs sites nationwide, reported Pierre Tariot, M.D., the study's other lead investigator. More than half (56%) were female, 79% were white, and 18% were African American. About one-quarter did not complete high school and 34% had a high school education or GED.

Nearly 60% were married or had been married at some point, 73% lived in their own homes, 16% lived in the home of a family member, and about 10% lived in an assisted living facility.

The patients' average Mini-Mental State Exam score was 15 and the Brief Psychiatric Rating Scale (BPRS) for conceptual disorganization, suspiciousness, or hallucinatory behavior showed moderately severe psychopathology with a fairly wide range.

In terms of functional independence, about three-quarters were receiving care equivalent to nursing home care.

The trial consisted of three phases. In phase I, all 421 patients were randomized to receive one of the three atypical antipsychotics or placebo.

“At any time if a patient was not responding, they could continue the medication, increase the dose, or order a switch to a new medication,” Dr. Schneider explained. “That was done in double-blind fashion to a medication not used previously.”

Of the 421 patients, only 77 remained in phase I.

Of the remaining 344 patients, 253 moved to phase II, which started when the patient was randomized in a double-blind fashion to a second medication. If the second medication was continued, the patients remained in this phase.

“At any time if a physician, patient, or caregiver thought it was in the best interest of the patient, the patient could be pulled out into a open choice phase of the trial where the physician would treat as he might in the community,” Dr. Schneider said.

By week 4 of the trial, about one-quarter of patients discontinued their medication in phase I for “all-cause” reasons such as inadequate treatment response, study drug not sufficiently optimal, symptoms worse, unacceptable side effects, study drug no longer needed, patient or caregiver decision, or death.

By week 8, almost half of study participants had discontinued their phase I medication, and by week 12, almost three-quarters had discontinued phase I. “People were leaving the initial phase very rapidly, [but] we have not done analysis of these data adjusted for dose or length of drug exposure,” said Dr. Tariot, professor of psychiatry, medicine, neurology, and aging and developmental biology at the University of Rochester (N.Y.).

“That's critical in understanding the full meaning of these data. It's probably premature to say this, but what I'm thinking about in my own practice is whether I should treat longer with the first agent I start on,” Dr. Tariot said at the meeting. “How long do we need to treat somebody to see an effect?”

Dr. Schneider noted that there are “multiple reasons” why a study investigator could have discontinued treatment in phase I. “One main reason is that they were not being required to keep the patient in the study for 10 weeks,” he said.

“Other reasons have to do with patients or caregivers discontinuing the trial, period. Lastly, switching medication at 2 and 4 weeks is congruent with what experts say when they're asked, 'How long do you keep a dementia patient with psychosis on an antipsychotic?' On average, it's 2–4 weeks.”

The investigators did not report any phase I clinical outcomes. Although they did not draw firm conclusions given the freshness of the data, Dr. Tariot did report that, collectively, active treatment with one of the three antipsychotics was “different” than placebo. Specifically, 39% of phase I patients who took olanzapine discontinued the drug for lack of efficacy, compared with 53% of patients who took quetiapine, 44% of patients who took risperidone, and 70% who took placebo.

In addition, 24% of phase I patients who took olanzapine discontinued the drug for reasons of intolerance, adverse events, or death, compared with 16% of patients who took quetiapine, 18% of patients who took risperidone, and 5% who took placebo.

More data from the trial are expected to be released this spring. The NIMH funded the trial and the pharmaceutical companies that manufacture the antipsychotics supplied drugs for the study.

SAN DIEGO – Phase I results from the Clinical Antipsychotic Trial of International Effectiveness-Alzheimer's Disease (CATIE-AD) unveiled for the first time at the annual meeting of the American Association for Geriatric Psychiatry are so new that the presenting investigators emphasized that they're still trying to make sense of it all.

“The data we're presenting today are preliminary. We've barely gotten to understand them ourselves,” said Lon Schneider, M.D., professor of psychiatry, neurology, and gerontology at the University of Southern California, Los Angeles, who is one of the study's lead investigators. “We first saw them Feb. 4. The data should be considered preliminary until the full report is evaluated by peer review for scientific validity and clinical importance. I hope you'll keep that in mind.”

The main goal of the trial is to compare the efficacy and effectiveness of risperidone, olanzapine, and quetiapine, and examine treatment algorithms over the course of 36 weeks in treating psychosis and severe agitation in community-dwelling patients with Alzheimer's disease. The trial design has been previously described in medical literature (Am. J. Geriatr. Psychiatry 2001;9:346–60).

“This is not your pharmaceutical company's clinical trial,” Dr. Schneider remarked. “This is not a simple randomization of drug or placebo and 10 weeks later declare victory for one or another. It's also not FDA's idea of an efficacy trial. The FDA needs trials from which they can generate labeling about a drug's use. We're trying to generate information to inform clinicians on the subtleties of using medication.”

Investigators enrolled 421 Alzheimer's disease patients with a median age of 78 years in the trial from 10 private clinic sites, 25 university sites, and 2 Veterans Affairs sites nationwide, reported Pierre Tariot, M.D., the study's other lead investigator. More than half (56%) were female, 79% were white, and 18% were African American. About one-quarter did not complete high school and 34% had a high school education or GED.

Nearly 60% were married or had been married at some point, 73% lived in their own homes, 16% lived in the home of a family member, and about 10% lived in an assisted living facility.

The patients' average Mini-Mental State Exam score was 15 and the Brief Psychiatric Rating Scale (BPRS) for conceptual disorganization, suspiciousness, or hallucinatory behavior showed moderately severe psychopathology with a fairly wide range.

In terms of functional independence, about three-quarters were receiving care equivalent to nursing home care.

The trial consisted of three phases. In phase I, all 421 patients were randomized to receive one of the three atypical antipsychotics or placebo.

“At any time if a patient was not responding, they could continue the medication, increase the dose, or order a switch to a new medication,” Dr. Schneider explained. “That was done in double-blind fashion to a medication not used previously.”

Of the 421 patients, only 77 remained in phase I.

Of the remaining 344 patients, 253 moved to phase II, which started when the patient was randomized in a double-blind fashion to a second medication. If the second medication was continued, the patients remained in this phase.

“At any time if a physician, patient, or caregiver thought it was in the best interest of the patient, the patient could be pulled out into a open choice phase of the trial where the physician would treat as he might in the community,” Dr. Schneider said.

By week 4 of the trial, about one-quarter of patients discontinued their medication in phase I for “all-cause” reasons such as inadequate treatment response, study drug not sufficiently optimal, symptoms worse, unacceptable side effects, study drug no longer needed, patient or caregiver decision, or death.

By week 8, almost half of study participants had discontinued their phase I medication, and by week 12, almost three-quarters had discontinued phase I. “People were leaving the initial phase very rapidly, [but] we have not done analysis of these data adjusted for dose or length of drug exposure,” said Dr. Tariot, professor of psychiatry, medicine, neurology, and aging and developmental biology at the University of Rochester (N.Y.).

“That's critical in understanding the full meaning of these data. It's probably premature to say this, but what I'm thinking about in my own practice is whether I should treat longer with the first agent I start on,” Dr. Tariot said at the meeting. “How long do we need to treat somebody to see an effect?”

Dr. Schneider noted that there are “multiple reasons” why a study investigator could have discontinued treatment in phase I. “One main reason is that they were not being required to keep the patient in the study for 10 weeks,” he said.

“Other reasons have to do with patients or caregivers discontinuing the trial, period. Lastly, switching medication at 2 and 4 weeks is congruent with what experts say when they're asked, 'How long do you keep a dementia patient with psychosis on an antipsychotic?' On average, it's 2–4 weeks.”

The investigators did not report any phase I clinical outcomes. Although they did not draw firm conclusions given the freshness of the data, Dr. Tariot did report that, collectively, active treatment with one of the three antipsychotics was “different” than placebo. Specifically, 39% of phase I patients who took olanzapine discontinued the drug for lack of efficacy, compared with 53% of patients who took quetiapine, 44% of patients who took risperidone, and 70% who took placebo.

In addition, 24% of phase I patients who took olanzapine discontinued the drug for reasons of intolerance, adverse events, or death, compared with 16% of patients who took quetiapine, 18% of patients who took risperidone, and 5% who took placebo.

More data from the trial are expected to be released this spring. The NIMH funded the trial and the pharmaceutical companies that manufacture the antipsychotics supplied drugs for the study.

SAN DIEGO – Phase I results from the Clinical Antipsychotic Trial of International Effectiveness-Alzheimer's Disease (CATIE-AD) unveiled for the first time at the annual meeting of the American Association for Geriatric Psychiatry are so new that the presenting investigators emphasized that they're still trying to make sense of it all.

“The data we're presenting today are preliminary. We've barely gotten to understand them ourselves,” said Lon Schneider, M.D., professor of psychiatry, neurology, and gerontology at the University of Southern California, Los Angeles, who is one of the study's lead investigators. “We first saw them Feb. 4. The data should be considered preliminary until the full report is evaluated by peer review for scientific validity and clinical importance. I hope you'll keep that in mind.”

The main goal of the trial is to compare the efficacy and effectiveness of risperidone, olanzapine, and quetiapine, and examine treatment algorithms over the course of 36 weeks in treating psychosis and severe agitation in community-dwelling patients with Alzheimer's disease. The trial design has been previously described in medical literature (Am. J. Geriatr. Psychiatry 2001;9:346–60).

“This is not your pharmaceutical company's clinical trial,” Dr. Schneider remarked. “This is not a simple randomization of drug or placebo and 10 weeks later declare victory for one or another. It's also not FDA's idea of an efficacy trial. The FDA needs trials from which they can generate labeling about a drug's use. We're trying to generate information to inform clinicians on the subtleties of using medication.”

Investigators enrolled 421 Alzheimer's disease patients with a median age of 78 years in the trial from 10 private clinic sites, 25 university sites, and 2 Veterans Affairs sites nationwide, reported Pierre Tariot, M.D., the study's other lead investigator. More than half (56%) were female, 79% were white, and 18% were African American. About one-quarter did not complete high school and 34% had a high school education or GED.

Nearly 60% were married or had been married at some point, 73% lived in their own homes, 16% lived in the home of a family member, and about 10% lived in an assisted living facility.

The patients' average Mini-Mental State Exam score was 15 and the Brief Psychiatric Rating Scale (BPRS) for conceptual disorganization, suspiciousness, or hallucinatory behavior showed moderately severe psychopathology with a fairly wide range.

In terms of functional independence, about three-quarters were receiving care equivalent to nursing home care.

The trial consisted of three phases. In phase I, all 421 patients were randomized to receive one of the three atypical antipsychotics or placebo.

“At any time if a patient was not responding, they could continue the medication, increase the dose, or order a switch to a new medication,” Dr. Schneider explained. “That was done in double-blind fashion to a medication not used previously.”

Of the 421 patients, only 77 remained in phase I.

Of the remaining 344 patients, 253 moved to phase II, which started when the patient was randomized in a double-blind fashion to a second medication. If the second medication was continued, the patients remained in this phase.

“At any time if a physician, patient, or caregiver thought it was in the best interest of the patient, the patient could be pulled out into a open choice phase of the trial where the physician would treat as he might in the community,” Dr. Schneider said.

By week 4 of the trial, about one-quarter of patients discontinued their medication in phase I for “all-cause” reasons such as inadequate treatment response, study drug not sufficiently optimal, symptoms worse, unacceptable side effects, study drug no longer needed, patient or caregiver decision, or death.

By week 8, almost half of study participants had discontinued their phase I medication, and by week 12, almost three-quarters had discontinued phase I. “People were leaving the initial phase very rapidly, [but] we have not done analysis of these data adjusted for dose or length of drug exposure,” said Dr. Tariot, professor of psychiatry, medicine, neurology, and aging and developmental biology at the University of Rochester (N.Y.).

“That's critical in understanding the full meaning of these data. It's probably premature to say this, but what I'm thinking about in my own practice is whether I should treat longer with the first agent I start on,” Dr. Tariot said at the meeting. “How long do we need to treat somebody to see an effect?”

Dr. Schneider noted that there are “multiple reasons” why a study investigator could have discontinued treatment in phase I. “One main reason is that they were not being required to keep the patient in the study for 10 weeks,” he said.

“Other reasons have to do with patients or caregivers discontinuing the trial, period. Lastly, switching medication at 2 and 4 weeks is congruent with what experts say when they're asked, 'How long do you keep a dementia patient with psychosis on an antipsychotic?' On average, it's 2–4 weeks.”

The investigators did not report any phase I clinical outcomes. Although they did not draw firm conclusions given the freshness of the data, Dr. Tariot did report that, collectively, active treatment with one of the three antipsychotics was “different” than placebo. Specifically, 39% of phase I patients who took olanzapine discontinued the drug for lack of efficacy, compared with 53% of patients who took quetiapine, 44% of patients who took risperidone, and 70% who took placebo.

In addition, 24% of phase I patients who took olanzapine discontinued the drug for reasons of intolerance, adverse events, or death, compared with 16% of patients who took quetiapine, 18% of patients who took risperidone, and 5% who took placebo.

More data from the trial are expected to be released this spring. The NIMH funded the trial and the pharmaceutical companies that manufacture the antipsychotics supplied drugs for the study.

SAN DIEGO – Donepezil is safe and effective in African Americans with mild to moderate Alzheimer's disease, a 12-week open-label study demonstrated.

The finding is important because African Americans are underrepresented in clinical trials even though they have a higher risk of developing Alzheimer's disease, compared with whites, Patrick Griffith, M.D., said during a poster session at the annual meeting of the American Association for Geriatric Psychiatry.

In addition, this is the first Alzheimer's trial to use the Fuld Object Memory Evaluation (FOME), which is thought to provide a culturally unbiased evaluation of memory. “The test has been validated in African Americans, and it operates independent of educational level or [social background],” Dr. Griffith, chief of the division of neurology at Morehouse School of Medicine, Atlanta, said in an interview. “It relies on touch and vision. We may have a measuring tool for future clinical trials that will avoid previous reports of educational or cultural bias.”

He added that the FOME was designed for elders who may have problems with hearing or attention.

Dr. Griffith and his associates enrolled 125 community-dwelling African Americans aged 51–98 from 30 sites in the United States with a clinical diagnosis of mild to moderate Alzheimer's disease and Mini-Mental State Examination (MMSE) scores of 10–26. The patients received donepezil (Aricept) 5 mg/day at the conclusion of their baseline visit; the dose was increased to 10 mg/day after 4 weeks–according to clinician judgment.

At weeks 4, 8, and 12, the investigators administered the FOME, the MMSE, and the Clinician Interview-Based Impression of Change with Caregiver Input (CIBIC-plus).

From baseline to week 12, patients demonstrated significant improvement on the FOME storage and retrieval scores, the MMSE scores, and the CIBIC-plus scores.

The most common treatment-emergent adverse events were diarrhea, hypertension, and urinary tract infection, and the incidences were similar to those reported previously in patients with mild to moderate Alzheimer's. Lab results were unremarkable.

Pfizer Inc., which manufactures donepezil, supported the study.

SAN DIEGO – Donepezil is safe and effective in African Americans with mild to moderate Alzheimer's disease, a 12-week open-label study demonstrated.

The finding is important because African Americans are underrepresented in clinical trials even though they have a higher risk of developing Alzheimer's disease, compared with whites, Patrick Griffith, M.D., said during a poster session at the annual meeting of the American Association for Geriatric Psychiatry.

In addition, this is the first Alzheimer's trial to use the Fuld Object Memory Evaluation (FOME), which is thought to provide a culturally unbiased evaluation of memory. “The test has been validated in African Americans, and it operates independent of educational level or [social background],” Dr. Griffith, chief of the division of neurology at Morehouse School of Medicine, Atlanta, said in an interview. “It relies on touch and vision. We may have a measuring tool for future clinical trials that will avoid previous reports of educational or cultural bias.”

He added that the FOME was designed for elders who may have problems with hearing or attention.

Dr. Griffith and his associates enrolled 125 community-dwelling African Americans aged 51–98 from 30 sites in the United States with a clinical diagnosis of mild to moderate Alzheimer's disease and Mini-Mental State Examination (MMSE) scores of 10–26. The patients received donepezil (Aricept) 5 mg/day at the conclusion of their baseline visit; the dose was increased to 10 mg/day after 4 weeks–according to clinician judgment.

At weeks 4, 8, and 12, the investigators administered the FOME, the MMSE, and the Clinician Interview-Based Impression of Change with Caregiver Input (CIBIC-plus).

From baseline to week 12, patients demonstrated significant improvement on the FOME storage and retrieval scores, the MMSE scores, and the CIBIC-plus scores.

The most common treatment-emergent adverse events were diarrhea, hypertension, and urinary tract infection, and the incidences were similar to those reported previously in patients with mild to moderate Alzheimer's. Lab results were unremarkable.

Pfizer Inc., which manufactures donepezil, supported the study.

SAN DIEGO – Donepezil is safe and effective in African Americans with mild to moderate Alzheimer's disease, a 12-week open-label study demonstrated.

The finding is important because African Americans are underrepresented in clinical trials even though they have a higher risk of developing Alzheimer's disease, compared with whites, Patrick Griffith, M.D., said during a poster session at the annual meeting of the American Association for Geriatric Psychiatry.

In addition, this is the first Alzheimer's trial to use the Fuld Object Memory Evaluation (FOME), which is thought to provide a culturally unbiased evaluation of memory. “The test has been validated in African Americans, and it operates independent of educational level or [social background],” Dr. Griffith, chief of the division of neurology at Morehouse School of Medicine, Atlanta, said in an interview. “It relies on touch and vision. We may have a measuring tool for future clinical trials that will avoid previous reports of educational or cultural bias.”

He added that the FOME was designed for elders who may have problems with hearing or attention.

Dr. Griffith and his associates enrolled 125 community-dwelling African Americans aged 51–98 from 30 sites in the United States with a clinical diagnosis of mild to moderate Alzheimer's disease and Mini-Mental State Examination (MMSE) scores of 10–26. The patients received donepezil (Aricept) 5 mg/day at the conclusion of their baseline visit; the dose was increased to 10 mg/day after 4 weeks–according to clinician judgment.

At weeks 4, 8, and 12, the investigators administered the FOME, the MMSE, and the Clinician Interview-Based Impression of Change with Caregiver Input (CIBIC-plus).

From baseline to week 12, patients demonstrated significant improvement on the FOME storage and retrieval scores, the MMSE scores, and the CIBIC-plus scores.

The most common treatment-emergent adverse events were diarrhea, hypertension, and urinary tract infection, and the incidences were similar to those reported previously in patients with mild to moderate Alzheimer's. Lab results were unremarkable.

Pfizer Inc., which manufactures donepezil, supported the study.

SAN DIEGO – Results from two studies presented during poster sessions at the annual meeting of the American Association for Geriatric Psychiatry paint a bleak picture of how primary care physicians are treating late-life depression.

Even though depression treatment guidelines have been available from the Agency for Healthcare Research and Quality (AHRQ) and other groups for more than a decade, only about one-quarter of physicians are using them in practice.

“Dissemination of guidelines is still a significant problem. Identifying depression is not enough,” Randall Espinoza, M.D., told this newspaper. “In terms of managing depression, we need to reach an extra level of surveillance. We have to do a better job.”

In one of the largest studies of its kind, Dr. Espinoza and his associates analyzed data from 895 patients in the “usual care” arm of Project IMPACT (Improving Mood: Promoting Access to Collaborative Treatment), a randomized, controlled trial of collaborative care management for late-life depression. The mean age of patients was 71 years, and the trial took place in 18 primary care practices in five states. (Patients in the intervention arm were assigned a care manager to provide medication support or counseling.)

Of the 895 patients in the usual care arm, 52% had both dysthymia and major depression, 32% had dysthymia only, and 16% had major depression only, reported Dr. Espinoza of the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles, Neuropsychiatric Institute. Nearly 70% reported two or more prior episodes of depression at baseline, and fewer than half were receiving depression treatment at the time of study enrollment.

“Only 28% had received guideline-concordant depression care during the 3 months prior to baseline,” he said. “Over 6 months, the modal experience was that patients experienced no change in depression treatment despite persistent depression symptoms.”

Of those who were not on an antidepressant at baseline, 73% did not receive one during the following 6 months, and 68% of patients who were on a selective serotonin reuptake inhibitor (SSRI) remained on the same type of medication.

At 6 months, only one-third of the sample showed significant improvement or remission of depressive symptoms.

Patients who were prescribed medications other than SSRIs were significantly more likely to improve but not more likely to achieve remission, Dr. Espinoza noted. Patients with dysthymia were less likely to improve or to achieve remission.

“So if you identify somebody in primary care who is chronically depressed, you may want to get them to a mental health specialist sooner, rather than later, or increase your surveillance and change medication sooner, rather than later,” he said.

The study was funded by the American Federation for Aging Research, the U.S. Department of Health and Human Services, the John A. Hartford Foundation, and the California HealthCare Foundation.

In another trial, Patrick Raue, Ph.D., and his associates examined the practices of physicians enrolled in the “usual care” arm of the Prevention of Suicide in the Elderly Project (PROSPECT). (In the intervention arm, a social worker, psychologist, or nurse provided care management to patients in the form of antidepressant treatment, psychotherapy, or both.)

Dr. Raue and his associates sought to discover whether physicians started antidepressant treatment after being informed of a diagnosis of major or minor depression in their patients and after being educated about the 1993 AHRQ guidelines for detection, diagnosis, and treatment of depression in primary care.

The investigators reviewed the charts of 107 patients with a mean age of 72 years in seven primary care practices in New York, Philadelphia, and Pittsburgh who met Structured Clinical Interview for DSM-III-R criteria for major or minor depression. They studied information on physician visits and antidepressant prescriptions for a 2-month period after physicians were informed of a depression diagnosis.

Physicians met or spoke by phone with only 30 patients (28%) within 2 months of being informed of a depression diagnosis, reported Dr. Raue of the department of psychiatry at Cornell University, New York.

Among these 30 patients, physicians began a new antidepressant in 13 cases, increased the dose in 6, decreased the dose in 1, and discontinued treatment in 6.

“I think it's particularly striking that 10 years after more clear guidelines for prescribing antidepressants, we're still finding that physicians in primary care aren't doing such a great job, even with being told that their patients are suffering from depression,” Dr. Raue told this newspaper. “There's very little follow-up. It's striking that these findings continue in the face of more educational efforts and more appropriate guidelines” for treating late-life depression.

The National Institute of Mental Health funded the study.

SAN DIEGO – Results from two studies presented during poster sessions at the annual meeting of the American Association for Geriatric Psychiatry paint a bleak picture of how primary care physicians are treating late-life depression.

Even though depression treatment guidelines have been available from the Agency for Healthcare Research and Quality (AHRQ) and other groups for more than a decade, only about one-quarter of physicians are using them in practice.

“Dissemination of guidelines is still a significant problem. Identifying depression is not enough,” Randall Espinoza, M.D., told this newspaper. “In terms of managing depression, we need to reach an extra level of surveillance. We have to do a better job.”

In one of the largest studies of its kind, Dr. Espinoza and his associates analyzed data from 895 patients in the “usual care” arm of Project IMPACT (Improving Mood: Promoting Access to Collaborative Treatment), a randomized, controlled trial of collaborative care management for late-life depression. The mean age of patients was 71 years, and the trial took place in 18 primary care practices in five states. (Patients in the intervention arm were assigned a care manager to provide medication support or counseling.)

Of the 895 patients in the usual care arm, 52% had both dysthymia and major depression, 32% had dysthymia only, and 16% had major depression only, reported Dr. Espinoza of the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles, Neuropsychiatric Institute. Nearly 70% reported two or more prior episodes of depression at baseline, and fewer than half were receiving depression treatment at the time of study enrollment.

“Only 28% had received guideline-concordant depression care during the 3 months prior to baseline,” he said. “Over 6 months, the modal experience was that patients experienced no change in depression treatment despite persistent depression symptoms.”

Of those who were not on an antidepressant at baseline, 73% did not receive one during the following 6 months, and 68% of patients who were on a selective serotonin reuptake inhibitor (SSRI) remained on the same type of medication.

At 6 months, only one-third of the sample showed significant improvement or remission of depressive symptoms.

Patients who were prescribed medications other than SSRIs were significantly more likely to improve but not more likely to achieve remission, Dr. Espinoza noted. Patients with dysthymia were less likely to improve or to achieve remission.

“So if you identify somebody in primary care who is chronically depressed, you may want to get them to a mental health specialist sooner, rather than later, or increase your surveillance and change medication sooner, rather than later,” he said.

The study was funded by the American Federation for Aging Research, the U.S. Department of Health and Human Services, the John A. Hartford Foundation, and the California HealthCare Foundation.

In another trial, Patrick Raue, Ph.D., and his associates examined the practices of physicians enrolled in the “usual care” arm of the Prevention of Suicide in the Elderly Project (PROSPECT). (In the intervention arm, a social worker, psychologist, or nurse provided care management to patients in the form of antidepressant treatment, psychotherapy, or both.)

Dr. Raue and his associates sought to discover whether physicians started antidepressant treatment after being informed of a diagnosis of major or minor depression in their patients and after being educated about the 1993 AHRQ guidelines for detection, diagnosis, and treatment of depression in primary care.

The investigators reviewed the charts of 107 patients with a mean age of 72 years in seven primary care practices in New York, Philadelphia, and Pittsburgh who met Structured Clinical Interview for DSM-III-R criteria for major or minor depression. They studied information on physician visits and antidepressant prescriptions for a 2-month period after physicians were informed of a depression diagnosis.

Physicians met or spoke by phone with only 30 patients (28%) within 2 months of being informed of a depression diagnosis, reported Dr. Raue of the department of psychiatry at Cornell University, New York.

Among these 30 patients, physicians began a new antidepressant in 13 cases, increased the dose in 6, decreased the dose in 1, and discontinued treatment in 6.

“I think it's particularly striking that 10 years after more clear guidelines for prescribing antidepressants, we're still finding that physicians in primary care aren't doing such a great job, even with being told that their patients are suffering from depression,” Dr. Raue told this newspaper. “There's very little follow-up. It's striking that these findings continue in the face of more educational efforts and more appropriate guidelines” for treating late-life depression.

The National Institute of Mental Health funded the study.

SAN DIEGO – Results from two studies presented during poster sessions at the annual meeting of the American Association for Geriatric Psychiatry paint a bleak picture of how primary care physicians are treating late-life depression.

Even though depression treatment guidelines have been available from the Agency for Healthcare Research and Quality (AHRQ) and other groups for more than a decade, only about one-quarter of physicians are using them in practice.

“Dissemination of guidelines is still a significant problem. Identifying depression is not enough,” Randall Espinoza, M.D., told this newspaper. “In terms of managing depression, we need to reach an extra level of surveillance. We have to do a better job.”

In one of the largest studies of its kind, Dr. Espinoza and his associates analyzed data from 895 patients in the “usual care” arm of Project IMPACT (Improving Mood: Promoting Access to Collaborative Treatment), a randomized, controlled trial of collaborative care management for late-life depression. The mean age of patients was 71 years, and the trial took place in 18 primary care practices in five states. (Patients in the intervention arm were assigned a care manager to provide medication support or counseling.)

Of the 895 patients in the usual care arm, 52% had both dysthymia and major depression, 32% had dysthymia only, and 16% had major depression only, reported Dr. Espinoza of the department of psychiatry and biobehavioral sciences at the University of California, Los Angeles, Neuropsychiatric Institute. Nearly 70% reported two or more prior episodes of depression at baseline, and fewer than half were receiving depression treatment at the time of study enrollment.

“Only 28% had received guideline-concordant depression care during the 3 months prior to baseline,” he said. “Over 6 months, the modal experience was that patients experienced no change in depression treatment despite persistent depression symptoms.”

Of those who were not on an antidepressant at baseline, 73% did not receive one during the following 6 months, and 68% of patients who were on a selective serotonin reuptake inhibitor (SSRI) remained on the same type of medication.

At 6 months, only one-third of the sample showed significant improvement or remission of depressive symptoms.

Patients who were prescribed medications other than SSRIs were significantly more likely to improve but not more likely to achieve remission, Dr. Espinoza noted. Patients with dysthymia were less likely to improve or to achieve remission.

“So if you identify somebody in primary care who is chronically depressed, you may want to get them to a mental health specialist sooner, rather than later, or increase your surveillance and change medication sooner, rather than later,” he said.

The study was funded by the American Federation for Aging Research, the U.S. Department of Health and Human Services, the John A. Hartford Foundation, and the California HealthCare Foundation.

In another trial, Patrick Raue, Ph.D., and his associates examined the practices of physicians enrolled in the “usual care” arm of the Prevention of Suicide in the Elderly Project (PROSPECT). (In the intervention arm, a social worker, psychologist, or nurse provided care management to patients in the form of antidepressant treatment, psychotherapy, or both.)

Dr. Raue and his associates sought to discover whether physicians started antidepressant treatment after being informed of a diagnosis of major or minor depression in their patients and after being educated about the 1993 AHRQ guidelines for detection, diagnosis, and treatment of depression in primary care.

The investigators reviewed the charts of 107 patients with a mean age of 72 years in seven primary care practices in New York, Philadelphia, and Pittsburgh who met Structured Clinical Interview for DSM-III-R criteria for major or minor depression. They studied information on physician visits and antidepressant prescriptions for a 2-month period after physicians were informed of a depression diagnosis.

Physicians met or spoke by phone with only 30 patients (28%) within 2 months of being informed of a depression diagnosis, reported Dr. Raue of the department of psychiatry at Cornell University, New York.

Among these 30 patients, physicians began a new antidepressant in 13 cases, increased the dose in 6, decreased the dose in 1, and discontinued treatment in 6.

“I think it's particularly striking that 10 years after more clear guidelines for prescribing antidepressants, we're still finding that physicians in primary care aren't doing such a great job, even with being told that their patients are suffering from depression,” Dr. Raue told this newspaper. “There's very little follow-up. It's striking that these findings continue in the face of more educational efforts and more appropriate guidelines” for treating late-life depression.

The National Institute of Mental Health funded the study.

A few years ago, Jerry Rogoff, M.D., became so engrossed in a woodworking project that he lost track of time.

An intercom system links his Vermont home to a workshop on the property. At some point in the day, his wife's voice resonated over the intercom speaker.

"Are you going to eat today?"

"Is it lunchtime?" Dr. Rogoff asked.

"No. It's suppertime," his wife replied.

He had been in the workshop 8 hours, but "had absolutely no idea what time it was," said Dr. Rogoff, a psychiatrist and psychoanalyst who practices in Boston. "There's a clock in the shop, but I never looked at it. I was totally absorbed," he said. "Woodworking does wonders for me."

About every other weekend, he and his wife drive from their Boston-area home to their second home in Vermont. There he has made two dining room tables, a chest of drawers, and children's furniture—all for family or friends.

He considers the hobby a form of solace and a way to be engaged in something. "It's physically creative; in psychiatry, you're not. Psychiatry is very sedentary. In the workshop I'm active, moving, and doing something all the time all day long," he said. "There's a real sense of working with my hands and creating something."

Physicians "need this type of play," he added. "They need something to get away from the intensity and pressure of work and both relax and fulfill themselves. That improves one's life, one's relationships with spouse and family, and I think it improves one's work with patients."

Dr. Rogoff first took up woodworking during his residency in 1968 at Massachusetts Mental Health Center as a way to "decompress, debrief, and escape from the pressures of work." He bought a radial arm saw and built on basic skills he learned in junior high shop class in Detroit. One of the first things he made was an analytic couch out of walnut for his psychoanalytic practice. It remains a fixture in his office.

He noted that woodworking provides him with a tangible measure of success that isn't always attainable in his field. "Psychiatric work generally goes very slowly," he explained. "You get some quick results with medication, but on the whole, your changes are measured in millimeters, not in miles. In the workshop, I measure them in miles. You create something. There's real change, and it's quick. You're in control of it. None of that applies to the psychiatric process. There you try your best, but you're often not fully in control of it and it's somewhat unpredictable. Change is slow. In the end, you don't always have something to show for your labors."

Carl C. Bell, M.D., said it's crucial for physicians to have a hobby outside of their job. "Medicine is ugly work, because you're constantly confronting trauma, death, disability, pain, and suffering," said Dr. Bell, professor of psychiatry and public health at the University of Illinois at Chicago "I have three principles: Save some lives, make some money, and have some fun. That's what I look for in a job. Sometimes two out of three aren't bad. You have to maintain balance. Otherwise, you're not good to anybody. From a hobby perspective, that's important."

Francis E. Rushton, M.D., can identify with that notion. About three times a year, he goes on brief backpacking adventures to clear his mind, usually with his sons or with other pediatricians. Because of his hectic work schedule, "I don't always have a lot of opportunities to spend time with my kids," said Dr. Rushton, who practices in Beaufort, S.C. "I'm so busy here in the office that when it comes to vacation time, it's hard for me to stop and sit. Somehow I just seem to keep moving. For me, backpacking is a way to stay active, but it's mindless. After 2-3 days, all of the worries of the office disappear and the only thing I have to worry about is, 'am I going to freeze to death?' or 'do I have anything to eat?'"

His journeys have included trails in the Sierra Nevadas, the Yukon Territory, Great Smoky Mountains National Park, and Baxter State Park in Maine, as well as footpaths in Norway, New Zealand, and Venezuela.

"It's a time for me to communicate with my kids, it's a time for me to see a different part of the country, and it's a time for me to physically work out some of the frustrations of the office," Dr. Rushton said. "[These frustrations are] physically taxing to me, and there's a sense of accomplishment when I get done. It's a cleansing of the mind. I come back, and I'm ready to charge forth again at work."

David Abend, D.O., also finds escape in physical activity. He works out at a nearby gym 3 days a week with a personal trainer, doing circuit training, followed by a half-hour of cardiovascular activity. "I also jog, but not competitively," said Dr. Abend, who practices family medicine and osteopathic manipulation in Westwood, N.J. "I think you do your patients a great disservice by leading an inactive life."

Music's another passion for Dr. Abend. "I just got an iPod, and I have about 5,000 CDs, everything from classical to metal music," he said. "I'm actually a closet metal head."

He also takes piano lessons and guitar lessons, and he's been to "concerts galore."

Photos of musicians and athletes adorn the walls of his office, and he shows popular movies in his waiting room. "A doctor is very one dimensional if he doesn't have hobbies," Dr. Abend said. "In primary care, you're seeing people from all walks of life. I can talk about art one minute or music and sports the next. There's not much I can't talk to you about."

Dr. Bell of Chicago regards the Chinese martial art of Chi Kung as not only his hobby but also his "survival strategy." He learned Chi Kung exercises from a martial arts instructor in 1976, and in 1995, he produced his own video, "Dr. Carl Bell's 8 Pieces of Brocade," which is now available as a DVD (for information, visit www.giftfromwithin.org/html/resource.html

"They're easy to learn and they massage all of the acupuncture points in the body," he said. "I used to have chronic sinusitis, and I used to do Western exercises. When I started the Chi Kung, my sinusitis went away."

Over time, he added, the exercises have helped improve his endurance, flexibility, and tolerance for pain, cold, and heat, as well as his memory, thought processing, and affect tolerance. "I'm healthy as hell," he said. "People think I'm 45, and I'm close to 60."

He was quick to point out that the exercises are not a one-time magic bullet—a detail he conveys in Chi Kung workshops he leads at various psychiatry meetings. "You have to do them regularly," he said.

Dr. Francis E. Rushton (right) with his two sons Will and Seth at Rae Lakes in the Sierra Nevada Range, Calif. Courtesy Dr. Francis E. Rushton

A Physician Masters the Ski Slopes

Ski racer Suzanne Boulter, M.D., flies downhill faster than most other snow skiers her age, and she has the credentials to prove it.

In 2003, she won the women's Masters National Championship in Park City, Utah, in the 55- to 59-year-old age category.

"It's neat at this age to still be working on things and trying to improve and see some results," said Dr. Boulter, a pediatrician with the family practice residency program at Concord (N.H.) Hospital.

Every Friday between Thanksgiving and the end of March, Dr. Boulter trains in a masters program at Waterville Valley, a New Hampshire ski area where she and her husband own a condo. The training usually alternates between slalom and giant slalom-all in preparation for the 10-15 races she competes in each year, mostly in the Northeast.

Her goal is to "get better technically and translate that into skiing faster in the course," she said. "Winning the nationals in 2003 was totally unexpected for me. There aren't large numbers of women in the older age groups at the nationals, so there is always opportunity there, but it was very surprising."

Over the years she's suffered a concussion and her share of broken bones from training and competing on the slopes, but few other sports provide her with the same sense of fulfillment.

"I have this physical outlet on the weekend, then I switch to the workday week, so it's a nice balance," said Dr. Boulter, a New Hampshire native who started skiing in high school. "If you have a lot of energy, you can make anything happen. During the child-rearing and professional-responsibility years, it does seem daunting to take any time for yourself and your own activities. When my kids were growing up, I didn't do anything like this, although I skied a little bit."

Outside of ski season, she stays active by biking and water skiing, playing tennis, and doing aerobics.

"If for whatever reason I could not continue ski racing, I'd still do those other outdoor activities for as long as I could," she said. "If I couldn't do all of those things, I'd probably read more books and journals."

Dr. Suzanne Boulter skis the slalom course on the slopes of Bromley Mountain in Manchester, Vt. Courtesy Dr. Suzanne Boulter

A few years ago, Jerry Rogoff, M.D., became so engrossed in a woodworking project that he lost track of time.

An intercom system links his Vermont home to a workshop on the property. At some point in the day, his wife's voice resonated over the intercom speaker.

"Are you going to eat today?"

"Is it lunchtime?" Dr. Rogoff asked.

"No. It's suppertime," his wife replied.

He had been in the workshop 8 hours, but "had absolutely no idea what time it was," said Dr. Rogoff, a psychiatrist and psychoanalyst who practices in Boston. "There's a clock in the shop, but I never looked at it. I was totally absorbed," he said. "Woodworking does wonders for me."

About every other weekend, he and his wife drive from their Boston-area home to their second home in Vermont. There he has made two dining room tables, a chest of drawers, and children's furniture—all for family or friends.

He considers the hobby a form of solace and a way to be engaged in something. "It's physically creative; in psychiatry, you're not. Psychiatry is very sedentary. In the workshop I'm active, moving, and doing something all the time all day long," he said. "There's a real sense of working with my hands and creating something."

Physicians "need this type of play," he added. "They need something to get away from the intensity and pressure of work and both relax and fulfill themselves. That improves one's life, one's relationships with spouse and family, and I think it improves one's work with patients."

Dr. Rogoff first took up woodworking during his residency in 1968 at Massachusetts Mental Health Center as a way to "decompress, debrief, and escape from the pressures of work." He bought a radial arm saw and built on basic skills he learned in junior high shop class in Detroit. One of the first things he made was an analytic couch out of walnut for his psychoanalytic practice. It remains a fixture in his office.

He noted that woodworking provides him with a tangible measure of success that isn't always attainable in his field. "Psychiatric work generally goes very slowly," he explained. "You get some quick results with medication, but on the whole, your changes are measured in millimeters, not in miles. In the workshop, I measure them in miles. You create something. There's real change, and it's quick. You're in control of it. None of that applies to the psychiatric process. There you try your best, but you're often not fully in control of it and it's somewhat unpredictable. Change is slow. In the end, you don't always have something to show for your labors."

Carl C. Bell, M.D., said it's crucial for physicians to have a hobby outside of their job. "Medicine is ugly work, because you're constantly confronting trauma, death, disability, pain, and suffering," said Dr. Bell, professor of psychiatry and public health at the University of Illinois at Chicago "I have three principles: Save some lives, make some money, and have some fun. That's what I look for in a job. Sometimes two out of three aren't bad. You have to maintain balance. Otherwise, you're not good to anybody. From a hobby perspective, that's important."

Francis E. Rushton, M.D., can identify with that notion. About three times a year, he goes on brief backpacking adventures to clear his mind, usually with his sons or with other pediatricians. Because of his hectic work schedule, "I don't always have a lot of opportunities to spend time with my kids," said Dr. Rushton, who practices in Beaufort, S.C. "I'm so busy here in the office that when it comes to vacation time, it's hard for me to stop and sit. Somehow I just seem to keep moving. For me, backpacking is a way to stay active, but it's mindless. After 2-3 days, all of the worries of the office disappear and the only thing I have to worry about is, 'am I going to freeze to death?' or 'do I have anything to eat?'"

His journeys have included trails in the Sierra Nevadas, the Yukon Territory, Great Smoky Mountains National Park, and Baxter State Park in Maine, as well as footpaths in Norway, New Zealand, and Venezuela.

"It's a time for me to communicate with my kids, it's a time for me to see a different part of the country, and it's a time for me to physically work out some of the frustrations of the office," Dr. Rushton said. "[These frustrations are] physically taxing to me, and there's a sense of accomplishment when I get done. It's a cleansing of the mind. I come back, and I'm ready to charge forth again at work."

David Abend, D.O., also finds escape in physical activity. He works out at a nearby gym 3 days a week with a personal trainer, doing circuit training, followed by a half-hour of cardiovascular activity. "I also jog, but not competitively," said Dr. Abend, who practices family medicine and osteopathic manipulation in Westwood, N.J. "I think you do your patients a great disservice by leading an inactive life."

Music's another passion for Dr. Abend. "I just got an iPod, and I have about 5,000 CDs, everything from classical to metal music," he said. "I'm actually a closet metal head."

He also takes piano lessons and guitar lessons, and he's been to "concerts galore."

Photos of musicians and athletes adorn the walls of his office, and he shows popular movies in his waiting room. "A doctor is very one dimensional if he doesn't have hobbies," Dr. Abend said. "In primary care, you're seeing people from all walks of life. I can talk about art one minute or music and sports the next. There's not much I can't talk to you about."

Dr. Bell of Chicago regards the Chinese martial art of Chi Kung as not only his hobby but also his "survival strategy." He learned Chi Kung exercises from a martial arts instructor in 1976, and in 1995, he produced his own video, "Dr. Carl Bell's 8 Pieces of Brocade," which is now available as a DVD (for information, visit www.giftfromwithin.org/html/resource.html

"They're easy to learn and they massage all of the acupuncture points in the body," he said. "I used to have chronic sinusitis, and I used to do Western exercises. When I started the Chi Kung, my sinusitis went away."

Over time, he added, the exercises have helped improve his endurance, flexibility, and tolerance for pain, cold, and heat, as well as his memory, thought processing, and affect tolerance. "I'm healthy as hell," he said. "People think I'm 45, and I'm close to 60."

He was quick to point out that the exercises are not a one-time magic bullet—a detail he conveys in Chi Kung workshops he leads at various psychiatry meetings. "You have to do them regularly," he said.

Dr. Francis E. Rushton (right) with his two sons Will and Seth at Rae Lakes in the Sierra Nevada Range, Calif. Courtesy Dr. Francis E. Rushton

A Physician Masters the Ski Slopes

Ski racer Suzanne Boulter, M.D., flies downhill faster than most other snow skiers her age, and she has the credentials to prove it.

In 2003, she won the women's Masters National Championship in Park City, Utah, in the 55- to 59-year-old age category.

"It's neat at this age to still be working on things and trying to improve and see some results," said Dr. Boulter, a pediatrician with the family practice residency program at Concord (N.H.) Hospital.

Every Friday between Thanksgiving and the end of March, Dr. Boulter trains in a masters program at Waterville Valley, a New Hampshire ski area where she and her husband own a condo. The training usually alternates between slalom and giant slalom-all in preparation for the 10-15 races she competes in each year, mostly in the Northeast.

Her goal is to "get better technically and translate that into skiing faster in the course," she said. "Winning the nationals in 2003 was totally unexpected for me. There aren't large numbers of women in the older age groups at the nationals, so there is always opportunity there, but it was very surprising."

Over the years she's suffered a concussion and her share of broken bones from training and competing on the slopes, but few other sports provide her with the same sense of fulfillment.

"I have this physical outlet on the weekend, then I switch to the workday week, so it's a nice balance," said Dr. Boulter, a New Hampshire native who started skiing in high school. "If you have a lot of energy, you can make anything happen. During the child-rearing and professional-responsibility years, it does seem daunting to take any time for yourself and your own activities. When my kids were growing up, I didn't do anything like this, although I skied a little bit."

Outside of ski season, she stays active by biking and water skiing, playing tennis, and doing aerobics.

"If for whatever reason I could not continue ski racing, I'd still do those other outdoor activities for as long as I could," she said. "If I couldn't do all of those things, I'd probably read more books and journals."

Dr. Suzanne Boulter skis the slalom course on the slopes of Bromley Mountain in Manchester, Vt. Courtesy Dr. Suzanne Boulter

A few years ago, Jerry Rogoff, M.D., became so engrossed in a woodworking project that he lost track of time.

An intercom system links his Vermont home to a workshop on the property. At some point in the day, his wife's voice resonated over the intercom speaker.

"Are you going to eat today?"

"Is it lunchtime?" Dr. Rogoff asked.

"No. It's suppertime," his wife replied.

He had been in the workshop 8 hours, but "had absolutely no idea what time it was," said Dr. Rogoff, a psychiatrist and psychoanalyst who practices in Boston. "There's a clock in the shop, but I never looked at it. I was totally absorbed," he said. "Woodworking does wonders for me."

About every other weekend, he and his wife drive from their Boston-area home to their second home in Vermont. There he has made two dining room tables, a chest of drawers, and children's furniture—all for family or friends.

He considers the hobby a form of solace and a way to be engaged in something. "It's physically creative; in psychiatry, you're not. Psychiatry is very sedentary. In the workshop I'm active, moving, and doing something all the time all day long," he said. "There's a real sense of working with my hands and creating something."

Physicians "need this type of play," he added. "They need something to get away from the intensity and pressure of work and both relax and fulfill themselves. That improves one's life, one's relationships with spouse and family, and I think it improves one's work with patients."

Dr. Rogoff first took up woodworking during his residency in 1968 at Massachusetts Mental Health Center as a way to "decompress, debrief, and escape from the pressures of work." He bought a radial arm saw and built on basic skills he learned in junior high shop class in Detroit. One of the first things he made was an analytic couch out of walnut for his psychoanalytic practice. It remains a fixture in his office.

He noted that woodworking provides him with a tangible measure of success that isn't always attainable in his field. "Psychiatric work generally goes very slowly," he explained. "You get some quick results with medication, but on the whole, your changes are measured in millimeters, not in miles. In the workshop, I measure them in miles. You create something. There's real change, and it's quick. You're in control of it. None of that applies to the psychiatric process. There you try your best, but you're often not fully in control of it and it's somewhat unpredictable. Change is slow. In the end, you don't always have something to show for your labors."

Carl C. Bell, M.D., said it's crucial for physicians to have a hobby outside of their job. "Medicine is ugly work, because you're constantly confronting trauma, death, disability, pain, and suffering," said Dr. Bell, professor of psychiatry and public health at the University of Illinois at Chicago "I have three principles: Save some lives, make some money, and have some fun. That's what I look for in a job. Sometimes two out of three aren't bad. You have to maintain balance. Otherwise, you're not good to anybody. From a hobby perspective, that's important."

Francis E. Rushton, M.D., can identify with that notion. About three times a year, he goes on brief backpacking adventures to clear his mind, usually with his sons or with other pediatricians. Because of his hectic work schedule, "I don't always have a lot of opportunities to spend time with my kids," said Dr. Rushton, who practices in Beaufort, S.C. "I'm so busy here in the office that when it comes to vacation time, it's hard for me to stop and sit. Somehow I just seem to keep moving. For me, backpacking is a way to stay active, but it's mindless. After 2-3 days, all of the worries of the office disappear and the only thing I have to worry about is, 'am I going to freeze to death?' or 'do I have anything to eat?'"

His journeys have included trails in the Sierra Nevadas, the Yukon Territory, Great Smoky Mountains National Park, and Baxter State Park in Maine, as well as footpaths in Norway, New Zealand, and Venezuela.

"It's a time for me to communicate with my kids, it's a time for me to see a different part of the country, and it's a time for me to physically work out some of the frustrations of the office," Dr. Rushton said. "[These frustrations are] physically taxing to me, and there's a sense of accomplishment when I get done. It's a cleansing of the mind. I come back, and I'm ready to charge forth again at work."

David Abend, D.O., also finds escape in physical activity. He works out at a nearby gym 3 days a week with a personal trainer, doing circuit training, followed by a half-hour of cardiovascular activity. "I also jog, but not competitively," said Dr. Abend, who practices family medicine and osteopathic manipulation in Westwood, N.J. "I think you do your patients a great disservice by leading an inactive life."

Music's another passion for Dr. Abend. "I just got an iPod, and I have about 5,000 CDs, everything from classical to metal music," he said. "I'm actually a closet metal head."

He also takes piano lessons and guitar lessons, and he's been to "concerts galore."

Photos of musicians and athletes adorn the walls of his office, and he shows popular movies in his waiting room. "A doctor is very one dimensional if he doesn't have hobbies," Dr. Abend said. "In primary care, you're seeing people from all walks of life. I can talk about art one minute or music and sports the next. There's not much I can't talk to you about."

Dr. Bell of Chicago regards the Chinese martial art of Chi Kung as not only his hobby but also his "survival strategy." He learned Chi Kung exercises from a martial arts instructor in 1976, and in 1995, he produced his own video, "Dr. Carl Bell's 8 Pieces of Brocade," which is now available as a DVD (for information, visit www.giftfromwithin.org/html/resource.html

"They're easy to learn and they massage all of the acupuncture points in the body," he said. "I used to have chronic sinusitis, and I used to do Western exercises. When I started the Chi Kung, my sinusitis went away."

Over time, he added, the exercises have helped improve his endurance, flexibility, and tolerance for pain, cold, and heat, as well as his memory, thought processing, and affect tolerance. "I'm healthy as hell," he said. "People think I'm 45, and I'm close to 60."

He was quick to point out that the exercises are not a one-time magic bullet—a detail he conveys in Chi Kung workshops he leads at various psychiatry meetings. "You have to do them regularly," he said.

Dr. Francis E. Rushton (right) with his two sons Will and Seth at Rae Lakes in the Sierra Nevada Range, Calif. Courtesy Dr. Francis E. Rushton

A Physician Masters the Ski Slopes

Ski racer Suzanne Boulter, M.D., flies downhill faster than most other snow skiers her age, and she has the credentials to prove it.

In 2003, she won the women's Masters National Championship in Park City, Utah, in the 55- to 59-year-old age category.

"It's neat at this age to still be working on things and trying to improve and see some results," said Dr. Boulter, a pediatrician with the family practice residency program at Concord (N.H.) Hospital.

Every Friday between Thanksgiving and the end of March, Dr. Boulter trains in a masters program at Waterville Valley, a New Hampshire ski area where she and her husband own a condo. The training usually alternates between slalom and giant slalom-all in preparation for the 10-15 races she competes in each year, mostly in the Northeast.

Her goal is to "get better technically and translate that into skiing faster in the course," she said. "Winning the nationals in 2003 was totally unexpected for me. There aren't large numbers of women in the older age groups at the nationals, so there is always opportunity there, but it was very surprising."

Over the years she's suffered a concussion and her share of broken bones from training and competing on the slopes, but few other sports provide her with the same sense of fulfillment.

"I have this physical outlet on the weekend, then I switch to the workday week, so it's a nice balance," said Dr. Boulter, a New Hampshire native who started skiing in high school. "If you have a lot of energy, you can make anything happen. During the child-rearing and professional-responsibility years, it does seem daunting to take any time for yourself and your own activities. When my kids were growing up, I didn't do anything like this, although I skied a little bit."

Outside of ski season, she stays active by biking and water skiing, playing tennis, and doing aerobics.

"If for whatever reason I could not continue ski racing, I'd still do those other outdoor activities for as long as I could," she said. "If I couldn't do all of those things, I'd probably read more books and journals."

Dr. Suzanne Boulter skis the slalom course on the slopes of Bromley Mountain in Manchester, Vt. Courtesy Dr. Suzanne Boulter

LA JOLLA, CALIF. — When you refer a patient to a provider of complementary and alternative medicine, keep in mind five liability management strategies, David M. Eisenberg, M.D., advised at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

The strategies, which he developed in collaboration with Michael H. Cohen, J.D. (Ann. Intern. Med. 2002;136:596-603), include the following:

1. Determine the clinical risk level. Decide whether to:

▸ Recommend yet continue to monitor the therapy.

▸ Tolerate, provide caution, and closely monitor safety.

▸ Avoid and actively discourage the therapy.

2. Document the literature supporting the therapeutic choice.

"It's very important to put this in the chart," said Dr. Eisenberg, an internist who directs the division for research and education in complementary and integrative medical therapies at the Osher Institute, Harvard Medical School, Boston.

"By the way, that is also true when we're using a novel or experimental drug with an inpatient. This is the same approach."

If treatment with a certain herb is recommended, "document the choice of herb, any recommendation regarding product or brand, and any discussion regarding therapeutic dose, and associated uncertainties regarding use of the herb," he said.

He also makes it a practice to keep a backup file of articles supporting the discussion or recommendation. "You could say this is a bit too conservative, like have suspenders and a belt," he said at the meeting, cosponsored by the University of California, San Diego. "But I think this is the best advice."

3. Continue conventional monitoring. "A lot of times we recommend something or accept that a patient is going to do something, and then we don't monitor or follow up," Dr. Eisenberg said. "Undue reliance on CAM may lead to a charge that the patient was dissuaded from necessary conventional medical care."

He added that maintaining conventional treatment "helps demonstrate that the physician has followed the standard of care, even if CAM is included."

4. Provide adequate informed consent. Describe the risks and benefits of using the CAM therapy and of delaying or deferring the conventional therapy, and spell out potential adverse interactions.

That is a lot to consider, but such information would be helpful "in the eyes of the law if something went wrong," he said. "You have to ask yourself, could I really defend this action or recommendation?"

Also, clear communication with the patient has been shown to reduce the risk of being sued for malpractice. "Inadequate informed consent is also a theory for malpractice liability in and of itself," Dr. Eisenberg said.

5. Familiarize yourself with providers to whom you refer. Ask yourself, would I refer a friend to this person?

"If the answer is 'I'm not sure,' then get some help in making the correct referral," he advised.

Understand any regulations regarding the use of CAM therapies by your relevant state regulatory board.

"You have to check the regulations and scope of practice," he said. "From a conservative legal standpoint, referring to somebody who does not own a license to treat a patient is risky business. Don't do it."

He pointed out that, in general, a physician is not liable merely for making a referral to a specialist.

But he cited three exceptions to the general rule:

▸ The referral led to delay or deferral of necessary medical treatment. "Do your day job first," he said.

▸ The referring provider knew or should have known that the referred-to provider was incompetent.

▸ The referred-to provider is considered to be the physician's agent, either because state law requires supervision or an extended form of consultation, or there is a "joint treatment" agreement between the physician and the CAM provider, Dr. Eisenberg said.n

LA JOLLA, CALIF. — When you refer a patient to a provider of complementary and alternative medicine, keep in mind five liability management strategies, David M. Eisenberg, M.D., advised at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

The strategies, which he developed in collaboration with Michael H. Cohen, J.D. (Ann. Intern. Med. 2002;136:596-603), include the following:

1. Determine the clinical risk level. Decide whether to:

▸ Recommend yet continue to monitor the therapy.

▸ Tolerate, provide caution, and closely monitor safety.

▸ Avoid and actively discourage the therapy.

2. Document the literature supporting the therapeutic choice.

"It's very important to put this in the chart," said Dr. Eisenberg, an internist who directs the division for research and education in complementary and integrative medical therapies at the Osher Institute, Harvard Medical School, Boston.

"By the way, that is also true when we're using a novel or experimental drug with an inpatient. This is the same approach."

If treatment with a certain herb is recommended, "document the choice of herb, any recommendation regarding product or brand, and any discussion regarding therapeutic dose, and associated uncertainties regarding use of the herb," he said.

He also makes it a practice to keep a backup file of articles supporting the discussion or recommendation. "You could say this is a bit too conservative, like have suspenders and a belt," he said at the meeting, cosponsored by the University of California, San Diego. "But I think this is the best advice."

3. Continue conventional monitoring. "A lot of times we recommend something or accept that a patient is going to do something, and then we don't monitor or follow up," Dr. Eisenberg said. "Undue reliance on CAM may lead to a charge that the patient was dissuaded from necessary conventional medical care."

He added that maintaining conventional treatment "helps demonstrate that the physician has followed the standard of care, even if CAM is included."

4. Provide adequate informed consent. Describe the risks and benefits of using the CAM therapy and of delaying or deferring the conventional therapy, and spell out potential adverse interactions.

That is a lot to consider, but such information would be helpful "in the eyes of the law if something went wrong," he said. "You have to ask yourself, could I really defend this action or recommendation?"

Also, clear communication with the patient has been shown to reduce the risk of being sued for malpractice. "Inadequate informed consent is also a theory for malpractice liability in and of itself," Dr. Eisenberg said.

5. Familiarize yourself with providers to whom you refer. Ask yourself, would I refer a friend to this person?

"If the answer is 'I'm not sure,' then get some help in making the correct referral," he advised.

Understand any regulations regarding the use of CAM therapies by your relevant state regulatory board.

"You have to check the regulations and scope of practice," he said. "From a conservative legal standpoint, referring to somebody who does not own a license to treat a patient is risky business. Don't do it."

He pointed out that, in general, a physician is not liable merely for making a referral to a specialist.

But he cited three exceptions to the general rule:

▸ The referral led to delay or deferral of necessary medical treatment. "Do your day job first," he said.

▸ The referring provider knew or should have known that the referred-to provider was incompetent.

▸ The referred-to provider is considered to be the physician's agent, either because state law requires supervision or an extended form of consultation, or there is a "joint treatment" agreement between the physician and the CAM provider, Dr. Eisenberg said.n

LA JOLLA, CALIF. — When you refer a patient to a provider of complementary and alternative medicine, keep in mind five liability management strategies, David M. Eisenberg, M.D., advised at a meeting on natural supplements in evidence-based practice sponsored by the Scripps Clinic.

The strategies, which he developed in collaboration with Michael H. Cohen, J.D. (Ann. Intern. Med. 2002;136:596-603), include the following:

1. Determine the clinical risk level. Decide whether to:

▸ Recommend yet continue to monitor the therapy.

▸ Tolerate, provide caution, and closely monitor safety.

▸ Avoid and actively discourage the therapy.

2. Document the literature supporting the therapeutic choice.

"It's very important to put this in the chart," said Dr. Eisenberg, an internist who directs the division for research and education in complementary and integrative medical therapies at the Osher Institute, Harvard Medical School, Boston.

"By the way, that is also true when we're using a novel or experimental drug with an inpatient. This is the same approach."

If treatment with a certain herb is recommended, "document the choice of herb, any recommendation regarding product or brand, and any discussion regarding therapeutic dose, and associated uncertainties regarding use of the herb," he said.

He also makes it a practice to keep a backup file of articles supporting the discussion or recommendation. "You could say this is a bit too conservative, like have suspenders and a belt," he said at the meeting, cosponsored by the University of California, San Diego. "But I think this is the best advice."

3. Continue conventional monitoring. "A lot of times we recommend something or accept that a patient is going to do something, and then we don't monitor or follow up," Dr. Eisenberg said. "Undue reliance on CAM may lead to a charge that the patient was dissuaded from necessary conventional medical care."

He added that maintaining conventional treatment "helps demonstrate that the physician has followed the standard of care, even if CAM is included."

4. Provide adequate informed consent. Describe the risks and benefits of using the CAM therapy and of delaying or deferring the conventional therapy, and spell out potential adverse interactions.

That is a lot to consider, but such information would be helpful "in the eyes of the law if something went wrong," he said. "You have to ask yourself, could I really defend this action or recommendation?"

Also, clear communication with the patient has been shown to reduce the risk of being sued for malpractice. "Inadequate informed consent is also a theory for malpractice liability in and of itself," Dr. Eisenberg said.

5. Familiarize yourself with providers to whom you refer. Ask yourself, would I refer a friend to this person?

"If the answer is 'I'm not sure,' then get some help in making the correct referral," he advised.

Understand any regulations regarding the use of CAM therapies by your relevant state regulatory board.

"You have to check the regulations and scope of practice," he said. "From a conservative legal standpoint, referring to somebody who does not own a license to treat a patient is risky business. Don't do it."

He pointed out that, in general, a physician is not liable merely for making a referral to a specialist.

But he cited three exceptions to the general rule:

▸ The referral led to delay or deferral of necessary medical treatment. "Do your day job first," he said.

▸ The referring provider knew or should have known that the referred-to provider was incompetent.

▸ The referred-to provider is considered to be the physician's agent, either because state law requires supervision or an extended form of consultation, or there is a "joint treatment" agreement between the physician and the CAM provider, Dr. Eisenberg said.n

LAS VEGAS — When it comes to effective risk management in electronic fetal monitoring, step No. 1 is to adopt a set of uniform definitions for fetal heart-rate tracings, Lisa A. Miller advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“If we are not speaking the same language in electronic fetal monitoring, we are not going to be able to effectively communicate,” said Ms. Miller, a certified nurse-midwife, lawyer, and perinatal risk management educator/consultant in Chicago.

Detailed guidelines for the interpretation of fetal heart-rate tracings were published 8 years ago by a panel of experts convened by the National Institute of Child Health and Human Development (Am. J. Obstet. Gynecol. 1997;177:1385ndash;90). The purpose of the effort was to develop “standardized and unambiguous definitions” for visual reading of fetal heart-rate tracings.

The panel included 16 physicians who specialized in maternal/fetal medicine or obstetrics, 1 epidemiologist, 1 NICHD physician, and 1 nursing expert.

Even though the panel clearly defined terms like baseline “variability,” “sinusoidal baseline,” and “prolonged acceleration” for use in clinical practice, Ms. Miller said that adoption of the NICHD nomenclature by clinicians during the last 8 years has been inconsistent. “It's all over the map,” she said. “In some [obstetrics] residency [programs], it's didactic. In some, it's hands-on. In some, it's a combination. In some residencies, they test for it; in some, they don't.”

She called the NICHD guidelines “the best that we have,” because they are easily teachable, they come from a panel of experts, and they're the most widely accepted in the literature.

“If you want to increase education, you want to decrease liability, and you want to make the world a better place, move to the NICHD nomenclature,” she said. “Standardization of terms can improve communication. Therefore, it should improve clinical management. We still need research on the clinical helpfulness of electronic fetal monitoring. But, she said, “meaningful research” requires that everyone use the same language.

She also advised physicians, nurses, and midwives to get their electronic fetal monitoring education together. “It is ridiculous to have the nurses going to one program and doctors going to another,” she said. “It makes absolutely no sense.”

According to the Centers for Disease Control and Prevention, 80% of American women have had some amount of electronic fetal monitoring during labor and delivery, making it the most common obstetric procedure in the United States.

LAS VEGAS — When it comes to effective risk management in electronic fetal monitoring, step No. 1 is to adopt a set of uniform definitions for fetal heart-rate tracings, Lisa A. Miller advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“If we are not speaking the same language in electronic fetal monitoring, we are not going to be able to effectively communicate,” said Ms. Miller, a certified nurse-midwife, lawyer, and perinatal risk management educator/consultant in Chicago.

Detailed guidelines for the interpretation of fetal heart-rate tracings were published 8 years ago by a panel of experts convened by the National Institute of Child Health and Human Development (Am. J. Obstet. Gynecol. 1997;177:1385ndash;90). The purpose of the effort was to develop “standardized and unambiguous definitions” for visual reading of fetal heart-rate tracings.

The panel included 16 physicians who specialized in maternal/fetal medicine or obstetrics, 1 epidemiologist, 1 NICHD physician, and 1 nursing expert.

Even though the panel clearly defined terms like baseline “variability,” “sinusoidal baseline,” and “prolonged acceleration” for use in clinical practice, Ms. Miller said that adoption of the NICHD nomenclature by clinicians during the last 8 years has been inconsistent. “It's all over the map,” she said. “In some [obstetrics] residency [programs], it's didactic. In some, it's hands-on. In some, it's a combination. In some residencies, they test for it; in some, they don't.”

She called the NICHD guidelines “the best that we have,” because they are easily teachable, they come from a panel of experts, and they're the most widely accepted in the literature.

“If you want to increase education, you want to decrease liability, and you want to make the world a better place, move to the NICHD nomenclature,” she said. “Standardization of terms can improve communication. Therefore, it should improve clinical management. We still need research on the clinical helpfulness of electronic fetal monitoring. But, she said, “meaningful research” requires that everyone use the same language.

She also advised physicians, nurses, and midwives to get their electronic fetal monitoring education together. “It is ridiculous to have the nurses going to one program and doctors going to another,” she said. “It makes absolutely no sense.”

According to the Centers for Disease Control and Prevention, 80% of American women have had some amount of electronic fetal monitoring during labor and delivery, making it the most common obstetric procedure in the United States.

LAS VEGAS — When it comes to effective risk management in electronic fetal monitoring, step No. 1 is to adopt a set of uniform definitions for fetal heart-rate tracings, Lisa A. Miller advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“If we are not speaking the same language in electronic fetal monitoring, we are not going to be able to effectively communicate,” said Ms. Miller, a certified nurse-midwife, lawyer, and perinatal risk management educator/consultant in Chicago.

Detailed guidelines for the interpretation of fetal heart-rate tracings were published 8 years ago by a panel of experts convened by the National Institute of Child Health and Human Development (Am. J. Obstet. Gynecol. 1997;177:1385ndash;90). The purpose of the effort was to develop “standardized and unambiguous definitions” for visual reading of fetal heart-rate tracings.

The panel included 16 physicians who specialized in maternal/fetal medicine or obstetrics, 1 epidemiologist, 1 NICHD physician, and 1 nursing expert.

Even though the panel clearly defined terms like baseline “variability,” “sinusoidal baseline,” and “prolonged acceleration” for use in clinical practice, Ms. Miller said that adoption of the NICHD nomenclature by clinicians during the last 8 years has been inconsistent. “It's all over the map,” she said. “In some [obstetrics] residency [programs], it's didactic. In some, it's hands-on. In some, it's a combination. In some residencies, they test for it; in some, they don't.”

She called the NICHD guidelines “the best that we have,” because they are easily teachable, they come from a panel of experts, and they're the most widely accepted in the literature.

“If you want to increase education, you want to decrease liability, and you want to make the world a better place, move to the NICHD nomenclature,” she said. “Standardization of terms can improve communication. Therefore, it should improve clinical management. We still need research on the clinical helpfulness of electronic fetal monitoring. But, she said, “meaningful research” requires that everyone use the same language.

She also advised physicians, nurses, and midwives to get their electronic fetal monitoring education together. “It is ridiculous to have the nurses going to one program and doctors going to another,” she said. “It makes absolutely no sense.”

According to the Centers for Disease Control and Prevention, 80% of American women have had some amount of electronic fetal monitoring during labor and delivery, making it the most common obstetric procedure in the United States.

LAS VEGAS — Electronic perinatal medical record keeping “has great potential for reducing errors and making our lives easier, whether you're a physician, midwife, or nurse,” Lisa A. Miller said at a conference on fetal monitoring sponsored by Symposia Medicus.

“In obstetrics we have lots of information that should be recorded, but we're about 10 years behind in the health care field in our use of information technology to make us more efficient and better clinicians,” added Ms. Miller, a Chicago-based certified nurse-midwife and lawyer who is a perinatal risk management educator and consultant.

Shopping for the right perinatal computer system for your practice can be a daunting task because “all the systems are different, and you have to do a careful assessment,” Ms. Miller said.

She listed the following features to look for when selecting a system:

▸ Secure sign-on and access.

▸ Complete record keeping from the prenatal period through hospital course of mother and baby.

▸ Integration of prenatal data into the hospital record without reentry by clinician. “How much time do you spend reentering data from a paper prenatal record into your system? There's no reason to. It's a waste of our time,” Ms. Miller said.

▸ Checklists as forced functions to avoid reliance on memory.

▸ Detailed and complete assessment data tailored to standardized definitions. “If you are going to use the National Institute of Child Health and Human Development [guidelines for fetal heart rate monitoring], you need to make sure that your system can adapt and be edited so that the terminology can be used,” she said.

▸ Display with adequate size for on-screen reading of fetal heart rate data. “You have to be able to see 10 minutes of data at real [paper strip] size or larger,” Ms. Miller said. “The small screens are fine for keeping an eye on things, but if you're reading [strips] and you've gone paperless, you need to make sure your display” is adequate.

▸ Drop-down menus with point-and-click capability that force inclusive charting.

▸ Ability to view data in multiple formats, such as timeline vs. graphic.

▸ Accurate and contemporaneous charting, with safeguards against falsification of records and accurate reflection of entry times. The record should be easy to read both on screen and when the records are printed out, Ms. Miller said.

▸ Automatic calculations to decrease possibility of error and save clinician time. “I shouldn't have to do math when I've been up for 24 hours or when I'm working a double” shift, she said. “The computer should do the math for me.”

▸ Visual cues to complete summaries with all pertinent information in the least amount of time and effort.

▸ Accurate and detailed listing of complications for labor and delivery and placenta and cord.

▸ Automatic record of newborn resuscitation for every delivery.

▸ Detailed and complete record of birth attendants and room for narrative comments. “You should always be able to pull up a box and type in a narrative, whatever system you're using,” she said.

▸ Safeguard features against incomplete records. These kinds of systems provide you with a warning sign or error message that informs you what fields you need to fill out before you can complete the record.

▸ Ability to produce statistics on any outcome. For example, you should be able to generate a report that shows how you've handled patients in the past 6 months who are positive for group B strep.

For additional information, Ms. Miller recommended contacting the Perinatal Information Systems User Group. This not-for-profit group provides forums and support for those buying perinatal computer systems. Visit www.pisug.org

Documentation Errors to Avoid

The following common documentation errors can be avoided if you choose the right electronic medical records system for your practice:

▸ Failure to document

▸ Incomplete charting

▸ Late entries

▸ Poor grammar and/or spelling

▸ Improper error correction

▸ Lack of standardized abbreviations

▸ Illegibility

Source: Lisa A. Miller

LAS VEGAS — Electronic perinatal medical record keeping “has great potential for reducing errors and making our lives easier, whether you're a physician, midwife, or nurse,” Lisa A. Miller said at a conference on fetal monitoring sponsored by Symposia Medicus.

“In obstetrics we have lots of information that should be recorded, but we're about 10 years behind in the health care field in our use of information technology to make us more efficient and better clinicians,” added Ms. Miller, a Chicago-based certified nurse-midwife and lawyer who is a perinatal risk management educator and consultant.

Shopping for the right perinatal computer system for your practice can be a daunting task because “all the systems are different, and you have to do a careful assessment,” Ms. Miller said.

She listed the following features to look for when selecting a system:

▸ Secure sign-on and access.

▸ Complete record keeping from the prenatal period through hospital course of mother and baby.

▸ Integration of prenatal data into the hospital record without reentry by clinician. “How much time do you spend reentering data from a paper prenatal record into your system? There's no reason to. It's a waste of our time,” Ms. Miller said.

▸ Checklists as forced functions to avoid reliance on memory.

▸ Detailed and complete assessment data tailored to standardized definitions. “If you are going to use the National Institute of Child Health and Human Development [guidelines for fetal heart rate monitoring], you need to make sure that your system can adapt and be edited so that the terminology can be used,” she said.

▸ Display with adequate size for on-screen reading of fetal heart rate data. “You have to be able to see 10 minutes of data at real [paper strip] size or larger,” Ms. Miller said. “The small screens are fine for keeping an eye on things, but if you're reading [strips] and you've gone paperless, you need to make sure your display” is adequate.

▸ Drop-down menus with point-and-click capability that force inclusive charting.

▸ Ability to view data in multiple formats, such as timeline vs. graphic.

▸ Accurate and contemporaneous charting, with safeguards against falsification of records and accurate reflection of entry times. The record should be easy to read both on screen and when the records are printed out, Ms. Miller said.

▸ Automatic calculations to decrease possibility of error and save clinician time. “I shouldn't have to do math when I've been up for 24 hours or when I'm working a double” shift, she said. “The computer should do the math for me.”

▸ Visual cues to complete summaries with all pertinent information in the least amount of time and effort.

▸ Accurate and detailed listing of complications for labor and delivery and placenta and cord.

▸ Automatic record of newborn resuscitation for every delivery.

▸ Detailed and complete record of birth attendants and room for narrative comments. “You should always be able to pull up a box and type in a narrative, whatever system you're using,” she said.

▸ Safeguard features against incomplete records. These kinds of systems provide you with a warning sign or error message that informs you what fields you need to fill out before you can complete the record.

▸ Ability to produce statistics on any outcome. For example, you should be able to generate a report that shows how you've handled patients in the past 6 months who are positive for group B strep.

For additional information, Ms. Miller recommended contacting the Perinatal Information Systems User Group. This not-for-profit group provides forums and support for those buying perinatal computer systems. Visit www.pisug.org

Documentation Errors to Avoid

The following common documentation errors can be avoided if you choose the right electronic medical records system for your practice:

▸ Failure to document

▸ Incomplete charting

▸ Late entries

▸ Poor grammar and/or spelling

▸ Improper error correction

▸ Lack of standardized abbreviations

▸ Illegibility

Source: Lisa A. Miller

LAS VEGAS — Electronic perinatal medical record keeping “has great potential for reducing errors and making our lives easier, whether you're a physician, midwife, or nurse,” Lisa A. Miller said at a conference on fetal monitoring sponsored by Symposia Medicus.

“In obstetrics we have lots of information that should be recorded, but we're about 10 years behind in the health care field in our use of information technology to make us more efficient and better clinicians,” added Ms. Miller, a Chicago-based certified nurse-midwife and lawyer who is a perinatal risk management educator and consultant.

Shopping for the right perinatal computer system for your practice can be a daunting task because “all the systems are different, and you have to do a careful assessment,” Ms. Miller said.

She listed the following features to look for when selecting a system:

▸ Secure sign-on and access.

▸ Complete record keeping from the prenatal period through hospital course of mother and baby.

▸ Integration of prenatal data into the hospital record without reentry by clinician. “How much time do you spend reentering data from a paper prenatal record into your system? There's no reason to. It's a waste of our time,” Ms. Miller said.

▸ Checklists as forced functions to avoid reliance on memory.

▸ Detailed and complete assessment data tailored to standardized definitions. “If you are going to use the National Institute of Child Health and Human Development [guidelines for fetal heart rate monitoring], you need to make sure that your system can adapt and be edited so that the terminology can be used,” she said.

▸ Display with adequate size for on-screen reading of fetal heart rate data. “You have to be able to see 10 minutes of data at real [paper strip] size or larger,” Ms. Miller said. “The small screens are fine for keeping an eye on things, but if you're reading [strips] and you've gone paperless, you need to make sure your display” is adequate.

▸ Drop-down menus with point-and-click capability that force inclusive charting.

▸ Ability to view data in multiple formats, such as timeline vs. graphic.

▸ Accurate and contemporaneous charting, with safeguards against falsification of records and accurate reflection of entry times. The record should be easy to read both on screen and when the records are printed out, Ms. Miller said.

▸ Automatic calculations to decrease possibility of error and save clinician time. “I shouldn't have to do math when I've been up for 24 hours or when I'm working a double” shift, she said. “The computer should do the math for me.”

▸ Visual cues to complete summaries with all pertinent information in the least amount of time and effort.

▸ Accurate and detailed listing of complications for labor and delivery and placenta and cord.

▸ Automatic record of newborn resuscitation for every delivery.

▸ Detailed and complete record of birth attendants and room for narrative comments. “You should always be able to pull up a box and type in a narrative, whatever system you're using,” she said.

▸ Safeguard features against incomplete records. These kinds of systems provide you with a warning sign or error message that informs you what fields you need to fill out before you can complete the record.

▸ Ability to produce statistics on any outcome. For example, you should be able to generate a report that shows how you've handled patients in the past 6 months who are positive for group B strep.

For additional information, Ms. Miller recommended contacting the Perinatal Information Systems User Group. This not-for-profit group provides forums and support for those buying perinatal computer systems. Visit www.pisug.org

Documentation Errors to Avoid

The following common documentation errors can be avoided if you choose the right electronic medical records system for your practice:

▸ Failure to document

▸ Incomplete charting

▸ Late entries

▸ Poor grammar and/or spelling

▸ Improper error correction

▸ Lack of standardized abbreviations

▸ Illegibility

Source: Lisa A. Miller

It's been 10 years since Elyse May was born with congenital adrenal hyperplasia, but her mother, Michelle May, M.D., remembers the experience as if it were yesterday.

While Dr. May suspected that her daughter had congenital adrenal hyperplasia, adrenal disorders “are not my area of specialty, so my husband ran to the medical library for books that might help,” recalled Dr. May, a family physician who practices in Phoenix, Ariz. “There I was, having given birth about 12 hours before and reading medical textbooks in my hospital bed.”

Once the diagnosis was confirmed, Dr. May and Elyse were discharged home without starting treatment. The endocrinologist told her it was unclear whether Elyse had the mild form of the disease or the severe form. “He said that if we started to treat the mild form, it would mask the severe form,” Dr. May said. Then the endocrinologist went out of town.

Once home, Elyse began vomiting and she became jaundiced and dehydrated. “By the time they decided to start her on the steroids, she was so sick that we put her in the hospital for 3 days,” said Dr. May. “We really did almost lose her. It was very scary to be a patient in that situation. I couldn't get anyone to listen to me about how sick she was until I finally begged them to let me take her into the hospital. The doctor there said that she probably could have died within 12 hours.”

Today, Elyse manages her condition by taking oral steroids three times daily. She wears a MedicAlert bracelet that attracts interest from her peers at school.

“Kids are starting to ask, 'Why do you wear that?'” Dr. May said. “She doesn't want to stand out. She doesn't want to be different. Because of the nature of her condition, if she goes to a sleepover or a birthday party, I have to let parents and other caretakers know about the potential seriousness if she does become ill or injured. I tell them you have to make a double effort to notify us if something happens because she could die of this if she's not treated appropriately.”

While the prognosis is excellent for Elyse “as long as she never has an adrenal crisis that is mismanaged, we still have to make sure we do the follow-up appointments and the routine blood work,” Dr. May said. “I am now more empathetic to patients who have chronic medical conditions that require a lot of attention. It's easy to get into a role of complacency, or you get busy and you don't do what you should right on time.”

Mark Heinz-Graham has a different set of special needs. Born with a moderate range of intellectual functioning, the 27-year-old currently reads at the pre-first grade level, “although he's very motivated to learn how to read,” said his mother, Lee Combrinck-Graham, M.D., a psychiatrist who practices in Fairfield County, Conn. “In fact, he has just started with a reading teacher who hopes that now that he is an adult, there are more strategies for helping him to learn. Numbers are elusive [to Mark]. Math is not in his repertoire.”

She noted that Mark relishes his full-time job as a grocery store bagger. He also likes to watch TV, play computer games, swim, play the drums, and listen to opera. “He's also in an art class,” she said. “He's learning to be more deliberate, careful, and thoughtful.”

She said the most difficult part about having a child with special needs is observing the social isolation that occurs. “For example, they can go to a birthday party with regular kids or with special-needs kids. But somehow their participation in it or their 'getting it' is at a different level, so they're sort of on the fringes,” Dr. Combrinck-Graham explained.

She added that families of special-needs children “shouldn't feel ashamed or try to hide their kid and shouldn't feel reluctant to invite people in to help. For instance, Mark is fairly independent. Sometimes we go away overnight and might say to one of our friends, 'Would you give him a call and say hi and see if he's alright?' Or sometimes when we go away someone will stay with him in the house. We do this so he has a larger circle of people paying attention to him while we're away. I've met some parents [of special-needs children] who say, 'Nobody would want to do that for my child.' That's not true. People really do want to know what to do, so they need to be included with your friends and family. Raising this child, loving this child, and making this child feel welcome is a collective activity. None of the tasks should be assigned to just one person.”

Dr. Combrinck-Graham noted that it took a while for her own mother to accept Mark as he became an adult. “She likes to have intellectual conversations and she constantly displayed disappointment [in him], which I don't even think she was aware of,” she said.

“I finally said to her, 'He's not what you wanted him to be, but he is who he is. You're missing out on a great opportunity, so why don't you get over it?' Now, most of the time she's really getting a kick out of him.”

Elisa Nicholas, M.D., reiterated the importance of focusing on the assets of a child with special needs. But she pointed out that the competitive, achievement-focused culture of medicine can pose a challenge to that effort. “If you sit around a doctor's dining room and everybody's talking about their over-achieving child, and you're simply trying to get your child to walk and talk, it is very difficult,” said Dr. Nicholas, whose 16-year-old son, Tom, has cerebellar ataxia. He copes with difficulty walking, general coordination problems, and cognitive challenges.

Tom—the first physically challenged student to be fully integrated into the Hermosa Beach (Calif.) School District—wears braces on his feet and uses a walker, crutches, or a wheelchair for mobility. “He can dress himself, but he will never be able to put his braces on by himself,” said Dr. Nicholas, a pediatrician who directs The Children's Clinic, Serving Children and Their Families, a system of six not-for-profit community health centers in Long Beach, Calif. “He's always going to need some assistance.”

She knows the caregiver role consumes many parents. “I think trying to achieve a balance is truly a great challenge,” she said. “I want Tom to reach his greatest potential. If that means I have to make personal sacrifices, I will do that. But it's very difficult to find that balance, because it can become all-consuming. While it can become all-consuming, it is imperative to take time for yourself, your spouse, and your other children.”

Dr. Nam Nguyen can identify with that notion. His 4-year-old daughter, Uyen, was diagnosed with autism when she was 18 months old. “Any activity we do at home is tailored or geared to part of therapy,” said Dr. Nguyen, chief of the division of pediatric surgery at the University of California, Irvine. “We put signs and toys in every room. Everywhere we go, every setting is a therapy for her. It's very much a constant thing.”

He credits his wife, Lan Nguyen, M.D., with providing the bulk of Uyen's therapy. She left her full-time anesthesiology practice to care for Uyen, and now works just 2 days a week. She spends the rest of her time at home engaged in exercises to help cultivate Uyen's communication skills and reading skills, and taking her to weekly speech therapy appointments.

While support for parents of special-needs children can often be found through forums tied to a social service agency, hospital, advocacy group, or on the Internet, sometimes it comes out of the blue. For example, The Children's Clinic serves 80% of the most severely disabled low-income children in the Long Beach area. In an effort to bond with her patients, Dr. Nicholas tells patients about Tom and her family and she asks about their family. One of her patients has three children who are moderately or severely mentally handicapped.

“She always remembers to ask about my son,” Dr. Nicholas said. “She struggles financially and carries a huge burden and responsibility for her children.” Considering her circumstances, she added, “it's amazing she can actually think about somebody else. You see a grace and resilience among these people who accept and work with what they have.

“You're going to have different phases in working with your child with special needs, just like with any child,” Dr. Nicholas observed. “Help them reach their greatest potential and accept them for who they are. I think all parents need to do that. But I think when you have a special-needs child you're forced to do that earlier. Be grateful for who your child is.”

“I am now more empathetic to patients who have chronic medical conditions that require a lot of attention,” said Dr. Michelle May, pictured with her daughter, Elyse. Courtesy Dr. Michelle May

Helpful Reading

The following books may be helpful to physicians who have children with special needs:

▸ “You Will Dream New Dreams: Inspiring Personal Stories by Parents of Children With Disabilities,” edited by Stanley D. Klein, Ph.D., and Kim Schive (New York: Kensington Publishing Corp., 2001).

▸ “Special Children, Challenged Parents: The Struggles and Rewards of Raising a Child With a Disability,” by Robert A. Naseef, Ph.D. (Baltimore: Brookes Publishing Co., 2001).

▸ “Uncommon Fathers: Reflections on Raising a Child With a Disability,” edited by Donald J. Meyer (Bethesda, Md.: Woodbine House, 1995).

▸ “Since Owen: A Parent-to-Parent Guide for Care of the Disabled Child,” by Charles R. Callanan (Baltimore: Johns Hopkins University Press, 1990).

▸ “A Difference in The Family: Living With a Disabled Child,” by Helen Featherstone (New York: Penguin Books, 1981).

It's been 10 years since Elyse May was born with congenital adrenal hyperplasia, but her mother, Michelle May, M.D., remembers the experience as if it were yesterday.

While Dr. May suspected that her daughter had congenital adrenal hyperplasia, adrenal disorders “are not my area of specialty, so my husband ran to the medical library for books that might help,” recalled Dr. May, a family physician who practices in Phoenix, Ariz. “There I was, having given birth about 12 hours before and reading medical textbooks in my hospital bed.”

Once the diagnosis was confirmed, Dr. May and Elyse were discharged home without starting treatment. The endocrinologist told her it was unclear whether Elyse had the mild form of the disease or the severe form. “He said that if we started to treat the mild form, it would mask the severe form,” Dr. May said. Then the endocrinologist went out of town.

Once home, Elyse began vomiting and she became jaundiced and dehydrated. “By the time they decided to start her on the steroids, she was so sick that we put her in the hospital for 3 days,” said Dr. May. “We really did almost lose her. It was very scary to be a patient in that situation. I couldn't get anyone to listen to me about how sick she was until I finally begged them to let me take her into the hospital. The doctor there said that she probably could have died within 12 hours.”

Today, Elyse manages her condition by taking oral steroids three times daily. She wears a MedicAlert bracelet that attracts interest from her peers at school.

“Kids are starting to ask, 'Why do you wear that?'” Dr. May said. “She doesn't want to stand out. She doesn't want to be different. Because of the nature of her condition, if she goes to a sleepover or a birthday party, I have to let parents and other caretakers know about the potential seriousness if she does become ill or injured. I tell them you have to make a double effort to notify us if something happens because she could die of this if she's not treated appropriately.”

While the prognosis is excellent for Elyse “as long as she never has an adrenal crisis that is mismanaged, we still have to make sure we do the follow-up appointments and the routine blood work,” Dr. May said. “I am now more empathetic to patients who have chronic medical conditions that require a lot of attention. It's easy to get into a role of complacency, or you get busy and you don't do what you should right on time.”

Mark Heinz-Graham has a different set of special needs. Born with a moderate range of intellectual functioning, the 27-year-old currently reads at the pre-first grade level, “although he's very motivated to learn how to read,” said his mother, Lee Combrinck-Graham, M.D., a psychiatrist who practices in Fairfield County, Conn. “In fact, he has just started with a reading teacher who hopes that now that he is an adult, there are more strategies for helping him to learn. Numbers are elusive [to Mark]. Math is not in his repertoire.”

She noted that Mark relishes his full-time job as a grocery store bagger. He also likes to watch TV, play computer games, swim, play the drums, and listen to opera. “He's also in an art class,” she said. “He's learning to be more deliberate, careful, and thoughtful.”

She said the most difficult part about having a child with special needs is observing the social isolation that occurs. “For example, they can go to a birthday party with regular kids or with special-needs kids. But somehow their participation in it or their 'getting it' is at a different level, so they're sort of on the fringes,” Dr. Combrinck-Graham explained.

She added that families of special-needs children “shouldn't feel ashamed or try to hide their kid and shouldn't feel reluctant to invite people in to help. For instance, Mark is fairly independent. Sometimes we go away overnight and might say to one of our friends, 'Would you give him a call and say hi and see if he's alright?' Or sometimes when we go away someone will stay with him in the house. We do this so he has a larger circle of people paying attention to him while we're away. I've met some parents [of special-needs children] who say, 'Nobody would want to do that for my child.' That's not true. People really do want to know what to do, so they need to be included with your friends and family. Raising this child, loving this child, and making this child feel welcome is a collective activity. None of the tasks should be assigned to just one person.”

Dr. Combrinck-Graham noted that it took a while for her own mother to accept Mark as he became an adult. “She likes to have intellectual conversations and she constantly displayed disappointment [in him], which I don't even think she was aware of,” she said.

“I finally said to her, 'He's not what you wanted him to be, but he is who he is. You're missing out on a great opportunity, so why don't you get over it?' Now, most of the time she's really getting a kick out of him.”

Elisa Nicholas, M.D., reiterated the importance of focusing on the assets of a child with special needs. But she pointed out that the competitive, achievement-focused culture of medicine can pose a challenge to that effort. “If you sit around a doctor's dining room and everybody's talking about their over-achieving child, and you're simply trying to get your child to walk and talk, it is very difficult,” said Dr. Nicholas, whose 16-year-old son, Tom, has cerebellar ataxia. He copes with difficulty walking, general coordination problems, and cognitive challenges.

Tom—the first physically challenged student to be fully integrated into the Hermosa Beach (Calif.) School District—wears braces on his feet and uses a walker, crutches, or a wheelchair for mobility. “He can dress himself, but he will never be able to put his braces on by himself,” said Dr. Nicholas, a pediatrician who directs The Children's Clinic, Serving Children and Their Families, a system of six not-for-profit community health centers in Long Beach, Calif. “He's always going to need some assistance.”

She knows the caregiver role consumes many parents. “I think trying to achieve a balance is truly a great challenge,” she said. “I want Tom to reach his greatest potential. If that means I have to make personal sacrifices, I will do that. But it's very difficult to find that balance, because it can become all-consuming. While it can become all-consuming, it is imperative to take time for yourself, your spouse, and your other children.”

Dr. Nam Nguyen can identify with that notion. His 4-year-old daughter, Uyen, was diagnosed with autism when she was 18 months old. “Any activity we do at home is tailored or geared to part of therapy,” said Dr. Nguyen, chief of the division of pediatric surgery at the University of California, Irvine. “We put signs and toys in every room. Everywhere we go, every setting is a therapy for her. It's very much a constant thing.”

He credits his wife, Lan Nguyen, M.D., with providing the bulk of Uyen's therapy. She left her full-time anesthesiology practice to care for Uyen, and now works just 2 days a week. She spends the rest of her time at home engaged in exercises to help cultivate Uyen's communication skills and reading skills, and taking her to weekly speech therapy appointments.

While support for parents of special-needs children can often be found through forums tied to a social service agency, hospital, advocacy group, or on the Internet, sometimes it comes out of the blue. For example, The Children's Clinic serves 80% of the most severely disabled low-income children in the Long Beach area. In an effort to bond with her patients, Dr. Nicholas tells patients about Tom and her family and she asks about their family. One of her patients has three children who are moderately or severely mentally handicapped.

“She always remembers to ask about my son,” Dr. Nicholas said. “She struggles financially and carries a huge burden and responsibility for her children.” Considering her circumstances, she added, “it's amazing she can actually think about somebody else. You see a grace and resilience among these people who accept and work with what they have.

“You're going to have different phases in working with your child with special needs, just like with any child,” Dr. Nicholas observed. “Help them reach their greatest potential and accept them for who they are. I think all parents need to do that. But I think when you have a special-needs child you're forced to do that earlier. Be grateful for who your child is.”

“I am now more empathetic to patients who have chronic medical conditions that require a lot of attention,” said Dr. Michelle May, pictured with her daughter, Elyse. Courtesy Dr. Michelle May

Helpful Reading

The following books may be helpful to physicians who have children with special needs:

▸ “You Will Dream New Dreams: Inspiring Personal Stories by Parents of Children With Disabilities,” edited by Stanley D. Klein, Ph.D., and Kim Schive (New York: Kensington Publishing Corp., 2001).

▸ “Special Children, Challenged Parents: The Struggles and Rewards of Raising a Child With a Disability,” by Robert A. Naseef, Ph.D. (Baltimore: Brookes Publishing Co., 2001).

▸ “Uncommon Fathers: Reflections on Raising a Child With a Disability,” edited by Donald J. Meyer (Bethesda, Md.: Woodbine House, 1995).

▸ “Since Owen: A Parent-to-Parent Guide for Care of the Disabled Child,” by Charles R. Callanan (Baltimore: Johns Hopkins University Press, 1990).

▸ “A Difference in The Family: Living With a Disabled Child,” by Helen Featherstone (New York: Penguin Books, 1981).

It's been 10 years since Elyse May was born with congenital adrenal hyperplasia, but her mother, Michelle May, M.D., remembers the experience as if it were yesterday.

While Dr. May suspected that her daughter had congenital adrenal hyperplasia, adrenal disorders “are not my area of specialty, so my husband ran to the medical library for books that might help,” recalled Dr. May, a family physician who practices in Phoenix, Ariz. “There I was, having given birth about 12 hours before and reading medical textbooks in my hospital bed.”

Once the diagnosis was confirmed, Dr. May and Elyse were discharged home without starting treatment. The endocrinologist told her it was unclear whether Elyse had the mild form of the disease or the severe form. “He said that if we started to treat the mild form, it would mask the severe form,” Dr. May said. Then the endocrinologist went out of town.

Once home, Elyse began vomiting and she became jaundiced and dehydrated. “By the time they decided to start her on the steroids, she was so sick that we put her in the hospital for 3 days,” said Dr. May. “We really did almost lose her. It was very scary to be a patient in that situation. I couldn't get anyone to listen to me about how sick she was until I finally begged them to let me take her into the hospital. The doctor there said that she probably could have died within 12 hours.”

Today, Elyse manages her condition by taking oral steroids three times daily. She wears a MedicAlert bracelet that attracts interest from her peers at school.

“Kids are starting to ask, 'Why do you wear that?'” Dr. May said. “She doesn't want to stand out. She doesn't want to be different. Because of the nature of her condition, if she goes to a sleepover or a birthday party, I have to let parents and other caretakers know about the potential seriousness if she does become ill or injured. I tell them you have to make a double effort to notify us if something happens because she could die of this if she's not treated appropriately.”

While the prognosis is excellent for Elyse “as long as she never has an adrenal crisis that is mismanaged, we still have to make sure we do the follow-up appointments and the routine blood work,” Dr. May said. “I am now more empathetic to patients who have chronic medical conditions that require a lot of attention. It's easy to get into a role of complacency, or you get busy and you don't do what you should right on time.”

Mark Heinz-Graham has a different set of special needs. Born with a moderate range of intellectual functioning, the 27-year-old currently reads at the pre-first grade level, “although he's very motivated to learn how to read,” said his mother, Lee Combrinck-Graham, M.D., a psychiatrist who practices in Fairfield County, Conn. “In fact, he has just started with a reading teacher who hopes that now that he is an adult, there are more strategies for helping him to learn. Numbers are elusive [to Mark]. Math is not in his repertoire.”

She noted that Mark relishes his full-time job as a grocery store bagger. He also likes to watch TV, play computer games, swim, play the drums, and listen to opera. “He's also in an art class,” she said. “He's learning to be more deliberate, careful, and thoughtful.”

She said the most difficult part about having a child with special needs is observing the social isolation that occurs. “For example, they can go to a birthday party with regular kids or with special-needs kids. But somehow their participation in it or their 'getting it' is at a different level, so they're sort of on the fringes,” Dr. Combrinck-Graham explained.

She added that families of special-needs children “shouldn't feel ashamed or try to hide their kid and shouldn't feel reluctant to invite people in to help. For instance, Mark is fairly independent. Sometimes we go away overnight and might say to one of our friends, 'Would you give him a call and say hi and see if he's alright?' Or sometimes when we go away someone will stay with him in the house. We do this so he has a larger circle of people paying attention to him while we're away. I've met some parents [of special-needs children] who say, 'Nobody would want to do that for my child.' That's not true. People really do want to know what to do, so they need to be included with your friends and family. Raising this child, loving this child, and making this child feel welcome is a collective activity. None of the tasks should be assigned to just one person.”

Dr. Combrinck-Graham noted that it took a while for her own mother to accept Mark as he became an adult. “She likes to have intellectual conversations and she constantly displayed disappointment [in him], which I don't even think she was aware of,” she said.

“I finally said to her, 'He's not what you wanted him to be, but he is who he is. You're missing out on a great opportunity, so why don't you get over it?' Now, most of the time she's really getting a kick out of him.”

Elisa Nicholas, M.D., reiterated the importance of focusing on the assets of a child with special needs. But she pointed out that the competitive, achievement-focused culture of medicine can pose a challenge to that effort. “If you sit around a doctor's dining room and everybody's talking about their over-achieving child, and you're simply trying to get your child to walk and talk, it is very difficult,” said Dr. Nicholas, whose 16-year-old son, Tom, has cerebellar ataxia. He copes with difficulty walking, general coordination problems, and cognitive challenges.

Tom—the first physically challenged student to be fully integrated into the Hermosa Beach (Calif.) School District—wears braces on his feet and uses a walker, crutches, or a wheelchair for mobility. “He can dress himself, but he will never be able to put his braces on by himself,” said Dr. Nicholas, a pediatrician who directs The Children's Clinic, Serving Children and Their Families, a system of six not-for-profit community health centers in Long Beach, Calif. “He's always going to need some assistance.”

She knows the caregiver role consumes many parents. “I think trying to achieve a balance is truly a great challenge,” she said. “I want Tom to reach his greatest potential. If that means I have to make personal sacrifices, I will do that. But it's very difficult to find that balance, because it can become all-consuming. While it can become all-consuming, it is imperative to take time for yourself, your spouse, and your other children.”

Dr. Nam Nguyen can identify with that notion. His 4-year-old daughter, Uyen, was diagnosed with autism when she was 18 months old. “Any activity we do at home is tailored or geared to part of therapy,” said Dr. Nguyen, chief of the division of pediatric surgery at the University of California, Irvine. “We put signs and toys in every room. Everywhere we go, every setting is a therapy for her. It's very much a constant thing.”

He credits his wife, Lan Nguyen, M.D., with providing the bulk of Uyen's therapy. She left her full-time anesthesiology practice to care for Uyen, and now works just 2 days a week. She spends the rest of her time at home engaged in exercises to help cultivate Uyen's communication skills and reading skills, and taking her to weekly speech therapy appointments.

While support for parents of special-needs children can often be found through forums tied to a social service agency, hospital, advocacy group, or on the Internet, sometimes it comes out of the blue. For example, The Children's Clinic serves 80% of the most severely disabled low-income children in the Long Beach area. In an effort to bond with her patients, Dr. Nicholas tells patients about Tom and her family and she asks about their family. One of her patients has three children who are moderately or severely mentally handicapped.

“She always remembers to ask about my son,” Dr. Nicholas said. “She struggles financially and carries a huge burden and responsibility for her children.” Considering her circumstances, she added, “it's amazing she can actually think about somebody else. You see a grace and resilience among these people who accept and work with what they have.

“You're going to have different phases in working with your child with special needs, just like with any child,” Dr. Nicholas observed. “Help them reach their greatest potential and accept them for who they are. I think all parents need to do that. But I think when you have a special-needs child you're forced to do that earlier. Be grateful for who your child is.”

“I am now more empathetic to patients who have chronic medical conditions that require a lot of attention,” said Dr. Michelle May, pictured with her daughter, Elyse. Courtesy Dr. Michelle May

Helpful Reading

The following books may be helpful to physicians who have children with special needs:

▸ “You Will Dream New Dreams: Inspiring Personal Stories by Parents of Children With Disabilities,” edited by Stanley D. Klein, Ph.D., and Kim Schive (New York: Kensington Publishing Corp., 2001).

▸ “Special Children, Challenged Parents: The Struggles and Rewards of Raising a Child With a Disability,” by Robert A. Naseef, Ph.D. (Baltimore: Brookes Publishing Co., 2001).

▸ “Uncommon Fathers: Reflections on Raising a Child With a Disability,” edited by Donald J. Meyer (Bethesda, Md.: Woodbine House, 1995).

▸ “Since Owen: A Parent-to-Parent Guide for Care of the Disabled Child,” by Charles R. Callanan (Baltimore: Johns Hopkins University Press, 1990).

▸ “A Difference in The Family: Living With a Disabled Child,” by Helen Featherstone (New York: Penguin Books, 1981).

SAN DIEGO — Older adults with depression who received collaborative care from a primary care physician and a care manager had significantly less suicidal ideation, compared with their counterparts who received usual care, results from a 2-year study showed.

The finding supports the use of collaborative care to reduce the risk of suicide in elderly patients, Jürgen Unützer, M.D., said at the annual meeting of the American Association for Geriatric Psychiatry.

Fewer than 10% of older adults with depression see a mental health professional. And when a primary care physician refers an older adult to a mental health professional, only about half follow through on the referral, said Dr. Unützer, professor and vice-chair of the department of psychiatry and behavioral health sciences at the University of Washington, Seattle.

In a randomized study, Project IMPACT (Improving Mood: Promoting Access to Collaborative Care), Dr. Unützer and his associates enrolled 1,801 older adults with a Structured Clinical Interview for DSM-III-R diagnosis of major depression and/or dysthymia to receive collaborative care for depression or usual care as recommended by their primary physicians. The 2-year study took place at 18 primary care clinics in five states.

Overall, 895 patients received usual care and 906 received collaborative stepped care at their primary care clinics. All patients were observed at baseline and at 3, 6, 12, 18, and 24 months. Patients in the usual care arm were told, “We're going to observe you, but you can do what you would normally do” for your depression, he said.

Patients in the collaborative care arm were encouraged to choose treatment in consultation with their primary care physicians. Care managers—usually a nurse or a psychologist—helped physicians follow and manage these patients by providing patient education, monitoring symptoms via interviews, and administering the Patient Health Questionnaire-9. They also helped with treatment such as behavior activation, support of prescribed antidepressant medication, and brief psychotherapy.

“We also added a consulting psychiatrist who would come to the clinic once a week for 1–2 hours and go over the caseload of all the patients these care managers were following and provide feedback on the care and, if needed, see a patient in consultation,” Dr. Unützer added.

Overall, about 17% of patients in the study met criteria for major depression, 32% met criteria for dysthymia, and 53% met criteria for both. “This is a pretty depressed group of older adults,” he said.

At 1 year, the percentage of patients in the usual care group who reported thoughts of suicide had risen from 13% to 16%, compared with a decrease from 15% to 10% in the collaborative care group. The rates were similar at 2 years: 14% for usual care and 10% for collaborative care.

In addition, between baseline and 1 year, the number of patients in the usual care group who reported having any bothersome thoughts about death or dying slightly improved from 58% to 51%, while patients in the collaborative care group greatly improved from 56% to 32%.

In surveys conducted 2 years after baseline, there was little change in the rate for patients in the usual care group (50%), but a higher number of patients in the collaborative care group reported having thoughts about death or dying (42%).

Dr. Unützer and his associates intervened 135 times for 108 patients whom they deemed at high risk for suicide. Of these, 89 times were for patients in the usual care group, while 49 times were for patients in the collaborative care group. There were no completed suicides.

Patient characteristics that were significantly associated with the rate of suicidal ideation at 1 and 2 years were advancing age, male gender, number of comorbid medical conditions, baseline anxiety status, baseline depression severity, and baseline overall quality of life.

SAN DIEGO — Older adults with depression who received collaborative care from a primary care physician and a care manager had significantly less suicidal ideation, compared with their counterparts who received usual care, results from a 2-year study showed.

The finding supports the use of collaborative care to reduce the risk of suicide in elderly patients, Jürgen Unützer, M.D., said at the annual meeting of the American Association for Geriatric Psychiatry.

Fewer than 10% of older adults with depression see a mental health professional. And when a primary care physician refers an older adult to a mental health professional, only about half follow through on the referral, said Dr. Unützer, professor and vice-chair of the department of psychiatry and behavioral health sciences at the University of Washington, Seattle.

In a randomized study, Project IMPACT (Improving Mood: Promoting Access to Collaborative Care), Dr. Unützer and his associates enrolled 1,801 older adults with a Structured Clinical Interview for DSM-III-R diagnosis of major depression and/or dysthymia to receive collaborative care for depression or usual care as recommended by their primary physicians. The 2-year study took place at 18 primary care clinics in five states.

Overall, 895 patients received usual care and 906 received collaborative stepped care at their primary care clinics. All patients were observed at baseline and at 3, 6, 12, 18, and 24 months. Patients in the usual care arm were told, “We're going to observe you, but you can do what you would normally do” for your depression, he said.

Patients in the collaborative care arm were encouraged to choose treatment in consultation with their primary care physicians. Care managers—usually a nurse or a psychologist—helped physicians follow and manage these patients by providing patient education, monitoring symptoms via interviews, and administering the Patient Health Questionnaire-9. They also helped with treatment such as behavior activation, support of prescribed antidepressant medication, and brief psychotherapy.

“We also added a consulting psychiatrist who would come to the clinic once a week for 1–2 hours and go over the caseload of all the patients these care managers were following and provide feedback on the care and, if needed, see a patient in consultation,” Dr. Unützer added.

Overall, about 17% of patients in the study met criteria for major depression, 32% met criteria for dysthymia, and 53% met criteria for both. “This is a pretty depressed group of older adults,” he said.

At 1 year, the percentage of patients in the usual care group who reported thoughts of suicide had risen from 13% to 16%, compared with a decrease from 15% to 10% in the collaborative care group. The rates were similar at 2 years: 14% for usual care and 10% for collaborative care.

In addition, between baseline and 1 year, the number of patients in the usual care group who reported having any bothersome thoughts about death or dying slightly improved from 58% to 51%, while patients in the collaborative care group greatly improved from 56% to 32%.

In surveys conducted 2 years after baseline, there was little change in the rate for patients in the usual care group (50%), but a higher number of patients in the collaborative care group reported having thoughts about death or dying (42%).

Dr. Unützer and his associates intervened 135 times for 108 patients whom they deemed at high risk for suicide. Of these, 89 times were for patients in the usual care group, while 49 times were for patients in the collaborative care group. There were no completed suicides.

Patient characteristics that were significantly associated with the rate of suicidal ideation at 1 and 2 years were advancing age, male gender, number of comorbid medical conditions, baseline anxiety status, baseline depression severity, and baseline overall quality of life.

SAN DIEGO — Older adults with depression who received collaborative care from a primary care physician and a care manager had significantly less suicidal ideation, compared with their counterparts who received usual care, results from a 2-year study showed.

The finding supports the use of collaborative care to reduce the risk of suicide in elderly patients, Jürgen Unützer, M.D., said at the annual meeting of the American Association for Geriatric Psychiatry.

Fewer than 10% of older adults with depression see a mental health professional. And when a primary care physician refers an older adult to a mental health professional, only about half follow through on the referral, said Dr. Unützer, professor and vice-chair of the department of psychiatry and behavioral health sciences at the University of Washington, Seattle.

In a randomized study, Project IMPACT (Improving Mood: Promoting Access to Collaborative Care), Dr. Unützer and his associates enrolled 1,801 older adults with a Structured Clinical Interview for DSM-III-R diagnosis of major depression and/or dysthymia to receive collaborative care for depression or usual care as recommended by their primary physicians. The 2-year study took place at 18 primary care clinics in five states.

Overall, 895 patients received usual care and 906 received collaborative stepped care at their primary care clinics. All patients were observed at baseline and at 3, 6, 12, 18, and 24 months. Patients in the usual care arm were told, “We're going to observe you, but you can do what you would normally do” for your depression, he said.

Patients in the collaborative care arm were encouraged to choose treatment in consultation with their primary care physicians. Care managers—usually a nurse or a psychologist—helped physicians follow and manage these patients by providing patient education, monitoring symptoms via interviews, and administering the Patient Health Questionnaire-9. They also helped with treatment such as behavior activation, support of prescribed antidepressant medication, and brief psychotherapy.

“We also added a consulting psychiatrist who would come to the clinic once a week for 1–2 hours and go over the caseload of all the patients these care managers were following and provide feedback on the care and, if needed, see a patient in consultation,” Dr. Unützer added.

Overall, about 17% of patients in the study met criteria for major depression, 32% met criteria for dysthymia, and 53% met criteria for both. “This is a pretty depressed group of older adults,” he said.

At 1 year, the percentage of patients in the usual care group who reported thoughts of suicide had risen from 13% to 16%, compared with a decrease from 15% to 10% in the collaborative care group. The rates were similar at 2 years: 14% for usual care and 10% for collaborative care.

In addition, between baseline and 1 year, the number of patients in the usual care group who reported having any bothersome thoughts about death or dying slightly improved from 58% to 51%, while patients in the collaborative care group greatly improved from 56% to 32%.

In surveys conducted 2 years after baseline, there was little change in the rate for patients in the usual care group (50%), but a higher number of patients in the collaborative care group reported having thoughts about death or dying (42%).

Dr. Unützer and his associates intervened 135 times for 108 patients whom they deemed at high risk for suicide. Of these, 89 times were for patients in the usual care group, while 49 times were for patients in the collaborative care group. There were no completed suicides.

Patient characteristics that were significantly associated with the rate of suicidal ideation at 1 and 2 years were advancing age, male gender, number of comorbid medical conditions, baseline anxiety status, baseline depression severity, and baseline overall quality of life.

SAN DIEGO — Donepezil is safe and effective in African Americans with mild to moderate Alzheimer's disease, a 12-week open-label study showed.

The finding is important because African Americans are underrepresented in clinical trials even though they have a higher risk of developing Alzheimer's disease, compared with whites, Patrick Griffith, M.D., said during a poster session at the annual meeting of the American Association for Geriatric Psychiatry.

In addition, this is the first Alzheimer's trial to use the Fuld Object Memory Evaluation (FOME), which is thought to provide a culturally unbiased evaluation of memory. “The test has been validated in African Americans, and it operates independent of educational level or [social background].”

Dr. Griffith, chief of the division of neurology at Morehouse School of Medicine, Atlanta, said in an interview. “It relies on touch and vision. We may have a measuring tool for future clinical trials that will avoid previous reports of educational or cultural bias.” Dr. Griffith and his associates enrolled 125 community-dwelling African Americans aged 51–98 from 30 sites in the United States with a clinical diagnosis of mild to moderate Alzheimer's disease and Mini-Mental State Examination (MMSE) scores of 10–26. The patients received donepezil (Aricept) 5 mg/day at the conclusion of their baseline visit; the dose was increased to 10 mg/day after 4 weeks—according to clinician judgment.

At weeks 4, 8, and 12, the investigators administered the FOME, the MMSE, and the Clinician Interview-Based Impression of Change with Caregiver Input (CIBIC-plus). From baseline to week 12, patients showed significant improvement on the FOME storage and retrieval scores, the MMSE scores, and the CIBIC-plus scores.

The most common treatment-emergent adverse events were diarrhea, hypertension, and urinary tract infection, and the incidences were similar to those reported previously in patients with mild to moderate Alzheimer's. Lab results were unremarkable. Pfizer Inc., which manufactures donepezil, supported the study.

SAN DIEGO — Donepezil is safe and effective in African Americans with mild to moderate Alzheimer's disease, a 12-week open-label study showed.

The finding is important because African Americans are underrepresented in clinical trials even though they have a higher risk of developing Alzheimer's disease, compared with whites, Patrick Griffith, M.D., said during a poster session at the annual meeting of the American Association for Geriatric Psychiatry.

In addition, this is the first Alzheimer's trial to use the Fuld Object Memory Evaluation (FOME), which is thought to provide a culturally unbiased evaluation of memory. “The test has been validated in African Americans, and it operates independent of educational level or [social background].”

Dr. Griffith, chief of the division of neurology at Morehouse School of Medicine, Atlanta, said in an interview. “It relies on touch and vision. We may have a measuring tool for future clinical trials that will avoid previous reports of educational or cultural bias.” Dr. Griffith and his associates enrolled 125 community-dwelling African Americans aged 51–98 from 30 sites in the United States with a clinical diagnosis of mild to moderate Alzheimer's disease and Mini-Mental State Examination (MMSE) scores of 10–26. The patients received donepezil (Aricept) 5 mg/day at the conclusion of their baseline visit; the dose was increased to 10 mg/day after 4 weeks—according to clinician judgment.

At weeks 4, 8, and 12, the investigators administered the FOME, the MMSE, and the Clinician Interview-Based Impression of Change with Caregiver Input (CIBIC-plus). From baseline to week 12, patients showed significant improvement on the FOME storage and retrieval scores, the MMSE scores, and the CIBIC-plus scores.

The most common treatment-emergent adverse events were diarrhea, hypertension, and urinary tract infection, and the incidences were similar to those reported previously in patients with mild to moderate Alzheimer's. Lab results were unremarkable. Pfizer Inc., which manufactures donepezil, supported the study.

SAN DIEGO — Donepezil is safe and effective in African Americans with mild to moderate Alzheimer's disease, a 12-week open-label study showed.

The finding is important because African Americans are underrepresented in clinical trials even though they have a higher risk of developing Alzheimer's disease, compared with whites, Patrick Griffith, M.D., said during a poster session at the annual meeting of the American Association for Geriatric Psychiatry.

In addition, this is the first Alzheimer's trial to use the Fuld Object Memory Evaluation (FOME), which is thought to provide a culturally unbiased evaluation of memory. “The test has been validated in African Americans, and it operates independent of educational level or [social background].”

Dr. Griffith, chief of the division of neurology at Morehouse School of Medicine, Atlanta, said in an interview. “It relies on touch and vision. We may have a measuring tool for future clinical trials that will avoid previous reports of educational or cultural bias.” Dr. Griffith and his associates enrolled 125 community-dwelling African Americans aged 51–98 from 30 sites in the United States with a clinical diagnosis of mild to moderate Alzheimer's disease and Mini-Mental State Examination (MMSE) scores of 10–26. The patients received donepezil (Aricept) 5 mg/day at the conclusion of their baseline visit; the dose was increased to 10 mg/day after 4 weeks—according to clinician judgment.

At weeks 4, 8, and 12, the investigators administered the FOME, the MMSE, and the Clinician Interview-Based Impression of Change with Caregiver Input (CIBIC-plus). From baseline to week 12, patients showed significant improvement on the FOME storage and retrieval scores, the MMSE scores, and the CIBIC-plus scores.

The most common treatment-emergent adverse events were diarrhea, hypertension, and urinary tract infection, and the incidences were similar to those reported previously in patients with mild to moderate Alzheimer's. Lab results were unremarkable. Pfizer Inc., which manufactures donepezil, supported the study.