Psychosomatics 40:90-91, February 1999
© 1999 The Academy of Psychosomatic Medine
Med-Psych Update
John L. Shuster, M.D. Med-Psych Update Editor
Key Words: Med-Psych Update • Psychopharmacological Literature, Abstracted
Keating NL, Zaslavsky AM, Ayanian JZ: Physicians' experiences and beliefs regarding informal consultation. JAMA 1998; 280:900–904
Kuo D, Gifford DR, Stein MD: Curbside consultation practices and attitudes among primary care physicians and medical subspecialists. JAMA 1998; 280:905–909
Abstracted by Charles McInteer, M.D.
Informal consultation (curbside consultation) represents a significant aspect of contemporary medical practice. The growth of managed care and physician group practices has caused speculation that use of curbside consultation is on the rise. Informal consultations can be of great benefit to the patient and to primary care physicians. The authors of these studies attempt to clarify the experiences, attitudes, and beliefs of primary care and subspecialist physicians about the practice of curbside consultation.
In both studies, self-administered surveys developed by the respective authors were mailed to physicians. In the Kuo study (performed in Rhode Island), 213 primary care physicians and 200 subspecialists (76.8% of the physicians sampled) responded to the questionnaire. In the Keating study (performed in Massachusetts), 705 primary care physicians and subspecialists responded (58% of those surveyed). Results from these studies indicated that informal consultations constituted about one-quarter of all consultations requested. Primary care physicians requested more curbside consults (3.2 per week in Rhode Island and 3 per week in Massachusetts) than subspecialists.
Subspecialists were asked to provide more informal consults (3.6 per week in Rhode Island and 5 per week in Massachusetts) than primary care specialists. In Massachusetts, it was noted physicians in health maintenance organizations, multispecialty groups, or single-specialty groups requested more curbside consults than physicians in solo practice (82%, 40%, and 28% more, respectively; all P<0.001). Curbside consultations were directed most often toward cardiology, gastroenterology, and infectious disease.
Endocrinologists, infectious disease specialists, and rheumatologists were asked to provide curbside consultations more often than formal consultations. Informal consultations were used most often to select tests, guide treatment plans, and determine the need for formal consultation.
Primary care physicians' overall approval of informal consultation was greater than subspecialists and the former thought it more beneficial to themselves and the patient. Subspecialists often thought that the information exchanged during an informal consultation was inadequate and that consulting physicians would be less likely to follow a consultant's recommendations resulting from informal consultations compared with formal consultations, but the subspecialists also felt that the practice is necessary to maintain good relations with colleagues. About half of the physicians surveyed felt that the practice of informal consultation saved money for patients and payers, but only about a quarter of those surveyed thought curbside consults should be used more often to minimize the frequency of inappropriate formal consultations. It was repeatedly noted that this area of medicine is important, that there remains disagreement about the proper role of curbside consultation, and that it is essential to study this practice carefully.
FOOTNOTES
Dr. McInteer is a resident in the Department of Psychiatry and Behavioral Neurobiology at the University of Alabama School of Medicine, University of Alabama at Birmingham.
Dalal S, Melzack R: Psychostimulant drugs potentiate morphine analgesia in the formalin test. J Pain Symptom Manage 1998; 16:230–239
Abstracted by John L. Shuster, M.D.
Psychostimulant drugs are gaining attention for their beneficial effects in the control of pain and other symptoms. In addition to counteracting the sedating effects of opiates, stimulants appear to have analgesic properties of their own. Dalal and Melzack report the results of a study (accompanied by a review article on the same topic1) that suggest that stimulants have synergistic analgesic effects when combined with morphine.
The formalin test is a clinically relevant rat model using a subcutaneous injection of formalin to produce pain of sufficient intensity and duration to mimic human pain. Prior to formalin administration, rats in this study were treated with varying doses of morphine combined with varying doses of either saline (placebo), methylphenidate, or dextroamphetamine on two different time schedules. Both methylphenidate and dextroamphetamine appeared to potentiate the analgesic effect of morphine against pain produced by formalin injection.
Though the most consistent analgesic augmentation was obtained with the morphine/dextroamphetamine combination, methylphenidate alone appeared to have a substantial analgesic effect in some of the experiments. It is difficult to extrapolate these results to human pain, but the results from this rat model do indicate that both methylphenidate and dextroamphetamine augment the analgesic effect of morphine.
REFERENCES
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Dalal S, Melzack R: Potentiation of opioid analgesia by psychostimulant drugs: a review. J Pain Symptom Manage 1998; 16:245–253[Medline]
McKenzie R, Fallon A, Dale J, et al: Low-dose hydrocortisone for treatment of chronic fatigue syndrome. JAMA 1998; 280:1061–1066
Abstracted by John L. Shuster, M.D.
The causes and treatments of chronic fatigue syndrome (CFS) are among the most frustrating medical mysteries—for patients who suffer with CFS and their physicians. Studies have suggested a wide range of potential etiologies, including viral infection, immune-system dysfunction, muscular disorders, autonomic nervous-system dysfunction, and psychiatric disorders, especially mood and somatoform disorders. Another hypothesis, that CFS is caused by disturbances of the hypothalamic-pituitary-adrenal axis, is tested in the study reported by McKenzie and colleagues by administration of low-dose hydrocortisone to patients with CFS.
Seventy adults with well-documented CFS (using Centers for Disease Contol and Prevention criteria) were treated with either placebo or 20 to 30 mg of hydrocortisone each morning combined with 5 mg of hydrocortisone each afternoon for 12 weeks. CFS patients enrolled in the study did not necessarily have clinically significant hypothalamic-pituitary-adrenal axis dysregulation or hypocortisolemia. Patients were asked to record a 0-100 Wellness score daily, as well as complete the Profile of Mood States, Symptom Checklist-90-R, Sickness Impact Profile, Beck Depression Inventory, and a 10-point activity scale every week. The Hamilton Depression Rating Scale was administered to subjects at study entry and again at completion of the study.
The Wellness score was the only measure that demonstrated a beneficial effect of hydrocortisone treatment compared with placebo in these study subjects with CFS. By some measures (improvement in mean Wellness score, percentage of subjects recording improvements of >5 points on the Wellness score) but not others (overall number of patients showing improvement on the Wellness score), treated subjects seemed to improve as measured by self-report of feeling better. Adrenal suppression was documented in 12 of the 30 patients treated with hydrocortisone. The authors were cautiously enthusiastic about their results, though the author of an accompanying editorial was less impressed.1
The authors note that the apparent benefit of this hydrocortisone treatment for CFS patients was outweighed by the risks of adrenal suppression. The search for an effective and well-tolerated pharmacologic treatment for CFS continues.
REFERENCES
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Streeten DHP: The nature of chronic fatigue. JAMA 1998; 280:1094–1095[Free Full Text]
Recent Review Articles of Interest
(Anonymous) JAMA patient page: Depression. JAMA 1998; 279:1760
Avery D, Lenz M, Landis C: Guidelines for prescribing melatonin. Ann Med 1998; 30:122–130
Lieberman S: Nutriceutical review of St. John's wort (Hypericum perforatum) for the treatment of depression. J Womens Health 1998; 7:177–182
Pitt B: Loss in late life. BMJ 1998; 316:1452–1454
Prather CM, Ortiz-Camacho CP: Evaluation and treatment of constipation and fecal impaction in adults. Mayo Clin Proc 1998; 73:881–887
Salzman C: St. John's wort. Harv Rev Psychiatry 1998; 5:333–335
Stroebe MS: New directions in bereavement research: exploration of gender differences. Palliat Med 1998; 12:5–12
Tinsley JA, Finlayson RE, Morse RM: Developments in the treatment of alcoholism. Mayo Clin Proc 1998; 73:857–863
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