Mary Ann Moon

An educational program in “mindful” communication produced striking improvements in primary care physicians' symptoms of burnout, according to a recent report.

By enhancing physicians' attention to their own feelings and experiences, the 52-hour program not only reduced participants' distress but also increased their empathy for patients and their ability to deliver patient-centered care, which in turn may improve clinical outcomes, Dr. Tait D. Shanafelt said in an editorial comment accompanying this report.

“Physicians in the United States will face a host of new challenges over the next decade as the nation reforms its health care system,” and the restructuring will likely “increase the already epidemic levels of burnout among physicians and overwhelm those currently near their limits.”

In response, some physicians will feel compelled to withdraw from their work. But this study “demonstrates that training physicians in the art of mindful practice has the potential to promote physician health through work,” said Dr. Shanafelt, director of the Program on Physician Well-Being at the Mayo Clinic, Rochester, Minn.

Physicians who participate in a mindful communication program will “continue to control the most sacred and meaningful aspect of medical practice—the encounter with the patient and the reward that comes from restoring health and relieving suffering,” Dr. Shanafelt said in his editorial (JAMA 2009;302:1338–40).

In the study, Dr. Michael S. Krasner and his associates at the University of Rochester (N.Y.) evaluated a continuing medical education course that they had designed to improve physician well-being. “The program aims to enhance the physician-patient relationship through reflective practices that help the practitioner explore the domains of control and meaning in the clinical encounter,” the researchers explained.

The program, spread over the course of 1 year, includes an intensive phase with 8 weekly 2.5-hour sessions plus one all-day session toward the end of this phase, followed by a maintenance phase of 10 monthly 2.5-hour sessions.

Each session begins with a brief presentation of that week's theme and may include guided meditation exercises, yoga-type exercises, large-group discussions, writing brief stories about personal experiences in medical practice, discussing challenges in medical practice, and sharing the written stories in pairs and small groups.

The weekly and monthly topics include understanding self-awareness of thoughts and feelings, examining perceptual biases, dealing with pleasant and unpleasant events, managing conflict, preventing burnout, reflecting on meaningful experiences in practice, setting boundaries, examining attention to patients, exploring self-care, being with suffering, and examining end-of-life care.

Throughout the program, participants are taught mindfulness—“paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.” Mindfulness includes lowering one's reactivity to challenging experiences; noticing and experiencing one's thoughts, feelings, and bodily sensations, even when they are unpleasant; acting with awareness and attention instead of “on autopilot”; and trying to disregard the labels or judgments applied to experiences in medical practice.

A total of 871 Rochester-area internal medicine, family medicine, and pediatric physicians were invited to partake in the program through the county medical society, and 70 accepted. These study subjects were assessed at five different times before, during, and after the program, using several instruments such as the Maslach Burnout Inventory, the Jefferson Scale of Physician Empathy, the Physician Belief Scale, the Profile of Mood States, and the Big Five Factor Structure personality scale.

Study subjects showed “striking” improvements in self-awareness and well-being, which included decreases in emotional exhaustion, depersonalization, depression, tension, anger, and fatigue, as well as increases in feelings of personal accomplishment, vigor, empathy, and psychosocial beliefs known to correlate with patient-centered behavior.

In previous studies, such changes have been associated with improved patient satisfaction and trust, more appropriate prescribing, fewer medical errors, reduced disparities in health care, and fewer lawsuits. Thus, a mindfulness-based intervention may improve not only physician well-being but also clinical care, Dr. Krasner and his colleagues said (JAMA 2009;302:1284–93).

In his editorial comment, Dr. Shanafelt concurred. Helping physicians “recognize and enhance the meaning they derive from the practice of medicine may help protect against burnout and promote patient-centered care for the benefit of both physicians and their patients,” he noted.

The study was funded by the Physicians' Foundation for Health Systems Excellence and sponsored by the New York chapter of the American College of Physicians. Dr. Krasner and Dr. Shanafelt reported no conflicts of interest.

An educational program in “mindful” communication produced striking improvements in primary care physicians' symptoms of burnout, according to a recent report.

By enhancing physicians' attention to their own feelings and experiences, the 52-hour program not only reduced participants' distress but also increased their empathy for patients and their ability to deliver patient-centered care, which in turn may improve clinical outcomes, Dr. Tait D. Shanafelt said in an editorial comment accompanying this report.

“Physicians in the United States will face a host of new challenges over the next decade as the nation reforms its health care system,” and the restructuring will likely “increase the already epidemic levels of burnout among physicians and overwhelm those currently near their limits.”

In response, some physicians will feel compelled to withdraw from their work. But this study “demonstrates that training physicians in the art of mindful practice has the potential to promote physician health through work,” said Dr. Shanafelt, director of the Program on Physician Well-Being at the Mayo Clinic, Rochester, Minn.

Physicians who participate in a mindful communication program will “continue to control the most sacred and meaningful aspect of medical practice—the encounter with the patient and the reward that comes from restoring health and relieving suffering,” Dr. Shanafelt said in his editorial (JAMA 2009;302:1338–40).

In the study, Dr. Michael S. Krasner and his associates at the University of Rochester (N.Y.) evaluated a continuing medical education course that they had designed to improve physician well-being. “The program aims to enhance the physician-patient relationship through reflective practices that help the practitioner explore the domains of control and meaning in the clinical encounter,” the researchers explained.

The program, spread over the course of 1 year, includes an intensive phase with 8 weekly 2.5-hour sessions plus one all-day session toward the end of this phase, followed by a maintenance phase of 10 monthly 2.5-hour sessions.

Each session begins with a brief presentation of that week's theme and may include guided meditation exercises, yoga-type exercises, large-group discussions, writing brief stories about personal experiences in medical practice, discussing challenges in medical practice, and sharing the written stories in pairs and small groups.

The weekly and monthly topics include understanding self-awareness of thoughts and feelings, examining perceptual biases, dealing with pleasant and unpleasant events, managing conflict, preventing burnout, reflecting on meaningful experiences in practice, setting boundaries, examining attention to patients, exploring self-care, being with suffering, and examining end-of-life care.

Throughout the program, participants are taught mindfulness—“paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.” Mindfulness includes lowering one's reactivity to challenging experiences; noticing and experiencing one's thoughts, feelings, and bodily sensations, even when they are unpleasant; acting with awareness and attention instead of “on autopilot”; and trying to disregard the labels or judgments applied to experiences in medical practice.

A total of 871 Rochester-area internal medicine, family medicine, and pediatric physicians were invited to partake in the program through the county medical society, and 70 accepted. These study subjects were assessed at five different times before, during, and after the program, using several instruments such as the Maslach Burnout Inventory, the Jefferson Scale of Physician Empathy, the Physician Belief Scale, the Profile of Mood States, and the Big Five Factor Structure personality scale.

Study subjects showed “striking” improvements in self-awareness and well-being, which included decreases in emotional exhaustion, depersonalization, depression, tension, anger, and fatigue, as well as increases in feelings of personal accomplishment, vigor, empathy, and psychosocial beliefs known to correlate with patient-centered behavior.

In previous studies, such changes have been associated with improved patient satisfaction and trust, more appropriate prescribing, fewer medical errors, reduced disparities in health care, and fewer lawsuits. Thus, a mindfulness-based intervention may improve not only physician well-being but also clinical care, Dr. Krasner and his colleagues said (JAMA 2009;302:1284–93).

In his editorial comment, Dr. Shanafelt concurred. Helping physicians “recognize and enhance the meaning they derive from the practice of medicine may help protect against burnout and promote patient-centered care for the benefit of both physicians and their patients,” he noted.

The study was funded by the Physicians' Foundation for Health Systems Excellence and sponsored by the New York chapter of the American College of Physicians. Dr. Krasner and Dr. Shanafelt reported no conflicts of interest.

An educational program in “mindful” communication produced striking improvements in primary care physicians' symptoms of burnout, according to a recent report.

By enhancing physicians' attention to their own feelings and experiences, the 52-hour program not only reduced participants' distress but also increased their empathy for patients and their ability to deliver patient-centered care, which in turn may improve clinical outcomes, Dr. Tait D. Shanafelt said in an editorial comment accompanying this report.

“Physicians in the United States will face a host of new challenges over the next decade as the nation reforms its health care system,” and the restructuring will likely “increase the already epidemic levels of burnout among physicians and overwhelm those currently near their limits.”

In response, some physicians will feel compelled to withdraw from their work. But this study “demonstrates that training physicians in the art of mindful practice has the potential to promote physician health through work,” said Dr. Shanafelt, director of the Program on Physician Well-Being at the Mayo Clinic, Rochester, Minn.

Physicians who participate in a mindful communication program will “continue to control the most sacred and meaningful aspect of medical practice—the encounter with the patient and the reward that comes from restoring health and relieving suffering,” Dr. Shanafelt said in his editorial (JAMA 2009;302:1338–40).

In the study, Dr. Michael S. Krasner and his associates at the University of Rochester (N.Y.) evaluated a continuing medical education course that they had designed to improve physician well-being. “The program aims to enhance the physician-patient relationship through reflective practices that help the practitioner explore the domains of control and meaning in the clinical encounter,” the researchers explained.

The program, spread over the course of 1 year, includes an intensive phase with 8 weekly 2.5-hour sessions plus one all-day session toward the end of this phase, followed by a maintenance phase of 10 monthly 2.5-hour sessions.

Each session begins with a brief presentation of that week's theme and may include guided meditation exercises, yoga-type exercises, large-group discussions, writing brief stories about personal experiences in medical practice, discussing challenges in medical practice, and sharing the written stories in pairs and small groups.

The weekly and monthly topics include understanding self-awareness of thoughts and feelings, examining perceptual biases, dealing with pleasant and unpleasant events, managing conflict, preventing burnout, reflecting on meaningful experiences in practice, setting boundaries, examining attention to patients, exploring self-care, being with suffering, and examining end-of-life care.

Throughout the program, participants are taught mindfulness—“paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.” Mindfulness includes lowering one's reactivity to challenging experiences; noticing and experiencing one's thoughts, feelings, and bodily sensations, even when they are unpleasant; acting with awareness and attention instead of “on autopilot”; and trying to disregard the labels or judgments applied to experiences in medical practice.

A total of 871 Rochester-area internal medicine, family medicine, and pediatric physicians were invited to partake in the program through the county medical society, and 70 accepted. These study subjects were assessed at five different times before, during, and after the program, using several instruments such as the Maslach Burnout Inventory, the Jefferson Scale of Physician Empathy, the Physician Belief Scale, the Profile of Mood States, and the Big Five Factor Structure personality scale.

Study subjects showed “striking” improvements in self-awareness and well-being, which included decreases in emotional exhaustion, depersonalization, depression, tension, anger, and fatigue, as well as increases in feelings of personal accomplishment, vigor, empathy, and psychosocial beliefs known to correlate with patient-centered behavior.

In previous studies, such changes have been associated with improved patient satisfaction and trust, more appropriate prescribing, fewer medical errors, reduced disparities in health care, and fewer lawsuits. Thus, a mindfulness-based intervention may improve not only physician well-being but also clinical care, Dr. Krasner and his colleagues said (JAMA 2009;302:1284–93).

In his editorial comment, Dr. Shanafelt concurred. Helping physicians “recognize and enhance the meaning they derive from the practice of medicine may help protect against burnout and promote patient-centered care for the benefit of both physicians and their patients,” he noted.

The study was funded by the Physicians' Foundation for Health Systems Excellence and sponsored by the New York chapter of the American College of Physicians. Dr. Krasner and Dr. Shanafelt reported no conflicts of interest.

Among patients with peptic ulcer disease, early eradication of Helicobacter pylori protects against the development of gastric cancer, Dr. Chun-Ying Wu and colleagues.

In a retrospective cohort study of more than 80,000 patients throughout China who were hospitalized for peptic ulcer disease, those who received therapy to eradicate H. pylori soon after recovery showed a risk of gastric cancer similar to that in the general population. In contrast, patients who did not receive such therapy until years later had a higher risk of developing gastric cancer.

In animal models, a causal link between H. pylori infection and gastric cancer has been proved, with studies showing that H. pylori induces the cancer by first causing atrophic gastritis, intestinal metaplasia, and dysplasia.

However, the findings in human studies have been conflicting.

Dr. Wu of China Medical University in Taichung, Taiwan, and colleagues conducted a retrospective study comparing 54,576 patients who received timely treatment with 25,679 who, for unknown reasons, did not receive treatment to eradicate H. pylori until 1 or more years after an index hospitalization for peptic ulcer disease.

All the study subjects were initially hospitalized between 1997 and 2005 with a primary diagnosis of peptic ulcer, including gastric, duodenal, and nonspecific ulcer. Treatment to eradicate H. pylori included a proton pump inhibitor or H₂ receptor blocker, plus clarithromycin or metronidazole, plus amoxicillin or tetracycline, with or without the addition of bismuth. All the subjects were followed for 2-10 years, with an average of 7.5 years of follow-up.

In the “early-eradication group,” the median interval between hospitalization for peptic ulcer disease and receipt of eradication therapy was 14 days. In contrast, in the “late-eradication group,” the median interval was 1,053 days.

The cumulative incidence of gastric cancer in the early-intervention group was similar to that in the general Chinese population, but such incidence was significantly higher in the late-eradication group. Moreover, gastric cancer risk was higher still in late-eradication patients who were at high risk because of older age, male sex, or ulcer complications. “The result [indicates that there is a] stronger protective role of H. pylori eradication in high-risk populations,” they said.

H. pylori eradication conveyed protection in all age groups, not just in young patients. “The highest protective effect was actually found in the 60-69 age group, with the second-highest protective effect in the 50-59 age group,” the researchers said.

The researchers were unable to determine whether treatment to eradicate H. pylori was successful or not.

This study was supported in part by China's National Health Research Institutes. No financial conflicts of interest were reported.

Among patients with peptic ulcer disease, early eradication of Helicobacter pylori protects against the development of gastric cancer, Dr. Chun-Ying Wu and colleagues.

In a retrospective cohort study of more than 80,000 patients throughout China who were hospitalized for peptic ulcer disease, those who received therapy to eradicate H. pylori soon after recovery showed a risk of gastric cancer similar to that in the general population. In contrast, patients who did not receive such therapy until years later had a higher risk of developing gastric cancer.

In animal models, a causal link between H. pylori infection and gastric cancer has been proved, with studies showing that H. pylori induces the cancer by first causing atrophic gastritis, intestinal metaplasia, and dysplasia.

However, the findings in human studies have been conflicting.

Dr. Wu of China Medical University in Taichung, Taiwan, and colleagues conducted a retrospective study comparing 54,576 patients who received timely treatment with 25,679 who, for unknown reasons, did not receive treatment to eradicate H. pylori until 1 or more years after an index hospitalization for peptic ulcer disease.

All the study subjects were initially hospitalized between 1997 and 2005 with a primary diagnosis of peptic ulcer, including gastric, duodenal, and nonspecific ulcer. Treatment to eradicate H. pylori included a proton pump inhibitor or H₂ receptor blocker, plus clarithromycin or metronidazole, plus amoxicillin or tetracycline, with or without the addition of bismuth. All the subjects were followed for 2-10 years, with an average of 7.5 years of follow-up.

In the “early-eradication group,” the median interval between hospitalization for peptic ulcer disease and receipt of eradication therapy was 14 days. In contrast, in the “late-eradication group,” the median interval was 1,053 days.

The cumulative incidence of gastric cancer in the early-intervention group was similar to that in the general Chinese population, but such incidence was significantly higher in the late-eradication group. Moreover, gastric cancer risk was higher still in late-eradication patients who were at high risk because of older age, male sex, or ulcer complications. “The result [indicates that there is a] stronger protective role of H. pylori eradication in high-risk populations,” they said.

H. pylori eradication conveyed protection in all age groups, not just in young patients. “The highest protective effect was actually found in the 60-69 age group, with the second-highest protective effect in the 50-59 age group,” the researchers said.

The researchers were unable to determine whether treatment to eradicate H. pylori was successful or not.

This study was supported in part by China's National Health Research Institutes. No financial conflicts of interest were reported.

Among patients with peptic ulcer disease, early eradication of Helicobacter pylori protects against the development of gastric cancer, Dr. Chun-Ying Wu and colleagues.

In a retrospective cohort study of more than 80,000 patients throughout China who were hospitalized for peptic ulcer disease, those who received therapy to eradicate H. pylori soon after recovery showed a risk of gastric cancer similar to that in the general population. In contrast, patients who did not receive such therapy until years later had a higher risk of developing gastric cancer.

In animal models, a causal link between H. pylori infection and gastric cancer has been proved, with studies showing that H. pylori induces the cancer by first causing atrophic gastritis, intestinal metaplasia, and dysplasia.

However, the findings in human studies have been conflicting.

Dr. Wu of China Medical University in Taichung, Taiwan, and colleagues conducted a retrospective study comparing 54,576 patients who received timely treatment with 25,679 who, for unknown reasons, did not receive treatment to eradicate H. pylori until 1 or more years after an index hospitalization for peptic ulcer disease.

All the study subjects were initially hospitalized between 1997 and 2005 with a primary diagnosis of peptic ulcer, including gastric, duodenal, and nonspecific ulcer. Treatment to eradicate H. pylori included a proton pump inhibitor or H₂ receptor blocker, plus clarithromycin or metronidazole, plus amoxicillin or tetracycline, with or without the addition of bismuth. All the subjects were followed for 2-10 years, with an average of 7.5 years of follow-up.

In the “early-eradication group,” the median interval between hospitalization for peptic ulcer disease and receipt of eradication therapy was 14 days. In contrast, in the “late-eradication group,” the median interval was 1,053 days.

The cumulative incidence of gastric cancer in the early-intervention group was similar to that in the general Chinese population, but such incidence was significantly higher in the late-eradication group. Moreover, gastric cancer risk was higher still in late-eradication patients who were at high risk because of older age, male sex, or ulcer complications. “The result [indicates that there is a] stronger protective role of H. pylori eradication in high-risk populations,” they said.

H. pylori eradication conveyed protection in all age groups, not just in young patients. “The highest protective effect was actually found in the 60-69 age group, with the second-highest protective effect in the 50-59 age group,” the researchers said.

The researchers were unable to determine whether treatment to eradicate H. pylori was successful or not.

This study was supported in part by China's National Health Research Institutes. No financial conflicts of interest were reported.

A program of telephone care management plus structured cognitive-behavioral psychotherapy yielded “significant and sustained benefits” for primary care patients starting treatment for depression, without raising health care costs appreciably, said Dr. Gregory E. Simon and his associates in the Group Health Cooperative, Seattle.

A similar telephone care management program without the psychotherapy component improved clinical outcomes to an intermediate degree and led to slightly lower costs, compared with standard care.

The investigators compared the two programs against standard care in a study of 600 patients attending seven primary care clinics in Washington State and Idaho. Both interventions were designed to improve the quality of medication management and continuity in patients who were beginning treatment for depression. Participants were identified using computerized pharmacy and visit registration records. Patients already receiving psychotherapy or other specialty mental health care were excluded. Depression severity was measured using the Symptom Checklist 90, and those with SCL-90 scores of 0.5 or above were enrolled. The mean age of participants was 44 years, and 74% were female (Arch. Gen. Psychiatry 2009;66:1081-9).

Dr. Simon and his colleagues previously reported the clinical outcomes in their study. In this report, they focused on health care costs associated with the interventions.

The 198 patients randomly assigned to the care management plus psychotherapy program received up to 12 phone calls from master's-level clinicians after receiving their first prescription for antidepressants from a primary care physician.

These calls focused on overall care management but also included a structured cognitive-behavioral psychotherapy program of eight initial sessions followed by “booster” sessions that targeted adhering to and/or refining each patient's patients' self-care plan.

The initial phone sessions lasted a mean of 31 minutes, and the booster sessions lasted a mean of 18 minutes.

The other intervention included the same telephone care-management program but not the psychotherapy component. This included five brief phone calls or mailings to monitor and improve antidepressant adherence and to support follow-up with the primary caregiver. These calls lasted a mean of 13 minutes.

After 2 years, depression scores were lowest with the first intervention, intermediate with the second intervention, and highest with standard care.

When measured in depression-free days during the 24 months of the study, patients in the management-plus-psychotherapy program gained 46 days without depression, and those in the management-only program gained 29 days, compared with patients who received standard care.

Costs were $650 higher with the first intervention and $450 higher with the second intervention, compared with standard care. Additional costs were mostly “up front”—greatest during the first 6 months of treatment, relatively small in the second 6 months of treatment, and absent after 12 months of treatment, the investigators said.

The investigators acknowledged that the main goal of depression treatment is to relieve suffering rather than decrease health care costs. “Our findings do, however, offer some guidance to insurers or health care systems considering efforts to improve care for depression.

“Efforts to improve depression treatment in primary care should consider incorporating structured psychotherapy interventions.”

The investigators noted that “a significant portion of participants was lost to follow-up over 2 years” and that possibly costs-benefits balance were different in the lost population.

This study was sponsored by the National Institute of Mental Health. Dr. Simon reported receiving consulting fees from Wyeth Pharmaceuticals and Bristol-Myers Squibb Co.

A program of telephone care management plus structured cognitive-behavioral psychotherapy yielded “significant and sustained benefits” for primary care patients starting treatment for depression, without raising health care costs appreciably, said Dr. Gregory E. Simon and his associates in the Group Health Cooperative, Seattle.

A similar telephone care management program without the psychotherapy component improved clinical outcomes to an intermediate degree and led to slightly lower costs, compared with standard care.

The investigators compared the two programs against standard care in a study of 600 patients attending seven primary care clinics in Washington State and Idaho. Both interventions were designed to improve the quality of medication management and continuity in patients who were beginning treatment for depression. Participants were identified using computerized pharmacy and visit registration records. Patients already receiving psychotherapy or other specialty mental health care were excluded. Depression severity was measured using the Symptom Checklist 90, and those with SCL-90 scores of 0.5 or above were enrolled. The mean age of participants was 44 years, and 74% were female (Arch. Gen. Psychiatry 2009;66:1081-9).

Dr. Simon and his colleagues previously reported the clinical outcomes in their study. In this report, they focused on health care costs associated with the interventions.

The 198 patients randomly assigned to the care management plus psychotherapy program received up to 12 phone calls from master's-level clinicians after receiving their first prescription for antidepressants from a primary care physician.

These calls focused on overall care management but also included a structured cognitive-behavioral psychotherapy program of eight initial sessions followed by “booster” sessions that targeted adhering to and/or refining each patient's patients' self-care plan.

The initial phone sessions lasted a mean of 31 minutes, and the booster sessions lasted a mean of 18 minutes.

The other intervention included the same telephone care-management program but not the psychotherapy component. This included five brief phone calls or mailings to monitor and improve antidepressant adherence and to support follow-up with the primary caregiver. These calls lasted a mean of 13 minutes.

After 2 years, depression scores were lowest with the first intervention, intermediate with the second intervention, and highest with standard care.

When measured in depression-free days during the 24 months of the study, patients in the management-plus-psychotherapy program gained 46 days without depression, and those in the management-only program gained 29 days, compared with patients who received standard care.

Costs were $650 higher with the first intervention and $450 higher with the second intervention, compared with standard care. Additional costs were mostly “up front”—greatest during the first 6 months of treatment, relatively small in the second 6 months of treatment, and absent after 12 months of treatment, the investigators said.

The investigators acknowledged that the main goal of depression treatment is to relieve suffering rather than decrease health care costs. “Our findings do, however, offer some guidance to insurers or health care systems considering efforts to improve care for depression.

“Efforts to improve depression treatment in primary care should consider incorporating structured psychotherapy interventions.”

The investigators noted that “a significant portion of participants was lost to follow-up over 2 years” and that possibly costs-benefits balance were different in the lost population.

This study was sponsored by the National Institute of Mental Health. Dr. Simon reported receiving consulting fees from Wyeth Pharmaceuticals and Bristol-Myers Squibb Co.

A program of telephone care management plus structured cognitive-behavioral psychotherapy yielded “significant and sustained benefits” for primary care patients starting treatment for depression, without raising health care costs appreciably, said Dr. Gregory E. Simon and his associates in the Group Health Cooperative, Seattle.

A similar telephone care management program without the psychotherapy component improved clinical outcomes to an intermediate degree and led to slightly lower costs, compared with standard care.

The investigators compared the two programs against standard care in a study of 600 patients attending seven primary care clinics in Washington State and Idaho. Both interventions were designed to improve the quality of medication management and continuity in patients who were beginning treatment for depression. Participants were identified using computerized pharmacy and visit registration records. Patients already receiving psychotherapy or other specialty mental health care were excluded. Depression severity was measured using the Symptom Checklist 90, and those with SCL-90 scores of 0.5 or above were enrolled. The mean age of participants was 44 years, and 74% were female (Arch. Gen. Psychiatry 2009;66:1081-9).

Dr. Simon and his colleagues previously reported the clinical outcomes in their study. In this report, they focused on health care costs associated with the interventions.

The 198 patients randomly assigned to the care management plus psychotherapy program received up to 12 phone calls from master's-level clinicians after receiving their first prescription for antidepressants from a primary care physician.

These calls focused on overall care management but also included a structured cognitive-behavioral psychotherapy program of eight initial sessions followed by “booster” sessions that targeted adhering to and/or refining each patient's patients' self-care plan.

The initial phone sessions lasted a mean of 31 minutes, and the booster sessions lasted a mean of 18 minutes.

The other intervention included the same telephone care-management program but not the psychotherapy component. This included five brief phone calls or mailings to monitor and improve antidepressant adherence and to support follow-up with the primary caregiver. These calls lasted a mean of 13 minutes.

After 2 years, depression scores were lowest with the first intervention, intermediate with the second intervention, and highest with standard care.

When measured in depression-free days during the 24 months of the study, patients in the management-plus-psychotherapy program gained 46 days without depression, and those in the management-only program gained 29 days, compared with patients who received standard care.

Costs were $650 higher with the first intervention and $450 higher with the second intervention, compared with standard care. Additional costs were mostly “up front”—greatest during the first 6 months of treatment, relatively small in the second 6 months of treatment, and absent after 12 months of treatment, the investigators said.

The investigators acknowledged that the main goal of depression treatment is to relieve suffering rather than decrease health care costs. “Our findings do, however, offer some guidance to insurers or health care systems considering efforts to improve care for depression.

“Efforts to improve depression treatment in primary care should consider incorporating structured psychotherapy interventions.”

The investigators noted that “a significant portion of participants was lost to follow-up over 2 years” and that possibly costs-benefits balance were different in the lost population.

This study was sponsored by the National Institute of Mental Health. Dr. Simon reported receiving consulting fees from Wyeth Pharmaceuticals and Bristol-Myers Squibb Co.

An educational program in “mindful” communication produced striking improvements in primary care physicians' symptoms of burnout, according to a recent report.

By enhancing physicians' attention to their own feelings and experiences, the 52-hour program not only reduced participants' distress but also increased their empathy for patients and their ability to deliver patient-centered care, Dr. Tait D. Shanafelt said in an editorial comment accompanying the report.

“Physicians in the United States will face a host of new challenges over the next decade as the nation reforms its health care system,” and the restructuring will likely “increase the already epidemic levels of burnout among physicians and overwhelm those currently near their limits.” In response, some physicians will feel compelled to withdraw from their work. But this study “demonstrates that training physicians in the art of mindful practice has the potential to promote physician health through work,” said Dr. Shanafelt, director of the Program on Physician Well-Being at the Mayo Clinic, Rochester, Minn. (JAMA 2009;302:1338-40).

In the study, Dr. Michael S. Krasner and his associates at the University of Rochester (N.Y.) evaluated a continuing education course that they had designed to “enhance the physician-patient relationship through reflective practices that help the practitioner explore the domains of control and meaning in the clinical encounter” (JAMA 2009;302:1284-93).

The program, spread over the course of 1 year, includes an intensive phase with 8 weekly 2.5-hour sessions plus one all-day session toward the end of this phase, followed by a maintenance phase of 10 monthly 2.5-hour sessions.

Each session begins with a brief presentation of that week's theme and may include guided meditation exercises, large-group discussions, writing brief stories about personal experiences in medical practice, and sharing the written stories in pairs and small groups.

Throughout the program, participants are taught mindfulness—“paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.” Mindfulness includes lowering one's reactivity to challenging experiences; noticing and experiencing one's thoughts, feelings, and bodily sensations, even when they are unpleasant; and acting with awareness and attention instead of “on autopilot.”

A total of 70 Rochester-area internal medicine, family medicine, and pediatric physicians participated in the program. These study subjects were assessed at five different times before, during, and after the program.

Study subjects showed “striking” improvements in self-awareness and well-being, which included decreases in emotional exhaustion, depression, tension, and fatigue, as well as increases in feelings of personal accomplishment, vigor, and empathy.

The study was funded by the Physicians' Foundation for Health Systems Excellence and sponsored by the New York chapter of the American College of Physicians. Dr. Krasner and Dr. Shanafelt reported no financial conflicts.

An educational program in “mindful” communication produced striking improvements in primary care physicians' symptoms of burnout, according to a recent report.

By enhancing physicians' attention to their own feelings and experiences, the 52-hour program not only reduced participants' distress but also increased their empathy for patients and their ability to deliver patient-centered care, Dr. Tait D. Shanafelt said in an editorial comment accompanying the report.

“Physicians in the United States will face a host of new challenges over the next decade as the nation reforms its health care system,” and the restructuring will likely “increase the already epidemic levels of burnout among physicians and overwhelm those currently near their limits.” In response, some physicians will feel compelled to withdraw from their work. But this study “demonstrates that training physicians in the art of mindful practice has the potential to promote physician health through work,” said Dr. Shanafelt, director of the Program on Physician Well-Being at the Mayo Clinic, Rochester, Minn. (JAMA 2009;302:1338-40).

In the study, Dr. Michael S. Krasner and his associates at the University of Rochester (N.Y.) evaluated a continuing education course that they had designed to “enhance the physician-patient relationship through reflective practices that help the practitioner explore the domains of control and meaning in the clinical encounter” (JAMA 2009;302:1284-93).

The program, spread over the course of 1 year, includes an intensive phase with 8 weekly 2.5-hour sessions plus one all-day session toward the end of this phase, followed by a maintenance phase of 10 monthly 2.5-hour sessions.

Each session begins with a brief presentation of that week's theme and may include guided meditation exercises, large-group discussions, writing brief stories about personal experiences in medical practice, and sharing the written stories in pairs and small groups.

Throughout the program, participants are taught mindfulness—“paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.” Mindfulness includes lowering one's reactivity to challenging experiences; noticing and experiencing one's thoughts, feelings, and bodily sensations, even when they are unpleasant; and acting with awareness and attention instead of “on autopilot.”

A total of 70 Rochester-area internal medicine, family medicine, and pediatric physicians participated in the program. These study subjects were assessed at five different times before, during, and after the program.

Study subjects showed “striking” improvements in self-awareness and well-being, which included decreases in emotional exhaustion, depression, tension, and fatigue, as well as increases in feelings of personal accomplishment, vigor, and empathy.

The study was funded by the Physicians' Foundation for Health Systems Excellence and sponsored by the New York chapter of the American College of Physicians. Dr. Krasner and Dr. Shanafelt reported no financial conflicts.

An educational program in “mindful” communication produced striking improvements in primary care physicians' symptoms of burnout, according to a recent report.

By enhancing physicians' attention to their own feelings and experiences, the 52-hour program not only reduced participants' distress but also increased their empathy for patients and their ability to deliver patient-centered care, Dr. Tait D. Shanafelt said in an editorial comment accompanying the report.

“Physicians in the United States will face a host of new challenges over the next decade as the nation reforms its health care system,” and the restructuring will likely “increase the already epidemic levels of burnout among physicians and overwhelm those currently near their limits.” In response, some physicians will feel compelled to withdraw from their work. But this study “demonstrates that training physicians in the art of mindful practice has the potential to promote physician health through work,” said Dr. Shanafelt, director of the Program on Physician Well-Being at the Mayo Clinic, Rochester, Minn. (JAMA 2009;302:1338-40).

In the study, Dr. Michael S. Krasner and his associates at the University of Rochester (N.Y.) evaluated a continuing education course that they had designed to “enhance the physician-patient relationship through reflective practices that help the practitioner explore the domains of control and meaning in the clinical encounter” (JAMA 2009;302:1284-93).

The program, spread over the course of 1 year, includes an intensive phase with 8 weekly 2.5-hour sessions plus one all-day session toward the end of this phase, followed by a maintenance phase of 10 monthly 2.5-hour sessions.

Each session begins with a brief presentation of that week's theme and may include guided meditation exercises, large-group discussions, writing brief stories about personal experiences in medical practice, and sharing the written stories in pairs and small groups.

Throughout the program, participants are taught mindfulness—“paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.” Mindfulness includes lowering one's reactivity to challenging experiences; noticing and experiencing one's thoughts, feelings, and bodily sensations, even when they are unpleasant; and acting with awareness and attention instead of “on autopilot.”

A total of 70 Rochester-area internal medicine, family medicine, and pediatric physicians participated in the program. These study subjects were assessed at five different times before, during, and after the program.

Study subjects showed “striking” improvements in self-awareness and well-being, which included decreases in emotional exhaustion, depression, tension, and fatigue, as well as increases in feelings of personal accomplishment, vigor, and empathy.

The study was funded by the Physicians' Foundation for Health Systems Excellence and sponsored by the New York chapter of the American College of Physicians. Dr. Krasner and Dr. Shanafelt reported no financial conflicts.

Men who have undergone screening for prostate-specific antigen or who have declined such testing say they often received only limited information about the test from their physicians, according to a survey of a nationally representative sample of men in the general U.S. population.

Only 21% of the men said that their physicians discussed the pros and cons of PSA screening and asked about their preference, as is recommended in virtually all guidelines from major professional organizations.

Dr. Richard M. Hoffman of the New Mexico VA Health Care System, Albuquerque, and his associates assessed these issues as part of the National Survey of Medical Decisions (DECISIONS) study, a survey of Americans aged 40 and older designed to characterize the decision-making process in various medical issues. The prostate cancer module of this study surveyed men who had accepted or declined PSA screening during the past 2 years.

Overall, 30% of the respondents said they never discussed PSA testing with their physician before deciding whether to undergo screening, a finding that Dr. Hoffman and his colleagues termed “disconcerting.” Fully 45% said they were never asked about their preference regarding PSA testing.

Of those whose physicians did discuss PSA testing, 87% discussed only the benefits and not the disadvantages of screening. Among men whose physicians discussed PSA testing, 79% went on to have the test done (Arch. Intern. Med. 2009;169:1611-18). No financial conflicts of interest were reported.

Men who have undergone screening for prostate-specific antigen or who have declined such testing say they often received only limited information about the test from their physicians, according to a survey of a nationally representative sample of men in the general U.S. population.

Only 21% of the men said that their physicians discussed the pros and cons of PSA screening and asked about their preference, as is recommended in virtually all guidelines from major professional organizations.

Dr. Richard M. Hoffman of the New Mexico VA Health Care System, Albuquerque, and his associates assessed these issues as part of the National Survey of Medical Decisions (DECISIONS) study, a survey of Americans aged 40 and older designed to characterize the decision-making process in various medical issues. The prostate cancer module of this study surveyed men who had accepted or declined PSA screening during the past 2 years.

Overall, 30% of the respondents said they never discussed PSA testing with their physician before deciding whether to undergo screening, a finding that Dr. Hoffman and his colleagues termed “disconcerting.” Fully 45% said they were never asked about their preference regarding PSA testing.

Of those whose physicians did discuss PSA testing, 87% discussed only the benefits and not the disadvantages of screening. Among men whose physicians discussed PSA testing, 79% went on to have the test done (Arch. Intern. Med. 2009;169:1611-18). No financial conflicts of interest were reported.

Men who have undergone screening for prostate-specific antigen or who have declined such testing say they often received only limited information about the test from their physicians, according to a survey of a nationally representative sample of men in the general U.S. population.

Only 21% of the men said that their physicians discussed the pros and cons of PSA screening and asked about their preference, as is recommended in virtually all guidelines from major professional organizations.

Dr. Richard M. Hoffman of the New Mexico VA Health Care System, Albuquerque, and his associates assessed these issues as part of the National Survey of Medical Decisions (DECISIONS) study, a survey of Americans aged 40 and older designed to characterize the decision-making process in various medical issues. The prostate cancer module of this study surveyed men who had accepted or declined PSA screening during the past 2 years.

Overall, 30% of the respondents said they never discussed PSA testing with their physician before deciding whether to undergo screening, a finding that Dr. Hoffman and his colleagues termed “disconcerting.” Fully 45% said they were never asked about their preference regarding PSA testing.

Of those whose physicians did discuss PSA testing, 87% discussed only the benefits and not the disadvantages of screening. Among men whose physicians discussed PSA testing, 79% went on to have the test done (Arch. Intern. Med. 2009;169:1611-18). No financial conflicts of interest were reported.

Treating mild gestational diabetes lowered the risks of fetal overgrowth, shoulder dystocia, cesarean delivery, and gestational hypertension, as well as decreasing maternal weight gain, according to a report in almost 1,000 women.

However, treating mild gestational diabetes did not improve the composite primary outcome of neonatal mortality, hypoglycemia, hyperbilirubinemia, hyperinsulinemia, and birth trauma in a multicenter, randomized trial designed to establish whether such treatment reduced perinatal and obstetric complications.

“The findings from our trial confirm a modest benefit from the identification and treatment of women with mild carbohydrate intolerance during pregnancy,” said Dr. Mark B. Landon and his associates in the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.

The investigators assessed 958 women with mild gestational diabetes—defined as a fasting glucose level of less than 95 mg/dL plus two to three timed glucose measurements that exceeded established thresholds—between 24 and 31 weeks' gestation. A total of 473 were randomly assigned to receive standard prenatal care and 485 to receive formal nutritional counseling, diet therapy, and insulin as needed (N. Engl. J. Med. 2009;361:1339-48).

The intervention group performed daily self-monitoring of fasting and postprandial blood glucose levels. The researchers verified compliance with glycemic monitoring and documented that target thresholds were achieved.

There was no difference between the two groups in the primary composite outcome of neonatal death and complications known to be associated with maternal hyperglycemia, nor did individual rates of complications (neonatal hypoglycemia, hyperbilirubinemia, birth trauma, and elevated cord-blood C-peptide levels) differ significantly, Dr. Landon of Ohio State University, Columbus, and his colleagues said.

However, the intervention significantly reduced mean birth weight, neonatal fat mass, the rate of large-for-gestational-age infants, and the rate of infants weighing 4,000 g or more.

Cesarean delivery was significantly less frequent in the intervention group (27%) than in the control group (34%), as were shoulder dystocia, gestational hypertension, and preeclampsia.

Moreover, both maternal body mass index at delivery and maternal weight gain during pregnancy were lower in the intervention group than in controls.

These study findings “provide further compelling evidence that among women who have gestational diabetes mellitus and normal fasting glucose levels, treatment that includes dietary intervention and insulin therapy, as necessary, reduces rates of fetal overgrowth, cesarean delivery, and preeclampsia,” Dr. Landon and his associates wrote.

This study was supported by grants from the National Institute of Child Health and Human Development, the General Clinical Research Centers, and the National Center for Research Resources. No financial conflicts of interest were reported.

Treating mild gestational diabetes lowered the risks of fetal overgrowth, shoulder dystocia, cesarean delivery, and gestational hypertension, as well as decreasing maternal weight gain, according to a report in almost 1,000 women.

However, treating mild gestational diabetes did not improve the composite primary outcome of neonatal mortality, hypoglycemia, hyperbilirubinemia, hyperinsulinemia, and birth trauma in a multicenter, randomized trial designed to establish whether such treatment reduced perinatal and obstetric complications.

“The findings from our trial confirm a modest benefit from the identification and treatment of women with mild carbohydrate intolerance during pregnancy,” said Dr. Mark B. Landon and his associates in the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.

The investigators assessed 958 women with mild gestational diabetes—defined as a fasting glucose level of less than 95 mg/dL plus two to three timed glucose measurements that exceeded established thresholds—between 24 and 31 weeks' gestation. A total of 473 were randomly assigned to receive standard prenatal care and 485 to receive formal nutritional counseling, diet therapy, and insulin as needed (N. Engl. J. Med. 2009;361:1339-48).

The intervention group performed daily self-monitoring of fasting and postprandial blood glucose levels. The researchers verified compliance with glycemic monitoring and documented that target thresholds were achieved.

There was no difference between the two groups in the primary composite outcome of neonatal death and complications known to be associated with maternal hyperglycemia, nor did individual rates of complications (neonatal hypoglycemia, hyperbilirubinemia, birth trauma, and elevated cord-blood C-peptide levels) differ significantly, Dr. Landon of Ohio State University, Columbus, and his colleagues said.

However, the intervention significantly reduced mean birth weight, neonatal fat mass, the rate of large-for-gestational-age infants, and the rate of infants weighing 4,000 g or more.

Cesarean delivery was significantly less frequent in the intervention group (27%) than in the control group (34%), as were shoulder dystocia, gestational hypertension, and preeclampsia.

Moreover, both maternal body mass index at delivery and maternal weight gain during pregnancy were lower in the intervention group than in controls.

These study findings “provide further compelling evidence that among women who have gestational diabetes mellitus and normal fasting glucose levels, treatment that includes dietary intervention and insulin therapy, as necessary, reduces rates of fetal overgrowth, cesarean delivery, and preeclampsia,” Dr. Landon and his associates wrote.

This study was supported by grants from the National Institute of Child Health and Human Development, the General Clinical Research Centers, and the National Center for Research Resources. No financial conflicts of interest were reported.

Treating mild gestational diabetes lowered the risks of fetal overgrowth, shoulder dystocia, cesarean delivery, and gestational hypertension, as well as decreasing maternal weight gain, according to a report in almost 1,000 women.

However, treating mild gestational diabetes did not improve the composite primary outcome of neonatal mortality, hypoglycemia, hyperbilirubinemia, hyperinsulinemia, and birth trauma in a multicenter, randomized trial designed to establish whether such treatment reduced perinatal and obstetric complications.

“The findings from our trial confirm a modest benefit from the identification and treatment of women with mild carbohydrate intolerance during pregnancy,” said Dr. Mark B. Landon and his associates in the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.

The investigators assessed 958 women with mild gestational diabetes—defined as a fasting glucose level of less than 95 mg/dL plus two to three timed glucose measurements that exceeded established thresholds—between 24 and 31 weeks' gestation. A total of 473 were randomly assigned to receive standard prenatal care and 485 to receive formal nutritional counseling, diet therapy, and insulin as needed (N. Engl. J. Med. 2009;361:1339-48).

The intervention group performed daily self-monitoring of fasting and postprandial blood glucose levels. The researchers verified compliance with glycemic monitoring and documented that target thresholds were achieved.

There was no difference between the two groups in the primary composite outcome of neonatal death and complications known to be associated with maternal hyperglycemia, nor did individual rates of complications (neonatal hypoglycemia, hyperbilirubinemia, birth trauma, and elevated cord-blood C-peptide levels) differ significantly, Dr. Landon of Ohio State University, Columbus, and his colleagues said.

However, the intervention significantly reduced mean birth weight, neonatal fat mass, the rate of large-for-gestational-age infants, and the rate of infants weighing 4,000 g or more.

Cesarean delivery was significantly less frequent in the intervention group (27%) than in the control group (34%), as were shoulder dystocia, gestational hypertension, and preeclampsia.

Moreover, both maternal body mass index at delivery and maternal weight gain during pregnancy were lower in the intervention group than in controls.

These study findings “provide further compelling evidence that among women who have gestational diabetes mellitus and normal fasting glucose levels, treatment that includes dietary intervention and insulin therapy, as necessary, reduces rates of fetal overgrowth, cesarean delivery, and preeclampsia,” Dr. Landon and his associates wrote.

This study was supported by grants from the National Institute of Child Health and Human Development, the General Clinical Research Centers, and the National Center for Research Resources. No financial conflicts of interest were reported.

Otamixaban, an intravenous anticoagulant, compared well with standard anticoagulant therapy in treating high-risk, non-ST-segment elevation acute coronary syndromes in a phase II study.

Otamixaban was associated with a 40% decrease in the composite outcome of all-cause mortality, myocardial infarction, severe recurrent ischemia requiring urgent revascularization, and “bailout” use of a glycoprotein IIb/IIIa inhibitor for recurrent ischemia or a thrombotic complication during percutaneous coronary intervention. There was no accompanying increase in bleeding events with the drug up to 7 days, study investigators reported.

Moreover, otamixaban has an almost immediate onset of action plus a 30-minute half-life. This allows rapid on-off anticoagulation, “a desirable feature in the setting of invasive management of an acute coronary syndrome,” wrote Dr. Marc S. Sabatine of Brigham and Women's Hospital, Boston, and his associates in this trial by the TIMI (Thrombolysis in Myocardial Infarction) Study Group.

Dr. Sabatine presented the results simultaneously with the publication at the annual congress of the European Society of Cardiology in Barcelona.

Otamixaban is a direct, selective inhibitor of factor Xa, “a key component of the prothrombinase complex that drives… the coagulation cascade” in acute coronary syndrome (ACS). Unlike unfractionated heparin, which has been the cornerstone of anticoagulant therapy for acute ACS, otamixaban doesn't cause thrombocytopenia and has predictable pharmacodynamic activity, so it doesn't require anticoagulation monitoring.

In a preliminary, dose-ranging study of 3,241 patients with acute ACS treated at 196 medical centers in 36 countries, study participants were randomly assigned to receive one of five doses of intravenous otamixaban or standard (control) anticoagulation therapy with unfractionated heparin plus eptifibatide. The study was funded by Sanofi-Aventis, the maker of otamixaban.

The two low doses of otamixaban appeared to provide inadequate anticoagulation, as patients who received these doses were at twice the risk as were those who received standard therapy for requiring a bailout glycoprotein IIb/IIIa inhibitor or for developing a thrombotic complication during PCI.

Conversely, the highest dose of otamixaban caused significantly more major or minor bleeding complications than did standard therapy.

The two intermediate doses of otamixaban, however, were associated with a 40% reduction in death, recurrent MI, or additional ischemic complications, compared with standard anticoagulation therapy. At these doses (0.105 and 0.140 mg/kg per hour), bleeding complications were similar between the drug and standard anticoagulation therapy (Lancet 2009 Aug. 30 [doi:10.1016/S0140-6736(09)61454-9

Otamixaban offers another advantage over heparin plus eptifibatide: With less than 25% excretion through the kidneys, it requires no dose adjustments in patients who have renal impairment, the investigators wrote.

In an editorial comment accompanying this report, Dr. John W. Eikelboom and Dr. Jeffrey I. Weitz of Hamilton (Ont.) General Hospital wrote, “These findings suggest that, like bivalirudin, otamixaban might be a useful alternative to heparin for patients who are undergoing PCI.

“However, do we need another parenteral agent for this indication?” they asked (Lancet 2009 Aug. 30 [doi:10.1016/S0140-6736(09)61529-4

“Without safety or convenience advantages, otamixaban would need to show efficacy that is superior not only to heparin but also to bivalirudin, before it would be adopted for clinical use. To our knowledge, there are no ongoing [phase III] trials to explore these possibilities, nor is otamixaban under development for other clinical indications,” Dr. Eikelboom and Dr. Weitz noted.

“Most of the attention in acute coronary syndromes has moved away from parenteral anticoagulants, such as otamixaban, and is focused on new oral agents,” they added.

Dr. Sabatine reports receiving honoraria and consulting fees from Sanofi-Aventis and Bristol-Myers Squibb Co. The TIMI study group receives research grant support from Sanofi-Aventis, Johnson & Johnson, Bayer Healthcare AG, and Daiichi Sankyo. Dr. Eikelboom has received honoraria, research support, or both from companies that are developing or marketing drugs mentioned in his editorial comment, including Bayer, Bristol-Myers Squibb, Eli Lilly & Co., GlaxoSmithKline, Regado Biosciences Inc., and Sanofi-Aventis.

Dr. Weitz also has received honoraria from companies that are developing or marketing drugs mentioned in his editorial comment, including Bristol-Myers Squibb, Sanofi-Aventis, and the Medicines Company.

Otamixaban has a quick onset of action plus a 30-minute half-life, allowing for rapid on-off anticoagulation.

Source Dr. Sabatine

Otamixaban, an intravenous anticoagulant, compared well with standard anticoagulant therapy in treating high-risk, non-ST-segment elevation acute coronary syndromes in a phase II study.

Otamixaban was associated with a 40% decrease in the composite outcome of all-cause mortality, myocardial infarction, severe recurrent ischemia requiring urgent revascularization, and “bailout” use of a glycoprotein IIb/IIIa inhibitor for recurrent ischemia or a thrombotic complication during percutaneous coronary intervention. There was no accompanying increase in bleeding events with the drug up to 7 days, study investigators reported.

Moreover, otamixaban has an almost immediate onset of action plus a 30-minute half-life. This allows rapid on-off anticoagulation, “a desirable feature in the setting of invasive management of an acute coronary syndrome,” wrote Dr. Marc S. Sabatine of Brigham and Women's Hospital, Boston, and his associates in this trial by the TIMI (Thrombolysis in Myocardial Infarction) Study Group.

Dr. Sabatine presented the results simultaneously with the publication at the annual congress of the European Society of Cardiology in Barcelona.

Otamixaban is a direct, selective inhibitor of factor Xa, “a key component of the prothrombinase complex that drives… the coagulation cascade” in acute coronary syndrome (ACS). Unlike unfractionated heparin, which has been the cornerstone of anticoagulant therapy for acute ACS, otamixaban doesn't cause thrombocytopenia and has predictable pharmacodynamic activity, so it doesn't require anticoagulation monitoring.

In a preliminary, dose-ranging study of 3,241 patients with acute ACS treated at 196 medical centers in 36 countries, study participants were randomly assigned to receive one of five doses of intravenous otamixaban or standard (control) anticoagulation therapy with unfractionated heparin plus eptifibatide. The study was funded by Sanofi-Aventis, the maker of otamixaban.

The two low doses of otamixaban appeared to provide inadequate anticoagulation, as patients who received these doses were at twice the risk as were those who received standard therapy for requiring a bailout glycoprotein IIb/IIIa inhibitor or for developing a thrombotic complication during PCI.

Conversely, the highest dose of otamixaban caused significantly more major or minor bleeding complications than did standard therapy.

The two intermediate doses of otamixaban, however, were associated with a 40% reduction in death, recurrent MI, or additional ischemic complications, compared with standard anticoagulation therapy. At these doses (0.105 and 0.140 mg/kg per hour), bleeding complications were similar between the drug and standard anticoagulation therapy (Lancet 2009 Aug. 30 [doi:10.1016/S0140-6736(09)61454-9

Otamixaban offers another advantage over heparin plus eptifibatide: With less than 25% excretion through the kidneys, it requires no dose adjustments in patients who have renal impairment, the investigators wrote.

In an editorial comment accompanying this report, Dr. John W. Eikelboom and Dr. Jeffrey I. Weitz of Hamilton (Ont.) General Hospital wrote, “These findings suggest that, like bivalirudin, otamixaban might be a useful alternative to heparin for patients who are undergoing PCI.

“However, do we need another parenteral agent for this indication?” they asked (Lancet 2009 Aug. 30 [doi:10.1016/S0140-6736(09)61529-4

“Without safety or convenience advantages, otamixaban would need to show efficacy that is superior not only to heparin but also to bivalirudin, before it would be adopted for clinical use. To our knowledge, there are no ongoing [phase III] trials to explore these possibilities, nor is otamixaban under development for other clinical indications,” Dr. Eikelboom and Dr. Weitz noted.

“Most of the attention in acute coronary syndromes has moved away from parenteral anticoagulants, such as otamixaban, and is focused on new oral agents,” they added.

Dr. Sabatine reports receiving honoraria and consulting fees from Sanofi-Aventis and Bristol-Myers Squibb Co. The TIMI study group receives research grant support from Sanofi-Aventis, Johnson & Johnson, Bayer Healthcare AG, and Daiichi Sankyo. Dr. Eikelboom has received honoraria, research support, or both from companies that are developing or marketing drugs mentioned in his editorial comment, including Bayer, Bristol-Myers Squibb, Eli Lilly & Co., GlaxoSmithKline, Regado Biosciences Inc., and Sanofi-Aventis.

Dr. Weitz also has received honoraria from companies that are developing or marketing drugs mentioned in his editorial comment, including Bristol-Myers Squibb, Sanofi-Aventis, and the Medicines Company.

Otamixaban has a quick onset of action plus a 30-minute half-life, allowing for rapid on-off anticoagulation.

Source Dr. Sabatine

Otamixaban, an intravenous anticoagulant, compared well with standard anticoagulant therapy in treating high-risk, non-ST-segment elevation acute coronary syndromes in a phase II study.

Otamixaban was associated with a 40% decrease in the composite outcome of all-cause mortality, myocardial infarction, severe recurrent ischemia requiring urgent revascularization, and “bailout” use of a glycoprotein IIb/IIIa inhibitor for recurrent ischemia or a thrombotic complication during percutaneous coronary intervention. There was no accompanying increase in bleeding events with the drug up to 7 days, study investigators reported.

Moreover, otamixaban has an almost immediate onset of action plus a 30-minute half-life. This allows rapid on-off anticoagulation, “a desirable feature in the setting of invasive management of an acute coronary syndrome,” wrote Dr. Marc S. Sabatine of Brigham and Women's Hospital, Boston, and his associates in this trial by the TIMI (Thrombolysis in Myocardial Infarction) Study Group.

Dr. Sabatine presented the results simultaneously with the publication at the annual congress of the European Society of Cardiology in Barcelona.

Otamixaban is a direct, selective inhibitor of factor Xa, “a key component of the prothrombinase complex that drives… the coagulation cascade” in acute coronary syndrome (ACS). Unlike unfractionated heparin, which has been the cornerstone of anticoagulant therapy for acute ACS, otamixaban doesn't cause thrombocytopenia and has predictable pharmacodynamic activity, so it doesn't require anticoagulation monitoring.

In a preliminary, dose-ranging study of 3,241 patients with acute ACS treated at 196 medical centers in 36 countries, study participants were randomly assigned to receive one of five doses of intravenous otamixaban or standard (control) anticoagulation therapy with unfractionated heparin plus eptifibatide. The study was funded by Sanofi-Aventis, the maker of otamixaban.

The two low doses of otamixaban appeared to provide inadequate anticoagulation, as patients who received these doses were at twice the risk as were those who received standard therapy for requiring a bailout glycoprotein IIb/IIIa inhibitor or for developing a thrombotic complication during PCI.

Conversely, the highest dose of otamixaban caused significantly more major or minor bleeding complications than did standard therapy.

The two intermediate doses of otamixaban, however, were associated with a 40% reduction in death, recurrent MI, or additional ischemic complications, compared with standard anticoagulation therapy. At these doses (0.105 and 0.140 mg/kg per hour), bleeding complications were similar between the drug and standard anticoagulation therapy (Lancet 2009 Aug. 30 [doi:10.1016/S0140-6736(09)61454-9

Otamixaban offers another advantage over heparin plus eptifibatide: With less than 25% excretion through the kidneys, it requires no dose adjustments in patients who have renal impairment, the investigators wrote.

In an editorial comment accompanying this report, Dr. John W. Eikelboom and Dr. Jeffrey I. Weitz of Hamilton (Ont.) General Hospital wrote, “These findings suggest that, like bivalirudin, otamixaban might be a useful alternative to heparin for patients who are undergoing PCI.

“However, do we need another parenteral agent for this indication?” they asked (Lancet 2009 Aug. 30 [doi:10.1016/S0140-6736(09)61529-4

“Without safety or convenience advantages, otamixaban would need to show efficacy that is superior not only to heparin but also to bivalirudin, before it would be adopted for clinical use. To our knowledge, there are no ongoing [phase III] trials to explore these possibilities, nor is otamixaban under development for other clinical indications,” Dr. Eikelboom and Dr. Weitz noted.

“Most of the attention in acute coronary syndromes has moved away from parenteral anticoagulants, such as otamixaban, and is focused on new oral agents,” they added.

Dr. Sabatine reports receiving honoraria and consulting fees from Sanofi-Aventis and Bristol-Myers Squibb Co. The TIMI study group receives research grant support from Sanofi-Aventis, Johnson & Johnson, Bayer Healthcare AG, and Daiichi Sankyo. Dr. Eikelboom has received honoraria, research support, or both from companies that are developing or marketing drugs mentioned in his editorial comment, including Bayer, Bristol-Myers Squibb, Eli Lilly & Co., GlaxoSmithKline, Regado Biosciences Inc., and Sanofi-Aventis.

Dr. Weitz also has received honoraria from companies that are developing or marketing drugs mentioned in his editorial comment, including Bristol-Myers Squibb, Sanofi-Aventis, and the Medicines Company.

Otamixaban has a quick onset of action plus a 30-minute half-life, allowing for rapid on-off anticoagulation.

Source Dr. Sabatine

Adult-onset asthma was associated with several measures of large body size, particularly abdominal adiposity, in a large longitudinal study of women.

Even being modestly overweight at baseline increased the risk of developing asthma over time, said Julie Von Behren of the Northern California Cancer Center, Berkeley, and her associates.

Moreover, a large waist circumference, even among women of normal weight and body mass index (BMI), appeared to raise the risk for asthma.

Noting that “obesity has recently been identified as a risk factor for adult asthma, particularly in women,” Ms. Von Behren and her colleagues examined the issue using data from the California Teachers Study, an ongoing assessment of women teachers and school administrators that began in 1995.

The 88,304 subjects included in the analysis were either actively employed by or retired from the state school system. Anthropomorphic factors were assessed at baseline and in 1997, whereas measures related to asthma were assessed in 2000.

The overall prevalence of obesity at baseline was 13%, and the overall prevalence of current asthma was 7.6%. The prevalence of asthma at baseline was 10.9% among women with class I obesity, 13.4% among women with class II obesity, and 18.3% among extremely obese women.

Compared with subjects of normal weight, those who were overweight had an odds ratio of 1.4 for asthma. The odds ratio rose steadily as weight increased, to 3.3 for women with class III obesity.

In addition to BMI, weight gain since the age of 18 years, waist:height ratio, and waist circumference also were strongly associated with the development of asthma. Waist circumference, which more closely reflects visceral fat than does BMI, showed a particularly strong and independent association with asthma: Even women of normal BMI who had a waist measurement greater than 88 cm had a higher rate of asthma than did women with smaller waists.

(A waist circumference of 88 cm is the National Institutes of Health's cutoff for increased risk for diabetes, hypertension, and cardiovascular disease.)

Overweight and obesity also were associated with asthma severity. Compared with women of normal weight, those who were overweight had an odds ratio for severe asthma of 1.31, those who were obese had an odds ratio of 1.32, and those who were extremely obese had an odds ratio of 2.00, the investigators said (Thorax 2009 [doi:10.1136/thx.2009.114579]).

There are several possible mechanisms by which excess weight or abdominal adiposity may cause or exacerbate asthma, the investigators noted. Obesity can affect airways via its effects on atopy, lymphocyte ratios, immune responsiveness, and systemic inflammation. It is also associated with gastroesophageal reflux, a risk factor for asthma.

The heightened effect of obesity on asthma among women, compared with men, suggests that estrogen and other hormones also may play a role, possibly through the modulation of cytokine production. The study was sponsored by the National Cancer Institute. No conflicts of interest were reported.

Adult-onset asthma was associated with several measures of large body size, particularly abdominal adiposity, in a large longitudinal study of women.

Even being modestly overweight at baseline increased the risk of developing asthma over time, said Julie Von Behren of the Northern California Cancer Center, Berkeley, and her associates.

Moreover, a large waist circumference, even among women of normal weight and body mass index (BMI), appeared to raise the risk for asthma.

Noting that “obesity has recently been identified as a risk factor for adult asthma, particularly in women,” Ms. Von Behren and her colleagues examined the issue using data from the California Teachers Study, an ongoing assessment of women teachers and school administrators that began in 1995.

The 88,304 subjects included in the analysis were either actively employed by or retired from the state school system. Anthropomorphic factors were assessed at baseline and in 1997, whereas measures related to asthma were assessed in 2000.

The overall prevalence of obesity at baseline was 13%, and the overall prevalence of current asthma was 7.6%. The prevalence of asthma at baseline was 10.9% among women with class I obesity, 13.4% among women with class II obesity, and 18.3% among extremely obese women.

Compared with subjects of normal weight, those who were overweight had an odds ratio of 1.4 for asthma. The odds ratio rose steadily as weight increased, to 3.3 for women with class III obesity.

In addition to BMI, weight gain since the age of 18 years, waist:height ratio, and waist circumference also were strongly associated with the development of asthma. Waist circumference, which more closely reflects visceral fat than does BMI, showed a particularly strong and independent association with asthma: Even women of normal BMI who had a waist measurement greater than 88 cm had a higher rate of asthma than did women with smaller waists.

(A waist circumference of 88 cm is the National Institutes of Health's cutoff for increased risk for diabetes, hypertension, and cardiovascular disease.)

Overweight and obesity also were associated with asthma severity. Compared with women of normal weight, those who were overweight had an odds ratio for severe asthma of 1.31, those who were obese had an odds ratio of 1.32, and those who were extremely obese had an odds ratio of 2.00, the investigators said (Thorax 2009 [doi:10.1136/thx.2009.114579]).

There are several possible mechanisms by which excess weight or abdominal adiposity may cause or exacerbate asthma, the investigators noted. Obesity can affect airways via its effects on atopy, lymphocyte ratios, immune responsiveness, and systemic inflammation. It is also associated with gastroesophageal reflux, a risk factor for asthma.

The heightened effect of obesity on asthma among women, compared with men, suggests that estrogen and other hormones also may play a role, possibly through the modulation of cytokine production. The study was sponsored by the National Cancer Institute. No conflicts of interest were reported.

Adult-onset asthma was associated with several measures of large body size, particularly abdominal adiposity, in a large longitudinal study of women.

Even being modestly overweight at baseline increased the risk of developing asthma over time, said Julie Von Behren of the Northern California Cancer Center, Berkeley, and her associates.

Moreover, a large waist circumference, even among women of normal weight and body mass index (BMI), appeared to raise the risk for asthma.

Noting that “obesity has recently been identified as a risk factor for adult asthma, particularly in women,” Ms. Von Behren and her colleagues examined the issue using data from the California Teachers Study, an ongoing assessment of women teachers and school administrators that began in 1995.

The 88,304 subjects included in the analysis were either actively employed by or retired from the state school system. Anthropomorphic factors were assessed at baseline and in 1997, whereas measures related to asthma were assessed in 2000.

The overall prevalence of obesity at baseline was 13%, and the overall prevalence of current asthma was 7.6%. The prevalence of asthma at baseline was 10.9% among women with class I obesity, 13.4% among women with class II obesity, and 18.3% among extremely obese women.

Compared with subjects of normal weight, those who were overweight had an odds ratio of 1.4 for asthma. The odds ratio rose steadily as weight increased, to 3.3 for women with class III obesity.

In addition to BMI, weight gain since the age of 18 years, waist:height ratio, and waist circumference also were strongly associated with the development of asthma. Waist circumference, which more closely reflects visceral fat than does BMI, showed a particularly strong and independent association with asthma: Even women of normal BMI who had a waist measurement greater than 88 cm had a higher rate of asthma than did women with smaller waists.

(A waist circumference of 88 cm is the National Institutes of Health's cutoff for increased risk for diabetes, hypertension, and cardiovascular disease.)

Overweight and obesity also were associated with asthma severity. Compared with women of normal weight, those who were overweight had an odds ratio for severe asthma of 1.31, those who were obese had an odds ratio of 1.32, and those who were extremely obese had an odds ratio of 2.00, the investigators said (Thorax 2009 [doi:10.1136/thx.2009.114579]).

There are several possible mechanisms by which excess weight or abdominal adiposity may cause or exacerbate asthma, the investigators noted. Obesity can affect airways via its effects on atopy, lymphocyte ratios, immune responsiveness, and systemic inflammation. It is also associated with gastroesophageal reflux, a risk factor for asthma.

The heightened effect of obesity on asthma among women, compared with men, suggests that estrogen and other hormones also may play a role, possibly through the modulation of cytokine production. The study was sponsored by the National Cancer Institute. No conflicts of interest were reported.

Implantable cardioverter defibrillators do not reduce all-cause mortality in women who have advanced heart failure, unlike in men, according to a meta-analysis.

“In other words, ICDs are being implanted in hundreds of thousands of women without substantial evidence of benefit, apparently based on the assumption that, to paraphrase the old saying, 'What's good for the gander is good for the goose,'” Dr. Rita F. Redberg said in an editorial comment accompanying the report.

This finding is particularly concerning because a “recent analysis of the National Cardiovascular Data Registry found that women have a 70% higher risk of major adverse events after ICD implantation than do men,” noted Dr. Redberg, editor of the journal and director of women's cardiovascular services at the University of California, San Francisco.

Dr. Hamid Ghanbari and his associates at Providence Hospital Heart Institute and Medical Center, Southfield, Mich., performed the meta-analysis because most of the patients in clinical trials of ICDs have been male. It has never been established whether women with advanced heart failure receive the same benefit from ICD placement for the primary prevention of sudden cardiac death.

The investigators pooled data from five randomized, controlled clinical trials that compared ICD implantation with medical therapy and included 934 women along with 3,810 men. Men who had heart failure with reduced left ventricular ejection fraction showed a significant decrease in all-cause mortality when they were given an ICD rather than medical therapy to prevent sudden cardiac death.

In contrast, women did not show a mortality benefit, either in the combined data or in any of the five individual trials, Dr. Ghanbari and his colleagues said (Arch. Intern. Med. 2009;169:1500-6).

The reason for this discrepancy is not yet known, and further study of the issue is warranted. One possible explanation is that women who receive ICDs are known to have more severe comorbidities than men who receive them, and thus may have more competing causes of death compared with men, the researchers said.

In her editorial comment, Dr. Redberg concurred that further study of this surprising finding is warranted (Arch. Intern. Med. 2009;169:1460-1).

Neither Dr. Ghanbari nor Dr. Redberg reported any financial conflicts of interest.

Implantable cardioverter defibrillators do not reduce all-cause mortality in women who have advanced heart failure, unlike in men, according to a meta-analysis.

“In other words, ICDs are being implanted in hundreds of thousands of women without substantial evidence of benefit, apparently based on the assumption that, to paraphrase the old saying, 'What's good for the gander is good for the goose,'” Dr. Rita F. Redberg said in an editorial comment accompanying the report.

This finding is particularly concerning because a “recent analysis of the National Cardiovascular Data Registry found that women have a 70% higher risk of major adverse events after ICD implantation than do men,” noted Dr. Redberg, editor of the journal and director of women's cardiovascular services at the University of California, San Francisco.

Dr. Hamid Ghanbari and his associates at Providence Hospital Heart Institute and Medical Center, Southfield, Mich., performed the meta-analysis because most of the patients in clinical trials of ICDs have been male. It has never been established whether women with advanced heart failure receive the same benefit from ICD placement for the primary prevention of sudden cardiac death.

The investigators pooled data from five randomized, controlled clinical trials that compared ICD implantation with medical therapy and included 934 women along with 3,810 men. Men who had heart failure with reduced left ventricular ejection fraction showed a significant decrease in all-cause mortality when they were given an ICD rather than medical therapy to prevent sudden cardiac death.

In contrast, women did not show a mortality benefit, either in the combined data or in any of the five individual trials, Dr. Ghanbari and his colleagues said (Arch. Intern. Med. 2009;169:1500-6).

The reason for this discrepancy is not yet known, and further study of the issue is warranted. One possible explanation is that women who receive ICDs are known to have more severe comorbidities than men who receive them, and thus may have more competing causes of death compared with men, the researchers said.

In her editorial comment, Dr. Redberg concurred that further study of this surprising finding is warranted (Arch. Intern. Med. 2009;169:1460-1).

Neither Dr. Ghanbari nor Dr. Redberg reported any financial conflicts of interest.

Implantable cardioverter defibrillators do not reduce all-cause mortality in women who have advanced heart failure, unlike in men, according to a meta-analysis.

“In other words, ICDs are being implanted in hundreds of thousands of women without substantial evidence of benefit, apparently based on the assumption that, to paraphrase the old saying, 'What's good for the gander is good for the goose,'” Dr. Rita F. Redberg said in an editorial comment accompanying the report.

This finding is particularly concerning because a “recent analysis of the National Cardiovascular Data Registry found that women have a 70% higher risk of major adverse events after ICD implantation than do men,” noted Dr. Redberg, editor of the journal and director of women's cardiovascular services at the University of California, San Francisco.

Dr. Hamid Ghanbari and his associates at Providence Hospital Heart Institute and Medical Center, Southfield, Mich., performed the meta-analysis because most of the patients in clinical trials of ICDs have been male. It has never been established whether women with advanced heart failure receive the same benefit from ICD placement for the primary prevention of sudden cardiac death.

The investigators pooled data from five randomized, controlled clinical trials that compared ICD implantation with medical therapy and included 934 women along with 3,810 men. Men who had heart failure with reduced left ventricular ejection fraction showed a significant decrease in all-cause mortality when they were given an ICD rather than medical therapy to prevent sudden cardiac death.

In contrast, women did not show a mortality benefit, either in the combined data or in any of the five individual trials, Dr. Ghanbari and his colleagues said (Arch. Intern. Med. 2009;169:1500-6).

The reason for this discrepancy is not yet known, and further study of the issue is warranted. One possible explanation is that women who receive ICDs are known to have more severe comorbidities than men who receive them, and thus may have more competing causes of death compared with men, the researchers said.

In her editorial comment, Dr. Redberg concurred that further study of this surprising finding is warranted (Arch. Intern. Med. 2009;169:1460-1).

Neither Dr. Ghanbari nor Dr. Redberg reported any financial conflicts of interest.

An educational program in “mindful” communication produced striking improvements in physicians' symptoms of burnout, according to a recent report.

By enhancing physicians' attention to their own feelings and experiences, the 52-hour program not only reduced participants' distress but also increased their empathy for patients and their ability to deliver patient-centered care, which in turn may improve clinical outcomes, Dr. Tait D. Shanafelt said in an accompanying editorial.

“Physicians will face a host of new challenges over the next decade as the nation reforms its health care system,” and the restructuring will likely “increase the already epidemic levels of burnout in physicians and overwhelm those currently near their limits,” he wrote.

In response, some physicians will feel compelled to withdraw from their work. But this study “demonstrates that training physicians in the art of mindful practice has the potential to promote physician health through work,” said Dr. Shanafelt, director of the Program on Physician Well-Being at the Mayo Clinic, Rochester, Minn. (JAMA 2009;302:1338-40).

In the study, Dr. Michael S. Krasner and his associates at the University of Rochester (N.Y.) evaluated a continuing medical education course designed to improve physician well-being. The 1-year program includes an intensive phase with 8 weekly 2.5-hour sessions plus one all-day session toward the end of this phase, followed by a maintenance phase of 10 monthly 2.5-hour sessions.

Each session begins with a brief presentation of that week's theme and may include guided meditation exercises, yoga-type exercises, large-group discussions, writing brief stories about personal experiences in medical practice, discussing challenges in medical practice, and sharing the written stories.

The weekly and monthly topics include self-awareness of thoughts and feelings, examining perceptual biases, dealing with pleasant and unpleasant events, managing conflict, preventing burnout, reflecting on meaningful experiences in practice, setting boundaries, examining attention to patients, exploring self-care, being with suffering, and examining end-of-life care.

Participants are taught mindfulness–“paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.” It includes lowering one's reactivity to challenging experiences; noticing and experiencing one's thoughts, feelings, and bodily sensations, even when unpleasant; acting with awareness and attention instead of “on autopilot”; and trying to disregard the labels or judgments applied to experiences in medical practice.

A total of 871 Rochester-area internal medicine, family medicine, and pediatric physicians were invited to partake in the program, and 70 accepted.

These subjects were assessed at five different times before, during, and after the program, using several instruments such as the Maslach Burnout Inventory, the Jefferson Scale of Physician Empathy, the Physician Belief Scale, the Profile of Mood States, and the Big Five Factor Structure personality scale.

Study subjects showed “striking” improvements in self-awareness and well-being, which included decreases in emotional exhaustion, depersonalization, depression, tension, anger, and fatigue, as well as increases in feelings of personal accomplishment, vigor, empathy, and psychosocial beliefs known to correlate with patient-centered behavior, Dr. Krasner and his colleagues said (JAMA 2009;302:1284-93).

The study was funded by the Physicians' Foundation for Health Systems Excellence and sponsored by the New York chapter of the American College of Physicians. Dr. Krasner and Dr. Shanafelt reported no financial conflicts of interest.

An educational program in “mindful” communication produced striking improvements in physicians' symptoms of burnout, according to a recent report.

By enhancing physicians' attention to their own feelings and experiences, the 52-hour program not only reduced participants' distress but also increased their empathy for patients and their ability to deliver patient-centered care, which in turn may improve clinical outcomes, Dr. Tait D. Shanafelt said in an accompanying editorial.

“Physicians will face a host of new challenges over the next decade as the nation reforms its health care system,” and the restructuring will likely “increase the already epidemic levels of burnout in physicians and overwhelm those currently near their limits,” he wrote.

In response, some physicians will feel compelled to withdraw from their work. But this study “demonstrates that training physicians in the art of mindful practice has the potential to promote physician health through work,” said Dr. Shanafelt, director of the Program on Physician Well-Being at the Mayo Clinic, Rochester, Minn. (JAMA 2009;302:1338-40).

In the study, Dr. Michael S. Krasner and his associates at the University of Rochester (N.Y.) evaluated a continuing medical education course designed to improve physician well-being. The 1-year program includes an intensive phase with 8 weekly 2.5-hour sessions plus one all-day session toward the end of this phase, followed by a maintenance phase of 10 monthly 2.5-hour sessions.

Each session begins with a brief presentation of that week's theme and may include guided meditation exercises, yoga-type exercises, large-group discussions, writing brief stories about personal experiences in medical practice, discussing challenges in medical practice, and sharing the written stories.

The weekly and monthly topics include self-awareness of thoughts and feelings, examining perceptual biases, dealing with pleasant and unpleasant events, managing conflict, preventing burnout, reflecting on meaningful experiences in practice, setting boundaries, examining attention to patients, exploring self-care, being with suffering, and examining end-of-life care.

Participants are taught mindfulness–“paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.” It includes lowering one's reactivity to challenging experiences; noticing and experiencing one's thoughts, feelings, and bodily sensations, even when unpleasant; acting with awareness and attention instead of “on autopilot”; and trying to disregard the labels or judgments applied to experiences in medical practice.

A total of 871 Rochester-area internal medicine, family medicine, and pediatric physicians were invited to partake in the program, and 70 accepted.

These subjects were assessed at five different times before, during, and after the program, using several instruments such as the Maslach Burnout Inventory, the Jefferson Scale of Physician Empathy, the Physician Belief Scale, the Profile of Mood States, and the Big Five Factor Structure personality scale.

Study subjects showed “striking” improvements in self-awareness and well-being, which included decreases in emotional exhaustion, depersonalization, depression, tension, anger, and fatigue, as well as increases in feelings of personal accomplishment, vigor, empathy, and psychosocial beliefs known to correlate with patient-centered behavior, Dr. Krasner and his colleagues said (JAMA 2009;302:1284-93).

The study was funded by the Physicians' Foundation for Health Systems Excellence and sponsored by the New York chapter of the American College of Physicians. Dr. Krasner and Dr. Shanafelt reported no financial conflicts of interest.

An educational program in “mindful” communication produced striking improvements in physicians' symptoms of burnout, according to a recent report.

By enhancing physicians' attention to their own feelings and experiences, the 52-hour program not only reduced participants' distress but also increased their empathy for patients and their ability to deliver patient-centered care, which in turn may improve clinical outcomes, Dr. Tait D. Shanafelt said in an accompanying editorial.

“Physicians will face a host of new challenges over the next decade as the nation reforms its health care system,” and the restructuring will likely “increase the already epidemic levels of burnout in physicians and overwhelm those currently near their limits,” he wrote.

In response, some physicians will feel compelled to withdraw from their work. But this study “demonstrates that training physicians in the art of mindful practice has the potential to promote physician health through work,” said Dr. Shanafelt, director of the Program on Physician Well-Being at the Mayo Clinic, Rochester, Minn. (JAMA 2009;302:1338-40).

In the study, Dr. Michael S. Krasner and his associates at the University of Rochester (N.Y.) evaluated a continuing medical education course designed to improve physician well-being. The 1-year program includes an intensive phase with 8 weekly 2.5-hour sessions plus one all-day session toward the end of this phase, followed by a maintenance phase of 10 monthly 2.5-hour sessions.

Each session begins with a brief presentation of that week's theme and may include guided meditation exercises, yoga-type exercises, large-group discussions, writing brief stories about personal experiences in medical practice, discussing challenges in medical practice, and sharing the written stories.

The weekly and monthly topics include self-awareness of thoughts and feelings, examining perceptual biases, dealing with pleasant and unpleasant events, managing conflict, preventing burnout, reflecting on meaningful experiences in practice, setting boundaries, examining attention to patients, exploring self-care, being with suffering, and examining end-of-life care.

Participants are taught mindfulness–“paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.” It includes lowering one's reactivity to challenging experiences; noticing and experiencing one's thoughts, feelings, and bodily sensations, even when unpleasant; acting with awareness and attention instead of “on autopilot”; and trying to disregard the labels or judgments applied to experiences in medical practice.

A total of 871 Rochester-area internal medicine, family medicine, and pediatric physicians were invited to partake in the program, and 70 accepted.

These subjects were assessed at five different times before, during, and after the program, using several instruments such as the Maslach Burnout Inventory, the Jefferson Scale of Physician Empathy, the Physician Belief Scale, the Profile of Mood States, and the Big Five Factor Structure personality scale.

Study subjects showed “striking” improvements in self-awareness and well-being, which included decreases in emotional exhaustion, depersonalization, depression, tension, anger, and fatigue, as well as increases in feelings of personal accomplishment, vigor, empathy, and psychosocial beliefs known to correlate with patient-centered behavior, Dr. Krasner and his colleagues said (JAMA 2009;302:1284-93).

The study was funded by the Physicians' Foundation for Health Systems Excellence and sponsored by the New York chapter of the American College of Physicians. Dr. Krasner and Dr. Shanafelt reported no financial conflicts of interest.